Are your premises functionally suitable?

Having picked up on some nationally released information in November 2010 the BBC issued Open Information (OI) Questions to trusts in England asking the above question with some more detail. The response from NHS organisations was quite interesting and generated not a little radio and television debate. During this I was asked to respond to the issues on radio programmes and to the paper media. Read on for a summary of the points raised by this debate.

NHS premises
November was a very interesting month starting as it did with the annual Scottish Healthcare Conference I reported on in the last article¹. With my mind buzzing from all the ideas and potential problems that event highlighted, I was looking at the consequences for our subscribers of the current and coming financial constraints and considering how some of the ideas could be implemented as cost saving measures when a call came in from the BBC. They wanted to discuss the fact that a fifth of the NHS premises in England were not functionally suitable for the provision of healthcare².

The BBC researcher and I had a lengthy chat around where the figures they were quoting had come from and how much (or perhaps more truthfully – how little) they understood of what the data set they referred to meant and why it was collected. There were several points of interest that came out of that initial discussion including the fact that they had not even looked at the definition of the functional suitability return. Having gone through the more obvious bits of the topic a number of other points of understanding became clear:
• The actual figure was not a fifth (20 per cent) but 17 per cent of the healthcare estate
• Functional suitability measures do not mean “unsuitable for use”
• Not all of the healthcare estate is used for patients
• Some responses from NHS Trusts showed naivety in dealing with the media
• The BBC were not interested in any of the good news from the report.

I will look at each of these points in turn as they highlight some interesting lessons for the NHS and indeed the Department of Health (DH) and The Information Centre (IC) to learn.

The statistics
The actual figure was not a fifth but 17 per cent of the healthcare estate: In all their TV and radio reports that I was either involved in or subsequently heard or saw the BBC reported as the headline that a fifth of NHS premises in England were not functionally suitable for the provision of healthcare. Only in the detail did they say that the figure was 17 per cent.

This 17 per cent figure is NOT from the DH or IC reports. It has presumably been calculated by the BBC and this would require some detailed analysis of different elements of the reports. The actual statement that the BBC used in its reports is: “The Department of Health figures show that 17 per cent of the NHS estate is classed as ‘not functionally suitable for use’. There are 142 sites with 50 per cent or more of their estate falling into this category, including 33 acute or specialist hospitals.”

Having run the report from the IC web site myself I find that of 387 reported NHS organisations only 23 report a figure of 50 per cent or greater. Of these six are Primary Care Trusts, four are Specialist Acute, five are Large Acute, two are Medium Acute, three are Small Acute, two are Mental Health and Learning Disability Trusts and one is an Ambulance Trust.

My point: You can make statistics say what you want. I have deliberately highlighted the information by organisation (as we tend to deal with the NHS as organisations) where the BBC chose to deal with it by sites (meaning hospitals) as that would catch the public eye. Quite valid and correct but it does sensationalise the figures and also loses the fact that a good proportion of the healthcare estate is not used for patient care but for support and management. Interestingly of course SHA premises are not included in the returns so there is no measure of the pure management element of the NHS for the statistics.

Suitable or unsuitable?
Functional suitability measures do not mean “unsuitable for use”: There was a clear belief in the questions being asked of me that the functional suitability measure meant that the facilities were UNSUITABLE for use. The actual definition of the data collected is: “Percentage of occupied floor area that is below Estatecode Condition B for functional suitability (i.e. below an acceptable standard, or unacceptable in its present condition, or so below standard that nothing but a total rebuild will suffice).”

To properly interpret this you need to understand Estatecode and also what the relevant “standards” are. There is a huge gulf between below an acceptable standard and so below standard that nothing but a total rebuild will suffice. With revisions in the space around beds in recent years as an example, there will be many areas that do not quite match this standard but are still quite capable of being used effectively for patient care. The NHS would very much like to match this standard for reasons of patient comfort and infection transmission but the value judgement has to be made – close the ward because of a small failure in space requirement or continue providing care in the same space as has been used for years until such time as funding allows for improvement.

One specific response from a trust will be highlighted later.

Use of the estate
Not all of the healthcare estate is used for patients: One of the measures in the ERIC returns is Patient Occupied Floor Area. From the figures on the IC website this is showing as 44 per cent of the total internal floor area of all reported organisations. Interestingly 24 organisations failed to report data in this important field and 15 reported zero – i.e. they have no Patient Occupied Floor Area. Unsurprisingly these are mainly Ambulance Trusts and their floor area is made up of offices, control centres, training facilities and ambulance stations. However, there are also two Primary Care Trusts, one Acute Teaching Trust and one Mental Health and Learning Disability Trust. I would be interested to know if the Department of Health has approached these for their data.

Within the data collected there is no way of linking the amount of patient occupied floor area with the functional suitability figures. As the fail points can be standards or condition related and there is no way of evaluating by how far the fail misses the Estatecode Condition B target or how much this could affect patients or patient related areas, this is a really difficult topic to deal with and this showed up in the way the BBC approached the issue. As an example of an area that is not functionally suitable I took a photo of a corridor in a major acute hospital recently. This is not functionally suitable because it is a circulation space being incorrectly used for the storage of trolleys.

Dealing with the media
Some responses from NHS Trusts showed naivety in dealing with the media: As noted above the topic is difficult to deal with from the statistics as they can be interpreted in any number of ways and in our discussions I pointed out to the BBC reporter and later in their radio programmes that the only real use of the figure would be to measure improvement over time. Because of this the BBC quite understandably wanted to use examples. They kindly shared several of the responses to the OI questions they sent to NHS Trusts with me and these show some cause for concern in the way the NHS responds to media questions.

This information was shared with me anonymously so that I could help the BBC understand what was being said; I do not know which trusts the specific comments relate to. Looking at one in particular immediately triggered a counter question back from me that the NHS organisation should have thought of and couched its response to avoid: “Wards at a children’s hospital half the size of what is needed for modern health care. Trust admits staff and families are forced to deal with the ‘cramped and inconveniently laid out wards and a lack of privacy’.”

For wards to be half the size required this must have been a growing problem over many years. The changes in bed space requirements cannot account for this degree of mismatch. My counter question is why the trust is  fitting twice as many patients into the area than is recommended? The other obvious question is what the trust is doing to ensure that adequate facilities and privacy will be provided in the short and long term future?

Rationalise accommodation
Another related issue that I picked up myself came out of BBC Radio Shropshire’s interviews with midwifery staff at their local hospitals. There has been an ongoing move to rationalise accommodation within the Shrewsbury and Telford Hospital NHS Trust area; currently many services are split across their two main sites. The long term aim is to rationalise and provide more effective and efficient single site based services whilst maintaining two functional hospitals.

Last year one element of the proposal was for consultant led maternity services to be provided from the Royal Shrewsbury Hospital but when looking at the functional suitability issue an interview was conducted in a treatment room used for scans; the comments being that it was old and too small for the volume of equipment needed for the modern service provision. Deliberately looking at this too simply, the obvious conclusion is that the proposal was to move services to an out of date and not functionally suitable building.

Knowing several of the estates and facilities team at this trust I know that this would not have been the case as there was a large refurbishment programme in the proposals and also a major new building project already on the site. As always it is the way the facts appear that registers in people’s minds and so we have to be very careful about how what is said can be seen or (mis)read in the context of other things already in the media spotlight.

No news is good news
The BBC was not interested in any of the good news from the report: I found it fascinating that the BBC chose to look at the functional suitability issue instead of any of the other issues that were actually in the DH report³. Functional suitability does not even appear in the DH report, so perhaps that was the motivation?

Some of the key points that come out of the report are (referring to change from the previous year):
• Floor area has grown by 2 per cent and land area has decreased by 4 per cent
• Backlog maintenance has increased by a small amount (0.29 per cent)
• Spending on hospital cleaning increased by 9.45 per cent
• Patient food costs increased by 11p per day
• 2.4m additional main meals (1.84 per cent) were provided
• The NHS Estate costs £6.6bn not including depreciation and the cost of capital

This makes estates and facilities one of the three highest cost items to the NHS along with staff and drugs – but of course the estates and facilities costs include staff costs. So the estate and related issues are really important to the NHS and clearly will be under significant pressure to reduce costs so the likelihood or further reducing the functional suitability figures looks remote.

There is a lot of really good news in the report as the rationalisation of the NHS estate continues, cleaning is improved and better resourced to assist in the drive towards reducing HAIs but this was not picked up on by most of the media.

Lessons to learn
Having said that there were lessons to learn I will close by highlighting some of these:

There needs to be a clear and easy to use link between nationally issued statistics and the definitions that underpin the data.

It is vital that the issue of national information is notified to all interested and related organisations so that we can be properly primed to answer media questions

Staff responding to media questions need to be trained on how to handle the media and also to think about the wider issues than the questions being put to them.

Responses need to be double or treble checked and tested against possible alternative use of the information provided.

Plan to build an ongoing relationship with local media so that they know to come to you for a response on local issues. This was done to great and positive effect by the previous CEO of the Shrewsbury and Telford Hospital NHS Trust with a regular appearance on BBC Shropshire.

Pre-empt issues by producing your own regular press releases on key issues.

Finally one of the lessons for me came from the BBC 5 Live Breakfast interview: I was given a 20 minute briefing by the programme researcher on the previous day. Having been kept hanging on the phone from 06:30 to 06:48 while they changed the running order the presenter did not touch on one of the areas I had been briefed by the researcher to expect. Thankfully I had done my own research and from comments received managed to handle the interview well enough. The second interview was with BBC 3 Counties at just after 07:00 the same day; a very different and more comfortable experience but rather spoiled by the local NHS body failing to put a representative forward. Opportunity lost!

References
1. Health Business Magazine 10.6 Page 45
2. The BBC News Web article is at http://www.bbc.co.uk/news/health-11769182
3. The Department of Health summary is at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/di...

For more information:
Web: www.hfc.org.uk