When planning new healthcare infrastructure there is a tension between those providing services and those needing to use them. Healthcare providers and their workforce are typically drawn to co-locate services close to a secondary acute site with generally bigger facilities. This makes sense with nearby support for emergencies, colleagues from different specialties available for opinion, and sufficient equipment to meet almost any eventuality. However, service-users can struggle to find their way around larger sites, while travel to them can be longer and more complicated, and parking congested. Users prefer smaller, more personal facilities within easy reach, but this means more of them. In this article we explore these tensions, and the ground rules for the optimal size and location for such facilities.
Polyclinics
The idea of polyclinics that emerged in the latter years of the first decade of this Millennium has recently been revived, with an interest in community diagnostic and treatment centres, in order – for instance – to meet the inequity of access to diagnostic facilities in the UK as compared with European neighbours. This tension between developing larger sites on or near existing infrastructure, rather than smaller sites away from acute hospitals, has been all too evident. While some standalone centres have been built with easy access and good parking – meeting the needs of end-users – others have appeared in hospital car parks or next to hospitals, meeting the needs of healthcare professionals. Behind this lies a fundamental paradox in healthcare: the best ways to deliver care are often the poorest ways to receive it. Behind this is an information paradigm, since healthcare professionals need to ‘cluster’ to maximise their impact, while patients prefer a personalised experience. We show this in Figure 1, where the X-axis represents centralised to remote, and the Y-axis stretches from large to small.
The information-access paradox
It looks like the result of this tug-of-war between centralised and remote, big and small, must trade off the satisfaction of one group against another. Perhaps if we can understand the rationale for these differing views, we may find a ‘comfort zone.’ For service-users, this may be to skip a long trek on public transport or from a car park to a clinic, avoiding the need to rest along the way, the confusion of hospital signage, or crossing crowded spaces. It may mean consulting with someone they know and who knows them. For healthcare teams it may mean the security and convenience of their own bricks and mortar, colleagues, policies and procedures, or even the (surely outdated) bleep system
Our first aim in this paper is to provide a rationale for setting limits on what constitutes too big or too small. We may not find the ideal balance, but hope to describe the space in which it must lie. To reach a solution, planners must balance what is sufficiently connected, safe, secure, and familiar, for healthcare workers, against a good patient experience. They must also propose what is functional. A single scanner or endoscopy suite in an isolated location will offer a poor return on investment, requiring intense staffing relative to the number of diagnoses delivered, since the staff required cannot be shared across isolated clinical suites or scanners. Configuration is also important, since back-to-back control rooms in scanning facilities, for instance, can release staff for other tasks.
Economies of scale
For diagnostic facilities there are economies of scale. An endoscopy unit’s decontamination suite is most efficiently provided when servicing a minimum of four suites. In medical imaging, scanners are best clustered, while there is an optimal number of clinical consulting rooms per member of administrative staff. Ancillary space such as changing facilities may not be given enough consideration, but can be multifunctional, providing space for patient preparation and education, the latter even being provided digitally to reduce staffing burden. Better planning of such space can reduce patient time in examination rooms or scanners, making best use of the scarce resource.
Benefiting from co-location
Beyond this, users benefit from colocation of services when they can access complementary services in a single visit. This makes a demand of planners to consider clinical pathways from the perspective of the multidisciplinary team, rather than individual specialties. This raises a second question that we hope to look at in this article: how do we identify a good mix of services on a single site?
However, there is something more, a third axis to our graph – see Figure 2 – which represents how much activity takes place in a digital or placed-based setting. Healthcare professionals have historically been attached to their surroundings, but during the pandemic remotely provided services exploded, with patients seen over video links, or radiologists reviewing scans from their home offices, while patients were encouraged to complete online triage ahead of GP appointments. This sea change came in overnight as all stakeholders tried to protect themselves. Fortunately, this technology has proven ‘sticky’; indeed we still e-consult, while some reporting of tests takes place in the home
Continuing desire for face-to-face appointments
However, this technological leap is not without problems. A recent publication from the Government’s Health and Social Care Committee looking at digitisation of the NHS found that 95% of patients still wanted to book appointments face-to-face or on the telephone, and that elderly patients, and therefore the most vulnerable, were most left behind by digital transformation. This discussion of digital and place-based is the tip of an iceberg, and raises the third question that we will address – namely how should planners try to make best use of the new combination of digital and place-based to reach the widest possible range of patients, with the best of what the NHS can offer?
We stand therefore at a pivotal point in healthcare provision in the UK, with an opportunity to develop communitybased centres for earlier and more rapid diagnosis, improve patient outcomes, support an over-stretched workforce to access facilities remotely, and build on this platform through technological and innovation adoption. Failure to pursue this opportunity by continuing to overdevelop busy hospital sites will only lead to ever greater pressure on secondary care – a vicious cycle that must be broken to improve health outcomes in the UK.
Size and scale: the limits
Because the ‘too small’ category is driven largely by healthcare needs, and the ‘too large and too remote’ category by the needs of patients, we have a relatively simple way to set upper and lower bounds. On this basis, a facility is too big (or sited on or next to a facility that is too big) if patients can’t get there easily. But which patients? We propose that the most helpful answer is to consider the 10% of patients who find it hardest, most tiring, most unaffordable, or most confusing to attend.
There may be many invisible barriers that impede access, but the NHS is now recognising communities that receive poorer care from the NHS than their surrounding, and better-off, neighbours. In practice, the 10% who find it least convenient or viable to attend are likely to determine whether the centre is a success. This is because their needs for care, and the cost of providing such care, will grow quickly the longer they have to with without diagnosis or treatment.
Potential measures
Health inequalities are too big a topic to address fully here, but already we can imagine the sort of measures we could apply. For instance, we could say that a site is too big if the 10% who struggle most to attend have to travel more than, say, 45 minutes from their front door to a seat with a healthcare professional in the facility. At the other end of the spectrum, we apply a similar rule to scope when there are too few staff to support the full range of services. Note that staff may be unable to provide service if there are too few colleagues to consult, if associated services (see next section) cannot run all the time, or if the rostering is so marginal that they collapse under normal staffing or demand variation. One might argue, for instance, that a centre is too small if 90% of the services are not fully operational 90% of the time.
We are not proposing these specific guidelines, but are illustrating the importance of having such guides and showing how they may be derived.
Scope: the options
To answer the question of what mix of services is best for a single site, we must think from the perspective of the patient with a symptom. If we use an example of haematuria (blood in the urine), the patient will be exposed to many tests, starting when a healthcare professional documents the history of the condition. Next, their urine will be tested to look for signs of infection, inflammation, or other tell-tales signs of disease. Following this, an ultrasound examination of the urinary tract will take place to look for calculi (stones), anatomical abnormalities, or obvious tumours. Then a urology specialist will perform a flexible cystoscopy to allow video examination of the bladder. Depending on the outcome of these tests a MR or CT examination may be required to localise and provide detail of any abnormality, or to ascertain what is causing the patient’s symptom if nothing conclusive has yet emerged. With so many tests required, a patient can end up with multiple appointments stretched over a considerable period of time.
All under one roof
In this scenario a well-planned centre would have consulting rooms, point-of-care testing stations, a medical imaging facility, and endoscopy and decontamination facilities, to allow the patient to have all the diagnostic tests required in a minimal number of visits, ideally one
Of course, there are many patient pathways, but the bulk of patients will need to access a healthcare professional, and have some form of laboratory assessment (i.e. phlebotomy or analysis of another bodily fluid), before having some form of direct or indirect visual examination.
So far we have taken account only of those in direct contact with the patient through their journey, and not those who may be analysing or reporting on these various tests. With this knowledge, however, we perhaps feel more comfortable about what needs co-locating.
Planners will need to factor in local needs and transport links to alternative services, but the basis for such decisions is becoming clear.
Shape: the future is digital as well as place-based
Our modern facilities therefore need co-located services based on patient pathways, with great transport links and parking to support users and providers alike. However, connectivity in a modern setting means more than transport links. Healthcare professionals and patients should be able to access and deliver services remotely where that creates convenience, efficiencies, or cost advantage, and still yields diagnostic or treatment goals. Connectivity not only allows healthcare data to be shared between a network of centres and hospitals, and the staff within them, but can also support the optimisation of provision across a geographical location, maximising the available resource.
In specialities such as cross-sectional imaging, technology already exists for less experienced members of staff to operate equipment with more experienced staff monitoring and supporting remotely, which reduces staffing pressures. A precedence for remote reporting of a variety of tests has long been established in large swathes of healthcare, including – among others – ophthalmology, cardiology, and dermatology. Support mechanisms for inter-specialty colleagues already exist in the form of dedicated virtual multidisciplinary team meeting software, which could easily be adopted to create a virtual ‘big, centralised’ centre around a smaller, more remote, physical centre.
AI and ‘smart’ algorithms
With connectivity and transferable healthcare data come the opportunity to enhance our healthcare professionals with artificial intelligence and their practice with smart algorithms. The rapid rise of AI means that repetitive, but critical, tasks can be performed by computers, enabling those making diagnoses and treatment decisions to do so more quickly. Predictive algorithms can set appropriate follow-up appointments based on personalised data pertaining to risk, rather than convention, reducing the costs of healthcare provision, and supporting those most at risk. Similar algorithms can scour individuals’ healthcare data to highlight potential risks or concerns not yet considered
In adopting these advancements, we must balance their improvements in healthcare delivery with the requirement for compassion expected from our caring profession. Gestures of reassurance or empathy are still difficult to emulate in a digital environment, and it is in these situations where we deliver sometimes life-changing news. Digital also enables digitally literate patients to move huge elements of their care onto the web: making appointments, collecting results, and conducting some appointments from home. The difficulty facing us right now is how few of the hardest-to-reach patients are ‘digital natives’, or have access to appropriate digital technologies
Conclusions
Designing healthcare facilities remains a challenging occupation. There are tensions between the expectations of users and providers. There are barriers to adoption of new ways of working and new technologies. With digital developments come data security concerns, and yet much of our lives are shared online. With remoteness from large central facilities comes concerns around isolation that could be overcome with numerous digital solutions. In order to meet the future needs of service-users, access to differing specialties should not be sequential, but rather – by clustering on the basis of pathways – more slick. We must exploit the (over-used) Big Data to target, predict, and prevent. Connectivity should be the foundation to future healthcare development.
And so our facility has developed into a physical location with digitally empowered professionals able to treat us effectively, efficiently, and locally, with the benefits of digital co-location with a larger centralised facility. Digital really disrupts the old paradox, enlarging the comfort zone for patients and staff
Professor Terry Young
After sixteen and half years as a research engineer, divisional manager, and Business Development director, Terry Young became a Professor at Brunel University London for 17 years. He has a BSc in Electronic Engineering and Physics, and a PhD in laser spectroscopy, both from the University of Birmingham, and is a Fellow of the British Computer Society. His research has been in health technology, health services, and information systems. He has taught information system management, project management, and e-Business. His awards include the Operational Research Society’s Griffiths Medal 2021, for analysing the return simulation methods offer when used to improve healthcare services. Prof. Young set up Datchet Consulting in 2018 to support innovation on the borders of academia, health, and industry.
Steve Powell
Steve Powell MBChB, MRCS, FRCR, MBA, enjoyed a highly successful career as a Consultant Interventional Radiologist with a particular interest in complex venous interventions, culminating in him leading a large teaching hospital department as Clinical director. He was President of the Vascular Access Society of Britain and Ireland, European Training lead for AngioJet thrombectomy, a member of the editorial board of the Journal of Vascular Access, and a member of the European Renal Best Practice Guideline group.
Following his Clinical director role, he moved into healthcare management, initially developing an NHS Trust’s strategy, and subsequently supporting the development of the outline business case for the merger of two large teaching hospitals. He became director of Accelerator, ‘the home for business’ on the Liverpool Health Campus, supporting technology adoption in healthcare settings, before leaving the NHS in 2017 to lead a diagnostic company, resulting in the establishment of the service’s first Community Diagnostic Centre, with an initial 10-year contract with the NHS in the South-West of England.
Currently leading healthcare consultancy, SKP Advisory Services, he has supported clients ranging from start-ups to government departments. He is Chairman at a healthcare-orientated software company, CEO of AI Sight, and a trustee at the Grade I listed St George’s Hall, Liverpool