Rising levels of backlog maintenance continue to haunt the health service. Historical under-investment, and the failure to fully commit capital allocations for this purpose in the past, threaten the NHS vision of an estate that’s fit for purpose. The 2017 Naylor Review of NHS property and estates was explicit in highlighting the estate’s maintenance shortcomings. The report cited a nine per cent rise in backlog maintenance between 2014/15 and 2015/16, totalling around £5bn in works required, with £1.5bn of this in London. Additionally, backlog maintenance of critical estate functions had risen faster than the overall average.
The Naylor Review believes these figures to be understated because there has been no real incentive to report the situation accurately. The figure of £5bn is likely to be a substantial underestimate. The report concludes that without investment in the NHS estate, the Five Year Forward View (5YFV) cannot be delivered, and the estate will remain unfit for purpose, continuing to deteriorate.
Primary care represents an especially fragmented part of the estate, with 7,600 GP practices in England. No equivalent national data is collected on the maintenance of the primary care estate, but the Naylor Review suspects that its age and condition is no better than that owned by NHS provider trusts. In 2014, 40 per cent of GPs surveyed by the British Medical Association described their premises as ‘inadequate’.
Primary care has a range of asset ownership models, with relatively little of the estate owned by the NHS. Fewer than 1,500 practices of the 7,600 GP practices in England are controlled by an NHS body and leased to the providers. With a mixed picture of ownership colouring the responsibility for maintenance and the means by which it might be approached.
The Naylor report suggests that the NHS consider linking payments to the quality of facilities and greater use of fit-for-purpose standards. It further recommends that the NHS Property Board should support GPs to meet these standards, taking advantage of private sector investment. The Royal College of GPs has flagged huge demand for investment in GP practice infrastructure, citing premises that are no longer fit for purpose, and practices under pressure to care for more patients while needing space to accommodate new services such as minor operations and specialist clinics.
The pain of finances
Practices are likely to be financially constrained and may not have budgeted for maintenance. Costs can seem daunting, but funding may be available. The Royal College of GP’s (RCGP) 2018 GP Forward View: Assessment of Progress Year 2 (a response to the 2016 NHS report GP Forward View) refers to progress on the Estates and Technology Transformation Fund (ETTF). At the end of March 2018, 974 schemes had been completed using the ETTF, and a further 738 active schemes were under way.
However, the RCGP also warns that due to the significant pressures on the general practice estate, there is more demand on the ETTF than it can deliver. One in 10 respondents to the RCGP’s tracking survey had either received ETTF monies or were in the process of applying for some, but 38 per cent of GPs surveyed said that their practices were unsuccessful with their application. Clearly there is tension between the Naylor report’s assertion that “NHS commissioners and regulators have considerable latent authority to insist that premises be fit for purpose” and the GP experiences described above.
On the critical list
Practices with a maintenance backlog are likely to be unfamiliar with construction work, and only a small number of practices will have a facilities management provider. A CQC inspection may have resulted in mandatory maintenance, or it may have been painfully obvious for some time that works are required.
Taking the temperature
GP practices often don’t know where to start—how to assess the scale of the maintenance, how to prioritise the workload and allocate the budget, and how to procure the works. The journey into the world of construction will be a one-time-only event for most. The first step is to assess what’s needed, and at Faithful+Gould we help our primary care clients determine this. Our building surveyors can provide the six-facet survey required by HBN 00-08 (NHS EstateCODE, obtaining baseline information on the premises’ physical condition (fabric and M&E), statutory compliance, space utilisation, functional suitability, quality and environmental management.
Planning the treatment
Faithful+Gould helps GP surgeries find the most creative and cost-effective ways to fund, build, operate and maintain their buildings, taking account of current and future patterns of use. We can advise on business cases for funding application, followed by procurement advice, accessing a range of frameworks or recommending members of our supply chain.
Services may include appointment of the design team, project management, principal designer, cost management, and management of the works on site. We understand the importance of keeping the practice open, scheduling works out-of-hours, minimising the effect on patients and staff, and maintaining an infection control-compliant environment.
We also appreciate that even a small practice has many stakeholders, all with their own expectations—from patients/service-users, partners/staff and community services, to the Clinical Commissioning Group, the CQC and infection prevention and control teams. Post-construction, our soft landings approach ensures that operational performance is optimised.
The aim is typically to create a more flexible facility that meets the needs of future service models. A well-maintained building makes a major contribution to the patient experience, as well as reinforcing partner and staff recruitment and retention, and improving the CQC rating. Operational costs, including energy efficiency, are also improved by attention to maintenance. For the future, a backlog should be avoided if at all possible—in our experience, funding is more likely to be forthcoming in smaller amounts, and a huge backlog may become very costly. A plan for ongoing proactive maintenance would be prudent, and we help many clients with this.
A recent project for Nottinghamshire saw us managing a programme of works at 19 surgeries. Fixtures and fittings were replaced in treatment rooms to achieve compliance with infection control guidelines, together with new flooring. Faithful+Gould provided a single point of contact for all the practices within the programme who managed all concerns keeping all stakeholders well informed ensuring that clinal operations were not disrupted and business as usual was maintained.