The hospital of the future - more than bricks and mortar
Over the last year the government has bestowed upon many NHS Trusts the envious privilege of developing new plans for their healthcare estate under the Health Infrastructure Plan (HIP).
The Plan promises a “strategic approach to improving our hospitals and health infrastructure” that commits to 40 new hospitals and a pot of cash for £3.7bn - this cash will not stretch beyond the 6 oven ready wave 1 schemes. The wave 2 schemes, and those still jockeying to get on the HIP list have been offered funding to help develop their proposition and navigate the NHS business case processes, but a significantly larger pot is needed to deliver 40 sets of brick, mortar and steel.
Given the scale of funding involved, we must look beyond the physical nature of these civic buildings and ask if they offer a return to the public purse and are not essentially politically driven “new for old”. What is an acceptable return on £3.7bn, let alone the £20bn plus price tag for 40 hospitals? This question must be at the forefront of the minds of those charged with delivering these cathedral-like structures – especially as this predominantly acute focused investment is at odds with the ”investment in primary medical and community services” of the NHS Long Term Plan. Therefore, the development process needs to look not just at the demands for healthcare for the next generation (more activity for less cost, anticipate and accommodate new treatments and interventions, shorter lengths of stay) and design and deliver assets accordingly, but also consider the place and role of these new assets in their community and society as a whole.
These hospitals are part of the health and care jigsaw. Their development must ensure that as a minimum they improve integration across the care providers in their areas and improve health and social outcomes of the population they serve. The HIP investment must therefore offer tangible returns to the primary, community, mental and social care system in which they operate. In a post Covid world, attendance at an acute setting will be less desirable and with more health interactions away from the acute setting, the investment in acute bricks and mortar must therefore offer return to the wider care sector and the local GP. It cannot offer more of the same types of assets in the same settings with the same patient journeys.
Furthermore, it would be a lost opportunity if the return generated only sat with the care system. Each HIP project director has the ability to reshape their socio-economic locality. They must ensure projects link to the differing layers of the education system, to industry, to science and to commerce and deliver robust and long-lasting impact to these sectors. Economists will highlight the multiplier effect from major construction activity, but more important should be the longer lasting impact from the development of local capabilities, from fostering local supply chains and engendering innovative educational programmes to match the needs of the healthcare system of the next generation. The construction needs to go hand in hand with localised employment strategies with tangible targets for long term employability and skills outcomes. Importantly the business case approvals process needs to capture and commit to these skills outcomes and hold project sponsors to account to deliver these.
This should not be judged difficult. Consider the last UK hospital investment programme – under the Private Finance Initiative. Whilst this delivered modern healthcare settings, and arguably better serviced environments, unlike the HIP projects, the return on these investments leaked out of the public system. They offered little back (aside a notional risk transfer). Capability, skills and knowledge were outsourced. The Trusts on the HIP programme must redress this. They must look inward to develop the next generation of deliverers of infrastructure, using these projects to cultivate project and programme leaders as well as promoting the skills to manage the built environment of the future. They must also look outward, to draw expertise from the market that is serving them and seek ways to retain knowledge in the development processes and foster the development of individuals en-masse. The HIP programme needs to be delivered locally, by locals and for the long-term benefit of the local economy. The HIP programme will be a failure if consortia design and construct the HIP schemes before retreating to London, Paris, Toronto, or Madrid, leaving an NHS client ill-equipped to manage the asset for the next 50 years. Failure at this level, would erode the future return to UK Plc.
The HIP Trusts (as with others), are the main employer and enabler of economic activity in their area. They need to reflect how we want our future NHS and society to be perceived, and therefore direct the public investment offered to them to maximise value to society. We should not rush to a ribbon cutting photo opportunity at the detriment of a more considered, holistic, and longer-term view of maximising legacy.