A recent British Medical Association (BMA) survey revealed that a lack of space is preventing many GP surgeries from improving and extending their services.
Modern teamworking has greatly expanded the number of nonmedical staff in surgeries. Many practices are now keen to increase their potential by providing extra services to patients such as minor surgery, physiotherapy and dermatology.
The reality is that the golden age of guaranteed Red Book traditional funding avenues – of improvement grants, notional rents and cost rent schemes – which worked well for GPs in the past has now gone.
Since the mid-1990s, the BMA claims, there has been no large-scale sustained integrated government policy of premises development in primary care, and cash-strapped primary care trusts have no spare funds.
The Department of Health's (DH) current policy is to channel new investment in primary care premises into high-profile individual developments, generally using NHS Local Improvement Finance Trust (LIFT) schemes or private finance initiative (PFI) projects.
These developments are generally concentrated in areas of deprivation or urban regeneration. Outside such priority areas, it is now nearly impossible for practices to secure the necessary funding streams to generate provision for the building of new premises.
The BMA has been concerned for some time about increasing problems with the provision and development of premises and its survey confirmed its worst fears.
Nearly six in 10 of the 251 practices that took part said their premises were not suitable for their present needs and three-quarters (182) felt their surgeries were not adequate for their expected future needs.
The report paints a picture of surgeries where every conceivable space has been converted for clinical use, with consulting rooms in former storage areas and doctors doing their paperwork in the kitchen.
Two-thirds of the practices said their clinical staff "hot desked". One GP wrote: "We all hot desk … on Friday we used the staff common room for flu vaccinations." Another said: "No clinician has their own room. I have had to move desks up to five times in a two-hour period."
Less than half (46%) of the practices felt they had enough room to provide training for GP registrars. More than a third of practices were unable to make the necessary adjustments to their premises to ensure compliance with the Disability Discrimination Act, while a quarter of respondents felt their practice premises posed some risk to the health and safety of their staff and/or patients. Cramped conditions also meant that confidentiality was an issue.
Four in ten practices in the survey had found some funding for improvements in the past five years. But the money came from a variety of sources, including loans and mortgages, practice savings, PFIs, grants and cost rent schemes.
Many practices in the survey had planning applications refused or were in listed buildings in a conservation area, making successful planning applications unlikely. Others said they had already extended as far as was possible or had no room to expand on their current site.
Frustrations over funding
Dr Hamish Meldrum, chairman of the General Practice Committee, warns: "If the government is serious in its intentions to transfer healthcare out of hospitals and into the community it has to recognise that we need somewhere to treat these patients. General practice premises are very clearly overstretched."
Linda Cox, practice manager of a four-partner rural dispensing practice in Northiam, East Sussex, says a lack of funding has frustrated their plans to expand as much as they would like. Two years ago, they unsuccessfully applied to their primary care trust (PCT) for funds to build an extension to the surgery.
Ms Cox says the practice would like to provide more outreach clinics for services such as chiropody, which their patients find hard to access, and also to provide a larger dispensary.
In the end, the GPs found another source of funding and are currently building an extension at the back of their surgery, although this is smaller than they had originally planned.
"Once it is finished we will be able to continue as a GP training practice – we will have one room to spare for a GP registrar," says Ms Cox. "It is a compromise situation because it would have been nice to have more room to accommodate changes for the future – our patient numbers never stop going up. It is better than nothing and we are not totally unhappy but it wasn't what we originally hoped for."
Influx of new patients
Karen Shirley, practice manager of Green Lane and Harnall Lane Medical Centres, an innercity practice in Coventry with more than 1,200 patients and seven doctors, has taken on so many new patients that it has already outgrown its two surgeries, built only 15 years ago.
The practice is under such pressure from an influx of asylum seekers that at one point it was forced to close its list. In the last two months alone, the practice has registered 500 new patients.
This has forced the hand of the PCT, which has agreed to fund 60% of the cost of a new extension. The practice has agreed to reopen its lists while the extension is being built and has taken on a new salaried GP. But space is so cramped and the new GP's list is growing so rapidly that on three days a week he has to hot desk.
The lack of space also makes Mrs Shirley's life more difficult. The branch surgery has no office and this means there is a lack of privacy when carrying out new registrations.
"I can't be in two places a once," she says. "I try to work from the branch surgery one day a week in order to support the staff who work there, and then I just have to plonk myself wherever there is a spare computer. I always take my own personal laptop just in case there isn't a PC free," she adds.
Mrs Shirley says the practice would like more space to be able to provide services such as physiotherapy and onsite support staff for health workers. Parking is also a big problem.
"The PCT is financially strapped, but they were backed into a corner and had to come up with some funding when we had no option but to close our list," she says.
Dr Charles Zuckerman, Medical Secretary of the Birmingham local medical committee (LMC), says there is a blight right across the whole of the UK on premises development.
"It is virtually impossible now to get any development funding for premises. Some practices are being strong-armed into LIFT projects while others are going to go into terminal decay because they're going to become terribly overcrowded and not fit for purpose. It's like going back to the 1960s before they introduced notional rents, improvement grants and the cost rent scheme."
But he warns: "If you sit back and wait for the premises funding fairy to arrive with a sackful of gold you are going to be waiting an awfully long time. General practice is now facing the economic pressures that everyone else is subjected to."
Dr Zuckerman says his own practice in Northfield, Birmingham was luckily able to get premises funding "before the shutters came down". They bought a large health centre in 2000 from the former health authority and spent £300,000 of their own money doing it up. The building work is now being paid for through the notional rent scheme. But Dr Zuckerman says they would not be able to do that now and he fears they will face problems in 10 years' time when the present building no longer meets their needs.
Stephen Mercer, a former practice manager and practice partner, and now chief executive of Avon Regional LMC, sits on several local strategic premises and estates committees and says there is virtually no funding at all for new practice developments.
"Premises development is a massive issue and we feel the government is being very insensitive in the way it seems to be blindly following the idea that multi-million pound, private-sector LIFT and PFI schemes will provide all the answers," he comments. "These are all big schemes for super surgeries, serving up to 15,000 patients. Many practices just want to build extensions costing £300,000–500,000."
But, Mr Mercer adds, although many practices are still seeking extensions to cater for core or standard services, and for which Avon and other LMCs still seek traditional notional rent funding, many new bids for premises funding are being made to accommodate proposed new services to be transferred from hospitals under such initiatives as practice-based commissioning (PbC). This, says Mr Mercer, begs the question of whether the latter can or should be funded from traditional notional rent.
As an LMC, they are now advising practices to start thinking differently about developing their premises and to consider joining forces to form PbC consortia. This way, practices can form bigger partnerships and benefit from economies of scale, save on overheads and borrow more money to upgrade and extend their surgeries.
Avon LMC has been actively discussing with their local PCTs the potential for developing GP premises on a business case model. Instead of putting in traditional Red Book bids for premises developments paid for by notional rents, larger partnerships with greater financial clout can consider making a business case for borrowing money based on the surpluses that are likely to be generated by moving services away from the hospital tariff to local provision.
"I don't think practices can expect the government to say that they will continue paying notional rents to provide for extra services to be moved from hospitals if the practice can make a lot of surpluses from providing these services more cheaply in their practices," says Mr Mercer.
"While we still need to lobby hard for new premises funding to provide accommodation for core services in areas of list growth, it is clear that the government wishes to see general practice moving away from the nice, cosy, Red Book assured income streams," he warns.
Health minister Lord Warner told Management in Practice that it is "absolute nonsense" to suggest that the government is not actively working to help the NHS improve GP premises.
He dismisses the BMA survey as being highly selective and misleading because it surveyed only 251 out of around 9,000 practices, and he claims that it is GPs who are blocking reform. He accuses the BMA of lobbying for a Changing Rooms style of makeover and of wanting to preserve a legacy of premises unfit for the future.
Government policy, he declares, is to work with PCTs to develop modern, purpose-built facilities, where GP services are often on the same site as pharmacies and social ervices as part of the NHS LIFT scheme.
They have a good track record of investment in primary care. This year, says Lord Warner, they have made available £2bn in capital allocations for acquiring land and modernising buildings and equipment. In 2005/06, GP premises, health centres, polyclinics and community hospitals are benefiting from £812m in private sector funding and £210m in public sector funding, which has already been injected through NHS LIFT alone. Around 3,000 surgeries – a third of all UK surgeries – have recently been refurbished.
The NHS, Lord Warner says, will open more new, one-stop-shop health centres over the coming months than Britain's biggest retailer, Tesco, will open new supermarket branches. The NHS expects to have 625 new one-stop-shop health centres open by the end of the year – up 125 from 500 at the start of 2005. Tesco expects to open just 111 new UK stores during the same period.
"The profession needs to realise that it cannot be the roadblock to reform. The NHS is often hampered from developing more modern premises due to the vagaries of the profession. Many GPs are simply not willing to share new premises with their colleagues. We will go on investing in better premises for primary care and community services, but in ways that benefit patients," says Lord Warner.
The BMA survey on GP practice premises can be downloaded from: www.bma.org.uk/ap.nsf/Content/surveygp