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Sunday 23 October 2016
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Grand designs

The Primary Care Transformation Fund has practices drawing up plans for revamps and extensions. But NHS England has changed the process and now clinical commissioning groups head up the bids 

The Prime Minister, David Cameron, had a busy 2014. April saw the appointment of Simon Stevens, chief executive of NHS England, in October there was the very public launch of the Five Year Forward View, and the year was rounded off with the announcement of the launch of the £1 billion Primary Care Infrastructure Fund (PCIF) as part of the spending commitments outlined in the Forward View Into Action plan.
Sitting alongside a number of other capital funding programmes, the PCIF forms a central pillar in the strategy to transform the NHS into a seven-day health service. The PCIF promised cash-strapped GP practices a total of £1 billion of funding spread out over four years to increase capacity, modernise facilities and offer new services.
If the offer of free money sounded too good to be true, that’s because it was. An improbably short turnaround time, a complicated bid process and the unrealistic demand that projects should be completed within a year are issues that continue to dodge the scheme to this day.
For phase two, launched in October last year, NHS England reconsidered its approach and rang in the changes. Renaming the scheme the Primary Care Transformation Fund (PCTF), NHS England has put the clinical commissioning groups (CCGs) in the driving seat, tying it up with CCG’s estates plans to ensure the focus of the spending is much more strategic.
The need to transform primary care is more essential than ever, and the money is there, but is the PCTF the best way to do it?

Historic underfunding
Spending on GPs and primary medical care services will grow at a higher rate than for other health services, with Stevens announcing an extra 4% to 5% increase in cash funding every year. It’s a good start in addressing the historic underfunding that has affected primary care, believes Andrew McHugh, medical practice director at the Horsefair Surgery in Oxford.
“We need to move away from the ‘cornershop’ model of care toward a much more corporate model of care,” he says, noting how there’s a collective desire to change and improve. It’s not going to happen without investment though, McHugh adds. Putting the challenge into context, he describes how he’s seen an increase of 50% in consultations at his practice, but a corresponding drop in income of around 20%.  
The PCIF was NHS England’s approach to providing this funding directly to the front-line. The first phase began on 15 January 2015 when practices were invited to submit bids, with an ambitious deadline of just over a month to complete the paperwork. Those who submitted bids and expected a simple process were to be disappointed. After initial enthusiasm, McHugh – manager of a relatively small practice – decided not to submit a bid, describing how many were put off by the sheer amount of paperwork involved. “The money comes with so many strings attached sometimes people think it’s not worth it,” McHugh adds. “It’s a great idea though,” he says describing with enthusiasm how phase two of the scheme could benefit more practices. “General practice needs to recognise and change – and this money can help us achieve that.”
In line with the 2013 Premises Costs Directions, practices who did claim from the fund were able to apply for grants up to 66% of the value of the scheme, with practices expected to cover the other 34%. Bids were accepted up to a total value of £5 million.
Details on successful bids from the first round are hard to come by, with NHS England describing the picture as “constantly changing”. To stretch the simile somewhat, the British Medical Association (BMA) has seen this picture and it doesn’t like it. In a recent poll of 207 practices (a quarter of the claimed 1,000 who have had bids approved), 54% of respondents said they had experienced delays of more than six months, with 22% stating that local NHS Area Teams might withdraw funding.
NHS England is diplomatic in its reply, with a spokesperson responding: “The ambition and range of projects we have seen means some projects may take longer than expected.”

Making a change
The BMA may strike a note of caution, but there is evidence that the fund is making a difference at a local level. In the first year there have been some substantial investments in practices across England. In Birmingham and Solihull five practices received a total grant of £1.3 million to add capacity, including increasing the number of consultation rooms across the area and improving wheelchair access. A more modest investment of £23,000 is helping Theale Medical Centre in Reading expand its car parking, a move that’s sure to prove popular with patients.
In one example of the sort of larger scale building work made possible by the fund, the Hayesbank Surgery in Kennington is using its £850,000
grant to carry out a major extension of the practice building, adding
seven new clinical rooms, a theatre for minor operations as well as
new reception and administration facilities. The first building work began in November 2015, and if all goes to plan, patients will be able to start using the new services from July this year. NHS England has promised that in the future it will publish periodic updates on the programme, beginning in spring this year.

Round two
Publically acknowledging the problems with the first wave, NHS England has chosen to rethink the programme.
The newly renamed PCTF, launched in October 2015, transfers responsibility for the administration of the programme to the CCGs.
Practices will still be able to bid, but it will be coordinated by the CCG, with the programme linked to the estates strategies submitted by all CCGs in December 2015.
NHS England is confident that these documents will help CCGs identify local gaps in provision, ensuring the funding is spent strategically.
It’s a view shared by those within the health service. “This time it’s more focused and directed to what’s needed for the local area for primary care,” believes Sarah Soan, an estates consultant at NEL Commissioning Support Unit (CSU) (formerly know as North East London CSU) who has worked with a number of practices and CCGs to submit successful bids.
“The estates strategies provide the insight that will help CCGs to deliver new models of care to their populations,” she adds.
Soan suggests the money is more likely to end up in practices that need it, not just those with the scale to submit bids.
The estates strategies also ensure that the CCGs are able to see the whole picture of care across an area. “CCG estate strategies have been put together in conjunction with the local authority and other key partners.”
When asked what this means for the fund, Soan is positive, adding: “This time it’s more focused and directed to what’s needed for the local area for primary care to deliver new models of care, including ensuring care is provided closer to home.”
Recognising that complex schemes are likely to take much longer than one year to implement, NHS England has changed the rules.
An NHS England spokesperson, described how all new PCTF projects will need to be completed by the end of March 2019, with CCGs asked to provide details of how funding will be structured as part of their bids.

CCGs in control
The new wave of the scheme is putting CCGs in the driving seat. Nicky Wilde, deputy executive for commissioning and planning at Telford and Wrekin CCG explains: “(The) CCG has delegated commissioning responsibility for Primary Care and as such is responsibile for ensuring that practices are aware of the opportunity to bid for funding against the transformational fund.” The CCG’s role is about levelling the playing field, ensuring that all practices are aware of the fund and have the opportunity to bid.
The central duty for the CCG in the process is about coordination at a local level. In Sheffield, the local CCG is using its four localities to work with local practices, ensuring bids meet the NHS England criteria and also its commissioning intentions strategy.
CCGs are increasingly working with CSUs to develop bids and implement them. CSUs have the skills skills and experience to manage the mountains of paperwork one bid requires. “As a result of the NHS changes, many of those with skills in estates have been dispersed across the whole country,” says Soan. “At NEL CSU we have a huge range of experience, and can call upon extensive networks to support CCGs.”
Over the past year, Soan and colleagues have worked with CCGs and practices in Waltham Forest and Tower Hamlets. Moving forward it’s highly likely that CCGs will seek the support and insights offered by CSUs, offering some much needed strength to this relationship.

Crisis in primary care
It’s clear from the positive examples that the fund is already adding much needed capacity to primary care – and, if the funding remains, will continue to do so until 2019. But one of the biggest concerns with the programme is that it doesn’t tackle what’s widely acknowledged to be one of the biggest issues facing primary care: recruitment and retention of staff.
“Do we really think that we can solve the current issues within the health services with more buildings and better IT?” Asks Sally Gainsbury, senior policy analyst at the Nuffield Trust. “Increasing access to GP services won’t be solved by new premises, it’s a lack of GPs and practice nurses that’s the problem.”
NHS England has publically acknowledged the issues facing GP recruitment, working with Health Education England, the Royal College of General Practitioners (RCGP) and the British Medical Association (BMA) GP Committee to create a new GP workforce action plan, which it hopes will at least address some of the issues facing the GP community. The programme is supported by a modest £10 million budget, but it’s unlikely to be big enough to generate a workforce capable of delivering the much vaunted 24/7 NHS envisaged by Cameron and Stevens.
Take a step back from primary care and consider the financial position of the whole health service and the situation becomes even more complicated. Acute hospitals are very publically struggling to manage within their financial allocation, with the Department of Health (DH) spending more than a billion pounds last year to bail out failing trusts.
The problem is arguably much bigger this year, and with the DH having its capital funding raided as part of the recent spending review, could this put funding for practices at risk? “I expect that the DH will be on the phone to a lot of CCGs and even practices to potentially delay spending,” Gainsbury cautions.
“I expect CCGs to slow down the spending because the DH is going to need to keep within its spending limit.”

Increasing capacity
Never ones to do things simply, NHS England has decided to shake things up once again, with CCGs faced with creating yet another plan – this time called the Sustainability and Transformation Plan. Inevitably shortened to STPs these five-year plans will challenge CCGs to show how they are planning for the medium term.
All STPs need to be submitted to NHS England by 8 February and will become the single application and approval process for accessing transformation plans in
the future.
A chequered past and an uncertain future shouldn’t discourage CCGs from trying to bid for money that can genuinely help them to transform – regardless of the strings attached. How successful it is will be down to NHS England helping CCGs to navigate the bureaucracy and expedite funding to the frontline.

Lawrie Jones, freelance health writer.