Premises under the new GMS contract. to modern primary care premises.

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1 briefing Premises under the new GMS contract The NHS Confederation and the National Primary and Care Trust Development Programme (NatPaCT) have developed a series of briefings to help primary care trusts (PCTs) and practices prepare for the implementation of the new General Medical Services (GMS) contract in England. This briefing provides a strategic overview of the new arrangements to maintain existing general practice premises and support modernisation programmes. More detailed guidance on implementation will follow later. Premises summary of new GMS contract The new contract recognises the need to support GPs in their responsibility to provide modern premises for patients and staff. Paragraphs 4.49 to 4.59 recognise the importance of having a modern primary care estate to support delivery of an expanded range of general medical services.they also set out revised arrangements setting minimum Quality Standards for GP premises, and provide details of the flexibilities designed to overcome obstacles to capital investment and to GPs moving Key points The new contract clearly recognises the need to ensure that GPs are able to provide services from modern premises for their patients. A modern primary care estate is required to deliver an expanded range of general medical services. There will be new flexibilities to support capital investment and the move to modern premises. Significant new funding has been secured towards future premises costs. New funding for premises will be held by a host PCT who will work with PCTs from the SHA area to decide priorities in utilising these resources. PCTs will need to develop strategic service development plans identifying what services are being made available in primary care settings. PCTs will be required to undertake an audit survey of their primary care estate. PCTs are encouraged to strengthen partnership working with local stakeholders eg. Social Services, voluntary sector to explore developing premises that provide an expanded range of interactive health-related activities. to modern primary care premises. Paragraphs 5.37 to 5.46 recognise the need to move away from ad-hoc funding arrangements for GP premises. A unified funding stream, separate from the global sum, will be allocated to PCTs. Existing spend commitments will be preserved as a baseline for GMS practices. Strategic growth funding will be provided to meet new premises development separately from PCT JUNE 2003 No. 5 01

2 allocations to contribute towards the costs of new premises identified in strategic service development plans (SSDPs). It is proposed that strategic growth funds will be allocated direct to a single host PCT within an SHA area who will then be expected to work collaboratively with other PCTs to decide priorities in utilising these resources. What does this mean in practice? A first tranche of premises flexibilities was introduced in January 2000, and the new GMS contract introduces the second set out in the boxes. These flexibilities are designed to overcome existing barriers to capital investment in areas where primary care most needs to be expanded. They will also offer effective incentives for GPs to move from old to modern premises that provide good working environments for themselves and their wider primary care team, while creating a welcoming setting for patients. Details on how the first tranche should operate can be found on care/index.asp, under Guidance. Details on the second tranche will be posted soon. The flexibilities are not limited to GMS practitioners they are also available to those under contract to the PCT to provide personal medical services (PMS). This allows all GPs to have equal access to the benefits the flexibilities offer for strategies to modernise the primary care estate. These flexibilities comprise: Existing flexibilities (from 2000) Health Authority (HA) joint venture interest in land Deprivation or needs factor for current market rents HAs taking a head leasehold interest in primary care premises Fund the re-conversion of owner occupied premises Guarantee minimum price for sale of redundant premises Extend scheme to reconvert registered social landlord properties Reimburse equipment leasing costs on new leasehold premises Mobile service delivery units New flexibilities (new contract) Possibility of grant to meet mortgage deficit costs, enabling GPs to sell their premises and move to an appropriate alternative location Possibility of grant to meet mortgage redemption costs Possibility of allowing primary care organisations (PCOs) to take an option on land Allowing PCOs to continue cost rent payments to GPs who buy premises from a sole / twopartner practice Allowing PCOs to review cost rent payments when GPs re-mortgage to lower interest rates Reimbursement of legal and other professional fees for GPs in new premises developed by public-private partnership Revised arrangements to pay notional rent in addition to cost rent when premises are modernised or extended Abatement of notional rent to pay full notional rent on GP capital invested in premises and abated notional rent for NHS capital equivalent to additional costs such as heating, lighting and maintenance Payment of notional rent to leaseholder GPs who improve their premises Extension of the timescale to repay improvement 02

3 Implications for PCTs Modernisation of the primary care infrastructure needs to avoid simple duplication of what s already in place. PCTs will need to develop SSDPs that identify what services are available in primary care settings and what changes can be made to improve patient access to locally-provided services. This may include NHS trusts providing more services away from hospital settings. The new contract will enable GPs to agree with their PCT the management and delivery of an enhanced range of services. Collaboration between primary care practitioners with special interests will play an important role in allowing patients easier access to services nearer to home. The SSDP will build on PCTs undertaking an audit survey of their collective primary care estate. The SSDP will also include the location and use made of other NHS services provided by, for example, pharmacists, dentists, social services and the voluntary sector as part of a wholesystems approach. An important part of the estates audit will be to determine, for example, state of repair, compliance with the Disability Discrimination Act 1995, and whether it would be more effective for providers to operate from shared modern premises. A range of current initiatives confirms the commitment to change and to encourage investment where it is most needed, including: NHS Local Improvement Finance Trusts (LIFT) introduced in 42 project sites covering around 40 per cent of PCTs A 30million investment in least doctored areas to create premises capacity for 550 new GP Registrars PCTs receiving 22million to establish 97 one-stop primary care centres Ongoing support for GPs to lease third-party developer premises Links to relevant national initiatives Diagnostic and Treatment Centres (DTCs) While the relationships among national, regional and local priorities should be well documented in their SSDPs, PCTs and practices need to stay aware of bigger picture initiatives and programmes, as well as of the opportunities for support and/or finance that any of these may offer. An important example is the DTC national programme for both publicly-funded schemes and locallyinitiated projects to improve access and choice for specific day-case services. The overall approach should include proper assessment of the impact on primary care services. New Planning & Design Guidance The Government is increasingly recognising the need for the internal and external environments of primary and community care premises to offer appropriately pleasing and practical facilities. Requirements are included in the guidance for stakeholders when planning new schemes, in particular when preparing the functional content and specification brief. Local Improvement Finance Trusts (LIFT) NHS-led LIFT now encompasses three waves, providing 42 new organisations and representing nearly 40 per cent of all PCTs in England. The first projects in the initial wave are expected to reach financial close soon. While the scope of this briefing paper does not include specific reference to LIFT, many of the issues arising from the new GMS contract regarding premises apply to both LIFT and non-lift areas. This reflects a commonality of health service interests in the face of a nationwide need. In the case of PMS arrangements and LIFT (that are by no means mutually exclusive), it is important to recognise that they represent particular structures and methods for delivering improvements and capacity. The strategic services planning process (especially SSDPs) is equally important for all. Similarly, many of the premises and development issues are the same, both within and outside LIFT, even if the applications differ. These include the need to demonstrate value for money, affordability and the balance sheet treatment of the completed property asset. Local examples of innovation and good practice Stockport PCT is taking a wholesystems approach to procurement, driven by a dynamic SSDP process and are working with the local authority. Plans include the provision of 11 new one-stop primary care centres and three joined primary care centres. Contact Alison Tonge: Alison.tonge@stockport pct.nhs.uk 03

4 Luton teaching PCT has developed a primary care development framework under which a panel of experienced developers has been selected from open competition and bid for individual practice based schemes. Contact Tonya Parsons: tonya.parsons@luton-pct.nhs.uk North Peterborough PCT is supporting the development of innovative multi-functional primary care centres to include a wide range of stakeholders including diagnostics and therapists. Contact Jacqui Cotton: jacqui.cotton@northpboropct.nhs.uk Torbay PCT is working with local practices and the acute trust to develop primary care infrastructure in a way that breaks down the barriers between primary and secondary care. It is working with three local practices to establish a new Integrated Care Centre, which will bring together GPs, community nurses and therapists, GPs with Special Interests (GPwSI) and Consultant-led teams and social care professionals. Contact Adrian Jacobs: adrian.jacobs@torbay-pct.nhs.uk Quick wins for PCTs PCTs may engage with the NatPaCT network, link with the NHS Confederation and its Future Healthcare Network (FHN) initiative or seek external advice. In developing new premises PCTs need to work with local stakeholders to explore opportunities for working in partnership and considering joint procurement of premises where appropriate. An expanded range of services may be accommodated within core primary care space and enhanced areas will enable flexible use of facilities. Employment and benefit advice, library services, Information Management and Technology (IM&T) community training, telemedicine facilities and even fitness studios are examples of other services that may form part of an integrated development. PCTs individually or collectively need to strengthen their estate management, project planning and procurement functions, referring to the revised competency framework on this matter. These responsibilities are not necessarily exclusive to individual PCTs but could be arranged on a shared basis, either covering a network of local PCTs or using Service Level Agreements (SLAs) with others. NatPaCT is organising a series of primary care premises development workshops during the second half of PCTs, practices and other stakeholders will be invited to identify the action plans and priorities required in order to deliver the changes. An NHS Estates team of primary care strategic advisors and project managers will, through SHAs, help PCTs deliver their estate strategies.together they will provide advice on property issues and support local developments, such as business development. Revised guidance future primary care premises development NHS Estates, in conjunction with NatPaCT (Modernisation Agency), has also been developing a new website which brings together current and proposed technical design specifications with future policy direction to advise PCTs, NHS primary care professionals and developers about future primary health and social care premises. It is planned that the website will integrate the provisions of appropriate Health Building Notes (HBNs) by supplementing and eventually replacing existing guidance available through the Statement of Fees and Allowances and supporting specifications contained in Medical Practice Premises a Commentary ( the Commentary ) from NHS Estates. secure/ or secure/ Username: qauser Password: hbn36 (both are case sensitive) Competencies NatPaCT s PCT Competency Framework is an online selfassessment tool that is being extensively revised to take account of the new agendas facing PCTs, including the new GMS contract. Under each domain the Framework sets out a number of statements of competency and examples of evidence, what should be achieved and how achievement can be recognised. Each domain is linked to discussion forums, relevant new stories, and a growing library of key resources. Domain 2 of the Framework, Primary Care, is being re-written to take into account these briefings, and will be posted shortly at The new Estates competencies (1.11) 04

5 and primary care premises (2.11) will be particularly relevant for premises development plans. PCTs should also pay attention to the commissioning requirements under Section 4 and to the direct provision of services arrangements under Section 3. The need for a costed plan for premises improvement and capacity development relates directly to the PCTs SSDPs and individualproject feasibility studies or business case documentation. Acknowledgements The NHS Confederation and NatPaCT wish to thank George Murdoch at Nexus Consulting for drafting this document, the NHS alliance, PCT colleagues and others for their contributions. PCTs should consider the range of skill-sets they need to tackle the range of tasks and responsibilities identified above, as well as filling skills gaps. These will include: general technical skills estate management developing new skills and knowledge-bases infrastructure issues behaviour, relationship, partnership issues and other organisational competencies signposting / decision tree format / evaluation templates / critical pathways. 05

6 Signposting and references The GMS contract Investing in General Practice, NHS Confederation/BMA 2003 outlines the framework for implementation. It can be accessed on the NHS Confederation website: The website also contains supporting documentation, and helpful resources such as a series of summary factsheets. The Modernisation Agency and NatPaCT websites signpost a number of local and national initiatives, programmes and support tools: NHS Estates has set up a primary care section on its website which provides a wide range of advice and guidance on primary care estate issues: National Primary and Care Trust Development Programme (NatPaCT) NHS Modernisation Agency 2nd Floor, Blenheim House West One, Duncombe Street Leeds LS1 4PL Tel Fax natpact@doh.gsi.gov.uk The NHS Confederation 1 Warwick Row, London SW1E 5ER Tel Fax enquiries@nhsconfed.org Further copies from: Tel Fax publications@nhsconfed.org Registered Charity no NAT00501