Primary Care Infrastructure Plan 2019/2026

Cleevelands Medical Centre, Bishop’s Cleeve Kingsway Health Centre, Gloucester

The Devereux Centre, Tewkesbury Churchdown Surgery, Churchdown Author: [email protected] 1 Final draft 12th August 2019 1. Table of contents Page

1. Table of contents………………………………………………………………………………………………………2

2. Introduction ……………..……………………………………..…………………………………………………… 3

Section A – Where are we and where do we need to Section B – How are we going to get to get to where we be? need to be? Page

3. Strategic context ………………………………..………………………………………………………………… 5 8. Ongoing delivery of 2016/ 2021 priorities and priorities 3.1 National policy- Long Term Plan 3.2 National policy- focus on primary care (primary care networks overview) to 2026 …………………………..………………………………………………………………………………………………… 29 3.3 National policy focus on primary care (primary care networks service development) 8.1 Methodology, approach and assumptions 3.4 Local policy Gloucestershire Integrated Care System (ICS) 8.2 strategic prioritisation 2021 to 2026 3.5 Local policy - ICS Strategic Service model 8.3 Revised priorities overall programme 2019 to 2026 3.6 Local policy –Integrated Locality Partnerships 3.7 Local policy - Primary Care Strategy 2019 to 2024 9. ILP, PCN and Practice summary ………………………..…………………………………………… 33 3.8 Service strategy implications on the primary care estate 9.1 Overview 4. The estate in 2019 …………………………………………………………………………………. 14 9.2 Cheltenham 4.1 The Challenge of the existing estate 9.3 Cotswolds 4.2 Increasing alignment across the ICS estates 9.4 Forest of Dean 4.3 Current primary care estate 9.5 Gloucester 4.4 Condition and suitability of primary care estate 9.6 Stroud & Berkeley Vale 9.7 Tewkesbury 5. Rising population ………………………………………………………………………………… 19 9.8 Programme 2019 to 2026 and estimated capital costs 5.1 – Forecast housing growth 2019 to 2031 by District 9.9 Revenue financial framework 5.2 - Housing growth and population growth estimates by District 5.3- Population growth and allocation to practices within Integrated Locality Partnerships 10. Process and Governance ………………………..………………………………………………………… 43 6. Delivery of 2016 to 2021 priorities ………….………………………………………… 23 10.1 Business case requirements 6.1 Completed and approved schemes 10.2 Improvement grants 6.2 Remaining priorities - progress status 10.3 Engagement and equality 6.6 Financial investment 10.4 Fees 7. Summary ……………….……………………………………………………………………………..…………… 27 10.5 Decision making and approvals 7.1 Where are we now? 2 2. Introduction

NHS Gloucestershire Clinical Commissioning Group (GCCG) has had delegated authority for primary care commissioning since April 2015. The CCG’s responsibilities with regards to premises are set out in The National Health Service (general medical services premises costs) Directions 2013 and include: • Managing the rents reimbursed to practices for the provision of general medical services in buildings owned by practices or another body, where the practice is a tenant • Managing the reimbursement of business rates for the provision of general medical services in buildings owned by practices or another body, where the practice is a tenant • Determining improvement grant priorities: the NHS is able to provide some funding to help surgeries improve or extend their building • Determining new primary care premises priorities • Funding the annual revenue requirements of new premises as a result of additional/new rent reimbursement requirements Currently, any capital funding requirements is not delegated to the CCG and NHS England approval is required. GCCG developed a five year prioritised Primary Care Infrastructure Plan (PCIP) to set out where investment is anticipated to be made in either new or extended buildings, subject to business case approval and available funding for the period 2016 to 2021. The PCIP was approved in March 2016. This is an updated version of the PCIP, which takes into account progress made on priorities, NHS policy development, a review of housing and associated population growth. It reaffirms existing key priorities and using the agreed methodology of the original plan, also sets out additional priorities for the period 2021 to 2026 and provides a revised programme for 2019 to 2026. This document replaces the previous version published in March 2016.

3 Section A Where are we and where do we need to be?

4 3. Strategic policy context

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5 3.1 National policy -NHS Long Term Plan

The PCIP in 2016 highlighted that a number of strategic plans recognised that whilst day-to-day primary care services were still core, some care currently provided in hospitals needs to provided in community settings. It assumed extended primary care services would include increased community services, Out of Hours services, other specialist-based services such as diagnostics, case management of vulnerable patients and closer links with non-statutory bodies. It anticipated that Practices would increasingly employ bigger teams which would work together as well as with other health and social care providers through formal ‘Networks’. It referenced emerging ‘super’ practices, where one practice operates from a number of sites and that Increasingly, local primary care services will be delivered for around 30,000 to 50,00 people. It noted that in order to deliver this strategy, some literature referred to the development of local primary care hubs within which practices are likely to be co-located. Published in January 2019, the NHS Long Term Plan builds on the Five Year Forward View and articulates a need to further integrate care to meet the needs of a changing population over the next decade. Focus is on the following:

- A new service model in which patients get more options, better support and properly joined-up care at the right time - The NHS will strengthen its contribution to prevention and health inequalities - Care and quality outcomes improvement ( cancer, mental health, diabetes, multi-morbidity, healthy ageing, including dementia, children’s health, cardiovascular and respiratory conditions, learning disability and autism amongst others) - Workforce development - Upgrade technology and digitally enabled care across the NHS - Increased financial investment of 3.4% over the next 5 years to support implementation

The PCIP still needs to respond to a commitment to increase care outside hospitals and for there to be 6 expansion of primary care services. Further detail is provided in the following sections. 3.2 National policy- Focus on primary care (Primary Care Networks- overview)

Set out in the Long Term Plan, over 1,250 Primary Care Networks (PCNs) came into existence from 1 July 2019. These are based on minimum registered list sizes of 30,000 patients – not usually more than 50,000 – commissioned through general practice in the form of a Directed Enhanced Service (DES) that forms the network contract. Between the practices, a mandated network agreement, with associated schedules, sets out the relationship and operating protocols of the PCN. Guaranteed real-terms investment of £4.5bn has been pledged for primary and community care from 2019/20 to 2023/24.

7 3.3 National policy - Focus on primary care (Primary

Care Networks – service development and delivery) The Key focus of service development and delivery over the next few years includes the stabilisation of the GP partnership model; the creation of 20,000 new staff working in general practice through additional roles; further dissolving the historic divide between primary and community care; a clear, quantified, positive impact for the NHS system and patients, with fewer patients being seen in hospital and more being seen and treated in communities.

Working at this new Primary Care Network (PCN) level service provision is wider than just general practice. It includes all of primary and community care staff, working together to deliver preventative, out of hospital, care for their patient population. So while GP practices are at their heart, and the initial partners from July 2019, they must grow from April 2020 to begin including these other partners. This will enable them to start commencing the new service specifications that will go live from April 2020, with some mirrored service specifications for community teams to support the staff integration and joint working: • Structure Medications Review and Optimisation • Enhanced Health in Care Homes; • Anticipatory Care for high need patients with several long term-conditions; • Personalised Care • Supporting Early Cancer Diagnosis • CVD Prevention and Diagnosis (from April 2021 • Tacking Neighbourhood Inequalities

From April 2020, every PCN will also receive a new national Network Dashboard to measure impact, including A&E attendances, admissions, prescribing and performance against these specifications. Also commencing in 2020 is a new national Network Investment and Impact fund, linked to performance against metrics in the Network Dashboard. This will mean that PCNs which demonstrate a positive, demonstrable, impact in these measures will receive further investment to support their growth.

8 3.4 Local policy - Gloucestershire Integrated Care System

Gloucestershire’s Integrated Care System (ICS) is underpinned by the shared mission to have a population which is healthy and well, with residents taking personal responsibility for their health and care and reaping the personal benefits that this can bring. These can include being less dependent on health and social care services for support, living in healthy, active communities and benefitting from strong networks of community services and support. People should be able to access consistently high-quality, safe care in the right place, at the right time. The ICS vison ‘To improve health and wellbeing, we believe that by all working better together, in a more joined up way, and using the strengths of individuals, carers and local communities, we will transform the quality of care and support we provide to all local people.’ The key strategic objectives are to: • place a greater emphasis on personal responsibility, prevention and self-care, supported by additional investment in helping people to help themselves • place a greater emphasis on joined up community based care and support, provided in patients’ own homes and in the right number of community centres, supported by specialist staff and teams when needed • continue to bring together specialist services and resources in to ‘Centres of Excellence’, where possible reducing the reliance on inpatient care across our system by repurposing the facilities we have in order to use them more efficiently and effectively in future • develop new roles and ways of working across our system to make best use of the existing workforce and bring new people and skills into our system to deliver patient care 9 3.5 Local policy - Strategic service model

Greatest impact on primary care facilities: Enabling Active Communities Building increased personal responsibility, promoting independence and supporting community capacity to make it easier for voluntary and community agencies to work in partnership with the NHS. One Place, One Budget, One System Gloucestershire is taking a place-based (locality) approach to the expansion of integrated working focused upon primary care, and encompassing community services, social care, mental health and the voluntary sector. The first priority focussed on a strengthened approach to urgent care. Clinical Programme Approach Reorganising care pathways to ensure that the right care is provided in the right place at right time.

10 3.6 Local policy – Integrated Locality Partnerships

Operational and Strategic partnership of senior leaders of health and social care providers and locally elected government and lay representatives informing and supporting integration at PCN level, unlocking issues and sharing responsibility for finding local solutions to deliver ICS priorities and tackling issues which arise locally which can only be resolved collectively.

Clinically-led integration, involving staff and local people in decisions, to support more people in the community and out of hospital.

ILP Plan to deliver defined population strategy including prevention and public health, with aligned priorities agreed to improve outcomes.

Develop multidisciplinary workforce models which will operate at PCN level.

ILPs will need to translate ICS objectives to meet the needs of their local population while enabling the PCNs to realise their plans to implement multi-disciplinary teams around the needs of their patients

11 3.7 Local policy – Primary Care Strategy (2019 to 2024) Vision Strategic objectives Patients in Gloucestershire can stay well for longer and receive joined- up out of hospital care wherever possible, we will provide a • Continue the dissolution of the historic divide between sustainable, safe and high quality primary care service, provided in services through 14 Primary Care Networks and 6 modern premises that are fit for the future. Integrated Locality Partnerships*; • Provide patients with more control over their own health, anticipatory care and personalised care when they need it and support early cancer diagnosis; • Utilise population health to tackle inequalities, assessing our local population by risk of unwarranted health outcomes to make services available where they are most needed; • Grow our multi-disciplinary primary care teams, attracting and retaining the best staff through promoting Gloucestershire as a great place to live and work, creating a better work-life balance for staff, and offering excellent training opportunities; • Ensure good access to primary care 7 days a week, meaning better support for patients while also reducing urgent demand at our hospitals to enable them to care for the most acutely poorly patients; • Digitally-enable primary care to maximise the use of technology; • Support Primary Care Networks and Integrated Locality Map of Gloucestershire Integrated Locality Partnerships and Primary Care Partnerships to explore how they can provide a greater Networks range of services for larger numbers of patients.

Further detail on Gloucestershire Integrated Locality Partnerships and Primary Care Networks provided in section 9 and appendix 3 of this document 12 3.8 Service strategy implications on estate

Service Estate implications strategy • Greater use of primary and community facilities Enabling active • Increased number of services to be accommodated communities • Greater use by community and voluntary sector • Increased group activity, some of which likely to take place in local surgeries as well as non health-related venues Reducing • Whilst partially offset by increased population, less requirement for acute-based unwarranted outpatient facilities for face-to-face appointments clinical • Greater requirement for primary and community facilities, in many instances variation provided through new models of care Clinical • Ensure suitable primary and community care facilities programmes • Assess the implication on acute hospital facilities • Assess the implication of hub and spoke service models One place, • Development of the acute hospital estate One budget, • Development of community hospital infrastructure One system • Development of primary care facilities • Greater range of services in local surgeries and increased numbers of professionals Long Term Plan • Some services offered across large populations of 30,000 to 50,000 and Primary • Building capacity of primary care infrastructure as many of the existing surgeries are care too small to accommodate increased populations and additional services • Development of large scale centres with co-location/merger of practices into fewer buildings 4. The estate in 2019

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14 4.1 The challenge of the existing estate

Across England, 40% of practices surveyed by the British Medical Association felt that GP premises were not adequate to deliver existing services and 70% were too small to deliver extra services. GCCG needs to ensure there is sufficient capacity for future need whilst maximising use of facilities and delivering value for money as limited financial investment is available to fund requirements. There needs to be a focus on enhancing patients’ experience and improving the environment for staff to provide the best care. GCCG commissioned an estates survey in spring 2015 which highlighted that some buildings have spatial constraints, whilst Winchcombe others are unsuitable for the long term and have unsatisfactory Medical functionality/layout. This was used to help determine the key Centre, priorities set out in the 2016/ 2021 plan. The survey suggests that Winchcombe Gloucestershire still needs a programme to improve the quality and capacity of primary care buildings. Whilst it is still essential to ensure that core primary care services are available, there is a also a need to modernise premises to ensure that more services can be delivered out of hospital and that this additional capacity will not be at single practice level. Improved and/or enlarged infrastructures can be both a catalyst for delivering change or an enabler to deliver agreed service models.

15 4.2 Increasing alignment across the ICS estate

The ICS needs a modern and flexible estate infrastructure to support the service ambitions and day-to-day working of Gloucestershire’s ICS and to maximise health and well being, improve the quality of care and patient experience, and deliver financial efficiency. Organisations are now increasingly working together to understand, collaborate and deliver the following objectives. • The strategic development and configuration of acute hospital sites to deliver new clinical models • The development of community infrastructure to deliver One Place, One Budget, One System requirements and the Clinical Programme Approach • Improved GP premises that accommodate planned population increases and changes in working practice within primary care. These will also facilitate aspects of enabling active communities with closer links to the voluntary sector • Support a resilient and sustainable primary care Kingsway Health Centre site, Gloucester • Bring the estate up to and date and reduce backlog maintenance requirements across the ICS • Dispose of surplus and unused buildings which are no longer required • Maximise opportunities to share space to facilitate service integration with the community and voluntary sector, minimise running costs and generate capital receipts

16 4.3 Current buildings

There are now 74 GP practices providing general medical services to 652,497 registered patients in January 2019. Appendix 1 highlights list sizes, building from the original baseline in July 2014, and projecting forward to March 2031. Services are provided in 100 buildings. There are 74 main buildings and 26 branches, although some practices operate as split sites. Sixty of the buildings are owned by the practices themselves and 39 of the buildings are leased, where the GP practice is a tenant. One building is part leased and part owned and in this situation, the practice is expecting Leckhampton Surgery, Cheltenham to have to vacate this site in the near future.

17 4.4 Condition and suitability of estate

A key part in determining future investment priorities for 2021 to 2026 relates to the current building condition. It comprises six separate surveys:

• Facet 1 – Physical Condition Survey (including mechanical and electrical aspects). A risk-based survey providing practical information for assessing building stock condition, covering 23 elements • Facet 2 – Functional Suitability Review - assesses the appropriateness of the function/facility in relation to the activities taking place • Facet 3 – Space Utilisation Review - assesses the physical use of the building, identifying low use, empty and overcrowded rooms • Facet 4 – Quality Audit - based on factors which relate to the quality of the internal spaces when assessed. Enables premises to be judged and compared with one another. It determines those that are most and least pleasant for both staff and visitors • Facet 5 – Statutory Compliance Review - an assessment of statutory requirements which helps practices understand their position against their legal obligations and the extent to which the facilities comply with the regulations • Facet 6 – Environmental Management Review - an assessment of the policies and procedures at the practice relating to the management of water consumption, energy usage, waste control and procurement (if applicable). It should be noted that facet 6 is not available for the Gloucestershire survey NHS England guidance recommends prioritising existing buildings where the physical condition and the functionality suitability review are deemed to be unsatisfactory. An updated summary of scores for Gloucestershire practices which have not been replaced are included as part of the strategic prioritisation in appendix 2. Scores of A and B are deemed as acceptable and scores of C and D are deemed not satisfactory (where buildings are likely to require improvement in the future).

18 5. Rising population

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19 5.1 Housing growth 2019 to 2031 - District

Out of scope Stroud District Local Plan review – possible changes including Berkeley, Whaddon, additional 4,887 housing at Stonehouse, 10,325 Wisloe-Green Future of MOD site at Beachley, Gloucestershire 9,368 Forest of Dean post 2026 3,417* Ministry of Defence site at

5,030 Ashchurch and the concept 7,295 of a Garden Town Any further Joint Core Strategy review across Cheltenham, Gloucester City 1,370 and Tewkesbury Any further review of Cotswold District Council

* Published housing plans in the Forest of Dean are to 2026. A further estimate is provided to increase list sizes to align with the County in addition to the number of homes provided in this 20 diagram 5.2 Housing forecasts and population growth by district council

District Number of new houses Population growth April 2019 to March assumption** 2031 Cheltenham 9,368 15,176 Cotswolds 5,030 8,149 Forest of Dean* (2026) 3,417 5,535 Gloucester 10,325 16,727 Stroud 7,295 11,818 South Gloucestershire 1,370 2,219 Tewkesbury (including Wychavon) 4,887 7,917 Total 41,692 67,541

*Forest of Dean housing plans to 2026

21 5.3 Allocated assumed registered list size growth 2019 to 2031 to each Integrated Locality Partnership

List size Revised PCIP 2016 PCIP predicted Allocation of Baseline List size growth list size ILP version growth list size 2031 in number of (July 2014) Jan 2019 assumption estimate assumption 2016 plan homes* ** in 2031

Cheltenham 151,475 21,000 172,475 158,483 10,219 16,555 175,038

Cotswolds 85,707 18,000 103,707 90,405 5,030 8,149 98,554

Forest of 4,818+ 62,495 11,000 73,495 63,678 2,974 71,937 Dean*** 3,441

Gloucester 165,612 25,500 191,112 174,477 13,536 21,928 196,405

Stroud & 120,003 9,000 129,003 121,509 6,368 10,316 131,825 Berkeley Vale 5,775+ Tewkesbury*** 42,253 6,000 48,253 43,945 3,565 50,230 510

Total 627,545 90,500 718,045 652,497 41,692 71,492 723,989

* Based on an assessment of existing housing strategies and discussion of these plans with District Councils. It is recognised plans change and these are forecast assumptions

** Based on 1.62 people per household – assumes 1/3 of homes are bought/rented by single individuals and that 10% result from individuals leaving existing households ( a dilution effect of existing homes) 22 *** Additional 5 years list size growth added from April 2026 to March 2031 based on average annual estimated housing growth until 2026 . Two practices in Tewkesbury ILP included 6. Delivery of 2016 - 2021 priorities

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23 6.1 PCIP 2016/ 2021 completed or approved schemes

ILP Practice(s) Status

Gloucester City Longlevens surgery - extension Completed and opened in Jan 2017

Tewkesbury Church Street & Mythe – a new primary care centre Completed and opened in March 2017

Cheltenham Sevenposts surgery (now Cleevelands) – new building Completed and opened in January 2019

Cheltenham Stoke Road Surgery – refurbishment and extension Completed and opened in June 2018

Stroud & Culverhay - refurbishment of existing building Completed in March 2018 Berkeley Vale

Gloucester City Churchdown - new surgery Completed and opened in March 2018

Gloucester City Hadwen Medical Practice – refurbishment and extension Completed and fully opened in September 2018

Gloucester City Rosebank health – new Kingsway surgery Completed and opened in December 2018

Cotswolds Stow Surgery – new surgery Approved and due to be open autumn 2019

Dockham Road and Forest Healthcare – new surgery in Approved and due to open in June 2020 Forest of Dean Cinderford Approved and subject to planning, construction is Berkeley Place, Crescent Bakery and Royal Crescent Cheltenham expected to start before the end of 2019 and open by surgeries New Year 2021 Gloucester City Health and Gloucester Health Access Centre Approved and subject to planning, construction is Gloucester City co-locating into one Primary Care Hub at the Quayside, expected to start before the end of 2019 and open by Gloucester City Centre New Year 2021 24 6.2 2021/2026 remaining priorities – progress status

ILP Practice(s) Scheme Status

Locking Hill, Stroud Business case expected autumn Stroud & Berkeley Locking Hill and Stroud Valleys are progressing a 3rd Party led Town Centre Valleys and Beeches 2019 and Beeches Green Plan Vale development. Secondly, long term strategic plan for the Beeches Green site Green 2020/ 2021 Stroud & Berkeley Business case expected Autumn Minchinhampton Replacement of existing surgery Vale of 2019 Development of primary care facilities for around 11,500 patients as part of Business case expected Cotswolds Phoenix the Chesterton housing development Autumn/ Winter 2019 Cirencester Health Development of single facility to replace the Avenue and St Peters Road Cotswolds Site options being scoped Group buildings Brockworth & Development of single facility to replace existing surgery sites for up to Business case expected August Gloucester City Hucclecote 25,000 patients 2019

Coleford and Brunston Business case anticipated New Forest of Dean Development of primary care facilities in Coleford for around 12,500 patients surgery Year/spring 2020

Development of new facility for around 10,000 patients to replace Romney Business case expected Autumn Cotswolds Phoenix (Tetbury) House 2019 New GP building to serve a population of around 10,000 by 2028 to 2031. Cheltenham North West Elms Delivery route to be agreed The housing development is likely to be phased over a number of years. Lydney Health Centre, In light of the Forest of Dean Community Hospital programme, to bring Forest of Dean Severnbank and forward and scope the development of primary and associated community Delivery route to be agreed Blakeney surgeries based services facility for around 17,000 patients Assumed a new surgery would be built on the west of Stonehouse as part of Stroud & Berkeley Stonehouse practices the new housing development led by Regent Street surgery for around 7,000 Need to review options Vale to 10,000 patients

25 6.3 Financial investment

The delegated premises budget agreed with NHS England for 2015/2016 was is made up of the following items and the 2019/2020 budget includes part year funding of schemes opening in 2019/2020 (new Stow surgery only)

2015/ 2016 2019/ 2020 Item budget £m* budget £m* Rent 5.632 6.835 Rates 1.765 1.361 Clinical 0.134 0.109 waste Refuse 0.109 0.226 Water 0.076 0.091 rates Glevum Way Surgery, Gloucester Grand 7.716 8.622 Total

*Source: NHS Gloucestershire CCG

26 7. Summary

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27 7.1 Where are we now? • Acceleration in strategies to develop more integrated care through NHS Long Term Plan • Gloucestershire is now an established Integrated Care System, with organisations developing shared service strategies and plans. It is expected that the strategic development of primary care premises will become even more aligned with other organisations and care sectors • Ongoing changes within primary care, with extended teams providing a greater range of services seven days a week in larger facilities or through practices working together (typically for around 30,000 - 50,000 patients) as part of Primary Care Networks • A number of new primary care premises have been completed, whilst others have been approved and are progressing in line with plans • Significant investment made around £1.3m of additional annual revenue to support around £45m capital costs of developments • Population growth in Gloucestershire between 2019 and 2031 (12 years) forecasted to be 71,492 people (in line with the 2016 plan) • The number of people in each new household has been adjusted from 2.19 to 1.62 people to take into account assumptions around the number of single people buying homes and the proportion coming from existing Gloucestershire households • There are still a number of practices providing services in facilities significantly smaller than would be expected. This position worsens over the next ten to fifteen years if there is no investment in new buildings or extensions • The current physical condition and functional suitability of some main GP surgery building are no longer satisfactory for the long term • There are likely to be a very small number of unique situations which the CCG will need to take into account as part of the strategic prioritisation process • As anticipated, the PCIP has been informed by other strategic developments. The Forest of Dean community services review means that the development of options for new facilities for primary and community-based services in the south of the Forest of Dean has been brought forward • Due to financial constraints, the CCG will not be able to invest in all the schemes it would like to. It will therefore strategically prioritise against the challenges and business cases for each proposal will ensure they provide a compelling case for change and represent value for money for the period beyond 2021, up to 2026 28

Part B How are we going to get there? Delivering the 2016 to 2021 plan and identifying priorities for 2021 to 2026

29 8. Ongoing delivery and future priorities

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30 8.1 2021/2026 PCIP – strategic prioritisation

How premises are prioritised • Only include practices not already prioritised • Have a high level assessment across five elements Condition of • Practices are awarded a point for each element it appears in building (normally maximum of five points) • Buildings assessed as being in an unsatisfactory condition in the recent estates survey receive one point Capacity of • Buildings assessed as unsatisfactory in the recent estates survey building in 2031 Determining Functionality of 45% or more building receive one point smaller than it should be key priorities • If the physical capacity of a building (the internal area in square – the metres) is 45% or more smaller than current NHS England sizing regulations. Two points are awarded (highlighting the importance of strategic prioritising practices that have a lack of space in 2019) elements • If the physical capacity of building (the internal area in square metres is estimated to be 45% or more smaller than current NHS Capacity of building in 2015 England sizing regulations, one point is awarded Specific, unique 45% or more factors smaller than it • If there are specific, unique factor, these have been taken into should be account • Priorities have then been put into groups Priority Groups explained Appendix 2 sets out the CCG’s additional priorities: • Priority group 1 schemes - top priorities • Priority group 2 schemes - important priorities expected to be developed over the five year period • Priority group 3 schemes – will continue to be reviewed but unlikely to be taken forward during the period unless there is significant change • Priority group 4 schemes – unlikely to be considered during 2021 - 2026 unless there is a fundamental change to existing circumstances 31 8.2 Forward look new priorities – 2021 to 2026

Integrated Locality Premises proposal Partnership Development/replacement of facilities for the Overton Park and Yorkleigh surgeries, ideally Cheltenham as colocated services in one building for around 22,000 patients Review of primary care facilities requirements across Drybrook and Mitcheldean to support Forest of Dean long term provision of local services with a single site for around 11,000 patients Review of options for the development of Gloucester City Bartongate surgery in Gloucester City for around 9,000 patients – expected extension Review of options for the development or replacement of Cheltenham Road Surgery in Gloucester City Gloucester for around 10,000 patients in Cleevelands Medical Centre site, Bishop’s Cleeve addition to extension of Highnam surgery Review of options for the development or Cotswolds replacement of Campden surgery in Chipping Campden for around 6,000 patients Development of Chipping surgery in Wotton- Stroud & Berkeley under-Edge, which was adopted as a priority Vale in 2018/ 2019 (being delivered through an improvement grant) 32 9. ILP, cluster and practice programme framework

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33 9.1 Overview

A full breakdown of plans and supporting evidence is attached at appendix 3 and the following Gloucestershire section provides a summary for each ILP ICS

Cheltenham Cotswolds Forest of Dean Gloucester Stroud Tewkesbury ILP* ILP* ILP* ILP* ILP* ILP*

PCN PCN PCN PCN PCN PCN North Aspen Berkeley St Paul's Cotswolds Vale Tewkesbury Forest of Dean HQR Winchcombe Central South Stroud Newent Peripheral Cotswolds Inner City Cotswold Staunton North South Severn Health Gloucester (NSG)

* Integrated Locality Partnerships (ILPs) are Gloucestershire’s localised version of NHS England’s ‘Place’ level The ILPs will help to deliver ICS, Health & Wellbeing and local priorities ILPs will also support PCNs to deliver Each ILP will collectively develop an ILP plan for their place 9.2 Cheltenham ILP summary

• Population projections - 175,000 patients by PCN Practices 2031 Corinthian Surgery • New Cleevelands Medical Centre completed Portland Practice and open

St Paul's Royal Well Surgery • Stoke Road refurbished and extended St Catherine's Surgery • St George's Surgery Winchombe extended Berkeley Place Surgery • Delivery of Prestbury Road Primary Care Crescent Bakery Surgery Centre due to be open end of 2020 Overton Park Surgery Central • Delivery and procurement approach for a Royal Crescent Surgery surgery at North West Elms housing Underwood Surgery Yorkleigh Surgery development Cleevelands Medical Centre • Condition of remaining estate relatively The Leckhampton Surgery acceptable but some surgeries undersized Peripheral Sixways Clinic • Overton Park and Yorkleigh – 2021 to 2026 Stoke Road Surgery Winchcombe Medical Centre priority • Reviewing options around Leckhampton and Sixways

35 9.3 Cotswolds ILP summary

• Population projections - 98,554 patients Chipping Campden by 2031 Cotswold Medical Practice North • Completion of Cotswold Medical Practice Mann Cottage Surgery Cotswolds refurbishment Stow Surgery White House Surgery • Completion and opening of Stow surgery Cirencester Health Group • Completion of new surgery in Tetbury Hilary Cottage Surgery • Completion of new surgery at Chesterton, South Phoenix Health Group Cirencester Cotswolds Rendcomb Surgery • New surgery to replace Avenue and St Upper Thames Medical Peters Road buildings Group • Business case for a new Campden surgery

36 9.4 Forest of Dean ILP summary

Blakeney Surgery • Population projections – 71,937 patients The Brunston & Lydbrook by 2031 Practice • Coleford Family Doctors Completion of new Cinderford Health Centre Dockham Road Surgery • Complete of new single surgery building in Drybrook Surgery Coleford Forest of Dean Forest Health Centre • Development primary care facilities across The Lydney Practice the wider Lydney (South of the Forest) area Mitcheldean Surgery • Review of primary care facilities to support Newham Surgery operational working across the Drybrook and Mitcheldean areas Severnbank Surgery

Yorkley & Bream Practice

37 9.5 Gloucester City ILP summary

Rosebank Health • Population projections - 196,406 HQR The Hadwen Medical Practice patients by 2031 Quedgeley Medical Centre • Completion of new Gloucester City Bartongate Surgery Centre Primary Care Hub to replace Gloucester City Health Centre Gloucester Health Access Centre and Gloucester City Health buildings Inner City Gloucester Health Access Centre

Kingsholm Surgery • Development of extension at Highnam surgery Partners in Health • The Alney Practice Development of options for Bartongate surgery Brockworth Surgery North South • Development of options for Cheltenham Churchdown Surgery Gloucester (NSG) Road surgery building Hucclecote Surgery • Potential small scale extension to Longlevens Surgery Quedgeley Medical Centre Aspen Aspen Medical Practice

38 9.6 Stroud & Berkeley Vale ILP summary

Acorn Practice • Population estimated to increase to 131,825 Cam & Uley Family Practice by 2031

Berkeley The Chipping Surgery • Culverhay refurbishment and extension Vale Culverhay Surgery completed Marybrook Medical Centre • Delivery of new Minchinhampton surgery Walnut Tree Practice • New joint surgery for Stroud Valleys and Beeches Green Surgery Locking Hill in Town Centre Frithwood Surgery Stroud • Development of strategic Plan for Beeches Minchinhampton Surgery Cotswold Green Health Centre site for 2021/2026 Painswick Surgery • Development of primary care facility in Rowcroft Medical Centre Stonehouse remains a key priority for Frampton Surgery 2016/2021 High Street Medical Centre • Refurbishment of Chipping surgery and Locking Hill Surgery Severn business case finalisation for phase 2 Prices Mill Surgery Health extension key priority for 2021/2026 or Regent Street Surgery sooner Stonehouse Health Clinic • Review development requirements in light of Stroud Valleys Family Practice Stroud District Council housing review, 39 particularly around Berkeley, Cam, Dursley and the Gloucester City fringe 9.7 Tewkesbury ILP summary

• Population projections expected to increase to 50,230 by 2031 • The possibility of the Ministry of Defence site Church Street Medical at Ashchurch being developed as part of a Practice new Garden Town of around 11,000 Mythe Medical Practice homes is not included. If the site goes ahead TWNS assume another surgery site will be Newent Doctors Practice required. However, in early years of, it is Staunton & Corse Surgery anticipated patients will register at the Deveraux Centre West Cheltenham* • Parts of Tewkesbury Borough housing targets impact on practices outside of Tewkesbury • Condition of remaining estate • West Cheltenham Medical Practice included in Cheltenham relatively acceptable but ILP Newent undersized and remains a priority figures • West Cheltenham housing (North West Elms) aligned with Cheltenham ILP geography

40 9.8 Overarching programme 2019 to 2026

Estimated Estimated Estimated ILP Premises proposal delivery capital m2 (GIA) year (open) cost

Cheltenham Single development for Overton Park and Yorkleigh surgeries for around 22,000 patients 2024/ 2025 1,626 £6.7m

Cheltenham New surgery for North West Cheltenham due to new housing developments for around 10,000 patients 2025/ 2026 869 £3.5m

Cotswolds Development of new GP surgery in Chipping Campden to replace existing building for around 6,000 patients 2023/ 2024 520 £2.2m

Phoenix Health Group - development of new facility at Chesterton to replace existing building and accommodate housing Cotswolds 2021/ 2022 980 £4.0m development for around 11,500 patients Cirencester health Group – new primary care centre to replace Avenue and St Peters surgery and possible Park Surgery Cotswolds 2023/ 2024 1,658 £6.5m (Upper Thames) for around 22,000 patients

Cotswolds Replace Romney House with a new surgery building in Tetbury for around 10,000 patients 2021/ 2022 874 £3.8m

Forest of Dean Development of a single primary care centre for Lydney and south of the Forest of Dean area for around 17,000 patients 2022/ 2023 1,315 £4.7m

Forest of Dean Development of primary care facilities for Drybrook and Mitcheldean for around 11,000 patients 2024/ 2025 926 £3.4m

Development of a single primary care centre in Coleford to replace current health centre and Brunston surgeries for Forest of Dean 2021/ 2022 993 £3.9m around 12,500 patients Development of primary care facilities for Alney Practice at Cheltenham Road for around 10,000 patients and a small 2026 onwards for Gloucester City 869 £3.5m extension to Highnam surgery new surgery Development of existing Bartongate surgery through refurbishment of overall building to accommodate up to 9,000 Gloucester City 2020/ 2021 150 £ 0.5m patients – brought forward as improvement grant funding likely to be available New surgery to replace the Brockworth and Hucclecote surgeries and cover major population growth with total list size of Gloucester City 2021/ 2022 1,892 £8.0m 23,000 - 25,000 Refurbishment and extension of Chipping Surgery in Wotton under Edge to accommodate up to 10,500 patients- brought Stroud & Berkeley Vale 2019/ 2020 £1.6m forward as ETTF improvement grant funding available Stroud & Berkeley Vale Joint development of new facility for Locking Hill and Stroud Valleys Family Practice for around 15,500 patients 2021/ 2022 1,300 £4.4m Stroud & Berkeley Vale Development of Beeches Green Health Centre for around 9,000 to 10,000 patients 2025/ 2026 788 £3.1m Stroud & Berkeley Vale Replace the existing Minchinhampton surgery for around 8,500 patients 2021/ 2022 808 £2.5m Grand total £62.3m

41 9.9 Revenue financial framework

The table below shows the budget changes and potential budget changes up to 2025/2026. Any proposals identified as opening after March 31 2026 are not included.

2015/ 2019/ 2020/ 2025/ 2016 2020 2021 2026 Item budget budget budget budget £m* £m* £m* £m* Rent 5.632 6.835 7.290 9.155 Rates 1.765 1.361 1.477 1.949 Clinical 0.134 0.109 0.111 0.122 waste Refuse 0.109 0.226 0.240 0.265 Water Glevum Way Surgery, Gloucester 0.076 0.091 0.093 0.103 rates Grand 7.716 8.622 9.211 11.594 Total

*Source: NHS Gloucestershire CCG 42 10. Process and governance

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43 10.1 - Business case requirements

New proposals will be subject to a two stage process: Stage 1 - a short proposal should be completed on the PID template (appendix 4) for revenue requests. NHS England documentation will be used for improvement grants and other capital requirements. Appendix 5 for proposals less than £1m and appendix 6 for proposals over £1m. Stage 2 – detailed business case, following stage 1 approval. This should demonstrate viability and service benefits to obtain CCG support and the necessary funding. It will need to be compliant with the principles set out in the HM Treasury’s Five case model style of business case development and should include: • Executive summary • Strategic context and the case for change • Options and options appraisal • The preferred option • Financial appraisal • Commercial case, including benefits and outcomes, value for money and affordability assessment • Patient and stakeholder engagement/consultation including, where appropriate, other health and wellbeing partners • Travel plans, if appropriate • Risk analysis • Project development adviser team and project timetable Practices, their advisors and/or their developers have some flexibility in producing their business case . If there is a capital requirement from NHS England, the NHS England business case format should be used. Practices are responsible for completing the documents. The CCG may offer help, advice and facilitation.

Business cases need to be at least 8 weeks prior to the proposed Primary Care Commissioning Committee formal review.

44 10.2 Improvement grants

The CCG recognises the importance of utilising the Improvement Grant (IG) Scheme as defined in the current 2013 Premises Costs Directions (PCDs) to assist practices expand and/or upgrade their existing premises.

Using IGs to make improvements to primary care premises deliver a direct benefit to patients, e.g. increased clinical capacity, improved access to services and compliance with national standards such as CQC, DDA, confidentiality, etc. Larger IG projects such as an extension could also help to ensure more services can be delivered out of hospital. Improving/expanding existing practice estate can also assist the wider Primary Care Network achieve its aspirations and in turn the wider CCG/NHS strategic aims. All practices in Gloucestershire are eligible to bid for an IG in line with national guidance and governance arrangements, regardless of whether the premises are owned by the practice or leased: • The PCDs provide a prescriptive list of the types of projects that can and cannot be funded • The maximum award that can be granted is up to 66% of the overall eligible project costs (meaning the practice needs to contribute at least 34%) • The IG scheme works on a reimbursement basis, meaning practices must pay invoices first; there is no scope for the CCG to reimburse contractors directly • If a practice is awarded an IG, the building works need to be completed and all funds spent in the same financial year that the grant is awarded (although exceptions have been made for larger projects) • The CCG has little flexibility in the application of the rules Where applicable, relevant documentation attached at appendices 5 and 6 will be used

45 10.3 Engagement and equality

Engagement in proposed primary care premises developments • The key stages for engagement begin with the involvement of the Patient Participation Groups and extend to wider engagement with registered patients • An engagement checklist and Standard Operating Procedures set out a framework for engagement during both the development of a business case and the detailed design and construction period • The NHS Constitution and other legislation establish the rights of patients to be involved in planning of healthcare services, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services

Equality and health inequalities • The CCG is required to commission accessible services that respond to the diverse needs of communities in Gloucestershire and meet its obligations under the Public Sector Equality Duty (2011) • There is an expectation that primary care practice development will consider the needs of all registered patients. Appropriate impact assessments should be completed to demonstrate that proposals consider equity of access and seek to reduce health inequalities

For further information and support about patient engagement and equality visit https://www.gloucestershireccg.nhs.uk/about-you/ or contact the Patient Engagement and Experience team: [email protected]

46 10.4 Fees and other cost assumptions

The CCG will follow the National Health Service (General Medical Services – Premises Costs) Directions 2013. Key elements regarding the reimbursement of fees: 1. In the case where notional rent payments are to be paid in respect of newly built or refurbished practices, the reimbursable professional expenses are: • Project manager costs to oversee and give advice to the contractor, up to a maximum reimbursable amount of 1% of the total reasonable contract sum relating to the construction or refurbishment • Reasonable surveyors, architects and engineers fees, which taken together may be paid up to a maximum reimbursable amount of 12% of the total reasonable contract sum relating to the construction or refurbishment • Reasonable legal costs in connection with the purchase of a site (where applicable) and the construction or refurbishment work 2. Where the practice premises are, or are to be, leasehold premises, the professional expenses are: • The reasonable costs of engaging a project manager to over the interest of and give advice to the contractor, up to a maximum reimbursable amount of 1% of the total reasonable contract sum relating to the construction or refurbishment work • The reasonable legal costs incurred by the contractor In the case where other fees may need to be paid by the contractor, such as Stamp Duty Land Tax (SDLT), there is no obligation for the CCG to reimburse any of these costs to the contractor. It is assumed that that fees will normally either be part of the overall financial appraisal considered for rent reimbursement, paid by the practice or paid by the third party developer. Only in exceptional circumstances will the CCG consider reimbursement. In such circumstances, there will be no commitment to 100% reimbursement.

47 10.5 Decision making and approval Wider ICS Review for strategic fit and financial Capital strategic envelope of approvals granted by the proposals alignment ICS Board and Primary Care Commissioning Governing Body Committee Stage 1 and stage 2 executive

Detailed review and formal approval Primary Care NHS England/ of proposals – stage 1 and stage 2 within the overall allocated budget Commissioning Improvement (for Committee Impact on capital elements) business cases Review of draft proposals, provision of of NHS England feedback on scheme details to practices Primary Care capital decisions and decision to recommend for approval Operations will need to be to Primary Care Commissioning considered by Committee for stage 1 and stage 2 Group CCG

The Group and team members will oversee the day-to-day delivery of the Premises Primary Care Infrastructure Plan. This is Development ICS Health the key resource for progressing plans with Estates Group Practices and developers to ensure Group/Team proposals meet agreed priorities, provide necessary patient benefit and represent value for money. Involvement, development opportunities Practice/ (constituent member organisation to fund Production of initial proposals Developer capital requirement/headlease for (Project Initiation Document ) and Premises proposal primary care proposal), alignment, business case documentation implication and review, where appropriate 48