Carl McKenzie, Elementa Principal and Chairman of the Professional Development Committee with the Institute of Healthcare Engineering and Estate Management (IHEEM), offers his views on the current and future state of the Healthcare Estates sector.
Since its founding in 1948, the National Health Service has played a central role in UK society and our shared identity. A grateful nation continues to express its admiration and gratitude for its lifesaving work in the face of the COVID-19 pandemic. These extraordinary times have turned our attention not only to the many achievements of the NHS but also exposed weaknesses – whether they be operational, preparedness or funding related.
Scrutiny has focused on key areas where the NHS was ill-equipped to respond to a pandemic including Intensive Care Unit (ICU) bed availability, shortage of equipment particularly ventilators, and the supply chains for basic personal protective equipment (PPE) items such as masks and gloves.
Set against these challenges, the Nightingale Hospitals have been an incredible achievement. The first Nightingale at the Excel Centre in London was delivered in just nine days to provide up to 4,000 new beds, specifically for COVID-19 patients. This strategy has relieved pressure on hospitals in the region, whose intensive care capacity has been strained by the pandemic and who still need to maintain continuity of care for non-COVID-19 healthcare patients. The planning and installation of these facilities are not only essential in mitigating the immediate threat but also it sets a precedent for future procurement and construction within healthcare estates.
What Happens Next?
How can building services engineers apply the lessons learned to support the NHS as it reviews its estates’ strategy as the pandemic comes under control?
Towards the end of last year, the government outlined its strategy for major investments in the UK healthcare system in the form of the Health Infrastructure Plan (HIP), which will be the biggest hospital building programme in a generation.
The HIP plan is a long-term, rolling five-year programme of investment in health infrastructure:
- providing capital to build new hospitals
- modernising our primary care estate
- investing in new diagnostics and technology
- helping to eradicate critical safety issues in the NHS estate by addressing its maintenance backlog
Central to HIP is a new hospital building programme, to ensure the NHS’s hospital estate supports the provision of world-class healthcare services. Six new large hospital builds that are to go ahead now – aiming to deliver by 2025, and 21 more schemes that have the green light to go to the next stage of developing their plans – with the aim of being ready to deliver between 2025-2030. In total this first tranche involves more than 40 hospital building projects.
In January 2019, the NHS published its Long Term Plan that included:
- £33.9bn by 2023-24 increase in cash funding for the day-to-day running of the NHS
- £2.1bn further capital for health infrastructure and a £2.8bn injection to transform hospital care.
NHS infrastructure goes beyond large hospitals, it is pivotal to the delivery of more personalised, preventative healthcare. The NHS Long Term Plan envisaged more community and primary care happening away from hospitals.
Some of the plans had already been put into motion. The COVID-19 pandemic has understandably led to it being paused for the time being, while resources are diverted to where they are needed most.
But this pandemic will pass, and with its passing will come the time and the need to restart these plans, with additional impetus and significant changes reflecting our experiences with COVID-19.
New Build Hospitals and Facilities
There is now even greater motivation to continue the planning and design of new healthcare facilities, alongside a higher level of urgency and dedication to reach completion as soon as practically possible.
Additionally, the NHS will be analysing their existing estates to identify the best use of space and function, understanding what they already have and how spaces could be adapted or converted for ICU’s or isolation units, should there be a need in the future.
And finally, the mobilisation of temporary healthcare facilities. The Nightingale hospital is a very specific installation to deal with a very specific problem, providing a very limited range of services. These facilities are only temporary, but for future planning for another pandemic, there will have to be proactive planning so that – should the need arise – we are able to upscale this type of facility again with speed. We will want to consider more flexibility of use depending on the scale and specific characteristics of the next health crisis.
Modernising Primary Care Estates
We need to ensure that primary care estates, being the front line of healthcare, are equipped and connected technologically with each patient’s healthcare history and information in order to better inform the required treatment at the proper time. Digital and phone access to general practice has spread rapidly alongside a crucial move to “total triage”, apparently with few of the usual concerns or objections.
We don’t foresee significant changes to this initiative as a response to the pandemic, however, COVID-19 has highlighted the benefits and potential life-saving advantages that this type of connectivity could offer. It is reasonable to assume that changes in consultation mode and systems should be among the first and foremost improvements to be developed.
The NHS will be looking closely at how other countries have tackled the challenges of the pandemic. Tools such as apps linked to the primary care centres, accessing patient’s healthcare data and creating effective communication channels – both to and from the patient to their doctors – are just one initiative being considered based on their effective use in other regions.
This crisis has shown that the public can assist the NHS by undertaking a much bigger role in taking care of their own health. People are realising that they are their own primary health carers, and so are taking greater responsibility for their own well-being rather than relying largely on their GPs. This is a change that will profoundly affect that relationship in years to come.
Improvements in Mental Health Facilities
There is expected to be a high demand on our mental healthcare system with widespread distress due to unemployment, isolation, confinement or any number of challenges to normal life.
More mental healthcare services and facilities will be needed, but for a much broader spectrum of causes. We can expect to see a rise in more serious mental health cases, needing specialised counselling and facilities that are able to deal with the more acute areas of mental health. Alongside this, we will also need the range of our mental health services to include more health and wellbeing organisations and other low range mental health areas, with a higher focus on outpatient facilities designed to reduce pressure from specialised facilities.
Investments in Technology and Diagnostics
Incorporating digital technology and big data into medical processes can better inform treatment decisions as well as predict when and where problems may arise.
The growing eHealth sector has been successful in places like Singapore where they have integrated their digital systems allowing them to quickly identify those in the community who are most at risk. The big data that eHealth has access to is going to become much more important to identify hot spots sooner, therefore bringing treatment to the places where it is needed most at the time that they need it most.
Remote consultations are a growing and important part of eHealth. By assessing and recommending treatment for minor health issues remotely, through an app or over the phone, healthcare professionals can see and treat more people in a shorter space of time. This then has a knock-on effect, reducing wait times for face to face appointments for those who need them most and removing the risk of a doctor to patient transmission of disease, or vice versa.
Eradicating Critical Safety Issues in the NHS Estate
Backlog maintenance has been a major issue in NHS facilities for more than a decade due to lack of investment.
NHS Trusts have had to take a short-term view, which has suppressed the ability to undertake vital repair and maintenance work on NHS buildings and facilities. The result is over £6bn of backlog maintenance, the highest level on record. Capital budgets have been redeployed to prop up day-to-day spending, a false economy that cannot be sustained. The strategic plan is meant to provide adequate investment to cover the day to day expenditure, mitigating the critical safety issues and to address the backlog maintenance issues.
Areas for Research and Development
The contribution made by the cleaning of spaces is one area that warrants further investigation and analysis following this crisis. Whilst the evidence is not yet conclusive, the primary transmission of COVID-19 appears mainly to be mainly caused by close contact and not necessarily airborne.
How treatment staff behave around a sick patient – operational control – may be more important than the environment that the patient is in to reduce transmission. There has been early dissemination of lessons learnt from organisations such as the Institute of Healthcare Engineering & Estate Management / International Federation Healthcare Engineers in the form of a Handbook of COVID-19 Prevention & Treatment (Zhejiang University, School of Medicine, China). It addresses issues including appropriate PPE for treatment staff, and the space required for treatment and zone management, including a contaminated zone, a potentially contaminated zone and a clean zone, with buffer zones between them.
Anecdotally there are suggestions of a correlation between some of the hardest-hit areas and associated zones of high levels of pollution. Higher levels of pollution may increase transmission rates as the virus can condense itself to pollution particles in the air. If found by research to be a valid mode of transmission, air filtration, especially within healthcare facilities, is likely to be stepped up to mitigate any perceived threat, and to help understand any role in a wider environmental regional mode of transmission.
Fitting out of the new Nightingale Excel hospital has drawn attention to the infrastructure requirements for medical gasses. There have been approximately 4 miles of medical gas pipework installed into the new facility for oxygen, covering enough to supply the maximum capacity of 4000 ICU patient beds. There may be merit in reviewing the UK standard medical gas design guidance, which tends to have larger demand flow rates and higher diversities than other international regions, resulting in larger pipework than our counterparts. It is possible that the UK is erring on the side of caution, particularly with respect to diversity. If demand during the current pandemic proves that the required levels of gasses are below the design level that our pipework can provide, then it would be worth reassessing the need for such large pipes. By reducing the size of the pipes saving will be made both in costs and the embodied carbon of the infrastructure. This would be both a clinical and an environmental step forward.
Research and development need to continue to take place to maintain infection control, mitigate a catastrophic outbreak, and to manage our resources and patients. We need to apply knowledge of virus epidemiology, mode of transmission, clinical course, ICU admission, complications, and predictors of outcome and treatment
Virus pandemic preparedness and response planning must be flexible and dynamic so that appropriate measures can be implemented as an outbreak progresses.