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Monday 26 September 2016
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Overseeing a self-built premises expansion

Premises & Facilities

NICK NURDEN
MBIFM MBA

Business Partner
The Ridge Medical Practice

Bradford, West Yorkshire

Nick is fairly new to the NHS, having joined the Ridge Medical Practice in January 2007. He previously worked in recruitment and facilities management for Orange. Nick lives in Leeds with his wife Bridget and her two teenage sons. He is a keen SCUBA diver and diving instructor. He loves to spend weekends cooking and entertaining friends, and keeps fit by swimming and running regularly

The Ridge Medical Practice is based in Bradford, West Yorkshire, and has 21,000 patients served from three surgery buildings. When I joined the practice in 2007, the partners had for some time been seeking a premises solution for the largest surgery to replace an outdated and outgrown facility.

Some years previously, the admin and management functions had moved out the surgery building into a separate office 250m away. This partially solved a space problem and provided more clinical space, but was far from ideal. A number of possible solutions had previously been considered but these all failed to progress due to financial, lease or suitability issues.

Our vision was to create a medical centre that would enable the practice to deliver top-quality primary care to our patients and broaden the range of services, but nonetheless felt like their own local surgery and was a welcoming and pleasant place to come to.
While we may be a large practice we have always been determined to have a "big but small" mentality in the way in which the practice "family" is run. We also wanted to co-locate as many other primary care trust (PCT) community nursing teams in the building so that we can deliver a truly joined-up package to our local community.

Options
I went back to square one and discussed with the GP partners the options and choices available, including self-build and use of a third-party developer. We wanted to own our own building, but taking on a large-scale construction project was a huge risk and lay outside our areas of expertise. We met with a number of third-party developers, who all presented us with possible locations, thinking this was the way forward for us.

However, in separate meetings both our bank and our accountants encouraged us to self-build. Their advice was that while third-party developers bring significant expertise to the table and shoulder much of the risk, they ultimately do this with long-term profitably in mind. Therefore if we could self-build, not only would we maintain a greater deal of control over our building but we could also keep more of that resource within our organisation and use it to develop and expand the range of services and care that we provided.

The bank recommended us to the healthcare division of a built asset consultancy firm, who would be able to provide us with the necessary support and expertise to realise the project. While this was an expense, without this support we would not have succeeded, and it was still a fraction of the cost compared to the ongoing revenue a developer would have made from us over the life of the building.

The consultancy firm worked with us to establish a good professional team and supported us through the complex process of producing a business case and financial appraisal, as well as consulting with the patients and getting bank, PCT and district valuer approval for the whole scheme. Meanwhile, I worked in parallel with the design team, led by the architect, who were getting the necessary planning permission, building regulation approvals and taking us through the building tender process.

We worked closely with the bank and our accountants to make sure it was securely funded. In the end, the best solution was to establish a limited company that now owns the new surgery – the shareholders are the practice partnership team. This gave us the ownership and control of the building we desired, plus some VAT benefits, but gave more protection to individual partners and their personal assets than putting the loan in the practice's name.

The downside of this is that it makes it very difficult in the future for any new partners in the practice to buy into the building company, so in time there will be a drifting apart of the two entities. We have, however, anticipated this and have set up the links between the organisations in a fair and transparent manner so that both organisations will benefit.

Spacious facility
The new medical centre comprises 3,000m2 over four floors, providing us with 24 consulting rooms, a nurse treatment room, two minor surgery rooms, a rehab gym, practice administration areas, meeting and training rooms (we are a training practice), a pharmacy and the space leased to the PCT community teams.
The bank has been very supportive in getting the right financial deal, and by tendering the pharmacy provision was able to get an attractive rent as well as a premium towards the capital costs of the building.

Overall, the net cost of creating the centre is just short of £10m. This has been made possible by the practice, the bank and the PCT working closely together to agree in advance some of the early rent reviews so that we could borrow against future income – this has delivered further value to the PCT.

By working together towards a shared vision, we have been able to produce a fantastic facility for our patients, which is a world away from what they were used to in our old building and is a platform to help us take our level of care to new places.

Location
We had settled on a one-acre site close to our existing location but prominently located on the Bradford ring road. This was just about big enough for us. We could do with a little more parking room now, but there were few (no!) suitable alternatives.
Indeed, things are never simple – we inherited with the site an old manor house at one end, which was derelict but was (and is) a listed building. Our new building had to sit comfortably alongside this, and we were required as part of our planning permission to renovate it. This made the process of getting planning far more complex.

Although the whole process took nearly three years, overall we completed the project in good time. Having started early in 2007, we had initial support and approval from the PCT, the bank and the local planning authority, and had completed the purchase of the land on 1 September 2007.

We also engaged with all our different teams to make sure we got the layout and functionality of the building absolutely right and to complete the detailed design of the building, get planning permission and tender the build. This process took a full year, which may seem a long time, but don't underestimate how involved planning is!

This planning phase paid off. Now we have moved in, the building performs as we wanted it to and we have found very few faults with our design. Naturally we had to make a few compromises along the way, due to the limitations of the site and practicalities of construction, but all of these were discussed openly and fully with the team so that once finalised the design was one the whole team agreed upon.

Integral to our design process has been a consideration of sustainability and the environment. As well as designing a well-insulated and efficient modern building, we have added many extra features to reduce our impact on the environment, including solar panels, natural ventilation systems, underfloor heating, minimal use of air conditioning and a natural cedam roof on one part of the building.

Our contractor started on site on 8 September in 2008, and the building was completed mid-September 2009; just a few weeks later than we had hoped. We moved in and were operational by mid-October.

Whole team approach
The key to us making such good progress was the quality of the professional team we gathered around us. We were lucky to end up with a team that became as passionate about delivering a quality end product as we were ourselves.

The team, which included an architect, quantity surveyor, mechanical and electrical consultant, structural engineers, solicitors, landscaping consultants, pharmacy consultant, VAT and capital allowances consultants, the bank's monitoring surveyor, the main contractor and the key sub-contractors, worked together extremely well.

We communicated openly and honestly, took a rational and fair approach to contractual/cost issues and, as a result, have ended up with a building that was delivered close to schedule, came in at only 3% over budget and has been independently assessed as being of the best quality.

Throughout the design and build period, we kept regular contact with our patient participation group (PPG) in monthly meetings. The architect attended these meetings in the early stages, and the PPG's input to the building layout led to some design changes. Members of the PPG with access issues were extremely helpful in the planning and design of the building signage. One PPG member also attended our monthly design and steering group meetings so that they were kept abreast of progress at all times.

Overall, it has been a challenging and busy three years – just how busy is only really sinking in now that things are calming down a bit. Working in a large practice, I am fortunate that I have an excellent management team that keeps the surgery ticking over on a day-to-day basis, and this enabled me to devote a significant amount of my time to this project.

This factor was instrumental in keeping the project on track – constant chivvying of the professional team to keep things moving, the ability to make quick decisions when needed and a regular presence on site to monitor the build progress were all crucial in ensuring the success of the finished product.

A number of things looked different in reality than on a plan. Early awareness of this did enable some minor changes to be made along the way with minimum cost and disruption. The focus given to the building did demand a huge time commitment and this did undoubtedly lead to some issues and strains on the practice team.

I was also very lucky to have a supportive partnership team that empowered me to make the necessary decisions and that trusted me to involve them when needed. They were very involved in the design process but had very little involvement in the construction stage, recognising the risk of disruption and expense if changes kept being made while construction was underway.

Having moved in, we have a building of which the whole team can be very proud. This project has given me a real sense of achievement.