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Published 26 January 2021
As the future patient experience continues to change in response to general trends such as technological evolution, and in response to the more immediate short-term impacts of the pandemic, infrastructure must adapt to ensure it facilitates the smooth – and safe – running of patient pathways. Stan Campbell explores.
New working methods and patient preferences for the way in which care is delivered mean there will be an added emphasis on digital infrastructure, while physical infrastructure must be designed with technology front and centre.
Part of this is already underway, of course, thanks to the Health Infrastructure Plan (HIP), building on previous initiatives such as the Naylor Report. We already know about the P2020 Framework & Standards policy set to replace P22, as well as the initial £3 billion+ investment in the 40 Hospitals Programme. Headway is being made on the £603 million Leeds project, among others, but the public sector should also be alive to new opportunities that may present themselves.
Community models, co-locating and experiential real estate are among the buzzwords permeating the property sector and this holds true for healthcare infrastructure, too. Fertile ground for new premises is arising from the struggles facing the high street. The Centre for Retail Research has said that, of England and Wales’ 125million square metres of retail floor space at least 12.5million square metres will have to be repurposed, saying “there is no alternative”.
The Centre reports that around 14,000 shops permanently closed during 2020, and that 10% of retail floor space is likely to need repurposing in the shorter term. That figure will increase over time, particularly for large cities.
With reduced demand for retail and office locations leading many to look at repurposing, the logistical access these sites benefit from makes them prime candidates for the healthcare sector to utilise.
From a primary care perspective, GP surgeries could be inserted into such centrally located properties, either through new development or through the conversion of large retail units.
“This benefits both the landlord, in having a tenant with reimbursed income on a long term lease, and the consumer, who is able to visit their GP in a town or city centre location,” says George Todrick, Associate Director, Healthcare, at Savills.
The domino effect would mean that vacant units may be taken up by complementary service providers such as dentists, opticians, physiotherapists and pharmacies, while retail units that remain will also benefit. The result would be a win-win.
“It is envisaged that patients will generate additional footfall, translating into sales, either before or after their GP visit,” says Todrick, who adds that this may be even more pronounced for senior and retirement living.
“Not only will the redevelopment and sale of the created units provide a lump sum of capital to the landlord, the occupants will provide a captive audience for the retail that surrounds them. This demographic is ideal because, if this was standard residential, the occupants would likely be of working age and therefore vacate the area from 9am to 5pm to attend their place of work, restricting the timeframes for custom.”
Connectivity and accessibility would also improve by virtue of retail sites commonly being on good bus routes, or close to commuter hubs.
Suburban campuses and city centre schemes adjacent to retail, office and hospitality space are prime areas for repurposing and development when it comes to primary care potential, but these sites are unlikely to be a silver bullet. City centre schemes require innovative solutions to maximise space, for instance. It is not so much lateral thinking, but vertical.
“It means going higher, rather than spreading laterally. So we are exploring creative balcony options and rooftop gardens to ensure we are getting the environment right,” explains Tim Meggitt, Director of Transactions at Affordable Housing & Healthcare (AHH), which operates across care homes and retirement communities.
Many of these development options simply would not have been available to healthcare providers pre-pandemic. Availability of suitable sites, mixed with the funding challenge, meant that healthcare infrastructure often moved at a snail’s pace.
Mark Rowe, Managing Principal of the Architecture Studio at Perkins & Will, notes that despite being thrust into crisis mode, the healthcare sector is abundantly displaying the resilience, fortitude and commitment that have made it such a point of pride for Britons. Snail’s pace progress has been overhauled, as a result. This is the case even in acute care settings where, for instance, the HIP, which aims to deliver a long-term rolling programme of investment in health infrastructure, is being rolled out “at pace”. Alongside the significant potential for primary care development and repurposing in town centres, this aspirational, ‘can-do’ mindset is driving some of the momentum for change.
“Clearly bandwidth is a concern at a time like this, but – to the credit of leadership figures throughout the healthcare community – the rollout and implementation of the Health Infrastructure Plan is happening apace and the pandemic has been an accelerating force, if anything.”
Todrick agrees. The need-for-speed is never more acute than in the midst of a crisis.
“Covid-19 has catapulted the NHS into the future, forcing it to change, adapt and react at a pace it hasn’t been seen to do for a long time, if ever,” he says. “It has broken down a significant number of barriers to change.”
A barrier to change that is ever-present, however, is funding. Change, by its very nature, must be financed.
The HIP came at the back-end of 2019, before the onset of Covid-19. The healthcare community is now grappling to assess which elements of those plans must be taken forward into the next normal, and which elements need to be re-thought in light of what the past year has thrown at the sector.
“The issue with initiatives such as HIP is that a large amount of money is being offered out to various trusts with a view to improving their estate, but in a lot of cases they are in a position where they are not quite sure how to proceed with placing the funding effectively,” says Todrick.
Selected sites have been given a percentage of the total allocated funding to come up with a proposal. Clearly, such plans must ensure public funds are being used effectively and due diligence around site suitability and asset condition assessment must be undertaken. This will continue, with a competitive process planned for a further eight hospitals to join the 40 Hospitals Programme.
There remains a place for private funding, too, if the vehicle and funding opportunity are right.
“Private investors and developers are typically able to act quicker and more efficiently than a public body and are therefore able to meet the demand for new premises,” says Todrick. “We are advising upon a number of new developments and forward funding deals where facilities will provide new and enhanced services to areas that need them most.”
Aside from the usual planning hurdles, bureaucracy remains the major braking factor.
“The development of such facilities can become protracted even before a spade has hit the ground, due to the number of parties and process involved,” says Todrick. “There is a requirement to ensure the scheme proposed and/or designed is appropriate, and to secure approval and commitment from the likes of GPs who will take a lease of the new premises, as well as getting sign-off from NHS England, the local CCG and the district valuer.”
The sector remains hopeful that the lessons Covid-19 has taught us about the power of collaboration and the strides forward that can be taken when leaders are empowered to focus on quick, bureaucracy-free decision-making, will translate into the next normal.
Private funding solutions are also becoming more creative, with AHH setting up its own advisory and fund management systems.
“This all sits under our shared ownership model which means there is a safe, secure income stream, and it makes it attractive to pension funds and other investors,” says Meggitt, formerly the property lead at Octopus Healthcare.
The NHS Long Term Plan relies on continuing to move away from a healthcare model of hospitals as siloed organisations, instead taking services out into the community. The marriage of technology and estates remains a core part of that conversation, and the pandemic has provided an environment for accelerated learning as leadership figures acknowledge the art of the possible.
Technology holds the keys to making things possible by adding science to that art. It will play a role in attracting investment and opening opportunities for greater public-private collaboration, while tech-driven design will streamline efficiency and secure safety for patients and the workforce alike.
The events of 2020 have heightened the need for healthcare to be efficient and safe, but have also helped to reset mindset and culture.
“Initially GPs as well as patients were reluctant to commit themselves to remote consultations. Now having been put in a position where face-to-face consultations are the exception rather than the rule, patients and doctors alike are accepting of this new norm in order to minimise risk,” says Todrick. “As a result, having got used to the technology, it would appear patients are a lot happier with the process.”
For health and social care, technology assists with everything from record-keeping and communications, to ease of care delivery, but its impact goes far beyond that.
“Our lifestyle management teams help residents use technology in all sorts of ways, even down to simply showing people how to connect with loved ones via tablets,” says Meggitt. “It’s incredibly empowering when they learn to use such devices themselves.”
“In retirement communities, it can help in simple ways such as tracking tools or viewing electronic food menus, but also in serving the community and improving quality of life,” he adds. “We often forget that the older you get the harder it can be to make new friends, and this can leave people feeling quite vulnerable. Technology can counter this: it may be book clubs that are formed on iPads but which translate into physical bonds and meetings. Once the fear factor has subsided, the elder generation are actually much better with technology than they get credit for.”
While emergency and acute care provision have seen temporary change imposed mid-pandemic, including using emergency Covid capital to reconfigure hospitals, make them secure and segregate Covid patients from non-Covid patients, longer-term thinking is also being adapted in light of the Covid shock factor.
NHS England’s focus going forward will include primary care data collection and audit, to enable primary care networks to form estates strategies that mirror what exists for acute care. In acute care, there is a £1.5 billion capital acceleration programme, while mental health dormitories and shared bathrooms are to be replaced over the next two years.
Key to all of these plans is sustainability, with a strong NHS focus on decarbonising the health service and its estate, reinforced by the October 2020 appointment of Dr Nick Watts as NHSE & NHSI Chief Sustainability Officer.
Simon Stevens, NHS Chief Executive, has emphasised that the climate emergency is also a public health emergency, and the NHS is committed to a 2040 net carbon zero target as part of its role in mitigating that emergency. Stevens has outrightly acknowledged that “as the biggest employer in this country…we are both part of the problem and part of the solution”.
The NHS is also developing a net zero hospital standard with the UK Green Building Council, but upgrading the 26 million square metre existing estate requires further thinking, especially considering uptake of the NHS’ retrofit accelerator has not been as high as hoped.
On the design front, greater clinical input is being sought, to ensure plans are based on what is most useful and necessary from a clinician perspective. There may also be lessons to learn from schools and prisons when it comes to pre-design, standardising layouts “and how to roll these out”.
The £3.7 billion 40 Hospitals Programme shows that big changes are clearly already in motion. It is also clear that flexibility is now a core part of the design and construction mix. Pandemic-ready Nightingale hospitals which could be used for other purposes is one flexible facility idea but, regardless of the specifics, the willingness to weave resilience, foresight and flexibility into all-things-infrastructure is encouraging.
Rowe has similar priorities when it comes to baking flexibility into every stage of planning and design.
“Resilience is something we are very much focused on. The temporary will, in some cases, become permanent. Future pandemics may be very different, with different vectors of transmission, so flexibility is vital. What use is a fortress that resembles a biocontainment facility if, for the other 99 years in a given century, you want to have open, connected, welcoming spaces?” he asks. “One solution is designing frameworks with the flexibility to include or omit certain elements from the build process when the time comes to begin construction.”
“One thing we have learnt is that a bit more space allows us to spring in different directions, responding to the specific threat we are faced with,” adds Rowe. “It is prudent to more away from focusing squarely on day-to-day efficiency, and having bagginess to build in resilience instead.”
Ultimately, when it comes to the future of healthcare infrastructure, the most important thing to build is going to be flexibility.
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