Resilience – the capacity to adapt to, withstand or to recover quicky from difficulties.

It’s a quality that is, and has always been, tested repeatedly in all aspects of healthcare – but never more so than during and post the Covid-19 pandemic. Globally, healthcare systems and personnel have needed to draw on their resilience as never before, as they continue to recover from its devastating impacts on so many levels.

Of course, challenges and pressures on health systems existed before the pandemic, both physically, in terms of the capacity and suitability of existing healthcare infrastructure – for example, many NHS buildings are several decades old, with around 18 per cent having existed longer than the NHS itself, and some dating back to the Victorian period¹ – and also in terms of people, with growing and ageing populations, and an increasing shortfall of qualified clinical staff to meet demand.

In the UK, for example, research was already indicating that without significant investment, “the NHS estate will remain unfit for purpose and will continue to deteriorate”.¹ That, of course, has a direct impact on recovery plans for the future and strategies for increasing capacity in the future. At last count, the NHS estate faced a maintenance backlog of approximately £10.2 billion,² an 11-per-cent increase on the previous year.

Even with well-maintained sites, older buildings mean that the facilities haven’t been designed for modern patient flow or current clinical practice, the latter of which is constantly evolving. All of this can have significant consequences for patients, as unsuitable buildings and unreliable equipment can decrease productivity and cause delays in care, or even lead to patient safety issues.³

And to replace them takes not only time (with traditional building projects taking many years from concept to completion) but also significant investment – both in the short-term and the longer-term, as maintenance and adaptation costs mount up and soar.

The pandemic exacerbated these existing challenges and confronted health systems across the world with added and immediate challenges: for example, how could they increase the physical infrastructure they had available in a way that could also maximise infection control? And how could they meet the need for healthcare professionals to respond to the rapid increase in patients?

Therefore, they were faced with the monumental task of adding high-quality, safe clinical spaces to their existing infrastructure, and doing so at speed. This was coupled with the need to refurbish existing infrastructure and accommodate the fast emergency of new technology. Solutions that were quick to deploy, flexible, sustainable and of high quality were required. Enter modern methods of construction (MMC).

As healthcare systems continue to evolve post-Covid and gradually recover, the need for healthcare spaces that are flexible, responsive and agile becomes increasingly apparent. The future challenge is to reimagine the hospital estate in a way that promotes sustainability; allows for speedy modernisation and updating; maximises positive patient outcomes; and provides the best possible working environment – and all in spaces that can be created or adapted quickly to meet changing needs.

It cannot be disputed that healthcare systems need to source innovative solutions to combat the current unprecedented elective care backlogs being seen around the world. They need to create dynamic and comfortable work environments for their staff to work in, as part of retaining their most valuable assets – their staff teams. And they need to do so in a way that maximises their investment for the long term.

What is becoming clear, through its successful deployment in the wake of Covid-19, is that MMC, and in particular, modular healthcare spaces, can play a huge part in meeting that challenge.

Modern methods of construction

What do mean by MMC or modular health facilities? Modular health facilities are constructed from individual modules that are built largely offsite, then installed onto a site to create a single structure, or series of structures. They can be used as standalone facilities on a particular hospital site, attached to an existing hospital building, or used in conjunction with a mobile facility (a mixed-modality approach). With appropriate maintenance, both modular and mobile facilities can last up to 60 years. Crucially, modular facilities can be designed specifically for the particular healthcare function for which they’re required, and repurposed and moved should needs change.³

Of course, the use of MMC in healthcare was not unheard of before 2020. Volumetric modular buildings have been used for the best part of a century, but their potential role in building resilience in healthcare has become clearer and more defined as its successful deployment and the benefits it brings becomes more widely recognised. The regenerative and ‘future-proof’ nature of MMC facilities, in particular, modular buildings, allow health systems to maximise outcomes across the board – financially and for both human and physical resources.

Let’s look, first, at the built environment that MMC or modular healthcare spaces can offer and their benefits.

MMC and off-site construction offer buildings that are comparable to traditional ‘bricks and mortar’ in their robustness and quality of finish, but their main benefit is speed of delivery when compared with traditionally built projects. Using MMC and off-site construction allows the on-site substructure works to take place while the manufacture of the building takes place at the same time. The overall result is that the time from design sign-off to first patient treatment is dramatically reduced.

MMC also allows for a total control of quality owing to the off-site manufacturing environment. There is a higher level of quality when compared with traditionally built projects and is also safer from a health and safety perspective, as it gives more control over the process.

Buildings can be delivered minimising defects, as they’re created in a factory-controlled environment. There are environmental benefits, too, with limited waste and reduced carbon associated with traditional build site deliveries.

Replication is a further benefit. Using a standardised structure means builds using MMC have a build ‘footprint’, where the structure can be replicated very quickly. If a hospital wanted to add a floor or extend, it’s far easier to do that with a modular solution. They also have the option to take the modular building apart and move it to another location, maximising how the facility can be utilised and the return on investment.

In Newcastle-upon-Tyne, a three-theatre bespoke-built ophthalmic hub has helped significantly reduce waiting lists for cataracts procedures. In Brisbane, Australia, the installation of a mixed-modality colonoscopy unit is allowing 6600 extra screening procedures to be performed per year, facilitating faster detection of one of the country’s most common cancers.⁴ Meanwhile, in the UK, the Royal Infirmary of Edinburgh was able to add a bespoke modular facility to a repurposed mobile unit to create a new minor injuries unit, to help improve efficiency in emergency care.^3,5

Challenges

The main challenge is to ensure projects are designed for manufacture and assembly to maximise the benefits of speed, quality, and enhanced environmental and sustainability credentials.

To work at optimum, MMC and off-site construction projects should be designed for manufacturing assembly. Projects must be designed from day one with this mindset. A fully defined design process, from conceptual design through to facility usage design and full production design, is key to overall efficiency and maximises the benefits of MMC.

It’s important that those planning the projects understand that any architects’ drawings initially designed for a traditional build option will need to change to allow for the footprint of any modular solution. Often the project design commences before MMC is considered, which then often involves a redesign process to align to modular and MMC principles. Early engagement with the providers of MMC is vital to ensure benefits are maximised. If that’s not done, they will potentially have to go back a step and redesign for modular and off-site construction.

For specialist MMC/modular manufacturers, that early engagement, particularly with clinical staff and facility users, ensures that the ‘use case’ for the building is understood and the design reflects these specific needs.

MMC is agile and offers the ability to standardise. As hospitals and facilities become more standardised, efficiency, value for money, and ESG outcomes will all be improved. Having an ‘off the shelf’ design that’s accepted by hospitals, healthcare systems and suppliers drives further cost and programme savings, ensuring that estate teams can match planned maintenance projects with standard designs and configurations.

MMC and people

But healthcare isn’t just about the space in which it’s delivered. The human aspects are vital and should always be at the forefront of our minds when designing healthcare spaces. Having robust and future-proofed healthcare systems relies entirely on providing work environments where people feel valued and safe, and where they enjoy working. It also relies on providing clinical spaces where patient experience is at its optimum.

One common misconception about modular facilities is that they’re less comfortable or customisable than a traditional hospital building. In fact, given the limitations often placed on older NHS buildings, some of which are grade-one or two listed, the opposite is often true. Although the earlier models of modular building used in the 20th century were often relatively basic, more recent models are made to be bright, airy and spacious, with many options for customisation or even bespoke design.³

In their review of modular diagnostic laboratories, Bridges et al⁶ found that, despite some initial misgivings, almost all of the users became ‘converts’ after stepping into the modular facilities. Similarly, in a study of three hospitals that had used modular facilities in Finland, Kyro et al⁷ found that across all sites, both staff and patients had commented favourably on the amount of natural light let into the modular units compared with the main building. In interviews with staff members, one manager who worked across multiple sites states that the hospital’s modular unit was the only facility about which they had never had a complaint about comfort.³

Kyro et al⁷ also pointed out that the ability to standardise modular facilities can

be a significant benefit, as it means that the layout and storage of equipment in each room can be the same, making it easier for staff to work in different rooms. Although more research is needed to gather patient and staff feedback, these initial case studies suggest that modular facilities are just as – if not more – comfortable and easy to use as traditional healthcare buildings.³

St George’s University Hospitals NHS Foundation Trust commissioned a three-theatre surgical hub to act as a standalone facility situated in the car park of Queen Mary’s Hospital in Roehampton. This standalone nature was valued by the staff who were able to get back to doing what they know best and staff who moved from the main hospital were able to recover from the feeling of burnout and fatigue.³

Working in the environment also allowed for a predictable workload each day, which further led to staff feeling a sense of relief and achieving a better work-life balance. Staff have also reported a strong sense of camaraderie with a focus on wellbeing. The Hub’s large staff room, for example, is highly valued among staff, who are often happier to work in the Hub, versus the main hospital, and where there is a sense of commitment to the work being carried out. Furthermore, patients have noted the positive interactions of the staff, which improves their own experience and leads to them receiving better quality care.³

Although modular facilities have the potential to be a great asset to healthcare systems as they tackle their patient and maintenance backlogs, it has been rightly pointed out that creating more space cannot solve the chronic shortage of healthcare staff. However, it’s possible that the more practical and pleasant environment provided by modular facilities could go some way in addressing this issue; research has shown that positive work environments, particularly those that encompass natural elements, such as plenty of natural light, can improve cognitive functioning, reduce stress, and even contribute to faster healing.⁸ Not only does this ‘biophilic’ design have implications for patient wellbeing, it could also improve the experience and morale of staff, which could, in turn, increase staff retention.^3,8

MMC and the nature of modular architecture also ensures that it can be maintained to keep up with the ever-evolving changes in clinical practice and policies, which is vitally important to clinical staff in helping them feel safe to practice.

In addition, modular facilities can more easily adapt to house the most up-to-date technologies and can be more flexible to align with changing needs over time. Modern environments equipped with the latest technologies not only increase clinical throughputs but also provide an exceptional environment that promotes staff wellbeing, recruitment and retention.

There are benefits, too, for patients being treated in modular facilities equipped with the most up-to-date technologies, not least in reducing the risk of infection.

Training

To have resilient health systems, we need always to be thinking ahead, and modular environments have proved to be valuable resources in providing a flexible training setting.

During the Covid-19 pandemic, for example, the suspension of elective activity meant that many opportunities for surgical training were lost. In a review of trainee logbooks (a record of operative experience that trainees are required to keep), Clements et al (2021) found a significant reduction in elective operative experience in 2020 compared with 2019, with trauma and orthopaedics being the most affected.⁹ This has created a barrier to progression, with a survey by the General Medical Counciil¹⁰ finding that 25 per cent of surgical trainees did not feel they were on track with their learning. Yet surgical trainees often struggled to access training opportunities before the pandemic, while many took a break from training after their foundation years because of burnout.¹¹ This suggests that surgical training not only needs to be restored to pre-pandemic levels but it also needs to be expanded and improved. Therefore, efforts to maximise patient throughput in surgical hubs must not come at the expense of training and development. Instead, these hubs should be viewed as a tool to invest in future surgical staff.¹²

Case study: Malmo

An example of a modular healthcare building combining with the latest in technology is the Ultra-Clean Spinal Operating Theatre at Skane University Hospital in Malmo, Sweden.

During an ongoing construction programme an urgent need arose for increased operating room capacity, as the existing operating rooms didn’t meet current health and safety requirements for high-risk orthopaedic procedures.

The hospital’s management wanted an interim solution that would be quick to implement, while being robust enough in the medium- to long-term to fill the gap for a period of up to ten years. Q-Bital worked closely with the hospital building team to prepare a plan that would deliver a modular operating room complex in just ten months.

The interim facility needed to be integrated and connected to the existing operating theatre department on the third floor of the hospital. This involved constructing the foundation and a precision-engineered steel construction to align at the same height as the existing OT facility, to ensure a seamless extension of the existing operating theatre complex. Initial prefabrication was carried out at Q-Bital’s production facility in the Netherlands, with the final construction being completed at a ‘pop-up building site’ in the Malmo area.

Q-Bital provided a complex with a footprint of 324m², providing two additional operating theatres and a preparation room, which were built to meet the strictest requirements for high-risk orthopaedic procedures.

The operating rooms were equipped with advanced surgical lights and pendants, video-routing system and a building management system developed in-house. This proprietary system provides ongoing insight into all functional installations within the complex. And it enabled a quicker response to any maintenance issues, which could have arisen. In addition, it provides important information for clinical staff, allowing greater control of the ultra-clean environment. As the operating theatres had to meet the most stringent requirements, an Opragon ultra-clean air system was installed to reduce the risk of infection during surgery.

The hospital was provided with the interim OT capacity it needed, in the form of two additional operating theatres and a preparation room, which were fully integrated with the existing facilities, to enhance capacity and, in turn, provide a safe patient environment.

For this project, Q-Bital Healthcare Solutions partnered with Avidicare, which provided an Opragon ultra-clean air system, to drastically reduce the risk of infection during surgery.

Conclusions

Several studies and reports have emphasised the importance of flexibility in healthcare infrastructure and spaces.^13-15 Healthcare technology, clinical practice, and policy can develop very quickly, so building projects that take many years are at risk of being out of date before they’re even finished.^3,16,17

In conclusion, flexibility is clearly one of the major benefits of using MMC in healthcare space creation. There is no silver bullet that can solve all the issues facing the UK healthcare systems, many of which, including patient backlogs, have been exacerbated to unprecedented levels as a result of the Covid-19 pandemic. However, innovative solutions that can help to create capacity and allow more efficient working are key to facilitating a recovery process that not only restores health systems to pre-pandemic functioning but also improves and prepares them for future challenges. Modular facilities, with their flexible and cost-effective nature, should be a serious consideration for trusts facing capacity issues.³

To ‘future-proof’ health planning and investment decisions, MMC solutions are certain to be required. They address the physical infrastructure needs of healthcare systems and strengthen their resilience by providing environments that enhance not only flexible, high-quality, and value-for-money clinical spaces but also people-friendly environments, which can support recruitment strategies and nurture healthcare professionals, leading to an improved quality of care for both staff and patients.

About the author

Sarka Oldham is business development and partnerships director at Vanguard Healthcare Solutions, Q-bital Healthcare Solutions.