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Your Best Practice - Primary Care and Community Services
Summer/Autumn 2026 edition
Dear colleagues,
Welcome to your latest edition of Your Best Practice - showcasing and celebrating some of the innovative and amazing work which takes place in primary care and community services, throughout the North East and Yorkshire region.
Dr Faisel Baig
In our last edition, we featured the developing work of four of our regional National Neighbourhood Health Implementation Programme (NNHIP) pioneer sites, now you can learn about some of the other sites in this newsletter and via our new dedicated Neighbourhood Health microsite.
Recent visits to our region from Professor Frankie Swords, National Medical Director and Dr Claire Fuller, National Priority Programme Director for Neighbourhood Health, have reinforced both the strength of our partnerships and the strides being made in implementation of these integrated ways of working.
The opportunity now is to keep that momentum going, continue learning from one another, and work together to create neighbourhood health services that make a lasting difference for the people and communities we serve.
Patient satisfaction across our North East and Yorkshire (NEY) region continues to improve, according to the latest GP Patient Survey 2026 and ONS Health Insights Survey. Across the region we performed at or above the national average across all headline measures of access and overall experience for general practice, dentistry, community pharmacy and out-of-hours services. GP practices across NEY continue to be recognised nationally for their activity and outcomes and these results are a testament to the dedication of colleagues across primary care - thank you for all your work to support better access, experiences and outcomes for patients.
With the publication of the cancer plan earlier in the year, we are also pleased to showcase some of our preventative work in primary care across the region during the month of September. We will be sharing examples on our website and across social media throughout our focus month – please follow us on the social channels bookmarked at the end of this newsletter.
Even more primary care colleagues have shared their experiences in our Transforming Primary Care podcast series which has received over 26,000 listens to date. Discussions have continued to support delivery of the 10-year plan and series 5 has now ended with an exploration of medicines waste reduction. Please help guide future series of the podcast by taking a few minutes to fill in our short survey.
Series 6 launches in September with discussions focusing on neighbourhoods, using a single point of access for Advice & Guidance and elective referrals, and a World Contraception Day focus on the NHS contraception service delivered in community pharmacy. Our example around the service being offered by a Leeds community pharmacy recently featured in national media activity about the free emergency contraceptive pill.
Around 4 in 5 people in England live within a 20-minute walk of a community pharmacy, and as we approach the bank holiday weekend, we are also reminding patients to ‘get bank holiday ready’ and ensure they have ordered all their necessary medication.
You can sign up to receive issues of this newsletter and alerts around new podcasts sharing examples of best practice, by emailing: england.ney.pctransformation@nhs.net.
For those of you who are able to take time off, have a great bank holiday and a big thank you goes to those colleagues who will be working over the long weekend. As always, a huge thank you to everyone for your continued individual, and collective efforts to deliver NHS services for our patients in these challenging times.
Dr Faisel Baig, GP & Medical Director for Primary Care
Annabel Johnson, Deputy Director for Primary Care
Tracy Wright, Deputy Director for Neighbourhood Health and Community Services
Annabel Johnson
Tracy Wright
Cross-sector, community and neighbourhood health
Putting relational public service into practice
Doncaster is taking a new approach to neighbourhood health, starting with people, not services.
As part of the Neighbourhood Health Implementation Programme (NNHIP), teams are working across small, hyper-local communities to better understand how people experience care and where the system can work differently.
Rather than focusing on single conditions, early learning from the site shows that people often experience clusters of needs, from mental health to chronic pain and long-term conditions. By bringing together insights from primary care, social care, housing and community services, teams are building a more complete picture of people’s lives.
A key focus has been strengthening partnerships and connecting organisations that are already supporting the same individuals, but often in isolation. At the same time, community engagement is being transformed - moving away from repeated consultation towards building trust and ongoing relationships.
This work is being developed as a “prototype” approach, learning and adapting in real time with residents. The result is a more personalised, joined-up approach shaped by communities themselves.
Ruth Bruce, NNHIP Coach at South Yorkshire ICB (pictured), explains:
“By bringing together data from multiple partners, we're developing a rich, contextual picture of people’s lives and how they interact with the system. What we've found is that clinical need rarely exists in isolation and that a person is not defined by the clinical conditions that they present to services with.”
NHS England senior leaders see neighbourhood health in action across the North East and Yorkshire
Senior NHS England leaders have seen first-hand how neighbourhood health is being delivered across the North East and Yorkshire, following a series of visits to Humber and North Yorkshire, South Yorkshire, West Yorkshire and North East and North Cumbria.
L-R Dr Faisel Baig, Dr Emma Olandj, Professor Frankie Swords, Professor Mike Holmes and Dr Tori Blake at the York Frailty hub
Dr Claire Fuller, National Priority Programme Director for Neighbourhood Health, together with Dr James Kent, National Adviser in the Strategy Directorate, and colleagues from NHS England and the Department of Health and Social Care, undertook a tour as part of the national neighbourhood health stocktake programme.
Professor Frankie Swords, national medical director, also demonstrated the importance of a neighbourhood approach with a recent visit to the York Community Frailty hub.
The visits highlighted both the progress being made and the shared ambition to transform care through stronger community-based models.
Read about all five visits on our dedicated Neighbourhood Health microsite.
General Practice
Holmside Medical Group: improving access and care by introducing online triage
Holmside Medical Group in Newcastle-upon-Tyne has transformed how patients access and experience care by combining digital tools with a strong focus on people.
Following a full system review, the Benwell-based practice introduced a new online triage model ensuring every patient request is reviewed and directed to the most appropriate clinician quickly and safely.
Working within the General Practice Improvement Programme (GPIP), the team simplified access so that all requests, both urgent and routine, come through a single, consistent pathway. This has reduced confusion for patients and improved response times.
The benefits are far-reaching. Dedicated visiting clinicians now support housebound and end-of-life patients, while proactive outreach has helped identify previously undiagnosed conditions through targeted health checks. The practice has also made significant improvements in regard to its mental health support provision.
Practice Manager Ruth McKeown (pictured) explains:
"Access alone doesn’t improve outcomes. This is particularly true in a population like ours, where 99% of patients live in areas of deprivation and health needs are often more complex. One of our biggest priorities has been mental health. With prevalence significantly higher than the North East and North Cumbria ICB average, we embedded mental health practitioners and social prescribing link workers into our core team. This means patients can often be seen on the same day following triage, preventing problems from escalating."
Read Ruth’s blog to find out how the team implemented the changes.
Creating faster access and more personalised care at Leyland Medical Centre
Leyland Medical Centre in Heaton, Bradford has transformed how patients access care through a triage-first approach that helps ensure people receive the right support from the right professional at the right time.
By combining experienced clinical triage with smarter use of technology, the practice now reviews online requests within around 30 minutes and can often arrange same-day appointments within the hour when needed. Alongside improving access, the team has increased screening and immunisation uptake and strengthened preventative care.
As a result of the changes the practice, which delivers care to around 18,735 people across three sites, has achieved an outstanding CQC rating.
Practice Manager Tom Baker reveals the detail behind the CQC rating:
“Change can feel daunting at first, but involving people throughout the process makes a huge difference. Successful transformation is about people as much as processes.”
Read Tom’s account of the changes his practice team have made.
Reducing vaccine wastage using digital innovation
Riverside Surgery in North Lincolnshire is transforming how vaccines are protected through using new technology.
By introducing smart panels and remote temperature monitoring, the team has eliminated vaccine losses, improved efficiency and reduced staff workload on a daily basis.
Previously, manual checks and reactive responses routinely created pressures and risk. Now, real-time alerts and an extended response time give staff more confidence and control - and even more importantly there is a positive impact on patient care due to fewer cancellations. The result is a significant financial saving and a more resilient system, especially given the impact of hotter summer temperatures in recent times.
Michelle Slimm, Business Manager (pictured), explains:
“Since introducing the system, we have not lost a single vaccine due to temperature variations.”
Learn how adopting new cold-chain technology has made a positive difference at Riverside.
Reducing duplication and delays with online patient registration
Sarah Armitage, Practice Manager at Treeton Medical Centre, Rotherham, explains how the NHS Register with a GP Surgery service has transformed patient registration
By enabling patients to register online at a time and place that suits them, the service improves access and inclusivity. Digital registration also reduces errors, improves data quality and helps practices match patients to NHS records more quickly. The addition of auto-registration further cuts administrative workload, freeing staff to focus on patient care.
Describing the impact of the service, Sarah said:
"It has made registration more accessible and inclusive. Online registration can be used by patients who may struggle with traditional routes, including those with hearing impairments, communication difficulties, mobility issues, caring responsibilities or demanding work schedules."
Read more about Treeton Medical Centre’s online registration implementation journey.
Helping people with COPD stay well and avoid hospital visits
A pioneering COPD improvement programme in North East and North Cumbria is helping patients stay healthier for longer while reducing demand on urgent and emergency care services.
Through the OPTIMISE approach, practices proactively identified patients most at risk of worsening health and invited them for structured reviews focused on medication, symptom management and self-care. Nearly 2,000 patients were reviewed across 159 practices, resulting in significant reductions in NHS 111 calls, A&E attendances, hospital admissions and respiratory bed days.
The outcomes from the programme are now informing future neighbourhood-based respiratory care in the North East and North Cumbria.
Claire Adams, Respiratory Programme Lead (pictured), said:
“A 68% reduction in bed days is just phenomenal. We saw very similar improvements to programmes delivered by specialist respiratory teams, but this was particularly meaningful as it was delivered through primary care.”
Learn how the programme helped more patients be treated in general practice.
Community Pharmacy
Only order what you need: reducing medicines waste across North East and Yorkshire.
Teams across North East and Yorkshire are helping patients reduce medicines waste by encouraging them to order only the medicines they need.
Through targeted campaigns, partnership working and patient engagement, the initiative is improving patient safety, reducing environmental impact and helping the NHS make better use of its resources. The work has highlighted common concerns, including fears about medicine shortages and uncertainty about how to dispose of unused medicines safely. By addressing these barriers and empowering patients to make informed decisions, local teams are reducing unnecessary prescribing and supporting more sustainable healthcare.
Megan Seymour from South Yorkshire ICB (pictured) explains:
“We worked with Age UK and carers who provide medication support in patient homes to be able to deliver the messages in their homes because they might be the only contacts that person has.”
Improving access to contraception through community pharmacy
Community pharmacies across North East and Yorkshire are helping women access contraception more quickly, conveniently and closer to home through the NHS Pharmacy Contraception Service.
The service provides free emergency contraception, as well as support to start or continue oral contraception, without the need for a GP appointment. Pharmacy teams report that extended opening hours, walk-in access and a consistent national offer are helping to reduce inequalities and improve patient choice. The service is proving particularly valuable for students, young women and other underserved groups.
At Wicker Pharmacy in Sheffield, Lead Pharmacist Julie Grigg (pictured) highlighted how pharmacies are often supporting women at times when other services are closed.
“Forty-three per cent of our emergency contraception consultations happen on a Saturday or Sunday when a lot of conventional services are closed.”
Julie also described the speed with which they can see young women through the service:
“It's not unusual for us to get a couple of teenagers coming in...We can see them straight away and the barriers to service are much lower than if they've got to book a GP appointment or attend a sexual health service.”
Listen to Julie and colleagues in our upcoming series six Transforming Primary Care podcast episode to mark September's World Contraception Day. Sign up here.
Dental
Helping children build healthy smiles through supervised toothbrushing
A supervised toothbrushing programme that began in Teesside in 2008 is helping children across the North East and North Cumbria develop healthy habits, improve oral health and reduce the risk of tooth decay.
Delivered in schools and nurseries, the programme supports children in areas most affected by health inequalities and has been shown to reduce levels of decay among participating pupils.
Kamini Shah, Consultant in Dental Public Health for NHS England – North East and Yorkshire (pictured), said: "Every child supported through this programme is another child being given the opportunity to develop healthy habits, improve their oral health and enjoy a healthier future."
Find out more about how the programme continues to expand, helping more children get the best start in life.
Communications campaign increases access to urgent dental care services
A communications campaign has helped to improve access to urgent dental care in the North East and North Cumbria.
The campaign aims to raise awareness of NHS urgent dental care services and encourage people to book their own appointments for urgent dental access centres online to alleviate pressure on NHS 111.
It includes new website content, leaflets and posters in GP practices, pharmacists and dental practices, social media and digital advertising, PR activity on radio, TV and press, plus engagement with stakeholders. A toolkit of resources, featuring EasyRead and easy print versions of materials, is available for partners to share information with their communities.
In the first three months of the campaign, the ICB's dentistry web pages had over 53,000 views. Direct patient bookings into urgent dental access centres increased by 14% while NHS 111 bookings reduced by 7%.
See the ICB web pages at https://northeastnorthcumbria.nhs.uk/nhs-dentistry and access the urgent dental care toolkit here: https://northeastnorthcumbria.nhs.uk/toolkits/dental.
More examples of urgent dental care across the region coming up in our Autumn/Winter edition. Details of the Humber and North Yorkshire Tiny Teeth campaign featured in our previous edition. Access resources including a dedicated section for Top Tips For Tiny Teeth here.
Bringing eyecare closer to home
A North East and North Cumbria Integrated Care Board team has recently participated in the Eyecare Closer Home project run by NHS Alliance.
The 'Bringing eyecare closer to home' project has aimed to develop a blueprint to improve support for Ophthalmology Glaucoma Services by building primary care capacity, ensuring that only those with Glaucoma are required to be assessed by Ophthalmology, and transferring the care of stable glaucoma to accredited optometrists situated on community high streets.
The resulting community-based optometry protocol-led glaucoma monitoring service delivered from multiple optometry practices has proved successful. In the catchment of Newcastle upon Tyne Hospital NHS Foundation Trust, patients stratified as low risk are transferred with a management plan to the optometry service. First year data indicates 7% discharge rates and 9% escalation to hospital for virtual review.
Patient experience was consistently positive. All respondents to a patient satisfaction questionnaire would recommend the service to a friend or family member, citing clear communication, shorter waiting times and care delivered closer to home.
One patient said: “The appointment was local to my home so no issue with travel or parking. Quick and on time, so less personal time spent attending.”
Read the full case study about the North of Tyne service
Access more guidance around moving eyecare into the community:
Digital inclusion
Helping older people access healthcare and independence through the NHS App
Age UK North Yorkshire Coast & Moors is helping older people gain confidence, independence and better access to healthcare through its Digital Inclusion Programme.
Over the past year, hundreds of older residents have received personalised support to use digital technology, including the NHS App, enabling them to order prescriptions, manage appointments and access health information more easily.
Alex Parker, Chief Executive Officer (pictured left), said: "When older people gain the confidence to use tools such as the NHS App, they gain much more than easier access to services. They gain greater control over their health, stronger connections with others and new opportunities to live well and independently."
Watch our video about NHS App sessions taking place in libraries across our region.
The importance of Reasonable Adjustment Digital Flags
Earlier this year we shared Northumberland GP Dr Hannah Brown’s blog about the importance of the Reasonable Adjustment Digital Flags in levelling the field for patients that need a little more help in accessing services. This video (click on the image to play on YouTube) featuring Hannah and patient Paul James who has a learning disability and a visual impairment demonstrates the reasons why the flag is so vital.
Transforming GP estates to support Neighbourhood Health
The South Yorkshire Primary Care Capital Programme is delivering one of England's most ambitious programmes of GP estate transformation.
Bringing together NHS organisations, local authorities and GP practices, the £57.4 million programme includes 11 projects ranging from refurbishments to major new-build health centres, helping create modern facilities that support better access to care, improve patient experience and reduce health inequalities. More than 155,000 patients are expected to benefit from the investment.
At Broom Lane Medical Centre in Rotherham, a redevelopment has created a modern facility that supports better patient care while bringing multidisciplinary teams closer together.
Dr Simon Langmead, GP Managing Director, (pictured) said:
"The result is a brilliant modern facility which has allowed us to deliver better patient care and bring the multidisciplinary team closer to the patient, whilst also providing better working space for our staff team."
North East and Yorkshire primary care teams recognised in the NHS Excellence Awards
Colleagues in primary care have been recognised for their transformative work in the NHS Excellence Awards.
Primary Care Teams Improvement Award – Gold Team Approach to Improving Palliative and End of Life Care in General Practice – Holderness Health
The Gold Team Approach at Holderness Health was recognised as a national winner for transforming palliative and end-of-life care in general practice. By addressing gaps in continuity and communication, the team developed a comprehensive model including a rapid-access Gold line – a help line for families and carers. They also provided proactive GP contact and a support pack for families. This work has reduced call waits to under a minute, improved patient identification, and earned praise from families and partners alike. The approach has enhanced staff morale and is already inspiring others to adopt this model.
Watch our Facebook reel featuring some of the GPs that are running the service
Delivering Value Award – Transforming Same Day Urgent Care and Winter Services across North Yorkshire – Nimbuscare
Nimbuscare was recognised as a regional winner for transforming same-day urgent care across North Yorkshire. Designed for direct booking via general practice and delivered in neighbourhoods, this laid the foundation for North Yorkshire’s first fully integrated 24/7 urgent care service. By shifting from walk-in to GP-bookable appointments, the service has streamlined the patient journey, offered alternatives to A&E, and generated significant cost savings. With high patient satisfaction, the model integrates Pharmacy First and a local Clinical Assessment Service bookable via NHS111, offering a scalable, efficient, and value-driven approach to urgent care that aligns with national policy.
Dr Tori Blake, Director of Urgent Care, said:
“We’re delighted to receive this award, which recognises a fundamental shift in how urgent care can be delivered. By integrating general practice, Pharmacy First and NHS111 into a single neighbourhood model, we’ve significantly improved access, reduced unnecessary hospital attendance, and ensured patients are seen quicker and closer to home. At its core, this is about delivering value across organisational boundaries, using our collective expertise and resources for the benefit of patients.”
If you work in primary care and community services and would like to share your own stories of best practice or sign-up to receive future Your Best Practice editions direct to your inbox email the Primary Care Transformation team at england.ney.pctransformation@nhs.net.
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