As lockdown restrictions are eased, attention is turning to economic recovery and the government’s manifesto commitment to build 40 new hospitals. In a briefing published today, I argue there are important lessons to be learned from the last round of hospital building which concluded a decade ago.
However, quite apart from the major challenges it poses for the resumption of more normal services, the continuing Covid-19 pandemic also has urgent implications for the new hospital building programme. Happily, the two sets of lessons tend to reinforce each other.
Less happily, the lessons of history tend to show that the ambition to build “bigger, better and greener” could too easily fall victim to building “faster” and cheaper.
Isolation is not splendid
Some excellent new facilities were built during the last major round of hospital building, but there were a set of problems and omissions that we should learn from and try not to repeat.
That programme was all about planning individual hospital developments, not about a system-wide approach to planning hospital, community and primary care services across a defined area, let alone planning for social care infrastructure as part of the mix.
Again and again, assumptions were made that the new hospital could be smaller, with fewer beds, because more care would be provided closer to home and demand would be managed. Neither of those optimistic assumptions proved to be fully justified, contributing to an enduring state of overstretch in the hospital estate with bed occupancy routinely exceeding 90 or even 95 per cent.
The pandemic has surely brought home once and for all the need to plan for integrated health and social care services – and to end any notion that care outside hospital is someone else’s problem.
Loose, adaptable, transformable, convertible
We entered the pandemic with fewer beds per head of population than most comparable economies, with lower critical care capacity and fewer MRI and CT scanners than our neighbours.
The NHS responded in a highly agile way at local level by converting operating theatres into temporary intensive care facilities and using staff and resources so flexibly that the flagship Nightingale hospitals were not needed. That task could have been eased if more of our hospitals had a greater proportion of reconfigurable space, something that was often lost due to financial constraints in the last round of hospital building.
As we move into HIP1, we would be wise to design in more convertible space, allowing clinical areas to be moved or re-equipped to much higher specifications without major building works. Generous room size specifications, known as “loose fit” and adaptable space where rooms are designed to change or accommodate multiple functions, would all be valuable.
Cost and time can be reduced by anticipating future needs. Regular inpatient rooms can be converted to critical care rooms if they are designed with this possibility in mind, with enough space for higher end medical equipment, access to suction, oxygen and extra power.
‘Soft space’ such as storage and administrative offices can be built around high-tech departments to enable them to expand with minimal upheaval and cost. Future electrical and engineering costs can be contained by deploying interstitial floors, and/or building shell space that allows for expansion or alternative use.
Designing for infection prevention and control
Covid-19 has exposed weaknesses in the way many hospitals are laid out and equipped. These need to be ‘designed out’ of new facilities and infection prevention, and control designed in.
We will need more spacious ward designs and a higher proportion of single rooms. Emergency departments need to be laid out with larger waiting areas, more cubicles, their own separate access to CT scanners, and the ability to segregate patients. Critical care departments will need negative pressure facilities and space that can be segregated.
Designs where one clinical area is accessed through another will be problematic. The ability to segregate different activities and to create ‘hot’/‘cold’ or infectious/non-infectious flows of patients will be important.
More shower, locker and changing facilities will be needed for staff as well as better common areas – these proved to be important even before the pandemic, and many had been removed.
Matching facilities to new patterns of practice
Clinical practice has changed and adapted at bewildering speed since the start of the pandemic, and that sense of urgency is affecting thinking about the need to reform and rebuild. Reconfiguration is being planned at pace. A strong drive for elective-only sites with post-operative critical care capacity is one example.
The past few months have also exposed bottlenecks in access to shared resources such as scanners and operating theatres, which need to be rethought to avoid pressure on waiting times.
Covid-19 has changed the number and frequency of outpatient visits that will be conducted on a face-to-face basis, with significant implications for design. Outpatient departments are likely to be smaller and more orientated to procedures, but there will be a greater need for well-equipped space to do remote consultations. We have also learned that quite a lot of administrative work can be done remotely, but there may be an opportunity to reduce the over one million square metres of administrative space in the NHS.
While do we need to bear in mind that delaying too long may result in funding being lost, the lessons of the present pandemic should point us to building flexibly and wisely for the future.
*This blog was originally published in the HSJ on 16 July and is reproduced with permission.
Edwards N (2020) “Covid-19: lessons for hospital building programmes”, Nuffield Trust comment.