It was great to see our PAM discussion group, held in conjunction with IHEEM and Capsticks LLP, featured in the recent edition of Health Estates Journal.
Read the full article below.
Health Estates Journal - June 2013
In late January this year the Department of Health (DH) released a revised and updated version of its NHS Premises Assurance Model (NHS PAM), a software-based tool originally launched in 2010 to enable estates and facilities managers to more easily gauge the condition of their built assets, provide premises assurance to their management Boards, and assure commissioners that healthcare is being delivered in fit-for-purpose buildings.
Having, in the March 2013 HEJ, described some of the key features and benefits of the latest Model, here, in the first half of a two-part article, we report on the morning session of the first in a series of IHEEM and DH-organised roundtable discussion events planned for coming months to help promote the Model, explain its benefits, and encourage wider, NHS take-up. The next HEJ (August 2013) will cover the afternoon’s debate.
Held at the Manchester Hilton Hotel, the first in a series of events staged jointly by IHEEM and the Department of Health, with the support of Finegreen Associates, to publicise and promote the revised and updated NHS Premises Assurance Model (NHS PAM), took the form of a panel discussion and debate. On the expert panel were chair, Julian Amey, the Institute’s CEO; Peter Sellars, head of profession at the Department of Health’s NHS Estates and Facilities Policy Division, and his colleague, Mike Bellas, senior estates analysis manager within the Division; Miles Timperley, director of Estates at Lancashire Teaching Hospitals NHS Foundation Trust; Lisa Geary, a Partner at law firm, Capsticks; Paul Mills, a Partner at built asset consultancy EC Harris, and Bill Murray, an IHEEM Past President, who spent many years in senior estates and facilities roles, and as a Trust CEO, in the NHS, before retiring from the service in November 2003 (his last full-time role was as Chief Executive of South Tees Hospitals NHS Trust). Before the wider debate started, Peter Sellars explained how the first NHS Premises Assurance Model came about; it was first developed following the investigation into the causes of a major outbreak of Clostridium difficile at hospitals in Kent operated by the Maidstone and Tunbridge Wells NHS Trust that occurred in 2005 and 2006. The subsequent inquiry suggested that a number of failings linked to the buildings and facilities used by the Trust contributed. Peter Sellars said: “Rob Smith, then head of the DH’s NHS Estates and Facilities Policy Division, and I, were invited to meet David Flory, the NHS’s Deputy CEO, who asked what our Division already had in place as regards assurance on NHS buildings and estates functions. We reported that we had nothing, and indeed in my own 26 years in the NHS, we had never had any such system. I explained that the estates and facilities functions of NHS Trusts had not been seen as an integral part of delivering good quality healthcare. David Flory asked us to develop a sensible tool that would help and support NHS Trusts in demonstrating assurance and corporate governance with respect to buildings and assets.”
Engagement with NHS Trust
The first Premises Assurance Model’s development saw in-depth consultation and engagement with NHS Trusts, and the formation of three working groups, with Miles Timperley heading the one for the acute sector, Alan Kenny leading the one representing mental healthcare, and Ted Griggs heading the PCT working group. Peter Sellars said: “The original NHS PAM was very much based upon what NHS professionals told us they need to be able to demonstrate good corporate governance. When the initial Model started to come together, I was approached by the Treasury to develop an efficiency model for the NHS estate. This was at the time the austerity measures were beginning to have an impact, and most people will know the NHS in England’s estates assets are worth some £44 billion at net book value, and would cost an estimated £83 bn to replace, and that we spend just over £7 bn annually managing them. Equally, we report quite a lot of the estate – in fact an area equivalent to the entire Tesco estate in the UK – ‘under-utilised’. Clearly the Treasury was aware of this, and wanted us to develop something that would help the NHS become more efficient and effective in managing its built assets. We built into the resulting Model’s ‘front end’ an economic model, having already undertaken extensive work with private sector retail organisations, asking them how they measured the value and efficiency of their built asset base. What we wanted was not just NHS estates professionals continuing to fill in our national returns saying that they were 100% efficient in managing their estate, but rather to link the Model into actual business activity.”
Prior to the first NHS PAM’s development, Peter Sellars explained that his team had already worked for some years on developing the SHAPE (Strategic Health Asset Planning and Evaluation) system – described on the Public Health England website as a ‘web-enabled, evidence-based application which informs and supports the strategic planning of services and physical assets across a whole health economy’. Meanwhile, in a previous NHS Estates role, IHEEM Past President, Bill Murray, had funded some research enabling the DH’s NHS Estates and Facilities Policy Division to bring in a clinical team of experts from Australia, in conjunction with Durham University, to look at all the clinical activity in the system, and the geography, demographics, and mapping – the aim being to guide the Department as to ‘the right size and location of the NHS estate to provide the right services in the future’. Peter Sellars said: “This data provided some extensive algorithms and analysis, which enabled us to include within the NHS PAM the efficiency ‘angle’. The Model clearly calculates and identifies how an individual Trust is performing against its peers; there is no subjectivity; it looks at the base evidence. It also highlights the costs of running the estate, and creates what we and are our academic project partners dub ‘a frontier’ – a level of performance being achieved by the best NHS Trusts that others should ideally be striving for.”
A two-part Model
Peter Sellars added that, in developing the original Model, his team had also brought in to help a company called Frontier Economics, ‘very highly regarded by HM Treasury on modelling, and good at getting behind the detail’. Returning to the Model, he said: “The NHS PAM has two key parts – a ‘front end’ which provides the metrics, and is aimed at Boards and CEOs, and which says: ‘This is where your Trust fits in comparison with the rest of the NHS’. It also identifies what we refer to as ‘the frontier’ – the Trusts considered to be the best-in-class for the size of assets and the activity going through them. “The second part,” he continued, “comprises the data, and we were under pressure, from early on, to ensure that we did not add excessively to the existing burden on Trusts to produce this.” This ‘challenge’, he explained, had meant Mike Bellas and his team making the optimal use of existing NHS data, which, once incorporated into the NHS PAM software, not only helped Trusts to identify their level of asset management performance against their counterparts, but also enabled the DH team to develop a question and answer section. This was based around those questions that directors of estates would need to answer to satisfy not only themselves, but equally their Boards, and external bodies such as regulators, that they do indeed have good corporate governance and assurance in place.
Merged into a single version
While with the first NHS PAM Model, separate versions were developed for acute, primary care, and mental healthcare Trusts, the revised version published this January was compiled in conjunction with a new working group headed by Alan Kenny, director of commercial services and asset management at Birmingham and Solihull Mental Health NHS Foundation Trust, and saw the three previous Models merged into one. The original 140 questions were also cut down to around 35 ‘really wellthought- out ones’, based on the extensive feedback from the NHS, ‘and rather more high level than those used previously’. Peter Sellars added: “We do, however, recognise that the estates and facilities activity the Model needs to reflect is by no means static; and it must have the capacity to adapt over time.
PEAT scheme now a decade old
“For instance,” he continued, “the new Patient Led Assessment of the Care Environment (PLACE) scheme, the successor to PEAT (the Patient Environment Action Team assessment scheme), will be introduced this April. PLACE has many questions around the environment, safety, and dementia patient-specific needs, and we will need to reflect these in the Model as time goes on. The whole system is starting to recognise how important infrastructure is in delivering care, and PAM will have a significant part to play in this going forward.” At this juncture, Peter Sellars’ DH colleague, Mike Bellas, outlined the workings of the latest Model, using visual aids, firstly explaining that, while the first Model had been based on a single Excel spreadsheet combining both Metrics and Self-assessment questions, it has subsequently, in response to feedback, been split into two, ‘partly because the Metrics section was so large’.
Five key Domains
The Model, he explained, broke everything down into five key ‘Domains’ – ‘Value for Money and Efficiency’, ‘Effectiveness’, ‘Board Governance’, ‘Patient Experience’, and ‘Safety’. He elaborated: “Board governance relates to how a Trust’s Board responds to the other four elements and the reported data on them. It is the ‘Safety’ area that involved the most work, while the Patient Experience questions and data also tallied strongly with the findings of the Francis Report. The Effectiveness heading is rather ‘the odd one out’; it covers areas such as sustainability that do not fit easily within the other four.”
The Model in more detail
Showing slides of the latest Model, (which is designed to run on Excel 2010, and is downloadable from the DH’s website, at:www.gov.uk/government/publications/ nhs-premises-assurance-model-launch), Mike Bellas firstly took the audience briefly through the self-assessment questionnaire (or SAQ) section, using the ‘Safety’ Domain as an example. He explained: “The self-assessment questions identify how, say, a user Trust is doing in particular areas of estates activity, while the Metrics show how its performance compares with others.” Each of the 35 ‘high-level’ selfassessment questions, he added, was now complemented by Compliance Evidence Questions, which set out what data the NHS organisation must be able to collect and record to be able to answer the question accurately. The SAQ section also now includes ‘relevance questions’, to determine whether any given question actually applies to the responding organisation. The potential answers to each question that does apply range from ‘Yes, (our organisation has) a well-managed approach with full compliance evidence’; ‘and ‘Yes, we are compliant, and are continually learning from best practice and benchmarking’, to ‘No; we are not yet compliant in this area’. Mike Bellas explained that, based on these options, respondents gave a corresponding ‘green’, ‘amber’, or ‘red’ (non-compliant) answer respectively to each question, although a new ‘blue’ response category had recently been added, designed for use by respondents who felt that not only was their organisation compliant on a particular issue, but that its performance in a particular area was ‘best-in-class’.
A straight ‘yes’ or ‘no’
Conversely, some questions, and especially those relating to the ‘Safety’ domain, only gave two options – ‘green’ or ‘red’ –‘identifying straight compliance or non-compliance’. He added: “Once all the questions have been answered, the NHS PAM software analyses all the responses, and the dashboard section then shows an overall ‘status’ for the Trust. There are, however, six specific questions within the Safety Domain considered to be so important that, should a respondent mark themselves ‘red’ against any one, the Trust in question will get an automatic ‘red’ for its entire NHS PAM assessment.”
Moving to discuss briefly the other questions, using the Patient Experience Domain as an example, Mike Bellas said these tended, typically, to be ‘softer’ – for instance one asked whether the responding organisation participated ‘in all relevant survey groups’. The next version would, he added, reflect the introduction of PLACE. He said: “While the questions might not change, the evidence required to answer them will.” In addition to there being a greatly reduced number, the self-assessment questions are also now linked to specific documentation – primarily to help those completing the questionnaire to reference particular standards, and say whether or not their organisation is achieving them. A series of prompt sheets, provided by Loughborough University – who worked in conjunction with a number of NHS Trusts to produce them – are designed to facilitate the process.
After this quick ‘walk-through’ explanation of the SAQs, Mike Bellas briefly examined the Model’s ‘Metrics’ element, which he explained related to four of the five Domains – Efficiency and Value for Money, Effectiveness, Patient Experience, and Safety. Taking, as an example, the Efficiency Domain Metrics, he explained that these would consider both how efficiently and how costeffectively space was being used, drawing on Estates Return Information Collection (ERIC) data. He added: “While the cost efficiency element is pretty straightforward, for spatial efficiency the team behind the Model, at Frontier Economics, analysed all the available HES (Hospital Episode Statistics) data, and structured it into 13 different clinical areas. This drives the identification of the levels of ‘frontier’ best performance in both cost, and spatial efficiency.”
Looking at a much wider picture
Mike Bellas said that, while the Model worked similarly to other benchmarking systems, the work by Frontier Economics had culminated in the ability for individual NHS organisations to compare themselves with others with a similar case mix from anywhere in England. He said: “The data we have also allows statistical benchmarking of peers to be undertaken for specific years against NHS organisations anywhere in England.” Looking briefly at the Metrics within the Effectiveness, Safety, and Patient Experience Domains, Mike Bellas explained that a series of ‘slider bars’ were used to highlight areas such as backlog maintenance cost over GIA, e.g. the amount of backlog per a certain square meterage. He added: “The Patient Experience Model currently makes use of PEAT and inpatient questionnaire data sets, but, with the introduction of PLACE, and the more general patient environment review, headings such as ‘Privacy and Dignity’ might stay the same, but the data underneath will almost certainly change. This will enable the Metrics for this Domain to remain consistent.”
More ‘all-encompassing’ data needed
The one area where Mike Bellas said the team behind the latest NHS PAM would like to see significant improvement was in the Safety Domain. Although the DH had ‘some good existing data’ on this area, such as ‘Risk-Adjusted Backlog Maintenance’ – in line with the current review on Critical Infrastructure Risk – it was generally acknowledged that this Domain’s data needed to be ‘wider and more all-encompassing’.
New version of the SAQs
“Historically,” Mike Bellas said, “Metrics and SAQs have been collected annually together, but NHS feedback has suggested we might begin the data collection for them separately, and adjust the SAQs more often – to reflect changing legislation and approaches. We thus plan to have the next version of the SAQs published in April this year, partly to reflect changes in the NHS landscape, and partly to reflect developments since the updated NHS PAM’s publication in January. We have also had suggestions from the NHS that, as changes to guidance, such as on preventing Pseudomonas, are released, we may publish updated SAQs to incorporate key information on the topic.” The DH team is also looking to see how the Model can be integrated with other systems, such as SHAPE. In concluding his presentation, Mike Bellas emphasised, again, that the latest NHS PAM was downloadable from the DH website. Peter Sellars added at this juncture: “The NHS PAM ‘frontiers’ will evolve yearly. If an organisation’s performance becomes ‘static’, the distance it will need to travel to become best-in-class the following year might be 30 per cent further away. The Model really will bring home to estates and facilities directors where their organisation sits within the national picture, and whether or not it is improving in key areas. There are some simple charts, but a huge amount of algorithms behind them.”
Feedback from the panel
Julian Amey at this point asked the panel members to give some feedback on the presentations from Peter Sellars and Mike Bellas. The first to speak was Bill Murray, who explained that he had formerly spent 18 years as an NHS estates director and director of group engineering, the last 13 as a chief executive – ‘quite a unique sort of animal, as very few director of estates sadly became CEOs’. He explained that the Trust in question was sizeable, employing around 5,000 staff, and had some £400 million of annual expenditure. He said: You would think that, on becoming Chief Executive, I would have had a lot of time to be a director of estates again, but I have to admit that, when I took on the former role, I could not be bothered with the details of estates work that I had pretty well become an expert in. When I was an estates director, I had also assumed that the rest of the Board should understand all of the functional suitability, space utilisation, and condition appraisal work, I was involved in, but the reality is that this doesn’t happen. A good CEO thinks more in business terms; about where is my expenditure?: around my staff; the estate, and consumables. He or she will also ensure that the Trust or other organisation’s various divisions and directorates work similarly. My experience was also that many Trusts kept their estates departments with a barrier around them; imbuing them with some sort of mystique.
Danger of disappearing
“Having read the new NHS PAM document from a CEO’s standpoint, (although I am now retired),” Bill Murray continued, “I think it’s a great document, and I would like to congratulate the team behind it. I have, however, seen similar documents produced and launched throughout my career, for instance on surplus and under-utilised properties in the NHS, but they often ended up purely as an estates thing, never getting embedded in general management practice. Thus, if I have a plea today, it’s that this is a fantastic starting point, but you must get the Chief Executives behind it. As a document, it will be fantastic for Boards and governors of Boards that the estate is being taken into account. My plea is that the Premises Assurance Model does not, over time, simply become a highly technical estates document. “The principles embodied need rather to become part of good quality general NHS management, where any manager thinks about the cost of their people, the cost of their estate, and the cost of their consumables. My question is: ‘Does Peter Sellars think this will be possible at the coalface?’”
No single point of responsibility
Miles Timperley, the next panel member to comment, said that, although considerable work had gone into the latest Model, there would still be ‘bits missing’, and the team behind it would thus welcome feedback on any areas needing to be addressed. He added: “Since the new Model encompasses many areas of both estates and facilities activities, I feel no one individual within a Trust should be responsible for completing the questionnaire; it should be about getting the right people around the table to work as a team.” He was also keen that Trusts use the Model as a benchmarking tool to help them understand where they could to better, and identify those areas where they were identified as exemplars. In the latter case, they could then go out and talk to other NHS organisations not faring so well to help them improve. Lisa Geary, of law firm, Capsticks, explained that, over the past 36 months, the NHS Trust clients the company had worked with had been ‘trying to focus on lots of different systems and agendas’, and on ‘pulling them together and linking them into some sort of centralised database’. She said: “Some systems work better than others. The driver now, particularly in our work with PCTs, seems to be to have the capability to accurately appraise and quantify an entire estate. To be able to do this means having everything, data-wise, centrally pooled, whether it be on risk management, or how estates strategy feeds into clinical strategy. I am wondering how we can develop things further, using NHS PAM, so that there aren’t too many different data sources to go to with overlapping compliance issues.” Paul Mills of EC Harris said the ability to collate, and then access, timely and accurate estates and buildings-related data from a wide range of sources through one integrated system, was one of the strengths of the NHS PAM. He said: “Ultimately what Trusts want to know is: how do we improve?; for the Model to prove effective in this respect, however, there will be an onus on all to provide accurate data.
“Another key element,” he added, “is how we can integrate the different elements in PAM with those in other similar models.” EC Harris had recently found that while, in the past, it might typically have been engaged by a Trust that needed a new building, it was now increasingly being approached by similar organisations keen to improve the efficiency of their existing built assets, but unsure how to go about this, something which the data in the NHS PAM could potentially greatly assist. Before the participants broke for lunch, Julian Amey asked those in the audience whether they had any other particular ‘burning questions’. John Allwork, who is head of estates operations at the Pennine Acute Hospitals NHS Trust, asked whether there was any chance that the ERIC data fed into the new NHS PAM in the near future would be more up-to-date than data for 2011/12, since it was important that the data estates personnel presented to Boards was ‘as current as possible’. Speaking from a primary and community care perspective, another audience member asked who would be responsible for completing the questionnaire in respect of community buildings, asking specifically whether it would be the new NHS Property Services company, or every individual provider.
NHS Property Services
Peter Sellars began by answering the second of the two questions. He said: “NHS Property Services have confirmed that they will adopt the NHS PAM as part of their governance and assurance, and will thus take responsibility for collating the data, and using it, for all the assets and buildings transferred to them.” He cautioned, however, that while plenty of estates-related data already existed for the acute sector, there was currently little specific data available to determine whether, for example, a particular primary care building was being efficiently used. He said: “We have already looked at this issue in different ways. For instance, is there something that can be done around the size of the population the community facility is serving? It is certainly something we would like to do. I am, however, confident that the Model for the acute sector is very robust. It’s the point that Paul Mills alluded to earlier – about the need for credible data to support any system.”
Looking at the issue of the ‘credibility’ of the Model, and the importance of good data, in answering another audience question, Peter Sellars said: “Our view, informed by experience with SHAPE, is that, once the information that has been nationally provided starts to be used, organisations soon realise that, if they aren’t providing good data, they will suddenly become an outlier – either for genuine reasons, or simply because they have not put the effort in to provide accurate data.” One audience member said at this point that he thought some Chief Executives and estates directors would be ‘uncomfortable at others being able to get access to their data’; he nevertheless believed the Model would be a powerful tool, especially where, in future, for example, it became possible to identify the element of the estates cost involved in a patient having a heart bypass. He said: “Perhaps you will then have clinicians using NHS PAM data and understanding it as well as the estates director, at which point the clinician might well say: ‘I need you to spend some of your capital on this or that equipment, as the lack of these facilities, and the condition of the buildings I am having to work in, are holding me back.’” At this point the participants broke for lunch. We will report on the continuation of the debate in the afternoon session in the next – August 2013 – issue of HEJ.