Andrew Simpson asks 'isn't it time to put planning at the heart of decision-making with regards to the future of the NHS estate'?
Andrew Simpson, planner and development manager at Dominic Lawson Bespoke Planning, and previously planning and regeneration director of South West London & St George’s NHS Trust, asks 'isn't it time to put planning at the heart of decision-making with regards to the future of the NHS estate'?
The NHS has in its ownership the most-valuable and under-exploited resource remaining available to government to generate value for long-term investment in UK Plc.
So why hasn’t the NHS done more to capture the value at its disposal to reinvest in health and social care, as well as in improving the wider social infrastructure whose neglect has done so much to generate the diseases of poverty that so challenge the NHS today?
When it comes to undertaking any form of property transaction, developers and investors constantly remark that the NHS is the most-difficult public sector body to engage with. The problem lies in the capital investment planning processes and the procurement arrangements that strangle NHS trusts and NHS Property Services in unnecessary and damaging red tape.
When it comes to undertaking any form of property transaction, developers and investors constantly remark that the NHS is the most-difficult public sector body to engage with
The capital investment process enshrined in the business case mechanism fails to provide a framework for considering the value and contribution of the estate, forcing organisations into regarding estate investment decisions as adjuncts to clinical service plans.
Clinical service plans change regularly and because the service models change and cost improvements are made, the programmes drive new patterns of service delivery. While this pace of change is inevitable and appropriate, real estate investment programmes cannot change in the same timescales. The result is that investment decisions are delayed while NHS organisations wait for the moment when their clinical delivery plans are set in stone, something that can never happen.
Is it so wrong then for an organisation with a real estate portfolio to drive its investment plans based on capturing the value in the estate as well as on meeting the ever-changing clinical needs of its services? At the very least this would prevent the scandalous growth of backlog maintenance that NHS bodies have accumulated since 1948, unlike their private sector counterparts who, by and large, have always looked after one of their prime assets, the land and buildings that they occupy. At best, it would mean that NHS bodies would be able to take long-term strategic decisions about the future of their estate, rather than relying on the relatively-ephemeral clinical models and indeed organisational structures that make the modern NHS so difficult to engage with.
The procurement arrangements developed over recent years by the NHS are another source of frustration and delay in proper real estate investment management. Private Finance Initiative (PFI) was, of course, the greatest source of delay of all, as well as being the process that delivered the largest NHS investment programme in recent times. However, we now know that it also delivered an unaffordable and inflexible set of new facilities that many trusts have lived to regret and that have saddled the NHS with contracts that provide the PFI providers with lucrative income streams while generating limited patient benefits at unacceptable costs to future service developments.
Many trusts lack the expertise to engage with the commercial development world, thus leaving them vulnerable to signing up to contracts that fail to generate the real benefits, both financial and clinical, that are available to them
We are now in an era when there is no new model for NHS organisations to use other than the ProCure 21+ framework, which is about to be renegotiated and which has resulted in the NHS relying on six major contractors to deliver a large proportion of its investments. While NHS Foundation Trusts are more likely to be able to negotiate their own arrangements outside this framework, many of them lack the expertise to engage with the commercial development world, thus leaving them vulnerable to signing up to contracts that fail to generate the real benefits, both financial and clinical, that are available to them.
How then to overcome these twin barriers to better estates performance?
The first thing that is required is a shift in the way that the NHS thinks about its real estate assets, and liabilities. There is no shortage of commercial real estate expertise in the UK as we can see in the major regeneration programmes that are sweeping through our cities. The key requirement is for the NHS to harness this expertise to its own advantage, through the development of market approaches based on a confident and assertive approach from the NHS to the value that is available from its estate that can be captured to the mutual advantage of NHS organisations and their private sector partners. Developers and investors are keen to exploit these opportunities and the NHS, at trust and central levels, needs to develop new investment strategies that enable the market to help it gain the benefits that are available.
To achieve this, a second strategy is required. Since the lifting of crown immunity, the NHS has seen town planning as a barrier to progress, rather than a framework to work within. The introduction in 2012 of the National Planning Policy Framework,with its presumption in favour of sustainable development should have signalled a new golden age of investment in NHS land and buildings, but instead it has seen a prolongation of the paralysis that set in with the demise of PFI. NHS organisations are desperately in need of high-quality planning and development advice which links real estate development to the generation of community benefits, both in terms of healthcare facilities and in terms of wider benefits to community health and wellbeing.
NHS sites ought to be at the heart of regeneration of our towns and cities, but instead they are still more likely to be distressed sites, full of aging and deteriorating buildings instead of being vibrant developments providing state-of-the-art, integrated health and social care services with affordable housing and community facilities as part of the mix
The development of mixed-use regeneration schemes, both large and small, have the potential, as seen up and down the country in commercially-led schemes, to generate commercial development gains that can be invested in public benefit.
NHS sites ought to be at the heart of regeneration of our towns and cities, but instead they are still more likely to be distressed sites, full of aging and deteriorating buildings instead of being vibrant developments providing state-of-the-art, integrated health and social care services with affordable housing and community facilities as part of the mix.
Where the NHS has successfully generated large-scale development it has been spectacularly successful. The strategic planning decision to develop New Addenbrookes Hospital in the green belt on the outskirts of Cambridge, rather than on the constrained site in the city has generated one of the most-successful biomedical campuses in the world. More than that, it has also released a large tract of land for residential development to support the ever-growing knowledge-based community growing up in this world-class city. Compare this with lost opportunities up and down the country, where new hospitals have been shoe-horned into sites constrained in planning terms, with sub-optimal results for both patients and the economy. Surely, therefore, now is the time to put planning at the heart of decision-making about the future of our NHS estate?