Reimagining our healthcare estate – a once in a generation opportunity

Reimagining our healthcare estate – a once in a generation opportunity 7 October 2020 / By Lee Hutchinson

A once in a generation opportunity – our healthcare webinar participants were unanimous in this viewpoint that today’s new normal has provided a high-profile platform for the healthcare estate with public and government support at unprecedented levels. 

The global pandemic has laid bare structural weaknesses in our healthcare system but has also demonstrated how public/private partnerships and effective collaboration can deliver incredible results in unthinkable pre-pandemic timescales. The Nightingale Hospitals’; an obvious example of agile planning, rapid mobilisation and highly focused and motivated delivery.     

Reconnecting our consciousness with the importance of healthcare facilities is a clear side effect of Covid-19, but there was no short-term thinking from our esteemed panel of Karl Redmond, Strategic Estates Lead for NHSE/I, Nancy West, who heads up Siemens Healthineers GB&I's Enterprise Services business, Tina Nolan, Executive Director of Healthcare Strategy and Planning at ETL, moderated by Lee Hutchinson, Managing Director for ISG’s Science and Health business.

Kicking off with how public investment could be best directed and utilised, Karl Redmond highlighted how a key objective of the ProCure 2020 framework was to focus funding into the right areas, so wider adoption of BIM methodologies and moving to ISO19650 standards and ‘end in mind’ thinking can be encouraged. The further adoption of the NEC4 contract would be a major step forward through its design, build and operate principles – with the latter element bringing the transformational step change for asset management. 

Dismantling silos and embracing collaboration

Karl’s response was a clarion call for holistic thinking and demolishing the silo structures that prevent cross functional collaboration to deliver better outcomes from every pound invested. The digital revolution will help focus on that operational output - recognising that the operational expenditure of healthcare facilities dwarfs the initial capital cost. He insisted that: 

“Frameworks can play a role in shifting sentiment away from the perceived transactional nature of construction, to focus on improving the delivery of assets, how they are integrated into estate programmes, the integration of technology into the existing estate, as well as encompassing digital partner programmes – using patient and resource planning data to better inform decision making.” 

Challenged by Lee Hutchinson on how we shift the conversation with clients to explore capital and lifecycle operational expenditure of built assets, Karl was clear that clients need to step up too and make sure they are better informed and learn the art of the possible. Not to continue doing the same thing as before, but ensuring that the client and professional teams come together earlier. 

Incredible opportunities 

Nancy West saw the prevailing environment as a wake-up call for construction, clients and manufacturers – an incredible opportunity for us all to shape healthcare provision for the future and deliver facilities fit for the next century. There is the very real opportunity to influence something that’s transformational through the investment in our healthcare services set against the enormity of the challenge facing health and care services in the present and post-Covid era.

Nancy was clear that patient experience must lie at the heart of decision-making and planning. It’s how we collaborate to optimise the patient journey, improve communications, reduce stress on patients and staff and optimise the use of every technology facet. The common theme emerging at this early stage being better use and application of data to drive and inform optimal decisions – that’s the way we’ll derive the most value from this increasing healthcare investment.

Supplementing inevitable resource gaps

Acknowledging the government’s rolling five-year Health Infrastructure Plan (HIP), Tina Nolan echoed the consensus that this was a once in a generation opportunity to create future-proofed healthcare facilities. Recognising that the focus of healthcare professionals in the short term is necessarily on frontline and service delivery, Tina was keen to stress that now is the time that the NHS needs more strategic planning capability and capacity from programmes like ProCure 2020, with frameworks supplementing those inevitable resourcing gaps created by Covid-19.

Back to data and Karl was definitive – data is the cornerstone and golden thread of estate planning. Without understanding existing medical and clinical data sets, we are at serious risk of wasting time and valuable resources in facilities planning. The key is linking resource and clinical planning data to objectively analyse patient flows, resource levels across individual geographies, demographics and Healthcare Resource Groups to provide a granular understanding of asset allocation. At this point we can look at what facilities we have, what gaps exist – whether we can adapt or need to build, and at what scale, what equipment we need to specify and how we can positively influence resourcing issues.

Data driven quantitative planning decisions

When we plug all these disparate data sets together, reject silo thinking and combine this analysis with estate teams, we have an exceptionally powerful asset allocation tool that we can forward project to make quantitative planning decisions. Karl notes that cultural change is a challenge to this methodology and the fact that property isn’t necessarily at the top of everyone’s agenda – but this data driven approach is central to future proofing our estate and addressing our 2050 net zero target.

Focusing on patient journey, Lee suggested that the High Street is emerging as an effective clinical pathway for primary care facilities and agreed that data would prove instrumental in targeting locations and resource targeting. This localisation works in parallel with our climate commitments, reducing both patient and clinician journey times and hence carbon footprint, whilst Karl added that this would also inform inventory, procurement and service level agreements as part of the property planning process. 

Benchmarking is key to delivering meaningful environmental enhancements in our estate. If we amalgamate pathology labs into central hubs, we need to understand the impact of additional traffic to the larger site and the community consequences. We can monitor, measure and manage and that’s how we make meaningful improvements – we need to have greater consideration for this measurement now – not when the building is handed over – that’s too late in some instances as costs for retrofitting can be very expensive and therefore prohibitive, according to Karl.    

Flexible working has proved the catalyst for change

On the subject of flexible working, the panel agreed that Covid-19 had proved the catalyst for change and widespread adoption of tech-led collaboration tools. Nancy focused on rapid development and implementation of technology with a flexible footprint from Siemens Healthineers, including remote bedside testing and CT scanners housed in contained environments outside main health care facilities to alleviate pressure on the existing estate. 

The exponential growth in remote patient consultations was highlighted as an excellent example of radical transformation that simply would not have been possible at the pace and scale it has been adopted without the intervention of the pandemic. Wider adoption of digital consultations paves the way for spatial change in our healthcare environments – Nancy theorised this could create more space for diagnostics and treatment in primary care settings. Innovations around flexible working are here to stay post-Covid-19 – this was a confident prediction.    

Tina was clear that we are at a tipping point on the journey towards integrated care systems, with providers working together across settings in the pursuit of enhanced patient outcomes. There's a major focus on the sizing of facilities with the rise in remote and out of hospital care consultations, as well as community based diagnostic hubs. These will all take pressure off acute hospital sites. The corollary to that in planning for the post-Covid-19 era is how we plan long term for irregular pandemic events around the percentage of single person rooms in our estate. Tina highlighted that England is behind the rest of the UK – where the devolved administrations stipulate 100% single person rooms. The guidance in the UK is 50% single person rooms and this has been the case since the 1990s. A lot of HIP programmes are grappling with that problem – with limited central guidance on what is the most appropriate number of single person rooms, what percentage of beds should be for critical care and isolation, and how do you deal with demand surges going forward? 

Designing for pandemics inevitably means duplication

Whole hospital zoning came under the microscope next. In a pandemic, how do you plan for the separation of the flow of plant care, the flow of infection positive and infection negative? You can achieve all of this for patients and staff, but clearly this will mean duplication and increased circulation space - and all of this has a spatial impact. Finally, and, most importantly for Tina, is the provision of space for staff – not just donning and doffing areas, but staff well-being and respite. She argued that for too long these critical areas have been value engineered out of infrastructure projects. But now all of these areas are adding pressure to HIP programmes and the affordability of these schemes moving forward.

Referencing master planning within a sector where technology and treatment regimes can evolve far quicker than the design and build development cycle, Tina had a core insight from her work on the ‘Adaptable Estates Strategy’, piloted by Guys and St Thomas' NHS Foundation Trust and King’s Health Partners. This takes a flexible shell and core approach to building space that is suitable for a range of high-tech and medium-tech clinical and research functions. The aim is to flex the space between research and clinical activity depending on requirements over time, with the proposition that clinical activity will coincide with commercial research.

Separate out construction and fit out packages to mitigate obsolescence

One of the key advantages of the ‘Adaptable Estates Strategy’ is that it separates out the business case for the shell and core, from the business case for the fit out. This model allows advancement of the shell and core, whilst conducting the detailed planning for the fit out. When you physically commence the fit out at the ‘last responsible moment’, it’s very likely that your facilities and design will have advanced in relation to a static traditional design methodology. All too often facilities are planned five or six years in advance of their opening, which means they are out of date through rapid healthcare advancements before they are even commissioned.  

On the final subject of standardisation in the healthcare estate, Nancy noted that as the last major health infrastructure programme in the UK - the Private Finance Initiative (PFI) brought an element of design competition in the way it was procured. This arguably enhanced the quality of design in the health estate, but also led to a series of bespoke healthcare building solutions – the antithesis of standardisation. Unencumbered with this historical procurement model, it makes absolute sense given the accelerated nature of the HIP programme to avoid constantly redesigning the same spaces. We have a body of evidence on what works spatially, so there is no need for NHS Trusts to dedicate time and investment in reinventing the wheel.

Standardisation principles go beyond repeatable rooms

ProCure 2020 is adopting standardisation principles, and this extends beyond repeatable rooms to assumptions around 24/7 access to care, operational hours, evening clinics and Sunday working. All Trusts should be doing the same planning, looking at these standardised occupancy targets for inpatient cohorts and critical care beds – there’s a great deal of learning to be shared from previous HIP schemes. 

Revealing huge opportunities counterbalanced by old and novel challenges, this is undoubtedly a pivotal time period for reimagining the healthcare estate of the future. What’s clear is that technology and data-driven decision making will help to shape our physical assets and there’s clear recognition that the catalyst for change may not necessarily come in a benign form.

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