Appendix 2 - Developing Person-Centred Primary and Community Services
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Appendix 2 - Developing Person-Centred Primary and Community Services NHS Lothian 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 Edinburgh 508.54 513.97 515.21 522.58 528.12 19.58 4.90 East Lothian 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.