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Grand designs: Capital funding for the NHS through developer contributions in areas of housing growth
Danny McDonnell – Strategy Manager, NHS England
Mike Simpson – Strategic Estates Planning, NHS Improvement
Eugene Prinsloo - Developments Director, Community Health Partnerships
Introduction • Government plans to build 1 million homes by 2020
• Several key corridors of growth – Oxford/Cambridge, Thames Estuary etc
• NHS and planning system MUST work together to plan for rising demand
• We can actively shape places to embed health and wellbeing (Healthy New Towns)
• We can also do more to make the case for funding in areas of growth and how the NHS and planning system should ideally interact to plan and deliver models of integrated care.
Session overview We will cover:
• Policy/Statutory background
• Current situation – housing development/estates processes and problems
• Doing it better, a more consistent approach
• Conclusion – wider healthy place-making agenda
Background A view of the current policy/statutory framework. Including:
• CIL/s106 overview - what they are, what their limitations are• Planning obligations under the Town and Country Planning Act, impact mitigation
posed by a development often known as developer contributions; Tariffs, or a figure per dwelling built are commonly used
• Limitations; lack of transparency, understanding that s106 are set out in draft heads of terms before grant of permission, challenging when moving into integrated hubs, as norm is GP, competing demands from highways, CiL not fully adopted, timelines
• Existing statutory guidance, governance, Naylor Review etc• The T&CP Act, NPPF, HUDU, TCPA docs, local plans, NHSE business case funding
Current situation - Process/problems • How to articulate estates/capital requirements
• National capital process, STP/OPE – estate strategies
• Interaction of the NHS and planning system at the earliest opportunity• Language, terminology barrier between professions,
• Touch points between NHS and planning • Local plan interaction early on through existing STP Governance – stakeholder
consultation on the local plans
• Review of existing estates, opportunities for appropriate disposal etc• STP’s/Trust/Partner estates strategies
• 20% of hospital trust estate predates NHS formation;
• Backlog maintenance has risen in recent years and presents a £5 billion liability;
• £10 billion in extra capital is needed to enable delivery of STP plans
• The Estate is highly fragmented in ownership and management.
• Most of the 7,600 GP Practices ill-equipped for the shift to out of hospital care;
• There is a lack of strategic leadership in place to deliver the changes required.
The context
• Identify the best route for meeting two DH targets set during the CSR: o Release £2bn of assets for reinvestment o Deliver 26,000 new homes
• Develop a new Estates Strategy for the NHS
• 17 recommendations for the Department, its arms-length bodies and for wider Government,
• Responds to the core themes identified by the Review:
o leadership and capability; o national planning and funding; and o incentivising local action
The Naylor Review
• Enable creation of a STP estates strategy & land disposal plan, clearly demonstrating how it
will enable the clinical strategy, supported by all partners
• Oversee delivery of the agreed and prioritised STP programme
• Support development of credible STP, system-wide capital plans
• Ongoing strategy support to local transformational projects
• Scrutiny and approval of proposals
• Circa 1.3 STPs per SEA with central support
• Transition to NHSE / NHSI by Autumn 2018
Strategic Estates Planning
Capital is the initial cost; Long-term running, staffing needs justification back to clinical modelling.
This is why, based on the HMT Green Book, NHSE/I Guidance, all publicly available, a business
case is crucial
• Business cases provide an evidence based framework for the;
o Transparent scoping and planning of spending proposals
o Optimisation of public value
o Demonstration of the need / urgency for change
o Identification, management and mitigation of associated risks
o Accountability for public funds
o Scrutiny and approval of proposals
Justification
The Five Case model - content
Strategic Case What is the case for change and how does it provide strategic fit?
Economic Case What is the best choice for optimising the net value to society of the proposal?
Commercial Case What is the deal to be done, and what is the best way to procure it?
Financial Case What is the impact of the proposal of the budget of the public sector?
Management Case What are the arrangements necessary for successful delivery of the proposal?
‘A well thought-out estate strategy is essential to the provision of safe, secure, high-quality healthcare buildings capable of supporting current and future service
needs. An estate strategy cannot be developed in isolation. Rather, it is an
integral part of service planning’:
Articulating estates/capital requirements - workstreams & Interdependences; Building a design as a system
To enable a plan, the idea of any design (whether new or old) needs to entail the right balance of partner representation and professionals – estates shouldn’t drive; • NHS Local SEAs key at connecting planning and health • Commissioners/Trusts STP workstream leads i.e. Urgent Care, elective, primary care – Population health management
• Town Planning and s106/CIL Local Planning Authorities – only part of the process, what about filling the capital gaps
• Financial Modelling – investment options/opportunities, disposal offset through existing estate, national PDC (STP/ETTF/OPE) or PPP, 3PD – not all will be funded purely through s.106/CiL and have to think about alignment of financial timelines
Articulating estates/capital requirements - workstreams & Interdependences; Building a design as a system Con’t…d • Workforce acute modelling differs to primary, community (balance)• Economical both estate and wider assessment benefits i.e. A&E reduction• Alignment with Digital Deliver technology enabled care • Property teams landlord processes, lease agreements & service contracts• Surplus Land Programme and its opportunities
Interaction (NHS & Local Planning Authorities)
• Important that systems don’t reinvent the wheel
• Communication – starts at engaging on Local Development Plans or ‘Infrastructure Development Plans’ – enables health to ensure ‘existing estate’ utilisation is prioritised
• STPs should have existing Governance which links well with Local Government (whether through OPE or not) and therefore, Local Planning Authorities have access to health • STP Strategic Estates Boards, Local Estate Forums or Local Estate Groups – all should have a
mixture of professions as detailed in previous slide where engagement starts early
Interaction (NHS & Local Planning Authorities) Con’t…d
• Best practice – What is Working and Why ? Areas are bespoke, but there is good guidance available from other STPs i.e. Nottinghamshire, Devon, Essex, Milton Keynes, London – that demonstrates engagement/Tariffs etc.
• NHSI – Guidance is in plan and for distribution to Trusts to support better, more integrated interaction as many LA’s do still go to each provider and CCG separately
1. Clear and Concise
4. Core challenges understood
5. STP Collaborative Vision
6. Clinical and operational strategy understood
STP estate strategy components: simple diagnostic• Sets strategic direction: Is straight-forward and easy to read with
clear sign-posting between sections and tells a coherent story
2. Strong STP governance and partnering
3. Alignment with other infrastructure enablers
• Demonstrates comprehensive engagement and collaboration across Provider, Commissioner, Specialist Commissioning and Local Authority, with clear accountability
• Two-way channel of engagement to align with other infrastructure initiatives, specifically Digital and Workforce (inc. Homes for NHS staff)
• Problem statement defined and set out from an operational and financial perspective
• Built around the STP collaborative “vision” for the future of how they would like the system to function
• Sufficiently understood to produce a cohesive estate strategy• Realism about status to move forward and financial position
7. Alignment of partner estate plans
8. Comprehensive estate data
9. Working together to optimise estate
10. Cross-STP prioritisation of requirements
11. Implementation capacity and capability
STP estate strategy components: simple diagnostic
12. Clear road map of next steps
• It should demonstrate that there has been thorough consultation and participation from all partners; plan alignment to STP vision
• Robust estate data for primary /community, acute and specialised estates; establish estate performance criteria / 80/20 rule
• Increase Utilisation; reduce BLM; drive estate and FM cost reduction• Direct ambitious Surplus Land opportunities -better than current SLP
• Coherent actions focused on a small number of critical schemes that deliver the greatest benefits in terms of clinical & financial sustainability
• Alignment with STP capital bids
• Early consideration of the resources needed to take forward the prioritised estate requirements
• Simple presentation of strategy/project milestones with important milestones and deliverables
Doing it better - a more consistent approach Drawing on the problems identified, what we need to do to achieve a consistent and appropriate approach to this through current policy frameworks and a brief discussion of what may change or should change in the future (ICSs, NHSI/E integration)
• Capital options outside of National PDC as per National STP Capital Guidance, DHSC Funding Delivery Routes Guidance
• Importance of estates in enabling models of integrated care
• Patients Journey and CCG testimonial
Guiding Principles for Public Capital and Debt Funded Investment
Capital Investment
Programme
New build
Public
Capital/CDEL
coverage
FRI / TIR lease
from PPP/3PD if
CDEL/RDEL
cover available
Fully serviced
occupancy through a
Project Agreement
with PF2 principles
from a PPP
Fully serviced
occupancy
through a
DBFO contract,
single SPV
PPP
Public
Capital/CDEL
coverage
Private Capital
Capital cost of
<c10m
Capital cost of
>c£10m
<£50m
Capital cost
of >c£100m+
Backlog
Maintenance
and statutory
compliance
Reconfiguration
of existing
estate
(variations etc)
Refurbishments,
alterations &
extensions
• Delivery and/or funding
• Public sector shareholding
• Asset ownership
• Risk transfer
• No backlog maintenance
• No CDEL requirement
Public Private Partnerships
Conclusion & the wider agenda• Review of all estate
• Not all economies are likely to benefit from full s.106/CiL funding
• NHS Improvement’s recent guidance for provider trusts
• General Practice Premises Policy Review
• MHCLGs Garden Communities
• Healthy New Towns principles
Putting Health into PlaceThe publication enables those involved in creating new large-scale residential developments, and those commissioning and providing health services in these developments, to create the conditions and systems for better long-term health outcomes across the whole local population.
It also explains how to put the 10 principles into practice and shares learning from the Healthy New Towns demonstrator sites and other sources in the form of tools, frameworks, checklists and case-studies.
• Leaflet due for publication very soon
• Full publication due March 2019
• Roadshow planned for early 2019
1 Plan ahead collectively• Barking + Darlington: health principles for new dev’s• Cranbrook: using public health intel in planning decisions• Ebbsfleet: healthy development ‘kitemark’• Fylde: embedding health in planning policy + S106s
2 Plan for integrated health services• Barking, Ebbsfleet, Halton: development of new care models• Bicester: predictive data modelling of future health needs• Bicester + Whitehill: creating a healthcare services vision • Ebbsfleet: an ICT programme across federated primary care• Northstowe: demographic modelling to plan for future healthcare• Whitehill & Bordon: Developing an MCP contract
3 Involve, empower and connect people• Barton, Darlington: community/stakeholder/residents’ initiatives• Ebbsfleet: inclusive growth and community leadership• Ebbsfleet, Halton: digital boards and info packs for residents• Whitehill & Bordon: Safe Places scheme
4 Create complete, compact neighbourhoods• Darlington: creation of parks with communities• Halton: spatial planning of health and wellbeing campus• Northstowe: health built into the design code for Phase 2 dev’t
5 Maximise active travel• Barton, Ebbsfleet: wayfinding strategies• Bicester: installation of walking and cycling ‘blue lines’ • Darlington: improved footpaths and resting points• Northstowe: travel planning
6 Make healthy eating easy• Barton: mapping access to food; breakfast club• Darlington: healthy eating programme• Ebbsfleet: Edible Ebbsfleet: community gardens, pop-up café• Northstowe: Soil Association’s Food for Life
7 Foster health in buildings• Bicester: health hub• Ebbsfleet: healthier workplaces programme• Northstowe: research on older people’s housing needs
8 Enable healthy play and leisure• Barking: blue space community project; place attachment and wellbeing cultural
installation• Ebbsfleet: Better Points winter challenge; arts + culture project• Northstowe: healthy living, youth + play strategy; sports offer
• Whitehill & Bordon: Hogmoor Inclosure
9 Use new models of care to help people stay well• Barking, Whitehill & Bordon: social prescribing• Bicester: primary care home and diabetes models• Cranbrook: pharmacy services• Darlington: platform to support digitisation of care pathways; primary care at
scale; health coaching• Ebbsfleet: digital health for older people
10 Create health centres that work for everyone• Barking, Barton, Cranbrook, Darlington, Ebbsfleet, Halton, Northstowe, Whitehill
& Bordon: health hubs
Putting Health into Place – The Healthy New Towns Principles
Healthy New Towns Network
