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The hospital of the future – more than bricks and mortar

By Paul Styler, Director of Infrastructure Solutions at Lexica (formerly ETL).

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After the 2019 election, the new government bestowed upon many NHS Trusts the envious privilege of developing new plans for their healthcare estate. This has become known as the New Hospitals Programme (“NHP”).

The Programme promises a “strategic approach to improving our hospitals and health infrastructure” and to deliver 48 “new” hospitals from a pot of cash for £3.7bn.

Since the inception of the programme the central team has chopped and changed and is yet to find 3rd gear in the drive to deliver these assets. Politics and finance now come into play and Trusts who once believed they were in pole position have found new “waves” or “cohorts” jumping in front of the queue.

The current composition of the programme is;

  • 8 “On-site” projects; these were approved and mostly started well before the last election cycle (and in some cases before the Conservatives came to power). These are near the finish line, have stalled or need cash to complete.
  • 10 “Early Adopters”; a mixed bag of (relatively) easier wins that have been in their planning stages for some time (or seen as politically important) and so offered a preferential route to push forward with the hope of completion in the near future (or at the very least, offer pre-election photos opportunities of a building site).
  • Some 30 other schemes, filtered across 4 cohorts to develop the notion of the hospital of the future, drawing on the experiences of the early adopters to develop the most modern, efficient, quickest, slickest, homogenised and centrally approved design solutions to set a blueprint for the UK Hospital of the Future.
  • There are also believed to be an additional 8 places still available, and NHP has recieved 100+ applicants. Shortlisting of these is apparently delayed – possibly until the autumn. It is reported that these places may favour mental health Trusts, overlooked in the first tranches.

The informed will recognise that £3.7bn into 48 doesn’t buy much hospital in the 2020s, and current market pressures are not helping.  Politics and financial constraints and lack of long term capital settlement for the NHS all play their part in the composition of the programme.

These hospitals are part of the ever-evolving health and care jigsaw. If the NHS is not in a state of flux, it is recovering from the last one, and 2022 is no different.

The recent changes in NHS governance structure and capital accounting (which are yet to be fully adopted and embedded) mean the levers of capital expenditure are shifting from the providers (NHS Trust) to the commissioning bodies (Integrated Care Systems).

Essentially the buyer of service is armed with economic levers to promote care where they want it (when considered in a longer time horizon), although it remains to be seen whether ICSs can face down the power of provider collaboratives.

The new emphasis is; system, place and neighbourhood. The aim is to develop a system that promotes healthier lifestyles and intervenes earlier at a smaller scale to prevent patients from needing to enter the larger acute based medical and clinical machines, and if they do, treat them swiftly and return them home (or close to home).

So as in 2019, 2022 still raises the question of the return of investment from the NHP, and challenges if the physical nature of these civic buildings offers a return to the public purse and are not essentially politically driven “new for old”.

NHP developments must ensure that at a minimum they promote integration across the spectrum of care providers in their areas and improve health as well as social outcomes of the population they serve.

The NHS is simultaneously investing in other capital intensive care initiatives – in response to an expanding backlog, and highlighted by the pandemic;

  • Cavell centres are new, homogenised, super community assets focusing on bringing care and intervention to the local setting – with a mixture of medical needs catered under one roof. Six pilot schemes are already in development with a larger rollout anticipated, and whilst an ambitious agenda, this alone will not fix the ills of the broken primary care business model which includes mixed tenure models and retiring single handers with no succession plan.
  • Backlog recovery “Elective Care Treatment Centres” are being planned with an imperative to be operational in the coming financial year – offering more theatre and bed capacity. Funding is secured, £2bn business cases, planning and procurement are happening across the country.
  • And over one hundred Community Diagnostic Hubs are being funded and developed, utilising existing NHS estate, to turbocharge the diagnostic capability of the system. If not already operational soon, 2023 will see many of these become so.

With the backdrop of these initiatives, the NHP must therefore offer tangible returns to the primary, community, mental and social care system in which they operate.

In the post-Covid world, attendance at an acute setting will be less desirable and more health interactions will take place away from the acute setting.

The investment in acute bricks and mortar must therefore offer a return to the wider care sector. It cannot offer more of the same types of assets in the same settings with the same patient journeys, especially when the system is changing around them.

What is an acceptable return on £3.7bn, let alone the probable £20+bn plus price tag for 40+ hospitals, especially when many quantifiable benefits (cancer detection rates, hips, knees and cataract waiting list. etc) will be delivered by doing the smaller things more often and more locally?

The NHP development process needs to look not just at the demands for healthcare for the next generation (offering more activity for less cost; anticipating and accommodating new treatments and interventions; shorter lengths of stay) and promote efficiency in the design construction and delivery of these assets, but also consider the place and role of these new assets in their community and society as a whole.

This is a tall ask given there is limited evidence of the link between capital investment and improved outcomes and that clinical interventions are judged to contribute only around 20% to health status.

Each NHP project must justify its development on the socio-economic stage.  Each must ensure links to the different layers of the education system, to industry, to science and to commerce and deliver robust and long-lasting impacts to these sectors.

Economists will highlight the multiplier effect of major construction activity, but more important should be the longer-lasting impact of these developments on local capabilities, on fostering and promoting local supply chains and engendering innovative educational programmes to match the needs of the healthcare system of the next generation.

Can these be maximised by a centrally managed procurement and supply chain process? Construction needs go hand in hand with localised employment strategies and with tangible, locally set targets for long term employability and skills outcomes.

Importantly the NHP business case approvals process needs to capture and commit to these outcomes and hold project sponsors to account to deliver for many years after the cutting of the ribbon.

NHS Trusts are the main employer and enabler of economic activity in their area. They need to reflect how we want our future NHS and society to be perceived and therefore direct the public investment offered to them to maximise value to society.

We should not rush to a ribbon-cutting photo opportunity at the detriment of a more considered, holistic, and longer-term view of maximising legacy. NHP should stand for New Healthy Populations.

Paul Styler is Director of Infrastructure Solutions at Lexica (formerly ETL). 

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