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Leith Mount practice is now almost exhausted and the establishment and relocation of the. Victoria practice has helped immensely over the last three years.
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Version December 2017: updated costs
1. Purpose of Report This report describes at locality and city level, a series of recommended actions to adjust the existing Primary Care Infrastructure to the needs of the steadily growing Edinburgh population. The report explains why Primary Care Premises investment of c£57m is required over the next decade. The report serves to provide the background and detailed actions (Appendix I) required by Primary Care to inform the City of Edinburgh Council Local Development Plan (LDP) Action Programme, and the supplementary guidance on Developers’ Contributions and delivery to support those actions. The report describes the requirement for developer contributions at a stage in the expansion of the City where all available capacity has been used. There are different Primary Care healthcare Premises and costs attached to development across the City, depending upon whether there are existing buildings which can be augmented, whether a replacement building is required for an existing practice to expand or whether entirely new premises is required for an entirely new population. Whilst attention has been paid to try to represent each situation accurately, the picture is very dynamic both in terms of population pressure and opportunity.
2. Background 2.1 Over the period 2010 to 2030 the population of Edinburgh is planned and expected to grow by approximately 100,000 (from c500,000 to c600,000). 2.2 Since 2009, the GP list size in Edinburgh has had an established growth rateof approximately 5,000 per year, equivalent to a new GP practice annually. 2.3 The LDP covers the period 2016 ‐ 2026 and gives a solid basis for these infrastructure recommendations. The LDP was examined and reported by the Scottish Government in September 2016 and the plan has now been adopted by City of Edinburgh Council (CEC). Although there will continue to be speculative planning applications from developers for sites not within the plan, it does allow for a more informed approach in planning the primary care response to the pressures generated by the considerable housing growth. The rate of growth is expected to continue for the life of the plan, and beyond. 2.4 Until the 2014 Report, Primary Care Infrastructure development in Edinburgh was 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. The linkage of premises development to population growth was previously largely opportunistic and not always adequate. 2.5 Since 1999, the following new premises have been developed: Table 1 Year Completed Original List Size Current List Size (Oct 2016) Craigmillar 1999 8,223 (Jan 2000) 8, Bellevue x 2 practices 1998 7,272 (Jan 2000) 13, Mountcastle x 2 practices
Leith Mount 2005 7,250 10, Slateford 2007 6,608 9, Conan Doyle 2007 3,500 3, Gracemount 2005 5,880 7, Westerhailes 2013 6,759 (Jul 2000) 7, West End 2014 7,925 9, Total 64,421 80, 403 In the same period (2000‐2016), GP list sizes grew 51,549 (489,241 to 540,790). Only about 16,000 of this growth was facilitated by the new builds in the table above. The remainder, some 35,500 people, have been absorbed by practices increasing their list sizes and two new practices having been established. It should be noted that until at least 2007 the rate of population was relatively slight and often erratic. Only in 2010/11 did public services in the City begin to recognise the implications of a long term and accelerated trend of population increase.
2.15 GPs emphasised, as part of the 2014 consultation, their reluctance to restrict their lists in this way and their willingness to work with Edinburgh Health and Social Care Partnership (EHSCP) to find a better balance between population growth and GP primary care capacity. The current proliferation of restrictions is an indication of how critical the current situation is. 2.16 In 2014, population pressure and restricted lists were very much a problem for the North of the City. Three years on, the problem is city‐wide. 2.17 In late 2012, a short‐term measure was designed and proposed; 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. 2.18 The LEGUP grant of £25,000 enables practices to implement the necessary actions required to grow by the agreed amount of 500 patients over a 12 month period. As there is a time lag in the income associated with list increases, practices had found it difficult to grow because of the associated costs – LEGUP enables the management of that pressure. 2.19 Dialogue with GPs across the city noted concern that the LEGUP mechanism might be seen as anything more than a short‐term solution to the mismatch between infrastructure and population growth. 2.20 A series of dedicated meetings in 2013 used a standard template and gave geographically sensitive information on likely population build up per Primary Care locality estimated from planned housing developments, (which is acknowledged to be lower than actual population growth). 2.21 These local meetings were universally welcomed by GPs, who embraced the opportunity of a more deliberately planned and consensual position on this issue. The meetings were held again in 2014 and widely acknowledged as useful. Due to the CEC Local Development (Housing) Plan being reviewed by the Scottish Government, no meetings were held in 2015. The LDP a s m o d i f i e d i n e x a m i n a t i o n was released in September 2016 and dedicated GP premises meetings took place in November 2016 across each of the ‘new’ locality areas.
3. Locality Overview (see appendices II ‐ V for detail) 3.1 Appendix I summarises the overall City position and gives indicative figures and timescales. Local Development Plan sites identify considerable development in green belt areas, particularly in the South East Wedge, West and North West. Scheduling now identifies that building will commence on most sites during 2017 and this could be accelerated as demand increases. 3.2 Appendices II to V set out the local consensual outcomes of these discussions. These recognise the long‐term need for new buildings, partly in response to poor existing accommodation and partly in response to population pressure. They also suggest more limited investment in existing buildings, where it is possible to augment or to expand list size. Thirdly, they prioritise those Practices who could be helped to keep their list size open, and continue to welcome new patients over the next three years (LEGUP grants). 3.3 North West (pop. 156k with 19 practices) Appendix II Some of the population increase in this area will be absorbed by a combination of the New Partnership Centre which is already underway and adjustments through extension/reorganisation grants and LEGUP. The planned increase on the Granton Waterfront predicted to be c10, 000 post 2019 is separate to the population increase in Muirhouse. A second new practice and new practice building needs to be established in this area of the City. There are three new development sites clustered around the Gogar roundabout, one of which has a new Primary School site anticipated. This would give opportunity for a combined infrastructure solution in the area. A small scheme investment was made at Davidson’s Mains and this additional capacity of c remains unused. There is also capacity at the Parkgrove Surgery provided a lease can be agreed post 2019. Together, these will be adequate to serve the imminent Cammo development. In 2017, South Queensferry will benefit from an Intermediate Scheme, potentially allowing a further 3000 to be offered General Medical Services (GMS) from the existing premises. There is a longstanding requirement to renew the accommodation of the Stockbridge Practices. There are several options including the opportunity of the Royal Victoria Hospital site development. 3.4 North East (pop. 125k with 18 practices) Appendix III As a part of the 2014 work, GPs looked imaginatively at their existing premises and c7,000 of potential new population capacity was identified as able to be accommodated through a combination of both extension/ reorganisation and LEGUP funded growth. The capacity of the Leith Mount practice is now almost exhausted and the establishment and relocation of the Victoria practice has helped immensely over the last three years. Since the 2014 recommendations, the Leith Walk scheme has been progressed and an additional 2,000 of physical capacity will be created by Spring 2017. In addition, the list of Leith Links has now re‐opened and is able to absorb a further 2000. North East Edinburgh is strong example of a series of modest investments and close working with practices averting a widespread local crisis. The next stage is to ensure that the North East HUB in Leith Walk or Gamechanger (Easter Road) or combination of both, are able to address the immediate requirements of the Brunton and Leith Links practices. An additional Leith Waterfront population needs to be considered separately. There is a further potential opportunity for renewal with the planned development
A further ‘intermediate’ scheme may be possible at the Grange practice to help with capacity in the medium term. The remaining area concerns the Hermitage Terrace practices, and potentially the Morningside practice which could be grouped together. The Phase 3 development of the Royal Edinburgh Hospital site offers a potential solution for this development and timing would fit with practice plans. The plans for the development of the Access practice currently in temporary accommodation in Spittal Street are well underway. There is a good option for this practice and the business case is well developed and should come forward when a rental and capital investment between NHS Lothian and CEC is agreed. 3.6 South West (pop. 130k with 17 practices) Appendix V Ratho surgery will be re‐provided in 2017 in new premises with increased capacity – sufficient to absorb early population build up from new developments in the West until a new practice is established. The other immediate challenge is that the Polwarth practice is now a 2c (directly managed) practice with a six‐month rolling lease. This requires an urgent solution in 2017 due to uncertainty of tenure. Discussions on a potential option at Tollcross Health Centre are ongoing. If successful this will avoid a capital investment of c £2.5M. Allermuir Health Centre will open in 2017 and provide new accommodation with increased capacity for Craiglockhart / Oxgangs and Firrhill Practices. There is sufficient physical capacity to accommodate the Craighouse development and the likely future development of Redford Barracks for residential use. The Pentlands Practice catchment area includes new developments already underway and likely to bring an additional cohort (approx 2,000 people) into the Practice catchment. The current building may be able to be augmented (Minor / Intermediate scheme) to facilitate.
4. Key Understandings 4.1 The population build‐up due to new housing has been estimated to account for c50% of the actual increase. These figures will be locality sensitive and the conclusions they provoke will be adjusted and refined annually. Accordingly, we have only recommended capital investment where we believe there is a high probability of substantial population increase and/or the urgent requirement to renew existing premises. 4.2 A further complicating factor is the student population. The student population equates to approximately one third of an average population in terms of primary care workload. It is important to recognise the administrative workload caused by high turnover and the concentration of this in October in particular. In some areas, notably central South East and more recently, central South West, an increase in dedicated student accommodation locally, can create rapid rises in list sizes which in reality are only associated with relatively modest clinical demand. It is important we do not either over‐react to this or fail to make adequate provision. The overall size of the student population continues, we understand, to be relatively stable. 4.3 The 2014 work recognised the strategic opportunity which occurs when an existing GP Partnership decides to reform into two new partnerships. This has provided a very welcome response to rapid population build‐up in two areas of the city (Niddrie and Victoria). 4.4 A further development has occurred for the large new North West Partnership Centre (Muirhouse) has agreed to seed or nurture the fledgling practice (‘Penny well’) and to make the list size sustainable. This innovation has so far proved a very attractive mechanism saving considerable cost and protecting patients against the risks of an unsupported clinical function. 4.5 The issue of practice size needs to be addressed as part of the planning process. Historically, a list size of c3000 was regarded as sufficient for stability and in many parts of Scotland it could be less for geographical reasons. The average practice size in Edinburgh is now 7,200. Only six practices out of 73 now have a list size under 5000. Four are set to grow beyond 5000 and the remaining two will be absorbed into neighboring practices or merged as senior partners retire. By 2020, it is likely that no practice in Edinburgh will have a list size under 5000, and the average practice size will rise to around 8000. 4.6 The issue of Practice boundaries has re‐emerged as a live topic further to the Locality and Clusters formations. There is an appetite for a rationalisation of current boundaries which are unfeasibly wide in many cases. This work will be taken forward during 2017. 4.7 Work was undertaken which suggested that the catchments of all 73 practices could be helpfully interpreted as 16 Primary Care delivery areas – or ‘sub clusters’ where groups of practices have significantly overlapping geographical concentrations of patients. This work is potentially helpful in a number of ways. Firstly, it helps to legitimise the clusters, i.e. when the natural population concentrations of practices are mapped they suggest affiliations between practices which accord with the cluster groupings. Obviously this becomes more subjective with some practices, e.g. Meadows practice could have been interpreted as an extension of the South West (SW) ‘Canal’ cluster or as part of the South East (SE) ‘North’ cluster. The decision was made to place it in the SE North cluster as it sat within the SE locality boundary. The overriding point is that no practice has been placed into a cluster arrangement which is not solidly founded on consideration of significant population in common.
5. Developers Contributions Methodology Developers’ contributions have been calculated using a range of options to address the variety of solutions to primary care premises infrastructure. The options vary from small schemes whereby a practice increases capacity through modest means, to full re‐provision or new build. This approach enables a flexible and proportionate response to the population increases arising from local developments. There are numerous variables that influence the proposed actions including; number of patients generated, type of solution (scale of refurbishment, use of shared building, condition of existing building, shared location, type of new build and availability of land/space), cost of solution, proportion of solution required to cater for new patients etc. The options and estimated costing are outlined below, and Appendix VI sets out the calculations for each proposed development in more detail. 5.1 Small Schemes Cost range: £0.01m‐£0.1m Schemes to increase capacity by creating additional consulting space / reorganisation within existing practice premises. Cost range is based on the work carried out for comparable schemes in over 20 practices in the past 3 years 5.2 Intermediate schemes Cost range £0.1m – £0.5m An intermediate scheme is a more substantial scheme for existing practice premises, where an extension is added or significant internal refurbishment is required to add sufficient increased capacity. Costs are based on completed schemes or schemes in development in the last 3 years. 5.3 Refurbishment/redesign entire practice premises Cost range £0.5m ‐ £1.2m This involves extensive redesign which may include augmentation of premises as well. If the redesign is not wholly attributable to new development pressures, only a percentage of the total scheme cost would apply for developers’ contributions e.g. If a practice of 8,000 patients requires a capacity increase to accommodate a further 2,000 growth from developments, then only the percentage costs relevant to the development would apply for contributions i.e. 20% of the cost of the total scheme. 5.4 New build Cost range highly variable Required when an entirely new building is needed or a new practice is required, needing both premises and staff. In particular the latter will apply in instances where there is no general practice provision in the area or that which is there is unable to respond to the increased need. Cost will vary dependent on solution to deliver scheme and the number of patients which the practice will serve. Indicative costs are based on Scottish Future Trust metrics.
6. Partnership Working 6.1 GPs continue to be receptive to the idea of sharing premises with neighbouring practices and indeed other public services. Much closer working between CEC, NHS and other agencies has developed over several years and the EHSCP. Buildings which are no longer required or which are considered unfit for purpose by one agency, may present a long‐awaited opportunity for a partner. 6.2 The ideal ‘partnership’ models have been brought together in developments such as WesterHailes and prospectively the new North West Edinburgh Partnership Centre (NWEPC) development. These are essential in areas which have high levels of economic deprivation, but are not necessarily a requirement in other areas of the City. We already have obvious Partnership groupings in several areas with high deprivation; - Craigmillar - Liberton and Gilmerton - Wester Hailes - North West Edinburgh Partnership Centre (NWEPC) (scheduled) 6.3 Areas with high levels of economic disadvantage which have no obvious public sector ‘hubs’, are; - Sighthill area – possible redevelopment of Sighthill - Craigentinny / Lochend – North East HUB / Gamechanger - Leith 7. Resources Sought (Primary Care Population Growth Funds) 7.1 Appendix V summarises the resources required with indicative timescales. 7.2 In 2014, c30 practices across the City told us that with a ‘reorganisation or extension’ grant (less than 50k per practice) they could increase their list size by 500 or more. Since then we have given out 17 LEGUPs and undertaken 17 minor works schemes to increase physical capacity. 7.3 The combination of a ’reorganisation and expansion’ grants scheme and the LEGUPs, have provided additional capacity for c10000 patients across the City. The cost of this was approximately £400k; a fraction of the cost of establishing a new practice and providing premises. 7.4 The modest annual provision of £200k for minor premises ‘reorganisation and expansion’ grants (less than 50k each), should be continued – in the last two years, only half was allocated albeit capital slippage augmented some of the shortfall. 7.5 8 ‐ 10 LEGUPs are required per year. In 2014, eight were given out, in 2015, this reduced to five and in 2016 only three were available. The number of restricted lists has risen accordingly. 7.6 Around 10 practices are currently willing to consider LEGUPs in 2017 and this is a way to augment capacity whilst further infrastructure solutions are put in place. 7.7 Further capital schemes are recommended with an indicative cost of £57m. These are proposed partly in response to poor current conditions and partly to respond to the growing population. Many are as a result of both influences.
9. Equalities Impact Assessment A Rapid Impact Assessment was undertaken on 23.1.2014. The assessment highlighted the following points: - The opportunity for Public and Third Sector services to plan for the population increase collectively through the Edinburgh Partnership. - The risks associated with any new population being unable to access a GP list or appointments are thought to be greater for areas of widespread economic deprivation. The consequences of substantial numbers of the population by‐passing Primary Care Services would be increased pressure on Acute and other direct access health and social care services.
10. Recommendations 10.1 Note the quantification of the significant under provision of suitable Primary Care premises in many parts of the city. 10.2 To note that c55,000 more people will live in Edinburgh by October 2026 and full implementation of the clear set of actions in Appendix I is required to match infrastructure to population growth. 10.3 To note (Appendix I) that an additional c£57m is required to provide and renew accommodation for the existing and additional population. To note that £21m investment is being made in 2017 which will give physical capacity for an additional 11,000 people. 10.4 To recognise the historic flexibility of Primary Care in absorbing the pressure of additional population demand. 10.5 To continue to support established practices to absorb new population, whether through new buildings or amalgamation of existing buildings. 10.6 To establish four entirely new practices in new buildings during this period. 10.7 To support the development of infrastructure which allows Practices to share services with relevant partners. To recognise that sustainable Primary Care practices embedded in their local communities and connected to local services are the preferred model. Where an opportunity arises, GP practices will also be sited together. 10.8 To note that the attached locality appendices (II ‐ V) will continue to be updated annually and discussed at local GP Representative Meetings across the city and with the GP Sub‐Committee. 10.9 To progress established developments (North West Edinburgh Partnership Centre, Leith Walk, Allermuir, Ratho) to implementation in 2017. 10.10 To continue to request c£0.7m Primary Care population growth funds each year as a interim measure to support LEGUP grants, small schemes and one ‘intermediate scheme’ per year. 10.11 To recognise that premises, GMS income and associated funding streams are only part of the service capacity which needs to be developed. This work needs to come together with the workforce capacity planning for all associated disciplines. 10.12 To note and support the partnership working with CEC Planning Department to quantify the expected growth from the Local Development Plan (LDP) and the CEC LDP Action Programme which identify Primary Care impact and actions attributable to the LDP. 10.13 To note support CEC Planning department in collecting developer contributions towards the Primary Care infrastructure required to support new housing. 10.14 To support a review of the IJB/CEC/NHSL governance arrangements to enable a timely response to urgent premises situations or opportunities which arise within a fixed timescale. 10.15 To note that this document reflects the position as at the beginning of 2017.
Location Details Estimated^ capacity^ increase Building required Estimated Capital Cost (BCIS 2017 Q4) £m Current status Urgency category / Scheme type South East New practice Gilmerton +/ ‐^ re ‐ provision of existing local practice(s) Establish new practice to mitigate impact of SE Edinburgh developments. Potentially combine with re ‐provision of Ferniehill and Southern 6, 2018 3 (8) Exploring options ‐^ potential development with 21stC Homes or Morrisons supermarket. N Edinburgh Access Practice Re ‐provision of unsuitable premises, temporarily in Spittal St 0 2018 2 Business case in development for city centre site R Southside Re ‐provision of premises due to loss of existing premises 0 2017
Underway ‐ moving to Conan Doyle S Morningside Re ‐provison of 2 ‐^3 practices 1, 2021
Speculative ‐potential opportunity Royal Edinburgh Development ph 3 N Meadows area Re ‐provision of premises for up to 3 practices 1, ? 3 Speculative ‐ limited site opportunities N Grange Intermediate scheme ‐ extension 2, 2018
Discussions with practice/exploring options **I Sub total 10,
South West** Ratho Surgery Re ‐provision with increased capacity 3, 2017
Underway N Allermuir Health Centre** Re ‐provision of Craiglockhart/Oxgangs and Firrhill practices 2, 2017
Underway N Pentlands Medical Centre Intermediate scheme ‐ internal refurbishment 1, 2018
Early discussions with practice I Polwarth Re ‐provision of premises due to loss of existing premises 0 2017
Exploring options for relocation to health centre **I Sub total 6,
TOTAL 68,
Edinburgh Health and Social Care Partnership ‐ Population and Premises Plan Appendix I URGENCY KEY SCHEME TYPE ***^ Revenue schemes, landlord developing Underway NEW BUILD
Total cost of partnership centre** Immediate ‐ 3 years REPROVISION 3 ‐^ 7 years INTERMEDIATE 7 years plus SMALL
Appendix II
Key Understandings
