The potential opportunities and benefits of the proposed Shrewsbury Health and Wellbeing Hub, by Dr Carla Ingram

I am a partner in a practice with five GPs. We operate from premises owned by former partners, who receive notional rent reimbursements from NHS England. The building itself is a former detached house, which is nearly 100 years old and has been extended and modified multiple times to make it fit for the purpose of providing general medical services as per our NHS contract. There is no lift. We do not have capacity to provide accessible adult change facilities. Our admin team work in a former first floor bedroom which did not provided adequate space for them to maintain safe distancing during the COVID-19 pandemic. The age of the building (and the lack of capital funding) means there is no realistic likelihood it will ever meet modern standards, which in turn affects our ability to deliver modern services. Staff have to climb steep stairs. Our clinical rooms are all required to be on the ground floor for patient access and so we do not have capacity to accommodate any more clinicians, for example, the new additional roles staff employed by primary care networks (PCNs). Our patient numbers have increased by almost 2,000 over the last few years and yet we have very limited ability to match this with our clinical service provision.

Our circumstance is far from unique. This system of reimbursing what is deemed to be an appropriate “market rent” to retired doctors acting as landlords is commonplace, at considerable cost to the NHS, up and down the length and breadth of England. Surely it would make far more economic sense if these funds were reappropriated into delivering modern, fit-for-purpose and far more future-proof primary care estate?

Notwithstanding the problems with capacity, the personal liabilities incurred by individual partners when signing a lease with landlords; be they retired former doctors or large private finance initiative (PFI) organisations, is causing a national crisis in recruitment and retention of substantive GPs. A GP may find themself in a situation where their partners leave the practice, perhaps due to retirement, relocation or illness, and they are left with sole financial responsibility. They are faced with the impossible decision to struggle on continuing to provide NHS services for the remainder of their lease term, or to hand back their NHS contract and be personally liable for future rent payments to their landlord for the remaining duration of the lease. In some circumstances such leases can be as long as 25 years. Why would any freshly qualified GP, emerging from training with medical school debts, a young family, a new home or a desire to travel choose to take on this degree of financial liability when they could work as a locum instead?

Hark, is that the death knell of the “family doctor” I hear?

But it doesn’t need to be like this. Integrated care boards (ICB) are a legal entity with new powers to own primary care assets. This is an exciting reform that will for the first time link the ‘budget holder’ (commissioner) with estate ownership, supporting the alignment of clinical and estate priorities across a given locality and meeting the needs of an individual community. PCNs and commissioners can drive improvements in the quality of the buildings that services are being provided from and tailor those services in a way that responds to local needs and enables genuine improvement in the support and wellbeing of patients.

Development of these bespoke centres will enable the phased disposal of sub-standard accommodation, and act as an exemplar for others in the primary care sector.
But – and this is the part I feel especially passionate about – it will also reignite a sense of pride in the role of the “family doctor”. A desire to work consistently within and for a community of patients and know that there is no personal financial liability one incurs by doing so.

My practice is one of six currently looking at co-locating into one such ICB-owned health and wellbeing centres. The interest shown by all practices is indicative of the appetite for change, and the direction of travel in primary care service delivery. Gone are the days of siloed working and isolated practices. The world has changed beyond all recognition since the partnership model was set up and required practices to source their own accommodation. The building will be owned by the ICB, and spaces will be shared between all practices , as well as other external allied service providers to support the wider (social) determinants of health. It will be community-facing and community-activating, and my hope is that it will be filled with energy and life. A place of wellness, not ‘ill health’. This model of ownership will also allow practices to focus on patient care, the reason I was first attracted to a career in general practice, rather than estate issues and landlord complications.

So, NHS England has my support in this direction of travel. I know there will be teething problems, but I look forward to a brave new world of place-based, collaborative and partnership working supported by a motivated multi-disciplinary workforce in a building that is fit-for-purpose and for fit for the future.

1. Each of the practices will also have an area of dedicated, allocated space. Admin space and back-office functions will be shared as far as possible.

Carla Ingram works part time as a GP Partner in Shrewsbury, Shropshire and also one day per week as a speciality doctor in Oncology for the local NHS hospital trust.

Having attended medical school and completed her GP training in Leeds she spent 7 years working as a salaried doctor in South Wales whilst her husband completed his speciality training in Cardiology.

Following the birth of their two sets of twins Carla and her family decided to relocate to Shropshire, where Carla grew up. In the rare moments when she is not working or twin wrangling, she can usually be found in her garage gym.

Read the original blog here