Next Steps
Paul Fenton MBE is Strategic Estates Advisor for the NHS Suffolk and North East Essex Integrated Care Board, one of the 11 Integrated Care Systems chosen to participate in a strategy pilot scheme. Following his last article for Fortis, Paul updates us on how it went
The original deadline to submit our Integrated Care System’s (ICS’s) estates infrastructure strategy was December 2023, but this was pushed back to the end of March 2024 to allow all 42 ICSs time to complete their strategies.
What we’ve learnt
Three things have come out of doing this at a local level:
- We need more information about the estate
There’s a lack of good Six Facet Survey information to ascertain backlog maintenance properly. While this year’s reported backlog maintenance figure for the NHS Estate is £11.6 billion [according to data released by NHS England in December 2023], many believe that figure is significantly more – perhaps £15-20 billion. It underlines where Trusts do not have reliable estates data and have not undertaken robust Six Facet Surveys. Therefore, Trusts may not truly understand the condition of their buildings and are reliant upon a historical ‘financial’ view of the situation rather than an informed ‘estates’ view.
We don’t have a single source of the truth for estates information. We’ve got information from the Strategic Health Asset Planning and Evaluation tool [SHAPE] on primary care estate, which often doesn’t hold much acute or mental health estate data – their information is on estate terrier spreadsheets and their CAFM [Computer Aided Facility Management] systems. There’s other information in ERIC [Estates Returns Information Collection], Model Hospital and various systems for GP assets, but we need robust information about the estate in a single, comprehensive database.
I’m amazed that some Trusts don’t know who owns some buildings, where its estate is, who occupies it, the terms and conditions of leases and the condition of it. Does it need a full renovation or is it structurally safe but needs some TLC? Supermarkets are a good example; many leading supermarket retailers know where all their stores are and what condition they’re in. The likes of Aldi and Lidl make some brilliant decisions regarding where to purchase land or old buildings to make into new stores. They hold comprehensive building information and make those decisions by looking at local development control plans, national infrastructure investment changes and where new roads and towns are expanding to construct new stores of the right type and size and in the right location for ease of access and an improved customer experience. Why isn’t the NHS doing this?
- We need closer collaboration between estates and facilities services
An acute Trust has maintenance and facilities teams, NHS property services have their teams, mental health Trusts have their teams and, if you expand it to one public estate, you’ve got local councils with their maintenance teams too. These teams often follow one another around the countryside maintaining buildings in close proximity – on some occasions on the same site! That’s not a good use of taxpayers’ money. We could save the NHS millions if we got it right.
- We need to have proper, adult conversations about where the capital goes
There’s a lack of investment in primary care estate and that is a uniformed view across most ICBs. One of the ways that we can solve the problems we’ve seen in the media recently – hospitals going into critical incidents, ambulances queuing – is to pump money ‘upstream’ into primary care. We know the acutes are capital-hungry due to the intense pressure the system is under, but it’s the system’s problem when acutes ‘fall over’. Therefore, we must invest in the system and have that discussion around where the capital goes.
The two learnings at national level are:
- We’ve got to stop ring-fencing money
Decisions made around cutting diagnostic imaging waiting lists have seen significant funding for community diagnostic centres and these have been a huge success. Then decisions are made around cutting length of stay, or slashing waiting times in emergency departments, so we pump millions into that, then it’s endoscopy initiatives – all of that is ring-fenced money. We don’t get a uniformed pot of money for the system to decide where its greatest need is and how to solve its biggest problems, so we’ve got to look at those funding streams and address the system’s issues rather than dealing with the latest political ‘hot potato’.
- We need to know what buildings cost for the entirety of their lives
It’s not just capital expenditure. We’ve got to look at the investment for the period for which you’ve built your building. For example, if you’re going to save £1000 now by installing a lesser quality air handling unit with a reduced life expectancy, it’s going to cost you £10,000 or £100,000 over 60 years due to breakdown, availability and replacement costs.
What underpins all of this is the need for proper health system planning. We must look at the elements within the ICS – their capacity, forecast demand over the next 10-20 years and the immediate problems to address – because that’s the only way we’re going to solve these problems. We need to get out of our silos and look at this on a system basis.
Standardisation of building designs and layouts would help, together with modern methods of construction to get a clearer view of what investment looks like and the life cycle element of that. In 21 years of working for the NHS, I’ve stood in operating theatres, inpatient wards, endoscopy suites and outpatient areas, some of which have taken six days to design and some which have taken three years, and they all looked pretty similar. We have a prescribed methodology around HBNs [Health Building Notes] and HTMs [Health Technical Memoranda], after all.
What our strategy looks like
I’m really pleased with the way the three alliances – North East Essex Alliance, Ipswich and East Alliance, and West Suffolk Alliance – have come together to work on this. North East Essex did a fantastic gap analysis of where GP practices are currently falling short. They visited all the GP practices within the area and deduced that they need 15,000 square metres of additional space, at a cost of nearly £100 million.
The estates team within the ICB have worked hard over the last few months with the alliance directors and their brilliant senior management teams. Now, for the first time, we’ve got a prioritised list of nearly 100 schemes that tells us where the practice is, how big it is, what the issues are, what the forecast size of the practice will be in five to 10 years and what that equates to in terms of space. It’s been shared at a high level but, when we share it more widely, it will start a 12-month journey to go round the GP practices and rank them in terms of priority.
Our infrastructure strategy will contain the top 10 strategic schemes. For example, we have a health centre that sits by a river and it has flooded several times over winter, resulting in closure. We need a new building outside the flood plain, which is a five-to-seven-year programme of finding a piece of land, going through planning, engaging stakeholders, etc.
Alongside our top 10 strategic list, we’ve got a top 10 ‘business as usual’ list where, for example, a practice needs an extension at a cost of £150,000 and there’s room in the car park for it. After those 20, we’ve got a prioritisation list of the other 80 schemes that need to go through a consultation process and will then be included in the strategy.
Advice to follow
In my previous article, I advised other ICSs to keep an open mind, engage in the process and be ready for difficult conversations.
I would add two things. Firstly, plan appropriately because you can’t eat the whole elephant at once. Plan around what’s achievable in your area in either estates and facilities services and/or in the use of the estate. Secondly, ask what the 10-20-year vision looks like. It’s really easy to deal with the low-hanging fruit, but what does the longer-term strategy look like and what do you need to start working on now to fulfil it?
What’s next?
There needs to be some guidance from NHS England that says nothing happens by way of investment within the ICS unless it accords with the infrastructure strategy and you can demonstrate it’s for the benefit of the system. If not, we’ll still be in a situation where, for example, some Trusts have five robots in theatres at a cost of £2 million apiece, but think of what that £10 million could do in primary care. It would deliver our top 30 ‘business as usual’ schemes. When looking at investment, we must ask: where does the system get the biggest ‘bang for its buck’?
NHS England’s National Strategy Lead, Matthew Ward, says:
“We’re going to pull the 42 strategies together into one set of documents and look at the picture that shows us – the innovations and what that means at local level, how much can be shared and what we need to do at NHS England to adopt learning and influence government, policymakers and legislation to facilitate this work. We also want to know what the difficulties are and what that means for our national approach. The ambition is that we have a comprehensive piece of work by the end of 2024.
“This is an ongoing programme. We’ll get strategies this year and add them up, but my expectation is that we’re going to be doing it again in another set number of years. It’s not just a document – the systems need to continue to oversee, deliver, implement and refresh their strategy. ICBs should have an infrastructure strategy and plan which should be supporting the delivery of their clinical plan and transformation across the system. They don’t need to wait for a national programme to take them through that journey.
“We will encourage systems to make collaborative decisions that are informed by data and based on value for money and the impact on people.”
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This article was taken from the May 2024 edition of FORTIS magazine.
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This article was written for the November 2024 edition of FORTIS magazine; a forum for the NHS to share ideas, innovations and case studies. To read the publication in full and access digital copies, visit FORTIS magazine. FORTIS magazine is free for NHS change-makers and leaders and is available as a print or digital copy. FORTIS magazine is managed and owned by Health Spaces Ltd.
