Beyond Sculpture: the purpose of infrastructure

1. Infrastructure vs Sculpture

Infrastructure is not an end. It is a means. It's purpose is to deliver an outcome (usually the facilitation of services). Sculpture is an end. The thing is the outcome.

And it's usually a pretty outcome.

Sir Rod Eddington's eloquent phrase 'bridges over puddles and roads to nowhere' paints a very simple picture of how divorcing the asset from its purpose corrodes value. These are sculptures or symbols. They are not practical solutions.

At the other end of the scale, Bridges to Prosperity (check them out here) are delivering last mile connectivity in poor rural communities through bridges. These bridges deliver disproportionate value for money. It's the same asset but delivered to overcome a specific and understood problem.

Bridges are neither good nor bad. They are good when they meet a need and deliver valuable outcomes. They are bad when they don't.

2. 'Keeping the rain off the services'

There is a cheeky saying that the physical hospital is just there to keep the rain off the services. That's a little unfair, but the point is right: a hospital is there to facilitate medical services rather than to add a building to the skyline.

Do medical services necessitate a hospital? Not necessarily, the NHS's roll-out earlier this year of lung cancer scanning trucks in the UK is a good example. That model allows the services to be taken to areas with the highest death rates from lung cancer rather than centralising the services and expecting people to travel to the services. It model makes use of existing car parks and increases accessibility and equity.

A similar model might not make sense for a kidney transplant, but it might for dialysis.

As with most chronic diseases, additional tertiary hospital infrastructure is not necessarily the answer (see previous commentary on Reducing Demand on Hospitals). The answer could be investment in alternative infrastructure (or prevention programs, new treatment methods or improved hospital processes). Others will have better insight on the best value solution.

In this context, it's worth noting that the benefits of non-tertiary intervention are likely to go beyond simple cost savings, given early intervention or better management drives improved social as well as financial outcomes (see previous commentary on Non-Financial Benefits).

3. Doing more with less

One the focus is on outcomes rather than form. Decision making should become easier.

Generally, if the outcomes sought through a new piece of infrastructure can be achieved:

• using existing infrastructure, then it makes sense not to invest in that the new infrastructure (for example, improving the private car / public transport mix may improve both. See also previous commentary on Better use of existing infrastructure);
• through less expensive upgrades or improvements to existing infrastructure, then it makes sense to make those improvements (for example, airport improvements have delayed significant capital expenditure);
• across a wider range of people for the same price, then that option represents better value for money (for example, by mobilising lung cancer screening equipment rather than centralising it); and
• earlier, then the accompanying social benefits are likely to increase representing better value for money.

There are always exceptions. Existing infrastructure has a useful life, needs change and demographics shift. But these are the very reasons we should focus on the outcomes sought and test assumptions about what is the best means of achieving those outcomes.