Helping shape the estate of Greater London’s PCNs

The Additional Roles Reimbursement Scheme (ARRS) was introduced in England in 2019 to improve access to general practice, and allowed Primary Care Networks (PCNs) to claim reimbursement for the salaries of 17 new roles within the multidisciplinary team – such as paramedics, pharmacists, physicians, and associates etc. The intention of the scheme was to relieve pressure on GPs and improve access for patients, support the delivery of new services, and widen the range of offers available in primary care.  

As of 2024, PCNs can appoint up to 20 full-time members of staff. This fits the vision of ‘integrated care’ as set out by the Fuller Stocktake Report, Next steps for integrating primary care (published in May 2022), through ‘streamlining access to care’, and ‘providing more proactive, personalised care with support from a multidisciplinary team’. 

However, the report also called for conditions ‘to enable locally led change and the supporting infrastructure to implement it’. There is no funding available to support the PCN estate in accommodating the new appointees – no support for expansion or redevelopment of the estate – and instead, PCNs are expected to accommodate the additional staff within the existing estate. The result is further increasing pressure on an estate that was already at breaking point.

Investment ‘hard to come by’

Investment in the primary care estate has been extremely hard to come by over recent years. While some funding is available through improvement grants, these are generally for small improvements and essential compliance upgrades, skirting around the basic question about whether they are actually fit for purpose. Even funding for the digitisation programme has dried up, which would have offered immediate, albeit short-term, assistance, to relieve pressure.

On the strength of our delivery of healthcare projects across South East London, Howarth Litchfield was approached by South East London ICB to assist in the assessment of the PCN estate and a review of what would be needed to address the ‘fit for purpose?’ question.  

South East London ICB paved the way in supporting its PCNs in the review, together with the preparation of individual PCN estates strategy reports tailored to each PCN.

We began this first piece of work in June 2021, and concluded it in September that year. 

Smoothing the process 

The Estates Strategy involves several strands to assess the portfolio:  

1  Modelling capacity – is the estate big enough to accommodate the demand of basic primary care? What space is required to accommodate the ARRS, and is that available across the PCN?

2  Clinical considerations – does / could the estate support the integration recommended through the Fuller Stocktake report? What are the aspirations of the PCN?

3  Site surveys of the physical environment.

4  Forward planning to ensure we can shape the estate to be more ‘fit for purpose’. Let us examine each in turn in more detail.

1: Modelling Capacity  

We model the capacity requirements of each PCN based on:

a) The space required to meet each practice’s basic primary care demand. This is modelled on an individual practice level. The modelling is tailored to each PCN and locality – what is the projected growth in the area? Are there specific health needs in the local population that would affect the number of visits to the GP etc?

b) The space required to accommodate the appointed ARRS. Once we have undertaken the modelling at the individual practice level we can see what space, if any, is available across the PCN to accommodate the ARRS. At the beginning of these studies, the ARRS staff were relatively new, and the accommodation needed to support them had not been tested. Not all the ARRS need a clinical room. Some tasks can be carried out at a workstation, and some in the community. We worked with the ICB, PCNs, and practices, to build a model of what spatial requirements would be needed.

c) The space required to accommodate the drive from government to move services from the hospital setting to more accessible community bases (a later addition to the strategy reports).

Again, this is layered at PCN level. By ‘consulting spaces’, we are looking at any space where a clinician can engage with a patient – whether through face-to-face consultations or a virtual setting – and we accept that the estate is not perfect – compliant 16 m2 clinical spaces across the portfolio are not the ‘norm’.  

As architects, we are well-versed in developing a Schedule of Accommodation from the baseline data, which allows us to build a picture of the size of the estate that would be required to meet the needs of the patient population – projected forward to 2040.

2: Clinical Strategy 

Clearly, the Estates Strategy should be supporting the Clinical Strategy. The discussions with the Clinical directors representing each PCN help form a picture of the challenges experienced by each PCN, the needs of its population, and the aspirations for service delivery. It is the intention that the recommendations in the output would then support the delivery of these aspirations. 

These discussions are fascinating. We have worked with nearly 75 PCNs so far, and no two are alike. Each is on its individual journey, with varying degrees of collaboration and different ambitions as to how it would change its service delivery if the estate (and funding) could support it. Of these 75, only two have had a documented Clinical Strategy; this is fine by us – our role is to see how we can manipulate each PCN’s estate to support it. 

3: Site visits 

The site visits and surveys are an essential part of the process, but can also be the most difficult to navigate. Many GPs are weary of data gathering. Recent years have seen many surveys undertaken – six-facet surveys, GIA checking for rent reviews, and the national Primary Care Data Collection programme which fed into a database of primary care information – all of which takes time away from seeing patients.  

To be fair, the latter did capture the number of clinical spaces on site. However, premises change with time – for example records are moved off site or digitised, garages are converted, and staff move to work from home, so it is important that we have a current picture of the baseline.  Furthermore, we are architects looking for options to address capacity issues – seeing each property helps us to visualise a solution.

We capture a huge amount of information on site – condition, accessibility, sustainability, and photographic record, for example, and we sketch floorplans – which perhaps sets us apart from health planning teams. All this allows us to paint a detailed picture of the estate.

As architects we are fully conversant with the challenges of working with listed buildings, in conservation areas, and building liens (a lien is a right to retain possession of another person’s property pending payment of a debt), which makes the options that we present viable.  

4: Forward planning 

With the results of the above assessments, we are then ready to assess how we can make the estate fit for purpose. There is an emotive descriptor in circulation to categorise individual premises, which is intended to assist the right investment decision, use buildings more effectively, and dispose of estate which is no longer suitable:

• Core – those premises that are flexible, fit for purpose, and integral to delivery for the medium to long term.
• Flex – estate that, with sufficient investment, has the potential to become a core site, or with the potential for expansion or better levels of utilisation.
• Tail – sites that are simply not fit for purpose, and should be disposed of in the short to medium term.

This is a sensitive area, as many smaller premises are GP-owned, operating out of a converted residential property, and the ‘tail’ descriptor brings uncertainties. It can be challenging discussing this with individual practices. At a borough level, the outputs are costed, prioritised, and programmed into short-, medium-, and long-term projects to give the ICB an overall picture of the investment required to create that ‘fit for purpose’ estate which will be able to support service delivery over the next 20+ years.

We understand that the estate strategy should be aspirational – creating an estate that will be flexible and suit the changing needs of the population for the next 20+ years. We should not be investing in ‘tail’ sites. However, we are currently working alongside a ‘tail’ site in Greenwich – a typical converted residential property.  With a list size of over 5,000 patients, healthcare staff are operating out of three clinical rooms. I can give them an additional clinical room relatively easily for c. £60,000 fully fitted, which would significantly alleviate the pressure in the local community, but I know this will come under question. Investing in a ‘tail’ site is merely a plaster on a gaping wound, but will the £8 m+ funding needed for a new, integrated hub magically appear before the individual sites fall over?

A typical study will take six to eight weeks to complete, and usually will incorporate the following outputs.  

Building on experience

This first piece of work in South East London was for a market-leader, and was completed towards the end of 2021, after which we started to prepare the Estates Strategy in the boroughs of Islington and Camden on behalf of North Central London (NCL) ICB. Subsequently, we undertook work in Ealing, on behalf of North West London ICB. We have recently kick-started the same piece of work on behalf of South West London ICB, which was due to conclude mid-May. 

Following the conclusion of the reports, as architects we are well placed to support individual practices, PCNs, and the ICB to take individual projects through, if funding becomes available. For example, we are working with one of the PCNs and NCL ICB to create an integrated hub to accommodate PCN services, Marie Curie, and NHS 111, as a joint venture between the council and external funders.

You see such a wide range of issues and potential obstacles when you undertake this kind of work, but there are some common themes which have emerged:

•  Lack of funding for capital projects: this will not come as much of a surprise. It is widely understood that there is very little funding available for estates in the NHS, with little prospect of any becoming available in the short or even medium term. However, the reporting strategies get the PCNs and ICB ready to pounce should a glimmer of funding become available. The assessments carried out, and the options prepared, should allow them to be ‘business case ready’ to apply for funding, setting them in a good position. 
• Vetting and approval / Governance: Navigating the NHS approvals process is tricky and time-consuming – with little consistency between ICB processes.  
• Cost increases due to delays in decision making: The time lag incurred by the approvals process leaves projects vulnerable to cost increases through inflation. Projects need to be fully tendered for a full business case; however the business case proposal is then subject to the lengthy approvals process, and a contractor is not able to hold its pricing for this length of time. This situation is made even more challenging by the turbulence of the British construction industry over recent years.

There is thus the imperative to optimise the available space and plan the interiors with greater efficiency – when speed and expertise are of the essence – and this is where we come into our own. 

If we look at the main challenges, these are: 

1  First and foremost – communication. These projects are led ‘top down’, and getting the word through to practice level about our appointment, what we will need to see, discuss, and measure, is always a challenge, particularly as we are working in a fully operational healthcare environment.

2  Organisation of workflow and coordination. The sheer volume of documents can be quite staggering. We are currently working on 77 sites across the two boroughs of Wandsworth and Richmond, for which we will need to provide healthcare modelling and site assessments. This is one small element – so, overall, the utmost care is needed with the planning of workflow to ensure accuracy and timely delivery of our report.

3  Precedent – or should I say, the lack of it. This has always been challenging, because there was no ‘go to’ best practice example for this kind of work. Toolkits are emerging fortunately. We also now need to factor in additional ARRS roles, so we have had to work all the statistics and measurements through from scratch.

4  Complexity of service delivery: Appropriate estate and capacity are integral to the planning and delivery of transformational changes, but there can be competing requirements, even within one area.

To address these challenges, we need to:

•  Allow more time – because the communications from the ICB Project directors do not always trickle down quickly to the PCNs, let alone to the staff working within the practices. Ideally, you need to allow at least two weeks from instruction to sending out the advisory note about what is going to happen – not just once, but twice – to ensure optimal awareness about what is going on, why it is necessary, and who will be undertaking the work. Clinical directors could also be briefed at their weekly meetings to help this process.
• Closer collaboration – once the study begins, one of the key challenges is when we must tell estate management personnel the bad news: that there really is insufficient space. Often the premises we are monitoring are run down due to a lack of investment. Estate management teams do not want to hear this, as there is not enough money to easily find a solution, but realistically we are usually telling them what they already know – our study just crystallises it.  
• Finding solutions, not raising problems: Working closely with the client team to put together a plan that addresses opportunities with costs and the issues that need to be considered. These may include digitisation, new IT infrastructure, sustainability, development of new hubs with short-, medium-, and long-term plans, and working at scale.
• What some of our clients say 

“The Howarth Litchfield team has brought diligence and creativity to the preparation of the estates plans, which have given the ICB a sound basis for future planning of the estate – recognising the long-term ambitions and constraints, as well as targeting immediate interventions that can alleviate pressures. The team understands the pressures and the need for a flexible estate, and helpfully brings lessons of best practice from other sectors to help challenge current thinking and deliver solutions to improve the primary care environment.” Tony Rackstraw, Director of Rackstraw Ltd, and former Interim director of South East London Clinical Commissioning Group.

“Howarth Litchfield worked collaboratively and proactively with the ICB team and fellow consultants to improve the estates planning across the ICB. The team understood that strategies were an important building block in the transformation of the estate, and was able to bring the architectural skills to assist in visualising how this might work from an individual site to a borough-level basis.” Kerry Bourne BSc Hons MRICS, Director, Property Directors Ltd.

“Our surgery is a lovely place to work. Because of the size, and the way it has been designed, we never feel hemmed in or claustrophobic, despite the lack of natural light. The patients also really like the premises; the most frequent term they use is ‘posh’! It isn’t the typical GP practice they are used to. They like the space and the freshness of the design, and are very impressed with the size of the facilities.” Helen Oakley, Business manager, Everest Health Partnership.

Freeing up potential space 

Our studies, which identify where there are deficits, also identify several strategies to address them. Accordingly, given that 15-25% is an agreed realistic target improvement (assuming 85% target utilisation), I believe the ability to free up this additional space would make a massive difference to most PCNs, and the opportunity to improve utilisation across any estate should be explored to meet future need and facilitate place-based integrated health and wellbeing service delivery.

With a proven record of PCN Estates planning across London, we are continuing  to bring invaluable experience to efficient community healthcare provision in the London boroughs, which, arguably, have a greater call on NHS services than many other areas. Our role is to ensure that the PCNs are not just compliant, but genuinely fit for purpose. However, if we could set the rules, we would recommend wider collaboration between consultants and PCNs to make the process much more streamlined and ensure consistency of thinking.  

We would also advocate setting aside commercial and intellectual property considerations, which can be an issue when one or more healthcare consultants are working together on a project for fear of sharing best practice approaches with potential competitors. In fact, better communication generally, from the top down, is needed, with more time for pre-project planning at PCN level so that practices are better briefed before we arrive about how long we will be there, and what we will need from them to assist our work.

Finally, of course, greater capital investment in community healthcare is essential. Where PCNs have appointed us, the studies we have produced are contributing to long-term planning to improve integration and the quality of healthcare facilities; with the introduction of ARRS, the demand for additional space within PCNs has never been greater. At a time when the availability of capital funding is likely to be minimal over the next few years, Howarth Litchfield’s work in the London boroughs should help to shape estates planning for the next 25 years, identifying the priorities that need addressing, and planning the necessary investment, so that the estate can support clinical delivery.