Bradford Keen and Martin Read consider the unique maintenance challenges faced by estates and facilities management personnel.
07 October 2019 | Bradford Keen and Martin Read
The criticality of maintenance within the NHS goes without saying. Yet changes in the political tide, with all their consequences for those designing and maintaining the NHS estate, appear constant. Most important, perhaps, is the NHS's backlog maintenance bill, estimated at around £6 million.
"There is limited sufficient capital funding within the system to enable us to effectively tackle backlog maintenance issues," explains Paul Featherstone, executive director of estates and facilities at Tameside and Glossop Integrated Care NHS Foundation Trust.
"Capital is severely constrained in the health sector and that's building an ever-greater problem for the future." Sometimes, the result is diverted revenue resources to "prop up buildings on a day-to-day basis", he adds.
Maintenance of healthcare assets requires following the government's health technical memoranda (HTMs). There is one for each area governing water, electricity, and so on.
"You can't get prosecuted for not following HTMs. But you'll get prosecuted for not following a legislative piece or regulation that flows down to an HTM," explains Nick Fox, a senior FM working in healthcare. Business continuity practice is understandably "highly managed within the NHS", he says, given the consequences of disruption to business as usual.
Finance notwithstanding, complex user patterns means complex asset maintenance. Today's healthcare trusts are sweating assets, with occupancy levels at around 90-95 per cent and no alternative accommodation. This, says Featherstone, can sometimes make it impossible to do the work because of a lack of access. "Either we haven't got the money or we can't get in," he says.
Accurate asset registers are critical. "The risk is much higher in a healthcare setting if you don't know what you're maintaining, who's maintaining it, and how often they're doing it," says Fox.
Compliance and risk
Compliance activity in support of power and fire systems is essential for estates teams as consequences of failure could be critical. Steve Harris, senior operations manager at Barts Health NHS Trust, tells of The Royal London Hospital having five generators when just three required to run the site.
But even compliance-light systems such as telephony can significantly affect patient experience and hospital reputation, says Harris. Telephony system failure can lead to penalties under a PFI. So having two telephones on different switches in each room means that if half the system fails, there's still a working phone to prevent the PFI's unavailability mechanism being triggered.
The problem, says Featherstone, is that "there's been a reduction in expertise in the healthcare sector", with "multiple instances of trusts failing compliance obligations. And that's because there has been a reduction in appropriately qualified people". The problem now, says Featherstone, is that for some "they don't know what they don't know".
It is an issue being addressed by NHS Improvement, the government body set up to focus on the health service's operational performance. NHS Improvement has taken over from the regional offices, which, says Featherstone, were valuable hubs for expert knowledge and advice.
The extent to which technical expertise should be outsourced is understandably contentious. For Nick Fox, using a service provider is likely to improve awareness and reporting of compliance when compared with an in-house team without compliance expertise. "Once you open up your doors to a service provider and a different way of working," says Fox, "you could argue that you tend to find compliance is at the forefront of everything you do because [as a service provider] you're penalised if you aren't compliant."
The compliance mindset's risk-based approach to maintenance is key to tackling the NHS's £6 billion maintenance backlog, says Martin Steele, chief operating officer of NHS Property Services.
"Technical compliance is all about evidence-based compliance. You need to be able to demonstrate that teams have performed a planned routine within a specific cycle [and] they have evidence they've performed a routine."
For this, the right technology platform is required. For its part, NHS Property Services has invested in securing "state-of-the-art technology to provide evidence-based technical compliance". This, Steele says, will "allow you to make sensible, rational risk-based decisions about how you use your opex or capex cost envelope to deal with the backlog maintenance".
NHS Property Services has also invested in a help-desk system to consolidate its reactive task booking - perhaps surprisingly, something the NHS did not previously have. Nor did it have, until recently, "a commercial-grade CAFM platform".
Space use and wear rates
Changing use patterns - hospitals taken above originally designed occupancy or new ways of working having left some buildings underused - have brought space utilisation to the fore, not least with an eye to future net-zero carbon targets.
If a clinical commissioning group (CCG) calculates that it no longer needs the space, Steele's team can dispose of it and "reinject those proceeds back into the health system."
NHS Property Services has also introduced a system for customers to book space on a sessional basis "so the customer is not paying for space that they don't need". Dubbed 'Open Space', it has been piloted across 20 sites.
There is considerable value in space use analysis for the special-purpose vehicles (SPVs) running PFI hospitals. Wear analysis enables more accurate asset replacement forecasting.
"If you know your lifts are doing three times the movements they were originally designed for, the life cycle on the ropes, diverters, brake shoes, door rollers is reduced to a third of what the CIBSE guide would say," Harris explains.
Nevertheless, it remains hard to predict lift footfall in the design phase. "PPM maintenance only goes so far in predicting condition; it's not an absolute science for forecasting life cycle."
This varied footfall makes user feedback difficult to gauge. Whereas an airport has fixed paths in the building along which people travel, hospitals do not. At the former, users can push the happy or sad faces for "low-complexity information" about their experience; healthcare estates don't have this controlled flow of people, making feedback harder to gather.
It behoves estates and facilities teams, then, to continually monitor space for better utilisation as well as co-location of services to improve patient flow and sweating assets in appropriate locations, explains Gary Lupton, executive director of estates and facilities, Medway Hospital Foundation Trust. "Sometimes we have non-clinical staff in key clinical blocks so you have to move them out of those blocks to maximise the clinical footprint and make sure we're using good clinical space for clinical activity," he adds.
"You don't need to have the same sort of space for support functions so we try to understand our building data in terms of room numbers: where they are, what is suitable to do in them, how many people can we get into those rooms. Also, working with service providers we ask about co-location of services. What tends to happen is we find an empty space and put a team in there that could be working with colleagues 400-500 yards away. So you really have the process of swapping people around and getting co-located and that improves interactions between teams."
Preston Gan, head of business services and performance, directorate of facilities at NHS Grampian, contends that "there needs to be a balance between qualitative and quantitative data (both building and user) that reflects and matches patient outcomes, their experience and wellbeing, that are intrinsically linked to building and FM data, which helps to inform and shape how we deliver our services across our estate".
The focus must always be on delivering the best patient experience. "For example, if one of the clinical outcomes is 'safe and effective care' that underpins the clinical strategy, what clinical data would you extrapolate? What building and FM services data would you extrapolate to support the clinical environment to meet this?"
Available data across NHS estates is huge. But there are also multiple systems and applications used to gather and process data. Gan says: "Without effective management, we run the risk of establishing silos and duplicating similar systems or functions in use." He suggests a better approach: categorise systems and applications as either core or specialist; the former required across the FM environment or across a number of FM service functions, the latter tending to be single-purpose and used by a single FM function.
Mapping core and specialist systems with associated data provides opportunities to optimise and maintain core systems and applications and potentially integrate with other systems, and identify systems and applications that can be eliminated, says Gan.
Ultimately, estates and FM activity in the NHS looks set to continue being influenced by a uniquely challenging mix of political, social, technological and technical shifts.
Hard vs soft FM in healthcare
In the NHS, hard and soft services tend to be categorised separately. Maintenance and hard FM projects fall under the estates umbrella, with soft services - cleaning, catering, portering - bracketed as FM. In Fox's experience the two usually fall under the responsibility of the estates director and so act as one team. But hard and soft services are not necessarily procured together with the "TFM concept" being uncommon, says Fox. "It tends to be put to separate providers or provided in-house."
Integrating hard and soft services is "a missed opportunity" says Featherstone, "because estates and facilities should be one. Those trusts that have taken an integrated approach generally have better outcomes," he says.
But professional boundaries remain. Estates teams usually comprise engineers, surveyors or architects who sometimes see FM, with its cleaning and portering as the "poor relation" of the estates team. And yet, as Featherstone notes, "FM" has bigger budgets, a larger workforce and more direct patient contact through those services. "Far and away, facilities is the bigger player," he says.
Integration of services can help to overcome inefficiencies. For instance, a domestic cleaner could help hard service teams to identify problem areas - a blocked toilet, a faulty light - before patients do. This is what happens at Medway Hospital Foundation Trust, says Lupton, because "the senior team is really integrated and they understand their impact on each other".
Lupton accepts that his situation is not the norm, as he's seen hard and soft services often separated, as are capital investment and operational estate teams. "Building something from a capital perspective, you need to think about the impact on the life cycle costs... don't just think about upfront capital spend, consider whole life cycle costs. Think about the maintenance; think about these guys already trained to understand these particular pieces of kit. You might want to pay slightly more for kit that these guys are going to recognise as a good brand."
NHS Property Services has successfully integrated its hard and soft services, but Steele notes that "the very nature of the NHS infrastructure means services get fragmented" as trusts have different perspectives on how they want hard FM or soft FM delivered.
"We're rebalancing our insource-outsource delivery. And that's given us a number of advantages," Steele says. "If we didn't have the scale and the geographic reach, we wouldn't be looking at this - but it's something we should at least consider. As a result, we're seeing the switch, and we're seeing our self-delivery model growing. That's given us some service and cost upside. And, in addition, we are getting better and more focused commercial contracts with our supply chain."
He stresses that he does not favour insourcing over outsourcing, merely the model that best suits a business's specific needs.