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Business Case Rosendale Surgery

GP Practice 103a Rosendale Road

Dulwich, London SE21 8EZ

Index

EXECUTIVE SUMMARY 1

STRATEGIC CONTEXT 2

CURRENT PREMISES 3

OPTIONS FOR CHANGE AND EVALUATION 14

PREFERRED OPTION 23

FINANCES 34

APPENDIX 38

1

Executive Summary The Rosendale Surgery (‘’the practice’’) is currently located at 103A Rosendale Road, West Dulwich, London SE21 8EZ.

The practice consists of 4 GPs (3 Whole Time Equivalent). The practice currently has approximately 5,600 patients and is a PMS practice.

The practice needs to secure alternative premises as a matter of urgency.

The case for change is:

1) The existing premises have been sold, and the practice needs to vacate them

by June 2015 (though extendable if new premises are secured) 2) The existing premises are not suitable for the delivery of modern primary

healthcare services, and do not fully meet CQC or DDA requirements 3) A unique opportunity has arisen to secure high-‐quality, suitable premises with

long term tenure

The practice wishes to continue serving the area, and in addition take this opportunity to provide an enhanced primary and community service offering at a new surgery development within the existing practice area.

This Business Case is seeking NHS England support for the revenue and one-‐off capital costs in carrying out the proposed development and re-‐location.

The benefits of this Business Case are:

1) It will secure the long term future of the practice 2) The new premises will be DDA compliant, accessible to patients 3) The new premises will bring a wider range of primary and community services

local to a larger group of patients.

2

Strategic context

Local Population The practice lies within the Thurlow Park ward of the London Borough of Lambeth. Patients also come from the Gipsy Hill ward (Lambeth) and the Village and College wards of the London Borough of Southwark.

The practice population has an extremely varied mix of patients. It includes estates of social housing, where there are pockets of deprivation, young couples living in privately rented small flats, families living in small terraced houses, through to those living in houses costing in excess of £2.5 million.

Local Health Need issues There are currently 311,700 people living in Lambeth, and this figure is projected to grow to 373,261 by 20311. This will lead to an increased need for primary care services, though only small population growth is currently predicted for the Rosendale practice area.

Like many areas of both Lambeth and Southwark, the practice area has high population mobility, with an approximate 10% annual inflow and outflow. Many come from abroad. This creates an additional challenge for the surgery, as many patients arrive with no medical records and/or poor command of English.

The Public Health areas of high, and increasing burden in both Lambeth and Southwark are:

• Child obesity prevalence • Alcohol consumption • Undetected diabetes • HIV prevalence • Prevalence of severe mental illness • Emergency hospital admissions, leading to high NHS expenditure

1 Lambeth CCG Information pack, April 2013, National Health England National General practice profiles, 2013 2 One patient found her mobility scooter was unable to make it up the hill

3

Current Premises

Context The current list size is approximately 5,600 patients of all denominations and cultures.

The Rosendale Surgery is a PMS practice, part of South Lambeth CCG. The surgery is located on the eastern edge of Lambeth, close to its boundary with Southwark.

The surgery is currently situated in a converted and extended retail unit in a small parade of shops in an otherwise predominantly residential area of West Dulwich, London SE21.

Need to vacate The current owner (Dr Chabuk) has sold the premises to Westbury Holdings, subject to vacant possession by June 2015. Westbury Holdings intend (and are seeking planning permission) to re-‐develop the property into a single ground floor commercial unit with residential apartments above, and a mews house to the rear.

There is no need for a contingency plan for interim premises, as the landlords are prepared to extend the completion date if new premises are under construction.

There is an agreement in principle in place between the Current Surgery, Dr Chabuk and Westbury Holdings to extend the vacation date beyond June 2015, so long as it can be clearly demonstrated that a deliverable plan is in place to vacate the premises within a reasonable timeframe. In order to extend, the plan must be supported by documentation and action, i.e.:

• A rent agreement has been signed on a new premises • Construction is under way at a new premises (if applicable)

Full correspondence outlining this agreement can be seen in Appendix C

4

Accommodation provision:

Figure 1. Existing premises at 103A Rosendale Road

Existing Layout The building’s accommodation extends to 312m2 over two floors, and comprises:

• Downstairs o Two medical consulting rooms of circa 13 and 14m2 o Two nurse treatment rooms of circa 16 and 18m2 o A front reception area o A small waiting area at the front by the reception area o A very small area in the corridor by the main nurses room o A small conservatory at the back of the building o Two patient toilets

• Upstairs (via secure internal stairs, no disabled access)

o A practice manager’s room o An small office o A very small secondary office o A small room suitable for use by counsellors o A small kitchen o Two staff toilets

• Upstairs from the back conservatory

o A meeting room, which is used as the third medical consulting room. This room has no disabled access.

5

Limitations of current premises 1) The building and rooms do not meet current NHS and CQC standards, and it is

not possible to improve them sufficiently for these standards to be met.

2) The Victorian building was converted into a surgery in the 1990s, and the long, thin building footprint resulted in irregular shaped rooms, accessed off a single narrow corridor with limited natural light

3) The building is in general poor state of repair, including damp ingress from both basement and roof, a damaged heating system, and defective plumbing

4) The rooms suffer from poor sound insulation (jeopardising patient confidentiality), and inadequate temperature regulation

5) One of the three consulting rooms is situated up a steep, narrow staircase with no disabled access

6) One of the two nurse consulting rooms has no window. The only natural light and ventilation comes from a small skylight

7) All downstairs clinical rooms are in constant use: The existing service provision is frequently disrupted due to lack of available rooms, as the 5th clinical room is up a flight of steep stairs. To operate efficiently (without disruption to services) the surgery needs 5 clinical rooms, all with disabled access.

Current use of rooms at Rosendale Surgery:

Clinical room

Mon am

Mon pm

Tues am

Tues pm

Wed am

Wed pm

Thurs am

Thurs pm

Fri am

Fri pm

1 HCA GP GP GP GP HCA GP GP GP GP 2 PN PN HCA PN PN PN HCA GP PN PN 3 PN PN HCA HCA MW MW HCA HCA PN PN 4 GP GP GP Physio GP GP GP Physio GP GP 5 GP GP GP GP GP Key to abbreviations:

! GP: General Practitioner ! PN: Practice Nurse ! HCA: Health Care Assistant ! MW: Midwife ! Physio: Physiotherapist

6

Patients

Patient Area

Figure 2. Map showing the current practice area. Black boundary indicates inner area. Light grey boundary indicates outer area

Rosendale Surgery

7

The majority of the patients live in the Thurlow Park and the Gipsy Hill wards of the London Borough of Lambeth. Some also live in the Village and College wards of the London Borough of Southwark. A scattergram of the patient distribution can be seen below. For reference, we have included the existing practice premises and the two proposed sites.

As the scattergram shows, the practice patient population is broadly centred around the existing site. The Old Dairy Site, whilst slightly off centre, is still located in very close proximity to the majority of the dense centres of patient population (red dots). Norwood HLC is much more distant from the dense centres of patient population, located amongst sparser blue dots, representing the lowest numbers of registered patients.

The Old Dairy

Norwood HLC

8

The practice catchment area is asymmetrically weighted towards the East. This reflects the lack of any GP surgeries in Dulwich Village, and the relative abundance in West Norwood. The net result of this is residents of Dulwich Village currently have to travel relatively further to reach a doctor compared to the residents of West Norwood.

Figure 3. GP locations in Lambeth and Southwark.

Blue triangle indicates The Old Diary, Green Triangle is Norwood HLC

9

KEY: A – The Rosendale Surgery

103a Rosendale Road, London, SE21 8EZ

B – Paxton Green Group Practice

Paxton Green Health Centre 1 Alleyn Park London SE21 8AU

C – The Lordship Lane Surgery

417 Lordship Lane, London, SE22 8JN

D – 306 Medical Centre

306 Lordship Lane, East Dulwich, London, SE22 8LY

E – Norwood Surgery

483 Norwood Road, London, SE27 9DJ

F – The Deerbrook Surgery

216 Norwood Road, London, SE27 9AW

G – Brockwell Park Surgery

117 Norwood Road, London, SE24 9AE

H -‐ Elm Lodge Surgery

2 Burbage Road, London, SE24 9HJ

I – The Tulse Hill Practice

4 Hardel Rise, London, SW2 3DX

J – Well’s Park Practice

1 Wells Park Road, Sydenham, London, SE26 6JQ

K – Knight’s Hill Surgery

130 Knights Hill, West Norwood, London, London, SE27 0SR

L – Crown Dale Medical Centre

61 Crown Dale, London, SE19 3NY

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M – Dulwich Medical Centre

163-‐169 Crystal Palace Road, East Dulwich, London, SE22 9EP

N – Herne Hill Group Practice

74 Herne Hill, London, SE24 9QP

O – East Dulwich Primary Care Centre

Dulwich Hospital, East Dulwich Grove, London, SE22 8PT

P – Forest Hill group Practice

1 Forest Hill Road, London, SE22 0SQ

Q – Melbourne Grove Medical Practice

Melbourne Grove, London, SE22 8QN

R – Palace Road Surgery

3 Palace Road, London, SW2 3DY

S – Water Lane Surgery

48 Brixton Water Lane, Brixton, London, SW2 1QE

Location of surgeries on map taken from NHS Choices

Patient demographics Patients come from across the complete range socioeconomic backgrounds, ranging from long-‐term unemployed resident in social housing and cared-‐for mental health patients in sheltered residential accommodation, through to national newspaper editors, senior lawyers and privy counsellors.

Compared to the average for Lambeth CCG, the practice has an over-‐representation of higher-‐need age bands: The under 4s and the over 65s (figure 4).

11

Figure 4. Practice Patient Age profile 2013. Data taken from National General Practice Profiles, Public Health England Website.

Service Offering

Primary The current practice opening hours are:

Monday Core 08:00 -‐ 18:30, plus extended late opening to 20:00

Tuesday Core 08:00 -‐ 18:30, plus extended late opening to 20:00

Wednesday 08:00 -‐ 18:30

Thursday 08:00 -‐ 18:30

Friday 08:00 -‐ 18:30

Weekend Closed apart from one Saturday morning each month, 9-‐12am

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The practice has 4 part time doctors offering a total of 22 clinical sessions of care during core hours (just over 3 WTE). A total of 77 hours of doctor appointment time are available each week. There is a mix of telephone appointments, appointments that are pre-‐bookable, and appointments available ‘on the day’. Three appointments for each surgery can be booked on line by patients. In addition to the clinical time, each doctor needs access to their computer for administrative work for a minimum of a further 3 hours each day.

In addition to 77 hours of doctor appointment time, a total of 46 nursing hours are available, plus 35 healthcare assistant hours per week.

A physiotherapist visits two sessions a week, and a midwife one session a week. This means that all the ground floor clinical rooms are fully utilised throughout each working day.

Services currently offered by the practice include:

-‐ Joint injections and cryotherapy -‐ A family planning service, including coil insertions -‐ A weekly baby clinic -‐ Travel advice, including travel injections -‐ A weekly diabetic clinic -‐ A phlebotomy service for patients with mobility difficulties -‐ A weekly ante-‐natal clinic, run by a visiting midwife from King’s College

Hospital -‐ 2 physiotherapy sessions a week, run by a visiting physiotherapist from King’s

College Hospital

The practice currently employs 17 people:

-‐ 4 GPs -‐ 1 Nurse Practitioner -‐ 2 Practice Nurses -‐ 1 Practice Manager -‐ 2 Administrators -‐ 1 Reception Manager -‐ 4 Receptionists -‐ 1 Healthcare Assistant -‐ 1 cleaning and maintenance assistant

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Community -‐ The practice offers the use of an upstairs room (if it is available) 2 sessions a

week to a visiting therapist from the Lambeth IAPTS service -‐ Regular meetings are held at the practice with other members of community

health care teams, such as district nurses, the community matron, and palliative care nurses from St Christopher’s Hospice

-‐ The practice has signed up to the new Lambeth Integrated Care service. The team leader has asked for a permanent office in the surgery, but unfortunately there is no available space for this. However, regular meetings on integrated care are held at the practice

-‐ The practice is in the process of bidding for funding in the new scheme to start in Lambeth offering core services 7 days a week

Other -‐ The practice teaches medical students from St George’s Hospital medical

school -‐ The practice provides a school medical officer service to 3 local schools –

Dulwich College, Alleyn’s School and James Allen’s Girls School. Between them these schools have over 3,000 students and 500 members of staff. The boarding pupils at Dulwich College are registered as patients at the practice.

-‐ It also provides a medical service to visiting overseas students to ‘Our World’ English schools operating in the locality during the summer months

Performance The practice is high performing:

-‐ From the latest available figures from September 2013, the total practice budget was 3% underspent, and inpatient activity was 16% underspent

-‐ It is within the top quartile for practice performance within London for 2012/13

-‐ It is consistently the lowest surgery in the CCG for attendances at A and E -‐ It consistently reaches full achievements on medicines management targets,

and for the last 3 years has been underspent on its drugs budget -‐ QOF achievement for year 2013-‐14 was 765 out of a possible 769

14

Options for change and evaluation

Objectives and Criteria In evaluating the options for the Rosendale Surgery premises, we seek to meet three criteria:

A) Local access: New premises should preserve convenient access to the surgery for the existing patients, minimising the distance of a new premises from the existing site

B) High quality premises: New premises should offer a high quality clinical service in suitable premises that meet all required standards

C) Room for growth: Service provision is sometimes disrupted at the current site (of 5 rooms) due to lack of accessible clinical rooms. New premises should offer at least 5 fully accessible clinical rooms to allow services to be delivered without disruption. Additional room to accommodate additional services in line with changes in NHS patterns of care (and supported by Lambeth CCG) is desirable.

D) Financial viability: The new premises should not place significant additional financial burden (either through loss of income or additional costs) on the practice

Search Study A street-‐by-‐street search was carried out in early 2012, and the practice (and its project manager) have remained vigilant since to potential opportunities.

Westbury Holdings have undertaken an extensive search in March 2014 based on criteria provided by the practice – as it was in their interest to assist the practice to relocate. This search did not identify any suitable premises. This site search is attached in Appendix C

The local area is characterised by relatively high-‐value residential properties, with limited existing commercial properties. When commercial premises come to the market they are mostly too small to accommodate a surgery of this size, and in all cases they have the possibility of residential use and are thus not economically viable for use as GP premises

15

Available options Options are:

1) Do nothing 2) Remaining in the existing building 3) Move to West Norwood Health and Leisure Centre 4) Move to another existing surgery or another site 5) The Old Dairy Site

Appraisal

1) Do nothing

Under the ‘Do nothing’ scenario, the practice will be evicted from its current premises in June 2015. If suitable alternative premises are not found, the surgery will be forced to close. In such a situation, it is anticipated that:

• All the staff will be made redundant – a loss of 14 local jobs • Drs Leonard and Howard will semi-‐retire, and substantially reduce their clinical

hours • Drs Leonard and Parihar will move to another local surgery, but there will only

be capacity for some (~40%) of the patients to follow them (limited by the capacity of the new surgery and Dr Leonard’s reduced hours)

This scenario is sub-‐optimal:

• There will be major disruption to patient continuity of care. • Responsibility of providing a GP to the whole of the list size (5,600 patients)

will fall to NHS England. • The local health economy will lose ~6,000 capacity of GP list size, placing

extreme pressure on other local practices (already close to capacity)

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2) Remaining in the existing building

Purchasing the building from the current owner is not an option: Contracts of sale have been exchanged with a new purchaser (Westbury Holdings).

3) Move to West Norwood Health and Leisure Centre • Space is available within a development in West Norwood Health and Leisure

Centre, that could be used to accommodate some of the activities of the Rosendale Surgery

• The premises have been purpose built, so meet all required standards

However,

• Location: Significant reduction in accessibility to existing patients and a resultant loss of patient continuity of care

Figure 5: Distance (by walking) from existing practice to Norwood HLC

o West Norwood Health and Leisure Centre is situated the furthest away from the existing site of all identified alternative premises, a 1.2km walk from the existing site

o It is located outside of the existing inner practice boundary: The inner practice boundary stops on the boundary of Robson Road and Norwood High Street, whilst Norwood HLC is situated to the West, off Knight’s Hill

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o West Norwood Health and Leisure Centre is not in close proximity to the majority of the patients’ homes:

! Travel times are significantly longer from major practice patient population centres than either the current premises or the Old Dairy Site

! Recent patient surveys (see page 28) indicate a substantial number of patients would be unwilling or unable to travel to WNHLC, instead seeking a GP at an alternative site

o It is located up a steep hill, making access difficult for patients with mobility problems2

o It is located in an area with several existing GP surgeries, whilst the Dulwich Village area becomes even more under-‐served

o There are poor public transport links between core population centres of the existing practice area and the proposed site: There are no direct bus or train routes (see access and travel summary)

o Only very limited visitors’ parking is available

• Available space: A move to West Norwood Health and Leisure Centre would mean reducing patient clinical services

o The 250m2 site offers 4 clinical rooms compared to 5 at the current premises: For un-‐disrupted service offering, the practice requires full-‐time use of 5 consulting rooms

o The practice is already near maximising use of its current facilities – it is not possible to reduce available clinical space and yet retain the existing service offering

o Whilst additional rooms can be booked at Norwood HLC, these bookings are for short-‐term use, not full-‐time (and booking them incurs additional cost to the practice)

2 One patient found her mobility scooter was unable to make it up the hill

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• Finance: Moving to West Norwood HLC would place an unsustainable financial burden on the practice

o Reduced income: Patient surveys (see page 28) indicate that most patients would not follow the practice to the new premises: The practice would lose significant income through a reduction in patient numbers.

o Increased costs: ! The practice would be required to fund ~£39,0003 per year in

un-‐refunded premises costs ! To retain the existing service offering the practice would have

to rent an additional consulting rooms almost full-‐time, at additional cost

4) Move to another existing surgery or another local site • Moving to another local surgery could provide continuity of care for some

patients

However,

• No local practice currently has sufficient spare capacity to accommodate anything beyond a minority of the existing practice population

• No local practice has spare capacity to employ any of the existing practice support staff

Realistically, moving to another local surgery would in fact be closer to the ‘Do nothing’ option, where the Rosendale Surgery closes down.

Westbury Holdings have undertaken a recent, extensive search of possible sites for a new surgery, and none, other than option 5, could be found (Appendix C)

3 Average non-‐reimbursed premises costs for years 1-‐5

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5) The Old Dairy Site • The site is 276 metres from the current surgery (450 metres by road). It is

closer to the centre of the practice catchment area than the current premises. It will provide continuity of care to the existing patient population, in close proximity to their homes, and with minimal service disruption.

• It will be purpose built, and will meet all required standards. • The site has much better access than the current premises (and other options

identified): o A bus stop and dedicated disabled drop-‐off bay are situated right

outside, on a flat level with the premises o Significant free street parking is available in the vicinity

• It is larger than the current premises. It offers 7 consulting rooms, as well as a large waiting area, a training/library room, and a large multipurpose communal room with a kitchen. This will allow the practice to provide increased primary and community services in line with changing NHS needs.

o Additional consulting rooms are desirable for: ! Allowing some room for expansion ! Offering additional services, as South Lambeth CCG have

indicated that they need additional space in the community to provide Integrated Care services

The practice recognises that at present its NHS services are only making use of 5 clinical rooms. It therefore proposes to fund the remaining rooms on a separate basis, using income from other sources, such as CCG integrated care services, or private health care services, such as chiropody or physiotherapy.

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Access and travel summary

Indicative travel times to current premises, The Old Dairy Site and Norwood HLC from major centres of patient population (spread across the current practice area) are shown in the table below. By travel time, the closest and furthest premises for each population centre have been indicated in green and red respectively.

Location Current premises Old Dairy Site Norwood HLC

Ling’s Coppice 8 mins

(walk)

2 min

(walk)

15 mins

(13 min walk, 2 min bus)

Martell Road 5 mins

(walk)

7 min

(walk)

7 mins


Court Lane 23 mins


23 mins


25 mins

(22 min walk, 3 min train)

Dulwich Wood Ave 17 mins


14 mins


27 mins


Turney Road 14 mins


8 mins


22 mins


Methodology:

- Leaving from mid-‐point of road named, at 9am on a Monday morning - Google Travel Planner has been used to calculate times - Waiting times for public transport have NOT been included - The fastest method of transport has been used (excluding cars) - Times assume the person does not have limited mobility or any disability

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Appraisal summary

Option 1 (Do nothing) is discounted as it fails all the criteria:

• Under the do nothing option the surgery will close

Option 2 (Remain in the existing building) is discounted as it fails criteria B) and C):

• The premises would require significant investment to meet a basic standard for high-‐quality service delivery

• The premises do not offer the space needed to provide additional services to the local population

Option 2 is not a long-‐term option: After June 2015 the surgery will be evicted – it is akin to the ‘Do Nothing’ option

Option 3 (Move to West Norwood Health and Leisure Centre) is discounted as it fails criteria A), C) and D):

• The distant location of West Norwood Health and Leisure Centre and lack of transport links represents poor local access for the existing patient population and would lead to significant numbers of patients having to seek alternative doctors

• It offers fewer consulting rooms than the current premises and likely would necessitate a contraction of service offering to the local population

• It would be financially unviable for the existing practice: The partners would be unable to accommodate the loss of income and additional costs associated with the move

Option 4 (Move to another existing surgery or another local site) is theoretically possible, however no suitable premises or sites have been identified. Only a small proportion of staff and patients could transfer to another operating surgery premises – this would disrupt continuity of care for most patients.

It is therefore discounted.

Option 5 (The Old Dairy Site) meets all 4 criteria, providing suitable premises within the current practice area that also offer opportunities for service development. We have chosen option 5 as the preferred option – it is explored in further detail in ‘Preferred Option’.

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Option: Criteria (A) Criteria (B) Criteria (C)

Criteria (D)

1. Do nothing

2. Stay in the existing building

3. Move to West Norwood Health and Leisure Centre

4. Move to another existing surgery

Depends on premises

5. The Old Dairy Site

Table 1. Summary of Options against criteria

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Preferred Option

Overview – The Old Dairy Site

Building -‐ The premises will be newly purpose built on the site of a disused old dairy. It is

in a small retail area of West Dulwich, with more than 15 shops, a small supermarket, 2 restaurants and a bank. The pharmacy currently next door to the existing premises plans to relocate to one of the retail units near the new site

-‐ The surgery will be part of a mixed development, incorporating four retail units and nine flats in a 3-‐storey building: Two flats will be on the 1st Floor, and seven on the 2nd Floor

-‐ The surgery will have prominent street frontage, with a reserved dedicated ambulance and disabled drop off bay directly outside the front door.

-‐ The front entrance is alongside the retail units, with similar frontage and street presence

-‐ The surgery will comprise 583m2 of net internal area, spread across two floors (459m2 on the ground floor and 124m2 on the 1st)

-‐ There are 7 identically sized consulting rooms. One of these will be fitted so it is suitable for minor surgery

-‐ All the consulting rooms are on ground floor level, with disabled access. They all have large windows facing onto a central courtyard, giving plenty of natural light

-‐ The building is considerably larger than the current premises, with more space for clinical work, administration, meetings and teaching

The premises will be built and fitted out in full compliance with current NHS design standards.

In addition, the developers are committed to meeting all building standards, including an ‘Excellent’ BREEAM rating.

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Location The premises are located 276 metres from the current surgery (450 metres by road), and are more central to the current practice area than the current premises. They are on a main bus route, with a bus stop directly opposite.

There is plenty of free, unrestricted parking in nearby streets, including directly on the street outside the front entrance (Croxted Road).

The building itself is part of a mixed-‐use scheme development, comprising a retail unit, private and social housing, and the self-‐contained GP surgery.

The practice population scattergram confirms that the Old Dairy Site is ideally located for the majority of the patients.

Funding The premises will be built to NHS specification by the Dulwich Estates. An agreed rent will be paid annually commencing at a level agreed with the DV. Full financial details can be found in the ‘finances’ section of this business case.

Figure 5. Proximity map between the Rosendale Surgery and the Old Dairy Site

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Detailed accommodation The premises are considerably larger than the current premises, allowing room for expansion in services.

-‐ 7 full size clinical rooms, all on the ground floor with disabled access (compared to only 3 of this standard currently)

-‐ One large central area, planned to be used as a waiting/reception area -‐ Large administrative and office spaces, located both on the ground and 1st

floor -‐ A multi-‐purpose meeting/activity space on the ground floor, and a further

large multi-‐purpose meeting/activity room on the first floor, with an integrated kitchen

-‐ A library/training room

The full proposed schedule of accommodation is given in the table below.

Room Name Proposed Area (m2)

No. TOTAL Area (m2)

Comments

Ground Floor

Entrance lobby 21.8 1 21.8 Pram park 5.5 1 5.5 Waiting Area inc child play area

63.2 1 63.2 5 chairs per clinical room

Reception 12.1 1 12.1 Limited Records storage required at reception

Admin area to rear of reception

35.8 1 35.8 Connected to rear of Reception

Tea Point 2.9 1 2.9 Interview Room 11.9 1 11.9 Close to reception easy

access for staff GP / Nurse Consulting Room

16 5 112

Nurse / Treatment Room 16 2 32 Clean Utility Room 11.1 1 11.1 Includes clinical storage

and fridges Dirty Utility Room 7.9 1 7.9 Stores 5.6

4.4 2.4

1 1 1

5.6 4.4 2.4

Patient disabled wc 5.5 1 5.5 Patient wc 2.5 2 5 Baby change 3.2 1 3.2 Staff w/c 5.7 1 5.7 General Refuse 2.8 1 2.8 Lockable Clinical Refuse 2.8 1 2.8 Lockable

First Floor

Staff Room inc.teapoint 40.1 1 40.1 Staff w/c and shower 3.2 1 3.2 Staff disabled wc 3.3 1 3.3

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IT Room / store 9.2 1 9.2 Administration Office 15.8 1 15.8 Stores 2.5

2.7 1 1

2.5 2.7

Records Store 23.9 1 23.9 Library / Training Room 13.4 1 13.4 Plant Room 5.5 1 5.5 Dependant on plant

selection

See Appendix A for detailed floor plans

Patients Changing patterns of care within the NHS, with a transfer of provision out of secondary care settings will lead to an increased need for primary and community care services.

The building offers the potential for 3 more full-‐sized consulting rooms than the existing premises. This would allow for 3 more full time doctors/nurses/healthcare assistants based on the rooms being fully utilised throughout the day. There is also increased space for administration and training.

The building caters for the disabled patient list significantly better than existing premises:

-‐ All the consulting rooms have disabled access -‐ There is a large central waiting area, with plenty of space for pushchairs,

wheelchairs and other mobility aids -‐ The upstairs administration rooms have disabled access via a lift (allowing the

employment of disabled staff)

Access and transport to the building is much better than the current premises:

-‐ There will be secure bicycle parking directly outside -‐ A dedicated disabled drop-‐off bay will provided on the street immediately

outside -‐ There are improved public transport links: It is nearer to West Dulwich station

than the current premises, and is on a main bus route -‐ Substantial free parking is available in the surrounding streets

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Patient feedback A patient participation survey was undertaken in March 2013, via on line and paper questionnaires.

Respondents were asked to rate in 6 categories a wide range of services provided by the practice. The category ratings were very poor, poor, fair, good, very good and excellent.

A total of 102 replies were received.

! 86% of respondents rated the doctors caring and concern as good, very good or excellent

! 80% felt that their involvement in the care was good, better or excellent, and 86% rated the doctors listening skills in the top 3 categories

! 86% of respondents rated the receptionists as good or better, and 30% felt they were excellent

! 49% of respondents were able to get an appointment the same day as they requested it, and overall 72 % of patients were able to get an appointment with the doctor of their choice within 72 hours

! 65% of patients felt the opening hours were good, very good or excellent, but 50% felt they could be improved by weekend opening. The practice has responded to this by having one Saturday morning surgery each month, and is now bidding for funding for core opening 7 days a week

! 75% of respondents felt that an online booking system for appointments would be helpful. In response to this 3 appointments are now available for every surgery via on line booking

Comments received in the survey included:

! “Everyone who works at the Rosendale Surgery is friendly and approachable. The level of care I receive is great”

! “I have found Rosendale Surgery to provide excellent care and information when required”

! “Every doctor and nurse I have seen in this practice is excellent, that is why I do not worry about waiting for an appointment to see a particular Doctor“

! “The reception staff are very efficient and really make so much effort to accommodate appointments”

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In addition to the formal patient satisfaction survey, 3 informal petitions were initiated in April 2014 concerning the future of the practice, with particular reference to its location.

! A paper survey set up by the surgery Patient Participation Group. ! An online petition on the surgery website (Petition Buzz website) ! An online petition set up by a patient on change.org.

Online survey Petition Signatures

Change.org 2704

Petition Buzz Website 4305

Total 700

Paper patient survey Question: Would you continue to use the surgery if relocated to West Norwood HLC?

Number of responses

Proportion of responses

No, I would not 1,109 92.5% Yes, I would 50 4.2% I am unsure 40 3.3% Total 1,199 100% In addition, 69 patients registered at other nearby surgeries signed to express their wish that the Surgery did not close, as it would impact on their service provision. The survey result above show an overwhelming patient opinion against relocating to West Norwood HLC. This has two implications:

! Re-‐locating would be explicitly against patient wishes, representing a poor response to patient demand

! It is likely the practice would lose significant numbers of patients, making it financially unsustainable

4http://www.change.org/en-‐GB/petitions/nhs-‐london-‐nhs-‐england-‐and-‐department-‐of-‐health-‐save-‐the-‐rosendale-‐road-‐surgery-‐west-‐dulwich-‐london-‐se21 5 http://www.petitionbuzz.com/petitions/rosendalesurgery

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Service offering Quality of care is of paramount to the practice. The Practice believes that:

-‐ Patients should be in charge of their own health and that they should be central to the delivery of primary care services

-‐ That there should be a whole-‐person approach to delivering and improving individuals care, taking into account all their physical, mental health and social care needs, and joining up services for them across different organisations

-‐ Staff should be empowered to work across traditional boundaries to improve care, by taking on new roles and working in new teams

-‐ By working together rather than separately with different health and social care providers, and sharing information, patients’ health and independence can be improved

-‐ Patterns of health and social care need to become better integrated to improve the overall care of patients

To deliver these aims, care will need to become more integrated across primary, social and community providers. The development of the Old Dairy site supports the delivery of this integrated care vision.

CCG Support The practice has held extensive discussions with Lambeth CCG. They have indicated:

- That they wholeheartedly support the practice moving to The Old Dairy Site o They are supporting Crown Dale Practice moving into Suite 2 of

Norwood HLC (I.e. They would NOT support a move of The Rosendale Surgery moving into Norwood HLC Suite 2)

o They support the practice’s plans for an increased primary service offering (as detailed below)

o They have indicated they would be willing to occupy any spare capacity at the Old Dairy Site for Integrated Care (community, primary, and obesity) services (as detailed below)

The locality group and London LMC also support the practice moving to the Old Dairy Site

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Primary In addition to all services currently being offered, the preferred option premises will:

-‐ Allow an improved minor surgery service, with a greater range of procedures on offer, such as vasectomy, and removal of ‘lumps and bumps’

-‐ Provide a dedicated room for the health care assistant, allowing an improved service for phlebotomy, and investigative procedures such as spirometry, ECG, and blood pressure monitoring

-‐ Provide space for 3 more full-‐time medical clinicians with an appropriate increase in skill diversity and availability

-‐ Allow an increase in the nursing staff in the surgery, with an improved skill mix. This will offer patients both an increase in the range of skills of the medical staff, and also a greater choice of clinician

-‐ Contain extra space for additional services that are health priorities for Lambeth, such as:

o Healthy living promotional activities o A teenage sexual health clinic o Health self-‐monitoring machines such as blood pressure and body

mass index o An improved smoking cessation service, including space for group

support meetings o Larger patient participation group meetings o Regular clinics for those with long term health conditions, such as

diabetes, COPD, heart disease and asthma -‐ The surgery intends to have 6-‐day per week core opening hours

Community The preferred option will also accommodate new community services such as:

-‐ Community nursing teams: There is an increasing recognition as part of the integrated care vision that district nursing teams as well as other care services need to be based in practice premises

-‐ Visiting hospital clinicians providing specialist services, such as neurology and gastroenterology, in the standard multipurpose clinical rooms

-‐ Mental health services, such as talking therapy sessions and counselling -‐ Meeting rooms for self-‐help and community support groups

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Other -‐ Clinical teaching: The practice is well placed to teach clinical students and

trainee GPs, with dedicated library and meeting space and highly-‐qualified doctors (full profiles in Appendix B)

-‐ Obesity service: The practice plans to set up an obesity service for the locality, in line with the local health priorities

o The preferred option is ideally located on flat terrain for those with limited mobility and/or cardiac problems – as prevalent in the obese population

o Childhood obesity is a health priority for Lambeth. At present there are only limited facilities (via the MEND) programme for tackling childhood obesity. The only current service for adults is via the LEIPS programme, which is only for those with other co-‐morbidities. The new premises are ideally suited to this, as there is a space on the ground floor where an exercise classes can be carried out. The large staff room, with an integrated kitchen on the first floor provides an ideal space for teaching the preparation of healthy meals, and a room will be available for a counsellor to discuss on a one to one basis any psychological issues underlying abnormal eating patterns.

Performance The increased ability to provide service within the community will improve both clinical and financial outcomes, especially with greater provision of integrated care.

The new premises will allow an improved multidisciplinary approach covering both medical and social needs, as a wider range of healthcare professionals will be based on site.

Our health outcomes in Lambeth are not as good as they should be: ! Too many people live with preventable ill health or die too early ! The outcomes from care in our health services vary significantly ! We don’t treat people early enough to have the best results ! People’s experience of care is very variable and can be much better ! Patients tell us that their care is not joined up between different services ! The money to pay for the NHS is limited and need is continually increasing ! It is taxpayers’ money and we have a responsibility to spend it well

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What we are trying to achieve: The Rosendale Surgery has always had good patient outcomes but we want the opportunity to be the best and over the next five years we can do this by:

! Supporting people to be more in control of their health and have a greater say in their own care

! Helping people to live independently and know what to do when things go wrong

! Making sure our primary care services are consistently excellent and with an increased focus on prevention

! Developing joined up care so that people receive the support they need when they need it

We are keen to ensure we work together with the community and secondary care teams to develop an integrated care system, delivered through the seven strategic interventions set out below: In this system integrated services will have resilient communities as the foundation:

1) Primary & community care (including social care) – universal service supporting our whole population

2) Long terms conditions, physical and mental health – supporting those with long term physical and/or mental health conditions

3) Priority pathways – support patients through episodes of care: ! Planned care ! Urgent and emergency care ! Maternity ! Children & young people ! Cancer

Underpinned by the characteristics of our integrated system:

! Build resilient communities ! Promote health and wellbeing ! Provide accessible & easy to navigate services ! Join up services from different agencies & disciplines ! Deliver early diagnosis & intervention ! Raise the quality of services to the same high standard ! Support people to manage their own health & wellbeing

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What do we mean by resilient communities? Research by the Kings Fund (2014) identifies nine key areas for improving the public’s health:

! Ensuring the best start in life ! Healthy schools and pupils ! Helping people find good jobs and stay in work ! Active and safe travel ! Warmer and safer homes ! Access to green and open spaces, and the role of leisure services ! Strong communities, wellbeing and resilience ! Public protection and regulatory services (including takeaway/fast food, air

pollution, and fire safety) ! Health and spatial planning

Resilient communities are a critical foundation for public health and clinical preparedness. They enable the sustained ability to withstand and recover from adversity: healthy individuals and families with access to health care, both physical and psychological, and with the knowledge and resources to care for themselves and others in both routine and emergency situations. Our ambition is that the wide-‐ranging expertise, passion and facilities in our new premises would act as a catalyst to raise aspirations, support local people to improve their own wellbeing and to work towards a healthy and vibrant neighbourhood.

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Finances It is proposed that the scheme will be financed under NHS GMS rent and rates reimbursement with the developer meeting the capital cost of the development works in return for a rent at the level set by the District Valuer Services. The practice is seeking funding from NHSE for 5/7ths of the new building. It will self fund the remaining 2/7th.

The rent at the current premises is disproportionately low, reflecting the fact that the current owner cannot remember the last time a rent review was undertaken, but believes it was more than 6 years ago.

Draft Heads of Terms are attached in Appendix D. The rentable value per m2 is as follows:

- Heads of Terms refers to rentable value of £240/m2 - Likely DV reimbursable rental opinion is nearer £250/m2 - The practice has in principle negotiated more favourable terms of £225/m2

This is the figure used below, and this will be reflected in amended HoTs made available to the DV

Annual recurring re-imbursement The annual re-‐imbursement required for the Old Dairy Site is given in the table below:

Item Old Dairy Existing site

Rent per m2 £225 £128

Rentable area (m2) 583 312

FRI Rent reimbursement £131,175 £39,996

CMR rent reimbursement (inclusive of 5%) £137,734 N/a

VAT £27,5476 N/a

Total excluding rates £165,281 £39,996

Rates and waste (or allowance for) £27,000 £13,651

Total cost of Old Dairy Site £192,281 £53,647

Total cost per m2 £330 £172

Cost per consulting room £37,469 £10,729

6 VAT would not be payable so long as the developer could have the building cost exempted from VAT. If the developer is required to pay VAT on the development cost, then they would charge VAT on the rent to recover this

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It has been proposed that NHSE fund the Old Dairy Site on the basis of providing the same number of consulting rooms as the existing site (5). The partners would then seek to let the remaining two rooms to other occupiers.

If NHSE were to fund the premises on this basis, the expected costs are calculated as follows:

Item NHSE Re-‐imbursement Practice I&E account

Cost per consulting room £27,469 £27,469

Consulting rooms occupied 5 2

Total cost £137,343 £54,937

For comparison, we have included below the current premises costs and proposed costs at Norwood HLC7:

Item Old Dairy (Pro-‐rated 5 rooms)

Current premises (2013)

Norwood HLC

Total area (m2) 416 (Pro-‐rated) 312 311

LPA/Rent £98,381 £39,996 £110,731

LPA VAT £19,676 NIL NIL

Capital Cost NIL NIL £8,463

Waste Disposal £19,286 (Pro-‐rated combined allowance)

£13,651 (combined rates and refuse)

£1,140

Rates £23,630

Total cost to NHSE £137,343 £53,647 £143,964

Total cost per m2 £330 £172 £463

Cost per consulting room

£27,469 £10,729 £35,991

The Lease for The Old Diary will be on typical GP friendly and DVO compliant terms. The Lease will be between the practice and Dulwich Estates along with an appropriate Agreement to Lease. The detailed Heads of Terms will be agreed at the same time as agreeing the initial rent with Dulwich Estate and the DVS.

It is expected ongoing reimbursement would be required from January 2016.

7 5-‐year average annual re-‐imbursed cost for Suite 2 at Norwood HLC

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Between Norwood HLC and the Old Diary, we believe the latter offers the best value for the taxpayer:

- The cost per consulting room is over 30% higher (over £8,000) at Norwood HLC than The Old Diary

- The total cost to NHSE per m2 is 40% higher at Norwood HLC than at the Old Dairy

Annual recurring cost to the Practice: The practice will incur non-‐reimbursable costs premises costs wherever they move. An indication of these likely costs is given in the table below:

Item Existing site (2013)

Old Dairy (estimates8)

Norwood HLC

Utilities £5,546 £10,000 £7,578

Insurance £1,017 £2,000 £1,590

Other charges £7,787 £15,000 £29,759

Total £14,350 £27,000 £38,927

Cost per m2 £46 £46 £125

Cost per consulting room £2,870 £3,857 £9,732

Based on the above figures, the practice stands to incur additional costs of ~£12,000 per annum by moving to Norwood HLC instead of The Old Dairy. The practice believes this represents a poor financial proposition for the partners, considering:

- The provision of only 4 consulting rooms (without incurring additional cost) compared to 7 at The Old Dairy

- The resultant practical restriction to patient list size and service offering from a premises with only 4 consulting rooms

- The likely loss of patient list resulting from: o The new location outside of the existing practice area o The restricted access up the hill o Indications from patient feedback that they will not move (instead

seeking places at alternative locations)

On this basis the partners believe the surgery, if situated at Norwood HLC, would not be financially sustainable. 8 Allowances for annual costs have been scaled up based on area from the existing practice premises costs, with allowances for energy efficiency where appropriate

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One-off cost re-imbursement: The premises development and relocation will result in the practice incurring significant one-‐off costs. The practice are seeking re-‐imbursement of certain one-‐off costs that it estimates it will incur in carrying out in securing and relocating to the new premises.

Item One-‐off cost

Rationale

Stamp duty and land tax £22,163 66% of £33,580; Based on an initial rent of £139,920 plus VAT

Legal fees £5,544 66% of estimated £7,000 including disbursements, plus VAT

Business case production £3,600 £3,000 plus VAT

Monitoring Surveyor Fee £14,256 66% of an estimated £18,000 plus VAT

Total ICT £30,000 £25,000 plus VAT; or as advised by CCG IT Department

Communications £2,400 E.g. Letters to patients advising re-‐location. £2,000 plus VAT

Total cost £77,963

The practice intends to meet other costs without further re-‐imbursement from NHS England, including re-‐location and removal costs, and the re-‐location and adaptation of the existing telephone and medical records systems.

It is requested that the rent and rates costs plus the one off capital costs set out above are met from the NHS revenue budget.

The increase in rent and rates as well as any capital costs, if approved, will take effect in early 2016, in financial year 2015/2016.

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Appendix

Contents

Appendix Page

Appendix A: Floor plans of The Old Dairy Site 39

Appendix B: GP Partner Profiles 42

Appendix C: Site search and premises vacation correspondence 43

Appendix D: Draft Heads of Terms Separate

39

Appendix A: Old Diary Site floor plans

Site Plan

40

Ground floor plan

41

First f loor plan

42

Appendix B: GP Partner Profiles

Dr Rosemary Leonard MBE MA MB BChir MRCGP DRCOG

Dr Leonard qualified in medicine from Cambridge University with Double First Class honours. She has 34 years of clinical medical experience, and has been a GP partner in the area for 25 years.

In addition she is a highly respected contributor in the national media on medical issues.

She has also been a non-‐executive director of the Health Protection Agency, and a member of the Government Committee on the Safety of Medicines. Most recently she served with Professor Sir Bruce Keogh on the Government’s review of safety in cosmetic interventions.

She was awarded a MBE for services to healthcare in 2004.

Dr Kerry Howard MBBS DRCOG

Dr Howard qualified from University College and Middlesex School of Medicine in London. She has 25 years of clinical medical experience.

She has particular expertise in child health, and is the Child Health protection officer for the practice. She also works as a GP appraiser.

Dr Shailender Parihar MBBS BSc MRCS DRCOG MRCGP

Dr Shailender Parihar qualified from the Royal Free School of Medicine in London. He has 10 years of clinical medical experience.

He has a particular interest in musculo-‐skeletal medicine and is also accredited by NHS London to provide minor surgery services.

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Appendix C: Site Search and premises vacation correspondence

Site search Email correspondence between Neil Stevens of Westbury Property (carrying out the site search) and Peter Fox (consultant and advisor to the Rosendale Surgery) -‐-‐-‐-‐-‐ Original Message -‐-‐-‐-‐-‐ From: Neil Stevens To: Peter Fox -‐ tp2mc Cc: Rob Maxwell Sent: Friday, April 25, 2014 3:13 PM Subject: RE: The Rosendale Surgery Rosendale Road West Dulwich Hi Peter I’m dropping you a line as promised to confirm that Rob & I have been trying to assist in locating alternative premises for the Rosendale Surgery. We’ve spent quite some time researching the catchment area as well as driving the streets (which is something we often do when looking for property) in an effort to spot something which may not be officially on the market but where we could approach the owners directly. As I mentioned, there isn’t anything which would facilitate the entire Practice in one single building let alone something that comes even close to Croxted Road in terms of location, convenience, ease of access and suitability to the community. We did come across some possibilities which we researched and just to give you a flavour here are 4 of them: Parkhall Business Centre Mortel Road SE21 – lots of space, would be ideal as around the corner from existing. Spoke with the landlord/freeholder and they would not consider permitting change of use 279 Rosendale Road SE24 – funnily enough this could well have once been a dairy. It seems it was originally owned by London Metropolitan Railway and is currently very run down. No idea what the size is or could be here. We have traced the owners who are listed at an address of an oriental restaurant in North London. We have tried to contact them including dropping by but with no success West Norwood Library SE27 – Not easy to get information from the council on this one as so many different departments involved but we spoke to the foreman on site who informed us that all space had been allocated a while ago. In fact I think one would have needed to get in very early on this as space use was predetermined

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Aspire Wellbeing Centre Park Hall Road SE21 – Possible size but have spoken with them & there are no plans to move in the foreseeable future Hopefully this helps a little and if you need any more from us please contact either Rob or me All the best Neil Neil Stevens Consultant

Suite 2 De Walden Court 85 New Cavendish Street London W1W 6XD +44 20 7612 1251 +44 7774 235999

neil [email protected]

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Premises vacation correspondence An email dated 5th March from the future landlord states:

You have asked me to give you an indication of our plans and thoughts for the property which I am more than happy to do. We exchanged contracts with Dr Chabuk in June 2013 with a completion date set for the end of June 2015. This long-‐stop completion was agreed to allow The Rosendale Surgery to secure terms to relocate to the new premises at Croxted Road once building works are completed. Our strategy is to obtain planning permission to develop the property as soon as possible to provide commercial on the ground floor with residential flats above and a mews house to the rear accessed from Charles Nex Mews. In order to achieve this, the property will need to be vacant before building works can commence therefore as soon as the contract to purchase is completed, we will be serving a 6 month notice on the tenants to vacate which will tie up with the expected practical completion of Croxted Road. I understand that there is unanimous support from the community and that everyone associated with The Rosendale Surgery is in favour of the move to Croxted Road taking place. It seems there is a delay in agreeing funding with NHS England and If this is not resolved in a timely manner the window of opportunity will be missed & the surgery may well be moving out at a time when there is nowhere suitable to move to. It is therefore in everyone’s interest for this to happen for the following reasons.

• The Surgery needs to move out of Rosendale as it has outgrown the premises which are also non-‐DDI compliant

• The whole community and everyone associated with The Practice is in support of this move

• The ideal property to relocate to is available now and in all certainty will not be replicated

• The commercial property market is still generally depressed however now that it’s following the residential upturn, the level of rent that can now be agreed will not be sustained if the surgery doesn’t secure Croxted Road imminently. Also it is our understanding that the Dulwich Estate will only hold the building open as an option for a certain period of time.

• As developers, we will be able to carry through our objective to develop the property which is why we bought it

I trust this clarifies our position and if I can be of any further help please let me know.

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