Healthcare Infrastructure
The APPG’s latest paper on Healthcare Infrastructure provides a welcome ‘line in the sand’ on the state of the nation’s healthcare.
Particularly welcome is the recommendation for a holistic, integrated approach to estates strategy development covering both primary and secondary care in tandem (Recommendation 1). This approach will enable the right sizing of not just community estate (which is likely to need an increase in floorspace), but also the secondary care estate – where there may be opportunities for ‘disinvestment’ and a reduction in floorspace. Thought of in this way, localised ‘disinvestment’ into acutes can be seen as a national investment into the primary care estate, bringing care closer to home, and further underscored by the intentions set out in Recommendation 3. As the APPG continues to develop their thinking on this topic, we would encourage a conversation around the practical changes that need to be brought forward to enable this ‘left shift’. More specifically, finding suitable solutions to the long-standing legal, operational, and cultural challenges within primary care (not least a separation between landlord and commissioner) that have so far prevented adequate progress on various iterations of this long-standing policy ambition.
Everyone deserves access to good, locally-based health and care services. That is why we also support recommendation 9, involving a critical review (including a ‘right sizing’ exercise) of the ongoing New Hospitals Programme. Hospitals, acute and urgent services have an important place in the future of the NHS, but lack of access and services in the community and primary arenas continues to put misplaced and undue pressure on hospitals. This perpetuates the perception that our future hospitals need to be ‘bigger’ to meet demand. The critical review will support best value by ensuring we do not overbuild costly new hospital estate, while supporting symbiotic conversations and exploratory solutions which will improve access to the right kind of care, closer to home. The roll out digital technologies in tandem with infrastructure solutions will further support reach and access to services within and between areas of rurality, as well as between primary and secondary care.
Challenges relating to utilisation (recommendation 6), parity between secondary and primary investment (recommendation 7) and increased partnership working within systems (recommendation 8) would all move towards being overcome were there genuinely commissioner owned and / or controlled floorspace in the community. Integrated services could be realised not through the market rent model (which is prohibitive to those organisations unable to sign lengthy fixed term leases), but on the basis of return on investment to the health economy – allowing complimentary services which address the social determinants of health – such as charities and / or Local Authority public health teams – to collocate under one roof. It would enable a gradual transition from a wholly privately owned primary care estate towards a mixed model. Building on the data collected as part of the primary care network toolkit exercise, this would enable commissioners to set out a road map on the future of primary care estates, prioritising investment in areas of highest need and releasing estate that is no longer fit for purpose, offering increasingly greater clarity over the future of the primary care estate locally (Recommendation 10).
To that end the authors also welcome the creation of an NHS investment task force (Recommendation 2) and a review of CDEL limits to enable the same (Recommendation 4). Any taskforce, however, must have cross party support, be given sufficient powers (including, where necessary, compulsory purchase and permitted development allowances) and a mandate well beyond the five-year election cycle, reflective of the decades-long period it takes to plan, design, develop and deliver complex infrastructure programmes at the scale the NHS requires. A culture must be established at both a local and national level that supports the empirically driven decisions of this (necessarily) apolitical taskforce such that its conclusions cannot be used for party political gain.
The NHS estate is multifaceted and complex – made even more so as the continually changing needs of current and future population health needs alter the requirements and expectations of clinical estate. And it is emotive; the estate’s maintenance is essential to the ongoing sustainability of the ‘national treasure’ that is the NHS.
And yet that is exactly why we need guts, leadership and impartiality from party politics
if difficult decisions are to be made. After all, disinvestment in one area creates opportunity for much-needed investment in other initiatives which will help transform in the way healthcare is organised and delivered and ultimately, improve health outcomes for all.
Harry Dodd MRTPI
Associate Director, Head of Primary Care, Archus Ltd.