Primary Care Planning Under PIP

Primary Care provisions under pressure as ‘GREEN LIGHT’ to ‘fast-track’ planning for 300,000 + new homes each year

What are the implications to the primary care sector and how will enough medical care be provided for the inhabitants of 300,000 new homes to be built each year? Adam Thompson, of property specialist, Primary Care Surveyors, comments

As part of the Government’s plan to get industry moving during COVID-19, planning laws have been relaxed to ‘kick start’ house building under the now controversial Planning in Principal regulations known as PIP. If, in principal, planning permission is granted, only then will the more granular aspects of the scheme be requested, and a technical planning application asked for. The result; new developments can be fast-tracked to save developers time and costs during the planning process.

The Government has already delivered more than a million homes since 2010, and in 2019 we saw the biggest increase in new housing stock in the UK for almost a decade, with over 217,000 new homes built. With the Government’s new plans to deliver 300,000+ homes per year by the mid-2020s, under PIP, planning permissions need to be fast-tracked, with homes for a generation of first-time buyers, and with an increasing ageing population who need new homes as their needs change*.

So, what does this mean for the primary healthcare sector? With house occupancy averaging 2.3¹ residents per dwelling, this rural expansion would potentially accommodate over 690,000 new residents. Within the UK the ratio of patients to FTE GPs varies across the country, with 2,000 patients being the mean average². With this increase in population this would make a case for over 330 new FTE GPs, in new surgeries and health centres to administer to that number of patients.

From research conducted in 2015 by HSCIC (Health & Social Care Information Centre) the average population per GP practice in the UK was 6,884 patients. For these new PIP developments and expansion, this would make a case for over 100 new primary care medical centres, without taking into consideration existing local capacity.

With so many homes planned, what healthcare provisions will be made within these new developments? How will new surgeries and health centres be funded and built?

It is customary for developers of new schemes to offer some form of infrastructure benefit that will enhance and aid the local area and community, in return for the planning authority granting permission to build. Known as Section 106 agreements, falling under the Town and Country Planning Act 1990, these offers are normally demanded by the local planning authority. Often referred to as ‘developer contributions’, the developer would bid what was thought to be an appropriate enhancement to the development, in terms of added benefits for the local community.

With regards to residential developments, these ‘developer contributions’ were never sufficient enough to provide new primary healthcare facilities to support growing populations associated with new housing. Now under PIP granted developments, Local Authorities will use the Community Infrastructure Levy (CIL) as a primary means of securing developer contributions towards infrastructure projects. These contributions could be used to fund new or safer road schemes, recreational improvements or, potentially, the building of new health centres or surgeries.

The CIL tariff is charged on the ‘gross internal floor space’ of a proposed development, which, on average, is approximately £150 per new residence. Historically, where a development is earmarked for a CIL contribution, developers have never bid high enough to provide sufficient funding to build new primary care facilities. With a minimum 300,000 new homes built each year, what would that new healthcare provision look like? With most of PIP developments planned in rural areas, where there will be a lack of existing primary medical clinics and GP surgeries, 300,000+ new homes will require substantial investment into medical facilities for those areas alone.

So, can CIL tariffs work? Can the contributions be relied upon to deliver new medical facilities? Negotiating developer contributions to affordable housing and infrastructure is complex, protracted and unclear. Outcomes can be uncertain, which further diminishes trust in the system and reduces the ability of local planning authorities to plan for and deliver necessary infrastructure. Over 80 per cent of planning authorities agree that planning obligations cause delay and can further increase planning risk for developers and landowners, thus discouraging development and new entrants³.

Currently developers are allowed an agreed profit on cost, up to a certain threshold. If profits exceed that threshold the developer is liable to a higher rate of tax. Now the Community Infrastructure Levy and the current system of planning obligations will be reformed as a nationally set, value-based flat rate charge (the ‘Infrastructure Levy’), with a single rate or varied rates being set. The plan would be to impose a new Levy to raise more revenue than under the current CIL system. This would deliver at least as much – if not more – on-site affordable housing as at present. This reform will sweep away months of negotiation of Section 106 agreements and the need to consider site viability. This will deliver more of the infrastructure existing and new communities require by capturing a greater share of the uplift in land value that comes with development³.

In light of the relaxing of planning under PIP, what is required is a complete review of the housing sector, with a need for sustainable developments, with a strong theme of mixed use and proper guidelines for CIL contributions, in order that essential healthcare provision can be planned to meet the expected growing demand, as well as providing the new level of multi-disciplinary services in health care; however, since COVID, those provisions are now changing.

Due to COVID

With a requirement for more medical centres to meet the needs of an increasing population, what has changed in the last 6 months due to COVID? What have we learned that would affect the way new primary care facilities would have to be designed and constructed? Has the rate of obsolescence of the current UK primary healthcare property portfolio been accelerated due to COVID?

Now new thinking needs to be adopted as to the way new property facilities need to be designed and better utilised when dealing with the needs of patients as part of the overall COVID plan. What are our changing practices as the building needs to support the way primary care is evolving?

Since COVID, footfall to see GPs has dropped considerably in both surgeries and medical centres. Due to social distancing, the ability to ‘flow’ patients through a facility has been seriously hampered due to design constraints within the building, with future design constraints including plans for ‘hot & cold’ zones, with wider corridors, and multi entrance and exit points being the norm. Combined with the need for extra accommodation for ‘self-diagnostic’ pods or rooms, there is an overwhelming case for fewer but larger facilities, with multi-disciplinary teams.

With patient numbers dropping from 500 a day to between 30 and 40, the need to see a GP has changed, with consulting practices using online methods, reducing a need for patients to physically come into the surgery. Whilst this has been welcomed as a more efficient, streamlined way of operating, many elderly patients still like to ‘walk in’ as this gives them purpose and the interaction may be the only contact they have all week.

With an increase of support from a more diverse healthcare team, including Advanced Nurse Practitioners (ANPs), who have the authority to make autonomous decisions in the assessment, diagnosis and treatment of patients, thus taking the pressure off overworked doctors, this begs another change in the models of delivery of health care, with practices moving away from the traditional GP model, to multi-disciplinary teams of ANPs, Paramedics, Pharmacists, Nurses and Health Care Assistants.

To conclude, if primary health care is going to benefit from the new CIL tariff and meet the demands of an increasing population, a ‘root & branch’ look at the future primary health care model is required, how it is responding to current and future needs and demands and what that property footprint may look like.

¹ 2011 Census – Office for National Statistics

² NHS Digital 2019

³ Planning for the Future White Paper – August 2020 – Ministry of Housing, Communities & Local Government

* BBC News