Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Clock Tower Surgery on 10 May 2017. Overall the practice is rated as outstanding.

Clock Tower Surgery was established in March 2000 in response to a national and local health care agenda. It is a specific GP practice commissioned to provide access to NHS primary care services for approximately 570 homeless and vulnerably housed patients. The vision and aim of the practice was to move patients on to mainstream GP practices once they had stabilised their lives and housing.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system in place for recording, reporting and learning from serious significant events. Lessons were shared across the organisation and with other practices within the organisation.

• The practice had clearly defined and embedded local and organisational systems to minimise risks to patient safety.
• Staff were aware of current evidence based guidance. GPs, nurses and locum GPs were skilled in caring for the patient group and had qualifications and experience in caring for patients with substance misuse, challenging behaviours and supporting patients who were homeless or vulnerably housed.
• One of the GPs working at the practice was a GPwSI (GP with a special interest) and prescribed medicines used in heroin, alcohol and opioid addictions. Between October 2016 and March 2017 83 patients were prescribed these medicines.
• Staff worked with the RISE service (Recovery and Integration Service) and hosted RISE six clinics per week at the practice allowing for closer communication between the RISE workers, practice staff and patients. The GPwSI was provided with clinical supervision from the RISE clinical lead.

• There was a proactive approach to understanding the needs of this vulnerable patient group. Staff acted as advocates and delivered care in a way that meets patients’ needs and promoted equality.

• Patients told us they were treated with dignity and respect and were involved in their care and decisions about their treatment.

• There was consistently positive feedback from the Friends and Family Test.

• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said they found it easy to make an appointment with the GP and said there was continuity of care, with drop in appointments and urgent appointments available the same day. An average of 300 patients per month had used the GP drop in service over the last three months (130 for the nurse) and 150 patients had attended booked appointments (45 for the nurse).
• The practice had good facilities and was well equipped to treat patients and meet their needs.

• There was a clear leadership structure and staff felt supported by local and organisational management. There was an atmosphere of mutual respect and team work amongst the staff group.

• There were systems in place to monitor and improve quality, identify business risk and systems to manage emergencies.

We saw three areas of outstanding practice:

There was a truly holistic approach to assessing, planning and delivering care and treatment to patients who use services. Staff worked collaboratively with many other providers, both within the hub and externally, to ensure the vulnerable patient group was supported to receive coordinated care which met their needs. Practice staff used opportunistic, innovative and efficient ways to deliver more joined-up care to patients. For example, the practice worked with the Hepatology Department at theRoyal Devon and Exeter (RD&E) Hospitals NHS foundation Trust to provide an outreach drop-in clinic to see patients with viral hepatitis. Since December 2016 the hepatology nurse had completed 12 fibrosis scans (a simple and non-invasive test that can reveal any fibrosis or fatty deposits within the liver) at the practice meaning patients did not need to attend the RD&E hospital.

The involvement of other organisations and the local community was integral to how services were planned and ensured that services met vulnerable patient’s needs. The staff worked as advocates and used innovative approaches to providing integrated person-centred pathways of care that involved other service providers and charities both within the hub where the practice was situated and externally. The aim was to move patients onto mainstream GP services once patients had stabilised their housing and social situations in conjunction with their health needs. As a result, between October 2016 and March 2017 the practice had enabled 123 patients to move on to mainstream services.

Practice staff provided a GP service to patients who had been barred from other services due to the nature of their behaviour. The practice staff used an Acceptable Behaviour Contract where needed to ensure behavioural boundaries were agreed whilst they received treatment. Practice staff had shared this contract with NHS England and other GP practices and given advice when requested of how to manage difficult situations.

The areas where the provider should make improvement are:

Review processes, systems and records for lower level incidents and occurrences.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice