Health and Social Care Committee
Wednesday 1st July 2026
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09:33
Speaker 1
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Speaker 1
Welcome to the Health and Social Care Select Committee. This is the second of our hearings on delivering neighbourhood health service, with a particular focus on the estates. And we're going to start with a panel to talk about primary care. Can we start, please, by asking you to introduce yourselves and what you do?Rob. James.
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09:34
09:34
09:34
Speaker 4
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Speaker 4
Um, I'm Louisa Wood, I am chief operating officer of Merseyside Medical, which is a group of three general practices in East Cambridgeshire. We serve about 45,000 patients. I'm also co-director and PPI lead of the Greater Cambridge and Suffolk Commercial Research Delivery Centre for Primary Care and Staploe Medical Centre. One of our sites is also the lead practice for Ely South Primary Care Network. We have a long history across our primary care networks of delivering at the neighbourhood level. Um and I also hold estates as part of my portfolio, and we're both owners and renters and we've got a wealth of experience trying to get new build schemes over the line, particularly Staploe, which is what I provided evidence about.
So I'm pleased to be here to share our insight.
So I'm pleased to be here to share our insight.
09:35
09:36
Speaker 3
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Speaker 3
Uh, what we know is the Darzi report revealed that 1 in 5 GP practices pre-date the NHS, and 53% of them are more than 30 years old. They were built for the purpose at the time they were built. For the future needs of neighborhood health services. And we need that infrastructure to keep pace. We've got workforce plans that we're expecting to be present needs. We've got 74% of practice managers saying they can't recruit to get into more GPS, into the building just because of lack of physical space.
And then we start looking at the rest of it and what expansion would mean that we want to make sure that we're delivering things. For the future needs of neighborhood health services. And we need that infrastructure to keep pace. We've got workforce plans that we're expecting to be published soon. Is there a ten year strategy for that?Will there be a ten year estates delivery strategy to go along with town planning and all those new home builders?
And then we start looking at the rest of it and what expansion would mean that we want to make sure that we're delivering things. For the future needs of neighborhood health services. And we need that infrastructure to keep pace. We've got workforce plans that we're expecting to be published soon. Is there a ten year strategy for that?Will there be a ten year estates delivery strategy to go along with town planning and all those new home builders?
09:37
Speaker 1
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Speaker 1
I just challenge you just a bit on that. So the premise it would seem is that yes, excited. But you're putting your yourselves very much at the centre of this. And there is some criticism out there that this is just what what GPS always do, right?Yeah. And actually, could it not be led by pharmacy?Could it not be led by by other people?I'll come on to neighborhood health centers in a minute. Um, I mean, is your view that GPS are in.
I think it was, uh, Minister Kinnock who said are going to be the conductors. Yes. And is that do you agree with him in that in reality.
I think it was, uh, Minister Kinnock who said are going to be the conductors. Yes. And is that do you agree with him in that in reality.
09:38
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09:38
Speaker 3
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Speaker 3
Be conductors?I think so, I think because we've got historical breadth of our outlook with patients and patient care and the gatekeeper role in the NHS, we have that responsibility of being aware of resources and using things appropriately, doing things efficiently, making sure that we can do increased productivity. You look at how we were before the pandemic, we're delivering 20% more appointments in general practice. At this point, 376 million last year felt like all of them came to my on call on Friday. But it was this thing of, you know, we are producing more and our patient populations are growing.
We're able to meet that. Even though numbers of GPS are staying fairly flat in comparison to.
We're able to meet that. Even though numbers of GPS are staying fairly flat in comparison to.
09:39
Speaker 1
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Speaker 1
An eye here in Abingdon that I met a community pharmacist who said that actually the local GP practices don't have a good relationship with them. In fact, it's a little bit, you know, we don't want to give this up because because if we're going to come on to funding at various stages during this. I mean, do you recognise that tension that actually there are other people who are as well placed to deliver some of the services that GPS deliver?It also that also have estates who also would desperately like some of that business.
Do you recognise that and how do you manage that?
Do you recognise that and how do you manage that?
09:39
09:40
Speaker 3
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Speaker 3
Not always a thinking that way. But I think it comes down to the the closeness and the proximity that we have to the patients in the community. Um, that there is a. Lack of a direct financial interest. When a patient sees their own GP, um, that, that I think puts us in an advantageous position in terms of building trust. And then obviously, you know, that's where they feel safe. That's where they want to come and sort of confide whatever their deepest, darkest fears may be when it comes to quite serious health problems.
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09:41
Speaker 4
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Speaker 4
Sure. So just to clarify, I'm not a GP. I'm a research doctor. Forgive me. No no, no. It's fine. You can still call me doctor, but I just don't want you to think I'm a GP. Um, so in in response to the specific question about what neighbourhood shift means, you know, for us it's about, um the vision for general practice and, and primary care as a whole. So on the pharmacy point, we work really closely with our pharmacies.
We have one that's co-located in our practice currently and the others that operate pharmacy first, we work really closely with, I don't perceive there to be a tension there because there are quite clear differences between what GPS are able and qualified to do. As Jamie has said, there's a massive breadth of competence. That is what defines general practice, and that's very different from what defines the pharmacist scope of practice. Um, it is about working well together, but I don't think it's either or at all.
And I think the scope of practice that a GP has is, is the broadest out there. You know, they are the consultants of Generalism and they hold the liability for that.
We have one that's co-located in our practice currently and the others that operate pharmacy first, we work really closely with, I don't perceive there to be a tension there because there are quite clear differences between what GPS are able and qualified to do. As Jamie has said, there's a massive breadth of competence. That is what defines general practice, and that's very different from what defines the pharmacist scope of practice. Um, it is about working well together, but I don't think it's either or at all.
And I think the scope of practice that a GP has is, is the broadest out there. You know, they are the consultants of Generalism and they hold the liability for that.
09:42
Speaker 1
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Speaker 1
The, the, the example I give you is vaccination. So we had a one off session on vaccination where we made a very strong recommendation that the government needs to be working with pharmacies to be delivering that at scale. And one of the things that I know happens is that there's a little bit of pushback sometimes from GP surgeries because they they rely on some of that income. And I'm afraid, you know, some of this is a little bit income driven. So there is that tension there.
I wouldn't say it's very clearly 100% black and white defined. There are some grey areas, wouldn't you agree?
I wouldn't say it's very clearly 100% black and white defined. There are some grey areas, wouldn't you agree?
09:43
Speaker 4
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Speaker 4
So there are definitely grey areas. But I would use our experience delivering the Covid vaccination programme as an example, where we were an early adopter and we delivered £150,000 in a really short space of time, working across all six of our PCN practices at the time. And that was about being really clever with the traffic flow and the patient flow through the building. Pharmacies are not set up for that kind, excuse me, kind of delivery model, because they are generally much smaller. I think the other kind of seasonal vaccination campaigns, um, you know, of course there's an opportunity with footfall coming through pharmacies on a daily basis to try to get vaccinations delivered to those patients.
I don't think any GP would have an issue with that. And similarly, when patients come into the practice, there are, especially with children's vaccinations, they're coming in for their baby checks and other health checks. There are lots of opportunities to try to improve that overall vaccination rate. So it shouldn't be seen as either or. I think the access to that funding scheme should be fair. So there have been times when we've been allowed to invite earlier than pharmacy and vice versa.
That's where some of the tension probably comes from. Um, but I think that's that's appropriate. We can't mop everybody up. We can run a campaign and then the pharmacies can also deliver their portion.
I don't think any GP would have an issue with that. And similarly, when patients come into the practice, there are, especially with children's vaccinations, they're coming in for their baby checks and other health checks. There are lots of opportunities to try to improve that overall vaccination rate. So it shouldn't be seen as either or. I think the access to that funding scheme should be fair. So there have been times when we've been allowed to invite earlier than pharmacy and vice versa.
That's where some of the tension probably comes from. Um, but I think that's that's appropriate. We can't mop everybody up. We can run a campaign and then the pharmacies can also deliver their portion.
09:44
09:45
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09:45
Speaker 1
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Speaker 1
I appreciate that. Listen, we have gone down a little bit of a rabbit hole, but I do want to start because the neighborhood health centers, as you'll be well aware, is kind of the vision that's in the ten year plan. That seems to be the the thing, I mean, Robert, I don't know if you've got a view on how do you see GP practices in the neighborhood health centers sitting together?Are they the same thing but a bigger footprint?Are they how in your in your mind, how does that work?
09:46
09:46
09:46
Speaker 2
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Speaker 2
So this has come back around. We we did have some successes then. And we feel that. And we fully support the, the direction of travel this time in terms of multi occupancy buildings. We also support the fact that GP should take that lead. They are innovators in the NHS. They are independent businesses. They run very, very efficiently. Um on the basis obviously 90% of patient contacts is in the primary care sector via GPS.
And therefore that shows that level of efficiencies that can be driven into that. I think the structure of how real estate fits around the neighborhood health center is going to be interesting on the basis that sitting under that are a plethora of different contract lengths, and how we structure that to make sure that those innovators in the system can grow services and adapt. Because we all know that one thing is for certain is the change, is that whatever we do now, in ten years time, the model will be different.
And therefore the real estate needs to change, and it needs to adapt to the way that the providers need to provide that service.
And therefore that shows that level of efficiencies that can be driven into that. I think the structure of how real estate fits around the neighborhood health center is going to be interesting on the basis that sitting under that are a plethora of different contract lengths, and how we structure that to make sure that those innovators in the system can grow services and adapt. Because we all know that one thing is for certain is the change, is that whatever we do now, in ten years time, the model will be different.
And therefore the real estate needs to change, and it needs to adapt to the way that the providers need to provide that service.
09:47
Speaker 1
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Speaker 1
Yeah, we're going to we're going to come back to that. We saw a lot of evidence from that, from Cornwall. Um, and the other thing that, you know, shift to community, yes, it is buildings, but we also have saw great examples when we, we did a visit to Cornwall about services being provided in community centres on high streets, in libraries, um perhaps Jamie, I mean is that something you do.
09:48
Speaker 1
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Speaker 1
Is there anything else you could do from those kinds of venues?Like really getting to especially, um. Parts of our community that are historically underserved. We know that going right to the heart of that community with a range of different services really helps to drive down those inequalities. I mean, is that something have you got concrete examples of things you do that that help with that?
09:48
Speaker 3
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Speaker 3
Like what?I'm in a deprived area in the black country. Um, and our vaccination rates are challenging. Uh, we use our own surgery, owning our own building. We love our Saturday morning surgeries. And it's not for the point of view of getting the reimbursement for the vaccines, but it's the point of contact when you can get 400 patients through a building in the morning that.
09:49
09:49
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09:50
Speaker 3
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Speaker 3
Particular barriers that we've seen in the past is the ensuring how you record note keeping on clinical systems when you're reaching out. Right. Obviously, that's one aspect of it. Sometimes there are issues to do with surge capacities or emergency situations. Um, but the advantages obviously is the potential space. If you've got a larger space, you can start thinking about how you can deliver group consultations, managing bigger populations of patients that you can manage in that one patient encounter within a surgery building.
Um, and then obviously where that patient feels comfortable, they can see the engagement with, you know, local representatives. So it has that community feel and increase the sense.
Um, and then obviously where that patient feels comfortable, they can see the engagement with, you know, local representatives. So it has that community feel and increase the sense.
09:50
09:51
Speaker 4
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Speaker 4
Um, yeah, I mean, I, I have to be honest, I think the potential is really narrow. Mhm. Um, health, you know, the health building notes regulations exist for a reason. Um, and so our practice premises are subject to those regulations in terms of the spec of what the building must meet in order to deliver the services that.
09:51
09:51
Speaker 4
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Speaker 4
Mean, it's about infection control fundamentally, you know, they're not general practice is not overly complicated. We're not building hospitals here. It's relatively simple. But the things that are in place are in place for really good reasons. Um, it's things like the minimum room size so that somebody in a wheelchair can actually turn their wheelchair around. It's things like having space, um, to have. Dual access either side to a couch. If you're performing a physiotherapy appointment and you need to access the patient on both sides, having private space that you can conduct confidential examinations.
So I think where it genuinely works is in those kind of non-clinical community site type services where those estates exist in our area, it's libraries, many of which are buses can't do much in a bus or village halls, so there's no confidentiality there, right?So it's really about group non-clinical type settings. So we have wellness hubs, um, all over the locality where people come. And that's about kind of social prescribing, well-being, mental health, fitness, and, and kind of the broader concept of wellbeing and health care and prevention.
But it's not, it's not applicable or appropriate to try to do a clinical consultation with a patient in a community setting because you don't have the confidential space, you can't do an examination easily. You need a couch, and there's there's no infection control. You know, the rules will not be adhered to in community settings. And then lastly, as Jamie has mentioned, the confidentiality of the data is really important. You can't access the patient record easily. You would need to VPN in to access your system.
Um, or you have to write it down on paper, which you could then lose on your way back to the practice before you enter it into the system. It's not ideal. So although the idea is lovely and it's brilliant for building community and building wellbeing, that is all part of that preventative agenda. Very supportive of that. It's not the case that we can move a lot of the services that we offer out into those types of settings.
So I think where it genuinely works is in those kind of non-clinical community site type services where those estates exist in our area, it's libraries, many of which are buses can't do much in a bus or village halls, so there's no confidentiality there, right?So it's really about group non-clinical type settings. So we have wellness hubs, um, all over the locality where people come. And that's about kind of social prescribing, well-being, mental health, fitness, and, and kind of the broader concept of wellbeing and health care and prevention.
But it's not, it's not applicable or appropriate to try to do a clinical consultation with a patient in a community setting because you don't have the confidential space, you can't do an examination easily. You need a couch, and there's there's no infection control. You know, the rules will not be adhered to in community settings. And then lastly, as Jamie has mentioned, the confidentiality of the data is really important. You can't access the patient record easily. You would need to VPN in to access your system.
Um, or you have to write it down on paper, which you could then lose on your way back to the practice before you enter it into the system. It's not ideal. So although the idea is lovely and it's brilliant for building community and building wellbeing, that is all part of that preventative agenda. Very supportive of that. It's not the case that we can move a lot of the services that we offer out into those types of settings.
09:53
09:54
Speaker 5
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Speaker 5
Thank you. I'm going to look a little bit about kind of some of the way that the contracts are structured, a bit of a kind of, uh, understanding about where things have gone wrong. Because obviously, if we're going to be looking at new, uh, new endeavours like this, um, we, we need to make sure that we kind of start from the right basis. Um, now, Rob, in my last evidence session with Lord Hutton, I leant quite heavily on um, Todmorden Health Centre in my constituency, uh, which is one of the 1059 properties that primary health care.
Uh, properties has a interest in. Um and. It's a really interesting one because it's a great building that is completely underutilized. Is that a problem that you recognise?Not for that specifically, but just kind of under utilization of property.
Uh, properties has a interest in. Um and. It's a really interesting one because it's a great building that is completely underutilized. Is that a problem that you recognise?Not for that specifically, but just kind of under utilization of property.
09:55
Speaker 2
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Speaker 2
And under utilization is, is an issue. Um, generally, I think it's. Looking at specifics in our estate, we have 1% of vacant space in the CHP. They've got a 3.4. And in NHS. PS about 5% vacant space. That particular the issue in terms of blockers to to progress is a very interesting one. So the structure of the lease in this particular circumstance is that NHS. PS hold the lease and.
Underneath that is an under lease to the GPS. The GPS want to expand their services into areas which are vacant and NHS. PS are essentially blocking that for reasons I really don't know. We would. We would really welcome a meeting with yourself and NHS PS and the GPS at site so we can understand because look, it's to our advantage that all the space within our facilities is is working to the maximum capacity.
Underneath that is an under lease to the GPS. The GPS want to expand their services into areas which are vacant and NHS. PS are essentially blocking that for reasons I really don't know. We would. We would really welcome a meeting with yourself and NHS PS and the GPS at site so we can understand because look, it's to our advantage that all the space within our facilities is is working to the maximum capacity.
09:56
Speaker 5
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Speaker 5
Yeah. No, I mean, it's, really interesting example because obviously one of the issues with it that I found. So, I mean, I, I've done some personal research on Todmorden Health Centre, uh, and that those are my notes and it's just kind of gone through pages and pages of stuff because it's such a complex ownership structure. Um, does the complexity of the kind of the way that the public private partnership is structured make it more difficult for us to utilise these spaces?
09:56
Speaker 2
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Speaker 2
I think that it's worth noting that the. The model that PFP work in predates PFI. So we work under a set of guidance called the Premises Cost directions, which are appended to the contract, and that allows for rental reimbursement to flow through that contract structure so that it's not PFI and such. Because essentially.
09:57
09:57
Speaker 2
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Speaker 2
Yeah. So under the premises cost directions, GPS and GP practices can get all their rent reimbursed. And under the contract. Um, so we utilize that part of legislation to develop new facilities and um, have that pass through cost. Another important note is that, um, our, all our leases will essentially say that the passing rent is the reimbursed rent. So there's no opportunity for us to be able to charge additional rent to GPS that we can't claim back from the NHS themselves.
09:57
Speaker 5
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Speaker 5
Okay. Sorry, I just, um, let me just have a quick look at my notes. Um, so again, like, I know that you've highlighted that you'd like to do more, uh, with, with some of these centres and turn them into neighborhood health centres. And make sure that they're underused. What, what would be the best enabling way to do that?How could we best, how, how could we best bring into use some areas that aren't being used?
09:58
Speaker 2
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Speaker 2
I think it's for the commissioners and the GPS themselves to, to approach us and ask us to, to, to act as an arbiter. And we could look at the lease structures in place, um, and work through a solution, whether that's a restructuring of the leases or whether that's, um, opening up to discussion regarding how the reimbursement works. It's on a, on a scheme by scheme basis, really on a, on an asset by asset basis. But yeah, we, we think I submitted 40 um, properties to.
NHS England that we thought were suitable for neighbourhood health. Uh, in, in the, in the current rollout. And we still, we still stand by that. Um, we have three that have been identified in the first phase of. 27 um, but we do feel that there's, uh, there is significant potential in the current estate.
NHS England that we thought were suitable for neighbourhood health. Uh, in, in the, in the current rollout. And we still, we still stand by that. Um, we have three that have been identified in the first phase of. 27 um, but we do feel that there's, uh, there is significant potential in the current estate.
09:59
09:59
Speaker 2
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Speaker 2
You pick on a good point there. I think that, um, look, when you, when you split down the ownership model, um, GPS own circa 60% of the estate private owned 20% and NHS CHP own around 14, 15%. So there's a, there's a different ownership model throughout throughout the sector. Um. PFI is very through the lift model is, is, is a financing lease. So essentially that lease serves a purpose to pay down a debt over a period of time on the third party development side, it's far more flexible because it's an occupational lease.
So there's no debt against that lease. There's an occupational lease and the, and the money and the rent flows through that through that process. We provide free assignment to to GPS. GPS can assign to other GPS, other NHS bodies. Whereas in under the lift model, it's a little bit more challenging on that.
So there's no debt against that lease. There's an occupational lease and the, and the money and the rent flows through that through that process. We provide free assignment to to GPS. GPS can assign to other GPS, other NHS bodies. Whereas in under the lift model, it's a little bit more challenging on that.
10:00
Speaker 5
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Speaker 5
There was a 2009 article in the Journal of Risk and Governance, which I don't expect you to have, uh, have read, but. It had had a line that said, if there's significant change in a product or service as originally specified, um, then. That. We find the words um, um, under the terms of the contract, the supplier may seek it as an opportunity to increase the revenue and lock the health service into inflexible contracts. That's essentially what happened, isn't it?
10:01
Speaker 2
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Speaker 2
In lift, possibly because of the way that it was. Um, what, what we call now as a DB FM contract. So essentially it was design build, facilities management, and that essentially built the building, rented it back and run that building in terms of hard and soft FM. Yeah, our sector is different from that completely. So we, we pass that FM control over to the GP if they want that or if they want us to manage that building. We don't impose management costs.
Um, it's very, it's, it's very transparent and we have a built in value for money process in place with this development.
Um, it's very, it's, it's very transparent and we have a built in value for money process in place with this development.
10:01
Speaker 2
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Speaker 2
Yeah. And I think that we're already showing that. So I, my message to, to government would be not to stick to one, one route. There are plenty of routes there. And we've already looked at the at the voluntary sector can provide services. We're looking at wider in the community can provide services. We're looking at third party development. We're looking at PFI. We shouldn't we shouldn't from the centre dictate how individual icbs want to deliver their models.
And I think the flexibility. So for instance, on some some of the projects I'm working on, we can we can take NHS capital, um to, to support the revenue, to reduce the revenue model. We can take section 106 and sell and we can plug that into the system. Now on a financing lease side on a PFI, that's not a straightforward to do. So we we are trying and finding different ways to deliver with our NHS partners.
And I think the flexibility. So for instance, on some some of the projects I'm working on, we can we can take NHS capital, um to, to support the revenue, to reduce the revenue model. We can take section 106 and sell and we can plug that into the system. Now on a financing lease side on a PFI, that's not a straightforward to do. So we we are trying and finding different ways to deliver with our NHS partners.
10:03
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10:04
Speaker 3
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Speaker 3
Uh, yes. So, um, the possibility that the GP space is being underutilized. Uh, well, it's not what our partners and patients are saying. Um, we have 64% of partners in our latest member survey saying they don't have sufficient space to accommodate new multidisciplinary team staff. We have, um, 500 practice managers. 74% of them say they can't recruit because they don't have a they have a lack of physical space for about 12.5 years before I started this role, I was a training program director in West Birmingham, and we allocate GP registrars to practices within the West Birmingham area, and we struggled to get placements where practices had capacity for three registrars.
All of a sudden, room capacity meant they could only take one. And so we are struggling to place people. And if people needed extensions, that became even more problematic. Um, we don't have empty rooms. There was a problem where we had, you know, we can't care from an empty chair and we needed more workforce. Now those chairs are full and we're having to work out some surgeries. I don't think we've got room for the midwife today.
And so we're having to ask them to go elsewhere. It was just like, but actually we want our midwives in our surgeries where our pregnant mothers can come and confide in a safe space that they feel safe in. And yet because of room space, we've had to ask them, I'm sorry, we don't have the room availability because we need to fit in. Our nurses, our doctors, our mental health therapists, physiotherapists, whatever that additional service seeing patients will be. So we are quite restricted in that respect.
And a lot of the vacancies and abilities that we do have available are upstairs next to the server that is heating up to 37 degrees in heat wave day. Uh, it is that thing of sort of that's where the empty space is. It's not patient facing space.
All of a sudden, room capacity meant they could only take one. And so we are struggling to place people. And if people needed extensions, that became even more problematic. Um, we don't have empty rooms. There was a problem where we had, you know, we can't care from an empty chair and we needed more workforce. Now those chairs are full and we're having to work out some surgeries. I don't think we've got room for the midwife today.
And so we're having to ask them to go elsewhere. It was just like, but actually we want our midwives in our surgeries where our pregnant mothers can come and confide in a safe space that they feel safe in. And yet because of room space, we've had to ask them, I'm sorry, we don't have the room availability because we need to fit in. Our nurses, our doctors, our mental health therapists, physiotherapists, whatever that additional service seeing patients will be. So we are quite restricted in that respect.
And a lot of the vacancies and abilities that we do have available are upstairs next to the server that is heating up to 37 degrees in heat wave day. Uh, it is that thing of sort of that's where the empty space is. It's not patient facing space.
10:06
Speaker 4
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Speaker 4
Um, I mean, I just have to laugh at the idea to be honest, that there's twice as much space available in our case, our Gia is 952m² for Stockholm Medical Center. Our icbs own formula says we should have double that. And the reason we don't is because of delays trying to get a new build built. And the consequence of that is really significant, and it makes me quite cross, actually, to think that there's a message out there that is telling you that it's easy, that we have lots of space, that the working environment that we can offer to our staff is anything approximating acceptable.
You know, it's embarrassing. We have to have staff meetings in our cars because there is no meeting room. We don't have enough consulting rooms to see the patients. Um, and you know, the underutilization point more broadly about non GP estates, that's it's all in the wrong place. So we can't make use of existing community facilities. I had a look on open space that um Martin Steele I think it was from NHS. PS referenced. The closest one to us is 18 to 36 miles away.
Depending on where you are in our catchment, that's up to three hours on public transport for a sick person to try to get there, to see their clinician. Um, I just am flabbergasted at the idea. I don't know, a single general practice in our locality that isn't suffering the same problem. So I don't know where the data have come from. I would urge you to challenge the data robustly. Um, and I think the other thing, key point I want to make about Underutilization is there's a difference between necessary slack in a building to accommodate for on the day fluctuations in patient demand and, um, temporal underutilization, which is a consequence of having to have enough space to accommodate your most busy days, as well as other spaces that you require, such as a hot room for somebody who might be infectious.
So underutilization needs to be measured in the right way as well also. In terms of what the opening hours are. So there are lots of ways to calculate that number to convey quite different messages.
You know, it's embarrassing. We have to have staff meetings in our cars because there is no meeting room. We don't have enough consulting rooms to see the patients. Um, and you know, the underutilization point more broadly about non GP estates, that's it's all in the wrong place. So we can't make use of existing community facilities. I had a look on open space that um Martin Steele I think it was from NHS. PS referenced. The closest one to us is 18 to 36 miles away.
Depending on where you are in our catchment, that's up to three hours on public transport for a sick person to try to get there, to see their clinician. Um, I just am flabbergasted at the idea. I don't know, a single general practice in our locality that isn't suffering the same problem. So I don't know where the data have come from. I would urge you to challenge the data robustly. Um, and I think the other thing, key point I want to make about Underutilization is there's a difference between necessary slack in a building to accommodate for on the day fluctuations in patient demand and, um, temporal underutilization, which is a consequence of having to have enough space to accommodate your most busy days, as well as other spaces that you require, such as a hot room for somebody who might be infectious.
So underutilization needs to be measured in the right way as well also. In terms of what the opening hours are. So there are lots of ways to calculate that number to convey quite different messages.
10:08
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10:09
Speaker 6
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Speaker 6
She she seemed to also suggest that because of the. Good job GPS are doing with triaging, that there's a lot of empty space during the afternoon. So suggesting that the capacity is within these buildings during the afternoon because GPS are out in the community. I mean, I don't know whether you've got any comments on the suggestion that you could use these rooms at different times of day.
10:09
Speaker 4
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Speaker 4
We do do that. We're still half the size we should be. So there is temporal flexibility. Absolutely. So in our case, the doctors are triaging in the morning. So the morning. But it's not the whole session. It might be the first couple of hours of the day. So then how do you offer two hours of space to somebody who needs a whole day?Some some things are not some Underutilization is unfortunately utilizable.
And that's kind of what I'm getting at is there's genuine opportunity needs to be separated from what the what the premises need to deliver the service to the to the variable patient demand that you have. We try to do that as best we can. Occasionally we might be able to say to a district nurse, yes, you can come in on that day because we know we've got people on annual leave, but it's that level of adjustment day by day. Um, it's not, it's not something that's easily modelled.
And I think there are assumptions feeding these national aggregate statistics that are resulting in a viewpoint that is totally divorced from the reality of delivering the service on the ground.
And that's kind of what I'm getting at is there's genuine opportunity needs to be separated from what the what the premises need to deliver the service to the to the variable patient demand that you have. We try to do that as best we can. Occasionally we might be able to say to a district nurse, yes, you can come in on that day because we know we've got people on annual leave, but it's that level of adjustment day by day. Um, it's not, it's not something that's easily modelled.
And I think there are assumptions feeding these national aggregate statistics that are resulting in a viewpoint that is totally divorced from the reality of delivering the service on the ground.
10:11
10:11
Speaker 6
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Speaker 6
Thank you. Just a few follow ups. So on. On that basis, are there any incentives to offer up those for you to offer up those free rooms, kind of spaces that could be multifunctional?I mean, I'm yeah, I kind of. This data is quite high level, but I recently visited a GP centre myself on a Friday and it was quite empty. Um, and I think the view was, you know, this is generally what happens on a early Friday in the day.
It gets very busy later on. But would, would there be ways of freeing up some of those spaces for, you know, a frailty clinic or another part of the NHS system, the community trust to, to use.
It gets very busy later on. But would, would there be ways of freeing up some of those spaces for, you know, a frailty clinic or another part of the NHS system, the community trust to, to use.
10:12
Speaker 4
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Speaker 4
I think in a in a larger building where you've got, you've accounted for the slack that you need to flex to your own demand. Don't forget, GPS have contractual, hard contractual obligations to triage every single contact that comes in the door. And that might mean bringing people down. So sometimes what we have is multi-user digital consultation space, where there are three clinicians in that room, and then they share the second room. So it might sometimes look empty because they happen to all be on the phone.
But you've you've still only used two rooms for three clinicians. So, um, there's a conceptualization of how we use the space that I don't think is filtering through. Once you've understood what you need for the GP service, of course there is flex. We, we used to accommodate podiatry, smoking cessation, various other community services, but we just cannot do it anymore. Apart from in a very ad hoc way. So I think in relation to can we do it now?Not really.
And it's very ad hoc. Could we do it in future?Absolutely. But the understanding of what what space is the minimum required to maintain a good GP service and then how the other services flex around that, I think is really important to understand.
But you've you've still only used two rooms for three clinicians. So, um, there's a conceptualization of how we use the space that I don't think is filtering through. Once you've understood what you need for the GP service, of course there is flex. We, we used to accommodate podiatry, smoking cessation, various other community services, but we just cannot do it anymore. Apart from in a very ad hoc way. So I think in relation to can we do it now?Not really.
And it's very ad hoc. Could we do it in future?Absolutely. But the understanding of what what space is the minimum required to maintain a good GP service and then how the other services flex around that, I think is really important to understand.
10:13
Speaker 4
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Speaker 4
Um, it's, it's a really interesting question. So there's a challenge between the clinical system, which is a patient booking, patient appointment booking system that the clinicians spend their life in. And then how you actually would, might make the space available in a room booking way. So I think one of the challenges actually is a lack of software that integrates with the way the clinical systems work and, and reconfiguring that to be.
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Speaker 4
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Speaker 4
But we do it manually. So because there isn't one single system where you can look at the availability and it's really, you know, it's not reasonable to expect a clinician who is in the middle of a clinic to start looking into a room booking system as well. Separately, we believe it needs to be kind of integrated with the EMR, but it is possible to do.
10:15
10:16
Speaker 2
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Speaker 2
So it's interesting as an interesting fact, I think we we've got exposure in Ireland and the HSC in Ireland are putting sensors in all their large units over there to, to track, uh, utilization, to inform what the future rollout is going to look like. So they've paused the, the current rollout, they go and they install on these monitors, they will understand utilization. And then their next rollout, will be informed through that data. So they, they will have real terms data in terms of frequency and use of rooms.
Um, going forward.
Um, going forward.
10:16
10:16
Speaker 4
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Speaker 4
Yeah, we've been, we've been looking into it for our new building because we, we five years ago, ten years ago, 22 years ago, in fact, when we started trying to get this building out of the ground, the vision was always about integrating other community services. At this point, what we have proposed in the business case from 2021 was to have exactly that. So we've been speaking out what that software might look like. But as I say, the challenge is that kind of interface with the clinical system so that it's as easy as possible for the clinicians running the service to know where they're meant to be and where they might be able to book a patient in, and then externally, other providers or other service providers be able to see where there is space and opportunity.
10:17
Speaker 6
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Speaker 6
You talked about, um, some of the kind of nature of the need for spaces being different and. Doctor Hynes, you mentioned kind of age of the estate predating the NHS. Are there clear up to date?Kind of design guides for what different sorts of neighborhood health services should look like in the 21st century. Not just I mean you mentioned floor space, ICB footprint, but actually the design, the mix of spaces, what those spaces is there kind of a kind of clear, clear and consistent guideline of what design should look like.
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Speaker 2
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Speaker 2
Design guide insofar as what adjacencies you need, what needs to go next, what facility, what support functions you require, the size of rooms, the amount of circulation, circulation it gives you, a guide plus a calculator. So essentially when as a designer, if you then present that to the to the NHS, it's quite hard for them to roll back and say it should be smaller on the basis you followed that patient demographic.
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10:19
Speaker 2
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Speaker 2
It is quite dated now. I think it's over ten years old. I think it could it would require updating for the neighbourhood plan, because there will be an opportunity to drive efficiencies with shared space. Yeah. Um, in the neighbourhood plan, uh, with the multiple users. And I think if, if, if that was, um, if the neighbourhood health centre program was a driver for that change, I think that would be a good thing.
10:20
Speaker 6
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Speaker 6
Yeah. That's helpful. And just turning to kind of financing and kind of sources of financing, um, doctor. You talked about trying to get a new build proposal off the ground. What was your experience of what is, was your experience of accessing funding streams?What funding model or streams were you looking at for that proposal?
10:20
Speaker 4
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Speaker 4
We've looked at all of the options we had to do. A full options appraisal. In our business case, um, the fundamentally the partners preference is for a GP led scheme, but that proved unaffordable largely because of two things. One is the district valuation methodology and the other is the lack of access to kind of government backed borrowing to GP partnerships. So, um, and then there's thirdly, a lack of access to other capital. So and then so as a result of that, we've looked at third party developers.
So sure. And PHP are our nominated um option, but that is also non-viable at the moment because of the district valuation methodology.
So sure. And PHP are our nominated um option, but that is also non-viable at the moment because of the district valuation methodology.
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10:22
Speaker 4
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Speaker 4
Know, because the interest rate is so high. And so then you look at third party developer, but they have shareholders to think about as well. So at the moment we're stuck because of the DV. I think, you know, by way of example, um our valuation was less than in 2019 at £220 a square metre. That was still viable in 2021. When we had the business case approved. Fast forward to 2024, when we're finally getting the planning sorted, which is another story, but, um, not relevant to here.
Five years later, the DV came back with only 4.5% increase against a backdrop of 40 to 50% increase in construction costs. And I challenged that and was told there's been nothing, nothing doing, really. And it's because of what, um, portfolio of estate the DV looks at in their assessment. But I also challenge the fact that our building was 30% smaller than the Icbs formula, because we were innovative in our use of space. Um, it was the business case was commended by NHS England as an exemplar for the region for innovative use of space, uh, and not so that 30% saving was not reflected in the valuation.
And similarly, we put forward about 280 000 of system savings by service transformation and improved care. That would have offset the increase in rent. And that was not accommodated, by the ICB as a strategic argument at the time, because they were treating the district valuation as a binding thing rather than an advisory thing. And I think the mechanisms for Icbs to make that strategic case and be comforted that the strategic case is strong enough for them to exercise their flexibility is not there. I think there's a national mandate needed on that point.
Um, so the DV methodology is a huge problem. It will take a long time to resolve it.
Five years later, the DV came back with only 4.5% increase against a backdrop of 40 to 50% increase in construction costs. And I challenged that and was told there's been nothing, nothing doing, really. And it's because of what, um, portfolio of estate the DV looks at in their assessment. But I also challenge the fact that our building was 30% smaller than the Icbs formula, because we were innovative in our use of space. Um, it was the business case was commended by NHS England as an exemplar for the region for innovative use of space, uh, and not so that 30% saving was not reflected in the valuation.
And similarly, we put forward about 280 000 of system savings by service transformation and improved care. That would have offset the increase in rent. And that was not accommodated, by the ICB as a strategic argument at the time, because they were treating the district valuation as a binding thing rather than an advisory thing. And I think the mechanisms for Icbs to make that strategic case and be comforted that the strategic case is strong enough for them to exercise their flexibility is not there. I think there's a national mandate needed on that point.
Um, so the DV methodology is a huge problem. It will take a long time to resolve it.
10:23
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10:24
Speaker 2
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Speaker 2
Yeah. Thank you. Um, we've seen a lot more flexibility coming through. Um, but unfortunately it's very regional. So we're seeing innovation in some icbs where um, they are accessing section 106 UMF money for instance, as well from the centre and using that then to, to plug into a particular project in order that that rental level can stay at a, at a level where the DV is happy. The fact that there's capital coming in to support that is, is a different story.
But, um, you know, we see significant success in, in the, in Bristol, in Gloucestershire, in parts of London, in Dorset, where the icbs are thinking differently and innovatively. Whereas unfortunately, in other icbs, we're hitting that block of, we must listen to the DV and we can't move past that. So we. We are starting to see the emergence of progress that. Things can be done differently in.
But, um, you know, we see significant success in, in the, in Bristol, in Gloucestershire, in parts of London, in Dorset, where the icbs are thinking differently and innovatively. Whereas unfortunately, in other icbs, we're hitting that block of, we must listen to the DV and we can't move past that. So we. We are starting to see the emergence of progress that. Things can be done differently in.
10:25
10:25
Speaker 2
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Speaker 2
I think it's it's due to the cycles the NHS works in and, and the length of time it takes to approve a scheme, you know, and, and invariably a housing developer will, will time limit that opportunity to, to be able to, um, hide that of a free site or to, um or to get the funding and the. NHS missed that window and therefore goes unspent.
10:25
Speaker 4
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Speaker 4
Just briefly on, so the proposal that we have on the table does benefit from some section 106 in the form of a gift of land. But then we also have a very supportive district council who are open to a sale application as. And when we bring it forward. The challenge we have is that there's a an assumption at the moment that CIL should abate the rent that is reimbursed. So you have an undervalued Divi assessment, and then any capital that you secure is then further abated on an assumption that it's it's double dipping in some way.
But still is private developer money granted or paid directly to a district council to spend at their discretion on infrastructure that they see of benefit to the population, to the community. And there's a disconnect there. The Pcds don't talk about CIL. They talk about section 106 explicitly being abated, but site is chosen to be silent on CIL. But yet there is an assumption that it should be fully abated in the same way. And that's a fundamental blocker for us.
And then just thirdly, if I may, as a as a commercial research delivery centre, you know, there's capital infrastructure available through Nir, but at the moment it's not for new builds, it's for equipment. Portacabins. Um, and mobile research vans. But the Vpg at the moment, although there's nothing restricting this in the agreement, as far as I can tell, there's no facility for capital for a proportional contribution to the Gea, the internal area for exclusive use of research, not asking for reimbursement of that area because it's funded separately.
But the capital to build, build the bricks and mortar would enable us to meet the UK life strategy, target to double and then double again. But we can't at the moment because we can't get that capital. So I would um you know, there is an ask about pace of approvals, meaning that money isn't lost. I think there's an ask about the rules around CIL and CIL abatement and how that's used or not, and how that interplays with district councils. And then I think, you know, personally for our scheme and for other crcs around the country, there is an ask to the Department of Health and NIH to look at a capital call specifically for commercial research delivery centres that are meeting that wider life strategy, life sciences strategy.
But still is private developer money granted or paid directly to a district council to spend at their discretion on infrastructure that they see of benefit to the population, to the community. And there's a disconnect there. The Pcds don't talk about CIL. They talk about section 106 explicitly being abated, but site is chosen to be silent on CIL. But yet there is an assumption that it should be fully abated in the same way. And that's a fundamental blocker for us.
And then just thirdly, if I may, as a as a commercial research delivery centre, you know, there's capital infrastructure available through Nir, but at the moment it's not for new builds, it's for equipment. Portacabins. Um, and mobile research vans. But the Vpg at the moment, although there's nothing restricting this in the agreement, as far as I can tell, there's no facility for capital for a proportional contribution to the Gea, the internal area for exclusive use of research, not asking for reimbursement of that area because it's funded separately.
But the capital to build, build the bricks and mortar would enable us to meet the UK life strategy, target to double and then double again. But we can't at the moment because we can't get that capital. So I would um you know, there is an ask about pace of approvals, meaning that money isn't lost. I think there's an ask about the rules around CIL and CIL abatement and how that's used or not, and how that interplays with district councils. And then I think, you know, personally for our scheme and for other crcs around the country, there is an ask to the Department of Health and NIH to look at a capital call specifically for commercial research delivery centres that are meeting that wider life strategy, life sciences strategy.
10:27
Speaker 3
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Speaker 3
And one of the things that we notice, our GP voice survey 2000, GPS, only 27% of partners have accessed funding for infrastructure in the in the time that they're reflecting on when they're feeding back to us, the reasons for that aren't explored in the voice survey, but obviously there are apprehensions about long contracts, about service costs, maintenance, all these kind of things. What the detail in that contract will be. And obviously sort of if that was tied into house planning, 5000 new homes in a particular area, overloading a service, is there a security for a new GP practice?An idea might be that you pump prime that practice to allow the growth of the list.
That wouldn't make it a viable business until it gets to the point where it's sustainable. That way you can provide for that community of however many people are occupying those new houses.
That wouldn't make it a viable business until it gets to the point where it's sustainable. That way you can provide for that community of however many people are occupying those new houses.
10:28
Speaker 1
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Speaker 1
And that, of course, is one of the big reasons people oppose development because they know it doesn't come until much later. Um, can I come back, please, to thank you to district valuers. Um, so we've got an issue in Oxford, a practice that is absolutely not fit for purpose across several floors. Victorian building desperately needs upgrading. There's a new site next door that the council owns that they are very happy to work with everyone with, including the ICB, and we are.
I think you said it would stuck. We are also stuck. So when you were having what I'll describe as a rant. Um, I. Resonated and I could see there were people in our audience here nodding away as well. Um, so this is a common problem. Can I focus in on some of the solutions to this problem?And, and your understanding, first of all, of what the district valuer's say and who decides how and what they do.
So tell us who we need to go after to help them to fix their methodology. Two I noticed Doctor Wood, you said that the Icbs should be taking this as an advisory figure rather than a mandatory figure. Can you delve into that slightly more?And if anyone else has got any other suggestions about what we might do to fix this, I'm all ears. Shall we start with you, doctor?
I think you said it would stuck. We are also stuck. So when you were having what I'll describe as a rant. Um, I. Resonated and I could see there were people in our audience here nodding away as well. Um, so this is a common problem. Can I focus in on some of the solutions to this problem?And, and your understanding, first of all, of what the district valuer's say and who decides how and what they do.
So tell us who we need to go after to help them to fix their methodology. Two I noticed Doctor Wood, you said that the Icbs should be taking this as an advisory figure rather than a mandatory figure. Can you delve into that slightly more?And if anyone else has got any other suggestions about what we might do to fix this, I'm all ears. Shall we start with you, doctor?
10:30
Speaker 4
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Speaker 4
So, um, I think. The ask is at the moment, obviously there's a long term need to review the methodology. The premises cost reductions have only just been updated. That took 11 years. So that will take more time. Who did that?I don't know. Um, I don't know. So the district valuation has never published its methodology. As far as I'm aware. I haven't seen it. Um we don't get appraisals for the new build schemes.
So I, there's no, there's no transparency then to debate how they've arrived at their valuation. At least that's been our experience. So I would ask that the Department of Health directs the district valuer to publish their methodology and publish their appraisals. That can be done right away and then create a kind of dispute resolution mechanism where there's a conversation between the ICB, the DV and the the practice and the developer or, you know, the stakeholders involved to try to reach an appropriate value that reflects the true market cost.
Um, and then when I said it was advisory and it's taken as directive, I think, um, I can't reference that to you, but our experience has been that it's taken as definite, but also there are powers, there are executive discretionary powers that icbs have to grant up to 100% under section 96 to offset any shortfall. Or there are other ways they can exercise discretion. And I think, um, you've got direct experience of that, Rob, please.
So I, there's no, there's no transparency then to debate how they've arrived at their valuation. At least that's been our experience. So I would ask that the Department of Health directs the district valuer to publish their methodology and publish their appraisals. That can be done right away and then create a kind of dispute resolution mechanism where there's a conversation between the ICB, the DV and the the practice and the developer or, you know, the stakeholders involved to try to reach an appropriate value that reflects the true market cost.
Um, and then when I said it was advisory and it's taken as directive, I think, um, I can't reference that to you, but our experience has been that it's taken as definite, but also there are powers, there are executive discretionary powers that icbs have to grant up to 100% under section 96 to offset any shortfall. Or there are other ways they can exercise discretion. And I think, um, you've got direct experience of that, Rob, please.
10:31
10:32
Speaker 2
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Speaker 2
Yeah. Well, we've been having this interesting conversation with DV for some time. Um, under the premises cost directions. There are the DV is afforded the ability to look at an appraisal led. Um assessment. Of rent and rather than a market rent. So the difference between those are is the market rent looks backwards. So essentially looks at rents that have been set in four years previous and then uses those to, to um, essentially inform the process of what the rent should be.
Under the premises cost directions and a piece of guidance by the Royal Institute of Chartered Surveyors GN60, they can have an appraisal rent, which means they look at the real terms cost of how this. These the delivery costs and reflect that in the rent. Now it suits the purpose of NHS England and the DV not to go down that route because essentially they are keeping the rents at a lower level. But what they are doing also is.
Under the premises cost directions and a piece of guidance by the Royal Institute of Chartered Surveyors GN60, they can have an appraisal rent, which means they look at the real terms cost of how this. These the delivery costs and reflect that in the rent. Now it suits the purpose of NHS England and the DV not to go down that route because essentially they are keeping the rents at a lower level. But what they are doing also is.
10:33
10:33
Speaker 2
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Speaker 2
Well, to a degree, but I think that the localised, as I alluded to earlier, the localised Icbs are getting frustrated with this and the lack of progress. Um and we are seeing icbs are working outside of the framework now. So they are saying, okay, well we respect your view on this, but we are moving forward with this because we need to, to, to put the patient first. And therefore we are moving projects forward in, in, in your particular region. Interestingly, um, we had a solution from the southwest that we brought into Oxfordshire and said, this is a solution that works.
And it was rejected by the DV and the ACP, even though we have schemes which are being delivered using that solution. There is a.
And it was rejected by the DV and the ACP, even though we have schemes which are being delivered using that solution. There is a.
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Speaker 2
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Speaker 2
Yeah. So it's frustrates us that we are making really good progress with, you know, innovation through different ways of funding, different access to capital, which will offset the revenue requirements from ICB. And then we put that model forward and they said, not for us. And that's frustrating because we feel that we can scale our offering. It's good value for money. It still offers that DV comfort that, you know, the passing rent is at a level, but we are supporting it through use of capital.
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10:37
Speaker 6
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Speaker 6
Yes. Um, we've already heard that the current premises reimbursement rules actively discourage GP practices from sharing space with wider neighbourhood services. I don't know whether there's any further comments you may want to make on that before I move on. Um, particularly in relation to how it should be changed. I mean, if there are no further comments, I'm the.
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10:38
Speaker 2
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Speaker 2
It's going to be interesting to see how this is structured because for a, um, for a funder of, of primary care premises, we require that security of tenure in order to access that lower cost of capital. If it's fragmented, like the contracts are fragmented, then that's going to be quite difficult to work out. So the idea is, is that someone will take a head lease and then they will sublease those elements underneath, which is good because that could drive efficiency. It could drive better utilisation, but it will require an active management process within that building to, to drive that.
But we need to be very careful that the innovators in, in there are the private sector, which are the GPS, and the GPS need the opportunity to adapt, to expand. And they can't be hamstrung through a state. So whatever we, we um, design as that model and the neighbourhood health centre needs to be flexible, adaptable and be able to increase in size in the future.
But we need to be very careful that the innovators in, in there are the private sector, which are the GPS, and the GPS need the opportunity to adapt, to expand. And they can't be hamstrung through a state. So whatever we, we um, design as that model and the neighbourhood health centre needs to be flexible, adaptable and be able to increase in size in the future.
10:38
Speaker 3
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Speaker 3
One of the things that we were looking was the, the level of evidence. One of the things that we're saying is, can we base it on what the existing knowledge is?The Icbs have been asked to produce primary care estates information. So far. We're getting some icbs publishing. What we need is all icbs to publish and have this consolidated data so that we're acting on the evidence. We've also got the National Neighbourhood Health Implementation Programme and the 43 wave one sites.
What's the feedback that we're getting on there from things like capital, capital and revenue?Uh, the digital experience, the patient experience, um, safety data and not forgetting obviously what's happening in deprived and rural communities because they're the ones where there's the greatest level of need and obviously making sure that the services are close to where patients can get to with the examples that Louise has said.
What's the feedback that we're getting on there from things like capital, capital and revenue?Uh, the digital experience, the patient experience, um, safety data and not forgetting obviously what's happening in deprived and rural communities because they're the ones where there's the greatest level of need and obviously making sure that the services are close to where patients can get to with the examples that Louise has said.
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Speaker 5
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Speaker 5
Um I'm going to now talk about NHS property services. BMA have reported that 65% of NHS property services tenants reported inaccurate charging. Um and the Royal College of GPS have said that the unsustainable costs, um, unpredictable rent increases and service charges that have forced people to reduce capacity or scale back services, um, doctor Jamie, why do so many GP practices report issues with NHS property services, such as the unsustainable rents in and, uh, and unpredictable charges.
10:40
Speaker 3
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Speaker 3
Because that's their lived reality in terms of when you own your own building, you have a vested interest in it. It provides a commitment towards the continuity. As a building's owner, I make a loss on the building, uh, in the, in the initial years, because the district value doesn't meet, the notional rent fall short of the repayments. That's an acceptance because it helps to facilitate the continuity of care that patients need. If I can get to 15 years in the practice, which I did five years ago, uh, then we're delivering 30% reduction in hospital hospital admissions, 28% reduction in out-of-hours attendances, 25% reduction in mortality through 15 years of continuity with the same GP.
Um, what we've seen is that when there is the NHS property services, the feedback from members has been that it was unpredictable, it was unsustainable. If you've got that kind of climate, how do you convince another partner to say you can buy into this?We can't promise when the rent will be increased, what the service costs, what the maintenance costs will be. So it is all to do with the feedback we're getting from the members of that experience. It didn't quite work in the way that it was intended.
Um, what we've seen is that when there is the NHS property services, the feedback from members has been that it was unpredictable, it was unsustainable. If you've got that kind of climate, how do you convince another partner to say you can buy into this?We can't promise when the rent will be increased, what the service costs, what the maintenance costs will be. So it is all to do with the feedback we're getting from the members of that experience. It didn't quite work in the way that it was intended.
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10:41
Speaker 3
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Speaker 3
Um, well, there are conditions that go with it, obviously, of making sure that the same conditions are passed on to trusts. But again, there is the potential for the rent increases and the instability of and the perception that that may present to a partner looking to come into that building and into that business. One of the things that you need to legislate for is the idea of getting to net zero, 16% of our carbon emissions come from our energy use, but yet we don't have same access as the hospitals and the schools do to things like insulation, heat pumps, cooling systems.
My goodness, I could have done with that. On Fridays. I thought, you know, it's that kind of thing of sort of, you know, are there opportunities to expand and do that in those kind of environments?You've got a little bit more nimble and flexibility when the GPS have that ownership and commitment towards the practice. By buying in.
My goodness, I could have done with that. On Fridays. I thought, you know, it's that kind of thing of sort of, you know, are there opportunities to expand and do that in those kind of environments?You've got a little bit more nimble and flexibility when the GPS have that ownership and commitment towards the practice. By buying in.
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Speaker 3
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Speaker 3
I would incentivize the ability to remain in that practice and provide that continuity of care, that long term perspective means that it needs to be aligned with workforce, with estates planning, with house building to make sure that developers have that. And it's built into the contractual frameworks, but a BMA territory, but having that contractual framework that facilitates easy district valuation and delivering the.
10:43
10:43
Speaker 3
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Speaker 3
The services, not the individual GPS themselves, but as a group of clinicians, you come together to provide the service to the community that you want to build that legacy with, and it becomes very easy when you've been in practice for 15, 20 years, because you can see the patient as they're coming in from the waiting room, and you can work out their walking differently. What's going on there?There's something not quite right. And consultations are very much on. Fast forward when you facilitate that level of continuity and incentivize somebody saying, I'm going to stick around.
This is somewhere I can grow my career.
This is somewhere I can grow my career.
10:43
10:43
10:43
10:44
10:44
10:45
Speaker 10
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Speaker 10
Thank you. My name is Bill shields. I am the chief finance officer for the Derby, Derbyshire, Lincolnshire and Nottingham. Nottinghamshire. ICB cluster. We came together earlier at the latter part of last year. We covered a population of about 3.3 million people, and that goes from the high peaks in Derbyshire all the way across to the North Sea. So we are now experiencing very, very diverse communities and bringing those organisations together and dealing with a lot of the legacy estate issues that we have to work through to make sure that we deliver on the neighborhood health plan.
10:46
Speaker 11
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Speaker 11
Thank you. Yes, I'm Sam Pluckrose Oliver, I'm policy and public affairs manager at locality. We are the National Network for local community organisations. Um, so we support more than 2000 of those local organisations across. The country. And for the last five years, we've been part of the DHSc and NHS England National Bcsc Health and Wellbeing Alliance, working with both bodies at a national policy level to inform a more community led approach to health, particularly in the context of neighbourhood health.
10:46
Speaker 1
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Speaker 1
So we've heard throughout this inquiry about fragmentation, lack of integration between NHS local authorities and VCs. So I think we've got a good panel to help me understand some of the tensions here. Um, we've also heard like one of the changes that could be made is an alignment of funding timelines, right?And so, um, what we're trying to get to the bottom of is how do we make this better?If we've got a locality that you've got everyone on board and this is what I'm experiencing in Oxfordshire, we've got the, we've got the district or city council, we've got voluntary sector, we've got the practice itself.
Um, and the ICB all trying to achieve the same thing. And yet they find themselves butting up against each other and not being able to, to make a building work. What do we need to do to unlock that?Joe.
Um, and the ICB all trying to achieve the same thing. And yet they find themselves butting up against each other and not being able to, to make a building work. What do we need to do to unlock that?Joe.
10:47
10:47
10:47
Speaker 9
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Speaker 9
This is sort of contextual, so I would for me it was interesting hearing all of the sort of governance and structure, structural challenges. The biggest block for me is a cultural one that with all of the parties I've mentioned, I am able as an organisation to transact, develop projects and deliver in good faith that, you know, you may have tough, tough commercial negotiations, but they'll be able to specify what they want, how they will go about realising the asset and how will they will fund it. Sadly, my experience in working with the NHS is you can literally, um, agree to build a facility.
Um, so an example is we did a um a housing regeneration scheme, so 88 homes with a new health centre for two GP on the ground floor. This completed at the end of 2022. So um residents, you know, moved private sale, some were sold for private sale, affordable housing. Residents moved in. The health centre has set out um vacant so needs fitting out as shell and core because of just multiple um delays in firstly, uh who which body in the NHS.
We were going to um contract the lease with. So first of all it was going to be the GPS, then the ICB said they weren't happy with that and it would have to be themselves, you know, a body in a neighbouring borough in Newham because they couldn't actually contract directly with us. Then they said they weren't happy with that body, so we'd have to contract with NHS Property Services. They also couldn't find a mechanism to fund the fit out. So we said we will we will lend you the money, so we'll borrow it from Public Works Loan board and lend it onto you at cost.
Um there was then the huge protracted negotiation with the district valuer. So which I won't go into detail again on because um the doctor who spoke earlier, that was exactly the same experience. I think you saw me nodding. So we had that long thing and we, we hit the um, the kind of the, the key blocker was we needed to recover our build costs and the fit out costs and the costs of the debt we were taking out. And the district value.
We were saying, well, it's not worth that level of rent. Um, but, you know, we can't, we couldn't contract at below that eventually. And we needed to. Um, existing GPS, their health centre had been sold to a small local developer, the MD of that developer phoned me up and said, look, we've been sitting on our project for over a year because we don't want to evict the GP surgeries. They do a lot of work in Waltham Forest. They value their relationship with the community, but they'd incurred costs of £1 million in developing the scheme.
The debt they'd taken out to do it. I had to say to that developer, no, it's not reasonable that you continue and it because you could be here, you know, working with the ICB, with the NHS for five years. We don't get the affordable housing. You're incurring more financing costs for a vacant site. So we had the ridiculous situation that the ICB had to move the two GP, GP practices into um space in other local GP practices. So all the local residents are now inconvenienced.
Longer journeys from their um, community. So and every time to move the project forward, it's taken. And this is not how we normally work in Waltham Forest. A letter um from the leader of the council to the chair of the ICB with, with a, you know, the, the statement that we will make this public unless you move further on because we were getting, you know, a situation that the council was being blamed for the situation when it was, um, you know, we will always say if we have a role to play, but it was NHS delays and just the sort of Byzantine system you go through and you never really get a sense that there's somebody there championing it other than the GP.
Um, so an example is we did a um a housing regeneration scheme, so 88 homes with a new health centre for two GP on the ground floor. This completed at the end of 2022. So um residents, you know, moved private sale, some were sold for private sale, affordable housing. Residents moved in. The health centre has set out um vacant so needs fitting out as shell and core because of just multiple um delays in firstly, uh who which body in the NHS.
We were going to um contract the lease with. So first of all it was going to be the GPS, then the ICB said they weren't happy with that and it would have to be themselves, you know, a body in a neighbouring borough in Newham because they couldn't actually contract directly with us. Then they said they weren't happy with that body, so we'd have to contract with NHS Property Services. They also couldn't find a mechanism to fund the fit out. So we said we will we will lend you the money, so we'll borrow it from Public Works Loan board and lend it onto you at cost.
Um there was then the huge protracted negotiation with the district valuer. So which I won't go into detail again on because um the doctor who spoke earlier, that was exactly the same experience. I think you saw me nodding. So we had that long thing and we, we hit the um, the kind of the, the key blocker was we needed to recover our build costs and the fit out costs and the costs of the debt we were taking out. And the district value.
We were saying, well, it's not worth that level of rent. Um, but, you know, we can't, we couldn't contract at below that eventually. And we needed to. Um, existing GPS, their health centre had been sold to a small local developer, the MD of that developer phoned me up and said, look, we've been sitting on our project for over a year because we don't want to evict the GP surgeries. They do a lot of work in Waltham Forest. They value their relationship with the community, but they'd incurred costs of £1 million in developing the scheme.
The debt they'd taken out to do it. I had to say to that developer, no, it's not reasonable that you continue and it because you could be here, you know, working with the ICB, with the NHS for five years. We don't get the affordable housing. You're incurring more financing costs for a vacant site. So we had the ridiculous situation that the ICB had to move the two GP, GP practices into um space in other local GP practices. So all the local residents are now inconvenienced.
Longer journeys from their um, community. So and every time to move the project forward, it's taken. And this is not how we normally work in Waltham Forest. A letter um from the leader of the council to the chair of the ICB with, with a, you know, the, the statement that we will make this public unless you move further on because we were getting, you know, a situation that the council was being blamed for the situation when it was, um, you know, we will always say if we have a role to play, but it was NHS delays and just the sort of Byzantine system you go through and you never really get a sense that there's somebody there championing it other than the GP.
10:51
10:51
Speaker 9
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Speaker 9
It's so, um, in, in my experience of local authorities, when you deliver a project, you look at the outcome you want to achieve for residents, and then you figure out how you do it. Yeah. I find often with working with the NHS, they will think about, well, there's this rule with the district valuer. There's this problem here, we can't do this for this reason. And there's not that problem solving attitude of how do you move forward. And then I think there's a big issue around accountability.
So our local councillors, we as senior officers are known in the community and visible. And, you know, we will meet with residents, councillors even more so are actually living in, you know, living in the community. And you don't get that sense in the NHS. And often every time you get a movement, there's another restructure. They move senior officers around again. And it's it's so I think it's a it's um, all the sort of technical work to sort out the guidance and the governance.
But then a new culture in the programme to say, actually we want to deliver change for our patients. And then that accountability. So, you know, because it, it seems and this is not just a local. If you look at the new hospitals programme, our local hospital, Whipps Cross, is meant to be built, rebuilt. Millions have been spent on that scheme, including on a a new um car park. And then the hospital is just pushed back sort of ten years hence.
And in other parts of the public sector. And I include other bits of central government. I used to run the public estate programme in London, working with the Cabinet Office. You don't really have that. You know, when when you want to do a project, there is a commitment that, yes, we we will we will see this through. And you don't always get that sense with the NHS.
So our local councillors, we as senior officers are known in the community and visible. And, you know, we will meet with residents, councillors even more so are actually living in, you know, living in the community. And you don't get that sense in the NHS. And often every time you get a movement, there's another restructure. They move senior officers around again. And it's it's so I think it's a it's um, all the sort of technical work to sort out the guidance and the governance.
But then a new culture in the programme to say, actually we want to deliver change for our patients. And then that accountability. So, you know, because it, it seems and this is not just a local. If you look at the new hospitals programme, our local hospital, Whipps Cross, is meant to be built, rebuilt. Millions have been spent on that scheme, including on a a new um car park. And then the hospital is just pushed back sort of ten years hence.
And in other parts of the public sector. And I include other bits of central government. I used to run the public estate programme in London, working with the Cabinet Office. You don't really have that. You know, when when you want to do a project, there is a commitment that, yes, we we will we will see this through. And you don't always get that sense with the NHS.
10:53
10:53
10:54
Speaker 10
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Speaker 10
Um, so I agree with quite a bit of that, but I think the and I'll kind of respond to thinking about the NHS more broadly rather than just um the area that I work in currently. Um, I think it's fair to say that in the NHS in the past we have been obsessed with rules, regulations, funding routes, particularly annual funding, which is something that mitigates against the flexibility that we require going forward. If you think about where Icbs are positioned or will be positioned going forward, they are strategic commissioners, and so they need to take an overview on strategic capital.
So strategically, what will the capital that's available in that area deliver?So rather than looking at piecemeal, um, developments, looking at backlog maintenance in some buildings, which are actually suboptimal, what could actually happen if that capital was pulled together and some of those developments could take place?I also think that we are really hidebound, not just in terms of regulations, but also some of the technical aspects. I heard the previous speaker talk about health, technical memoranda and some of those things. Most of the care that we're talking about being delivered does not require a clinical space.
And if you look at this from a public estate perspective, there is a lot of space, leisure centres, libraries, other facilities where healthcare could be delivered. There is a plethora of estate that is being underutilized. And I agree with some of the comments that were made by Penny Dash. If you look at the points she made in terms of the silos that we've had with CDC being separate from community hospital development, being separate from new hospital programme, these things need to be brought together so that we can look at this in the round and look at what is required for the populations and the communities that we serve.
So strategically, what will the capital that's available in that area deliver?So rather than looking at piecemeal, um, developments, looking at backlog maintenance in some buildings, which are actually suboptimal, what could actually happen if that capital was pulled together and some of those developments could take place?I also think that we are really hidebound, not just in terms of regulations, but also some of the technical aspects. I heard the previous speaker talk about health, technical memoranda and some of those things. Most of the care that we're talking about being delivered does not require a clinical space.
And if you look at this from a public estate perspective, there is a lot of space, leisure centres, libraries, other facilities where healthcare could be delivered. There is a plethora of estate that is being underutilized. And I agree with some of the comments that were made by Penny Dash. If you look at the points she made in terms of the silos that we've had with CDC being separate from community hospital development, being separate from new hospital programme, these things need to be brought together so that we can look at this in the round and look at what is required for the populations and the communities that we serve.
10:55
10:55
10:55
10:55
Speaker 10
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Speaker 10
I think that, um, uh, unfortunately sometimes in the NHS we conflate safety with quality. Um, and so we need to be really clear about the fact that this is a publicly funded service. It is something that's cash constrained and we need to absolutely the best that we can with the money that we've got. That does not mean that we can always provide a gold standard. It means that we've got to provide something that is both safe and is the best that we can do with the available money, and it behoves us to make sure that we establish value for money.
And I think some of the discussion earlier in terms of, for example, some of the issues around the DVS role, the Valuation Office part of HMRC, I think. So, you know, and one of the issues there is, is this something that is about ensuring value for money for the public, or is this about something that relates to the tax take. So I think some of there needs to be some flexibility there and much more cross-governmental working in terms of how DHS, HMRC and other governmental departments can work together to get the best outcome.
And I think some of the discussion earlier in terms of, for example, some of the issues around the DVS role, the Valuation Office part of HMRC, I think. So, you know, and one of the issues there is, is this something that is about ensuring value for money for the public, or is this about something that relates to the tax take. So I think some of there needs to be some flexibility there and much more cross-governmental working in terms of how DHS, HMRC and other governmental departments can work together to get the best outcome.
10:56
10:56
Speaker 11
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Speaker 11
Yes. Um, I think from a from a local perspective, the culture change point is, is absolutely key. Um, I think the position most often adopted or forced to be adopted by the sector is of the kind of supplicant partner within that relationship between the NHS and the health system. Um, so we very much talk about the idea of the sector as an equal partner. And I think that's nowhere more strategically important and impactful than when it comes to, uh, to health, to neighborhood health, to prevention, to the, to the wider determinants of health.
Um, as those being places, those organizations in those community spaces that have the trust relationship and connection to those communities to, to make the biggest impact on those things. When it comes to spaces, um. Absolutely. That is, that is that has to be borne kind of first in mind. I mean, I think I'm my to. Get back to kind of a sort of, I think it does come down to kind of strategic national policy support and enabling for, for icbs and local health partners and their sector to do this.
And I think about the much deserved praise that somewhere like the Bromley by Bow Centre got and gets and was held up as the example of a neighbourhood health centre in the run up to the last election and the disconnect with now the approach that had been taken by the governments by NHS England towards neighbourhood health centres as being very much, uh, NHS um and and and local authority or NHS particularly led um. There is when it comes to the kind of the role of the, of the community sector, there are I think the figure is now about more than 9000 community spaces across the country that are nominated as assets of community value.
Um, there are, I think at last assessment in 2019, about 6300, uh, assets that are under under community ownership. And these are kind of key, uh, local community assets that have depending on their form and they will take different forms in terms of buildings and spaces and green space that have a huge role to play in the delivery of neighbourhood health. As I said, in those kind of trusted, um, connected spaces for, for the local community. But because of that kind of because of the sort of the, the, the junior partner role, because of a really kind of, uh.
Lack of joined up capital funding for community ownership because of a serious problem with availability of revenue funding. Um.
Um, as those being places, those organizations in those community spaces that have the trust relationship and connection to those communities to, to make the biggest impact on those things. When it comes to spaces, um. Absolutely. That is, that is that has to be borne kind of first in mind. I mean, I think I'm my to. Get back to kind of a sort of, I think it does come down to kind of strategic national policy support and enabling for, for icbs and local health partners and their sector to do this.
And I think about the much deserved praise that somewhere like the Bromley by Bow Centre got and gets and was held up as the example of a neighbourhood health centre in the run up to the last election and the disconnect with now the approach that had been taken by the governments by NHS England towards neighbourhood health centres as being very much, uh, NHS um and and and local authority or NHS particularly led um. There is when it comes to the kind of the role of the, of the community sector, there are I think the figure is now about more than 9000 community spaces across the country that are nominated as assets of community value.
Um, there are, I think at last assessment in 2019, about 6300, uh, assets that are under under community ownership. And these are kind of key, uh, local community assets that have depending on their form and they will take different forms in terms of buildings and spaces and green space that have a huge role to play in the delivery of neighbourhood health. As I said, in those kind of trusted, um, connected spaces for, for the local community. But because of that kind of because of the sort of the, the, the junior partner role, because of a really kind of, uh.
Lack of joined up capital funding for community ownership because of a serious problem with availability of revenue funding. Um.
10:58
10:58
Speaker 11
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Speaker 11
To that. Yeah. Um, it could have all leads to the example of the VSC, even more so than I know is already the case within locally, the NHS and local authorities, the VSC having to kind of scramble, scramble around to, to get together resources and make their voices heard within that, within that relationship.
10:59
10:59
Speaker 9
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Speaker 9
It's so we've got a number of health centres being delivered on big private led schemes on private land, and you will find most developers commercially want to deliver a health centre in in certainly in a London context, because having, you know, local GP surgeries and community health facilities drives residential values. And it's a key selling point when they sell the private sale units. Um, the issue with time limiting is one, but it's usually not because of the developer. It's the ability of the NHS to move quick enough to actually say who will occupy the space, how the revenue will be funded, who will fund the fit out, who's going to do it.
So I think it's certainly the Waltham Forest experience is not it's not an issue with private sector developers trying to renege on their responsibilities. It's more a concern. And we put a huge amount of work into sort of chivvying the local health system along to actually take up that space. And my, my view would be if we don't do that, we simply it wouldn't happen. We'd be left with vacant spaces in the developments. The section 106 obligations would time out and the developer would be able to let them to a, you know, a supermarket or another another commercial use.
And I think really that's the space needs to be used. And if the NHS can't move in a reasonable time scale to occupy it, ultimately that's what needs to happen. So, so.
So I think it's certainly the Waltham Forest experience is not it's not an issue with private sector developers trying to renege on their responsibilities. It's more a concern. And we put a huge amount of work into sort of chivvying the local health system along to actually take up that space. And my, my view would be if we don't do that, we simply it wouldn't happen. We'd be left with vacant spaces in the developments. The section 106 obligations would time out and the developer would be able to let them to a, you know, a supermarket or another another commercial use.
And I think really that's the space needs to be used. And if the NHS can't move in a reasonable time scale to occupy it, ultimately that's what needs to happen. So, so.
11:00
11:00
Speaker 9
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Speaker 9
Well, it. Are probably the most challenging partner to work with. We will always work with them because of the the critical need for new GP surgeries in London. And it's something that elected members of all parties are. It's probably the first um bit of social infrastructure when we're delivering new housing. After asking how much affordable housing is delivered, the next question is will there be a new health centre or GP surgery?So we will always championing that and, you know, commit the resources to try and make it happen.
But it often feels like an uphill battle working with the NHS.
But it often feels like an uphill battle working with the NHS.
11:01
11:01
Speaker 10
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Speaker 10
Can I just add to that?Just just two things really. One is that, um, I think for that to be successful, then the health infrastructure requirements need to be identified early and need to be embedded within local planning and development decisions. I don't think that's something that always happens. And it also needs to be some realism from the health perspective, which is that the developer contributions on their own will really be sufficient to fund that in, in, in, in complete nature. So there will still be a contribution.
I don't think that's always the case. And sometimes that's missed and assumed that that will be fully funded.
I don't think that's always the case. And sometimes that's missed and assumed that that will be fully funded.
11:02
11:02
11:02
Speaker 6
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Speaker 6
Was on that that point, Bill. Actually, I think we've had evidence before that the NHS should be involved in the planning system or built into the planning system. I guess the question is what that looks like and what that leads to, because it sounds. Joe, in your experience, it certainly my experience when I was in charge of regeneration planning in Camden for seven years, that wasn't necessarily a lack of involvement. That was the problem. It was a lack of the ability to make decisions.
That was the problem for the NHS. Do you agree that there should be more involvement in the planning system for the NHS?And if so, what should that look like?I think.
That was the problem for the NHS. Do you agree that there should be more involvement in the planning system for the NHS?And if so, what should that look like?I think.
11:03
Speaker 9
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Speaker 9
The where the NHS is strong is on identifying the strategic need and coming up with the strategic plan and strategy where it's more deficient is in the delivery of that strategy. So, you know, we have an infrastructure delivery statement as part of the local plan, which is updated annually that matches section 106 and still contributions to need. And we work very closely with health partners and health planners to inform that where we come more and stuck is around, um, taking that aspiration into delivery. And it's not actually delivering the new floor space.
It's, it's getting NHS partners to fund the fit out deal with the issue. Um, bill identified around it will never cover the full cost of the asset from, you know, from a single development and then actually occupy it. So I think it's not it's not the front end involvement. It's more the downstream delivery involvement. And that focus on we need to make this happen.
It's, it's getting NHS partners to fund the fit out deal with the issue. Um, bill identified around it will never cover the full cost of the asset from, you know, from a single development and then actually occupy it. So I think it's not it's not the front end involvement. It's more the downstream delivery involvement. And that focus on we need to make this happen.
11:04
Speaker 6
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Speaker 6
The services that similar analogy to school provision. There are different ways of assessing school place planning. Obviously this is a. A is kind of the local authority generally, as well as the planning authority too. In your experience, does that process work better in terms of identifying school places need the formulas for assessing what payments may or may not be. Do you have any views about the differences or similarities in the challenge of meeting school kind of provision and health provision to the planning process?
11:05
Speaker 9
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Speaker 9
I think you've seen some of the sort of way back when pre maths academisation that was a much easier process when most schools were maintained and the local authority was the the emissions authority. I think with school places with um a lot of academies, which are their own emissions authorities, it's almost become more like working with GPS, which are a range of independent organisations, um, where the ICB doesn't have sort of as director of sort of overall coordination, relationship with them. Um, but I think, you know, local authorities, we take because, um, the success of the school estate is so linked to there being the right number of pupils and, uh.
A, a level of surplus capacity. That doesn't mean schools are underfunded. We're very focused on that. I'm not sure. I, I you'd have to ask colleagues from Icbs, do they have that same level of focus on GP facilities?
A, a level of surplus capacity. That doesn't mean schools are underfunded. We're very focused on that. I'm not sure. I, I you'd have to ask colleagues from Icbs, do they have that same level of focus on GP facilities?
11:06
Speaker 10
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Speaker 10
I mean, I think that the, you know, answering this as the way things have been and the way things are is going to be very different from the way things will be. So Icbs will be much bigger. They are much bigger. They're linked with local government is going to be with mayoral authorities increasingly rather than with the planning authorities. So we need to think about how that will be delivered going forward. And I think that's through neighborhoods. So I think that.
11:06
11:06
11:07
Speaker 6
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Speaker 6
Group of local GP vision. In my area. Now, two Icbs merged about 4 million people now in my ICB across north and central London. You know the grip of local GP provision, GP provision and the development opportunity that's coming from one of the 11 local authorities. It's become more challenging in the new super. I think.
11:07
Speaker 10
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Speaker 10
That's where it's really incumbent on Icbs to make sure that they're really clear about what neighbourhood looks like and what those neighbourhoods do and how those neighbourhoods engage with the planning authority going forward, because the ICB can set the strategy. But for ICB, that covers 3.3 million population, a 4 million population to engage directly in each of those developments going forward is not going to be feasible.
11:07
Speaker 6
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Speaker 6
It's a big risk. As part of the changes. Do you think that because the NHS Bill going through at the moment, as you say, removes local authority representation on Icbs move to mayoral system?The mayor obviously has a usually has some sort of strategic planning approach across the city, but very light touch, you know, call in type process. Certainly not managing GP provision per se. Do you think that's a retrograde step?Do you think that local authorities should still have a seat at the table?Would this help in planning these sorts of infrastructure?
11:08
Speaker 10
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Speaker 10
Well, I think the specific example of the ICB cluster that I work for, there are three local authority representatives, so they cannot represent every single local authority. They can't represent the five local authorities that we currently deal with. So it's arguable that that will be something that's very different with two mayoral representatives. At least then we will have representation from two mayors covering the strategic requirements of each of those areas in the East Midlands and then potentially Greater Lincolnshire. Very different views probably will do in terms of how that should be taken forward.
But I think that's the right level for us to engage with. If we are covering a population of 3.3 million people.
But I think that's the right level for us to engage with. If we are covering a population of 3.3 million people.
11:09
Speaker 6
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Speaker 6
It sounds like one of the challenges here is the joint working between the planning authority, the local authority and the ICB. Doesn't sound like that is going to be easier in the new model. I mean, there might be other benefits from representation, but. Things we need to consider in this new approach to improve what is already, by the sounds of it, a bad situation for the joint working between local authorities and Icbs on a planning perspective.
11:09
Speaker 10
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Speaker 10
I wouldn't say it's a bad situation. I wouldn't say it's a bad situation between health and local government in any of those areas, whether it's around planning, whether it's around social care. But there are tensions, and I think we've got to be realistic that there will be tensions in two parts of the public sector that are funded in very, very different ways. And sometimes those tensions come to the fore. And some of those conversations, and I think what we expect is to have adult conversations about how we resolve those tensions.
11:10
Speaker 9
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Speaker 9
I mean, I think that is that is a potential issue with the new model that will need to be managed through. So I think, um, strategic engagement is really good. And I agree with Bill's point around in most ICB areas, you have 1 or 2 local authorities representing local government. I think what will be key with the new model is if the strategic relationship is via mayors, is what are those local?What are local delivery teams doing working with, um, individual local authorities to deliver the part of the plan that relates that local authority.
And I don't think that necessarily needs, um, you know, local authorities sitting on every body, but it is the good day to day relationship. So health need is matched with housing growth and demographic change. And those facilities are well planned for funded and then executed, I guess.
And I don't think that necessarily needs, um, you know, local authorities sitting on every body, but it is the good day to day relationship. So health need is matched with housing growth and demographic change. And those facilities are well planned for funded and then executed, I guess.
11:10
11:11
Speaker 9
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Speaker 9
I think I think it's all it's the from in my experience, it's the ability to actually transact and conclude property deals. So need is identified reasonably well. It's planned in and it's often delivered. But it's when assets are delivered, it's getting actual, you know, the lease signed, the fit out funded and the new services moving in. Is it at that stage I've experienced the challenges less so at the strategic planning stage. And that was my experience when I ran one public estate in London.
There were all sorts of area based and strategic plans. It was actually taking that plan into reality and delivering it.
There were all sorts of area based and strategic plans. It was actually taking that plan into reality and delivering it.
11:11
Speaker 6
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Speaker 6
That's helpful. And just finally, you you talked about the ability for the local authority to, to move in a different way. How much is that dependent on the local authority can borrow and the general fund, obviously, the housing revenue account as well, potentially, but more constrained. Um, how much is the challenge of the NHS that it faces quite different ability, you know, abilities to borrow. Um it's quite rigid and centrally imposed kind of capital expenditure limits. How much of this challenge is basically that, that you as a local authority can borrow against lots of different revenue streams?You have quite a lot of flexibility.
The health system doesn't Icbs can't.
The health system doesn't Icbs can't.
11:12
Speaker 9
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Speaker 9
I think that's a huge challenge. And actually, um, the very prescriptive governance heavy way capital is rationed into the system has a cultural impact as well. And so, you know, if you're working with a range of funding streams that could be, you know, section 106, CIL grant, prudential borrowing, which is what local authorities do. Commercial income. You take a, your, your approach to delivery to say, how do we blend that funding to deliver the outcome?If you're if you're used to working in a highly governance heavy top down model, you don't use that.
You don't. It doesn't facilitate that problem solving mindset. And I'd say in the, the role of the district valuer is a subset of that. So, you know, in my, I'm a chartered surveyor in my job, I use valuations all of the time. We know the 1972 Local Government Act requires us to show best value in property transactions, but we don't have one source of of the absolute truth. So we take a range of advice, and then we need to assure members, yes, based on the range of advice, this is what we recommend as officers for these reasons.
And having the district valuer as the single source of truth. Helps that. So it's both the sort of funding flexibility and also how you apply, you know, market knowledge and values to, um, to, to make a scheme viable and stack up.
You don't. It doesn't facilitate that problem solving mindset. And I'd say in the, the role of the district valuer is a subset of that. So, you know, in my, I'm a chartered surveyor in my job, I use valuations all of the time. We know the 1972 Local Government Act requires us to show best value in property transactions, but we don't have one source of of the absolute truth. So we take a range of advice, and then we need to assure members, yes, based on the range of advice, this is what we recommend as officers for these reasons.
And having the district valuer as the single source of truth. Helps that. So it's both the sort of funding flexibility and also how you apply, you know, market knowledge and values to, um, to, to make a scheme viable and stack up.
11:14
11:14
Speaker 10
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Speaker 10
I think about the NHS, I mean the NHS almost four decades and as long as I've been in the NHS, we've always been talking about capital slippage. So it's a feature NHS capital programming. We are not good at spending the money that we have. I think there are a couple of reasons for that. Um I think that we've got this constant tension between governance and flexibility. I think we could delegate much more, um, relatively small investments still require regional and national approval.
And that then means that we've got very, very elongated approval process. And that speaks to the points that I made earlier about then developments not happening, the opportunity being lost. So I do think there needs to be much more agility and much more flexibility there and much more trust as a consequence of some of these developments taking place. There clearly will always be an issue in terms of governance from a public sector perspective and public expenditure. But I do think there could be more delegation in there currently.
And that then means that we've got very, very elongated approval process. And that speaks to the points that I made earlier about then developments not happening, the opportunity being lost. So I do think there needs to be much more agility and much more flexibility there and much more trust as a consequence of some of these developments taking place. There clearly will always be an issue in terms of governance from a public sector perspective and public expenditure. But I do think there could be more delegation in there currently.
11:15
11:15
Speaker 10
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Speaker 10
I think most of the above actually. I mean, I think that strategic level, it's absolutely right for the the ICB to be determining what the priorities are for that area because they are the strategic commissioners and the capital distribution should relate to what they wish to commission strategically. But then I think, and we've already got a greater level of delegation to NHS trusts with the change in the capital regime this year. So there isn't system capital in the way that there was before. The problem with that is that then that oversight that used to exist, even at a level that's below the current size of icbs has gone.
And then the temptation for NHS trusts in particular, would be to deal with backlog issues, to deal with some of the maintenance issues that they've got and not think bigger in terms of what they could do with that capital if they were to pull it together.
And then the temptation for NHS trusts in particular, would be to deal with backlog issues, to deal with some of the maintenance issues that they've got and not think bigger in terms of what they could do with that capital if they were to pull it together.
11:16
11:16
11:16
11:16
Speaker 1
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Speaker 1
Making. The government's view is, I mean, we've been asking for clarity, which we've been. Finding challenging from the department on exactly how the place based integration between local authorities and the NHS is going to work. We challenged them on the boards issue just because of the cultural point. And they've come back and basically keep saying health and wellbeing boards. So so if that is it, what do we need?If that's going to be the main mechanism by which place based decisions happen, what then do they need to have to for it to be a success?I guess is my question.
11:17
Speaker 9
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Speaker 9
To my experience of local government. My concern, if I was Department for health about, you know, increased borrowing powers across the system would be that people borrow too much money, couldn't couldn't pay it back. And in the local authority context, there's, there's the legal requirement every year to set a balanced budget, which you don't have in the NHS. And I think, you know.
11:17
11:18
Speaker 9
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Speaker 9
And it's but it's where but it's where that is because because because the Health and Wellbeing Board is a is a partnership rather than a constituted organisation. It's, it's ensuring that sort of hard governance and accountability. And I think that, um, I, I, as a local authority person would, I'm a huge supporter of devolved budgets, but it's ensuring an accountability mechanism that makes an organisation accountable overall for the spend and the accountable body for that budget. And the risk with boards is it's diffuse to council accountability over a range of different partners.
11:18
Speaker 10
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Speaker 10
I agree with that. And I think that in principle, health and wellbeing boards have that oversight makes a lot of sense because of the space that they occupy. I think that the devil's in the detail. In terms of the governance arrangements, how you would actually delegate a budget to a non-statutory body, what would happen in the event that there was an overspend?Who would be responsible for that?So I think that regulatory framework needs to be understood and worked out for that to be something that could be successfully done.
11:19
11:19
Speaker 12
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Speaker 12
Thank you very much. Um, when we were in, in, in Cornwall, indeed in my, my constituency, we, we saw a range of, of um community and can I say kind of creative methods of, of, uh, of, of delivering um neighbourhood health facilities, uh, which, which achieved. Um, very. Substantial value for money. Um um working. Kind of to, to an extent outside the, the procurement rules because they were using, for example, community interest companies to, to deliver, to deliver projects.
I mean, to what extent would you say from your experience that the, the rules within which you operate actually are counterproductive in terms of, of value for money?Sorry. It's very, um, in terms of both value for money and, and in terms of achieving the intended outcomes. Sorry, I, it's so loud outside, I don't know whether you even heard the question.
I mean, to what extent would you say from your experience that the, the rules within which you operate actually are counterproductive in terms of, of value for money?Sorry. It's very, um, in terms of both value for money and, and in terms of achieving the intended outcomes. Sorry, I, it's so loud outside, I don't know whether you even heard the question.
11:20
Speaker 10
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Speaker 10
I did, I did. Um, and, uh, I've actually worked in Cornwall in the past. And so I'm familiar with some of the things that you've said in terms of the community interest companies and lift co schemes in Cornwall. And I think that whether we're looking at when we're looking at alternative finance, where it's lift, whether it's public private partnerships, whether it's PFI, um, one of the issues I think is, is what works today is something that's also got to work in ten, 15, 20, 25 years, the length of contracts and length of concessions of some of these arrangements is significant.
And the delivery of healthcare in a way that healthcare actually operates over that period is likely to change quite significantly. So I think one of the issues that we've had is getting locked into very long term arrangements. Um, in terms of being able to access alternative finance, um, it's very seldom the case, even if there's significant risk transfer that that will prove to be cheaper to the public purse than actually accessing government borrowing. So we really need to think really carefully about what we do and the flexibility that's going to be delivered and whether that represents long term value for money for the public sector.
So I would urge a bit of caution there. I think in terms of new types of public private partnerships, um, the issues are still the same. The private sector will always price risk and there'll be a premium for that risk. The public sector is not as good at, I don't think managing that risk. And that means that certainly over the cost of a over the period of concession, it will be more expensive. Now, that might be the right thing to do.
Because if you think about, for example, a PFI hospital, you will have life cycle built into that, which is something that wouldn't happen in a traditional construction. And therefore, at the end of the concession, the building should be still in the same state it was at the start. That's very, very different from the way the NHS is built. Things when it comes to lift Co, I think one of the problems there is that we've seen in some cases too many assets being constructed and not always thinking about that.
As I said before, from a strategic perspective, do we actually need that development?Could we repurpose something that's already there?The public sector estate is significant, and I think we're quite guilty in not repurposing what we've got and using what we've already got.
And the delivery of healthcare in a way that healthcare actually operates over that period is likely to change quite significantly. So I think one of the issues that we've had is getting locked into very long term arrangements. Um, in terms of being able to access alternative finance, um, it's very seldom the case, even if there's significant risk transfer that that will prove to be cheaper to the public purse than actually accessing government borrowing. So we really need to think really carefully about what we do and the flexibility that's going to be delivered and whether that represents long term value for money for the public sector.
So I would urge a bit of caution there. I think in terms of new types of public private partnerships, um, the issues are still the same. The private sector will always price risk and there'll be a premium for that risk. The public sector is not as good at, I don't think managing that risk. And that means that certainly over the cost of a over the period of concession, it will be more expensive. Now, that might be the right thing to do.
Because if you think about, for example, a PFI hospital, you will have life cycle built into that, which is something that wouldn't happen in a traditional construction. And therefore, at the end of the concession, the building should be still in the same state it was at the start. That's very, very different from the way the NHS is built. Things when it comes to lift Co, I think one of the problems there is that we've seen in some cases too many assets being constructed and not always thinking about that.
As I said before, from a strategic perspective, do we actually need that development?Could we repurpose something that's already there?The public sector estate is significant, and I think we're quite guilty in not repurposing what we've got and using what we've already got.
11:22
11:22
Speaker 9
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Speaker 9
I agree with all of that. Where for me, private finance and alternative financing models work best if you're dealing with portfolios of assets and you have the ability um, to. To swap assets in and out of the model where, where you hit a real challenge is a lot of the lift co facilities were let on 25 or 30 year concessions that wrapped in the debt payment, the lease payment and facilities management costs. And then if you have revenue cutbacks, you could have the situation where the services have all been cut back.
And, you know, London, when I was running one public estate in sort of 2015 to 2017, was littered with part vacant or fully vacant lift co assets because there had been revenue funding reductions and services had closed down where I could see a private finance model is safe for smaller GP surgeries where, you know, there's a need for X number of years. But if it's no longer needed, it could be solved by the JV partnership for a for a different use or redeveloped. And we've Wolf and forest have used that for housing acquisition, where we know we've got an immediate need, but we have the ability to, to move um, assets out of the JV partnership.
Um, should they no longer be needed and traditional private finance and lift code doesn't give you that flexibility.
And, you know, London, when I was running one public estate in sort of 2015 to 2017, was littered with part vacant or fully vacant lift co assets because there had been revenue funding reductions and services had closed down where I could see a private finance model is safe for smaller GP surgeries where, you know, there's a need for X number of years. But if it's no longer needed, it could be solved by the JV partnership for a for a different use or redeveloped. And we've Wolf and forest have used that for housing acquisition, where we know we've got an immediate need, but we have the ability to, to move um, assets out of the JV partnership.
Um, should they no longer be needed and traditional private finance and lift code doesn't give you that flexibility.
11:23
Speaker 12
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Speaker 12
Okay. But but I'm not just talking about I'm talking about community interest companies, not yet organisations that which are delivering those those projects. But I mean, in the main, you are therefore saying that that, that that all of the rules, the accounting rules and within which you, you have to operate and the procurement rules in which you have to operate, that actually it is. I think you're saying, Bill, that it's preferable to work within those rules, those constraints, those straitjackets. Um, are even if it results in, in not achieving the value for money in terms of the, the initial capital outlay on the building that you could have achieved in the first instance, significantly cheaper elsewhere, but by other models of delivery.
11:23
Speaker 10
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Speaker 10
I mean, you know, one of the significant changes that's taking place between a lot of the concessions and commencing and now is IFRS 16. So operating leases that were, um, not on balance sheet and now on balance sheet. And so you've then got to account for those in both revenue and capital terms that counts against capital expenditure limit. And that then mitigates against the flexibility that we've seen in the past where operating leases didn't. So that's a very, very different environment to the one when you.
11:24
11:24
11:24
11:25
Speaker 10
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Speaker 10
I think it's reduced flexibility. I think in terms of having greater transparency in some of the financial instruments that we've utilized, it's reduced flexibility and reduced our ability to be able to do these things over a longer period. So, you know, I think it's a case of in accounting terms, it's right in terms of flexibility and what makes sense for the things that we're trying to develop. It's very, very difficult.
11:25
Speaker 12
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Speaker 12
But, but but as a non accountant explaining in simple, in the simple terms in which I require it, because I'm not an accountant, I mean the IFRS 16 rule you're saying is something which which what protects the public interest in some in some manner, but actually creates an inflexibility, which means that you can do less and it might end up being more expensive because as I understand it, it brings the value of the lease into capital budgets and can cause a trust or ICB to breach their capital limits. Where we're funding.
Funding is otherwise available, which seems rather counterproductive.
Funding is otherwise available, which seems rather counterproductive.
11:25
Speaker 10
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Speaker 10
An unintended consequence of having more transparent accounting. So the purpose of IFRS 16 was to ensure that, um, leases were much more transparent. In the past, operating leases operated very differently from finance leases. It was possible for an organisation to lease an asset, whether it was a piece of equipment or a building, and that wouldn't feature on the balance sheet. Internationally, accounting standards moved to ensure that those were on the balance sheet, and that was to increase transparency. So from accounting perspective, it's absolutely fantastic.
It's really transparent from a pragmatic perspective. It means that that then counts against capital limits. And that is very constraining because it's almost like a double whammy. We're accounting for these in a revenue sense and a capital sense. And that makes that really does constrain the ability to look at alternative alternative finance in the public sector. It's been a massive constraint.
It's really transparent from a pragmatic perspective. It means that that then counts against capital limits. And that is very constraining because it's almost like a double whammy. We're accounting for these in a revenue sense and a capital sense. And that makes that really does constrain the ability to look at alternative alternative finance in the public sector. It's been a massive constraint.
11:27
Speaker 12
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Speaker 12
I mean, just taking one example, I saw in the the HST that. Um, that that. Your, your cluster had pulled out of a £33 million neighbourhood fund. Um, I mean, why it's obviously this is something which, which was desired presumably. Um, I mean, what was the basis of that had had had simply the, the estimates changed, the valuation has changed or had. The accounting rules caused it to trip up.
11:27
Speaker 10
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Speaker 10
I think that's, that's that's the other constraint working in the NHS at the moment across the the cluster where I work, we have a significant number of organisations who are in significant financial difficulty. So, um, almost every one of the acute providers has got a significant deficit. The choice that we were faced with was continuing to preserve the transformation fund. And this is always an issue between what will work in the long term and what has to happen in terms of short term requirements.
So to preserve that and facilitate the shifts that we want to see in terms of the shift from sickness to prevention, the shift from acute to community or support organisations and help them deal with their deficits. So Non-recurrent for this year only, we have used most of that transformation fund to support those deficit organisations. But being very, very clear that the proposals that we wanted them to bring forward, we still expect that to happen. We inevitably would not have been able to start everything on the 1st of April anyway.
And so we're still working through those proposals with the intention that from the 1st of April 27, we will have this year's transformation fund in next year's Transformation Fund, therefore, £66 million to facilitate and to fund those changes so far from ideal. Um, but we had to be pragmatic and recognise that having every organisation with a deficit was not something that would be acceptable.
So to preserve that and facilitate the shifts that we want to see in terms of the shift from sickness to prevention, the shift from acute to community or support organisations and help them deal with their deficits. So Non-recurrent for this year only, we have used most of that transformation fund to support those deficit organisations. But being very, very clear that the proposals that we wanted them to bring forward, we still expect that to happen. We inevitably would not have been able to start everything on the 1st of April anyway.
And so we're still working through those proposals with the intention that from the 1st of April 27, we will have this year's transformation fund in next year's Transformation Fund, therefore, £66 million to facilitate and to fund those changes so far from ideal. Um, but we had to be pragmatic and recognise that having every organisation with a deficit was not something that would be acceptable.
11:28
Speaker 12
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Speaker 12
I mean, do you think that the, um the financial reforms announced in the in the ten year plan, particularly, um that of setting five year capital budgets?Because you were mentioning earlier, the, the constraint of actually having sort of annual budgets and having to kind of work within that when in fact, you know, obviously construction can the whole planning, the pre-planning, the predevelopment, the development, the aftermath is clearly going to stretch beyond one, one single financial year. So, so do you think that those, those, those new freedoms, presumably they will be freedoms will, will help.
And what else can help, if you like, create that, that environment of, of well, of creativity and, and flexibility to achieve value for money and to deliver the projects.
And what else can help, if you like, create that, that environment of, of well, of creativity and, and flexibility to achieve value for money and to deliver the projects.
11:28
Speaker 10
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Speaker 10
I think two things. One is, yes, I do agree that having five year capital budgets will be advantageous. I think that will allow us to plan over a much more realistic and reasonable time horizon. I think the second thing is greater flexibility in terms of the ability to move capital and revenue, and vice versa. Um, that is traditionally not really happened other than to support the revenue position, but we should be able to be much more flexible if we have a development that has capital and revenue components, we shouldn't be constrained by how much of that is capital and what the capital limit that we're working within is.
11:29
11:29
11:29
Speaker 5
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Speaker 5
Yeah. So I'm just going to talk a little bit about some of the financial risk around, um, around it and kind of where it's held, um, where is the financial risk for neighbourhood estate projects currently being held and is it being held in the right place?I think Bill might be the best place to answer.
11:30
Speaker 10
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Speaker 10
So, um, currently, um, in terms of neighbourhood, there's when I think about the cluster, there's a mixture, um some of that has been delegated. And so it sits between um the primary care provider board, particularly in Derbyshire and one of the community providers, um going forward we will need and we are working on developing governance arrangements in terms of how we actually manage that risk. So um, what would we delegate in terms of budgets. And then what would be the governance arrangements around that?We're still working through what the neighbourhood footprints will look like.
We think there'll be a range of those. Um, one of the things that we're really keen to do is that our experience is that while if we do things at a very, very small scale with very small cohort, we can see some of those, um, changes take place and we can actually observe that we have to do this at scale. So we have to do this for 3.3 million people, not cohorts of 50,000 people. And the greatest respect to VCs colleagues, they can help us to understand some of those things and be really, really nimble.
One of the things the NHS has struggled with is actually taking that, um, nimbleness and some of those innovations and scaling it up. We haven't been very good at that. So the one thing that we need to think about is how do we scale those things up and do them across the whole geography?
We think there'll be a range of those. Um, one of the things that we're really keen to do is that our experience is that while if we do things at a very, very small scale with very small cohort, we can see some of those, um, changes take place and we can actually observe that we have to do this at scale. So we have to do this for 3.3 million people, not cohorts of 50,000 people. And the greatest respect to VCs colleagues, they can help us to understand some of those things and be really, really nimble.
One of the things the NHS has struggled with is actually taking that, um, nimbleness and some of those innovations and scaling it up. We haven't been very good at that. So the one thing that we need to think about is how do we scale those things up and do them across the whole geography?
11:31
11:31
11:31
Speaker 9
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Speaker 9
Um it that is a very common challenge with working with the VCs. A lot of organisations are hyper local and exactly as Bill says, it's how you take that learning and that involvement and that role in service provision and scale it up. And the larger the geography, the harder the harder that becomes. I mean, in terms of the financial risk from a, you know, from an immediate local authority perspective, one of the challenges because I, you know, what I mentioned about, um, the track record of NHS actually following through on leasing spaces at the moment of the health centre, I was referring to the financial risk is sitting with us in that it's sat vacant for three years, will be probably with a good window another year at least before it's occupied.
That's four years of lost rental income. We took the debt out, you know, six, seven years ago to build the facility. And so it's about £100,000 a year. So I reckon we'll we will have lost. And this is sort of local taxpayers, half £1 million by the time that opens, and that's money we could have spent on delivering other facilities for local people.
That's four years of lost rental income. We took the debt out, you know, six, seven years ago to build the facility. And so it's about £100,000 a year. So I reckon we'll we will have lost. And this is sort of local taxpayers, half £1 million by the time that opens, and that's money we could have spent on delivering other facilities for local people.
11:32
11:32
Speaker 9
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Speaker 9
It is a I mean, obviously, local authorities have had, you know, circa 40% budget cuts since 2010. And I think, you know, that has presented huge challenges. But there are also now in in local government is a commerciality and a real focus on needing to make the right investment, get the return. And I think sometimes it's a different system in the NHS where you haven't had the same level of financial austerity as in local government.
11:33
11:33
Speaker 11
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Speaker 11
Yes. Thank you. Um, to yeah. Feels like an opportune time to talk about the, the VC sector in this, in this perspective. Um, I think the absolutely understanding and agreeing with the pressures that the NHS partners and local authorities face financially in terms of service delivery requirements, I think the, the, the point, the point you made very well was the need to and, you know, um, Claire talked about this in her stocktake report, the need to think much more expansively about the health estate, not just about repurposing primary care or building new primary care, um, GP, NHS, but thinking we look directly back to the experience of the Covid pandemic and the role that community space has led in the vaccination programme.
Absolutely fundamental to that working because they knew where people were, people trusted who might otherwise not have come for their vaccination, could come to those spaces to get it. And I think the part of the solution, part of the very complex solution, obviously here is speaking to that point around the the. Appetite and the demand for community led spaces. So the Community Ownership Fund, which closed at the beginning of last year, we.
Absolutely fundamental to that working because they knew where people were, people trusted who might otherwise not have come for their vaccination, could come to those spaces to get it. And I think the part of the solution, part of the very complex solution, obviously here is speaking to that point around the the. Appetite and the demand for community led spaces. So the Community Ownership Fund, which closed at the beginning of last year, we.
11:34
11:34
11:35
Speaker 11
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Speaker 11
Say so. Spaces that are run and led by community organisations. So whether that's a local charity, whether that's a type of social enterprise that is community benefit society, a CIO, that kind of thing, rather than led by the local authority or the NHS or private space. So community Center, a community cafe, that sort of thing.
11:35
11:35
11:36
Speaker 2
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Speaker 2
I think the other thing I would say is, is that in terms of managing the financial risk, when when we think about delegation of budget and delegation of financial responsibility, um, I think it leads me to certainly to think of a lead provider arrangement. So if they're dealing with, um, all of the health care in that neighborhood, it needs to be an organization that has got the ability to deal with that. But that doesn't mean that they shouldn't be involved in that arrangement.
11:36
11:37
11:38
11:38
Speaker 3
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Speaker 3
One, which is about, um, demand and which is about models of, of, of governance, I think. So they're about 1.8 billion was the total. There is a huge amount of demand for communities and the spaces assets of community values in those places to, to, to be brought into community ownership. So what's been incredibly interesting, I think it seems to compare very starkly to the wider national health, its wider neighborhood health center agenda is the neighborhood mental health center agenda, and the very small pilot that starts now and is being grown out under the under the ten year plan, the six initial places, um, that, that nationally that took part in that pilot, four of which, uh, happened in.