Pitsmoor Surgery

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Patient feedback with regard to access by telephone and to an appointment was significantly negative. The provider had mechanisms in place for reviewing and acting on patient feedback, however, actions taken were not sufficient to improve patient feedback with regard to accessing the practice by telephone or to an appointment at the time of the assessment and required review. Staff and leaders had an excellent understanding of their patient demographics and needs of the local population and complied with the accessible information standards. They had arrangements in place to identify peoples’ communication needs and preferences and had carried out some positive work for some of their patients whose circumstances may make them vulnerable, for example, the primary mental health care project.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not receive any feedback or concerns from people regarding this. The 2023 National GP patient survey data showed 77.3% of patients said they were involved in decisions about their care (expected 90%). Data from the published 2024 survey reviewed by the practice showed 90% of patients felt involved in decisions about their care (national average 91%).

The practice had published a paper detailing the work that they had undertaken to engage with some of their more vulnerable patients who were not responding to services. For example, the practice had been supporting a primary mental health care project for a number of years. Leaders told us the practice served a population twice the city average and 3 times the national average for severe enduring mental illness. The project provided a holistic model of care to patients over 16 years suffering with enduring mental health problems. It aimed to promote psychological, social and physical wellbeing and the practice employed and managed the 3 project staff directly. Support was offered to patients through one-to-one sessions as well as through group activities such as the knit and natter group and the healthy walks scheme.

Staff and leaders had an excellent understanding of their patient demographics and needs of the local population and complied with the accessible information standards. They had arrangements in place to identify peoples’ communication needs and preferences and offered interpretation services for those patients whose first language was not English.

The provider worked with a charitable organisation to provide a horticultural therapy project for patients with severe mental health needs by offering the space they needed to unwind and support with social interaction. They also worked with their primary care network to offer support to their patients. For example, by staff attending monthly MDT meetings where updates, topics and issues specific to the area were discussed and resources and training shared with other practices in the area.

The practice supported several care homes for patients with mental health issues and allocated time to visit and complete care plans. They had interpreter services available daily for patients.

We did not receive any concerns from people regarding not being able to access appropriate, accurate and up-to-date information in a way that suited their need.

Staff explained the process for registering patients with no fixed abode. Staff told us information was available to patients in different formats and told us some letters were translated into other languages for patients. For example, letters to advise about medicines interactions.

There was an accessible standards policy in place. Interpreter services were available for those patients whose first language was not English. Both sites had hearing loops available. All consultations took place on the ground floor level and first floor with disabled facilities available including access to the first floor via a lift if required.

The practice had had an active patient participation group with 15 members up until recently. The group last met in April 2024 but the meetings scheduled for July and October did not proceed. The patient services manager was not sure why this had occurred and had a plan to review and try to restart the group. The practice did review how likely a patient was to recommend the service to friends and family via the national Friends and Family test.

Leaders told us they were aware of patient feedback with regard to access from the national GP patient survey data, from on-line reviews and from complaints received into the practice. The provider had completed a quality and outcome review of access in 2023. This identified that patients’ main concerns were about not being able to book a non-urgent appointment and being held in a queue for long periods of time when telephoning the practice. Changes were made to the telephone system to allow a maximum of 30 patients to be on hold at any one time and a callback feature was introduced. The number of future bookable appointments was increased by 30%. Practice review of changes to see if there had been any improvements showed they now offered a 58% same day and 42% future bookable GP appointment compared to 73% and 27% at the start of 2023/24. However, despite these changes, and at the time of this assessment patients continued to feedback that they were struggling to access the practice by telephone and to make an appointment with many commenting that they get cut off if there is more than 30 in the queue and by the time they can get through the appointments for the day have gone. Eleven of the practice’s 33 complaints since April 2024 were regarding access to services. Audits and reviews of feedback were taking place but the actions being taken were not sufficient to improve patient outcomes.

The practice had a complaints policy and kept a log of patient complaints. We reviewed 2 complaint responses and found these were dealt with appropriately. Patients received an apology when appropriate, and were informed of any action taken. The practice had a complaints leaflet which included details of where to escalate their concerns if they were not happy with the practice’s response to their complaint. The practice had a whistleblowing policy which included freedom to speak up arrangements which staff told us they were aware of.

People told us through give feedback on care forms into CQC, through Sheffield Healthwatch, the NHS website, on-line reviews and data from the national GP patient survey data that they had difficulty getting through to the practice by telephone and had difficulty accessing an appointment. The 2023 national GP patient survey results showed 13.6% responded positively to how easy it was to get through to someone at their GP practice on the phone. This was a significant negative variation from the national average of 49.6% and there had been a continual downward trajectory of satisfaction since March 2021. The national GP patient survey data for 2024 showed 17% of patients said it was easy to get through to the practice by telephone (national average 50%). We received feedback from 79 patients as part of this assessment, 34 were positive about care and treatment and the remaining 45 related to difficulty accessing an appointment and getting through to the practice by telephone, with several commenting they struggled due to the current system of only being able to make an appointment by contacting the practice by telephone at 8.30am which was difficult when at work, taking children to school and people with mental health problems. Sheffield Healthwatch received feedback in the last 12 months from 22 patients, these mainly related to poor access and the majority of the on-line reviews were negative about access by telephone and to an appointment.

Leaders told us that they were aware of patient feedback with regard to access and had reviewed their systems and processes. They had removed the ability to book appointments on-line as they felt this was not equitable to all patients and was being used for minor ailments resulting in urgent problems not being prioritised. They had reviewed the phone system and tried to implement ways to improve it, for example, they had introduced a callback system so callers did not have to hold in a queue and had limited the number who can join the queue. However, at the time of this assessment these changes had not sufficiently impacted on patient feedback as a high number of patients continued to report difficulties.

The current appointment system was to call at 8.30am. The practice did not offer any other route to book an appointment, either on-line or at the reception desk. The provider told us there was a system in place for patients who were deaf and could not use a telephone. There were an unlimited number of lines into the practice, with between 3 and 7 care navigators answering the calls. The phone system would not allow more than 30 calls to be waiting at any one time. After 30 calls were in the queue, people would have to hang up and call again. Appointments would be triaged by 1 duty doctor who supported the care navigators, including if someone presented at reception with an emergency, for example, an unwell child. Once the triage appointment slots were full, the care navigators would signpost people to alternative services, for example, the walk-in centre, pharmacy or they could call back the following day. Both sites were open 8.30am to 12.30pm and 1.30pm to 6pm Monday to Friday with the exception of Wednesdays when the afternoon clinic started at 2pm and Thursday afternoons when the branch site was closed. When the practice was closed, calls would be transferred to the out of hours service. The practice had access to the extended hours clinics in the city which they could book patients directly into, these clinics were open until 10pm. Current data available, including national GP patient survey data, feedback into CQC, NHS website and Sheffield Healthwatch indicated that patient satisfaction with access was low. The provider had completed quality improvement work and had made changes to the telephone system with regard to the number of patients who could be in the telephone queue at one time, a call back option and more pre-bookable appointments. However, at the time of this assessment these changes had not sufficiently impacted on patient feedback which continued to be negative with regard to accessing services. The service offered home visits where appropriate.

Feedback from people into CQC, NHS website, Sheffield Healthwatch, on-line reviews, practice complaints and from the national GP patient survey results showed patients dissatisfaction with getting an appointment or getting through to the practice by telephone.

Leaders told us that they respected and appreciated people's backgrounds and cultural values. Leaders told us they were aware of patient feedback and tried to balance the appointment system with staff wellbeing. Leaders discussed ways they were looking to reduce the number of calls into the practice, for example, they had introduced an on-line system in the previous month which patients could use to request administration requests, for example blood test results or to request sick notes. At the time of this assessment the changes to the appointment and phone system had not resulted in improvement to patient feedback.

The practice complied with legal equality and human rights requirements, including avoiding discrimination and having regard for the needs of people with different protected characteristics. The practice had information available in alternative formats, access to interpreter services and equipment in place to support patients who had a hearing impairment. The service sought the views of people by reviewing feedback on the national friends and family forms and by reviewing the results of the national GP patient survey data, although any actions taken to address feedback with regard to access had not improved patient experiences at the time of the assessment.

We did not receive any feedback or concerns from people regarding this.

Staff told us they attended regular MDT meetings where patients who were receiving end of life care were discussed and we were told their medical records were updated to reflect any actions or changes made to their care plan. Patients with complex medical and mental health conditions living in the care homes had care plans in place and a dedicated GP who supported the home.

The practice had systems in place to support patients at the end of their life. We reviewed 5 records of patients who had a DNACPR (do not attempt resuscitation) or ReSPECT form (personal plan used to record a person’s clinical care and treatment in a future emergency) in place. All had been completed appropriately following national guidelines.