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Published in June 2019 by NHS England in collaboration with the Department of Health and Social Care, the Royal College of General Practitioners, the Strategic Estates Advisors service, NHS Property Services, Community Health Partnerships, the Care Quality Commission, District Valuer Services, NHS Clinical Commissioners and the General Practitioners Committee of the British Medical Association following on from the agreement of the 2018/19 General Medical Services (GMS) contract.
Against the backdrop of the recent settlement of the GMS contract, in January 2019 the NHS Long Term Plan and the Five-Year Framework for GP contract reform set out key ambitions for the next ten years which included the introduction of Primary Care Networks (PCNs) as the foundation of Integrated Care Systems (ICSs) partially delivered through the new Network Contract Directed Enhanced Service (DES). These will seek to deliver major developments in primary care through:
The above developments have therefore been considered as part of the wider ongoing implications for general practice and the primary care estate. The review sets out a series of policy responses; in some cases further negotiation with GPC England will be required around the ‘detail’, and where a policy response involves new financial commitments these will be dependent on the capital available.
De-Risking Leases in strategically important estate
Assignment of Leases to NHS bodies (or other entities) where they are deemed to be of Strategic Importance
This speaks in part to the ‘last person standing’ problem identified by the NHS England commissioned partnership review published earlier in 2019 by Dr Nigel Watson, in that direct assignments to NHS bodies (such as NHS Property Services), followed by shorter term sub-letting agreements to GP Contractors could potentially remove concerns surrounding GPs bound by Leasehold liabilities – thus present one way of separating partnership ownership concerns from operational considerations.
The policy review document identifies that this would only be considered as a method of last resort and only where premises have been identified as having ongoing importance for delivery of services, or considered strategically important.
Associated ongoing and capital cost attached to this would clearly be significant depending on the detail as to which Leases are of strategic importance.
The review also highlighted the need to improve the level of trust between NHS PS and the wider GP community if this recommendation was to be “effectively operationalised”.
Property ownership as part of the partnership model
NHS will encourage practices to separate the decision to enter premises ownership from the decision to enter into a general practice partnership and the operation of primary services. Development of best practice guidance for all property-owning GPs in this respect. Future NHS capital investment would come with a requirement to demonstrate robust governance around property ownership
One of the key messages coming from this review was that risk and the perception of risk has been identified as one of the major factors which can discourage GPs from becoming partners. We can see from this review that the NHS are looking to head towards developing systems that allow GPs to focus on operational considerations through removing considerable ownership obstacles. From this we can also expect the NHS to be looking to firm up premises ownership governance standards and thus expecting a good standard of professional management accordingly. Where NHS is investing capital in premises owned by GPs, evidencing robust governance will be key, with NHS potentially looking for assurances across five key aspects:
It is noted that NHS expect more practices to want to separate the decision to enter premises ownership from the operation of primary medical services, as we generally observe a reducing level of willingness for GPs to want to own property. Systems that do separate the two functions may also be considered evidence of good governance.
Professionalisation of property ownership and management
Clearer guidance on the expectations of owners and occupiers around maintenance and standards
A key aspect raised by the premises policy review was that a general lack of understanding and awareness surrounding the responsibilities of all parties involved in estate ownership can lead to failure to meet those responsibilities. This is regardless of whether the property in question is owned or rented. Lack of maintenance and repair will ultimately reduce the value of property, it’s overall viability for the future and thus impact proposals for investment.
The review document discussed maintenance and obligations but, notably, did not specifically address aspects such as premises “standards”.
The review also recommended the production of a Customer Charter for adoption by all parties involved in property which would set out core principles of premises management along with each party’s obligations. Providing this is produced in a simplified format then this would assist in bringing clarity to all.
New models and the Premises Costs Directions
Pilot alternative premises reimbursement arrangements at network level, to give networks greater autonomy to manage and minimise their costs relating to estates across their premises. Pilot a simpler model of premises provision in which the NHS directly bears costs of premises in multi-use new build schemes, removing the need for bureaucratic premises reimbursement systems, promoting integration of service delivery and optimal use of space
At a fundamental level, this proposal looks to enable PCNs to attempt to control and minimise premises costs through adopting an alternative to funding governed by the Premises Costs Directions. Options such as the single payment approach were considered during the review and one of the key areas of concern highlighted was the cumbersome, complicated and misunderstood nature of the current Premises Costs Directions.
Concern will be as to the mechanism of reviewing success or failure of alternative arrangements and given the heterogenous nature of ‘property’, one method which may work for one PCN may be completely inappropriate for another. Further, the system of Notional Rent as covered by the Premises Costs Directions allows for a full dispute resolution process thus is essentially a self-contained model that is based on a ‘market rent’ system.
Being divorced from a budgetary controlled mechanism is a key aspect of notional rent that has of course always been enshrined within the Premises Costs Directions. Shifting approaches in a piecemeal manner could lead to a patchwork of methodologies with no fundamental legislative framework for those systems.
It was identified that the current Premises Costs Directions do not adequately support integrated care hubs or estate with multiple providers, and that in those circumstances the NHS would favour directly meeting the costs associated with the hub, with practices covering those aspects which are currently non-reimbursable under the Premises Costs Directions.
In many respects a similar system which ultimately removes contentious aspects and obstacles such as onerous Service Charges for GP tenants will simplify and separate ‘tenure’ from ‘operation’ to improve service provision and occupation.
Developing greater support for community and primary medical care in local estates planning and in developing strong and future-facing ICS capital funding bids
Develop a package of support relating to primary care engagement in STPs’ and ICSs’ capital strategies and the capital allocations process
It is evident from the review that NHS are seeking to create a fuller picture of the wider primary care estate to enable better future estate planning. NHS are unable to identify the level of existing estate which is not fit for current delivery or future purposes, for example, thus strategic plans are to be encouraged by STPs and ICSs so that a clear picture of their local estate can be produced.
NHS have therefore identified a need for data collection projects to develop a centralised dataset to support estate planning across the wider primary care sector. A data collection project has been set up by the NHS Property Board, led by NHS England, in which data will be collected during 2019/20 with recommendations that this data is to include details on Leases, utilisation and available space and condition. This data will be used as part of future strategic determinations.
Encourage networks to start now working out their future estates needs, taking into account joint working and the estate of their community partners. Focus our primary efforts on understanding what it would take to ensure we have premises that are fit for purpose, as part of the Spending Review.
It is becoming critical to review GP premises needs, from considering space utilisation and availability to reviewing premises condition and repair/improvement requirements, particularly in light of the direction highlighted above following the premises policy review. Thus we should see more localised and regionalised strategic activity feed into national level.
Ultimately a key concern here will be the determination of the criteria and standards behind what will comprise ‘fit for purpose’ as we have a vast range of property build types and standards across the sector, across the country, and as we know, modern design standards evolve over time thus to what extent will compliance with latest design guidance be used to measure and determine what is ‘fit for purpose’?
Sue Pyatt, Practice Manager
Francis Mulhern, Bretton Medical Practice Peterborough
Dr Adnan Mohammad, GP Partner, Newsome Surgery, Yorkshire
Jill Foster, Practice Manager, Beacon Primary Care, Lancashire