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Creating the foundation for primary care at scale

With GP practices based on sites ranging from terraced houses to shiny, purpose-built health centres the role of premises management for local commissioners can be a tricky one.

Working with CCG and NHS England local teams, PCC primary care adviser Mike Simpson considers some of the thorniest issues around the funding and use of primary care premises. This includes the likely impact of an imminent revamp of premises cost directions (PCDs) – the do’s and don’ts which govern reimbursements to practices for their premises costs.

As Simpson says: “Clinical commissioning groups (CCGs) and practices need to work together to use PCDs in a way that best ensures delivery of the changes set out in the Long Term Plan. It is about ensuring that directions are an enabler of new care models and not a blocker of change.

The current PCDs don’t fully support new care models very well but the changes we expect to see shortly are a first step in addressing that. There won’t be a radical change but they should be a step in the right direction.”

One likely change is that improvement grants – currently limited to a maximum of 66% of the cost of work to premises – could soon fund the full value of the work, where appropriate. However, there is likely to be the need for an ‘exceptionality test’ and a value for money test in such instances.. 100% grants will likely be restricted to genuinely transformational schemes that deliver the hubs of care envisaged in the Long Term Plan.

Other changes are likely to include additional measures to ensure the NHS does not pay twice for the same space through abatements for third party use of practice space. NHS England is also aiming to reduce the number of rent reviews going to NHS Resolution’s appeals process.

Practices seeking to develop their premises to deliver integrated care at scale may be looking at improvement grants to fund one-off projects.
Simpson notes that CCGs should ensure they – and local GPs or practice managers – know the rules covering such grants.

“Make sure your contractors talk to you. They are independent but they should not be working in isolation. The directions prevent you approving grant applications where the GP has already entered a contract or has started the work,” he pointed out.

Direction 10 requires a GP practice in leasehold premises seeking a grant to prove to the commissioner that it has security of tenure for the remaining period of the lease, guaranteeing NHS use. That figure varies between five and 15 years depending on the value of the scheme.
Addressing the challenge of leased premises, Simpson said: “There can be issues around getting practices to sign leases and there are a large number that have not done so. Where no lease exists, practices have limited protection under the Landlord and Tenant Act 1954 but they could be given six months’ notice to vacate the premises. That is not a very good way to run a large business. If there is no lease in place an improvement grant can’t be approved.”

As improvement grants are capital funding (over £5,000) and CCGs do not hold capital, Simpson said practices need to submit their proposals to their CCG well in advance because they are bidding at a national level.

Even support from the local CCG for funding a particular improvement could be rejected by NHS England if many other projects are already in that year’s funding pipeline – so active planning is fundamental to minimise that risk. There is – or has been – a staggering and mystifying variation in CCG spending on premises.

The premises review here , undertaken in 2019, made recommendations to consider;

  • assigning existing practice leases to NHS bodies or other appropriate entities where they are of strategic importance,
  • supporting the availability of an ownership model which continues to make sense for GP practices, but with the expectation of more practices wanting to separate the decision to enter premises ownership from the operation of primary medical services.
  • providing clearer guidance on the expectations of owners and occupiers around maintenance and standards, as part of professionalising property ownership and management;
  • piloting alternative premises reimbursement arrangements at a network level, to give networks greater autonomy to manage and minimise their costs relating to estates across their premises;
  • piloting a simpler model of premises provision in which the NHS directly bears the cost of premises in multi-use new build premises, removing the need for bureaucratic premises reimbursement systems, promoting integration of service delivery and optimal use of space;
  • developing a package of support relating to primary care engagement in Sustainability and Transformation Partnerships’ (STPs) and ICSs’ capital strategies and the capital allocations process;
  • encouraging networks to start working out their future estates needs now, taking into account joint working and the estate of their community partners;
  • focussing 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;
  • following the spending review, developing and publishing a premises implementation framework.

It will be interesting to see if the final solutions that emerge from this review result in transformational change to both GP and community estate and the ownership models and complex reimbursement processes surrounding it.