Your Area

We would like you to come and talk to a group of people interested to find out abit more about BHH LIFT and how they will be catered for. How can this be arranged?

Contact the BHH LIFT office either via email or telephone where there will be someone to deal with your queries and assist you further.

How does LIFT benefit the local health economy?

•  Current investment process in Primary Care sector is fragmented and piecemeal – LIFT draws this together.

•  Holistic approach of LIFT will ensure resources concentrated on areas and facilities with greatest need.

•  It is a flexible approach allowing for a whole range of service and property solution.

•  It draws all the key players together within the local health economy.

QUESTIONS FROM GPs

What is NHS LIFT from a GP’s perspective?

Some of the current premises delivering primary care services in BHH are inadequate in terms of the full service potential of the practices based at these premises.

The perceived problems presently seem to be:

•  The sheer space not being sufficient to provide GMS services

•  The space being adequate to provide the essential and additional services under the new contract but not the enhanced services

•  The space being adequate to provide all aspects of the new GMS service contract but not for joint working with other professions, eg Health Visitors, Social Worker, dieticians, physiotherapists, etc

LIFT allows a re-drawing of the primary care infrastructure in our locality without disadvantaging anyone but for the betterment of the patients and service providers. Before stepping into the subsequent tranches of LIFT a detailed mapping of all primary care and other premises will take place allowing grassroot GPs to express their views in terms of:

•  Location of the new premises

•  Composition of the new premises

•  Size of the new premises

The ownership of all new LIFT premises will remains under LIFTco. GP practices will be able to have the security of a lease at these premises. In most cases this will be a practice premises co-located with other primary care providers, local authority functions, pharmacists, opticians, dentists, Trust staff, etc. in a healthy living centre type environment.

How does the new GMS contract sit with LIFT?

The new GMS contract gives GPs, working with the PCT, the opportunity to provide enhanced services. Some practices may not have space to do this at present and LIFT will enable GPs to use rooms in new LIFT developments to provide these services. The PCT would expect to receive income for the use of these rooms but GPs will be able to offset this cost against the additional income they will receive from providing enhanced services.

LIFT will also enable GP practices to relocate to purpose built premises with enough space to ensure the continued provision of primary care and at the same time facilitate the attainment of quality targets.

Why should I consider being involved in the LIFT project?

•  Flexibility: NHS LIFTs will offer GPs flexible lease arrangements (currently GPs are often tied into long leases). This should help attract more GPs to work in inner city areas.

•  Scale and speed: NHS LIFTs will help deliver a significant number of new premises in a short period of time

•  Integration of services: Patients expect to find as many of the services they need in one place as possible. NHS LIFTs will actively seek to co-locate additional services and facilities (for example space can be used by a range of related health care professionals as well as Social Services).

•  Common approach: avoiding individual GP practices or local teams having to develop an approach and all the documentation for each scheme, PfH is establishing a common approach that LIFT schemes across the country can adopt.

How do I find out if LIFT can help me/my practice?

Initially contact LIFT office (tel. 020 8861 8840) and speak with Geoff Easton, Project Director. Alternatively contact the GP Champion, Dr Nizar Merali via email on nizar@gpdirect.co.uk or telephone on 07836 599099.

What approvals would my proposals need?

Business Case approval from the LIFT Strategic Partnering Board supported by the local PCT. LIFT office will advise on the process involved.

What is a Lease Plus Agreement (LPA)?

The term “Lease Plus” is used because it offers more than a traditional lease. The precedent LPA has taken many years to develop with the input of many individuals and now runs at over 300 pages and it is a fairly complicated document. An LPA covers not only the actual building but also full maintenance of the building (“hard facilites”). You will no longer have the responsibility of worrying about the leakages, the internal and external painting rounds, the insurance, the bulbs in need of replacement, the heating system failing, security systems, etc. Imagine the time saved of the partners and the manager. It may not be appropriate for a GP practice to enter into this standardised but complicated LPA directly and your local PCT may be willing to offer a sub-LPA leading to a more flexible arrangement overall. The PCT can come to an arrangement for all GPs involved in one particular LIFT building or for that matter any LIFT building being offered same and standard terms that need to be approved by one firm of solicitors on behalf of all GPs thus keeping the costs down.

LIFTCo (the landlord) undertakes to maintain the premises and repair it over the lifetime of a 25 year agreement. Lease Plus offers flexible serviced accommodation, for an inclusive rent. A simple payment mechanism is designed to incentivise LIFTCo to perform to agreed standards based primarily upon the concept of availability of accommodation. It respects the principle of no service, no payment.

How will GPs benefit from the LPA?

AnswerThe real benefit to the GPs is that it leaves the landlord with the obligation to keep the premises in a high state of repair at no extra cost to the GPs combined with a range of remedies to incentivise high quality performance. Presently GPs receive no Red Book funding for internal repair and meet this cost out of general GMS funds.

To reduce what could otherwise amount to expensive, time consuming and lengthy negotiations with a wide number of GPs, standard documentation will be used that will have the endorsement of the BMA.

Where the GPs enter into an underlease with the PCT it will in most circumstances mirror the terms of the PCT’s own Lease Plus head lease save principally for the length of the lease which in many cases will be less than 20 years, depending on GP requirements and circumstances.

Are GPs bound to accept the terms of the LPA?

No, but it is likely that if they wish to participate in LIFT developments, their scope for unilateral negotiation will be limited.

In such circumstances it is important that GPs are fully appraised of the balance of risk set out in the LPA. The LPA is a new form of leasehold occupancy agreement improving upon standard third party developer leases or other conventional leases in many respects. This has a number of advantages as well as some disadvantages of which GPs should be fully appraised. It is essential independent professional advice should be taken by each practice considering entering into an LPA.

Who will meet the pass through costs?

The costs of insurance, rates and utility costs are initially met by the Landlord and “passed through” to be paid by the Tenant monthly. There is no profit element made by the Landlord in this respect.

Can GPs transfer assets into Liftco?

GPs may contract as individuals, or as a partnership if they operate through a GP Partnership. Although there may be restrictions on the transfer of property in their Partnership Agreement, there are no special restrictions affecting GPs in regard to LIFT and they should be able to contract like any other person or group of persons.

Can GPs subscribe for and hold shares in a Liftco?

GPs, either as individuals or on behalf of a partnership, can subscribe for and hold shares.

Many GPs own their existing premises. Whilst this is a sound estate investment in the long run particularly in view of the fact they you are your own tenant, there are several risks of this traditional model.

•  The premises do not comply with changing standards eg, size in relation to the services provided, legislative changes under the disability discrimination act the need for access to a ramped access, disabled toilet and an elevator lift to the first and subsequent floors. To be compliant with these there would need to be further investments periodically.

•  As senior partners retire and younger partners join in there may be a reluctance of buying equity. This limits exit strategies for the seniors at the time of their retirement.

•  At the time of the retirement of single and two partner practices, the PCT may not wish to continue the provision of service from those particular premises.

•  The additional cost of conversion of premises to its previous use eg, shop, residence, etc under the scenario illustrated under c).

Subscribing for and holding shares in LIFTCo on the other hand gives you all the benefits of sound investment without the risks above. All the equity that one can realise from the sale of the old premises can be re-invested into the new company. Those GPs who hitherto have never been owners of their premises can now join in and invest if they so wish.

More importantly under the DoH primary premises flexibilities rule some of the costs of converting existing premises back into previous uses; the cost of breaking the loan agreements; the costs of breaking the lease terms, etc can all be supported by the PCT

If GPs are to hold shares in Liftco, there may be a concern about conflicts of interest between GPs medical and investor roles. The GMC have comprehensive guidelines governing conflicts of interest and, in particular, on financial interest in hospitals, nursing homes and other medical organisations. Any financial or commercial interests must not affect the way a GP prescribes, treats or refers patients. In addition, if a GP has a financial or commercial interest in an organisation to which he plans to refer a patient, he must tell the patient about his interest. When treating an NHS patient, he must also tell the healthcare purchaser. The guidelines also suggest that for GPs with financial interests in residential or nursing homes, it is inadvisable for them to provide primary care services for their patient in those homes.

It is suggested that in most instances LiftCo is unlikely to be providing healthcare and that its role will be largely confined to that of a “lease plus” landlord. However, if LiftCo were itself to provide residential or nursing home services, GPs may need to consider their position in more detail.

What are the incentives for GPs to hold options or shares?

The incentive for the GPs to hold options or shares is as an alternative offer to replace the investment they have in their property when they are owner occupiers, potentially in a “negative equity” situation, and the investment in LIFT may help provide a better return to them in the longer term. Independent advice should be sought however, by any GP considering investing in LIFTCo for comparison of risk and return with other forms of investment.

Will NHS LIFTs force GPs to move/sell-up?

•  Existing development grants – which enable GPs to improve current premises – will continue to be available

•  NHS LIFT is about providing improved primary care facilities – not – about determining where GPs are located

•  NHS LIFT will provide incentives to GPs wishing to relocate. For example, many GPs are tied into long-term leases which they cannot terminate easily. NHS LIFT will be able to “buy-out” these leases enabling GPs to move.

Will this initiative ignore single-handed GPs?

All GPs, including single-handed GPs, will be welcome to participate in the NHS LIFT initiative.

Is this initiative linked to the introduction of the PMS scheme?

The objective of NHS LIFT is to improve the quality of the physical primary care estate. It is not linked to other developments, such as the PMS scheme.

At what stage should the GPs commit themselves?

Ideally this should be in the early stages before the PCT engages in the procurement process. In practice this is not possible as terms will not be known until later. There are therefore 3 stages: the early non binding approval by commitment letter; exchange when the GPs become legally bound into Lift; and final transfer when any existing GP premises are finally transferred.

Can GPs be appointed as Directors of LIFTCo?

There is nothing to prevent a GP being a Director of a company. By acting as Directors, however, GPs may face conflict of interest issues.