gp hot topics presentation

28 March 2012

English Institute of Sport, Sheffield

PROPERTY

James Williams BSc (Hons) MRICS

Principal Surveyor RICS Registered Valuer

Maximise your premises to boost surgery income and enhance

patient experience…

Regulated by RICS T: 0845 143 0019 I E: info@gpsurveyors.co.uk I W: www.gpsurveyors.co.uk I

UK’s leading Chartered Surveyors for GP Surgeries Our primary aim is to gain financial benefits for doctors Worked with over 1,900 surgeries nationwide Notional rent reviews, market valuations, developments, pharmacies, sale & leaseback RICS registered

GP Surveyors:

"Before being contacted by GP Surveyors we were not aware of this service being available. The service was extremely efficient and you won us an upward valuation to boot!" Kathy Shipp, Maidstone Road Surgery, Chatham

Compliance

New Build

Extensions

Refurbishment

Improvements

Energy Efficiency

Advice & Feasibility

… A N D e n s u r e e s s e n t i a l s t a n d a r d s o f p r e m i s e s q u a l i t y

a n d s a f e t y

Mark Dean - Director MCIAT mark.dean@bowmanriley.com

| t 0113 3917570 | f 0113 3917571 | Leeds + Skipton + Delhi Toronto Square · Toronto Street · Leeds · LS1 2HJ

Compliance

New Build

Extensions

Refurbishment

Improvements

Energy Efficiency

Advice & Feasibility

| t 0113 3917570 | f 0113 3917571 | Leeds + Skipton + Delhi Toronto Square · Toronto Street · Leeds · LS1 2HJ

Bowman Riley Healthcare team have over 16 years experience in the healthcare sector providing specialist architectural design services .

We deliver comprehensive packages of design, architectural and project

management to the healthcare sector for GP Practices, NHS Trusts, Framework Partners, Contractors, Developers and Aged Care providers

architectural design

master-planning interior design

listed building and conservation work ADB 3D Room Generation

BIM Modeling project management

health facility co-ordination 6 Facet Surveys

• CQC Essential Standards • Health & Social Care Bill • NHS:

The Changing Environment

Patient choice & experience Service enhancement & diversification Greater space requirements Quality of premises

Care Quality Commission

independent regulator of all health and social care services in England set up in 2009.

Background

care provided meets government standards of quality and safety (GP’s April 2013)

Standards

Enforcement

Insist on improvements and check they have been made

treating people with dignity and respect. making sure food and drink meets people’s needs. making sure that the environment is clean and safe. managing and staffing services

Issue fines, warning, stop admissions, suspend or cancel services

care provided meets government standards of quality and safety

making sure food and drink meets people’s needs.

making sure that the environment is clean and safe.

Issue fines, warning, stop admissions, suspend or cancel services

Care Quality Commission

Over 60% of premises will not meet the standards

Reality

CQC to inspect 10% of practices from April 2013

CQC Registration by April 2013

Economy

The Health and Social Care Bill

Premises not fit for purpose

Care Quality Commission Outcome 10 - Safety and Suitability of Premises What do the regulation's say?

Safety and Suitability of Premises

15.—(1) The registered person must ensure that service users and others having access to premises where a regulated activity is carried on are protected against the risks associated with unsafe or unsuitable premises,

suitable design and layout;

appropriate measures in relation to the security of the premises;

adequate maintenance and, where applicable, the proper— operation of the premises, and use of any surrounding grounds, which are owned or occupied by the service provider in connection with the carrying on of the regulated activity.

Care Quality Commission Outcome 10 - Safety and Suitability of Premises What should people experience? Safe, accessible surroundings that promote wellbeing

the design and layout of the premises being suitable for carrying out the regulated activity

appropriate measures being in place to ensure the security of the premises;

the premises and any grounds being adequately maintained

compliance with any legal requirements relating to the premises

Take account of any relevant design, technical and operational standards and manage all risks in relation to the premises.

Are premises fit for purpose!

How are Surgeries funded?

• Premises Reimbursement • NHS Premises Costs Directions 2004 Notional Rent Cost Rent

• Notional Rent Premises Improvement Patient Experience Value / Income Stream Enhancement Capital Value

• PCT Funding – ‘NHS Capital’ (Abatements!)

Maximising Surgery Income

Pharmacy “Implantation” New Development Internal Re-Development Extension Letting Out Surplus Space

Can your premises work harder?

Pharmacies Pharmacies

[Cornwall]

[Blackwell]

[Leeds]

Development

New Development

[Sheffield] [Sheffield]

[Sheffield]

Re-Development

[Uttoxeter]

[Bath]

[Colchester]

[Kent]

[After] [Before]

Extension

[Newcastle]

First Steps The Journey! Step 1 - How to meet the CQC Requirements?

Appraises with regard to fitness for purpose for health care buildings in terms of use, condition and compliance. The six facets are assessed and ranked are:

physical condition; Mechanical and electrical - Legionella Structural Buildings internal and external fabric - DDA, Accessibility &HTM’s

environmental management; Energy performance i.e EPC ratings functional suitability;

Internal space relationships Support facilities and location

space utilisation; How well space is been used i.e empty, generally used, overcrowded

quality;

Amenity i.e. facility, pleasantness etc. Comfort Engineering Design – DDA and Accessibility, Infection Control

fire, health and safety requirements; Statutory legislation

Commission a 6 Facet Survey

Infection Control

Accessibility

Example

Feasibility Study / Business Plan

All development work requires PCT approval!

First Steps The Journey! Step 2 - How to meet the CQC Requirements?

Business Case and Feasibility Study

Develop a robust business case Issues highlighted by the 6 facet survey Service led Look at the asset you hold What do your require? What are the benefits? How much will it cost? Additional services

Feasibility Study Identify potential sites Initial Proposals: Plans Land Take Budget Cost Potential increased income

Letting out surplus space Sports injury specialists Opticians Eye clinics Chiropodists Dentists Masseuse Physiotherapists Counselling services

Always seek advice on usage and terms!

Asset Management

• Proactive Management • Maintenance

– Program of Planned Maintenance (PPMs) – Defect Diagnosis and Costings

• Budgetary planning – Prevent a small cost spiralling into a major financial liability!

Maximising Premises The Journey!

Why?

Refurbishing Existing Premises

Compliance with CQC and statutory regulations

Professional Team to Oversee Project Phased Works

Infection Control Accessibility Comply with current HTM’s Internal Environment Functionality – Better use of Space

Potential Additional Services Energy Efficiency and Savings Improvement Grants/Rent

Reimbursement? Self-Funding?

Refurbishment Example

Maximising Premises The Journey!

Why?

Extend Existing Premises

Appoint a Professional Team

Site Constraints Like your existing location

Potential Additional Services Pharmacy, Dentist

Collaboration Improvement Grants/Rent

Reimbursement? Self-Funding?

Extension Example

Maximising Premises The Journey!

Meets all the requirements of the CQC and future proofed

New Build

Appoint a Professional Team

Find a Site in the right location? Size of premises

Additional Services can be incorporated Local Authority Dentists NHS Services Physiotherapy

Collaboration/Mergers Efficiency Savings on space

Funding Capital Cost – Bank, Investor 3PD Joint Ventures

New Build Example

Images courtesy of The Ridge Medical Practice

Procurement The Journey! Appoint a Professional Team

Electrical Consultant

CDM-Coordinator

Appoint a Professional Team

Type of Contract

Quantity Surveyor Architect

Other specialists

Mechanical Consultant

Structural Engineer

Statutory Approvals

Summary

Is doing nothing an option?

Appoint experienced healthcare professional at an early stage

Remember! • Notional Rent or Cost Rent? • When was your last review? • PREM1 Forms! • PCT Approval • Business Plan • Patient Experience • Seek Advice!

For additional information and free advice contact: GP Surveyors

0845 143 0019 / info@gpsurveyors.co.uk www.gpsurveyors.co.uk

& Bowman Riley Healthcare Architects

0113 391 7570 / mark.dean@bowmanriley.com www.bowmanriley.com

PEOPLE

People Management and CQC

Ruth Ingman

ruth@utilios.co.uk

In Context

• It will happen ... February start planning

• July 2012 Registration opens

• September 2012 Assessment begins

• April 2013 Registration complete

• Time

• Money

• Responsibility

CQC Compliance

• This is not

– A box ticking exercise

• This is

– Embedding processes within your practice

– Seeing organisational change

– Demonstrating compliance – “Prove It”

• This is not

– As scary as you thought – probably!

CQC Outcomes

• Outcome 12 Regulation 21

• Outcome 13 Regulation 22

• Outcome 14 Regulation 23

What do you need?

• Contracts and Staff Handbook

• Documented Processes and Procedures

– Recruitment Procedure

– Induction Process

– Performance Management System

– Discipline, Grievance and Appeal Processes

• Archive Appropriate Documentation

• Sound Communication Protocols

People Management and CQC

Ruth Ingman

ruth@utilios.co.uk

PLACE

NCSEM - Sheffield

Transforming Sheffield into The City of Physical Activity

To be recognised as the City that created a Culture of Physical Activity within its

communities, workplaces and people through the Legacy of London 2012 Olympic and

Paralympic Games.

Vision

Through a unified and city wide approach we will support evidence based initiatives that;

• seek to reduce the burden of disease across the City, • promote economic growth through a sports culture, • improve the health and productivity of the City's workforce and • facilitate more active lifestyles for the population of Sheffield as a

whole.

Mission

• To bring benefit socially & economically we are aiming for:

• 1% stepped change in physical activity at a population level year on year

• 15% Reduction in back pain related absenteeism in 5 years

• 15% reduction in back pain referrals in 5 years

• 2-3% reduction in CVD risk factors at population level over 5 years

• These changes are challenging but evidence based

• Represent a significant attempt at a cross population implementation project.

Measures of success

• If the average risk factors across Sheffield were reduced by 2% - 3% over five years this could:

• reduce annual admissions by up to 1,235 per year,

• prevent up to 426 premature deaths per year and

• save up to £3.7 million per year on acute hospital costs alone

• Non-recurrent cumulative savings over the five year period could be as high as £11.2 million.

Based on Whitfield et al., 2008

Modest - Invest to save

• If the average risk factors across Sheffield were reduced by 5% - 6% over five years this could:

• reduce annual admissions by up to 1,984 per year,

• prevent up to 640 premature deaths per year and

• save up to £5.9 million per year on acute hospital costs alone

• Non-recurrent cumulative savings over the five year period could be as high as £17.7 million.

Based on Whitfield et al., 2008

Optimistic - Invest to save

• Ecological model of physical activity • Provide targeted and universal support • Focus on Musculoskeletal (MSK) conditions & mental health • A whole city approach to establishing legacy • Connected through one brand, one message.

Three Interconnected Themes

Physical Activity

Workforce Wellness

Sporting Economy

• Promotion of ‘physical activity’ at an individual, group, community and population level in a wide range of settings across the City

• This bespoke physical activity comprises two forms: – ‘primary prevention’, increasing physical activity in

people with no health restrictions to activity

– ‘secondary prevention’, tailored physical activity for people with some health restrictions to activity.

Physical Activity

• Guided by current literature, there will be a particular emphasis on;

• developing an environmental infrastructure that facilitates physical activity

• challenging and changing the culture around physical activity/inactivity

• promoting physical activity among disadvantaged groups who may not have access to activity/sport or sport and activity-related facilities.

• The process of delivering a physical activity legacy is not one of investing solely and immediately in interventions

• Pilot programmes and allow the evaluation/research evidence to inform any potential roll out.

Physical Activity

• Harnessing workplaces in the promotion of healthy living at an individual, group, community and population level in a range of settings across the City (i.e. workplaces, schools, homes)

• Evidence based approach to interventions with a focus on musculo-skeletal conditions (MSK) & mental health and wellbeing

• Embedded within organisational culture, business owning the bottom line benefits

• Reduced absenteeism and increasingly more productive workforce (presenteeism).

Workforce Wellness

• The development of a sporting economy in Sheffield through the NCESEM and associated projects

• Unlike the physical activity and workforce wellness themes, the evidence for leveraging a sporting economy through interventions is limited

• Programme of in-depth stakeholder consultation and 'real-world' research to inform interventions later in the programme (years 3-5).

Sporting Economy

Sporting Economy

WP - 1 • How can the NCESEM help create a reputation for

Sheffield as an international City of Sport?

WP - 2

• How can the NCESEM be used to strengthen links between events, sporting participation and sporting economy?

WP - 3

• Can we develop an economic model for Sport to demonstrate cost-effectiveness (cost to save) benefits for the NHS and health sector?

What does NCSEM mean for you and for Joe?

• A physical activity solution for Sheffield

• Clinical impact and evidence-driven

• Embedded into communities

• Support for you and for Joe

Thank you for Listening

Dr Robert Copeland C.Psychol

Principal Research Fellow

r.j.copeland@shu.ac.uk

0114 225 5635

Paul Hudson

English Institute of Sport - Sheffield

Coffee Break

POUNDS

Lloyds TSB HealthCare

“GP Led – Surgery Developments - How to Fund a Medical Development

– the right way!”

Sheffield 28th March 2012

Graham Scott ACIB – Senior Healthcare Banking Consultant

Lloyds TSB HealthCare

•OPEN FOR BUSINESS

Lloyds Banking Group Healthcare Yorkshire Area

Craig Bennett Senior Manager Key Markets Commercial

14 Church Street, Sheffield Mob: 07595 124404

Craig.bennett@lloydstsb.co.uk

Graham Scott Healthcare Banking Consultant

5 St Helen’s Square, York Mob: 07921 105405

graham.scott1@lloydstsb

Steve Midgley Healthcare Relationship Manager

20 Market Place, Dewsbury Mob: 07725 426639

steve.midgley@bb.lloydstsb.co.uk

Stephen Denham Healthcare Banking Consultant

14 Church Street, Sheffield Mob: 07738 311942

steve.denham@lloydstsb

Julian Blythe Healthcare Relationship Manager

14 Church Street, Sheffield Mob: 07825 111188

Jjulian.blythe@bb.lloydstsb.co.uk

Lee Rycraft Healthcare Relationship

Manager 6/7 Park Row, 1st Floor, Leeds

Mob: 07725 426655 lee.rycraft@bb.lloydstsb.co.uk

Wendy Ramshaw Healthcare Relationship Manager

2 Pavement Branch, York Mob: 07725 426604

Wendy.ramshaw@lloydstsb.co.uk

Your local specialists cover the following sectors:

CARE HOMES OPTICIANS DENTISTS DENTISTS VETERINARY PRACTICES PHARMACIES GENERAL PRACTIONERS LEARNING DIFFICULTY CHILDRENS NURSERIES

Completed and Work in Progress Projects in Last Two Years

• South Yorkshire – 3 New Surgery Developments • South Yorkshire – 2 New Projects • West Yorkshire – 1 New Development • West Yorkshire – 2 New Projects • North Yorkshire – 2 New Projects • Lancashire – 1 New Surgery Development • Lancashire – 2 New Projects • Yorkshire – 7 Projects at Early Stage Discussions

These are all active examples and we are actively looking for more business.

Yours could be the next one!!!

Healthcare Index Wave 2 - All Sectors

31 %

25 %

19 %

13 %

38 %

6 %

47 %

3 %

17 %

23 %

33 %

7 %

24 %

4 %

44 %

9 %

30 %

11 %

0 %5 %

10 %15 %20 %25 %30 %35 %40 %45 %50 %

Expansion of business

Required by

regulation

Relocating to new

area

Merging with

another

Improve facilities

Other

GPs

Pharmacists

Dentists

Why are you likely to move to a new business/practice premises within the next 5 years?

27 %

23 %

17 %

25 %

9 %

28 %26 %

16 %19 %

10 %

29 %30 %

16 %

21 %

4 %

0 %

5 %

10 %

15 %

20 %

25 %

30 %

35 %

Definitely Probably Probably not Definitely not Don’t know

GPs

Pharmacists

Dentists

In the future would you like to be involved in premises ownership?

• Do you own your own house?

• Do you have a mortgage?

• Who pays your mortgage?

• Tax Relief

• Pension?

Surgery Developments – Why Ownership

• Do you own the building you are currently in and does the scheme refer to this building.

• Is the PCT aware of scheme and support obtained.

• Who will we be lending to?

- Prop Co / Op co? Structure?

• Has Business Case been produced

• Has a Financial Case been produced

Surgery Developments – the starting point … What stage has been reached???

• Has Notional Rent been agreed by DV / PCT.

• Are there any key dates that need to be met besides a start and completion date

• Has the scheme been submitted before to PCT, planners, professionals etc. If so what was outcome/decision.

• Have any professionals already been appointed? Who are they?

• Is there any information available on the scheme – drawings, plans etc.

Surgery Developments – the starting point … Gaining an understanding

• Agreement in Principle – issue of

Indicative Terms.

• Professional Valuation appraisal.

• Formal commitment – with full supporting information.

• Appointment of Professionals:- – Monitoring Surveyor – Bank Solicitor

• Funding for the land acquisition • Funding for the development • Agreement on the long term funding

Surgery Developments – the next steps … Funding commitment

• Architect / Project Manager

• Surveyor/ QS

• Solicitor

• Accountant

• Bank

• Capital Allowance Expert

• VAT Expert

Surgery Developments – the next steps … Specialist Team

• Protecting your Risk:- - Hedging options - Protecting the Partners

• Monitoring and drawdown - The role / responsibilities of the HBC and Relationship Manager - Early discussion on variances

• Drawdown on the Commercial Mortgage

- Interest only option - The start of the hedging strategy

Surgery Developments – the next steps … Moving through the project

Surgery Developments – summary checklist ………….

• Buy or Rent?

• Who is going to own?

• Who is going to be responsible within the practice?

• Have we got our team together?

• Who else do we need to speak to?

Surgery Developments – the next steps…

Thanks for listening – any questions???????

Graham Scott ACIB Senior Healthcare Banking Consultant, Lloyds TSB Bank PLC Email graham.scott1@lloydstsb.co.uk Telephone - 07921 105405

POLICY

GP Hot Topics

Legal Issues in Primary Care

Michelle Hayward and Mark Serby

Significant Change

• Registration of Primary Care providers with CQC – 1 April 2013 • Industrial action re pension changes

• Health & Social Care Bill

Outline

• The importance of Partnership Agreements

• Retirement

• Some CQC issues

• New developments applicable to Primary Care

• Employment Law

The Importance of Partnership Agreements

CQC impact: A partnership is a practice that has “arrangements in place for joint and several liabilities which all members of the partnership

agree to”.

• But a written agreement is not a pre requisite to registration

• Is there a Partnership Agreement?

If so, is it up to date?

New and retiring partners

Unsigned Agreements - acting in accordance with the unsigned Agreement

The consequences of not having an express Partnership Agreement:

The Partnership Act 1890 applies

Dissolution

• Breach of CQC requirements and PCT requirements to give advance notice of changes

• S26 - any partner can dissolve the entire partnership by notice with immediate effect.

• PCT has ability to terminate S560.10.2 if “an event happens that makes it unlawful for the business of the partnership to continue or for members of the partnership to carry on in partnership together”.

Expulsion:

• S25 - the partnership has no ability to expel under Partnership Act 1890

• Must have express provision to expel

• Partners could be breaching CQC outcomes and/or GMS/PMS contract with no ability to oust defaulting partner

• But PCT’s often require notices of partnership changes to be signed by all partners. How likely in the case of expulsion? Include Power of Attorney.

• Dovetail expulsion events with breach of CQC outcomes and events whereby the PCT can terminate the contract.

Death and Bankruptcy

• PCT has the ability to terminate (for GMS S560.10.2) but contrast S540 which suggests that the contract can continue with the remaining partner, (if a general medical practitioner).

• S33 – death and bankruptcy dissolve the entire partnership

Profits

• S24 equal entitlement

Legal/Practical Issues on Retirement

• Run off cover: e.g. MDU – claims made basis but discretionary cover only for claims once no longer a Member

• How many months’ notice?

• That death/retirement of 1 partner does not dissolve the partnership;

• Property – key asset: provision for valuation. Who is it owned by? Any outstanding loans/mortgages?

• Does incoming partner have funds to buy into the property?

• Payment terms for outgoing partner

• Indemnity

• Default retirement age?

• Restrictive covenants

CQC Issues - Timetable

• Online registration – July 2012

• Application submission – from September 2012

• Practices pick 28 day window for submission, applications processed – September 2012 – March 2013;

• Registered Manager – day to day control of regulated activities: CQC states a partner will be most appropriate.

• Pulse foresee sale and leaseback

Outcome 10 – safety and suitability at premises

• Where will financial assistance come from if non-compliant?

~ Relationship with Equality Act 2010 – only allows you to ask candidates about health/disability after job offer and then make reasonable adjustments.

Outcome 12 – requirements relating to workers:

• Effective recruitment procedures to ensure:

~ Of good character;

~ Has the qualifications, skills and experience necessary for the work to be performed;

~ Is physically and mentally fit for the work;

• Introduce fees to lodge a tribunal claim and to progress it to hearing

Employment Law Reform

• Increase the minimum qualification period for an unfair dismissal claim from one year to two

• Introduce a compensated no-fault dismissal for micro firms (those employing ten or fewer employees)

• Introduce a “rapid resolution” scheme for simple tribunal claims, which could involve an independent legal expert reaching a decision on written evidence.

• Oblige all Claimants to submit their claim to ACAS before it can be taken to tribunal, in order to give conciliation a chance.

Employment Law Reform

• Extend the right to request flexible working and modernise maternity leave so it becomes shared and flexible parental leave.

• Introduce a system of “protected conversations” to allow employers to raise issues with employees free from the worry that this will later be used in tribunal proceedings.

• Tiffin v Lester Aldridge – recognised a fixed share partner as self employed

Legal/Case Update

• RCN limit nurses indemnity cover in general practice;

• Fixed share partners

• Flasz & others v Greenwich and Havering PCT

Legal Issues in Primary Care

Michelle Hayward & Mark Serby

Partners at Wake Smith LLP

0114 266 6660

michelle.hayward@wake-smith.com | mark.serby@wake-smith.com

Ask the Experts:

Michelle Hayward – Wake Smith LLP

Graham Scott – Lloyds TSB

Ruth Ingman - Utilios

Mark Dean – Bowman Riley Healthcare

James Williams - GP Surveyors

Thank you