These – he said – included collating, analysing, and acting upon, accurate, up-to-date information on the estate’s condition and utilisation, identifying further decarbonisation opportunities, and rationalising and centralising services where this improves efficiency and patient experience. HEJ editor, Jonathan Baillie, reports
Stuart Douglas’s presentation on 11 May followed two preceding keynotes by Judith Paget CBE, Director General of Health and Social Services, and CEO, NHS Wales (see pages 34-36), and Nicola Pyygodidcz, CEO at the Aneurin Bevan University Health Board. He began: “I’m delighted to follow Judith and Nicola in speaking to you today, and look forward to sharing with you some thoughts on the challenges we face in managing the NHS estate in Wales. There are, of course, a whole host of such challenges – but I’m going to pick three, picking up on some of the points made by Judith and Nicola earlier.” The three ‘challenges’ the speaker then focused on were:
‘Managing today’s estate’;
‘Developing a deliverable estate vision for the future’, and
‘Achieving decarbonisation’.
Stuart Douglas said: “If we look at the first of the three, ‘Managing today’s estate’, I was quite struck this year that we operate from two million square metres of floor area across Wales, which is huge, and all needs to be heated, ventilated, maintained cleaned, and serviced. Within this, we now have a maintenance backlog of over £1 bn (excluding the impact of RAAC) . People have been surprised by this figure, but for me, particularly, the fact that £650 m of this is ‘high’ and ‘significant’ risk maintenance is the biggest concern.” If this category was not ‘arrested’, Stuart Douglas warned, Wales’s healthcare estate would deteriorate ‘at an accelerating rate’. He told delegates: “In response to these challenges – I’m going to use a sailing term – I suggest that we use navigation aids. When you go to sea it’s essential to know where you are, and what the destination is. I’d like to see if we need to look at the aids to navigating the challenge to the existing estate.” He continued: “Having the immense privilege of working across Wales, the backlog doesn’t surprise me, but looking at the EFPMS (Estates and Facilities Management Information System) returns, it’s not clear that the country’s Health Boards are investing in good survey data, and keeping current – i.e. knowing where you are and ensuring that your Board are there with you.”
Importance of investing in good current surveys
He encouraged delegates to impress upon Board members at their organisations the importance of investing in good, current surveys, and promoting action plans which respond accordingly, to meet their statutory obligation to provide a safe estate. He said: “Health Boards need that information to know that they are operating safely.” He explained that the guidance document, A risk-based methodology for establishing and managing backlog, published by the Department of Health and NHS Estates in 2004, set out the approach to recording and risk assessing backlog in the estate based on predicted impact and likelihood. He expanded: “The value of this is, firstly, that it provides a comprehensive management framework, and, secondly, that it is used across the NHS, and is therefore widely understood.” The guide recommends the estate is subject to a detailed survey of all assets five-yearly, with ‘less formal’ annual updates in between. Stuart Douglas said: “Naturally, the estate risks should be linked to, and inform, the corporate risk log, so that your colleagues on the Board can see how the ‘Estates picture’ fits within the whole.”
Risks from single points of failure
He continued: “As Judith did earlier, I’d like to emphasise the risks presented by single points of failure, which must be shared with our organisations. There are, of course, articles on events in hospitals in Scotland, England, and Wales, where failures have stopped activity or services, and of course we really need to maintain service continuity.” Stuart Douglas explained that NHS Wales Shared Services is currently working with Welsh Government to develop ‘heat maps’ highlighting where the areas of greatest challenge are backlog-wise, and in fire compliance engineering infrastructure. These would help in generating an easyto-read dashboard indicating where risk of non-compliance is, and where resources are required.
A deliverable ‘estate vision’
Moving on to the next challenge – ‘Developing a deliverable estate vision’, Stuart Douglas said: “Our ‘Estates’ vision must be focused on service. Nationally we are seeing a desire to ensure that all public services are ‘joined-up’.” Here he showed a slide highlighting examples of recently completed community and acute care developments in Wales – including the new Grange University Hospital in Llanfrechfa, the Integrated Care Hub in Cardigan, and the Wellbeing Hub at Maelfa in Cardiff. The speaker said: “Many of us would like a portfolio comprising such modern, efficient, and patient-facing stock, but it’s clearly not the case across our patch.”
The ‘first step in planning’, Stuart Douglas said, would be to create ‘a full picture of the estate’s performance beyond just backlog and running costs, identifying how well it meets its function’. He asked the audience: “Are we really able to understand how well our estate meets the service needs? Do we know how much underutilised space or ‘could be’ underutilised space we have? We really need to understand the configuration of such a vast estate.”
Utilisation of office space
The speaker wondered, ‘as a test and a challenge’, whether Welsh Health Boards were now optimally using all the office space they had pre-COVID. NHS Wales Shared Services had – he explained – developed an ‘agile working strategy’, and was hoping, in the coming months, to ‘rationalise its accommodation to meet that challenge.
In developing the strategy and vision of ‘where the service wanted to arrive at’, NHSWSSP had also looked at what public sector colleagues are doing. Stuart Douglas explained that he he had attended a conference in December at which a UK Government Property Strategy for 2022-2030 had been introduced. This offers a framework for planning and transformation of the public sector estates for police services, fire, local authority, health, and education. He said: “The thing that struck me most was that there are three main ‘missions’, which I’ll briefly describe as we might consider them in healthcare terms. Mission One,” he explained, “is to ‘transform places and services’ – for us to make our healthcare estate a positive and integrated part of the community we serve, contributing to the overall process of levelling up communities in Wales.” Mission Two, meanwhile, involved ‘creating a smaller, better, and greener’ public estate. The speaker said: “I think we are all ready to embrace a better and greener public estate, but our strategy should work to make our estates smaller. As Judith noted, we’re holding onto a surface area of some 20 football pitches unutilised. We need that space to be freed up on our congested sites, and we need the savings from all underutilised accommodation to focus on the space in order to build or maintain in the future. We cannot have better without smaller”. Stuart Douglas wondered whether new investment proposals in the future should be linked to disposable disinvestment more explicitly, which in some cases might enable Health Boards to release space, because – as in England – closing some sites was ‘very difficult for people to see’.
‘Improving professional excellence and insight’
Mission Three was, he explained, ‘to improve professional excellence and insight’. With new hospital estate costing around £10,000 per square metre, it was imperative to ‘sweat the asset we hold’. The speaker said: “We need to plan the estate very carefully, and when we have it, must ensure that its use is managed optimally to ensure that it provides the value we’re looking for. We have the ability to plan our space, and need to plan what we need. We’re in a digital age, where we should see space not just as offices, but as our theatres and diagnostic and treatment spaces, which we need to be ‘sweating’ from morning through to very late.”
With the three ‘missions’ in mind, Stuart Douglas said he would now like to suggest to delegates ‘the way you may wish to consider developing your estate strategies on three broad levels’. He explained: “Firstly, let’s think about organisational things you can do internally, collaboratively with your NHS partners, and then public sector-wide, with full multi-agency planning. So,” he said, “looking at the first – organisational, there are certainly good opportunities to re-think and rationalise what we do across our sites, and Nicola mentioned some of these areas – the new Grange University Hospital being an example.” He explained that the decontamination unit at the Grange had drawn together services supplying multiple sites, and was thus a rationalisation, while at Glangwili Hospital, a central decontamination hub serves the associated needs for all the hospitals operated the Hywel Dda University Health Board region.
Maintaining resilience when ‘rationalising’
Stuart Douglas said: “There are clear opportunities for rationalisation, but when we do rationalise, we need to make sure we maintain resilience. Then there is collaborative; as Nicola mentioned, there are opportunities and rewards for wider collaboration.” It had been great, he said, to see the recent news that Cwm Taf Morgannwg University Health Board, Aneurin Bevan University Health Board, and Cardiff and Vale University Health Board, had joined together to plan a diagnostic and kidney centre in Llantrisant in a recently acquired former BA hangar, with Rhondda Cynon Taf Borough Council playing a major role in securing the site. The speaker said: “It’s good to see local authorities teaming up with the NHS to plan and deliver services in the right place.”
“Thirdly,” Stuart Douglas said, “there is full public sector collaboration.” This area of wider collaboration perhaps offered the greatest opportunity, although sometimes it could be ‘a tall order’. In Wales, he noted, it was ‘already on the agenda’, with the Integration and Rebalancing Capital Fund which offers incentives and support for integrated planning across agencies, while in England, the NHSE/I is piloting Integrated Care Systems with NHS and local authority partners and others in developing estate strategies together. The speaker said: “We in Shared Services are very interested in hearing feedback from this, and seeing how this might be applied in Wales, and certainly value the thoughts and insights of professionals in the sector as well.”
The ‘decarbonisation challenge’
Turning next to ‘the challenge of decarbonisation, Stuart Douglas said that in the period since the declaration of ‘climate emergency’ in 2019, the NHS in Wales had been faced with the introduction of challenging targets to reduce carbon use. He said: “We now face having to progress these amid the constraints of safe engineering infrastructure and limited funds. For those who thought we could just plug new technology into existing health sites, it’s been a rude awakening.” There were, however, ‘opportunities’ – which all had a responsibility to try to identify. He said: “When I look at the portfolio of EFAB (Estates Funding Advisory Board) projects delivered by you across the NHS, it is fantastic to see increments of progress being made on solar farms, introduction of PV, and BMS controls; it is fantastic to see the imagination. I would encourage you to look at the portfolio we have produced, see what other people did, and share your valuable experiences.”
Other funding sources
Stuart Douglas noted that there were also other sources of funding – such as Re:fit Cymru, adding: “Looking at our infrastructure, we need to be ensuring that we’re planning for the introduction of any future power capacity for us to be able to rapidly reduce fossil fuel. We need to develop in anticipation of when electric vehicle charging demand becomes greater, so we have the electrical capacity to respond to that. It’s great to see collaboration across NHS Wales in supporting the joint working parties we’re running to plan a national electric vehicle charging policy.” Having a consistent and unified approach in meeting these challenges was – he said – ‘vital’.
Need for ‘clear, risk-adjusted information’
“Finally,” the NHWSSP speaker told delegates, “as with so many initiatives, we need to promote individual responsibility to achieve decarbonisation, requiring leaders across the NHS to champion the cause – people like us. In conclusion,” he added, “in response to the challenges outlined, we need to ensure that we provide our Health Board leadership with clear, risk-adjusted information on the condition of the estate. We need to develop a deliverable vision for the future, which takes the capital opportunities, at organisational, collaborative, and fully public sector-wide level. We also need to embrace decarbonisation through incremental and good housekeeping measures. We need to ensure that our engineering infrastructure needs are identified, and that we monitor emerging technologies, and changing attitudes.
Showing appreciation
“In the rush to meet our workload,” Stuart Douglas added, “and under the tremendous pressures we face, we are in danger of falling into the trap of highlighting only what is wrong, and what still needs to be done. An NHS colleague reminded me that it would be ‘nice to show appreciation for what is right, and what has been done’. One of our roles at Shared Services is to pass on various messages from Welsh Government during the course of our work, and on this occasion, I’m particularly pleased to pass on the sincere thanks of Deputy Director of NHS Capital and Facilities, Ian Gunning, and the wider team, for all the work you do. Added to that are my own thanks, and best wishes for a successful and rewarding conference.”
Acknowledgment: HEJ would like to thank the Communications Team at NHS Wales Shared Services Partnership – Specialist Estates Services, for its help in obtaining images used to illustrate this article.