As you might expect from an organisation with the size of estates and level of purchasing power wielded by the NHS, there is a high level of strategic planning that goes into deciding the level and type of healthcare provision that’s required across the country. However, between planning and delivery, the brief for investment in the NHS estate often evolves, based on feedback from practitioners and clinicians. Such changes to the original brief can lead to wasteful over capacity, creating physical environments that may reflect levels of patient need but are not aligned to local delivery resources.
It’s a complex strategic planning issue. The involvement of clinical user groups in providing frontline feedback on facilities required is essential to creating modern, technically-advanced healthcare facilities that are both efficient in terms of workflows and design and geared towards the needs of the local demographic.
However, that localised thinking does not usually benefit from bigger picture strategic input that considers how services connect across different facilities, Trusts and local authorities. Neither does it take a practical approach to balancing capacity and resources, which can lead to over-capacity in terms of physical space due to limited staffing resource or specialist provision.
For example, I once worked on a scheme where the user group requested that provision be made for 28 physiotherapy bays; a requirement that was based on the level of patient need and potential future capacity. However, the number of physiotherapists available at any one time was much lower than 28, which meant that providing so much specialist provision would represent wasted use of square footage and budget.
Ready for change
It’s a problem that’s exacerbated by the pace of change across the NHS. Not only are there future political, structural and managerial changes to anticipate, but NHS estate development schemes must also be delivered against a backdrop of advances in medical technology and treatment methods, changes in demographics and clinical need, operational cost and resourcing challenges.
What this means in practice is that we must balance the need for specialist facilities with the imperative to create flexible environments that can be adapted quickly, easily and cost-effectively to meet current and future conditions related to capacity, demand and specialist provision.
The issue of capacity is still paramount and the key to balancing capacity and need is for clinical commissioners and user groups to communicate effectively throughout the planning stages of a project. The good news is that CCGs are now maturing and, as a result, there is a much more holistic understanding across local area boundaries of what’s required. Maintaining these parameters aligned to budgetary constraints while working closely with user groups to improve facility design, efficiency and flexibility should result in future-proofed schemes that manage resources and improve standards of care/provision.
There is an added bone of contention, however. While the most cost-efficient way to manage NHS estates would be to create capacity where there is resource and need, the income generation structures that sit at the heart of NHS Foundation Trusts create competition for procedures and, therefore, specialist facilities. As a result, it is in the interests of Foundation Trusts to ensure that any development schemes include specialist facilities for high value procedures – even if neighbouring hospitals already have those facilities on site.
Once again, this can lead to over-capacity on a local or regional basis, which undermines the strategic spending focus of the CCGs. It is vital therefore that the business case for each area of provision within a healthcare scheme is built on the needs and capacity of the entire catchment area rather than simply on the individual hospital or Trust.
The good news is that there is significant progress in this regard. Best practice sharing and best value have already become embedded in NHS procurement and delivery cultures and the squeeze on budgets is driving an even keener appetite to leverage this at all levels. Initiatives such as Procure 21+ and the success of NHS LIFT (Local Improvement Finance Trust) are creating a new era for collaborative procurement best practice across the NHS schemes for primary and community care, out of hospital care and hospitals has created a funding model that can now be rolled out at a macro level.
The other major step forward is the development of the Strategic Estates Groups, which combine the knowledge and agendas of local authorities, CCGs and providers to plan services and facilities in a more integrated way across local areas. This co-operative approach and knowledge sharing will not only prevent capacity from being duplicated in the future but will also ensure that forward planning is informed by genuine data outlining socio-demographic changes in the local area. For example, local authority input can provide valuable insights into housebuilding strategy, which will impact on the number of service users and the types of services they require.
It should also help to inform capacity planning, enabling more effective resourcing to ensure that the clinical routes available within a specific location keep pace with the level of need.
Forward planning will always be a challenge in the healthcare sector because there are so many variables. However, with NHS budgets under such pressure and scrutiny, it’s essential that all delivery partners and users work together to square the circle of need vs capacity.
For architects and contractors, that means designing and delivering healthcare environments that are flexible enough to meet both future and current requirements and for CCGs it means being advised rather than guided by clinical user group feedback.
Most importantly, the managerial structures that are needed to address the financial and administrative boundaries of the NHS must not be allowed to create barriers to effective strategic capacity planning.