Norfolk Primary Care Quality Account 1 st April 2024 to 31 st March 2025
“ Putting the patient central to the delivery of quality healthcare for the local communities and beyond”
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CONTENTS Quality Account: Definition & Scope .......................................................................................................... 3 Norfolk Primary Care at a glance ................................................................................................................ 4 Part 1……………………………………………………………………………………………………………………5 1.1 Statement on Quality from the Chair & Chief Executive ......................................................... 5 1.2 Core Values & Vision .................................................................................................................. 7 Part 2…………………………………………………………………………………………………………………..10 Our Services – An overview of Quality & Safety Performance in 2024/2025 ........................................ 10 2.1 An Overview of Norfolk Primary Care ..................................................................................... 10 2.2 ‘Core’ Services – Planned Care ............................................................................................... 11 2.3 Urgent Care Services - Unplanned Care ................................................................................. 21 2.4 Research, Education, and Training ......................................................................................... 26 Part 3…………………………………………………………………………………………………………………..32 Clinical Quality & Safety Assurances ....................................................................................................... 32 3.1 Information Governance & Data Protection - Data Security & Protection Toolkit (DSPT) . 32 3.2 Infection Prevention and Control (IPAC) ................................................................................ 32 3.3 Audit - Clinical and Administrative ......................................................................................... 34 3.4 Safeguarding ............................................................................................................................. 35 3.5 Patient Safety Statement .......................................................................................................... 36 3.7 Learning from Complaints & PALS Concerns ....................................................................... 39 3.8 Service Feedback – Patient and Service Users Experience Survey and Appreciations.... 41 3.9 Staff Experience Surveys – Clinical & Non-Clinical Staff...................................................... 43 Part 4…………………………………………………………………………………………………………………..47 Our Key Priorities ....................................................................................................................................... 47 4.1 Review of Key Priorities for Quality Improvements for 2024/25 – “We Did”....................... 48 4.2 Current Focus: Key Priorities for 2025/26 .............................................................................. 49
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Quality Account: Definition & Scope
What is a Quality Account? A quality account is an annual report published by healthcare organisations and providers to inform the public about the standard of quality of the NHS commissioned services they deliver. These reports focus on three main areas of quality standards: 1. Patient Safety : Ensuring treatments and care are safe for patients. 2. Clinical Effectiveness : Evaluating how effective the treatments are. 3. Patient Feedback : Gathering and analysing patient experiences and satisfaction The primary purpose of quality accounts is to encourage healthcare organisations to continuously improve their services based on evidence and feedback. Scope and structure of the Quality Account This quality account details the development, performance, and achievement of quality domains in our service delivery, as well as our plans to improve over the coming 12 months. It is presented in 4 main parts: 1. Statement of Quality from the Chair & Chief Executive – An overview of the organisation’s commitment to quality and a summary of the year’s achievements. 2. Review of Services – An evaluation of the services provided over the past 12 months and their alignment with quality and patient safety performance. 3. Clinical Quality and Safety Assurances – A review of staff and patient experience feedback and the commitment of the organisation to monitor and improve quality through audits, analysis of key themes in complaints and incidents, and education & training. 4. Key Priorities – Review of 2023/24 key quality performance targets and plans for key priorities for quality improvements in 2025/26. If you or someone you know needs help understanding this report, or would like the information in another format, such as large print, easy read, audio or Braille, or in another language, please contact our Chief Clinical Officer by calling 01603 576091 or emailing emma.smith@norfolkprimarycare.com
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Norfolk Primary Care at a glance Formerly known as North Norfolk Primary Care Ltd (NNPC), which was incorporated in 2017, the organisation rebranded as Norfolk Primary Care (NPC), with its successful launch in April 2024. This name change reflects an expanded vision and a strengthened commitment to serving a wider geographic area across Norfolk. It marked a fresh chapter for the organisation, reinforcing its focus on community well-being and establishing NPC as a key contributor to the region’s healthcare landscape. In August 2024, NPC was then transitioned to a Community Interest Company (C.I.C.). This inclusive approach ensured that the benefits of the C.I.C. model reach a wider population, enhancing healthcare delivery across the region. This, alongside the new name, embodied the organisation’s mission to provide and support a wider scope of member-provider practices in the delivery of comprehensive, integrated primary care that addresses the needs of all the Norfolk & Waveney region residents. What is a Community Interest Company? A Community Interest Company (C.I.C.) is a form of social enterprise created to benefit the community, with all profits reinvested into the organisation to further its mission. The transition of Norfolk Primary Care into a C.I.C reflects a commitment to improving healthcare services while prioritising the needs of the community in its organisational objectives. This model aligns seamlessly with NPC’s values, enabling the organisation to focus on enhancing the delivery of care to communities in Norfolk and Waveney without the constraints of profit generation. The transition was designed to foster greater transparency, accountability, and community engagement, which are essential elements for ensuring high-quality primary care services in the future. Looking ahead to 2025/26 and beyond, NPC is dedicated to exploring new opportunities within the Integrated Care System (ICS). Through strategic collaboration, NPC seeks to implement innovative and refined healthcare delivery methods that will enhance patient outcomes and community well-being. This transformation is expected to yield significant benefits for primary care services, General Practitioners (GP’s), the Norfolk and Waveney Integrated Care Board (ICB), and, above all, ensure the safe and high-quality provision of patient care across the Norfolk and Waveney healthcare system.
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Part 1 1.1 Statement on Quality from the Chair & Chief Executive
We are pleased to present Norfolk Primary Care’s Quality Account for 2024/25 - a year of significant transformation and progress. This period has marked the transition from North Norfolk Primary Care to Norfolk Primary Care and our formal establishment as a Community Interest Company. In support of these pivotal changes to the organisational structure, our core commitment remains: to deliver safe, high-quality, and patient-centred care to the communities we serve. A key milestone this year has been the journey to adopting the Patient Safety Incident Response Framework (PSIRF). This represents a fundamental shift in how we approach patient safety – one which enhances our culture of learning and improvement from patient safety events. PSIRF enables a more compassionate, systems-based response to incidents and reinforces our commitment to transparency, accountability, and continuous improvement. By embedding this framework into our governance processes, we are better equipped to ensure that learning from incidents leads to meaningful change and safer care for our patients. Our dedication to quality is deeply rooted in our organisational values - care, integrity, collaboration, leadership, accessibility, and teamwork. These values are brought to life every day by our exceptional workforce, whose professionalism, resilience, and shared purpose drive the impact we make across Norfolk and Waveney. In a reflection of their commitment to our organisation, we were proud to achieve Learning Organisation status in 2024, which is a recognition of our commitment to fostering a culture of reflection, growth, and sustainability within the Primary Care workforce. This, our fifth Quality Account, provides a transparent and comprehensive overview of our achievements, challenges, and priorities in the coming 12 months. It reflects our ongoing efforts to support a sustainable, high-performing health system and our ambition to be a proactive partner in the Norfolk and Waveney Integrated Care System. Looking ahead to 2025/26, our focus remains on innovation, integration, and inclusion. In alignment with the NHS Long Term Plan, we are committed to strengthening neighbourhood working and fostering collaboration between primary care, community services, and local partners. By embedding these principles, we aim to improve access to care, enhance health outcomes, and
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support the long-term sustainability of Primary Care services whilst ensuring that the voices of our patients, staff, and stakeholders continue to shape the future of care delivery. This Quality Account has been prepared by our Chief Clinical Officer and is fully endorsed by the Board. To the best of our knowledge, the information contained within is accurate and reflective of our work and achievements during the 2024/25 period.
Dr Peter Lawson, Chair
James Leeming, Chief Executive
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1.2 Core Values & Vision Our commitment to excellence is guided by our values and mission, which further strengthens our dedication to serving the communities in the Norfolk & Waveney region.
Core Values Since our inception, our organisational values have remained steadfast, guiding our approach to both existing and new opportunities: • Care – Delivering high-quality, patient-focused, holistic healthcare within the local community and beyond.
COLLABORATION
INTEGRITY
CARE
CORE VALUES
TEAMWORK
ACCESSIBILITY
LEADERSHIP
• Integrity – Upholding ethical standards and maintaining accountability in all that we do. • Collaboration – Building strong partnerships to enhance the delivery of quality healthcare services. • Leadership – Pioneering change, fostering trust, and driving efficiency • Accessibility – Ensuring inclusivity and openness to all. • Teamwork - Embedding our shared values within our team, fostering mutual appreciation and respect to create a safe and positive work environment. “Our organisation is guided by our core values that prioritise the delivery of high-quality, accessible care for all. We foster a culture of teamwork and collaboration , strengthened by strong leadership and upheld with unwavering integrity .” Our Vision We strive to be a compassionate and trusted organisation in the healthcare system, dedicated to empowering every individual in our diverse and dynamic community to achieve optimal health and well-being. Our commitment is to provide accessible, respectful, and personalised care, tailored to the unique needs of those we individuals and communities we serve. Through support, openness, empathy, and innovation, we foster hope, resilience, and lifelong wellness for all. Our organisational structure for Quality Performance ensures that this ethos is implemented and closely monitored.
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Organisational Governance Structure for Quality & Safety Performance Monitoring - 2025/26
Norfolk Primary Care - Board of Directors
Executive Management Team
Senior Management Team
Quality & Safety Committee
Patient Safety Incident Response Group
Information Governance Steering Group
Policy Committee
Colour Key – Lines of Reporting Assurance Reporting to: Board Delegation, Accountability, Reporting to: Management Delegation, Responsibility, Reporting to: Responsibility, delegation, Reporting to:
Services Operational and Clinical Management Team
Service & Clinical Leads MDT
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1.3 Care Quality Commission (CQC) Registration NPC is registered with the CQC to provide the following regulated services:
• Treatment of disease, disorder, and injury • Diagnostic and Screening procedures • Maternity and Midwifery Services • Family Planning • Surgical Procedures The CQC Registered Manager is James Leeming, CEO.
The nominated individual for regulated activities is Emma Smith, Chief Clinical Officer.
In June 2021, the organisation - then known as NNPC - underwent a targeted inspection. As a result of this, we received a rating of ‘Good’ in the areas of safety, effectiveness, and leadership.
Therefore, NPC has an overall CQC rating of ‘Good’.
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Part 2 Our Services – An overview of Quality & Safety Performance in 2024/2025
2.1 An Overview of Norfolk Primary Care
NPC services have delivered circa 184,010 appointments over the 2024/25 period
We had 384 members of staff who worked for us on a permanent or locum basis across our services in the 2024/25 period
From our patient feedback survey : We had a total of 10,433 responses with an average of 94% of them rating the service as ‘Excellent’ or ‘Very Good’ and an average of 96% for the Friends & Family Test. There was an overall 5.6% response rate to our patient feedback surveys
From our staff survey: 85% of our staff believe that high quality patient care is of NPC’s top priority and 84% of them would be happy that their family or friends were treated in one of our services.
In the 2024/25 period, our complaints to patient contact ratio was 0.08% and our SE/SI to patient contact ratio was 0.06%
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We strive to ensure our services are: SAFE : Protecting individuals from abuse and preventable harm. EFFECTIVE : Delivering care, treatment, and support that achieve positive outcomes, enhance quality of life, and are grounded in the best available evidence. CARING : Treating everyone with compassion, kindness, dignity, and respect. RESPONSIVE : Providing services that are tailored to meet individual needs. WELL-LED : Ensuring that our leadership, management, and governance foster high- quality, person-centred care, encourage learning and innovation, and promote an open and fair culture. 2.2 ‘Core’ Services – Planned Care Covid Vaccination Programme Support – East and West Norwich Practice Care Networks (PCN’s) Over early May and mid-June 2024, NPC supported practices in the East and West Norwich PCN’s to deliver their Spring 2024 campaign covid vaccinations to housebound patients. We supported the administration of 523 vaccines over this time. Enhanced Access (EA) Service NPC continue to support the delivery of EA Services on behalf of some of the PCN’s in the Norfolk & Waveney Region. EA services form part of the Network Contract Directed Enhance Services (DES), which stipulates the number of contracted hours which each Practice Care Network (PCN) must deliver as part of this. NPC supports the PCN’s to achieve delivery of those hours by providing clinicians, operational support, and clinical systems to allow practices to access appointments for their patients. NPC has worked closely with each PCN to ensure that their delivery model is bespoke to them, which is reflected in engagement with the PCN’s local patient population and health needs. Over the course of 2024/25, NPC has delivered 13,698 EA Service appointments in 13 individual hubs in the PCN’s it supports across the Norfolk & Waveney region. Health & Safety (H&S) / Infection Prevention & Control (IPAC) Support Service NPC’s Health & Safety Manager provides invaluable support to practices in meeting health and safety compliance with regulations and laws. Throughout 2024/25, our membership practices have benefited from H&S advice, risk assessments, audits, and individual staff risk assessments.
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Additionally, IPAC advice and support has been provided to our membership practices by the undertaking of audits and risk assessments in individual practices. Home Visiting Service – Norwich NPC commenced the home visiting service on 1 st April 2024 on behalf of 17 practices across three of the Norwich PCN’s. This service is commissioned by the practices directly with NPC via the Proactive Healthcare funding, which provides vital home visiting support to housebound patients and runs Monday to Friday from 9:00 – 17:00 hours. The team consists of a care co-ordinator, two part-time GP’s (joint clinical leads), four experienced nurses, and one paramedic. The service provides: 1. Same/Next day requests for home visit for adult housebound patients who have need for urgent care or assessment 2. Patients who need same day assessment to have onward referral to another agency 3. Patients who need same day assessment to remain safely at home 4. Long-term condition reviews for housebound patients, when capacity allows, including diabetic reviews, dementia reviews, and learning disabilities annual health assessments This is with the aim of: 1. Reducing the number of A&E attendances and admissions 2. Reduce pressure on individual general practices 3. Provide holistic, integrated packages of personalised care to patients in their own home Throughout the 2024/25 period, we have successfully seen the team of clinicians meet the aims of the service by providing care at home to 7,584 patients. Through collaboration with the practice, community, voluntary, and social care teams, the home visiting service has successfully prevented 7,105 hospital admissions, representing 94% of the total patients seen. The holistic approach to patient care from the team promotes good communication, which is centred around the care of the patient, with 94% of patients saying that their care was ‘excellent’ and 98% saying that they would recommend the service to their family and friends over the 2024/25 period.
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What did the patients say about the Norwich Home Visiting service?
“Whole process was excellent. The Dr who attended was thorough, understanding, professional and very pleasant. Very much appreciated.” Patient, Norwich Home Visiting
“Absolutely first class treatment. Thank you” Patient, Norwich Home Visiting Service
“Excellent service, caring compassionate staff , thank you” Patient, Norwich Home Visiting Service
The home visiting team have developed a bespoke approach to clinical supervision and training, which has been successfully embedded into their daily practice.
Through NPC’s commitment to keeping our home visiting team safe, we have implemented the StaySafe Lone Worker app for use by the home visiting team while they are carrying out their work. This ensures that the team can raise an alarm if they need assistance, the care co-ordinator can carry out welfare checks when needed, for example. This gives our team the confidence and reassurance that they would receive help should they ever need it during their work in the communities. We also plan to extend the use of the StaySafe Lone Worker app for use by our Vulnerable Adults and Asylum Seekers services.
Norwich Health Centre (NHC) Located on Rouen Road in Norwich, NPC has been providing services at Norwich Health Centre since December 11, 2023. Since then and over the 2024/25 period, we have worked closely with the practice teams to enhance the patient experience. With a monthly average of 11,148 registered patients at the practice, there has been 36,811 appointments delivered from 1 st April 2024 – 31 st March 2025. These have been carried out by the dedicated clinical teams of GP’s, Nurse Practitioners, Practice Nurses, Clinical Pharmacists, Health Care Assistances, and physiotherapists.
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The NPC management team has worked with the team at Norwich Health Centre to implement new initiatives to make the practice more accessible to patients. The practice is striving to further improve the quality of care provided by patients by applying new ways of working the appointment system and increasing the workforce to a capacity, which enables timely access to those appointments.
Over the 2024/25 period, the patient survey results show that 91% of patients think that the service is ‘Very Good’ or ‘Good’ and demonstrates that 91.5% of them would recommend the service to their Family & Friends.
What did the patients say about the Norwich Health Centre service?
“Sometimes it can be a bit of a wait to get an appointment. The staff are all very friendly and today I was in and out within 20 minutes.” Norwich Health Centre, Health Watch Norfolk Patient Survey Feedback WHAT WE DID: We introduced a new appointment system designed to enhance patient access by strategically reviewing and optimising the capacity of our clinical workforce.
“Everything ran on time and the nurse was charming and efficient in taking my blood, I didn't faint which is good! It can be frustrating waiting on the phone and the amount of messing about pressing one for this and two for that, it's hard to talk to who you need to talk to.” Norwich Health Centre, Health Watch Norfolk Patient Survey Feedback
“I was seen quickly, the nurse was lovely and explained everything so well. It was good and she explained the next steps to me too.” Norwich Health Centre, Health Watch Norfolk Patient Survey Feedback
In addition to the appointments delivered at Norwich Health Centre, there has been 2,774 walk-in phlebotomy appointments delivered via a clinic which is held at the Walk-In Centre. This supports patients to access drop-in appointments for blood tests from the hours of 08:00 – 12:30 hours, who would otherwise attend their own registered GP practice. Patients who attend are required to bring a request form with them, which their own GP practice would have generated prior to their attendance to the walk-in phlebotomy clinic. The last CQC inspection of the Norwich Health Centre and the Walk-In Centre was in February 2022, and both were rated overall as ‘Good’. Note : This was carried out while both services were under a previous organisations’ management.
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The Vulnerable Adults Service (VAS) and Asylum Seeker Service The VAS and Asylum Seeker service is based in Norwich on Westwick Street and operates as a ‘branch practice’ of the Norwich Health Centre. It supports access to Primary Care Services to those adults who have complex needs and severe multiple disadvantages. The services teams have carried out a combined 2,301 appointments over the 2024/25 period.
During the 2024/25 period, the NPC team has consistently sought opportunities to enhance service quality. This has involved actively identifying areas for improvement and engaging staff to determine key focus areas. A strong emphasis has been placed on listening to staff and patients, valuing their feedback, and incorporating their perspectives into the design and implementation of quality improvement initiatives.
The services patient feedback was enhanced and relaunched and in January 2025 and has resulted in 93% of the respondents saying that the service is ‘Excellent’ or ‘Very Good’, alongside a 97% Family & Friends recommendation.
What did the patients say about the Vulnerable Adults & Asylum Seeker services?
“I feel safer there than any other doctors service I have been to. And feeling safe is what vulnerable need to feel” Service User, Vulnerable Adults & Asylum Seeker Service
“Overall, it's a great place to be. Always treating me well and outstanding support and care 10/10” Service User, Vulnerable Adults & Asylum Seeker Service
“I think take care of you to the best of their ability without the vulnerable adult service I would not be here today and be as strong and settled clean individual” Service User, Vulnerable Adults & Asylum Seeker Service
i. The Vulnerable Adults Service (VAS) The VAS provides GP registration to people who are homeless, or at risk of homelessness, sex workers, prisoners on release, and Gypsies, Travellers & Roma’s. The aim of the service is to ensure that appropriate support is put in place to stabilise the health of the patient, usually over a short time (ideally being less than 6 months). Over the 2024/25 period, there was a monthly
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average of 103 patients registered with the service. The VAS team work closely with the 7 identified Norwich PCN based practices who are ‘Inclusion Health Practices’ to transfer and integrate care back in mainstream Primary Care as soon as possible, in order to plan for ongoing health needs for the patient. ii. The Asylum Seeker Service NPC employs the Asylum Seeker Community Healthcare Team (ASCHT) who work together with the Norfolk County Council People from Abroad Team (PfAT) to support asylum seekers to access healthcare services in the Norwich asylum dispersal area of the Norfolk & Waveney region. The service offers an integrated approach to social and health support for asylum seekers, migrants, and refugees. The ASCHT undertakes an holistic initial healthcare checks, support GP practice registration, specialist support, and onward referral to appropriate clinical pathways where required. The team supports fair and equal access to healthcare for this group of patients with the aim of maintaining, improving, and supporting health and well-being.
In June 2024, representatives from ASCHT and PfAT attended the MJ Awards ceremony, which celebrates the contributions of local government in supporting communities and improving lives. The team was honoured to be nominated for an Achievement Award in the category of ‘Care and Health Integration’, recognising their unified health and social care approach to supporting vulnerable migrants and addressing health inequalities. Although they did not take home the award, being part of such a prestigious event was a proud and memorable moment.
Practice Care Network (PCN) Support Team The PCN support team continue to work with the practices to provide access to advice and information utilising decision aids and tools to best support the delivery of high-quality patient care. They provide a variety of support, which consists of the following:
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What did the practices say about the PCN Support Team?
“The support from NPC has been incredible from start to finish. The Team work tirelessly to get our PCN structure set up with transparency, from day one. We are provided with clear information about our DES requirements and viable options to support us to make the best decision for our PCN and our patients. “ Practice Manager, East Norwich PCN
“We have found everyone (and we really do mean everyone) at NPC to be responsive, efficient and knowledgeable within the scope of their role and beyond…….Overall, I would say we feel very confident in recommending the support and service from NPC, particularly because of the level of expertise and reassurance this has offered us not just as a Network, but an individual practice too.” Assistant Practice Manager, North Norwich PCN
“My experience to date of working with NPC has been positive. The NPC team have diligently analysed and reported on the financial status of the PCN and carefully and diplomatically steered the PCN Board through some difficult decision-making.” Business Manager, Kett’s Oak PCN
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The NPC team supported care navigation training to the West and East Norwich PCN’s in late 2024. This was well received with the practice teams to which it was delivered.
2.3 Elective Recovery & Innovation
Community Gynaecology Clinics – Supporting the James Paget University Hospital NHS Foundation Trust (JPUH) Throughout March to June 2024, NPC supported the JPUH with the referral validation and delivery of community gynaecology clinics for 396 patients to enhance the care given to those groups of patients who had waited more than 34 weeks to see a specialist, with the following outcomes:
Appointment Outcome
Number of Patients Percentage of Patients
43
10.8% 29.3% 48.7%
Referral Validation
116 193
Treated
Treated and follow up arranged at JPUH
22 22
5.6% 5.6%
Patient returned to JPUH Patient did not attend clinic
Grand Total 100% The gynaecology service patient feedback has resulted in 94% of the respondents saying that the 396 service is ‘Very Good’ or ‘Good’, and a 96% Family & Friends recommendation. What did the patients say about the Community Gynaecology service?
“Feeling rather anxious and uncomfortable about the appt I was absolutely bowled over by the caring and considerate way in which I was treated.” Patient, Community Gynaecology Service
“Pleased to have seen a consultant after such a long wait since referral” Patient, Community Gynaecology Service
“A1 service, after so long I finally got answers and help I'm so impressed with them”
Patient, Community Gynaecology Service
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Lower Gastrointestinal Support Service (LGISS) – Supporting the Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH) and the James Paget University Hospital NHS Foundation Trust (JPUH) The Lower GI Support service was introduced initially as a three-month pilot in May 2022, and over this time had been de-commissioned, then recommissioned throughout 2022-2024. Over this time, it expanded from supporting the NNUH, to including all three acute Trusts in a recommissioned service from May 2024 to March 2025. This service was originally commissioned by the Cancer Alliance, and then by Norfolk & Waveney ICB on behalf of the 3 acute Trusts in the region. The aim of the service was to reduce waiting times for patients with a high risk of colorectal cancer by working with the Lower Gastro Intestinal (GI) Teams at the Trusts to stream suitable Faecal Immunochemical Test (FIT) negative patients into a primary care-led rapid diagnostic service. Symptomatic patients could then receive expert review and relevant diagnostic tests through specialist primary care triage, whilst increasing capacity within secondary care for managing those higher risk patients on a 2 week wait cancer pathway. In the 11-month period from May 2024 until March 2025 802 patients were taken off the 2 week wait Lower GI pathways of the NNUH, JPUH and QEH. This allowed a timelier response for those higher risk patients who met the 2ww criteria, thus easing capacity pressures for three hospitals 2 ww Lower GI departments. The service was showcased as best practice at regional cancer alliance events throughout the year. None of those 802 patients were diagnosed with colorectal cancer, but 4 of them were diagnosed with other forms of cancer (2x Pancreatic, Oesophageal, and Lung), which may not have been diagnosed had they not been redirected to our service. The Lower GI Support Service was decommissioned on 31 st March 2025, with the continuation of the 2ww Lower GI referral work being carried out by the Acute Trusts without prior triage by a specialist Primary Care led service. The patient feedback results for this service over this period was that 93% of patients said that their appointment was ‘Very Good’ or ‘Good’ with a 100% Family and Friends recommendation.
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What did the patients say about the LGISS service?
“Informed me of my recent test results. Gave me some good advice concerning my issues. Overall, very helpful.” Patient, Lower Gastrointestinal Support Service
“The doctor who phoned today was very clear and informative with his explanations and answers to my questions” Patient, Lower Gastrointestinal Support Service
“The nurses and Doctors are excellent very caring and helpful” Patient, Lower Gastrointestinal Support Service
Rapid Diagnostic Service (RDS)
The Rapid Diagnostic Service is an urgent suspected cancer pathway for patients who have Serious Non- Site-Specific Symptoms. Patients are referred to the RDS when GP practices, community pharmacists, or Clinicians at a hospital's emergency department suspect a patient has cancer, but they are unsure of a specific site of origin. The RDS has continued to be commissioned by the Norfolk & Waveney ICB throughout the 2024/25 period.
The RDS Team with representatives involved in a community pharmacy RDS referral pilot
In April 2024, a national report for the ‘Faster Diagnosis Programme Evaluation’, specifically the East of England (North) section, included NPC’s service as an exemplar. We were thrilled to have contributed to this initiative and immensely proud to see our performance in a national context. Our cancer diagnosis conversion rate of 8% and 72% for non-cancer diagnosis compares extremely well to other models, which are primarily delivered by secondary care. The RDS Team had a total of 1,187 referrals over the 2024/25 period, of which 775 patients were seen. The patient feedback results for this service were exceptional, in that over this period 97% of patients said that their appointment was ‘Very Good’ or ‘Good’ with a 100% Family and Friends recommendation.
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What did the patients say about the RDS service?
“Doctor was thorough, very respectful and understanding” Patient, Rapid Diagnostic Service
“RDS was an absolute lifeline for me. I was in chronic pain; my condition was noticed by an RDS team member who referred me. I was then fast tracked through the system to a successful treatment plan.” Patient, Rapid Diagnostic Service
“It was an excellent service from initial contact right through to discussion of results and ongoing referrals and treatment. A wonderful resource.” Patient, Rapid Diagnostic Service
2.3 Urgent Care Services - Unplanned Care Between 1st April 2024 and 31st March 2025, NPC’s unplanned care services - comprising the General Practice at the Front Door (GPFD) Services and the Walk-In Centre - facilitated access to same-day Primary Care appointments for 119,265 patients. This figure underscores the pivotal role these services play in the local healthcare system. By providing timely, accessible care, these services significantly reduce the burden on Emergency Departments across Norfolk & Waveney. They serve as a critical frontline resource, helping to manage the increasing demand for urgent and emergency care, and ensuring that ED teams can focus on patients with the most acute needs. General Practice at the Front Door (GPFD) Service The aim of the GP at the Front Door Service is to offer suitable patients access to a Primary Care appointment instead of being seen by the Emergency Department (ED) team. The service is operational 7 days a week (including Bank Holidays) from 09:00 – 21:00 hours and has bases at all three acute hospital Trusts in the Norfolk & Waveney Region. It is designed to be delivered as a ‘satellite hub’ to give patients the opportunity to have a consultation with an Advanced Nurse Practitioner or General Practitioner on the same day instead of waiting in the ED to be seen, but with the consultation will take place within the hospital setting itself. This is not a patient-initiated referral service and may be only accessed via a clinician-led streaming process on a patient’s walk-in attendance to the ED front door. The clinician who sees
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the patient has full access to the clinical record, which promotes safe, effective primary care modelled healthcare to patients and supports a general practice service on behalf of the patients registered practice
i.
James Paget University Hospital NHS Foundation Trust (JPUH)
The JPUH GP at the Front Door Service has been delivered by NPC since September 2021. It has streamed an average of 44% of patients who walked into ED to be seen during the GP at the Front Door Service operational hours. The equates to 39,755 patients streamed and 17,346 of those being seen, assessed, and discharged, admitted, or onward referred into the hospital. NPC continuously works with the ED management teams to improve and implement quality improvements for the benefit of supporting the ED department and, ultimately, the patient experience.
For the period from 1 st April 2024 to 31 st March 2025, the patient feedback survey for the JPUH GP at the Front Door Service resulted in an average of 88% of patient saying that the service was ‘Excellent’ or Very Good’, and an average of 90.5% Family and Friends recommendation.
What did the patients say about the service
“Waiting time was reasonable, 1 hour, but could be improved. But the assistance was good, and this is very positive feedback. Thanks so much” Patient, GPFD Service, JPUH
“Having the GP Streaming service is an excellent idea and hopefully this is helping with cutting times in A&E- thank you” Patient, GPFD Service, JPUH
“Perhaps an additional clinician during busy periods?” Patient, GPFD Service, JPUH WHAT WE DID: Worked with the JPUH Management Team to implement an extra clinician at particularly busy periods or in situations such as NHS Strike action or Bank Holidays
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ii.
Queen Elizabeth Hospital NHS Foundation Trust (QEH)
Initiated in January 2022, the GP at the Front Door Service at the QEH streamed 38,262 patients and saw 15,111 patients over the period of 1 st April 2024 to 31 st March 2025. This equates to 39% of all walk in patients to ED during the hours of 09:00-21:00 hours were identified as appropriate to be seen by the GP at the Front Door Service. The inclusion & exclusion criteria for the service are the same across all 3 acute Trusts and is always adhered to by the streaming clinician. These are:
Inclusion Criteria All patients who present to the ED, if they are registered with a GP Practice within the UK and are assessed by a suitably trained clinician to be appropriate for Primary Care. Children over three months may be seen by the service for minor illness complaints where appropriate as assessed by the clinician. All children 3-12 months will have a temperature recorded and documented by the streaming clinician with an aim to be seen within 15 minutes. Patients with potential dental issues that require urgent medical treatment. Exclusion Criteria Any patient requiring intervention or investigation within ED as an urgent measure (i.e. the same day) NOTE: Patients that may require onward referral to a specialty MAY be seen by the GP at the Front Door Service and should be encouraged to support inappropriate ED attendances; depending on the nature of their symptoms, further investigations should not delay this process. Non-traumatic chest pain. Any patients with signs or symptoms of stroke. Children under 3 months and Children aged from 3-12 months without a temperature recorded on streaming slip. Patients identified as allocated to the Special Allocation Service (SAS).
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The inclusion and exclusion criteria have been established to ensure that patients directed to the GP at the Front Door Service receive appropriate care, with a strong emphasis on patient safety and experience. The GP at the Front Door Service team collaborates closely with the Emergency Department (ED) teams to support and uphold the shared commitment to delivering high-quality care for patients deemed suitable for the General Practice at the Front Door Service pathway. For the period from 1 st April 2024 to 31 st March 2025, the patient feedback survey for the QEH GP at the Front Door Service resulted in an average of 90% of patient saying that the service was ‘Excellent’ or Very Good’, and an average of 96% Family and Friends recommendation.
What did the patients say about the service?
“I was completely happy with the service and don’t think they could have improved how I was treated” Patient, GPFD Service, QEH
“You have been brilliant as always! You are doing an amazing work! Well done!”
“The care I received today was outstanding and probably can’t be improved on” Patient, GPFD Service, QEH
Patient, GPFD Service, QEH
iii. Norfolk and Norwich Hospitals NHS Foundation Trust (NNUH) NPC has delivered the GP at the Front Door Service at the NNUH since July 2023, and in that time has seen, assessed, and discharged or onward referred 16,919 patients. The NNUH operates an alternative streaming model from the JPUH and the QEH streaming model, with the NNUH ED clinical team being the ‘streamers’ to the GP at the Front Door Service.
However, the service inclusion and exclusion criteria are still adhered to support the identification of suitable patients for the service. The NNUH ED and NPC management teams work closely together to ensure that the patient experience is consistent with the JPUH & QEH model of streaming.
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For the period from 1 st April 2024 to 31 st March 2025, the patient feedback survey for the NNUH GP at the Front Door Service resulted in an average of 82% of patient saying that the service was ‘Excellent’ or ‘Very Good’, and an average of 87.5% Family and Friends recommendation.
What did the patients say about the service?
“It was great. My child is only 2 and he was seen to immediately. Saved me lots of anxiety.” Patient, GPFD Service, NNUH WHAT WE HAVE DONE: We have implemented a process to identify priority patients as they are booked in to the service, in accordance with their clinical need
“You were dealing with so many people I think you did a brilliant job”
“Use a system that books people in, in the order they arrive at the clinic.” Patient, GPFD Service, NNUH
Patient, GPFD Service, NNUH
WHAT WE DID: Worked with the ED team to ensure that patients who are streamed to the service have a numbered slip in accordance with their arrival to the reception desk
Between 1st April 2024 and 31st March 2025, the three General Practice at the Front Door Services successfully supported seeing an impressive 49,376 patients face to face. During this time, 6,659 of those patients shared their experiences through our anonymous patient surveys - an encouraging 13.5% response rate that reflects strong patient engagement.
Norwich Walk-In Centre (WiC) Service The Norwich Walk-In Centre is located on Rouen Road in Norwich city centre. It provides a valuable service to those patients seeking support on the day for acute minor illness, and minor injuries. It operates 7 days a week, including Bank Holidays, from 07:00 hours to 21:00 hours ( Note : As of April 2025, the opening hours have changed to 07:00 hours to 19:00 hours).
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Throughout the period of 1 st April 2024 – 31 st March 2025, the team of dedicated GP’s, Nurses, and administrative staff saw 69,889 patients. Many patients who attend are in the Norwich area but is open for access to all patients registered with a GP Practice in the UK. The WiC team continues to implement improvements to improve the service provided to the patients. Clinical triage remains at the
front door to maintain patient safety, with initiatives being put in place to ensure that the patients get a timely assessment in accordance with their presenting problem. In August 2024, Health Watch Norfolk visited the WiC and the Norwich Health Centre to gain an insight into the patient experience. The reviews had an average star rating of 4.1 out of 5 for the WiC and an average of 4.3 out of 5 for the Norwich Health Centre. Overall, patients were satisfied with their experiences at both services. These results are reflected in the very recently introduced patient surveys which NPC carry out, which demonstrates that 93% of patients think that the service is ‘Excellent’, with a 100% Family and Friends Test result. What did the patients say about the service?
“The service I received was all that I needed” Patient, Norwich WiC patient
“Keep going like that” Patient, Norwich WiC patient
“Please don’t close it, we desperately need it, thankyou” Patient, Norwich WiC patient
2.4 Research, Education, and Training As a core component of the NPC’s five-year Business Strategy, we are committed to establishing ourselves as leaders in Primary Care education, training, and research. We recognise that embedding these elements within care delivery is essential to improving patient outcomes and strengthening workforce development. Integrating research and education into Primary Care not only enhances the quality of care provided to patients but also supports staff in delivering high standards of clinical practice, thereby contributing to a more resilient and capable workforce.
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International Recruitment Norfolk Primary Care, in collaboration with the Norfolk & Waveney Integrated Care Board (NWICB), has successfully explored and facilitated ways to enhance international recruitment, recognising the value that global expertise brings to Primary Care. This is along with the enhancement of the workforce to meet the ever-increasing demands for the provision of staff in Primary Care. International professionals can enrich clinical practice, alleviate staffing pressures, and improve patient care. Through this partnership, NPC aims to strengthen education and training by facilitating knowledge transfer, mentorship, curriculum development, and technological innovation. Additionally, the potential of collaboration with international academic institutions can support research, professional growth, and higher accreditation standards, ultimately contributing to a more sustainable and high-quality Primary Care workforce. Learning Organisation Status – General Practice at the Front Door Services at JPUH & QEH Following the successful application for Learning Organisation status for the GPFD Service at JPUH in May 2024, we proudly welcomed our first GP trainee in October 2024. This milestone was soon followed by another achievement—the successful Learning Organisation status application for the GPFD Service at QEH in September 2024. Being recognised as a Learning Organisation marked a pivotal moment for NPC, reaffirming our dedication to fostering a culture of continuous education, training, and research. This recognition not only reinforces our commitment to professional development but also strengthens our role in shaping the future of healthcare education. By embedding these principles into our ethos, we ensure that NPC remains a hub for innovation, collaboration, and excellence in patient care. Dr Parithi Vetrivel – Our first GP Trainee at the GPFD Service, JPUH.
Becoming a Learning Organisation has had a direct and meaningful impact on patient care by:
Continuous Improvement: By fostering a culture of ongoing education and research, healthcare professionals stay updated on the latest medical advancements, best practices, and innovative treatment methods.
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Enhanced Training: A structured approach to learning ensures that staff - especially trainees - receive Primary Care focussed high-quality, hands-on experience, improving their clinical skills and confidence. Evidence-Based Practices: With a focus on education and research, patient care decisions are increasingly guided by the latest scientific evidence, leading to more effective treatments and better outcomes. Collaboration & Knowledge Sharing: A learning organisation encourages interdisciplinary teamwork, where different specialists exchange insights to provide well-rounded and comprehensive patient care. Patient-Centred Approach: An environment committed to learning naturally places patient needs at the forefront, ensuring services continuously evolve to offer the best possible care. Higher Staff Engagement & Morale: Healthcare professionals working in a learning-focused setting tend to be more engaged, motivated, and proactive—leading to better communication, decision-making, and overall patient experience. In essence, it not only strengthens the skills of healthcare providers but also enhances the quality, safety, and effectiveness of patient care. Norfolk Research Hub The Norfolk Research Hub has continued to grow since NPC commenced delivery in December 2023. It commits to delivering Primary Care clinical research at scale, which benefits Norfolk patients the opportunity to participate in research projects whilst providing an additional income stream to practices. The Research Champions Delivery Group (RCDG) continues to grow, which has patient representatives to help shape the future of research delivery in Norfolk. The bi-monthly forum meetings are open to anyone from Norfolk and Waveney Primary Care teams, and they help to showcase some of the following research projects which we have delivered in the period from 1 st April 2024 – 31 st March 2025, such as: ActiveBrains - Academic study on dementia. Inherited from the previous provider of the Norwich Research Hub and completed by NPC.
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