HFC Briefing Note 1: A Better Understanding of the Carter Report

The Estates and Facilities have quite rightly featured highly in two recent and important reports, the Carter Review and Delivering the Forward View: NHS Shared Planning Guidance 2016/17 – 2020/21, published in December 2015. Both of these reports make clear that better use of estates and facilities has a crucial role to play in providing high quality, safe and efficient facilities and services. Estates and Facilities staff across the NHS will be looking to maximise their expertise and experience in supporting their colleagues to use the estate to its best effect, whilst planning for future change.



The Carter Review (Full title: Operational Productivity and Performance in English NHS acute hospitals: unwarranted variations: an independent report for the Department of Health by Lord Carter of Coles1) builds on the interim report produced last summer. It recognizes that whilst many NHS bodies have some exceptional performances, more support would be needed if the NHS was to deliver £5 billion of efficiency over the next three to four years. One of the most important points that Lord Carter makes is his finding that:

….the provision of high quality clinical care and good resource management go hand-in-hand. All trusts should therefore grasp the use of their resources more effectively

His review found unwarranted variations in running costs, sickness absence, infection rates and prices paid for supplies and services. The report argues that using the “model hospital” examples, the NHS could save £5 billion a year by 2020/21, as well as tackling the many unjustifiable variations in cost and quality including in core estates and facilities issues including running costs, procurement and asset utilization. It also focuses on promoting better workforce wellbeing and productivity, another estates and facilities priority given the size of the workforce. Playing a major role in the discussions will enable Estates and Facilities colleagues to demonstrate the validity and importance of the link between the infrastructure and patient care.

He also stresses the importance of a single reporting framework and making comparisons with best in class performers. Estates and Facilities teams will be familiar with the value of getting a strong grip on data, and carrying out benchmarking to drive improvements, and the Carter Review endorses the creation of an NHS “model hospital” to promote the ability to aim to deliver best in class performance. This will also make it easier for Trust Boards to compare performance and ask key questions about why there are differences and what improvements can be made. The report also makes clear that all aspects of healthcare and its infrastructure have to collaborate to ensure that they support top quality and efficient care, for instance to ensure that patients are treated in the most appropriate setting and have the best quality, most appropriate environment to support their treatment and recovery – and again, Estates and Facilities has an important part in shaping those settings and ensuring that clinical productivity is as high and transfers are as smooth as possible. Lord Carter identifies that a significant proportion of the £5 billion that could be saved is tied up in delays in transfers. He also highlights the potential for savings through greater cross-organisational collaboration, something which a number of NHS estates teams are already operating, sharing premises or managing neighbouring estates.


Lord Carter’s report recognises the complexity and diversity of the NHS’s estate and the many different settings in which healthcare is delivered – and that this can make it difficult to benchmark or compare costs of estates and facilities management. However, his report showcases a dashboard co-produced with over 30 NHS Trusts, that is intended to give each NHS body clarity about their costs, where they might make efficiencies and what return on investment they could expect to see if they could perform at the level of the most efficient. The dashboard covers all aspects of the operational management of the estates and facilities function, including energy consumption, patient food, cleaning and linen and laundry services. His report is clear that there are too many unwarranted variations – and significant savings to be made if all Trusts made changes to move them closer to the performance of the top performers. His report analyses use of space and looks ahead to the introduction of benchmarks by April 2017 and more robust reporting. He also highlights the savings that NHS bodies can make through better management of energy consumption, including LED lighting, combined heat and power units, and smart energy management systems.

Clearly all NHS bodies will come under pressure to meet these standards and benchmarks, and to a tight timescale – Lord Carter recommends that all trusts should operate at or above the average benchmarks for all aspects of the operational management of the estates and facilities function by April 2017, with NHS Improvement setting the levels by April 2016. To support sharing of good practice, an estates and facilities portal has been set up which includes a range of case studies.

NHS Shared Planning Guidance – Creating Sustainability and Transformation Plans

NHS Shared Planning Guidance2 sets out the context and template for NHS bodies to make more rapid progress in taking the necessary step change to produce the NHS of the future. It has been produced by six leading national health and care bodies: NHS England, NHS Improvement (Monitor and the NHS Trust Development Authority), Care Quality Commission (CQC), Health Education England (HEE), National Institute of Health and Care Excellence (NICE), and Public Health England (PHE). The document sets out: “the steps to help local organisations deliver a sustainable, transformed health service and improve the quality of care, wellbeing and NHS finances”. It is supported by substantial NHS funding, including a fund to which NHS bodies can bid.

As part of the planning process, all NHS organisations are asked to produce two separate but interconnected plans covering both the shorter and longer terms:

  • A local health and care system ‘Sustainability and Transformation Plan’, which will cover the period October 2016 to March 2021; and
  • A plan by organisation for 2016/17, reflecting the emerging Sustainability and Transformation Plan

Its key themes are a focus on “place-based planning” (focusing on local populations not individual NHS organisations) and “systems leadership” which includes:

  • Local leaders coming together as a team;
  • Developing a shared vision with the local community, which also involves local government as appropriate;
  • Programming a coherent set of activities to make it happen;
  • Execution against plan; and
  • Learning and adapting.

The new guidance aims to drive faster changes and greater efficiency, including speeding up the introduction of new care models including but going beyond the series of Vanguard pilots and improvements in access to primary care, technological change etc.

Plans will need to set out how NHS bodies will introduce new care models and the rollout of digital healthcare, including the importance of collaboration across different clinical networks, and demonstrating how each local area is learning from best practice both within the UK and internationally, as well as learning lessons from other sectors. It emphasises the importance of patient safety and infection control, how the infrastructure will support clinical priorities and the importance of being at the forefront of workforce development and being at the forefront of science, research and innovation.


Section C asks: “How will you close the finance and efficiency gap?”NHS bodies have to explain how they will achieve financial balance across their local health system and improve the efficiency of NHS services. Among the checklist of questions are several specifically about Estates and Facilities:

  1. How will you deliver the necessary per annum efficiency across the total NHS funding base in your local area by 2020/21?
  2. What is your comprehensive and credible plan to moderate demand growth, including new models of care?
  3. How will you reduce costs (as opposed to growing income) and how will you get the most out of your existing workforce?
    This applies just as much to estates and facilities staff and procurement approaches as to clinical staff
  4. What capital investments do you plan to unlock additional efficiency? How will they be affordable and how will they be financed?
  5. What actions will you take as a system to utilise NHS estate better, disposing of unneeded assets or monetising those that could
    create longer-term income streams? How does this local system estates plan support the plans you’re taking to redesign care
    models in your area?

It also annexes the Government’s mandate to NHS England 2016/17, which includes overall measurable goals and clear priority deliverables for 2016/17, including at Section 3: Balancing the NHS Budget, which references the goal of securing £1.3 billion of efficiency savings through implementing Lord Carter’s recommendations and collaborating with local authorities on Continuing Healthcare spending; and ensuring CCGs’ local estates strategies support the overall goal of releasing £2 billion and land for 26,000 homes by 2020.

How can Estates and Facilities respond – and how will HFC help?

Estates and Facilities Management staff are often viewed by colleagues as “the people who keep things going”. Whilst this is of course true, there is a lot more to the modern E&FM function than meets the eye. Not only are they responsible for at least one third of the Trust’s revenue budget, but they have a significant role to play in clinical care planning. Steering colleagues through planning and strategic appraisal of valuable space is a major role and one which if not carried out professionally can result in significant resource wastage.

These two major new reports offer EFM colleagues great opportunities to demonstrate how your knowledge, expertise and skills can support your Trust in finding better ways of working. EFM staff can respond by:

  • Ensuring that you can brief their colleagues on the role played by Estates and FM
  • Ensuring that you have a strong grasp of how the estate is being used, why your Trust’s figures are what they are – and what if any improvements could be made both in terms of efficiency but also in terms of how the infrastructure and services can be shaped to enable better delivery of clinical care
  • Being able to demonstrate what safety standards must be met – and how investment or changes in practice can make this easier to achieve, with risks well managed
  • Understanding how redundant or under used estate could be reconfigured or re-used, for instance in partnership with other local organisations to enable the introduction of better models of care
  • Contributing to reductions in staff absence by ensuring staff are well managed, have clear roles, adequate training and support, and by ensuring that all Health and Safety standards are met

There has been a significant increase in Condition Surveys and 6 Facet Surveys in the last six months. Many PCT/Interim Trusts are using the Condition and Statutory for Due Diligence on property transfers. Foundation and Acute Trusts and now mental health, primary care premises are coming under close scrutiny with the PAM metrics, which look to provide a nationally consistent approach to evaluating performance against national indicators.

With ever increasing demands on the health estate and budget constraints, prioritised maintenance plans with risk assessments are critical for the future business planning in the NHS. Estates professionals need the knowledge and skills to demonstrate the role that EFM plays, and what could be the consequences both of investment and of cuts.

Estate professional have for many years carried out surveys to get a grip on important data and monitor trends. Fortunately, EFM has well established and well tested standard approaches that reflect the Carter Report’s focus on standardization and best practice. If your Trust has not reviewed its practice for a while, now would be a good time to revisit these techniques and ensure you are getting the most from your estate and its capability to meet clinical demands and strategic goals.


Core among these approaches is the Three Stage Plan, covering the three core parts of EFM:

Space utilization
Condition survey and
Suitability study

Practice and improvement has developed this into the Six Facet Plan:

Facet 1 – Physical Condition
Facet 2 – Functional Suitability
Facet 3 – Space Utilisation
Facet 4 – Quality
Facet 5 – Statutory Compliance
Facet 6 – Environmental Management

The multidisciplinary structure of the Practice ensures an integrated approach to any strategic process. The aim of these facet reports is to provide the trust with a fully comprehensive plan to form the core information required by each NHS Trust as identified in NHS EstateCode and the Risk Based Methodology for establishing backlog costs. In addition, carrying out these functions enables trusts to undertake surveys against Premises Outcomes 8 and 10 of the Essential Standards of Quality and Safety, CQC National Government Standards.

How will HFC help?

Performance Analysis (Benchmarking)
Members receive free annual benchmarking performance analysis and trend report based on ERIC, enabling them to identify areas for improvement, and we offer a highly competitive consultancy service too. If you need an extra pair of hands to complete Premises Assurance, assess your performance or put together your policy documents – we can help.

A safe, secure environment
Created with industry leaders Nulogic Fire Limited, our Fire Risk Assessment service will give you peace of mind in ensuring compliance with Regulatory Reform (Fire Safety) Order 2005. It offers a flexible, value for money approach whether you want a fully managed fire risk assessment service or just the tools for your team to collect and analyse the data quickly and easily. HFC members receive preferential rates.

Best practice
Members receive regular newsletters and bulletins on up to date issues. We have also created a network of contacts from which we can seek views and experiences on Members’ behalf. In addition, our Document Exchange contains scores of Board-level policies and protocols, saving you time and money – all free to members.

Accredited Training
To support the NHS achieve these important objectives, HFC offers three key courses through our training partner Grovenbridge Academy, all of which are available at a 50% discount to delegates from Trusts that are HFC Members.

  • CELL Level 3 Award in Estates and Facilities Information Management – Driving Cost Improvement (QCF): a one day introductory course designed to inform and reinforce the importance of facilities information, generated from a range of sources already available within NHS Trusts, in the cost effective provision of NHS services to the local community.
    Course details
  • CELL Level 5 Award in Estates & Facilities Information Management – Premises Assurance (QCF): designed to inform and reinforce the importance of Premises Assurance including the responsibilities, from Director down, and show how the NHS Premises Assurance Model (NHS PAM) can be used in practice.
    Course details
  • Estates & Facilities Information Management – Risk Assessed Backlog Maintenance: a one day introductory course designed to inform and reinforce the importance of the NHS procedures relating to the production of Risk Assessments relating to Backlog Maintenance information for Statutory Returns and day-to-day use.
    Course details

Bespoke training
Together with Grovenbridge Academy, HFC also offers bespoke courses, again at a discount to HFC Member Trusts. Accredited courses can be delivered either as a Ofqual accredited or a customised non-accredited version specifically for your team. If you have a group of 6 or more staff, this option offers training at your own location offering time and cost savings for your organisation.

Promote your training opportunities through HFC
We know many NHS colleagues have existing courses running in their Trusts, often given by specifically trained staff up-skilling colleagues. As part of our initiative to promote training opportunities widely, HFC would be pleased to hear from you as we can jointly promote them to a much wider audience, both increasing the transfer of skills but also helping NHS bodies generate some income.

Join our Training Advisory Group
In keeping with our focus on Partnering with the NHS, we see the value of establishing a training advisory group from HFC Members.This group will assess the key areas affecting current E&FM services and together with HFC, source appropriate material to add to the training profile above. We are seeking nominations to sit on this group which will be restricted to 10 members so and early registration is essential to ensure your needs are taken account of. Get in touch now – see contact details below.

Contact us
To find out more about booking on to one of our scheduled courses or to enquire about bespoke courses, e-mail us, call us on 01327 227166 or complete the online enquiry form.

1 https://www.gov.uk/government/publications/productivity-in-nhs-hospitals
2 https://www.england.nhs.uk/ourwork/futurenhs/deliver-forward-view/