Time to get real

A loss of faith in politics results in a loss of trust in policy and the ability to implement change. What currently frightens me is the very real collapse in the public’s faith – on all sides of the political spectrum -in our system of government and the damage to our body politic that the last 2 years have inflicted.

The health sector must regain a culture of procurement and delivery, a culture that we have largely lost. The DoH must set out its stall with greater clarity - demonstrate in a series of pioneering developments what the component parts of the new healthcare estate will look like – along the lines of the model villages of the 19th century – Port Sunlight etc . Currently people do not really understand the direction of travel and conflate change with funding cuts. We cannot allow service reconfiguration to be seen as another binary choice.

Singapore has been identified as one in a multiplicity of models for a post Brexit UK. Politicians should be very wary of lazy geographical analogies – they do not travel well. Singapore is an extremely consensual society that has traded democracy for affluence – and for good reason. It has been through 10 or 11 five year national development plans and all of these have been delivered. They believe in the future because it keeps happening. The UK does not really – in all of this current mayhem no party has envisioned the future of this country with any passion or detail. The health sector has very mixed views about the future - a decade of inactivity in infrastructure investment has lost a generation of expertise and with it the ability to address risk and uncertainty. We have lost memory.

The majority of my colleagues would agree that working today on healthcare projects is like dealing with Dicken’s Office of Circumlocution. Procurement systems have evolved to ensure that nothing much can or will happen – please don’t think that this is exaggeration I could give you scores of examples. We cannot blame austerity for all or even much of this. In one of London’s 4 quadrants over £150 million has been spent in the last five years on service reconfiguration without its getting anywhere – business cases are done and redone and each iteration replaces strategy with process, sense with dull stamina – and in reality they only protect the approvers not the approved project.

In a post PFI world– hurray – we have to talk with much greater maturity about what funding is available, how we can overhaul procurement and approvals processes and what we should be planning to deliver. So let’s get positive.

1. Stop putting things in the too difficult box

2. Face up to reality.

Funding Planning and Policy:

Funding

You have to come clean;

A £9 billion budget has been identified – 33% public, 33% private, 33% disposal receipt but the chancellor has ruled out PFI without replacing it and currently we have only achieved £300 million in sale – therefore we got little more than a third up the steeple fund

If government cannot fund what is needed other means have to be identified.

Get real - there is a lot of capital about. PFI has poisoned the well of private development for good reason but there have to be other models that need not involve design or construction

Funding through disposals

I fundamentally disagree with wholesale land disposals and if these have to be undertaken I disagree that trusts should hang onto the money.

1. The trust does not profit – the developer does

2. It is geographically unfair and deepens inequality – of the £3 billion, a third or a half of this is in London.

3. Think creatively.

4. Selling to housebuilders is depressing. A vision of a very backward looking Britain.

5. Visualise the future more clearly. Healthy New Towns. Healthy old towns. Use the land to build health campuses – PLAN for once

Planning

There is a 10 year plan now but this needs funding and significant changes in the approvals processes and clear thinking about procurement methods or it will get stifled once again. Simon is speaking next and he has much to say ….

Approvals:

The 5 case model for business cases is antiquated and cumbersome and incredibly expensive. It can cost up to £3 million for an OBC which is insane. I do not consider that it offers protection anyway. How can we expend 48 pages on the do nothing’ option in a 480 page OBC? We must move to an exceptions based protocol methodology based on deviation from benchmarks to accelerate the process and save everyone months / years of wasted time and effort.

You could argue that we do not need to build anything in our towns and cities if the high streets are emptying at their current rate. The new integrated hubs will be between 2 – 5 00m2 and are well within the range of high street opportunities but if it takes you 14 months to get a business case approved that opportunity when M and S vacates will long be gone. Why not set up a close working relationship with retail sector landlords? - Consider simple primary/community developments that may well flex over their lifetime as serviced office accommodation. Think of a community health building as an office building with a wash hand basin in each room and specialise up from this as necessary – you will immediately knock 25% off the budget. Deconstruct the specificity of health care design – challenge firecode.

Integrated care

We have been advocating integrated models of care and population based systems for 25 years. My position is that integrated care can only be achieved by integrated development. The NHS has always suffered from being a single sector developer – LIFT theoretically should have changed all this and should be recalibrated and revivified. Example: Where land is at a premium in a city build three floors of social housing on top of a hub – it’ s what every residential developer would do. Example: developing health villages as previously suggested. At the moment obvious avenues all end up in the too difficult box for most healthcare development and the eyes glaze over. To the average Jo like me this seems somewhat unambitious. We were organising mixed funding streams for social housing developments back in the 1980s – it’s not beyond the wit of man to do so today.

And finally – improve the brand – the design of the service is far more important than the design of the building but one need not preclude the other. We need simple but inspiring buildings – the Maggie project is an enormous success. We have far greater resources than at any time in the past – let us reform the procurement process to put these to best use.