Thinking long term: Planning for the NHS estate of the future

23 Jan 2019

BPF Healthcare Committee Chair and CEO of Assura plc, Jonathan Murphy has written a guest blog piece subsequent to the release of the NHS Long Term Plan and in anticipation of the government’s comprehensive spending review. 

As the saying goes, a week is a long time in politics. The last week or so has seen the publication of the NHS’s Long Term Plan and the National Audit Office’s assessment of the NHS’s financial sustainability, both of which make for sobering reading when it comes to the task of improving the buildings from which one million patients are treated every 36 hours, and in which one of the world’s biggest workforces operates.

The plan for the NHS’s front-line services over the next decade, including the allocation of additional funding with a particular emphasis on prevention, primary and community health services and access to mental health support, has been broadly welcomed. The plan was never intended to set out the capital investment which will be needed alongside, but it does nod to the challenges ahead: “Some of our estate is old, in parts significantly older than the NHS itself, and would not meet the demands of a modern health service even if upgraded. Equally, meeting our future aspirations will require our digital capability and diagnostic equipment to be enhanced significantly.”

It’s in this context that the comprehensive spending review is now underway, considering the long-term capital needs of the NHS. There are many pieces in play, here: a ten-year strategy for the health service which pushes for more capacity in primary and community health services, easier access to digital consultation options and ever closer integration of the different providers who care for us. A primary care estate which is hugely fragmented and, in many cases, unfit for purpose – without the space, layout or facilities that will be needed in future. A £1bn backlog maintenance list for Trusts which shows no sign of shrinking, as hospitals struggle to keep on top of existing demand with the buildings they have – let alone look to the future. Revenue budgets which continue to be plugged by cash transferred from capital budgets. And the National Audit Office warning that spending in areas such as estate could affect the NHS’s ability to deliver the priorities of the long-term plan, especially if funding for these areas reduces.

There are two key asks of the spending review for those working to improve the NHS’s buildings for the people who use and work in them. First, a long-term capital plan must be just that: long-term. Give the system a clear sense of the funding it will have to invest in its buildings, technology and facilities over at least the next five years and Trusts, CCGs and clinicians can really make headway on the capital projects which will make the biggest difference for their patients and in delivering the Long Term Plan. Second, use the Plan itself to determine the priorities for allocating capital. The recent, welcome,  announcement of the latest Sustainability and Transformation Partnership capital funding had 75 projects on the list -those judged to be the most transformative of schemes. But only a proportion of these focus on primary care and health services in the community – fewer than one in five. Given the Long Term Plan’s vision for preventative healthcare, and the prioritising of front-line funding to primary and community services, are we backing that vision with the infrastructure these services are going to need? 

The most transformative capital investment of all would be that which creates the capacity and facilities for the services, tests and treatments the NHS wants to deliver away from hospital, in the community, and which allows hospitals to plan the complex schemes to upgrade and improve their creaking buildings for managing the most serious and complex healthcare needs. We don’t yet know the timing or scale of the spending review, but let’s hope the Long Term Plan offers a clear framework for talks on NHS capital.  

Because if a week is a long time in politics, a ten year plan for the NHS can seem like an ice-age. But given the scale of the health service’s infrastructure challenges, it won’t be long before we’re asking, in the words of Dr Seuss: “How did it get so late so soon?”