2.0 Performance of NHSScotland’s Assets
This section of the report provides an overview of the current state of NHSScotland’s assets whilst also reviewing asset and facilities services performance. The intention is to gain an insight into the significance of this asset base and also to appreciate where opportunities lie for improving performance.
The data used within this report is based on that currently available and reported from the beginning of the financial year 2017/18 i.e. April 2017. This includes:
- The latest asset performance information provided by NHS Boards in May 2017 covering property, office accommodation, vehicle and medical equipment assets.
- The latest facilities management costs published within the Scottish Health Service Cost Book (published in December 2016), covering NHS Boards’ annual accounts for the reporting period 2015/16.
- PPP/PFI service charge costs from NHS Board’s audited accounts for 2016/17.
- Information from NHSScotland’s 2016 patient questionnaire survey which reports every two years.
- The limited information available on eHealth IM&T asset cost information, which was collated in 2012.
All 22 NHS Boards have contributed to this report by submitting their annual asset performance returns during May 2017.
All costs reported in this document include the impact of inflation but exclude the cost of VAT or other on-costs, unless specifically noted.
2.1 The Current Status of NHSScotland’s Property Assets
The following provides an overview of the current status of NHSScotland’s assets, with some comparative information on annual changes. More detailed information on the current status of property assets can be found in Annex A of this report.
Current status of NHSScotland’s property assets
|Floor Area (‘000’s sq.m)||2015||2016||2017|
|Age (% less than 50 years old)||2015||2016||2017|
|Condition (Good – category A or B)||2015||2016||2017|
|Estate Utilisation (Fully Utilised)||2015||2016||2017|
|Functional Suitability (Good – A or B)||2015||2016||2017|
|Including Inflation uplift Excluding inflation uplift||£898m £809m||£887m £763m||£899m £723m|
This reports an overall improvement this year in the status of NHSScotland’s property assets; including its age profile, condition, functional suitability and backlog maintenance (inflation uplift excluded).
2.2 The Current Status of NHSScotland’s Vehicle Assets
The following provides an overview of the current status of NHSScotland’s vehicle assets, with some comparative information on annual changes. More detailed information on the current status of vehicle assets can be found in Annex B of this report.
Current status of NHSScotland’s vehicular assets
|Number of Vehicles||2015||2016||2017|
|Staff Car Scheme:||5,548||5,356||5,154|
|Long term hire:||155||222||240|
|Age (% less than 5 years old)||2015||2016||2017|
|Total Mileage (000’s)||2015||2016||2017|
|Staff Car Scheme**:||27,049||21,533||27,422|
|Private Car Business Travel:||51,690||51,093||49,345|
* 66% of NHSScotland’s owned vehicles belong to the Scottish Ambulance Service.
** The Leased figures and Staff Car Scheme figures do not include Long and Short Term Hire vehicles
This information reports a general reduction in the number of vehicles yet an overall increase in mileage, thus suggesting greater usage of the available vehicles. The age profile of these vehicles has further improved suggesting that they are in good condition and well maintained; some Boards indicate that those beyond 5 years old are often due to their lower annual mileage enabling an extended life.
An example of how the Scottish Ambulance Service is investigating the environmental benefits of introducing ‘cleaner fuel’ vehicles is provided in Annex F.
2.3 The Current Status of NHSScotland’s Medical Equipment Assets
The following provides an overview of the current status of NHSScotland’s medical assets, with some comparative information on annual changes. More detailed information can be found in Annex C of this report.
Current status of NHSScotland’s medical equipment
|Renal dialysis equipment||£16m||£16m||£15m|
|Other high value equipment:||£440m||£438m||£436m|
|Other low value medical equipment||n/a**||£108m||£116m|
|Radiotherapy equipment |
(linear accelerators & CT simulators)
|Number of items:||35||38||38|
|Proportion within minimum lifecycle age:||100%||100%||100%|
|Number of items:||2,745||2,658||2,838|
|Proportion within minimum lifecycle age:||69%||70%||57%|
|Number of items: Proportion within minimum lifecycle age:||3,850 85%||3,926 78%||3,999 78%|
|Number of items: Proportion within minimum lifecycle age:||20,190 76%||20,757 73%||20,920 76%|
Current status of NHSScotland’s medical equipment (cont’d)
Number of items:
Proportion within minimum lifecycle age:
Number of items:
Proportion within minimum lifecycle age:
* estimated cost of replacing all medical equipment, & leased / privately financed equipment
** n/a – represents comparative data not available in 2015
Medical equipment is a valuable asset both in monetary terms and in the important role it plays in the delivery of quality and safe healthcare across NHSScotland. There has been a small increase in the overall replacement cost of medical equipment between 2016 and 2017, which is mainly due to the introduction of decontamination equipment into this reporting category.
The careful management of medical equipment is enabling it to be used beyond its ‘supplier recommended’ lifecycle replacement date which supports more sustainable and realistic replacement programmes whilst still maintaining patient safety as the highest priority. This is particularly the case with the programme of active management of asset life across all imaging equipment; however, radiotherapy equipment continues to benefit from the nationally coordinated replacement programme with all equipment being replaced within the minimum lifecycle.
2.4 National Asset and Facilities Performance Framework
A key objective of this report is to monitor year on year change in asset and facilities services performance, and the National Asset and Facilities Performance Framework (below) has been used since first introduced in 2011 to provide an essential link between asset and facilities services performance and patient needs, as defined in the NHSScotland Quality Strategy’s three Quality Ambitions.
The Framework uses 20 key performance indicators to monitor year on year progress in asset performance towards the achievement of the 2020 Vision targets. It should be noted that the 2020 Performance Targets are (a) aspirational and can be subject to review to reflect funding availability, and (b) based on the qualification that their attainment will not reduce service quality. Broadly, half of the KPIs are based on quality measures and half are based on cost measures.
Annual changes to these KPIs are further explained in the following section.
2.4.1 Changes in National Asset Performance Framework KPIs
The following provides an overview of performance change over the last 5 years, along with a short commentary on the changes.
KPI Nos 1 to 10 – Derived from property appraisal information and PAMS provided by Boards
(Note: 'Percentage of properties' indicators are based on floor area, unless otherwise stated).
Over that last four years there has been a steady improvement in the reported physical condition of the estate. Contributions to this improvement includes:
- Completion of the Queen Elizabeth University Hospital in Glasgow.
- The substantial programme of new primary & community care facilities across Scotland.
- Improvements made to the retained estate.
New hospital projects in Dumfries and Orkney, plus other planned smaller but as important health and care facilities, are expected to expand this modernised estate and replace outdated accommodation.
Unsurprisingly, the quality of the internal accommodation is in line with the physical condition of the overall and is expected to further improve as more new developments and refurbishment project of the existing estate are completed.
Patient Rating of the Hospital Environment
This indicator is now only published every two years; hence, the figures for 2016 and 2017 are the same. They do, however, show a continued gradual rise in this indicator of patients’ opinion on the quality of the hospital environment. Patients with a positive response to their environment is now at 92% which is an extremely encouraging response rate.
Properties less than 50 Years Old
This indicator is affected by the introduction of new properties, the sale or disposal of older accommodation, and also the natural aging of the estate. Over the last 5 years, NHSScotland’s investment programme has enabled an important shift in the age profile of the overall estate, with more new facilities introduced than the rate of the existing estate reaching an age beyond 50 years.
Future investment projects are expected to compensate for a naturally aging estate to support continued improvement in this indicator, which includes:
- The new Dumfries Hospital.
- The new Balfour Hospital in Orkney.
- The new Elective Centres programme across Scotland.
- The new Royal Hospital for Sick Children in Edinburgh.
- The new Baird Family Hospital and Anchor Centre in Aberdeen.
- The programme of investment in primary care facilities.
- And several other important investment projects which will replace old and outdated accommodation.
Overall percentage compliance score from SCART2
SCART is a self-assessment tool that indicates general compliance with policies and procedures related to property related statutory compliance. A new question set has been introduced which is currently being adopted by Boards. This introduces a new KPI benchmark point beginning from 2017. Current compliance status is equivalent to previous years but further improvements are expected as this new assessment process is fully implemented.
Backlog Maintenance Cost per sq.m.
This indicator, which excludes the cost impact of inflation, continues to reduce gradually; which reflects the continued focus on reducing backlog maintenance across the NHSScotland estate.
Section 2.4.3 provides further details on the current status and movement of reported backlog maintenance.
Proportion of Significant & High Risk Backlog Maintenance
The proportion of significant and high risk backlog has reduced by two percentage points over the last twelve months, which is a significant achievement over this short period. It also demonstrates that resources are being focussed on areas of greatest priority in terms of backlog maintenance.
This year has seen a small improvement in this indicator to keep it around the 70% mark. Further improvements are expected in years to come, particularly as new hospital facilities become available over the next few years.
Fully Utilised Space
After several years of continued improvement in this indicator, the last 12 months has remained constant at its highest level. Space utilisation continues to be a key indicator of the effectiveness of usage of accommodation, which is further supported through the rationalisation of empty properties once services are moved to new accommodation.
KPI Nos 11 to 20 - Cost Book Derived KPIs
Note: The latest SAFR 2017 Cost Book data is based on financial information for financial year 2015/16
Space Utilisation - Building Area per Consumer Week
This indicator shows the hospital estate floor area relative to inpatient service activity. The SAFR 2017 data is based on reported cost information for 2015/16 which is similar to that reported in the previous year.
Higher cleaning standards as a response to increased HAI standards of cleanliness, increased activity and usage of space, and normal inflationary / salary cost pressures have all impacted on this KPI. However, this seems to be offset by efficiency performance improvements which have resulted in below inflation increases.
Property maintenance costs
Property maintenance costs have increased slightly this year which is mainly as a result of varying revenue spend on backlog maintenance included in the expenditure figures for property maintenance.
PPP – Service Charge Costs
This KPI shows only the service charge element of PPP/PFI operating costs taken from NHS Boards’ audited accounts (i.e. not from Cost Book information). It doesn’t include interest or recharge payment elements of a unitary charge. The 2017 KPI hasn’t changed from that reported last year despite inflationary cost pressures.
This KPI has remained fairly static when compared with the previous year despite an increase in consumption due to colder temperatures during the reporting year.
Furthermore, as energy cost changes are outside the direct control of NHSScotland then energy efficiency improvements are the main measure for reducing consumption and thus overall costs. Further information on energy performance is provided in Annex E.
Rates are generally index linked to inflation and subject to rates review changes, which are the main reason behind the small increase in this indicator.
Catering Cost £/consumer week
This KPI has reduced for the first time over the five year reporting period despite increasing cost pressures such as increased patient choice, improved food quality, and inflationary cost increases.
Boards explain that their Portering service is being used to carry out additional tasks in order to reduce pressures on front-line staff and the need for additional security staff in some instances. This is a key reason why the cost per consumer week has steadily risen since SAFR 2013.
The reduction in this indicator in SAFR 2016 was due to the removal of linen costs, and this year shows a further small reduction despite typical cost pressure increases.
Efficiency measures such as the move from conventional linen to fitted bedding have helped to control any cost increases.
The cost associated with increased regulation on clinical waste and stricter controls over the segregation and disposal of waste have both put pressure on overall waste costs since 2012; however, this KPI still reports only small annual increases.
The scale of the above cost charts has, when convenient to do so, been kept at 0 - 50 to enable comparison of the scale of costs between charts.
It should be noted that a number of the above Cost Book derived KPIs use “consumer weeks” as the denominator in the KPI. This is primarily a measure of inpatient activity however it also takes some account for day patient activity. Studies have shown that it is primarily inpatient activity which drives the numerator in each of these KPIs i.e. the two variables in each of these KPIs are highly correlated.
2.4.2 Performance variation across Boards
The Performance Framework is intended to provide a useful “national picture” of performance on a range of asset and facilities management services. The tables that follow compare each Board’s performance on each of the 20 KPIs in the Framework. They are arranged to group NHS Boards into their regional areas. However, it should be recognised that comparisons between NHS Boards should be treated with some caution because:
- The size and scope of each Board’s estate has historically developed in different ways over time.
- Increased spending can be a result of an improvement initiative.
- Boards may use different service delivery models to suit local circumstances i.e. number and type of duties carried out by domestic services staff may vary from site to site.
- Smaller Boards will be unable to achieve the economies of scale evident in the larger Boards.
- There are different specifications between Boards in the scope of each service.
- Allocation of costs between services and sites may not be uniform.
- Annual variances in non-recurring expenditure may distort operational KPIs i.e. expenditure on backlog incorporated within annual property maintenance costs.
- The introduction of new initiatives which improve performance take time to implement across NHSScotland.
- Clinical complexity / specialist services vary between hospitals and may drive cost differentials i.e. specialist clinical activity may result in higher clinical waste quantities and costs.
- Differences in pay and supplies costs across geographic areas i.e. some Boards may incur higher cost arising from remote and rural locations.
|NHS Board||Properties categorised as either A or B for Physical Condition||Properties categorised as either A or B for Quality||Positive response on patient rating of 'hospital environment’||Percentage of properties less than 50 years old||PAMS Quality Checklist Score (%) - 2017 scores||Overall compliance score from SCART||Cost per square metre for backlog maintenance||Percentage of significant and high risk backlog maintenance||Properties categorised as either A or B for Functional Suitability||Properties categorised as ‘Fully Utilised’ for space utilisation|
|NHS Greater Glasgow & Clyde||70%||56%||87||80%||76%||75%||218||49%||59%||94%|
|NHS Ayrshire & Arran||55%||84%||89||75%||76%||27%||275||21%||86%||65%|
|NHS Forth Valley||82%||80%||91||82%||73%||13%||93||15%||84%||96%|
|NHS Dumfries & Galloway||79%||53%||91||70%||66%||70%||591||54%||58%||48%|
|NWTCB - Hospital||94%||93%||100||100%||77%||90%||10||0%||80%||96%|
|The State Hospital||100%||100%||-||98%||79%||69%||214||100%||100%||87%|
|NHS Board Average 2017:||72%||70%||92||77%||69%||63%||211||45%||69%||83%|
Backlog in this table includes the cost impact of inflation.
The NHS Board Average 2017 excludes NHS National Boards.
Some SCART scores may be a combination of SCART I & SCART II scores.
The PAMS Quality Checklist review is carried out every two years when Boards submit their full PAMS, which is this year in 2017.
|NHS Board||Building Area sq.m per Consumer Week||Cleaning Costs £ per sq.m.||Property maintenance costs £ per sq.m||PPP Serivce Charge Costs £ per sq.m||Energy Costs £ per sq.m||Rates Costs £ per sq.m||Catering Cost £ per consumer week||Portering Costs £ per consumer week||Laundry Cost £ per consumer week||Waste Cost £ per consumer week|
|NHS Greater Glasgow||3.8||35.2||25.8||62.0||28.9||15.7||74.9||66.2||11.1||10.9|
|NHS Ayrshire & Arran||2.8||44.8||35.1||126.0||26.0||12.2||84.0||62.7||37.3||11.1|
|NHS Forth Valley||3.0||46.0||40.2||195.0||28.6||22.6||97.6||35.3||27.6||18.2|
|NHS Dumfries & Galloway||2.9||64.6||46.7||54.0||30.6||14.5||106.0||28.0||34.1||21.2|
|NHS Western Isles||3.2||43.8||45.0||0.0||37.2||28.0||114.0||37.3||37.7||17.1|
|NHS Scotland 2015/16 Cost Book Average||3.63||42.91||32.79||122.31||27.54||15.26||85.82||55.08||23.12||12.08|
Comparisons between NHS Boards should be treated with some caution for the reasons outlined at the beginning of this section.
Cost information is sourced from the latest Cost Book data for 2015/16.
PPP Service Charge Costs are derived from Boards’ annual accounts and their proportion of PPP accommodation.
2.4.3 Current status of Backlog Maintenance
The current backlog maintenance expenditure requirement is the base cost required to bring those parts of the existing estate which are currently not in satisfactory condition, back to Condition B (satisfactory). It is, however, only a singular reference to understanding the current state of the estate and should not be considered in isolation to other important indicators such as the physical condition, age, and functional suitability of available accommodation; as described earlier in the National Asset and Facilities Performance Framework.
The 2017 backlog maintenance expenditure requirement is reported as £899m, which is an increase of circa £12m since 2016. However, when the impact of inflation on costs is excluded from this indicator there is a reduction in backlog maintenance of circa £40m. Several Boards have contributed to this reduction, including the following:
- NHS Greater Glasgow & Clyde: (£28m).
- NHS Lothian: (£8m).
- NHS Tayside (£7m)
- NHS Highland: (£8m).
The main increase in backlog this year is from NHS Fife who have identified the need to invest in the external wall facade to the tower block at Victoria Hospital, Kirkcaldy.
The following chart provides a breakdown of the current total £899m of backlog maintenance across each NHS Board:
Note: the above chart includes all 22 NHS Boards and National NHS Boards but those whose backlog is below 1% have not been separately identified for clarity of presentation reasons only.
Improved asset management practice introduced since 2010 requires that all identified backlog maintenance is risk assessed so that appropriate mitigation actions can be implemented and maintenance activity can be logically planned and prioritised. This provides the necessary governance arrangements to enable the expected life of property elements to be extended and backlog to be managed in a safe and financially sustainable manner.
The total backlog in the estate has been risk assessed and the results of this are shown in the chart that follows.
The proportion of Significant and High risk backlog maintenance has reduced from 47% reported in 2016 to 45% reported this year, which is particularly attributable to NHS Greater Glasgow & Clyde, NHS Highland, and NHS Forth Valley. This is mainly due to these Boards taking direct action to resolve priority areas of backlog maintenance, and also by reviewing their current risk assessments to ensure that they appropriately reflect the level of risk to service and business continuity once adequate mitigation actions have been introduced.
The variation in risk profile across the different NHS Boards is highlighted in the following table:
Although backlog is identified as an expenditure requirement, in practice it is likely to be addressed by a combination of:
- Estate rationalisation and disposal of older properties avoiding the need for expenditure on backlog. The scope of planned disposals over the next 5 years is outlined in Section 4.
- Replacing older properties with new facilities and avoiding the need for expenditure on backlog e.g. the estate rationalisation following the completion of the Queen Elizabeth University Hospital in Glasgow and further estate rationalisation once the new hospital replacement projects are completed in Dumfries and Orkney.
- Incorporating backlog works within major redevelopment, modernisation and refurbishment projects.
- Undertaking specific projects to target the high and significant backlog.
- Incorporating backlog work within operational repair and cyclical maintenance.
These strategies have been used to reduce the backlog maintenance expenditure requirement since a total figure of £1,010m was first reported in the 2011 SAFR. The following table provides a summary of the progress that NHS Boards have made in reducing this backlog between 2011 and 2017 (i.e. excluding inflationary cost adjustments and any additional newly reported backlog in that period):
|SAFR Reporting Year||Change to backlog costs since originally reported in 2011 SAFR (£m)|
The table shows that NHSScotland has been able to successfully reduce the backlog maintenance expenditure requirement identified in 2011 by £481m to a current total of £529m in 2017. However, as identified earlier, the total backlog expenditure requirement reported by Boards in 2016 is £899 million which takes account of the impact of inflation on maintenance costs as well as additional newly identified backlog over the same period. Hence, the backlog reported by Boards in any one year is a total figure which incorporates both the impact of their investment to reduce the backlog identified in previous years, and any new backlog and cost adjustments identified within the year.
It should also be recognised that newly identified backlog in buildings and engineering systems is an inevitable consequence of aging buildings that occurs as a result of:
- Building and engineering elements coming to the end of their operational life, which can vary significantly depending on the element – engineering components and systems can have relatively short operational lives with most requiring replacement within 20 years whereas building elements tend toward longer operational lives of up to 60 years.
- Variations in normal day to day operational usage which can result in shorter than expected operational lives of elements and in some cases unpredicted failure of systems and the need for earlier than expected replacement.
The following chart uses the original backlog figure reported in the 2011 SAFR to track the actual annual change in this backlog (i.e. excluding the impact of newly reported backlog or inflation) up to 2016/17, and then plots the future reductions needed to meet the aspirational target of reducing this total to below £500m by 2020 with no outstanding High risk backlog maintenance:
* excluding newly reported backlog & inflation
The chart shows that NHS Boards are close to reaching the aspirational target of reducing the original 2011 backlog total to below £500m by 2020; however, continued focus will be needed if they are to also eliminate all High Risk backlog within this period. Furthermore, the growing level of new backlog which arises as existing properties age will need to be incorporated into any future property improvement plans.
It is recognised that in practice new build and refurbishment / upgrade schemes will inevitably reduce all categories of risk assessed backlog when, for instance, this backlog is in the same building/area in which the high and significant risk backlog is present; hence, it is accepted that some reduction in low and moderate risk backlog will continue to take place in parallel with the reductions in high and significant risk backlog and is a practical consequence of undertaking improvement works in buildings.
Whilst this analysis and projections of future backlog provides a high level indication of how backlog might be reduced over the next few years, it needs to be recognised that in practice it is very difficult to accurately project changes in backlog in existing buildings, and timings for estate rationalisation can be influenced by a number of factors including operational priorities and market forces (in relation to disposals).
2.4.4 Asset Performance for Office Accommodation
The NHSScotland Smarter Offices Programme was established in October 2013 with the aim of encouraging better utilisation of office accommodation across NHS Boards and National Boards.
By drawing on wider research undertaken by UK Government, the Programme has developed a set of performance measures covering workplace standards and benchmarks which this report has adopted as the Office Performance Framework. This includes setting a benchmark of 8sq.m. per Whole Time Equivalent (WTE) (i.e. space per person) for new and refurbished office space and 10sq.m. per WTE for all other office accommodation. It also includes a Desk to WTE of 80% (i.e. desks per person).
The tables over the page show NHS Boards’ position in relation to these benchmarks, as well as the annual change in costs associated with this accommodation type.
This Office Performance Framework shows a steady improvement in the effective and efficient use of this office based accommodation; with National Boards getting close to the benchmark standard of 8 sq.m per whole time equivalent (WTE); currently at 8.8 sq.m./WTE.
Occupancy costs have risen slightly this year, with increases in the National Boards’ accommodation only at 1.5%, whereas for the regional NHS Boards the increase is higher at 15% - this includes a re-adjusted Soft FM cost reported by NHS Greater Glasgow & Clyde and NHS Lothian.
Each of these indicators suggests that NHS Boards are improving the effective utilisation of this accommodation type; however, there are variations across Boards and within individual offices, hence providing scope for further improvements, which will continue to be monitored to ensure ongoing cost effectiveness.
Green cells indicate an improvement on the previous year, whereas the rose cell indicates an increase.
2.5 Property and Asset Management Strategies (PAMS)
The Scottish Government’s “Policy for Property and Asset Management in NHSScotland” requires all NHSScotland bodies to have a Property and Asset Management Strategy which is reviewed and approved annually by its Board. Health Facilities Scotland has provided comprehensive guidance and training to support Boards in developing their PAMS.
A Property and Asset Management Strategy (PAMS) is the key strategic document for demonstrating how each NHS Board is performing against ongoing policy objectives both now and in the longer term. The Performance Framework also includes an average score for PAMS quality (KPI No 5). This results from a detailed review of each Board’s PAMS.
2.5.1 Review of PAMS submitted in 2017
The State of NHSScotland Assets and Facilities Report provides an opportunity to review and compare each Board’s PAMS to ensure that their future plans are aligned with NHSScotland’s strategic investment priorities, and that proposed changes to their asset base will deliver tangible benefits to the delivery of health and care services whilst also improving the condition and performance of those assets.
The submission and review of Boards’ PAMS documents is now undertaken every two years and, with a newly introduced PAMS guidance setting out more specific and challenging expectations, this year provided opportunity for greater scrutiny of the strategic nature of these forward looking plans. It is therefore difficult to directly compare this year’s overall PAMS Quality score with the previous score in 2015, which suggests a reduction in score for this year, as shown in the following chart.
Overall, Boards seem confident in explaining the current status and geographic spread of all their assets and how the performance of these assets has improved over time; however, they are less successful in describing how this information is influencing understanding of their future investment needs. This is a similar feature when Boards successfully describe the local planning context behind their service plans but again find it difficult to link this to the likely impact on their assets and their future investment needs. Investment plans are thus regularly provided which set out each Board’s short to medium term plans but are limited in how they are prioritised using Strategic Assessments (a new requirement of the Scottish Capital Investment Manual), or what their longer term strategic plans are beyond the five year investment planning cycle.
The PAMS assessment results for each Board are shown in the table over the page. The colour coded key to this table is indicated below:
Note: NHS Health Scotland and Healthcare Improvement Scotland are not shown in the above table as their position was unchanged in relation to PAMS in 2017.