This is the first part of our series of articles and reports on how the health and care sector can overcome change paralysis in their estates. In this article, Leighton Chumbley, Prime’s Chief Executive, uses his experience in strategic property development and funding to share insights from working with trusts and NHS leaders on how to forge ahead during these uncertain times.
Are you finding that:
- Your approach to estate is being stalled by uncertainty around policy and funding?
- You are waiting for government announcements and keep missing the boat when it comes to new initiatives?
- You are being encouraged to sell off land but aren’t sure how to release it in the best way, or think you might need it in the future?
- Operational performance is not what you’d want it to be, you have limited options for developing your services, your Trust CQC rating is being affected by poor facilities and patient experience is suffering?
- Staff morale is low and recruitment is difficult?
If you identify with a number of these issues, the chances are that your estate is suffering from change paralysis: you are putting sticking plaster upon sticking plaster to fix problems as they arise but not actually treating the root cause. Nobody would deliberately run their estate like this but if there is little or no budget, what option is there?
There is a tendency for experts to say: “Here is the answer: make this one change and everything will magically work.” But it is not as simple as that. Every trust, care operator and GP practice has a unique set of issues requiring creativity backed up by experience and know-how to develop a way forward.
But planning that way forward today is essential. The longer you wait to solve estates problems, the more expensive they become and the more costly it is to operate struggling properties. The Department of Health is unable to fund what is required, but if you know where to look and how to take a commercial approach, finance is readily available.
Look at University Hospital Southampton, who developed a new main entrance and retail area using private investment. This improved staff and patient experiences, while at the same time creating value for their future.
Although every plan will be unique to the local situation, there are a number of steps that can be taken to create momentum in every health and care organisation.
If you need a plan and finance…
Step 1. Ignore the noise and start masterplanning
There are conflicting messages around how to do (and not to do!) things – the latest guidance, accounting policy insight, tax, data, fashionable quick-fix must-have… If you listen to it all, it becomes impossible to take action. Instead, take a long-term view of how to create a sustainable organisation and infrastructure. Without distractions, plot out your big picture masterplan: what will the next 10 to 20 years require? Will you need space for new models of care?
Step 2. Don’t go down the rabbithole
Most hospitals and many surgeries have been on the same site for more than 70 years. Technology like the diagnostic and surgical equipment we have now, would have been unimaginable back then. Times will move on but we will always need quality space to train, collaborate and deliver healthcare to local people. Engage with those who use your facilities now and those who choose not to so you can build flexibility into your plans.
Step 3. Work out how to deal with the estate you have now
How can you make it safe? How will you deal with backlog maintenance? Start with your own cash for backlog maintenance and then look to capital budgets and work out how can you ensure your estate works flexibly depending on changing needs. Examine what commercial opportunities exist.
Step 4. Create an experienced, innovative, influential team
Put in place a group of people who will act as a positive force for change in your organisation. Start at the top and get estates a place on the boardroom agenda. Identify an enthusiast on the Trust board or a senior GP within a primary care setting, someone who will be a real advocate for the estate and the masterplan, and can gain NED alignment. Invite key members of the clinical team to feedback on your ideas so far.
Then bring in outside experts. Find an architect that understands the health system and has hospital experience. Bring in a commercial entity with experience of building income streams and private funding. They can provide a level of realism that is particularly important when talking to NEDs, who often have a private sector background.
Step 5. Switch the noise back on and kickoff
Work out the opportunities and commercial opportunities available right now that you can push forward on and get those aspects of your masterplan completed. What is the first project that could unlock the whole masterplan?
- Is there a cost-neutral commercial opportunity open to you?
- Where are the opportunities for partnerships with other health, care and community organisations in your area?
- If you have been promised government funding, what do you need to do to unlock that?
Make some good tactical decisions and take action.
If you have a plan and finance but have hit a wall…
Difficult local politics and convoluted approvals processes can mean that it takes four or five years from planning to talking meaningfully about starting to build. In that time, costs have inevitably risen and millions more are now needed to complete the project.
You could carry out a redesign but this costs money, entails further delays and in the end you get back to the same point of non-affordability but with something that is smaller than when you started. Instead, it’s better to push on and find other ways of paying for the extra costs.
You can try selling some of your assets or carve certain parts of the project out of the main scheme for different funding. Is there a commercial area such as office space, residential accommodation, retail premises, car park or pathology service that you could legally separate? Then you could channel extra external funding into that piece of infrastructure.
Many estates teams and business managers are having to patch and mend estate with decreasing amounts of capital and often how they do that is quite remarkable – keeping these complex buildings running with not very much money at all. But it’s not a comfortable position to be in, knowing that things are patched together and clinicians and patients could suffer if the seams come undone.
The good news is that investors have money that they want to invest and rates are at historic lows so if you can plan for the long-term, wade through local politics and complex approvals with the support of a strong team, you are well on your way to creating an estate to be proud of and confident in.
Sign up for our in-depth report on overcoming change paralysis.
If you want to discuss the options open to your NHS estate, get in touch for an informal, informed chat.