Associate director at AA Projects, Sarah Butler, discusses a new resource, ‘Building for Health: The role of Estates in reducing health inequalities’, created by NHS England, and developed through desk-based research and engagement with a range of stakeholders. Its principal aim is to demonstrate how, as an anchor organisation, the NHS can use and manage its estate ‘as a catalyst to boost social value, address local priorities, and enhance the wider determinants of health, contributing to the reduction of health inequalities’
The NHS is one of England’s largest landowners. As an anchor institution and as a partner in its local community, the NHS can strategically and intentionally manage its land and buildings in a way which adds social value (positive social, economic, and environmental impacts), enhances the wider determinants of health, and reduces health inequalities
New resource created
To help realise this potential, increase awareness, and inspire action, NHS England has commissioned the creation of a new resource called ‘Building for Health: The role of Estates in reducing health inequalities’ to support the reduction of health inequalities. The content has been developed through desk-based research and engagement with a range of stakeholders from across the NHS, the wider public sector, and the Voluntary Community and Social Enterprise (VCSE) sector
The resource covers the following
Understanding the foundations – setting the context for health inequalities, the role of Estates, and the NHS as an anchor.
Building blocks for impact – The 10 ways that NHS estates can help to reduce health inequalities.
Being inspired – 10 case studies.
Putting it into practice – A checklist and top tips to use at each stage of your project.
Creating the landscape for change – A call to action.
Equipped to act
This article is an extract of what this work will provide to NHS estates teams, so they feel equipped to act. Firstly, it is important to understand what health inequalities are in order to take action in minimising them. Health inequalities are unfair and avoidable differences in health across the population, and between different groups within society. These include how long people are likely to live, the health conditions they may experience, and the care that is available to them.
The conditions in which we are born, grow, live, work, and age, can impact our health and wellbeing. These environmental, social, and economic factors are often referred to as the social or wider determinants of health. These determinants are often interlinked. For example, someone who is unemployed may be more likely to live in poorer quality housing, with less access to green space, and to fresh, healthy food. This means that some groups and communities are more likely to experience poorer health than the general population. These groups are also more likely to experience challenges in accessing healthcare or having a good experience.
How can estates contribute to reducing health inequalities?
A well-maintained, resilient estate is the bedrock upon which clinical services are delivered. It is essential that the buildings used by the NHS meet current and future service needs, provide a good patient experience and quality healing environment, and support the NHS and Government’s Net Zero carbon strategies.
As an anchor organisation, the NHS can use and manage its estate as a catalyst to boost social value (positive social, economic, and environmental impacts) in order to address local priorities, and enhance the wider determinants of health, contributing to the reduction of health inequalities
Examples of how this is achieved could be through:
1. Delivery of new healthcare buildings, e.g. the New Hospital Programme, and development of community diagnostic centres (CDCs).
2. Modernisation of NHS facilities.
3. Use of NHS buildings and spaces to support community development.
4. ‘Disposal’ of facilities the NHS no longer needs.
5. Addressing estates workforce needs, as set out in the NHS Estates and facilities workforce action plan (2022).
Strengthening relationships
Integrated Care Systems (ICS) present an opportunity to strengthen relationships between the NHS, local government, and other local partners to deliver shared aims. One of the four key roles of ICSs is ‘helping the NHS to support broader social and economic development’. The management of the NHS estate and how the NHS influences the use of partner estates and wider planning issues will contribute to this.
As a result of the work done, NHS England has grouped the ways NHS estates can add social value, enhance the wider determinants of health, and help reduce health inequalities into 10 key building blocks, and these are the focus of the resource – by splitting each building block down and highlighting what opportunities they bring.
1. Supporting community development.
2. Improving location and access.
3. Supplying healthy communities.
4. Facilitating economic development.
5. Enhancing access to green space.
6. Access to good inclusive employment and training in estates.
7. Improving design.
8. Access to quality and affordable housing.
9. Reducing negative environmental impact.
10. Social value in procurement.
Supporting healthy communities
In order to show how this will work, we will use the building block supporting healthy communities. Through desk-based research and engagement across the NHS it was identified that supporting healthy communities is one consideration that NHS Estates teams can strategically use when implementing their estate plans in order to reduce health inequalities and add social value.
These projects could include
Providing healthy and affordable food options for patients, visitors, and NHS staff.
Improving connectivity to wider public services in areas of greatest need.
Enabling social interactions and reducing isolation through volunteering.
Inclusive indoor and outdoor exercise facilities, supporting prevention programmes.
This resource provides 10 exemplar case studies that illustrate the potential of NHS estates and their role in helping reduce health inequalities through the service’s role as an anchor and partner in place.
Case study: Lambeth GP Food Co-op
One of the case studies identified as a best practice example is Lambeth GP Food Co-operative. Part of the primary care sector, the Co-op builds gardens on land occupied by GP practices and NHS hospitals. Currently supporting 10 locations, the project allows for people to learn how to grow food in a safe, secure, and supported environment. The gardens provide a space for people to socialise and learn to grow food together. Patients with long-term health conditions are given opportunities to join gardening groups at their local practice. The groups are supported by an experienced gardener to learn how to grow fruit and vegetables, and they will often make new friends
Addressing isolation issues
The work across the Lambeth GP Food Co-op has been linked to three of the 10 essential building blocks that Estates teams can use in order to add social value within their strategies.
Working to address isolation issues and support self-care and community resilience, the Co-op can support the reduction of long-term conditions, improve the mental health of patients, and promote physical activity within the community.
Top tips for making an impact
The ‘building blocks’ can be used to identify and explore estates opportunities to ensure that they add social value, enhance the social determinants of health, and reduce health inequalities. They can be applied:
to all types of NHS estate.
at any stage of the planning and management lifecycle – from scoping and defining, through to operations and maintenance, to disposal.
at an ICS level.
to estates strategy, business case, decision-making, and wider planning issues
A checklist and framework are provided in the resource. These can be used at any stage of an initiative, but would be most valuable if used as early as possible and iteratively throughout development and delivery. They could be incorporated into most existing project management processes
Other key focus areas include:
1. Focus on what matters. Estates opportunities should be as impactful as possible, so they could address identified priorities and population needs identified in NHS England’s Core20PLUS5 approach to reducing healthcare inequalities or health priorities set out by the Integrated Care Board (ICB), Integrated Care Partnership (ICP), the Trust, or other place-based priorities.
2. Working in partnership with communities and stakeholders. Working in partnership with communities and stakeholders will help identify what is important and of value, support innovation, and help ensure that local assets are utilised and enhanced where possible. The resource provides signposting for working in partnership with people and communities.
3. Evaluate and iterate. To check that the initiative is making a difference, it is important to evaluate the impact. This can inform the next steps, including any iterations required. Sharing impacts also supports transparency and accountability, and allows successes to be shared and celebrated. The resource provides signposts for how we can evaluate the impact.
Creating the landscape for change
There are many good examples of how NHS estates are consciously and proactively adding social value, enhancing the wider determinants of health, and helping to reduce health inequalities. However, this practice is not ‘mainstream’, and where benefits are being realised, they are not always being recognised, reported, or celebrated. The full resource proposes a call to action for national organisations, ICSs, and NHS providers, set out under the following headings:
Increase awareness and understanding.
Strengthen leadership and culture.
Embed into guidance, strategy, and business cases.
Develop new ways of working
Advancing and spreading good practice
Examples of how providers can advance the spread and scale of practice, as well as make these actions more systemic, could be through training and development, ensuring that all public sector supply chains share an understanding of their community’s health inequalities, as well as embed health inequality considerations into business cases to ensure that future capital investment and estate plans consider the reduction of health inequalities as a key priority.
Case study: St Basils Live and Work Scheme
The St Basils / Sandwell and West Birmingham Hospitals NHS Trust’s (SWBNHST) Live & Work scheme is a unique and innovative example of successful partnership working, which demonstrates the importance of taking a holistic approach to address the joint needs for housing and employment of homeless young people between the ages of 16-25. The Trust partnered with St Basils homelessness charity to transform an empty unused hospital building into use for homeless youth, who then lived and worked on the Trust estate.
Split into two aspects, the housing aspect of the scheme has involved taking on an empty unused building and refurbishing it to offer affordable shared living accommodation in close proximity to Sandwell General Hospital. The employment aspect of the scheme offers training and follow-on paid apprenticeships in a potentially wide range of NHS skills, which include Health and Social Care, Business Administration, and Customer Service areas across a wide range of SWBNHST departments, including Physiotherapy, Cardiology, Phlebotomy, Oral Surgery, and the Birmingham Midland Eye Centre. The training provides valuable work experience, leading to a NVQ Level 2 qualification, which in turn leads to the opportunity to apply for a permanent job or further training within the NHS Trust, or elsewhere.
Facilitating economic development
The St Basils / SWBNHST project is a perfect example of the application of multiple ‘building blocks’ in order to reduce health inequalities. By facilitating economic development through the repurposing of unused NHS estate, the innovative partnership has provided individuals with access to good inclusive employment and training, as well as access to quality and affordable housing.
Sarah Butler
Sarah Butler has over 10 years’ experience in the property industry via several operational and strategic roles, including a PPP property organisation within the NHS. She has played an essential role in the completion of the ‘Building for Health: The role of Estates in reducing health inequalities’ initiative commissioned by NHS England. Currently associate director at AA Projects, where she has been for seven years, her MBA dissertation research on technology and the impact on the estate in the NHS has been published by FM World and the EuroFM Network.
She has experience in managing programmes, stakeholder engagement, estate strategies, funding applications and business cases, options appraisals, space utilisation studies, feasibility studies, project implementation planning, and benefits realisation studies