Hospital planning: challenges or opportunities?
ABSTRACT
The quality and suitability of the hospital environment is a key contributor to the patient experience. Although major improvements have been made to NHS hospitals in England over the past 20 years, a significant proportion of the estate remains unfit for purpose. Affording investment in capital schemes will be increasingly challenging for NHS trusts and foundation trusts given the projected financial constraints facing the NHS; robust and effective planning is needed more than ever to ensure that any capital funding available delivers tangible benefits to patient care. Early and consistent clinical engagement is vital to enable true alignment of clinical services and facilities. It is essential that the planning of hospital facilities responds to changing models of care and is undertaken through a genuine ‘whole system’ approach. Providing a fit for purpose patient environment across the health economy must be a key target for all commissioners and providers alike.
Introduction
In the hospital of the future….patient experience is valued as much as clinical effectiveness1
It may be possible for a patient to have a positive experience of hospital care in an environment that does not meet their needs, but there is no doubt that well-planned, well-designed, well-constructed, well-run facilities enhance the delivery of treatment and care.
The needs of patients change. Models of care change. Ways of working change. The benefits of technology change. Hospitals must change to keep pace, to remain fit for purpose. Hospitals are not buildings; they are systems through which a wide range of healthcare services are delivered. They are not constrained by sites or boundaries, whether physical, organisational or geographic.
And yet the built environment is fundamental to the concept of the hospital and needs to be treated accordingly. Hospitals are assets; they should be planned, designed, operated, utilised and maintained in a way that befits their importance as a vehicle for the delivery of safe patient care and as a key contributor to the quality of the patient experience (Fig 1). There are many NHS hospitals in England that provide high quality facilities and that enable the effective delivery of healthcare services; there are however many that do not. If a new model for clinical care is to become reality across the NHS, then the patient environment must be planned accordingly; positive outcomes require effective asset strategies and plans.
Most, if not all, capital development projects will be aimed at meeting clinical service needs; business cases will explain how the scheme and the contextual estates strategy are designed to deliver a trust's service strategy. Service-led investment objectives will be set and expected benefits identified. However in reality many hospital developments end up being estates-led, often for understandable reasons such as site constraints, budgetary pressures or implementation timescales. These realities have to be acknowledged, yet it is clearly essential that hospitals are planned and re-planned on the basis of how care should be delivered to meet patients’ needs.
One issue that illustrates this point is the configuration of hospital wards. The Future Hospital Commission report1 makes much of the need to avoid moving patients from ward to ward and stresses the importance of the clinician coming to the patient. However the concept of the ward as a physical unit is still embedded in the vision for the hospital of the future, whereas it can be argued that there is a need for much greater fluidity and flexibility in the organisation and use of inpatient beds. Although hospitals in England are planned and designed on the basis of units of beds, a more responsive configuration can be achieved through the increased provision of single rooms. This idea was beginning to gain traction in the mid to late 2000s, as reflected in the construction of the first hospital with 100% single rooms in Tunbridge Wells in 2011. However, while high proportions of single rooms may remain an aspiration for many trusts, others are seeking only to achieve compliance with the Department of Health 50% standard, at best. Again, space constraints and the need to maximise capacity may be understandable drivers for this approach, but it reduces the ability of the hospital to respond to the new models and principles of care that the RCP and NHS England, among others, are advocating.
If hospital facilities in England are to be universally fit for purpose and responsive to the expected (and unexpected) future changes to the delivery of health care, there are a number of issues that NHS trusts and foundation trusts (FTs) will need to address, in particular
the quality of the patient environment
the effectiveness of strategic service and capital planning
the use of limited capital funding
the need for a whole-system approach.
Each of these issues impacts on the ability of NHS organisations to provide healthcare facilities that allow visions of the hospital of the future to become reality.
Improving the patient environment
The physical environment should be suitable for all patients.1
The quality of the environment in which care is delivered is a fundamental component of a positive patient experience, a key outcome for NHS providers.2 However, despite the extensive programme of hospital developments in England since the 1990s, a significant proportion of the NHS estate is still not fit for purpose. There are numerous examples of buildings that do not have appropriate standards of patient safety, privacy or dignity, that are inefficient in terms of service delivery and staffing models, that are under-utilised and that do not comply with statutory requirements, CQC registration requirements or best practice space standards.
Although there has been a marked change in the age profile of the NHS estate over the past five years (the proportion of estate developed since 1995 has increased from 17% in 2009 to 35% in 20133), there remains a significant amount of hospital building stock, in many cases less than half-way through the expected 60-year lifecycle, that is of poor quality in relation to issues such as privacy and dignity, infection control, space between beds, provision of single rooms and accessibility and is not configured for current practice in service delivery. The concepts of flexibility and adaptability are well-established now but were arguably less considered in the pre-private finance initiative (PFI) era. There is also evidence of a lack of backlog or lifecycle maintenance expenditure in some trusts, which has been recognised in the past year by the Government as a major area of concern.4
One of the factors holding back improvements in the patient environment is the difficulty in demonstrating tangible financial benefits through capital development. Although many capital schemes aim to improve efficiency, increases in capital charges can negate any reductions in operational costs. Focus tends to be on providing capacity in order to increase revenue, and recent experience at a number of trusts suggests that design quality and in particular space standards may be compromised in order to maximise the provision of additional beds, etc. Most trusts commence planning capital developments with the aspiration of achieving ‘best practice’ or even delivering ‘world-class hospitals’, but a combination of financial pressures (both in terms of availability of capital funding and affordability of the revenue consequences), space constraints on congested sites and the increasing requirement to refurbish existing accommodation at the expense of new builds is in many cases leading trusts to reduce room sizes and remove support facilities from designs. This may enable provision of additional capacity but at the cost of functional suitability, flexibility and future adaptability.
An analysis of space standards in hospitals, nationally and internationally, undertaken in 2013 showed that UK hospitals generally have a smaller overall floor area per inpatient bed than in other countries (EC Harris LLP, unpublished data; Fig 2). An observed trend to challenge and derogate away from the space standards recommended by the Department of Health is likely to increase this differential.
Perhaps the most significant challenge is to provide hospital facilities and a patient environment that adequately respond to changes in service configurations and models of care. A King's Fund report in 2013 noted that ‘there has been investment in buildings that are in the wrong place, and others that now appear to be surplus to requirement, or are rapidly becoming out of date as treatments and care change’.5 Examples of over-specification, under-use and unsuitable configuration abound, as does the retention of estate that new buildings were intended to replace.
Clearly the improvements in the quality of hospital facilities that have been made in the past 15–20 years do provide some optimism as to what can be achieved by way of providing a fit-for-purpose environment for patients. The requirement now is to ensure that the best facilities are used for maximum benefit and that every effort is made to replace or vacate assets that do not provide an appropriate patient environment. The key to ensuring that hospital facilities meet future service needs lies with the alignment between capital development and strategic planning and the effective and appropriate use of limited financial resources.
Delivering strategy-led capital developments
It should be axiomatic that major capital developments in the NHS are totally focused on supporting implementation of a trust's strategic plan. However:
strategic planning in the FT sector has been found to be poor in many cases
timescales for strategic plans and capital developments are rarely aligned
the pace of policy change far outstrips capital development programmes
too many developments are estates-led rather than service-led
pressures on capacity, poor quality facilities and opportunistic approaches can lead to poor decision-making.
While Monitor's review of strategic planning by FTs did not specifically address capital developments, it has identified fundamental estates issues in a number of ‘challenged’ FTs and health economies, including the costs of under-used capacity, the financial impact of PFI contracts and the difficulties associated with staffing clinical services on multiple sites. In a recent appraisal, the National Audit Office reported that the NHS Trust Development Authority (NHS TDA)'s review of NHS trusts’ two-year plans submitted in April 2014 identified a number of trusts with ‘capital issues that needed further work’;6 in some cases this has prevented NHS trusts from achieving FT status.
The need to improve strategic planning within the NHS has been recognised by both Monitor and the NHS TDA. In a study conducted in 2013, Monitor found that ‘only a small number [of FTs] were found able to perform a full range of planning tasks to a high standard and had produced well-articulated, evidence-based longer term plans’.7
This statement alone reinforces the challenges trusts face in aligning capital developments with future service models; if only a small proportion of FTs, by definition those whose performance has enabled them to secure greater freedoms in terms of investment decision-making and access to capital, are able to develop effective longer-term strategic plans, then the difficulties inherent in changing the hospital estate to match new concepts of the ‘hospital’ in service terms are clearly very significant.
In response to this analysis, Monitor has recently published an extensive Strategic Planning Toolkit that provides a ‘seven-stage framework of strategy development’ aimed at helping NHS FTs to ‘achieve the vision, principles and values of the NHS by sustaining safe, effective patient care’.8 The importance of the considered use of capital investment as a driver for implementing a trust's strategy is emphasised throughout the toolkit; the list of ‘key strategic levers and choices’ includes among others:6
strategic investments in clinical technology
operational efficiency and productivity programmes, eg asset utilisation
major capital expenditure
buildings and land rationalisation and/or development
creating joint ventures to provide services.
Two changes that would help to ensure greater alignment of service needs and capital developments are a greater strategic approach from estates directors, including a more significant presence at board level, and more active engagement of clinicians at the early planning stages. The need for a more strategic estates influence within NHS trusts and FTs was emphasised at the recent IHEEM conference, the key forum for NHS estates professionals. The outgoing chair of IHEEM, Greg Markham, observed that
We [ie estates directors] need to be more business-like and less engineer. We need to talk about the financial benefits and, if finance directors are wary, then we need to show them what we have already done. We need to engage at board level and talk their language. Our time is now, so start knocking on the door of the director of finance and start talking about money and return on investment.9
A stronger estates influence at board level would provide a greater impetus for ensuring that hospital facilities fully supported the delivery of hospital services, in a way that is not universally achieved at present.
It is also essential that clinicians are more actively engaged in advocating improvements to NHS facilities and in shaping trusts’ capital development plans. Too often medical and nursing staff are brought into capital developments at the design stage rather than being central to the early planning, briefing and business case processes. There is evidence to suggest that having designated clinical leads for major capital developments results in more service-focussed capital plans and more successful projects.
Making effective investments
Since the downturn in the economy in the late 2000s and the introduction of major cuts in public expenditure, there has been a significant reduction in capital investment in the NHS, a trend which has only been reversed in the past year (Table 1). Capital expenditure in 2013/14 was less than two-thirds of the 2010/11 level.
These capital investment figures include maintenance and medical equipment as well as new builds and refurbishments. The number of complete new hospital builds in England is undoubtedly diminishing and most new capital developments now relate to additional or replacement facilities alongside retained buildings on existing campuses; Monitor reported that FTs did not complete any ‘individually significant constructions’ in 2013/14.10 There are only two major new hospital facilities under construction (Alder Hey Children's Hospital and Northumbria Specialist Emergency Care Hospital), although the Midlands Metropolitan Hospital project in Sandwell is now progressing. Other major schemes such as Papworth Hospital, Royal National Orthopaedic Hospital and University Hospital of North Tees continue to stall, in some cases because of the lack of funding to cover the revenue impact of capital developments.
Although the increase in capital expenditure should be seen as a positive development in the context of ensuring hospital facilities are fit for purpose and delivering essential improvements in the patient environment, there are indications that there may not be a lasting upturn. The financial position among FTs deteriorated in first quarter of 2014/15 and FTs spent less on capital than planned, though actual spend was 12% higher than Q1 2013/14, which suggests that FTs continued to invest despite the pressure on trust finances.11 Monitor's Q1 report observes that in the medium term, ‘the current level of capex is unsustainable unless operating margins improve’.11 In addition, the National Audit Office has expressed concern at the future revenue impact of new assets on the financial position of NHS trusts and FTs,6 particularly in light of the challenges they have recently highlighted, a situation the chair of Public Accounts Committee has described as ‘wholly unsustainable’.
Given these revenue pressures and the corresponding impact on the affordability of capital schemes, it can be argued that capital investment should be assumed to be a scarce resource over the longer term and treated carefully as a result. Clearly it is essential that capital investment really does enable delivery of the benefits proposed, which is arguably not consistently the case at present. This means there is a need for more robust and consistent approaches to capital investment decision-making. There are now major differences in approach, both between NHS trusts and FTs and within the FT sector (for example NHS trusts are required to have capital schemes approved by the NHS TDA, whereas Monitor does not approve business cases by FTs, instead assessing the expected impact of capital developments on their financial risk-rating). There is substantial evidence of both the application of robust, thorough processes, with appropriate stakeholder engagement and independent scrutiny and of the reverse. It is known that both Monitor and NHS TDA are aware of the issues and shortcomings and recognise the need for improvements, particularly in the context of the financial constraints outlined above.
Adopting a whole-system approach
Every prognosis for the future of the NHS, every national policy document, every major vision, strategy or plan emphasises the need for ‘whole system working’, breaking down the boundaries between acute care, primary care, community care and social care. This has become a fundamental principle for the NHS. The Future Hospital Commission report states that ‘we need all parts of the health and social care system to work together to deliver sustainable change’ and recommends ‘new ways of working across the hospital and between hospital and the community’. The hospital of the future ‘should not be constrained by macro-service organisation (eg trust boundaries)’ and ‘links with primary and community care’.1
The existing structures and concepts of ‘ownership’ of healthcare facilities, whether acute hospitals, specialist hospitals, community hospitals or primary care centres, are not designed to enable a whole-system approach to the delivery of care. For instance, in some parts of the country, the dissolution of primary care trusts (PCTs) resulted in acute hospital trusts being given the given the option to take on the ownership of the PCT's estate – on the surface a helpful precursor to a ‘whole system’ approach and a potential means of reinvestment in the full range of facilities. However, it became apparent that once the terms of the transfer from the PCT to the trust were agreed, the accompanying conditions were so onerous that trusts did not see any benefit in taking on the risks of ownership when these far outweighed the rewards. For example, the ownership of the asset was potentially short-term, as once a trust lost even a small element of their clinical contract, all of the transferred properties had to be offered back to the secretary of state. The trust did not have the automatic right to retain the property and determine its optimum future use. This short-termism removed any incentive the trust may have had to invest capital and reconfigure its estate in the longer term. The creation of NHS Property Services in 2013 enabled the development of new models of asset ownership and operation in the primary care and community sectors; the challenge now is whether such arrangements could be extended into the acute hospital sector, to enable a truly joined-up approach to the provision of healthcare facilities.
While there are examples of acute trusts developing and implementing plans for joint use of estates and/or assets, such as Papworth Hospital and Addenbrooke's Hospital, there is as much if not more evidence of trusts failing to co-operate. Ownership and control of assets is of critical importance to NHS trusts and FTs, not just as a vehicle for delivery of services, but as a means of exercising control, as a means of financial leverage and as a symbol of status. In this context it is understandable that in geographical areas where there is more than one major acute trust owning the hospital assets, such as London, Birmingham and Manchester, competition in capital development is more in evidence than collaboration. In a recent study, Monitor found that ‘nearly all the providers we heard from told us that they are working with other acute providers in partnerships or networks’12 yet this seems to be truer of workforce and service models than the use of hospital estates and facilities. Clearly in remote and rural areas shared, flexible use of hospital and community estates is challenging, but in most urban areas, the concept of collaboration between providers can and must be extended to the built environment if a ‘whole system’ approach to healthcare delivery is to become a reality. The new NHS Five-Year Forward View sets out the potential for local networks of services or hospitals under a single leadership team, which may create an opportunity for multi-organisational utilisation of assets.13
Not only would greater collaboration over the use of hospital facilities support a more pluralist approach to service delivery, based on patients’ needs rather than organisational boundaries or finance arrangements, it should also enable more effective use of constrained capital and revenue funding and provide a greater return on investment for the whole health economy. Whichever approaches are adopted in the future, it is difficult to argue with the King's Fund's assertion that ‘The current model of ownership and operation needs to be challenged’.5
Conclusions: towards asset-based transformation
Models of hospital care in England have changed and will continue to change; there may be differing views on the direction of travel – the increase in specialisation, the viability of smaller hospitals, the shift of activity into the community – but few commentators would suggest that the existing concept of hospital care is sustainable. As systems and processes for the delivery of hospital services evolve, so the built environment in which these services are provided must be adapted accordingly.
The ‘form follows function’ approach suggests that the planning and design of hospital facilities must respond to clinical service strategies and new models of care. Most major hospital developments will take far longer to plan, design, procure and construct than the five-year strategic planning periods that NHS trusts/FTs are expected to adopt, so the timescales and pace of change for services and facilities will rarely align, making responsive capital plans that much harder to achieve. An alternative approach, adopted by many trusts at present, is to consider what hospital facilities can be provided through refurbishment, re-development or new builds and to plan clinical service delivery accordingly. The optimal solution lies somewhere between these approaches, assets can be used as a key strategic driver to enhance the patient experience but they must be planned, created and continually redefined to enable the delivery of changing models of care.
The following steps can be taken to ensure that all hospitals are fit for the future.
Engage clinicians fully at the earliest stages of planning, not just in design development.
Use the business case as a decision-making process, not simply as a means of approval.
Set and achieve high quality standards for the patient environment, not just ‘compliance’.
Consider in detail how facilities should flexibly support the new model of care before plans are made, not as an afterthought.
Plan for strategic scenarios, not a single future outcome - ask ‘what if’.
Articulate the ‘case of need’ precisely as a means of testing a plan, not to just to endorse it.
Adopt a more rigorous approach to benefits realisation planning, using it for developing solutions, not justifying them.
Assess risks more robustly and use risk registers as an active management and planning tool, not just as a reporting mechanism.
Pursue opportunities for real collaboration with other providers; don't work in isolation.
Ensure that the maximum value is obtained from the available funding; don't discount the opportunity costs.
Planning the hospitals of the future is not something to be done in isolation, by any one profession or organisation. It is essential that within NHS trusts and FTs the clinical, managerial, planning, estates and finance teams are of one mind in ensuring that hospital services and hospital facilities are completely aligned, and that providers work together with other providers and commissioners to deliver a fit for purpose patient environment across the whole health economy.
Acknowledgements
The author would like to thank Isobel Esberger, Petya Ilieva, Rhian Anstey and Helen Davis for their support and contributions to this article.
- © 2015 Royal College of Physicians
References
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- Monitor
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- NHS England
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