Thistlemoor Named Best Team in East Anglia for Its Inclusive, Grassroots Approach to Community Care

Thistlemoor Medical Centre has been honoured with the Royal College of General Practitioners (RCGP) Practice Team Award 2023 for East Anglia, recognising the centre’s innovative approach to population health management. The award acknowledges outstanding teamwork and commitment to improving patient care, highlighting the impact of a pioneering project led by the centre’s social prescribing team.

At the heart of this success is a collaborative initiative spearheaded by Gina Goubran, an MBA degree-level social prescriber, alongside GP trainees Moamar, Ijeoma, and Susan Waller. Working in partnership with Peterborough Council and Peterborough CVS, the team sought to understand why certain patients—often referred to as ‘frequent flyers’—were making repeated visits to GP services and emergency departments despite having no clear medical diagnoses on record.

The project involved a deep dive into the underlying social and economic factors affecting these patients. By integrating targeted interventions, including social prescribing, community-based activities, and direct support for employment, housing, and financial wellbeing, the team was able to make a significant impact. The results were striking: a 75% reduction in GP appointments and a 30% decrease in emergency attendances, demonstrating the power of holistic care in improving patient outcomes.

Thistlemoor Medical Centre has long been a leader in offering additional support beyond traditional medical care, including Tai Chi and Yoga sessions, as well as guidance on employment and housing. The award-winning project further reinforced the effectiveness of these initiatives and provided a model for how primary care practices can address broader determinants of health.