Health on the High Street™ – White Paper
Overview of Health on the High Street™
In December 2020, NHS Confederation published a report with NHS Reset and Power to Change titled ‘Health on the High Street’, looking to reimagine the relationship between the NHS and the high street, and the role of health in supporting economic and social recovery. It highlighted a number of immediate opportunities for the NHS to become directly involved in the high street policy agenda, including:
- Running health services from vacant high street properties
- Broadening the range of health services provided within communities
- Supporting and participating in the design of healthy communities and places
The following paper specifically focuses on the first of these opportunities, running health services from vacant high street properties. It takes an in depth look at the issues faced by NHS Trusts and high street enterprises, the impact this has had on patients and the community and the potential benefits that provision of health services on the high street could therefore bring to each of these groups. To download this report as a pdf, click here.
Running health services from vacant properties
The NHS has been suffering from a demand and capacity imbalance in recent years, with health inequality, waiting lists for treatment, and the corresponding waiting times for patients, growing at a significant rate. The UK high street has also been suffering from a prolonged period of decline, with footfall and sales falling year on year over the past decade driving an ever increasing number of vacant stores and a loss of community health and wellbeing.
The Covid pandemic has served to significantly exacerbate both of these issues. Over 4.5 million patients are now awaiting NHS elective treatment, with nearly 250,000 of them having waited in excess of 12 months, whilst 14,000 high street stores closed in 2020 and 13.7% of the properties now sit vacant. In a recent article, The Times highlighted the significant challenges the high street faces, ‘The collapse of Debenhams and Arcadia has magnified a problem for landlords: what to do with the glut of redundant retail space tainting Britain’s towns. Neither Boohoo nor Asos, which have picked up Debenhams and Arcadia brands including Topshop, Topman and Dorothy Perkins, have opted to take on the leases for the shops.
That means almost 15m square feet of space – equivalent to roughly 200 full-size football pitches – will hit the market in England and Wales, according to property adviser Altus Group’. The solution, as the title of the paper alludes, is to provide health services on the high street. This is not necessarily a newconcept, but one that the Covid pandemic has necessitated, both for the health of the UK population, and the long-term sustainability of the high street.
Covid has understandably had a significant impact on the NHS, not only for the staff and the patients being treated, but also for the patients that have not been treated as a result. This is the ‘hidden’ cost of Covid, as it is often referred to, which is to say the impact on the patients that urgently need treatment but have had it postponed due to the pandemic. The scale of this is only fully understood when you look at the associated national data which tracks the number of patients currently awaiting treatment. The following referral to treatment data shows how the current elective waiting list changed in England from February 2020 to December 2020 as a result of Covid:
- Total patients waiting: 4.43 million to 4.5 million
- Patients waiting over 18 weeks : 745,000 to 1.45 million
- Patients waiting over 52 weeks: 1,600 to 224,000
It goes without saying the impact that the delay to the treatment of these patients is likely to have had, and something that as we begin to emerge from the third (and hopefully final) wave of Covid is a very real problem that the NHS will have to overcome. However, taking a longer term look at this same data also reveals that even before the Covid pandemic, there was a very worrying trend in the growth of NHS waiting lists. The following referral to treatment data shows how the current waiting list changed in England from February 2015 to February 2020:
- Total patients waiting: 2.94 million to 4.43 million
- Patients waiting over 18 weeks: 200,000 to 745,000
- Patients waiting over 52 weeks: 442 to 1,613
‘Even without Covid, there is still a very real and deteriorating problem that the NHS has to solve’
This data highlights that despite Covid exacerbating the problem, the reality is that even without Covid, there is still a very real and deteriorating problem that the NHS has to solve. This is being driven by two main factors:
1) Demand for NHS treatment is increasing, driven by a combination of trends including:
- An ageing population – As the age of the national population continues to increase, so will the demand for the NHS. The elderly make up a significant proportion of the patients requiring NHS treatment and as this population grows there will be an inevitable increase in the demand for treatment across most services.
- Increasing health inequality – As health inequality continues to grow, as evidenced by the increasing life expectancy gap between affluent and deprived areas (as much as 23 years), public health continues to decline. Issues such as obesity continue to increase, driving up the number of health-related conditions such as diabetes and the demand for supporting health services.
- The net result is that from 2014 to 2019, the number of annual referrals for elective treatment increased from 20.4 million to 23.4 million.
- In other words, within a 5 year period the NHS has been asked to treat an additional 3 million patients per year.
2) Supply is increasingly constrained. The NHS has faced a significant challenge in being able to respond to these demand pressures:
- An increase in ‘winter pressures’, the surge of patients over the winter period requiring non elective care, has significantly reduced capacity for elective treatment as wards and staff have had to be prioritized to support A&E and emergency activity.
- The cost improvement targets that have been enforced means there has been very little budget for capital expenditure to increase capacity through the development of new facilities.
- This has meant that additional capacity has often been created only through short term measures, such as the development of temporary or “bolt on” facilities, which can be more costly and/or less efficient to run than purpose built units, due to conflicting priorities and building constraints.
- The result, as evidenced by the waiting list statistics, is an 8.6% YOY growth in the size of the national elective waiting list, increasing by an average of 300,000 patients per year over the last 5 years.
- If this trend continues, the NHS would need to treat an additional 380,000 patients in 2021 simply to prevent the waiting list from growing further. ‘Within a 5 year period, the NHS has been asked to treat an additional 3 million patients per year’
The growing problem on the high street
The UK high street has been in decline for over a decade. The growth of online retailers and out of town shopping centres is increasing competition and making it difficult to maintain a profitable business on the high street. This has led to a reduction in footfall and sales, resulting in an increase in store closures and vacant properties. In addition to affecting local enterprise, this has a knock-on effect on local communities, due to the important role the high street plays in providing a focal point for community activity and wellbeing.
With almost 7,000 recognised high streets nationally, the following statistics highlight some of challenges being faced:
- High street footfall has fallen for 10 consecutive years
- From 2012 to 2017 high street retail businesses fell 2%, while all other retail increased 6%
- 1 in 12 shops on the high street closed from 2013 to 2018
- On average, 11.5% of high street properties were vacant from 2015 to 2019
- Property vacancies were 50% higher on the high street than retail parks from 2015 to 2019
As with healthcare, Covid has only served to accelerate the trend:
- Footfall on the high street was down 89.9% in April 2020
- Sales on the high street were down 92.8% in April 2020
- 14,000 stores closed in 2020 across UK high streets
- Estimated 180,000 high street job losses in 2020 13.7% of high street stores vacant in December 2020
And it may be that the long-term impact of Covid on the high street is not yet realised. With a rapid move to remote working, it is expected that demand for office space will decline as more business choose to reduce costs and operate remotely. As of 2020, 10% of current high street properties are offices (as high as 38% in some areas), meaning that a reduction in demand for offices could further increase the proportion of vacant high street property.
The resulting reduction in footfall provided by office workers could also mean a knock-on effect to retail and other services on the high street. The result is that many retailers, and almost all high street property owners, face an uncertain financial future after a decade of decline accelerated by the Covid pandemic. With increasing pressure on local authorities to find a way to secure the long-term sustainability of the high street, it is clear that solutions need to be identified and implemented as soon as possible.
Health on the High Street™: a solution to both problems
The solution, as the title of this paper alludes, is to provide health services on the high street. More specifically, for NHS healthcare providers to move a portion of their service provision into vacant high street premises. Although not appropriate for all patients, there are a significant number of services provided within hospitals for low acuity care, that is for patients that do not need to be admitted to hospital or do not require any complex diagnostics or treatments. These services include outpatient clinics, day case procedures, simple diagnostic tests, physical therapy etc.
This will increase the capacity for the NHS, provide a purpose for vacant retail units on the high street and offer a large number of patients a more convenient and accessible location to access these services, who in turn will increase the volume and diversity of people on the high street.
By moving provision of these services to the high street, you could create purpose-built facilities designed to efficiently treat a large number of patients without the need for significant capital or equipment expenditure. This will increase the capacity for the NHS, provide a purpose for vacant retail units on the high street and offer a large number of patients a more convenient and accessible location to access these services, who in turn will increase the volume and diversity of people on the high street. The wider benefits for each stakeholder group are summarised below:
How will this help the NHS?
- The high street offers a low-cost alternative to capital expansion through the repurposing of existing buildings, rather than requiring ground up development of greenfield sites/expanding existing hospital buildings
- There are a wide range of government backed / charitable funds assigned to support redevelopment of the high street that the hospital may have access to support the development of healthcare services on the high street
- The space also offers a “blank canvas” for hospitals to design purpose-built facilities to maximise efficiency and throughput, something that often requires compromise when expanding facilities on existing sites due to other restrictions/conflicting priorities
- Moving low acuity services such as outpatients, diagnostic and day case treatment to the high street can also provide a number of benefits to the main Acute hospitals: It can significantly reduce footfall at the Acute site, helping to alleviate existing problems with limited parking/public transport issues and improving infection control. It can free up valuable space to expand high Acuity facilities, increasing provision of services that must be delivered on the main hospital site, such as additional wards/bed space to support increasing emergency demand and operating theatres to treat more high Acuity patients.
- Purpose built facilities on the high street are also likely to offer a nicer environment for staff, with an increasing consensus that the physical environment improves staff wellbeing and productivity
How will this help the high street?
- NHS trusts offer an attractive proposition for high street property owners to secure long term tenants and a reliable income source
- The provision of healthcare services is likely to attract a more diverse range of people who may not otherwise frequent the high street
- It is also likely to increase footfall and reinvigorate the high street as the focal point of the community, which could then attract investment and other enterprises back to high street
- It could also provide a renewed purpose or additional opportunities for complementary businesses nearby i.e. pharmacies, health food shops, shoe shops for podiatry patients, opticians for audiology / ophthalmology patients, baby shops for maternity patients etc.
How will this benefit the patients and the community?
- Provision of healthcare services on the high street could help to reduce health inequality, by significantly improving accessibility of healthcare services via cheap and well established transport links, as well as providing a focal point to access health education and other support services that contribute to wider public health
- The close proximity to other local amenities and places of work will also make accessing healthcare more convenient. It may mean people do not have to take time off work or find alternative sources of childcare in order to access treatment, which could help to improve attendance rates
- This, along with the additional capacity provided by these services, could help to reduce waiting times and allow patients access to appropriate care sooner, whether this is on the high street or in the hospital
- This is likely to be a crucial enabler to reversing the growing waiting list trends referenced earlier in the paper, and to mitigate the impact that Covid has had on exacerbating this problem
- As with the NHS staff, purpose built facilities on the high street are also likely to offer a nicer environment for patients to receive their care, with a large number of studies highlighting the positive impact this can have on patient outcomes and recovery times
- From a community perspective, the increased diversity and public health benefits on offer will help to increase community wellbeing. However, the increased footfall and potential investment could hopefully help to re-establish the high street as the focal point for the community, with a wide variety of other social and economic benefits beyond the high street themselves.
The provision of healthcare services on the high street is not a new concept and is one that has likely been needed for a number of years given the increasing demand for hospital treatment and the ongoing decline of the UK high street. However, it is the Covid pandemic that has likely provided the catalyst and necessity for this to become a widespread reality in the near future, both for the health of the UK population, but also the future economic health and sustainability of the high street. The pandemic has increased the open mindedness of healthcare providers to explore new options to deal with a rapidly deteriorating waiting list position, and offers a lifeline to high street enterprises struggling to maintain sustainable business prospects.
It provides a cost-effective solution for hospitals looking to expand their capacity, a long term income stream for high street property owners, accessible and timely healthcare for patients and a needed reinvigoration for the local community.
In other words, providing Health Services on the High Street can offer a win-win for all parties involved, through the collaboration of local NHS, authorities and enterprises and the engagement of patients and the community.
- Wood M, Finlayson S (2020), Health on the High Street. NHS Confed, https://www.nhsconfed.org/resources/2020/12/healthon-the-high-street, accessed February 2021
- NHS Statistical Work Areas Consultant-led Referral to Treatment Waiting Times https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/, accessed February 2021
- NHS Statistical Work Areas Consultant-led Outpatient Referrals https://www.england.nhs.uk/statistics/statistical-work-areas/outpatient-referrals/, accessed February 2021
- Office for National Statistics High Streets in Great Britain https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/highstreetsingreatbritain/march2020, accessed February 2021
- BDO High Street Sales Tracker https://www.bdo.co.uk/en-gb/high-street-sales-tracker/home, accessed February 2021
- ‘Crisis Driven Vacancies Continue To Climb’ Local Data Company https://www.localdata company.com/blog/crisis-driven- vacancies-continue-to-climb, accessed February 2021
- Holder J (2019), ‘High street crisis deepens: 1 in 12 shops closed in five years’. The Guardian https://www.theguardian.com/cities/ng-interactive/2019/jan/30/high-street-crisis-town-centres-lose-8-of-shops-in-five-years, accessed February 2021
- ‘What will happen to all of Britain’s empty shops’, The Times, George Hammond and Alice Hancock, accessed February 2021
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