Hospitals are back in fashion. After years of down-talking and downsizing the district general hospital, the government has published a national plan for hospital building. It is the first since 1962, when the then health minister, Enoch Powell, launched his ill-fated Hospital Plan for England and Wa l e s . The difference between the two is that the latest will rely more on private finance than the public purse.
And although lack of investment in primary and community care was blamed in part for the runaway costs of Powell's plan, little has been heard of this government's NHS plan proposals for primary care premises.
The targets are ambitious: up to£1bn investment through a public-private partnership called NHS LIFT (Local Improvement Finance Trust), the replacement or refurbishment of 3,000 GP premises and 500 'one-stop health centres' bringing primary, community and, where possible, social services under one roof - all by 2004.
Since the plan was published last July, there have been few clues to how these targets will be met. NHS LIFT, awaiting legislation in the Health and Social Care Bill, has failed to take off, grounded in a fog of incomprehension - even NHS chief executive Nigel Crisp had difficulty remembering what 'LIFT' stood for at a conference last month (see bluffer's guide, overleaf).
Meanwhile, the Department of Health is considering all the options: more radical ideas include the private sector running and financing primary care centres, including some clinical services.
Small wonder, then, that a survey of nearly 30 health service managers and GPs, reported exclusively in HSJ, shows that most believe the government's targets are unachievable, and that change w i l l be hampered by lack of finance and the regulatory framework.
1Although most saw thirdparty developers as the way forward, there was confusion over how the arrangements might work. Only one manager 'thought' he had heard of NHS LIFT, and many doubted whether it could attract enough finance to meet the government's aims.
The research was carried out over four months from November last year by Dearden Consulting, sponsored by Brackley Investments and Primary Health Properties. It involved telephone and faceto-face interviews with eight GPs and five business managers from 10 GP practices, together with 11 decision-makers at primary care group/trust, health authority and regional level.
Included in the latter were one regional primary care director, three PCG/T chief executives, two PCG chairs and one HA chief executive.
Also interviewed were an independent consultant, an HA planner and a dean of postgraduate general practice.
The 27 interviewees were based in Southampton, Birmingham, Walsall, Berkshire, Tyneside and London, encompassing urban and rural areas. Some were known to have been recently involved in premises development, and others through PCG development work.
Views were sought on the development of primary care premises in the light of government targets, in particular timescale, implementation and policy achievability.
Interviewees broadly backed the need for development but felt constrained by lack of clarity and guidance from the centre. They believed little was being done to address practical difficulties.
'There was an overall feeling that the proposals in the NHS plan would not be achievable - the timescale for those who had successfully completed development of new premises was, on average, two years after locating a suitable site, ' says the report, making the target date of 2004 unlikely.
'The lack of identifiable funding' was seen as a major constraint, as was the fact that 'developments tend to be governed by the Red Book limits on cost-rent schemes'.
The latter was seen as a restriction in terms of space, flexibility of use and the financial viability of schemes.
There was a strong feeling that the Red Book 'does not relate to the new NHS'. Even where there was more flexible local interpretation of the rules, it fell short of what was needed to meet the extra demands on primary care. 'It will allow us to do what we want to do now, but not what we will want to do, ' said one respondent.
'The prospect of funding additional space is limited in the current system, ' says the report. Devolution of care [from the acute sector] is seldom accompanied by material resources and. . . it is not clear whether new flexibility on funding will be accompanied by flexibility on interpreting the regulations. '
Difficulty in finding suitable sites and the time needed to go through the planning process were cited as obstacles. 'GPs, in particular, thought that the amount of time needed to negotiate and develop such changes would affect their delivery of care to patients, ' says the report.
There were concerns about how relocation might impact on GPs' patient lists and doubts about whether current regulations provided sufficient inducements for dentists, pharmacists and opticians to relocate into 'one-stop health centres' from more commercially attractive high-street locations, as envisaged in the NHS plan.
Managers also questioned the benefits of one-stop centres. Where is the evidence that this is what the public or healthcare professionals want, or that it will provide better services, they asked. One 'back-of-the-envelope estimate' was that such centres would need to serve a population of at least 35,000 patients, with as many as 20 GPs, to be viable for other services such as complementary therapies.
Respondents were even less convinced by the government's refurbishment plans, which they felt were politically motivated rather than based on health need. They could not see why the private sector would be interested, 'with clearly no return on investment', and doubted that improvement grants could be used for the sort of 'brightening up' implied by the NHS plan. 'Upgrading premises was not to be taken lightly and they saw little incentive for struggling practices in deprived areas to take this on willingly in response to government policy, ' says the report.
Nor was there any optimism about the ability of NHS LIFT or PCTs to change things, with some people seeing LIFT as 'an unclear policy', says the report. 'It was viewed as not having 'enough realistic resources to achieve what it intends to throughout the NHS'. ' The fact that 'as a policy backbone, it has neither been understood nor heard of by the vast majority of those questioned. . . must be seen as a concern. '
Few GP practices saw opportunities in the move to PCTs and their potential to own property. Three with experience of working in trust-owned health centres were dissatisfied with the facilities and management, one describing the trust as 'dreadful landlords', with high service charges, poor security and 'completely lacking in vision'. Respondents saw little prospect of improvement with PCTs: 'it will be the same people managing badly'.
Respondents were cynical about PCTs' ability to deliver change. 'The PCT will be no different to the HA, ' said one.
Managers were 'more optimistic that PCTs would be in a better position to develop local partnerships, be better landlords and relate better to practices. '
Views on private developers were mixed: practices were enthusiastic about specialist developers, but mistrusted 'non-experts'. Respondents were 'not keen' to see developers provide facilities management as in hospital PFI deals. They wanted control over tenancy agreements and sub-letting. 'We have to think of our reputation, ie not a McDonald's next to the waiting room, ' said one.
Maryan Pye, associate consultant with Dearden, says the research highlights the 'huge constraints' in the system and the fact that 'policy-making is getting ahead of the regulatory framework needed to back it up'. She says:
'The problem is that GP practice premises are by and large governed by out-of-date regulations that relate to how general practice used to be rather than what is needed now. GPs want to provide modern primary-care services with bigger teams of people and a wider range of services, and to blur the boundaries between primary and secondary care. But they are not being given any more space or resources to do it. '
She is concerned that there are no central or local drivers for such change, although this might change with PCTs taking responsibility for primary care across an area.
Building 500 one-stop centres will mean relocating 10,000 GPs, on the advice that each centre would need about 20 GPs to be viable, she says.
This would represent about a third of England's 27,000 GPs - more if you include plans for redeveloping 3,000 premises. If each one-stop centre serves 35,000 patients, '17. 5 million patients would have to be written to, asking if they want to stay with their GP, who is moving. . . This is potentially a huge, huge disturbance, given there is no-one to lead it. '