Hospitals of the future

This article first appeared in Health Business

Before Covid-19, the government announced plans to build 48 new hospitals by 2030, supported by an initial investment of £3.7 billion. While the NHS has responded to the challenges of the pandemic, these investment programmes have continued.

Our work with a number of the largest new hospital programmes over the past year – where development plans have progressed despite the disruption of Covid-19 – mean we’ve seen first-hand how hospitals have had to quickly adapt their plans to respond to changing needs.

The pandemic has accelerated a number of trends in the delivery of healthcare, which now need to be supported by appropriate infrastructure. It has taught us that we can – and should - work differently to deliver healthcare, and exposed the need for some fundamental changes to hospital infrastructure going forward:

We need to accelerate the delivery of out of hospital care

The pandemic forced the NHS to work very differently. Communities were mobilised to provide mental and physical care, with 4,300 community support groups recruiting three million people; community providers also took an enhanced role in discharging hospital patients. Meanwhile, patients avoided hospital and sought advice elsewhere – A&E attendances dropped by 42 per cent while 111 calls increased by 33 per cent.

Whilst not all of these changes were appropriate, and in some instances led to delays in patient treatment, they succeeded in improving efficiency and freeing up vital NHS capacity for emergency care. As such, many will be sustained in the long term, which will require a different type of hospital infrastructure in the future. Hospitals will still exist, but they will need to be supported by better preventative care, community discharge and alternatives to A&E.

We can deliver the majority of elective care virtually – except diagnostics

We also saw the rapid uptake of patients on virtual channels. The proportion of face-to-face GP appointments dropped from 70 per cent pre-pandemic to 23 per cent during the pandemic. Registrations on the NHS App increased 111 per cent and any outpatient appointments took place virtually.

Virtual appointments are not without risk or consequence; patients missed out on essential diagnostics, including up to 50,000 cancer diagnoses and elective admissions dropped by 72 per cent. The impact of these delayed diagnoses and treatments will be long-standing.

The opportunity for broadening the scope and complexity of virtual care in the future is great, and we now need the digitally enabled infrastructure to leverage it. This needs to be combined with early diagnosis and effective elective capacity to ensure patients have access to physical infrastructure when they need it.

We need to be able to separate elective and emergency flows

During the pandemic, our hospitals were not able to effectively protect elective (non-Covid-19) patient flows from emergency (potential Covid-19) flows. As a result, elective work was cancelled, and hospitals were designated as ‘Covid’ or ‘non-Covid’.

Protecting elective capacity from emergency demands has been a long-standing aim of many hospital reconfigurations. Covid-19 demonstrated this separation is not only needed for efficiency and flow, but also to ensure effective infection control.

This means future hospital infrastructure needs to accommodate separate elective and emergency flows and access points; this could also mean more use of designated elective sites, separate from emergency sites. Another key learning of the pandemic is that our buildings need to be different to accommodate the unpredictable demands of the future and to respond to changing needs.

Offering flexible and adaptable capacity

Covid-19 tested the ability of the NHS to rapidly respond to unexpected demands. The system was able to increase capacity, including increasing adult critical care capacity from c. 4,100 beds to c. 6,800 beds. However, the spiralling rate of infection meant hospital capacity was quickly limited and the NHS required 11 Nightingale hospitals to provide additional capacity for up to c. 16,000 beds.

In future, hospital infrastructure must be adaptable to fluctuations in demand – not just to equip them to handle future pandemics but also to pre-empt long-term trends in healthcare need (including an ageing population, rising acuity of hospital admissions, the expansion of diagnostics and increasing pace of clinical innovation).

Providing enhanced infection control

Currently, c. 30 per cent of hospital beds are in single rooms. Before the pandemic, the NHS was targeting at least 50 per cent single rooms to provide protection from infection but offer privacy and dignity. Covid-19 has reinforced the need for such infection control; the need for single rooms post-pandemic is likely to be even greater. This means future hospital infrastructure needs to provide more single rooms, with implications for design and staffing.

Contributing to a net zero future

The NHS currently comprises c. four - five per cent of UK carbon emissions, including 6.1 million tonnes of direct CO2 emissions (tCO2e). The NHS has committed to carbon net zero by 2040, with an 80 per cent reduction by 2032. Infrastructure is a significant part of this, with NHS buildings comprising c. 62 per cent of the direct carbon emissions of the NHS.

The New Hospitals Programme has committed to a Net Zero Carbon Hospital Standard by Spring 2021 (a hospital development could generate >300,000 tCO2e without mitigation, for example). This will involve both the use of innovative, low-carbon materials, and new designs. This means infrastructure has a big role in reducing carbon emissions, including through net zero developments, efficient energy and water use, reducing waste and supporting sustainable transport infrastructure.

Delivering at pace

The critical Nightingale hospitals were primarily delivered within three weeks, demonstrating that changes can – with the right conditions – be delivered at great pace. Similarly, the new hospital programmes that made most progress during the pandemic were those that maintained their dedicated programme teams – who were protected from the Covid-19 response.

This reinforces the need for dedicated programme teams to support infrastructure delivery, supported by senior cover, so they are not compromised and distracted by the wider environment.

Operating within a limited economic envelope

The economic consequences of the pandemic are huge, and there is a need for infrastructure to support the wider economy as we recover from Covid-19. The economy has shrunk by 11 per cent while the deficit has risen to £394 billion (19 per cent of GDP) and the national debt has risen by £2.3 trillion (>100 per cent of GDP). Unemployment is forecast to rise to 7.2 per cent in 2021.

In this context, infrastructure investment will need to demonstrate excellent value for money. This can be achieved by maximising the returns (including healthcare benefits, cashable savings and wider economic impacts), reducing cost (through modern methods of construction and effective demand management), and demonstrating significant incremental value for money.

Modern methods of construction (including off-site construction and modular buildings) have the potential to deliver quickly and reduce capital costs by 10–20 per cent through economies of scale and better use of space. As a result, infrastructure investment needs a robust business case that impresses the imperative for hospital infrastructure in comparison to other public sector priorities.

Supporting a wider recovery

As part of this, we know hospital infrastructure can make a big contribution to the local economy and national economic recovery. Hospitals are anchor institutions and make a big difference to the places they serve. This is amplified by investment in infrastructure; investment in the New Hospitals Programme could generate 14–17,000 new jobs.

Much of this benefit can support the government’s aim of ‘levelling up’. 36 of the 48 new hospitals are outside of London and the South East, including large towns and cities outside of London, former industrial regions, coastal regions, and isolated rural areas. This shows that hospital infrastructure investment can help support wider economic recovery and direct this recovery to the areas most in need of support.

Towards new hospital infrastructure

These lessons of 2020 have reinforced the need for a flexible infrastructure that can meet modern healthcare needs for integrated, virtual and safe care. They have demonstrated that it is possible to rapidly introduce big changes to how hospitals are designed and operate, leading to improved flexibility, sustainability and a more positive wider societal and economic impact of our hospitals.