Clinical estate priorities

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These broad themes shape the trust’s clinical estate priorities, set out and discussed in detail below:

• KMPT must continue to improve the quality, safety, security and therapeutic value of its environments for patient care and their staff
• The trust must strive to reduce overall costs, especially support costs, so that investment can be focussed where it is most needed
• KMPT must ensure it has the right types of property in the right locations
• To achieve its ambitions, the trust must be bold, and deliver not just improvement but estates transformation
• The trust must improve the environmental sustainability of its building and services
• The estate and any changes to it must work hand-in-hand with its clinical technology strategy.

Quality, safety, security and therapeutic environment

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This means that facilities need to be fit for purpose and meet current NHS guidelines for estates and facilities. Patients, staff and visitors alike deserve an environment that protects their security, but in a way that is proportionate to the risks involved and is conducive to a therapeutic environment. The safety agenda includes the need for robust fire protection systems, such as those mentioned in para 30, above.

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Service users have a range of needs. For example, people resident in our low and medium secure units would have a different profile of risk to, say, patients with advanced dementia. Yet, appropriate measures to protect patients, staff and visitors requires specialist intervention, both in the way that care is managed and delivered and in the build environment itself.

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The key principle is that patients should be managed in the least restrictive environment possible in order to facilitate safe treatment and, wherever there is the potential, rehabilitation and recovery should be promoted. The design of the patient care environment must have in place appropriate measures to ensure the safety and security of service users and all the building users. This can lead to trade-offs between the competing requirement for security, balanced against the requirement to ensure that care environments are as homely and non-institutional as possible, very much a live issue for the CQC.

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The CQC provides important guidance and interpretation on safety factors in ward environments in particular. The trust has worked closely with them on seclusion suite design, for example, work which has informed the new layout of the Willow Suite PICU, due for completion in June 2019. A current CQC focus is on sexual safety in ward environments, with both design and gender issues (single or mixed sex accommodation) undergoing review. In the trust’s most recent inspection, the issues of disability access, garden area provision, identification of blind spots and, of course, ligature point removal/ reduction all featured prominently.

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The CQC’s most recent mental health inspection publication, authored by Paul Lelliot, identifies a number of ward environment issues with estates implications. They look at both the “social” and “physical” environment, picking out how institutional features such as “locked” wards can dovetail with a poor staff culture around the patient-staff “power relationship” in the social environment, and how over-zealous infection control requirements and poor maintenance can lead to institutional physical environments.

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It is likely the Health Building Notes (HBNs), which govern mental health ward design, will be reviewed soon and there is a major expectation around ensuring “co-production” approaches to design and improvement of wards, and elsewhere, to enable the views of people, who may have experienced life as a patient, inform any physical and social environment changes. The trust has a growing co-production team and they are increasingly actively involved in estate design work.

Prioritising investment on frontline care

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After staffing, estates costs represent the trust’s highest cost. It follows that the more efficiently the estate is run, the less it will cost, which in turn means leaving more funds for investment in the frontline clinical staffing requirement. At just over £19m, the trust’s expenditure on the estate is more than 16 per cent of its total income

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The estates team has delivered significant cost reductions in each of the past three years, as well as releasing significant capital receipts, with substantial revenue profit, over a number of years. As each year passes, with demands tending to increase rather than decline and opportunities for improved efficiency taken, it becomes increasingly difficult to “squeeze” running costs. At the same time, operational and technological improvements in productivity and efficiency will provide further opportunities and the team is focussed on trying to deliver nearly £700k in cost improvement programmes for
2019-20.

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Paragraphs 25-27 above point to potential KMPT opportunities and targets in terms of ensuring the estate is efficiently utilised and, where surplus to requirements, unfit accommodation is disposed of, thus reducing costs. The trust will use all the information at its disposal to pursue support cost reduction, while maintaining quality. The Model Hospital information will be a starting point for the efficiency programme. The estates team already works closely with the information technology team, where electronic document management (fewer filing cabinets), room booking systems and small footprint computers are examples of crossover efficiency schemes. By continuing to focus on all aspects of estate and facilities costs, the trust can ensure investment in the clinical frontline is maximised.

The right kind of buildings in the right locations

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One of the most important things about trust buildings is that they must be as accessible as possible to the people the trust serves. Access is partly about the building facilities such as Disability Discrimination Act (DDA) provision, lifts, security access, signage etc. The other important access issue is about geography. The trust services need to be available to people as near to where they live as possible, within reason. And they need to be located on transport routes that make travel as straightforward for service users as possible. The trust has reduced its estate “footprint” significantly over recent years, shedding unfit buildings, acquiring new and centralising and integrating services into what it calls community “hubs” in major towns. While the drive to develop hubs will continue, the trust will not lose sight of the need to provide access to service users as widely as possible.

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One of the trust options for ensuring wide access is to work with partners to identify opportunities to work from one another’s buildings. Working collaboratively with partners in the health and social care economy, and more widely across the public sector through One Public Estate forums, the trust aims to generate opportunities to better share space, which can include other third sector parties.

Estates transformation

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To tackle the twin challenges of using space efficiently and having the right buildings in the right locations, the trust has had a unique Estates Transformation Programme (ETP) in place for a number of years. Through this, the trust has replaced unfit accommodation with fully modernised, fit-for-purpose accommodation in both community and inpatient services, delivering the “pillars” of the trust strategy. The particular focus of ETP has been on development of a network of community “hubs”, providing opportunities to centralise, dispose of surplus accommodation and use the capital receipts to support the capital programme.

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The ETP team has also used knowledge from ERIC and PLACE, supported by 6 Facet Surveys and audit programmes, to prioritise their aims as follows:

• Reduce instances of under-utilisation through a combination of site rationalisation, asset disposal and consolidation
• Prioritise the capital programme to facilities that require refurbishment or modification to meet the high standards aspired to for all premises
• Review the costs of premises and prioritise attention to reducing commitments to high cost-to-occupy premises in order to release resources to invest in an estate that will have a lower footprint, but with capacity maintained through improved utilisation and with a higher quality patient care and staff working environment overall
• The trust will be launching a new office accommodation transformation scheme this year to further develop efficient, modern and comfortable office environments, combining improved utilisation and productivity with workplace comfort, harnessing hot-desking, and open-plan working on a wider scale.

Develop more environmentally sustainable building and services

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As a large, multi-site mental health organisation, the trust has a significant environmental impact. It generates substantial waste and carbon as a result of clinical activities and the travel and transport needed to deliver goods and services and to move staff, patients and visitors impacts on local air quality. Without a firm strategy and plans to manage and reduce its environmental impact and improve efficiency and resilience, the cost of delivering services will rise and become more challenging.

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To that effect, KMPT’s ambitious Sustainable Development Management Plan (2015-2020) sets out a clear vision, strategy and objectives for delivering sustainable healthcare across Kent and Medway. A sustainable health and care system delivers high quality healthcare within the available social, economic and environmental resources. It also provides added value for taxpayers and improves public health within the context of diminishing financial and natural resources. No organisation can change the past, but all have a moral and ethical responsibility to leave behind a world that is not polluted or depleted of essential resources for future generations. This is a strongly held view across the trust workforce, as evidenced in the comments contained in the stakeholder feedback collated at the start of this document, and repeatedly through staff surveys.

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In 2020, the trust will review its strategy as the previous strategy focussed largely on estates efficiencies around energy, water, waste and travel. The scope of the new strategy will be expanded to encompass wider issues of health, wellbeing and social value while moving KMPT closer to achieving long-term carbon reduction targets. To help inform the content of this new strategy, and ensure that it covers all aspects of sustainability, the trust will be using guidelines set out by NHS Innovation and the Sustainable Development Unit.

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Themes for the updated sustainable development strategy will be developed and applied across the 10 modules of the healthcare sector tool for measuring and improving qualitative sustainability performance. This tool is known as the Sustainable Development Assessment Tool, or SDAT. The ten modules will be used as a basis for defining the updated strategy as shown below:

• Corporate approach
• Asset management and utilities
• Travel and logistics
• Adaption
• Capital projects
• Greenspace and biodiversity
• Sustainable care models
• Our people
• Sustainable use of resources
• Carbon/GHGs

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The trust is legally obliged to address climate change, with a national target of 80 per cent reduction in carbon emissions required by 2050 - set out in the UK’s Climate Change Act (CCA). This informs carbon reduction targets of 34 per cent by 2020. KMPT will continue to demonstrate its compliance, commitment to sustainability, reducing its carbon emissions and minimising its impact on the environment and climate change through various initiatives and projects.

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Using the Carbon Trust Sustainability reporting metrics for the healthcare sector, the trust had delivered a 28 per cent reduction by 2017-18 against a 2015 baseline (with a 34 per cent reduction target by 2020), making good progress, particularly in areas including buildings, energy consumption, travel, behaviour change and a corporate approach to contracts, etc.

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KMPT can demonstrate significant carbon reduction achievements, of which the trust and its staff can be proud. As the trust looks to the future, however, it is clear that most of the quick-win opportunities have been taken and it is now time to challenge ourselves to tackle the more difficult aspects of carbon reduction. The graph in Annex C sets out some of the specific sustainability initiatives over recent years and it also shows the comparison of emissions with business-as-usual (BAU) increases and reduction targets, demonstrating that KMPT has exceeded the target trajectory to date.

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Over the coming year, KMPT will continue to play a pivotal role as part of the STP process through building stronger links between sustainability and quality improvement as well as demonstrating the environmental, social and economic co-benefits of delivering new models of care through closely integrated services. Collaborative work with partners and stakeholders will further enable KMPT to improve the environment.
Clinical Technology Strategy.

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Throughout this document, reference has been made to the overlap of estates and information technology/clinical technology projects. The trust is in the process of drawing together its Clinical Technology Strategy, due around the middle of 2019.

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That strategy is primarily about supporting clinicians to better access and manage the clinical patient information required to deliver the care patients need, in the right way and at the right time. But there are also significant technological devices and projects which can yield substantial dividend to the estate in terms of both quality and productivity. There is usually an initial cost to these advances, which will require careful consideration, but the potential benefits are substantial.

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Obvious examples, referenced elsewhere in this document, include the development and deployment of patient and staff apps which can be used to improve communication, engagement and information and even book appointments; building management systems capable of managing temperature and energy use; agile working devices allowing staff to operate from multiple sites to suit their work demands and support a healthy work-life balance; better room booking systems; quicker and easier access to networks; integrated ICT/telephony systems; and unobtrusive patient welfare monitoring systems.