Prescribing a greater role for ‘integrated hospitals’

I am proudly British, a passionate advocate for the NHS, and work in developing and implementing new health and care models, both here and overseas. My company, MHealth’s skills include hospital and healthcare planning, and working to provide Healthy Living Communities — as per United Nations Sustainable Goal 11. During my career I have worked with the NHS overseas to support British export effort — a valuable resource that clearly highlighted UK expertise. This expertise is, in my view, still evident in many areas of the NHS, but not in hospital planning, design, and construction. Now we have the experience of learning from other countries — and this has been truly inspirational. Some of these countries have overtaken the UK in the world comparisons of health outcomes.

This is a critical time for the NHS, with considerable recent activity surrounding the service, and some influential reports published, some of which I will refer to. While the Prime Minister stated, within the first weeks of becoming Prime Minister, that he would not increase the NHS Budget unless a new strategy is proposed and approved, the Budget increase was necessitated to resolve the staff payment disputes. However, it does not lessen, indeed it reinforces, the need for a new strategy. The pre-budget NHS expenditure showed that hospitals accounted for 78% of the overall spending. The greater emphasis on prevention is hard to afford by the DHSC Budget alone. This article offers some thoughts on the way NHS care is currently provided, and my own vision of the benefits that greater use of integrated hospitals, with increased focus on people, as well as patients, can bring, looking ahead.

On 7 April 1948, the World Health Organization’s (WHO) Constitution came into force, with its definition of health stated as: ‘Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity’. On 5 July 1948, the UK National Health Service (NHS), seen as a forerunner of universal healthcare, was founded, with a stated aim of ‘providing everyone in the UK with healthcare based on their needs, and not on their ability to pay’ — i.e. healthcare that is free at the point of use.

The comparison of the two shows that the aim of the NHS was political — and it has stood up as a worthy political aim. The WHO, unconstrained by political consequences, provided a more altruistic vision — one that anticipates evolution.

Hospitals ‘the backbone of the NHS’

The hospital has been the backbone of the NHS, as the institution that is built, staffed, and equipped, for the diagnosis and medical and / or surgical treatment, of sick and injured patients.

Here indeed is ‘the rub’: NHS strategy is focused on patients, not people — resulting in the failure of an important business and service discipline — ‘market awareness’. Through greater such awareness, the population and demographics would inform the delivery of health services. Understanding this better would allow the NHS to be more proactive, in place of what is — in my and many other observers’ view — its current reactive tack, i.e. of seeming to be always running to catch up.

Distracted by the political moment?

An additional complication is that NHS strategic thinking has at times been distracted by the political moment, one example being the adoption of the PFI/PPP financial model, which — by its nature — was based on a contract related to the financial ‘security of form’, thereby frustrating the flexibility that is so necessary to respond to the dynamic human activity of a hospital.

The iconic nature of the NHS gives it political status that has defined the service as the sole custodian of all health services. While this has been its strength, it is now — I would argue — becoming its weakness. Health and care are evolving, as the WHO anticipated, to an ever-greater emphasis on ‘complete physical, mental and social well-being and not merely the absence of disease or infirmity.’ This is much more complicated to measure, and therefore, for politicians and managers to grasp. This is widening the scope of health and care to promote greater prevention of non-communicable diseases — a greater transfer from cure to prevention. Prevention is an increasing part of the role of primary care, with the need for additional diagnostic services.

The word ‘prevention’ changes the connotation of the function of a hospital. In 1948, the hospital was the key demonstrable function of the NHS, supported by primary care. Now ‘prevention’ requires increasing primary care and out-of-hospital services to promote it, and the role of the hospital is to take action when prevention fails. Lord Darzi’s recent report, Independent Investigation of the National Health Service in England, was published in September last year. An NHS Confederation summary and analysis, titled ‘The Darzi investigation: what you need to know,’ published on 12 September, said Lord Darzi’s review offered ‘clear illustrations of the key systemic and structural issues beyond NHS leaders’ control that if perpetuated will continue to set the service up to fail’. These include ‘the failure to divert resources into more preventative care and the pressure on primary care, an oversized centre (including regulators) with a heavy burden of regulation and inspection, and a lack of consistency and clarity around the role of integrated care boards (ICBs)’.

Clear illustrations of ‘system and structural issues’

The NHS Confederation briefing added that these ‘systemic and structural issues’ included ‘the growing focus of the NHS budget and staffing on hospital-based care… alongside factors that reinforce this distribution. Namely, performance standards focused on hospitals, not primary care, community services or mental health, single-year budgets, and politically driven short-term funding decisions that hamper innovation and transformation’. The briefing continued: ‘The investigation also helpfully illustrates that despite spending over half our budget on hospitals, we have not invested in creating a healthy ecosystem for them to operate in. This is both within hospitals, which have seen underinvestment in capital, hindering their ability to deliver efficiently and effectively, and lack of investment in primary, community, and social care services that keep people out of hospital and enable them to be safely discharged when ready to leave. The NHS needs to shift to provide more care closer to home, with a proportional increase in preventative investment upstream into primary care, mental health, and community-based services.’

However, there was no reference to two important points that we come across in improving health outcomes in other countries. These are:

• It is not patients that (should) determine the overall planning of hospitals nor healthcare. It is the population — the demographic change. Planning starts with understanding the demographic change over previous years and projecting that forward — this translates into a forecast of future (the lifetime of a new hospital), not just existing, patient needs. This demonstrates the clear need for flexibility of planning the facilities.
• Lord Darzi’s comment about ‘structural issues beyond NHS leaders’ control’ suggests prevention cannot be the sole responsibility of the NHS. Instead, it requires a multisectoral approach — and acceptance of this is enabling some countries to start to forge ahead of the UK with their health outcomes, incidentally often achieved with lower healthcare budgets at their disposal. As prevention becomes a shared responsibility across sectors, this offers the opportunity for private funding participation without compromising the public nature of the NHS. Both can lead to greater co-operation to achieve better health outcomes without placing it all on the NHS / DHSC budget, which, as we can see, cannot cope. More money will not solve the problem, because key areas of prevention fall outside their gambit, as Lord Darzi indicates. This is important, and raises many points over ‘integrated care’.

Today, health is one of three pillars of a healthy society — Health, Wellness, and Social Interaction. Where and how we live is the background of these three pillars. The term ‘integrated care’ is defined by the NHS as ‘care that is planned with people who work together to understand the service user and their carer(s), puts them in control, and coordinates and delivers services to achieve the best outcomes’. It goes on to say that Integrated Care Systems (ICSs) are partnerships that bring together NHS organisations, local authorities, and others to take collective responsibility for planning services, improving health, and reducing inequalities across geographical areas.

The World Health Organization adds that a hospital ‘complements and amplifies other parts of the health system’. At a Summit of the Future on 2 September 2024, the Director General of the WHO, Dr Tedros Adhanom Ghebreyesus, made the following points as regards ‘a commitment to promote, provide, and protect health’: “Health is not created in clinics and hospitals. It’s created in streets, homes, communities, schools, markets, workplaces, and parliaments. It’s created in the air people breathe, the food they eat, the water they drink, the conditions in which they live and work, and in our changing climate. When people do need care, they must be able to access the health services they need, when and where they need them, without facing financial hardship by paying for care out of their own pockets.”

Hospital functional planning not sufficiently evolving

The NHS has not sufficiently evolved its functional planning of hospitals for 30+ years. This was highlighted by Professor Ted Baker (Chief Inspector of Hospitals in England from 2017-2022) in an online BBC News Health story, NHS ‘not fit for 21st Century’, says Chief Hospital Inspector — published on 30 September. He said: “The model of care we have got is still the model we had in the 1960s and 70s.

“One of the things I regret is that 15 or 20 years ago, when we could see the change in the population, the NHS did not change its model of care. It should have done it then — there was a lot more money coming in, but we didn’t spend it all on the right things. We didn’t spend it on transformation of the model of care.” Professor Baker noted that the number of pensioners had increased by a third in the previous 30 years, and said the system had not been able to deal with the increase in the number of elderly people, in particular.

At the level of ‘form’, the NHS argues that it has made considerable progress towards Net Zero impact in hospital building, and that deserves credit. However, that misses the point. While an important priority, it should not detract from a hospital’s functional activity.

What is failing is the continuum of care. Continuum requires ‘anticipation’ — forward planning — and benefits from a multi-sectoral approach. If we are to accept that healthcare is evolving from cure to prevention, how does it affect the role of the hospital, and can we emotionally, politically, and functionally, accept the idea of integrating hospitals into the wider activities — including the community, or must it stay a separate function? Can we accept that that cure is the backstop to the failure of prevention?

Early diagnosis and encouragement towards lifestyle change are key to maintaining affordability. Early diagnosis is a combined effort of primary care and access to diagnostic equipment. Everyone is now recognising and accepting that health and care are changing ‘from Cure to Prevention’, but the strategic consequences of this are less well understood, and this is because the planners and deliverers of healthcare see it as an adaptation of what they have been doing for many years. A shift ‘From Cure to Prevention’ requires a real step change, with greater co-relations with other factors that are considered part of the wider health and care remit — the expansion from health to health, wellness, and social interaction.

This change is easier for those countries that are still learning how to deliver universal healthcare; they do not have the NHS’s history and culture in terms of a tendency to hold on to a long-established working model despite an evolving society, and changing patterns and types of illness and demographics.

How things have changed. For the moment, if we set aside COVID-19, today the key health and care problems are more related to non-communicable diseases (NCDs) and the other largely lifestyle-related conditions that are preventable. The WHO definition is thus ever more pertinent.

While, the NHS has consistently been in the top 10 as regards access and quality of hospital service, if one considers both the economic and social wellbeing required to sustain good health, including health outcomes, health systems, sickness, and risk factors, as well as mortality rates, the NHS slips to 34th in national ratings.

Some interesting projections

Information from the ONS National Population Projections: 2021-based interim, released on 30 January last year indicate that:

n Over the 15 years between mid-2021 and mid-2036, the UK population is projected to grow by 6.6 million people (9.9%), from an estimated 67.0 million to 73.7 million; this includes 541,000 more births than deaths, and net international migration of 6.1 million people.

• The UK population is projected to reach 70 million by mid-2026; this growth is faster than in the 2020-based projections released in January 2023, with the projected rise mainly resulting from international migration.
• The population projections for the UK are based on an assumption of long-term net international migration of 315,000 per year from the year ending mid-2028 onwards; this is based on expert views and the latest data covering the last 10 years. Note that migration assumptions do not directly account for recent and future policy or economic changes, and there is always some uncertainty in estimates of migration, meaning that actual levels of future migration and resulting population may be higher or lower than those assumed in these projections.
• There will be an increasing number of older people; over the next 15 years the size of the UK population aged 85 years and over is projected to increase from 1.6 million (2.5% of the total population) to 2.6 million (3.5%). This is putting ever greater strain on social care and the services provided.
• UK health outcomes are falling, one reason being that old people who are medically fit to leave the NHS acute hospital cannot do so, due to the lack of social care packages to support them after discharge. One, and perhaps the main, reason for this is people living alone. This emphasises the need for a robust inter-generational delivery of both homes and services which will encourage interaction between those of different ages. This has the potential to mitigate, or even eliminate, escalations of local authority and private sector costs.

Demographics

If we now we turn to the scenario in 2024, and start with the demographics, we are now an ageing society. Between 2010 and 2020, the ratio of over 65s exceeded the young, 0-14-year-old age group. It is interesting to look at the ONS data for the UK population demographic shift since 1970, looking forward as far as 2050 (see Table 1).

• The significance of over 65s overtaking the 0-14 age group has tended to have been overlooked, thereby causing growing problems and increasing costs both to the NHS and local government social services.
• Although one in six of the UK population is currently aged 65 and over, by 2050 one in four will be. The pensioner population is expected to rise despite the increase in the women’s state pension age to 65 between 2010 and 2020, and the increase for both men and women from 65 to 68 between 2024 and 2046.

This demographic trend is one of the reasons that many of the problems within the NHS have built up over time, and they are related to underlying lack of long-term planning, and lack of consistency in capital investment. A look at international comparisons is not about technology (the NHS has superb surgical, clinical, nursing, training, and research resources), but rather to see how other health systems get the basics right in ways that the NHS and the politics around 
it fail.

The NHS focus on centralisation

An observation of other countries indicates that often the best healthcare systems are less centralised. NHS England operates as a single health service for the country’s entire population of 56 million people from the centre. It even seeks to have a single hospital model. This is cumbersome and inflexible. Over-centralisation of the NHS creates the wrong attitudes within the management. Given the size of the country and the population, healthcare systems in other countries are delegated to give more genuine control at local levels, thereby enabling real ownership over how healthcare is organised and delivered within their population and communities.

The inappropriateness of centralisation is indicated by data from NHS Digital, which recorded the variance of the average age of hospital admission — a span of 49.9 years in London compared with 57.2 years in the South East. In Table 2, we show the UK Census average age in 2021 at 40.7 years. The UK average age projections for the year 2030-2050 are from Statistica, while the average hospital admission age for 2021, shown in the first column, is from NHS Digital. The projected average hospital admission age in the columns headed 2030-2060 are from MHealth extrapolations.

These average age and hospital admission figures and projections have significant implications for hospital design if the NHS is to better manage issues such as how to relieve bed blocking — the term used to describe when patients who are medically fit cannot be discharged owing to inadequate community and social support, and difficulties in finding suitable residential care facilities. Nationally, bed blocking accounts for about 17% of acute beds, rising to one in three (33%) in the worst affected areas, a real factor in aggravating waiting lists. The projections show how this will further aggravate waiting lists.

This is recognised elsewhere, where the importance is recognised of a different design of hospital, to replace large acute facilities with ‘integrated hospitals’ — a combination of acute and sub-acute beds fully connected on the same site. This hospital model is proving successful in countries like Singapore.

Integrated care requires reform to reorient health services, shifting away from fragmented supply-oriented models towards health services that put people and communities at their centre, and surround them with responsive services that are coordinated both within and beyond the health sector. Most importantly, an integrated hospital provides both better continuity of care, and connectivity to the community that it serves. The failure to embrace such a model within the NHS is a major strategy failure, and has an ever-growing impact on out-of-hospital services, such as primary care, impacting particularly pre-hospital admission and post-discharge care, including step-down (e.g. for those who live on their own), rehabilitation care, and care at home. The resulting strain on the NHS creates a comparable strain on social services. Affordability of health and social care is only achieved by continuum of care — which is a more multi-sectoral version of integrated care.

I used to manage and participate in hospital design and build in many countries. Our success, with little or no cost or time overruns, was due to efficient planning and mutualistic contracts — a clear stakeholder agreement between finance and delivery. This requires managers who know how to develop without interference, thereby being more cost-efficient.

The PFI/PPP influence on NHS hospital design put form ahead of function, and this has proven to be responsible for many of the aforementioned failures. Some of my key conclusions — based on my experience and the work I have done in the planning and management of hospitals, include:

• Hospitals need to be designed to suit the population they serve.
• NHS capital budgets need to be protected, and not raided by NHS revenue budgetary needs.
• Hospitals need a consistent development budget for new-build projects, renovation, and maintenance.
• With the footprint of a hospital tending to expand, rather than reduce, as a rule, the NHS must retain its land and avoid selling it off to help pay for the cost of development — a false economy. Land cannot be easily replaced.
• Planning of a hospital is about function — form is dictated by function.
• Hospital planning has two related elements:
n The population that the hospital serves — the patients of tomorrow.
• The patients that a hospital admits and treats — including the understanding of oncoming new treatments and technologies.

Both elements try to anticipate the future, and that requires building flexibility into hospital design.

I have shown some of the key characteristics of the NHS hospital building programmes of the last 25+ years, and how they reflect poor NHS strategic thinking — with insufficient attention to changing demographics, and the associated post-discharge challenges.

Since 2007, I have been working on this combination of acute and stepdown. My company undertook a recent analysis on a new build 1,000-bed hospital, compared with a combined unit of 950 beds and 250 step-down beds. While the capital and operational costs were almost identical, the latter model achieved 20% more beds — a major aid in to relieving bed blocking

My experience of working in many countries is that integrated care is not just a health service responsibility, as the evolving nature of health has three pillars — health, wellness, and social interaction. Only through addressing these three pillars can health outcomes be both improved and more affordable. Such a solution requires three key initiatives:

• New strategies.
• Recognition that this is multi-sectoral — and beyond the responsibility of a single government department.
• The ability to share ownership and/or responsibilities.

At the heart of the matter

The key question, and one currently exercising the minds of those leading the NHS — is whether to keep hospitals as an isolated building or blend them into integrated care. Thus I present a contra-argument; Figure 1 shows a more flexible design approach. We had to provide a costing analysis when we first introduced this model to justify the case. In recent months, I used one of my company’s models to indicate the UK comparison of the cost difference between a 1,000-bed acute hospital and a 950-bed acute hospital combined with a 250-bed step down facility (i.e. a total of 1,200-beds). As previously stated, the capital and operational costs were almost the same.

This is important even in the private sector where, in many countries, the private health insurance companies use the ‘Diagnostic Related Group’ payment model, based on fixed term patient stays. By way of example, the integrated hospital could provide 4-acute + 3-sub acute stays for the same or lower price than 5-acute day stays.

The associated advantages and key features of a ‘step-down’ facility, for more inclusive integrated care, include:

• A patient hotel — particularly important for children and relatives and those seeking out-of-hospital treatment, such as haemodialysis, and cancer treatment — such as chemo- and radiotherapies.
• Rehabilitation — both physical and mental.
• The association of wellness to rehabilitation.
• Social interaction facilities (lounge, café, sitting area, and even workshare) — particularly important for lonely people.

Such a plan also provides the capability for rapid isolation of the step-down component to create a Pandemic Isolation Unit.

Figure 2 shows a briefing diagram for a MHealth project in the Far East.

Complementing and amplifying

Hospitals complement and amplify the effectiveness of many other parts of the health system, providing continuous availability of services for acute and complex conditions. They concentrate scarce resources within well-planned referral networks to respond efficiently to population health needs. They are an essential element of Universal Health Coverage (according to the WHO, ‘Universal Health Coverage (UHC) means that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship’), and will be critical to meeting the Sustainable Development Goals (SDG: according to the WHO, ‘a call to action to end poverty and inequality, protect the planet, and ensure that all people enjoy health, justice and prosperity’.)

Hospitals are also an essential part of health system development. Currently, external pressures, health system shortcomings, and hospital sector deficiencies, are driving a new vision for hospitals in many parts of the world. In this vision, they have a key role to play to support other healthcare providers and for community outreach and home-based services, and are essential in a well-functioning referral network.

Hospitals matter to people, and often mark central points in their lives. They also matter to health systems — by being instrumental for care coordination and integration. They often provide a setting for education of doctors, nurses, and other healthcare professionals, and are a critical base for clinical research.