11. Building and Resources

Provided by the local authority or PCO (health centres)

In April 2013 the responsibilty for PCO-owned primary care health centres was passed to NHS Property Services Ltd (otherwise known as ‘Propco’), as a result of the Health and Social Care Act 2012. The aim of this was to set up a corporate organisation to manage former PCO health premises, the hope being that there would be more efficient use of premises and better financial scrutiny. The only exception to this is where an occupant (e.g. a community trust, individual practice) with more than 50% occupancy was given an option for leases to be passed to them.

All GP practices, irrespective of whether or not they are in formerly owned PCO property, now pay rent and rates and should have a formal lease in place. The process of rent reimbursement is outlined in the following section on leasehold rent reimbursement. Previously such charges were simply passed through costs via the PCO as the PCO owned the building and provided the reimbursement. The introduction of NHS Property Services has been hugely controversial. The transition was difficult with loss of organisational memory. Many practices have had significant increases in their rent and service charges, as NHS Property Services have gone for full recovery of costs. It has led to many practices saying they are financially unviable and refusing to pay. Many practices state there is no transparency on the increases and they do not reflect current market rates. The British Medical Association (BMA) is now involved and national discussions are taking place to resolve the issues. Although the rent and business rates element is reimbursed by the PCO, the service charges for facilities management are not. The level of rent reimbursement is calculated in the same way as leasehold rent reimbursement – see the following section.

The development of GP at Scale models radically changed the way in which accommodation is provided to GPs. Pressure continues to mount on small practices to either merge together or move into newly established primary care centres. There is no doubt that this trend will continue as public finances come under greater scrutiny and pressure. However, the majority of practices are still financed and reimbursed by more traditional ways of developing and financing general practice accommodation. NHS property services have their own capital budgets and may improve their premises in conversation with the GP practice. This in turn could have effects on rent reimbursements and service charges. With the former, the PCO and District Valuer will have to be involved as the rent reimbursement could be affected.

Rented premises – leasehold rent reimbursement

Practices that rent their premises have their rent reimbursed by the PCO to a level known as the leasehold rent reimbursement. When a practice rents a space for providing services, they need a lease in place whether it is NHS property services or a private landlord. The level of leasehold rent that may be granted is determined by the current market rent (CMR) of the premises, or the actual lease rent, whichever is lower.

The CMR value of the premises is as assessed by independent valuation conducted by the district valuer, who must determine what might be reasonably expected to be paid for the premises.

The CMR is assessed based on notional lease terms, which assume a 15-year term tenant internal repairing obligations with the landlord responsible for external and structural repairs and insurance.

The CMR is reviewed by the district valuer every 3 years. But it is important that practices keep a track of this and make certain that CMRs are carried out every 3 years, in order to ensure adequate funding.

Rates are also reimbursed. VAT is included. Under regulations now in force, PCOs must continue funding notional rent at the current level but are not obliged to meet any increase, although in practice they do. It is vital when signing leases with a private landlord or health and social care landlord that the rent payable to them matches the rent re-reimbursement from NHS England. Otherwise the practice will have to pick up the difference. It is important that when signing a lease, appropriate legal and surveyor advice is obtained. The NHS premises directions allows reimbursement of these costs to certain thresholds. It is important to contact the PCO in advance of such dealings.

Personal Medical Services (PMS) practices may have their rent reimbursement rolled up within their contract and they need to check that an annual uplift is included. In this case opting for a 3-year review means taking this notional rent element out of the contract, which may be disadvantageous. Practices will have to decide whether or not to take the risk. A private landlord or health and social care provider may have their own capital budgets and may improve their premises in conversation with the GP practice. This in turn could have effects on rent reimbursements and service charges. With the former, the PCO and District Valuer will have to be involved as the rent reimbursement could be effected.

Doctor-owned premises – notional rent and cost rent

If a practice owns their own building, they still get rent and rates reimbursement, as if they were renting the property. This is called notional rent. This rate is worked out in the exact same way as leasehold rent reimbursement. There is also the cost rent scheme which essentially combines notional rent and improvement grant funds. Under the now almost defunct cost rent scheme, loans are available from the PCO to fund building or substantial alteration of practice premises. The owners receive a reimbursement from the PCO, in the past from an earmarked fund. As with notional rent, the reimbursement is based on an evaluation and reviewed every 3 years. The cost rent takes into account the actual building costs of the premises to a level agreed, i.e. it will cover building an extra room for a registrar for a training practice, but will not cover speculative needs. This means that a practice that anticipates growth will almost certainly have to look elsewhere to fund space that it cannot currently demonstrate that it needs.

Cost rent may cover not only the land and the building, but also external work on the site, architects’, other professionals’ and local authorities’ fees, and exceptional costs, e.g. those related to demonstrating that a site that had previously been a chemical factory no longer poses a danger to health. Cost rent will not cover furnishings and furniture, equipment, garden landscaping or insurance premiums.

Even if a PCO awards a practice a cost rent, it is unlikely to fund the full cost of the project.

Cost rent is reviewed every 3 years by the District Valuer. As with notional rent, PCOs must continue funding cost rent at the current level but are not obliged to meet any increase.

As rents rise, the notional rent on cost rent-funded premises is likely to exceed the cost rent, and at that point the practice can opt to have the notional rent reimbursed. However, it cannot switch back if the notional rent then falls.

The cost rent scheme was very attractive to doctors because it provided a largely interest-free loan for the purchase of premises which would almost certainly accumulate substantially in value by the time they came to retire and sell their share. However, since the cost of land and property has increased dramatically over recent years, the cost rent scheme is no longer as popular with either GPs or PCOs.

NHS LIFT (England only)

LIFT (Local Improvement Finance Trust) was established in 2001 to enable private and public partnerships to improve premises within primary care. The PCO carries the risk of LIFT financing but this means that the doctors have no long-term investment in the property, and they do carry the risk that the notional rent will be higher than the PCO is prepared to meet. For better or worse, they may find themselves sharing a building with other primary care services. It is also possible that private companies that form part of LIFT consortia may wish to use the premises to provide Alternative Provider Medical Services (APMS).

Local LIFT projects are intended to build and refurbish primary care premises, which they will own and then lease out to GPs and other primary care stakeholders. It is suggested that LIFT will help address the underinvestment of the last 30 years or so within NHS estates.

This provides a major opportunity for some GPs who may be working out of cramped, poorly maintained premises, particularly those working within the inner cities where it can be difficult to facilitate changes, with the knowledge that they have the security of the support and expertise of their PCO behind them.

Before committing to a LIFT proposal, practices might consider the following points, particularly if they own their current premises:

Some of the answers to these questions will be obviously apparent; however, some will require thought and direction. Moving premises is particularly traumatic, whoever is footing the bill.

That aside, LIFT will provide many GPs with flexibility and may attract GPs in deprived inner-city areas. The projects may also provide more integrated services and space for developing primary healthcare teams.

Practices considering LIFT are strongly advised to seek independent advice to ensure that their interests are protected.

Private finance

There are a number of finance companies that offer finance for premises. They will take the hard work out of a building project, helping to find the land and managing the project.

Such companies will be intending to make a profit from the building, and the terms of the practice’s lease need to be carefully scrutinised. In addition, the company may wish to go into partnership with the practice in the provision of services. Practices looking for funding through such organisations should ask themselves the same questions as those considering a LIFT scheme. Practices are strongly recommended to engage independent advisors to clarify what the benefits and risks of a joint venture would be, and to protect their interests.

Some GPs may be able to fund new or extended premises themselves, although they carry the risk that the PCO will not fund the notional rent to an affordable level.

Improvement grants

Some PCOs have a source of money to fund modifications or extensions to upgrade existing premises. It is essential to apply to the PCO before starting work. Applications for work that has already been contracted for will be refused.

Improvement grants may cover additional rooms, enlarging rooms, extending telephone systems, improved access and facilities for the disabled, improvements to help children and the elderly, and improvements to such things as toilet facilities, fabric, car parking and security. As stated previously, PCOs/CCGs are less likely to fund such grants due to current financial constraints, and more likely to help in an ETTF bid.

Fundraising

Fundraising and donations from patients and others will not fund a new build, but in a reasonably affluent area may provide money for refurbishment and also provide the community with a worthwhile project.

Financing new premises in Wales and Scotland

NHS LIFT does not operate in Wales or Scotland. The Welsh Assembly has earmarked capital for premises development. Practices should contact their Local Health Board (LHB) for advice on arrangements, which are said to be flexible, and information on how to apply. In Wales all new buildings have to be approved by the Welsh Design Council. In Scotland the Scottish Executive passes funds for premises to each Health Board, which decides its priorities. Applications should be made to the Health Board.

For further information on funding of premises in England see https://www.bma.org.uk/advice/employment/gp-practices/premises.

Consulting rooms

Many GPs spend more time in their consulting room than they do at home, so it is no surprise that consulting rooms reflect their owner’s personality with photographs, certificates, mementoes, dying plants and clutter. But the pressures on space mean that no room can remain unoccupied for long. Hot-desking is here to stay. GPs being able to modify their personal space has to be balanced with CCQ requirements such as infection control.

Consider how the following will be accommodated and what facilities each will need: GP partners; sessional GPs; GPs with a special interest (GPwSI); trainees; Foundation Year 2 (F2) doctors; practice, district and specialist nurses; health visitors; health care assistants; counsellors; psychologists; visiting consultants; drug workers; housing, benefits and other advisors; dietitians; podiatrists; physiotherapists, etc. Some practices like uniformity of rooms in terms of equipment and forms, so that any clinician can go to any room and feel comfortable to practice without having to look for things.

Will there be separate examination rooms?

Waiting area

Consider both the number of consulters and how long their appointments are. A children’s play area is space-consuming but sanity-saving. Ideally the waiting room could be used for patient meetings.

Music in the waiting room

Background music in the waiting room may be good for patient and staff morale, and it can help confidentiality by masking conversations and telephone calls. It also has the capacity to annoy. Many practices also have TV screens in the waiting areas for the same reason, either showing normal TV programmes or content to improve people’s lifestyle with public health messages.

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Who chooses the music? A patient complained about the easy-listening music Parkwood Practice played in the waiting room. Why should she have to listen to music she disliked? The practice discussed the complaint. Receptionists pointed out that they were listening to the music all day and not just for half an hour or so. The practice decided to play light classical music with some easy listening music at quiet times and children’s music during baby clinic. The occasional patient who complains is told ‘We do not take requests for music’.

Practices need a performing rights licence to play music, whether via a radio or CD, or a TV licence to use a television, in the waiting room. The charge is payable annually and is related to the number of seats. The licence costs 50% more if you apply retrospectively. Extra charges apply if you use music in any other capacity.

For information see the Performing Right Society at https://www.prsformusic.com/

Reception area

Ideally this should include a privacy booth. If that really isn’t possible, consider where receptionists can take patients who need to speak in private.

How will patients book in? Will there be an interactive screen?

How will information be conveyed? Will there be an LED or similar display and where will it go?

How will patients be called for their appointments? Will they be collected by the consulter, informed by receptionists, or will there be an electronic system with a board? If the latter, where will it go?

Telephone/receptionist administration area

Only in the smallest practice can a receptionist be dealing face-to face with patients as well as answering patients’ calls, and even then ideally the two functions should be physically separate for confidentiality reasons. A back area out of patients’ hearing with telephones and adequate space for paper notes is essential.

Practice manager and administration area

The practice manager’s room should be close to staff involved in IT, administration and secretarial functions.

IT and telephones

Servers need appropriate space, i.e. secure and cooled. What will be the IT and telephone requirements of each room?

Meeting rooms, coffee rooms, libraries

Staff need somewhere to relax, preferably with an adjacent kitchen. The practice can decide whether a telephone is essential for a coffee room or an abomination. A room for meetings is highly desirable and ideally needs to be large enough to accommodate the whole team. The move to electronic information means that the practice library is losing its importance.

Toilet facilities

Essential for patients and for staff; remember that both groups may include someone with a disability. A toilet near the treatment room for providing specimens, possibly with a hatch for delivering the specimen pot, is desirable. Are the toilets DDA (Disability and Discrimination Act) compliant?

Disposal of waste

A sluice, an area for cleaning of clinical equipment, and space for bins for disposal of clinical and non-clinical waste should be available.

Storage

It is easy to skimp on storage space and regret it later. Adequate space is needed for:

Prams and buggies

Where will parents be able to leave these when they attend clinics?

Parking

The availability of private and/or public car, bicycle and perhaps motorbike parking needs to be considered.

Other

A shower, and a garden for use by staff and perhaps patients, could also be provided.

Room sharing and hot-desking

As practice teams increase in size, most practices sooner or later find there is pressure on space and that rooms have to be shared.

Well-entrenched doctors (and nurses) may resent the intrusion on what is often a very personal space, and may not be aware how difficult it is for someone else to use a room that they have moulded to their own habits. They do not realise that for other doctors who use their room, finding the tools of the trade is an exercise in industrial archaeology. The resulting wasted time and enforced underperformance is a risk for patients, for the clinician and for the practice. Nor is it just other doctors who are at a disadvantage. A cluttered room piled high with papers does not provide the right atmosphere for a counsellor, and every user needs space to write. Patients, too, are put off by untidiness.

Room sharing has potential for stirring up resentment and this needs to be managed tactfully. Room owners resent having to move out before they have finished their day’s work and the visitor can be faced with having to dislodge the incumbent and then tidy up, leading to a late start. Untidiness is hard to cure. Obliging partners to use one anothers’ rooms for a morning can be a salutary exercise.

It is essential that any potential user of a terminal can access the computer system through a personal log-in. Much time is wasted getting people onto the system.

Ideally, the tools of the trade are in the same place in each room, e.g. speculums in the same drawer under the examination couch, medical certificates in the same desk drawer. It is easier to set this up in new premises than it is to institute reform, but a desk-tidy with essential forms in each room, kept filled, is a start. Consider drawing up a list of forms, directories, equipment and information which should be available in every consulting room (ask a locum for help). If all users are given the list and asked to identify missing items, and the form is then given to someone with responsibility for restocking, much time is saved and visitors, both clinicians and patients, will have a better opinion of the practice.

Clinicians or administrative staff who have to use different rooms can be provided with portable filing boxes in which to keep their personal equipment/files. There needs to be space for these to be stored when the owner is not working. However, most practices are moving towards paperless systems, with online folders and intranets for clinicians to keep their paperwork.

It is important that one person is responsible for allocating rooms and that they are kept informed by the practice manager and visitors themselves as to who will be in on each day so that they can plan and identify days when personnel look like exceeding space available.

Consider a reminder notice to everyone to leave a room in the state they would wish to find it.

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Before you leave this room, please • close down the computer • leave the room tidy • return equipment • clear away used cupsdo not leave patient-identifiable paperwork in the room

Hot-desking

Most practices have a broom cupboard that ends up being converted into a work space. Rather than condemn the registrar or locum to a third-rate working environment, consider using it as a ‘hot-desk’ for administrative tasks. A computer terminal, a phone, decent lighting, and a booking system for the space are essential.

The Equality Act 2010

The Equality Act 2010 gives disabled people rights to:

Definition of disability

The Equality Act 2010 defines a disabled person as someone who has a physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on their ability to do normal daily activities.

For the purposes of the Act, long term means the impairment has lasted or is likely to last for more than a year. For further information see https://www.gov.uk/guidance/equality-act-2010-guidance

How does the The Equality Act 2010 apply to general practice?

Making ‘reasonable adjustments’ includes:

Practices are also required to take reasonable steps to tackle physical barriers to the use of services, including features of premises, like steps or narrow doorways, that prevent, or make it unreasonably difficult for, a disabled people to access their services. Examples of reasonable physical changes include:

Exactly what individual practices need to do will depend on their particular situation and the needs of their disabled clients.

What action can a disabled person take?

A disabled person who feels he or she has suffered discrimination has four options:

Building regulations and access for disabled patients

The building regulations made under powers provided in the Building Act 1984 exist to ensure the health and safety of people in and around all types of buildings (including domestic and public buildings). Part M of these regulations deals with access and facilities for disabled people. Until recently their aim was that all new buildings must be accessible to and usable by disabled people. An improved version of Part M came into force in May 2004 that extended the provisions to alterations on existing buildings and introduced the concept of access and use for all – not simply for those with recognised disabilities.

Further information can be found at:

Disability Rights Commission http://www.drc.org.uk

Building regulations – government guidance as part of the DDA 2005: http://www.legislation.gov.uk/ukpga/1995/50/part/III

Defining the existing problems

Practices generally become very adept at making the best of what they have and it is often not easy to quantify other than the most obvious problems. Even these will vary in importance amongst those using the building, but deficiencies and priorities must be agreed. Once this has been done the scale of the problem will become evident, and whether it can be solved by a small extension or alteration, or whether major reorganisation, major building work, or even new premises are needed, may become apparent.

For help defining the problem see ‘Accommodation’ earlier in the chapter.

Speaking to the PCO

It is never too early to speak to the PCO about your problems and aspirations. They will advise on your likely priority for any available funding and explain the pros and cons of the various schemes.

The PCO may also be able to help you with finding the professional advice that you will need. They may know those architects who have experience of survey work and a proven track record of client satisfaction within your area. The PCO is unlikely to be willing to recommend a specific architect, but they may well be prepared to provide a short list.

Finding your architect

Finding the right architect is a key factor in the building process and one that requires time and careful consideration. An architect’s previous experience of surgery work is important, but the personal recommendation from previous well-satisfied clients is invaluable. A suitable architect will be willing to show you examples of their work; ideally, you should visit the architect, who will be able to explain how and why a particular design evolved.

Your prospective architect will normally be happy to meet and discuss the scope of the project without charge and then make a proposal to you with regard to an appointment. This should clearly set out the scope of the architect’s work, the responsibilities of each party and the proposed fee basis. If more than one architect is approached, then it is very important that the proposals and fee bids are carefully compared and, if necessary, brought into line before the formal appointment is made.

Briefing your architect

Your architect is trained in establishing a brief of your requirements and will help and guide you through the most important of stages, but it demands considerable input from the practice. If the brief is wrong the building design will be wrong.

Arrange for one or at most two members of the practice to brief the architect, and ensure that they have the time and authority to make decisions for the practice as a whole. It is important that the practice representatives have consulted and engaged with all practice staff, so all issues are picked up early. Briefing will normally take the form of questions and answers that are likely to stimulate the need for deep thinking by the practice before final decisions are made. Stress those issues and requirements that are most important to you, but where you are able to leave the architect with design freedom, do so.

Feasibility

Once the brief has been established, your architect will normally consider the feasibility of your requirements in terms of the physical limitations of the site or building, the Local Authority’s Planning Policy, financial constraints, etc.

Almost every practice looking to expand will, quite rightly, first consider the potential of their existing premises. One fundamental advantage is the very fact that you are ‘established’ both in terms of your patients and in terms of the Planning Authority (i.e. you will not need permission for any change of use, only for any building extensions or alterations). On the other hand, the fundamental disadvantage is that all building work has to be carried out while you continue to practice. The feasibility assessment will need to look at whether your requirements can be achieved and also whether the design can be such as to allow phased building work in and around a functioning surgery. If necessary the PCO will normally fund temporary accommodation on the site, but space needs to be allocated and its best use determined.

If a new site for building is being proposed, the architect will be considering some or all of the following: its location in terms of your patients; whether the local authority is likely or unlikely to grant planning permission for a surgery on the particular site; whether the site is of suitable size for the surgery and the required on-site car parking (minimum parking standards are normally dictated by the planning authority); whether any gradients on the site will adversely affect design; generally, to determine the feasibility of the client’s requirements on the particular site.

If the practice is considering the conversion/adaptation of an existing building (other than their present surgery) then the feasibility study will take a similar form but also consider the potential (or lack of potential) of converting and, if necessary, extending the building. In this instance the study needs to extend into ‘preliminary designs’ to ensure that satisfactory design solutions can be found at economic cost and to prove that one available building is more or less suitable for acquisition than another.

In all instances the architect will try to give you some guidance on likely building or conversion costs, but do remember that at this early stage they are going to be no more than ‘guestimates’.

The likely time scales should be considered as they become increasingly important as PCO funding is geared more and more to the financial year. Do remember, however, that there are many time factors that are impossible to quantify accurately (e.g. the length of time to obtain planning permission).

The feasibility report should also consider the likely need for other professional consultants such as quantity surveyors, structural engineers, etc.

Your architect will normally make a comprehensive report for you and provide guidance as to the feasibility of your requirements. Options that are open to you will be explained and recommendations made.

Just occasionally, the site or building is so perfect that there can be confidence to proceed knowing that your requirements can be met; more usually, the report will show where compromise may be necessary, or where there are very real problems to be overcome, or where the site/building must be considered unsuitable.

Land and building acquisition

If your expansion involves the purchase of land and/or buildings, you will need further professional help, e.g. solicitors, commercial surveyors, valuers. If existing buildings are involved, you will need structural surveys, etc.

Before becoming committed to these, the practice needs to be certain that the project can become a reality.

Outline proposals

While some of the foregoing is under consideration, the architect and other consultants are likely to be preparing outline proposals. This will involve a more detailed analysis of the client’s requirements and ‘fine tuning’ of the brief. The proposals will take account of premises costs directives; further guidance from the PCO; preliminary discussions with the planning authority; possibly discussions with local amenity societies, residents, etc. The outline proposal will normally take the form of preliminary drawings, sketches, and a report including further approximation of costs, and will be presented to the practice for comment and/or approval.

Scheme design

The architect and other consultants (where appointed) will develop the scheme design from the outline proposal, taking account of amendments requested by the practice. The scheme design will illustrate the size and character of the project in sufficient detail to enable the practice to agree the spatial arrangements, materials and appearance. An approximate cost estimate will be prepared and an indication of possible start and completion dates advised. The proposals will be submitted to the practice for comment and/or approval.

Planning application

Once a scheme design has been approved, the architect will advise with regard to the necessary planning application. At its simplest this may be to seek permission for a small sympathetic extension to an existing surgery where the application involves little more than form-filling and the submission of plans. At the other extreme may be a planning application for a large new building on a sensitive site. Your architect will have advised earlier of the ‘degree of difficulty’ in obtaining full planning consent and will now advise on how the planning application is best presented.

Hopefully, planning consent (normally with conditions) will be obtained – but can never be guaranteed. If a refusal is given, a document stating the reasons is issued by the Planning Authority and urgent discussions are necessary in order to review the situation. An appeal procedure is possible but can be lengthy and expensive.

Detail design

The design will now be developed and approval sought under Building Regulations, etc. During this stage there will be very close liaison between the designers and the practice to ensure that the completed building contains services, fittings, fixtures, furnishings, etc. to suit.

Involving staff

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Example A practice decided to save money by not putting a floor in the roof void. Within two years they were short of storage space and found that boarding the roof void cost much more than they had saved by not doing it during the build.

Involve your staff from the very beginning so that they have a feeling of ownership of the new premises. Like moving house, moving workplace is a significant life event, and staff who do not feel involved will take the disruption and change in working patterns much less comfortably.

Staff know what their working needs are. Discuss the facilities and layout of the proposed building and incorporate staff members’ views into the architect’s brief.

Staff should be involved in discussion of furnishings and furniture and should have a major say in the layout and colour scheme and style of their room.

Keep the plans up in the coffee room and keep staff updated on the progress of the building. Arrange a tour for them when the building is ready.

Remember that moving is very stressful and depends on staff goodwill. Reward them appropriately.

Involving patients

Patients need to understand the reasons for the new build (it may be obvious, but it may not; they will not necessarily be aware of the demands of modern general practice).

Discuss the scheme and the plans with patients, perhaps starting with the Patient Participation Group and see if they come up with any good ideas. In particular, the waiting room is the patients’ domain. They have to sit in the chairs and look at the walls; find out what views they have on furniture and colour schemes.

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Examples of patients’ contributions to new premises When planning permission was refused for new premises, a patients’ group lobbied the council and the decision was eventually reversed. Blind and deaf patients were invited to advise on patient call arrangements for new premises. Disabled patients tested out all the facilities at the earliest possible moment, and as a result minor improvements were made before the building opened. Builders leave the outside space tidy (hopefully) but not beautiful. Patients at a practice with new premises donated plants and set up a rota to tend them. Patients made curtains for the waiting room and consulting rooms, including curtains for the examination couches. Elderly and disabled patients were invited to try various chairs to ensure that the seating in the waiting room was comfortable for them. A patient who ran a pet shop donated a fish tank for the waiting room and gave advice to the patients who formed a rota to care for it. New premises often have a lot of empty wall space. Patients at one surgery donated artwork. The practice ensured that all items were of sufficient quality, framed and suitable for display, and that practice staff could live with seeing them every day. A patient who was a keen amateur photographer kept a record of the building process and was on hand to record the move, which provided the practice with valuable and sometimes amusing memories. A patient who baked cakes for the removal day was gratefully remembered ever after.

Explain how the practice services will be affected by the move to new premises and beg patients’ understanding during the settling-in period.

Production information

The design team will be preparing production information from which builders will tender and eventually build.

Tender action

Your architect will normally agree with you a list of prospective building contractors who are to be invited to tender, and any information that you can provide will be useful, particularly if the architect is working outside their local area.

When tenders are received, the architect and/or quantity surveyor will make a report to you giving an analysis of the tenders received; this will normally include details of the offer, start and completion dates, etc.

Hopefully, the tenders received will be within budget but, if not, appropriate reductions may need to be made or further funding considered.

Project planning

The architect will advise on the appointment of the contractor and on the responsibilities of the practice, contractor and architect under the terms of the building contract. The formal contract will be prepared for signature by both parties.

Operations on site

The architect will administer the terms of the building contract during operations on site and will visit the site as appropriate to inspect the progress and quality of work.

The appointed builder will take possession of those areas being made available, either the whole site or parts of an occupied building, on a stage-by-stage basis. If the project involves a new building or adaptations and extensions of unoccupied premises, then the practice’s involvement may be limited. If the project involves alterations and extensions to the existing surgery, then there will be much involvement and some of the following may be helpful:

Completion

The completed building will be formally handed over to you and normally there will be a 6- or 12-month defects liability period, according to the contract, during which time the contractor will be responsible for any necessary remedial work.

The architect will make an inspection at the end of the defects liability period and instruct the contractor to carry out any remedial and corrective work.

On satisfactory completion the architect will issue the final certificate for payment based upon the agreed final account. The building contract is then concluded and all that may remain is to provide final documentation to the PCO, accountants, etc. Hopefully, by this time, the project will have proved to be a complete success.

The preceding paragraphs have assumed that practices needing to build new premises will take on both the project management and the financial burden of such a scheme, and although there is likely to be a long-term capital incentive, some practices may wish to consider the other options available to them. These may be of interest to those affected by deprivation, negative equity, recruitment problems or those that are no longer working within a traditional partnership arrangement.

Moving premises

Do not underestimate the emotional, financial and organisational cost of the move, or the time it will take. However cramped and unsuitable the old building, staff and patients may have strong sentimental attachments to it, and the inevitable problems of the new premises can induce the feeling that the past was a golden age which the present can never match. Preparation is vital in order to minimise the disruption and distress.

Re-establishing normal service

Consider longer appointments and shorter surgeries as everything will take longer at first.

Receptionists should remind patients who are booking appointments that the practice has moved.

Check that routine tasks are being carried out.

Keep a log of problems and comments to which all staff contribute.

Keep morale up as much as you can.

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Example Three days after moving premises a practice discovered no-one had backed up the computer. The practice manager realised that staff were so occupied with settling in that a number of routine tasks had been forgotten.

The elements of maintenance

An annual detailed property survey should be carried out to cover all items that may require maintenance, from tap washers to the roof. This should be undertaken by an appointed representative from the practice and either a professional maintenance organisation (if funding allows) or a skilled handyman. If using a contractor you should ensure that they submit an itemised and priced list of works to the practice for approval and an order, prior to any work commencing. The list should include relevant points under the following headings (please note – the following lists are not exhaustive and there will be local variations according to the type of premises that the practice occupies):

Types of maintenance

Responsibility for maintenance

It is necessary to appoint a senior member of the practice team to be responsible for the maintenance of the building, and a deputy to cover their absence. The appointment in itself will raise the profile of the task, and their job description should include:

Manager’s maintenance checklist

Risk assessment

Risk assessment must be carried out by the responsible person and will involve a comprehensive assessment of fire risks to which people may be exposed. Special considerations should be given to people deemed at special risk, such as young people, the disabled, and perhaps pregnant women and the infirm.

You should also include:

Your PCO has a responsibility to ensure that all practice premises are fit for their purpose, and as such may be able to support you with your assessment by either recommending a competent person to carry out the task on behalf of practice or by providing resources – perhaps in the form of training – to allow one of your team to develop competencies. Your local fire safety officer may also be prepared to offer you advice on the matter.

If the assessment does fall to you, however, it is probably a good idea to design a specific questionnaire to aid your assessment.

Examples (although by no means conclusive) of appropriate questions to support the assessment are as follows.

Practice fire team

Allocating specific roles to staff and training them properly minimises the damage of a real fire. The fire officer, with overall responsibility for fire prevention and training, is generally the practice manager. A fire marshall is trained to take overall control in the event of a fire, and staff are given responsibility for specific tasks such as calling the fire brigade, collecting the fire wallet, ‘sweeping’ allocated areas of the building and reporting to the person assigned to take the roll call.

Fire drill

Practices should hold a full-scale fire drill once a year plus give all staff a general talk on fire precautions. All new staff must receive training about fire safety and procedures, including being walked round the building. The procedures should include:

what to do if you discover a fire

what to do if you hear the fire alarm

where the emergency exits are located

means of raising the alarm

means of contacting the fire brigade

assembly points

identification of people with special responsibilities in fire situations

roll calls

regular testing of equipment and procedures

procedures for people at risk, i.e. the disabled.

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Example A practice manager asked the team to say where the fire extinguishers were and which type should be used for what sort of fire. Not even the doctors had a clue.

The practice fire drill should be as realistic as possible; the least number of people should know beforehand. Fire drills can be stressful, and someone should be designated to help any sick people who are in the surgery at the time to minimise their discomfort.

Introduction

Doctors’ surgeries have always been a target for burglary because of the drugs and prescription pads that may be kept on the premises. The value of surgery equipment is rising as primary care becomes more technical and practices purchase computers, video equipment for teaching purposes and ECG machines. This increases the burglary risk.

Personal security has always been a concern for GPs and practice staff. We have to remember that patients visit GPs when they are often vulnerable, stressed and anxious about their health. GPs and staff can be the subject of abuse and sometimes violence.

Security of practice premises and personal safety and security are important issues for managers and GPs to consider.

Security of practice premises

There are three important areas:

When considering security it is worth getting advice from the local Crime Prevention Officer at an early stage. He works from the local police station and he will visit the surgery. His advice is free. If a new building is planned, the Crime Prevention Officer should be contacted at the planning stage.

Burglar alarms

The presence of a burglar alarm will act as a deterrent to burglars, and the box advertising the alarm on the outside of the building should be placed prominently. If a burglar enters the premises a flashing light will alert the burglar that the alarm has been activated. A loud alarm is also sounded, the noise being so loud that it is physically unpleasant to remain in the building. Some police forces insist that the noise does not begin until some time after the alarm is activated to increase the chance of arrest; this does, of course, increase the time that the burglar has to work.

Most alarms in use in surgeries have a digital communicator, which transmits a message to a monitoring centre, informing them that the alarm has been activated. The monitoring centre is usually managed by the company that supplied the alarm. The monitoring centre will telephone the premises during office hours to ensure that the call is not a false alarm. The police and a keyholder are then informed. Each alarm will have a code word to ensure security, and keyholders or receptionists who may answer the phone during the day should know this. Out of hours, it is always worth the keyholder checking with the monitoring centre that the call is genuine, before attending the premises.

It is possible for digital communicators to handle other channels, for example fire alarms.

A system without a digital communicator is cheaper, but will need to rely on its deterrent effect and the goodwill of neighbours to inform the police if the sounder is activated.

There are two basic types of detection equipment for burglar alarms:

A combination of both is ideal.

Security of access

A number of questions need to be considered:

As always, there will need to be a compromise between allowing free access to staff and patients and keeping out people who should not be on the premises. Doors that are available to patients but should only be accessible to staff can be controlled by a lock to which only staff have a key, or a lock with a key pad and security number.

the National Security Inspectorate (NSI) (www.nsi.org.uk)

(With thanks to Ivor Allen of Chubb Alarms Limited for help with the preparation of this section.)

Personal security

There are two major causes of aggression in the surgery: anxious patients and those who have been kept waiting. Therefore, there are a number of ways in which violence may be prevented or minimised:

Procedures for handling violent situations should be discussed beforehand. The following should be considered:

Extended opening hours

With increasing numbers of practices offering extended surgery opening hours, the security of your staff and premises will be at risk if they are not managed appropriately. It is suggested that access arrangements during extended hours are limited to those patients with pre-booked appointments, and that access to the premises is controlled from within by the receptionist when he/she is sure that the person requesting access is who they are expecting.

Lone working

There may times when clinical staff or admin staff may be alone in the practice. This will normally be after the practice shuts, but could be in practice time, for example in a small branch surgery.

Staff working alone must be suitably experienced, have received suitable instructions and, if necessary, had training on the risks they are exposed to and the precautions to be used. The general principal is that a staff member should not open the main doors and allow a patient to enter the practice until another staff member (clinician or non-clinician has arrived).

Some staff may have medical conditions that could make them unsuitable for working alone. This aspect of the assessment is conducted through Occupational Health.

Consideration will be given to routine work and foreseeable emergencies, which may impose additional or specific risks.

The practice manager should ensure adequate supervision in lone worker situations. Adequacy of the supervision will depend on the level of risk, types of risk and duration of exposure.

Adequacy of supervision may involve some of the following:

Remote working

Most GPs will do home visits on an emergency or routine basis. In addition, practice nurses may visit patients who are housebound for the purpose of flu jabs and long-term condition checks. The security and safety of these clinicians should have the same parity as in practice working. Having clear lone worker policies and appropriate risk assessments is important.

In the vast majority of home visits, there will be no risks to the visiting clinician. However, in a minority of cases there could be risk (i.e. physical or emotional) related to the context of the patient. Such examples include areas of severe mental health issues, forensic history, domestic violence and drugs, known aggression, drug and alcohol problems, or house environmental factors. This is not an exhaustive list, and it is the responsibility of the visiting clinician to review the medical records and alerts of the index patient prior to visiting that patient, to identify any risks.

The clinician may deem it necessary to take a colleague to the home visit (this may be a clinician or non-clinician). Reasons for this may include needing a chaperone for an intimate examination, providing extra safety in walking from the car to the patient’s home on winter nights, requiring an observer during the consultation itself.

However, taking a colleague in itself does not provide extra protection if there is genuine risk involved, and in fact it may lead to two staff members being put at risk.

If there is genuine risk established, the clinician should consider contacting the relevant statutory agencies to accompany them on a visit. For example, if there is genuine physical risk, the clinician should consider contacting the police to ask them to accompany the patient on the visit. If the house is not safe due to contamination, animals, structural issues, etc., the clinician should contact the environmental health department at the council.

Where a clinician perceives that a home visit may be inappropriate for personal safety reasons, after the above options have been exhausted, then this concern should be raised with the practice manager.

It should be the responsibility of the clinician to consider and identify an alternative means of delivery of the service to the patient.

Staff may decline to make a home visit where:

Other aspects of the visit may cause concern, for example:

Questions when developing a policy include:

Controlled drugs

See Section 10.

Prescription pads

All prescription pads must be kept in a locked cupboard or drawer. This includes the prescription pad currently in use on the doctor’s desk, and unfilled computer prescriptions.

As well as securing prescription papers, whether blank for computer-printed or pre-stamped for hand-written prescriptions, they should be tracked by serial number. If some prescription paper is placed in a printer in a room, the serial numbers of the first and last prescription paper should be documented, as well as the date and location of the printer. Similarly, if a pre-stamped prescription paper is given to a specific GP, the name of the GP it was given to and the serial number should be documented. The tracker can be on the practice intranet or be paper based. A member of staff should be allocated to monitoring this. This means that if there is theft, the NHS protect service can track the prescriptions. Further information (CQC myth busters) can be found at https://www.cqc.org.uk/guidance-providers/gps/nigels-surgery-23-security-blank-prescription-forms

Dispensing practices can stamp dispensed prescriptions ‘DISPENSED’ to prevent them being used a second time if stolen.

Patient notes

The sight of paper patient notes may attract someone to break in, but paper notes are more likely to be the focus of incidental vandalism during a burglary. Destroyed notes are irreplaceable and scattered notes will be time-consuming to reassemble. To maintain patient confidentiality and trust it is essential that patient records are kept securely. As a general principle, think about security at all times:

Electronic records

What can general practice do about climate change?

A new threat is likely to have an overwhelming effect on our health and wellbeing, and therefore on doctors’ work, over the next decades – climate change. Yet the NHS, the UK in general and the rest of the world are only just beginning to address the problem. This section explores how practices will have to react to the consequences of climate change and the steps they can take to reduce the damage. The challenge is enormous but low-carbon actions pay off, both financially and in health gains. And the earlier we start acting, the more we stand to gain.

UK government, the NHS and climate change

The NHS is the largest public sector organisation in the western world and the UK’s largest public sector contributor to greenhouse gas emissions.

The NHS is committed to reducing inequality, and climate change disproportionately affects the poor and the sick, who cannot afford to insulate themselves against its effects. Low-carbon policies pay off with significant benefits to the health of the public. The NHS has set up a Sustainable Development unit and developed a carbon reduction strategy in 2009 (see https://www.sduhealth.org.uk/policy-strategy/engagement-resources/nhs-carbon-reduction-strategy-2009.aspx).

Clearly, hospitals are inefficient and there is huge waste, not just in heating and powering equipment, but of food, medication, equipment (increasingly ‘disposable’), unnecessary consultations, transport, use of paper and failure to recycle. Primary care, being at the ‘low-tech’ end of the NHS, has fewer big wins; but there is a lot that can be done, and it is in a position to advocate and to set examples to patients and other organisations.

Why is climate change a matter for GPs?

Where does climate change stand in general practice’s hierarchy of obligations?

Each practice will have its own answer to that question, which will be influenced by government and NHS policy and incentives, by the ethical culture of the practice, and by how easy and worthwhile it is to take action. But as climate change increases costs and health problems, pressures will also increase. There are already win–wins, and those that take advantage of them will help themselves and others. But the practice’s policy and decisions need to be owned by the whole team.

Definitions

Global warming is the increase in the average surface temperature of the earth due to the increase in greenhouse gases.

Climate change is the term now preferred to describe what is happening to the planet. The warming melts the ice caps, leading to changes in ocean currents, which set off large-scale changes in weather systems. The worldwide climate is increasingly unstable, as demonstrated by the increase in extreme weather conditions and in climatic dangers such as hurricanes.

Greenhouse gases keep our environment habitable because they trap the sun’s heat. Carbon dioxide (CO2), methane, nitrous oxide (N2O) and water vapour are the main greenhouse gases. Their production and absorption were in equilibrium, but they are now being produced at twice the rate that they can be absorbed.

Carbon dioxide is produced by burning fossil fuels (coal, oil, gas) and is absorbed by forests. Fossil fuel use is accelerating and so is the destruction of forests. The major effects of CO2 are felt 20 years after its release, which is why the problem will get worse before it has any hope of getting better.

Carbon dioxide equivalence. For ease of comparison, production of non-CO2 greenhouse gases can be expressed as an equivalent amount of CO2.

Methane is produced when things rot. Rubbish dumps, felled forests and detritus of agriculture, e.g. rice and sugar cane, are the main sources. Coal mines and burping ruminants, e.g. cows, also give off methane.

Nitrous oxide is largely a product of agriculture: cultivation, animal waste and fertilisers. Manufacturing, especially of artificial fabrics, also generates N2O.

Water vapour is a naturally produced greenhouse gas, although global warming increases the air’s ability to hold water vapour, thereby making the problem worse.

Sustainable development means living within our means. That way, in the future we will have the means to live.

Carbon is often (as here) used as a shorthand for CO2. If carbon is used as the measure, the figure should be multiplied by 3.7 for the CO2 equivalent.

Carbon footprint is a measure of the effect of human activity on the level of greenhouse gases, measured in units of CO2. The NHS’s carbon footprint is estimated to be around 18 million tonnes of CO2 per annum; the average person in the UK is responsible for about 10 tonnes per annum, of which around half is personal, i.e. household fuel, transport and consumer goods, and the other half is each person’s share of the infrastructure, i.e. public services, manufacture and supply of goods. A sustainable personal carbon footprint is 2 tonnes, i.e. on average each person in the UK needs 5 planets (10/2) to sustain his/her lifestyle. Many websites offer carbon calculators for individuals, households and organisations (see below).

Carbon emissions are the amount of CO2 produced – essentially the same as carbon footprint.

Carbon neutrality is achieved when an organisation balances its carbon usage with actions that either sequester or offset the same amount of carbon.

Carbon offsetting is paying money to organisations to support activities that decrease green- house gases, e.g. renewable energy projects or planting trees. Large businesses that have a cap on their carbon production can get away with producing more if they offset it; individuals may choose to offset the carbon they use in order to be carbon neutral. Offsetting is controversial, in part because it does not encourage reduction in emissions.

Peak oil is the point in time when global oil production is at its maximum. After that point production declines, and unless usage also declines, alternative power sources will be required to compensate. As a planet, we are probably near peak oil.

Fuel poverty: at least 10% of UK households experience fuel poverty, i.e. they need to spend more than 10% of their income on domestic fuel. As prices rise and if winters get colder the percentage will increase, perhaps dramatically.

How to go about it

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Box 11.1 Health effects of climate change already experienced in Europe • The allergy season getting longer. • Tick-borne diseases and other pestilences occurring in more northerly latitudes; spread of vectors such as rats, flies and fleas. • Heat-related deaths, the very old, very young, sick and isolated being most at risk. Reduction in cold-related deaths is small and likely to be temporary. • Rates of diarrhoeal diseases, e.g. salmonella, increasing in proportion to temperature. • Air pollutants (principally ozone and particulate matter) increasing respiratory and cardio- vascular disease. • Floods, causing death, injury, waterborne diseases and psychological stress due to loss of homes and businesses. • Social stress due to migration from countries already suffering climate stress. (Mediterranean countries most affected, but knock-on effects already felt in the UK.) • It should also be borne in mind that road accidents are a result of man’s addiction to carbon.

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Box 11.2 Direct health effects that can be expected • Increase in cataracts and skin cancers due to increased exposure to sunlight/UV light. • Other pestilences, e.g. malaria, likely to spread to areas in which they were previously eliminated or unknown.

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Box 11.3 Indirect health effects of climate change • Drought leading to food and water shortage, increasing malnutrition and decreased resistance to all types of disease, increased risk of waterborne diseases (because less likely to be clean), skin conditions (no water for washing), increase in conflict. • Increase in natural disasters, e.g. Hurricane Katrina, which illustrates the many health and social consequences. • Starvation. • Diarrhoeal diseases. • Increased social conflict and migration due to pressure on resources. • Increase in armed conflict (already climate change is a factor in armed conflicts worldwide). • Crowding. • Injuries due to conflict. • Psychological stress due to uncertainty and crowding.

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Box 11.4 Barriers to action • ‘Global warming is a myth.’ Climate change denial gets a lot of media exposure, and as the problem is so big and so hard to tackle, denial probably appeals to the ostrich in all of us. In fact, no-one denies that greenhouse gases are increasing, though some deny that it causes global warming or that it is due to man’s activities. But the overwhelming majority of scientists feel that there is incontrovertible evidence that man has brought about a change in the climate that is potentially disastrous for the planet. • ‘It’s too late to do anything about it.’ Experts are divided on this, though many are optimistic that if the world implemented just seven measures already available, disaster might be avoided. But the longer we wait, the more likely it is that it will be too late. • ‘Technology will be developed that will save us.’ The general opinion is that we can’t afford to wait as every year the problem gets much more serious. • ‘I can’t make a difference.’ True, going round switching off lights at home can seem wasted effort when office tower blocks are ablaze all night. But most people want to ‘do their bit’, and GPs and their practices can not only set an example, they can pressurise PCOs, commercial companies, the NHS and government to take action and to legislate. Enough bottom–up pressure will stimulate top–down action.

Some suggestions for working in a sustainable way are outlined below. They are intended to stimulate thought rather than be prescriptive. Undoubtedly many new ideas will appear in the coming years, and sources of advice are included.

Transport

Cars are noisy, they pollute the atmosphere, they cause accidents. And in crowded city centres they don’t go any faster than horse-drawn carriages used to. Changing to walking, cycling or public transport leads to a safer, more tranquil environment. People are likely to be fitter and less obese, and probably happier and more productive.

Getting to work: encourage walking and cycling; subsidise staff use of public transport; actively support car-pooling.

Consider installing facilities for recharging staff electric cars.

Consider a practice vehicle (motorbike with low emissions or sustainable bio-fuel car) for emergency visits.

Install a secure cycle rack outside the surgery.

If the practice sees drug reps, consider asking them to offset the carbon emissions created by their visit.

Negotiate bus routes with local transport companies.

Sustrans (www.sustrans.org.uk) offers information and advice about what individuals and organisations can do to promote sustainable transport.

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Example A semi-rural practice managed to arrange a subsidised morning and evening return minibus run from an out-of-town estate to the surgery. This significantly reduced car usage.

Drugs and prescribing

Much of the medication dispensed is never taken by the patient, or taken incorrectly, so a large amount of carbon is used with no benefit to health. More patients are on multiple medications, increasing the risk of interactions and increasing the cost to the patient and the NHS. Reducing the number of prescriptions could reduce costs and carbon usage and actually improve health.

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Example An organisation held a conference to discuss how it could become sustainable. The caterer provided plates of tropical fruit, which did not encourage conviction.

Questions for staff:

How can we find out who doesn’t take the drugs as prescribed?

How can we tighten up on repeat prescribing?

For what conditions are non-drug treatments available? Exercise, often available on prescription, is a win–win alternative.

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Example – Exercise instead of drug therapy A practice made a list of conditions for which exercise might reduce the need for drugs. Among the conditions they listed were hypertension, cardiovascular disease, hyperlipidaemia, diabetes, chronic obstructive pulmonary disease (COPD), depression, anxiety, agitation (both the young and the demented), stress in all its psychological and physical manifestations, many rheumatological conditions, constipation.

National organisations concerned with climate and health

Other sources of information

Case study

The Cranberry Practice wanted to demonstrate its commitment to reduce its impact on the environment and climate change by developing a practice policy to cover areas where it felt it could make a real impact.

The key to the implementation of such a policy is to get practice-wide support for it. Try and involve as many people as you can in developing the policy. Successfully implementing such a policy is about changing people’s ‘hearts and minds’ and convincing every member of staff that they can play a vital part in reducing threats to the environment.

Feel free to use the following policy as a template for your own practice policy.

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The Cranberry Practice Environmental Policy 1. INTRODUCTION The Cranberry Practice aims to play its full part as a practice in the preservation of natural resources and in the prevention of environmental pollution. The Cranberry Practice environmental policies in regard to internal housekeeping, procurement and operational practice are set out in this document. 2. HOUSEKEEPING As a medical centre dealing with thousands of consultations a year, the Cranberry Practice’s primary product is the written word. This involves writing in medical records, filing correspondence and running a computer system. We adopt conservationist policies as described below.

Energy All reasonable measures will be taken to reduce the consumption of energy in the use of office lighting, heating, electrical and electronic equipment. The following specific guidelines will be followed: • Lights will be switched off when a room is not in use. • Energy-efficient lighting systems will be used. • Desks will be placed so as to make optimum use of natural light. • The heating system will be regularly serviced to reduce inefficiency.

Office consumables All reasonable efforts will be made to economise in the use of paper and other office consumables and to dispose of waste and used items in such a way that they can be recycled or re-used. The following specific measures will be taken wherever possible: • Waste paper will be sorted into categories for recycling, suitable paper being made available for quality recycling. • Partially used paper will be made into scrap pads where feasible. • Used files, ring-binders, etc., will be re-used. • Disposable crockery and cutlery will not be used. Continuing consideration will be given to improvements in insulation and draught proofing. • Heating systems’ temperature controls will be reduced to a minimum over weekends and holidays when the building is not in use. • In cold weather the office heating will be maintained at a level that is comfortable when wearing a pullover or cardigan. • In warm weather, blinds and open windows will be used to keep the offices cool. The use of fans will be kept to a minimum. • Electronic equipment will be switched off when not in use, unless it is required for security purposes or for the receipt of incoming information outside working hours. • Electronic equipment will be used in stand-by or energy-saving modes wherever possible. 3. PROCUREMENT Environmental factors will be fully taken into account in the selection of all regular suppliers, special purchases and leasing arrangements. Purchasers are required to include these issues in their decision making within the general policy of obtaining the best value for money. The following specific issues will be among those considered: • The ECO-labelling initiative will be made use of wherever possible. • Recycled and eco-efficient paper will be used. Recycled paper should bear the NNPM kite- mark or be guaranteed to meet the HMSO criteria of consisting of at least 10% genuine post-consumer waste. • Water-based labels will be used. The purchase of disposable products will be avoided. • The purchase of products containing ozone-depleting substances such as CFC, HCFC, halon, carbon tetrachloride and I.I.I trichlorethylene will be avoided wherever possible. Care will be taken in use and disposal of any such products that must be used, to ensure that no ozone-depleting substances escape into the atmosphere. • Over-packaging will be avoided where possible and the attention of suppliers drawn to the waste involved. • Battery-operated equipment will be avoided wherever possible. Any re-chargeable batteries purchased will have minimum levels of lead, cadmium and mercury.

4. OPERATIONAL PRACTICE In daily operational practice, all staff must cooperate in an effort to conserve natural resources and reduce pollution. The following specific measures will be strongly encouraged: • Paper will be used on both sides wherever possible. • Double-sided copying and printing will be encouraged. • Electronic methods of communication, filing and archive storage will be used wherever possible to replace the use of paper.

• Copies will be made only when required for a specific purpose: consideration should always be given to circulating a single copy rather than distributing several. • The use of individual heaters and cooling fans will be avoided wherever possible. • Standard mail services, facsimile or electronic mail will be used wherever possible rather than motorised services. 5. TRANSPORT Every effort will be made to minimise the use of cars on practice business. Public transport will be preferred wherever possible. Car users will be encouraged to have their cars regularly serviced to avoid excessive emission of hydrocarbons.