OPINION

Many of us will share the sentiments behind the recent comments of Department of Health head of access policy, development and capacity Bob Ricketts that we must be more flexible about how we provide services and ditch expensive 'monuments' (news, page 6, 9 June).

The age of the all-singing, alldancing palatial hospital should be over, but many health economies are only just starting to pick up the bills for private finance initiative deals signed several years ago. With the increasing evidence about the advantages of community- and home-based care it is hard to justify builds of over 700 beds for communities of 250,000 but I hear that they are still occurring.

New PFI facilities with many beds will struggle under the payment by results regime. Over the past few years I have spent many a happy hour involved in the planning of several PFI schemes, over this time the risks involved have changed dramatically for the provider organisation.

In the recent past the commissioners were, during the process, required to underwrite the investment. Commissioner support for the increased costs of the build was crucial. Many primary care trusts or previously health authorities were required to pre-commit revenue to support these builds - but no longer.

The role of PCTs and the nature of the financial support has changed drastically. While they should be actively involved in agreeing the models of care, working with the acute trust to develop the type of facility most suited to the local population, the trust has now to ensure that the build can finance itself under the payment by results regime.

The business case must now demonstrate how the new build will provide care at tariff or cheaper.

The tariff reflects the average capital cost of the NHS and we know that many buildings are old, even Victorian, and therefore cheap.

The increase in capital costs from a new build in some high-cost areas is very large. While there is some transitional funding for possibly the first three years business cases must show quite spectacular efficiency assumptions in many instances.

In addition, practice-based commissioning and the introduction of choice also increase the uncertainty of patient flows. While a new build might encourage the local population to keep attending it is unlikely that if patient choice develops there will be the same certainty of workload.

Many of the headline-grabbing developments are the large acute teaching hospital developments but many community hospitals are being redeveloped to support the new community-focused intermediate care strategies. The problems they face are slightly different. Payment by results is not so clear-cut. Many of these facilities support their large acute colleagues in step-down rehabilitation care.

There is little clarity about how we allocate resources in this mixed pathway of care. There is much more variation about how patients are admitted.

The level of community resource varies quite dramatically between communities and so developing a robust payment tariff is more difficult.

Another dilemma is the relationship with social care. As was predicted, the introduction of the 'fines' for delayed discharges in acute beds promoted the swift discharge of patients awaiting transfer to nursing homes into community hospitals. This pressure was further increased this year by the need to protect the transfer of acute patients from accident and emergency departments into acute beds.

A symptom of this inappropriate use of beds is the length of stay of patients in these community units. It is not uncommon for the average length of stay to be measured in months. It suits both the acute trust - which usually provides the medical cover - and social services to have a reservoir of beds to take the slow-stream patients. Change is not a high priority.

Many old community hospitals have significant numbers of patients who are simply awaiting a nursing-home placement. In new developments where the model of care is based on active rehabilitation, respite or GP admission, beds quite simply cannot be used in this way.

More-prompt transfer of patients into nursing home beds is being seen unfairly as cost shifting by social care - the expansion of the 'fines' into community facilities is to be welcomed.

However we must recognise the impact that new facilities have on the perception of care and the actual delivery of care to patients.

In the past few months Brent PCT has taken delivery of a new community hospital and the reaction from the public has been fantastic. Patients are now cared for in single rooms not Nightingale wards, children have their own 'sized' facilities and community services are no longer delivered in cupboards.

The buildings are a visible signal to the community of our drive to improve the local NHS. Staff, over the opening weekend, managed the transfer of all patients with a smile and are now more committed to developing services to be the best.

So, Bob Ricketts is right. We must make sure that what we build is appropriate, but those facilities should not be shoddy or second rate.

What we build is a concrete sign of our drive to deliver quality care and they might be here for a long time. .

Lise Llewellyn is chief executive of Brent primary care trust.