NHS buildings: obstacle or opportunity?

Comments: 5
There has been little real attention given to how the NHS estate could help to improve efficiency, move more care out of hospitals and exploit new technologies. This Perspectives piece demonstates how models of care are still designed around buildings, and asks whether re-thinking the way that the NHS uses its estate could catalyse change.

This is the first in a series of four papers that aim to crystallise ideas for change in areas where, we believe, new thinking is required. Subsequent papers will focus on the health and social care workforce; use of technology; and role of patients and service users. The papers draw on ideas generated by seminars, discussions with experts and feedback from the Time to Think Differently programme.

NHS buildings: obstacle or opportunity? A perspectives piece for TIme to Think Differently

No. of pages: 8

Comments

#40658 David Pencheon
Director
Sustainable Development Unit, NHS England and PHE

Typically perceptive and well written piece by Nigel Edwards. He shows clearly, eloquently and practically how any system nowadays needs to be adaptable, flexible and nimble. Dinosaurs which expect the system to move around them will learn that survival is not compulsory. In fact this article on buildings is a metaphor for large and unsustainable systems anywhere, especially those that purport to provide a service. One of the most telling sentences is "...perhaps the
most important concern is that opportunities for new models of care are not being maximised and that existing estate is an obstacle to innovation." It suggests that innovation is about legitimising risk taking, and understanding that innovation happens when barriers (real or perceived) are removed. Innovation cannot be made a statutory duty, but one can certainly make it easier to happen, flourish and disseminate quickly. Some of the solutions to the wicked problems we face are probably already with us and being successfully implemented...somewhere. The future has already arrived - it's just a little unevenly distributed. It's a bit like looking into a starlit night. A multitude of very bright stars - but still dark, and little sign of dawn... If the NHS, the public health system, and social care system knew what it knew about how to support and enable a healthier population, with the assets already within its control, and it did it more collaboratively with shared visions, shared incentives, and shared delivery mechanisms, we really would have one of the best systems in the world. Looking forward to the next three pieces...

#40659 Nathaniel Hobbs
Director
MJ Medical

Nigel Edwards argues convincingly that a reconsideration of approach could result in significant opportunities for improvements in both care and value for money. Given that levels of investment in the NHS estate are likely to face constraints for the foreseeable future, the focus for the deployment of scarce investment should be on maximising the use and usefulness of the resulting facilities. Too many of the development projects undertaken over the last 20 years have prioritised initial capital expenditure considerations over lifetime utilisation and efficiency. In addition, models of care are all too often being design around the buildings in which they are delivered rather than the other way round

As Edwards’ report highlights, the break-neck speed of clinical best-practise and technology development means that much of the resulting design has become sub-optimal in terms of functionally. This means some of the newest parts of the NHS Estate are not fit for purpose or underutilised, thereby wasting significant amounts of resource and investment.

Flexible and responsive spaces are essential in ensuring that efficiency and delivery of cutting edge clinical care are achievable throughout a building’s lifespan. Realising these qualities in a healthcare facility’s design requires a robust approach to estate strategy development, a commitment to gathering evidence based solutions from ‘real-world’ and research sources around the world, knowledge of the direction of travel in terms of future clinical practise and technology, and an innovative and open-mined approach to translating these into a design that supports the associated models of care.

Well-designed healthcare facilities enable the delivery of an optimum quality and quantity of care, and as such exist as the primary financial asset to a healthcare provider. Poorly designed facilities inhibit the achievement of excellence and act as a financial drain. A focus on evidence-based design in the re-configuration or development of healthcare facilities can realise significant financial and quality of care returns. Herein lies the opportunity for the NHS estate.

#40675 Christopher Shaw
Senior Director
Medical Architecture

This piece summarises the outcome of the last 20 years of NHS estates well-meaning but dysfunctional efforts. It illustrates the disjuncture between a capital process and the operational and revenue impact. Standard business case procedures simply miss the point and placed in uncreative hands conspires towards the over-specified “tight fit” and inflexible health facilities we have today. What is equally worrying is the lack of effective feedback to improve the system we have.

For example in England the NHSProcure21 Framework resulted in £2-3bn of Treasury funded buildings being developed without having any idea of the usefulness or quality of the investment. All the measures were based around the success of the procurement - “on time, on budget” etc. The current successor framework is little better.

It makes you want to weep.

We need to recalibrate the NHS investment case process to be more opportunistic along the lines Nigel Edwards suggests. Sadly, I don’t think that NHS England’s Project Appraisal Unit seems to have quite the right lineage for the job.

As far as the investment model goes, we are all too aware of the shortfalls and inflexibility of PFI. However the NHS is going to have to borrow money to provide the infrastructure required to implement some of the significant structural changes currently being discussed, for example consolidation of hospitals in London. Whatever arrangement, we should assume that medical facilities need to adapt and change on a 5-15 year cycle, more like a commercial office or retail setting and closer to the equipment cycle. This implies shell and core buildings with tiered finance.

Much of the vast NHS estate assets will need creative reconsideration to adapt to Lord Darzi’s NHS Next Stage Review. Those moribund concrete framed 1970’s tower and podium hospitals that are being squeezed under pressure for efficiency are a terrific asset and often in the right place for the communities they serve. These buildings need a complete rethink whether by entrepreneurial developer or a rejuvenated NHS Property Services. Our experience of doing just this at Kidderminster is that with older buildings a “tight fit” is much less possible, flexibility easier to build in and renovation can deliver excellent long term value. Look around your local city and you will see office and housing developments / stock from the 60’s and 70’s that have been rejuvenated and are better now than it ever was.

Let’s hope this is the start of something.

#40716 Nigel Myhill
Director of Facilities

This make a strong case for a NHS Property Service for acute and FT’s. It does not examine how trusts use their assets to leverage P&L flexibility, but this is not a show stopper. As a NHS Facilities professional I am sure we will all up for the challenge so that we provide the best quality services for our patients and staff.

#40731 Fides Matzdorf
Manager, Public Sector FM Network
Sheffield Business School

An encouraging paper - sharp, no-nonsense analysis and sound ideas for the way forward. I agree with Nigel Myhill's point that it does not go into much detail about the 'how to to get there' - that would be the outcome of a different (follow-on?) report, one that would focus on examples and case studies of good practice (such as the examples Nigel Edwards mentions), with more detail and more information on the process (not the procedures!).

Some good examples should be expected from the Public Sector FM Conference in Sheffield, which focuses on new purposes for under-used, unused and redundant buildings (12 Sep) and new and emerging models for re-purposing such assets.

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