Published: 10/04/2003, Volume II3, No. 5850 Page 40 41

As small communities grow and new ones are developed, local healthcare facilities are struggling to cope with the increased demand. Alison Moore reports

Kings Hill, in Kent, is a pleasant community of 1,500 new homes on what was once a Second World War airfield. Within a few years, the number of houses will nearly double and it will have become a small town.

Yet despite having a large supermarket, a primary school - with a second one planned - and a pub, inevitably called the Spitfire, there is no GP surgery.

Since the first residents moved in nine years ago, they have had to travel to West Malling three miles away to see a doctor. This put extra pressure on that practice, which at one point had to stop taking on new patients.

The problem dates back to the planning of the development more than a decade ago. No site was initially identified for a surgery and when one was later found it was unsuitable and too expensive. An acceptable site was finally found and a surgery is being built, which will be run by the West Malling practice as a personal medical services project.

'It has been torturous, ' agrees Maudie Vanden Berghe, primary care development manager for Maidstone Weald primary care trust. 'However, now we do have good working relationships with the local planning department and they contact me if there is a planning application for more than 20 dwellings.'

Things may have changed in the last 10 years but there are still fears that building new communities will put pressure on existing health facilities and that providing additional services will lag behind the expansion in population. Kent county council - which will house two areas recently earmarked for massive development - has already voiced its concerns, calling on the government to give 'cast iron guarantees' that additional resources will be provided for health and other services for the 80,000 new homes the county is expected to absorb.

The rhetoric coming out of government seems to recognise this, with departments being asked to look at 'front loading' money for essential community facilities (see box above).

But the record of the NHS at anticipating new development and planning services has been patchy. Milton Keynes General trust, for example, has found the demands of the growing town it serves has outstripped its capacity - the population has doubled since it was built in the 1970s - and is now adding a diagnostic unit which will give it an extra 60 beds.

A spokesperson says: 'Everybody accepts that Milton Keynes General Hospital has been playing catch-up.'

Even at existing rates of growth, Milton Keynes is expected to need another 400 hospital beds by 2031 and 6070 additional GP teams.

Extending the existing hospital - or adding a second one - would require a lead-in time of at least five years. To have it ready in advance to cope with the growing population would require tens of millions of pounds.

A major problem is that the funding stream tends to follow the growth in population, says Milton Keynes PCT chief executive Barbara Kennedy.

The PCT is keen to work with the local council, the strategic health authority and other NHS bodies to raise awareness of the need to plan in advance, even for the growth it is expecting now - let alone the effects of deputy prime minister John Prescott's recent announcement in Commons that he wants huge growth in building in the South.

'It is about getting the planning connected so that healthcare is as much a part of the picture as housing and other infrastructure requirements, ' Ms Kennedy says. 'There will have to be some seeding... It will have to come in ahead of the growth in population to be sustainable.'

In Kent - which will see both the Thames Gateway area and Ashford expand under the government's plans - there is already a group looking at the implications of rapid population growth for the NHS, including representatives from the SHA, PCTs and the government office for the South East. Finance has been top of the agenda and it is making representations to the Department of Health for resources to develop the infrastructure to meet the needs of the growing population.

Medway PCT chief executive Bill Gillespie has taken the lead in this for the three PCTs affected by the Thames Gateway area, which has already seen extensive development.

He points out that the stress on denser housing in Mr Prescott's announcement could lead to far quicker population growth than expected.

But two of the three PCTs in the area - Swale and Medway - will still be£17m below their combined target capitation by 2005-06. Mr Gillespie would like to see the move to target capitation accelerated for areas facing rapid growth.

But it is also the make-up of the population that matters, according to Jan Stubbings, chief executive of Swindon PCT, which is coping with the effects of decades of rapid growth.

Swindon has seen an influx of trained, experienced workers who tend to be 35 years-plus in age. Within a few years, this will mean they start to need more healthcare - Swindon's over-40s are expected to rise by 14 per cent by 2006 and its over-65s by 8.6 per cent. 'The funding formula does not really allow for that at the moment. These people come with recognised health needs, such as an increased need for statins, ' Ms Stubbings says.

This is complicated by not knowing exactly how fast the town is growing. It grew by 5 per cent between the 1991 and 2001 censuses, and another 4 per cent growth is expected by 2006.

The PCT has already put money into a 60-bed intermediate care unit, reflecting the ageing population, and the area has a new PFI-funded hospital, Great Western Hospital.

However, this has fewer beds than the hospital it replaced and has already had to cancel some operations at times of peak pressure.

Just adding capacity to reflect the likely additional population may not be the right answer: flexibility may be the key to coping with increased demand. With this in mind, Medway PCT is trying to ensure new primary and community facilities in the area are capable of expansion and can be used in different ways to reflect how services might be provided.

As recruiting GPs is already difficult, changes in skillmix and the use of same-day treatment centres may be the way ahead for the area.

'But there comes a point when you have to say this is about as visionary as we can be - let's get on and implement it, ' says Mr Gillespie.

But while rapid development does present some problems for healthcare, there could also be opportunities - including the chance to look at the health impact of large building schemes and manipulate this to generate health gain. New primary schools could be planned in a way which makes it easy and attractive for children to cycle or walk to school, suggests Mr Gillespie.

New housing could also offer new employees for the NHS and work with schools and community groups could encourage people to consider healthcare as a career.

Beautiful south: how the government plans to meet housing need

When deputy prime minister John Prescott told Commons recently that 'all governments have failed to meet housing need', it became clear he wanted a massive growth in building in the south. The four areas targeted are:

Ashford, in Kent;

Thames Gateway, covering east London, south Essex and north Kent;

Milton Keynes and south Midlands;

London-Stansted-Cambridge.

Most of these areas already have extensive growth planned but February's announcement took this a stage further with claims that London and these four areas could provide an extra 200,000 homes above those already planned for the next 15-20 years. For example, Ashford could provide 31,000 new homes in total and the Milton Keynes and south Midlands area - which covers Luton, Bedford and Northampton - a whopping 370,000.

More details on numbers and location of houses are expected soon.

Some government money has been promised to these areas -£446m to the Thames Gateway and£146m to the other areas - but there are no details yet on how it is to be spent.

Into the move: initial practice allowance

Dr Peter Crouch will be moving for the third time in under five years early next year - this time into the permanent site earmarked for his surgery in Taws Hill, on the northern edge of Swindon.

The area is designed to become a flourishing village centre, serving the new community which has sprung up over the last few years. Eventually 30,000 people will live in the area, clustered around three village centres.

Dr Crouch's practice was set up with a part-two initial practice allowance back in 1999, one of the few ways in which the NHS funds facilities in advance for growing communities.

This guarantees partners an income based on average net remuneration for five years, even though they may have few patients in the early stages. Their expenses are also met but they cannot benefit from private work such as medical examinations or reports.

GPs can opt out of this funding at any point during the five years and go through the normal procedures, but they cannot then opt back in. Crucially, there is no cost to the primary care trust - funding comes from the Department of Health, rather than out of local budgets. To date, only a handful of GPs across the country have gone down this route, with varying results.