Cost model: Primary healthcare

Introduction

The NHS Plan aims to make health services more customer-focused. In most instances, patients' first point of contact with the NHS is the GP surgery. Many of these are small-scale and offer a welcoming and easy-to-access building. Strengthening the service delivery at the local level is a key objective in achieving the NHS Plan.

The "Planning and priorities framework for 2003-06" has recognised the urgent need for well-designed and located primary care facilities. Targets have been set for up to 3000 GP premises to be either upgraded or replaced.

The NHS Plan is being supported by advancing medical technology and the development of a wider range of expertise in primary care including GPs and nurses with specialist interests. It is anticipated that these arrangements will shift a significant number of outpatient appointments from the acute to the primary care sector, enabling hospitals to concentrate on more serious cases.

Several elements of the move to a more community-based service will have an impact on the design and cost of the GP surgery:

• Integration of health and social services across a broad front potentially including general practice services, dentistry, pharmacy, social services and so on. There is evidence that greater integration of primary and social care services provides benefits to the local community, but this integration typically occurs in the larger facilities delivered via the Local Investment Finance Trust (LIFT) programme.
• Co-location of healthcare workers to enable the delivery of specialist services.
• Customer focus - greater emphasis on putting patient needs, such as convenience, accessibility and patient comfort.

The evolving primary care model

Typical primary care centres of between three to seven GPs are at the front line of the NHS. These centres are being included in regeneration and sustainable community schemes as an integral part of new residential areas such as the Lower Lea Valley or London Riverside. Primary care centres have already been included in the Greenwich Millennium Village, accommodating not only GPs but also practice nurses, health visitors and district nurses. Further integration into mixed-use community buildings such as social services centres or libraries is being encouraged through the LIFT model, described in Davis Langdon's cost model (28 October 2005).

This approach to delivering healthcare is supported by the larger "one stop" primary care centre accommodating eight to 10 GPs, which offer a much wider range of primary care services than is typically available. These typically include space to support the specialist skills that GPs are developing in response to local health needs, outreach facilities such as a children's health centre and community initiatives covering areas such as community mental health or learning disabilities.

The Forest Road Primary Care Centre in Enfield, north London, was designed by Dransfield Owens da Silva and integrates GP surgeries, a dentist, a baby clinic, health visitor services, drugs and alcohol abuse clinic, speech therapy facilities, a pharmacy and cafe

Planning for the next 20 years

It is anticipated that advances in technology and social change will have an impact on future healthcare delivery. These changes will occur during the life of the buildings being developed for GPs. Examples of future issues that need to be addressed now include:

• Rapid developments in information, medical and communication technology. These innovations are likely to produce great changes in the delivery of healthcare and the design of the healthcare environment. The development of "telemedicine" that allows real-time links between primary and specialist centres will require dedicated rooms, enhanced IT and enhanced security.
• Demographic shifts to an increasing elderly population. Increasing life expectancy and higher quality-of-life expectations will see a growing GP case load of long-term or chronic conditions. Accessibility issues will have a greater profile as a result.
• Greater public access to health information and choice. The public will become more informed about healthcare choices and the treatment options available to them. Competition for patients between different healthcare providers is likely to emerge.
• Specialist outreach centres - hospital specialists undertaking consultations and investigations in primary care centres, requiring more flexible clinical facilities.
• Greater emphasis on community-based preventive medicine initiatives, such as well woman clinics, requiring group space.
• Special facilities and room allocations to accommodate GPs with special interests, nurse practitioner clinics and health visitor services.

Design issues

The modernisation agenda set out in the NHS Plan recognises the impact of the function and aesthetic quality of buildings on the patient experience. It aims for high-quality, well-functioning primary healthcare premises that meet patients' needs for privacy and dignity, while also being welcoming, accessible and non-institutional. CABE's view is that good design has a key role in breaking down barriers and improving community access to healthcare.

The NHS Estates' "Achieving excellence: design evaluation toolkit" provides GPs involved in developing proposals with a checklist of patient-focus issues including:

• Accommodation - ensuring that the provision of space is adequate for current and expected needs.
• Environmental quality - high-quality facilities using layout, daylight, finishes fittings and building services to provide a welcoming and comfortable environment.
• Access, waiting and circulation - creating a sequence of spaces that guide patients and staff to their destination. Waiting rooms should be a generous size and welcoming. They should provide appropriate levels of privacy and be compliant with the Disability Discrimination Act. Clear and discreet patient call systems should be used.
• Treatment rooms - it is usually better to allow separate clean and dirty treatment rooms. Clean rooms are for those procedures that do not generate large amounts of waste materials.
• Security - secure entrances and controlled access around the building.

Funding and procurement issues

General practices recover elements of the cost of their premises through contractual arrangements with their local primary care trust. The general medical services contract (GMS) includes provisions to support the development of a modern primary healthcare estate and also incorporates minimum development standards to ensure that GPs commission appropriate facilities. The overall plan for the allocation of a PCT's development funding is set out in its strategic service development plan (SSDP). In addition to the LIFT procurement route, GP practices broadly have two funding options:

Self development - The practice takes on the role of construction client and raises finance, commissions the design, obtains planning and employs the contractor. The PCT provides support for borrowing costs only, in accordance with a formula - adjusted for location and project abnormals.

Following this route, a practice can commission a purpose-built facility, will benefit from the capital appreciation of the asset, revenue flows from complementary activities such as a pharmacy and a favourable tax regime. On the downside, the practice has to accept the risks and responsibilities of being a construction client and long-term liability for the upkeep of the building. They will also be responsible for a large loan and will be exposed to risks associated with negative equity. Furthermore, if a project is not completed, all up-front costs associated with the development are the responsibility of the practice.

Premises rental - The practice takes a lease on a purpose-built facility, with the PCT providing a contribution calculated on the basis of a formula.

The advantage of the lease approach is that the practice should gain access to professional development skills targeted at delivering health projects within agreed rent levels. The downsides, other than reduced control over the design and delivery of the building and having less discretion with respect to long-term adaptation of the building fabric, are that the practice has no continuing interest in the escalating value of the building.

Also designed by Dransfield Owens da Silva, Alexandra Avenue primary care centre in Harrow, north London, is due to be finished in June this year

Competing for funds

In both instances, GP practices will be competing with one another to obtain limited PCT funding. As a result, meeting minimum development standards, close alignment of proposals with the SSDP, and maximisation of healthcare outcomes to generate income are key issues.

Other sources of revenue and funding opportunities include:

• Savings from practice-based commissioning activities;
• Sourcing of land or facilities via contributions from a private development in connection with a section 106 agreement;
• Revenue streams from commercial activities associated with the surgery such as a pharmacy.

Because of the bespoke nature of general practice premises, and the relative inexperience of healthcare professionals in the commissioning of construction projects, GP surgery schemes are ideally developed following a consultant-led procurement model.

However because of the risk exposure that the client body retains - for example, cost escalation risk on self-developed projects being solely the practice's responsibility - then a design-and-build route that transfers risk to the contractor after the tender stage is the sensible option. Following this route, designs should be completed to at least stage D to enable a firm scope of work to form the basis of the contract.

Traditional lump-sum contracting is also a common approach in this sector. Under both options, the discipline of the client with respect to avoiding design change post-tender and the quality and completeness of the design work are key determinants of a successful project outcome.

Floor area allowance and planning

In order to allow for future change of use it is recommended that surgeries are planned on the basis of a limited number of generic room types. The basic planning module of these rooms is 4.5-5 m², to allow for future adaptation. The range of generic room types and their guide sizes are set out in the table below.

(See table: Guideline areas for generic spaces)

Building services design criteria

Ventilation - For general areas, a single fan motor is acceptable. For dirty areas or WCs, a separate extract system providing 10 air changes per hour is required. The ventilation system should be controlled with a building management system.

Water supply - Cold water storage should be at 20ºC. The minimum hot water storage temperature should be 60ºC with distribution at 55ºC.

Lighting - 300 lux lighting level for the general examination rooms with adjustable task lighting to provide 400 lux for treatment areas.

Security - The building should be equipped with an intruder alarm system for out-of-hours operation. Personal attack alarms should be made available to vulnerable staff, with panic alarm buttons located in rooms where staff members are with patients.

Communications - Staff call systems and assistance alarms for areas where the public are left temporarily alone in the centre.

Cost drivers

• Gross internal floor area.
• Planning constraints - scale and height of building, requirements for car parking, use of materials.
• Single-storey construction, high proportion of substructure and roofing costs, wall-floor ratio.
• Ground conditions.
• Solar shading, passive solar inputs and the desire to provide as much natural light as possible. This should be balanced against the costs of additional security measures.
• Providing adaptability for future innovations.
• Client brief - the range of clinical, therapeutic and other services offered, their effect on finishes and specification of building services. The number and range of room types required, level of internal cellularisation and circulation.
• Security - internal control points, external entrances and secure storage for medical equipment, particularly if telemedicine systems are in place.
• Storage space for equipment.

Wider development issues

Third-party liaison - The identification of the stakeholders involved including GPs, local medical committee, primary care trust.

Environmental - impact assessments These are increasingly becoming a requirement of the local authority planning approval process. Issues of traffic generation and parking, and the safe storage and disposal of clinical waste products may require special attention.

Accessibility - The site should be easily accessible so as to support social inclusion. The location should take account of local transport plans and be on public transport routes.

Service continuity - If an occupied site is to be redeveloped, provision for maintaining healthcare services during construction should be considered, with the costs being factored into the development budget.

Sustainability - NHS sustainability guidelines need to be taken into account, but progress towards environmental aims will need to be offset against affordability as determined by the PCT's funding settlement.

Taxation - If the development is to be GP led then recovery of VAT can be an issue. GPs will have to pay VAT on construction works, but may not be able to claim it back. On lease arrangements, VAT is also chargeable on rent.

Primary healthcare centre cost model

The cost model overleaf is based on a single-storey, new-build, primary healthcare centre built on a brownfield site. It consists of six consulting rooms, three nurse rooms, two treatment rooms (one clean and one dirty), a health visitor room, a general purpose room and administration space. This will provide 510 m² gifa of accommodation, including an allowance for circulation based on a 28% net-gross ratio.

The building has a reinforced insitu concrete ground slab, masonry cavity walls and single-ply membrane roofing on precast concrete planks. Windows and doors are double-glazed aluminium. Internal subdivision is in plastered blockwork. The building is naturally ventilated with mechanical ventilation to WCs and treatment rooms only.

The unit rates are derived from competitive lump-sum tenders and are current at second quarter 2006, based on a South-east location (see overleaf for location factors). The building only cost of £1243/m² compares with mid-quartile costs collected by the BCIS of £900-1,325/m² for new-build GP surgeries.

The costs exclude enabling works, demolitions, external works and services. The costs of non-fixed furniture, cupboards and medical equipment are also omitted as are professional fees and VAT. Unit rates should be adjusted for location, site conditions, programme and procurement route.