AFA FIAB MIHM MAMS FinstCPD
Independent Healthcare Consultant
Director of Primary Care
National Services for Health Improvement
Steve is a former Royal Navy Officer, and joined the health service as a chief management accountant in 1984. He has worked at all levels of the NHS. He was an associate tutor at the Institute for Health Policy Studies at the University of Southampton and has worked for the professional development committee of the Institute of Healthcare Management
“Without the right environment to work in, neither staff nor patients will enjoy the best healthcare experience. Your environment is critical to the success of the practice.”
Your practice premises may not have a direct impact on the day-to-day running of your practice, but failure to manage this aspect properly could result in difficult problems in the future. Services may become interrupted or cancelled due to non-availability of space or equipment.
Sometimes, such problems may still arise no matter how effectively a practice is managed. I am sure we have all heard of, or even experienced, the workman who has just cut through the local electrical power supply. Believe it or not, such events happen more frequently than you might think.
The upcoming requirement to register with the Care Quality Commission (CQC) and the Commissioner’s Investment and Asset Management Strategy (CIAMS) being undertaken by primary care trusts (PCTs) means there is an even greater requirement to ensure that your practice is “fit for purpose”. Although the need for registration is not due until 2012, now is the time to focus on how your current premises meet
Obviously, there are a number of day-to-day issues that need to be managed, but equally there will be a number of longer-term requirements that could easily be overlooked. Day-to-day issues might include the servicing of public areas, such as toilets and the waiting room. Less frequent activities might include grounds maintenance, boiler repairs and electrical testing.
Facilities provision is about evaluating what facilities the practice already has and whether more are needed or better utilisation can be made of the existing building/s. Facilities management is not just about how the existing premises are used, but also takes into account any legislative requirements, such as disabled access. It will also deal with the aspect of how the premises are financed, who owns them, leasehold agreements and the like.
It is important to listen to other members of staff. Very often the person who is working in the environment will be able to add valuable comments about the use of the room or how a particular part of the building might be used. It is also important when dealing with a major refurbishment or new build to ensure that you consult the relevant staff about how a room might be laid out or designed.
Security is not just about the premises, but is also about safeguarding the welfare of staff and patients. Despite adequate security arrangements, at times complacency will set in and sometimes a door or window may be left unlocked. Opportunistic crime accounts for significant security breaches. Consideration should be given to staff to ensure that they all have somewhere secure to store valuables if needed. Unfortunately, it is not uncommon for handbags, purses and mobile phones to be taken almost directly under the noses of staff.
Practice procedures should stipulate which areas should be maintained as secure and the responsibilities of staff to secure doors, locks or computers. Should a breach of security take place, you may then consider whether a member of staff has failed in their duties and, as such, should face disciplinary action.
The last statement may seem severe, but it is important to ensure that all staff are aware of the need to take security seriously. Similarly, if a practice fails to secure premises effectively, a member of staff may take out a grievance against the employer. Try and make sure that everyone understands the need for good security. This will be a benefit to everyone.
Try and ensure that all relevant staff are aware of what to do if a member of the public becomes aggressive or violent [see Fiona Dalziel’s article on managing the risk of violence on page 24]. There should be a clear policy of when police involvement may be required and when this authority may be exercised. Very often, the layout of premises will determine the mood of the building and sometimes a well-designed reception will alleviate many potential situations from arising.
Make sure someone is identified to oversee any changes to the practice premises. Very often, the project will be above and beyond the normal day-to-day activities of the practice. The amount of work needs to be evaluated in respect of the time required to complete the project. There will be either a resourcing requirement or a direct cost involved in completing the project.
Using existing staff runs the risk that you may inadvertently mask the true cost, because the chosen member of staff will have to relinquish one of their other tasks to complete the project work. Any building project within the practice will be additional to normal duties. Before you commence a project, undertake a feasibility study and determine how this can be managed inhouse and by whom, or if it is better outsourced.
The key function of this strategy is to ensure PCTs (as commissioners) manage property effectively and ensure that future estate development meets service needs. They will primarily concentrate on PCT-owned premises or those procured under Local Improvement Finance Trust (LIFT) or Express LIFT schemes. However, in time they will also include all primary care premises under this remit.
Knowing what premises you have and their functionality is a key requisite for making good local commissioning decisions. Very often, different parts of the PCT will retain information about property at any given time, and this may not always be available to the Commissioner when he needs it.
The PCT will need to consider whether a building is “fit for purpose” now and whether ongoing maintenance and serviceability is practical. This will need to be linked to the PCT’s short, medium- and long-term local development plans. In the future, all aspects of primary and community services will need to be considered, including GP surgery provision, dental practices, pharmacies and opticians. This will also be extended to include nursing homes, charitable partnerships and third-sector organisations.
The PCT will need to demonstrate a complete understanding of the total health estate, and must demonstrate that this estate complies with minimum standards and is therefore “fit for purpose” to provide high-quality health services. In the future it will have the power to close down premises that are not deemed to meet the minimum criteria.
While it is not a requirement to register with the CQC until 2012, the prudent practice will consider the existing requirements of registration for healthcare providers. The rules are quite strict and will involve a premises inspection prior to the organisation being given permission for accreditation.
Many high-street clinics and therapy centres already undergo this process. General practice doesn’t need to. As a result, a lot of practices have fallen below minimum requirements and are probably in many respects no longer “fit for purpose”. However, the future need for registration with the CQC and the impact of CIAMS will start to address this issue.
Current registration with the CQC will expect to see compliance with the following:
- The Town and Country Planning Acts 1990/1991 and the regulations and orders.
- The Building Act 1984 and the building regulations and approved documents.
- The Health and Safety at Work Act 1974 and the relevant regulations, orders and approved codes of practice.
- The Ionising Radiations Regulations (1999) and corresponding approved codes of practice.
- The Disability Discrimination Act 1995 and BS 8300:2001.
- Relevant British and European standards for design, materials and products.
- Health Building Notes, Health Technical Memoranda and Health Facilities Notes published by NHS Estates.
- Publications by the Chartered Institute of Building Services Engineers (CIBSE).
Your local council’s building control department or, in some cases, a privately approved inspector, will check your compliance to current building regulations. The key areas that they will check are the plans and calculations for compliance, facilities for disabled people and the local fire authority. They will also inspect the actual premises for compliance.
Normally, the same inspector will provide written evidence of compliance. This in turn will be accepted by the CQC. This is not normally a problem if the practice owns the freehold to the building. Problems can arise if there is a leasehold agreement with a third-party landlord. The same level of compliance must be obtained from the landlord.
In addition to this, all the usual facilities, such as gas, water and electric, need to show current compliance. Where appropriate, any special provision – such as the storage of controlled drugs or gases – needs to be addressed.
Even if you believe that your current practice facilities are ideal, can you be absolutely sure that you are currently “fit for purpose” or do you already know something needs to be looked at? It is not yet known the exact pace of change expected, or whether the CQC will expect full compliance at first registration. However, you do know whether or not your existing premises meet all the necessary requirements – and you can do something about that now.
Department of Health
Developing an estates strategy (2nd edition). London: DH; 2007.