MASTERPLANNING
Making estates more commercial and sustainable
Conor Ellis, national head of Healthcare at independent construction, property, and management consultancy, Rider Levett Bucknall (RLB UK), says that despite the Wave Four funding offered last December to NHS Trusts, ‘we are now in an era where there is less real healthcare capital expenditure in the UK’. With ‘a relatively modest public capital’ of around £1 bn per annum for new buildings, no announced successor to PF2, and, as he puts it, ‘fresh from the debacle of Project Phoenix three years of pain’, the clear tenet for all healthcare providers will, he believes, be increasing self-reliance for project capital.
We all know that the demand for healthcare greatly exceeds the funding available in the state health sector today. Total healthcare expenditure in the UK for 2017 was 9.6% of gross domestic product (GDP),1
compared with 9.7% in
2016, which was the second lowest of the seven nations in the G7,2
a position that
has remained unchanged since UK health accounts were introduced for 2013.3 It is estimated that for OECD (Organisation for Economic Co-operation and Development) countries, both health and long-term care will be driving up public spending, with an average public healthcare expenditure projected to increase from 5.5% of GDP in 2010 to 8% in 2060, and long-term expenditure estimated to rise from 0.8% to 1.6% of GDP by 2060.4
The economic gap is already being demonstrated by less, or longer, access to care, and the reduced scope of our healthcare services. This budgetary deficit is also reflected in the poor condition and unsuitable buildings of our healthcare portfolio, with a £5.55 bn in backlog in building facilities that need to be brought up to the required standard. We now have many Trusts that have declared £50 m or more in high risk/significant capital backlog.
Evidence trumps assumptions Almost the starting point for such projects is the real measure of future demand. The NHS has seen significant improvements in modelling toolkits – from published datasets like the NHSI SHAPE tool, to the Model Hospital, which help NHS organisations to analyse and map current and future demand. However, the largest area of issues lies in the assumptions that we are seeing in transfer to the community by speciality, the drop in follow-up ratios, streamlining performance or length of stay, and the move of day cases to OPD (the Outpatients’ Department). While there is
some conformity across providers, many outcomes depend on investment in the community and its relationship to the population, demographic profile, health, and poverty indicators. To achieve transformational change that not only improves organisational performance, but precisely understands the demand drivers, requires better modelling.
Achieving a more ‘accurate fit’ We can stratify by age and speciality type to achieve a more accurate future fit. We now have data to 2033, while the ONS (Office of National Statistics) provides a 2030 viewpoint giving a circa 11-year timeline. This can then be extended to mapping locations and ‘heat maps’ (see Figure 1), which can drill down as accurately as individual six digit optimum postcode location for services versus demand, travel, and other indicators.
Growth
Assumptions can be made and criteria applied to demonstrate how the baseline
population or sections of the population will grow and change. Growth is applied by the Office of National Statistics (ONS) age bands up to the planning horizon year of 2025. The impact of this growth on Emergency Department demand (Table 1) is summarised by adult/child below: Adult 6.93% Child 3.66%
The distribution of attendance for the peak hour is set out for each day of the year, and then reordered to illustrate the impact of applying a confidence interval more clearly (see Figure 2). Likewise, all our major practices will provide two or three differing scenarios – case mix, growth rates, and model of care variations. In this way we can ensure that we meet not just the business case type sensitivity, but also look at the spread of risk. Where we see the market as very light in terms of a public sector response is workforce modelling. The cost of capital is 1/50 or less the cost of running the operational unit, yet we constantly ignore
400 to 899 200 to 399 100 to 199 30 to 99 10 to 29 3 to 9 0 to 2
Figure 1: An example of modelling community services in London by postcode ‘heatmap of activity’.
August 2019 Health Estate Journal 35
©Microsoft Corporation
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