Something must be done about the NHS's vast and costly estate. A one-stop-shop approach could help. Time to bring back Lord Darzi's polyclinics?
The NHS estate in England has a floor area that would cover the City of London ten times over. To date, there has been little real attention given to how this huge resource could help improve efficiency, move more care out of hospitals and exploit new technologies. Models of care are still designed around buildings, but could re- thinking the way that the NHS uses its estate catalyse change?
The NHS has many under-utilised properties, and a significant amount of its estate is in poor condition or not fit for its current purpose. The NHS Information Centre latest data shows that the cost of clearing the total backlog of maintenance required is more than £4bn.
But some of the newer estate built to deal with historic issues has created new problems of its own. New buildings have often been over-specified, inflexible and too expensive to operate and to reconfigure. The use of private finance initiative to procure these buildings exacerbates the problems because of inflexible contracts in which the costs of adaptation and change often lie with the NHS.
NHS-owned primary and community care estate suffers from many of the same problems, including inappropriate buildings, wasted space, inadequate space for expanded services, over-specified rooms and facilities that are unused for large parts of the week.
We need a more ambitious whole-system approach to the use and design of health buildings. This would bring together health and social care alongside housing, private sector provision of long-term care and other related services in a more integrated way ― creating more value for local communities.
There is a case for creating multi- purpose, flexible facilities for extended primary care teams, integrated community and social care staff, diagnostics and specialist consultation. Investment in large numbers of individual primary care schemes that are not linked to a wider strategy should be avoided.
While the polyclinic model proposed in Lord Darzi’s NHS Next Stage Review was not sold well and was poorly implemented, the idea is sound and needs to be developed.
Providers need to be more willing to use non-NHS buildings to provide care. This would make services more flexible and accessible, and money saved on running premises could be used to invest in staff and technology. Providers could use space in a variety of locations; hospitals operated by other organisations, residential and nursing homes, primary care premises, schools, retail premises or the patient’s own home. Where new buildings are needed, providers should build in a way that allows flexible use and should avoid creating highly specialist and specified buildings.
The ownership model, payment methods and incentives in the current system make it difficult for all but the largest organisations with a substantial portfolio of spare assets or access to reserves or charitable funding to make major changes to their estate. The development of new approaches to the ownership and financing of the estate are also needed.
We should think too about active management. The NHS estates management function has historically been concerned largely with maintenance and operation of buildings, with little development of more entrepreneurial property management skills. There is a strong case for NHS organisations to develop much better expertise in this area. For most organisations this will mean buying in advice or developing joint ventures or alliances with organisations that understand property management. Boards also need to develop a more strategic approach to the estate and to think much more creatively about how it is used.
A new approach to the estate that looks across the whole system has the potential to reduce costs and improving efficiency. But it can also improve the experience for patients, provide opportunities for service co-ordination and collaboration, and contribute to the ‘social value’ in local communities. Developing the expertise and vision to do this is the key to unlocking innovation.
Nigel Edwards is a senior fellow at The King’s Fund. His co-author is Amy Galea, a senior researcher at the Fund
