Without premises cash, the shift of work to primary care is doomed
Ministerial bloody-mindedness has seen GP premises upgrades grind to a halt, threatening the Government’s own reforms, writes GPC negotiator Dr Peter Holden
Surgery premises of adequate size and design are crucial to the delivery of quality general practice. So unfortunately, Government policy to shift care from a secondary to a primary care focus is doomed to failure because of lack of suitable premises from which to deliver extended primary care.
There has been no coherent policy universally applicable in the UK for general practice premises since the removal of ring-fenced funding in 1990, under Ken Clarke's new GP contract. And there has been no funding available for GP premises on a universal basis since 1996, when the government of the day initiated a policy that all new funding should come through the private finance initiative (PFI). PFI turned out to be nothing more than an off-balance-sheet Treasury scam, one which benefited property developers and left future generations of taxpayers with no freehold, and big bills.
The 1966 GP cost-rent scheme was the first – and arguably the most successful – PFI, delivering quality general practice premises in significant quantities at a reasonable price.
The secret to that success was government willingness to enter into long-term secure contracts with the GPs themselves, the only party with a personal vested interest in the success of such a project, and also – crucially – only allowing purchase and sale at a valuation determined by the district valuer.
Arguments rage over the whole business of cost rent. It's a system predicated on doctors being able to borrow money for premises on an interest-only basis, with evergreen loans procured from banks that understand the nature of borrowing costs reimbursement. Some argue that GPs personally benefit from the capital appreciation of an asset. At best such arguments are misguided – those of you who own your own premises have had to contend with significant negative equity, and many may have to use some of their pension lump sum to cover negative equity incurred in providing premises for NHS use. Others argue that PFI as currently understood is a very expensive method of procurement and as most understand it today, it is.
Hitting a brick wall
For 14 years I have been trying to secure premises funding for general practice. In that time, ministers have only been interested in large-scale (£3-5m), ribbon-cutting, sound bite-friendly projects.
But what we need is a large series of extensions to existing GP practices. Government policy and Department of Health guidance have, for some time, aimed to create large polyclinics where doctors ‘hot-desk' from room to room.
It is estimated that there is currently £4bn worth of GP premises available for the use of the NHS, the majority of which are funded by GPs themselves. In 2003 I negotiated for the 2004 GP contract a sum of £250m, annually recurrent, to support a £2.5bn premises development. But it was used to fund the minimum practice income guarantee (MPIG) – and the rest is history.
In 2006 the GPC premises survey showed most GP premises were of high quality and purpose built, but no longer had sufficient space for 21st century practice – not surprising, given that the average age of GP premises was 38 years.
Successive governments have been fixated upon short-term contracts while failing to recognise that practice premises are a long-term commitment. The consequence is that the Government can no longer rely upon private investors to invest in GP premises in the large amounts required without it also making a long-term commitment.
Despite goodwill from senior civil servants, we have faced ministerial directions from governments of both colours fuelled by ignorance, bloody-mindedness and poor briefing. This has resulted in the complete cessation of primary care building activity with the exception of a few flagship projects. If we want to keep delivering top-quality care and make the savings needed in the NHS for a cost-effective system, ministers have to listen to the profession and make the necessary investments in practice premises infrastructure to permit the secondary to primary care shift.
Dr Peter Holden is a GP in Matlock, Derbyshire, and the GPC negotiator responsible for practice premises