Just what the doctors ordered

The NHS owns 25 million m2 of real estate valued at £24bn. But half of the stock is more than 60 years old and maintenance alone costs in the region of £2bn a year. In general terms most of the stock is simply unsuitable for current needs and the lack of investment in building maintenance has led to escalating running and repair costs.

Traditionally, GPs have been contracted by the NHS to deliver primary services and have been reimbursed for the cost of their premises. Many GPs have provided services from converted houses and shops with cramped conditions, problems with access, a lack of parking, poor transportation links and a lack of space to expand. Such conditions make it impossible to provide additional services on site and appropriate care to the community. Delivering a modern healthcare service in this way is not sustainable.

Demand for improvement in GP facilities is only one of a number of issues driving the NHS to reform primary care facilities. New pressures come from the desire to move the delivery of non-acute services from hospitals to the community, creating the need for primary care resource centres. Further pressures come in the desire to integrate delivery of both health and social care and deliver this from a single client-focused range of services. These drivers have forced a re-evaluation of the ways healthcare should be delivered within the community setting. The emerging vision is one of providing a "one stop shop" model of a broad range of healthcare delivered locally by teams of multidisciplinary health and social care workers from both public and private sectors. This ultimately will provide for wider community accessibility to local primary care and elective treatment "centres of excellence".

The increasing need to justify public spending on healthcare infrastructure and deliver best value risk management has also forced the NHS to re-evaluate traditional approaches to funding and development. In response to these challenges, local government, health authorities and the construction industry have been examining ways to achieve affordable public sector investment. There is therefore an opportunity to establish new models of integrated mixed-use social care developments.

Government policies

In 2000 the government published the NHS Plan setting out ambitious targets and reforms for the NHS to be completed by 2010. This has been updated more recently with the NHS Improvement Plan and more specific documentation on issues such as practice-based commissioning, payment by results, patient choice and the reorganisation of primary care trusts. Last month, the white paper, Our Health, Our Care, Our Say was published, detailing further structural changes.

The aims of these initiatives have been to:

• Improve the patient experience through giving greater patient choice
• Improve the quality of service through more accessible and convenient services for patients including reduced waiting times
• Increase capacity and improve productivity
• Manage information better
• Reduce risk
• Stimulate innovation through an open healthcare operator market
• Improve the outcome and audit of long-term care management

Under these policies, funding will follow patients and they will have choices of where they receive care. People will be able to register with doctors at home and at their place of work to improve convenience of access to services. Increasingly there will be a demand for centres that provide a "one stop shop" with additional services and therapies available on sites where GPs operate. Doctors will offer a wider range of services and cater for specialist interests and services from within their own premises.

Government response

The government anticipated the impact this step change in services would have on the built environment, particularly given the poor condition of the existing estate. It was recognised that new premises were required and that they must allow for more complex uses and multiple occupants able to respond to community needs and the changes from secondary to primary care. Developing mixed-use healthcare facilities, particularly within areas of deprivation, can form an anchor for greater regeneration and encourage long-term investment opportunities. These new premises need to be future proof and flexible, allowing for future changes in services and expansion, creating space to enable services to transfer from secondary to primary care.

A procurement process was created that supported private investment and encouraged initiative but that would also allow the PCTs and their partners to benefit from the income generated. In July 2001 the government launched the NHS LIFT initiative.

Private sector approach

Alongside LIFT, private developers continue to provide new facilities for primary and intermediate care through Third Party Development(3PD) schemes. In these developments they enter directly into lease arrangements with GPs and PCTs. To maximise return from investments, developers take a more holistic approach to risk and can be more ambitious and opportunistic. Traditionally, PCT-led schemes tended to focus on clinical response elements only. 3PD schemes typically consist of multiple uses covering health, social, commercial and residential elements.

Mixed-use healthcare facilities can form an anchor for greater regeneration

Private sector-led developments can have time and cost benefits and, similar to LIFT schemes, they retain responsibility for ongoing maintenance and repair of the premises for up to 25 years, which prevents them falling into disrepair caused by under-investment.

Under new regulations in NHS primary care, revenue money for PCTs is restricted to funds derived by transfer from secondary to primary care. This impacts on the ability to develop new NHS primary care premises and limits PCTs in their ability to develop services. Most PCTs believe that only one or two centres can be implemented every two years as there are restrictions on revenue budget increases.

The diagram on page 50 shows the types of operators from both private and public sectors that investor/developer Community Healthcare Investments site together, to deliver an integrated range of services to clients. Overlapping areas indicate degrees of multi-agency service delivery and these could expect to increase over time as healthcare process models adapt and change (see www.lrp.co.uk).

Dr Michael Morgan, managing director of CHI , says: "We can look at potential developments in a more opportunistic way. Traditional models focus on mainly GP-led health centres with basic nursing and pharmacy support. Our model sees the development of primary health resource centres that are designed with flexibility and expansion in mind, allowing both the NHS and private sector to co-locate and deliver services together. The use of common service areas allows the integration of these services to deliver a client-focused one stop shop solution."

Types of schemes

Regardless of the procurement process, mixed healthcare schemes vary in content and each scheme is specific to the particular needs of the local communities served and the local health economy's needs and funding limitations.

In London the contribution new health facilities can make to the urban setting has been acknowledged by the establishment of the Healthy Urban Development Unit (see www.healthyurbandevelopment.nhs.uk). This organisation gives advice to those commissioning health buildings about creating the best solution in the urban environment. It has recognised the potential for healthcare services as a community regenerator through the surgery at Bromley-by-Bow, east London. This has evolved through close community and health collaboration and has been heralded as a flagship primary care project (www.bbbc.org.uk).

In its assessment of the health services required in the Thames Gateway, the Healthy Urban Development Unit notes that the challenges of delivering better patient outcomes and improvements to the service will be achieved through a number of means. Existing large hospital facilities will increasingly focus on complex and high-tech unplanned care. This will be supplemented by an expansion of diagnostic and treatment centres and independent sector treatment centres, a secondary care centre run by the private sector. In addition to this there will be a significant expansion in primary and community centres promoting healthy living.

At the heart of their proposals are new primary care models based on the One Stop Primary Care Centre (OSPCC). These centres will accommodate approximately eight to 10 GPs and offer a much wider range of primary care services than traditional GP surgeries. The OSPCC will have up to three integrated modules:

• A core primary care centre (PCC) providing GP services and a number of practice nurses
• A specialist module addressing a particular local health need and using the services of one or more GPs with a special interest
• A community initiative or outreach module tailored to local need

These centres will be designed flexibly so they can adapt to future changes in community or particular health conditions.

The PCC and the OSPCC will be linked in a hub and spoke configuration. A PCC will not only accommodate GPs, but practice nurses, health visitors and district nurses. The larger centres may house on-site dentistry and pharmacy. They may also be integrated within mixed-use community buildings, such as libraries, schools or community centres. Such integration will be encouraged.

Finally there will be some centres where the OSPCC is combined with a diagnostic and treatment centre to become a primary care diagnostic and treatment centre. It will include outpatient services, clinic space and basic diagnostic facilities, such as x-ray or endoscopy.

A primary care diagnostic and treatment centre could also include a specialism, and local need will be the key factor in establishing particular developments. It may be possible in some locations to provide an intermediate care centre with beds managed by specialist GPs. For instance, in an area where "extra care" housing is required and this is coupled with GPs with a gerontology specialism, the two could be combined in a mixed-use development. These complementary uses are beneficial to both the providers and the recipients of the care.

The Healthy Urban Development Unit summarises its approach for the Thames Gateway: "The primary care model is consistent with the direction of the NHS Plan and the Thames Gateway partners' aspirations for sustainable communities. The model recognises the central role health has to play in creating social and economic regeneration - building healthy cohesive communities of the future and linking existing residents with new arrivals."