Navigating the new requirement for 10-year NHS infrastructure strategies
Martin Rooney discusses the new requirement for every integrated care system to develop a 10-year system-wide infrastructure strategy that aligns to its clinical vision, delivers the NHS Long Term Plan and sets out how the local estate will be used.
NHS England has launched its 2024/25 Priorities and Operational Planning Guidance, detailing a requirement that all Integrated Care Systems should have a new 10-year Infrastructure Strategy published by the summer. The work will be championed nationally by the NHS Estates and Facilities Team and has been helpfully supported by detailed guidance on how to successfully complete the task in 2024.
The aspiration picks up from the equivalent strategy programme in 2018 and 2019 for all STPs – now Integrated Care Systems – to have an Estate Strategy. As part of my previous role, I was fortunate to lead that work nationally, along with a brilliant strategic estates advisory team. That programme was, in the majority of cases, enthusiastically embraced by local NHS leaders as a way of driving improvements in patient care. It was also linked to the release of central NHS Capital – i.e. good strategy equalled an unlocking of capital funding, as per Naylor’s Report recommendations. Of course, a lot has happened to the NHS since then and the focus over the last 5-year period has shifted in several areas. Having reflected on these changes, I have taken the opportunity to share my observations on the important differences reflected in the new guidance.
NHS Land: Along with delivering fit for the future estate, in the immediate post-Naylor era we were fascinated with identifying NHS surplus land, planning capital cash receipts and delivering prospective new housing – largely to satisfy other government departments. It clearly was difficult for system leaders to openly declare their Naylor fair share (£), due to perceptions they might be promoting unwelcome disinvestment in the NHS estate without adequate public consultations. The new guidance uses a more sensible categorisation of estate; core, flex and tail (although sometimes hard for local leaders to precisely define them), to help targeting of investment plans and without the pressured drive to sell land assets.
Workforce: The guidance specifies that work force challenges are now to be explicitly addressed in strategies – a major positive step. After all, addressing staffing capacity and capability challenges in the estate and facilities community is as important as for the wider NHS workforce. For example, advocacy for apprenticeships in estates and facilities professions is a progressive step. However, the role of Integrated Care Boards, as they don’t themselves employ these staff, is more strategic than practical. The ability to positively influence and successfully align relevant stakeholders within the system will be critical to realisation of the positive benefits sought.
Sustainability: The imperative for measures which address the global climate crisis has grown significantly in need and awareness since 2019. Accordingly, we now see requirements for Green Plans, a Net Zero Building Standard and the need to address biodiversity net gain. Much of this is new territory for NHS commissioners to engage with and, for many, the support of qualified expert resource will be required. Even still, clarity on the extent of ambition here, how it is to be funded and how transition is planned are big questions not only for Integrated Care Systems but for society, politicians and the wider NHS.
Local capital investment pipelines: These remain important, of course. Yet system-owned prioritisation of often very long lists of capital funding need is an incredibly challenging task. From resolving crumbling primary care premises to fixing crumbling acute buildings; in the face of finite budgets, how do you choose what’s more important? The development of a strategy presents an opportunity for systems to put measures in place which help navigate this complex landscape, with agreed metrics for measuring return on investment in terms of risk reduction, service transformation and clinical benefit.
Community, primary care estate: The importance of investing in the provision of care in settings away from the hospital continues to gain recognition and leaders are encouraged to develop strategies that ask, and answer, questions about future of their LIFT buildings, once leases start expiring later this decade. Similarly, the encouragement is to seek better use of community-based NHS buildings and create better patient care experiences in out of hospital environments – although ICBs may often feel they do not have sufficient control to direct this. Successful implementation here will be contingent on the development of clinical and digital strategies being developed to a degree of detail that allows for identification and alignment of clear infrastructure-specific recommendations.
Governance and leadership: This remains rightly noted as a key enabler and this has not changed since 2018, when we were clear that getting this right needed to be a key objective; embracing local government especially. Ensuring infrastructure investment strategy is transparently developed and locally owned is key; and back then aimed to ensure that NHS organisations were locally aligned and shared the mission. Now, in 2024 the increase in prevalence of Combined Authorities and Elected Mayors, the pivotal role of Local Authority public health departments and the role of the Planning System in supporting disease prevention and healthy lifestyles mean that clear priorities and long-term planning are worth so much more. It’s also worth mentioning the role of NHS infrastructure spend in driving economic growth and delivering wider social value to local communities; a duty that the NHS has much scope to develop more fully in delivering long-term investment.
So, while there is much that remains familiar, there is also vast new ground to be covered. At the same time, the development of a system-level infrastructure strategy will only be successful if it is based on both quality data and clinically robust solutions which recognise scarce resource, are resilient to demographic change and are adaptable to new models of care. This is how we can create infrastructure strategies which enable meaningful change in the way health infrastructure is planned and delivered across the NHS estate, and ultimately help achieve better outcomes for all.
