“You’re a big man but you’re in bad shape”. This oft-quoted line from the movie Get Carter, wouldn’t be out of place in the recent work of another Carter. That’s Lord Carter (of Coles) whose report on performance and productivity in acute hospitals has sent ripples through the NHS similar to those that hit the Newcastle underworld when Michael Caine’s gangster came looking for who killed his brother. And the similarities don’t end there; this Carter has told (some) hospitals they’re too big and in bad shape, with the implication that if they don’t do something about it there could be consequences.
However, unlike the movie, this Carter’s arrival on the scene was generally welcomed – at least at first. Dr Jennifer Dixon, chief executive of the Health Foundation saying; “We welcome Lord Carter’s review. The emphasis on workforce and transparency is sensible, as is the focus on reducing unnecessary variation between hospitals”. Lestyn Williams from the Health Services Management Centre also welcomed “the measure of common ground encapsulated and consolidated”, while the Nuffield Trust’s Nigel Edwards was wary of “top down…knee-jerk centralisation,” he agreed “with many of the problems and issues listed…Lord Carter has spotted some real opportunities for future savings”. Even anointed sceptic Roy Lilley, who in the past has referred to Carter as Lord Bog-Roll, described the report as a “rewarding read”.
But just three months later, and as the Five Year Forward View becomes the Three Year Forward View, there are doubts. Not about the Carter messages but about trusts’ ability to respond amongst a blizzard of initiatives. Ridiculing health secretary Jeremy Hunt’s claim that Carter is “motoring”, Health Service Journal editor Alastair McClellan has counter-claimed that “it’s stuck in the garage”. And as Get Carter devotees who recall the car park scene will be aware, loitering in automotive-related places can be dangerous.
If there is a lack of momentum in responding to Carter, one reason may be that, as several commentators have observed, a lot of this is not new. Take for example the analysis of opportunities for efficiency in the NHS estate where the metrics employed have been part of trusts’ annual reporting (ERICS returns) for over a decade and it was as long ago as 1983 that the Davies Report observed that, “Valuable resources (in the NHS) are wasted by the underuse of space in buildings and by the retention of surplus land”. This is not to deny the relevance of the Carter diagnosis and prescription. On the contrary, given the scale of the financial challenge currently facing the NHS, optimising the use of the estate has never been more important. So if it’s such a good idea and it’s been around for so long, why hasn’t the NHS done this?
Let’s look at just one of the estate performance metrics cited in the Carter report: non-clinical space as a percentage of a trust’s total gross internal area where the target is for this to be no more than 35% by 2020 (and let’s leave aside – for the moment – the different starting points of trusts in terms of old vs new, PFI vs non-PFI, urban vs rural, single vs multi-site etc). For one of the trusts that Essentia is working with the current figure is 45% which, given the size of its estate means that to hit the 2020 target it needs to shed the equivalent of 2.5 premier league football pitches worth of people and materials which have to be compressed, outsourced, digitised or suspended from drones. This is a trust in the fortunate position of having a substantial capital investment programme over the next ten years but this is fully committed to increasing capacity, replacing dysfunctional accommodation and addressing outstanding backlog maintenance – all consistent with the broader Carter agenda.
So how does a trust like this find the additional resources – financial, organisational, intellectual – the sheer bandwidth to deal with those football pitches? Fortunately, Lord Carter has a helpful suggestion, albeit it’s one of the less headline grabbing of his 15 recommendations. At number 11, the Department of Health, NHS England and NHS Improvement are urged “to work with trust boards to identify where there are opportunities for better collaboration and coordination of efforts … across their local health economies”. While Carter has exhorted acute trusts to improve their individual performance, he recognises that most significant gains, including in estate efficiency, will be achieved across whole health care systems.
As we have seen, the NHS has been told to shape up its estate since not long after Get Carter was released (1971, film trivia fans). What can, and must, be different this time is that the challenge – and opportunity – is attacked at health economy level with Sustainability and Transformation Plan footprints providing the ideal framework. Getting this right will mean that the NHS estate – how it’s owned, how it’s managed and how it can enable much more agile and asset-light service delivery models – could look very different.
A traditional one-to-one relationship between trusts and sites looks increasingly outmoded and so resolving the mismatch between clinical service and asset lives will become urgent. The longstanding question of whether providers need to own their facilities may be about to be answered.
