A Future for NHS Infrastructure
Christopher Shaw
Founder of Medical Architecture (now retired) and past Chair of Architects for Health
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:
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.
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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.
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:
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:
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.
Health Economist and Health Facilities Planner
4 个月The need is great. Lord Darzi places an emphasis on the patient and her needs. Planning for greater capacity in an effective health system should be both patient- outcome and evidence-based. I am not reading any role for evaluating operational effectiveness of the infrastructure proposals. My research and the European evidence is that the capital spend for equipment,ITC systems and facilities to house clinical care should be specific to the clinicalcare being provided. Times are changing rapidly in healthcare delivery. Based on the evidence i would argue that a focus just on the building in an industrial approach will fail to deliver effective clinical care that forms a strong basis for future improvements. Similarly, ?entrally determined capital funding focussed on an economic filip places political priorities before patient requirments. Under this prioritised project approach, some patient services will benefit but most patient services will miss out. It is a system that creates more losers than winners over an electoral cycle. We live in an era that expects continuous improvement in access to technicaly and clinicaly appropriate services. As you say Chris, Old standards, and value engineering need to be looked at anew.
Chris, great analysis and well said ! Let’s hope the investment in the built environment does flow through otherwise I fear for the future.
Project Consultant - Healthcare and HE Sectors
5 个月That’s a really interesting post making a big subject digestible thank you. Lots of good points especially on the shift out of hospital. I’d be very interested to hear more about the staff spaces, nurse base, teaching spaces ideas .. in hospital schedules of accommodation
Divisional Director at Drees & Sommer UK
5 个月Excellent article, Chris. This has put into words my thinking exactly. One can only hope that a fraction of this comes to pass..
Director at Medical Architecture
5 个月Excellent read Chris. One particular area I think you nail is the ‘more focus on system business cases rather than individual project business cases being predicated on (an often imaginary) set of revenue savings.’ ICBs need to have teeth like Strategic Health Authorities had. Really thorough response to the Darzi Report ????