The pandemic and the NHS estate
How has NHS capital strategy been shaped by Covid-19? Hospital Times welcomed Simon Corben, Director and Head of Profession NHS Estates and Facilities, & Dr Sue O’Connell, Chief Executive of Community Health Partnerships to a Virtual Healthcare Breakfast to discuss the topic.
The phrase “new normal” has become the cliché to describe an era of apparent seismic change for the health sector. Clinicians and sector leaders seem to be embracing profound digital transformation, clinical innovation and rapid integration of health and care services. To bottle these reforms for the long term, the NHS requires a flexible, optimised and effective healthcare estate. It is perhaps the physical space in which healthcare is administered that will require the closest examination of all following the pandemic.
Covid-19 has posed, and will continue to pose, major challenges to those responsible for the NHS estate. As Director and Head of Profession NHS Estates and Facilities, NHS Improvement, Simon Corben’s brief is as fascinating as it is challenging. Simon joined a host of sector leaders for a timely discussion into the estate response to Covid-19 and the implications for future NHS capital strategy.
The immediate crisis
When we last spoke to Simon at our Hospital Times seminar last year, he stressed how the key to improving operational efficiency across the estate lay in data. Recent improvements made in this regard appear to have aided his team in responding to Covid-19. “The last 10 years of improved data supply from the estates community sets us in a place where we can start highlighting vital performance indicators on the estate,” said Simon.
Such indicators include measuring oxygen supply across hospitals, which has proved an incredibly useful tool in determining where the Covid pressure points are. Demand upon mortuary services has also provided critical insight into which trusts were suffering from higher mortalities.
Data was also a key learning for the private sector estate, much of which has had to rapidly repurpose to aid the NHS in its hour of need. Dr Sue O’Connell, Chief Executive of Community Health Partnerships, who set up public private partnerships through LIFT schemes, says they were asked to repurpose 307 community hubs to respond to the emergency. “Fortunately, we have comprehensive data on our buildings; this helped the NHS identify additional capacity and alleviate pressure on hospital sites.”
Fortunately for Sue and her team, they were able to quickly respond to the demands of Covid, thanks to the responsiveness and effectiveness of their partners within the LIFT community. “LIFT joint-ventures are already locally based within the community; the access to additional skills an capacity proved invaluable to responding to what the NHS needed.”
In Simon’s case, he was already overseeing the development of a more flexible NHS estate, but this crisis brought challenges that no one could have prepared for. Although in recent years, facilities have been optimised with flexibility in mind, to help move patients around safely and swiftly, it was not previously anticipated that these patients would need to be using oxygenated beds. Further, Simon’s team has had to deliver thousands of these beds to live clinical settings.
The National Oxygen Programme was crucial for Simon’s team to understand and support the needs of NHS trusts based on local clinical priorities. The program has so far helped complete 20 individual projects, delivering 2,921 oxygenated critical care beds. Plans are now being taken forward for further projects as part of this national programme of work.
“The education aspect was essential here,” said Simon, “and there are still areas we look at daily to ensure that we have the necessary infrastructure capacity to deal with further spikes in Covid-19.”
In the face of these challenges, Simon’s facilities team has responded swiftly. Over 30 standard operating procedures have been set up to establish efficient workstreams and a Project Management Office has formed a core component of the team’s governance approach. In terms of the design approach for the estate, a Covid specification (HVN) that was rolled out across the NHS, this proved to be hugely successful as the crisis developed.
Reconfiguration is key
“Utilisation of space is the big learning curve,” said Simon, who emphasised that the NHS must now examine its ratio of non-clinical space, currently at 30 per cent, to achieve somewhere around 15 per cent. “We have a million square feet of admin space in the NHS estate. We really need to examine how we utilise this as this will greatly increase our surge capacity to deal with future pandemics.”
In addition to utilisation, it was clear from the webinar that greater onus must be placed on the flexibility with which our estate can be repurposed. Indeed, the ability to reconfigure healthcare estates must be built into the design from the outset. As the Government looks to progress with its bold manifesto pledge of rebuilding 40 new hospitals, this must be a key consideration.
Making this case was Nigel Edwards, Chief Executive of the Nuffield Trust, who clearly held some reservations about the benefits of this program – he identified several lessons from previous hospital build programs to take forward. “In the past we have seriously underestimated the importance of reconfigurable space,” said Nigel. “The soft space and loose designs were stripped out in the name of ‘value engineering’.” The consequences of this, he says, are visible in the narrow corridors and restricted hospital space seen across the NHS estate.
Nigel was not isolated in his concerns on the rush to tick manifesto commitments, as this will not address the need to build appropriate, functional and flexible buildings that meet our healthcare system’s requirements.
Addressing this point from a different angle was Anita Charlesworth, Director of Research and REAL Centre for the Health Foundation. Anita’s concerns centred around how we ensure that tech enablement is built into the heart of all future hospital design. “Historically we have been far too building focused and, while this crisis has highlighted the importance of an integrated IT and data approach to design, we are still a long way from achieving this. How do we integrate diagnostic equipment and IT and how do we view this systemically?”
Simon certainly agreed with Nigel’s emphasis on capturing estate learnings regarding space, acknowledging the many historical issues that have hampered UK hospital design in the past. To this end his team has begun implementing hospital standardisation plans to ensure appropriate design for new builds.
However, Simon warned against any sort of pause in the Government’s hospital build program, given that the 40 identified sites represent a tiny portion of the estate, and were chosen specifically for their condition and age. He said, “we are working with teams such as Nigel’s to ensure we learn from Covid and the opportunity to develop designs going forward.” In answer to Anita’s digitally orientated point, Simon reassured delegates that NHSX is intrinsically involved in the development of the 40-hospital build, insisting that tech enablement must be placed at the forefront of all design considerations.
With a major part of Simon’s role overseeing NHS capital strategy across England, it did not take long for the question of private finance to come up. Former Chief of Staff to Theresa May, Lord Gavin Barwell posed the question on what sort of role private finance will play in securing future estate improvements, or indeed whether public finance will bear the brunt of the cost?
Simon was candid in addressing what has been a highly controversial issue for the health sector in recent years. “To be honest this will always be a difficult question to answer. The private sector has played an enormous part in the delivery of healthcare and of the health estate, but private finance is a slightly different discussion,” he said. In acknowledging the difficult times seen with the recent demise of major contractors, Simon warned that this it is still a very vulnerable space. However, his core message on private finance was that, when applied, it must be kept simple. “My view is that we can offset risk by using private finance on more targeted projects with understandable products that do not directly impact clinical care, such as boiler houses, energy centres etc.” While suggesting that there is an appetite to get discussions on private finance moving, Simon does not anticipate major progress on its use any time soon.
The estate beyond Covid-19
As Simon outlined in his presentation, it is in no way controversial to recognise the ability of the NHS to repurpose its estate. There is now a new clinical model running throughout the NHS and primary care estate, under the circumstances this is a major achievement. Simon is hopeful that the Prime Minister’s recent announcement of an injection of capital funding will help his team continue to drive further optimisation of the NHS estate.
What was pertinent during Simon’s presentation was his description of an estates and facilities “community”. This community is made up of hidden heroes across the country, 35 of whom have lost their lives to Covid-19. While gratitude is rightly extended to our frontline clinicians for their sacrifice, the hidden heroes of the estate’s community, whether it be porters, cleaners or other facilities staff, must not be forgotten. They have achieved great things in the face of deadly adversity.
While, thankfully, the full additional capacity delivered by the Nightingales has not yet been required, the delivery of these facilities remains a source of pride to Simon and his team. “There was much fanfare around the Nightingales, and rightly so,” said Simon. “They are a beacon of hope and act as an insurance policy to the NHS, providing resiliency and flexibility to test things across the NHS estate.” These temporary facilities are but one example of how the NHS can rapidly adapt to increase capacity, which could yet prove critical if we can expect further spikes of Covid.
In terms of her own observations from the pandemic, Dr Sue O’Connell emphasised the newfound sense of collaboration that has permeated throughout the health sector. “Past barriers have disappeared, and service coordination has become a new buzzword,” says Sue. The collaborative working that the sector has demonstrated must be bottled if we are to develop holistic estate considerations going forward.
What was also evident from the webinar was that health sector leaders are already looking ahead. The Government’s new “build, build, build” program has placed new onus upon capital development and healthcare will be at the forefront of new build considerations. While Simon rightly places a focus on the need for reconfiguration, and the need to reassess the non-clinical usage of the NHS estate, the road ahead in achieving these goals is far from certain.
The task for the NHS estates community will be in fulfilling ambitious proposals for rejuvenating the healthcare estate but in the context of a virus that is unlikely to disappear any time soon. However, if they can apply the same vigour and resource with which they have responded to the immediate crisis, there could indeed be positive long-term developments for the NHS estate.