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The seaside surgery

22 April 2016

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An interest in sports medicine and an innovative approach to helping patients with substance misuse issues in a deprived area has helped Providence Surgery attain an outstanding rating from the Care Quality Commission

When one thinks of Bournemouth, families enjoying the beach and promenade, or perhaps a resident population older than the national average choosing to live out their days by the sea may well be the first images that come to mind.
However, not far from the buckets and spades on seafront is the area of Boscombe, which although was once a seaside resort in its own right has fallen on hard times.
Yet the area boasts a GP practice far removed from outmoded images of what one is expected to look like or provide for its patients.
Four of the seven most deprived areas in the local borough fall within  Boscombe West and all are within the 10% most deprived in England.
However despite this, Bournemouth council also notes that the area is also well supplied with health facilities, including GP surgeries. And a group of those practices, Providence Surgery, has just been awarded an outstanding Care Quality Commission (CQC) rating, the only one to get such a rating in the region of Hampshire, Dorset and Wiltshire.

“If they don’t know the area people do tend to think we are in an affluent area with a higher level of income, but as a practice we have many issues to deal with,” says Providence Surgery commercial manager David Beale. The surgery also employs an operational manager but does not employ practice managers, preferring to have what it terms supervisors to oversee day-to-day operations at the practices, without having managerial responsibility.
Boscombe’s population has a higher than average number of people claiming unemployment-related benefits and a large number overall, around 20%, are white non-British  (largely east European and south European). Almost a third (32%) of children living in the ward are classed as living in poverty and 9% of residents described themselves as being in ‘bad health’ or ‘very bad health’, the highest figure in the borough.
While much of the surgery’s work and facilities were rated as good, it was particularly noted for its work on substance misuse and detoxification protocols and its in-house MRI scanning, X-ray and ultrasound facilities. (The CQC awarded an outstanding rating to the measures ‘Are services responsive to people’s needs?’ and ‘Are services well-led?’).
These two services, while rather different, demonstrate the different ways in which the practice offers extended care to its patients.

The set up
Providence Surgery is currently made up of three practices, Providence Surgery and its branch surgery Strouden Park Medical Centre and Crescent Surgery, the third having recently gained CQC approval to do so. Mr Beale says the practice’s aim is to reach the target of 30,000 patients and there may be mergers ahead to attain this number. “Unless the CCG [clinical commissioning group]/NHS change plans, we will be in a strong position to commission our own services,” says Beale.
Each surgery now shares a cloud-based telephone system, including voicemail and call redirection, to join a cloud-based patient record system with medical dictation notes accessible by any of the practice’s medical secretaries.
“In addition to the fourth potential surgery, we are talking to a number of other GP practices who are struggling that may merge with us and also become associate partners,” says Mr Beale.
He explains the practice’s business model. “For the last five years or so
it has been our lead partner and clinical director Dr Ni’Man’s approach to gain income from elsewhere other than standard services. Hence the purchase of two MRI scanners about a year ago, one at Providence Surgery for use by our patients, the other mobile, based at Strouden Park Medical Centre, used by our patients and also hired out. These are in addition to an X-ray machine and ultrasound,” says Mr Beale.
“We believe our use and lease of these MRI scanners, as a GP practice, is unique.”
In addition to the surgery’s patient list MRI use is contracted to local provider Dorset County Hospital Foundation Trust for around 40 patients a month and to private patients.  
“It was a business risk to purchase the mobile MRI scanner, as they cost about £100,000 to buy and about £25,000 a year to run, including staffing costs. But it is a service that is of benefit to patients,” says Mr Beale. “Income from NHS contracts and private services all goes into the business pot and means we can afford to have it available to the benefit of our NHS patients.”
Ultrasound is available twice a week and the MRI for two and a half days a week.
It is also contracted to health providers in West Dorset and the Isle of Wight and there are plans to lease it for use at events such as rugby and football tournaments.     
 “In Bournemouth there is an event called Bournemouth 7s [a music and sports festival], which every year has dozens of players having to be taken to accident and emergency after injuries.
“It could be beneficial to have an MRI scanner on site instead and we would love to do that,” explains Mr Beale.  
One unusual offshoot of private care delivered by the practice is to the local football team AFC Bournemouth. Dr Ni’Man, whose special interest is sports medicine, was formerly the team doctor since its days languishing in division two. Now the team is in the premier league and has its own medic team he is now a tunnel doctor [to advise touchline medics] during matches.       

Tackling drugs
A focus on substance misuse – all its 14 salaried GPs, plus a partner and Dr Ni’Man, are trained in substance misuse and detoxification protocols (holding Royal College of General Practitioners certificates in the Management of Drug Misuse) – came about in order to improve patient care.
Why such a move has been taken is evident when it becomes clear the extent to which substance misuse is an issue locally.
Around 20% of its patients have substance misuse problems. The surgery does not run a methadone clinic but does provide privately funded community (home) based detoxification care.
A large number of patients in recent years have been referred by the probation service, looking to resettle offenders who often have complex mental and physical health needs.
In 2012 it was revealed there were 60 drug and alcohol rehabilitation facilities in the Boscombe area.
In addition, Mr Beale explains a large number of the practice’s patients are younger, working in seasonal jobs or transient occupations such as the building trade, leading
to a high turnover of patients of around 35% (the national average is around 5%).
Typically transient patients live in overcrowded, poor quality accommodation (in 2015 over a third (34.5%) of households were found to be living in overcrowded conditions based on the number of rooms) and have a poor diet and lifestyle.
“This creates a funding issue as patients under 35 are funded at a lower rate as it is assumed they will be in better health, but our patients are often not,” says Mr Beale.
Mr Beale adds that there are concerns that the practice will be seen as being overrun by drug abusing patients, which could be detrimental when it comes to attracting patients from all walks
of life.
“We have asked that the large number of people being moved here locally by the probation service be stopped, as this is not helping the community as a whole.
“It is not the doctor surgery’s problem to stop drug use, this is society’s problem as a whole. It is a GP’s job to treat people who are unwell without prejudice, even if this can cause problems with other patients,” explains Mr Beale.
“But whatever we do is for the good of the patient. Our approach is to encourage all our patients to be healthy – and that can include getting rid of drug addiction.”  
Mr Beale adds that the surgery’s work with a local homeless shelter – a GP from the practice visits the shelter every weekday evening – often means working with the same group of patients as those with alcohol and substance problems.   
“We try to encourage this at risk group to register too, so we can help resolve all health issues,” he says.

Language barriers
Another patient issue is literacy. Around 20% of patients are unable to read and write English well. The practice’s own GPs and staff are able to provide coverage for about 85% of languages spoken by its patients – who themselves come from around 32 countries – including Arabic, Polish, Russian, Spanish and Portuguese. Interpreters are sometimes needed for languages spoken in smaller countries such as Latvia.    
The practice was also commended by the CQC for its participation in wider community work, particularly the Boscombe Community Forum, which works to improve the area and raise awareness of local issues to the local council and councillors. Dr Ni’Man’s wife Linda Ni’Man is an active member of the forum and other local community groups.  
“Local infrastructure investment and increased tourism will help the area and in turn help our patients,” says Mr Beale.

To the future
Meanwhile Providence Surgery has ambitious plans for its own patch of Boscombe. In addition to intending to grow to 30,000 patients and beyond, the practice is looking to create a ‘hub’ of more services to be created on site, with the possibility of other GP surgeries also being located in the same premises. Mr Beale says it is intended to have created this as yet unnamed hub, in the model of something like the Vitality Parrtnership in Birmingham (which has 60,000 patients and offers an integrated care model including general practice and specialist services including hospital services), within the next two to three years. A further possibility is to have a 50 to 60-bed care home, perhaps located on the site, or elsewhere.  
“It is also our intention to continue to work and merge with other GP surgeries in need of support.
“Single-handed practices are a thing of the past. We have to think in terms of scale,” says Mr Beale.

Emma Dent, freelance health reporter.