Why clinical commissioning groups must shed any reluctance to get involved in the crucial task of estates planning. By Alison Moore
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It’s a cliché to say that the NHS is not about the buildings - but while it may be true that NHS services are the important thing for patients, they are often determined in part by where they are delivered.
The NHS has an enormous estate, much of which is not suited to the way it wants to deliver services. Buildings may no longer be fit for purpose; they may be in the wrong place as care moves closer to home; and they may be surplus to requirements.
As NHS organisations look to drive efficiencies and improve services for patients, it is natural that they should be looking at what role their existing buildings will play in this. But this should not just be an issue for providers - commissioners, as drivers of change in their local health economy, should be addressing this as well.
However, the separation of the commissioning function from providing services means most clinical commissioning groups own very little property and won’t take the decisions on how it is used. Instead they will need to influence what providers do through their plans for commissioning.
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Think about it
“Commissioners have to think about their needs for facilities and how they interact with NHS Property Services, Community Health Partnerships and trusts around this and the delivery of services,” says Jessica Kohler, a partner in Capsticks commercial division.
“We have to invest in setting up new services and new ways of doing things before we can disinvest in the old bricks and mortar.”
Sheila Childerhouse - until recently interim chair of Bedford CCG - says: “I think the key thing is to be clear about what we want to commission. Too often it is the providers who are providing the running. If you have that clarity about services you want for your population then you can start to look creatively at how you can achieve this.”
‘We have to invest in setting up new services and new ways of doing things before we can disinvest in the old bricks and mortar’
Sometimes being creative can bring greater health and wellbeing benefits for an area, for instance, the redevelopment of a community hospital in Norfolk (see case studies, overleaf). But she says there is an opportunity for CCGs at the moment because projects like this fit into the integrated care agenda and there is political will behind it.
But are CCGs yet grasping this opportunity? Perhaps in some areas, but so far they have been reluctant to get involved in estate planning, possibly not seeing it as their role, adds Ms Kohler. But this is very much what system leaders should be doing.
She says a lot of the working on the ground has been driven by providers wanting to use their estate better. CCGs generally own little property themselves, so don’t have the immediate link into estate use, and need to get involved in driving that agenda forward.
Capsticks partner Hilary Blackwell points out that NHS Property Services and Community Health Partnerships are set up to do what commissioners want them to do. “CCGs need to consider estates early on as they develop clinical strategies - that will give them the time needed to move their area’s estate into line with the services they want delivered and to help deliver QIPP savings.”
The Health and Social Care Act 2012 made provision for a number of changes to the NHS which affected many areas, none more so than the NHS estate.
On 1 April 2013, some of the NHS primary care trust estate was transferred to the NHS providers, namely trusts and foundation trusts. NHS Property Services Limited was set up by the Department of Health to manage the remaining PCT estate, apart from Lift (local improvement finance trust) buildings which were transferred to Community Health Partnerships, another DH-owned company.
As part of the drive towards achieving sustainable efficiency savings, NHS provider organisations have come under increasing pressure to maximise returns on their estate. This may include effectively managing and disposing of properties which are no longer required by the NHS for the delivery of services, capital redevelopment, or a combination of both, ie funding redevelopments through property disposals.
NHS Property Services is under similar pressure to reconfigure the estate, although any decision as to whether a property is surplus to requirements and should be released for disposal should be led by commissioners.
In his address at the Cambridge University Land Society Lecture at the Royal Institution in March, chair of NHS England Professor Sir Malcolm Grant challenged NHS estates professionals to develop a comprehensive asset register and consider more flexible working practices for clinical staff.
NHS bodies should take stock of their current estate, carry out a space utilisation review and align their estates strategy with the local clinical services strategy.
Community Health Partnerships has been leading the way with their work on strategic estate reviews.
There is a process set up for identification of pipeline projects and prioritisation within the local area. NHS England has taken a lead on this; and used proactively this should help with effective use of scarce NHS resources. It is important that a system-wide overview is taken, led by the CCGs who are closest to their population and their particular needs, with an eye to more effective care pathways. Without proper planning the required savings, maintenance and improvement of service quality will not take place. Fortunately the arrangements have been put in place to facilitate this and we look forward to continuing to support NHS transformation.
Hilary Blackwell is a partner in the real estate department at Capsticks solicitors.
Willingness to engage
While CCGs have faced issues such as competing priorities and a lack of estate expertise, how much progress is made can sometimes depend on personalities and their willingness to engage with these issues, she says.
For well thought through investments, money can be found. “Things under £1m don’t have a very onerous process and even up to £3m there is a delegated system to push it through the appropriate system. It’s a very iterative process,” she says. “There is money but you need to be in the pipeline.”
However, there is help at hand for some CCGs. Community Health Partnerships took on 301 leases of Lift (local improvement finance trust) properties when the Health and Social Care Act came into force last year. Since then it has been looking at each Lift area to do a desktop examination of likely needs for facilities - drawing on a variety of plans across health and local authorities - and to match this against what is available.
What is coming out of this is a mixed picture: some areas will be well served for facilities and may want to dispose of some, others will need more. The important thing is that commissioners need to sit down with other parties and talk.
CHP commercial director Graham Spence says that the next year will see more detailed work. “The commissioners have been working very hard with their clinical strategy so we have been saying we can help with the estates side.”
‘For NHS trusts, spare capacity can be a headache’
While the new CHP system has taken some time to bed in, he points out that a Lift plan has already been brought to fruition in south east London.
This has seen contracts signed on a community hospital for Eltham, which will also house two GP surgeries. Its facilities will include diagnostic services, 40 intermediate care beds, outpatient consulting rooms and a minor surgery suite. Community services will also be relocated to the site. The design has been used to create maximum flexibility in the use of space.
Greenwich CCG chair Hany Wahba said: “This will benefit patients by bringing health and social care together in one place for easy access. This will be especially beneficial for those with complex needs and long term conditions.”
The hospital should be in use next year and is a public private partnership between CHP and four companies forming Lift Healthcare Investments. To proceed, it has required the support of many stakeholders - particularly the CCG - and to meet tests laid down by the health secretary in 2010 around siting and appropriateness of the care it will provide.
For NHS trusts, spare capacity can be a headache. Even if wards or whole buildings are closed, there can still be costs associated with them such as security and maintaining the fabric in a safe condition.
“You can stop using a ward but you can’t take it out of the hospital,” says Mr Spence. Sometimes this space can be used to increase throughput of other patients, especially in the elective area.
The trouble with free space
But disposing of sites or parts of sites can be a challenge - especially for acute trusts which are likely to have a small numbers of sites, and potential public hostility to closing one.
Space freed up within an operational hospital can be difficult to use for other purposes - although other health related services can be a possibility.
Ms Kohler points out there can be a number of options for trusts that want to sell or redevelop part of their estate. It can be sold on the open market, trusts can enter into partnerships with other NHS bodies, or they can form a joint venture with a private partner. What is the best solution will depend on the individual circumstances and the aims of the organisations involved.
Many trusts, feeling the economic chill, will try to sell vacant land and buildings for the highest price.
‘Space freed up within an operational hospital can be difficult to use for other purposes’
But the National Housing Federation is trying to persuade the NHS that there could be alternative uses for the land which can deliver improved health outcomes and potentially reduce the burden on the health service in the future.
This could include developing facilities for mental health patients who need supported accommodation or housing suitable for the elderly with long term conditions which allows them to be supported to live independently rather than moving into care.
Patrick Vernon, health partnership co-ordinator at the NHF, said the organisation was trying to understand the barriers - both real and perceived - which stop NHS organisations pursuing developments like this, and to engage with NHS organisations around the issue. The organisation has already met with the chief executives of some mental health trusts in London to start a dialogue.
One structural issue is that the impetus for service development which might be aligned with this sort of approach comes from CCGs - but it is cash strapped trusts which generally have the land.
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