The changing NHS landscape
Improved access to primary care is needed for a growing, ageing population, managing more chronic illnesses, and taking the strain off expensive hospital provision. This key NHS strategy is underpinned by increased investment to support the shift to more primary and community care, and is reflected in NHS estate plans.
Improving primary care
In 2015/16, NHS England began a multi-million investment programme to support primary care and general practice in making improvements to premises and technology, as part of the overall estates strategy for the local NHS.
Investment in the GP estate is needed not just to improve or extend existing facilities. More flexible facilities are needed to accommodate multi-disciplinary teams, innovations in care for patients and the increasing use of technology . Population growth and enabling patient access to a wider range of services are also drivers in the delivery of Primary care for the future.
Better GP premises
Many GP practices have premises that urgently require improvement, are too small, no longer fit for purpose, or in the wrong place. Some have unused or underutilised buildings, and some are configured with an outdated ratio of clinical to back-office space. Working with their Clinical Commissioning Groups (CCGs) and estates advisors (such as F+G), practices are being encouraged to use their buildings productively and effectively.
Investment in the GP estate is needed not just to improve or extend existing facilities.
At the same time, GPs are under pressure to deliver more services, to provide joined-up out-of-hospital care for patients, to integrate with social care and community services, and to consolidate activity on specific sites.
In this complex context, most practices are exploring ways of federating, replacing, upgrading or better utilising their premises.
Most GP premises are owned by doctors or by private companies and are paid for through the rental reimbursement scheme. Increasingly, some practices are choosing to sell and leaseback their premises in order to release equity.
The funding picture for improvements/replacement is complex, and investment may come from a range of pots. The Estates and Technology Transformation Fund (ETTF) aims to accelerate the development of infrastructure to improve joined-up community care—there have been widely reported concerns that this funding is insufficient. Additional capital of £900 million is available nationally for investment in general practice between 2016 and 2021, as part of the General Practice Forward View.
Another secondary source is the Better Care Fund Programme, which invests in integrating healthcare with social care and community services. Other funding is available, but not all funding streams are available to all practices. All streams require practices to submit detailed proposals, and they may not be successful. Some GP partners may choose to secure bank lending and self-fund.
GPs may consider engaging a Third-Party Developer to construct a new health centre. The developer can build the premises for the GPs to own, or the developer can retain ownership and enter into a lease agreement (typically 20-25 years) with the GPs. Some GPs will prefer a third party to own and manage the building, thus avoiding the risks of ownership. Rental revenue can be claimed from NHS England, provided that the facilities comply with clinical and District Valuer requirements.
Getting the best from Third-Party Development
Practices face many challenges in navigating the third-party development route. Business case options need exploring, and in some cases, a tender exercise is undertaken to select the specialist developer.
There are also considerations around the space itself:
- Ergonomic planning of space
- Flexible layouts
- Infection control compliance
- Position of equipment
- Design compliance with Health Technical Memoranda and Health Building Notes (HTM & HBN)
- Building Regulations compliance
- Accessibility, parking, wayfinding, security, emergency preparedness
- Engineering services, utilities
- Technology requirements
- Administrative space
- Sustainability, energy considerations
- Facilities management and maintenance
- Rental reimbursement suitability
- Future-proofing (but not over provision)
- Operational costs
Why use a professional advisor?
Faithful+Gould acts for GP practices as a professional advisor, sometimes called client’s representative or technical advisor. Pre-construction, we provide support on the business case, look at the options from both the construction and cost viewpoints, and help the practice understand the construction issues. Translating jargon is part of our role, as is bridging the culture gap between the world of construction and the world of medical care.
Some GPs will prefer a third party to own and manage the building, thus avoiding the risks of ownership.
We’ll be ensuring the proposed building fits on the site, and that the site meets the requirements. We check the schedule of accommodation and schedule of requirements, get approval of floor plans and compile room data sheets. We advise on selection, review and approval of specification items, and ensure they meet infection control requirements.
Once the project is on site, we check everything proposed is being built correctly. We monitor progress, attend team meetings and report to the GP client. We advise on occupier-led responsibilities such as phone lines and data systems. We then monitor the project through to completion and ensure that it meets all necessary quality and infection control standards.
Phased construction may be needed, potentially demolishing part of a building and relocating to a part-built new facility. Noise, dust, heat and infection control in a live environment must be considered, and a move management plan implemented. We ensure move dates are adhered to and the IT co-ordinated.
We also check that the facility is as defect-free as possible, attending snagging and 12-month post-completion meetings to ensure all defects have been addressed.
Doesn’t the developer do all this?
The surgery team are often surprised to learn that the developer is not necessarily their new best friend! It’s great when there is a good relationship—and of course there often is—but when ensuring specifications are correct, that materials are good quality, low-energy and low maintenance, and that what’s being delivered is what was promised, a professional advisor is on the GP’s side.
Cost-effective ways to build and operate GP surgeries
Faithful+Gould helps GP surgeries find the most creative and cost-effective ways to build and operate their buildings, taking account of current and future patterns of use. We have 50 years' health sector experience, spanning all aspects of capital development, estate rationalisation, facilities management, strategic investment planning and environmental support.