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New rules will help but commissioners and practices need to keep talking about premises

In updating rules that guide the funding of GP premises, NHS England has been stretching the definition of “imminent” for more than two years.

PCC premises and finance adviser Mike Simpson argues that even if the new premises costs directions (PCD) were available, they would not resolve all the issues commissioners and primary care providers face around the funding and use of premises.

He was however able to explain to the Southend and Castle Point and Rochford CCG staff and GPs who attended the two half day seminars on GP premises funding he ran recently what changes might be in the pipeline. Simpson was also able to help them think about which areas need reform in the era of primary care networks and more out-of-hospital care.

Jenni Speller, associate director of primary care at the CCGs said: “Something that comes up again and again is using GP practice premises for services not covered by the core GMS contract.

“Mike did tell us in the session that services delivered through the primary care network (PCN) would be covered by the directions but we have mental health workers working in primary care premises.

“That is in line with national strategy and policy but it’s not done through the PCN route. We need clarity around the arrangements for funding that work in GP practices; around funding for approaches that foster long-term working but that are broader than what is in the current national service specification.”

Another issue raised during the sessions is 100% improvement grants for increased capacity in practices driven by an influx of new patients from housing developments.

The current directions do not permit 100% funding of practice premises improvements but Simpson told participants that this rule is regularly misused.

Speller suggests that the publication of updated premises costs directions presents an opportunity for training those working in general practice.

“Every situation is different: it is not a case necessarily of understanding the directions in detail but having a sense of what they mean in a particular situation for a particular piece of work.”

Simpson highlighted some of the key policy conclusions of the general practice premises policy review. These include:

  • Shifting existing leases for strategically important practices to NHS bodies if the length of the lease and the liabilities built up “prevent the healthy renewal of partnerships and the estate”
  • Developing an ownership model that is good for GP practices but that separates premises ownership from the operation of primary care medical services – to be supported by best practice guidance for all GPs who own their premises
  • Tying future NHS capital investment to a requirement to show robust governance around property ownership
  • Clearer guidance around expectations of owners and occupiers with regard to maintenance and standards
  • Piloting alternative premises reimbursement arrangements at a PCN level so networks have more autonomy to manage and minimise costs
  • Piloting a simpler model in which the NHS directly covers premises costs through new multi-use buildings – reducing bureaucracy and promoting service integration.

However, after warning that some CCGs and practices play fast and loose with existing rules, Simpson said: “CCGs need to stick to the rules or they could be at risk of judicial review. They should try to see the premises costs directions as enablers, ways to get things to happen. If you are thinking of straying outside them to help one practice just consider the impact – including setting a precedent for all the practices in your area. Take professional advice if necessary and develop policies that allow you to manage applications efficiently and consistently.”

Addressing practice managers and GPs, Simpson’s overriding message was to keep commissioners informed of any plans and ensure they had at least their backing in principle before committing to any new ownership arrangements or improvement works.

The arrival of primary care networks has further complicated the already complex policy environment of GP premises.

Adapting traditional GP practice buildings to meet the changing needs of patients and the drive to provide more out of hospital care – and how that work is funded – is just one of many challenges facing local health economies.

That’s why commissioners in south Essex commissioned PCC to deliver separate sessions to clinical commissioning group (CCG) staff and to practice managers and GPs on the subtleties and idiosyncrasies of the premises costs directions (PCDs).

Jenni Speller, associate director of primary care at NHS Southend CCG and NHS Castle Point and Rochford CCG, says the sessions were part of a membership development project and a wider programme to support local practices.

“We have a clear primary care strategy across the five CCGs in south Essex with a locality strategy for out-of-hospital care. A premises strategy sits below that and we need to think about the role that GP practice buildings play.

The CCGs were aware that both their staff and practices struggled with the complex rules and regulations round GP premises and estates.

“We felt that with a lot of changes coming up around co-location of services and additional staff working in practices we wanted people going into those discussions with a good understanding of the rules and regulations. Those questions were starting to come thick and fast.”

Looking back on the two half-day sessions, Speller feels that both CCG colleagues and practice managers and GPs do have more insight as a result.

“Feedback from both sessions suggests it was a bit of an eye-opener for some people around how complicated some of the regulations are. Conversations with practice staff and CCG people show that the sessions made them think back to past experiences around premises funding and they now see the importance of getting it right at the beginning of an improvement scheme. We need to sit down together and understand what any proposal to improve premises or change ownership arrangements actually means.”

For Speller, the sessions are likely to affect how some of her own decisions are seen by colleagues.

“Sometimes I feel that I am seen as ‘the computer says no’ person but now they understand how complicated the directions and policies are.”

For advice about premises strategy, including local workshops and facilitated sessions for commissioners, please contact enquiries@pcc-cic.org.uk