The NHS estate is more than just 'bricks and mortar'

Source: NHE March/April 2019

Claudia Martinez, research manager at Reform, talks about maximising the value of the NHS estate.

In his review of NHS property and estates, Sir Robert Naylor argued that an adequate healthcare infrastructure was crucial to achieving the goals set out in the NHS Five Year Forward View. The transformation would come at a price tag of £10bn.

Two years on, concerns over the long-term capital needs of the NHS estate show no sign of abating. Maintenance backlogs across NHS trusts remain stubbornly high, rising by 9% to £6bn between 2016-17 and 2017-18. Concerns over access to capital funding and “nightmarish” approval processes for capital bids pose challenges for trusts, which struggle to navigate what is deemed to be a complex and resource-intensive system.

In some parts of England, GP practice buildings are in a poor state, with half considered unfit. Furthermore, in areas such as mental health, poor infrastructure risks impacting the quality and safety of patient care, with the CQC warning of “hundreds” of inappropriate wards. The NHS Long-Term Plan, the blueprint for the future of the health service, recognises that some of the current estate is well beyond its sell date and that, even if upgraded, “it would not meet the demands of a modern health service.”

Delivering an NHS estate fit for the future is a challenging yet not insurmountable task. Progress is being made in transforming estates and modernising facilities, with a continued focus on efficiency, utilisation, and better patient pathways. In some areas, this has been supported by a reconfiguration of models of care to better match demand for services. For instance, some GP practices have transformed into locality-based “super hubs” with integrated primary care, community services, and out-of-hospital functions under one roof.

Achieving real transformation will require a concerted effort to ensure that estate strategies align to local needs. The NHS has embraced the devolution agenda to provide better and higher-quality services, and there are great examples of this across the country. This should not be any different when it comes to the NHS estate. Research by Reform shows that local providers are best placed to ensure that capital investments match clinical strategies and can help guide the design of health infrastructure.

At a systemic level, delivering a 21st century estate requires genuine devolution of powers within STP and ICS areas, along with a joined-up approach to developing estate strategies. The experience of Southampton, where the city council and the CCG have been working in partnership to optimise two community hospital sites, is a good example. The project, supported by a pooled budget, considers transferring under-utilised NHS land to the council to build key worker accommodation, a care home, and housing with care units.

The capital requirements of the NHS estate cannot be delivered through public sector funding alone. The NHS should continue looking at alternative financing mechanisms for attracting investment into estates, including selling NHS land and setting up strategic estate partnerships with the private sector. Importantly, any new capital funding from the Treasury must be accompanied by clear guidance for trusts to understand how funding will be allocated and capital bids evaluated.

Finally, the government has been clear about its ambition to modernise health services, shift care towards community settings, and promote digitally-enabled care. This could have enormous implications for buildings and infrastructure. More than ever, the NHS should ensure that healthcare infrastructure – both the adaptation/extension of existing facilities and new builds – are future-proof. Technology must be embedded within planning processes to identify how new solutions might change treatment pathways and shape building design. Similarly, greater expertise at a local level must be enabled so innovations that improve workflow, staff efficiency, and utilisation of space are harnessed. The Royal Wolverhampton NHS Trust is a good example of this approach.

NHS and local government leaders are looking ahead to the forthcoming Spending Review for a long-term capital plan for healthcare estates. Whatever funding is provided, unlocking the potential of the NHS estate will still be contingent on trusts, GP practices, and the acute sector identifying opportunities for delivering better quality, utilisation, and efficiency. This must continue being supported by integrated working, new delivery models, and a greater understanding of the strategic role of the NHS estate.


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