1. Introduction

The NHS is a significant estate and infrastructure owner, occupying over 29 million m² at a cost of more than £10 billion per annum.

Healthcare infrastructure is critical to the delivery of safe, high-quality clinical services and a key enabler for transformational change and quality improvement. A fit for purpose estate means that we can deliver the kind of modern, digitally enabled patient care pathways that we know result in significant improvements for patients, staff and anyone involved with the NHS.

If the NHS is to deliver its own plan for change, it must invest in the infrastructure and buildings it needs to underpin clinical service provision and demonstrate to government how and where capital investment is required.

The need is therefore clear for each integrated care system (ICS) to have a clear and well planned strategy for is infrastructure.

This practical guidance, based on learning from pilots and best practice across government, supports ICSs to develop a 10-year strategy. More detailed information, templates and best practice examples are available on the NHS Estates Collaboration Hub.

In developing their infrastructure strategy ICSs need to focus on, but not be limited to, having a clear understanding of the following:

• how the estate, digital, equipment and workforce models contribute to delivery of the overarching system strategy, related clinical pathways and national priorities
• what estate sits in a system, the condition of that estate and how it can best be used
• what the required additional investment is in the short and long term
• what the options and plans are for property or land that is no longer required, or needs repurposing or acquiring
• what needs to be done to deliver against sustainability and net zero ambitions
• how the estate’s cost-effectiveness, productivity and efficiency can be increased and long-term running costs reduced
• what resources are required at the system level and within partners, and how the system collaborates with non-health bodies such as the local authority and voluntary, community and social enterprise (VCSE) sector.

2. Why are we asking ICSs to develop a 10-year strategy?

NHS England is working to produce a nationally agreed set of infrastructure priorities, informed and shaped by local needs and requirements.

This builds on work instigated by the Government’s response (2018) to Sir Robert Naylor’s independent review of NHS property and estates (2017). This response accepted recommendations that local systems should develop affordable estates and infrastructure plans (recommendation 9), and that local systems that fail to develop sufficiently stretching plans should not be granted access to capital funding (recommendation 10). In 2018/19 NHS England mandated the completion of sustainability and transformation partnership (STPs) estate strategies to inform ‘STP Wave 4 and Wave 4b’ capital funding. Those strategies included a prioritised capital pipeline, which now needs to be reviewed and updated.

In 2022, Dr Claire Fuller’s stocktake report Next steps for integrating primary care highlighted the need for a detailed review of the space available in each system, service by service, to inform future ICS-level infrastructure planning. It also identified the need for a significant increase in the number of healthcare practitioners locally and therefore space and increased capacity for them to deliver healthcare is more than likely to be needed. In response to the report, all 42 ICS chief executives committed to take forward the actions.

While the main focus of these strategies is the physical resource we have at our disposal, ICSs must consider their estates workforce. The NHS People Plan 2020/21: Action for us all and NHS Estates and Facilities Workforce Action Plan focus on how we need more people, working differently, in a compassionate and inclusive culture to deliver patient care. Including an estate workforce plan within the ICS infrastructure strategy will identify how the ICS will contribute to these national objectives and ensure it has the capacity and capability in place to deliver complex ICS infrastructure requirements and ambitions.

Lastly, the Delivering a ‘Net Zero’ National Health Service report became statutory guidance following the assent of the Health and Social Care Act in July 2022. This commits the NHS to be net zero in core emissions by 2040, with an 80% reduction by 2032. Energy emissions from buildings and other aspects of estates work make up the largest share of core NHS emissions. Estates teams will need to develop trust-level and ICS strategies that integrate their heat decarbonisation plans for transition from fossil-fuel heating systems to net zero systems. The infrastructure strategy will help ensure plans are developed in line with future development.

3. Areas of focus for effective infrastructure planning

ICSs need to implement appropriate building blocks for strategic estates planning, to allow them to plan effectively for the long term, demonstrate value for money, and ensure risk is managed and any major developments are evidence-based and overseen effectively. They should:

• embed infrastructure and estates leadership within their governance and risk assurance from an early stage
• prioritise effective partnership building across and within systems
• establish a clear capital pipeline as a baseline
• demonstrate increasing estate productivity and efficiency, including by having a plan for reducing long-term running costs
• establish baseline data for both demand (population need and service model) and supply (estates usage, condition, asset management and pipeline of investment)
• identify and map system-wide core, flex and tail estate
• embed estates and specialist skills or expertise and/or the ability to draw on these in the system design
• share learning with other systems, across partners and with national bodies

4. What should be covered in a 10-year infrastructure strategy?

Below we outline the content for the main sections in all infrastructure strategies, but these sections are not an exhaustive list.

The shape and structure of ICS infrastructure strategies may vary by organisation, depending on local context, ICS maturity and local priorities. We request, however, that strategies follow the templates and toolkits provided on the NHS Estates Collaboration Hub to ensure consistency across the system.

Below we outline the content for the main sections in all infrastructure strategies, but these sections are not an exhaustive list.

Executive summary

This should summarise the main points from each section of the strategy and provide a high level ‘system roadmap’ that looks back at achievements over the past few years and 10 years into the future.

Introduction

This should provide the ICS context, including the number of employees, services provided, size, geography and population demographics, and any other background information that informs infrastructure planning.

This section should also outline the system partners, their joint priorities and how the ICS works, and provide details of the ICS’s governance relating to estates (including for the estates team, senior responsible officer (SRO) and reporting mechanisms).

There should also be details of how the strategy will be monitored, including appropriate success metrics, and how often it will be reviewed and/or updated. We recommend this is at least every 2 years, but it will depend on local and national circumstances. .

ICS priorities

This section should outline existing ICS priorities, transformation programmes and structure, and the importance of estates and infrastructure as an enabler for delivery.

It should set out how the ICS’s priorities and the strategy will align to national drivers such as:

• delivering care: The NHS Long Term Plan, NHS Five Year Forward View – New Models of Care, NHS Five Year Forward View for General Practice
• efficient estate: Fuller Stocktake Report, Joint Forward Plan, Naylor Report, Carter Report, One Public Estate
• sustainability: Delivering a ‘Net Zero’ NHS, sustainability agenda
• workforce: NHS Estates and Facilities Workforce Action Plan, NHS People Plan, NHS Equality, Diversity and Inclusion Plan

See the appendix for detail on the programmes that should be referenced.

It should set out the future clinical model for the ICS and details of how infrastructure will support this and the required level of investment and resource.

Where are we now

This section should describe the estate and infrastructure progress over the past 5 years; for example, new developments, estates efficiencies.

It should outline the opportunities and challenges with the existing estate and infrastructure across the system, including age, backlog maintenance, critical infrastructure risk, non-clinical space, utilisation, possible disposals and investment to date.

This information should be supported by data analysis and show how data is used for effective decision-making and prioritisation.

Where do we want to be

This section should set out the ICS’s vision for its estate and infrastructure, including the key estates and infrastructure priorities for the next 10 years, and how this prioritisation will realise the overall vision.

It should list the specific objectives. These should be SMART and have a specific deadline or timeline.

The section should describe:

• how the ICS will incorporate stronger, safer and greener buildings to contribute to the NHS commitment to be a net zero health service for direct emissions by 2040
• how digital transformation and innovation will be used to improve capacity in built and other assets while achieving the aims of the Digital Clinic Safety Strategy
• how workforce will be used to deliver more and improved capacity in built and other assets while achieving the aims of the NHS Estates and Facilities Workforce Action Plan
• opportunities for greater efficiency and productivity of the estate and other commercial opportunities; for example, income, valued added, invest to save
• acquisitions, disposals and repurposing
• how resource will be more efficiently used and allocated, including through local government collaboration to promote effective investment decisions.
• For those ICSs that have a project within the New Hospital Programme, it is important that they demonstrate an understanding of the impact that Hospital 2.0 will have on the provision of out of hospital services.

How do we get there

This section builds on the objectives in the previous section, setting out detail on the required workstreams, deliverables and action to achieve them over the next decade.

For each workstream, this detail should include:

• which organisation is taking the lead
• any specific opportunities and challenges
• what governance and capability is provided and how these will support integrated working across estates teams to realise the ICS’s vision as well as deliver strategic aims across the whole system, not just at an organisational level
• any risks the ICS would face if the existing workstream did not continue or the proposed workstream go ahead, with proposals to mitigate or manage the risks
• how the ICS will fund the workstream priorities

5. Support available

Additional resources are available for NHS estates teams on the NHS Estates Collaboration Hub, including templates, data packs, case studies and examples of best practice.

The national NHS England Estates Strategy and Planning team will run regular webinars over the coming months to support strategy development; details can be found on the hub.

Please direct any enquiries to national NHS England Estates Strategy and Planning team at England.estatesandfacilities@nhs.net

Appendix: Programmes to reference in infrastructure strategies

Workforce programmes

Estates and facilities workforce action plan

The NHS Estates and Facilities Workforce Action Plan (WAP) sets out how we will fulfil the ambitions of the NHS People Plan and NHS People Promise for our estates and facilities workforce across England over the next 10 years. It highlights 4 priorities:

1. developing our people
2. building the next generation of estates and facilities management people
3. embedding equality, diversity and inclusion
4. improving the health and wellbeing of our people

What to consider

• A commitment to the 4 priorities above and how these are being embedded across the ICS estates and facilities workforce.
• Reference to the key estates and facilities workforce challenges in the ICS area – for example, skills shortages, vacancy levels, staff morale, recruitment and retention, sickness levels. Are these challenges specific to certain geographical locations?

NHS Estates and Facilities Apprenticeship Challenge 2022/2023

The apprenticeship challenge was launched in 2022 to create 1,000 apprenticeship starts in estates and facilities each financial year.

An apprenticeship toolkit specific to estates and facilities has been developed to support this challenge, and can be used to explore different apprenticeships, find example career pathways, understand how to fund apprenticeships and develop the team.

What to consider

• Are apprenticeships embedded across the estates and facilities workforce – that is, across estates roles and facilities roles? And across apprenticeship levels (entry level 2 through to level 7 master’s degree level?)
• Are apprenticeships being used to attract new people, particularly those under 25 year olds, into the workforce?
• Are apprenticeships being used to upskill and retain the existing workforce?
• What are the opportunities to develop apprenticeships across the ICS, so that apprentices can work across multiple organisations to gain the breadth of experience needed?
• What new skills are needed to future-proof the workforce?

Aspirational training and development goals for NHS Estates and Facilities 2023-2028

1. To have a minimum 5% of the estates and facilities workforce on an apprenticeship programme annually.
2. To be actively engaged in widening participation/local employment schemes including Project Search or the supported internship scheme.
3. To increase engagement and awareness of estates and facilities management (EFM) career opportunities among school-aged children by encouraging NHS staff to become NHS ambassadors.
4. To explore graduate routes into EFM careers through degree-level apprenticeships and graduate scheme development opportunities.

What to consider

• Commit to developing ICS-level estates and facilities apprenticeships with rotation across organisations.
• Ensure trusts are growing their apprenticeship numbers both in terms of recruiting new talent and developing the existing workforce.
• Promote the NHS Ambassadors programme to increase the number of estates and facilities staff going into schools to talk about career opportunities and pathways.

Health inequalities

ICSs have a critical role in driving efforts to improve population health and tackle inequalities in their local areas.

The unemployed are more than five times as likely to be in poor health than those in employment (the Health Foundation, 2022). ICS estates and facilities can help deliver better health outcomes in local communities by increasing levels of employment in deprived areas, and offering training and development through apprenticeships and widening participation initiatives.

What to consider

• Reference the correlation between public health and levels of employment – that is, higher levels of employment equate to better health outcomes.
• Identify how the ICS will improve awareness of job opportunities to drive this agenda, particularly targeting areas of deprivation. To do this, refer to entry level estates and facilities roles, apprenticeship training and development opportunities, widening participation, etc. NHS England » NHS estates and facilities workforce action plan

Sustainability programmes

ICS Green Plan (mandatory)

In the Delivering a net zero NHS report the NHS committed to reach net zero by 2040 for the carbon emissions it controls directly, and by 2045 for those it can influence (such as those embodied within the supply chain). 

Green plans provide a structured way for each trust and ICS to set out the carbon reduction initiatives it has underway and plans for the next 3 years (for this cycle, 2022/23 to 2024/25). The 3-year timeframe should allow green plans to strike an appropriate balance between immediate carbon reductions in some areas, alongside strategic development of capability in others. All  green plans should reflect national priorities by aligning with the plans, actions and timescales laid out in Delivering a net zero NHS.

Each ICS was asked to develop and publish a consolidated system-wide green plan by 31 March 2022, signed off by its board or governing body and peer reviewed regionally. These green plans summarise those of relevant member organisations, and system-wide priorities and co-ordination, including  the integration of trust green plans with the efforts of primary care, local authorities and other local care partners.

From: Greener NHS Green Plan guidance

What to consider

• What does the ICS green plan commit to?
• What actions and strategic aims are specifically related to estates and facilities?
• Who is responsible for the green plan? Do they have oversight of the ICS estates infrastructure strategy process?
• What is required to incorporate the findings and infrastructure needs arising from secondary care heat decarbonisation plans?
• What actions are needed to meet the requirements within the NHS clinical waste strategy? What investment might be required for waste infrastructure?

NHS Net Zero Building Standard (mandatory)

The NHS Net Zero Building Standard provides technical guidance to support the development of sustainable, resilient and energy efficient buildings that meet the needs of patients now and in the future. The standard applies from February 2024 to all investments in new buildings and upgrades to existing facilities that are subject to HM Treasury business case approval, and those that were at pre-strategic outline business case approval stage on that date.

What to consider

• What construction and refurbishment projects will need to comply with the Building Standard?
• What energy sources will they need? Can these be supported by local area energy plans (see below)?
• What local planning conditions are there that relate to net zero? Note: some local planning requires carbon offsets, which are not included in the Building Standard.

Biodiversity net gain (mandatory)

Biodiversity net gain (BNG) is the recovery of the habitat for wildlife in the development of land, and from November 2023 is a requirement for developments to which the Town and Country Planning Act 1990 applies, unless exempt. It will apply to small sites from April 2024.

Land managers can sell biodiversity units.

Developers must seek to avoid loss of habitat in the land they are developing, and if they cannot, they must create habitat either on-site or off-site. On-site means on the land that is being developed, and off-site is either own land away from the development site or units bought from a land manager. If neither option is possible, the developer must buy statutory credits from the government, but this must be a last resort with evidence provided for why it is the only option. Government will invest in habitat creation elsewhere in England.

A BNG can made up of all 3 options, but this must be discussed with an ecologist as evidence will be needed to prove why there is no alternative option. Approval from the local planning authority must be obtained before building starts.

From: Understanding biodiversity net gain

What to consider

• What planned developments might need to consider BNG? Is there space on-site to create habitat and if not, does the ICS healthcare estate have any land available to create this off-site?
• Are any ICS sites planning to enhance or develop their green spaces and if so, can the ICS work with the local authority to develop plans to sell biodiversity units?

Local area energy planning (best practice)

Local area energy planning (LAEP) is a data driven, whole energy system and evidence-based approach to identifying the most effective way for the local area to contribute to both the national and the local net zero targets. Its scope is electricity, heat and gas networks, future potential for hydrogen, and the built environment (industrial, domestic and commercial) – its fabric and systems, flexibility, energy generation and storage, and provision of energy to decarbonised transport; for example, charging infrastructure for electric vehicles.

Local government leads LAEP and develops a fully costed, spatial plan collaboratively with defined stakeholders. The plan sets out the changes needed to energy use and emissions in the local energy system and built environment, detailing the ‘what, where and when and by whom’ over incremental time periods. The level of detail for an area is equivalent to an outline design or master plan.

LAEP defines the long-term vision for an area but should be updated about every 3–5 years, and identify near-term actions and projects, providing stakeholders with a basis for taking forward activity and prioritising investments and action.

What to consider

• What LAEPs are being developed in the ICS geography?
• What stakeholders have they identified? Does the ICS have a role in this?
• Do LAEPs set out future scenarios or programmes that will impact on the system’s energy use; for example, heat networks, large-scale renewable energy or storage, hydrogen networks?

Local nature recovery strategies (best practice)

Local nature recovery strategies (LNRS) are a system of spatial strategies for nature and environmental improvement required by law under the Environment Act 2021. Each strategy must:

• agree priorities for nature’s recovery
• map the most valuable existing areas for nature
• map specific proposals for creating or improving habitat for nature and wider environmental goals.

The main purpose is to identify locations to create or improve habitat that will most likely be of greatest benefit to nature and the wider environment.

Under the regulations, responsible authorities must work with partners when preparing their strategy and later when reviewing and preparing it for republication. This will:

• provide a single vision for nature recovery and the use of nature-based solutions that all interested parties have contributed to and will be working towards
• build and strengthen the local partnerships that will be important for enacting the strategies as well as preparing them
• involve the people who own and manage the land, and those who take regulatory decisions, so they can contribute to what action is being proposed, where and why

From: Energy Systems Catapult

What to consider

• How do LNRS areas relate to your ICS boundary?
• What green space are there in the ICS and are there any future plans for it (that is, development, disposal)?
• What green space programmes or reviews have been undertaken that could inform the LNRS?
• Is there capacity to support the development of a LNRS as a contributor or reviewer?

Health and care adaptation report 2021 (best practice)

Over the next 5 years ICSs and regions should have a clear understanding of the potential risks to service continuity and patient and resident health across their geography. Additionally, appropriate ongoing surveillance should be in place to gauge the levels of preparedness and resilience across primary, secondary and social care, and provide targeted feedback. With this and improved alignment of health system leaders, regions, local authorities and local enterprise partnerships, ICSs should be able to develop a sense of the infrastructure investment and action priorities needed to reduce identified risks.

The report includes several actions for ICSs:

• All ICSs will build long-term adaptation planning into their green plans by 2025. Adaptation planning should consider how staff will be supported during severe weather events, risks to local transport infrastructure, and barriers to delivering care in patients’ homes while maintaining essential care delivery. This should include a stress test of business continuity plans over a wide geography; for example, flooding affecting multiple trusts in a region.
• All ICS net zero board-level leads will manage mitigation and adaptation activities. They will be accountable for adaptation planning and overseeing prioritisation and implementation of adaptation actions.
• Each ICS will identify all sites with evidenced overheating risk to ensure investment in new buildings or retrofitting, including passive and active cooling measures. There needs to be more awareness and understanding of the risks of overheating across the health and care sector. Providers may need support in making the case for building fabric investments, such as by highlighting existing tax incentives or providing subsidies.

From: Health and care adaptation report 2021

What to consider

• What risks have been identified through EPRR or local resilience forum processes?
• What sites are at risk of overheating? How do they relate to core, flex, tail?
• What sites are at risk of flooding? The Okta platform includes a flood risk toolkit, which was developed by NHS England Estates & Facilities and the Environment Agency. This includes consideration of future risk from climate change.

Publication reference: PRN00545