Sherford is a new town being built near Plymouth and plans for its health services promise to test support for new models - just don't mention polyclinics. Lynn Eaton takes a look
Imagine you are given a blank piece of paper and asked to design from scratch a new town that by 2016 will provide 4,000 homes. Where do you start?
That is what Devon primary care trust is considering. Town planners have come up with what they think is an appropriate network of roads, houses and community buildings for the 1,200-acre site. But healthcare provision is needed for the new development of Sherford on the outskirts of Plymouth, and that is where the PCT comes in.
In early May around 100 people gathered at a conference suite in Exeter to hear what these health plans might be and what opportunities there might be for them. While the event's official title - Market Testing Open Day - was hardly a crowd-puller, local GPs, independent sector providers, dentists, opticians and mental health providers all congregated to listen to presentations on the development. While some were eagerly scribbling notes, others were more cynical about just how viable the community will be when there are few obvious employment opportunities in the proposed development.
Others - the GPs - cut straight to the chase: asking just how many spaces there will be in the health centre car park.
It is early days. The May meeting marked the start of the procurement process, with any willing provider invited to submit their business case to the PCT. Inviting all potential providers to one single event was, in part, about the PCT trying to reassure itself that it was going about the tendering process in the correct way. The process has to be acceptable to potential providers as a commercially viable model, rather than just setting out exactly what the PCT wants and asking who is interested in providing it.
Yet it is far from clear exactly what is wanted. Building a new health facility 20 or even 10 years ago would have been a lot more straightforward. Traditionally a small hospital would have been felt necessary and primary care services would have been built around several individual GP practices. But the shape of healthcare is changing, with an emphasis on community rather than hospital care and on one-stop-shop health centres that can provide minor treatments. The primary/secondary care model that has been the mainstay of the NHS for the last 60 years may no longer be appropriate.
Driven to change
Nigel Beckett is project director at the development company Red Tree. He showed the open day audience pictures of the proposed site and early plans. Drawn up in 2004, they show a small hospital and several small GP surgeries, but those schemes have been jettisoned in favour of a single health and well-being centre, designed to house eight GP surgeries on the one site. No one mentions the word "polyclinic".
"Somebody said, 'what if we were to take the requirement for eight GP surgeries and combine them into a single facility?'" says Mr Beckett, without shedding light on who the somebody was. And that is what the developer is planning: a single 3,500m sq health centre in the middle of the town which it will build, and own the freehold. Car parking facilities will be included. After the meeting in Exeter, it looks as if the building size may have to increase a little.
It also seems it may need more parking spaces than the district council might like. Local GPs know that, despite planners' attempts to change habits, patients still want to drive to their doctor's surgery - especially if they are ill or have a disability and find walking or using public transport a problem.
Jenny Richardson is a GP at the Ridgeway practice in Plympton, an outlying suburb on the east of Plymouth. As hers is one of the nearest existing GP practices to the proposed new town, she wonders if a health clinic in Sherford might draw patients away from her practice but feels patients will prefer to see the same GP at each visit.
"They are not going to get continuity of care in a polyclinic," she argues.
Devon PCT has attempted to estimate how many day cases, x-rays, minor injuries and other referrals the clinic might expect to receive in a year. The estimate is based mainly on current referrals from the nearby towns of Ivybridge, Yealm, Plympton and Plymstock to the nearest big hospital, Derriford, part of Plymouth Hospitals trust.
Chicken and egg
These estimates have been included as access to the hospital from Ivybridge and nearby areas is difficult. So it could make sense for patients to use the health centre for services they might previously have gone to the hospital for, even if they continue to use their own local GP.
Just how many potential providers there might be out there remains to be seen. Some of the more entrepreneurial GPs in the area might want to bid.
But there is a dilemma. While people living in and close to Sherford might boost potential patient numbers for minor operations and diagnostic procedures, initially the town's population will be too small to support a GP practice. The health centre will not be built until there are at least 3,500 people living in the town, so Devon PCT acknowledges the need for some kind of temporary unit until then. This may have to be a satellite clinic of an existing nearby surgery, if it is not commercially viable as a separate entity. One GP asked if Red Tree would consider offering the health centre at a reduced rent until such time as the town's population made the GP surgery viable financially.
"It's a chicken and egg situation," says Mr Beckett. "We have to know what services are going to be provided. I have to understand the building model to make sure it works."
The PCT is still open to suggestions: one provider might provide all services from the centre, or there might be a separate contract for primary care and another for other services.
Primary care trust deputy chief executive Rebecca Harriott says she would prefer to have a single provider leasing the building rather than multiple providers.
That one provider would organise the variety of services needed on the site. But she knows this might not be simple to achieve.
"We haven't got a fixed view," insists Ms Harriott. She admits: "We've got more questions than answers. Whether there are providers out there interested in tendering for the whole thing is the area we are interested in having further discussions about."
One option might be to use a shell company - a management company overseeing services provided on the premises, under contract to the PCT while leasing the premises from Red Tree. The company would buy in the necessary services from GPs and other clinicians. Doctors could then operate on a salary, rather than being partners in a practice.
Opticians and dentists, meanwhile, welcoming the prospect of a high-street frontage, were keen to be involved in the project.
"To have a retail space in the high street but be part of the health centre would be very attractive to us," says one optician at the event.
But whether that will be what Sherford's patients want remains to be seen. Patient representatives did not appear to have been invited to the event in Exeter.
"Maybe there's not yet enough certainty to involve patients," suggests Plympton GP Paul Giles.
Forget Milton Keynes, think Poundbury
Sherford is to be built on the eastern edge of Plymouth in an area of farmland, wedged between two main roads.
The development is driven by the government's desire to build suitable housing in underpopulated areas. It has been a controversial proposal - there have been protests at plans to carve up yet more countryside and with no obvious existing major employer in the area, questions have been asked about where the new residents will work - but building is due to start in 2010.
Forget Milton Keynes and Harlow. This new town will look like a traditional high street with a mix of buildings that hark back to more historical styles, not dissimilar to Poundbury near Dorchester, which was designed in association with the Prince of Wales. Sherford has been designed with support from the Prince's Foundation for the Built Environment, which aims to encourage an ecological approach to building design.
Modelled on Marlborough in Wiltshire, the town will have a main road running through the centre with shops on either side, rather than a 1960s housing estate with neighbourhood shopping parades. The emphasis is on having accessible amenities, so car use will be minimised.
Sherford's facilities will include a sports centre, swimming pool, 200-hectare community park and two wind turbines intended to provide half the town's energy requirements. The site is, though, rather inconveniently hilly - "a house-building challenge", admits Nigel Beckett, project director at developers Red Tree.
"There were very few places we could put the health centre where it wasn't on a slope," he says, before adding: "You wouldn't want to travel from the top of the high street to the health centre in a wheelchair."
The local council has also insisted 20 per cent of homes are built to lifetime home standards (wheelchair accessible) and 100 high-dependency units will be provided. Red Tree is also in discussion with retirement home providers about suitable accommodation close to the town centre for older people.
'A blank piece of paper': what the open day participants thought
Ricardo Windas, director of business development with independent primary care providers ChilversMcCrea Healthcare, thought last month's open meeting on Sherford's healthcare was useful.
"We got a huge amount out of it. Sherford has the unique advantage of being healthcare with a blank piece of paper. It isn't a legacy situation."
The question now, he adds, is whether Devon primary care trust will go for a single big contract for all services, to run the proposed single health and well-being centre, or whether it will opt for a series of smaller ones.
"It makes it easier for the PCT to contract manage [if they go for a single provider]," he says, but acknowledges this would put a lot of power in the hands of one company.
Mr Windas's company needs to decide whether it would bid to provide just primary care services or to team up with others who might be able to bring in secondary care services and bid for the entire facility.
Philip Carvalho, director of client services and business development with Health Dialog UK, found that for his company, which offers data analysis of patients to identify likely health requirements, the development is too far off to be of immediate interest. The firm thought GPs in Sherford might be interested in buying its services in order to predict what would be needed and build a self-help programme for those most at risk.
"But unless we have 50,000 patient lives to analyse, we run the danger that the analysis may not be accurate," he says.
Mr Carvalho feels the event demonstrated a divide between the more entrepreneurial companies and more traditional local GPs. GPs, he says, seemed more defensive and less willing to embrace the potential opportunities.
Paul Giles is a GP with the Ridgeway practice in nearby Plympton and believes his practice could be affected by a new clinic at Sherford.
"The fact that the PCT has made it clear its preferred result is to contract with a single provider means the chances of bidding as a consortium of GPs for the primary care services is probably not an option. I very much suspect the big players will bid for the whole project."
Doctors may yet decide to bid for some of the primary care work in the new centre, but they still need to discuss how they would do that, he adds. Dr Giles is concerned that otherwise primary care facilities could end up with a series of either locum or salaried GPs providing care rather than a named and known doctor.
"If that happened, I would certainly be worried about the quality of primary care for the people of Sherford. It's probably true that the traditional GP model is being squeezed out by default," he says.
For Devon PCT deputy chief executive Rebecca Harriott, the day achieved what it set out to. "I was pleased, overall," she comments. One of her worries was that the planned procurement process might not be acceptable to potential providers, but she felt those fears were allayed.
The fact that developers Red Tree will be the landlord of the property, retaining the freehold, was a new model for the NHS, she adds.
"We don't want to have a relationship with the building," she says. The PCT has, though, taken into account some of the points raised about the need for the building to be able to adapt and possibly expand to meet future needs.
Red Tree's Nigel Beckett, meanwhile, says the event was useful. "We were able to identify those groups that would wish to tender for the services to be provided at Sherford. It gave us an insight into the types of issues the PCT needs to resolve and the level of input that these groups would wish to have into the design of the health and well-being centre."
As for parking, that, he says, "will be in accordance with very specific local and central government guidance".