IHEEM - How can we do more with Less
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The document discusses the need for change in how the NHS manages its estate and facilities. It outlines 10 things that are currently wrong with the NHS estate, including that there is too much underutilized estate, poor energy efficiency, inadequate funding models, and inflexible facilities that are difficult to adapt. It then provides 10 things that must be done to change, such as developing an infrastructure plan, abandoning problematic procurement methods, redefining the relationship between NHS centers and trusts, and exploring emerging models of integrated health and care centers. The overall message is that the current NHS estate model is outdated and not sustainable, and a new strategic vision and approach is needed.
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IHEEM - How can we do more with Less
- 1. HOW CAN WE DO MORE WITH LESS? John Cooper Christopher Shaw
- 2. Introduction WHY DO WE NEED TO CHANGE? HOW DO WE NEED TO CHANGE?
- 3. Context Achievements since the foundation of the NHS • Major building programme started with Enoch Powell’s Hospital Plan (1962) and has been accelerated in recent years. It affects both the hospitals and primary health care. Latterly it has been largely financed not directly by the Treasury, but by the Private Finance Initiative (PFI), or public-private partnership.
- 4. Hospital beds 500 000 1948 1958 1968 450 000 350 000 250 000 200 000 150 000 100 000 1988 1998 Total number of hospital beds 400 000 300 000 1978 Beds in use 2008
- 5. Clinical staffing 50 000 1948 1958 1968 1978 1988 1998 2008 40 000 30 000 200 000 150 000 Number of nurses per 1000 Number of doctors/dentists
- 6. Consultant episodes 1100 000 1000 000 900000 800 000 700 000 600000 500 000 400 000 300000 1948 1958 1968 1988 1978 Number of hospital FCES/population 1998 2008
- 7. NHS reform 1948 1958 1968 1978 1998 1988 2008 Two decades of reform and turmoil Devolution of the NHS NHS Constitution NHS Direct Foundation Trusts 2004 Francis Report 330 MRIs in the UK 55 CTs in the UK CQC 390 CT SCANNERS Commissioning a patient-led NHS Arthroscopic surgery Dialysis widely available chemotherapy DNA discovered Computing Fibre optics Laparoscopic surgery Salk vaccine NHS Hospital Plan 1962 Stagnation and disillusion 1989 internal market The NHS Reform and Health Care Professions Act NHS Plan 2000 Our health, our care, Health and Social our say Care Act 2001 Health and Social Wanless Review Care Act 2012 GP Contract Labour invest heavily £20bn savings
- 8. 1998 PFI 1988 ACAD Central Middlesex Chelsea & Westminster 1978 Nucleus Hospitals 1968 DROC Oxford Method 1958 Greenwich and Northwick Park Best Buy 1948 Harness Hospital procurement 2008
- 9. Where next? 90 000 1948 80 000 70 000 60 000 50 000 40 000 30 000 20 000 10 000 1958 1968 1978 1988 1998 2008 District general hospital system is out of date
- 10. Level of investment The quality of NHS premises has long lagged behind those of other western countries. • Value of DH Estate £48.3bn (Annual Report & Accounts 2011/2) • Capital expenditure Property, Plan & Equipment £2.23bn (under-spend of £566m)
- 11. Quality and fit of the estate
- 12. The problem is NOT capacity Size of the NHS estate • Measured by its floor area 28.4 million m2 (DH England only 2009/10 Statistics) Area of the NHS estate • Buildings, grounds and gardens 7,462 hectares Number of Hospitals • Roughly 2,300 hospitals in the UK (Kings Fund – key statistics 2013) Cost of the NHS estate • Direct costs of the NHS estate are £6.6 billion (DH England only 2009/10 Statistics)
- 13. Current situation For Staff • The system dictates the culture • Over managed • A fragmented treatment conveyor belt • An investment in capital, not revenue For Patients • Different journey, same outcome • Mechanistic processes • Treatment not care
- 14. Current situation Fear • • • • • • fear of risk fear of failure fear of infection fear of fire fear of innovation fear of abstraction
- 15. Lack of self image
- 16. Information Industrial age medicine Tertiary Information age medicine Encouraged Individual self care Secondary Family and friends Primary Self help networks Professional facilitators Professionals as partners Discouraged Professionals as authorities
- 17. Where to care? Major Hospital Specialist Hospital + Elective Hospital Community Hospital +
- 18. 20-20 vision Tertiary Hospital District General Hospital Community care Primary care tertiary care complex diagnostic treatment and inpatient care admission avoidance step up step down chronic disease management primary and home based care care
- 19. Health & care centre New model Hospital Primary Care Centre Property development District General Hospital Civic / regional involvement Health and social care amalgamate Possibilities of commercial funding Community hospital Critical treatment hospital Tertiary Hospital Health Centre End of the DGH
- 20. Why do we need change? 10 THINGS WRONG WITH THE NHS ESTATE
- 21. 1. There is too much estate Poorly utilised (1,974,983 m2 declared unutilised) and inefficient Demands ineffective maintenance Retained because of lack of planning and inertia Risk level Backlog maintenance £ million Percentage +/- 2008-09 2009-10 High risk 267.9 300.8 + 12.3 Significant risk 1,175.7 1,107.1 - 5.8 Moderate risk 1,452.8 1,514.1 + 4.2 Low risk 1,188.3 1,174.4 - 1.2 Total 4,084.7 4,096.4 + 0.29
- 22. 1. There is too much estate The area of the NHS Estate (England only) is 7,462 hectares
- 23. 2. Abysmal carbon and energy performance Unsustainable and expensive Anti-social and irresponsible Poor planning and engineering 2840 million kg CO2 per year = 7500 million kw/h
- 24. 2. Abysmal carbon and energy performance The NHS estate produces 2840 million kg CO2 per year . Equivalent of 550 Boeing 747’s crossing the Atlantic (return) every day of the year.
- 25. 3. Inadequate and dysfunctional funding Distribution of budgets Relationship between revenue and capital The demise of the Capital Investment Manual Absurd VAT arrangements
- 26. 4. Inflexible and difficult to adapt PFI not your fixed assets but “fixed” Hampers efficiency and impedes change Fosters a “make do and mend” mentality Leads to a spiral of degradation
- 27. 5. Poorly imagined public realm Poorly integrated with surrounding population Seldom adequately reflected in local or regional planning Absence of social or civic engagement or opportunity Lack of brand value and identity
- 28. 6. Demise of logistics Reduces efficiency and increases costs Ties up revenue Adds risk and frustration
- 29. 7. Badly signposted Clutter and meaningless signage Ill-considered wayfinding In-accessible (particularly for those with dementia) Raises stress levels and demands on NHS staff
- 30. 8. Reactive rather than Strategic Planning Contingent and often inept development Unforeseen and negative consequences Diminished opportunity for adaptation and change
- 31. 9. Poor Quality of Environment Lowers expectations Undesirable workplace for high value staff Difficult and costly upkeep Communicates an unprofessional ethos The NHS estate hard FM costs,£ 3,811 million. Soft FM costs £2,832 million per year
- 32. 10. Arms length procurement Obscures design responsibility Separates the designer and user client Self-referential performance criteria Stakeholder “engagement” is NOT change management
- 33. How do we need to change? 10 THINGS THAT MUST BE DONE
- 34. 1. Develop an Infrastructure Plan There are scores of inadequate tertiary hospitals Closures and consolidation Absence of vision or planning
- 35. 2. Don’t invest in estate that cannot adapt well Appraisal of existing assets – expect to be surprised Mapping of existing fabric to future utilisation Challenge conservation or move elsewhere Embrace the short term – don’t imagine it’s a solution
- 36. 3. Abandon cumbersome PPP Procurement Look for alternative procedures Grade investment to meet the required flexibility • Bond Issues for 99 year hospital site infrastructure • Equity for 33 year shell and core structure (capacity) • Debt finance for 9 year departmental fit-out and equipment Alternative Asset Classes will emerge
- 37. 4. Redefine relationship between Centre and Trusts Some things need central planning Direction and guidance Data and norms Protecting the NHS brand
- 38. 7. Rebuild the Capital Investment Manual Decide who approves – NHS England / Monitor Focus on lifetime value Flexibility and Adaptability Reflect public benefit
- 39. 5. Hospitals return to what they should be Aggressively reorganise Trauma and Emergency 72 hour model Training and academic research
- 40. 6. Challenge UK assumptions Clinical models (midwife/obstetrics)! Benchmark against International Hospitals Alternative scales & strata
- 41. 8. Simulation modelling not just 3D visuals Clinical process simulation Public flows and staging Energy and environmental modelling Planned maintenance and FM
- 42. 9. BIM is a disruptive tool M&E design out of step with the rest of the world Undermines dubious industry “economies” Your asset register needs a radical rethink
- 43. 10. Develop the vision of a better future Patients and carers value a therapeutic setting Staff require a purposeful and enviable workplace Public expect hospitals to be civilised
- 44. Emerging models Barrhead Health and Care Centre • • • • • Health and local authorities partnership Health and social care Nimble – 5 500m² Achievable budget - £18 million Acknowledges its civic and social responsibilities
- 45. Emerging models Kidderminster Treatment Centre • Consolidation of LGH to provide planned care with GP led urgent care • Acute and Primary Care Services • Loose fit use of 13,500m² • Achievable budget - £22 million • Raises public expectations
- 46. Flaring off capital The NHS has been really rather poor at redeveloping its estate and providing a new generation of health facilities
- 47. Legacy of flaring off capital: example one
- 48. Challenge
- 52. Value of the London NHS Estate - £10bn* joint ventures VAT vehicles property development *rough estimate 2013