Managing the PCT estate of the future

The future of the PCT (primary care Trust) estate has come into sharp focus in recent times with the suggestion that any, or all, of the primary care sector’s estate could be transferred to the private sector in the form of “PropCos”. Depending upon your opinion, this is either a way of making healthcare estate management more efficient or, alternatively, of covering liabilities necessitated by the change in the accounting treatment of private finance deals. Either way it could mark the completion of the drive to make the NHS wholly service-focused, leaving supporting functions to the operational management of others. But there is perhaps another reason to reconsider how we manage the primary care estate and who should own it: worldclass commissioning (WCC) is still (relatively) immature, but its stated aims, to improve the quality and personalisation of healthcare while improving life expectancy and reducing inequalities, are a “whole-system” challenge to the NHS – the estate, IMT (“intelligent manufacturing technologies”), and equipment, included. Equally, the opportunities and potential that WCC can provide to services mean that the way we view our estate, its function, its management, and perhaps its ownership, may need to change. For now Department of Health guidance is that ownership should remain with PCTs, but the status quo may not always be the best solution. In recent years the view of healthcare buildings has shifted away from them being simply a facility to accommodate services, to one that understands that buildings can play a crucial role in supporting and enabling how the healthcare professional works. WCC will demand that the care providers, who may be very different from those we have known, develop new ways of working and interacting with the public, their patients, their community, and other providers.

Location

The key strategic question is where the PCT, now acting as a commissioner, believes responsibility for property and related issues best resides to maximise the benefits from WCC, especially where providers may not be a (former) public sector organisation, and certainly will not be directly managed. We, as a company, are currently working with primary care organisations helping them to consider the key issues for their services and their population. The most fundamental principles, for most PCTs, are whether they will require commissioned providers, and, equally, if they are providing an existing, extended, or new service, be required: r to operate from particular premises (i.e. those currently used by the NHS ALOs). r to operate within a particular geographic area (i.e. to support a locality system of “hub and spoke”), but not in defined premises. r to be free to select their own premises (and thereby location). To some extent this will be dependent on the particular service commissioned – a clear distinction can be made between, for example, PCT-wide services and neighbourhood services. However, if a provider perceives that NHS premises are inadequate, or are not value for money, then it may petition to provide services elsewhere. This may mean that the NHS is left with empty properties that it owns, or with leases that it no longer requires. Either position will entail a cost to the commissioner, as there will be residual liabilities from ownership of the property or a retained lease. Conversely, if the NHS directs providers to use particular facilities, the commissioned provider may view this, given the lack of flexibility of many existing premises, as a restraint on them offering new service models. A further complication surrounds mobile facilities such as breast screening, but such models of care are being used in other areas – for example where GP practices are coming together to jointly commission shared services that may move between the practices or clinics. Such arrangements have obvious advantages in terms of economies of scale and flexibility but, again, who should “own” the equipment, and who is responsible for ensuring that the right supporting facilities and services are available?