Development partners include NHS organisations such as PCTs, GPs and other primary care providers and, potentially, the private sector, social services and voluntary agencies.
It is important to understand the financial implications of involving various development partners. The funding of primary care premises (or parts of premises) is dependent on the category of healthcare provider operating from the premises. This will also have a bearing on the type of approval process required. For funding purposes, healthcare providers should be categorised as follows:
There are a number of options for the inception, funding, ownership and procurement of primary care premises. Viable projects will probably be based on a partnership between a number of stakeholders. These may include:
There are strong arguments for seeking to provide private sector/local authority services alongside primary care services. Such an arrangement is most effective when the activity of the private sector/local authority is well established and accepted in the local community. If the service provided by the private sector/local authority is some kind of shopping facility, this will allow those visiting primary care premises to access services other than just healthcare. Alternatively, shoppers may be more prepared to 'drop in' for optional activities at primary care premises, such as health promotion clinics. It is important to ensure that frequent users of primary care services – for example elderly people - have easy access to any additional services. Care should be taken when integrating facilities where they may, at some future date, have different legal identities and insurance requirements. The ability of primary care providers to encourage healthy lifestyles may be enhanced by locating social activities – such as a fitness centre, recreation centre or community centre – on the same site as primary care services. Use of appropriate spaces may be shared. As a result, space utilisation will be improved, running costs reduced and information-sharing improved. It is important that all partners and other agencies involved in the development of new primary care premises work together from the start – and are party to any compromises and reconciliation that may need to be made during the planning and design process.
Involvement of the private sector
Where the private sector is involved in new primary care premises, it may have a significant influence on the nature and content of the premises and will be integral to the conceptual development of the premises. A private developer may become involved in the provision of primary care premises in a number of ways. For example as project facilitator, owner, land finder, manager or administrator. In the past, GPs – acting as individual private developers or tenants or in association with finance companies in sale and leaseback schemes – have provided the only development route for GMS primary care premises. New sources of funding – via PCTs, LIFTs and other initiatives – offer a more co-ordinated approach to private finance bringing together GMS and other services, such as hospital and community health services. Buildings are being provided through public capital and, increasingly, PPP. Where there is a major PPP arrangement to build a new hospital, the NHS will, where appropriate, include local NHS primary and intermediate redevelopment too. This ensures that capital investment is contributing to the redesign of local services across a whole health economy. For further information on funding options, see ‘Identifying sources of capital’.
Issues relating to PMS practices
The NHS (Primary Care) Act 1997 sets out guidance on the establishment of PMS pilots. The objectives of the pilots are to:
Feedback from the first and second wave pilots has led to the adoption of a standardised contractual framework but leaves performance measures to be defined locally. Two main sources of funding make up the pilot’s allocation:
The funding of primary care premises (or parts of premises) is dependent on the category of healthcare provider operating from the premises. For funding purposes, healthcare providers should be separated into the following categories:
GP practices
For GP practices providing general medical services to NHS patients, the practice is reimbursed by the PCT by a sum equating to the actual market rent or the DV’s assessment of the market rent. Where the GP practice is the developer, this reimbursement provides a means of raising the capital for developing the premises. Where the GP practice is the tenant, it provides the means of paying the rent and provides security for the GPs in taking a lease, which, in turn, provides security for the developer.
PCTs
PCTs can invest NHS capital in primary care premises or can take leases in premises owned by others. Again the lease provides the security for the developer. There are financial implications for PCTs in increasing their estate in the form of NHS capital charges; it will generate a financial risk and may be a disincentive. PCTs should exercise appropriate discretion when defining which services are to be funded from GMS, PMS or community budgets. It is possible to take funds from all these sources simultaneously so as to fund different spaces within an individual project. This could take the form of GPs having clusters of GMS clinical facilities, shared waiting and meeting facilities, and access to health promotion, therapy and other rooms, which could be funded from non-GMS sources.
Acute trusts
The financial situation for acute trusts is the same as for PCTs but they are unlikely to put capital into primary care premises.
Other primary care providers
These may include the following commercial providers of primary care services:
Generally, these service providers take leases for the space they occupy. If they have sole use of that space they will normally fund the fitting-out of it themselves. Where the space is rented on a sessional basis the fitting-out will be included in the rental.
Voluntary sector and cafe services
The voluntary sector and those providing cafe facilities may be required to pay rent but this will depend upon the owner or leaseholder’s philosophy and purse.
Social services
Social services (as part of local authorities) invest capital in primary care premises within the parameters of current legislation. Alternatively they can enter into a lease. Some of the development partners may not be able to commit themselves to leases that are long enough to provide security for raising development capital or satisfying the requirements for a business case as required by 'CIM'. In these instances NHS LIFTs or PCTs should provide the security to enable the development. The service plans for some primary care premises, particularly resource centres, will include drop-in treatments, x-ray and other diagnostic and therapy services. The plan will have established the need for and expected use of the services but the financial responsibility for providing the premises that will house them may not be clear. There are precedents of community trusts/PCTs taking this responsibility and also of capital being provided directly from SHAs.
Approval processes
Primary care projects being progressed as capital schemes by NHS trusts are subject to the approval processes laid down in 'CIM'. Projects being progressed by GPs with an element GMS capital or revenue funding are subject to the approval processes laid down in the 'Directions 2004'. Projects being progressed jointly by NHS trusts and SHAs, and independent contractors of a PCT, where there is an element of GMS capital or revenue funding, will need to follow concurrently, as appropriate, the approval processes laid down in 'CIM' and the 'Directions 2004' respectively.