by Ian Oddy
It is now six months since I was invited to become property adviser to the NHS Management Executive — the body which is charged with the management of the NHS, including its estate. Prior to this, my contact with the NHS had been minimal and my knowledge of the NHS estate was somewhat sketchy.
For these past months I have therefore been learning — a situation which has been greatly assisted by the Hospital and Care Premises Management Exhibition and Conference held at the NEC, Birmingham, from October 31 to November 2. This event was really three events rolled into one — the commercial exhibition, which displayed the best and latest equipment, products and services across a wide range of subjects; the NHS Quality Care exhibition and seminars in which every regional health authority in England and Wales demonstrated and spoke on aspects of care provided by the NHS; and the estate management conference which covered a variety of topics of current interest to NHS managers — focusing mainly on the changes which will take effect next April with the implementation of the NHS reforms. The complete event was an outstanding success; the exhibitions were visited by more than 20,000 people including NHS staff from all over the country, and the estate management conference drew more than 500 people on each of its three days. The success of the event was a clear indication that NHS staff are vitally interested in the service they are providing and are determined to make it a quality service — it showed that estates staff, in particular, are preparing to take full advantage of the opportunities which will be presented as the NHS reforms are implemented.
The NHS reforms represent the biggest change to the NHS since its birth in 1948. Previous changes — and there have been several — have been mainly organisational: the present reforms are not only organisational but also deal with matters of philosophy and attitude. NHS patients will not notice a great deal of difference from next April — since it will be some months before the benefits of the changes are noticeable by patients — but for NHS staff they will be real from day one, and the transition will be a major challenge and a crucial test of management ability.
NHS estates staff will be at the forefront of change: indeed it cannot be otherwise, because the estate, along with finance and manpower, is one of the major resources of the service. The estate is both large and complex; it totals some 46,000 acres of land and buildings comprising about 1,700 major hospitals and many smaller buildings — clinics, ambulance stations, offices, stores, workshops etc — with about 100,000 staff residences. In 1987 the existing use value of the estate was over £18bn and every year more than £1.5bn is spent on its operation and maintenance. Although there was a programme of rebuilding in the 1960s and 1970s the estate is still that which was inherited from local authorities and the voluntary societies in 1948. It is therefore very mixed in terms of style and age. It has nearly 800 listed buildings, including over 300 mansions or large houses, more than 100 ex-work-houses, nearly 50 chapels and churches, and over 20 monuments and statues. Two hundred of the listed buildings pre-date 1800.
NHS estates staff are well used to change. In the 1950s they were busy coming to terms and making the best use of the estate inherited in 1948. The 1960s and 1970s saw the start of a major hospital rebuilding programme which moved from large single-scheme hospitals of 800-plus beds to the smaller 300 to 600-bed hospitals to a standard design. Today the “Nucleus” hospital design package is used throughout the NHS, and in many countries abroad.
From the 1950s to the 1980s estates staff (or “works staff” as they were originally known) led a separate existence from other NHS staff — works staff were very much confined to planning and providing new hospitals and maintaining existing buildings and grounds, and as a result the planning of services was not always in step with the planning of buildings and facilities. This situation began to change in the 1980s under the impetus of a working party (on which my predecessor, Sir Idris Pearce, was a leading member) which produced a report entitled Under-used and Surplus Property in the NHS.
This report, published in March 1983, showed a clear need for works staff to be much more closely involved in service planning, and for the employment of staff professionally qualified in estate management. It also recommended that health authorities should embark on a systematic rationalisation of their estates under a seven-stage programme of establishing a database; analysing use, condition and performance; rationalising to planned service requirements; evaluation alternatives; establishing estate investment programmes; instituting site and district estate control plans; and finally producing site and district estate operational plans.
The report led to the recognition and acceptance that estates work is not just about providing buildings and maintenance but also about proper estate planning, dovetailing with service planning to make the best use of the estate as a key resource in the provision of patients’ services. It has led to a much greater appreciation of the need for a professional input into estate strategies — with most regional health authorities now employing professionally qualified estate surveyors (registered in the General Practice division of the RICS) at senior level, establishing locally recruited property panels to advise on disposal strategies.
All this has certainly paid off. The systematic process of rationalisation and the increased estate professionalism in the service has resulted in the disposal of several hundred acres of NHS land each year. Since 1980 proceeds have totalled over £1.1bn; in 1989-90 they amounted to £231m and this year, despite the depressed state of the property market, proceeds are expected to exceed £200m. All this money is retained by health authorities for reinvestment into new patient services.
The emphasis on professional estate management and rationlisation has not, however, been at the expense of new build. The current NHS building programme is the largest ever in the history of the NHS. Nearly 500 schemes, each costing over £1m, have been completed in the last 10 years. A further 500 schemes with a total value of £5bn are now at various stages of planning, design and construction. Included in the building programme are two “state of the art” energy-efficient hospitals — one on the Isle of Wight, which will shortly open, is designed to achieve a 50% energy saving over an equivalent sized conventional hospital, while the other at Ashington, is due for completion in 1992 and which, with the aid of a wind turbine, is designed to achieve a saving of 60%.
The NHS estate and its management has come a long way since the 1970s; there are, however, still many challenges for it to face. Foremost among these are:
- The maintenance backlog. Like any large estate, continuing maintenance is necessary, and yet when money is scarce maintenance is among the first services to be cut or reduced. This has happened in the NHS, and recent estimates indicate that there is a national maintenance backlog of some £1.3bn.
- The continuing need for space utilisation and rationalisation. Although much has been achieved there is still much more to be done. The achievements so far have been in respect of what was fairly obvious; we now need to go one step further and develop a more ambitious and creative approach with a view to identifying the under-used space which is not immediately obvious. As a start in this direction the department has been involved in a number of large-scale utilisation projects and will shortly be publishing a report on what can be achieved, given a creative approach and the will to make changes.
Both of these matters are being examined by the Audit Commission in their first-ever look at the NHS estate, and it is clear that considerable attention and resources will have to be directed to these challenges. The NHS reforms will help. On the maintenance side, hospitals (which will be provider units) will be entering into contracts with health authorities (which will be purchasers of health services) with the condition of the estate being an important part of that relationship. In addition the element of competition between hospitals which the reforms will engender will tend to highlight standards, including those of maintenance. And further rationalisation will follow as a consequence of the introduction of a system of capital charging which will very clearly focus attention on the cost of the estate and the financial advantage of utilising property effectively. But we cannot just rely on the reforms to solve these problems for us — and therein lies a personal challenge to all estate managers and their staff.
In addition to meeting those particular challenges estates staff will be much affected by the NHS reforms. The three aspects of the reforms which bear heavily on estate staff are:
- The loss of Crown immunity which will require health authorities not only to comply with a variety of statutory and safety requirements but will leave them vulnerable to action by the appropriate authorities if they fail to meet them.
- The devolution of functions from region to district and to units which will require a much greater experties and estate management professionalism to exist at unit level and at the same time require regional health authorities to maintain oversight of the estate activities of districts and units and to retain the ability to act as an informed client.
- The greater competition between provider units which will sharpen attitudes to services and costs and require greater levels of effectiveness and efficiency.
This all adds up to not only a major challenge but also a major opportunity, and leads me back to where I began — the Hospital and Care Premises Management Conference. At the conference I was able to meet and talk with many of the estates staff who will be meeting these, and no doubt other, challenges. And I was very encouraged by what I saw and heard. I saw and heard staff who were dedicated to their task and who were approaching it in a thoughtful and confident way. I have no doubt that they will play their part in implementing the reforms and ensuring that the new style NHS is more responsive to local needs, more effective in dealing with its many problems and more efficient in delivering patient care. As Duncan Nichols said at the conference, when giving his keynote speech, the NHS estate is one of its three major resources which has to be managed by competent professional staff to provide the appropriate quality environment to meet the aims of the NHS reforms.
