‘Meeting the Short, Medium and Long-Term Needs for NHS Infrastructure’ is the first report of the All-Party Parliamentary Group (APPG) for Healthcare Infrastructure. Intended to inform, and sit alongside, the 10-year Capital Strategy being produced by the Department for Health and Social Care (DHSC), its scope focuses on NHS E&F, the equipment used by the NHS and physical elements required to enable digital care.
Speaking at the launch of the report, Chris Green MP, Committee Chair acknowledged the growing problem of backlog maintenance, which according to the 2021/22 ERIC figures now stands at £10.2 billion, 52% of which is classified as high or significant risk. As the NHS capital budget for 2022/23 stands at £7.9 billion, the ability of providers and their system partners to eliminate backlog maintenance and invest in the latest equipment, technology and a modern estate is therefore severely limited.
“When budgets are being squeezed it’s easy to put off the big infrastructure projects for another day,” Chris Green said. However, the urgency to act is there now. Delaying those decisions creates significant problems both now and down the line. “We really need to challenge the Government immediately, through this report and wider conversations in the House.”
He also acknowledged the impact of the transition to Integrated Care Boards, which introduce new leadership, at a time of political upheaval and lack of national decision-making and direction. “This report and the work of the APPG is immensely important in informing this debate and making sure that Parliament is in a better position to champion the cause, and also challenge the Government.”
The report has been informed by a broad spectrum of contributors, including ICS leads, NHS estates experts, members of the public and two former Secretaries of State for Health. In spite of the diversity of this base, there is a good deal of consensus over key factors and decisions that need to be made.
Underpinning the recommendations made in the report is the conviction that the move to Integrated Care Systems(ICSs) is a “unique opportunity to put in place a joined-up vision of health infrastructure.” This means an infrastructure that connects facilities, the workforce and equipment provision, ensuring that these three parts work together in harmony, which is essential for the NHS to deliver quality care.
Crisis of confidence
“Our work uncovered considerable concerns around the delivery of the [New Hospitals] Programme, which has led us to conclude there is a crisis of confidence growing around it.”
Evidence heard by the APPG revealed a “clear political and public demand for investment through the NHP,” however, there are concerns. Lack of clarity around funding, lack of transparency in the delivery mechanisms and outcomes, delays to projects where building work is waiting to begin and inflationary pressures are leading to a lack of confidence in the capacity of the NHP to deliver.
In addition to its core recommendation, the report also wants the Government to invest in a new cohort of infrastructure, alongside the NHP, which would focus on delivering primary care and acute services to local communities, especially in areas that are currently under-serviced. By integrating care across the system at a local level, pressure on admissions and delayed discharge from the acute setting will be reduced, as the delivery of care closer to home is supported.
Infrastructure priorities
“Evidence given from all three ICSs to our inquiry highlighted the poor state of the health infrastructure they are inheriting.”
ICSs are seen as an opportunity for the NHS to create a high quality estate that is sustainable and flexible, takes a strategic view of the healthcare needs of people across their system and how to deliver it and considers alternative approaches, such as sharing facilities across systems to unlock efficiency gains.
There is a strong warning against ignoring the needs of social care infrastructure, investing in which will enable the sector to support the NHS in clearing the backlog of elective care. Consideration of sharing estate and facilities should not be confined to NHS property alone, but across social care providers and local authority facilities as well, thus breaking down the traditional silos.
Making the best use of all available primary care estate is also essential, particularly where estate is under-utilised following the increase of virtual appointments during the pandemic. In the longer-term, the needs of local populations could be served better by devolving the management of assets and buildings from property companies including NHS Property Services (NHSPS) and Community Health Partnerships (CHP) to the relevant ICS.
Funding
“The NHS is an outlier on capital spending with the UK falling below the OECD average for investment, even with the additional funding announced in 2021.”
In its 2019 Health Infrastructure Plan, the Government committed to meeting the country’s health infrastructure needs through public funds alone. The APPG report concludes that this is no longer viable, given the high levels of national debt post-pandemic, together with rising inflation and interest rates. Whilst the flaws of PFI have been well documented, there are other models involving third-party funding that have been proven to work. The report cites the NHS Local Improvement Finance Trust (LIFT) Programme as representing value for money for the taxpayer and an alternative source of finance that the NHS can draw on.
Digital delivery
“The greatest opportunity afforded by the creation of Integrated Care Systems is the chance to deliver fully digitally-connected ICSs.”
It may be a big opportunity, but digital integration is also a significant stumbling block, with lack of interoperability, multiple systems, equipment and software that is outdated and not able to integrate and no central standard. However, the first step for digital care needs to focus on getting the basics right - and even this is not a given - such as good and reliable WiFi, strong technical infrastructure and electronic patient record systems.
The digital infrastructure of the NHS is at present a barrier rather than an enabler, and there is a view that NHS England (NHSE) should take a lead on this issue, embedding a central standard for software to ensure interoperability, and creating a coherent and flexible data strategy for all ICSs. In addition, the APPG supports the view that ringfenced funding should be made available to ICSs for retrofitting core digital infrastructure into older care settings across the acute sector and primary care.
Looking ahead, and the rapid development of Artificial Intelligence (AI) and its transformative potential for the future must be planned for now. Any IT infrastructure must therefore be sufficient to support sophisticated AI.
Not a silver bullet
“Investment in quality health infrastructure will be meaningless without the staff to operate it.”
The rollout of Community Diagnostic Centres (CDCs) is a core part of the Government’s response to tackling the backlog in elective care. Whilst this will help, it is not in itself sufficient, and the issue of workforce shortages cannot be separated from the challenge of the estate, equipment and facilities in the ability of the NHS to deliver the care needed by its local populations.
Once again, encouraging collaboration across the system is put forward as a possible solution. NHSPS recently expanded its NHS Open Space for providers and landlords, and the APPG is calling on the DHSC and NHSE to work with NHSPS, as well as CHP and ICSs to ensure the widest range of possible providers can join the platform from 2023. This would fully utilise the existing NHS estate alongside the move to integrated care.
Key recommendations
1. Set and report clear delivery dates and milestones for each promised scheme under the NHP, committing to a cost envelope for each project that will rise with inflation, and provide clarity on the scope of these projects.
2. Each ICS area should devise an ‘ICS Infrastructure 2050’ submission to the Treasury in time for the next Spending Review.
3. The DHSC and NHSE should convene a National Forum to develop a strategy that will allow for cross-ICS movement of patients between social care settings and ensure the needs of people moving between health and social care are not overlooked.
4. The Treasury should undertake an independent, urgent review to report after the next General Election, so as not to politicise the issue, which conclusively sets out its position on independent sources of finance in building health infrastructure.
5. Each ICS should undertake an audit of key equipment in use across clinical specialties in acute, primary and secondary care settings. The Government should also fund and devolve a programme of rolling equipment upgrades to each of the 42 ICS areas.
6. Create a single, nationwide patient health and social care data platform with NHSE as the single data controller.
7. The Future of Work Review must set out recommendations for how planning reforms and other building regulations can be shaped so more health and care services are available in community and high street settings.
8. Estates and property management must be clearly devolved to each of the 42 ICS areas.
9. The Government and NHSE should consider third-party partnerships for GP premises and provide a targeted fund to modernise and upgrade the oldest parts of the estate.
10. Rules on building utilisation must be reviewed and relaxed to maximise investment in some of the most modern, fit-for-purpose primary care estate available to the NHS.
