Agenda item

The Integrated Care Board (ICB) and the County Council (Infrastructure Planning) to provide a joint presentation. The focus for this item is NHS estates and the use of developer contributions, the identification of areas where there are perceived challenges, an update on the key projects being progressed and an overview of each of these projects.

The Committee received a joint presentation from the Integrated Care Board (ICB) and the County Council. The presenters were Simon Doble of the C&W ICB and Janet Neale from WCC’s Infrastructure Team. Tim Sacks (ICB) was also present to respond to questions. In opening the item, the Chair mentioned that the focus was on estates aspects rather than access issues. Janet Neale commenced the presentation covering the following areas:

• The Local Plan process, with an outline of the key stages leading to formal adoption of the Local Plan. There was a clear need for both WCC and the ICB to be very involved in this process.
• Section 106 (S106). This was a legal agreement between local authorities and landowners/developers detailing obligations required as a result of a planning application. Effectively it was a charge against the land.
• Community Infrastructure Levy (CIL). A tax on net new floor space set locally and paid to the district or borough council. The requirements around levying and use of CIL were outlined. In Warwickshire to date, only the Stratford and Warwick Districts had adopted CIL, with Rugby Borough pursuing the use of CIL currently.
• Further slides showed the pros and cons of the S106 and CIL approaches.
• The proposal to introduce a new mandatory Infrastructure Levy, set locally (similar to CIL). This would be based on the assessed uplift value of the land, as a result of development. This approach had attracted strong challenge during the consultation process by a wide range of organisations.

Simon Doble then spoke to the NHS aspects:

• Primary Care Estate Context. This included the transfer from the former Clinical Commissioning Groups (CCGs), frustrations for general practice and responding to known population growth with limited funding.
• Primary Care Estate Environment. This confirmed there was no new funding, a historic lack of investment, before raising the challenges from existing funding streams, build costs, workforce aspects and ownership of premises.
• The current picture. A slide giving an understanding of the ICB’s position, the baseline and portfolio of the ICB estate. It detailed the current and projected population and the known shortage of rooms for patient appointments. 

• Growth areas and priorities for further work.
• Opportunities, including a collaborative working approach.

Questions and comments were invited with responses provided as indicated:

• The Stratford and Warwick District Councils were producing a joint Local Plan for the South of Warwickshire. Such plans included a ‘target’ number of new dwellings, and one consideration was whether to extend existing settlements, or development of new settlements. It was questioned from a health perspective which option would be easier to plan more reliable services for.
• Tim Sacks replied that there were challenges both in terms of buildings and workforce with a need to increase both, to improve access to services. The S106 funding received was not sufficient to build new premises. Options were expansion of existing premises within the funds available, or providing a new premises which was reliant on an external funding contribution to make up the shortfall, currently estimated to be around 40%. The S106 funds were used to maximise existing practices, but this meant no new premises were built due to the capital finance challenges. Simon Doble added that S106 was inflexible, which was frustrating. There was a commitment for the ICB and WCC to work effectively with districts and boroughs. For significant developments, Janet Neale touched on the potential for developers being required to build the premises, rather than negotiating a financial contribution.
• Local authorities were required to provide a prescribed number of additional houses and for the Warwick and Stratford areas this was some 39,000 homes in the next 10 years. It was questioned if the health sector made representations to the Planning Inspectorate regarding development allocations. There were real concerns about the impact of such additional development on health services due to the lack of sufficient funding to provide the services required.
• Janet Neale stated the need to work together and inform the Local Plan process at an early stage. The move from three CCGs to a single ICB and consistent approach was helpful. Officers were trying to address the current position and to inform future local plans at a very early stage, providing a robust evidence base of service need. This evidence would inform the Planning Inspector.
• Further points were made about the timescales for completion and adoption of a local plan, that the NHS was not speedy at dealing with such issues and developers sought to avoid or reduce commitments through S106 agreements. The member was very concerned at the impact for future health services. The Chair wondered if officers were being put in an impossible position. Officers reiterated the commitment between the ICB and WCC. There were endeavours to collaborate with all councillors and planning colleagues, to make this work.       
• In North Warwickshire, the closure of a Polesworth surgery required patients to transfer to Dordon. A lack of public transport caused issues with some patients unable to access this surgery. There was a satellite surgery in Polesworth which was underused currently and could be more effective. Residents voiced their frustrations to the local councillors. The point was acknowledged. An audit was taking place of all 153 surgeries and their current utilisation. This included 33 branch surgeries, which were not used on a full-time basis. Whilst it was far more efficient to operate from a single premises, there was a known shortage of estate. Part of the review would look at the potential to make more use of underused premises. Workforce shortages were raised, along with the public transport issues and the projected population growth in both Polesworth and Dordon. A written reply would be provided on the current utilisation of the branch surgery in Polesworth.  
• It was noted that some 4,500 new homes were planned for the Polesworth and Dordon areas. A view that another GP practice should be established to create competition.
• Some people needed to use medical services in neighbouring areas. This was acknowledged and for those living close to a county boundary, typically 15-20% would use services in neighbouring areas. Similarly, the S106 funding for new developments would rest with the local area where the development had taken place. There were regular discussions between adjacent ICBs. It was evident that when people moved home into Warwickshire they may stay with the previous GP and continue to use the same pharmacy.
• Discussion about primary care contracts. In some areas, alternative provider medical services (APMS) contracts were used. Additional costs were often incurred, alongside challenges for finding additional premises and issues around continuity of care where there were  shorter-term contracts. Securing the funding to build a new premises was difficult so the driver was population increase, not creating competition.
• A suggestion that planning law needed to be changed so that a lack of GP services was a ground for refusing an application. However, GPs were not a consultee to the planning process. In the Stratford area, there was a high number of care and nursing homes. This placed additional demands for GPs in that area with the requirements for home visits reducing capacity. The area had lost two surgeries and the remaining surgery was struggling to cope with the service demand from 30,000 residents. The Government should be lobbied on changing planning law.
• A member summarised the challenges raised during the presentation, asking how they would be addressed to balance supply and demand. Simon Doble replied that this was more to do with access than estates. NHS England was undertaking a project on primary care access recovery guidance. ICBs had been asked to work with primary care in responding. Effectively this would set out the overarching approach. It would lead to a roadmap and then delivery plan to address known issues. Creating a modern general practice, implementing changes and being innovative were cited as examples. There was no capacity within budgets. Every decision to fund something had to be offset by a corresponding saving elsewhere, so using existing buildings rather than new building and making more use of technology were further examples quoted. There was not the funding to create more capacity though extra buildings in every location. There needed to be different ways of working, which were mutually agreed and making better use of existing premises. 
• Further discussion about the Government’s proposal for an Infrastructure Levy to be introduced as part of planning reforms. Another proposal was to reduce the time period for the local plan process from typically 8 years to 30 months. Members were encouraged to be involved actively in responding to these consultations.
• The relationship between estates and workforce was raised by Chris Bain of HWW. A need to think about timelines for recruitment and retention across both the NHS and the care sector. This may provide an assurance for the population. Points about population growth,  having regard to demographic data and that from the Joint Strategic Needs Assessment (JSNA) too. On collaboration, this was seen as the way forward. A need to engage with social care, the voluntary sector and communities, as well as Healthwatch. The points raised were acknowledged, with an outline given of the joint work with primary care to match staff placements and available space. Collaboration did need to include all sectors.
• Councillor Bell, Portfolio Holder said the outcome of the NHS estate audit would be interesting to see. She spoke of the challenges faced in securing a pharmacy for a new health centre in Hartshill. It was questioned why this had proved to be so difficult. Furthermore, pharmacies were private businesses. There seemed to be a reluctance to create competition, but additional pharmacies could offer extra support for GPs. It was questioned what changes were proposed to improve internal processes for delivery of GP surgeries. Where large developments like that at Upper Lighthorne took place, people moved in, registered at existing surgeries and placed additional demands on them, long before the new surgery was available. It was important that the new facilities were built at the right time.
• Similar concerns were raised for the Kenilworth area, where 2,000 new homes would be built placing demands on the two surgeries serving that area. The local member would welcome a discussion outside the meeting. There was a recently opened school and potential for a new community facility to be provided as part of the development. It was questioned if one of these could include a room for use as a GP surgery.
• Tim Sacks agreed to pick up the points raised with the members. There was a need to be realistic as ‘outreach’ services were more costly in staff time when compared to having multiple clinics in the same location. If premises were of sufficient size, they effectively became a surgery and did add value.
• For the Nuneaton area, points were made about encouraging GPs to locate in areas of new development, planning tensions and the regeneration planned for this area, which may yield suitable premises for an additional surgery. It was questioned what the ICB could do to encourage GPs to locate in new or multi-use centres, or presently unused premises which could be converted to be a surgery. Tim Sacks reiterated that whichever building was used, the NHS still paid for it through a notional rent. The ICB would look at each primary care network (PCN) area to see what was needed and the potential to be innovative, whether it required extension to an existing practice or an additional one. The key was having a joint solution for each area, recognising the financial constraints, and the growing population to ensure access to services. He was not aware of GPs showing resistance to move into premises.   

The Chair closed the item, thanking the presenters and members for their questions. Any follow up questions from this item should be submitted to Democratic Services, in order that a response could be requested.