“Primary care networks are expected to have a transformational effect on primary care services. It’s hard to imagine how they’ll pull that off unless they can also transform their premises and estates. And right now that’s one of the biggest challenges facing PCNs.” So says Mike Simpson, primary care premises and finance adviser with PCC.
Why are premises so important?
“Because new services involving bigger, multidisciplinary teams need to be delivered somewhere – and not just anywhere but where it makes most sense and is most convenient for the people who will use them,” he says. “How services are run and where to put them is the subject of intense discussion among networks. If it’s not the biggest issue for clinical directors, it’s going to be in the top three for most.”
There are three issues PCNs need to address and three that are out of their hands.
Among the things clinical directors can influence are:
- Working together to make the best use of existing space
- Finding the right balance between the interests of individual practices and the network and its patients
- Navigating complex premises and estates regulations to make the most of the opportunities they present as well as the duties and obligations of themselves and commissioners.
- But PCNs also depend on policymakers and commissioners to sort out other issues that could hold them back, specifically:
- Reform of the arcane premises costs directions – the rules that govern the use of primary care premises and the reimbursement of rates and maintenance costs
- Understanding of the complex rules with their many grey areas on the part of commissioners, which has a bearing on how (and how fairly) premises funding is disbursed
- The availability of funding for improvements and new builds to enable premises transformation to keep pace with changing services.
So what’s to stop PCNs doing more to use the space they already have?
Simpson identifies two issues: reaching agreement about how to do it, including any financial arrangements; and the suitability of existing premises.
“Many can and do come to informal arrangements to accommodate professionals from other services – hospital consultants working in the community, district nurses and others who they don’t employ themselves.
“That’s fine up to a point, but there are limits. You hear of practices that are bursting at the seams. They simply don’t have the rooms available. Not only is demand going up but PCNs are adding staff. A typical PCN might have anything up to five new staff in the near future. Where are those people going to sit? Where will they see patients?
“Of course there are some things that can be done to make space. Sometimes they can get improvement grants, but before doing that they could think about how existing space is used. The days when every GP had their own consulting room that only they would use are fast disappearing.
“Practices have successfully reduced the pressure on their premises by changing appointment booking systems, doing more triage or appointments by phone or video. Digitising records will also free up space – quite a lot of space in some cases.”
But Simpson acknowledges that there are limits to what can be done by improving processes or rearranging the furniture.
“Many premises are unsuitable for current needs, let alone to meet the ambitions of expanded, high-quality services that PCNs are talking about.”
Another potentially contentious issue is how practices are reimbursed for the use of their premises.
“While many will be prepared to make informal arrangements in the spirit of collaboration, it’s perfectly reasonable that those who share their premises with other service providers expect the costs to be shared too.”
This is where practices will need to be aware of the rules. For instance, if practices decide to rent out rooms for the delivery of non-GMS services, commissioners should reduce accordingly the amounts paid to them under existing rent reimbursement schemes.
“To put it simply, any re-use of premises where money is changing hands could have an impact on your existing funding.”
Simpson’s advice is to check the rules before entering into any agreement.
“I would give networks the same advice I already give practices, which is make sure you keep your commissioner informed about your plans if there are any changes to premises use. Do it as early as possible to avoid nasty surprises on either side. Where practices claim money they’re not entitled to, even if it was an honest mistake, CCGs are within their rights to claw it back.”
New premises costs directions have been a long time in preparation, partly because they rest on some outdated legislation and partly because they have acquired
complexity over years of tweaking and tinkering.
Commissioners and PCNs have every reason to hope that the new rules will bring some clarity to the situation and address existing gripes and anomalies. Mike Simpson is optimistic that revised directions will appear soon, but he cautions against expecting too much.
“Everyone is hoping for more clarity, but the directions won’t answer every question. Regulations always lag behind the needs of the system, which are always changing. There’s a lot of innovation going on within networks and very little guidance about how premises fit in. You can bet your bottom dollar that someone will come up with something innovative about their premises use that will be very difficult to deal with under the directions.”
While they may not solve everything, Simpson is hopeful that the new directions will at least prevent some of the problems that have occurred in the past by clarifying the responsibilities of practices.
He gives the example of improvement grants, which have been used in some cases to pay for things that are explicitly excluded from the regulations.
“If a practice has rotten windows or a leaking roof, that’s a maintenance issue and their responsibility. Unfortunately some of these things have been paid for with improvement grants. We can waste time blaming the practices for putting in these claims or commissioners for agreeing to them, but it’s not what the funding was for and it means that ultimately more deserving cases are going without. It’s not about applying the rules for their own sake, but about what’s equitable,” he says.
Simpson repeats his warning to all sides not to pin too many hopes on forthcoming regulations to answer the questions they have, or as an excuse for not getting on with vital improvements.
“With or without the new directions, we will be left with plenty of grey areas. Of course we hope to see PCNs come up with their own innovative solutions to premises problems just as they will in all other areas of improvement. But where they have a poor grasp of the rules – or where rules simply don’t exist to cover what they want to do – then it’s vital that they sit down and work it out with commissioners.
His greatest hope is that in the era of PCNs we can move the debate on premises beyond some of the mind-numbing technical and legal detail, and align the national strategy with policy initiatives designed to achieve better integrated, higher quality services.
“We should be transforming the way facilities are used. There’s been a lot of talk about hubs, community services, voluntary sector, primary care services all being co-located – and think about it from the patients’ point of view: they don’t care whether they’re community services, primary care or voluntary sector, they just know that they go to one place and get seen by whoever is most appropriate. That’s got to be the way forward.”
For advice about premises strategy, including local workshops and facilitated sessions for PCNs and commissioners, please contact firstname.lastname@example.org