The shortcomings of the average London GP's surgery were pointed out to the Government in 1992 in a report by Professor Bernard Tomlinson: 'Forty-six per cent of premises in the four inner London Family Health Service Areas (FHSA) are below minimum standards, compared with an England average of 7 per cent . . . the difficulty of securing good quality premises lies at the root of many of the problems surrounding general practice in inner London that have been reported to us.'
Converted terraced houses or high street shops cannot offer the range of services found elsewhere in the country, he said. This type of accommodation has no room for district nurses, health visitors or specialist staff - for example chiropodists and physiotherapists - that patients now want.
Peter Waugh, service development director of Camden and Islington FHSA, says inadequate premises are 'depressing both for patients and staff'. Mr Waugh also claims that working on different levels, running up and down stairs 'wastes time and absorbs energy'. Perhaps more importantly, he says surgeries with sub-standard accommodation are unable to attract the best doctors.
The Hoxton Health Collective in north London is typical of many inner London surgeries about to reap the benefits of a government commitment to spend an extra pounds 34.5m this year (a total of pounds 170m over the next six years) on improving primary health care in London.
Housed for the past decade in a converted flat on a Hackney council estate, the surgery has around 3,000 people on its list. The collective is much in demand but the surgery's inadequate facilities means it is now having to turn patients away. Two small consulting rooms are shared between two doctors and two nurses. A chiropodist, who visits once a week, treats patients in a mobile van parked outside, while the psychotherapist sees her patients in the tiny kitchen- cum-staff room.
The collective is also one of the few surgeries in the area registered to prescribe methadone, the heroin substitute used by addicts. The waiting room has on average two heroin addicts a day waiting for their weekly prescription. They are often aggressive, but lack of space means they wait their turn along with mothers and babies. The situation, staff say, is far from ideal. Prescribing methadone also encourages break-ins. The door has been kicked in and windows smashed.
Rosa Banato, the collective's administrator, unrolls plans for its new pounds 1.7m building which will house four practices, each with a separate entrance. Three big rooms upstairs will be used for group therapies and exercise classes. In another large upstairs room the collective will have, for the first time, its own baby clinic.
In Brixton, south London, Dr Richard Williams is forging ahead with a pounds 500,000 expansion. 'Conditions were so bad patients often had to stand,' he says. 'In winter the cold water pipes periodically froze. The house was too small to house the central computer and the phone system was so antiquated that the receptionists found it difficult to run an efficient appointment system.'
Break-ins were also common and assaults on staff a worry. Doctors and nurses were sharing the four consulting rooms and there was no treatment room.
There are some discreet safety features. Anyone attempting to leap over the reception desk will receive a bang on the head from the lighting pelmet, which has been set deliberately low.
Assault-proof reception desks, alarms on all the windows and an electronic beam that protects the staff areas on the upper floors will all, in time, become standard in inner-city surgeries. So too, say the architects, will custom-designed furniture and art works.
Elegant desks that would look at home in Heal's have been designed which allow the patient to sit beside their doctor. 'Some doctors want to preserve that idea of authority,' said Dr Williams, 'but we were very keen that when we need to take someone's pulse we can look them in the eye.'
A water sculpture, which will soon be installed in the surgery's small courtyard area, will also have its practical uses. The doctors hope the splashing of water will drown conversations taking place in the consulting rooms.
There is now space to screen off a part of the reception area to show videos on a range of health problems, such as asthma, which parents can watch while their children play in a specially designed children's corner.
It is left to GPs to decide how they want to fund a building project. Many join a GP's cost rent scheme. Some rent out their waiting rooms for meetings and even wedding receptions. Others, like Hoxton Health Collective, will lease premises from a developer.
Many of the architects who are now working on improving London's surgeries talk of the need to make the buildings 'welcoming' and 'unclinical'. They frequently describe plans for desirable waiting rooms as 'light and airy' with views on to courtyards or gardens; natural materials and colours are used to provide 'warmth'. Doctors, on the other hand, say they want to break down the barriers between them and their patients, make the surgeries more secure and vandal- proof, provide better access for the disabled and mothers with pushchairs, and create communal facilities such as creches and pharmacies. Between the architect and doctor a new prototype surgery is being born.
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