Speaking at the International Federation of Healthcare Engineering’s 2022 Congress in Toronto, IHEEM’s CEO, Pete Sellars, and President, Paul Fenton, argued that the planning and construction of ‘siloed’ hospitals ‘is over’. Their key point was that ‘the way we measure hospital workload is outmoded – what matters now is the wider health and social care system: there is no such thing as a good hospital; there is only a hospital that is good for the system’. They presented a very different model for future healthcare planning
Pete Sellars and the then IHEEM President, Paul Fenton MBE, delivered their message on the need for a major shift in thinking on healthcare planning in an hour-long opening keynote address, titled ‘A common language for planning and design of new hospitals’, on the first morning of the 27th IFHE Congress, which took place from 17-21 September at the Westin Harbour Hotel in Toronto. When I spoke to the IHEEM CEO a few days later, he admitted that they had initially not been sure – given the potential language barrier, with delegates attending from many countries where English is not the first language, and with very different clinical and estates practices and terminologies employed worldwide – how clearly their message would resonate.
A fantastic response
However – as it transpired – they had a ‘fantastic response’. Following the presentation, they were approached by ‘a steady stream’ of delegates from as far as field as Australia, Brazil, South Africa, and the US. All these personnel – ranging from EFM professionals to surgeons – were keen to discuss with them their ideas on how current healthcare planning practice requires a serious re-think if future hospitals are to be fit for purpose. Many of those they spoke to were keen to take back the ideas to their own countries for discussion with policy-makers and peers.
Pete Sellars’ and Paul Fenton’s key message – which has been the focus of discussion over the past two years for a Working Group made up of academics, healthcare personnel, architects, healthcare planners, and IHEEM members that Peter Sellars first brought together in 2021 to address the issue – is a simple one, but will require overcoming some complex challenges to implement. The premise is that current healthcare planning methods are deeply flawed. In particular, the Working Group believes, there is an overemphasis when planning new hospitals on their capital costs, with insufficient consideration to their through-life costs, or to the revenue implications of designing them so that they are able to ‘flex and adapt’ to changing healthcare demands and trends, and emerging technologies. Equally – the Group argues – healthcare facilities need be designed and planned using acuity and the optimal patient care pathways for the local population as they key determinants of the clinical care services provided. The hospitals’ overall value to the wider healthcare system also needs to be afforded higher priority, they argue. Currently, the Group’s members feel, many NHS acute hospitals operate as ‘silo’ units, with little regard to their contribution to the wider healthcare ‘system’.
Developing a ‘common language’
It was against this this backdrop that Pete Sellars and Paul Fenton delivered their address. In it they outlined the work that IHEEM has already done – jointly with the European Health Property Network (EuHPN) and University College London’s Bartlett School of Architecture – on the development of a new healthcare planning model that brings together hospital masterplanning, design, and operational management, based around three key elements:
Acuity – Using Acuity to determine the clinical care services provided.
Using System-Wide Economic Modelling when planning new healthcare facilities, rather than ‘traditional’ m2 capital costs, to determine the benefits of the investment.
Using an Integrated Health Planning Framework – through ‘a common language to facilitate dialogue’ between stakeholders and decision-makers.
Sharing news of their UK work
Pete Sellars explained to the Congress audience that he and Paul Fenton would share the work they are leading in the UK to develop ‘A common language and approach for undertaking healthcare planning’ – work they argue is ‘hugely important and much needed’ to improve how the current planning, design, and construction, of both new and existing hospitals is undertaken. Although driven by the ambition to change healthcare planning delivery in the UK, Pete Sellars said the fundamental concept and principles were ‘very much transferable globally across all healthcare settings’.
Five key areas of focus
The pair’s presentation was divided into five key areas:
1. The background to, rationale behind, and drivers for, developing ‘a common language’ and approach for healthcare planning.
2. Setting out the three ‘key stages’ of this common language, and how it can be applied.
3. Highlighting the aims, benefits, ambitions, and challenges, in influencing change.
4. Progress to date, the tools and support, training development, the Working Group, and the next steps.
5. A Q/A and discussion session.
The need for change and a ‘common language’
Beginning by explaining why there was a need for ‘a common language’ around healthcare planning, Pete Sellars acknowledged that strategic healthcare planning was ‘not easy’. Not only were there many diverse stakeholders to engage with, but each of these professional roles tended to bring what he dubbed ‘their own specific suite of ideas and unique vocabulary in how the collective should comply with the programme brief’. Pete Sellars said: “It’s clear that most people actively involved in healthcare planning – regardless of their professional or personal background – aim to deliver a new hospital and services that improve clinical outcomes, and provide an environment that enhances staff wellbeing, and bring better patient outcomes and experiences.”
Healthcare planning decision-makers, meanwhile – whether at national, strategic, or local level – had to consider ‘a wide range of complex, competing, demands’. “For example,” Pete Sellars explained, “public health experts will be attentive to health inequalities and future healthcare demands, architects will focus on aesthetics and functional layouts, engineers will prioritise infrastructure resilience, system efficiency, and new technologies, and clinicians, patient safety, clinical ethics, and quality.”
Patient priorities
He continued: “Our evaluation of previous successful hospital investment programmes suggests the greatest success comes when all key stakeholders share a common language of understanding.” A key benefit of this for ‘investment decision-makers’ was that it gave them ‘the evidence’ to easily explain their rationale for recommending their decisions to key stakeholders in government or policy
In recent decades, Pete Sellars and the Working Group believe hospitals in England have been encouraged – ‘by custom, policy, and law’ – to act as independent bodies, ‘largely answerable to themselves, unless there has been a major failure in their activities’. He said: “They may operate well, indifferently, or badly, they may or may not meet clinical standards, performance targets, or financial balance, and indeed they may be valued (or not) by patients, staff, and communities. What is fundamentally clear, though, is that in most cases they fail to contribute as fully as they could to the wider requirements of the health and social care system they serve.”
The Working Group believes that if hospitals continue to be planned, designed, and financed, largely as independent standalone units, they will have limited ability to adapt ‘to meet wider systemic future healthcare challenges’.
How investment decisions are driven
Pete Sellars said his experience was that investment decisions about healthcare capital assets were ‘almost always driven by business cases that link planned activity (outputs of hospital services) to a m2 cost value, and primarily focused on the hospital as a standalone entity’. He said: “We all want to see hospitals driven by new and emerging technologies, and changing epidemiology and demography, taking into account the requirements and expectations of clinicians, patients, and different modes of governance and public accountability.” To achieve this, a move to a more appropriate way to determine the clinical workloads of hospitals, and the economic appraisals to support these investments, was required. A new ‘common language’ would not only, he said, provide ‘the rational means to discuss and agree on what is to be delivered and constructed’, but should also ensure that all involved understood how to effectively deliver future healthcare planning requirements, and that decisions were not simply driven ‘by who shouts the loudest’
The IHEEM CEO’s next slide showed the Working Group’s ‘Three Key Stages’ towards the ‘common language’:
1.Using Acuity to determine the clinical care service models.
2. Using System-Wide Economic Modelling, rather than ‘traditional’ m2 capital costs, to determine the benefits of the investment.
3. Using an integrated health infrastructure planning framework, ‘through a common language to help facilitate and unite dialogues between stakeholders and decision-makers’.
Extending the definition of ‘Acuity’
Turning to ‘Acuity’, Pete Sellars said the World Health Organization defined it as ‘relating to the severity of a patient’s condition’ (‘Low, Emergent, and Critical’). He said: “Our healthcare planning approach broadens this to also use Acuity to measure patient and population health status, severity of disease / condition, and characteristics of frailty and multimorbidity. It can thus become the key clinical workload planning metric to determine how best, and where, patients receive their care.” The Acuity metric was also ‘scalable’ – meaning it could inform individual patient healthcare planning decisions, care pathways, individual or regional care facilities, the nature of the services within them, and the roles of the staff. The Working Group had also added ‘recovery’ to the broad compass of the term – to emphasise the importance of good care environments for rehabilitation.
Broader definitions
Pete Sellars said: “These broader definitions are better aligned with the range of assessments regularly made by clinicians working in primary, secondary and tertiary care, and are frequently used in clinical care pathway development, referral, and discharge decisions, between health and social care bodies.” The Group thus proposes using existing clinical measurements of how ill or well patients are – as individuals or larger patient cohorts – as a core part of the common language, ‘to inform strategic healthcare planning decisions to determine where patients are best treated’. This would in turn inform key investment decisions on service planning, staffing, infrastructure, and new technologies. “So, to summarise,” Pete Sellars said, “our proposal is to use Acuity as the currency for future healthcare planning.”
Rethinking care pathways
Pete Sellars’ next slide was titled ‘Rethinking care pathways’. The message here was that current care pathway models are dependent upon primary and secondary care clinical interventions, and patient movement across boundaries, which often ‘break down’ – frequently due to ‘outdated clinical gatekeeping and payment regimes from standalone clinical units’. This clinical gatekeeping model – ‘outdated, and often associated with siloed standalone healthcare providers’ – prevented fast, timely access to the appropriate level of treatment and care the pathways intended.
Hospitals should thus in future look to work within, and become a key integral component of, a wider integrated health and care system. Pete Sellars said: “In England, with the healthcare system now recognising that this approach is needed to ensure patients are treated in the right place, at the right time, and with the right level of clinical care and expertise, we have seen Integrated Care Systems introduced. These new organisations are being given powers to oversee the management and delivery of services across health and social care. We believe using acuity as the planning currency is the most appropriate method to support ICS delivery of these strategic changes.”
Plan and design differently based on Acuity as the currency
If future healthcare planning is taken forward using acuity as the common currency, Pete Sellars said it should then ‘become quite easy’ to translate these requirements to determine the healthcare care setting required, and the subsequent infrastructure requirements’. He elaborated: “By using patient acuity at the system and population levels, we can anticipate future needs, make rational judgements about the operational and capital resources required to meet them, and – critically – examine the most appropriate locality to deliver timely, appropriate patient care.
Moving to discuss ‘Designing for Acuity’, Pete Sellars said there was ‘a strong link between acuity and design here’, adding: “Just as ‘form follows function’ as a general design principle, in many healthcare settings buildings are designed to reflect how patients are treated, but very rarely by patients.
Example of the ‘acuity approach’
Here he handed over to Paul Fenton, who he explained would discuss the next two stages of the Working Group’s healthcare planning process, and share examples of how its acuity approach was already being used to influence healthcare planning in the UK.
Paul Fenton began: “Sometimes patients, rather than clinicians or architects, provide the input concerning the ‘function’ of a healthcare facility, as seen in the Maggie’s Centres, which emphasise a non-clinical, homely design. Future hospital planning needs to review the ‘departmental concept, and focus more on models of care and patient pathways.” Explaining why, he said: “Having a theatre department that carries out day, elective, and emergency surgery may seem to make logistical sense, but in the event of emergencies and bed blocking, day and elective lists may be cancelled. We must radically reorganise the constituent parts of the hospital if we are to reduce significant patient backlogs, and develop facilities better suited to the types of procedures, avoiding dependency on ICU beds.”
Addressing the ‘known unknowns’
Paul Fenton said ‘design for acuity’ must also address ‘the known unknowns – those semi-predictable or unpredictable events that can quickly overwhelm and destabilise hospitals and wider health systems’. He added: “As well as new technologies, new procedures are developing, and more operations are using ‘blocking’ rather than general anaesthesia (e.g. endoscopy facilities will change, due to orally administered devices that can relay images to a computer, and injections will be used instead of surgery in eye care). We propose a reorganisation that challenges the fundamental flows into, around, and out of, the health system. It will expand our knowledge of emergency and recovery through a focus on acuity, and thus drive integration around the health and support cycle.
“Our proposition will radically challenge the settings for diagnostics, surgery, and recovery, and show how acuity adaptability can be enhanced through the creation of virtual or physical hubs. We will use acuity as the basis to evaluate and adapt systems, and will develop an advanced hospital system workload model.”
‘More than just bricks and mortar’
Paul Fenton’s next focus was ‘SystemWide Economic Modelling’. The Department of Health & Social Care was, he noted, ‘explicit’ that health infrastructure was ‘more than just bricks and mortar’, and hospitals, ‘more than land, equipment, and maintenance budgets’. In addition to being ‘the embodiment of improved care pathways and technological innovation, and enablers of staff development’, they should be ‘integral partners of local health systems, supporting the delivery of community and home care systems, and pivotal in the efforts to integrate tertiary, secondary, primary, and social care services’. The hospital thus had a social and economic value to the wider community far beyond the land, buildings, and equipment, it owns
If hospitals are to be ‘embedded partners in a fully functional integrated care ecosystem’, the Working Group believes their value should be assessed through some form of System-Wide Economic Modelling. “Hospitals are centres of knowledge, expertise, and the latest technologies, richly made up of highquality staffing resources, and usually highly capital- intensive,” Paul Fenton said. “However, ultimately in an integrated health system, the overall operation and efficiency of the system should take precedence over one individual hospital.”
Rigorous assessment
For these reasons, investments in new hospitals should be rigorously assessed ‘through the lens’ of ‘What does this investment and design add to the overall system capacity to address the local, strategic, or national population and health needs?’ Paul Fenton elaborated: “Crucially, System-Wide Economic Modelling introduces the notion of ‘trade-offs’, i.e how to reconcile the competing demands of the brief, also taking into account new priorities such as carbon reduction, budgetary constraints, and increased infrastructure resilience post-COVID.”
Returning to a point made earlier by his co-speaker, Paul Fenton said that ‘for many decades’, decisions about healthcare capital asset investments had been driven by business cases linking planned activity to a cost per /m2 (‘mostly based on historic values’), and ‘a standard capital envelope’. The result was ‘an inflexible, highly risk-averse’ cost ceiling, ‘focused only on the hospital as a standalone entity, and unlikely to take account of factors such as coming changes in clinical models mostly driven by emerging technologies and changing epidemiology/demography, a need for rapid adaptation of the physical estate, and different modes of governance and public accountability’.
Need for capital headroom
Without some capital headroom to build in significant capacity to ‘flex’ the estate, and ensure robust, future-proofed, high quality design and construction, new hospitals would always struggle to achieve sustainability targets, and to offer patients and staff an environment conducive to the highest care standards. Paul Fenton said: “The focus on capital cost, here and now, is all the more puzzling given that the value of the capital is negligible, when compared – as it should be – with the through-life cost of running the facility.”
He continued: “By far the biggest cost of running a hospital is that associated with the human capital – the staff who make it work. Preliminary and simplified Discounted Cash Flow modelling undertaken for this bid (the Working Group’s proposals were the focus of an entry to the Wolfson Economics Prize 2021*) – based on data for an existing English NHS hospital business case – suggests a hospital with a capital expenditure of around £250 m will have a discounted lifetime Net Present Value of cost, mainly of clinical and associated services, of well over £4 bn.” It was thus ‘more important to ensure that the billions are spent efficiently and productively over the hospital’s lifetime, than to play around with a few millions on the capex number now’. Equally, a small productivity enhancement enabled by new buildings and equipment ‘well aligned with the business model and health system’, with productivity change designed in from the start, would ‘rapidly, quantifiably, and provably, recompense any required associated uplift to the upfront cost’.
Flexibility to accommodate ‘game-changing advances’
There was ‘a cost, but also an opportunity’, in allowing some additional capital budget to accommodate ‘highly innovative and potentially game-changing’ advances in construction techniques and emerging technologies (e.g. AI, robotics, and telehealth) during planning and design. Nevertheless, Paul Fenton acknowledged, there was an imperative to ensure value for money in all public procurement projects, and the two speakers would later describe ‘a systematic, highly integrated means to marry cost savings at the design and construction phases, with a lifecycle approach to hospital capital investment’.
The question of capacity
A hospital’s capacity was, the IHEEM President told delegates, ‘categorically not well captured by the number of beds’; capacity was the ability to do work, and what a hospital does could only be evaluated in the context of the system it is embedded in. He said: “What matters then is the capacity, cost, and performance of the system, with and without the hospital concerned. Equally, the accepted desirability of having extra ‘flexibility/ adaptability’ could be cogently addressed as the need for extra buffer capacity. A system-wide modelling framework can create scenarios to tackle the question over the size of the premium worth paying to retain spare capacity needed to meet future contingencies.”
Paul Fenton said the key aim of developing an Integrated Healthcare Infrastructure Planning Framework was to ensure that future healthcare investment plans were primarily being decided, accessed, and approved, ‘based on their clinical needs, functions, and benefits, to the wider healthcare ecosystem required to serve that population’. He said: “Only when this phase is completed and agreed, should design, procurement, and construction take place; in theory, this phase should not be contentious. There is a strong legacy and successful history of many successful hospital build programmes due to the extensive expertise available to deliver and build these facilities.”
Result of an inconsistent approach
Failed or wasted healthcare investment was, he argued, ‘almost always associated with an inconsistent approach or poorly governed healthcare planning process, usually due to unrealistic political constraints relating to time, and capital spending, lack of healthcare planning expertise, or just simply by he who shouts the loudest getting what they want’.
Paul Fenton noted here that the information he and Pete Sellars were sharing originated in detailed work undertaken by IHEEM in partnership with academic colleagues at The Bartlett School of Architecture at UCL and the European Health Property Network (EuHPN) in 2021. “The principles of what we are discussing today are already being taken forward and supported by some hospitals in England,” he explained. “For example, London’s Moorfields Eye Hospital is implementing new pathways for patient diagnostics that will cut waiting times from hours to minutes, while the SameYou charity is working with UCLH Bartlett to offer a highly integrated neuro-rehabilitation service tailored to patients’ individual needs, drawing on high-tech, digitally-enabled programmes of movement, dance, and art, that will provide a step change in patient recovery.” A large district general hospital in the North East of England, meanwhile, had already reorganised its staffing and infrastructure, and was exploring how best to move its diagnostics and imaging provision out of the main hospital into the high street to support integrated care in the community.
Ongoing commitment
Although these were ‘just small examples’ of where new services are being taken forward using the principles of Acuity for healthcare planning, and starting to adopt the principles of an Integrated Health Care Planning Framework, with ‘a long way to go’, IHEEM, The Bartlett, and EuHPN, were, he stressed, committed to building on this successful work, ‘by providing further proof of concept to help influence change both in UK and internationally’
Looking next at the ‘Benefits of building differently – aims, ambitions, reality’, Paul Fenton said previous hospital and health facility investment programmes in the English NHS had shown the capital investment approvals process to be ‘bureaucratic and sclerotic’. He said: “Capital allocation and planning are geared to ‘shovel-ready’ projects, rather than strategic priorities, build quality is often compromised by deadlines and costcutting, while stakeholder consultation is usually underpowered, and often fails properly to inform planning and design.” Although some new technologies were factored into designs, the Working Group says there should be ‘greater ambition’ in relation to use of robotics, smart building technology, tele-tracking, and digitalisation.
Catering for change
On a different note, he said: “Facility design typically fails to take sufficient account of future adaptability needs, and of course it is important to train staff in new ways of working early on; not once the building is nearing completion.” Sustainability-wise, he said, investment in high-quality infrastructure, adaptable to future needs, ‘pays off over the long term in both carbon and cost’. Also key were to harness the best evidence on reducing stress for patients and improving staff working environments. ‘Value engineering’ should not be allowed ‘to cheese-pare these benefits to the bare minimum’
The Working Group says that by providing ‘a common language and a single source of truth to all stakeholders’, it should be possible to:
Create centralised, clear guidelines for facility planning and design, based on the principles of acuity adaptability and whole-system economic modelling.
Enable the delivery of rapid and detailed briefing. n Use existing and in-development ‘readyto-use’ design components.
Use modular construction techniques ‘where possible and appropriate’.
Share knowledge and learning reliably between project teams.
Incorporate the latest technologies, and build in capacity to adapt these short to medium term.
Private sector’s part
Paul Fenton emphasised that the proposals he and Pete Sellars had outlined were not the sole responsibility of the public sector. Private and third sector stakeholders and partners needed to be formally engaged, and ‘proactively encouraged to contribute their skills and expertise’. Moving to the progress so far, IHEEM had already put in place a number of tools, training, and support measures ‘through its partnerships and associations with leading organisation across the globe’.
One of IHEEM’s partners, the Total Alliance Health Partners International (TAHPI), was, he said, ‘one of the most prolific authors of international standards and guidelines for healthcare design, customised for different regions of the world’. Paul Fenton explained: “TAHPI offers a range of accredited training courses and software packages to support solutions in healthcare infrastructure, and works with IHEEM to deliver courses including the Health Facility Planning Course and Health Facility Briefing System. It has also given members access to its set of International Health Facility Guidelines, which can be found via the IHEEM Knowledge Portal.”
The European Health Property Network (EuHPN), meanwhile, describes its ‘mission’ as to ‘promote better standards, and more effective investment in health property, across Europe’. Paul Fenton explained that IHEEM works with the EuHPN to share knowledge and best practice, and that the two organisations are looking to collaborate to deliver joint webinars and seminars.
Technical Platform’s role
IHEEM’s recently established Strategic Estate Management Technical Platform, comprising experts from the architectural, building, and estate management sector, would also undoubtedly be contributing expertise and input to the Working Group and its continuing work to shape a new healthcare planning model.
Next steps
Looking at the next steps, Paul Fenton explained that active discussions on the proposals were either ongoing, or planned, with a range of health and healthcare organisations – including hospitals, charities, regional, and (potentially) national, agencies. He said: “We are also seeking funding opportunities, and will be looking to involve the European University Institute Partner Network members as co-producers of case studies and pilot projects. Our aim is to influence policy on planning and designing hospitals as part of wider health and social care systems, based on evidence and strategic intent, using the best available modern technologies.” With this, the joint presentation closed, and the two speakers invited questions.
The Working Group’s proposals on a new model for future healthcare planning formed the basis of its submission to the Wolfson Economics Prize 2021 last year. Pete Sellars and Paul Fenton would particularly like to thank the European Health Property Network’s Executive Director, Jonathan Erskine, and Professor Grant Mills, Faculty Lead for Health at the Bartlett School of Sustainable Construction at University College London, for their input and expertise on the project.