Health on the High Street – an updated view
Introduction
Early last year we published a paper exploring the opportunities to deliver Health On The High Street, a concept outlined in an NHS Confederation Paper in December 2020 which involves re-purposing vacant high street properties to deliver healthcare services.
Given the steady decline of British high streets over the last 10 years and an ever-growing waiting list in the NHS, the premise is a relatively simple one; create a cost-effective solution to expand NHS capacity, whilst at the same time rejuvenating the high street and bringing people back to the heart of the local community.
Fast forward 18 months, and as we emerge from the Covid pandemic, we wanted to further explore and understand the impact that the Covid pandemic has had on both the NHS and local high streets, as well as take a look at some pioneering organisations starting to make the Health On The High Street concept a reality.
The following paper specifically focuses the growing problem for both the NHS and the high street, but in addition we also look at how healthy high streets are now starting to become a reality. With the need, therefore, greater than ever, we look at some of the enterprising NHS Trusts putting Health On the High Street initiatives into practice to understand what it takes to turn the concept into a viable reality.
Outlined in this updated white paper are some of the stories, emerging benefits and lessons learned from real world examples, as well as some thoughts on how you could take the Health On The High Street concept even further.
The growing problem in the NHS
The impact that Covid has had on the NHS is widely publicised. However, what we identified in the previous paper was that even prior to the Covid pandemic, the NHS was unable to keep up with the growing demand to treat patients. Between February 2015 and February 2020, total patients waiting for elective treatment increased by over 50%, and patients waiting over 18 weeks/over 52 weeks increased by 370% and 365% respectively.
In short, more patients needed treatment than the NHS was able to deliver, and the result was a significant increase in the time patients had to wait for their care. This trend was obviously exacerbated significantly by Covid, as most elective treatment was stopped, and outpatient activity significantly reduced, resulting in further delays to those patients already awaiting treatment and a significant backlog of patients awaiting initial review.
The result was that between February 2020 and December 2020, there were an additional 700,000 patients waiting over 18 weeks, a 95% in year increase, and an additional 222,400 patients waiting over 52 weeks, a staggering 14,000% increase. Refreshing this analysis for the most recently published data (June 22) indicates that the deterioration in the waiting list position has continued:
From December 2020 to June 2022, a further 2.2 million additional patients have been added to the NHS elective waiting list. The number of patients waiting over 18 weeks has increased by over 1 million patients and a further 130,000 patients are waiting over 52 weeks.
In fact, the position has declined so severely that a completely new metric has been introduced, tracking the volume of patients that have waited more than two years (104 weeks) for treatment. This number peaked in January of this year, when there were almost 24,000 patients who had been waiting in excess of 104 weeks.
The good news is that since then this number has been gradually reducing to the current position of just under 4,000 patients, but even so there are now still more than double the number of patients waiting over 104 weeks for treatment than there were waiting over 52 weeks back in February 2020.
Despite nearly a year having passed since the end of the last Covid lockdown, it is therefore clear that the NHS has not even scratched the surface in beginning to tackle the ever-increasing problem of the elective waiting list.
With demand only looking to increase further, the NHS will need to think radically differently if they are ever to clear this backlog of patients, and concepts such as Health On The High Street are therefore now more important than ever.
The growing problem on the high street
The outlook for the high street has been similarly troubling.
In the height of the Covid pandemic, sales and footfall on UK high streets were down close to 90%, with the impact being an average of 40 store closures per day through 2020, increasing to 50 closures per day in the first half of 2021. This accelerated the increase in rising high street store vacancies to a peak of 14.5% (1 in 7) in Q2 & Q3 2021.
Post Covid, trends for footfall on UK high streets are moving in the right direction, with the latest data by the British Retail Consortium indicating that in July 2022, footfall was only 13.9% below June 2019, an improvement on the three-month average of 14.8%. The result is that high street store vacancies have declined for the third consecutive quarter, albeit are still two percentage points above pre Covid.
But as with the NHS waiting lists, this was a problem that had been manifesting well before Covid. Prior to 2020, the high street had seen footfall decline for 10 consecutive years. 1 in 12 shops on the high street closed from 2013 to 2018 and on average 11.5% of high street properties were vacant between 2015 and 2019, a rate almost 50% higher than the equivalent retail park vacancy rates.
Achieving a return to pre-pandemic levels is therefore by no means a sign of a “healthy” high street, and there are other trends in the wake of Covid that threaten the position further:
There has been a permanent shift towards working from home
- Consultancy Advanced Workplace Associates surveyed office workers in June and July 2022 and found that the number of days employees are working from the office now averages only 1.5 days, down from 3.8 days pre pandemic. These numbers are stark, and not necessarily representative of the total UK workforce, but even if this simply indicates a general trend, the implication is clear: where offices are located in or around UK high streets there is likely to be a significant reduction in daily footfall as people increasingly work from home. As of 2020, 10% of current high street properties are offices (as high as 38% in some areas). Not only could this trend towards home working therefore drive a further increase in vacant high street properties, it is also likely to have a knock on impact on the sales of high street retail businesses.
The pandemic has accelerated a move towards online shopping
- Almost all businesses had to rapidly adapt to continue to offer their products and services during Covid, which in many cases has led to vastly improved capabilities to deliver products to customers’ doorsteps. The convenience that this offers continues to make it harder for the high street (and other physical retail outlets) to compete with the online sales environment. The cost of living crisis is affecting consumer confidence and increasing retail costs – GFK’s consumer confidence index, which surveys the public about their opinion on the economy, is at the lowest level in almost 50 years. The resulting trend has been a steady decline in high street sales, which coupled with surging energy prices is making it increasingly difficult for retailers to make ends meet.
- The combined result of all of these is that even the most established high street brands are having to make changes. M&S recently announced plans to close or move 32 stores away from town centres due to “increasing cost pressures and consumer uncertainty”, as well as a notable shift to online sales in the last two years. As with the NHS, the future of the high street is going to be dependent on thinking differently and finding new ways to attract people back to the heart of the community. And as with the NHS, Health On The High Street may be a great solution to this.
The cost of living crisis is affecting consumer confidence and increasing retail costs
- GFK’s consumer confidence index, which surveys the public about their opinion on the economy, is at the lowest level in almost 50 years. The resulting trend has been a steady decline in high street sales, which coupled with surging energy prices is making it increasingly difficult for retailers to make ends meet.
Making Health on the High Street a reality
With the need therefore greater than ever, we wanted to take a look at some of the enterprising organisations putting Health On the High Street into practice to understand what it takes to turn the concept into a viable reality.
Outlined below are some of the stories, emerging benefits and lessons learned from real world examples, as well as some thoughts on how you could take the Health On The High Street concept even further.
The emerging benefits and lessons learned
There are many NHS organisations currently working with local authorities and communities to scope out opportunities to launch health services on local high streets. But to this point, there are still relatively few that have “gone live”.
In many respects this is not a surprise, as the NHS has faced a monumental task in tackling arguably the biggest national health crisis in its near 75-year history. But what this also points to are some of the many challenges faced in actually delivering health services on the high street.
Prior to the Covid pandemic, one of the biggest challenges was achieving suitable planning permission to convert former retail (or similar) space into a facility that could offer health services. The introduction of “Class E” Planning Use in the Town and Country Planning Regulations in September 2020, which looked to simplify the planning process with the objective of encouraging mixed use high streets, removed a considerable hurdle to this.
But there are other areas where overcoming the associated complexities of launching a healthcare facility on the high street are not so straightforward.
Take for example a sexual health clinic setup in Leicester’s town centre in 2019.
The previous location had been in an area of the city where users reported not feeling safe at night, with limited parking facilities and public transport links. The layout of the building itself was inappropriate and dated, the internet facilities were not fit for modern services and the running costs of such a dated building were extremely high.
Contrast this with a well-lit, city centre location offering fantastic parking and public transport facilities, in a modern shopping centre that offered far cheaper running costs. The likely benefits to those running and using the services are relatively obvious, but there were many who were sceptical, concerned that the facility did not offer sufficient privacy or would attract “the sort of people who use sexual health services”, which some businesses and residents in the vicinity commented would be a negative aspect.
In reality this was not the case, with patients commenting that they really like the convenience offered by the location, and that the considerations put in place for protecting privacy were in many ways better than the previous location due to the “fit for purpose” design and layout. Neither has any conflict with local businesses or residents materialised. In fact, the added bonus, as was predicted from the start, is that the regular footfall this brings to the shopping centre from staff and patients is helping to boost local businesses in the area.
Although a notable success story, what this example does highlight is the huge variety of stakeholder groups that need to be consulted in the planning of a project such as this, and the journey these stakeholder groups have to go on to fully understand and appreciate the benefits this can offer, rather than the perceived (and often inaccurate) downsides. Engaging each of these stakeholder groups from the outset is therefore critical to the success of any Health On The High Street initiative. There are other examples where the lessons learned through Covid have actually helped deliver health services on the high street.
In December 2021 University Hospitals Dorset (UHD) opened an Outpatient Assessment Clinic in the Dolphin Shopping Centre on Poole high street.
Suffering from a significant waiting list backlog, the aim was to create an accessible outpatient and diagnostic facility that could help to ease the burden on the existing hospital sites struggling to cope with the huge numbers of patients that needed appointments. The team were able to learn from the challenges faced by many hospitals struggling to ensure adequate social distancing in existing facilities, by designing the layout and patient flow in such a way that it both maximised the number of patients that could be seen, whilst ensuring safe social distancing for staff and patients. Not only this, they were also able to repurpose building materials and equipment from the decommissioned Nightingale hospitals to build it.
The result was the rapid development of purpose-built capacity, at a fraction of both the time and cost it would have taken to redevelop or build new capacity from scratch on the existing hospital sites. It is anticipated that this one facility could offer 75,000 outpatient appointments per year by the end of year two.
Staffing these facilities effectively is obviously key, and as many NHS organisations will point out, staffing, not just the physical capacity, continues to be a constraining factor in the wake of Covid.
But even here Health On The High Street is having a positive impact. From a range of examples we reviewed there has been feedback to suggest that working in these facilities could help to improve staff retention. Splitting an employee’s week between the hospital and the high street can make an NHS role more appealing by bringing more variety and convenience to the job.
These facilities can also offer a more positive work environment than many existing facilities for both staff and patients, with an increasing consensus that the physical environment improves staff and patient wellbeing and staff productivity.
Recently we have also seen the launch of a brand-new community diagnostic centre in Wood Green’s The Mall. Hosted by Whittington Health NHS Trust, the centre will initially offer a combination of diagnostic and
outpatient appointments in x-ray, ultrasound, phlebotomy (blood tests) and ophthalmology (eye clinics) with additional services due to come online in Autumn 2023.
The location of a shopping centre was specifically chosen to make it easier for people to attend their healthcare appointments. Previously Haringey residents had to travel further for diagnostic tests than other residents in Barnet, Camden Enfield and Islington. Wood Green is in the middle of the borough and The Mall is easy to get to for most people.
In conclusion, whether it is offering:
• High street landlords the prospect of long-term tenants and a more secure financial future
• Staff the opportunity to work in a different and more appealing setting
• NHS Trusts a low-cost option to rapidly create additional capacity
• Patients more convenient access to care
• Or local businesses a boost in customers
It is clear that the potential benefits outlined in the concept paper by NHS Confederation are beginning to come to fruition.
Which then raises the question, could you take this further?
Why stop here? Introducing the ‘Civic Supermarket’
Working with a London council, Fleet Architects have been involved in a feasibility study to explore a far greater and more ambitious plan.
There have been discussions to potentially develop a community diagnostic centre facility further into what would be the countries first civic supermarket, providing a central hub for primary, secondary and community health services as well as a range of education and wellbeing services.
In addition to the planned diagnostic and outpatient services, this could potentially also include:
• 2 – 3 GP practices
• Both an adult and children’s library
• Community health services for the local Acute Trust i.e. MSK, audiology, podiatry
• Adult education services
• A citizens advice bureau
• “Agile” working space for wider public sector services to use on a semi-flexible basis
As a community for which these services are currently dispersed and not always easily accessible, the intention is that by consolidating into one place the residents could have access to a far broader range of services in a more convenient and central location to the community.
As with the previous examples, this type of project is likely to give the local community renewed purpose and additional opportunities for complementary businesses nearby i.e. pharmacies, health food shops, children’s shops, opticians for audiology /ophthalmology patients, shoe shops for podiatry patients and so on, as well as increasing the footfall to the high street and providing all the benefits previously outlined on a far greater scale.
If Health On The High Street is the concept now becoming a reality, then the civic supermarket may be the future.
REFERENCES
1. Wood M, Finlayson S (2020), Health on the High Street. NHS Confed, https://www.nhsconfed.org/resources/2020/12/health-on-the-high-street, accessed initially February 2021 and August 2022
2. NHS Statistical Work Areas Consultant-led Referral to Treatment Waiting Times https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/, accessed initially February 2021 and
August 2022
3. Centre for Cities High Street Recovery Tracker https://www.centreforcities.org/high-streets/accessed August 2022
4. British Retail Consortium’s Vacancies Monitor https://brc.org.uk/retail-insight/content/monitors/vacancies-monitor/reports/2022q2_vr accessed August 2022
5. ‘Leicester: running a sexual health clinic in a shopping centre’ Local Government Association https://www.local.gov.uk/case-studies/leicester-running-sexual-health-clinic-shopping-centre accessed August 2022
6. Health Spaces Webinar (Building a Way Out of the Backlog) ‘Community Diagnostics on Your High Street’ , accessed August 2022*
7. Health Spaces Webinar (Building a Way Out of the Backlog) ‘Wood Green CDC: Opening Summer 2022’ , accessed August 2022*
8. Welcome to the Wood Green Community Diagnostic Centre: https://www.themall.co.uk/woodgreen/whats-hot/2022/welcome-to-the-wood-green-community-diagnostic-centre/ accessed August 2022
Health Spaces specialises in NHS design and build. Putting health services back into the heart of the high street. Find out more.
Whilst Health Spaces was pleased to host the Health on the High Street webinars as part of the ‘Building a way out of the backlog’ webinar series, the Wood Green CDC and Poole Outpatient Assessment Centre (and the projects discussed in this white paper) are not projects delivered by Health Spaces.
To learn more about the Wood Green CDC, visit: MRI and CT scanning now available at the Community Diagnostic Centre, The Mall Wood Green – North Central London Integrated Care System (nclhealthandcare.org.uk)
To learn more about the Poole CDC, visit: Think Big (uhd.nhs.uk)
