Appendix 2 - Developing Person-Centred Primary and Community Services

NHS Primary Care Premises – a Strategic Overview

Appendix 2 - Developing Person-Centred Primary and Community Services

NHS Lothian

Primary Care Premises – A Strategic Overview

1. EXECTIVE SUMMARY

1.1 This document describes, at Health and Social Care Partnership level (HSCP), a series of recommended actions to adjust the existing Primary Care Infrastructure to the needs of the increasing demand driven, in significant part, by the steadily growing Lothian population and the under provision of suitable Primary Care premises.

1.2 Primary Care has, historically, demonstrated flexibility in absorbing the pressure of additional demand.

1.3 Within this document there has been a presumption against the establishment of new Practices, in favour of facilitating existing Practices to absorb new population, except where there is evidence of overwhelming need or a strategic opportunity . There has also been a presumption to support the development of infrastructure which allows Practices to share services with relevant partners.

1.4 The HSCP strategic plans, currently in development, will include a detailed strategy to address the Primary and Community premises issues highlighted in the attached appendices. These Premises Strategies will be updated annually and discussed at local GP Representative Meetings across Lothian, to establish a clear set of funded strategic actions to match infrastructure to population growth, up to and beyond 2024.

1.5 There is a need to establish Primary Care Population Growth funds which will facilitate practices to grow their list sizes. This would focus on practice manpower and any opportunities there may be to increase list size without investment in premises, see 2.7 below. There is also a need to establish a funding mechanism, based on the previous Initial Practice Allowance, to facilitate and support the establishment of new (additional) practices, where these are the only option available.

1.6 It is recognised that premises, GMS income and associated funding streams are only part of the Primary and Community services capacity which needs to be developed to meet the national and local strategic goals. This will have workforce planning implications, in addition to those of premises associated capital and revenue funding.

Appendix 2 - Developing Person-Centred Primary and Community Services

2. BACKGROUND

2.1 Over the period 2010 to 2030 the population of Lothian is expected to grow by approximately 165,718 1 (from circa 837,000 to circa 1,000,000). This increase equates to 33 additional practices of 5,000 patients each, or 1.5 per year.

2.2 It should be noted, however, that there is a significant disparity between NRS population projections and actual practice list size, as reported for any given year. In 2012 this equated to the GP list population being circa 38,000 more than the NRS projected population.

1000’s Persons Persons Persons Persons Persons Persons Year 2010 2011 2012 2013 2015 2020 NRS Projections 836.84 856.20 883.86 925.34 GP List Sizes 881.66 885.93 894.50 903.16 Table 1: NRS/GP List Variance 1&2

2.3 Since 2009, the GP list size in Lothian 2 has had an established growth rate of circa 7,200 per year. However, historically, the linkage of premises development to population growth has been largely opportunistic, being driven by a response to the poor state of existing premises, the capacity of individual practices to raise awareness of their particular issues and the opportunities created by sites becoming available.

GP List Size Changes by CH(C)P (1000’s) List Increase Average CHP 2009 2010 2011 2012 2013 2009-13 PA 508.54 513.97 515.21 522.58 528.12 19.58 4.90 101.59 102.15 103.96 103.39 104.22 2.63 0.66 Midlothian 85.73 86.13 86.59 87.61 88.40 2.67 0.67 West Lothian 178.50 179.41 180.17 180.93 182.42 3.92 0.98 Lothian 874.35 881.66 885.93 894.50 903.16 28.80 7.20 Table 2: Lothian GP List Size by CH(C)P 2

2.4 19 of Lothian’s 127 general practices, currently all in Edinburgh City but with similar pressures elsewhere in Lothian, are declaring their lists full or restricted at any given time. This is a substantial increase on five years ago when this status was used only in exceptional circumstances as a mechanism for recognition of capacity pressures.

1 NRS Population Projections, 2010 based 2 Trend of GP practice populations by gender and age-group as at 01 October 1999 – 2013 (ISD 2013.12.17)

Appendix 2 - Developing Person-Centred Primary and Community Services 2.5 This creates a ripple effect on neighbouring practices, as patients are required to register further afield and in turn creates capacity issues for those practices who may have been managing their list size satisfactorily.

2.6 GPs have emphasised, as part of this exercise, their reluctance to restrict their lists in this way and their willingness to work with NHS Lothian to address the imbalance between population growth and Primary Care capacity.

2.7 In late 2012, a short term measure was designed and proposed, by Edinburgh CHP, the Edinburgh List Extension Grant Uplift (LEGUP), to help with the immediate pressure. This was intended to help Practices who could extend their list sizes to do so, and release pressure from surrounding Practices. It is not the solution to the mismatch between infrastructure and population growth.

3. STRATEGIC PLANS

3.1 Across Lothian, 38 practices have been identified as requiring premises solutions to current capacity, compliance or quality issues and to address the future population growth.

3.2 The capital costs, of the above developments, are estimated to be between circa £64m and circa £84m. Whatever the final solution identified for development, in each individual case, there will be significant revenue implications for both Primary and Community services.

3.3 The scale and cost of these projects will vary from small amounts, for relatively minor alterations to increase physical capacity, to larger amounts for premises re-provision for existing practices or new premises for additional practices.

3.4 Each HSCP will continue to work on these, currently high-level, plans to produce detailed Primary Care Premises Strategies as part of their HSCP Strategic Plans.

3.5 High-level summaries of the identified needs addressing population/capacity issues, by HSCP, is provided in the appendices to this document together with the NHS Lothian Premises Prioritisation List, which deals, primarily, with the quality and suitability of the current physical infrastructure.

3.6 Primary Care Premises planning will also need to factor in significant additional accommodation and manpower resources for community services to address the increasing population numbers, changing demographics, “Shifting the Balance of Care”, the integration of Health and Social Care and changing models of care, to provide the capacity required and enable the delivery of core services. Appendix 2 - Developing Person-Centred Primary and Community Services Appendix 1: Edinburgh HSCP Summary

Numerically, the majority of the Lothian-wide population increase has, and will continue, to take place within the City of Edinburgh.

GP List Sizes by CH(C)P @ October Each Year List Increase 2009- Ave' 1000's 2009 2010 2011 2012 2013 13 PA Edinburgh 508.54 513.97 515.21 522.58 528.12 19.58 4.90 Data Source: ISD GP List Sizes at October Each Year, Published December 2013

The trend of annual list size increases, demonstrated above, precedes the period in planning although NRS projections suggest that this will continue, if not increase.

NRS projections suggest that the Edinburgh population will increase by circa 52,000 over the next 10 years, equivalent to one new GP practice per year through to 2024.

There has been a significant level of practice facilities development within Edinburgh HSCP and this is on-going. Current developments will increase list capacity, in Edinburgh by circa 6,500.

Further work has been, and is being, undertaken to develop mechanisms to address the continuing population expansion within Edinburgh and the capacity pressures this is creating for GP practices.

These developments do not focus on premises in isolation (i.e. LEGUP see 2.7 above) and look to increase capacity within existing practices, where this is possible. However this, within the physical capacity of the current premises, will not address the population increases indicated above.

The current Edinburgh HSCP premises development plan looks at a range of options from relatively minor works, to improve space utilisation, the extension or re-provision of individual practice premises, the re-provision of multiple practices within single buildings and the need to create new and additional practices within Edinburgh.

The capital build costs involved in building new practice premises, or extending existing, vary considerably. As an outline guide, each 1,000 patients require approximately 90sqm of space so a practice of 5,000 will have an associated build at a cost of circa £2m and associated revenue costs.

This development plan affects 19 (27%) of the 71 GP practices (17 premises) within Edinburgh HSCP, over the short, medium and long term and the overall costs are estimated to be between circa £25m and circa £30m capital and £100k and £150k p.a. revenue.

Appendix 2 - Developing Person-Centred Primary and Community Services

Appendix 2: East Lothian HSCP Summary

The mixed rural and township nature of East Lothian amplifies the impact of house building, and/or inward migration for other reasons, on individual practices, many of which are the only practice in a locality.

Overall, between 2010 and 2013, the GP list population has increased sufficiently to justify the creation of a single practice.

GP List Sizes by CH(C)P @ October Each Year List Increase 1000's 2009 2010 2011 2012 2013 2009-13 Ave' PA East Lothian 101.59 102.15 103.96 103.39 104.22 2.63 0.66 Data Source: ISD GP List Sizes at October Each Year, Published December 2013

NRS projections suggest that the East Lothian population will increase by circa 12,000 over the next 10 years. However, the Housing Land Audit projected house building to 2020 (c4,000), suggests a minimum population increase of circa 8,000 in that period.

Extrapolated through to 2024, this would equate to circa 6,000 additional dwellings with an estimated additional population, to that of 2014, of 13,000. The latter indicates the need for two or three, new and additional GP practices through to 2024, or the significant expansion of existing practice and their facilities.

Of note is the NRS projection that East Lothian will also experience a 25% increase in their elderly population over the same period, with the increased demand this will place on GP and Community services.

There will be significant pressures on practices in East Lothian in addition to that addressed in response to previous population expansions. This will rapidly outstrip the current capacity and/or the suitability of practice premises, including:

• Haddington (3 practices, facilities and population), • (facilities and population), • (high deprivation and population) • Cockenzie and Port Seton (facilities) • (facilities and population)

The current framework does not address the potential of the Blindwells development, the initial phase of which would deliver circa 1,600 houses with an additional population of circa 3,500. A new practice will be required to address this.

Appendix 2 - Developing Person-Centred Primary and Community Services The capital build costs involved in building new practice premises, or extending existing, vary considerably. As an outline guide, each 1,000 patients require approximately 90sqm of space so a practice of 5,000 will have an associated build at a cost of circa £2m and associated revenue costs.

The overall costs are estimated to be between circa £6m and circa £9m capital and £100k and £150k p.a. revenue.

Appendix 3: Midlothian HSCP Summary

The mixed rural and township nature of Midlothian amplifies the impact of house building, and/or inward migration for other reasons, on individual practices, many of which are the only practice in a locality.

Overall, between 2010 and 2013, the GP list population has increased sufficiently to justify the creation of a single practice.

GP List Sizes by CH(C)P @ October Each Year List Increase 1000's 2009 2010 2011 2012 2013 2009-13 Ave' PA Midlothian 85.73 86.13 86.59 87.61 88.40 2.67 0.67 Data Source: ISD GP List Sizes at October Each Year, Published December 2013

National Records (NRS) projections suggest that the Midlothian population will increase by circa 4,000 over the next 10 years.

The Housing Land Audit projected house building to 2020 (circa 6,000), suggests a minimum population increase of circa 15,000 in that period. Extrapolated through to 2024, this would equate to circa 9,000 additional dwellings with an estimated additional population, to that of 2014, of 21,000.

This latter would be the equivalent to 4 or 5, new and additional GP practices through to 2024 or the significant expansion of existing practices and their facilities.

Given the above there will be significant pressures on practices in Midlothian not having previously experienced capacity issues and in addition to that addressed in response to previous Local Development Plans. This will rapidly outstrip the current capacity and/or the suitability of practice premises.

The priorities within Midlothian, driven by the above, include:

• Loanhead (re-provision) • Mayfield (re-provision) • Gorebridge (extension) Appendix 2 - Developing Person-Centred Primary and Community Services • Dalkeith, Bonnyrigg and Newtongrange triangle (new Practice) to relieve pressures created by completed and anticipated additional housing • Danderhall (upgrade and extension)

The current framework does not address all of the potential of the Shawfair development which may deliver circa 4,000 houses with an additional population of circa 9,000.

The overall costs, to address the immediate capacity issues, are estimated to be between £10m and £15m capital and £50k and £100k p.a. revenue but need to be subject to a detailed review.

Appendix 4: West Lothian HSCP Summary

Between 2009 and 2013, the West Lothian GP list population has increased by 3,920, equivalent to an additional 2 partner GP practice. This has been absorbed by existing practices expanding their lists and increasing manpower.

GP List Sizes by CH(C)P @ October Each Year List Increase 1000's 2009 2010 2011 2012 2013 2009-13 Ave' PA West Lothian 178.50 179.41 180.17 180.93 182.42 3.92 0.98 Data Source: ISD GP List Sizes at October Each Year, Published December 2013

There are significant core development areas, within the Local Development Plan, already impacting on GP and Community provision. As these develop further, demand will quickly outstrip capacity in terms of both.

West Lothian population has grown by 10% in the last 10 years to 175,990 (GRO Scotland mid-2012 population estimates). It is anticipated that the population will continue to grow to around 208,285 over the next 10 years, an increase of approximately 20% (33,295). This takes account of GRO projections and Housing Land Audit housing completions estimates.

The projected population increase above will require the equivalent of an additional 6 GP practices with average list sizes of 5,500.

The CHCP have undertaken an audit of practices and existing premises and have identified the following priorities for development to manage service integration and capacity issues.

• Armadale Partnership Centre: This will include development of a new GP Practice and re-provision of community health and council services. Appendix 2 - Developing Person-Centred Primary and Community Services • East Calder Partnership Centre: This will enable expansion of existing GP and community provision in the core development area, along with development of Council based services • Linlithgow Partnership Centre: This will enable expansion of existing GP and community provision • Winchburgh Partnership Centre: This will enable expansion of existing GP and community provision in core development area, along with development of Council based services • Murieston Medical Practice: This is only new practice to be established in last 10 years and is currently in temporary accommodation. The Health Centre stock in West Lothian is aging and the following have been identified as needing refurbishment to ensure statutory compliance and meet required standards and demand.

• Dedridge Health Centre: • Carmondean Health Centre • Whitburn Health Centre

The overall capital and revenue costs, to address the immediate and long term capacity issues are still to be determined. Appendix 2 - Developing Person-Centred Primary and Community Services

Appendix 5: NHS Lothian Draft Primary Care Premises Prioritisation List

Rank Existing Premises HSCP Priority Score 2 Leith Walk Surgery Edin 26 3 Southside Surgery Edin 24 5 Brunton Place Surgery Edin 22 5 Granton Waterfront Development Edin 22 6 Dalkeith Road Surgery Edin 21 7 Ferniehill Surgery Edin 20 7 Southern Medical Group Edin 20 10 Edinburgh Homeless Practice, Cowgate Edin 17 11 Meadows Surgery Edin 16 12 Hermitage Terrace Surgery Edin 15 15 Edinburgh University Health Centre Edin 11 16 Morningside Surgery Edin 10 17 Polwarth Surgery Edin 9 17 Rose Garden Surgery Edin 9 18 Durham Road Surgery Edin 8 20 New Leith Practice Edin 6 4 Blindwells Development East 23 9 Prestonpans Health Centre East 18 12 Cockenzie Health Centre East 15 13 North Berwick Health Centre East 14 13 Health Centre East 14 14 Newton Port Surgery, Haddington East 12 19 Surgery East 7 4 Shawfair Development Mid 23 8 Gorebridge Surgery Mid 19 8 Sutherland House, Loanhead Mid 19 9 Danderhall Surgery Mid 18 11 Loanhead Surgery Mid 16 1 Armadale Medical Centre West 28 1 East Calder Health Centre West 28 5 Linlithgow Health Centre West 22 6 Winchburgh Health Centre West 21 7 Murieston Health Centre West 20 8 Dedridge Health Centre West 19 9 Carmondean Health Centre West 18 10 Whitburn Health Centre West 17 14 Craigshill Health Centre West 12 15 Bathgate Primary Care Centre West 11 16 Boghall Clinic West 10 16 Howden Health Centre West 10 17 Stoneyburn Health Centre West 9 18 Blackridge Health Centre West 8 20 Kirkliston Health Centre West 6 20 Strathbrock Centre West 6 21 Fauldhouse Partnership Centre West 4 21 West Calder Medical Centre West 4