There is growing concern that the lack of investment in surgery premises means a significant level of primary care estate is in a poor state and not fit to provide medical services to the public.
Lack of suitable premises is placing the ability of a large number of practices to embrace the push to provide more services economically from their own surgeries at significant risk
While there are examples of modern health care premises remaining empty, there are cases where otherwise well-performing practices have both commissioners, and in some cases the CQC, questioning the standard of surgery premises and their appropriateness for the delivery of primary care services.
This comes amid a drive to ensure a greater array of services than ever before is delivered in a primary care setting. Lack of suitable premises is placing the ability of a large number of practices to embrace the push to provide more services economically from their own surgeries at significant risk.
GPs have traditionally practised from a variety of different kinds of premises. This may include operating their business from part of a purpose-built health centre to running their practice from converted houses in residential areas. The latter offers limited scope for development and modernisation and is often simply not equipped to operate in the same way as purpose-built premises. This may affect practice sustainability.
While it is believed that there is capital available within NHS England to fund new surgery premises projects, this has not been matched by a revenue budget to support the notional rent or rent reimbursement required
A practice in this type of building is not best placed to fulfil the requirement for GPs to take on certain services traditionally delivered from a hospital setting, placing them and the communities they serve at a disadvantage. In addition, the CQC Fundamental Standards require that all premises be suitable for the purposes for which they are being used and properly maintained.
These should not seem like unrealistic requirements, but with the availability of funding being severely limited, it is unsurprising that practices are falling foul of this requirement.
The NHS has seen a substantial and well-documented reduction in the flow of new surgery development projects in the last five years owing to budget restraints. While it is believed that there is capital available within NHS England to fund new surgery premises projects, this has not been matched by a revenue budget to support the notional rent or rent reimbursement required for these new surgeries.
The abolition of PCTs and the creation of NHS Property Services means commissioners of primary care services and property owners are no longer the same and, hence, consistency in priorities cannot be guaranteed
Given the uncertainty with this funding, a number of projects for modern, bespoke premises to enable GPs to deliver the required range of services have been put on ice pending the greater availability of the revenue budget. Against this backdrop, and without the backing of NHS England, investors and developers have not been able to provide the types of building needed to ensure the seamless changes to the way services are delivered from the primary care sector.
Even where practices have been willing to fund development themselves, availability of private finance has been limited given that the relatively-short duration of contracts for certain enhanced services means they do not provide the security for long-term property investment.
A further difficulty arises from organisational change. The abolition of PCTs and the creation of NHS Property Services means commissioners of primary care services and property owners are no longer the same and, hence, consistency in priorities cannot be guaranteed.
While decisions on the commissioning of most core primary care services lies with NHS England, other primary care services are commissioned by local CCGs. One of the aims behind the creation of NHS Property Services was to put the operation of the NHS estate on a commercial footing. Inevitably this has taken time and has impacted the ability of commissioners to determine where investment in the NHS estate should be prioritised.
We are seeing an increase in the number of new schemes achieving business case approval, and it is hoped that as working between commissioners and NHS Property Services beds in we will see an increased push to modernise the ailing primary care estate
Investment decisions have been delayed while NHSPS have been establishing their estate priorities and looking to see whether their own vacant estate can be filled before new projects are authorised. There are many examples of GPs needing new premises being encouraged to take up space in NHSPS or LIFT facilities which, in some cases, carry service costs they find difficult to afford, rather than being offered any backing with regard to a private development that may ultimately be a cheaper option.
A potential solution to the ability of some practices to deliver a wider array of services comes in the growth of GPs working together in networks and federations within their localities to provide some out of hospital services. In such cases GPs in a particular area can agree to share their skill sets and resources for the collective provision of a greater number of services which would, for example, permit practitioners in cramped or out-of-date surgeries to work with colleagues in more-modern or state-of-the-art surgeries. This kind of working is not without its own problems. It will only work in an area where there is a reasonable spread of facilities and skills and, in itself, does nothing to address the poor state and condition of existing surgery premises. It does offer resourceful practitioners the opportunity to pool what is available to place them in the best-possible position to offer the types of services being expected of them, and gives a chance for collaborative working.
There are signs that things may be beginning to change. We are seeing an increase in the number of new schemes achieving business case approval, and it is hoped that as working between commissioners and NHS Property Services beds in we will see an increased push to modernise the ailing primary care estate. Until this happens, the policy objectives for broader primary care service delivery are unlikely to be matched by the availability of suitable premises, leaving GPs to innovate or make do and mend in finding ways of providing the array of services.
Edwina Farrell is a partner at national law firm, Weightmans
