This article was originally published in the Health Estate Journal and Edited by IHEEM’s Architecture and Design in the Built Environment (ADBE) Technical Platform
We all do it – all day every day, whether we realise it or not. From the moment we wake up, we start thinking and organising our day – what’s happening, how do I get there, what shall I wear? Short term thinking is pretty automatic – thinking further ahead takes a little more effort, especially if other people are involved. Thinking about really complicated issues often seems mindboggling.
Whether it’s short, medium or long-term, what we all do with varying degrees of success is – planning. If we are working with complex systems, trying to make sense of our strategic objectives and work out how to achieve these – that is masterplanning.
Within the healthcare world, it is all too easy to concentrate on the comfortable - to narrow the horizon and solely consider known specialist, acute or primary care portfolios. What is actually required is a broader view, taking in the whole local health economy. Masterminding this approach to masterplanning necessarily takes in a large range of topics, with a focus on service quality outcomes backed up by supportive clinical service planning.
Many general cases for change are seemingly robust but are often relatively introverted in their content. Recently, the 44 Sustainability and Transformation Plans (STPs) for England have been published, with some reservations as to interrelationships. With change comes unrest and it will be crucial to take all stakeholders including public opinion along the journey as the STPs are developed.
Quality is a key watchword which is often ill defined and if masterplanning on this scale is to succeed, definitions and metrics around quality will be vital.
With any approach to masterplanning, be it a locality or a wider horizon, there are key headlines to consider, such as:
- What are the current arrangements and need for change?
- What are the objectives and how are they aligned between stakeholders?
- What are the quality drivers and how are they measured?
- Which locality best suits the service?
- What is the strategic best fit and
- How do these strategic benefits link with national and local strategic investment priorities
Wth these issues defined, principles can be established as the design tool for masterplanning. Whilst this list is not intended to be exhaustive, the agreed set of goals and objectives will allow comparison between existing and proposed systems, in readiness for option development and economic appraisal.
This approach will produce many objectives and critical success factors for masterplanning but service quality and patient outcomes must be first and foremost. Efficiency through rationalisation should be supportive of process re-design.
Options and solutions may well include new-build proposals; but the masterplan can also address challenges associated with property in poor condition, inefficient space utilisation, functionally unsuitable accommodation to support emerging patterns of service delivery.
Moreover, it should also address financial deficits across the whole regional health economy, including primary and secondary care from commissioner to provider, culminating in excellent patient care through whole system planning.
Pivotal to all of this is the masterplanning strategy, aligned to the local health and social care economy, whilst maintaining sustainability, addressing current health outcomes and driving improvements to the health needs of its population. This should seek to deliver the following aspirations and outcomes:
- Redirection, where possible, of resources towards interventions, aiming to prevent ill health; reducing demand for hospital and residential services (Intervention for prevention)
- Promote improved individual self-care and responsibility for health; through better use of information technology and education (Self care and education)
- Joint working - pooling resources, budgets; commissioning together; sharing responsibilities for service delivery; sharing risk. Thus, to provide the best possible treatment and care, with the resources available (Collaborative working)
- Delivering accessible services within communities; improving the experience of moving between primary, secondary and social care (care closer to home)
- Efficiently reconfigure, build and utilise the built environment, skills and resources of providers and communities (Built environment, appropriate for use)
Within the acute setting – ‘Five Year Forward View’
The NHS published the strategy, ‘Five Year Forward View’, in October 2014 (further reinforced in The Next Steps in March 2017), which reinforced the requirements to meet the changing needs of patients, new treatment options and specific challenges such as support for frail elderly patients and patients with mental health issues. The strategy sets out a clear direction for NHS organisations, outlining a shift in service delivery to meet the evolving demands of the population. Traditionally, there has been a division between care providers, which introduces barriers for effective, efficient, personalised and co-ordinated care. Thereby highlighting the requirement for steps to break down these barriers and promote innovative approaches for synergy between primary and secondary care providers. An example of this, in June 2015, NHS England reinforced key principles, emphasising the need for a plan for transforming urgent and emergency care pathways and provision, the encouragement of illness prevention and strengthening care outside of acute hospital settings.
NHS England, through the Department for Health, ring-fenced capital funding provision as part of the Estates and Technology Transformation Fund (ETTF) programme to allow for primary care providers to facilitate improvements to the their care provision, by meeting the following core criteria:
- Improved access to effective care
- Increased capacity for primary care services out of hospital
- Commitment to a wider range of services as set out in the CCG’s commissioning intentions to reduce unplanned admissions to hospital
- Increased training capacity.
All of which supports the Five Year Forward View and provides opportunities to attract funding to deliver locality hub provision in a primary care facility to supplement care and alleviate pressures of secondary care within the acute setting.
The Carter Review stipulates that by April 2017 all Trusts are expected to have a plan to operate with a maximum of 35% of non-clinical floor space and 2.5% of unoccupied or under-used space. By April 2020 Trusts are expected to deliver against the targets.
In response to the Carter Review, the strategic approach for masterplanning should be used to measure productivity and space use within estates to develop an aligned plan to achieve the required benchmarks.
Underpinning the Foreword View and supporting the objectives of the Carter Review, the Naylor Review (March 2017) calls for the overhaul of NHS infrastructure to meet the needs of modern service delivery. Without this, the Five Year Forward View cannot be effectively delivered. The report echoes sentiments around estates form following and supporting services strategies evolving through local Sustainability and Transformation Plans (STPs) and whole system approach to health and social care delivery. The resultant being released assets, generating capital receipts for investment in delivering new homes, culminating in reduced revenue expenditure.
The report makes 17 recommendations in the following areas:
- Improve capability and capacity to support national strategic planning and local delivery - formation of the NHS Property Board o provide leadership and delivery support for STPs
- Encouraging and incentivising local action – to deliver of STPs, affordable estates aligned to the Five Year Forward View
- Funding and National Planning – national approach to robust capital investment plans by summer 2107 and securing public and private investment for NHS needs
Designing a workforce based upon service need and levels of care relative to patient type in the location of service provision. ‘The right care in the right place at the right time.’ Thus, the employment and deployment of staff in the appropriate numbers, with the appropriate skills, with the appropriate values and behaviours to deliver the highest quality of care required in a location and facility appropriate for its use. All provided with alignment to the Health Education England guidance on developing people for health and healthcare.
The location of service provision should be optimal for the principles of treating patients closer to home, where practical, within the context of the existing and required Trust estate, together with alignment to the CCG STP’s. Opportunities for co-location within a primary care setting, for outpatients’ services and step down care should be embraced. This culminates in rationalisation on hospital sites to provide efficiencies, which will support the economic and financial case for value for money and affordability from a whole life cost perspective, resulting in a ‘spend to save’ principle.
Capacity and flexibility
Within the bounds of reasonable skill and care, Trust’s should uphold the objective to deliver services from an estate which is flexible and has sufficient capacity or adaptability for capacity for future demand in safe and appropriate setting.
All along the journey, Trusts should work towards aligning with the corporate strategic objectives, visions and values, whilst operating within their financial parameters.
Under the requirements of section 242 of the NHS Act 2006, Trust are obliged to engage with its patients and public in the event of a significant change to the provision of its services. As such, prior to embarking upon the major design development journey there is the requirement to develop a public consultation strategy, including the production or a pre-consultation business case with objectives to achieve:
- Coordinated support from commissioners/CCGs
- Public and patient engagement
- Demonstrable clinical evidence base
- Alignment with national drivers/standards
- Patient choice
Following completion of which, CCGs should lead on a full public consultation and a pre-cursor to the usual business case processes aligned to the Capital Investment Manual / Scottish Capital Investment Manual.
Mark Simpson BSc (Hons) DipProjMan MBA MRICS MAPM MIHEEM, for and on behalf of IHEEM’s Architecture and Design in the Built Environment (ADBE) Technical Platform. Mark Simpson, is a Director at AA Projects who has recently joined to head up their health sector consultancy services, with a wealth of experience in the sector across multidisciplinary roles.
Dr Manju Patel PhD; MA (Distinction); MBA; FIHEEM, Chair of Architecture and Design in the Built Environment (ADBE) Technical Platform. Dr Manju Patel, is a Programme Manager / Project Director for Physical Infrastructure Projects –NHS Grampian.