NHS Efficiency and Productivity Programme/ National Benchmarking Programme

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1 NHSScotland Estates and Facilities Benchmarking Project March 2009 NHS Efficiency and Productivity Programme/ National Benchmarking Programme

2 NHSScotland Estates and Facilities Benchmarking Project March 2009 NHS Efficiency and Productivity Programme/ National Benchmarking Programme The Scottish Government Health Delivery Directorate Improvement & Support Team Set-up and Planning Review and Adapt Data Gathering Determine Gaps Improvement Phase The Scottish Government, Edinburgh 2009

3 ii NHSScotland Estates and Facilities Benchmarking Project Crown copyright 2009 ISBN: The Scottish Government St Andrew s House Edinburgh EH1 3DG Produced for the Scottish Government by RR Donnelley B /09 Published by the Scottish Government, May 2009 Further copies are available from Blackwell s Bookshop 53 South Bridge Edinburgh EH1 1YS The text pages of this document are printed on recycled paper and are 100% recyclable

4 Contents iii Contents Foreword 1 1 Executive Summary 2 2 Strategic Overview and Benchmarking Context 6 3 Project Overview, Approach and Methodology 8 4 Estates Management 10 5 Energy and Waste Management 18 6 Facilities Management 23 7 Overall Estates and Facilities Scorecard 26 8 Findings and Recommendations 29 9 Acknowledgements Appendix A Appendix B 34

5 iv NHSScotland Estates and Facilities Benchmarking Project

6 Foreword 1 Foreword The changing nature of health service provision in Scotland is driving changes to NHSScotland estates and facilities services. We are building new hospitals to support improved delivery of acute and specialist services, new health clinics and joint resource centres which, in partnership with other providers, are being developed to bring services closer to local communities. This modernisation of the estate and related services to support Better Health, Better Care continues to demand significant investment of time, money and energy in major projects to bring about real change. It is right that we know the extent to which improvements in estates and facilities services are making a real difference to patients and staff and delivers Best Value. One of the keys to gaining a better understanding is the ability to benchmark the provision of estates and facilities services on a like-for-like basis across Scotland and where appropriate with other health services. NHS have focused attention on ensuring the delivery of major capital projects to bring about this step change in healthcare provision. However, it is equally important that all are able to draw a consistent picture of how well the totality of existing estates and facilities services are performing against ongoing policy objectives both now and in the longer term. Over recent years, NHSScotland has developed benchmarking information in a number of areas including energy and waste management performance, capital project delivery and some elements of facilities services. Building on these activities, work started in to determine what is needed to measure and compare estates and facilities management on a comprehensive basis to support continuous improvement. This report draws together these strands of work and sets out in the recommendations how to develop an understanding of the performance of estate and facilities services over the short, medium and longer term across a range of policy perspectives: cost, patient quality, operating efficiency, environmental sustainability and future development. This work will allow us to recognise the contribution that ongoing investment in service improvement is making to achieve the long-term goals of improving the quality of the healthcare environment, shifting the balance of care closer to home, meeting environmental commitments and delivering value for money through increased productivity and efficient use of resources. The NHS Efficiency and Productivity Steering Group will oversee implementation of this report and the delivery of other Benchmarking Reports to be published later this year. NICOLA STURGEON, MSP Deputy First Minister and Cabinet Secretary for Health and Wellbeing

7 2 NHSScotland Estates and Facilities Benchmarking Project 1. Executive Summary 1. Introduction NHSScotland Estates and Facilities activities involve expenditure of approximately 1.2 billion per annum (15% of total net operating costs). There are opportunities to improve quality and cost effectiveness in carrying out these activities through improving productivity and implementing more efficient ways of working. This report identifies the key indicators, considers best practice and sets out a robust action plan which will allow Estates and Facilities teams within NHS to identify, share and spread good practice and act on opportunities to secure improvements in performance as part of the wider need to deliver improvements in efficiency and productivity to meet local and national efficiency targets. To improve on delivery, NHS will need to: address information gaps; establish consistent service definitions; measure the performance of key activities and service improvement initiatives; align this work with the development of new and existing information systems; and accelerate the adoption of best practice. This report recommends that NHSScotland establishes a set of balanced scorecards for estates, energy, waste, and facilities management to co-ordinate and progress this work. The use of a Balanced Scorecard in these areas will allow NHS to analyse all activities in each of these areas so they can be compared on a like for like level. The report also considers the January 2009 Audit Scotland Report on Asset Management in the NHS in Scotland and is consistent with the key findings and recommendation. 2. Timescales This report contains 21 recommendations. The Programme Board (recommendation 1) will set detailed targets and agree prioritisation of recommendations in consultation with NHS during 2009 to ensure overall delivery by Project Objective The objective of the Estates and Facilities Benchmarking Project is to support the improvement of health service delivery by gaining a common and deeper understanding of what our current position is with regards to Estates and Facilities. Our approach is to use a range of comparative information to: compare key aspects of performance; identify gaps in performance; identify how improvement can be achieved; support NHS to implement improvement; and monitor progress and review benefits.

8 Executive Summary Project Approach A high-level review of comparative performance has identified areas of wide variation between NHS. Further investigation within these areas to identify gaps in knowledge and the adoption of good practice has the potential to deliver improvement. However, as this report was being compiled it became clear that there is not a consistent approach to gathering data and, specifically in relation to Asset Management, major gaps in information exist. This view is supported by Audit Scotland Report Asset Management in the NHS in Scotland (Audit Scotland, 2009). Consequently, developing the capacity and capability for like for like benchmarking is essential in ensuring continuous improvement through the dissemination of Best Practice to NHS. However, this needs to be preceded by work which effectively addresses existing information gaps as a necessary first step to action. 5. Findings and Recommendations High-level review of the comparative performance of NHS across the range of estates and facilities activities requires consistent, reliable and comparable information to support detailed analysis. NHS are in the process of developing measures to monitor the implementation of major aspects of environmental sustainability, patient quality and future development strategies. Consequently, analysis at this time has focused on comparative cost and operational efficiency where data is available. The information available within Estates and Facilities indicates wide variation in performance between NHS across many aspects of activity. The existence of this level of variation is the first area to be addressed within the proposed action plan. There are many excellent examples of good practice, however, information on such practices is not readily shared or widely adopted. Knowledge on Best Practice must be effectively disseminated throughout and implemented where appropriate. To support improvement in terms of quality improvement and cost effectiveness, the following actions should be taken: Key Recommendations A dedicated Programme Board should be established chaired by a NHS Board Chief Executive. The Programme Board will provide leadership for the implementation of the recommendations in this report and will report to the NHS Efficiency and Productivity Steering Group. Recommendation 1 The Programme Board is expected to work with NHS to develop and oversee a programme of work that co-ordinates and delivers improvement activities across estates, energy, waste, and facilities management. Recommendation 2 The NHS Efficiency & Productivity Steering Group should make available resources for project management to oversee and report on implementation of the recommendations in this report. Recommendation 3 Health Facilities Scotland (HFS) should be commissioned to project manage implementation of this report and use its established network of Estates and Facilities management groups to work with NHS to re-focus attention on benchmarking; accelerate the adoption of good practice; and support action-based performance improvement. Recommendation 4 A performance management framework for Estates and Facilities should be developed by adopting an overall Balanced Scorecard supported by function-specific scorecards underpinned by consistently defined outline measures to benchmark the continuous improvement of NHS. Recommendation 5 This performance management framework will be supported by the development of appropriate information systems, such as Asset Management System (AMS) and Facilities Management System (FMS), to collect and regularly report on all aspects of Estates and Facilities performance across all operational settings. This is in keeping with recommendations in the Audit Scotland Report: Asset Management in the NHS in Scotland (January 2009). This will be developed and delivered by HFS. Recommendation 6

9 4 NHSScotland Estates and Facilities Benchmarking Project HFS should ensure that existing Estates and Facilities working groups focus on developing benchmarking activities and supporting the identification and implementation of good practice. Recommendation 7 NHS should develop appropriate information systems to collect and collate risk management information into a high-level, Estates and Facilities risk register. This should enable high-risk, high-priority matters to be consistently monitored and financial resources appropriately matched to business risk. The Benchmarking Project Steering group will monitor progress on this. Recommendation 8 6. Specific Findings and Recommendations Estates Management NHS currently demonstrate wide variation in terms of key operational efficiency indicators. Space utilisation, risk management, estate configuration and rates costs are all areas where potential improvement is likely to justify further investigation and benchmarking: NHS should ensure that asset and space utilisation is effectively monitored on a regular basis, using consistent data definitions, to ensure that space is used efficiently and surplus assets can be identified, disposed of and resources reinvested. Effective, efficient and economical use of space should be a key performance indicator within new measurement frameworks to be developed by NHS and HFS. Recommendation 9 NHS should ensure that estates risk management information is collected systematically on a regular basis, aligned with business continuity and other service risk data and used to inform decisions concerning the prioritisation of financial and other resources. Recommendation 10 NHS should ensure that property rates information is aligned with estate management data systems to ensure accurate and prompt adjustment of rates valuation, charges and reliefs in response to property changes and transactions. Recommendation 11 NHS should work with HFS to improve and develop the Joint Premises information dataset to support joint premises development. Recommendation 12 Energy Management NHS Board energy performance displays narrow variation. However, this activity has focused on hospitals at site level. It is anticipated that future service development will focus on hospital specialties and the shift to community and joint/shared facilities. To accommodate future changes: Energy performance benchmarking should be extended to the full range of NHS owned and leased operational settings to improve accountability in an area which recently experienced price inflation. This will support in measuring their carbon footprint and achieve HEAT targets in this area. Recommendation 13 NHS should ensure that relevant performance metrics are re-measured on a timely basis. In the longer term, energy usage should be attributed by operating department or speciality to improve accountability and control. Departmental like-for-like benchmarking should then support continuous improvement. Recommendation 14 The planned extension of the Energy Performance Benchmarking System to include non-hospital energy consumption should be implemented. Recommendation 15

10 Executive Summary 5 1 Waste Management NHS Board waste management performance displays wide variation. Some have actively pursued Waste Management Strategies while others are currently implementing new sustainability strategies. The Waste Management Advisory Group are actively working towards benchmarking for waste which will, in the future, be incorporated into the Environmental Monitoring and Reporting Tool (EMART): NHS should seek to establish the cause and effect relationships underpinning the improved levels of waste management delivered by better performing and use this information to improve the implementation of local waste action plans. Recommendation 16 Internal waste recycling capabilities and external processing capacity with local Councils or alternate providers should be developed. Existing good practice should be shared to support this process. Recommendation 17 The planned extension of the Waste Management Benchmarking System to include non-hospital waste should be implemented. Recommendation 18 Facilities Management In order to support improvements in efficiency across the Soft FM services: A detailed study of existing cleaning arrangements be undertaken to establish the cause and effect relationships underpinning the improved levels of cleaning performance delivered by better performing. This information should be used to inform NHS improvement plans and to develop a shared learning resource to promote Best Practice and maximise potential improvement gains. Recommendation 19 NHS should work with HFS to support the planned establishment of a national catering and nutrition database and encourage its use by all NHS to assist local performance improvement. Recommendation 20 The implementation of agreed improvements for laundry services should be accelerated to enhance existing service capabilities and maximise potential improvement gains. Service requirements should be determined by examining future demand and necessary capacity across the whole service. NHS should work with HFS to develop a collaborative action plan for improvement. Recommendation 21 Conclusions The services provided in Estates and Facilities have a major contribution to supporting Health Service delivery. There is an associated cost with the provision of such services, however, the need for efficiency is clear. In order to identify opportunities, baseline data needs to be available. This report highlights shortcomings in this area. The development of a Facilities Management System and Asset Management System will support the development of a firm baseline and allow for the ongoing development of best practice across all. The action plan and recommendations set out in this report are designed to support the delivery of improvement in Estates and Facilities provision.

11 6 NHSScotland Estates and Facilities Benchmarking Project 2. Strategic Overview and Benchmarking Context Scale of Annual Expenditure Annually, NHSScotland directly spends 1.2 billion (15-16% of Total Annual Net Operating Costs) to provide operational facilities and related support services. This figure excludes the property costs of independent service providers which are paid indirectly through various annual service contracts. The estimated additional indirect expenditure on independent primary care facilities is approximately 0.2 billion billion per annum. Estates Management Objectives NHS are facing the challenge of controlling and containing estates costs while improving other key aspects of performance required by Better Health, Better Care to support the delivery of better health outcomes. Productivity and Efficiency Improved service activity rates, capacity utilisation and reduced waiting times demand the effective and efficient use of existing operating facilities and services. Service Change Emerging health priorities and service developments require the re-configuration of existing operating space to meet changed functional requirements. Shifting the Balance of Care from hospitals into community-based services is an example. Environmental Sustainability Government policy on climate change and other environmental issues requires facilities and services to reduce direct and re-direct harmful emissions and waste. To achieve this, changes to corporate behaviour are necessary to ensure more sustainable practices are embedded in the organisation. Patient Focus Improved service-user satisfaction demands require a focus on providing clean, accessible, good quality healthcare environments with flexible and responsive support services. Estates Performance Challenges Estates data submitted would indicate that overall Estates revenue expenditure has remained unchanged between and , the most recent years for which figures are available. The increase in property costs is significant. It broadly reflects the annual recurring costs of facilities and equipment which have been newly commissioned in At the present time, NHS are in the process of delivering a programme of new/refurbished hospitals and community health facilities which will impact on key performance aspects but will also increase recurring costs through increased capital asset values. Property costs as a percentage of Total Net Operating Costs are anticipated to rise as a result of renewed facilities with corresponding pressures on other estates and facilities management expenditures.

12 Strategic Overview, Approach and Methodology 7 2 Role of Estates Benchmarking In this strategic context, estates benchmarking enables NHS to learn from each other in order to better address these challenges. The aim of the first stage of the estates benchmarking process is to examine high-level quantitative and qualitative information on comparative NHS Board estates performance in order to: indicate aspects of operational performance where some appear to be stronger than average; indicate areas where further investigation into local practice has identified the potential for more widely applicable good practice that may significantly impact NHSScotland performance to be disseminated; and indicate performance or information gaps where further investigation may provide opportunities to usefully benchmark local processes and practices. Work at this stage does not involve an examination of detailed local estates management processes and practices from which necessary learning and improvement is expected to emerge; this will follow on from the recommendations of this first step benchmarking work.

13 8 NHSScotland Estates and Facilities Benchmarking Project 3. Project Overview, Approach and Methodology Background The NHSScotland Estates and Facilities Benchmarking Project 2008 implements the first stage of benchmarking activity identified overleaf. It builds on the comparative analysis of property and estates performance carried out in This work updates the analysis; follows up outstanding issues; identifies issues for further investigation; and develops recommendations for further action. Purpose The principal objective of the Estates and Facilities Benchmarking Project is to improve the cost effectiveness, environmental sustainability and quality of service contribution that Estates and Facilities services make to the achievement of better health outcomes and patient experience. Approach Using a Balanced Scorecard approach to evaluate comparative performance, the Project will seek to lift the operational achievement of all participants towards the level of the best performers. Each NHS Board will have its own priority areas to consider. However, developing appropriate information systems and ensuring robust systems are in place to promote best practice will allow to improve performance in all areas through a programme of local prioritisation. This report highlights indications of good performance to: aid the identification of the cause and effect behind significant performance variances; establish a common understanding of where change should be achieved; and aid understanding of key constraints and success factors for converting potential into realised improvements. In addition, examples of good practice which contribute toward improved performance, have been identified (a list of which can be found in Appendix A). Completed Project Work The following project work has been undertaken: Scoping the benefits/practicalities for continuously improving the performance of the NHSScotland estate. Reviewing currently available data. Collecting additional quantitative and qualitative data. Scoping current issues with the availability and integrity of data through Board interviews. Identifying outputs for strategic and operational focus. Identifying examples of good practice. Agreeing recommendations and actions for improvement. Balanced Scorecard Development High-Level Strategy Map Using an Estates and Facilities Balanced Scorecard approach to evaluate comparative performance requires that key perspectives of activity are measured and aligned. The Estates and Facilities strategy map [Box 1] provides a generic framework for Estates and Facilities benchmarking.

14 3 Project Overview and Approach 9 Box 1 High-Level Strategy Map and Scorecards Overall Function Services ^ High-Level Estates and Facilities Scorecard Estates Energy Waste ^ Property ^ ^ ^ Facilities Services ^ Cleaning ^ Catering ^ Laundry Box 2 Example Data Availability by Indicator Category Financial Patient Focus Output Cost Sustainability Quality Operations Price Use/Volume/Risk Mix Future Leadership Data Staff/Culture Investment Good Patchy Limited None Derived >75% of >25% of <25% of No data ISD Developed Data Box 3 Example Data Availability by Site Category Site Type Owned Leased PPP/PFI Other Hospitals Health Centres and Clinics Other Cascaded Strategy Maps, Scorecards and Indicators While the high-level strategy map outlines key perspectives for performance measurement, the functional complexity involved in the provision of Estates and Facilities services requires this framework to be cascaded to the main streams of activity: estates management, energy, waste management and facilities management. This approach allows appropriate focus on specific drivers of performance in each area. Information Gaps Balanced Scorecard Performance Data NHS do not currently use a high-level Balanced Scorecard to report Estates and Facilities performance. Therefore, data needed to inform high-level performance indicators, covering the key perspectives of estates and facilities performance, is limited in some areas. To provide a clear picture of data sufficiency and availability in estates, energy, waste and facilities management, the broad level of data provided by individual NHS for is recorded in a data availability chart [see Box 2 for an example]. This chart is reproduced in each section of this report to give a quick overview of the data position and the relative focus of existing information in terms of the key performance dimensions. Site Category Performance Data Similarly, there are different categories of operational facility such as hospitals, health centres and clinics, independently provided facilities and joint facilities where performance data is limited. To provide a clear picture of data sufficiency and availability by category of operational facility, the broad level of data provided by individual NHS for is recorded in a data availability chart [see Box 3 for an example]. Data Definitions and Comparability At the present time, Estates and Facilities data definitions are broadly interpreted by NHS which allow major comparability issues to be explored but hampers more detailed investigation of cause and effect The development of consistent definitions and information collection systems will be required to support future comparison and investigation. Good Patchy Limited None Derived >75% of >25% of <25% of No data ISD Developed Data

15 10 NHSScotland Estates and Facilities Benchmarking Project 4. Estates Management Box 4 Total Estates Management Costs Category m % Total Depreciation Capital Charges Rent and Rates Occupancy Costs Hard FM Costs PPP/PFI Costs Total Estate Management Costs Benchmarking Scope Estates Management costs cover expenditures incurred by NHS in the management and maintenance of land and buildings. These costs comprise three main elements [Box 4]: Occupancy Costs Hard FM Costs Including depreciation of buildings, plant and equipment, capital charges and rent and rates. Including building maintenance, engineering and repair activities. PPP/PFI Costs Including payments under PFI/PPP operating contracts for the provision of operating space and hard FM services. Energy, Waste and Soft Facilities Management costs and activity are covered in sections 5 and 6 of this report. Revenue Cost Summary Property Management costs amount to million ( million ) per annum, approximately 6.2% of the annual NHSScotland total net operating expenditure. Proportionate costs have increased in recent years, ranging from 5.8 to 6.3% of total net operating costs, effectively rising faster than revenue resource, staff Whole Time Equivalent (WTE) and patient activity levels and reflecting the impact of the current major capital investment programme. In future years there is likely to be significant pressure on property management costs as transformational change in the NHS estate with the renewal of the existing building stock and its reconfiguration to meet modern service needs. These changes will require an increasing share of overall revenue resources. Influence of Operational Gearing The age, condition, functionality and suitability of NHS existing building portfolio drives asset valuations which underpin annual accounting calculations and determine levels of depreciation and capital charges. Portfolio characteristics also impact maintenance programmes and repair costs. In addition, PPP/PFI operating charges represent further levels of largely fixed financial commitments. This high level of operational gearing, the ratio of fixed to total costs, is approximately 90% of estates management costs. This limits the flexibility with which existing cost profiles and activity can be altered. Costs can only materially change as the building portfolio is re-shaped over time.

16 4 Estates Management 11 Box 5 Total Property Costs NHS Board m % NOC Orkney Forth Valley Dumfries and Galloway Grampian Borders Highland Fife Greater Glasgow Shetland Ayrshire and Arran Lanarkshire Tayside Western Isles Lothian State Hospital Golden Jubilee All Scotland Building Portfolio Development NHS Board recurrent estate management costs reflect the characteristics of their underlying building portfolios. Modernised NHS Board estate incorporating new build hospitals generates higher occupancy and lower maintenance costs. Ageing estate generates higher maintenance costs but lower occupancy costs since buildings coming to the end of their operational life are often heavily written down. A rough indicative snapshot of differences in these costs is provided by an analysis of individual NHS Board estates management cost as a proportion of total net operating costs [Box 5]. The data reports wide variation in proportionate spend on estates management and by implication wide divergence in the characteristics of building portfolios. Comparison of age, condition and backlog maintenance data collected by survey from NHS in summer 2008 reflects a similar picture. In recent years, the Scottish Government Health Directorate (SGHD) has supported NHS in undertaking significant capital investment programmes to modernise and re-shape major aspects of their estate to deliver service improvements. Examples include the Edinburgh Royal Infirmary and the new hospital in Forth Valley. The SGHD expects this investment to: improve productivity (new space designed for modern services); increase efficient use of overall space; (enabling disposal of surplus assets) improve underlying building characteristics (condition, functionality, flexibility etc); increase environmental sustainability; enhance patient experience (better quality of physical environment); and make improvements to patient safety and support national guidance and initiatives aimed at the reduction of Healthcare Associated Infections (HAIs). While individual post-project evaluation is conducted at the local level, the impact of capital investment projects on the overall performance of NHS Board Estates and Facilities in terms of these service outputs has not been measured in a comprehensive and systematic way. The absence of an Estates and Facilities baseline based on consistent data definitions and measures has contributed to this existing information gap.

17 12 NHSScotland Estates and Facilities Benchmarking Project Workstream Strategy Map Comparative analysis is hampered by NHS Board performance being in significant transition due to step change improvement expected from substantial investment projects. Nevertheless, it is still important to establish a consistent baseline to monitor expected improvement across key perspectives of performance. An estates management strategy map and an outline Balanced Scorecard have been developed to undertake this task. Key Focus Areas Costs, operational efficiency and productivity have been selected as key focus areas for high-level comparative data analysis. This choice is guided by the following underlying performance priorities: High operational gearing demands good asset utilisation. Good risk management improves quality and controls costs. Effective configuration supports productivity and reduces costs. Detailed analysis examines data on: hospital space utilisation and productivity; estates configuration in terms of non-hospital utilisation and joint working capabilities; risk management; and other identified cost control issues. Box 6 Data Availability by BS Indicator Category Financial Patient Focus Output Cost Sustainability Quality Operations Price Use/Risk Mix Future Leadership Data Staff/Culture Investment Good Patchy Limited None Derived >75% of >25% of <25% of No data ISD Developed Data Box 7 Data Availability by Site Category Site Type Owned Leased PPP/PFI Other Hospitals Health Centres and Clinics Other Restricted Scope of Existing Data Balanced Scorecard Data The data needed to populate an outline estates management Balanced Scorecard across the key perspectives of performance is limited. Indicators to monitor sustainability, quality and parts of future development initiatives on a consistent and comparable basis have still to be developed [Box 6]. A specific benchmarking survey has resulted in financial and operational activity data being collected for estates management by specific benchmarking survey for this report. Site Category Data Hospital data has been provided and this can be related to information collected by National Services Scotland Information Services Division (ISD) to support utilisation, productivity and cost analysis. Unfortunately, the majority of NHS have been unable to provide data for health centres, clinics and shared facilities. Therefore, the scope of service data is limited [Box 7]. Inconsistent estate measurement data (for example, area space in m 2 ) remains a potential problem for comparative analysis given the diversity of hospital sites involved and configuration differences. NHS are undertaking re-measurement exercises to improve data consistency and reliability. However, it is possible that there may be some inconsistencies in the estates management data included in this report as a consequence of these input difficulties.

18 4 Estates Management 13 Future Developments Asset Management System The new Asset Management System currently being procured by the SGHD, HFS and NHS will address these information gaps and support the development of consistent activity definitions, measurements and management reporting and therefore this forms part of the key recommendations. Good Practice Estates management professionals have identified space allocations, information systems on use and space charging processes as key drivers for improved management of space utilisation. A regularly updated Asset Management System that allows estates managers to identify unused or under-used space on a room-by-room level are vital to the improvement of space utilisation within NHS. The introduction of these information systems and space management practices require management attention, time and resources. However, this will provide significant opportunities for performance improvements. A number of NHS are exploring the introduction of these practices (Appendix A). Box 8 Joint Premises Progress Performance JP JP JP Indicator Plans Operations System NHS Board Y/N Y/N Y/N Ayrshire and Arran Yes Yes Yes Borders Yes No No Golden Jubilee State Hospital Fife Yes No No Greater Glasgow and Yes Yes Yes Clyde Highland Yes Yes No Lanarkshire Yes Yes Yes Grampian Yes Yes Yes Orkney Lothian Yes Yes Yes Tayside Yes Yes No Forth Valley Yes Yes No Western Isles Dumfries and Galloway Shetland Joint Working Capabilities Policy changes have resulted in the balance of care moving from hospitals into the community. This has required NHS to establish networks of owned, leased and shared facilities with other local service providers which has resulted in new and more flexible service delivery arrangements. Estate configuration is changing with increasing amounts of space being leased and shared. The ability to develop joint premises is becoming increasingly important in order to maximise service benefits while reducing costs and risks for NHS by sharing them with other local service providers. Estates managers were asked to comment on the current status of joint premises activities in their NHS Board area by indicating: whether their NHS Board had current plans to develop shared facilities whether the Board currently operated shared facilities and whether the Board had developed a systematic approach to planning, developing and managing shared facilities. The data indicates narrow variation around the planning and operation of individual joint premises projects but wider variation with regard to the establishment of systematic approaches to development including joint information collection, analysis and reporting [Box 8]. This situation suggests that further work to share good practice and support the systematic development of joint facilities needs to be encouraged.

19 14 NHSScotland Estates and Facilities Benchmarking Project Good Practice The effective development of appropriate community-based operating space whether owned, leased or shared is the key driver underpinning improved performance in joint working. A number of NHS have well-developed partnership relationships and experience in developing facilities that reduce costs, improve service functionality and provide a high quality environment for patients. (Appendix A) Box 9 NHS Board Estate Risk Management Physical Condition, Planned Preventative Maintenance (PPM) and Backlog maintenance Column A B C D E F Note Estates Satisfactory Backlog Backlog/ Overall Performance Indicator Budget Condition PPM Maintenance Budget Rank Score NHS Board m % % m % Golden Jubilee Borders Ayrshire and Arran Fife Lanarkshire Lothian Tayside Grampian State Hospital (Note 3) NSS Forth Valley Highland Orkney Greater Glasgow and Clyde Dumfries and Galloway Shetland 48 Western Isles 48 Notes: 1 Column B: Estimated proportion of existing property in satisfactory physical condition calculated as total land and building value expressed as % of total land and building value plus cost to achieve Satisfactory physical condition. 2 Column C: Reported proportion of planned property maintenance activity achieved in Column D: Backlog Maintenance estimates are drawn from NHS Board Estates Benchmarking Survey In cases of material estates refurbishment this cost has been approximated to reflect committed project development costs. 4 Column E: Column D/Column A. 5 Column F: Relative Board performance in across the 3 key indicators [Columns B, C & E) has been estimated by ranking performance for each indicator, weighting the rank score as follows: Column B (Rank score x 2), Column C (Rank score x 1) and Column E (Rank score x 1) and aggregating these scores to provide an overall ranking score. No response by an NHS Board has been given a rank score of 12 for each indicator. This is intended to provide a proxy for the current scale of risk, impact and mitigation.

20 4 Estates Management Comparative Analysis Effective estates risk management aims to address issues that are likely to impact business continuity in the short and longer term. These issues can arise from the poor physical condition or functional suitability of buildings or equally from a lack of statutory or environmental compliance. Risk-based approaches are used to manage estates maintenance and repair to ensure that resources are allocated to required works according to agreed prioritisation criteria. However, NHS Board estimates of the proportion of their estate in satisfactory physical condition, achieved rates of planned preventative maintenance and outstanding backlog maintenance demonstrates wide variation [Box 9]. The overall ranking score seeks to highlight the relative risk position of different with respect to estates [Box 9 Column F]. Potential Increased Expenditure The data on risk management [Box 9] suggests that there is potential for improvement in many but that there is likely to be a need for increased expenditure to mitigate and reduce existing levels of risk being incurred at this time. Wide variations in the achievement of planned preventative maintenance and the levels of backlog maintenance as a proportion of recurring estates expenditure suggest that there is likely to be some benefit from further benchmarking of existing risks and potential financial implications. There is an argument that some backlog maintenance figures are unusually high due to Board decisions to invest in new facilities, driving a desire to avoid spending money on buildings that are soon to become surplus to requirements. However, re-providing facilities usually entails increased expenditure and it is still therefore likely that estates expenditure will have to rise to address these issues. In these circumstances, it will be important that regularly monitor key risks and ensure that necessary investment is appropriately highlighted and budgeted. Good Practice Effective risk management enables preventative maintenance targeted at maintaining high levels of space utilisation and compliance with relevant building standards. It also reduces costs in the longer term by addressing, in a timely fashion, problems which will generate greater investment demands if they are delayed. A number of NHS have well developed risk management programmes, which illustrate the benefits of regular and consistent risk evaluation and mitigating action (examples of which can be found in Appendix A).

21 16 NHSScotland Estates and Facilities Benchmarking Project NHS Board Rates Charges and Relief Box 10 NHS Board Comparative Performance Column A B C D E F G Disabled Empty Rates Rateable Rates Person Property Charge/ Relief/ Rates/ Performance Indicator Value Charge Relief Relief Value Charge 1000m 2 NHS Board m m m m % % Tayside Highland Lothian Lanarkshire Grampian Greater Glasgow and Clyde Ayrshire and Arran Fife Borders Orkney Golden Jubilee State Hospital NSS Dumfries and Galloway Forth Valley Shetland Western Isles Comparative Performance Comparative property rates data from NHS for is set out above [Box 10, A D]. A gradual increase on the level of annual rates paid by NHS in recent years highlights the need to carefully monitor these costs. Rates charged as a proportion of rateable value for individual NHS have varied from 32.5% to 57.8% in Rateable values can and do vary across Scotland due to different local property market circumstances. Charging levels differ depending on the decisions of individual local authorities, however, the total rates bill is also impacted by the effectiveness with which NHS manage their use of buildings and how well they access available reliefs. In , NHS demonstrated an inconsistent approach to monitoring property usage and rationalising operating activities to reduce or eliminate occupancy costs with the effect that rates payments indicated wide variations. Current data suggests that these variations continue to exist and that there is some potential for cost savings through careful review of the way in which space is used. Potential Improvement Based on the data, there is potential for to achieve improvements in how they manage rates and relief issues. Differences in local property markets, rates levels and the diversity of and the configuration of their estate will mean some may gain more significant benefits from this area than others. Good Practice Estates management professionals have identified that accurate and timely information systems are a key driver for improved management of rates costs. Aligned information systems which alert finance and property managers to potential changes in rates calculations are a practical way to address over payment or unclaimed reliefs and reduce costs. The shift in the balance of care from hospitals to the community and increased use of community or local facilities require investment in better monitoring systems to avoid unnecessary costs (Appendix A).

22 4 Estates Management 17 Box 11 Total Estates Costs Category m % NOC Property costs Energy and Waste costs FM costs Overheads Total Estates costs NOC Total Net Operating Cost 7,933 million Box 12 Energy Cost Differences ISD HFS Diff NHS Board m m m % Ayrshire and Arran (1.3) 68 Dumfries and Galloway (0.5) 75 Borders (0.2) 83 Western Isles (0.1) 83 Lanarkshire (0.7) 85 Forth Valley (0.2) 92 Fife (0.2) 94 Grampian (0.4) 94 Golden Jubilee State Hospital Orkney Shetland Greater Glasgow and Clyde Highland Tayside Lothian Total Box 13 Waste Cost Differences ISD HFS Diff NHS Board m m m % State Hospital Orkney Forth Valley (0.5) 38 Ayrshire and Arran (0.6) 45 Fife (0.6) 45 Greater Glasgow and Clyde (1.5) 57 Tayside (0.3) 67 Lothian (0.6) 70 Grampian (0.1) 92 Golden Jubilee Western Isles Shetland Lanarkshire Dumfries and Galloway Highland Borders Total (3.7) 70 Cost Summary NHSScotland energy and waste management costs for amounted to 76.6 million ( 76.4 million ) or approximately 1.0% of annual total net operating expenditure [Box 11]. As a proportion of total expenditure, these costs have fallen in recent years. In future years, environmental levies and fuel price inflation are expected to exert pressure on resources. Outturn data for suggests that energy and waste management costs rose to 80 million for the year, HFS estimate that these costs will increase in to approximately 90 million per annum. Maintaining proportionate spending on energy and waste management will become increasingly dependent on continued improvements in operational efficiency. Existing Benchmarking Activity Energy performance has been subject to benchmarking for more than 20 years as a result of the need for NHS to report on their environmental performance. Waste management performance is a more recent addition to national benchmarking activity and is less developed. Data Differences NHS provide cost and activity data on energy, utilities and waste management on a monthly basis to HFS, who administer an extensive database on behalf of NHSScotland. A separate statement of energy and waste expenditure is provided by to NSS Information Services Division (ISD) annually as part of the published NHS Cost Book data. The cost data contained in these separate datasets differs and is not routinely reconciled by NHS. HFS energy cost data, which is drawn from hospital sites only, should be less than the published ISD figures which reflect total Board expenditure. In practice, this position holds for the substantial majority of but some HFS reported figures exceed the ISD amounts [Box 12 and Box 13]. Waste cost differences occur due to the inclusion of portering and transport costs in waste expenditure by some who transfer waste to central processing facilities. In this section, this report has relied on the HFS data to maintain consistency with other related hospital activity data.

23 18 NHSScotland Estates and Facilities Benchmarking Project 5. Energy and Waste Management Box 14 Data Availability by Indicator Category Financial Patient Focus Output Cost Sustainability Quality Operations Price Volume/Use Mix Future Leadership Data Staff Investment Good Patchy Limited None Derived >75% of >25% of <25% of No data ISD Developed Data Box 15 Data Availability by Site Category Site Type Owned Leased PPP/PFI Other Hospitals Health Centres and Clinics Other Data Availability Energy benchmarking data has been collected from NHS Board site records by a well-established web-based information system and used to support national and local decision-making. The system provides financial and operational benchmarking data needed to populate a balanced scorecard. Indicators to monitor patient focus and future development initiatives are not yet in place [Box 14] benchmarking data is still focused on hospital sites only [Box 15]. The extension of these benchmarking systems to include non-hospital settings is planned for to generate further procurement, efficiency and sustainability improvements. Inconsistent estate measurement data (for example, area space in m 2 ) remains a potential problem for comparative analysis given the diversity of hospital sites involved and configuration differences. NHS are undertaking re-measurement exercises to improve data consistency and reliability. Differences in NHS Board energy performance need to be considered in the light of these potential reporting errors. However, despite these limitations there is sufficient data to support comparative analysis of performance across a range of indicators.

24 5 Energy and Waste Management Individual Performance Indicators Energy performance data from hospital sites for is analysed by NHS Board across key performance indicators [Box 16, B E]. Energy management performance for is tightly grouped compared to the wider experience of Estates and Facilities benchmarking. This is especially so when allowance is made for the inherent differences in the scale of Board operations and site configuration. This indicative data snapshot suggests that energy performance improvement is likely to present restricted opportunities for significant short-term improvement. There are no clear examples of under or over performance by with the potential to contribute to material gains for NHSScotland NHS Board Comparative Energy Performance Box 16 NHS Board Comparative Performance (Hospital Sites Only) A B C D E BSC B1 C1 E1 Performance Indicator Cost Efficiency Economy Sustainability Overall NHS Board m GJ/100m 2 /GJ CO 2 Tonnes/ CO 2 Tonnes/ Rank Individual PI 100m 2 GJ Score Rank Scores Fife Ayrshire and Arran Dumfries and Galloway Forth Valley Tayside Lanarkshire Borders Shetland Greater Glasgow Grampian Lothian Highland Golden Jubilee Orkney State Hospital Western Isles Overall Balanced Scorecard Performances Recent energy price inflation [not reflected in these figures] and the need to reduce CO 2 emissions due to the impending implementation of the UK Government carbon reduction commitment in 2010 have increased the importance of collective performance across all indicators. Relative performance in across the range of key indicators has been estimated by ranking performance against energy efficiency [Column B], economy [Column C] and sustainability [Column E] and aggregating these individual indicator rank scores to provide an overall ranking score [Box 16, B1 E1 and BSC]. The calculation of the key efficiency indicator is dependent on the provision of estate measurements of area space in metres squared. This gives rise to the possibility of unrepresentative information being generated for some with outdated metrics. Nevertheless, the comparative data is intended to signpost NHS toward areas for further investigation including inaccurate data capture and re-measurement if necessary. The overall ranking indicates that better performing produce or purchase energy more economically, consume it more efficiently and achieve this with a better mix of fuel sources to reduce both relative CO 2 emissions and costs. The Energy Benchmarking System should be extended to monitor overall performance using a balanced scorecard to identify incremental improvements which can be delivered in the medium term.

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