A Future for NHS Infrastructure

With the publication of Lord Ara Darzi’s Independent Investigation of the National Health Service in England, the new government has signalled a significant shift in focus for NHS England [https://www.gov.uk/government/publications/independent-investigation-of-the-nhs-in-england]. This report can be read alongside several by the same author since 2008 pointing to similar reforms. Although governance of the health service is devolved to national governments, change will inevitably have an impact across the UK.

The key themes can be summarised as follows:

• Re-engage staff and re-empower patients.
• Lock in the shift of care closer to home.
• Simplify and innovate care delivery for a neighbourhood NHS.
• Drive productivity in hospitals.
• Tilt towards technology.
• Contribute to the nation’s prosperity.

It's not surprising that these are familiar. The focus on workforce is now common to all health systems. For around thirty years there has been a broad consensus in the NHS that a ‘left shift’ away from hospitals and towards more local preventative care and treatment is the sustainable direction. What is worrying is how little progress there has been.

Unusually for a policy review, the role of infrastructure and capital investment is identified as being an essential enabler of change. It identifies a gap in funding of ￡37 billion ($49 Bn.) since the millennium - measured against the capital funding of peer countries.

The burst of investment stimulated by the private finance initiative (PFI) during the 1990’s briefly met the expected rate of outlay, however the effect of outsourcing commissioning and management of the estate led to a dispersal of essential skills from the health service and the disbanding of NHS Estates. The forthcoming repatriation of NHS PFI infrastructure at the end of their concession terms, comes at a time when estate management experience in the NHS is at a low point.

The legacy of the last three decades has been crippling for NHS buildings, equipment and information technologies. Backlog maintenance in the acute, community and mental health estate is widely reported to have reached ￡11.6 billion ($15.3 Bn.) by 2022. Others have pointed out that this eye-watering sum is an underestimate as it excludes consultants fees, inevitable decant costs and taxation. The real cost is likely to be twice this level.

Added to that the report points out that the backlog costs of general practice premises are excluded from these figures. An extract rather pointedly states: “The primary care estate is plainly not fit for purpose. Indeed, 20 per cent of the GP estate pre-dates the founding of the NHS in 1948 and 53 per cent is more than 30 years old. More recent buildings are bedevilled by problems with the management of LIFT (PFI-type) schemes that give GPs too little control over their space.”

The new UK government has come into power inheriting a fragile economy. The chancellor has signalled that tight control of public expenditure will continue for the foreseeable future. However, the messaging is clear, treasury capital is going to be deployed to stimulate growth in the economy. So what kind of health infrastructure investment are we likely to see and how should planners, engineers, architects and the construction industry be tooling-up to respond to the challenge?

Firstly, we do need an NHS infrastructure plan, and quickly. Ad-hoc procurement driven by political expediency damages the industry and delivers astonishingly poor value. Where central public capital is being released it will be calibrated to stimulate the economy. This works best with a long-term pipeline which the industry can look to and plan growth with confidence. I expect a simplification of the green-book procedures with more focus on system business cases rather than individual project business cases which are commonly predicated on (an often imaginary) set of revenue savings. Strategic and outline business cases may be co-ordinated more centrally.

Secondly, planning for workforce recruitment and retention as a priority will mean re-evaluating design priorities. Old standards and schedules of accommodation will have to go and ‘value engineering’ will have to embrace an entirely new set of priorities. Offices, nursing stations, restrooms and seminar spaces all need a major rethink. Alongside new IT systems, the NHS workplace will have to adopt the kind management and appeal that are commonplace in the hospitality industry but utterly absent from hospitals.

Thirdly, the focus of investment will shift to primary, community and mental health infrastructure. There are the barriers to achieving change, much of this estate is dispersed, poorly suited to modern care, inflexible and inaccessible.

Neighbourhood NHS

Primary care services which includes general practice, community pharmacy, dental, and optometry services, form the largest part of most people’s experience of health care, providing the first point of contact in the health care system and acting as the ‘front door’ of the NHS. The ownership and valuation of practice premises operated with NHS rent reimbursement is absurd model. Some of these will simply have to be purchased and re-sold by the state.

Community health teams play a vital role in health promotion, school health and health visiting supporting people with complex health and care needs to live independently in their own home for as long as possible. Here modernisation of management, infrastructure and enabling technologies could achieve a step-change.

Mental healthcare provides services for adults as well as children and young people. Demand for services has increased rapidly in recent years with particular shortfalls in some specialist services such as perinatal, child and adolescent mental health and eating disorders. Most treatment takes place in a community setting. A small proportion require dedicated inpatient facilities. The services have a long history of underinvestment.

New class of infrastructure

With the exception of inpatient facilities, none of these services require the costly, specialised equipment and buildings that are necessary for acute and specialist hospitals. What is required is the right amount of fairly generic infrastructure in the right place. A new class of buildings that will be high quality, cater for high volumes of utilisation and be designed to be flexible and adaptable for changing service needs. These could equally be new-buildings or reuse of redundant retail or offices.

• Capacity: A new strategic approach that provides generic capacity based on a more accurate evaluation of population, disease prevalence and economic deprivation using a standard glossary of terms.
• Planning: A single methodology applied across all projects. Based on a well designed library of repeatable room clusters – a kit of parts- that can be assembled in attractive and functional arrangements that have been tested to meet a range of configurations and site conditions.
• Construction: A general planning system based on a hierarchical dimensional system that maximising the opportunities for modern methods of construction, off-site manufacture and the use and of standardised components. This open system encourages innovation and market competition.
• Sustainable: Applying recognised design principles to allow growth and change and achieve adaptability that can meet the imperatives of a circular economy. With energy systems and fabric that will cater for the NHS ambition to achieve Net Zero by 2040.
• Appealing: A civic building system that communicates the positive ethos of the NHS and which can be customised to suit the local context. Adaptable building form with alternative material finishes. The design should recognise the importance and function of ‘softer elements’, a welcoming foyer, external landscape and an urban presence.
• Digital: An environment that is conceived for a digital age. A networked data-rich hub with access and monitoring systems that maximise comfort and utilisation of space. An environment and communications infrastructure that places equal value on physical and remote consulting, diagnosis and monitoring.

Development should maximise the utilisation of the site at each setting potentially acting as an enabler for “One Public Estate” initiatives. I don't have a view on the funding or procurement model. The barbed comments about LIFT would indicate an alternative form of operational management. There would have to be some consolidation of the NHS estate. The new infrastructure could fit into three basic hub types of differing scale and content that respond to the demands of the different patient populations. They are:

• ‘Place’ serving a 25-35k patient population
• ‘Neighbourhood‘ serving a 30-40k patient population
• ‘Anchor’ serving a 40-50k patient population

This approach has a particular appeal if delivered at scale. It is comparatively cheap and acts as an enabler for system change – and that left shift of services from hospital to community takes the heat out of the acute sector enabling more considered and effective planned change. This would:

• Enable integrated operational change faster, relieving pressure on acute hospitals.
• Be smaller individual projects enabling the construction industry and supply chain to ramp up skills and capacity more effectively.
• Be nationally distributed, providing equitable and visible investment.

More productive hospitals

However, for the foreseeable future, there will continue to be a baseload of managed change to the existing hospital fabric. We will need to be more creative in the sustainable repurposing of what is currently a poor quality, inefficient hospital estate. Both the tilt towards technology and a dispersal of services closer to home should have the effect of freeing up space on acute hospital sites. A focus on planning for productivity should mark a step away from the piecemeal, expensive and ad-hoc approach common to the beleaguered NHS estate team spending resources in keeping critical buildings operational with little or no room for manoeuvre.

The productivity debate often assumes that individuals always make rational or self-interested decisions. But behaviour is rarely rational, and is shaped by a mix of environmental factors. This might be a better lens through which to view productivity in the NHS. Thea Stein's recent piece for the Nuffield Foundation provides an excellent commentary. [https://www.nuffieldtrust.org.uk/news-item/productivity-in-the-nhs-what-s-getting-in-the-way]

The New Hospital Programme will need rethinking. A requirement for investment in some very large acute projects will not go away but we need to consider this large scale infrastructure on a longer timescale and much more strategically than we have so far. We have a generation of “Best Buy” system hospitals which are now obsolete with inherent risks. These will need to be re-provided but not necessarily on the site next door.

Redevelopment of large teaching hospitals need careful consideration in a national system-wide context. In many cases replacing is not the best option, the compromises inherent in multi-phased redevelopment on constrained urban sites does not make sense. As well as health system coherence, wider economic factors, employment, transport, education, research and industrial factors must have a stronger representation in hospital planning. Only when we have all of these working in concert do we generate the kind of inertia that will make a substantial contribution to the nations prosperity.

A longer term horizon

The political messaging describes a new “NHS Long Term Plan”. This may seem quite brave, two election cycles. Actually we need to start considering something much more ambitious, an NHS infrastructure plan with a 100 year horizon.