Last July we launched our work on NHS estates with a blog that set out why it was an important area on which to focus, as well as some of the challenges and opportunities to be grasped by the NHS. Today we publish a report based on our learning from the last year.
When we began our work, we said that an effective organisation ensures through its estates strategy that people with the right skills and experience work in an environment that makes it easier for them to do their job properly. An effective system sees the efficient use of their collective estate and other infrastructure, such as IT, as an enabler to health and care staff working in partnership. And the whole point of organisations working in partnership in systems is to improve outcomes and experience for patients.
People must be at the centre
But organisations don’t do things; people do things. Perhaps the most important message from our work is that people must be at the heart of every estates strategy. Focusing entirely on the technical aspects of the location, size and funding of buildings, seeking to fit an off-the-shelf solution to a complex local problem, is likely to fail.
A strategy with a much greater chance of success will be one developed by system leaders who truly connect with the needs and potential of the population they serve and the staff they employ, who have a deep understanding of the benefits that can be realised through partnerships with local authorities and industry, and who work with advisors that bring creative solutions to well understood challenges.
That isn’t to downplay the other challenges of developing and implementing estates strategies. Getting it right when it comes to the design and financing of new buildings, as well as changes to the existing estate, requires a great deal of technical expertise and experience, and an understanding of clinical and support services.
And we found that plenty of technical expertise is available to the NHS, although – as Sir Robert Naylor reflected in his report – it may no longer all be ‘in-house’. The creation of the strategic estates planning function will be a step forward in helping local systems to make best use of the multiplicity of advice that’s available.
It’s difficult to find the time
But technical expertise is not enough. One of the greatest challenges for the local teams we worked with was finding the time to work together effectively, and to connect with the people around them.
For many, our workshops provided their only opportunity to spend time with each other away from the cut and thrust of the day job. Our workshops were held over winter, and by the second and third time they met, teams said they had made much less progress than hoped. System leaders, and indeed estates departments themselves, were entirely focused on managing the extreme pressures in urgent care – there was literally no time to think about the longer term, or space to build relationships with other groups of people.
And those relationships are critical. Again and again in our discussions we came back to how vital it is – from a very early stage – that a wide range of people are engaged in developing estates plans. For that engagement to be really effective requires a great deal of trust, and trust takes time and space to build.
Be open to new partners
A particular challenge for the NHS is to build trusting relationships with new partners. Not just between NHS partners, but across the health/local authority divide too. The NHS often views local authority relationships through the lens of social care provision, but local authorities have much more to offer estates strategies.
From a metropolitan or unitary authority perspective, it can be easy to forget that in many places the authorities granting planning permission and enabling access to other sources of funding are the district councils – bodies with which, historically, the NHS has had relatively little interaction. Local authorities are also at the heart of developing local industrial strategies – another way for the NHS to build partnerships in the wider economy that benefit estates planning.
A second group that NHS organisations need to spend time with is their own staff. Where significant changes are proposed, staff will be concerned if they affect their daily travel or other practical arrangements. And of course, staff who are working in the estate every day are well placed to identify inefficiencies and suggest improvements.
The teams recognised that many of the developments being discussed would only deliver the anticipated benefits if staff also adopted new approaches, such as mobile working. Estates strategies need strong organisational development input, just as much as they require input from estates professionals.
Gaining the public’s trust
Finally, the trust of local people is critical. One of the most widely read papers in the compendium supporting our work was an article by Andy Cowper setting out what NHS buildings can mean to local people. Andy drew out three lessons for leaders:
- appreciate the underlying relationship between the NHS organisation and the population it serves
- accept that service change is politically sensitive
- explore disagreement.
Building trust in a relationship needs honesty and openness from both parties. We have to be able to say difficult things, hear difficult things, and work through them together.
We also need to have a shared vision for what can be achieved through building trust. We hope for a different vision for the NHS estate of the future – one that maintains its position at the heart of the community, and one where the NHS estate positively contributes to improving health, rather than being a place for the treatment of ill health.
Buckingham H (2018) "Building for the future: putting people at the heart of estates plans”, Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/building-for-the-future-putting-people-at-the-heart-of-estates-plans