NPS0003

Written evidence submitted by British Medical Association

The BMA is a professional association and trade union representing and negotiating on behalf of all doctors and medical students in the UK. It is a leading voice advocating for outstanding health care and a healthy population. It is an association providing members with excellent individual services and support throughout their lives.

Key points

• NHS Property Services (NHSPS) have significantly increased service charges to GP practices without the practices’ agreement. The BMA questions the legality of such a practice.
• Comprehensive breakdowns of service are not routinely, reliably and uniformly provided by the NHSPS leaving some GP practices unclear why their costs have increased, or if the amount requested is correct.
• Numerous instances have been reported to the BMA of practices being incorrectly charged by NHSPS either for services they have not received or being charged twice for the same service.
• Disputes over service charge increases can prevent practices securing a lease agreement, which in turn impacts the recruitment of new partners and the ability of practices to claim development grants, both of which effects the practices’ ability to support and treat patients.
• NHSPS has expressed the intention of agreeing a ‘charging schedule’ detailing all services and costs supplied by them to individual GP practices. Progress rolling this out has been slow and the BMA is calling for an update and indication of when these schedules will be agreed with the majority of practices.

1. General practice - disputed service charges

1.1  Over the last three years, GP practices leasing their surgeries from NHSPS have seen fees rises, some by more than double in a year, without their agreement. BMA survey findings published in 2019 found that eight in 10 practices leasing from an NHS organisation said they had been invoiced with charges that were inaccurate in the last 12 months, with only 5% reporting these issues had been resolved[1]. As part of this increase many practices are receiving charges for services that they have not requested and are not receiving. The NAO noted that about half of the current NHSPS debt is subject to review “because it has been challenged by tenants for a number of reasons, including inaccurate information or inappropriate apportionment of costs”.[2] These charges are being challenged by a range of tenants including trusts and CCGs, examples of these charges which have been reported to the BMA from GPs include[3]:

• A practice which was invoiced for fees for a lift that did not exist
• A practice charged for CCTV that did not exist
• Practices charged for maintenance work which was not undertaken
• Payment being requested more than once for the same service, in effect a ‘double payment’.

1.2  While it is clear in many instances that charges are being included for services not carried out, or that a second payment for work already paid for is being requested, some practices have faced increases which NHSPS is unwilling or unable to itemise. In many instances practices have told us that they are simply not able to access a clear breakdown of what the charges relate to, such a situation may lead to non-payment as the practice is unable to reach an agreement on the correct charge with NHSPS. Despite repeated requests for clarification regarding the basis for these increases, NHSPS has yet to provide the BMA with any credible explanation. This supports the NAO assertion that “the same tenants continue to re-appear on the [NHSPS] non-payment list, suggesting the underlying reasons for non-payment are not being addressed”[4].

1.3  The BMA has discussed with NHSPS their intention to create a ‘charging schedule’, agreed with each practice which would include a list of services provided by NHSPS to the practice and the cost of these services. To date the development of these ‘charging schedules’ remains unacceptably slow. The BMA would like confirmation as to what percentage of practices NHSPS have agreed a ‘charging schedule’ with and the timescale that NHSPS is expecting to have this agreement in place with the majority, if not all practices, by.

1.4  The impact of these unfair, and often unaccounted for, service charge increases from NHSPS to practices is significant as many practices are left unable to meet the increased costs. At a time when GP full time equivalent numbers continue to fall and waiting times are rising it is inconceivable that practices futures’ are being put in jeopardy by these unprecedented and unjustified charges.

1.5  Because of the unsatisfactory nature of the NHSPS resolution and arbitration services these issues can remain unresolved indefinitely causing unnecessary stress on GP partners and a delay in practice maintenance and upgrades necessary for the delivery of patient care.

1.6  The ongoing situation is directly impacting on practices abilities to recruit new partners, because of outstanding disputes, lack of formalised leases and premises which are in need of modernisation and renovation. Case studies outlining the experiences of practices in Tower Hamlets and Hampshire are included as ANNEX 1. and provides an overview of the type of problems and challenges associated with NHSPS which practices are experiencing on a daily basis.

1.7  We find it astonishing that despite many practices, trusts and CCGs reporting incorrect charging, and significant delays in addressing these concerns, including through inability to provide itemisation of charges, that NHSPS is awarding bonus payments above nearly all the other national NHS entities. The HSJ worryingly reported that in the same year NHSPS recorded a £40.9m deficit (2017-18) it paid its chief executive a bonus in the £75,000-£80,000 band, on top of her £220,000-£225,000 salary[5]. We consider this to be a poor use of taxpayer’s money, given the failure of NHSPS to deliver the most fundamental of its duties in a timely and accurate manner.

2. GP premises leases

2.1  GPs are in a unique situation due to the General Practice partnership model which means GPs have unlimited personal liability for any practice issues. GPs are personally at risk of bankruptcy due to the impact of these inflated and unreasonable charges. This means that GPs are anxious to ensure that they do not expose themselves to these unsubstantiated liabilities and are more unlikely to settle disputed charges without adequate resolution.

2.2  The BMA’s General Practitioners Committee (GPC) has written to NHSPS regarding their assertion that they can vary premises’ leases without the consent or agreement of practices based on a change in their internal policy (i.e. to move to full cost recovery of actual costs including service charges). NHSPS have been asked to urgently respond to concerns over these rises in service charges faced by GP practices. In a letter of claim, (copied to DHSC) BMA lawyers have set out in detail the reasons why it believes NHSPS is acting unlawfully. If a satisfactory response is not received, the BMA has issued a press release outlining that it intends to take NHSPS to court over the issue[6].

2.3  NHSPS aspires to move all practices on to formalised contracts, currently 70% of its tenants have no signed lease agreement in place[7]. While GPs are not opposed to this approach, practices with disputed service charges are finding this is a barrier to formalising their leases. The BMA believes that NHSPS must address current disputes if it wants to be successful in encouraging more formal lease arrangements.

3. Impact on patients

3.1  Failure to secure investment for GP premises is seriously impacting on the facilities available to patients in some practices.[8] Earlier this year the Patients Association published a report which found that patients are concerned about various internal and external aspects of their local GP practice premises. The report found many premises need to make important adjustments to improve accessibility and that many properties are in need of investment.[9] Echoing this, the BMA GP premises survey found that only half of practices considered their premises to be fit for present needs.[10] This number falls to just over 2 in 10 practices when asked if they thought their premises are fit for the future (taking into account population growth).[11]

3.2  Worryingly practices can be refused development grants to make urgently needed improvements, because they do not have a lease agreement. This clearly impacts on the delivery of care to patients by enabling practices to be maintained or made accessible. It can also mean that practices are unable to expand, resulting in a lost opportunity to meet increasing patient demand.

3.3  Even NHS England’s flagship schemes such as the Estates and Technology Transformation Fund (ETTF) have not been delivered in practices owned by NHS Property services due to these ongoing issues related to service charges and a lack of lease arrangements.

3.4  The financial pressure and emotional strain on doctors caused by increased services charges, and their repercussions on lease agreements is significant. The BMA is particularly concerned that it may cause some practices to consider handing back their GMS contract. We are aware that some practices have already made this hard choice, such as, Whyburn, a Nottingham based practice, who decided to hand back their contract in December 2018, due to increased NHSPS charges[12].  

4. Conclusion

4.1  The BMA would dispute concluding comments made in the NAO report Investigation into NHS Property Services Limited, which stated that “In our view, too many NHS organisations and GPs seem to regard paying for their premises as optional, with almost £700 million either written off or still unpaid”. Doctors have a moral and ethical duty to spend public money carefully and current billing practices and service charge increases applied by NHSPS are unjustifiable and for some practices unsustainable. Until NHSPS is able to provide insight into its charging policies, the ability to accurately breakdown what it is charging for and mechanisms to avoid double and inaccurate charges being levied, doctors will be forced to continue to contest charges and increases where they have reason to suspect that these charges are incorrect.

4.2  BMA guidance is clear that practices should engage with NHSPS, identify areas where there is a dispute and where appropriate pay any undisputed amounts. Agreements between NHSPS and practices need to be reached which are affordable and include any commitments from previous commissioners. Practices should not be forced into any agreement which places the viability of the practice at risk and solutions must be sustainable. The NHSPS must prioritise putting in place ‘charging schedules’ agreed with all practices, as well as urgently streamlining and improving their dispute resolution processes.

ANNEX 1.

Case study 1. Tower Hamlets

Tower Hamlets LMC  is made up of practising GPs and practice staff elected by local GPs to represents the interests of all local GPs and their teams

“Our experience in Tower Hamlets is that NHSPS have taken a very heavy handed and unsophisticated approach to the service charges on GP premises. We have had practices in health centre premises, jointly occupied with for example CAMHS, where NHSPS have tried to charge the practices for the whole building. Rates have been charged twice and service charges have quadrupled without itemisation. Practices have politely demanded itemisation and said that they will agree to service charges when they are satisfied that the charges are reasonable and pertain to the practice in question.

Other practices who are already signed up to an NHSPS lease have had appalling service. We have a practice in Tower Hamlets in a very new building with a terrible damp problem, so bad that shelves have fallen off the wall. The drains are in an appalling state and faecal matter has leaked into the bathrooms. They have had great difficulty in getting NHSPS to sort these things out. NHSPS have outsourced the facilities management to an external agency and the practice fall between the two.”

Case study 2. Hampshire

The Wilson Practice in serves 14,700 patients. It has occupied part of Alton Health Centre since 1974.

“We do not have a lease in place despite sporadic attempts by NHSPS to offer one on less than favourable terms to us. The last time our records and those of NHSPS showed Wilson Practice payments in balance with NHSPS invoices was in 2014/15. Since then we have tried to engage with NHSPS. This has been frustrating, time consuming and often receives no reply at all, each time discrepancies and confusion arise. It has not been possible to resolve the widening gap between our understanding of what we believe we should be paying and the invoices we receive.

We received a statement in August 2019 stating that the practice now owes NHSPS £470,958. We have written to dispute this figure and have been offered a meeting. It is a significant concern and, as we are in recruitment mode, takes some explaining to would-be GP partners- it clearly makes The Wilson Practice less attractive than others in these challenging times. The issue is made up of two elements:

The practice pays rates direct to the local council for its share of occupancy of the building but despite us informing NHSPS of this on many occasions they continue to include rates to the practice as part of the service/FM charges.  We do not know whether NHSPS is duplicating the rates payment we are making for the space we occupy.

The change to ‘full cost recovery invoicing was announced and implemented with no discussion or negotiation with us as tenants. There is increased transparency with ‘annual charging schedules’, but the figures are not supported by any evidence and are sometimes hard to believe. They also include a % levy for management charges which, given the lack of management of the building and the figures, and how hard it is to engage with NHSPS, we believe is difficult to justify.

An example of poor management would be the practice becoming aware that there was no security alarm monitoring when, on 12 December 2018, the alarm system failed and no alert was raised. This was not resolved until late January 2019 despite it being deemed an urgent security problem.  The solution implemented (and which we presume will be factored into future charges) was for a twice-nightly ‘drive-by’ from a security company.”

Submitted September 2019