Although a lot of the medicine practised in UK hospitals may be cutting edge much of the NHS still runs on antiquated paper-led systems in old buildings, Nick Martindale says that has to change
09 October 2017 | Nick Martindale
As the NHS prepares to turn 70 next year it is under significant pressure, which threatens to fundamentally alter the provision of healthcare as envisaged by Aneurin Bevan.
It is also in the middle of a period of significant change, as outlined in this year's Five Year Forward View; one that will ultimately see more local delivery of services using new models such as the sustainability and transformation partnerships, with the aim of easing pressure on hospitals themselves.
This, too, is having an impact on FM, both in how it delivers core services and in the kinds of areas it can influence in the health sector, and associated facilities. In the hospital space, the Carter Report, produced in 2015, remains extremely relevant, says Craig Smith, head of corporate affairs at ISS, with its vision of delivering £5 billion worth of savings, with £1 billion of that coming from FM.
"He's looking for 2-3 per cent efficiency savings year on year, which if you take that to 2021 is a 10-15 per cent real-time reduction," says Smith. "We're almost getting to the stage in some places where that could affect patient safety because the cuts have been so deep."
Catering has been particularly badly affected, he adds, as the sector has been hit by a wave of inflationary pressures - to the point where some trusts are now realising they need to increase spend just to continue to deliver the same service.
Yet Smith also believes that a significant number of FM contracts or services are not market-tested, meaning there could be considerable potential for efficiency savings by making better use of tendering.
"My calculations are that only about 30 per cent of the NHS FM market is market-tested," he says. "We have found that the first time a trust market-tests and 'privatises', because it could be in-house teams as well, they find savings of around 10 per cent. But if 60 per cent of them aren't doing that, perhaps this is where we should be looking for the savings."
Financial pressures are forcing trusts to look at the fundamentals of how they deliver services, rather than relying on providers to tweak them from inside, believes Mike Cant, director of Larch Consulting and chairman of Mercury Alliance. "We've got to a position where we've pushed the cost base down as low as it can get without falling over," he says. "With the blocking and stacking of support services within a healthcare environment you find that you can't say you're going to reduce the hours of expertise that is required. What then happens is that it's about making fundamental changes to the way the whole thing works rather than bits of it.
"It's much more of an integrated philosophy and historically that's not been something that institutions, healthcare or otherwise, have been very keen on," he adds. "The outcome for the FM sector is that we have to far more align ourselves with the research and innovation to get change pushed into the healthcare environment rather than the other way around."
Paperless environments and mobile technology
Much of the recent innovation in the sector has come about through the use of technology, both in the delivery of FM and other services and in the provision of healthcare itself. From a building management perspective, Barrie Beckett, healthcare director for Rydon, says the use of CAFM, BIM, paperless environments and mobile technology are becoming widely adopted.
"Our clients increasingly want real-time information, reporting and interaction on the performance of their buildings rather than waiting for a monthly report," she says. "Innovation can take many forms, from the technological - using LED lighting systems that may cost more initially but are more energy efficient and require less maintenance - to organisational - matching service scheduling of assets in line with frequency of use rather than timed intervals to maximise efficiency."
Smart building technology, where managers can use data on the occupancy and use of areas to control heating, lighting and ventilation, is also having an impact. "Modern building technology can have sensors in place so if the temperature is too high it can be adjusted down," says Smith. "We can link into those areas so we can treat the building as it is intend ed for, so if there's nobody in there the lights shouldn't be on. All those kinds of thing would help the NHS."
Despite this, there is room for improvement in the sector's use of technology. A Freedom of Information request by The Times found hospitals still use 130,000 pagers, accounting for 93 per cent of the estimated 140,000 still working in Britain, at a cost of £6.6 million a year.
Digitising paper records is another area where FM providers can help by improving processes. "This enables the health service to update and safeguard operations, giving NHS data an unbroken audit trail which is quickly retrievable and fully compliant with current and upcoming data protection regulations," says Nigel Dews, managing director of Harrow Green.
"Fully audited records management, such as scanning and secure disposal services, improves process efficiency and frees up real estate. Continuing innovation can help unlock legacy paper records so that the physical originals no longer need to be stored."
Cutting decontamination time
Other developments are more focused on making day-to-day services more efficient. Steven Cenci, managing director of healthcare at Compass Group UK & Ireland, points to a decontamination solution it has implemented in several trusts, using UVC lights as part of the disinfecting process. "This helps save a great amount of time as a job that would usually take about four hours can be limited to 20 minutes," he says.
Compass has also undertaken a number of patient-focused studies to see how things could be done differently or more efficiently, including a report on patient food, drink and meal service preferences, which identified a need to develop different options for patients of particular ages or ethnic backgrounds.
It has also developed a 'Dignified Dining' toolkit which it has rolled out to 60 hospitals and care homes to improve the quality of food but also the dining experience for those suffering from dementia, including using blue plates and a specially designed finger-food menu. "Research shows that the use of a bright, contrasting colour plate helps people see their food more easily and encourages people with dementia to eat more to maintain a balanced diet," says Cenci. "Our blue-plate range and finger-food menu has been rolled out to 30 hospital trusts where we deliver food to patients."
Sodexo has also been looking for areas where it can improve efficiency. "These can range from electronic meal systems, which have helped reduce the time between the patient ordering their meal and it being delivered as well as reducing food waste, to on-site food waste solutions to reduce the costs associated with organic waste disposal," says James Taylor, CEO of its UK & Ireland healthcare business. Another focus is lighting; the business has been carrying out surveys with trusts to monitor energy usage by department and assess whether they would benefit from the use of LED tubes or motion-sensor lights.
In addition to more efficient running of buildings, more effective use of NHS land and other assets is also in focus, after being highlighted by the Naylor Review. It described the current set-up as "unfit for purpose". This opens up the possibility of parts of estates or land being sold or used for other purposes, potentially creating a role for FM providers in helping to develop both the business case or prepare assets for alternative uses.
"Commercial expertise is essential for realising the NHS estate's full revenue-raising potential," adds Taylor. "As Naylor points out, bids for estate transformation funding will require robust business cases. Business services companies have wide-ranging experience and expertise in the optimisation of the property and infrastructure from which NHS organisations deliver their services. This includes reducing the operating costs, rationalisation of the estate and development of commercial opportunities." In some cases it may be more beneficial to use land for revenue-raising purposes, he adds, rather than selling off land altogether.
This could also see providers develop and run new facilities in health service buildings. Compass recently signed a new 15-year contract with Milton Keynes University Hospital NHS Foundation Trust to deliver retail services. The organisation funded the development of a new main entrance, which now includes a number of high-street brand outlets including Costa Coffee, Subway and Little Fresh convenience store.
Many trusts need help to revitalise estates to make better use of buildings. "Estates refurbishment is a critical priority for the NHS, due to historic under-investment in property which has resulted in a substantial backlog of buildings in need of repair," says Dean Ruck, Interserve's director of health and social care. "Hospital trusts are increasingly looking for strategic partners who can both design and deliver upgrades that promote intelligent use of spaces."
Cant, meanwhile, believes there will be a gradual realisation that new buildings will often represent a more efficient and practical option than restoring older ones. "The cost of conversion is starting to become too high relative to new-build," he says.
"To refurb a facility and get it to where you want to be, not only do you have the problem of what you do while you're doing it, but you also have to make so many compromises to get from A to B. If you take the technical infrastructure in an ICU, you'd need to have a completely different layout because we work so differently now. Old existing facilities will have to ultimately be replaced by completely new ones, and then they will have to put everything leading-edge into the new facility and then disband the old one."
The nature of contracting is also likely to change in coming years, with more of an emphasis on building strategic partnerships than the traditional client/supplier relationship, believes Taylor. "Contracts are more focused on outcomes rather than process," he says. "Both client and provider have a responsibility to ensure that the overall business objectives are achieved, so KPIs are agreed and everyone is very clear on the ultimate goals."
Larch also believes providers will have to become partners to the business, if they are to continue to remain relevant. "This will be a big shift," he says. "The reason for it is that if they do not integrate more fundamentally then inefficiencies will come that can't be supported.
"I am in the wilderness yelling on this one but there is no evidence now that external providers can do any better than internal teams when it comes to expertise and training and the other things that were so needed in the 1990s," he adds. "It all depends on how you manage it." He believes there will be a longer-term trend towards insourcing, as clients realise they can operate organisations just as effectively themselves.
Most of the focus for the immediate future is likely to be on the new sustainability and transformation partnerships and new care models, says Ruck. "The community model will need to be integrated and aligned to the main acute trust with the use of localised cancer care units, renal dialysis centres, step-down facilities to avoid bed shortages and better provision for mental healthcare," he says. "These will all define new models of support service functions and the need for the public sector to develop longer-term partnerships and better informed procurement."
A final issue the industry must react to is Brexit, particularly as the FM sector relies on overseas labour. "We're often the first port of call for people who come across on the freedom of movement," says Smith. "Most of them are coming into low-skilled jobs, and FM often falls into those services. If that tap is turned off we could face serious issues."