Time to Re-Think the Hospital? How to Avoid Future Builds Absorbing the Problems of the Past
By Richard Darch
There is something specific to say about the planning, specification, delivery and funding of new hospitals, and it goes to the core of what a hospital is and what it will become. The narrative around "smart hospitals" and "digitally enabled" is not enough. There are a number of external pressures and competing demands that now require a fundamental rethink.
The Wrong Problem in the Wrong Building
The reality is that in the NHS, current pressures and systems mean that designs are not led by thinking around acute care models of the future but social care models of the past and present. The lack of a model of funded social care in communities means that the acute hospital picks up the demand.
The amount of capacity that is required for what is in effect social care is massive and just not sustainable. It is leading to ever bigger buildings to house a societal problem that needs fixing in different ways. We can no longer "warehouse" that problem in hospitals.
A Lesson From the Past
A similar pressure existed in the 19th and early 20th centuries with the gradual then increasing growth of workhouses. These were buildings that "warehoused" the societal problem of the poor. When the ongoing building of them became unsustainable, a different approach had to be taken. The Liberal government of 1906-1915 devised a contributory health insurance policy. The Baldwin administration of 1924-1929 thanks to Chamberlain implemented national employment assistance and abolished new workhouses. The National Assistance Act of 1948, which introduced the NHS, got rid of them altogether as they were subsumed into the NHS as local and community hospitals.
This transformation required external funding. Just like the abolition of the asylums in the 20th century required the "double running cost" funding to allow new community and acute mental health capacity to be built whilst funding the gradual run down of the asylums.
So acute care models of the future can only be planned and designed when social care is adequately addressed. And the capital required to transform the estate has always needed to come from somewhere beyond the existing envelope.
The Scale of the How, Not the What
In the UK the New Hospital Programme has done much to introduce and engrain thinking around standardisation and the benefits that can be brought by industrialised construction; as well as designing an effective procurement model for such a complex Programme. However, this is all about the "how" and not the "what". The hospitals being delivered through the new hospital programme are required, but they will be redundant in their design over their lifetime.
The capital cost of a "general acute hospital" replacement is now pushing £2 billion. With 30 odd hospitals in the programme and some 200 hospitals in England that were built before 1990, replacing hospitals with the existing planning model is unsustainable.
What Comes Next and How Do We Fund It?
Drone technology is radically rethinking defence capability and the planned destroyers have been scrapped. AI, robotics, targeted therapies and monitoring at home will do the same for current hospital design as drones has and will do for military equipment design. So being able to plan for true hospitals of the future that are smaller, lower cost but completely tech enabled (and constructed) will take time and require a societal problem of social care to be addressed. I am afraid no answers to social care here but just some optimism that a growth in cross party thinking to address these intractable issues is a chink of light.
It does not stop the opportunity to develop this thinking now and start to build exemplar projects. And just as major transformation requires additionality in funding (see the asylum example) the same applies here. External capital has a role to play and play it effectively to deliver projects in a tight discipline and to time and to cost. As the footprint and land take of the NHS reduces that land can be put to good use to address housing and even social care challenges and even raise money to allow for co-investment alongside private capital to help affordability. There are significant pools of patient long term capital that are available for this transformation. The cost of that capital is not significantly above gilts and that "premium" can be shown to offer value for money when delivering at scale, at pace and within planned costs.
A Different Landscape
A few challenges laid down here, not least a pretty big one in solving social care. But just as it became unsustainable and unaffordable to warehouse society’s poor then it will, and is, becoming unsustainable to warehouse society’s frail. Once that is finally addressed then we will have a very different landscape indeed in what our communities see in their hospitals.
Richard Darch is UK Chair at Tektology, Founder of Infracare Partners Limited and has spent over three decades at the intersection of healthcare infrastructure, transformation and public-private partnership. Richard's work focuses on the funding, planning and future shape of the healthcare estate. He is also a Trustee of the Royal Osteoporosis Society.