Specialist developer Rachel Beverley-Stevenson lets GP Dr Keith Hopcroft into the secrets of getting funding to improve your premises
Where can I go for capital funding to develop my premises?
There are many routes, although getting capital funding has become much harder because of the current financial climate in the NHS. Potential routes include:
• LIFT agreements
• PCT funding
• grants from deaneries
• partnership with third-party developers.
Cost-effective, well-justified solutions that are presented with a well thought-out business case could still be funded, but you may have to be pragmatic about what you aim for. Sometimes it is better to apply for renovation of old premises and wait until there is more money for new build.
Are primary care organisations still approving funding for new premises?
Yes, but only very high-priority ones where there is a desperate need. If you have been in talks with your PCO about new premises for some time you have more chance of being successful than with a new proposal, but since the white paper PCTs are no longer able to enter into any new agreements relating to property (acquisition, disposal or management) without the approval of the SHA.
In some cases, if the scheme is already well-developed – for instance had PCT sign-off and leases were agreed, even if only in draft – this additional approval may not be needed. But this does vary between PCTs.
How can we make a good bid to our PCO?
A good bid or business case would be one that demonstrates benefit not just to your practice, but also to the local community. Highlighting benefits such as being able to provide a wider range of services, including those typically provided in secondary care, is key, as is showing savings and cost efficiencies, such as sharing a new building and services with other practices.
First, set out the reasons why the building is no longer suitable – for instance not compliant, not safe or provides no room for growth. Then explain the benefits that a new build or extension would bring to the PCO, such as provision of any services that help the PCO meet its goals.
In some cases, it would probably be more prudent to ‘make do and mend' and consider a refurbishment or extension. PCOs like practices to ‘sweat their assets' and by reorganising, refurbishing and perhaps extending, a building can be kept going for a few more years until a new one can be afforded. For more details on how to put your business case together take a look at my previous Pulse article on upgrading GP premises [1].
We live in PCO-owned premises but historically, the PCO has done very little to maintain them – we've paid for work ourselves. We feel the building needs a lot of refurbishment now. How can we put pressure on our PCO to do this? Might this prompt an unwelcome review of our service charges?
First, you need to review your lease and see who is responsible. If you have a standard commercial TIR (tenant insuring and repairing) lease then, as a general rule, the landlord is responsible for the bricks and mortar and external aspects of the building, and the tenant is responsible for the upkeep of the interior. If you have an FRI (full repairing and insuring) lease then the onus is on you as the tenant to maintain the building. The landlord has very little responsibility in this case. It would be prudent to look carefully at your lease and see what specific responsibilities you have. These should be outlined in a list of covenants for both tenant and landlord. Specific requirements should also be outlined in a definitions section. For example, it might state in the tenant's covenants that they are responsible for maintenance of the heating system.
Then you need to analyse what work needs to be done. Is it the fabric of the building or the fittings inside that are in need of attention?
Once this is done, you can instruct an independent surveyor to assess your requirements (they should do this free), which will then give you the right documentation to present to the PCO. Your service charges should not be affected as this is a separate issue.
How can we get funding to upgrade the security of our premises?
The security of a practice should be paramount and you can survey your premises by following guidelines set out by your local police force [2] This will help you compile a report on whether the building's lighting, windows and locks are secure and installed to the right specification.
If you own your practice, the report you compile may help you to justify investment through an improvement grant that can be applied for from the PCO with a persuasive business case. If you lease your premises, then check your lease and see if your landlord is responsible. You may still need to present a business case to your landlord.
Part of the registration requirements for the Care Quality Commission concern premises. What aspects of premises will the CQC scrutinise, and what could happen if we fail to tick all their boxes?
The main aspects the CQC will scrutinise will concern premises being accessible and fit for purpose. You will need to ensure your premises are accessible to frail, elderly and disabled people, and meet the required standards on health and safety, infection control and control of hazardous substances. You must also have conducted a risk assessment on the security of your surgery.
It is likely that half the practices in England will fail on at least one criterion, particularly those in converted houses.
A gradual warning system will probably be set up where practices are given time to address and resolve their issues, but this has not yet been announced by the CQC.
I recommend you read the CQC document ‘Essential standards of Quality and Safety' [3], which will help you understand what you need to do. Don't forget, branch surgeries will be subject to the same rules as main surgery premises.
We would like to begin training, but are very pushed for space and facilities. Is there premises funding available specifically for training purposes?
Traditionally, funding for improved training facilities has been provided by your local deanery, although accessing this is becoming increasingly difficult. Contact your deanery for more information about how to apply for a grant to develop training facilities at your practice.
If funding is not available via your deanery it may be possible to apply for a PCO improvement grant. This would need to be backed up with a well-presented business case (see earlier question). Another option is for your practice to fund the additional space and facilities, but you would need to consider the return on investment over the longer term.
Is it worth looking at using our premises to make money? How can we do this?
Surgery premises are traditionally under-used, as GPs have a habit of thinking consulting rooms are ‘theirs' and should not be used by anyone else. But if you can offer additional services that can deliver both patient and financial benefits then hiring out rooms can be well worth the inconvenience.
For instance, could you rent your meeting room out to community groups or nearby practices? Is there a physiotherapist who could rent a room on a sessional basis? Is there a pharmacist who might want to relocate to your building? A property specialist could assist you with this by analysing the use of space and providing marketing expertise. Or you could do this yourselves by writing to local health professionals and pharmacies.
A local property specialist or architect could also be enlisted to look at the premises to see what options there are. Think of every inch of your building as an asset and consider if every room is being used to its potential.
What are the benefits and drawbacks of leasing new premises?
Leasing new premises from the PCO or a third-party developer can be a good solution, although you must think carefully before entering into any agreement.
Will the new premises be purpose-built, or adapting old premises? Will they be economical and easy to run and maintain? If they are being adapted, what about the quality of the materials they use? The main benefit of leasing new premises is that there is no risk during the construction phase and the ongoing responsibility is minimal, but it has to be useable once you move in.
How do I go about disputing my notional rent valuation, and is it likely to be worthwhile?
The first thing to understand is why you feel the need to dispute the valuation. Have you benchmarked this against similar practices? There are independent expert valuers that can come and assess this for you. If they feel you have a case they will also be able to negotiate for you. See Reference 4 for more information.
Our PCO wants to make investment in our premises contingent on us agreeing certain performances targets – can they do this?
It is important to understand that the PCTs have to answer for every penny they spend to the SHA and to the outside market, especially during these times of cutbacks. It is therefore only fair that practices also have to justify the investment and be accountable for real improvements to patient care or improved services in line with local strategy. This is an opportunity for practices to develop, and the local patient population to benefit – neither of which should not be perceived as a negative.
I heard that Sainsbury's was planning to offer GPs in store branch surgeries. Is it worth partnering with a private provider to upgrade or replace my current surgery?
Independent sector providers can provide outside view that can help to develop and sustain practices in a competitive environment, but you should only look at this option after a thorough business review. Once you have had opportunity to review your business you can then discuss how you will work together i.e. sale and lease back, joint ventures or full partnership.
Who will control premises funding under the NHS reforms?
This is unclear at the moment but the most obvious and talked about answer is that a new government body would be set up to manage existing primary care estates (possibly the NHS Commissioning Board). Fundamentally we do not envisage that the process for justifying investment in new premises will change. It may however slow down as the restructuring is implemented and we could potentially see new strategies being formed.
I am worried that we will miss out on the drive to base more services in primary care with GP commissioning because our premises are so poor. How can we get an upgrade earlier?
You need to open up discussion with your local commissioning groups and with your PCT to establish an understanding of what services are needed by your local population and how you could justify investment. If you are unable to do this there are specialist companies like ourselves that can open doors and identify opportunities for you. A specialist company can advise you on what is happening elsewhere on a local and national level.
The other option is to invest yourself but you need to consider this carefully so that you can be sure that the investment you make will return improved patient care and satisfactory income levels.
Rachel Beverley-Stevenson is chief executive of One Medical, a specialist developer of GP premises and One Medicare, a primary care service provider. Dr Keith Hopcroft is a GP in Laindon, Essex
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