Coming out of COVID-19
Ashleigh Boreham and Nick Jenkins talk to Fortis about the Covid legacy and how to reimagine our buildings and estates
Three and a half years after the Covid-19 pandemic hit the UK, the lessons learnt from how care had to be quickly reconfigured and delivered in a highly agile way are now shaping design and build projects in the longer term.
The most obvious examples are the emergence of elective surgical hubs for high volume, low complication elective work on ‘cold’ sites, separate from emergency care. Others include the relocation of outpatient clinics and diagnostic test centres to community sites closer to where patients live – in repurposed retail sites in town centres and mobile units.
In hospitals, too, there was a realisation that spaces needed to be flexible and adaptable for multiple uses without always having to resort to major building works. Modular theatres and repurposing of other hospital space emerged as solutions. There was also acknowledgement that, for infection control requirements, more single bedrooms for inpatient stays and appropriate ventilation were important.
Health on the high street
Moving outpatients, patients and diagnostics out of the hospital setting into the community is something Dorset have been at the forefront of, says Ashleigh Boreham, Deputy Chief Officer Strategy and Transformation at NHS Dorset.
“What we learnt from the pandemic is that we can work differently – collaboratively, bringing people together with energy and a tempo, speeding up or slowing down depending on who you are working with as stakeholders.
“It’s important to bring the community on a journey, moving at a speed that works for them,” says Ashleigh.
“We’ve learnt that some services can work outside an acute hospital, and we can leave hospitals to focus on the things they do really well.”
NHS Dorset concentrated on delivering a ‘Health on the high street’ or ‘Health Village’ model, repurposing retail units and council offices to deliver outpatient clinic care and diagnostics closer to where patients live. The first of these was in repurposed shop premises previously occupied by the Beales Department Store in Poole; a second was set up in a council office space in Dorchester.
Ashleigh says: “It’s 50% cheaper to repurpose a building compared to building a new one and post-pandemic there was a lot of empty retail space.
“We didn’t need to build a car park, a railway station or a road, as these already existed on these sites. We are putting a plug into a socket that is already well-established.”
The outpatient centres housed multi-disciplinary team clinics, alongside social care and support from the third sector. This meant that everything was centred around the convenience of the patients – rather than them having to visit multiple locations, they could visit one centralised place.
“This also helps revitalise communities and the high street because we are revitalising space that was not being used. This space is being repurposed for community health and wider health, including social prescribing, community fridges and community hubs where people are,” says Ashleigh.
“What we’re passionate about is the flow of a building and how it connects with services and productivity and effectiveness of care. We can also use the third sector and multi-disciplinary teams from a service office concept, which can be handed over to other users, so it’s not just one organisation using a space. We can have generic clinics and move equipment in and out – that’s really our Nirvana.
“This also creates a vibrancy on the high street, increasing footfall, connects with communities and utilises existing infrastructure.”
Ashleigh stresses that the centres were co-designed by the public, third sector and social care, as well as hospital staff. “Everyone has a vision and a view on the plan,” he says.
Engaging the community: Rehearsal of Concept
Three one-day public engagement events were held to canvass opinions, ideas and concerns, and patient governors were appointed. Members of the public were also recruited to act as volunteers to support patients attending facilities. This culminated in a Rehearsal of Concept (RoC) drill to bring stakeholders together.
“The purpose was to refine the agreed plans, identify gaps and reaffirm the purpose of the task. It was held in an open space with a one-in-four scaled drawing of the site on the floor, with all the stakeholders physically in the room; in effect, a dress rehearsal in a risk-free and inclusive environment to ensure all voices are heard,” says Ashleigh.
The reconfiguration had immediate benefits on waiting lists. Figures from December 2021 to June 2022 showed a 52% reduction in the total waiting list for orthopaedics and a 92% drop in those waiting 78 to 104 weeks. An extra 15,535 patients were seen across 13 services and dermatology tripled their pre-pandemic capacity so that 96 patients can now be seen in a three-hour morning clinic.
Hospital wards: infection control
Infection control is integral to the design of hospital wards.
The new Concept Ward at James Paget University Hospitals NHS Foundation Trust, opened in May of this year, features a high percentage of single ensuite rooms, and has modern ventilation throughout the ward, with both positive and negative pressure available. There are also two slightly bigger isolation rooms which incorporate ante-rooms for infection control; able to receive 15 air changes per hour, they can accommodate a low-level ICU critical care-type patient.
Repurpose don’t rebuild
Rapid reorganisation of existing space – for vaccination centres and Covid-19 and non-Covid-19 work – during the pandemic has also illustrated that hospitals don’t always need to rebuild but can repurpose existing space.
Dr Nick Jenkins, Consultant in Emergency Medicine at West Suffolk NHS Foundation Trust, says: “Lots of hospitals do not have the space to put new buildings on site – they may already be short of car parking spaces, for instance, so that’s not always the best solution. It may be then that repurposing existing space – if a hospital has it – is a better option.”
West Suffolk NHS Foundation Trust created a rapid assessment and treatment unit (four trolleys and four reclining chairs) from a disused medical records office next to the A&E department in 2019.
“This was making use of existing space to frontload tests for emergency patients under the direction of a senior doctor,” says Nick. “Instead of waiting hours to be seen and then waiting for tests and results, the patients can have their tests at the beginning and have the results when they see the doctor, so the doctor can treat them right away without waiting for results to come through.”
Part of the medical records department space had earlier been redesigned as an ambulance receiving centre, helping to reduce ambulance queues outside the hospital significantly.
Nick says the unit was built in double-quick time and was a cost-effective solution until the hospital rebuild is completed by 2030.
“There can sometimes be this idea that a hospital is too small and, if you’re not careful, there can be a knee-jerk response that therefore the hospital needs more beds – but does it? It may be that you do not necessarily need more beds, but more flow, and part of this is better use of space and finding out where the bottlenecks are.
“Managing flow of patients is not new, of course, but it has become more mainstream in recent years since Covid-19,” he says.
Three key lessons learnt from Covid-19
- Infection control needs skilled professionals. “It is becoming abundantly clear that designers and architects should involve skilled Infection Prevention & Control (IP&C) professionals — preferably with engineering qualifications — to ensure our future hospitals are safe from the day they are opened. Their expert knowledge and insight provide key stakeholders, at all stages of project development, a clear understanding of the critical requirements of IP&C standards and policies to ensure patient safety within the NHS.” – Liz Waters, MBE MSC RN, retired Assistant Nurse, Director/Consultant Nurse IP&C Aneurin Bevan Health Board
- Flexible spaces in the community, including retail outlets that can be repurposed for outpatients and diagnostics, can take pressure off acute hospital sites.
- Standalone surgical hubs for high volume/low complexity ‘cold’ elective work, separate from emergency care, are supported by the Royal College of Surgeons and can help the NHS keep running in pandemics and winter flu season. At the end of 2021, when the country was still in the grip of Covid, The Hospital Times quoted the then Royal College of Surgeons, England President, Professor Neil Mortensen saying Croydon and Redbridge hubs had already had an “electrifying” effect on staff morale.
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This article was taken from the September 2023 edition of FORTIS magazine.
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This article was written for the September 2023 edition of FORTIS magazine; a forum for the NHS to share ideas, innovations and case studies. To read the publication in full and access digital copies, visit FORTIS magazine. FORTIS magazine is free for NHS change-makers and leaders and is available as a print or digital copy. FORTIS magazine is managed and owned by Health Spaces Ltd.
