Economic climate change – the impact on healthcare facilities

In the last edition I noted that in a recent television interview NHS chief executive David Nicholson spoke about the challenge of delivering efficiency savings and how facilities management can contribute while adding value to the patient experience. Specifically he outlined 5.5 per cent growth over the next two years but after that several years with very little growth. He noted: “We need to think five years rather than two…over the next two years when we have money to invest we must invest it in things that will improve productivity across the system as a whole and that is where we want to see people focusing their attention.”1

Public spending cuts
It has been interesting to note the reaction to the David Nicholson interview I quoted in the last edition as I have travelled around the UK meeting healthcare facilities teams. This has been brought into an even tighter perspective by the recent Flourishing FM Conference in Oxford (16-17 September) as the morning news was full of Gordon Brown having mentioned “cuts” in public spending. He specifically noted that there would be no cut in front line services BUT there is no real definition as to what are considered front line services by the politicians. To put this into perspective:
    
In round figures facilities management represents about 30 per cent of the national healthcare spend and employs approximately 25 per cent of healthcare staff. But facilities are often quoted as providing 100 per cent of the patient (and visitor) experience.
    
Some of the items that have been brought up in this context are very enlightening2:

• If there is to be no cut in front line services (medical and nursing teams) this means the budget reductions will fall in unequal proportion on the support staff including the facilities team.
• We have been struggling to get the funding from our board to properly fund the cleaning regime to maintain the hospital to the National Standards for Cleanliness – how are we now supposed to do this with a cut in budgets?
• Having worked very hard towards our environmental targets the reduction in electricity use has moved us down a pricing band, which means our actual bill has gone up. We need to use about two or three per cent more electricity to show a saving on the bills.
• We have highlighted the potential loss of staff within healthcare facilities locally and note that this aligns with the national overview that HFC provided at its conference in September 2008. This prompted us to look at training and staff development within the facilities team but there is already little or no training budget other than for medics and nurses. What hope have we got with cuts coming?
• We are being driven to address the single sex accommodation issues but at the same time being asked to explain why our available bed days figure is increasing as we reconfigure the multi-bed bays within wards. These things are not mutually exclusive but they do impact on each other.

Demoralising effect on staff
While I am not one to propagate doom, gloom and despondency it behoves us all, from the chief executive down, to bear in mind the demoralising effect that much of the current media speculation about public sector cuts has on our junior staff. The fact that this is then reflected in the middle and senior managers whose comments I have distilled into the snapshots above just reinforces the point that staff involvement at all levels is really important while there is so much uncertainty. So the first question has to be “What are we doing to ensure that all of our staff are fully appraised of the current situation and how we envisage it affecting our ability to continue to deliver our services in a clean and safe environment?” After all – is this not part of the primary objective of any healthcare provider organisation?
    
So what can we do about any of this? Firstly; do what you do well and to the very best of your ability. We should always be striving to provide cost effective, efficient and reliable services in support of the healthcare provision that is provided from within the facilities we manage. This means that we should have proper planning in place to ensure that our facilities services properly support healthcare delivery to our local community. From the statutory inspections to the Estates Strategy, from the cleaning schedules to the menus and meal delivery – does what we plan properly support the primary objective? Having planned we should then be monitoring; are we providing the planned service? Do we meet our SLA targets? How do our costs look compared with others? Are we meeting quality standards? All this requires proper monitoring regimes and also willingness to benchmark, whether internally or externally, between NHS teams or with contract teams. If you do not have a target you will never ever hit it.
    
One of the biggest costs to the NHS, after staff and drugs probably, is the cost of the buildings we use, so it follows that if we are not going to cut services we need to look at how we can save money by better and more efficient use of our buildings. Within the estates discipline we are all too used to surveying our buildings for maintenance, safety and energy issues, so we have tried to look at space utilisation and functional suitability in more recent years but I get the distinct impression that there is much more that could be done in these two areas.
    
Although we can probably assess quite easily the spare capacity in our buildings it is a much more complex matter to see how we can then re-align building use to free up disposable space, especially when our larger hospital sites tend to be relatively self contained. Selling off an old ward block that could be surplus to requirements is not easy (or even possible) when it is in the middle of an active District General Hospital. But this should not discourage us from being pro-active in assessing the actual use of our premises and seeing if some buildings or even floors of buildings could be mothballed to help meet potential budget reductions.

Areas of saving
Areas we can look at for possible quick wins are out patients, office and other administrative support areas. For example, how many consultants still have their “own” office that is actually used for only a few hours a day or even a week? In simple terms space costs money and empty space (i.e. space that is not in actual use) is money wasted. For an average Acute Trust in England the cost of occupancy in the 2007/08 year was £226.56/square metre so for every unnecessary filing cabinet or equivalent this is a potential saving. If the average office is 28m2 then the potential saving is £6,343.68 per year. This might appear to be small bier but some figures I saw recently showed that one trust has office accommodation running at about 18 per cent occupancy.
    
There are some simple expedients that can be applied to certain staff groups that can help with our occupancy of space too. Our medical typists provide a really important service in support of our clinicians but do they have to work 9 to 5? Do they really need to be all in the office at the same time? Could they split shifts and so reduce the space requirement by hot desking? Indeed do they actually have to be on hospital premises to do the work they do? Modern communications technology prompted one Trust to look to outsourcing their service to India but they could have simply looked to use a proportion of their team as home workers with VoIP phones and good, secure network access. This could also be used to support some of the “green” issues as we would be reducing the greenhouse gasses by reducing staff journeys and potentially also reducing the car parking pressures on site and so easing one of the biggest gripes from our visitors and patients.
    
I am not picking on medical typists but citing this as an example of the questions that may be worthwhile asking. Just because space is currently occupied does not mean that has to be the case long term. We may need to think a little laterally to come up with some really innovative and productive solutions that could actually improve our staff working conditions and productivity as well as relieve our reliance on space within the hospital environs. A start point has to be the use of a properly designed and managed space management information system linked with the CAD drawings of our estate. We can then start to analyse the space we use, what it is used for, how suitable for purpose it is and how much it is used. Space is not a free good.
    
At the recent Flourishing FM Conference4 that I noted at the start of this article it was interesting to hear the nurse practitioners talking about the progress they had made with their estates colleagues by implementing a rapid improvement team in response to a “poor” audit visit and report. The result was more effective use of the nursing staff and saved space. The keynote at this conference was delivered by Paul Kingsmore from Health Facilities Scotland and he spoke about Facilities at the Heart of Healthcare citing five core issues: Quality, Innovation, Safety, Productivity and Sustainability.
    
He noted that although we work under differing political contexts we all work towards the same goal – delivering healthcare! Specifically he said that “we will have to do more with less over the next 10 years – need to be more efficient – individually make a difference”. As we move into an era framed by the profligacy of the banking sector and the governmental response to shoring this up, we all need to ask ourselves “how can I make a difference in my organisation?”

Notes:
1. The David Nicholson interview is on Focused FM TV and can be viewed at www.focused-fm.tv from any computer equipped with a browser and media software
2. Comments distilled from various discussions and questions raised at recent conferences, meetings and day events
3. HFC Benchmarking Club information for Acute Trusts
4. The Flourishing FM Conference was held at the Kassam Stadium Oxford on the 16th & 17th September and the presentations from the conference are available on the HFC web site www.hfc.org.uk