Mastering the estate

Mastering the Estate in Health and Education By John Kelly, Director of Healthcare Planning and Kate Campbell, Associate Director at Essentia

Both the health and higher education sectors have similar challenges and objectives in relation to developing successful estates strategies. In this article, we compare the two and look at potential solutions that can be exported from the health sector into higher education.

  • Ensuring that estate strategies are aligned to clinical and academic objectives

In an ideal world, organisations developing or revising their estate plan would have a clear and up-to-date business strategy. Ideally, this would include:

  • An analysis of the operating environment;
  • A response to the opportunities and threats this presents;
  • A view about the changes likely in the short, medium and long term.

In practice, complex organisations such as NHS Trusts and universities may fail to tick all the strategy boxes, meaning that a clear brief for a masterplan may be elusive. For those with a linear “first-things-first, form-follows-function” frame of mind, this can be frustrating.

An alternative approach is for business and estate strategies to be developed iteratively, delivering results much faster.

This worked recently for a major NHS Trust emerging from a period of financial challenge, recovery from which had absorbed organisational bandwidth and capacity.  Against this backdrop, it became clear that a refreshed clinical strategy would take several months to complete, partly because of an exacting consultation and approval process.

By agreeing key principles and fixed points, it was nevertheless possible to commence developing an estate strategy which could be refined progressively as clinical priorities were finalised.  

Another benefit of this approach is that properties can be identified that are surplus to requirements under any service scenario, releasing resources for re-investment.

  • Maintaining agility in a volatile policy context

Fast-changing environments mean that it’s difficult for organisations to pin down their clinical or academic strategies. The description of the future as trumpet-shaped, implying a wide range of possibilities, has never seemed more apt.

Within the NHS, the development of Sustainability and Transformation Plans (STPs), intended to join up the components within 44 health and social care systems has created more uncertainty around what capacity a major acute hospital should plan for.

For one hospital, a capacity of around 1,200 beds (the bottom end of the trumpet bell) would be sufficient, assuming full implementation of initiatives to reduce admissions and expedite discharge. But if current demand were to continue, the hospital would require an additional 400 beds by 2028.

Parallels can be found in the higher education sector as institutions consider their investment decisions against a backdrop of potential changes to the student loan regime and the uncertainty of the Brexit effect on research funding.

Dealing with this kind of uncertainty is a key masterplanning challenge with the risk of under-capacity and foregone income if investment is too low or excessive running costs and the embarrassment of empty wards or seminar rooms if investment is too high.

One idea, used by the hospital above, is for the masterplan to hedge the uncertainty by the progressive replacement of existing wards in new accommodation, allowing the Trust to monitor the impact of system-wide demand management and discharge initiatives. If these are effective, the older ward accommodation can be converted to non-clinical use or demolished, but if the initiatives fail to deliver the older ward capacity can be retained and, in time, replaced. 

Testing masterplan options for their robustness to deal with different possible futures is a good idea. A major academic and health science centre might consider future campus scale and configuration under varying assumptions including the extent of digital disruption, devolved versus centralised models and the off-site outsourcing of support services.

  • Harnessing investment in estates and facilities to catalyse new ways of working

A study in a tertiary hospital in the USA (Zimring, 1990) identified that the annual cost of staff time spent in giving directions to patients and visitors was around £0.25m. While this is a relatively small amount in comparison to total running costs, it nevertheless underlines the impact which estate configuration has upon service delivery.

In healthcare, a significant opportunity was identified in a recent project where outpatient consulting suites were dispersed in small clusters across a hospital campus. Analysis identified that productivity, measured in annual attendances per room was around half that which could be achieved through improved scheduling and progressive centralisation to release the stranded capacity. As well as reducing overall space requirements the new model will improve patient experience with a one-stop service and enable more effective use of staff. 

Similar opportunities can be found across the health and academic estates when masterplans address the legacy of piecemeal development to improve adjacencies, streamline pathways and logistics and reduce inventory though just in time delivery.  

A useful way to assess how far a masterplan contributes to process efficiency is through the application of a LEAN scorecard which measures improvements in the flows and reduction in waste. LEAN methodology has been applied extensively across the health sector internationally over the past decade, minimising waste which is defined as unnecessary steps in a process or excess space. While the application of LEAN has been less evident in the education sector, it is just as relevant when considering how the campus reconfiguration can reduce staff and student travel time, improve space utilisation and reduce occupancy costs.  LEAN can be applied at different phases of a masterplan and as part of benefits realisation.

  • Overcoming data deficits and avoiding analysis paralysis

A successful estate strategy for a large academic and health sciences campus requires careful consideration of information requirements.

It is common for organisations seeking to develop an estate strategy to identify data deficits in areas such as existing building condition, space utilisation, future activity levels and, as noted above detailed business strategy. One response is to initiate a major data gathering exercise. While appropriate in some cases, this can delay the development of the strategy and, if unfocused, risks wasteful investment in compiling information which may be irrelevant to the strategic questions to be answered. 

An alternative approach is to identify which information gaps are likely to be significant in the development of the strategy and, crucially, when. With a targeted approach to filling the gaps that matter, abortive effort can be avoided, alternative methods such as peer group benchmarking can be considered and, with the estate strategy proceeding in parallel, data requirements can be defined more precisely.

  • Maintaining momentum

Of course, achieving sign off for a completed estate strategy is just the beginning and what matters next is implementation.  Central to achieving this is stakeholder support which will involve a wide range of interests and disciplines. This should be a key objective from the outset and it’s important to recognise that different organisations will be in different states of readiness. Successful implementation also requires clear and realistic timescales, designed to provide early demonstration of benefits.

And finally, the best strategies are living frameworks, capable of ongoing revision in response to an, inevitably, changing environment.

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