Governing Body meeting (held in public) body... · 2016. The Estates Strategy ... Agenda Item:...

DATE: 28 January 2016 Title

Estates Strategy Update

This paper is for Discussion

Recommended action for the Governing Body

That the Governing Body:

1. Note the progress to date on the CCG’s Estates Strategy and that a draft has been submitted within required timescales;

2. Discuss and Comment on the CCG’s draft Estates Strategy (Appendix 2);

3. Note the Primary Care Transformation Fund (PCTF) criteria and the intention to submit bids for all areas included within the Strategy;

4. Note and Approve the need for additional estates support to help finalise the Strategy, to submit Primary Care Transformation Fund (PCTF) bids by 28th February, carry out an options appraisal for CCG Headquarters accommodation and to deliver the Estates Strategy going forward (as the expertise and capacity is not available in-house).

Potential areas for Conflicts of interest

GPs may be conflicted in areas of the Estates Strategy.

Executive summary

There is a national expectation that all CCGs would have a draft Estates Strategy by December 2015. The first draft for Bexley CCG has now been submitted and is presented for information at Appendix 2, discussion and comment. The final Estates Strategy needs to be completed by 31st March 2016. The Estates Strategy Working Group meets monthly and workshops have taken place both locally and at a Strategic Partnership Group level. Bids for underspends on the 2015/16 Primary Care Infrastructure Fund have been submitted to further the Strategy development; and the CCG has already commissioned eight utilisation reviews to better understand estate capacity in Bexley’s key health centres in the major planned development/growth areas.

ENCLOSURE: E Agenda Item: 08/16

Governing Body meeting (held in public)

Future bids for Primary Care Transformational Funding (PCTF) will need to be supported by the Estates Strategy and it is therefore important that the Strategy is robust. It will therefore be further developed over the coming weeks. One Public Estate is a bid led by the London Borough of Bexley on behalf of themselves and other partners, including the CCG. The bid is for £430,000 of revenue and targeted funding. This follows an earlier successful bid of £50,000. The Business Plan is centred around three themes, collaboration, coordination and co-habitation. Part of the bid has been successful but further details are awaited. The CCG is now commissioning Sweet (UK) Ltd to undertake some work to help finalise the Strategy, to submit Primary Care Transformation Fund (PCTF) bids by 28th February and carry out an options appraisal for CCG Headquarters accommodation. It is expected that all of this work will be completed by 31st March 2016 and will be paid for from the finance consultancy budget. However, it is expected that further estates expertise will be required to deliver the Estates Strategy on an ongoing basis as the expertise and capacity is not available in-house. Attached at Appendix 1 are the criteria that will be used by NHS England when assessing PCTF bids. This may be updated for final guidance. It is also well known that any bids will need to link clearly to the estates Strategy. Sweet (UK) Ltd will use these criteria when preparing bids for Bexley. It is felt that initially bids should be submitted for all areas included within the Strategy.

How does this paper support the CCGs objectives?

Patients: The appropriate utilisation of assets will support the development of e.g. Local Care Networks which will improve patient care closer to home.

People: N/A Pounds: N/A Process: N/A

What are the Organisational implications

Key risks

The implementation of the Estates Strategy may need substantial investment that may not be available within current CCG funding, which may result in delays in implementation. Without additional estates capacity and expertise, the CCG will not be able to deliver the Estates Strategy.

Equality Not applicable

Financial The implementation of the Estates Strategy may need

substantial investment that may not be available within current CCG funding. Additional running costs will be incurred from the additional estates support required.

Data Not applicable.

Legal issues Not applicable.

NHS constitution Not applicable.

Engagement The Estates Strategy Workshop has representatives from main partners, with estate, in Bexley. A workshop has also taken place with good engagement.

Audit trail The draft Estates Strategy has been shared with the CCG’s stakeholders represented at the Estates Strategy Working Group. Comments have been incorporated where possible. Further work will be undertaken with stakeholders to finalise the Strategy before 31st March 2016.

Comms plan Not applicable Author: Theresa Osborne Chief Financial Officer

Clinical lead: Dr S Deshmukh GP Finance lead

Executive sponsor: Theresa Osborne Chief Financial Officer

Date 31 December 2015

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Estates Strategy Update

Introduction On dissolution of Primary Care Trusts, responsibility for property transferred to NHS Property Services (NHSPS), Community Health Partnerships (CHP) or directly to providers. No property assets are now held by CCGs. Despite this, nationally CCGs have each been asked to prepare a draft Estates Strategy by December 2015. Progress to date Estates Strategy Working Group Prior to the request for an Estates Strategy, it had become evident that the CCG needed to reinvigorate the agenda and work closer with partners, to ensure that the estate within Bexley works to best advantage to deliver national, London and local Strategy, including Local Care Networks. An Estates Strategy Working Group (ESWG) was formed, that meets monthly. Members include representatives from the Local Authority, Oxleas, NHSPS, CHP, HUDU and NHS England. Dr Bill Cotter also represents Primary Care and the CIC. A representative from Peabody, who own substantial estate in Thamesmead has also now been invited, as well as Dartford, Gravesham & Swanley CCG. The ESWG has met a number of times and is working well. Estates Strategy Workshop A joint workshop was run locally in October to discuss estates plans in Bexley and the development of the Strategy. The workshop was well attended and participants were actively involved with a number of clear priorities coming from the event. Estates Strategy As mentioned above, there is a national expectation that a draft CCG Estates Strategy would be submitted by December 2015. This is not expected to be fully developed but to at least baseline the borough’s assets. CHP and NHSPS have been appointed nationally to support CCGs with this. CHP, supported by Essentia, are supporting Bexley. To ensure that information contained within the Strategy is robust, the CCG has commissioned eight utilisation reviews of key health centres in the major planned development / growth areas in Bexley, primarily along the Thames corridor as follows:

• Erith Health Centre • Cairngall Medical Practice

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• Belvedere Medical Centre • Northumberland Heath Medical Centre • Lyndhurst Medical Centre • The Albion Surgery • Crayford Town Surgery • Barnard Medical Practice

A further detailed utilisation review was carried out on Lakeside Health Centre. As a result CHP have agreed to carry out work to the common space to improve the facilities and better utilise the available space. Bids have been submitted against Primary Care Infrastructure Fund underspends, in a number of areas, which if successful will also help develop the Strategy and submit bids for future year’s transformation funding. A 6-facet survey was undertaken covering all practices in Bexley (bar 2, one of which is new) in 2011-12. This is the same across South East London. Estates advisors have confirmed that this is still valid for a current Strategy. An estates database is now in place across the borough, which includes assets relating to practices as well as Oxleas and the London Borough of Bexley. This is currently being updated by NHS England and Essentia, but it is expected that this responsibility will transfer to CCGs over time. The Strategy incorporates mention of the Borough’s growth Strategy, including 24,500 new homes, as well as for example the development of Local Care Networks and the improvement of digital technology. The first draft has now been submitted (Appendix 2) and is being brought this meeting of the Governing Body meeting for discussion. The final estates Strategy needs to be completed by 31st March 2016. The CCG is now commissioning Sweet (UK) Ltd to undertake some work to help finalise the Strategy, to submit Primary Care Transformation Fund (PCTF) bids by 28th February and carry out an options appraisal for CCG Headquarters accommodation. It is expected that all of this work will be completed by 31st March 2016, and will be paid for from the finance consultancy budget. Primary Care Transformation funding (PCTF) PCTF previously named the Primary Care Infrastructure Fund (PCIF), is a £1 billion fund over four years (£250 million a year) 2015-16 to 2018-19. The current year’s funding accepted bids from practices and in most cases were not strategic. Any bids for future year’s funding will be expected to link to CCGs’ estates strategies, be strategic and led by CCGs. Bids to improve digital technology will also be considered. Details are still awaited but the initial letter has been received with an expectation that any bids will be submitted by 28th February 2016.

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Strategic Partnership Group (SPG) (South East London) level Estates Planning Work on a South East London level Strategy has been slow. However, it is expected that the six CCG’s own strategies will form the basis of a SPG level plan. An initial workshop was held in September 2015, with a further meeting held in November. Regular meetings have now been diarised. Representatives for Bexley include the CCG, Local Authority and Oxleas. The CCG has now asked that Dartford & Gravesham NHS Trust are also included in these meetings. The CCG has also attended an estates workshop to inform the Dartford, Gravesham & Swanley CCG’s (DGS) estates Strategy. DGS also attend Bexley CCF’s estates Strategy meetings. This ensures that cross boundary issues with Dartford and Swanley are considered. London Estates Planning A London Estates Programme Board is in place. This is attended by Malcolm Hines, CFO, Southwark, on behalf of South East London. This Board assists in facilitating the SPG level work mentioned above. It is envisaged that a virtual estates team will be put in place across London to further support this work. Funding is taken from the Healthy London Partnership contributions made by CCGs (0.15%). One Public Estate One Public Estate is a bid led by the London Borough of Bexley on behalf of LBB, the CCG, Oxleas NHS Foundation Trust, the London Borough of Lewisham, the London Fire Service, Peabody Trust and the GPU for £430,000 of revenue and targeted funding. Part of the bid has been successful but further details are awaited. This follows an earlier successful bid of £50,000. The Business Plan is centred around three themes, collaboration, coordination and co-habitation. Collaboration is central to the success of the business plan. This will be achieved by the creation of a Partnership Board with common aims and objectives for the future of real estate in Bexley (and beyond where appropriate). The Board will ensure that efficient, cost effective, modern service delivery is the key driver in all decision making rather than real estate itself. We would expect further public sector partners to join as the project progresses. It is hoped that this will build on the Current Estates Strategy Working Group. A central database of public property in the LB Bexley is already now partly in place and this will be extended to other localities relevant to the partnership. Future decision making, although remaining ultimately with the individual partner, will be taken against an agreed set of criteria including the backdrop of full market information and availability of options in the context of public land and building availability. The Business plan has an emphasis on themed initiatives and site specific related feasibility work to release surplus land and buildings for alternative uses such as

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housing, education and community need by combining and sharing property requirements. The long term plan is to move towards greater integration as long as the operational efficiencies and individual objectives of partners are not compromised. The Business Plan focusses not only on the essential propositions of creating the board itself, developing a shared assets database and undertaking a top down combined asset management view of all properties but also on three site specific first phase projects - a shared depots Strategy between Bexley and Lewisham, feasibility work on shared administration facilities in Bexley between the NHS and Council and a potential mixed use scheme at Slade Green. As stated above the CCG has commissioned an options appraisal for the CCG’s headquarters location for further discussion at a future meeting. The OPE bid is one of a number of initiatives underway to modernise and rationalise the public sector asset base in Bexley whilst also using property to stimulate regeneration and growth. PCTF Criteria Attached at Appendix 1 are the criteria that will be used by NHS England when assessing PCTF bids. This may be updated for final guidance. It is also well known that any bids will need to link clearly to the estates Strategy. Sweet (UK) Ltd will use these when preparing bids for Bexley. It is felt that initially bids should be submitted for all areas included within the Strategy. Conclusion Following submission of the draft Estates Strategy, the CCG will continue to work with partners to submit a final Strategy by 31st March. Discussions with Sweet (UK) Ltd will take place early January to progress the estates agenda. Recommendations

1. Note the progress to date on the CCG’s Estates Strategy and that a draft has been submitted within required timescales;

2. Discuss and Comment on the CCG’s draft Estates Strategy; 3. Note the PCTF criteria and the intention to submit bids for all; areas included

within the Strategy; 4. Note and Approve the need for additional estates support to help finalise the

Strategy, to submit Primary Care Transformation Fund (PCTF) bids by 28th February, carry out an options appraisal for CCG Headquarters accommodation and to deliver the Estates Strategy going forward (as the expertise and capacity is not available in-house).

Criteria Primary Care Transformation Fund Appendix 1

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PCTF Criteria Examples of outputs Yes/No Comments Transformational projects

Locational strategy pulls together a range of key services to deliver community services/one stop shop – health/social /integrated care hub/centre

Improvements to Access in Primary Care/7 days 8 to 8 p.m. 12 hour working

Reduces A&E attendances Release back office function space to increase more clinical space deliver virtual teams Internal reconfiguration of space to create more capacity, including public areas

Improvements Community/Collaborative Partnership working

New building/redevelopment opportunities that support land swap or reconfiguration of services to deliver from one central hub or hub and spoke combined

Provider Out of Hospital initiatives –

Supports new model of healthcare outreach specialty clinics in communities e.g. Multi-Specialty Community Providers Supports LCNs expansion of Locally Enhanced Services/

Improving patient access

IT solutions that support increased consultations via web link or Skype On-line ordering repeat prescriptions/ Booking clinical appointments

Remodelling/Modernisation/new site opportunities

Addresses capacity issues

Reality of delivery Supports future SPG/local CCG clinical strategy plans

Flexibility

Release back office function space to increase more clinical space virtual teams/home working/new working practices that changes old way of working

Mixed Schemes-

shared solutions with stakeholder partners 3PD options/Voluntary sector Linked to s106/DIFS/CIL

Risk

Failure to deliver impacts health delivery and other wider commissioning initiatives on a longer term basis

Affordability Identifying source of revenue and capital Supports Population Growth converting non clinical rooms into clinical space Reduces high FM/other estate related costs/ releases unwanted

Supports efficiency savings by co-locating, centralising services to existing sites wherever possible

Void strategy/disinvestment

strategy plan for addressing significant voids e.g. PFIs, LIFT, other which are being paid by health economy

Maximise space- existing users and accommodates new service delivery

reconfigure/make better use of existing space

Appendix 2

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BEXLEY CCG ESTATES STRATEGY – DECEMBER 2015

Version 1.1 30th December 2015

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Important Notes 1. With regard to any need to undertake service change and comply with various statutory duties: - The options set out in this document are for discussion purposes. The involved NHS bodies understand and will comply with their statutory obligations when seeking to make decisions over estate strategies which impact on the provision of care to patients and the public. The options set out do not represent a commitment to any particular course of action on the part of the organisations involved. 2. In respect of any request for disclosure under the FoIA: - This is a confidential document for discussion purposes and any application for disclosure under the Freedom of Information Act 2000 should be considered against the potential exemptions contained in s.22 (Information intended for future publication), s.36 (Prejudice to effective conduct of public affairs) and s.43 (Commercial Interests). Prior to any disclosure under the FoIA the parties should discuss the potential impact of releasing such information as is requested.

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1. Contents 2. Executive Summary ......................................................................................................................... 5

2.1 Introduction .................................................................................................................................. 5

2.2 Drivers for Change ........................................................................................................................ 5

2.3 Vision for the Estate ...................................................................................................................... 7

2.4 Overview of Existing Estate ........................................................................................................... 8

2.5 Estates Gap Analysis ..................................................................................................................... 8

2.6 Delivering the Strategy ............................................................................................................... 10

Short term work actions ............................................................................................................... 10

Longer-term work actions ........................................................................................................... 10

Conclusions and Actions ......................................................................................................................... 11

3. Introduction and Local Overview .................................................................................................. 12

3.1 Objectives and rationale ............................................................................................................. 12

3.2 NHS Bexley: Mission, Vision, Values and Outcomes ................................................................... 12

3.3 Scope ........................................................................................................................................... 13

3.4 Methodology ............................................................................................................................... 14

3.5 The local borough (geography, transport, population and demographics): .............................. 17

3.6 Estate partners ............................................................................................................................ 18

4. Drivers for Change ........................................................................................................................ 22

4.1 Service drivers ............................................................................................................................. 22

4.2 Population, Health Needs and Regeneration Drivers ................................................................. 27

4.3 Technological drivers .................................................................................................................. 29

4.4 Estates drivers ............................................................................................................................. 30

5. Bexley’s Vision for the Estate Infrastructure ................................................................................ 34

5.1 Future Model of Care and Service Priorities ............................................................................... 34

5.2 Our vision .................................................................................................................................... 37

5.3 Hub sites...................................................................................................................................... 38

6. The Current Estate ........................................................................................................................ 40

6.1 Overview ..................................................................................................................................... 40

6.2 Utilisation .................................................................................................................................... 46

6.3 Asset condition ........................................................................................................................... 49

6.4 Financial Summary ...................................................................................................................... 50

6.5 Other Estate Issues ..................................................................................................................... 51

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6.6 Current Disposals ........................................................................................................................ 51

6.7 Challenges and opportunities ..................................................................................................... 52

7. Planning for Growth ...................................................................................................................... 55

7.1 Planning for Growth .................................................................................................................... 55

7.2 Population growth and demographic change............................................................................. 55

8. Gap Analysis .................................................................................................................................. 64

9. Estates Options for Change ........................................................................................................... 77

9.1 Summary of estates options ....................................................................................................... 77

9.2 Evaluation process and criteria ................................................................................................... 78

10. Delivering the Strategy ............................................................................................................. 79

10.1 Short term work actions ............................................................................................................. 79

10.2 Ongoing medium and long term work actions ............................................................................... 79

11. Financials ................................................................................................................................... 81

12. Outline Implementation Plan .................................................................................................... 82

12.1 Programme plan and milestones ................................................................................................ 82

12.2 Enablers of change and managing constraints ........................................................................... 82

12.3 Risks and mitigations .................................................................................................................. 83

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2. Executive Summary 2.1 Introduction

This Local Estates Strategy is an essential element of the strategy programme to support the delivery of new models of care. It is important to understand the capacity of the capital assets, estates and facilities across the borough to utilise, reduce or develop these in the most appropriate way to meet the needs of the population. The strategy has been compiled by engaging within the CCG and with the Local Authority, NHS England, GPs, Providers, neighbouring Commissioners and the NHS Property Companies. This collaborative input helps to ensure that this is a fully functioning working estates strategy for the borough that shapes the way that the estate is used as an enabler for change.

2.2 Drivers for Change A number of recent national, London-wide and local strategies have recognised the importance of infrastructure in terms of enabling the delivery of new models of care. This section summarises key drivers and changes that are anticipated over the next few years and the resulting implications for infrastructure. The NHS five year forward view sets out an integrated agenda and new care models over this and the next four years. In addition, Better Health for London outlines the evidence base for re-evaluating the utilisation and value of NHS estate in London which is being progressed via the Healthy London Partnership Estates Programme. The development of this estates strategy reflects this wider London level estates programme that is led by CCGs and NHS England. The main drivers for change, impacting on the infrastructure requirements of the borough, are summarised in table 1 under four key themes: Table 1: Drivers for Change Drivers Summary

Service drivers • Our Healthier South East London strategy and working with the SPG in South East London

• The Trust Special Administrator (TSA) recommendations and Secretary of State support regarding Queen Mary’s Hospital, Sidcup

• Out-of-hospital and 24/7 care to reduce use of hospitals • Increase provision of care in people’s own homes – particular

significance to patients requiring care at the end of life • The significance of primary care is recognised including its role

in larger care organisations and operating at scale • Greater emphasis on organisations being integrated and

working together in Local Care Networks to provide community based care and joined up services to whole populations

• Unprecedented financial pressures facing the NHS and social care is driving different models of care

• Preventative care – supporting people to remain healthy & independent and avoid inappropriate use of hospitals and care

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homes • Growing need to address lifestyle risk factors

Population, health needs and regeneration drivers

• Growing population will increase the burden on physical infrastructure and demand for services

• Increasing demands arising from an ageing population & noon-healthy lifestyles.

• Changing disease burden – increase in life expectancy coupled with greater proportion of comorbidity

• The need for improvement in health inequalities • Ambitions in the Council’s growth strategy set out to regenerate

the north of the borough including 24,500 additional new homes by 2030 set out in the London Borough of Bexley’s publication “Direction of Travel” (it should be noted that these figures have since been revised upwards and shall be revised again)

• Lack of community resilience in the population and families • The proposed river crossing at Belvedere or Gallions Reach • The Crossrail development to Abbey Wood and possible

extension to Belvedere / Erith • Need to create sustainable neighbourhoods within higher

density mixed use developments, focussed on public transport hubs.

Technological drivers

• Greater use of technology in the provision of healthcare making services better connected and efficient

• Drive to digitalise GP patient records as a means to free up capacity (space) in primary care

• Digitalisation of patient records is facilitating change in where and how patients can access services

• Move to more remote and flexible working has implications on the type and use of infrastructure

• Investment in technology that reduces the need for face-to-face consultations and meetings

Estates drivers • Pressing need for housing in London with all public sector organisations under pressure to release sites

• Variability in the quality of primary care estate where space is not always functional

• Under-utilisation of some assets provides opportunities for more services, or estate, to be rationalised as well as providing capacity for the anticipated growth

• The financial pressure facing the NHS and public sector partners means that there is a need to unlock value from the estate where possible

• Co-location and joint working with other organisations can be a

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more efficient model • Bexley has a significant number of branch sites which can lead

to inefficient working practice • The move to market rents for NHS organisations means that

there is a case for reviewing options for locating some services and functions longer term

• Premises to be compliant with CQC and DDA requirements • Ensuring General Practice premises close to population sites in

Frognal/Clocktower are suitable for service expansion

2.3 Vision for the Estate The development of Local Care Networks (LCNs) will be the mechanism by which Bexley responds to the need to change how services are organised and delivered locally. The services available will be proactive, accessible, coordinated, integrated and provide continuity, with a flexible, holistic approach to ensure every contact counts. This will be primary care led to geographically coherent populations, at scale, whilst still encouraging self-reliance. In Bexley there are three emerging LCNs, North Bexley, Clocktower and Frognal. There is a single GP federation, Bexley Neighbourhood Care Community Interest Company (CIC), of which all practices are members. Bexley CCG and its partners are committed to the following principles and priorities for ensuring that the primary and community care infrastructure facilitates the required service change:

• Secures Queen Mary’s Hospital, Sidcup, and Erith Hospital as the health hub and spoke for Bexley’s population in recognition that Bexley has no acute site.

• Aligns with the London Borough of Bexley’s Growth Strategy and addresses any service and infrastructure needs that result

• Ensures there is sufficient capacity for primary and community care services to be provided in out of hospital settings in line with population needs

• Advance technological solutions that reduce the need for face-to-face consultations, better equip patients to self-manage, enable more preventative care and strengthen communication and collaboration between organisations

• Reduce reliance on clinical and office space through use of remote and mobile working • Improve seven day access to effective care • Seeking to rationalise GP branch sites where this enables more efficient ways of

working, without hindering patient access • Ensuring there is sufficient training and workforce development capacity • Greater partnership working across providers through co-location of services • Delivery of the emerging LCN strategy including provision of hub sites, preferably in the

most accessible locations • Maximising use of purpose built, high quality, affordable estate for clinical purposes

including exploring the potential for offsite administrative and storage functions at a lower cost

• Identify where buildings are surplus to requirements for all partners and consider options for utilisation before disposing of assets

• Ensure any changes are beneficial to patient access and do not exacerbate health inequalities

• Maximise the use of space through exploring with partner organisations how space can be reconfigured to deliver maximum value to the public sector.

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2.4 Overview of Existing Estate

Across Bexley there are 27 GP practices occupying 41 premises (including multi-occupied & branches with 1 admin only site). In addition there is 1 main health provider with 27 occupations. The main provider is as follows:-

• Oxleas NHS Foundation Trust (Oxleas) provides a range of health services in south east London, specialising in community health, mental health and learning disability services. Oxleas have over 125 sites in a variety of locations across the London Boroughs of Bexley, Bromley and Greenwich and into Kent. They own the Queen Mary’s Hospital and Erith Hospital sites where a range of community and acute providers occupy space to provide services. Queen Mary’s Hospital and Erith Hospital are the CCG’s health hub and spoke in Frognal and North Bexley localities / LCNs.

• Other providers include King’s College Hospital Foundation NHS Trust (King’s), Lewisham & Greenwich NHS Trust (LGT), Guy’s & St Thomas’ Foundation NHS Trust (GSTT), Dartford & Gravesham NHS Trust (DGT) and South London & the Maudsley Foundation NHS Trust (SLAM.

Bexley CCG has divided the borough in to three Local Care Networks and for the purposes of planning is proposing to divide the borough into these three constituent areas:

• North Bexley (inc. Thamesmead East, Belvedere and Erith) • Clocktower (inc. Welling and Bexleyheath) • Frognal (inc. Sidcup and Bexley)

2.5 Estates Gap Analysis

The estates gap analysis used basic demand modelling to analyse the current health provision within the high growth areas across the borough. The demand modelling summarised the current provision and analysed its capacity to cope with anticipated population growth, providing some key findings. Detailed demand modelling is proposed as a short-term work plan and will enable a greater depth of analysis. Wards that have GLA projected population growth greater than 1,000 between 2015 and 2025 were analysed. Six Wards across the Borough satisfied these criteria:

• North Bexley LCN/Locality: o Crayford o Erith o Thamesmead East o Belvedere o North End

• Clocktower LCN/Locality: o Christchurch

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Table 2: Key estates gap analysis Ward Key Findings New Health

Facilities Required? Crayford No health centres in the Ward; Crayford Town

Surgery has some spare capacity; Lyndhurst Medical Centre in Barnehurst Ward approximately 2km west; development in Crayford Town driving population growth; current facilities likely able to absorb population growth if GLA population projections are correct. However, 1,000 new homes predicted by Bexley Council in addition to GLA projections.

Yes - Dependant on realisation of Bexley Council Projected Housing Figures

Erith One large health centre and one community hospital; good GP provision; some spare capacity; significant anticipated population growth; Slade Green to contribute to population pressures with some large developments due for completion in short-medium term. 4,500 new homes predicted by Bexley Council in addition to GLA projections.

Detailed feasibility study recommended

Thamesmead East

Lakeside Health Centre is a LIFT building within the ward that could act as a core hub site, and is generally under-utilised; scope to reconfigure non-clinical space as clinical space. Ward not predicted to undergo significant growth according to GLA projections. 5,000 new homes predicted by Bexley Council in addition to GLA projections. Additionally, significant potential for development in Lower Belvedere that could impact this Ward.


Belvedere No health centres in the Ward; Erith Health Centre, Erith and District Community Hospital and Lakeside Health Centre in neighbouring wards; good GP provision in south of the Ward. 11,000 new homes predicted by Bexley Council in addition to GLA projections; significant potential for development in Lower Belvedere through East Thamesmead Industrial Area and the Pirelli Site.


North End No health centres in the Ward; GP practice is being expanded; Erith Health Centre in neighbouring ward may be able to absorb some capacity. 4,500 new homes predicted by Bexley Council in addition to GLA projections. Cross-border issues with Dartford may also impact.

Detailed feasibility study recommended

Christchurch Some incremental population growth; one health centre in the Ward. Upton Road site has been designated surplus to requirements by Oxleas and has the potential to be a core hub site in Clocktower. However, it is not expected that new facilities will be required.

No – current provision is sufficient

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2.6 Delivering the Strategy Delivering the Local Estates Strategy for the CCG will be complex and time consuming. It will require skilled programme and project management resources and involve multiple stakeholders with their own service strategies. Collectively, the stakeholders need to see the advantage and benefits of working collaboratively across health and social care, to achieve the new models of care that will maintain or improve patient health and social care outcomes whilst realising system savings. Organisations that are successful in delivering complex change adopt excellent programme and project management practices and have:

1. Well-defined milestones and metrics 2. Committed senior management 3. Ownership and accountability 4. Standardised project management practices 5. Strong sponsorship

Short term work actions To finalise the Local Estates Strategy by the end of March 2016, it is believed that there is further work required to bring all the stakeholders together and to develop an agreed, joint strategy. In section 8, we have outlined the further actions that we believe should be undertaken between January and March 2016, to inform the Primary Care Transformation Fund (PCTF) applications at the end of February and the final version of the Local estates strategy by the end of March 2016. Key actions are:

• Agree governance arrangements for the Local Estates Forum (LEF) • Obtain missing data to fill gaps • Clarify the stakeholders estates strategies • Test the interim gap analysis at locality level with stakeholders • Obtain greater clarity about the services included in LCNs and proposed locations • Develop project management plan • Develop work streams and identify and start planning pilot projects and quick wins

Procure funding for utilisation studies and demand modelling through the PCTF • Submit applications for PCTF • Understand ICT and workforce implications on the estate • Investigate cross-border issues • Procure estates expertise to take Estates Strategy forward

Longer-term work actions We believe the following medium and long term actions will need to be progressed:

• Continuation of the LEF • Identify & Procure / assign project management resources • Link estates, IT and workforce strategies

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• Options appraisal and business case development for core investment projects that require additional investment

• Feasibility studies, options appraisal and business case development for core sites and where investment is required

• Where required, procure resources to develop business cases for investment projects • Improve utilisation and site management at core sites • LES refresh every 12 months • Maintain SHAPE database. • Further develop links with the Local Planning Authority.

Conclusions and Actions Delivering for the first time a borough wide Local Estates Strategy, for health and other public sector stakeholders, will be a huge, complicated and time consuming challenge. It will need skilled leadership and resources, experienced in programme and project management of health facilities and other skillsets. This will need additional support to that currently held within the CCG and will need to be obtained within current running cost constraints. The CCG will need to lead and use its influence to bring stakeholders together and to obtain their agreement to a combined strategy that benefits all. All providers and the local authorities need to work together to develop opportunities for co-locating, integrating services and then rationalising their respective estates The IT and workforce strategies and their delivery are key to enabling new ways of working, without which major estate rationalisation will be difficult to achieve. Funding for project resources will have to be identified and applied for in a timely manner, so early action for PCTF applications will need to start in January 2016 and discussions held about accessing CIL monies, when they are available.

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3. Introduction and Local Overview 3.1 Objectives and rationale

This document sets out Bexley CCG’s local estates strategy which will support the delivery of Bexley’s Commissioning Intentions including the transformation of primary care. Set out below is the strategic context, drivers and vision for the development of the estate and supporting infrastructure that will underpin the delivery and transformation of health care in Bexley over the next few years. The Department of Health wrote to CCGs in June 2015 setting out the need for a Local Estates Strategy to be developed by commissioners with relevant health partners, to be ready by December 2015. The strategy would set out the context for further investment in clinical infrastructure locally. The letter also confirmed that each CCG would have a Strategic Estates Advisor (either from NHS Property Services or Community Health Partnerships (CHP)) that would assist commissioners in taking an independent whole healthcare system approach, generate improvements and efficiencies from the estate and the services it supports, and to help deliver future changing estate infrastructure needs. This will help local healthcare systems to:

• fully rationalise its estate • maximise use of facilities • deliver value for money • enhance patients’ experiences.

Bexley CCG has been appointed a strategic estates advisor is from CHP, supported by Essentia. The strategy has been compiled by engaging within the CCG and with the Local Authority, NHS England, GPs, Providers, other Commissioners and the NHS Property Companies. This collaborative input helps to ensure that this is a fully functioning working estates strategy for the borough that shapes the way that the estate is used as an enabler for change.

3.2 NHS Bexley: Mission, Vision, Values and Outcomes This strategy seeks to support the delivery of the CCG’s objectives. Our mission, vision and values are consistent, with national priorities and also the vision and priorities of the “Our Healthier South East London” strategy. NHS Bexley CCG’s Mission NHS Bexley CCG’s mission, or overarching purpose, is to commission high quality services locally that improve the physical and mental health and wellbeing of Bexley residents. Our mission statement is “Excellent healthcare, locally delivered.” The ambition to keep services local wherever possible means appropriate and sufficient capacity must be in place.

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NHS Bexley CCG Vision “Our vision is for Bexley’s residents to stay in better health for longer, with the support of good-quality integrated-care, available as close to home as possible – backed up by accessible, safe and expert hospital services, when they are needed.” In order to deliver this vision the configuration of acute and community services is key to ensure that services are accessible but high quality and sustainable in the long-term. NHS Bexley CCG Values In working towards realising its vision for local health services, the CCG adopts the following values in how it operates with others to achieve the ambition. The mnemonic, aspire makes these more memorable:

• We are accountable to our members, stakeholders, partners and ourselves • We support our staff to be the best they can be, so we can deliver the best for our

population • We commission for quality to deliver improved outcomes for our patients • We encourage new ideas and innovation • We respect the diverse needs of our population and the expertise of our delivery partners • We aim for excellence, working to high standards and increasing transparency

Bexley CCG’s Commissioning Intentions – Our Plans 2016-2018

This is the CCG’s main strategic plan and sets out what is to be achieved from 2016-18. It is built on the foundation of the South East London strategy ‘Our Healthier South East London’, and sets out how these plans and aspirations will be implemented in Bexley over the next two years and beyond under the following areas: • Primary & Community based care • Planned care • Urgent and emergency care • Maternity • Children’s and young people • Cancer (including end of life care) Under each area, local Bexley initiatives supplement all that is to be delivered across south east London to improve these services for all and address the inequalities in access and patient experience currently present. The CCG’s commissioning intentions also includes the continued development of our hub & spoke - Queen Mary’s & Erith Hospitals, securing them into the future. The model is a multi-provider health ‘hub’ – at Queen Mary’s Hospital and a ‘spoke’ – at Erith Hospital.

3.3 Scope The focus of the Bexley Estates Strategy is to ensure that there is the required community based healthcare infrastructure in place to meet the needs of the population over the next decade. This is the first iteration that will evolve into a final strategy document by 31st March 2016. It will need to be reviewed and refreshed annually to ensure that it is still relevant and reflects the current and future infrastructure needs of the borough.

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The Government will be looking at the Estates Strategies during 2016 with a view to providing further advice on the drafting of longer term strategies. The scope of this estates strategy includes:

• All 27 GP practices operating out of 41 sites (including one admin only site) • All community sites where healthcare services are provided • Non-clinical NHS estate, such as office/administrative bases. • Assets owned or leased by the London Borough of Bexley where there are strong

working relationships with health services (e.g. bases/sites for Social workers, children’s centres etc.).

• Pharmacies, Dentists, Ophthalmology premises will be considered where relevant to this strategy.

Whilst this estates strategy does not seek to address every organisation’s estates plans, the aim of the engagement process has sought to identify where there are clear synergies, opportunities and needs that partners can help each other to address in an efficient and cost-effective way. Historically, public sector departments and organisations have tended to work in silos, which have meant that there was no transparency about the size, tenure, condition and utilisation of the respective estates. This estates strategy, covering all health and social care premises, allows, the CCG and its partners the opportunity to understand the whole estate across the borough. As there are no acute hospitals within the borough or significant assets owned by acute trusts, engagement with this sector has been at a South East London level. The main acute providers have been asked to share any estates plans that currently exist to ensure alignment with this local strategy but none have been provided. As more defined plans are formed around occupation of specific sites, engagement with secondary care, community and third sector organisations will be undertaken where necessary. The CCG has a track record of working with providers on multi-provider sites and their development. It will therefore build upon the success of QMH & Erith to implement this strategy. The continued development of services at QMH and Erith will future proof these sites.

3.4 Methodology Since June 2015 and with the assistance of the Strategic Estates Advisor from CHP, Bexley CCG has engaged and collaborated with its various partners to develop this estates strategy. In doing so, the following activities have been conducted:

• Monthly estates working group meeting with representatives from key local partner organisations (see section 3.6 below)

• An estates survey was completed by all practices in August 2015 to assess capacity constraints

• An estates workshop was held in October, with partners and adjacent CCGS, to aid development of the strategic priorities and consider cross-border implications

• Collation of key strategic and estates documentation from all partner organisations • Estates database information collated by NHS England • Assets identified for disposal shared

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• Financial information collated • Desktop utilisation studies, of key purpose built health facilities that are in areas of

growth, initiated. • Identify suitable locations for Local Care Network services

Data gathered during the process is being uploaded to the Public Health England (PHE), Strategic Health Asset Planning and Evaluation (SHAPE) database. This is a web-enabled, evidence-based application which informs and supports the strategic planning of services and physical assets across a whole health economy. This draft estates strategy is the product of this work with further engagement and analysis to be undertaken ahead of the strategy being finalised in March 2016 and translation into a delivery plan. The work left to be undertaken to complete this Estates Strategy includes:

• Finalisation of utilisation reviews and agreement to outcomes • Financial analysis • To develop an options appraisal and feasibility study for the development of health

provision to meet the Primary and Community healthcare needs current and future population in Belvedere ward

• To carry out a feasibility study for the development of health provision to meet the Primary and Community healthcare needs current and future population in Erith ward

• Review of current Primary and Community healthcare needs and provision in Crayford in the light of current need and future population growth

• Review of current Primary and Community healthcare needs and provision in Thamesmead East in the light of current need and future population growth

• To carry out a feasibility study for the development of health provision to meet the Primary and Community healthcare needs current and future population in North End ward

• Complex demand modelling • Review of the opportunities for Community services, specialist providers and the Local

Authority to co-locate, integrate and rationalise their respective estates. • Complete investigations around the costs for Upton Road and establish feasibility.

Appendix 2

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The figure below pictorially represents the process that has been followed in developing this estates strategy: Figure 1: The Estates Strategy Delivery Process

The Delivery Process

Estate Condition

Commissioning & Service Plans

Hypothesis Testing & Revision

Estates Strategy &

DeliveryPlan

Resources

Estate Use

Service Need

EstateCapacity

JSNAPublic Health

Data

H&WB BoardsCCGsTrusts

Commissioning Plans

Service PlansNational Policy

QIPP plans

Local Authorities

CCGsNHSETrusts

GPs

NHSPSCHP

LIFTCos

Estate surveysCondition

surveys

Servicecontract

LocationRationalisation

UtilisationIntegration

ApprovalsRisk/benefit

sharingChange

management

ChallengeCentre Management

AccountabilityBenefit realisationFinancial

allocations

Occupation & utilisation

CostsLocation

Ownership

Demand for Property &

Service Requirements

Supply of Property

Gap Analysis and

Hypothesis Development

Agreed Objectives / Evaluation

Criteria

Appendix 2

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3.5 The local borough (geography, transport, population and demographics):

Geography The London Borough of Bexley is an outer London borough in south-east London which borders the Thames to the north, the boroughs of Greenwich to the west, Bromley to the south and the County of Kent to the east. It covers an area of 23 square miles (6,400 hectares) and has four major district centres - Crayford, Erith, Sidcup and Welling. The town of Bexleyheath is the main town centre, and there are nine primary employment areas in the north of the borough where industry is based. A map of the Borough of Bexley is shown at Appendix x (to be added for final version). Transport The principal roads through the borough include the A2 trunk road and the A20 Sidcup bypass which serves as the southern boundary and both connect with the M25. The nearest Thames River crossings are the Dartford QEII Bridge, Blackwall tunnel and the Woolwich Ferry. There are three suburban railway lines crossing the Borough, all predominantly running east-west. Bexley has no London Underground lines, Docklands Light Railway or London Overground. However, from December 2018 Crossrail services will commence from Abbey Wood which will speed up connections with central London. There is also a consultation underway for further river crossings to be located at Belvedere and Gallions Reach, together with various associated public transport options. Demography The latest Greater London Authority (GLA) borough population projections recorded Bexley’s resident population at 240,644, in 2015. The population of Bexley’s registered population is slightly lower at 233,654 as at June 2015. Key characteristics of Bexley’s population as identified in the 2011 census include the following: • the population aged 90 and over increased by 37% (1,700) between the 2001 and 2011

censuses • adults aged 35-39 decreased by17% to 15,000 over the same period • children aged under 5 increased by 14%

The population pyramids (below) created using 2011 census resident population data, show pictorially how Bexley’s population has changed.

https://en.wikipedia.org/wiki/London_Underground

https://en.wikipedia.org/wiki/Docklands_Light_Railway

https://en.wikipedia.org/wiki/London_Overground

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Figure 2: 2011 census population pyramids

The population is predicted, by the GLA, to increase by 9% between 2011 and 2020, compared to a national estimated increase of 7.8%. This increase is predicted to continue beyond 2020, rising to 280,000 by 2035, an overall increase of 22% compared to a projected overall increase of 17% across England. The increase is expected to be seen across all age bands with the most significant increase being those aged 65+ with a much smaller increase for those of working age (16-65 years). This is shown in the following graph. Figure 3: Bexley population projections by age bands

Source: Population Projections Unit, ONS. Crown copyright 2012.

3.6 Estate partners NHS Bexley CCG established the Estates Working Group in June 2015 to bringing together all key partners to progress the estate infrastructure agenda locally. A series of meetings and a workshop have been held to engage all key partners, to help inform the development of this strategy. The Estates Working Group includes the following organisations:

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1) Commissioners 1a) NHS England (NHSE) - Its main role is to improve health outcomes for England’s residents. NHSE sit on the group as they directly commission Primary Care, including Primary Medical Services (General Practice, nationally commissioning enhanced primary care services and out of hours primary medical services (where practices have retained responsibility).

1b) NHS Bexley CCG – responsible for planning, monitoring and commissioning the majority of health services used by Bexley residents. This includes:

Since April 2015, NHS Bexley Clinical Commissioning Group (CCG), along with the other CCGs in South East London, has taken greater responsibility and involvement in the design, shaping and commissioning of local general practices, in a level 2 joint commissioning arrangement with NHS England, known as co-commissioning. This arrangement allows the CCG to work more closely with those responsible for securing the provision of general practice, NHS England, and will support local plans to improve primary care services in the borough including the estate infrastructure. The Primary Care Joint Committee meets regularly in public to consider and take decisions on local primary care services including changes that relate to the estate.

1c) London Borough of Bexley (LBB) - The Local Authority is responsible for commissioning social care and local public health services including: • Social care services • The Healthy Child programme for school age children, including school nursing • Sexual health services • Mental health promotion, mental illness prevention and suicide prevention • Local programmes around nutrition, physical inactivity and obesity • Substance misuse services • Early diagnosis of dementia and delivery of dementia services

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LBB also formulates the wider regeneration and development plans for the borough enabling infrastructure and population growth to be adequately taken into account in planning for future population pressures, service impacts and hence estate needs.

1d) NHS Dartford, Gravesham & Swanley CCG – this CCG is represented to ensure that there is alignment between the plans for the two adjacent boroughs and cross boundary implications are fully considered and planned; particularly around the proposals for 17,270 new homes in Dartford with an estimated additional population of 41,448.

Bexley CCG is also actively involved in the South East London Estates Working group which ensures that there is alignment across South East London. 2) Providers

2a) General Practice (GPs) – General Practitioners look after the health of people in their local community and deal with a range of health problems. The LMC and a Practice Manager have recently joined the group. 2b) Oxleas NHS Foundation Trust (Oxleas) – Oxleas provides a range of health services in south east London, specialising in community health, mental health and learning disability services. Oxleas occupy over 80 properties and utilise sessional clinical space in a variety of locations across the London Boroughs of Bexley, Bromley and Greenwich and into Kent. They own the Queen Mary’s Hospital and Erith Hospital sites where a range of community and acute providers occupy space to provide services, and are the CCG’s health hub and spoke.

2c) GP Federation – There is a single GP federation operating in the borough, Bexley Health Neighbourhood Care CIC. This consists of all member practices and provides the entity for practices to work together at scale. This is both a strategic response to the commissioning framework for primary care but is also necessary to mitigate the workload and financial pressures which practices report that they are experiencing. 2d) Acute – As there are no acute sites within Bexley, acute providers are engaged at the South East London Estate Strategy group (SPG level)

3) NHS Property Companies

NHS Property Services manages the former Primary Care Trusts’ (PCTs) property portfolio amounting to some 3500 buildings across England. This includes the CCG’s Headquarters, 221 Erith Road, and Erith Health Centre.

Community Health Partnerships (CHP) manages the Department of Health’s investment in the LIFT companies and 300 new healthcare projects built around the country in approximately the last 10 years. This includes Lakeside Health Centre.

A representative from CHP is the CCG’s nominates estates advisor for the Estates Strategy. The Estates Working Group is also supported by the Healthy Urban Development Unit (HUDU), the CHP Strategic Estates Advisor and supporting estates consultancy from Essentia.

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Recently Peabody Housing Association, who is working on regeneration of the Thamesmead area, has also joined to group to strengthen links between their plans and any impact on healthcare services.

4) Other Primary Care Providers

4a) Dentists - 29 NHS dental practices with 125 performing dentists.

4b) Opticians – 14 opticians

4c) Pharmacies – 45 pharmacies

4d) Care homes – 35 care homes

These providers are not currently represented on the LEF but will be played in as appropriate.

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4. Drivers for Change There are a number of factors leading to the need for a clear strategy for changing the way that services are delivered in Bexley and hence the estate infrastructure. These drivers for change are described in this chapter under the following themes:

• Service drivers • Population, health need and regeneration drivers • Technological drivers • Estates drivers

4.1 Service drivers We know that a 'one size fits all' healthcare model will not work for the NHS, which is why Bexley CCG is responding to local needs and taken the insight, evidence and direction provided by NHSE London, SE London and national policy agendas and embedded these into this emerging local strategy. This includes the following key strategy documents:

• The TSA recommendations and Secretary of State support regarding Queen Mary’s Hospital, Sidcup.

• NHS Five Year Forward View • Better Health for London • Transforming Primary Care in London: A Strategic Commissioning Framework • Our Healthier South East London • Bexley CCG’s Commissioning Intentions • Bexley CCG’s Primary Care Strategy

It has also taken into account the One Public Estate, the Better Care Fund and such other initiatives that are current and relevant. Further details of a number of these are provided below. Five- Year Forward View The NHS 5 Year Forward View (5YFV) was published in October 2014 and sets out a clear direction and vision for the NHS showing why change is needed and what it will look like. It recognises that in the last 15 years the NHS has dramatically improved, but we can still do more. The key points of the 5YFV are:

• There needs to be radical upgrade in prevention and public health. The NHS needs to back hard hitting national action on obesity, smoking, alcohol and other major health risks.

• When people do need health services, then patients need far greater control over their own care.

• The NHS must take decisive steps to break down the barriers in how care is provided. It recognises England is too diverse for a “one size fits all” care model, but we need to support and develop new delivery options (not letting “a 1,000 flowers bloom”). There are opportunities for new integrated care models and these will be tested and developed, some of these will be similar to Accountable Care Organisations being used in other countries.

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• The national leadership of the NHS needs to act coherently together, and provide meaningful local flexibility. Growing demand could mean a resource gap of £30 billion a year by 2020/21. Action therefore needs to be taken on the three fronts of demand, efficiency & funding to help close the gap.

• The significance of primary care is recognised including its role in larger care organisations.

The need to upgrade primary care infrastructure and scope of services was recognised and the integration agenda will all lead to different locations and infrastructure requirements. Transforming Primary Care in London: A Strategic Commissioning Framework The Framework was developed by the London Primary Care Transformation Board and published in 2015. It captures some of the core aims of primary care transformation centred on three “specifications”: proactive care, accessible care and coordinated care. The framework recognises that to deliver the specification, larger primary care organisations will be necessary as well as Multispecialty Community Providers (MSP): organisations that align to a single population catchment. The commissioning framework also sets out the various enablers needed to deliver the transformation agenda with estate and technology recognised as key. However, it is recognised that this is an aspirational strategy requiring significant investment. Our Healthier South East London (OHSEL) “Our Healthier South East London” is a five year commissioning strategy which aims to improve health, reduce health inequalities and ensure all health services in south east London meet safety and quality standards consistently and are financially sustainable in the longer term. There are nine key issues identified with the south East London heath system:

• Too many people live with preventable ill health or die too early • The outcomes from care in our health services vary significantly and high quality care is

not available all of the time • We don’t always 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 social care system is under increasing pressure • The money to pay for the NHS is limited and need is continually increasing • Every one of us pays for the NHS and we have a responsibility to spend it wisely

This all means that the way in which some health services are delivered will need to change, with more care provided in community settings outside hospital and with a greater focus on helping people to stay well, making services more joined up and making sure that everyone gets the care and outcomes they expect from their NHS. This is not about closing a hospital, but about avoiding the need to build a new one, which would not be affordable, by improving health and outcomes and delivering services which better meet people’s needs. Six areas of healthcare have been identified as the priorities for improvement across South East London:

• Primary & Community-based care • Planned care • Urgent and emergency care • Maternity

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• Children and Young People • Cancer (including End of Life Care)

Mental Health is relevant to all areas and is therefore fundamentally considered within each workstream. The community based care strategy sets out a whole system integrated model with Local Care Networks (LCNs) being the foundation to providing person-centred services to populations. The diagrams below set out the vision for LCNs and all that they must encompass. General practice working at scale is a key component of the model. Each CCG within South East London is responsible for ensuring that the LCN strategy is developed and implemented locally. This strategy sets out Bexley’s approach to LCNs (section 4). Figure 4: Community Based Care / Local care Networks model

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Figure 5: The Community Based Care / Local Care Networks Target model

Bexley CCG’s Commissioning Intentions

The development of our Commissioning Intentions 2016 (public strategy document) is an iterative process with our GP membership, clinical leads, managerial leads, and public and stakeholders. For 2016 the cornerstone of these is the Our Healthier South East London project/ strategy. We have then worked across the CCG to determine necessary additions to these. A very successful stakeholder event was held on 3rd November 2015 where these were discussed in detail and further input sought. Feedback from the event has been extremely positive and demonstrates the CCGs on-going commitment to our stakeholder engagement programme. The GP membership has also been asked for comments. The outputs from both of these work streams will be synthesised and the attached document, updated in December 2015, to enable the development of the final version for January 2016 Governing Body approval. As a result of the development of these – and our on-going QIPP programmes we have then developed Provider Commissioning Intentions issued to our main providers at the end of

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September and in October 2015. These are completed to reflect national good practice as a first point in the 2016/17 contracting processes. Bexley CCG’s Primary Care Strategy Bexley CCG’s Primary Care Strategy was approved in September 2015. It sets out the CCG’s plans to improve coordination of care, access to services and take a more proactive approach to our patients’ health and wellbeing. This is set in the context of the specific challenges that Bexley faces such as a growing and ageing population, variability in access, over-use of hospital services, significant health inequalities, high obesity rates and an ever increasing prevalence of dementia. The strategy also recognises that change cannot happen without having the necessary workforce, estate and technological infrastructure in place, so plans on how we can make meaningful change in these areas is also detailed. Whilst this strategy has been driven by local need and circumstances, it responds to the same range of national, London-wide and South East London strategies (detailed above), that all place a significant focus on the change needed in Primary Care. Most notably the Five Year Forward View, Better Health for London and the Strategic Commissioning Framework for Transforming Primary Care in London have all provided the strategic context for this Bexley strategy. Figure 6: Bexley CCG’s Primary Care Commissioning Intentions

Figure 6 pictorially shows the CCG’s high level primary care commissioning priorities for the next two years responding to the challenges faced in Bexley.

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4.2 Population, Health Needs and Regeneration Drivers Health challenges for Bexley The health of people in Bexley is good when compared to other areas in England. However Bexley residents do experience health inequalities, and there are some health measures where we are performing less well. In Bexley, the Joint Strategic Needs Assessment (JSNA) shows that:

• Life expectancy for men living in the least deprived parts of the borough is nearly 6 years higher than for men living in the most deprived parts of the borough. In women, the difference is over 4 years.

• The changing make up of our communities, especially the ageing population and the growth in black and minority ethnic (BME) communities, particularly in the north of the borough, will have an impact on how we deliver against our priorities.

• Life expectancy in Bexley is steadily increasing in line with the trends nationally and in the London region and has been constantly higher than both the London and national averages

• As with the rest of the UK the main causes of death in Bexley are cancer, cardiovascular disease, COPD and digestive disease.

• Mortality from circulatory disease has fallen dramatically in recent years and there has been a steady fall in cancer mortality but this has not been as dramatic.

• Mortality from digestive disease in Bexley has increased by 4.5 per 100,000 population compared to a national fall of 2.9 per 100,000.

• Mortality from chronic obstructive pulmonary disease (COPD) has decreased at a faster rate in Bexley (5.9 per 100,000 decrease) compared to a fall of 2.9 per 100,000 nationally.

• Bexley has lower levels of deprivation than the England average with less than 10% (9.2%) of its population living in the most deprived quintile and approximately 53% living in the two least deprived quintiles (24.3% in least deprived). Despite this, the most deprived part of the borough is in the north where modifiable lifestyle risk factors are highest.

Services therefore need to be tailored to reflect the following key messages from the JSNA:

• To target health inequalities – targeting the north of the borough, • To increase levels of physical activity and reduce obesity in adults and children – the

approach to address this needs to take account of environmental, behavioural and community driven methods,

• To improve early detection of illness – increased focus on screening uptake, • To better co-ordinate end of life care – there is a need for more care to be provided in

people’s own homes and to address patients with increasingly complex health needs. • Supporting people with addictions (including smoking, alcohol and drugs) • Dementia

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Bexley’s Growth Strategy Population growth pressures are already being felt in the borough and this is going to continue. Bexley is already flagged as one of the borough’s most able to respond to London’s pressing need for more housing and is at the heart of a South East London/North Kent ‘Productivity Corridor’ which embraces the North Bexley opportunity areas, the Ebbsfleet Garden City and the associated Paramount Leisure theme park development at the Swanscombe peninsula. The London Borough of Bexley (LBB) has developed its emerging vision for growth over the next 15-20 years that sets out plans for the delivery of at least 24,500 new homes, 10,500 new jobs and supported by significant investment in transport infrastructure. The growth scenario, known as PH3, is set out in the LBB publication “Direction of Travel” and the figures are summarised in the figure 7. However, it must be noted that these figures are the subject of further work and will continue to be refined as the Council develops its more detailed growth strategy. Figure 7: Bexley’s Indicative growth

Much of the development will be dependent upon the transport infrastructure improvements such as Crossrail being extended and further river crossings being built. Realisation of development potential in opportunity and growth areas will significantly increase the burden on physical infrastructure and demand for services (including health). Ensuring there is the health infrastructure and sufficient workforce to meet this increased demand needs to be planned in line with the growth strategy.

Indicative growth figures:

1: 5,000 new homes

2: 11,000 new homes

3: 2,500 new homes

4: 2,000 new homes

5: 1,000 new homes

Rest of the borough: 3,000 new homes

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The CCG will need to look at the areas where there is planned growth to ensure that there is sufficient GP and other (e.g. community health) provision especially where current healthcare provision is scant, e.g. Lower Belvedere, Slade Green and Thamesmead. Other areas of focus are Erith and Crayford. To accommodate growth of the scale envisaged, it will be necessary to plan for high density mixed use development concentrated around highly connected public transport hubs. The nature and location of health provision will also need to reflect the more intensive configuration of development within Bexley. Further details on regeneration and population growth and change are shown in Chapter 7.

4.3 Technological drivers Primary and community care services are already making considerable advances in the use of information technology and this will continue to grow over the years to come benefiting patients, providers and practices whilst facilitating more cost effective services. The emphasis will continue to be on reducing paper processes and putting in place systems and procedures that will speed up services whilst at the same time improving data quality and data capture. The aim is also to enable more holistic patient care through the sharing of patient data with local Bexley providers for the purposes of direct patient care. Information and IT is a key enabler for service transformation locally and can support staff in new ways of working and empower patients to be active participants in their care. Each CCG has its own IM&T strategy and implementation plans. In Bexley, technological investment priorities will focus on a number of key programmes as follows, some of which are already implemented, some that require focused work to enhance usage, whilst others will need investment before being progressed:

• Digitalisation of patient records – exploring whether hard copies of the GP patient record can either be stored off site or scanned and destroyed. This will help free up capacity within practices allowing space to be used for clinical purposes.

• Electronic Discharge Notifications (EDT) – aimed to eliminate the need for sending discharge summaries by post and include automated capture into GP system work flows. Some acute hospitals are beginning to migrate to a fully compliant system, and the CCG is providing necessary support in the delivery of all patient correspondence to GPs electronically.

• The CCG has been working with Oxleas to encourage Bexley practices to implement the Docman Hub solution, that Oxleas has procured, to ensure efficient electronic clinical communications with practices (30th Oct 2015 completion date).

• Electronic Prescription Service Release (EPSR2) has been rolled out to all practices and pharmacists to enable GPs to send prescriptions directly to a chosen pharmacy. The CCG is driving the implementation and utilisation of this system.

• Business grade secure WIFI devices for all practice sites and the CCG are being installed as part of the second phase of the wireless router programme.

• Web conferencing and video conferencing are being promoted as a resource within the CCG and across member practices to enhance effective use of time and resource

• Through the CCG’s Bexley Linked Care programme the CCG is facilitating the sharing of patient data across Bexley GP practices and the two Urgent Care Centres.

• Connect Care Programme – joining up patient records across practices, acute providers (Lewisham and Greenwich NHS Trust and Dartford and Gravesham NHS Trust), community, mental health and learning disability services (Oxleas) and eventually social care.

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• Mobile devices such as ipads and laptops are increasingly being used by practices and providers.

• Patients Online Services is supporting GP practices to offer and promote online services to patients, including access to records, online appointment booking and online repeat prescriptions.

• iPlato is a SMS replacement service for NHS Mail SMS which allows practices to send appointment reminders to patients and enables patients to respond to the text alert to confirm or cancel the appointment. It also allows health promotion messaging to be sent to patients. The CCG is also utilising the module to capture responses for the Friends and Family test.

• Electronic Referrals (eReferrals) integrated into the GP IT system with longer term development including the ability for GPs and patients to track where the patient is in the system following the initial referral.

• Exploring benefits of the Vibe system which serves as a web-based virtual platform for sharing documentation that needs to be accessed for collaborative purposes to assist GPs and Practice Managers in administration and assisting in CQC visits.

• Utilising Web GP, a web-based system for accessing a range of self-help resources and the ability to complete an e-consult for review by a GP.

• Use of Apps. There are a number of IM&T priority areas that are being driven forward nationally and South East London CCGs are collaborating to ensure that there is a consistent approach at a South East London level. A primary requirement is for health and care systems to be interoperable to enable south east London health information systems and professionals to work together within and across organisational boundaries in order to more effectively deliver healthcare to people and communities. Collaborative work with the Healthier London Partnership and its interoperability programme is a key area that the CCG is linked in with and this strategy ensures that the work undertaken within Bexley Linked Care and the Connect Care programmes are fully aligned with the principles and standards that follow from the interoperability framework.

4.4 Estates drivers There are a number of London-wide estates issues that are driving the need for the public sector to review its estates strategy. These are summarised below, as well as how they apply to Bexley. Table 3: Estates Issues London Pressure Bexley Relevance London is facing a huge land challenge. There is not enough land to meet the current and future needs of the population and therefore all boroughs are encouraged to release sites for alternative development.

As an outer London borough, Bexley has more space relative to the more densely populated inner boroughs. Bexley is already flagged as one of the boroughs most able to respond to London’s pressing need for more housing. The regeneration plans described in section 7 show how the north of the borough will be regenerated to develop at least 24,500 new homes and supporting infrastructure (PH3 scenario set out in LBB’s Direction of Travel).

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The quality and efficiency of usage of London’s NHS estate is highly variable and much does not meet evolving needs. There is significant scope to transform the way that estate is used across London.

In Bexley there is considerable variability in the quality of the primary care estate. There are a number of practices that operate out of converted houses that do not necessarily provide the functional space required.

A proportion of the estate is under-utilised. Poor utilisation and unsuitable types of estate has been a result of:-

• Perverse incentives, insufficient investment and fragmented decision-making on primary and out-of-hospital estate,

• A lack of incentives for GPs to rationalise the use of estate, and

• Inflexibility of lease arrangements

There are currently some buildings that are not fully utilised. Desktop utilisation studies of the largest practices located in the areas of planned growth have recently been undertaken to assess whether there is sufficient long-term capacity to meet the needs of a growing population. Whilst this needs further analysis the study found that a number of sites have capacity. Linked with the technological changes that are taking place in primary care, this has an impact on the utilisation of space and the type of infrastructure needed. However, the reconfiguration of space to better utilise it will likely take significant investment.

There is a need to unlock value:- • The NHS does not have any new

money and therefore must look at how to unlock value from the current estate and capital regime to address the issues within the system.

Both Oxleas and the London Borough of Bexley have identified sites that are surplus to requirement which can free up valuable capital without prejudicing efficient and effective service provision in the future, which must be re-invested within Bexley. The implementation of the Oxleas’ estates strategy is predicated on the re-investment of this capital to improve its existing healthcare estate. The CCG must ensure that the QMH and Erith sites are secured for the population of Bexley, in line with the TSA recommendations.

There are opportunities across the public sector for organisations to co-locate and share sites to meet the growing pressures of more housing and school places.

All estates partners are working together to ensure that any sites that are valuable to partners are utilised rather than disposed of. The One Public Estate programme involves Bexley public sector bodies working collaboratively to look more strategically at the use of assets to drive a shared ambition to provide modern, effective and efficient services, in the right locations, and release surplus capacity.

Ensuring that all GP practices are fit for purpose in line with CQC requirements and are DDA compliant, energy efficient and comply with infection control standards.

Bexley has a number of branch sites and converted residential property that may need reconfiguration and remedial work to be fit for purpose to accommodate service expansion.

In addition to the areas identified above there are other Bexley specific estate drivers:

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• Although we are one of the London boroughs with the fewest number of practices (27), there are nine practices that have at least one branch site and one practice that has three branch sites. In total there are 41 sites that practices operate from. There may be scope for these to be rationalised bringing about more fit for purpose and efficient use of the estate and the staff resource working within whilst ensuring that the right capacity and services are available to Bexley’s residents. With practice staff spending less time travelling between sites, access to appointments will increase.

• From the 1st April 2016, all NHS organisations will pay market rent for buildings that they occupy and are owned by NHSPS or CHP. This will drive the need for organisations to reconsider whether the current buildings occupied are the best value for money. This will hold true for the CCG headquarters where rent is projected to more than double in 2016/17. As part of One Public Estate the CCG will conduct an options appraisal on the location of its headquarters to ascertain the most cost effective and fit for purpose base within Bexley.

• There is no acute hospital in the borough; the CCG therefore works with many providers for provision of acute services. The Queen Mary’s Hospital site, located within the Frognal LCN, which is owned by Oxleas NHS Foundation Trust, is the main community services hub for the borough. Erith Hospital (also owned by Oxleas), within the North Bexley LCN, is the borough’s spoke. A third location within the Clocktower LCN, at Upton Road, will be considered.

One Public Estate The One Public Estate programme is an initiative delivered by the Local Government Association (LGA) and the Cabinet Office to fund councils to work in partnership to jointly explore using their assets more effectively to deliver service transformation and local economic growth. The following three work streams were submitted as areas that the council and health partners are working on:

1. Planning for Growth through the Public Estate This involves mapping existing public landholdings within the high growth opportunity areas to consider the needs and requirement that these ‘new’ communities will have over the coming years. A key element will be aligning with health infrastructure and seeking to identify and test opportunities for better and more integrated forms of service provision, including shared front doors and integrated service models, building on the many workstreams seeking to better embed service delivery at a local level.

2. Scope to better deliver depots and heavy vehicle land uses across a range of users Bexley has two ageing depots, both located at or close to boundaries with neighbouring boroughs, so intends to jointly explore potential for consolidation or shared depot use. In addition there are several other heavy-use vehicle users operating within the borough where there is potential to relocate from residential areas to a more suitable shared location. Service efficiencies and releasing sites for residential or commercial development would be added benefits.

3. Maximising the potential of shared head office and support services This study will include the scope for further rationalising the Council’s estate into their headquarters and the potential for consolidation with partners such as the CCG.

33

Bexley was successful in receiving a proportion of the funding requested to progress this work, but further details are awaited as to which of these workstreams this is intending to fund.

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5. Bexley’s Vision for the Estate Infrastructure 5.1 Future Model of Care and Service Priorities

As part of the CCG’s aim of bringing care closer to home and the broader south east London strategy, primary, community and social care services need to be more accessible and better integrated, supporting a preventative and holistic approach to patient care over time. There is a commitment to strengthen joint commissioning arrangements with the council to ensure that the full complement of services is joined up around the patient along pathways of care. Primary care plays an integral role in delivering our strategic priorities, whether as a provider within the care pathway, or by ensuring that there are good processes in place for referral and management of patients following their interaction with more specialist acute or community services. This community based care model will empower people to manage their own health positively to prevent deterioration where possible. Following an episode of ill health the LCN will take a rehabilitative / reablement approach to return patients to their previous capabilities, resuming self-care if appropriate. The development of LCNs will be the mechanism by which this service model will be delivered across South East London, although each LCN in Bexley will be driven from the bottom-up with provider organisations leading the development of service change to best meet the needs of their populations and Commissioning Intentions. The services available will be proactive, accessible, coordinated and provide continuity; with a flexible, holistic approach to ensure every contact counts. This will be primary care delivered to geographically coherent populations, at scale, whilst still encouraging self-reliance. This will be a universal service covering the whole population ‘cradle to grave’. A LCN will involve primary, community and social care colleagues working together and drawing on others from across the health, social care and voluntary sector to provide proactive patient centred care. Services within LCNs will be delivered in ways that respond to the varied needs and characteristics of the community it serves. It is also anticipated that from 2016 General Medical Services will need to be provided from 8am to 8pm 7 days per week. The service model for this is yet to be determined but a federated model is likely whereby the extended access is operated from a hub(s).

In Bexley there are three LCNs that align with the existing locality networks of practices shown in figure 8.

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Figure 8: Bexley’s three LCNs

The three LCNs include the following practices and populations:

Table 4: LCN Practices & Populations

Locality Total population

Practice Population Practice Name

Clocktower 80,386

10,330 BELLEGROVE SURGERY 11,529 BEXLEY GROUP PRACTICE

MAYFAIR MEDICAL CENTRE STATION ROAD SURGERY

NUXLEY ROAD WELLING ADMIN OFFICE

4,691 BURSTED WOOD SURGERY 8,722 CROOK LOG SURGERY 4,400 DR THAVAPALAN AND

PARTNERS 5,108 INGLETON AVENUE

SURGERY 14,146 THE ALBION SURGERY 8,532 THE WESTWOOD SURGERY

PICKFORD LANE SURGERY 12,928 WELLING MEDICAL PRACTICE

HOLLY HOUSE SURGERY

Frognal 53,784

15,316 BARNARD MEDICAL GROUP MARLBOROUGH PARK

AVENUE THWAITES

7,339 PLAS MEDDYG SURGERY 8,448 SIDCUP MEDICAL CENTRE

231 BURNT OAK LANE

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10,168 STATION ROAD SURGERY 2,337 THANET ROAD SURGERY

10,176 WOODLANDS SURGERY

North Bexley 100,191

8,524 BELVEDERE MEDICAL CENTRE

16,313 BEXLEY MEDICAL GROUP HURST PLACE SURGERY ERITH HEALTH CENTRE

3,484 BULBANKS MEDICAL CENTRE 9,620 CAIRNGALL MEDICAL

PRACTICE CUMBERLAND DRIVE

SURGERY 7,371 CRAYFORD TOWN SURGERY 6,099 GOOD HEALTH PMS

BARNEHURST ROAD 16,192 LAKESIDE MEDICAL 8,334 LYNDHURST ROAD MEDICAL

CENTRE 2,450 MILL ROAD SURGERY 9,688 NORTHUMBERLAND HEATH

MED.CTR. 7,185 SLADE GREEN MEDICAL CTR.

COLYERS LANE MEDICAL CENTRE

4,931 THE PARKSIDE The figure below shows the location of GP practices and how this maps to where patients live at a lower super output area (LSOA).

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Figure 9: Location of Bexley GP practices

Due to a number of practices having branch sites (which are not labelled on the above map), there is not complete geographical alignment between the locality that the practice is a member of compared to the geographical locality where their patients live. One practice has a branch in Greenwich and two other practices have significant populations that sit outside of their own localities. The LCN Programme Board is yet to agree the approach to how these populations are treated in terms of LCN alignment and priorities for each LCN. There is a single GP federation, Bexley Neighbourhood Care Community Interest Company (CIC), where all practices are members. Working through the LCN programme board, the CCG with the London Borough of Bexley and provider partners seeks to expand and enhance the service offering around populations.

5.2 Our vision It is critical that public sector organisations locally make the most efficient and effective use of their estate so that over the long-term, there is the required infrastructure in place to support the delivery of services in the locations that best respond to the need. In terms of primary care, it is vital that the technological and estate infrastructure reflects new models of service delivery that form part of the primary care transformation agenda and the development of LCNs. In order to do this, there needs to be fit-for-purpose, well utilised, sustainable, affordable estate located to best meet the health needs of the population. The development of primary and community care infrastructure in the borough needs to help facilitate delivery of the following priorities:

• Aligns with the London Borough of Bexley’s Growth Strategy and addresses any service and infrastructure needs that result, across Bexley, including ensuring sufficient GP provision across Bexley e.g. in Belvedere, Slade Green, Thamesmead and Erith.

• Ensures there is sufficient capacity for primary and community care services to be provided in out of hospital settings.

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• Advance technological solutions that reduce the need for face-to-face consultations, better equip patients to self-manage, enable more preventative care and strengthen communication and collaboration between organisations.

• Reduces reliance on clinical and office space through use of remote and mobile working. • Improve seven day access to effective care. • Seeks to rationalise branch sites where this enables more efficient ways of working,

without hindering patient access, ensuring remaining practices, across the borough, are fit for purpose and have the required capacity to meet the needs of Bexley’s population.

• Ensures that all practices in the borough are CQC compliant, meet DDA regulations and that premises are fit for purpose and meet the CQC requirements.

• Ensures that there is sufficient training and workforce development capacity. • Greater partnership working across providers through co-location of services. • Delivers the emerging LCN strategy including the consideration of hub sites. • Maximises the use of purpose built, high quality estate for clinical purposes through

exploring the potential for the relocation of administrative and storage functions off site at a lower cost, or through digitalisation.

• Identifies where buildings are surplus to requirement for all partners and investigating there potential for use across the borough before disposing of assets.

• Ensure any changes are beneficial to patient access and do not exacerbate health inequalities.

• Maximise the use of space through exploring with partner organisations how space can be reconfigured to deliver maximum value to the public sector.

• Ensures the maximisation of digital technology to facilitate patient care.

5.3 Hub sites To help implement new commissioning arrangements such as the integrated MSK service, cardiology service, urgent and unscheduled care service and ophthalmology service the CCG has been working with its partners to develop and transform both Erith and Queen Mary’s hospital sites as ‘smaller viable hospitals’ / community sites. Oxleas NHS Foundation Trust owns both sites, and there are a range of providers operating from the sites to deliver the services shown in the diagram overleaf. Bexley CCG and partner organisations are committed to the continued development of the Queen Mary’s site as a multi-provider health “hub” with Erith Hospital as a “spoke”. There are plans in place for renal and cancer services to be developed upon the Queen Mary’s site.

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Figure 10: Queen Mary’s and Erith Hospital services

Queen Mary’s is well placed to serve the Frognal LCN and Erith Hospital North Bexley but the potential for a third hub will be explored that would serve the Clocktower LCN. This would not necessarily need to house the range of services located at Queen Mary’s and Erith Hospital but could be a site for providing the extended primary care service that is likely to be commissioned by NHS England from April 2016. However, it is recognised that LCNs are about service provision and healthcare wrapped around the patient, as well as how services connect with each other rather than the physical locations of services; and with the direction of travel being towards more self-care options, it is anticipated that investment in technology will replace investment in physical assets.

Appendix 2

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6. The Current Estate 6.1 Overview

This chapter describes the current health and local authority estate and the buildings that are delivering services across Bexley. It will focus on key sites reviewing the cost, size, utilisation, condition and ability of these sites to absorb population growth and increases in services demanded within the borough. It will analyse the estate held by service providers in the Borough. Across Bexley there are 27 GP practices operating from 41 sites. There is one main health service provider (Oxleas), with seven other organisations providing services in Bexley as follows:

1. Oxleas NHS Foundation Trust (Oxleas) – is the community health, mental health and community learning disabilities provider in Bexley. It owns Queen Mary’s and Erith Hospitals.

2. King’s College Hospital NHS Foundation Trust (KCH) – provides integrated MSK services from Queen Mary’s and Erith and District Hospitals and dental services in the community.

3. South London and Maudsley NHS Foundation Trust (SLaM) – Provides substance misuse services in Bexley.

4. Lewisham & Greenwich NHS Trust (LGT) - provides services from Queen Mary’s Hospital and Erith Hospital.

5. Guy’s & St Thomas’ NHS Foundation Trust (GSTT) – provides services from Queen Mary’s Hospital.

6. Dartford & Gravesham NHS Trust (DGT) - provides services from Queen Mary’s and Erith Hospitals.

7. The Hurley Group – provides Urgent Care and Out of Hours services from Queen Mary’s and Erith Hospitals.

In line with the One Public Estate, Department of Health and NHS England initiatives, the Local Estate Strategy should also include relevant Local Authority estate where services might be integrated and co-located. Provider accommodation Key Facts A brief summary of the key facts about organisations that operate within Bexley have been displayed in Figure 11 below. Maps of each provider’s estate have been included in the Appendix X to X (to be added for final version).

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Figure 11: Provider accommodation key facts

Organisation No. of Sites

Total Sq M Occupied

% of total estate occupied

Ownership Status

Comments

General Practices 41

9,754

14.11%

25 Freeholds 16 Leaseholds

Oxleas 20 51,820

84.69% 6 Freeholds

5 Leaseholds 1 LIFT 5 PFI

2 Licences

Total sqm includes 38,751 sqm at QMH,

excludes Bracton. Plus sessional

use in a number of properties.

KCH* 4 TBC

TBC 4 Licences

1 Leasehold

At Barnard Health Centre, QMH,

Erith Hospital and Erith Health

Centre

SLaM 1 833

1.2%

TBC

Provides outpatient

services at Erith Health Centre

GSTT 1 TBC TBC

1 Leasehold At QMH Hospital

LGT 2 TBC TBC 1 Leasehold

1 TBC

At Barnard Medical Practice

and QMH

DGT 2 TBC TBC

TBC At QMH and Erith

Hospital

Sub-Total 76 69,149 100% Other Occupiers

Council Properties 17* 20,052

TBC

TBC

*Sites of possible co-location with council and health care

Pharmacies 45 TBC TBC TBC Dentists 29 TBC TBC TBC Opticians 14 TBC TBC TBC

Care Homes 35 TBC TBC TBC

Total 216 88,368

Multi occupied properties have not been double counted

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GP Estate The GP estate has been summarised in Figure 12 below: Figure 12: GP Estate summary No. of Practices

Practice Premises

converted buildings/ purpose built premises

Single handers

Branch sites (incl. admin building)

No. of WTE GPs

No. of Patients

Average list size

Average Patient per GP WTE

27 41 30/11 5 14 114 234,361 5,716 2,055

Bexley has a higher patient per GP ratio (2,055) than the Department of Health average ratio of one GP per 1,800. However, Bexley is the joint highest in London for Nurse WTE at 0.27 per 1,000 patients. Bexley is 24th out of 32 areas in London for combined GP/Nurses with 0.67 per 1,000 patients. The average list size in Bexley is 5,716, which is below the 6,015 average for the other five South East London Boroughs. Out of hours service provision is provided by the Hurley Group, who also provides the CCG’s two urgent care centres and currently support the 111 service with GP dispositions. This service is provided for all patients registered with a Bexley surgery. The out of hours service is provided out of Queen Mary’s Hospital. Bexley’s two Urgent Care Centres (UCC) are based at Queen Mary’s Hospital, Sidcup, which is open 365 days a year and 24 hours a day and Erith District hospital which is open from 8am to 10pm 7 days a week. There are no Walk-in Centres in Bexley. Figure 13: GP Practices across the borough

Key: The above map has been generated from the SHAPE database. Because of the scale, where GP premises are closely located, they are depicted by a number on the map, i.e. 4 denotes 4 GP in that location.

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The graph below shows the size range of the GP occupation against patient list sizes across the Borough. It illustrates that smaller practices have the potential to increase their list sizes considerably. Further practice specific research will be needed to identify where this is possible. There may also be the need for significant investment to reconfigure space the make this possible. Figure 14: The size of GP practices compared to patient list size

Community Estate The community and mental health providers in Bexley are Oxleas, KCH, GSTT, LGT, SLAM and the Hurley Group. They provide a range of community, mental health and learning disability services across the borough which are summarised below: Oxleas provide community nursing services, community, acute inpatient and rehabilitation mental health services, health visiting, specialist nursing, specialist childrens’ services, inpatient intermediate care, MSK and a number of other services. The trust occupies 20 occupations across the borough alongside sessional use at a number of other sites. Generally community services are provided from a mix of purpose built health centres ranging in size, age and condition. A site fact sheet of key buildings is located in Appendix XX (to be completed for final version of the Local Estates Strategy). KCH, GSTT, DGT, LGT, and SLAM also provide community and mental health services:

• KCH - occupies 4 (licenced occupations) locations across the Borough. Generally MSK services are provided from Queen Mary’s and Erith Hospital. KCH also provide dental services from Lakeside Health Centre and other services at Barnard Health Centre.

• GSTT – provides cardiology services at Queen Mary’s Hospital.

• DGT - provides a wide range of services from Queen Mary’s Hospital and a more limited number of services from Erith Hospital.

• LGT – manages phlebotomy services at Queen Mary’s and Erith Hospitals.

0

200

400

600

800

size

in m

sq

patient list size

Size in Sq M of GP Practices against patient list size

2,000 - 4,999 5,000 - 7,999 8,000 - 10,999 11,000 - 13,999 14,000 and above

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• SLaM - provides a substance misuse service from Erith Health Centre

• The Hurley Group – provides urgent care and out of hours GP services on the Queen Mary’s and Erith hospital sites.

The graph below shows the size (sqm) of the community and mental health estate across Bexley. Figure 15: The size of Community & Mental Health estate across Bexley

Key sites are defined by cost and size but, exclude QMH, which has 31,349 sqm.

Within the community estate there is Lakeside is a new, multi-use health centre that was built under the Local Improvement Finance Trust (LIFT) initiative. The health centre was constructed in 2007, is in very good condition and has potential to deliver long term healthcare in this part of the borough. A site fact sheet for this LIFT building is located in Appendix XX (to be completed for final version of the Local Estates Strategy). .

0

1000

2000

3000

4000

5000

6000

7000

8000

Size of Community and Mental Health Estate

Oxleas SLaM KCH

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Figure 16: below provides a brief summary of the Lakeside Health Centre LIFT building.

LIFT Buildings Head leaseholder Tenants Age

Size (GIA m2)

Annual Cost Charges

Lakeside Health Centre SE2 9LH

CHP Oxleas KCH GPs

2007 2,033 £ 1,149,588

There are a number of sites that will be central to the gap analysis in Chapter 8. These buildings are key to the estate strategy moving forward. These sites are purpose built health centres that are ranging in size, age, and condition and include Erith Health Centre. Figure 18 below shows all of the community estate in Bexley. Figure 17: Community Estate with Bexley

Figure 19 shows the cost of the estate for each provider:

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Figure 18: Community Estate £ per sqm

Local Authority Estate Data from the local authority has been provided and will be included in the final document.

6.2 Utilisation Introduction Effective utilisation of space across the health estate enables property assets to achieve value for money and cost efficiencies. Better utilisation of the estate is fundamental to the principles of the Local Estate Strategy and will assist with the delivery of the emerging integrated LCN model, which aims to focus patient care in the community. To date, a very few utilisation studies have been commissioned on buildings within the Borough, considering the cost of undertaking such reviews. These reviews suggest capacity is available and further analysis will be undertaken before being included in the final strategy. GP Practices The GP estate has not been subject to a formal, independent utilisation review and data has been taken from practices’ responses to the Property and Service Review Survey undertaken in September 2015. To date 38 out of 40 questionnaires have been completed by Bexley GP Practices.

The recent survey provided a simple understanding of the utilisation of GP practices across Bexley. A common theme was the need for additional clinical and non-clinical space, including storage for patient records and administrative space and a limitation to the number of patients

0

200

400

600

800

1,000

1,200

Cost

in £

Community estate £ per sqm

Oxleas SLaM KCH

47

that can be seen and the range of services offered. Figure 20 below illustrates the utilisation across the GP estate. Figure 19: GP survey utilisation

Figure 19 shows the GP Practices’ self-assessment of their buildings’ utilisation. Bexley CCG commissioned desk top utilisation reviews of 2 health centres and 6 of the larger GP practices across the borough. These were chosen as they were mainly sited in areas of expected high population growth. These were commissioned to understand the current capacity and occupancy of key sites. Initial findings suggest that these sites have the potential to increase their capacity by extending the hours of use. This utilisation study will be further reviewed before being included in the final Local Estates Strategy. Community Estate

Only one utilisation study has been undertaken across the community estate. CHP commissioned a study of Lakeside Health Centre in July 2015. The purpose of the study was to understand the utilisation and capacity at the health centre including the GP space and its waiting area. The report concluded that:

• The GP practice is at 100% utilisation, with high occupancy levels throughout the day and over-crowding in the waiting area.

• The first floor and second floors leased to Oxleas are under-utilised.

The Capita report highlights that there is an opportunity to locate other services into this building and adapting the 2nd floor for clinical use. Following the study, further work is being carried out by CHP to develop the reception area and plans for a feasibility study to improve the utilisation of the upper floors. Oxleas is also progressing plans to remove some of the existing admin services from this site, which will allow the space vacated to be converted for clinical use by any provider. Lakeside Health Centre is a key site for the Bexley, Local Estates Strategy. It’s a modern, purpose built health facility in the East Thamesmead area of the borough with potentially high population growth. Also, it is located very close to the border with Greenwich, which is anticipating high population growth in the ward adjoining the health centre. Lakeside is the only Bexley GP in Thamesmead. It is therefore vital that GP provision is reviewed within this area and Belvedere, which also borders Thamesmead and is also an area of significant planned growth and limited GP provision.

11%

89%

GP SURVEY UTILISATION RESULT

High 60 - 80% Excellent >80%

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Bexley CCG has commissioned formal independent utilisation reviews at 2 other health centres, Barnard Health Centre and Erith Health Centre. As with the GP practices, initial findings suggest that these sites have the potential to increase their capacity. However, this may be subject to significant investment to re-configure space to change its use. This work will be further analysed before being included in the final strategy. Oxleas Oxleas regularly review their estate and have plans for the re-location of services and disposal of redundant sites, as described in this document, to improve efficiency. The utilisation information provided by Oxleas and displayed in figure 21 includes the vacant properties for which disposal plans are being progressed. Figure 20: Oxleas’ survey utilisation

Local Authority The Local Authority has provided estates information which is currently being analysed and will be included in the final strategy. The CCG will be undertaking an options appraisal to review its Headquarters’ accommodation. One option may be to re-locate with LBB. Engagement will also take place regarding the co-location of both clinical and administrative services. Pilot utilisation scheme To better manage building utilisation, CHP has proposed undertaking a pilot scheme in Lambeth. If this proves to be successful then it could be rolled out across other boroughs. The CCG and local providers are committed to improving the utilisation of the estate and any lessons learnt through this pilot will be considered for implementation.

17%

12%

12%

59%

UTILISATION OF OXLEAS COMMUNITY ESTATE

Very Poor <40% Poor 40 -50% Average 50 - 60% High 60 - 80% Excellent >80%

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6.3 Asset condition During the process for compiling the strategy, asset condition information has been gathered from various sources, some of which is approximately three years old and some is based on opinions provided by various estates leads from the provider organisations. Compliance Surveys for GP surgeries, undertaken by independent building surveying consultancy between 2011 and 2012, have been provided. GP Estate Data extracted from the GP Survey Questionnaires and the Compliance Surveys show that the majority of the GP occupations are in converted properties that have been constructed pre 2000. 11 practices are located within purpose built facilities. Criteria for assessing the suitability of premises need to be agreed with stakeholders in order to inform future business cases and investment decisions. Figure 21: Type and age of GP estate

The Compliance Surveys conducted on the Bexley PCT, GP estate in 2011 by NIFES Consulting Group have been reviewed and the findings are shown in the pie chart below. Figure 22: GP Compliance Surveys

74%

26%

TYPE OF BUILDING

Converted Purpose built

20%

23%

20%

14%

13%

10%

AGE OF GP ESTATE

1900 - 1929 1930 - 1949 1950 - 1979

1980 -1989 1990 - 1999 2000 - 2009

45% 55%

GP COMPLIANCE SURVEYS Amber Green

50

The risk matrix has been included in Appendix XX. (to be completed for final version of the Local Estates Strategy). As the Compliance Surveys are 4 years old, some remedial works may have been undertaken which would generate an improved score. Several bids have also been submitted as part of the 2015/16 Primary Care Infrastructure Fund. However, the survey information and other data provided give an overview of the age, condition, and types of building occupied. Community Estate With regard to the community estate, Oxleas has provided internal data which indicates the current condition of its estate. As illustrated in figure 24 below, the condition of the estate is generally believed to be in good condition. The unknown relates to properties that Oxleas occupy as sessional use and those properties that are double counted, i.e. QMH & UCC. Figure 23: Condition of Oxleas Estate

The key community buildings in the Borough are predominately purpose built sites that range in age from the 1980’s to 2007. Queen Mary Hospital is the largest health site in the borough. Its part owned freehold by Oxleas and part held under a PFI contract. The freehold areas have been indicated as having an amber rating and the PFI elements as green. Condition data about Erith Hospital is not available but, will be included in the final version of this estates strategy. Going forwards with this Local Estates Strategy, condition surveys and feasibility studies may be required to assist in the investment decision process in order to achieve this strategy.

6.4 Financial Summary Financial information about premises costs across the Borough is currently being developed and will be completed for the final submission in March 2016. To date GP reimbursement information has been provided by NHS England and some high level financial data has been

30%

37%

33%

CONDITION OF OXLEAS ESTATE

Amber Green Unknown

51

received from Oxleas, and KCH. Data has been received from LBB which will be included in the final version of the strategy. Data is awaited from DGT, GSTT & LGT. Table 5: Financial summary

Provider Total Occupation Cost per annum

GPs £3,128,324

Oxleas £3,926,766*

KCH £218,315

SLaM TBC

Council Properties £1,479,427 Total £8,752,832

* These costs do not include QMH or Bracton

Further cost information is provided in Appendix XXX (to be included in the final version) and will be updated for the final submission in March.

6.5 Other Estate Issues As of 16th April 2016, NHS Property Services are proposing to charge current market rent for Bexley CCG’s headquarters building at 221-225 Erith Road. The building is underutilised and options need to be considered. An options appraisal will therefore be undertaken to look at suitable accommodation within the borough.

6.6 Current Disposals The current disposal list identifies a number of opportunities to reduce the estate. Further opportunities for rationalisation could potentially occur where leases have expired or break clauses exercised, subject to the relocation of the health services to alternative premises. Also GP retirements may facilitate practice mergers and or relocation to alternative locations. Oxleas has provided details of its plans for the implementation of its estates strategy. They currently have a good understanding of sites that are core to the services they provide, sites that will need further review before a decision can be made and sites that will be disposed of over the next 5 years. They also have plans in place for the re-investment of the proceeds from the planned property disposals. NHS Property Services has provided a disposal list for South East London and has no assets identified at present for disposal in Bexley. The table below set out the Oxleas site disposals.

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Table 6: Oxleas Site disposals Sites Type of

disposal Date L/H

values Existing use value

Value with planning permission

Number of residential units

Upton Day Hospital

F/H 2015 N/A £600,000 £1,500,000 6/7

Colyers Lane

F/H 2016 N/A £175,000 £300,000 7/8

Murchison Clinic

F/H 2016 N/A £350,000 £1,800,000 8/9

Stuart House L/H Oct 2016 £150,000 N/A N/A N/A

Woodside L/H 2016 £35,000 N/A N/A N/A

Bedonwell L/H Oct 2015 £35,000 N/A N/A N/A

6.7 Challenges and opportunities The NHS and in turn the CCGs are under financial pressure to ensure that the health estate is rationalised and that assets are maximised to their full potential. This will present a number of challenges as well as opportunities to improve the functionality of the estate in line with the service strategy. Identification of the challenges and opportunities will enable the chance to address these issues and act on the opportunities that arise. Engagement with the key stakeholders in the borough has led to identification of the challenges and opportunities that Bexley faces. Estate Challenges There are a number of challenges that stakeholders will have to address in order to create an efficient health estate within Bexley. The estates challenges should be able to be mitigated to create opportunities.

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Table 6: Challenges & Mitigations Challenges Mitigation

Growth scenarios still being developed for the LBB growth strategy.

Maintaining a constant dialogue about population growth with relevant stakeholders

Not knowing what accommodation (particularly clinical) is available.

How to create an effective system that allows different organisations to share space and facilities effectively.

Development of shared estates database that can be accessed by all stakeholders.

CHP currently piloting room booking system.

Lack of capital investment for development/reconfiguration

Local Estate Strategy will set out improvement that can be applied for though the Primary Care Transformation Fund.

Constraints of leases and budgets

Working with the NHS property companies and NHSE, creating a flexible lease framework for service providers.

Population distribution and health inequalities

Ensuring Health hubs are accessible for all

Lack of transparency within each agency

Creating local estate meeting with key stakeholders on a regular basis to encourage engagement.

Availability of transport to certain key hubs

Engagement with council to ensure that key hubs are well serviced by public transport.

Better utilisation of expensive clinical buildings

Relocation of admin and storage facilities to cheaper accommodation / digitalisation of records; conversion to clinical where appropriate.

GP Freehold and retiring partners Early engagement with practices over succession planning

Impact of large scale housing development in adjoining CCG areas

Early cross border discussions and agreements with other CCGs.

Consideration of the balance between Local Care Network hubs and more locally provided care.

Working with community providers and GPs to plan for local care to be available where appropriate within LCNs / localities.

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Estate Opportunities

The Local Estate Strategy presents an opportunity for all stakeholders in Bexley to create an estate for the future that will be able to provide integrated care to all patients. It also presents an opportunity to:

• Continue to secure Queen Mary’s Hospital and Erith Hospital as the main health hub

and spoke for Bexley’s population in recognition that Bexley has no acute site. • Map, collect and maintain real estate information across the estate. • The Local estate strategy will set out to create meaningful forums to discuss needs and

match with capacity. • Improve the uses of clinical rooms in all key estate. • Engage in cross boundary discussions to ensure that the need for health services is met

in the borough. • Create an hierarchy of services – decide what we want, how we provide it and where • Creating one voice for the estate. • Look at other boroughs where success is evident, in terms of technology, estate strategy

and patient care. • Co-locate services where possible and sensible. • Create a system for all health estate and wider public estate so that organisations have

the opportunities to share, swap and borrow buildings. Although Electronic Property information management systems (EPIMS) exist currently, it is regarded to not be fit-for-purpose and it is therefore not used.

• Dispose of single service sites over time and where sensible. • Identify and exiting leases where there is poor value for money. • Rationalise branch sites where possible. • Maximise the use of Bexley’s health facilities and ensuring all sites are fit for purpose,

DDA and CQC compliant.

There are a number of opportunities that can be implemented through the transparency of estate information between providers. These opportunities would be regarded as effective and requiring little capital development.

Appendix 2

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7. Planning for Growth

7.1 Planning for Growth This chapter focuses on regeneration and population growth and change. The future estate will need to accommodate an increasing demand for services resulting from population growth and demographic change. The development and regeneration of areas provides site opportunities to modernise and rationalise the estate. The planning system can help identify future health infrastructure requirements and secure financial contributions from developers in the form of s106 contributions and Community Infrastructure Levy (CIL) to mitigate the impact of development.

7.2 Population growth and demographic change In 2011, the resident population of Bexley stood at 233,000. According to the 2014 round of GLA population projections (SHLAA-based, capped household size, short-term migration scenario), the population of the borough has increased to 240,600 in 2015 and will increase further by a further11,000 between 2015 and 2025, or 4.6% over the decade (although Bexley’s GP registered population is lower than this). By ranking population growth between 2015 and 2025 across London boroughs, historically Bexley has been considered to be a ‘low growth’ borough (ranked 30th out of 33 boroughs). However, this is likely to change through the development of the Borough’s growth strategy. Population growth is uneven and concentrated in different parts of the borough. This presents different challenges for service and estates planning. Population growth is currently concentrated in Erith ward with a GLA projected increase of 29% between 2015 and 2025. The next highest growth ward is Christchurch ward with 10% growth over the next decade. However, the GLA population projections above do not take into account the Council's emerging Growth Strategy, which would transform Bexley from a low growth to a high growth borough with significant infrastructure implications. These high growth areas include Belvedere, Erith, Thamesmead, Crayford and Slade Green. As an outer London borough, Bexley currently has the sixth lowest population density in London (at 3,972 persons per sq. km). It is one of the greenest boroughs in London with over 100 parks and open spaces. With rapid housing growth, the population density and character of areas will change placing pressure on local services and infrastructure. There is also evidence that in some areas increasing household size has increased population density.

Appendix 2

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Figure 24: Bexley Population growth 2015-2025

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Demographic change The population age profile of the borough shows that the proportions of young people aged 19 and under and older people aged 65 and over are higher than both the London and national averages. The GLA projections suggest that the number of 0-4 year olds will fall between 2015 and 2025, whereas the number of 5-19 year olds will increase by 11.6%. Compared to London there are fewer working age residents aged 20-64 and the proportion in this age group will remain static over the next decade. Whereas the proportion of older people aged 65 and over will remain relatively high (17.9% compared to 12.7% in London), the GLA projections suggest a relatively lower increase in this age group compared to London as a whole. However, the GLA projections may not fully reflect local demographic factors and therefore should be treated with caution. The wards of Thamesmead East and North End have the highest numbers of children aged less than 15 years. The highest numbers of older residents aged 65 and over are found in Longlands, Brampton, St Mary’s and Sidcup. Bexley is becoming increasingly diverse. The number of White residents continues to fall, but the proportion at 2015 remains significantly higher than the London average (79.0% compared to 57.9%). The Black, Asian and Minority Ethnic (BAME) population is projected to grow by 27.1% between 2015 and 2025 but will still remain proportionately smaller than London as a whole. The largest BAME group is Black African which is projected to increase by 5,440 over the decade. Thamesmead East is the most diverse ward in Bexley and shares characteristics with many inner London areas. It is the only ward in the Borough where, in 2011, the majority of residents were from BAME groups (52.7%) compared to 40.2% in London as a whole. The 2010 Indices of Multiple Deprivation indicates that Bexley was ranked 180 out of 326 local authorities in England (by rank of average rank). However, according to the 2015 Index, Bexley is less deprived as it is now ranked 195 in England and ranked 26th amongst London boroughs. There are pockets of high deprivation in the north and south east of the borough with the wards of Thamesmead East, North End, Lesnes Abbey, Crayford and Cray Meadows containing areas (Lower Super Output Areas) within the most 20% deprived in England. North End has the greatest concentration of deprived areas. Life expectancy for both men and women is higher than the England average. However, life expectancy is 6.8 years lower for men and 5.2 years lower for women in the most deprived areas of Bexley than in the least deprived areas.

Appendix 2

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Figure 25: Map of Bexley GP practices against index of multiple deprivation

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Housing supply and Opportunity Areas The Mayor of London’s Further Alterations to the London Plan (March 2015) established a new minimum target for Bexley of 446 net additional homes per annum between 2015 and 2025, which would provide 4,460 new homes over the decade. This crudely equates to a population growth of 11,195 between 2015 and 2025 (based on an average household size of 2.51 from the 2011 Census), which aligns with the GLA population projection over the decade. According to the Council, there is a five year supply of 2,370 new homes (April 2015 - March 2020) which is in line with the housing target. 681 units are currently under construction as of April 2015. Opportunity Areas are designated in the London Plan and are large areas of brownfield land which have significant capacity for housing and employment growth. Housing and population growth is concentrated in Opportunity Areas. The London Plan identifies Bexley Riverside Opportunity Area and Thamesmead and Abbey Wood Opportunity Area as having the potential combined capacity to accommodate a minimum of 7,000 new homes and 11,000 new jobs. It is expected that the minimum new homes figures will be exceeded. The Mayor of London’s ‘City in the East’ report (2015) provides a higher housing estimate of 21,500 new homes for the Bexley Riverside and Thamesmead and Abbey Wood (Opportunity Areas). Abbey Wood and South Thamesmead (part of the Opportunity Area in Bexley) has been designated as a Housing Zone by the Mayor of London (October 2015), where funding will be available to support infrastructure and unlock individual schemes. Bexley Council and Peabody Trust have identified a potential for over 1,300 new homes, capitalising on the new Crossrail at Abbey Wood from 2018. It should also be noted that the emerging LBB Growth Strategy shall include higher levels of growth than the current GLA projections. Regeneration and site opportunities The Bexley Growth Strategy (Direction of Travel, June 2015) proposes 24,500 new homes by 2030 in the borough, known as scenario PH3. The growth projections to 2036 (PH4) are being developed further as part of a master planning exercise looking at higher densities at new and enhanced town centres / transport hubs and growth in the rest of the borough. The latest growth scenario (PH4) forecasts 29,200 homes between 2016 and 2036, with 18,000 new homes between 2016 and 2026. This would equate to a population increase of 41,600 over the decade, or 17%. A revised scenario, PH5, is currently being developed. The high level of growth is partly dependent on major transport improvements, such as the extension of Crossrail to Gravesend via Belvedere, Erith and Slade Green stations, new river crossings and other highway and transport infrastructure. The high growth (PH4) is focused in five locations: • Thamesmead / Abbey Wood, 5,000 new homes • Belvedere, 11,000 new homes • Erith, 4,500 new homes • Slade Green, 4,500 new homes • Crayford, 1,000 new homes

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In considering future health service and infrastructure needs the latest available growth projections will need to be considered. Figure 26: London Borough of Bexley’s emerging growth vision

Thamesmead/Abbey Wood Currently, over 1,300 new homes are proposed in the Abbey Wood and South Thamesmead Housing Zone. A South Thamesmead Regeneration Framework was adopted in 2012 which covers the three housing estates of Parkview, Lesnes and Southmere. The regeneration of Southmere Village is underway comprising 800 new homes, plus new community facilities, including a health centre and a community hall. Phase 2 comprising 81 net residential units and library and retail space is complete. Belvedere The Belvedere Park development in Picardy Manor Way provides 400 residential units and is close to completion. If the emerging growth plans are realised, then the population of Belvedere will increase dramatically to become Bexley’s most populated ward and possibly anther town centre. No sites have been formally re-allocated as part of the Local Plan process. This will occur as part of the development plan process following the adoption of the Growth Strategy.

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Erith The area contains large development sites at Erith Quarry and in the Erith Western Gateway area. The Erith Western Gateway Development Framework (January 2012) identifies a potential for at least 500 new homes. The new Bexley College campus opened in September 2014. There is a current planning application on the former Riverside Swimming Centre to provide 71 homes and commercial floor space. Redevelopment of Erith Quarry site, in Fraser Road will provide up to 600 residential units, a primary school and 530 m2 of non-residential floorspace. There have been discussions regarding the possibility of a health centre as part of the proposals. Slade Green The area currently contains three large development sites. Up to 622 residential units are under construction at Erith Park (the former Larner Road estate). The development will be completed in 2017. 372 new homes are under construction at the Howbury Centre, Slade Green Road and nearby 336 residential units and 500 m2 of retail / community floorspace has been approved on the former Linpac site in Richmer Road. Crayford Crayford Town hall and library has been redeveloped to provide 188 new homes, a library, health centre and shops. Crayford Town Surgery relocated into the refurbished building in December 2014. Currently up to 1,000 new homes are proposed in the area. 359 residential units are proposed on the Electrobase / Wheatsheaf Works site, Maxim Road. 247 dwellings are under construction at the former Samas Roneo Site in Maiden Lane. The Cray Waterside Village site has potential for 130 homes. Cross boundary demand and opportunities There are two areas of the borough where significant housing and population growth crosses borough boundaries. In the following areas, a coordinated approach to service and estate strategy and investment is required: • Thamesmead and Abbey Wood (with Greenwich CCG) • Bexley Riverside and the proposed Ebbsfleet Garden City, Kent (with Dartford, Gravesham

& Swanley CCG).

Appendix 2

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Figure 27: South East London population growth 2015-2025

Local Plan and Infrastructure Planning Local Authorities are required to keep their local plans up to date with evidence on physical and social infrastructure required to support housing and commercial development. An infrastructure study based on the latest housing and population growth projections can help identify social infrastructure requirements, including healthcare and future site opportunities and better use of public sector assets. The infrastructure study will also help allocate Community Infrastructure Levy receipts. A report ‘Testing the Service Requirement Impacts of Future Housing Growth in Bexley’ was prepared by ERM consultants in June 2007 to inform the LBB Core Strategy. However, the Council is currently reviewing the growth and service planning assumptions used and will produce a revised Development Infrastructure Funding Study early in 2016. This local estate strategy should be developed in parallel with the Infrastructure Study. In December 2015, LBB in partnership with the London Borough of Lewisham and Bexley CCG joined phase 3 of the One Public Estate programme. The programme brings public sector bodies in an area to together to develop a joined up approach to managing their land and property, enabling partners to release assets and share land and property information.

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Sources of Investment The Local Estates Strategy seeks to coordinate and make best use of all available funding for premises development. This includes the Primary Care Transformation Fund (PCTF) and Improvement Grants, NHSPS customer and landlord capital, CHP investment, NHS Trust capital investment, and developer contributions in the form of Section 106 contributions or CIL. To some extent additional demand can be accommodated within the existing estate by using the estate more effectively, but there will be demand hotspots where new investment may be needed, particularly in the Opportunity Areas. Section 106 contributions / Community Infrastructure Levy (CIL) Prior to the introduction of the borough Community Infrastructure Levy (CIL), s106 health contributions were routinely secured from planning applications. It is estimated that approximately £722,000 of s106 health contributions have been secured; however, very little of this remains. Future CIL contributions may be received as developments commence and are completed. The borough introduced its CIL in April 2015. The CIL Regulation 123 List identifies infrastructure projects and themes which CIL could contribute towards. The list includes ‘health’, but no specific projects are mentioned. The list will be reviewed and updated regularly as required. The Primary Care Transformation Fund On 28 October NHS England sent a letter to CCGs to confirm the approach for funding primary care infrastructure for 2016/17 to 2018/19. Key points are:

• Total funds available from 2015 to 2019 is £1bn • The bulk of the fund will be deployed to improve estates and accelerate digital and

technological developments in general practice, and will be subject to an initial bidding process, the initial deadline of which is 28th February 2016.

• Criteria for funding recommendations for 2016/17 are: o increased capacity for primary care services out of hospital; o commitment to a wider range of services as set out in commissioning intentions

to reduce unplanned admissions to hospital; o improving seven day access to effective care; o increased training capacity.

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8. Gap Analysis The strategy can divide existing estate into three broad categories:

• Suitable for long term use and able to meet future requirements with only routine adaption. These are the core sites, part of the ‘estate of the future’.

• Suitable for long term use but only likely to meet future requirements with major investment and change.

• Unlikely to be suitable long term. These buildings could, potentially, be disposed of, or disinvested from.

In addition, the strategy should clarify where there are gaps with no current estate capability to meet future service requirements. At this point, the plan has established the overall strategic direction of the estate: what needs to change over time, and the relative urgency, to meet future service requirements. Overview The Borough will be divided into the three designated Local Care Networks for gap analysis on a more local scale. This division of the Borough enables a more accurate application of the Local Care Network model, which focuses on population-based care within specific geographic locations; 50,000-130,000 people per LCN has been proposed as a guide by OHSEL. The Local Care Networks within Bexley are:

• North Bexley • Clocktower • Frognal

Appendix 2

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Figure 28: Map showing the 3 LCNs within Bexley

Dividing the estate for analysis to match the location of the LCNs in Bexley is deliberate. To encourage effective set-up and operation of LCNs, analysis of the local needs must be consistent with the desired service delivery model. Clearly the GP Federation will play a key role within the LCN model in helping patients to access the necessary services provided in both the community and in hospitals, co-ordinating care so that it is received in the appropriate settings.

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The core General Practice facilities within Bexley, based on size and proximity to the growth areas have been identified as:

• The Albion Surgery • Crayford Town Surgery • Belvedere Medical Centre • Cairngall Medical Practice • Erith Health Centre • Lyndhurst Medical Centre • Northumberland Health Medical Centre • Barnard Medical Practice

The remainder of the estate requires further assessment against an agreed criteria for assessing sites’ long term suitability and criteria are proposed in section 9.2.: In order to determine its suitability for major investment and long term use. Bexley CCG will ultimately take responsibility for the direction of investment, however it is important that its stakeholders all have an input throughout the process as it is recognised that collectively they hold the majority stake in healthcare properties across the borough, therefore acting as key decision makers and enablers of change. Each of the key stakeholders operating within Bexley has their own estates programmes, and will work collaboratively to ensure future decisions reflect the needs of all organisations. The Estates Working Group will continue to meet regularly with attendance by key stakeholders to further develop this strategy and take forward the workstreams included. Demand Modelling The vision for estate, as set out in Chapter 2, describes the changes in service delivery driven by a number of different factors, and addressed in estates terms through the coordination of LCNs. The current estate will need to accommodate these changes towards the LCN target model of care whilst also accommodating for a growing population. Chapter 6 gave an overview of the current estate in Bexley and provided analysis of several facets including utilisation, condition, and cost. Chapter 7 then identified population growth across the Borough over the next ten years. What is clear is that growth will be incremental in large parts of the Borough but additionally there will be large scale housing developments in adjoining boroughs (e.g. cross-border with Greenwich and DGS) that will result in opportunity areas where there will be proportionately higher population growth. The two opportunity areas within the borough are Bexley Riverside, and Thamesmead & Abbey Wood. No complex demand modelling has been carried out at this stage. However, this will be needed as part of the short term work plan. Complex demand modelling aims to calculate the spatial and workforce requirements resulting from predicted population growth, taking into account socio-economic factors, which can have a measured effect on the specific health needs of a population. This can then be modelled against the current estate to determine the gaps in current and future estate/workforce provision, effectively modelling demand against supply. For the purposes of this exercise basic gap analysis has been undertaken which focuses on the high growth areas within the Borough.

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Basic Demand Modelling Analysis of the wards with predicted population growth greater than 1,000 by 2025, using both GLA population projections and Bexley Council’s latest Projected Housing Figures are as follows:

• North Bexley LCN/Locality o Crayford o Erith o Thamesmead East o Belvedere o North End

• Clocktower LCN/Locality

o Christchurch

More effective utilisation of the existing estate should allow for anticipated low population growth to be accommodated in existing facilities. Successful IT rollout, culture change and training will also alleviate pressure on the current health estate, for example through new ways of working e.g. hot-desking and remote/mobile working. Additionally, the opportunities to “do things differently” and to relieve pressure in the system needs to be explored with the local pharmacies, dentists, opticians and the voluntary sector. However, areas of anticipated high population growth are likely to necessitate new investment in integrated health facilities. Data in relation to the number and age of GP WTEs, and list sizes, is provided as a total for the practice, including all main and branch sites. In Bexley, all patients have the ability to use either the main or branch site with which they are registered. It is therefore not possible to break this information down by individual building.

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Table 7: Summary of Health provision

North Bexley

Ward Current Pop.

GLA Pop. Growth by 2025

LBB Pop. Growth by 2025 (assuming 2.5 wte per new home)

WTE GPs No. of GP Premises

No. of Health Centres

No. of Pharmacies

Specialist Treatment Sites

Mental Health Only Sites

Crayford 12,986 +1,004 + 2,500 1.9 1 0 3 0 0

Analysis Summary of Health Provision

One Health Centre:

• Crayford Town Surgery (532 sq.m. NIA) o Capacity – Main surgery no branch sites. 1.9 WTE GPs, with none aged

60+. List size is 7,373 – GP-to-patient ratio is 3,880. GP Survey comments there are 12 sessions per week available in consulting rooms and 6 sessions per week available in treatment rooms. Patient catchment is spread evenly across the ward. Crayford Town is undergoing significant development with several residential schemes accommodating 100+ units. Several schemes were completed in Q3 2014, and the former Electrobase and Wheatsheaf sites had an application submitted earlier this year for 359 residential units. This could result in significant pressure on the current facilities.

o Suitability – No condition survey on file. Converted premises forms part of the ground floor of the Town Hall that was redeveloped as part of the Town Hall Place development, completed in Q3 2014.

Summary There are no health centres in the ward offering fully integrated services. However the GP Survey comments indicate some spare capacity in Crayford Town Surgery. Neighbouring wards do have existing facilities that may have the capacity to alleviate pressure in this ward. Lyndhurst Medical Centre in Barnehurst ward is approximately 2km west of the site.

Significant population growth is anticipated in the ward resulting from development within Crayford Town. Current facilities may have the capacity to absorb anticipated population growth if GLA projections are correct.

Bexley Council Projected Housing Figures – 1,000 new homes predicted. This will add significant pressure on current facilities and it is unlikely there would be the capacity to absorb this population growth.

Erith 12,826 +3,739 + 11,250 16.6 4 1 2 0 0

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Four GP Practices:

• Bulbanks Medical Centre (257 sq.m. NIA) o Capacity – Main surgery no branch sites. 1.7 WTE GPs, with one aged 60+.

List size is 3,485 – GP-to-patient ratio is 2,050. GP Survey comments there is no spare capacity. Majority of the patient catchment is from the north side of the ward, with some spill over from Belvedere. Area undergoing significant development with a number of schemes with 100+ residential units, including the Erith Quarry scheme with an application for 600 residential units submitted in April 2015. This will significantly increase pressure on the current facilities if/when completed.

o Suitability – Amber RAG rated on inspection (2011) – TBC whether works carried out since to correct. Converted two storey building constructed in circa 1950s.

• Erith Health Centre (Bexley Medical Group & Good Health) (702 sq.m. NIA) o Capacity – Branch site to Bexley Medical Group. 8.9 WTE GPs, with 1 aged

60+. List size is 16,317 patients – GP-to-patient ratio is 1,833 (GP workforce data covers main and branch sites). No GP Survey response. Majority of patient catchment is from the south of the ward. Development in the ward as described above likely to significantly increase pressure on the current facilities. Additional developments in Slade Green will likely add further pressure – Erith Park Phase 1 completed in December 2015 with a total of 343 residential units. Phase 2 gained planning permission in April 2015. Construction of Ratio (Howbury Centre) scheme is anticipated to complete in Q3 2016 delivering 372 residential units. Outline application for re-development of the former Linpac Site comprising of up to 336 residential units was granted in October 2015.

o Suitability – Green RAG rated on inspection (2011) – indicating statutory/CQC compliant. Purpose built three storey LIFT health centre, constructed in circa 2000. Practice occupies part of the ground floor.

• Good Health PMS (177 sq.m. NIA) o Capacity – Main surgery with one branch site. 1.6 WTE GPs, with 0.2 aged

60+. List size is 6,101 patients – GP-to-patient ratio is 3,813 (GP workforce data covers main and branch sites). GP Survey comments there is no spare capacity. Majority of patient catchment is from the south of the ward. Population growth pressures same as described above for Erith Health Centre.

o Suitability – Same as described above for Erith Health Centre. • Northumberland Heath Medical Centre (334 sq.m. NIA)

o Capacity – Main surgery with no branch sites. 4.4 WTE GPs, with 0.5 aged 60+. List size is 9,667 patients – GP-to-patient ratio is 2,197. GP Survey comments there are 10 sessions per week available for use in the treatment rooms. Patient catchment runs across Northumberland Heath and Erith wards. Population growth pressures largely the same as described

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above for Erith Health Centre but with Slade Green not likely to impact as heavily.

o Suitability – Amber RAG rated on inspection (2011) – TBC whether works carried out since to correct. Purpose built single storey building constructed in circa 1990s.

One Health Centre:

• Oxleas – Erith Health Centre (599 sq.m. NIA) o Services – Community HIV; Podiatry; School Nursing; Diabetes; Mental

Health Service; Erith Carers Group; MSK Service; Continence Advisory; Children’s Community Audiology; Family Consultation; Contraception and Sexual Health; Multiple Sclerosis; Parkinson’s Disease; Together Community Support.

o Capacity – Oxleas comment that the property is excellently utilised (>80%). o Suitability – Oxleas comment that premises is Green RAG rated.

One Community Hospital Site:

• Oxleas – Erith Hospital (1,541 sq.m. NIA) o Services – MSK Service; Children’s Services; Urgent Care Centre,

Phlebotomy, Outpatient clinics, x-ray o Capacity – Oxleas comment that utilisation is average (60-80%). o Suitability – Oxleas comment that the building is Amber RAG rated.

• Oxleas – Erith Centre & Park Crescent Centre (1,857 sq.m. NIA)

o Services – Community Mental Health Centre o Capacity – Oxleas comment that utilisation is average (50-60%). o Suitability – Oxleas comment that the building is Green RAG rated.

Summary One large health centre and one community hospital in the ward offering integrated

services to the local population. Good GP provision in the ward with some spare capacity noted in Northumberland Heath Practice. Further capacity TBC.

Significant anticipated population growth from developments within the ward and in neighbouring wards, particularly Slade Green where there are some large developments due for completion in short-medium term. This will increase patient demand for services significantly and the capacity to absorb that growth will need to be carefully assessed.

Bexley Council Projected Housing Figures – 4,500 new homes predicted. These projections are not taken into account in the GLA quoted figure of +3,739. It will add significant pressure on current facilities and it is unlikely there would be the capacity to absorb this population growth.

Dartford Projected Housing Figures – 17,270 new homes is significant housing growth projected for Dartford, which may have an impact on the services being run in

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North End ward.

Thamesmead East

12,718 +657 + 12,500 12.5 1 1 0 0 0


One GP Practice:

• Lakeside Medical Centre (447 sq.m. NIA) o Capacity – Main surgery no branch sites. 12.5 WTE GPs, with 0.8 aged

60+. List size is 16,191 – GP-to-patient ratio is 1,295. GP Survey comments there is no spare capacity within GP demise including an inadequate waiting room space. However the rest of the building is generally under-utilised. Patient catchment is spread evenly across the ward, with some spill over from Thamesmead, Greenwich. Area undergoing significant development under the Peabody scheme – Southmere Village Phase 2 completed in Q1 2011 delivering 220 residential units and an application. Phase 3 is expected to be submitted in 2016 that will deliver 296 residential units. This will significantly increase pressure on the current facilities if/when completed and the GP Practice may be required to increase their demise within the existing building.

o Suitability – Green RAG rated on inspection (2011) – indicating statutory/CQC compliant. Purpose built LIFT health centre. Practice occupies part of the ground floor.

One Health Centre:

• Oxleas – Lakeside Medical Centre (280 sq.m. NIA) o Services – Health visiting; other services TBC. o Capacity – Oxleas comment there is average utilisation (50-60%). o Suitability – Green RAG rated on inspection (2011) – TBC whether works

carried out since to correct. • KCH – Lakeside Medical Centre (274 sq.m. NIA)

o Services – Community Dental Care. o Capacity – No utilisation info provided. o Suitability – Amber RAG rated on inspection (2011) – TBC whether works

carried out since to correct.

Summary Purpose built LIFT building in the ward that could act as a core hub site. GP Survey comments the building is generally underutilised (outside of the GP’s demise). There is scope to re-configure non-clinical space as clinical space to cope with anticipated population growth. The ward is not predicted to undergo significant growth according to GLA figures and if these remain true the current facilities may have the capacity to absorb the anticipated population growth.

Bexley Council Projected Housing Figures – 5,000 new homes predicted. Significant potential for development in Lower Belvedere that could also impact on

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facilities in this ward if realised. These projections are not taken into account in the above GLA quoted figure of +657. It will add significant pressure on current facilities and it is unlikely there would be the capacity to absorb this population growth.

Greenwich Projected Housing Figures – 3,000 new homes is significant housing growth projected for the adjoining ward in Greenwich, which may have an impact on the services being run in Thamesmead East ward.

Belvedere 12,851 +236 + 27,500 TBC 4 0 3 0 0


Four GP Practices:

• Belvedere Medical Centre (346 sq.m. NIA) o Capacity – Main surgery no branch sites. GP workforce data TBC. List size

is 8,529. GP Survey comments there is no spare capacity, the Practice cannot take on more clinicians or become a training practice due to lack of rooms. Patient catchment is spread evenly across the ward, with some spill over from Lesnes Abbey and Erith wards. Some development in the area – Belvedere Park completed in Q3 2015 delivering a total of 402 residential units. Population growth in Erith ward is likely to spill over, particularly from schemes in the west side of Erith ward as have been described in the Erith ward analysis.

o Suitability – Green RAG rated on inspection (2011) – indicating statutory/CQC compliant. Purpose built two storey property constructed circa 1999.

• Cairngall Medical Practice (352 sq.m. NIA) o Capacity – Main surgery with branch site Cumberland Drive Surgery. 5.9

WTE GPs, with 2.3 aged 60+. List size is 9,614 – GP-to-patient ratio is 1,630. GP Survey comments there is no spare capacity within GP demise. Patient catchment is spread evenly across the south of the ward, with some spill over from Lesnes Abbey and Erith wards. Population growth pressures as described above for Belvedere Medical Centre.

o Suitability – Amber RAG rated on inspection (2011) – TBC whether works carried out since to correct. Converted three storey building that was extended and reconfigured in 1999.

• Nuxley Road Surgery (99sq.m. NIA) o Capacity – Branch site of Bexley Group Practice. 3.3 WTE GPs, with 1 aged

60+. List size is 11,533 – GP-to-patient ratio is 3,495. GP Survey comments there is no spare capacity. There is potential for the Practice to merge this site with Station Road Surgery in order to expand service provision and consolidate two sites into one site. Patient catchment is spread evenly across the south of the ward. Population growth pressures as described above for Belvedere Medical Centre.

o Suitability – Amber RAG rated on inspection (2011) – TBC whether works

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carried out since to correct. Converted circa 1960s building. • Station Road Surgery (86 sq.m. NIA)

o Capacity – Branch site of Bexley Group Practice. GP workforce data the same as described above for Nuxley Road surgery. GP Survey comments that this site is used as the administrative space for the whole Practice, and that there is no spare capacity. Patient catchment is spread evenly across the south of the ward. Population growth pressures as described above for Belvedere Medical Centre.

o Suitability – Amber RAG rated on inspection (2011) – TBC whether works carried out since to correct. Converted terraced building forms part of a small retail parade.

Summary No health centres in the ward – Erith and District Community Hospital, Erith Health Centre and Lakeside Health Centre located in neighbouring wards that will likely act as core hub sites for this area. Good GP provision in the south of the ward. Current facilities will be adequate to cope with population growth figures as published by GLA (+236).

Bexley Council Projected Housing Figures – 11,000 new homes predicted. East Thamesmead Industrial Area and the Pirelli Site in Lower Belvedere have combined development potential to accommodate circa 5,000 new homes. This is not taken into account in the above GLA quoted figure of +236. It will add significant pressure on current facilities and it is highly unlikely there would be the capacity to absorb the population growth that would result from 11,000 new homes.

North End (Slade Green)

11,882 +946 + 5,100 3.2 1 0 1 0 0


One GP Practice:

• Slade Green Medical Centre (239 sq.m. NIA) o Capacity – Main surgery one branch site (Colyers Lane Surgery). 3.2 WTE

GPs, with 1.5 aged 60+. List size is 7,173 – GP-to-patient ratio is 2,242. GP Survey comments there are 3 consultation rooms available in the new extension, and an option for the Practice to take an additional 2 consultation rooms which hasn’t yet been exercised. Patient catchment is spread evenly across Slade Green. Slade Green is undergoing some development – Ratio (Howbury Centre) scheme is expected to complete in Q3 2016 and will deliver 372 residential units. Planning was granted in October 2015 for the Linpac Corrugated Cases scheme which will deliver 336 residential units.

o Suitability – Green RAG rated on inspection (2011) – indicating statutory/CQC compliant. Purpose built two storey property that was constructed in circa 1990's. Site was refurbished and extended in 2011.

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Summary No health centres in the ward. However GP Practice is being expanded to increase capacity and ability to absorb incremental population growth as predicted in GLA figures. However, this does not take into account the LBB growth. Erith Health Centre in neighbouring ward able to offer integrated services, although population growth in Erith might limit the buildings capacity to absorb growth in Slade Green.

Bexley Council Projected Housing Figures – 4,500 new homes predicted. Some areas with potential for residential development. Some development in Dartford – Northern Gateway Strategic Site to provide up to 2,040 new homes with new primary health services, and Dartford Town Centre to provide up to 1,030 new homes. This is not taken into account in the above GLA quoted figure of +946. It will add significant pressure on existing facilities and it is highly unlikely that there would be the capacity to absorb such population growth.

Dartford Projected Housing Figures – 17,270 new homes is significant housing growth projected for Dartford, which may have an impact on the services being run in North End ward.

Clocktower

Ward Current Pop.

Pop. Growth by 2025

WTE GPs LBB Pop. Growth by 2025 (assuming 2.5 wte per new home)

No. of GP Premises

No. of Health Centres

No. of Pharmacies

Specialist Treatment Sites

Mental Health Only Sites

Christchurch 11,231 +1,083 9.7 0 1 1 3 1 (Bexley Youth)

3 (Upton Day +Florence House+Bexleyheath)


One GP Practice:

• The Albion Surgery (473 sq.m. NIA) o Capacity – Main surgery no branch sites. 9.7 WTE GPs, with 0.8 aged

60+. List size is 14,167 – GP-to-patient ratio is 1,461. GP Survey comments there is no spare capacity and the GPs would like to expand facilities to include additional consulting rooms on the first floor to accommodate nurses and doctor, and that at present it would be difficult to employ more doctors or nurses due to lack of space. Majority

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of the patient catchment is from Christchurch and Barnehurst. Area undergoing some incremental development with the Pinnacle Square scheme the most significant in the area providing 127 residential units, completed in Q2 2015.

o Suitability – Amber RAG rated on inspection (2011) indicating minor works required for statutory/CQC compliance – TBC whether works carried out since to correct. Purpose built property, two storey with large extension to the side and car parking to the rear, constructed in circa 1980's.

One Health Centre:

• Oxleas – The Albion Surgery (sessional occupation) plus sole use of Annex (Stanley Terrace)

o Services – Health Visiting (Baby Clinics). o Capacity – Sessional use in Surgery and full time use of Annex. o Suitability – Amber RAG rated on inspection (2011) – TBC whether

works carried out since to correct.

Three Mental Health Sites:

• Oxleas – Florence House (size TBC) o Services – Dispersed Intensively Supported Housing Project which

provides intensive support for 24 people recovering from severe mental illness living in their own homes.

o Capacity – Oxleas comment utilisation is excellent (>80%). o Suitability – Oxleas comment condition is Green RAG rated.

• Oxleas – Bexleyheath Centre (1,075 sq.m. NIA) o Services – Older Adult Psychology Service which provides psychological

services for people aged over 65 years. o Capacity – Oxleas comment utilisation is excellent (>80%). o Suitability – Oxleas comment condition is Green RAG rated.

• Oxleas – Upton Day Hospital (1,075 sq.m. NIA) o Services – Memory Service; Older Adults Community Mental Health

Team. o Capacity – Oxleas comment utilisation is very poor (<40%) with

approximately 665 sq.m. of void space. Plans being progressed for disposal.

o Suitability – Oxleas comment condition is Green RAG rated.

Specialist treatment centres:

• Oxleas – Bexley Youth Advisory (233 Broadway) (sessional) o Services – Sexual Health services. o Capacity – Sessional occupation. o Suitability – No condition information provided.

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Summary Some incremental population growth is anticipated in the ward. There is one health centre in the ward but Oxleas services provided only on a sessional basis. Upton Road site is poorly utilised and has significant void space. It is highlighted for disposal by Oxleas but is being investigated as a possible Clocktower hub site. Neighbouring wards do not have high anticipated population growth. New facilities will not be required. Work ongoing to identify core hub site in Clocktower locality.

Further work will be needed on the remainder of the GP estates in Bexley to assess their condition and potential. Several practices were successful in securing Primary Care Infrastructure funding during 2015/16. This work will also include an assessment of the borough’s branch surgeries to establish whether these can be rationalised to maximise access capacity on fewer sites, especially where practices are operating across a number of sites in close proximity. Demand Modelling The basic gap analysis above does not take into account a shift in investment strategy focused on investment in key assets and disinvestment from assets deemed unsustainable for long term investment. Site disposals will be encouraged where appropriate when existing facilities have the capacity to absorb the additional demand. Core hub sites will need to be “flexible, adaptable and accessible facilities” that can accommodate a number of services in line with the LCN model. Four have been identified in Bexley as listed above, which are all modern, purpose-built buildings, built within the last eight years to a high specification. The initial assessment of all remaining sites will be against the criteria in section 9.2.

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9. Estates Options for Change 9.1 Summary of estates options

In the earlier sections we have identified the key drivers for change, the CCG’s vision of the emerging Local Care Networks, the current estate and we have undertaken a gap analysis. The GLA data informs us that historically Bexley has been regarded as a low growth borough. However, the London Borough of Bexley is developing its Growth Strategy which includes much higher levels of projected growth with at least 24,500 new homes by 2030 (PH3). Much of this development would be in the North of the borough in Thamesmead, Belvedere, Erith and Slade Green, along with the provision of major transport infrastructure improvements, potentially including an extension of Crossrail and new river crossings. We have undertaken a number of utilisation studies that suggest assets are not being used to their full potential. Therefore, we have assumed that with improved utilisation much of the exiting estate can be used to meet the increased demand in the wards where there are small population increases. This is a very general view and may not apply to small or all premises, so to make more informed decisions, further utilisation studies may be necessary. Where we are aware of opportunity areas and likely or known development plans, including their timescales, and where investment is going to be required, feasibility studies need to be commissioned and subsequently project teams need to be formed. Project Initiation Documents (PIDs) need to be approved and the business case process should be commenced with a view to providing facilities on time to meet the increased population’s needs. The business case process is set out in the NHS England, Business Case Approval Process – capital, investment, property & ICT guidance. It will require early engagement with NHSE, Projects Appraisal Unit PAU), who assure property and ICT investment business cases for the NHS England Board, prior to approval. All cases at each key stage (e.g. strategic outline case (SOC), outline business case (OBC), full business case (FBC), as appropriate are required to adhere to the principles of best practice set out in the HM Treasury Green Book, the Capital Investment Manual and the (DH 1994) and NHS Estates Code (DH 2007). As this process can be lengthy, the CCG and its partners need to plan ahead and engage with key stakeholders. Essential to this process is early knowledge of development proposals and an assessment of their likely impact on health services in that ward. Horizon scanning and placing of markers with the Local Authority that additional facilities may need to be provided is essential. Also, markers should be placed in estates strategies and with NHSE PAU to highlight future funding requirements. There is already a list of potential projects/studies as follows:

• Belvedere – potential under provision • Queen Mary’s Hospital – development plans being progressed • Health Centres – better utilisation of sites • Erith Hospital – future utilisation being discussed by CCG/Oxleas • Lakeside – better utilisation and cross-border issues with Greenwich CCG • Thamesmead - potential under provision

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• Cross-border issues with Dartford, Gravesham & Swale CCG • Slade Green - potential under provision • Digital improvements for patient records etc. • Clocktower locality – consideration of a further hub. • Practice branch rationalisation • Ensuring practices are fit for purpose, DDA and CQC compliant

These new projects will allow, over time, the replacement of sites that do not meet the agreed investment criteria. Additionally, GP retirements and practice merger opportunities will further facilitate the reduction in the estate and the development of larger practices working at scale and supporting the LCNs. More work needs to be done to look at opportunities for Community services, specialist providers and the Local Authority to co-locate, integrate and rationalise their respective estates. We see this as a key workstream for the next phase of the Local Estates Strategy development and essential for informing the final version of the document.

9.2 Evaluation process and criteria We suggest that all sites should be initially assessed on the basis of the following criteria:

• Good geographic location to support growth areas • Good public transport accessibility • Statutory compliance – including access to and around buildings • Fit for purpose and capable of being ICT enabled • Capacity to co-locate integrated services into multi-use accommodation • Functionally suitable, good quality, flexible accommodation • Freehold or Leasehold with ten plus years remaining • Ability to convert administrative offices to clinical space • Premises to be sustainable and capable of working at scale

Those sites that do not meet the above criteria should be exited once alternative facilities are available. In the meantime, minimum investment should be maintained to keep buildings compliant. However, QMH and Erith Hospitals are considered fixed points and must be secured for the Bexley population. Therefore, if any review shows under-utilisation, on these sites, the services will be expanded to maximise use. The principles of best practice for options appraisals are set out in the HM Treasury Green Book, the Capital Investment Manual and the (DH 1994) and NHS Estates Code (DH 2007) and these should be clearly evidenced and adhered to. Where sites are to close and services relocated there needs to be a well-planned and initiated communications plan for patients and stakeholders to keep them fully briefed about the strategy and specific proposals for services.

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10. Delivering the Strategy 10.1 Short term work actions

These are the actions that we believe should be undertaken between January and March 2016, to inform the PCTF applications at the end of February and the final version of the Local estates strategy by the end of March 2016. However, a number of these require investment and is therefore dependant on external resources being available.

• Obtain missing data to fill gaps • Incorporate the latest LBB growth data, PH5, in assessing future health service and

infrastructure needs • Procure estates expertise to take Estates Strategy forward • Data completeness/validation of all data • Clarity of stakeholders estates strategies • Test the interim gap analysis at locality level with stakeholders • Greater clarity around LCNs in terms of specific services to be housed and where to be

located • Develop a timeline for the proposed new housing developments • Develop workstream for stakeholders to discuss and agree co-location and integration

opportunities • Procure funding and arrange utilisation studies to core estate to better understand

capacity • Procure demand modelling consultancy services to better understand impacts of

proposed population growth and for core sites and investment projects • Agree the criteria for investment and then consider which sites/projects might need

funding • Investigate voluntary and community use of buildings • Continue involvement in SEL estates strategy meetings to ensure awareness of cross

border issues • Further development of the Estates Strategy with completion by end March 2016 • Identify best practice and knowledge sharing across SEL • Identify and start planning pilot projects and quick wins

10.2 Ongoing medium and long term work actions We believe the following medium and long term actions will need to be progressed:

• Feasibility studies, options appraisal and business case development for core sites and where investment is required

• Procure condition surveys of core buildings requiring investment • Develop communications plan for engaging with stakeholders • Better understand ICT and workforce implications on the estate • Continual review of the estates strategy and individual project governance for new

schemes, with a formal review every 12 months • Ensure robust communications between the SEL estates, ICT and workforce

workstreams • CHP to roll out Procurement of project managers, health planners and design team for

working up refurbishment projects or new schemes • Options appraisal and business case development for core investment projects that

require additional investment

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• Delivery of improved utilisation at Lakeside and Erith Health Centres and other major sites

• Ongoing development and maintenance of the SHAPE database • Further engagement with Local Planning Authority to ensure CCG and stakeholders

have early warning of development proposals and to give them time to consider the health impact and to apply for S106/CIL contributions.

Appendix 2

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11. Financials Financial information is being gathered and there are still gaps which will be completed for the final submission. Information relating to Oxleas’ proposed disposals is shown in table has provided us with the following disposal plans:

Disposals

Table 8: Oxleas potential capital receipts Sites Type of

disposal Date L/H

values Existing use value

Value with planning permission

Number of residential units

Upton Day Hospital

F/H 2015 N/A £600,000 £1,500,000 6/7

Colyers Lane

F/H 2016 N/A £175,000 £300,000 7/8

Murchison Clinic

F/H 2016 N/A £350,000 £1,800,000 8/9

Stuart House L/H Oct 2016 £150,000 N/A N/A N/A

Woodside L/H 2016 £35,000 N/A N/A N/A

Bedonwell L/H Oct 2015 £35,000 N/A N/A N/A

Oxleas have plans in place for reinvestment of all proceeds from their planned property disposals. No pipeline disposals have been provided by LBB and other providers at this stage but, it is hoped more detail will be forthcoming once their estates strategies are further developed and can be included in the final version of this document. Void Costs Void cost data has been supplied by CHP and NHSPS and will be confirmed before inclusion in the final strategy. Savings Possible revenue savings are in the process of being calculated, and will be dependent on agreement of estate utilisation. This will be included in the final Estates Strategy. However, any savings are likely to be incurred only by significant investment in the reconfiguration of estate or investment in e.g. digitalisation.

Appendix 2

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12. Outline Implementation Plan 12.1 Programme plan and milestones

A high level timetable is included below and will be further developed over the next few weeks. Key milestones are the Primary Care Transformation Fund (PCTF) applications at the end of February 2016 and the final version of the Local Estates Strategy by the end of March 2016. There will be numerous other milestones to add to a full plan, which will be developed jointly with stakeholders. Figure 29: High level timetable and milestones

12.2 Enablers of change and managing constraints With so many parties involved and so many potentially competing views, it is easy for the process to become stuck. The plan identifies the following enablers of change:

• National SEP Steering Committee • London SEP Lead • SE London SEP Lead • Local Strategic Estates Adviser • Senior Managers and stakeholders in the estates strategy • QMH (& Erith) Programme Board • LCN Programme Board

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12.3 Risks and mitigations Table 9: Risks and Mitigations Risks Mitigations Lack of capacity and estates expertise to further the agenda

Work with strategic estates advisors; Procurement of estates expertise

National economy and housing market No mitigation NHS funding – changes in priorities No mitigation Inadequate and/or poor data Work with providers of data to make it as

reliable as possible S106/CIL contributions Ensure good engagement with LBB to ensure

health requirements are built into local development plans

Poor engagement from Providers Ensure strong leadership and buy-in from all parties to the value of working together

Lack of funding / running costs available to invest in necessary work to enable the strategy

Bid for PCTF funding where possible

Lack of funding available to reconfigure estate to increase utilisation of for digitalisation

Bid for PCTF funding where possible

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