It is fair to say that we remain in turbulent times across the healthcare sector. We have all emerged from the pandemic hoping for some much-needed stability, and while there are promising signs of things getting back to some form of normality, it is clear that it will not be ‘business as unusual’ for quite some time yet. Added to this, the structure of the NHS is going through important changes – most notably with the new Integrated Care Systems (ICSs) being established across England – that will help to transform how different organisations plan and deliver joined-up health and social care services in different regions.
It is also a time of huge political change – at the time of writing, two politicians are battling to become the country’s next Prime Minister, and by the time you are reading this, one will have been selected, and will have started setting out their own vision for the UK, including what the NHS of the future might look like. So, the health estate finds itself in a perfect storm of political uncertainty, a changing NHS landscape, and with the after-effects of the pandemic still being felt.
A track record of resilience
As we know, however, the NHS has remarkable track record of being resilient for more than 70 years, never more so than in recent times. While there is understandably a desire to turn the page on the pandemic and start a new chapter, it would be a missed opportunity not to reflect on what worked (and what didn’t) during COVID. Understanding how the NHS survived the challenges of the past two years can offer us invaluable lessons on how we can set up the health estate of the future to deal with whatever might come next – in simple terms, as we look to the future, we must also learn from the past. In writing this article, I therefore wanted to try and capture some of the key ‘lessons learned’ – both from my own experiences, and from those of colleagues and industry partners from across the health estate.
The primary care estate’s vital role
When we think about the role of the health estate during the pandemic, our attention is naturally drawn to major hospitals, the acute sector, and emerging new facilities such as the Nightingale centres. This is completely understandable, of course, given the heroics that these buildings, their staff, and volunteers, performed around the clock; the images on the nightly news of the battle for COVID being lost and won on busy hospital wards made for harrowing, but compelling, viewing
However the primary care estate – and the estates professionals that manage this vital part of the NHS – also emerged as one of the quiet successes of the UK’s COVID response. I saw this at first-hand in my role as CEO of Fulcrum Infrastructure Group, an investor in more than 40 community health facilities delivered in partnership with key parts of the NHS family under the NHS LIFT programme. As the Chair of The LIFT Council – the representative body of private sector investors in the NHS LIFT Programme – I also saw the vital role that other NHS LIFT providers, their buildings, and EFM staff, played during the pandemic.
In just two years of the pandemic, many of the 350+ primary care buildings across the LIFT estate effectively took on three different ‘COVID lives’, each creating their own changes and challenges from an estates management point of view:
Firstly, as ‘Hot and Cold hubs’, with temporary new layouts created to allow day-to-day services to continue as normal, while other space could be safely created to deal with the emerging pandemic, and the need for diagnosis and treatment space. In several Fulcrum buildings, for example, such as Akerman Health Centre in south-west London, and Waldron Health Centre in south-east London, large areas of temporary partitioning were used to create a temporary re-routing of patients and a clear barrier between COVID-related facilities and ‘business as usual’ services;
Secondly, as vital testing facilities – LIFT buildings are located in the heart of the community, so they offered a perfect location for NHS testing services, meaning residents and vulnerable people could access the help they needed on their doorstep, avoiding the need to travel too far at a time when long periods of lockdown meant everyone’s mobility was hugely restricted;
Thirdly, and finally, as vaccination centres – again by making use of the buildings’ community-based location to offer millions of residents a convenient place to get vaccinated as the COVID fightback began
‘Business-as-usual’ role
In parallel with the three ‘COVID lives’ of NHS LIFT buildings, their role in offering vital day-to-day health services (GPs’ surgeries, dentistry, pharmacies, and social care etc) also continued where it was safe and practical to do so. From the moment the pandemic began to gather pace in the spring of 2020, NHS LIFT buildings (and the estates professionals that manage them) were thrust into an ever-changing journey, where the same four walls had to constantly adapt and evolve to offer a lifeline to local communities, whether it was for testing, treatment, vaccines, or many other health and social care services in between.
It was a unique challenge, and probably one that many health estates professionals will not see again in their lifetime. In circumstances like these, it is always tempting to come up with a clever statistic about how many square metres of new clinical space were quickly created, how many miles of temporary partition walls were installed, or how many variation requests were approved at record speed and so on. However, the reality is that the urgent changes to our buildings happened so quickly that it would be impossible to track, and even if numbers were available, it is unlikely they would capture the true scale of the unprecedented changes and challenges that estates professionals faced.
Building flexibility into the primary care estate
The speed at which these changes happened points to two fundamental strengths of NHS LIFT buildings – which are vital elements to build into any plans or decisions about the primary care estate of the future. Firstly, as modern, innovative buildings, LIFT facilities had the space and flexibility to quickly adapt to the needs emerging from the pandemic – something that simply wouldn’t have been possible with older parts of the NHS estate. LIFT buildings are significantly bigger than traditional primary care buildings so, taking the creation of ‘Hot and Cold Hubs’ as an example, it was much easier to create the separate entry and exits necessary to separate the space. Indeed, this capability is now being built into future variations to space to make LIFT buildings able to deal with what the future has in store.
What the pandemic helped to underline is that demand on the NHS (and the primary care sector in particular) is constantly changing, evolving, and generally increasing. There is a clear ‘lesson learned’ – that it is not only vital that we create enough capacity to meet future demand, but also that we make that capacity as flexible as possible, so that it can be quickly adapted to a range of possible future needs.
Partnership working and embracing the private sector
It is not only a case of what NHS estates capacity is created in future. Who is involved in delivering it is also a key consideration, and points to the second underlying strength of the NHS LIFT estate that we saw during the pandemic – namely, the important role that the private sector has to play. To briefly recap, the NHS LIFT Programme was designed to bring together private sector investors with Community Health Partnerships (CHP), a key part of the NHS family. As long-term partners and co-investors, CHP and the private sector partners share a common interest in ensuring that LIFT healthcare facilities continue to be wellused, well-maintained, and best serve the local community. It is a partnership that has a 21-year track record in delivering for local communities and the NHS, with over 350 community health buildings now delivered across England under the LIFT programme
The role of the private sector in the NHS is understandably a ‘hot potato’, and one that quite rightly attracts much debate and scrutiny. It’s important, however, that the debate covers all parts of the argument. The financial support offered by the private sector is crucial, especially at such a challenging time for public finances, but we shouldn’t only focus on money – this is also about the expertise, skills, and resources the private sector can offer to help tackle existing and emerging challenges in the NHS.
Ability to adapt
The pandemic was a perfect illustration of this where, as I set out earlier, many of the community health buildings delivered under the NHS LIFT partnership needed to quickly adapt to help the NHS’s fightback against COVID. The vital role of the private sector in the LIFT partnership meant that quick decision making, and additional funds and resources, were more easily available, allowing our buildings to very quickly adapt to emerging health needs – whether it was for testing, treatment, or vaccination. It really was an ‘all hands on deck’ scenario of people working for a greater good, regardless of whether they were from the public or private sector. A good example of this is the Tessa Jowell Health Centre in Dulwich in south London, which is the newest building to be delivered under the LIFT partnership. This was a building that was literally ‘born’ during COVID, opening its doors right at the peak of the pandemic.
A ‘dual challenge’
As the project neared completion, it was faced with a dual challenge where the emerging health crisis meant the delivery of vital healthcare facilities became even more urgent, but where lockdown restrictions made the completion and opening of the building ever more challenging. The public and private sector delivery partners tackled this dual challenge head-on, and were fully committed to tackling whatever hurdles emerged to ensure that the building could be opened as planned. A small anecdotal example shows the considerable lengths the key partners went to in keeping delivery on track: when faced with a construction working area that was too small to allow workers to adhere to social distancing guidelines, the site teams went to great lengths to identify two workers from the same household ‘bubble’ who could safely work together in the same small area, ensuring that valuable construction time was not lost.
Despite the considerable challenges created by COVID-19, the building was completed on time and on budget, allowing the Tessa Jowell Health Centre to open to patients and NHS staff in May 2020 – a critical moment right at the peak of the first lockdown period.
Keeping the delivery of the new facility on track in the middle of a pandemic was only possible because of the public and private sectors working together – a great example of the importance of partnership working, with the public and private sectors shouldering the challenges and sharing the successes together. It underlines that the private sector has a vital role to play, not only financially, but also because of the experience and expertise it can offer to secure the best possible outcomes for the NHS.
The changing face of the primary care estate
For the primary care estate, and LIFT buildings in particular, a further consequence of the pandemic was the urgent need to relocate key services out of major hospitals into community-based settings. Clearly, this was a move forced upon us by COVID, and an essential step in helping to reduce the burden on major hospitals at such a critical time – but what was done at great speed and out of necessity has actually helped to change the mindset of how capacity in the primary care estate could be used over the longer term. What we are seeing is that it is now much more acceptable for services traditionally delivered in a hospital to be provided elsewhere; gone are the days where community-based primary health facilities are earmarked for GPs’ surgeries, pharmacies, and little else. The pandemic has shown us the huge advantages of making better use of capacity in the primary care estate, moving a wide range of services out of hospital settings and into community-based facilities.
Shaping a more permanent outlook
From a LIFT perspective, some of the temporary changes to our estate during the pandemic are now helping to shape a more permanent outlook, and we are seeing at first hand the changing face of the primary care estate. As an example, in October work will start at the Bath Street Health Centre in Warrington to deliver new capacity for breast screening services right in the heart of the community – a timely moment as people across the health sector mark Breast Cancer Awareness month. The same month will also see World Mental Health Day – a subject that will only increase in importance after the impacts of the pandemic on loneliness, isolation, and mental stress in communities across the country. The LIFT estate is already helping to tackle this increasing health challenge, with the Gracefield Gardens building in south London, for example, recently benefitting from £2.3 m of investment to help create a new Living Well Network, offering thousands of residents a single access point for mental health services.
Offering alternative birthing options
Other examples include the provision of a new midwifery unit and birthing centre at Lowe House Health Centre in St Helens, helping to reduce pressure on local hospitals by offering alternative birthing options for families in the local community; or the Tessa Jowell Health Centre mentioned earlier, where traditional services such as a GPs’ surgery and family services sit alongside state-ofthe-art medical facilities such as a renal dialysis unit, cardiology, and respiratory diagnostics.
So, from mental health to maternity, renal dialysis to cancer screening, the face of primary care is changing – and changing for the better. The adaptations and building variations thrust upon us by COVID have led, somewhat unexpectedly, to a shift in mindset about how the primary care estate could and should be used in future. I firmly believe it is a change we should all embrace, and not make the mistake of reverting to the models of old, where rigid lines were drawn between what services should sit in the acute and primary care sectors.
Embracing this change could be a transformative step for the NHS and local communities, but one that will also require a change in mindset in how we operate as health estate professionals; we will need to be more open-minded about what services and facilities can be accommodated in our buildings, and continue to find new and innovative ways to adapt the spaces we manage.
Equally, it is not just our own buildings we should keep an open mind about. While we as healthcare professionals take pride in the quality and variety of services offered in our own buildings, this should not prevent us from being openminded about whether future healthcare provision could be better served in places and spaces beyond our immediate remit. Instinctively, we always think about using existing NHS estate, but COVID has changed this for the better. The public have shown us that they are happy to access testing and vaccine services pretty much anywhere – a shopping centre, a football stadium, at drive-through locations, and many more.
Preventing ICUs from being overwhelmed
A great example of this is the work during COVID by gbpartnerships – a leading investor and developer in health and social care. As the pandemic began to gather pace, it became clear that ICU facilities around the country could be quickly overwhelmed, so the gbpartnerships team worked closely with NHS partners to develop plans to add capacity in stepdown beds, allowing patients to be shifted out of ICU as soon as possible.
gbpartnerships worked across a range of sites, including a major sports facility, where plans were quickly developed to create 350 beds on site, to be delivered in just six weeks. The beds were created in a combination of temporary structures and retrofitted existing accommodation, and, by making use of the venue’s commercial catering facilities and ample toilet facilities, the key partners were surprised to discover how amenable a hospitality and event building was to adaptation for inpatient use.
Examples like this not only show the ingenuity of estates professionals, but also the possibilities that exist by looking beyond just the health estate. This could, and should, be a real step-change for future decision making about how and where we locate health services, and is a chance to tackle not just health priorities, but also wider goals such as ‘levelling up’. For example, it is easy to see how using empty retail space for health services would not only be of huge benefit to local communities, but could also help to reinvigorate our high streets.
Firm foundations to tackle whatever comes next
Clearly, the pandemic has had a profound impact on the NHS, and to paraphrase Dickens, it has been ‘the best of times and the worst of times’ for the health sector – the worst of times because we saw an unprecedented health crisis stretch the NHS to its very limit and where, sadly, many people lost their lives. However, it was also a period when we saw the NHS, its staff, and buildings, at their very best, going above and beyond to deal with unprecedented challenges, and adapting to every twist and turn of the pandemic to keep supporting patients throughout.
For very obvious reasons, there is a desire to put the pandemic behind us, but from crisis comes opportunity, and it would be a mistake not to take the lessons learned from COVID and use them to help shape decisions about the health estate of the future. For those of us in the primary care sector in particular, the pandemic showed the extraordinary flexibility and resilience of our existing buildings, and the need to build this flexibility into future primary care provision so that any new investment in ‘bricks and mortar’ is futureproofed.
It also showed us the strength of the public and private sectors working in partnership to make changes at record speed, and how the private sector still has a vital role to play in the health sector, not just from a financial point of view, but also because of the expertise, skills, and resources it brings.
Changing mindsets
Perhaps most profoundly, the changes we saw during the pandemic have further shifted mindsets about what the primary care estate could and should be used for. The face of primary care is changing, with a ‘blurring of the lines’ between what services should be in major hospitals, and where the opportunities lie to move them into the community by making better use of capacity in the primary care estate. With these changes, challenges, and opportunities will come a need for us as health estates professionals to also adapt our mindset and our ways of working, but everyone involved in the NHS estate has already shown what we are capable of. Just as our buildings were able to adapt to the huge pressures of the past two years, so too were the thousands of estates professionals able to rise to the challenge presented by COVID, and play their own vital role in supporting the NHS and local communities. The sector should rightly be proud of what it has achieved throughout the pandemic, and use it as a firm foundation to give us the confidence and momentum to tackle whatever challenges come next.
Sarah Beaumont-Smith
Sarah Beaumont-Smith is the CEO of Fulcrum Infrastructure Group – the private investor in over 40 healthcare centres delivered in partnership with the NHS through the NHS LIFT programme. She joined Fulcrum in 2009, and brings more than a decade of experience in investing in quality community healthcare facilities. In 2020 she was also elected as Chair of The LIFT Council – the representative body of investors in the NHS LIFT Programme.