Strategic asset management for improved healthcare infrastructure planning in English NHS Trusts

The management of physical healthcare assets is vital for efficient delivery of healthcare services along with improving quality and productivity, amidst significant structural and funding re-organisation within the NHS. Capital allocations are under pressure and advanced strategic planning of healthcare infrastructure is required to maintain services. In doing so, the complexity of multiple interacting systems and mixed stakeholder expectations and competencies need to be addressed. The relationship between stakeholder public consultation and estates strategy development in theory and practice is poorly understood and further theoretical development is required to advance our knowledge in Strategic Asset Management (SAM). This thesis adopts an interpretivist paradigm, and an abductive approach with a case study design methodology. Data were collected from six case studies comprising 91 participants (focus groups and workshops); 6 unstructured interviews; 907 questionnaires; and observations resulting in over 30 hours of transcribed data, along with web-based document analyse (desk studies) within 149 NHS Trusts. The data were further analysed using thematic analyses. Findings reveal how localised conditions within individual healthcare Trusts influence the ways in which national initiatives are interpreted and incorporated; these impact existing ways of developing an estates strategy and in some cases, have implications on the usability of associated healthcare infrastructure spaces. This had clear implications on existing SAM practice, which were diverse, driven by individual project team competencies and associated project management practice. In practice, more focus was given to technical competencies (knowledge of SAM datasets and tools) and behavioural competencies were downplayed. Thus, the integrative Strategic Asset Management (iSAM) framework developed in this research, established a unique baseline to develop SAM plans from a complex interaction of care, estates and transport, providing a valuable resource for healthcare planning teams. Stakeholder consultation should be selective (representative sample) and the content of consultation should be appropriate at various SAM stages. Trusts should clearly indicate how their plans have been influenced, given the feedback from stakeholder consultation. Thus, moving it from a tick box exercise, to one that adds value in the decision making process. Empirical findings revealed that although literature promoted tools and methods to facilitate SAM, in practice, these were hardly used and most teams within English healthcare Trusts were not aware of best practice tools and solutions. Structuration theory was further used as a heuristic device to theoretically triangulate the empirical findings and contribute to a nuanced understanding of SAM within healthcare Trusts. In doing so, a middle range theory for integrative SAM (iSAM) was developed. It revealed that a dynamic system of individual action and organisational structure both constrained and enabled SAM. It was evident that the process of SAM is an open, emergent process of sense making rather than a pre-determined and closed process following prescriptive rules. This thesis has advanced knowledge in SAM and has raised the importance of front end project management within English healthcare Trusts. The new integrative and interdisciplinary iSAM framework facilitates the development of estates strategy and stakeholder consultation decision-making within healthcare Trusts.