1. 28 March 2012
English Institute of Sport, Sheffield

2. PROPERTY

3. Maximise your premises to boost
surgery income and enhance
patient experience…
James Williams BSc (Hons) MRICS
Principal Surveyor
RICS Registered Valuer
Regulated by RICS T: 0845 143 0019 I E: info@gpsurveyors.co.uk I W: www.gpsurveyors.co.uk I

4. GP Surveyors:
 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
"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

5. … AND ensure
essential standards
of premises quality
and safety
Mark Dean - Director
MCIAT
mark.dean@bowmanriley.com
| t 0113 3917570 | f 0113 3917571 | Leeds + Skipton + Delhi Toronto Square · Toronto Street · Leeds · LS1 2HJ

6. 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
| t 0113 3917570 | f 0113 3917571 | Leeds + Skipton + Delhi Toronto Square · Toronto Street · Leeds · LS1 2HJ

7. The Changing Environment
• CQC Essential Standards
• Health & Social Care Bill
• NHS:  Patient choice & experience
 Service enhancement & diversification
 Greater space requirements
 Quality of premises

8. Care Quality Commission
Background
 independent regulator of all health and social care services in England
set up in 2009.
 care provided meets government standards of quality and safety
(GP’s April 2013)
Standards
 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
Enforcement
 Issue fines, warning, stop admissions, suspend or cancel services
 Insist on improvements and check they have been made

9. Care Quality Commission
Reality
 Economy
 The Health and Social Care Bill
 Over 60% of premises will not meet the standards
 CQC Registration by April 2013
 CQC to inspect 10% of practices from April 2013
 Premises not fit for purpose

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

11. 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!

12. How are Surgeries funded?
• Premises Reimbursement
• NHS Premises Costs Directions 2004
 Notional Rent
 Cost Rent

13. Maximising Surgery Income
• Notional Rent
 Premises Improvement
 Patient Experience
 Value / Income Stream Enhancement
 Capital Value
• PCT Funding – ‘NHS Capital’ (Abatements!)

15. Can your premises work harder?
 Pharmacy “Implantation”
 New Development
 Internal Re-Development
 Extension
 Letting Out Surplus Space

16. Pharmacies
[Cornwall]

17. [Blackwell]

18. [Leeds]

19. Development

20. New
Development
[Sheffield]
[Sheffield]

21. [Sheffield]

22. Re-Development
[Uttoxeter]

23. [Bath]

24. [Colchester]

25. [Kent]
[Before] [After]

26. Extension
[Newcastle]

27. First Steps
The Journey!
Step 1 - How to meet the CQC Requirements?
Commission a 6 Facet Survey
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;  fire, health and safety requirements;
Mechanical and electrical - Legionella Statutory legislation
Structural
Buildings internal and external fabric - DDA, Accessibility &HTM’s
 environmental management;
 functional suitability; Energy performance i.e EPC ratings
Internal space relationships
Support facilities and location
 space utilisation;
How well space is been used i.e empty,
Infection Control
generally used, overcrowded
 quality;
Amenity i.e. facility, pleasantness etc.
Accessibility
Comfort Engineering
Design – DDA and Accessibility, Infection Control

28. Example

29. Feasibility Study / Business Plan
All development
work requires
PCT approval!

30. 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

31. Letting out surplus space
Sports injury specialists
Opticians
Eye clinics Always seek advice
Chiropodists on usage and terms!
Dentists
Masseuse
Physiotherapists
Counselling services

32. 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!

33. Maximising Premises
The Journey!
Refurbishing Existing Premises
 Why?
 Compliance with CQC and statutory regulations
 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?
 Professional Team to Oversee Project
 Phased Works

34. Refurbishment
Example

35. Maximising Premises
The Journey!
Extend Existing Premises
 Why?
 Site Constraints
 Like your existing location
 Potential Additional Services
Pharmacy, Dentist
 Collaboration
 Improvement Grants/Rent
Reimbursement?
 Self-Funding?
 Appoint a Professional Team

36. Extension Example

37. Maximising Premises
The Journey!
New Build
 Meets all the requirements of the CQC and future proofed
 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
 Appoint a Professional Team

38. New Build Example
Images courtesy of The Ridge Medical Practice

39. Procurement
The Journey!
 Appoint a Professional Team
 Architect
 Quantity Surveyor
 Mechanical Consultant
 Electrical Consultant
 Structural Engineer
 CDM-Coordinator
 Other specialists
 Statutory Approvals
 Type of Contract
 Appoint a Professional Team

40. Summary
Is doing nothing an option?
Appoint experienced healthcare
professional at an early stage

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

42. 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

43. PEOPLE

44. People Management and CQC
Ruth Ingman
ruth@utilios.co.uk

45. In Context
• It will happen ... February start planning
• July 2012 Registration opens
• September 2012 Assessment begins
• April 2013 Registration complete
• Time
• Money
• Responsibility

46. 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!

47. CQC Outcomes
• Outcome 12 Regulation 21
• Outcome 13 Regulation 22
• Outcome 14 Regulation 23

48. 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

49. People Management and CQC
Ruth Ingman
ruth@utilios.co.uk

50. PLACE

52. NCSEM - Sheffield
Transforming Sheffield into The
City of Physical Activity

53. Vision
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.

54. Mission
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.

55. Measures of success
• 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.

56. Modest - Invest to save
• 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

57. Optimistic - 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

58. Three Interconnected Themes
Physical Workforce Sporting
Activity Wellness Economy
• 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.

59. Physical Activity
• 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.

60. 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.

61. Workforce Wellness
• 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).

62. Sporting Economy
• 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).

63. Sporting Economy
• How can the NCESEM help create a reputation for
Sheffield as an international City of Sport?
WP - 1
• How can the NCESEM be used to strengthen links
between events, sporting participation and sporting
WP - 2 economy?
• Can we develop an economic model for Sport to
demonstrate cost-effectiveness (cost to save)
WP - 3 benefits for the NHS and health sector?

64. 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

65. Thank you for Listening
Dr Robert Copeland C.Psychol
Principal Research Fellow
r.j.copeland@shu.ac.uk
0114 225 5635

66. Paul Hudson
English Institute of Sport - Sheffield

67. Coffee Break

68. POUNDS

69. 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

70. Lloyds TSB HealthCare
•OPEN
FOR
BUSINESS

71. Lloyds Banking Group Healthcare
Yorkshire Area
Your local specialists cover the following sectors:
CARE HOMES OPTICIANS DENTISTS
DENTISTS VETERINARY PRACTICES PHARMACIES
GENERAL PRACTIONERS LEARNING DIFFICULTY CHILDRENS NURSERIES
Craig Bennett Graham Scott Steve Midgley
Senior Manager Key Markets Commercial Healthcare Banking Consultant Healthcare Relationship Manager
14 Church Street, Sheffield 5 St Helen’s Square, York 20 Market Place, Dewsbury
Mob: 07595 124404 Mob: 07921 105405 Mob: 07725 426639
Craig.bennett@lloydstsb.co.uk graham.scott1@lloydstsb steve.midgley@bb.lloydstsb.co.uk
Lee Rycraft
Stephen Denham
Healthcare Relationship Julian Blythe Wendy Ramshaw
Healthcare Banking Consultant
Manager Healthcare Relationship Manager Healthcare Relationship Manager
14 Church Street, Sheffield
6/7 Park Row, 1st Floor, Leeds 14 Church Street, Sheffield 2 Pavement Branch, York
Mob: 07738 311942
Mob: 07725 426655 Mob: 07825 111188 Mob: 07725 426604
lee.rycraft@bb.lloydstsb.co.uk steve.denham@lloydstsb Jjulian.blythe@bb.lloydstsb.co.uk Wendy.ramshaw@lloydstsb.co.uk

72. 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!!!

73. Healthcare Index Wave 2 - All Sectors
In the future would you like to be involved in premises
ownership?
GPs
35 %
29 % 30 %
Pharmacists
30 % 27 % 28 % 26 %
25 % Dentists
25 % 23 %
21 %
19 %
20 % 17 % 16 % 16 %
15 %
9% 10 %
10 %
4%
5%
0%
Definitely Probably Probably not Definitely not Don’t know
Why are you likely to move to a new business/practice
premises within the next 5 years?
47 % GPs
50 % 44 %
45 % 38 % Pharmacists
40 % 31 % 33 %
35 % 30 % Dentists
30 % 24 % 25 % 23 %
25 % 19 %17 %
20 % 13 %
15 % 9% 11 %
6% 7%
10 % 3% 4%
5%
0%
Expansion Required Relocating Merging Improve Other
of business by to new with facilities
regulation area another

74. Surgery Developments – Why Ownership
• Do you own your own house?
• Do you have a mortgage?
• Who pays your mortgage?
• Tax Relief
• Pension?

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

76. Surgery Developments – the starting point …
Gaining an understanding
• 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.

77. Surgery Developments – the next steps …
Funding commitment • 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

78. Surgery Developments – the next steps …
Specialist Team
• Architect / Project Manager
• Surveyor/ QS
• Solicitor
• Accountant
• Bank
• Capital Allowance Expert
• VAT Expert

79. Surgery Developments – the next steps …
Moving through the project
• 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

80. 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?

81. 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

82. POLICY

83. GP Hot Topics
Legal Issues in Primary Care
Michelle Hayward and Mark Serby

84. Significant Change
• Registration of Primary Care providers with CQC – 1 April 2013
• Industrial action re pension changes
• Health & Social Care Bill

85. Outline
• The importance of Partnership Agreements
• Retirement
• Some CQC issues
• New developments applicable to Primary Care
• Employment Law

86. 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

87. The consequences of not having an express Partnership Agreement:
The Partnership Act 1890 applies
Dissolution
• 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”.
• Breach of CQC requirements and PCT requirements to give advance notice of changes

88. 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.

89. Death and Bankruptcy
• S33 – death and bankruptcy dissolve the entire partnership
• 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).
Profits
• S24 equal entitlement

90. Legal/Practical Issues on Retirement
• 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
• Run off cover: e.g. MDU
– claims made basis but discretionary cover only for claims once no longer a Member

91. 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.

92. Outcome 10 – safety and suitability at premises
• Where will financial assistance come from if non-compliant?
• Pulse foresee sale and leaseback
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;
~ Relationship with Equality Act 2010 – only allows you to ask candidates about health/disability
after job offer and then make reasonable adjustments.

93. Employment Law Reform
• Increase the minimum qualification period for an unfair dismissal claim from one year to two
• Introduce fees to lodge a tribunal claim and to progress it to hearing
• 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.

94. Employment Law Reform
• Oblige all Claimants to submit their claim to ACAS before it can be taken to tribunal,
in order to give conciliation a chance.
• 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.
• Extend the right to request flexible working and modernise maternity leave so it becomes
shared and flexible parental leave.

95. Legal/Case Update
• RCN limit nurses indemnity cover in general practice;
• Fixed share partners
• Tiffin v Lester Aldridge – recognised a fixed share partner as self employed
• Flasz & others v Greenwich and Havering PCT

96. 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

97. Ask the Experts:
Michelle Hayward – Wake Smith LLP
Graham Scott – Lloyds TSB
Ruth Ingman - Utilios
Mark Dean – Bowman Riley Healthcare
James Williams - GP Surveyors

98. Thank you