Part 10: Shared Services: Hard Facilities Management
ABOUT THE PROGRAMME
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The key drivers for change were identified by Directors and Heads of Facilities Services across NHSScotland.
- Skills shortages and a need to share scarce specialist resources
- A need to develop services, building on models of good practice already extant in NHSScotland
- A need to reduce variation and exploit the economies of scale offered by NHSScotland
- A need to share intelligence amongst NHS Boards regarding major contracts
- Changes in legislation and government policy in relation to improved environmental standards
- Health and social care integration which will require closer working between NHS Boards and Local Authorities
- Improve the quality, efficiency and resilience of facilities services
- Support change in healthcare delivery and, where possible, accelerate change
- Ensure that facilities services are fit-for-purpose to support NHS Boards to deliver the 2020 Vision
- Build on the opportunities offered by wider collaboration with public and private sectors
- Ensure better use of specialist resources, ensuring specialist skills are shared across NHS Boards
These objectives are supported by a number of workstream specific objectives:
- Ensure the capital programme is delivered
- Ensure proper skills are available for delivering maintenance
- Ensure better investment of capital in relation to sterile services
- Improve procurement for transport
- Increase contract management capacity and capability
- Capital and Hard FM
- Sterile Services
- PPP (Public-Private Partnership)
- Completion of an options appraisal to assess options for service delivery to address skill and staffing shortages in relation to capital planning. Development of a regional model of capital planning to share resources and build on good practice already extant, for example, in NHS Grampian and NHS Highland.
- Establishment of a contingency plan and business continuity arrangement in relation to the provision of sterile services. Quantification of spare capacity through a review of decontamination of endoscopy and primary care equipment.
- A review of all logistics routes has been completed, the results of which will be used to rationalise routes and vehicles.
- Establishment of a national advisory group to share best practice in relation to operational management of PPPs to drive significant savings from PPP contracts to ensure best value and improved delivery of patient care. Up-skilling of staff to enable challenge of contracts, with the involvement of the Scottish Futures Trust (SFT).
- Development of common standards and training systems in relation to waste management to encourage recycling and reduce the level of waste sent to landfill to achieve compliance with the Waste (Scotland) Regulations 2012.
- Full engagement of NHSScotland in the programme (including NSS Project Management Service, National Procurement, Health Facilities Scotland (HFS), NHS Boards and staff side).
- Transition of Hard Facilities Management to business as usual including identification of areas where NHS Boards are purchasing the same supplies and services which could be procured through a national contract by National Procurement.
- Development of a common barcoding and tracking system to enable tracking and traceability of instruments enabling NHS Boards to share more costly equipment and resources.
- Implementation and embedding of standardised principles for car leasing in all NHS Boards.
- Development of a PPP core team to advise on operational management of PPP contracts and transition of this workstream to business as usual through HFS.
- Transition of the waste workstream to business as usual through HFS.
Programme Case Study
Public Private Partnership and Private Finance Initiative
Background and context
A Public Private Partnership (PPP) is a government service or private business venture which is funded and operated through a partnership of government and one or more private sector companies. Private Finance Initiative (PFI) is a specific type of PPP whereby capital investment is made by the private sector on the basis of a contract with government to provide agreed services and the cost of providing the service is borne wholly or in part by the government.
NHSScotland currently has 28 live PPP and PFI contracts. The first buildings were occupied in the early 1990s and had a total estimated capital value of £1 billion at the time of construction.
These PFI/ PPP contracts have a total unitary payment for the participating nine NHS Boards of £215 million per annum. The service element is £86 million per annum, giving a non-service or financing element of £129 million per year. This financing element is generally fixed unless refinancing is negotiated; in the current economic climate this could be considered feasible for a very small number of contracts.
Contract management skills throughout NHSScotland are variable. This means, in some instances, NHS Boards are not receiving the level of service they are paying for. In addition, there is variability between NHS Boards who have contracts with the same provider, meaning that some NHS Boards are paying a greater sum for the same service.
Contract management practices vary between and within NHS Boards. In some NHS Boards there may be a number of contracts, each one being run by a separate team leading to a lack of consistency. There is also a large amount of duplication throughout NHSScotland and within each NHS Board, which results in poor resource utilisation.
As each NHS Board operates in isolation there is a lack of sharing of good practice, knowledge and expertise between NHS Boards and no option to participate in critical mass opportunities.
A more powerful, consistent client-side, empowered with contract management skills and the knowledge of good practice, would help to ensure that NHS Boards receive what they pay for within their existing contracts.
The PPP/PFI project was established as part of QuEST's Facilities Shared Services Programme in 2012. The project objectives were established as:
- Improve contract management of the variable element within PFI/PPP contracts and to deliver a 2 per cent (£2.16 million) recurring reduction in the variable element costs with no diminution in service. The variable element would be defined as the service element of £86 million plus energy costs of £22 million, thus giving a total of £108 million.
- Produce a Recommendations Report to the Facilities Shared Services Programme Board on improving the effectiveness of contract management and monitoring within PFI/PPP contracts by December 2013.
- Produce an Options Appraisal to the Facilities Shared Services Programme Board for the management of operational PFI/PPP contracts across NHS Scotland based on three options: local (individual NHS Board), regional (geographically based) and national by December 2013.
In October 2012 NHS Lothian hosted a workshop to identify the common issues in the monitoring and management of operational PFI/PPP contracts across NHSScotland.
A range of issues were identified and one of the identified priorities was the establishment of an advisory group to share good practice, lessons learned, and to provide mutual support. A PFI/PPP Advisory Group was established to meet this need. The group has representation from all NHS Boards with PFI/PPP contracts and colleagues from Scottish Futures Trust (SFT).
Following establishment of the PPP/PFI project a data gathering exercise was undertaken across NHS Boards to identify the current PPP/PFI contacts. Data was gathered on the contract value, timeframe, provider, services provided and contract management arrangements. In addition this was also an opportunity to identify the issues and priorities for NHS Boards in relation to PPP/PFI contracts.
A gap analysis was undertaken based on the NHS Board priorities, comparing the as-is state to the desired to-be state. Following the gap analysis a Recommendations Report on improving the effectiveness of contract management and monitoring within PFI/PPP contracts was presented to the Facilities Shared Services Programme Board. This report was accepted and endorsed in December 2013.
An option appraisal process to identify options for the future delivery of operational PFI/PPP contracts in NHSScotland was undertaken by the Core Project Team and the Advisory Group. At a workshop event held in October 2013, the group scored the shortlisted options on the basis of non-financial benefits and identified a preferred way forward. All shortlisted options were costed and the non-financial and financial benefits then combined to give the recommended preferred option. This workshop played a crucial part in engaging stakeholders in co-creating the solution.
The preferred option was identified as a regional model with national support. NHS Boards will share/ re-deploy staff resources so that PFI/PPP contracts are managed by teams of contract management and contract monitoring staff arranged on a geographical or functional basis. The responsibilities of these regional / grouped teams will include day to day monitoring, managing cyclical tasks, including benchmarking, dispute resolution, compliance and variations, together with the development of the new HubCo, Non-Profit Distributing (NPD) and other revenue funded schemes.
Additionally there will be a central specialist support team established to provide expert advice on PFI/ PPP/ NPD / HubCo, and to act as a single point of contact for the regional teams. The responsibilities of this support team will include training and developing capability in client side expertise, providing central advice on legislation/ guidance, sharing and dissemination of best practice nationally, providing independent review and support, and maintaining strategic oversight of contracts in NHSScotland.
The report on Options Appraisal for the management of operational PFI/PPP contracts across NHS Scotland based on three options: local (individual NHS Board), regional (geographically based) and national was accepted and endorsed by the Facilities Shared Services Programme Board in December 2013.
The Business Case was approved in August 2014.
The following results have been achieved by the PPP/PFI project:
- A PFI/PPP Advisory Group has been established to share good practice, lessons learned, and to provide mutual support. The group has representation from all NHS Boards with PFI/PPP contracts and colleagues from SFT.
- As a result of the data gathering exercise, for the first time there was visibility at NHSScotland level of the PPP/PFI contacts in place and also of the level of variation between contracts. This has enabled negotiations to be undertaken with providers to standardise some of these variations.
- A PPP/PFI Specialist Support Team has been established to provide expert advice and support to contract management staff within Boards. The team will provide a 'knowledge centre' for existing PFI/PPP contracts and future private revenue funded projects, for example NPD and HubCo.
- Savings of £670,000 were achieved in 2013-14. It is estimated that savings of £1.07 million will be achieved in 2014-15 and savings of £2.16 million will be achieved in 2015-16.
- Collaborative working with SFT has been established and SFT personnel are embedded within the Specialist Support Team to carry out in-depth contract reviews and provide focused commercial support to NHS Boards to negotiate changes to individual contracts.
- Facilitation of NHS Boards working together to share expertise and skills to drive maximum value from PPP/PFI contracts.
The following patient benefits are anticipated as a result of the PPP/PFI project:
- Significant savings will be realised by NHS Boards which can be reinvested in patient care.
- Patients will be in a better environment and will receive a better level of service including cleanliness, quality of catering, increased and more timely maintenance.
The following staff benefits have been realised as a result of the PPP/PFI project:
- Staff responsible for contract management feel empowered and able to do a better job.
- Staff responsible for contract management will have access to consistent, specialist central advice and will be able to share good practice and skills.
- Staff based within PPP/PFI sites will know how to report defects.
- Staff will be in a better environment and will receive a better level of service including cleanliness, quality of catering, increased and more timely maintenance.
Efficiency savings and productive gains
In 2013-14 recurring efficiency savings of £670,000 were achieved as a result of negotiated savings as an alternative to Soft FM benchmarking - installation of energy efficient lighting and removal of theatre humidification.
In addition this model offers the potential for:
- Maximum resilience as a larger regional operation may have a wider range of expertise that can be shared
- Greater consistency across larger geographical areas to minimise variations
- Potential to benefit from economies of scale
- Potential to share training opportunities
The establishment of the Specialist Support team will ensure that savings and benefits continue to be realised. The provision of on-going support to NHS Boards will help to build capacity and capability in respect of contract management expertise. In addition, a training programme will be implemented to ensure that the requisite skills and expertise are available in-house.
The following key lessons have been learned:
- It is crucial to use a project management approach to manage change. Using a structured approach with clear plans and milestones helps to maintain momentum and drive the change forward. Project and programme management is also important to ensure that benefits are captured and realised. As the project transitions to business as usual, these tools and techniques will continue to be used.
- It is important to engage with stakeholders to ensure buy-in to the process. Engagement with stakeholders to identify their needs and issues, and to co-produce a solution ensures that the change is sustainable.
- This project was driven by a desire to improve the quality of service rather than realise savings. However, this is also a benefit of the work.
- The Project Team will undertake a process to establish benefits realisation processes and undertake lessons learned reviews.
- Although work has commenced it is necessary to recruit additional posts to the Specialist Support Team including a Senior Advisor and a Project Support Officer.
- A key area of focus will be the identification of priorities for the Specialist Support Team using a work plan approach (it is anticipated that the number of HubCo/ NPD contracts will increase). A number of requests for consultancy support and SFT in-depth review have already been received suggesting there will be a large demand for the service.
- The Business Case will be reviewed at the end of March 2016. At this point it will be decided whether the team will transition to business as usual and become a core function.
NHS Board Case Study
Patient Transport Project
Background and context
An Integrated Patient Transport Strategy was agreed to implement the following:
- development of alternatives to use of patient transport services
- development of voluntary sector transport services - 'Getting You There' single booking system for community transport established (Change Fund)
- Integrated Day Service Transport - dedicated service established in Peebles
- discharge transport - improved booking systems, dedicated daytime discharge vehicle, reduced use of private ambulances
- renal transport - establishment of dedicated service
- Overspend on patient transport budget
- Patient-centred service efficiency
To conclude cost-saving elements of the Patient Transport Strategy and deliver remodelled patient transport services to meet changing service delivery models.
- establish dedicated renal transport service provided by Scottish Ambulance Service (SAS) and release funding currently allocated to renal transport
- commission single provider service for NHS and Scottish Borders Council (SBC) older peoples day services and release SAS resource from day hospitals
- release recurrent £50,000 funding for out-of-hours vehicle
- continue to reduce spend on private ambulances to a minimum (aim to ensure all transport is within £80,000 budget)
- establish effective performance monitoring and governance of transport, including mainstreaming operational management of patient transport
- Establish dedicated renal transport:
- Extensive negotiations to establish a solution continue with SAS as the concept of a dedicated renal service provided by SAS contravenes Patient Transport eligibility criteria. Other service providers are also under consideration.
- Commission single provider service (Haylodge)
- Release recurrent £50,000 funding for out-of-hours vehicle:
- To achieve this goal required the release of the SAS vehicle/staff from the single provider - Haylodge Joint Working initiative with SBC, however, SAS have been, and continue to, experience resource challenges and a reluctance to accommodate shift patterns that reflect Borders General Hospital (BGH) peaks which has not enabled this to succeed. SAS are currently involved in a recruitment drive whereby shift patterns offered will reflect BGH peaks (predominantly between the hours of 2pm and 6pm) which should address and release the recurrent funding.
- SAS TD15 funding - £30,000 savings realized as of April 2014.
- Reduce spend on private ambulances:
- 2012-13 £81,300
- 2013-14 £35,448
- Establish effective performance monitoring and governance:
- Transport bookings (SBAR) are transposed into an excel spreadsheet which automatically creates data charts that allow us to study the results of our actions each day from service utilization, daily sitrep, cost, peak challenges, etc. and allow us to react effectively and efficiently based on supported evidence.
- Daily calls to SAS to establish service provision for that day/week vs average discharge (SAS transport calculator/schedule)
- Transport bookings only once med/letters are with patient
- Attendance at Alpha Zone/Delta Zone
- Attendance at 11am meeting
- Quarterly finance tracking/invoice reconciliation
- PTS DATIX - review/report/address
- SAS/PTS manager meetings
- Engagement with Winter Planning Group
- SBC Sustainable Transport review
- Operational Transport Group - BGH, SBC, public participation members, private ambulatory services, voluntary groups
- Transport packs provided to wards, emergency department and community hospital with details of all available transport/support options, contacts and telephone numbers
- Patient standard operating procedures/eligibility assessment
Patient expectations are managed through clear, concise and consistent communication utilizing all available transport (SAS/voluntary/private) to ensure an improved, timely and appropriate discharge experience.
Expectations are now successfully managed and working relationships between staff and providers have improved considerably, promoting flexibility and dual directional support further promoting a patient-centred experience.
Efficiency savings and productive gains
Efficiency is consistently delivering more, lowering costs, whilst improving service quality:
- 2012-13 - £461,255
- 2013-14 - £359,001
An exit strategy meeting has been held to establish if there is an appetite to engage a PTS manager/coordinator or divide the activities between current staffing complement.
This has yet to be decided.
NHS Board Case Study
Bespoke Care Facilities for two Learning Disability Patients with Complex Needs
Background and context
Patient A had a long standing history of unpredictable behaviour and required to be managed in a secure setting not available in Fife.
Patient B also had complex needs and was being cared for within an assessment and treatment facility within Fife.
Due to the complexity of their needs Patient A had been cared for in a facility in England for a number of years. Following a review of the placement it was found that it no longer adequately met the patient's clinical or social needs and was at the extreme high end in terms of cost.
Patient B's needs were not being adequately met within the assessment and treatment facility particularly as the facility had a high turnover of patients which did not readily allow for a quiet environment being maintained. This resulted in a high staff to patient ratio in order to safely care for the patient who has extremely challenging behaviours.
To provide a cost effective local facility to meet the complex needs of patients A and B. To provide increased therapeutic involvement from a multidisciplinary care team with the aim to provide improved health outcomes. The ultimate aim is to integrate the patients into the service's mainstream provision.
Following an assessment of the local NHS Fife estate an opportunity was identified to refurbish a unit within the existing Learning Disability campus. The unit was designed with the input of the patients, the patients' relatives and specialist staff to meet the patients' needs, provide a stable and homely environment for the patients and their families and to promote the multidisciplinary provision of therapeutic care.
Patient A - although progress is slow, the clinical view is that therapeutically the patient is stabilising and there has been significant improvement in the patient's anxiety levels and their ability to engage with staff.
Patient B - the patient has a team of dedicated staff which ensures continuity of care, as a result the staff to patient ratio has been reviewed and with a change in the patient's behaviour has been gradually reduced. The relocation of the patient has also allowed for increased capacity in the assessment and treatment unit.
Having returned to Fife, Patient A has benefited from closer and more regular contact with their family. The environment is bespoke to the patient's individual requirements and their clinical care is tailored to meet their complex needs.
Patient B's parents are able to visit on a daily basis and have positive input in the treatment plan. The patient has benefited from the quieter environment and behaviour has improved to the extent that the patient has now been categorized fit for discharge (albeit to a highly supported package).
There is a crossover of staff in managing the care of these patients within this small unit. Staff benefit from the co-location with other learning disability services in terms of communication, staff training, and line management.
Efficiency savings and productive gains
In financial terms a recurring efficiency saving of £320,000 was identified by relocating Patients A and B to the bespoke facility. The quality of life of both patients and their families has been significantly improved and the quality of care has also been improved.
The individuals care packages are funded on an on-going basis. The bespoke unit is part of the NHS Fife estate and as such will be maintained and serviced as part of that estate.
A review of the placements of patients with learning disability and complex needs revealed opportunities to improve patient care and reduce costs on an on-going basis. Investment in existing but underutilised estate allowed the development of a cost effective specialist facility which will meet these individuals medium to long term needs.
NHS Board Case Study
NHS National Services Scotland
NSS Office Consolidation and Rationalisation Programme
Background and context
In accordance with the Scottish Government Health and Social Care Directorate's Policy for Property and Asset Management in NHSScotland CEL 35(2010), NHS National Services Scotland (NSS) has a Property and Asset Management Strategy (PAMS) which is reviewed, updated and approved annually by the NSS Board.
Between 2003 and 2011 NSS successfully completed a significant number of property acquisitions and disposals across Scotland (primarily in Edinburgh, Glasgow and Aberdeen) aimed at consolidating and modernising its portfolio of office accommodation.
NSS identified that its office estate was oversized as a result of reducing numbers of staff requiring office space together with changing technologies and ways of working. This opened up the potential for reducing the size and cost of NSS's office estate going forward.
Since 2011, NSS has continued to progress a programme of further consolidation and
- rationalisation of its office estate with a view to:
- improving space utilisation and driving out inefficiencies
- reducing recurring revenue costs
- providing well designed space that supports changing working practices and new technology and enables the introduction of agile working
- achieving synergies from sharing accommodation and support services with other NHSScotland NHS Boards
NSS, supported by the Scottish Government, has been proactive in identifying opportunities to optimise the utilisation of office accommodation in Edinburgh and Glasgow by generating co-location opportunities with other Special Health Boards, thereby both reducing accommodation costs overall and also achieving best value in terms of shared facilities and services.
NSS has delivered key results in terms of:
- its own office property portfolio consolidated into fewer sites and less space
- reducing costs, maintaining or improving services and providing modern and flexible working environment for staff
- sharing its estate and estate services with other NHSScotland NHS Boards, e.g. Scottish Ambulance Service, NHS Health Scotland and Healthcare Improvement Scotland all now work out of a Special Health Board 'Hub' at Gyle Square, Edinburgh
- tangibly contributing to the wider public sector 'smarter offices' agenda
- The financial benefit delivered between FY12 and FY14 has been £1.20 million per annum and as our activity plan continues through to 2016 we expect to see a further £1.44 million per annum of efficiencies delivered.
The replacement of NSS's stock of old, inflexible and dilapidated office accommodation with modern, fit for purpose facilities has resulted in a better working environment for our staff, making NSS a better place to work; one of our four strategic objectives.
Efficiency savings and productive gains
The following table illustrates the changes in the NSS's office estate from FY12 to the present date and through to FY16:
Please refer to table below.
The following chart illustrates the recurring revenue savings as a consequence of implementing the NSS programme of office consolidation and rationalisation since 2012 to the present date and then forward over the next ten years to 2024:
Please refer to chart below.
From a FY Baseline of £10.38 million per annum the total cumulative savings (baseline plus inflation v actual) over the 13 year period amount to £48.4 million which is broken down as follows:
- FY12 - FY14: £2.7 million
- FY15 - FY19: £18.8 million
- FY20 - FY24: £26.9 million
NSS is also playing a leading role in developing and delivering the NHSScotland Smarter Offices Programme in conjunction with Scottish Futures Trust. The programme is focused on the corporate office portfolios territorial and special NHS Boards and its key objectives are to:
- improve the utilisation of office accommodation across NHS corporate office facilities by identifying opportunities for
- consolidation and rationalisation, increased agile working and shared use of space with other public sector partners
- identify appropriate key performance indicators (KPIs) for monitoring and benchmarking of performance through the national performance framework
- use the national performance framework to improve the utilisation of NHS office accommodation through benchmarking and comparison with best practice and industry standards
- review of asset management strategies and provide challenge to improve performance
- agree target areas for improvement with each NHS Board
- identify areas of best practice within each NHS Board and develop plans for rollout
- develop investment and savings plans
|NSS Office Accommodation||FY12||FY14||FY16||FY12 v FY16|
|Space (m² NIA)||Total||27,366||24,418||20,320||(7,046)||(25.7%)|
|% of total estate||38.4%||35.8%||31.9%||(6.5%)||(16.9%)|
|Cost of space (recurring Revenue)||Total||£10.38m||£9.18m||£7.74m||(£2.64m)||(25.4%)|
|% of total estate||69.7%||65.4%||60.9%||(8.8%)||(12.6%)|