Strategic Planning and the NHS Estates

Monday 27th September 1999 at the RIBA, London.

Seminar Overview

Strategic Planning in the National Health Service is suspected of being less robust than it should be, and is not supporting the changes required for the cost effective delivery of a high quality service. Recently, the need to achieve successful major PFI projects and organisation changes in the NHS has not always been conducive to achieving structural growth in harmony with need. Questions are raised about the extent to which changes and developments should be/are planned or should be/are opportunistic. What strategic planning processes are still relevant? Where are we going?

This seminar addressed the need for strategic planning, the benefits to be achieved from it, and the means of achieving it, including the designer’s contribution to the process. It is believed that new guidance is under consideration. How can we influence this review.

The programme started with an introductory overview of the financial and political options for the NHS by Professor Nick Bosanquet, and a brief historical footnote on strategic planning in the NHS by Professor Raymond Moss. It continued with papers from Ronnie Pollock on the directions and choices for service planning, from Kate Priestley, Chief Executive of NHS Estates, on current policy directions, and from Rob Thompson of NHS Estates on tools for implementing strategic planning.

Responses to the presentation were given by Dr Deirdre Cunningham, Professor Ceri Davies and John Cole, Head of Estate Planning for Northern Ireland Health Estates.

Below are AfH’s suggested structures for the presentations and responses. Speakers were at liberty to follow or diverge from these suggestions.

Presentation and Response Outlines

Part 1 – The Presentations

1. Introduction – ‘Future Healthcare Strategies’
By Professor Nick Bosanquet, Professor of Health Policy, Imperial College of Science, Technology & Medicine

  • Limiting factors: 6% GNP and rationing
  • Public / Private balance
  • Primary care led NHS: What does this mean for acute provision?
  • Changes: consumer expectations, medical advances, IT.
  • Political and financial policy options.
  • Future delivery strategies: prevention vs. cure, hospital vs. home, new visions.
  • Assessment of overall direction.

2. Introduction – ‘Planning Practice: past, present and future’

By Professor Raymond Moss
Founder Partner, MPA International Health Strategy & Planning
Founder, Executive Member & Former Chair of Architects for Health

After the arrival of the NHS, the first ‘official’ mention of a hospital building ‘programme’ was the Hospital Building Operations Handbook, which appeared in 1953. This handbook required Regional Hospital Boards to meet with one another and prepare plans for capital development on a twelve month planning cycle. Following the preparation of these plans, the Boards engaged in a debate with the then Ministry of Health as a result of which a capital allocation for each Board was proposed. But, before these ‘allocations’ became ‘programmes’, a further round of Ministry / Board meetings took place, essentially to resolve problems round Regional Boundaries. In addition, and so that the Ministry knew exactly what was going on, plans for all projects costing more than £10K had to be submitted and receive formal approval.

However, it was not until the issue of Circular HM (61) (4) that all Regional Hospital Boards and Board of Governors who managed the teaching hospitals, were charged with the responsibility of looking at the long-term requirements, and submitting proposals for capital development for the following ten years, with reviews annually.

This ten year planning horizon, updated each year, had three main aims:

  • To fit immediate needs into a longer, broader view over time;
  • To give a clearer indication of priorities in terms of a particular scheme’s place in the broader picture;
  • To clarify the position of minor works proposals. What a good idea! It’s all so obvious when one really thinks about it.

All these data were collected into a clear policy statement, and published as Command Paper 1604 1962, ‘A Hospital Plan for England and Wales’. My early years in the NHS were spent managing one segment of a Regional Health Authority’s programme. Looking back it was an amazing time – each year we would have a programme of schemes being processed – some at the building stage, some at the planning stage, and some at the research and briefing stage.

The plan brought some order within which there were times for thinking and times for action. It was not always smooth efficiency – of course there was chaos and confusion as ever, but there was also sharp focus. Because of the time allocations, especially in the design process, options were investigated in considerable detail in an attempt to achieve more efficient and economical ways of doing things. This is in sharp contrast to what happens all too often these days, when unrealistic pressures are put on design teams to produce solutions far too quickly.

This is frequently sickening to architects who know only too well that the planning and design process is not only the cheapest episode of the procurement process, but it is also the time when, by design, substantial savings can be made over the lifetime of the building.

But, planning horizons have broadened beyond the individual project and hence the accounting framework has broadened too, and these more recent political, financial and planning climates are reflected in the fact that Project Management Codes have become Capital Investment Manuals. Ceri Davies and his colleagues illuminated this landscape for us in the now famous report, ‘Improving the Efficiency and Quality of the Government Estate’, and in doing so have provided us with an idea of the Estate’s real value as a National asset, and the Estate as a potential source of benefit for, and contributor to the Service. These issues are set out by Jonathan Millman in a recent issue of HD (10/98).

These are tools for the strategic planner, and the Mereworth exercises have become models of multi-disciplinary planning and problem solving, establishing clearly the links between planning for service delivery and physical outcome, and the role of physical planners within the whole process.

But, from what one sees and hears, after a decade of NHS reorganisation on the basis of the internal market, with introspective, semi-autonomous competing Trusts soon to be joined by the more ambitious Primary Care Groups, plus the pressures generated by a knotty Private Finance Initiative, former planners have had their roles reduced, or have been side-lined, or at worst, done away with altogether. Indeed, it is claimed by many that over the last 10 year or so, planners have practically been driven to extinction.

I mention this merely to underline the fact that even if we wanted to change our planning practice now, it might be painful to do so.

When deciding about the future, we should consider not only the fate of planners, but also what we have learned about the process itself, where in the past, the vision, impetus and innovation resulted from collaboration between the Centre and the Regions – and now, when change comes about largely as a result of the energy, entrepreneurship and determination of individual Trusts, in partnership with the private sector.

  • Review of strengths and weaknesses of previous planning approaches.
  • The Hospital Plan and the DGH.
  • Ceri Davies Report and Mereworth.
  • General Management, Internal Markets, PFI and planning practice.
  • Role of the planner and multi-disciplinary: skills and training for the professional planner.
  • So what is new? The relevance of lessons from the past.
  • A Hospital plan for 2010 – do we need one?

3. Medical Planning & The Estate – ‘Confronting some realities’
By Dr Ronnie Pollock, Partner, MPA International Health Strategy & Planning

  • Future medical practice: staff levels, specialisations and organisation.
  • Service delivery: size, location and content of acute and other facilities.
  • Update on the 1992 Oxford Report.
  • Evidence based medicine and changes to the organisation of practice.
  • Philosophy of models of care for the future.
  • The real priorities now and in the future.
  • Does the environment matter?

4. The view form the centre and the new ‘party line’ – ‘Updating guidance on Strategic Planning’
By Kate Priestley, Chief Executive, NHS Estates

  • New requirements, policy initiatives and guidance – why now?
  • Roles for NHS Estates, the Regions, Health Authorities, Trusts, Primary Care Groups.
  • Roles for professional advisors, both internal and external.
  • Backlog maintenance and surplus stock: what progress? What potential?
  • Strategies for quality, value and delivery.
  • Estate planning and the role of the private sector in facility provision and management.
  • Organisation and management of strategic Service and Estate Planning.

5. Procedures and Processes for Strategic Planning – ‘Tools for Best Practice’
By Rob Thompson, NHS Estates

  • Managing change.
  • Current planning practices, objectives and procedures.
  • New planning tools and guidance: reviving Mereworth!
  • Handling finance, staffing and the estate interactively.
  • Role of Estate data and the Estate Control Plan.
  • Encouraging participation: who, how and what?
  • Boundary assumptions and present management structures: considering these as part of the problem.
  • Re-developing a planning culture.
  • Cost effective problem solving.

Part 2 – The Responses

6. The Community Physician and Strategic Planning – ‘Defining Needs’
By Dr Deirdre Cunningham, Director of Health Policy & Public Health, Lambeth, Southwark and Lewisham HA

  • The interface between the population and the Health Authority.
  • The Community Physician’s input to the Strategic Planning process.
  • Distortions of the present system and how they could be rectified.
  • Distribution of services: highlighting the pattern of change.
  • Update on presentation at the Reform Club.
  • Funding cure and care and the development of flexible facilities.
  • Promoting the dialogue between doctor and planner: documentation, measurement and assessment of health need.
  • Comments in particular on the presentations of Professor Bosanquet and Dr Pollock.
  • My recommendations for new guidance.

7. If I could now rewrite that report! – ‘The Davies report – the Millennium Edition’
by Professor Ceri Davies, Professor of Estate Resource Management, University of Wales, Cardiff

  • What I would repeat, change and add.
  • How I would develop Mereworth estate appraisal, estate development and control.
  • Trust responsibilities for planning and utilization.
  • Implementing change: the lessons learned from trying t
  • tackle backlog maintenance and surplus estate.
  • The Deken case and the limits to the acceptance of change.
  • Comments in particular on the policy, strategy, tools and processes from NHS Estates.
  • My recommendations for new guidance.

8. Trying to resolve theory with practice – ‘Some of what the Designer knows’
By John Cole, Head of Estate Planning, Northern Ireland Health Estates

  • Developing the strategic brief.
  • Interaction of brief and design and the role of the user in planning.
  • Design as cost effective inquiry.
  • Working together (Region and Trust, Doctor and Planner, Professional and User).
  • Promoting interaction between the service plan and the estate strategy.
  • Fee competition and Planning: making appropriate appointments and managing the process.
  • Comments in particular on the tools and processes from NHS Estates.
  • My recommendations for new guidance.

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