Sitting comfortably? It's more than likely you're not, if the results of the latest Management in Practice survey are to go by, but I'll begin anyway. In our poll of 379 practice managers, 38% said that their current surgery premises were "not fit for purpose", with small, cramped and outdated buildings being widely cited as major problems. The same proportion also said that they lack an appropriate level of office space, with many staff having to "hot desk" and use limited space for several purposes (see Box 1).
This latest online survey, sponsored by healthcare property development specialists One Medical, put the spotlight on practice premises, and was conducted in July. At a time of swine-flu headline dominance, managers may feel the state of their surgery building does not top the current agenda – however, just under a quarter (24%) of all respondents said their patient services suffered as a result of premises restrictions, so this issue is about far more than bricks and mortar.
Indeed, the survey suggested a level of frustration among many managers who were committed to practice-based commissioning (PBC), but were scuppered in their drive to offer new services by building constraints. With more treatments moving across to primary care, and with polyclinics and GP-led health centres being introduced, the suitability of GP premises is arguably more important than ever.
The survey is mainly indicative of English practices, where 90% of respondents were from. Five percent of managers were from Scotland, with the remainder split between Northern Ireland and Wales. Respondents were generally experienced primary care professionals, with more than half (53%) having worked in general practice for over 10 years. Nearly three-quarters (73%) were from urban practices. The average practice staffed three whole-time equivalent GPs and the mean patient list size was between 4,000 to 8,000.
The vast majority of respondents (89%) were practice managers. In addition to this, 6% were business managers, and the remainder were made up of administrators, GPs and nurse managers.
It's important not to stress the negatives of these results. The clear majority (62%) of respondents said their premises were fit for purpose, and even many of those that did not said their patients were unaffected by the building's deficiencies.
Nonetheless, the significant difficulties reported by many practice managers in manoeuvring themselves and their staff through ill-suited premises should not be ignored. Of the 38% who answered that their premises were not fit for purpose, comments included:
Forty percent of managers unhappy with their premises had no plans to upgrade their premises, with one in five unable to secure funding.
Dr Prit Buttar, a GP and chair of the British Medical Association's (BMA) Practice Finance Sub-Committee, said in response to the survey: "Overall the numbers don't surprise me at all. Premises expenditure has been seriously neglected. A significant number of practices have very serious problems on a variety of fronts."
Louise Matthews, Head of Primary Care at built asset consultants EC Harris, was likewise unsurprised. "There are a high number of practices that are not fit for purpose," she said. "These may be single-handed GPs effectively working out of their front room. We have seen practices that are woefully short on non-clinical accommodation – including a practice that is storing patient records in the staff loo!"
She added: "The overall figure masks a considerable degree of variation across the country, and even between different localities within a single primary care trust (PCT)."
Access for disabled people
An important area highlighted by the survey was that of GP surgery access for disabled patients. More than a quarter (27%) said their premises were not compliant with the DDA.
Describing the shortfalls in this area, respondents were forthcoming. "No disabled facilities, small doorways, no disabled toilet – the list goes on," said one manager. "We have conducted an audit and the faults are too numerous to mention, although we have addressed those that were possible," said another.
Issues of both access and safety for disabled patients were highlighted. "The fire exit at the rear has two steps up to it. Most consulting room doors are not wide enough for wheelchairs," said a practice manager from Lancashire, who added: "No amount of money will get us DDA compliant. Relocation is the only answer."
However, the results are unlikely to reflect a need for major reconstruction work in all instances, according to Louise Matthews. "Some minor works may address DDA issues in some cases and flexibility may be required," she said. "A building that could never be fully DDA compliant in itself, because of upstairs facilities where a lift could not be installed, could still comply with the DDA, provided all services can be made available in a downstairs room for disabled service users, and that there is no barrier to the employment of a disabled member of staff."
Yet in some cases the lack of space is so acute that this would be a problem. "We could not employ a person in a wheelchair as no space to move," said a practice manager from Argyll, who wrote of working in a "windowless cupboard".
Furthermore, the survey suggests that practice upgrades for disability legislation compliance would not come cheap. When asked how much additional funding would be needed to make their premises DDA compliant, the largest group (43%) said this would be more than £20,000; just 14% estimated this would cost less than £5,000.
As Figure 1 shows, a combined 38% of respondents plan to upgrade their premises or relocate – 60% of which were those who said their current surgery was not for purpose. One in five (19%) of those who said their premises were not fit for purpose said they would like to upgrade/relocate, but had been unable to secure funding.
Responding to the survey findings, a spokesperson from the Department of Health (DH) said: "In 2004, the NHS set out the minimum standards for practice premises to ensure all premises funded under the provisions of the General Medical Service and Personal Medical Service practices are fit for purpose. We recognise that there are parts of the primary care estate which need investment to provide modern environments for both patients and staff.
"This is being addressed in PCT areas participating in the Local Investment Finance Trust (LIFT) initiative, through which special investment LIFT companies are set up to deliver premises modernisation strategies.
"To date, nearly £1.6bn has been invested in 207 new buildings, which are fully DDA compliant, providing opportunities for different GP practices to co-locate with other primary care contractors in multifunctional facilities that have been designed to adapt to changing primary care requirements.
"From 1 April 2009, this was extended to all PCTs through Express LIFT. PCTs can all now access strategic planning for their estate by procuring a LIFT partner."
However, just 13% of managers updating their premises said they were using LIFT (the majority said upgrades would be via deaneries, third-party development or funded by the practice partnership). Furthermore, more than half (54%) of respondents said they did not know whether their PCT had a LIFT partnership. More than a quarter (27%) said they did not understand the concept of LIFT, with a further 38% saying they did not understand it fully.
Dr Buttar was not surprised by this apparent confusion: "I would have thought that probably a higher proportion don't really have a grasp what LIFT is, and I'd go as far as to say that there's plenty of PCTs that aren't sure as well."
He added: "LIFT is the government's preferred mechanism for major premises funding, but the complexities of the LIFT scheme mean it is by no means a universal solution, and the number of practices that have been able to benefit from it – compared to the number of practices that benefited from the Cost Rent Scheme – is really very small indeed."
Louise Matthews was more positive. "Although the scheme has been criticised as costly, the Audit Commission has reported that LIFT can deliver value for money for the public sector," she said. "LIFT may also allow for practices to participate in a scheme with other services, eg, specialist community health services."
Yet according to Simon Carvell, a GP and practice partner currently seeking a premises upgrade, the scheme has drawbacks: "GPs and practice managers are often, and understandably, reluctant to lose autonomy and submit to LIFT projects – as we are. Therefore it's stalemate".
Dr Buttar agrees with this assessment. He said: "It's a really contentious issue this, but it seems to me that we had a system in the Cost Rent Scheme that actually served the NHS, the taxpayer and general practice very well. It's been replaced by a series of increasingly bureaucratic mechanisms that are not as good. The rules and regulations are often so byzantine that people are just put off them and walk away from it. In the end, the whole thing is so hamstrung by a shortage of funding it all becomes academic anyway."
Just under a third (31%) of survey respondents said the level of support offered by PCTs was "poor", with slow responses and an unwillingness to commit funding being the main objections. A manager from Shropshire said: "We are regarded by the PCT as one of their highest priorities, but get very little practical support or advice on the project and have still to receive confirmation that real funding is available, despite some verbal promises a couple of years ago."
Many respondents bemoaned the lack of available premises funding from PCTs. However, according to Louise Matthews, additional funding is not necessarily the answer. "I think new investment proposals need to be subject to robust business cases and, given the overall budget, it is not a bad discipline to work towards overall cost neutrality for new schemes."
Patient services, PBC and polyclinics
The survey strongly suggests that plans to engage in PBC, the government's flagship primary care policy, are being thwarted by premises that cannot support extra services.
A high proportion (72%) of respondents said they were proactively involved in PBC. Of these, 37% said PBC plans would require additional space. Responses included:
Dr Buttar, whose practice is currently undergoing plans to transfer to new premises, identified with the frustration shown in these responses. "One of the big drivers for us [to relocate] was that we couldn't do all of the nice things we would like to do with PBC, because we don't have the premises," he said.
Of the managers who said their premises were not fit for purpose, 58% said patient services were suffering as a result of their building's limitations. A multitude of responses told the same story: that managers would like to expand services, but could not do so in their current building.
Could "polyclinics" or GP-led health centres be a solution to such problems? After all, such buildings will resolve issues of disabled access, cramped conditions and lack of clinical space. But most practice managers are still opposed to them, it seems: just 21% said they supported the introduction of these centres. The opponents' concerns indicated that, while they solved the drawbacks of smaller surgeries, "super surgeries" created new problems:
For Dr Buttar, the main drawback of polyclinics was that of travel. "You're only going to build one polyclinic in an area – any benefits you get from these accessible buildings are lost because there are fewer of them. Disabled people who have struggled to get into inadequate local buildings are now going to have to travel further to access healthcare," he said.
It would not appear to be the best time for those wanting to expand their premises. A significant number (38%) said the current financial climate had impacted on their plans for premises expansion, with a squeeze on PCT/health board funding.
"At a time of financial pressure, there is a risk that PCTs will see GP premises upgrading as a low priority and development monies may be in shorter supply," said Practice Management Consultant Fiona Dalziel. The result is that practice managers will have to be as resourceful as possible, she added. "Practices should undertake thorough risk assessments of their premises, covering as many risk areas as they can identify, share these with the PCT and record the response. This will demonstrate that, should a problem arise, the practice has tried to take action to minimise risks."
Louise Matthews said: "The practice manager will have to be smart with scheduling, and all may have to accept changes in working practices. We may have to decide that we can no longer afford doctors to have dedicated consultation rooms if they are empty for long periods in the day."
So where does this leave patients? According to a spokesperson from the Patients Association, the MiP survey reflects that choice is not always possible: "Patients should be able to expect good, safe and hygienic premises for their healthcare in the 21st century. Where patients get a raw deal, they are unable to do much about it because they are bound in a geographical straitjacket. Second-rate PCTs compound their problems.
"So if you are disabled, elderly or both, and on the list of someone who is making little effort to improve facilities, with a weak PCT, you are trapped. Polyclinics may offer a range of services for patients but unless they are nearby, with easy access to the patient's preferred GP, they risk compounding the problems revealed in this important survey."
The MiP GP Premises Survey has been kindly sponsored by One Medical, a professional developer delivering the bespoke primary care premises you always wanted, leaving you free to concentrate on your patients.