GP partner and PCN Clinical Director Dr Sarit Ghosh offers strategic advice on acquiring extra premises space to suit your PCN needs
Notwithstanding the pandemic, the Network DES has presented a significant challenge for practices over the past two years.
Recruitment, training, and supervision of Additional Roles Reimbursement Scheme (ARRS) staff has been resource intensive for PCNs, and this has been further complicated by the lack of availability of adequate primary care estate. This has in some cases led to staff being allocated according to available space rather than by weighted patient list size, which is unfair on many practices.
Treasury constraints have prohibited any funded expansion of estate and the nascent Integrated Care Systems (ICSs) are still catching up to address this gap.
Many areas have estates commissioning teams that are assisting PCNs with the development of local estates strategies, but these tend to prioritise use of void space or cost minimising solutions.
Meanwhile the process for assessment and approval of estate proposals is opaque, with considerable variation between regions. The criteria for a successful practice expansion project initiation document (PID) still seems largely to be centred around the Health Building Note 11-01 guidance, which models space based on core primary care activity only, with outdated assumptions on list size and activity.1
This guidance was published back in 2013 and the derived space calculator is designed to inform commissioners on how to assess requests for additional space, incorporating key parameters such as projected list size growth. However, the new landscape with more staff working within primary care and the goal to shift activity from acute trusts to the community does not lend itself well to the current methodology.
In March 2020, following NHS England’s General Practice Premises Review, Community Health Partnerships (CHP) in partnership with National Association of Primary Care (NAPC) published a document called ‘Critical thinking in developing an estate strategy’, which outlined a new approach to developing PCN Estate Strategies, recommending that the requirement for space should be contingent on the health care model set up to meet the needs of the local PCN population, rather than the other way around.2
Although the guidance is very helpful, with several case studies, it only touches on how to take a business case forward and access any available funding. With the Estates Transformation and Technology Fund (ETTF) coming to an end, further national investment was contingent on a government spending review, and in the context of a pandemic now seems unlikely to materialise.
Moreover, the new Premises Cost Directions (PCDs) making provision for up to 100% capital grants, which were meant to accompany the GP contract for 20/21, have yet to be published.
With all this in mind, here are some tips for acquiring new estate based on my PCN’s experience of planning and securing funding to provide a dedicated shared space for our ARRS staff to deliver services.
Firstly, it is crucial to undertake a comprehensive review of the available estate. This is often completed in conjunction with local estates teams, but it is important that practice partners or managers take ownership of the process as assumptions about utility may not reflect the reality. For example, the modelling used for anticipated average contacts per year and patient attendances per week underestimates current levels of activity. Also it is often assumed that clinical rooms are available for patient consultations throughout most of the opening hours, ignoring the proportion of time required to undertake the non-patient facing administrative activities that are key to running a practice.
Be prepared to challenge any assertion that significant numbers of staff can work from home. We find most ARRS staff need constant supervision, and this requires co-location with their supervisors. In addition, an increase in face-to-face consultation, and feedback that staff want to work as part of larger teams, rather than be isolated at home, preclude such remote working arrangements.
Once the workforce gap analysis is completed and reconciled with the PCN’s recruitment plans, you will need to consider how these staff will fit into an effective clinical service delivery model for your PCN.
In my large network, with over 160,000 patients, we soon realised that it would not be possible to expand each of our 21 individual premises to meet staffing targets for 2024, with staff allocated on a weighted list size basis, as most practices do not have space to host the workforce they are entitled to.
We already had a progressive estates strategy in motion, with a super-practice of fifteen sites in the process of consolidating and merging down to nine premises, on a completely cost neutral basis to commissioners. As part of this, we decided that building remote consultation hubs at several of our sites to house groups of ARRS staff, supervised by GPs, would allow us to accommodate the necessary teams. Staff can then rotate between these ‘e-suites’ and face-to-face consultations at the practice sites; being based at an e-suite helps build a team as well as supervision and training, but practices still get access to face-to-face support.
The next step is to create and submit PIDs to the local commissioning team. In our case these were only approved on the basis that the PCN would take on all capital and revenue implications for these expansions.
The system reported that it could not support us financially in any way in view of the current PCDs. However, as we would not be able to grow our PCN without this key enabler, our landlords (providing the capital) and member practices (the revenue) together agreed to self-fund, the latter out of the shared PCN income streams, and proceed at risk, with the hope that legislation may change down the line with respect to the funding of PCN space.
In many cases, PCNs may not be willing to take the same approach, and may need to explore other innovative options – for example, capital funding options through Section 106 (Town and Country Planning Act 1990) monies from the local authority, use of void space within the ICS footprint or an arrangement with a local trust.
It is likely that if they have not already, networks will run into real consulting space issues in the next year and it is important to raise this early as historically most estates projects have taken years to get off the ground.
In the meantime, let’s hope the PCDs do come out soon and recognise the infrastructure needs of the new landscape of primary care.
Dr Sarit Ghosh is a GP partner at Medicus in North London and clinical director at Enfield Unity PCN
2. NAPC and CHP. Primary care networks: critical thinking in developing an estate strategy. [Accessed 03.09.21]
1. UK Government. Health Building Note 11-01: Facilities for primary and community care services. Published 20 March 2013
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