Introduction

The healthcare estate directly contributes to the delivery of high quality healthcare for patients and it is a key enabler to change in the health system with its contribution largely undervalued and untapped (Naylor, 2017). Unfortunately, for senior management in public healthcare organisations the often vast and valuable facility portfolio presents significant challenges for decisions surrounding the long term planning of future options for the estate (i.e. new-build, modernisation, refurbishment or disposal). These decisions need to relate to the changing demand for care, driven by the aging population, epidemiology issues (change in disease pattern) and the potential impact of new technologies that have been taking place over the last forty years and that will continue with increasing impact in the coming decades. Today hospitals are structures whose design and configuration reflects the practice of healthcare and patient requirements often from a bygone era (McKee and Healy, 2000). Therefore, they are neither efficient nor functional when it comes to efficiently addressing the demands of the service now and in the future. At the same time there is an increasingly austere financial climate in many developed countries that results in cuts to public expenditure which in turn has affected budgets within the healthcare sector (Nunes et al., 2015, Stuckler et al., 2011). An increasing need has arisen to adapt the estate to reflect both current and future demands in order to avoid affecting adversely the quality of health offered to patients and its economic viability (Naylor, 2017). Responding to these challenges is the subject of much debate within academia and amongst practitioners around the nature of the new strategies required to support the long term planning of healthcare estates which deliver quality services in an efficient and effective manner, while being aligned to the organisational business strategy, organisational goals and priorities. In other words, to achieve the best value that can be delivered from the estates. This is the case within National Health Services (NHS) Scotland which has embarked on a journey in which optimising the value of the healthcare estates has been a key priority. To this end, researchers, advisory bodies and consultants have been developing assessment tools such as performance measurement systems to help asset managers to proactively deal with their portfolios through for example Balanced Score Cards with feed-forward loops, the Soft Landings Framework and the Building Asset Performance Framework (BAPF). Performance measurement systems are tools that encompass the processes of establishing goals, developing a metric set, setting targets, collecting, analysing, interpreting and communicating performance information and results within the organisation and its key stakeholders, implementation action plans for each perspective and the inclusion of causeeffect relationships between performance measures and goals (Brudan, 2010; Gimbert et al., 2010). Støre-Valen and Lohne (2016) mentioned that the analysis of performance data can contribute to strategic decision-making concerning future planning and its potential. In addition, a number of studies in the asset property management literature have identified that performance measurement provides a tool for decision making, considering whether or not to make an investment and to assess the appropriateness of facilities to ensure their alignment with the organisation mission, requirements for facility expansion, real estate acquisition and facility’s renovation and retrofit (Lavy et al., 2014 a; Cable and Davis, 2005).