The Power (and Politics) of Health Buildings

1. The Power (and Politics) of Health Buildings Barrie Dowdeswell Executive Director European Health Property Network

2. OECD OECD societies are healthier than ever, spend more on health care - buthealth inequalities and variances persist • The question is simple: is the rise in costs affordable and are health care systems becoming more efficient and delivering more value for money? • Key priorities, are: • Overcoming health inequalities • Managing demographic & epidemiological transitions • Delivering sustainable value

3. The need for a better ‘Capital Asset’ evidence base to plan for the future A Pan-European Evaluation of Capital Investment Strategies: • The European “Fit for Purpose Capital Study” • EuHPN / European Observatory as partners • 14 case studies • Thematic analysis across 12 dimensions of process and effectiveness • First results now - publication early 2009 Capital - as a catalyst for change Capital - as responding to change Capital - as a defining value in healthcare

4. Performance gradation of case studies, potentially extreme lifecycle variations TR • Performance • Perspectives • Corebusiness • efficacy • Financial • viability • Adaptability • Lifecycle cost • profile • Lifecycle • economic • value RIK N 1 KAR NIR COXA SIT RK JP VAL ‘Design excellence’ PFI Weak Strong Sustainable ‘business’ effectiveness and efficiency

5. Five critical dimensions • Evidence-based investment decision-making • Flexible investment strategies – e.g. disinvest to reinvest – and refinancing • Technical knowledge and competency • Politics • Leadership

6. A new paradigm? • In a future era of economic uncertainty • Growth through redistribution will be critical to resolving and heading off future health inequalities

7. The dynamics of change – Capital Investment, rapidly increasing community focus Contraction Technical dimensions Societal and efficacy dimensions Hospitals ‘Hospital’ networks Localised diagnosis & care Community facilities growth reconfiguration integration Patients, € and staff are increasingly mobile Markets and PPPs are often used by Governments to outsource ‘risky’ change

8. Facilitating health reform, whole systems efficacy: towards a new investment balance We are now squeezing the balloon Institutional technical efficiency Trajectory of reform A political, professional & cultural barrier to change Systems efficiency Disease pathway frameworks Allocative efficiency Evidence-based resource reallocation Disease / Service Model efficacy

9. COXA clinical and care / design synergyCapital investment as defining a change in systems and values theatre before ward and diagnostic ward after Theatre check in Recovery / rehab prog Diagnostic programming CPs Coxa Hospital and patient flow, 90+% compliance with care programmes Capital investment designed for whole systems networked integration

10. Performance Headlines • Activity – from 1,500 to 3,500 • Systems – 70% patients discharged to PC • Structures – wholly integrated regional model • Quality - complication (infection) rates < .1% • Cost – 10% price reduction for 2008

11. Rhoen Klinikum “Quality through standardisation & service volumes& new integrated portals / information highways” A wholly integrated multi-disciplinary model High intensity care Patient treatment and discharge pathway Emergency Diagnosis Theatres Hot floor technologies High level care General care Quicker and better community support Rehab Community portal Polyclinic Core principle - integrated, multi-disciplinary, systemised care pathways & capital investment / design synergy

12. Public Hospital Average cost per case € 3870 Capital investment element €270 RK Hospital Average cost per case € 2660 Capital investment element €720 RK – capital investment value Hospitals are ‘recycled’ every ten years – technology as per cost efficiency

13. The capital investment and planning conflict in Europe • Service outcome evidence • Benefits of integrated care pathway models of care • Capital investment outcome evidence • Benefits of technically competent - care pathway shaped - planning, design, financing and procurement • Ideological trends • Towards market led episode delivery strategies • The flight to PPPs, but ----- rarely evidence based

14. Capital / ServiceSynergy vs Dislocation A hospital is a combination of people, technologies, buildings and facilities working together for common benefit The clinical, technologies, care and professional services PFI Relationship governed by a contract structure and design set 5 to 7 years prior to commissioning - for 25 / 40 yrs The building, its environment and facility services A principal aim of PFI has been macro government debt management

15. The problem is often (?usually) politics and evidence free ideology • Unrealistic populist manifestos • “More beds / more hospitals” • Emphasis on mid-term ‘apparent’ success / progress • An obsession with targets • Gestures – was the NHS ‘deep clean’ really relevant • Service / capital change dissonance - re time scales • The hidden hand of Treasuries • Economic rationalism • Aversion to planning beyond parliamentary cycles Politics can ‘block the view’

16. Candelit vigil as hospital protest grows Doctors threaten to quit Farce as junior health minister joins protest against NHS closures Health Warning - Fixed Assets are classically used as a defence mechanism against change Protests over Irish hospital closure plan Tuesday 18th December Government ignoring public on polyclinics – Lib Dems Cabinet member joining hospital protest 'just doing my job as MP' Blears accused of hypocrisy after joining protest over hospital closure Million protest as surgeries make way for the polyclinics Protest over closure of cancer services at hospital Greve Hopital Calmette LE HAVRE - Personnel en colère

17. The Key Issue, stating the obvious! Investing for sustainable value • From - Cost saving and standardised guidelines • To - Lifecycle effectiveness, value and sustainability Integrated capital and revenue budgeting Health impact Money People Politics Clinical process systemisation Adaptable capital assets Redistribution of capital assets is difficult, controversial but critical

18. Thank You • barriedowdeswell@aol.com • euhpn.org • European Centre for Health Assets and Architecture, ECHAA