Health Business

Within our offices we have recently heard (but not yet been able to verify) of a large acute Trust in England that has successfully reduced its electricity consumption to the point where they were moved down a tariff band and as a result now have larger bills. The supposed solution to this problem is to leave lights on in certain buildings overnight to increase consumption just enough to move back into the lower tariff band. As always, non verified stories like this circulate freely and are hard to confirm but do serve to highlight the potential for conflict between the energy reduction programmes and the need to save money.
    
The recent Health Facilities Scotland Conference1 was entitled Developing a Sustainable Care Environment and as you would expect there was much spoken on this topic. In the welcome session Paul Kingsmore, director, Health Facilities Scotland (HFS), introduced a short video that highlighted key areas. Some of the phrases that stuck in my mind are very meaningful: “In difficult times innovation is essential for continual development.” “Technology does not always mean the use of more energy.” “Together we CAN make a sustainable NHSScotland.” As chair of the opening Plenary Session Rob Smith, head of Estates and Facilities at the English Department of Health, noted that the above points are as relevant around the world as they are in Scotland.

Business continuity
So as we look at sustainability we must consider all of the relevant areas. It is pointless as a business (or as health provider organisations) to address all the key environmental issues only to load the organisation with ‘green’ overheads so large that the core activity is no longer viable. Once we bring business sustainability (or continuity – a phrase that is perhaps more recognisable in this context) into the equation we start to realise the breadth of what is really before us.
    
We can only do any of this if we plan to keep the ‘business’ running into the future. This highlights the need for Board Level Leadership especially as we are “entering a period where public expenditure will be constrained. We will all have to work very hard to continue to provide facilities appropriate for healthcare delivery in the future”.
    
Much of this serves to point us back to the basics of good management. While boards quite rightly focus on the core activities of the NHS, healthcare service delivery, there has to be board level recognition that without the facilities to delivery from the core cannot function. Properly resourced, managed, maintained and cleaned premises are absolutely essential for correct and effective delivery of healthcare. We have battled long and hard to have the importance of facilities management within healthcare recognised. The improvements (reduction) in HAIs are in no small part due to the work of local domestic services teams and managers supported by the Association of Healthcare Cleaning Professionals (AHCP) whose importance was recognised through their involvement in the revised NHS Cleaning Manuals launched at their conference earlier this year in Glasgow. It will be a great shame if we start to lose this kind of benefit and improvement through short sighted cost saving measures brought about because of the UK government measures to address poor management and profligacy in the banking industry.
    
Getting off my high horse, which in fairness I was actively helped onto by facilities folk from all over the NHS in the UK, there are some very real issues here.

Looking at spend
In round figures facilities management (FM) accounts for about a third of the healthcare spend and a third of that is the utilities bill. This means that one ninth of the overall budget is taken by an area that shows costs increasing because of climate levies and the like. While the politicians have been very keen to tell us about how they have increased the healthcare spend year on year (around 5-8 per cent) at the same time the FM teams have been in an efficiency savings budget downturn year on year of between 3-5 per cent. No complaints here as we have become leaner and more efficient and some technology developments have helped with savings in both staff time (cost) and energy use (cost).
    
It appears that the NHS may be asked to save something around 25 per cent of the overall budget from 2011 through to 2015. With political promises of no reduction in front line services2 the obvious question is where will this come from without reducing the improved standards recently so hard won and without putting patients in harms way?

Revolutions in healthcare
One possible area of savings comes from the use of evidence based design and this was highlighted by Blair Sadler, senior fellow, Institute for Healthcare Improvement, as he noted that there are three current revolutions in healthcare:

1.Quality and safety: Reduce mortality; e.g. coronary and HAI

2.Reimbursement: Not so relevant in the UK but still applicable as we look at outcome based methods of payment

3.Built environment: The impact this has on healthcare outcomes

Focusing specifically on 1 and 3 above we should be able to identify areas where small modifications to the built environment (the facilities or premises) or to the way in which we use them can influence quality and safety issues to the betterment of patients and visitors as well as the staff team. If we could reduce staff injuries (say lifting injuries) by installing ceiling mounted hoists we could reduce Nurse Bank or overtime budgets and also improve staff morale. Alongside this we have the potential to reduce patient falls (as they will be more inclined to ask for help once they see they are not a burden to the nurses) with the obvious knock on benefits for bed occupancy and associated costs. Blair cited the potential cost reductions achievable by expending an additional 5 per cent on new build to provide 100 per cent single room occupancy based on the Fable Hospital3. While this exercise was based in America in 2004 it would be useful to see if the assumptions are borne out in practice at the newly commissioned Aneurin Bevan Hospital in Gwent.

Notes:
1.The Health Facilities Scotland Conference was held at the Crieff Hydro on the 12th and 13th November 2009 and attended by some 411 delegates with 33 speakers supported by 47 exhibitors
2.Gordon Brown TV interview 17 September 2009 (from memory)
3.http://www.ihi.org/IHI/Results/WhitePapersUsingEvidenceBasedEnvironmentalDesignWhitePaper.htm quoted in address at the above conference