Written evidence submitted by Assura Plc (FGP0210)


This submission outlines some of the current challenges for accessing general practice which are exacerbated by the sector’s premises and infrastructure, and next steps which would help.


Who we are:


Assura is a FTSE 250 listed specialist real estate investment trust based in Warrington, working only on healthcare premises. We are the long-term owner of more than 600 GP surgery, primary care, diagnostic and treatment centre buildings around the country, with a property portfolio valued at just under £2.5bn. Our buildings serve more than 5.6 million patients, and we work with patients, GPs, CCGs, NHS Trusts and emerging Integrated Care Partnerships to expand, reconfigure and improve existing primary care buildings, and to create new premises needed for the future. These buildings serve as the gateway to wider NHS services and are often held up as the locations where most patient contact in the NHS takes place. Our Assura Community Fund[1] has distributed more than £1.3m to health and social prescribing projects in the communities around our buildings, reaching almost 180,000 people on issues such as mental health, isolation and skills.


What are the main barriers to accessing general practice?


The state of the nation’s GP and primary care estate is among the barriers to accessing general practice for many patients. Why?


  1. The legacy of under-investment:


Prior to COVID-19, the NHS was already facing unprecedented and well-documented infrastructure challenges, as its Long Term Plan[2] set out: “Some of our estate is old, in parts significantly older than the NHS itself, and would not meet the demands of a modern health service even if upgraded.”


Primary care buildings serve as the gateway to wider NHS services and are often held up as the locations where most patient contact in the NHS takes place. However, many are unfit for purpose, without the space, layout, design or digital capability needed to deliver a hybrid of both face to face and remote primary care to growing patient lists, to support the need for greater diagnostic capacity, to support care at scale as Integrated Care Systems develop and to expand the range of health services being delivered in local communities.


Research from the Patients Association highlights the power of these buildings for the patient experience of accessing health services in the community[3]. In the most recent premises survey by the British Medical Association (BMA), 50% of practices said their premises are not fit for purpose and 80% of practices said their premises would not be able to cope with expected future growth in demand[4].

Far more recently, in a survey of more than 1,000 healthcare professionals[5] including doctors, nurses, midwives, ambulance workers, public health staff and people in NHS facilities and maintenance roles by YouGov:



  1. Inequality of access - impacting use of primary care for those who most rely on it:


In July, a series of commitments aimed at building a ‘better and fairer life for all disabled people’ were published in the Government’s National Disability Strategy[6].


Among the challenges noted in the strategy are ‘visiting the GP surgery’. The strategy states: “Of those disabled people who had found difficulty accessing public buildings at least ‘sometimes’, about three quarters had experienced at least some difficulties accessing health services (78%)…Access to healthcare services appears to have been particularly impacted by the COVID-19 pandemic – disabled people more often indicated coronavirus had affected access to healthcare for non-coronavirus related issues than non-disabled people (40% compared with 19%).”


The publication of the strategy follows the launch of a recent report[7] from the national charity Dimensions as part of its national #MyGPAndMe campaign – which highlights the role of primary care and GP buildings and their environments in reducing inequality of access to local NHS services.


The research on the experiences of hundreds of people with physical disabilities and impairments, learning disabilities and autism in primary care buildings found that:


  1. The impact of poor infrastructure on primary care recruitment:

Recent research by the British Journal of General Practice[8] highlighted how people living in areas of greater deprivation can find it more difficult to see a GP or other primary care professional, in places where health inequalities are most acute.

The study found that workforce shortage for GPs, paramedics and other NHS roles are disproportionately affecting more deprived areas, where people are more likely to experience poor health driven by living, employment, education and financial circumstances.

The space and premises which GP practices have at their disposal are a contributing factor to their recruitment challenges: infrastructure continues to be one of the biggest investment asks from general practice[9], with regular reminders that there is “no room for growth.” [10]

Whether as primary care staff or patients, experiences of primary care buildings can have a real impact on perceptions of care, how it is delivered and on willingness to engage with local health services at all. The way in which health spaces are designed and improved can play an important part in reducing health inequalities.


  1. Competing priorities for the NHS

The quality of primary care premises has traditionally taken somewhat of a back seat in the debate about funding pressures for the NHS. Around 340 million patient consultations take place each year across c.9,000 primary medical centres[11], of which an estimated 3,000 centres are unfit for purpose. Given the expanded role for primary care at the heart of the Long Term Plan and the capacity which will be required to deal with rising waiting lists and unmet demand, a more strategic focus on both physical and digital infrastructure for primary care and community health is needed.


The British Property Federation has estimated that 1,300 new primary care buildings are needed to replace unfit GP surgery premises in England, requiring an investment of £5bn[12]. Sir Robert Naylor’s 2017 review of NHS estates highlighted that without investment in the NHS estate, transformation of services cannot be delivered[13].


Publication of government’s Health Infrastructure Plan[14] included the much-welcomed pledge to introduce a new five-year rolling programme of investment in NHS infrastructure – responding to the consistent calls for a long-term approach to and view of capital funding. But so far this has predominantly focused on the acute estate. We continue to look forward to further detail for the wider primary care and community health picture. 


How can these barriers be tackled?


Historically, a range of funding models have been used to improve the primary care estate, and a list of these is attached as appendix 1. The level of improvement needed to the primary and community healthcare estate is highly unlikely to be met from government capital or land receipts alone. If the Health Infrastructure Plan’s commitments to improve the primary care estate are to be delivered and if the challenges facing the health service when it comes to recruitment, waiting lists and capacity are to be addressed, Government’s leadership to support the health service in identifying and implementing sources of good value, transparent funding into premises will be essential.


There are many options which could complement public capital or inspire new funding programmes to accelerate improvements to the primary care buildings which are a gateway to the wider NHS, putting the Health Infrastructure Plan into action. The healthcare property sector is keen to work with national, regional and local governments, the voluntary sector and community groups to explore innovative new funding approaches. One emerging new model that we are exploring at the moment with Modality Partnership would allow a primary care at scale organisation to own and run its estate in a joint venture partnership with Assura – giving the primary care organisation true co-ownership with equal control, property benefits and income. This would give the primary care organisation immediate access to capital to acquire practice premises, improve existing sites or develop new buildings, with the support of a healthcare premises specialist. 

We believe this is one, innovative way to help address some of the historical issues which continue to constrain improvement to and modernisation of the primary care estate.


Ownership of GP premises infrastructure remains very mixed - allowing for the diverse preferences of individual GPs, partnerships, practices and at-scale primary care organisations. However, the overarching goal must be of a modern primary care estate which is fit to deliver accessible care both face to face and remotely. Third party or shared ownership of premises can drive funding into this infrastructure and reduce the risks for GPs by:



Given the transformational ambitions for primary care and the subsequent implications for the buildings in which that care is delivered, third party or shared ownership (such as in a joint venture with a third party premises specialist) is a strong option to support many GPs in reducing their premises risk, and to ensure there is sufficient investment in the primary care estate of the NHS to prepare for the long-term. Third party ownership also opens up opportunities for closer working between the NHS and its estates functions, GPs and independent expertise to ensure primary care is making best use of its existing estate and equipping it for a mix of face to face and digital provision, and that opportunities to modernise the places where we access health services in the community are used to their full potential for the NHS’s services, staff and patients.


To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?


Whilst remote appointments are certainly one way to help ease the pressures on the physical infrastructure of general practice, there will still be the need for some face to face diagnosis, testing and care (the Royal College has estimated that things would level at a roughly 50-50 split, in time), and the quality of primary care premises and the space available for face to face services away from acute sites remain a huge challenge for the health service as described above. Existing buildings must also be configured to facilitate remote appointments, and to make the best use of space in a hybrid care model.


The Government’s plan also highlights the work to broaden access in primary care to other allied health professionals in that setting: 


“The Government’s manifesto commits to expanding the number of other primary care professionals by 26,000. This is essential to expanding general practice capacity and bringing a wider range of skills to the primary care team, enabling GPs to focus on what only GPs can do. PCNs have flexibility to employ any of 15 different roles and are successfully employing over 10,000 extra staff already.”


But as RCGP chair Dr Martin Marshall described in the summer[15], the service currently does not have the physical space to accommodate those professionals once recruited: “We need an expanded workforce with the appropriate support and premises if we are to improve access, reduce health inequalities, ensure patient safety, and give GPs more time to care for and build trusting relationships with their patients.”


The current plan from government and NHS England does not address these infrastructure challenges.


How does regional variation shape the challenges facing general practice in different parts of England, including rural areas?


See above points relating to recruitment of primary care staff, where regional variation in premises capacity and investment is impacting upon primary care’s ability to recruit and retain staff, which in turn impacts upon equality of access to services to patients and should be a core component of levelling up communities.


What are the main challenges facing primary care in the next five years?


Waiting lists, capacity, working at scale and hybrid delivery:


COVID-19 has driven significant changes in the way that primary care serves the public – perhaps most notably, an acceleration in the use of digital technology to offer remote triage and consulting, where appropriate for individual patients. Primary care sites have been used as places to support COVID-19 specialist care – we have put vacant space into action, for example, at Birkenhead Medical Building to create room for respiratory day care – and GPs continue to report an increase in the range of activities being delivered in primary care which would normally be completed at acute sites[16]. Practices are building from their move into primary care networks to increasingly operate at scale, albeit that this varies enormously in scope and implementation all over the country.


For all of these challenges, updating and improving the primary care estate will be key. Our research and innovation project[17] to explore what a medical centre of 2030 could look like – building from primary care’s growing adoption of digital technology and the potential to co-locate diagnostics and other services away from hospital – has already offered an insight into how buildings will need to change in step with the impact of COVID and the evolution of the delivery of care. Failure to accelerate the pace of the estate’s change will constrain primary care’s efforts to evolve its working model, bring in a wider range of professionals, play its part in reducing waiting lists and to keep pace with growing patient lists. As the King’s Fund has described it, estate and technology are twin enablers of primary care of the future[18].


The NHS’s journey to net zero:


As described above, the nature of the current estate means that primary care will face particularly significant challenges in reaching net zero carbon. Healthcare buildings face a number of unique issues: good design practice encourages the use of natural light to promote wellbeing through connectivity with the outside and daylighting. But this can conflict with net zero features such as smaller windows designed to reduce energy loss.  Similarly, front doors, which are constantly opening and closing as patients walk in and out of surgery sites, make it incredibly difficult to minimise heat loss and reduce energy use in the colder months.


Another key factor is the cost and financial viability of the design elements required to push buildings closer to net zero. A timber frame for a medical centre could drive down carbon considerably, but could send insurance rates skyrocketing. Equally, insurers have warned against structural insulated panels (SIPS) which can be highly toxic when combusted.


The 2019 Health Infrastructure Plan set out the broad approach to improving the NHS estate, and an Estates Net Zero Carbon Delivery Plan for the NHS has been launched. All work is seeking to meet the Government’s budgetary guidelines and NHS’s mandatory design requirements, so that new developments remain viable and affordable for the long-term. But in practice, many of these things are difficult to reconcile with the pace of change our climate requires.  


Our portfolio has long included buildings with sustainable technologies, such as West Gorton Medical Centre’s photovoltaic panels and heat retaining insulation, or Ardudwy Health Centre’s insulated timber frame and biomass boiler. All our new developments are BREEAM Very Good or Excellent already, but we are driving towards 2026 from when we have pledged to deliver only buildings which are net zero for both their construction and operation[19].


As part of our SixbySix[20] social impact strategy and our World Green Buildings Council Net Zero Buildings Commitment[21], we are supporting this work with investment into moving every property we own to EPC B or better in the same timeframe.   


Developing net zero buildings should not cost the earth. Meeting this goal cost-efficiently means thinking about natural ventilation, moving to more sustainable lighting and heating systems, improving insulation, and building performance. Simple changes such as setting windows back into their frame or reducing glazing on south-facing elevations reduces heat gain and flattens the temperature curve. Making buildings more modular and rectangular helps to match a timber frame more effectively ‒ probably the single biggest component in reducing embodied carbon.


The giant leap for the NHS will be making these changes quickly across all schemes, so that innovation can be focused on the more complex elements. The will is there; the technology, materials and supply chains are not – yet.


Under current GP Premises Cost Directions[22], District Valuer Services (the Valuation Office Agency’s specialist property arm responsible for setting NHS rent levels) does not specifically consider sustainability improvements to buildings in valuation for rent reimbursement. This means that, despite often having invested significant sums to make a building more energy efficient, a GP or third party owner will not benefit from any rent uplift to account for this investment. By contrast, another owner could take the decision not to improve the sustainability of a healthcare building, but under current directions still receive the same rental income.


How can the current model of general practice be improved to make it more sustainable in the long term? In particular, is the traditional partnership model sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

As described above, the constraints of some primary care buildings make a huge contribution to the difficulties of the practices within them, when it comes to offering a broader range of services and growing into a hybrid model of both face to face and remote care.

In addition, poor premises and lack of space to accommodate additional staff are exacerbating recruitment challenges in primary care[23], and the traditional GP partnership model - which included ownership of practice buildings - remains a significant blocker at some practices, when younger professionals opt not to buy into building ownership. As described in our submission to the review of GP premises policy in appendix 2, there are many potential ways to address premises challenges for primary care and in doing so, help to make general practice more sustainable for the long term.   

Has the development of Primary Care Networks reduced the administrative burden on GPs?


Our observation from working with both primary care networks around the country and with primary care at scale organisations such as Modality Partnership is that one of the administrative areas which isn’t yet fully benefiting from the development of PCNs and economies of scale is premises and estate. There is huge potential for primary care networks and at-scale organisations to further reduce the administrative burden on GPs by beginning to plan for and manage their premises as a collective rather than individually, but the mixed ownership of premises and the traditional partnership model often makes this prohibitively challenging in practice.

Contact information:


If you would like further information or have any questions about Assura’s wider work, please contact Claire Rick, Head of Public Affairs:

Appendix 1: Historic and existing sources of investment for primary care infrastructure:


  1. Self-funding by GPs: over the years, some GPs/GP partnerships have chosen to take on the personal risk and liability of borrowing as individuals to fund their own premises improvements and developments. Increasingly rare in the current climate of general practice


  1. Government capital options:


Sustainability and Transformation Partnership capital funding: so far, 158 schemes have received a share of the capital announced following Sir Robert Naylor’s review of the NHS estate – with the government pledging around one-third of the £10bn capital called for by Sir Robert. These are judged to be the most transformative of estates schemes to support STPs around the country in achieving their vision. But only a small proportion of these focus on primary care and health services in the community.

Estates and Technology Transformation Fund: £1bn of funding made available as part of the GP Forward View, to support the improvement of practice technology and premises. The programme is now in its final year, and has supported extension/improvement works to waiting rooms, consultation and treatment spaces; Assura has worked with NHS England on schemes at sites such as Coalville in Leicestershire, and at Wide Way in Merton. We are also working with NHS England on a model for the treatment of ETTF capital in new builds at places such as Bourneville in the West Midlands. Demand for ETTF has far outstripped supply and GPs will be looking at what next steps beyond 2019-20 will be for this sort of ringfenced capital.

PPP - Local Infrastructure Finance Trust (LIFT): a series of local joint ventures which began in 2001 to fund and deliver primary and community care premises in specific areas. There are now 49 individual LIFT companies throughout the country which have delivered more than 339 facilities, among some of the most expansive and most architecturally striking in the NHS. The programme’s next phase was set to be the Regional Health Infrastructure Company scheme.

Local authority borrowing: councils can invest in capital schemes, as long as they meet affordability/policy tests. With their ability to borrow funds at lower rates than the NHS, councils can be an attractive source of funding for primary care estate but every local authority works independently, so there is no single model and no consistency of approach. 


  1. Third party development (3PD): GPs continue to use this decades-old model to build new premises off the government’s balance sheet (as the final building is typically leased direct to GPs). It offers swift access to financial capital and development expertise without risk to the taxpayer, options to unlock existing loan or lease commitments held by GPs and straightforward, transparent legal arrangements – negating the need to involve many different legal and commercial advisers which can add cost and time to projects using other models. A standard suite of leases is specifically tailored to the individual needs of practices, including flexible assignment clauses for retiring or leaving partners and flexible repairing options. Rent must be agreed with the Valuation Office Agency and is reimbursed to GPs by the NHS. This option has also been employed by NHS provider trusts to fund health infrastructure in the community. 


  1. Developer contributions: Section 106 and Community Infrastructure Levy monies can be attached to planning permissions to mitigate the impact of a development for existing local health infrastructure. Recent examples of developer contributions in action include a land contribution for the development of Saxon Spires Practice’s new building in Brixworth, Northants. This option isn’t used to its full potential for the NHS, but could be improved with closer joint planning between the health service and local government. We are not yet aware of a case of Community Infrastructure Levy being used to support new NHS infrastructure.


  1. Proceeds of land disposals: the NHS has focused hard in recent years on the disposal of surplus land to reinvest in new health facilities and infrastructure, as well as for supporting new homes and key worker accommodation. This remains a big theme although, again, the approach is individual to each local area and gaining public support can be challenging.



Appendix 2:


2018 Submission of evidence to General Practice Premises Policy Review: call for solutions



Key considerations: what does good look like?


We have focused here on the stakeholders most relevant to our work:


Patients: primary care buildings are pleasant physical environments in which to receive care, which exceed CQC requirements for healthcare buildings and which have appropriate access for people with disabilities, poor mobility and parents with children. Premises are fit for the purpose of healthcare, with the facilities, space and layout staff need to carry out their work effectively. Ideally, patients can access community pharmacy and other health services at the same site. 


GP/practice tenant: primary care buildings are pleasant physical environments in which to work and deliver care, with appropriate access for staff with disabilities or poor mobility. Premises are fit for the purpose of healthcare with the facilities, space and layout tenants need to carry out their work for patients effectively. Their landlords have an in-depth knowledge of the specialist needs of primary care tenants; are responsive and effective at meeting those needs and addressing premises issues; and are proactive in looking for ways to continually improve the building for its core purpose of serving patients. Local NHS systems are able to support premises which are deemed essential and fit for purpose for ongoing healthcare services in that community, particularly in the case of unforeseen events such as a practice failure or a ‘last partner standing’ scenario. The quality of premises helps to recruit and retain staff, while high-specification building management systems help to reduce running costs for the practice and the internal environment.


GP/practice owner: primary care buildings are pleasant physical environments in which to work and deliver care, with appropriate access for staff with disabilities or poor mobility. Premises are fit for the purpose of healthcare with the facilities, space and layout tenants need to carry out their work for patients effectively. Owners have access to clear information on the options available to them to fund and deliver premises improvements, or to change ownership if they should wish.


Commissioners: primary care is delivered from fit-for-purpose premises, and commissioners have the power to support premises which are deemed essential for ongoing healthcare services in the community in the case of unforeseen events such as a practice failure or ‘last partner standing scenario’ – through a form of ‘step-in’ provision as described below. Buildings are flexible to enable new models of care and to create the conditions for optimal usage of the building (for example, specialist rooms are avoided unless a clear case for them is made).    


Occupiers of shared buildings: are able to pool budgets for premises, where appropriate, to deliver a broader range of services to patients in communities. Local NHS systems are able to support premises which are deemed essential and fit for purpose for ongoing healthcare services, which in the case of shared buildings may mean taking a head lease to enable collaboration through many different services and budgets.


Commercial landlord: primary care buildings are pleasant physical environments in which to receive and deliver care, with appropriate access for people with disabilities or poor mobility and parents with children. Premises are fit for the purpose of healthcare with the facilities, space and layout staff need to carry out their work effectively. Landlords work closely with the NHS, its estates functions and GPs to ensure primary care is making best use of its existing estate, and that opportunities to modernise the places where we access health services in the community are used to their full potential. Local NHS systems are able to support premises which are deemed essential and fit for purpose for ongoing healthcare services in that community, in the case of unforeseen events such as a practice failure or a ‘last partner standing’ scenario. Premises cost directions are updated to enable investment in new development schemes, to progress projects in communities where they are desperately needed. 


Ownership models:


We are supportive of the current system, which allows for a range of ownership models for GP premises depending on the choice of individual GPs, partnerships, practices and local NHS bodies. We also note the premises review’s encouragement for this mixed economy and strongly agree that the overarching goal of its work must be a primary care estate which is suitable to deliver GP services, individually or at scale.  


There are, however, steps which could be taken within the current system to further support those GPs who choose to work from third party owned buildings. Typically, this is via two routes: by entering into a sale and leaseback arrangement, or by becoming a tenant of new primary care premises built by a third party developer:




Regardless of their route to operating from a third party owned building, GPs typically retain full control of all internal repair and maintenance in a third party owned building, with autonomy to choose their own suppliers and contractors – unlike other lease models. 


Third party ownership reduces the risks of building ownership for GPs by:



Third party ownership is still the minority option - the BMA’s data[i] shows that one-quarter of GPs say they would like to work in third party premises, while a small proportion of GPs state that they are no longer supportive of the model of GPs owning their own premises.


However, given the transformational ambitions for primary care and the subsequent implications for the buildings in which that care is delivered, third party ownership is a strong option to support many GPs in reducing their premises risk, and to ensure there is sufficient investment in the primary care estate of the NHS to prepare for the long-term. Third party ownership also opens up opportunities for closer working between the NHS and its estates functions, GPs and independent expertise to ensure primary care is making best use of its existing estate, and that opportunities to modernise the places where we access health services in the community are used to their full potential for the NHS’s services, staff and patients.


As the premises review itself states, there are a number of issues which GPs may raise around third party ownership options, including perceived risks of longer leases and ‘last partner standing’ scenarios, use of space in primary care buildings and the revenue implications of more modern premises. 




In considering how general practice estate could be best supported in future, the review could look to Scotland’s work to implement a model[ii] which plans to “end the presumption that all GPs should own their own premises”, with the potential to limit or eliminate the risks to GPs of holding a long-term lease on a building. Under this model, it is proposed that regional NHS boards will gradually take the role of tenant on leases with a third party owner, where this is desired by the practice - eliminating the possibility of a ‘last partner standing’ scenario, assuaging any perceived concern from GPs about future funding for general practice and instead offering a long-term premises partnership between the NHS board, the practice and the third party owner.


Evidence of this thinking has also been seen with practices in England and Wales where, when the primary care building in question is considered to be fit and appropriate for the provision of GP services in that community but there is no GP in a position to take the lease (eg where only locums are being used), the foundation trust or local health board has stepped in to take the lease - at least temporarily - to protect key community locations for primary care services.


The consistent application of those options to any practice considering third party ownership would allow GPs to eliminate their premises risk while – most importantly – securing high-quality, long-term accommodation for primary care services in communities for the NHS. Additional stability would come from a legally binding commitment from the NHS that if a primary care building is deemed by commissioners to be essential for NHS services and passes a ‘fitness for purpose’ test, any replacement service provider must take an assignment of the lease and continue to operate from the property. This form of ‘backstop’ could foster closer working relationships between GPs, third party owners, CCGs and trusts, offering even greater potential for partnership and collaboration on improving primary care infrastructure.


Of course, an assignment of the lease to an NHS body should only be activated upon the demonstration by the GPs that they have explored every possible option to retain the lease, without success, and when the NHS is clear that the premises in question are fit and essential for the provision of primary care in that location.


Clearly, such an arrangement does present implications for the NHS’s balance sheet. However, in existing cases where we have seen this approach used, in Wales and in Scotland’s emerging work, it is clear that this is considered a pragmatic approach for the NHS to support and protect the provision of general practice from those key locations, provide appropriate working environments for its staff and to serve its patients for the long-term. 


There are other options which can reduce the perceived risks of third party ownership. Clauses permitting a break in the lease - in the hugely unlikely event of the NHS’s policy of rent reimbursement to GPs ceasing completely, leaving practices with no alternative source of rental income - are being seen. Such clauses should apply only in circumstances where rental reimbursement from the NHS has ceased through no fault of the tenant GP/GPs. Although these clauses are becoming more commonplace, their introduction can have a detrimental impact on the investment value of premises and the viability of projects.


In its template lease for premises owned by NHS Property Services, the BMA promotes a tenant break clause which can be triggered by the cessation of the tenant’s NHS contract by any means. Whilst this may prove attractive to GPs, the adoption of such a lease by other third party owner models would likely prompt prohibitively high rental costs, to mitigate the risk held by the landlord of being left with a vacant property.


A middle ground option would be a form of ‘step-in’ provision by the NHS, as described above, which would apply where premises had been deemed essential for ongoing healthcare services in that community and were also assessed as fit for purpose. The ‘step-in’ would apply in unforeseen events such as a practice failure or a ‘last partner standing’ scenario. In such an event, an NHS body would take an assignment of the lease and the existing tenants would cease to be liable for the lease obligations, save for any pre-existing breaches of tenants’ covenants. We believe that such an arrangement would singularly remove the perceived risk of GP partners signing long leases for modern, high-quality premises.


In the case of shared buildings, a de-coupling of the building’s ownership/leasing and the service provider – under which an NHS-guaranteed body could take head leases and sub-let to individual providers as directed by NHS commissioners - would overcome the conflict between short term (5-10 year) provider contracts and long term (20-25 year) leases required by property investors. Leases of these lengths are required to achieve the most cost-effective and affordable premises; shorter, more flexible leases will require significantly higher rents in order to amortise the capital costs over the lease term. The current funding system works well for 100% GMS utilisation, but falls down when other CCG-commissioned services are co-located within the building and rooms are shared. 


Funding and contracting


We note the review’s guidance that proposals for supporting general practice estate in the future should be cost-neutral, as it cannot be assumed that additional funding will be available for general practice premises policy. However, it should also be noted that to provide suitable primary care estate – “vital for the delivery of high quality care”, as the review notes – considerable investment is unavoidable, both in terms of capital investment to improve, extend and, if necessary, replace existing infrastructure; and revenue funding, to reimburse GPs for the costs of owning or renting more modern buildings. GPs in modern, purpose-built healthcare estate offering state of the art facilities for patients in a key community location will require a higher level of recurrent revenue costs than GPs working from an ageing residential building with inadequate space for patients: modern healthcare buildings cost more than a converted former bungalow.


For national perspective, Sir Robert Naylor’s review of the NHS’s buildings recommended that at least £10bn would be required to bring the whole NHS estate up to scratch. Since then, the Royal College of General Practice is among the organisations which have flagged that demand for Estates and Technology Transformation Fund grants to improve GP buildings has far outstripped supply[iii], and capital funding through the Sustainability and Transformation Partnership bidding process[iv] has only gone so far. As such, it would be misleading to suggest that the process of bringing the country’s primary care estate up to par can ever be a cost-neutral process. However, these costs must be weighed against the benefits for patients of the services which can then be provided from improved premises and their experience of using the building to receive their care, the impact of better working environments upon NHS staff[v] and the building’s ability to reduce the NHS’s energy use, facilitate its adoption of digital technology and to flex with NHS services as they change in the future (see examples below).


It is our view that revenue implications (increased rent reimbursement, VAT and business rates) of new premises developments are, in many parts of the country, a barrier to new investment. It is understandable that CCGs look to the short-term impact of these additional costs in the context of the financial constraints they must work within. However, this is detrimental in the medium to long-term: deferring these decisions will lead to further deterioration of capacity and frustration of wider STP and local health strategic outcomes.


To help address the national capital shortfall for premises, Assura joined with colleagues in 2017 to flag the potential of the third party development model to invest in primary care estate – with the capacity to inject more than £3bn over five years into new primary care buildings: the equivalent of 750 new medical centres across the country[vi]. The third party development model is not currently used by the NHS to its full potential, despite decades of its application by GPs themselves to improve premises and its simpler financial and operating structure than other public-private partnership routes. It is one example of how the significant capital sums needed might be raised to create the primary care estate which can facilitate the NHS’s vision of the future.   


This year’s changes to GP premises costs directions were a step in the right direction. Allowing the Estates and Technology Transformation Fund to support the full cost of improvement schemes and to buy land for extensions has been welcomed by GPs and although this funding has now been extended to new build projects, a lack of clarity over the approvals and funding mechanism has led to delays. In many cases, ETTF has raised false hope for GPs aspiring for new premises, and CCGs have also been slow to recognise that there are recurrent revenue costs even with ETTF funding some of the capital costs.


A final challenge for funding and contracting is lack of awareness of and information on the range of funding options available to improve GP premises or new primary care development. As work by the Nuffield Trust highlights, independent, high-quality advice and guidance to STPs and local systems on the most appropriate investment routes for different types of project would be invaluable[vii]. The government’s work since the Naylor review to offer strategic estates planning support via NHS Property Services is welcome, but there is more to be done.     


See under ‘ownership models’ for other recommendations on contracting/lease models which could support general practice estate in the future and remove barriers currently facing GPs.


Sub-optimal utilisation of premises

“There is significant scope to improve infrastructure and a great opportunity to scale up community services by investing in a new primary care estate,” according to the think tank Reform[viii]. Indeed, the BMA’s research in 2015 found that: “Three quarters (75%) of GPs say they would like to work in GP premises with access to local primary care hubs providing diagnostics, extended care in the community and out of hospital services, compared to 14 per cent who say they would not[ix].”

The constraints of some buildings in which primary care is currently delivered – buildings which are unfit for the scope of modern primary care – are contributing to the difficulties of the practices within when it comes to offering a broader range of services. It is also fair to say that some modern primary care infrastructure has not always reached its full potential to enable collaboration between different services and working at scale - due to the complexity of local service planning, historic ways of working in the NHS and the constraints of individual service budgets.

Of course, developers of primary care estate can – rightly - only build that which the NHS requests, approves and will reimburse rental to GPs for. Sustainability and Transformation Partnerships are well-placed, with their focus on population health and the estate which will best serve their vision of services in communities, to improve effective collaboration within and utilisation of NHS buildings at planning and commissioning stage for new schemes.

There are many strong examples of fit-for-purpose primary care buildings which have acted as the conduit to local services coming together and in fostering of different ways of working – all to improve the patient experience. These include:

Sudbury Community Health Centre


Completed in 2014 and described by a local councillor as “a great success story”, this was one of the first projects in the country to be delivered by 3PD with NHS Property Services. Assura was selected by NHS PS to deliver this unique, £9.2m building capable of offering all services under one roof including general practice, dental, mental health, pharmacy, paediatrics, dermatology, MSK physiotherapy, X-ray and diagnostics – services which previously had been delivered in outdated, unfit premises elsewhere in the town. The warmth of its reception from the local community, where concerns about continuing availability of primary care services had been longstanding, is one of the project’s most important legacies.


Ahead of its time, this building created space to bring together two GP practices, more than 150 healthcare professionals, pharmacy, minor operations and a huge range of other health and community services under one roof - serving more than 30,000 patients and sitting next to the new community hospital. The space itself is credited with helping many different professionals, people and teams to be part of multidisciplinary meetings and planning work - looking in the round at things which help individual patients to stay away from hospital, from prescriptions to occupational therapy, walking groups or tea and chat. The approach has achieved a significant fall in emergency admissions to hospital. Their innovation is such that it's hit the national headlines[x] and won an award from the Prime Minister[xi].

Before co-location in new primary care centre:



After co-location in new primary care centre:


Before co-location into a new primary care centre:


After co-location into a new primary care centre:


The £1.1m transformation of this Leicestershire primary care building created urgently-needed space and more effective layout for three recently-merged practices working together from one site. With investment from NHS England’s Estates and Technology Transformation Fund and from Assura, Long Lane Surgery in Coalville now offers a minor operations suite, eight new clinical rooms, better administration space and improved waiting areas for its 14,600 patients. Patients were at the heart of the project, from helping to shape the design to feeding into work to extend opening times and introduce more services in the new-look building. With careful planning over the last year, the surgery was able to continue its work throughout the renovations.


An overhaul and refurbishment of an empty surgery building created a state-of-the-art new space for a Kirklees GP surgery and its 2,600 patients, allowing it to move from a cramped, converted former house. The new-look building includes four treatment rooms and a room for minor operations in accessible space which meets all the latest clinical requirements, as well as improved waiting areas and administration space. Since moving to the refurbished building in October, almost 300 more patients have joined the practice’s list. Crucially, it now has space and facilities to better cope with this increased demand.













[1] https://www.assuraplc.com/assura-community-fund

[2] https://www.longtermplan.nhs.uk/

[3] https://www.patients-association.org.uk/news/gp-premises-the-patient-perspective

[4] https://www.bma.org.uk/advice-and-support/gp-practices/gp-premises/gp-premises-survey-results-2018

[5] https://www.assuraplc.com/news-items/nhs-premises-restrict-patient-care-and-efforts-clear-covid-19-healthcare-backlog

[6] https://www.gov.uk/government/publications/national-disability-strategy

[7] https://dimensions-uk.org/get-involved/campaigns/make-gps-accessible-mygpandme/accessible-healthcare-facilities/

[8] https://bjgpopen.org/content/5/5/BJGPO.2021.0066

[9] https://www.rcgp.org.uk/about-us/news/2021/july/general-practice-sos-rescue-plan.aspx

[10] https://www.bmj.com/content/374/bmj.n1691

[11] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00620-6/fulltext

[12] https://www.housinglin.org.uk/_assets/Resources/Housing/OtherOrganisation/Unlocking-Investment-in-Primary-Healthcare-Infrastructure.pdf

[13] https://www.gov.uk/government/publications/nhs-property-and-estates-naylor-review

[14] https://www.gov.uk/government/publications/health-infrastructure-plan

[15] https://www.rcgp.org.uk/about-us/news/2021/july/general-practice-sos-rescue-plan.aspx

[16] https://www.gponline.com/hospital-tasks-dumped-half-gps-covid-19-creates-tsunami-extra-work/article/1687310

[17] https://www.assuraplc.com/designing-future

[18] https://www.kingsfund.org.uk/publications/technology-NHS-estate

[19] https://www.assuraplc.com/making-a-difference/net-zero-healthcare-buildings

[20] https://www.assuraplc.com/making-a-difference/our-sixbysix-strategy

[21] https://worldgbc.org/sites/default/files/Assura%20Indesign%20Profile_Final.pdf

[22] https://www.bma.org.uk/advice-and-support/gp-practices/gp-premises/rent-reimbursement-for-gp-practices

[23] https://www.bmj.com/content/374/bmj.n1691

[i] https://www.bma.org.uk/collective-voice/committees/general-practitioners-committee/gpc-surveys/future-of-general-practice

[ii] https://www.bma.org.uk/-/media/files/pdfs/collective voice/committees/gpc/gpc scotland/premises-code-of-practice-gp-contract-scotland-2017.pdf  

[iii] http://www.rcgp.org.uk/-/media/Files/Policy/General-Practice-Forward-View/RCGP-annual-assessment-GP-forward-view-year2-aug-2018.ashx?la=en?la=en

[iv] https://www.gov.uk/government/news/nhs-gets-funding-green-light-for-new-buildings-wards-and-beds

[v] http://www.picker.org/wp-content/uploads/2014/10/Designing-GP-Buildings-staff-and-patient-priorities-for-the-design-of-community-h.pdf

[vi] https://www.assuraplc.com/~/media/Files/A/Assura-Plc/documents/reports-and-presentations/Ad-hoc/Position%20paper%20final.pdf

[vii] https://www.nuffieldtrust.org.uk/files/2018-06/nhs-restates-briefing-v6.pdf

[viii] http://www.reform.uk/wp-content/uploads/2018/01/Primary-Care-Estate-report.pdf

[ix] https://www.bma.org.uk/-/media/files/pdfs/working%20for%20change/negotiating%20for%20the%20profession/general%20practitioners/future%20of%20general%20practice%20full%20survey%202015.pdf

[x] https://www.theguardian.com/commentisfree/2018/feb/21/town-cure-illness-community-frome-somerset-isolation

[xi] https://www.pointsoflight.gov.uk/compassionate-frome/


Dec 2021