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Should CCGs let providers determine the local estate strategy?

Who is best placed to drive estate strategy in the community – CCGs as commissioners providing a whole economy overview or providers who know what premises they need to best support the services they deliver? Ian Greggor, who has years of experience in health estate planning, explores the issues. 

One of a few issues that didn’t seem to form a core part of the Health and Social Care Act, the future of estates was especially uncertain as CCGs took over from PCTs. With the introduction of NHS Property Services, the resurgence of Community Health Partnerships (CHP), and the transfer of the PCT property portfolio, CCGs, depending on your view, either have plenty of support or have been squeezed out of leading estate development. So should CCGs let providers take the helm; or is a strategic hand still needed?

Broadly, commissioners are there to determine ‘what and when’. Many CCGs have decided that ‘how’ should largely be up to the provider. So what if providers decide that ‘where’ should be too?

So much of government policy has determined that patient choice should be a touchstone. If location is important, then it will become part of the patient’s decision-making process and if there is enough demand for a service somewhere then local providers will see the opportunity. Indeed, if commissioners are determining where things should be, they may slow down innovation as providers will need to consider contractual issues as well as operational ones.

But perhaps, too, the need for CCGs to ensure accessibility means that they have to consider the exceptions to the rules rather than ‘the norm’. So we continue to determine that the town centre, the traditional hub of societies and transport, should be the focus of our facilities – not the new shopping and social centres, increasingly out of town, which are becoming the new ‘norm’.

Where CCGs are determining design and deciding whether to invest in or change a property, surely this also means that commissioners are, by default, determining how providers can operate – but ‘how’ was one of the things they most wanted to leave to providers. And, of course, the tariff also includes an element for estates costs – if commissioners have decided where a provider will work from, they will effectively not just influence service models, but also how providers use their resources.

So, CCGs leading estate strategy might, I suggest, stifle innovation and reinforce the status quo. But what if we allow providers to determine estates in what some may regard as a free-for-all?

Many will worry that providers will be tempted to find the cheapest premises, often well away from main population centres. They will, in essence, move away from the patient’s prayer – ‘fit in with my life – don’t force me to fit in with you’.

Commissioners may be concerned about providers, who could of course be transitory, gaining ownership over the estate. Some fear that once providers change, they could hold the new providers to ransom to use the existing premises or force them to find new ones.

That doesn’t paint too rosy a picture of the relationships in the health economy. Are providers really that rapacious, that determined to skew a market? I doubt it very much. But at the same time, they must secure their own future as well as deliver quality services for their patients and commissioners. There is more than a danger of short-termism, especially where service contracts cannot be let for longer than the time any sizeable premises requires to be decided on and built.

There are particular barriers the whole health market has to recognise. Equity of access will be key to selling the radical changes that most believe are essential. If we are asking staff and patients to accept change, then demonstrating benefits, one of which must be to ensure equity of access, will be critical. Secondly, the world is changing; the health service estate, as it currently exists, is becoming an anachronism – technology means we can do more in the home or away from hospitals. That process has to be controlled though, as we will still need a hierarchy of facilities.

Two deliverables in particular must determine final leadership on estate. 1) We must now build tools not temples that enable our services and don’t decide them, now or in the future. 2) We must be anticipatory not reactive wherever we can.

Neither CCGs nor providers alone can deliver both of these with any certainty. Working together, even if we have to use referees like NHS Property Services or CHP to soothe the competitive edge, will be the only way forward – together we can balance innovation with equity , value with quality, and choice with certainty.

About the author

This article was written for NHE by Ian Greggor when he was a director at Sweett Group, a global provider of professional services for the construction and management of building and infrastructure projects. He has since moved to Community Health Partnerships (CHP).

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