Stewart Gregory Healthcare Partner
Sustainability and Transformation Plans (STPs) are now at the heart of the NHS’ reforming and upgrading of its estates. In the primary care sector, however, the GP Forward View is of equal significance. There are two important elements to this:
- the Estates and Technology Transformation Fund (the “ETTF”);
- and the development of STPs and their commitment to investment in general practice.
Much has already been written on the delivery of the ETTF and other funding issues. In this article I will look at the second element – the development of STPs and their potential impact upon the primary care estate.
How are Sustainability and Transformation Plans developing?
One of the key things NHS England set out to do through the STP process was to “develop and implement a local plan to address the sustainability and quality of general practice”. The 44 STPs have now been developed to plan for local healthcare delivery until 2020/21. They are therefore very important vehicles for the delivery of NHS England’s stated aim. With two years having now passed since the publication of the GP Forward View, it is interesting to review how STPs are developing in the context of the primary care estate.
The first point to note is that there are several STPs in which the GP Forward View was hardly mentioned. In addition, funding for improvements to the estate was often not identified, was ring fenced, or was contingent on other savings from the STP delivery. This was surprising given the importance of primary care to the delivery of the STP aim of delivering new models of care.
Investment, whether in the estate or in general practice more widely, was an issue flagged as being of concern in many STPs. Where investment was allocated to general practice it was often allocated to deliver new initiatives, to extend GP access, or to produce substantial savings, rather than to help “get-on-top” of current issues facing general practice. From a property perspective this was again surprising given the well-known issue of backlog maintenance within the estate. It is difficult to see how primary care can be asked to deliver more from its existing estate without funding to first bring it up to the standard required to deliver the new initiatives being requested of it.
Importantly though, the funding issue was recognised in the NHS Operational and Planning and Contracting Guidance 2017-19 published jointly by NHS England and NHS Improvement. This provides local NHS organisations with an update on the national priorities for 2018/19. One of these priorities is the GP Forward View, and the guidance outlines the planning requirements of CCGs to support local implementation of it.
Common features central to most Sustainability and Transformation Plans
Two central features of most STPs are:
- the need to implement new models of care, to relieve pressure on hospitals by transferring more care into the community and to other providers working collaboratively together (in place-based “systems of care”), and
- a commitment to providing extended access to GPs.
General practice therefore faces an increased demand and is central to the delivery of that care. The estate has an important role to play in delivering transformation on this scale. There are many examples emerging from STPs of ambitious plans to transfer activity from secondary to primary care, and large, modern facilities will be required to accommodate this. An increase in the use of the “Hub” model is one noted in some STPs as a way of allowing GPs to work more efficiently by collaborating and coordinating services. But this model will not work in all cases (e.g. in rural areas) and will sometimes depend upon funding being available to develop new facilities to accommodate this way of working.
As already noted, a big part of the problem for STPs is the fact that much of the existing primary care estate is not fit for purpose or for the proposed new ways of working. In many areas the problem is compounded by a lack of capacity in the estate as well. Implementation of the Hub model may also require significant changes to the estate. If practices are to be brought together and combined with other health and social care services then they will often require new, larger premises to operate from, and this may require significant investment.
Another common feature of STPs is a plan to rationalise the primary care estate. In conjunction with the development of new Hubs the logic of this can easily be seen. Again though, this will not work in all areas and, in many, will be politically difficult to achieve – planned closure of a GP practice or a local district hospital will attract a lot of local interest.
However, underlying any STP plans for the estate, the funding issues remain. It is interesting to note that some STPs’ estates plans are actually dependent upon ETTF funding being made available. Whether that funding will be available, or sufficient, must place a serious question mark over the deliverability of estate plans that are dependent upon it. With this in mind, it may be that STPs need to look at alternative sources of estates funding to implement their plans; for example, PPP arrangements, capital from estates sales, and local authority funding have all been seen as possibilities within STPs.
Is GP engagement and feedback an issue?
A further area of concern from GPs was the relative lack of engagement with them in a number of STPs. Whilst the “GP Forward View Interim Assessment” is now over a year old it is still interesting to note that in it the RCGP reported that many of their Ambassadors had struggled to secure involvement in the STP process.
Things have of course moved on since that was published in January 2017 and there are many examples of good engagement with the primary care community in STP development, but we understand the picture remains patchy. Given the tight timescales within which the original STPs had to be compiled then this may be understandable. However, as STPs now develop we would suggest that processes to further engage the wider primary care community can only be beneficial – examples may include STP estate teams working with LMCs at a local level; or facilitating the establishment of local estate forums on which GPs and other primary care practitioners are represented, to feed in comments to STP development.
In conclusion, it is encouraging to note that the pressures on the estate caused by STP proposals for new ways of working are being recognised by many plans, and that estates funding issues are being tackled. However, the fact remains that many STP areas are working with an estate that is under-capacity and not fit for purpose for its current role, never mind the increased role it will be expected to play in delivering new ways of working. We also understand that there is still concern amongst GPs that if the savings proposed by the STPs are not delivered each year as projected, then funding for estates and other practice support initiatives may not be available. As STPs continue to develop it will therefore be interesting to see how the thinking on primary care estates issues develops from the initial draft plans, and this is something we will look at further in due course.
For further information or comment on Sustainability and Transformation Plans and the Primary Care Estate please contact Stewart Gregory, Healthcare Partner at Rix & Kay.
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