If I Were an NHS CFO: Preparing for the Return of PPP in Primary & Community Infrastructure

PPP may be back and NHS trusts that prepare now will be the first in line for investment.

The publication of the NHS’s 10-Year Plan marked a significant shift with the re-introduction of public–private partnership models for primary care, community diagnostics, and neighbourhood health hubs. Acute hospitals are explicitly excluded from any new PPP framework, reinforcing a clear message: future of capacity growth should be delivered through community- based assets, not in large acute footprints. 

My colleague, Matt Custance wrote about this when the 10 Year Health Plan was published in the Summer – Why NHS Trusts Need a Plan B for Capital Investment- and a Smaller Hospital Footprint. His argument is even more relevant now.

For the first time in almost a decade, NHS leaders may have access to a structured route of private capital investment.  We’ll find out in the Autumn Statement in a little over a week.  NHS leaders should be asking themselves whether they’re ready to take advantage of the opportunity, should it arise.

If I were a CFO in the NHS, I would be preparing for this.  The organisations that have completed the groundwork - and some already have - are likely to be best positioned to secure early investment and therefore unlock the productivity and patient benefits.  

This is what that preparation might look like:

Know the full estate portfolio

The NHS estate is fragmented, ageing and has a range of different ownership arrangements. Few trusts appear to have a complete, integrated and documented view of their estate: precise use of each building, utilisation, ownership and associated terms and conditions, condition, backlog maintenance, digital readiness, accessibility and clinical suitability for modern pathways.  This information is often incomplete, and fewer organisations have a strategic view of their estate needs over the next 5-10 years, particularly as PFIs and LIFT projects approach expiry.

If PPP becomes available for smaller, sub-£50m neighbourhood-scale projects, this estate intelligence will give trusts a competitive advantage. Organisations that move early are likely to have decided what should stay on the acute site, what needs to be modernised and what needs to be moved to the community.

Build the case

As CFO, I would:

✔ Build a single, comprehensive asset register

Not simply a list of buildings, but an integrated assessment taken from multiple information sources:

• Ownership and lease terms and conditions

• Remaining life

• Backlog maintenance

• Lifecycle cost exposure

• Utilisation

• Net zero condition

• Digital and technology readiness

The detail underpinning each point is important. Start by consolidating existing data - ERIC and 6-facet surveys – into a single estates matrix. This becomes a foundation for decision making and prioritisation, regardless of whether the eventual funding route is PPP, public capital or hybrid models.

✔ Align clinical strategy with estate needs

Because so much of the NHS’ estate is in poor condition that trusts can become over focused on fixing buildings rather than designing a modern, fit-for-purpose healthcare system.  The rationale for reintroducing PPP to primary and community healthcare is fundamentally operational, acute hospitals are seriously constrained all the time, occupancy is over 90% and flow is disrupted.  In addition, many services currently provided in acute hospitals are not acute and it would be more convenient for users if they were easier to access. 

Trusts should understand how each of the following services will be delivered over the next 10 years:

• Outpatient care

• Diagnostics

• Same day emergency care

• Integrated mental health and community care services

• Older people and frailty services

• Out of hospitals services for long-term conditions

• Children and young people services

• Neighbourhood multi disciplinary teams

Estates decisions should follow the clinical model, not the other way round.  No trust can select the right neighbourhood scheme without a full picture of its estate. This requires a 5-10 year programme developed with clinical and operations leaders to understand which pathways are constrained by the acute footprint; what activity can be moved out of the acute safely so it is closer to people’s homes; whether productivity can be improved as a result of modern design and greater digital use and whether new configuration will reduce travel time.

✔ Identify the schemes and get them project-ready

If PPP is announced in the Budget on 26th November, it will only apply to neighbourhood schemes.  Trusts should develop:

• A clear clinical case for change

• Clearly defined scope– which services and which site

• High level layouts, adjacencies and required flexibility

• A view on refurb or new build

• Affordability is going to be critical in the current climate, so an early assessment is important

• Demonstrable financial and social value

A trust with a scheme already scoped—sites identified, service models designed, planning flags known—should be first in line.  PPPs involve more stakeholders than publicly funded capital projects. A well-defined project must satisfy DHSC/ NHSE requirements and be attractive to the private sector - funders, investors, contractors, all of whom will scrutinise both the scheme and the trust leadership team.

Develop the case for change

Start to articulate how shifting services out of the acute site will:

• Reduces pressure on acute beds

• Improves productivity and flow in the acute (same-day pathways, increased diagnostic throughput, tech-enabled community care)

• Increase diagnostic throughput

• Benefit patients and staff

• Reduce recurrent operational costs (travel time, staff deployment inefficiencies, estate running costs)

PPP should complement not replace NHS Capital

PPP will not solve many of the issues in the NHS estates, but if it is reintroduced, it can relieve some pressure on the acute estate resulting in:

• Faster elective recovery

• Improved flow

• More efficient outpatient and diagnostic services

PPP should be seen as one of several funding sources alongside NHS capital.

In summary

Regardless of whether or not PPP is confirmed in the budget, the NHS is moving toward a community-first infrastructure model. The organisations that prepare now - clinically, financially, and operationally - will be those that unlock the next wave of investment.  Trusts must be ready from day one to benefit from this.

If you’re working on your estate strategy and exploring how to move services into the community, I’d love to hear your thoughts – please comment below or connect.