Can NHS England's review solve the GP premises crisis?

As part of the GP contract negotiations for 2018/19 the GPC and NHS England agreed to launch a review of GP premises. GPonline looks at what the review will need to address.

Practices have struggled to access funding for premises improvement (Photo: iStock.com/bobhackettphotos)
Practices have struggled to access funding for premises improvement (Photo: iStock.com/bobhackettphotos)

What is the GP premises review?

NHS England and the GPC agreed to carry out a review of GP premises policy to ensure that the system was 'fit for purpose both now and in the future' as part of the contract negotiations for 2018/19.

NHS England has confirmed that the review is being chaired by its director of primary care delivery Dominic Hardy who will be supported by a core steering group made up of key stakeholders including NHS England, the DHSC, the GPC and the RCGP. There will also be a wider advisory group, which will include NHS Property Services (NHSPS) and Community Health Partnerships (CHP) and 'other interested parties', NHS England said.

The review began in June 2018 and is expected to run for six months. A report, including recommendations, is due to be published in early 2019.

What is the current state of GP premises?

Many GP practices are struggling in inadequate premises without the resources to expand or improve.

A BMA poll in 2014 found that four out of 10 GP practices in England did not have adequate facilities to deliver services to patients and more than half of practices had received no investment in their premises for more than a decade.

Since then, NHS England has launched its Estates and Technology Transformation Fund (ETTF) as part of the GP Forward View. The ETTF is a programme to deliver £900m investment into practice facilities and technology between 2015/16 and 2019/20. However, a BMA assessment of the GP Forward View in June this year found that many schemes funded by the ETTF have been delayed and that securing funding for large-scale projects has been difficult.

Meanwhile, the RCGP's latest assessment of the GP Forward View found that there was ‘more demand on the ETTF than it can deliver’ with many practices reporting that they had been turned down for funding and concern that the application process was overly bureaucratic.

What’s more, restrictions in the premises cost directions until this year meant that grants could only cover up to 66% of the cost of premises improvement works. New cost directions, agreed as part of the 2018/19 contract negotiations, will allow 100% grants.

The BMA is due to repeat its premises survey imminently to assess the current state of GP premises and establish if there has been any improvement over the past four years.

Are there any other problems?

The liabilities associated with premises are also a major problem. GPC chair Dr Richard Vautrey told the UK LMCs’ conference earlier this year that premises were now 'one of the biggest problems facing practices', and have been the deciding factor forcing some partners to hand back their contracts. He added that young GPs were 'steering clear' of the risks of premises ownership and the risks involved in long-term leases.

Central to this is the issue of last person standing, where the last GP in a partnership can be left with huge premises liabilities that they are personally responsible for whether the practice owns or leases its building.

What will the review look at?

NHS England has not confirmed exactly what the review will address. However it is running in tandem with the GP partnership review, chaired by Wessex LMC chief executive Dr Nigel Watson, and there will obviously be significant cross-over. For example, one of the key questions for the partnership review is whether there is a way to limit the risk to partnerships holding a long-term lease and how the risk of owning a practice building can be reduced.

GPC executive member Dr Krishna Kasaraneni told GPonline that the fundamental question the review needs to address is ‘what is the plan for premises going forward in England’.

He says that broadly the review needs to address three key issues: last person standing, how to ensure GP premises are fit for purpose and service charges.

‘There’s no point building premises up to scratch for 2018 and thinking that’s it we’re done,’ says Dr Kasaraneni. ‘What we really need to be planning is what general practice is going to evolve into over the next few years and the extra space that’s needed to train more GPs, to provide more care and help practices continue to grow.’

Last person standing issues are a ‘huge barrier to the recruitment of new GP partners,’ Dr Kasaraneni says, while issues around practice management and services charges are threatening some practices’ financial viability.

In July it was revealed that GP practices owed £202m in unpaid fees to NHSPS and CHP, although it is unclear how much of this relates to service charges.

The GPC has been in negotiations with NHSPS and CHP over soaring premises charges, which have left some practices facing six-figure increases, for some time. In May it seemed as though a national deal might be close to being agreed - it is unclear if the premises review will help to speed this process along.

Can GPs contribute to the review?

GPs will be able to contribute directly to the review. An NHS England spokesperson said: ‘As part of the review we will be looking to engage widely through a Call for Solutions process to be launched shortly.  This will enable all interested parties to put forward proposals for how the current barriers in the system could be addressed and how the system could work differently in future.’

As mentioned above, the GPC will be conducting a survey of GPs to find out the current state of GP premises. Dr Kasaraneni says that the results will help the GPC to take an informed approach to the premises review and highlight the key issues that the it needs to address.

When would any changes be implemented?

The review’s recommendations will feed into contract negotiations for 2019/20.

NHS England has already said that 2019/20 could see ‘the most substantial changes to the GP contract since 2004’. Alongside the premises and partnership reviews, there are also proposals on the table to overhaul the QOF and the Carr-Hill formula, which dictates practice funding, is also set to be revised.

Do GPs still want to own premises?

Dr Kasaraneni says that the last survey the GPC carried out showed that two out of three GPs still want to own their own premises and 'see it as something that they want to invest in'. However, he says that the barriers to ownership ‘may have become too big compared with what was perceived to be the positive aspect.'

Under the new Scottish GP contract, which came into effect in April 2018, all GP partners who own their own premises will be offered interest-free sustainability loans, with the aim of transitioning to a new model where GPs no longer own their building by 2043. Meanwhile, NHS boards will take over responsibility for leases for practices in leased premises. Would the GPC in England consider such a move?

Dr Kasaraneni says the situation in Scotland is different to England and the GPC does not want to pre-judge the results of its survey. But, he adds: 'We still want premises ownership to be something that GPs can aspire to, but only if the conditions are right.’

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