Ruth McKeown, Practice Manager at Holmside Medical Group, explains how their new online system has helped increase access for their patients – leading to an outstanding rating in a recent assessment.

When our practice was awarded an Outstanding CQC rating, it was a proud moment for everyone at Holmside Medical Group. But for us, it wasn’t a finish line, it was recognition of years of questioning how we work, listening to our patients and staff, and being willing to do things differently.

Things changed quickly for us as a result of the Covid 19 pandemic. In 2022, we carried out a full review of our appointment system, involving staff and patients at every stage. We knew we had to improve access, but we also had to protect our workforce from the pressures that were building due to increased demand.

Ruth McKeown

Moving to a structured triage model gave us a way forward. Every patient request is now clinically reviewed and directed to the most appropriate professional, ensuring that people get the right care first time.

Rethinking access and appointment systems

Alongside this, we made better use of technology and data. Having introduced cloud-based telephony early on, we were able to build a clearer picture of demand and respond accordingly. The result has been a 25% increase in GP reviews, alongside improved navigation for patients and better continuity for those with complex needs. We also introduced a dedicated visiting clinician, providing consistent support to our elderly and housebound patients. This has allowed for more time with patients, stronger relationships, and better identification of wider needs beyond immediate clinical issues.

Tackling health inequalities using proactive care

However, 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. This approach has also released over 700 GP appointments over the past year, enabling GPs to focus on patients with more complex medical needs.

Prevention and early intervention have also been central to our approach. Through our NHS Health Check link worker project, we focused on reaching people who wouldn’t normally engage with us. This wasn’t about sending letters – it was about picking up the phone, and building trust. It was also about persistence – we often had to invite people more than once. In one year, we completed over 350 health checks, identifying dozens of patients at risk of cardiovascular disease, referring more than 50 patients to our in-house pharmacist, and even diagnosing new cases of diabetes and pre-diabetes. It reinforced that giving people access isn’t enough, we have to actively bring care to people who need it most.

Strengthening support for long-term conditions

Our work on long-term conditions reflects that same principle. We’ve seen steady year-on-year growth in reviews, increasing from 1,656 in 2023 to 2,145 in 2025. A key part of this has been our nurse associate-led home visiting service, which delivered over 140 reviews for housebound patients in a year. These visits go far beyond routine checks -they help us uncover safeguarding concerns, medication issues, and social challenges such as loneliness that might otherwise remain hidden.

None of this would be possible without investing in our people. We’ve focused on “growing our own” workforce, supporting colleagues to develop into new and extended roles. This includes independent prescribers, advanced practitioners, and staff progressing through entirely new career pathways. Many of our team have been with us for over a decade, and that continuity makes a real difference to both patient care and team resilience.

Building a ‘safe-to-speak’ culture

Just as important as what we do is how we work together. We’ve built a culture where people feel safe to speak up, suggest improvements, and say when something isn’t working. If a system isn’t right, we change it and we do it quickly. That agility has allowed us to adapt not only to day-to-day pressures but also to significant challenges, including responding to unexpected incidents while maintaining support for both patients and staff.

If there’s one lesson we’ve learned as a team, it’s that real, meaningful change comes from understanding your population and having the bravery and support to do things differently. It’s about building services around real need, not assumptions, and recognising that improvement is always ongoing.

Our CQC rating has given us the opportunity to share our story, but the real achievement lies in the work behind it. The creation of a committed team, a strong set of values, and a shared goal of delivering the best possible care for our community.