Keep the primary care estate at the centre of reform

The structural changes to the NHS implemented by the Health and Social Care Act have affected many service areas, but none more so than on estates.

While many service areas have started to come to terms with the changes and have found ways of making them work, the same cannot currently be said for estates.

‘CCGs lack the capacity and capability to drive the estate solutions their out of hospital strategies require’

The abolition of primary care trusts left commissioning processes for the improvement of existing estates and for the commissioning of new estates unclear at best. While the estates expertise from PCTs was subsumed into NHS Property Services, the responsibility for commissioning new developments has not followed it, creating a huge vacuum.

Property Services is primarily focused on managing and rationalising those properties on its own books. Having inherited a large and diverse range of staff from PCTs across the country, and been fast pulled into a comprehensive rationalisation programme of both estates and staff, new developments and forward planning have not to date been at the top of its list of priorities.

• What is the DH’s strategy to improve GP premises?

NHS England, meanwhile, has announced an informal freeze on approvals for new developments not already in the system, while it decides what principles should govern new developments moving forward.

Lack of expertise

The power of commissioning has primarily now been devolved down to the new clinical commissioning groups. But with the expertise in estates issues stripped out to Property Services, CCGs lack the capacity and capability to drive the estate solutions their out of hospital strategies require.

In Nene CCG’s area, for example, a local community hospital development has ground to a halt due to a lack of expertise to take it forward. There has also been a lack of clarity as to who is responsible for taking forward the section 106 applications for new housing developments, meaning that the NHS risks missing out on the funding it is entitled to.

There is, however, private sector enthusiasm for investing in NHS estates. The local improvement finance trust (LIFT) model proved to be a particularly effective investment model, bringing together private sector expertise and finance with local stakeholders and practitioners to build and manage premises which are tailored to suit local community needs.

This approach ticks many of the boxes currently being prioritised for primary care policy, particularly developing integrated care facilities based on community needs at a local level.

‘What is needed is a clear and open estates strategy across NHS England, which can be easily coordinated at a local level’

But the lack of certainty within the system is a major turn off for investors, and the longer this uncertainty continues, the more risky such investment will appear to them. The appetite is still there but it is beginning to wane.

What is needed is a clear and open estates strategy across NHS England, which can be easily translated down to and then coordinated at a local level. CCGs and local area teams need a mechanism to align estates with the local five year commissioning strategies. This would ensure estates functions as an enabler rather than a barrier, and serves to build positive, ongoing relationships with investors, rather than alienating them.

To make this work, each local area needs access to those people with the right skills to facilitate the process. There needs to be a mechanism, whether via area teams, CCGs or NHS Property Services, to create local teams who have the knowledge and understanding to be able to develop and implement an effective estates strategy to support local plans for system transformation.

What is needed is the development of local estates forums, modelled perhaps on LIFT’s strategic partnering boards, to enable CCGs, health and wellbeing boards, local area teams, commissioning support units, local authorities, LIFT companies and the local outposts of Property Services to map estate needs and plan what is necessary to deliver the new five year plans. These forums could potentially be formed as a subcommittee of the wellbeing boards to ensure that they are locally focused and led.

Estate development an afterthought

For far too long now estates development has come as an afterthought to service development. The changes required in local health and social care systems to enable quality to be improved within the funding envelope available means that the current vacuum within which estates in the NHS is operating cannot be allowed to continue.

Estate strategy has to have a central place within future policy development. It is not possible to transform general practice, integrate health and social care, or shift services out of hospital without a coherent and implementable estates strategy.

It is an essential requirement of service development, particularly given the scale of change required over the next five years. Done well, estates can be one of the most effective catalysts for change and service improvement.

Ben Gowland is chief executive of Nene Clinical Commissioning Group and Emma Carr is director of strategy at the LIFT Council