The UK’s NHS is currently undergoing the biggest hospital building programme in a generation, with the government planning to build or redevelop 40 new hospitals by 2030. According to the five-year plan, all hospitals will prioritise sustainability, digital technology and the latest construction methods to see them built as quickly as possible, and to the highest standards. To date the majority of projects have not secured full planning permission and the entire project is currently being investigated by the National Audit Office.
A growing “crisis of confidence” around the delivery of the programme was flagged in a report from the All-Party Parliamentary Group (APPG) for healthcare infrastructure, which found nine out of ten NHS leaders feel their attempts to address health inequalities are being hindered by decades of under-investment in estates.
This crisis of confidence is something that was shared by many speakers at the annual Healthcare Property Development Conference. I was particularly interested in attending this conference to develop a deeper contextual understanding of the sector and to explore potential alignment with the recent Digital Placemaking for Health and Wellbeing scoping project I led to inform the infrastructure strategies of NHS North East London (NEL).
The conference was attended by some of the biggest names in healthcare property – including NHS Trusts, global engineers, investors, developers and private healthcare providers – so it felt like a perfect opportunity to learn about developments and challenges in the sector and, importantly, discover how Calvium can play a meaningful role.
As I am speaking at the prestigious European Healthcare Design 2023 conference in June, about the NHS NEL research, I revisited my notes from last year. This article contains some of my key takeaways, plus reasons why digital technologies are fundamental in addressing many of the core place-based challenges faced by the NHS.
Healthy places: changes and challenges
The conference opened with a keynote speech from Matthew Holmes, the global solutions director of health infrastructure for engineering giant, Jacobs. Responsible for healthcare policy development and delivering healthcare estate that is fit for a post-pandemic UK, Holmes outlined some of the key changes that are needed to transform the UK’s increasingly complex healthcare system, including:
- Decarbonising and updating estates and facilities
- Designing and delivering future care models
- Delivering equitable access for all and ensuring care is delivered right through the community
- Responding to complex care needs that come with our ageing population
- Digital transformation, for example integrating medical records, buildings and personal data to support personal health.
- Driving investment and funding required across the healthcare system.
Holmes addressed the government’s current health infrastructure plan, too, for which he acknowledged many things are still unknown as to how it moves forward. Interestingly, he suggested we should be looking at future care models and workforces like those in Canterbury in New Zealand, which has an integrated community model that brings complex community and tertiary solutions together. You can read some of the key findings from Canterbury’s model here. Indeed, there are certainly many valuable lessons to be learned.
I was inspired by Holmes’ rhetorical questions around the location of current healthcare estates and whether they are delivering equitable healthcare access for all citizens. This speaks exactly to digitally enabled place-based solutions – and highlights the significance of the Digital Placemaking for Health and Wellbeing research that I undertook recently for the NHS. He noted work being undertaken in Singapore “to wrap care around the patient” and to “deliver care right through the community?” – this involves bringing caregivers into the care setting and training them. Another question posed, “How do we integrate primary networks connected seamlessly into the acute setting?” Holmes went on to address “a key component – Digital”, and discussed the importance of bringing digital technologies into the care setting. He gave the example of data-driven predictive health outcomes helping clinicians make informed decisions (here, I point to the urgent need to avoid bias in any models). So, all in all, digital placemaking for health and wellbeing should clearly be a core aspect of future healthcare estates development as it dovetails with the points and opportunities raised.
The first panel brought together central government and NHS and Private Healthcare property experts, to discuss key challenges and opportunities facing the sector and how the built environment ecosystem can team up to deliver tangible outcomes.
Peter Dowd MP, Co-Chair of the All Party Parliamentary Group (APPG) for Health and a member of the APPG of Healthcare Infrastructure, addressed the critical challenge of inflation at a time when the government is expecting 2% productivity gains (historically the NHS has been able to deliver approx 1% productivity gains). This is a significant issue for both the NHS as a whole and also for NHS infrastructure and property services – evidenced by revenue and capital expenditure, as well as a significant backlog in the maintenance budget. Dowd summed up his introduction by saying “With the productivity requirement, fiscal retrenchment, and inflation at 10%, there is a big challenge in the next few years for the NHS.”
Dowd also highlighted the importance of tying health inequalities into the general issue of regional inequalities, such as the gap between life expectancy. We have a health and social care system that focuses its attention on the needs of people in different areas, but we need the NHS to be able to reflect the needs of the particular areas they work in.
Pressures on the NHS are much greater post-Covid due to inflation and uncertainty about the construction delivery programme, explained NHS Property Services’ (NHSPS) development and planning director, Adrian Powell.
He went on to explain that the NHS does not have a continuous and stable capital funding structure. It has not really had a lot of long term capital therefore has not been able to plan over a long period of time. As such, it doesn’t resource its construction or development capacity fully, or train up the right people with the right qualifications and experience around capital projects. Powell said the NHS is having to work harder to realise the most value in the shortest period of time.
Powell discussed an approach to healthcare buildings that will see them smaller and more efficiently used, supported in part by the flexible Open-Space digital booking system rolled-out across 200 properties across the country (an example of digital place management). Here, we are seeing digital platforms supporting the use of buildings by medical practitioners.
Like Dowd, he also highlighted the link between social deprivation and healthy lifespan, noting that 50% of discretionary investment is moving to places of high social deprivation.
In their written submission to the aforementioned APPG report, NHS Providers pointed out that, despite recent increases, the NHS capital budget for 2022/23 is £7.9 billion, compared to a maintenance backlog of £9.2 billion, thereby “limiting the capacity of providers and their system partner to eliminate the maintenance backlog and invest in new, modern, world class equipment, technology and estates.”
A recent survey of NHS trust chief executives and finance directors, meanwhile, found that 68% were not confident their trust would have access to sufficient funds to address the maintenance backlog over the next three years.
This was a key and disappointing issue highlighted by panellist Jenny Coombes, programme director at Local Partnerships, who said it is especially challenging around social care and funding.
“We need to treat the place as well as people. In developing a new or reconfigured healthcare estate we can think about that. Where is a new building to be located? – is there access to good public transport, are opportunities for generating renewable energy being taken, addressing social value in procurement, is affordable housing being included in the disposal of assets, and think about greening the environment – all these ought to help reduce health inequalities in the long-term” said Coombes, while talking about inequality in the healthcare system, which was great to hear given it aligns so closely with Calvium’s own mission.
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She calls for the patient experience to lead the design and delivery of healthcare services, noting that working in partnership with patients brings more efficient use of resources. Browne points to different needs across the country and highlights the “tension between generic needs and specialist needs” and asks healthcare estates professionals to “Work with patients to understand what those needs are so as to design services around them.” Taking a bottom-up approach and designing and delivering healthcare solutions in partnership with patients is key to delivering innovative ideas that ultimately help to reduce costs and increase efficiency. Again, I point to the Digital Placemaking research I undertook that had stakeholder community engagement at its heart – patients, carers, residents and NHS staff.
A critical question Browne asked was “How do you involve ‘hard to hear’ patients – more than 20% of the population are considered hard to reach – how do you hear various patient stories and understand the patient journey?” One answer she suggested was to engage with charities and other representative bodies in the third sector, to amplify the voices of marginalised groups.
Browne’s contribution was spot-on. The findings from my NHS digital placemaking research aligns with her position and insights.
Finding solutions with digital placemaking
According to the APPG Healthcare Infrastructure report, the greatest opportunity afforded by the creation of integrated care systems (ICS) is the chance to deliver fully digitally connected ICSs.
The report recognises the need to first get the basics right – from reliable Wi-Fi to strong technical infrastructure to electronic patient record systems – before digital technologies can be integrated in a way that enables patient data to flow freely across ICS boundaries and health and care settings.
The work we have been doing with the NHS NEL, however, goes beyond this framing. While it is really encouraging to see how much of our research chimes with some key themes in the APPG report and those being discussed at the conference, our findings go further and provide greater opportunities for place-based health.
The project has evidenced how digital technologies, and digital placemaking solutions in particular, are an essential part of delivering on different aspects – from locality and place, to being aware of different communities, designing inclusively and supporting population health locally.
A key output of the research was the Experience Design Framework for Health and Wellbeing, which was used to underpin the project’s stakeholder engagement. The framework is composed of nine themes enabled by seven active principles that make up its cultural approach. The themes – which spanned transport & mobility to identity & belonging – were chosen as ‘ways in’ for people to think about NHS healthcare estates and their neighbourhoods as places to enhance public health and wellbeing.
The project was shaped by the voices of stakeholder communities – residents, patients, carers, NHS staff – from start to finish, with some of the ideas participants came up with demonstrating how entwined people, places and tech have become.
As digital innovation gears up to radically reshape the NHS, digital placemaking has a major role to play in improving people’s relationships with places and, in turn, health and wellbeing across the country.
Having attended this conference, I am even more excited by the potential of the Experience Design Framework to be used to help different NHS Trusts achieve their strategic aims, and as a foundation to embed digital placemaking solutions into the future of the NHS built environment.