This was one of the fundamental questions posed at global management, engineering and development consultancy Mott MacDonald’s 2019 Healthcare Facilities Forum, held at London’s Royal College of Physicians earlier this month (7 November).

Peter Ward, director of real estate at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, provided the low-down on the adaptable and flexible estates strategy of King’s Health Partners – a partnership between Guy’s and St Thomas’ NHS Foundation Trust, King’s College Hospital NHS Foundation Trust and South London and Maudsley NHS Foundation Trust, and King’s College London – one of the largest Academic Health Science Centres in Europe and one of six in the UK.

With the NHS having recently turned 70, Ward suggested the next 70 years could see a lot of activity “building on collaborations between higher education and the NHS, where you’ve got a ready population of clinicians and academics working together, a population of students bringing that talent pool forward, and a population of patients that can help develop what you want”.

Ward explained how US commercial real estate services firm Jones Lang LaSalle was brought in to look at the North American experience, and the factors that drive success in clustering health, higher education, and translational life sciences and research organisations. The most noticeable characteristics identified were an existing culture of collaboration, a willingness to cross traditional silos, and a talent pool that can be nurtured in a way that allows innovation to develop. Embedding new technology and data, added Ward, will spark innovation in the workspace, and inevitably flow through into clinical research and practice. A trend towards growth through mergers and acquisitions is also likely to support the growth of entrepreneurial life science clusters.

These themes have driven the development of an aspiring clustering model in London, which looks as follows:

• The Westminster Bridge campus, including St Thomas’ Hospital, will become a medical technology hub, focused on imaging, healthcare engineering and relevant specialties, including emergency and cardiovascular care, the Evelina London Children’s Hospital, and rapid diagnosis and treatment. The hub is expected to attract international medtech firms, which will trial new techniques in partnership with the NHS and universities;
• The London Bridge campus, including Guy’s Hospital, will become a biomedical hub focused on cell and gene therapy research, cancer treatment, elective care and immunology. Integrated teams – including medics, mathematicians, physicians and chemists – will work alongside each other to unlock new discoveries, attracting international research bodies, as well as biomedical and pharmaceutical firms.
• The Denmark Hill campus, including the Maudsley and King’s College Hospital, will become a translational biomedicine hub, integrating psychiatry, psychology and neuroscience in the treatment of physical and mental health. It will also build on clinical and research strengths, including haematology, neurological conditions, transplantation, stroke, trauma and neurosurgery, in addition to deploying digital networks to improve local care.

An adaptable estate

This aspiration, explained Ward, needs an adaptable estate. The partners’ Adaptable Estate Specification seeks to develop a ‘design guideline’ for a generic shell and core approach to building developments that suits bespoke fitout for different space typologies – healthcare, research, teaching and commercial – that can adapt over time. The strategy intends to allow building to maximum site capacity in order to open up commercial opportunity, attracting rent-paying tenants and third-party commercial parties, as well as the NHS and university. 

The adaptable estate strategy also covers a number of minimum performance requirements. A series of adaptable ‘base’ buildings, said Ward, will provide a robust platform of features including structure, core, lifts, MEP plant, FM and fire strategy. These will be equipped to meet more flexible parameters, including their use and fitout, which are likely to change over the building life, and meet qualitative parameters, such as their look and feel, community engagement, access to nature, and so on.

Separating the fit-out business case from the shell and core (adaptable buildings case) is vital, said Ward, who explained how it “massively de-stresses some of those design decisions in the minds of clinicians, who find it as difficult as the rest of us to predict healthcare needs 60 years in the future, which can tend to result in over-specified and complex designs”.

Summing up, Ward tapped into the social importance of this new approach: “Our most important commodity isn’t our land, capital, or even our staff, important as those things are; our most important commodity is hope. That might be the hope of our patients that they’ll have access to the best treatment and understand their care; the hope of the parents of a child with a rare condition, that we’ll draw on the latest thinking to find a treatment; the hope of a medical student that they’ll have a fulfilling career in a respectful environment; or the hope of the next generation that we’ll make a significant effort to address the climate emergency. Providing a platform that supports the fulfilment of those hopes has to be our main mission.”

The system of systems

Broadening this picture out into the urban realm, Clare Wildfire, Mott MacDonald’s global practice lead for cities, offered some insights into how healthcare organisations can be an agent of change towards healthier and more sustainable living. 

“The 20th century was generally about providing efficient, affordable, reliable services and avoiding capacity failure,” she said. “In the 21st century, those things are still important but other things are beginning to move up the agenda. Research shows that citizens are becoming more individualistic, so things like quality of life become more important; health, safety, wellbeing, and convenience of services.” 

Urban psychology, she suggested, could be a field of discussion in the future, in relation to people moving into cities and growing urbanisation. Looking at current healthcare metrics in this context could be helpful. The NHS, for example, is the leading public-sector culprit for carbon emissions. Five per cent of all road traffic in the UK is related to the NHS, with more than half the trips associated with the sector estimated at less than five miles, and many of these journeys single occupancy.

“We’re also realising that so much of what we’re advising on is a system of systems,” said Wildfire, who added that we’re getter closer all the time to understanding these inter-dependencies.

Healthcare and city living

Mobility as a Service (MaaS) is one fresh take based on outcomes not outputs. Embracing innovation around active travel can generate virtuous cycles, with benefits in health and wellbeing, air quality, traffic congestion, and energy efficiency. 

“The whole agenda of future mobility is changing how we’re designing future spaces, and accessing the facilities we provide,” said Wildfire. “It’s no longer the last mile, it’s the last five miles. In the past, people might not have wanted to walk or cycle more than a mile, but with electric bikes and scooters, you can feel that flexing.” 

Digital advances also bring the ability to visualise through scenario planning, while more accurate real-time feedback can give healthcare facilities professionals a much better understanding of how an asset is used. In the urban realm, there is a shift to creating healthcare facilities that are attractive to visit, more permeable, and less separated from city living. They can also be knowledge disseminators, added Wildfire, for example on issues such as healthy living, diet and active travel.

“There’s significant potential to bleed out good from the centre if we think about healthcare as something that’s more linked to general city living,” she concluded.

Learning from how other industries have designed their system processes and used technology as an enabler was the thrust of the next pair of talks. Steve McGuire, founder and director of Health Innovation International, guided delegates through his imagined world where healthcare resembles the model used by aviation. 

“The healthcare sector is designed around treating illness,” he said. “The aviation and automotive sectors made massive investment in predicting failure. The consequence of that is operating costs have massively reduced. I fail to see why that logic can’t be applied to health.”

Imagining a smart health utopia

In McGuire’s utopian vision, huge reductions in health infrastructure costs have been made, with the savings redirected into forming a national investment programme in smart health technology. Pre-conditioned routine health screening is in place across the UK by virtue of a national screening service. McGuire describes a situation where his NHS smart phone picks up a change in his physiology, and a medical appointment is automatically made in his diary at a convenient time. AI and Blockchain technology are used to make a diagnosis, and a treatment plan is devised with a clear start and end date. Before his scheduled date at the treatment centre, his smart wristband, which has a chip containing all his personal details, arrives in the post. On arrival at the treatment centre, the wristband triggers an alarm and he is met by a receptionist who knows his name, the reason for his appointment, and is trained in the check-in process. 

As at the airport, there is a duty-free lounge, but here he receives his information pack for his stay. He’s called to his gate, where he’s met by a care co-ordinator who takes him to his room and informs him of his itinerary. His treatment and progress are monitored by the hospital tracking control centre. He then leaves hospital on the planned day at 2pm – the standard departure time for hospitals across the whole of the UK.

All the hospitals where he lives in South London have been demolished and replaced with one fully integrated treatment centre for elective patients, supported by a regional diagnostics centre. His treatment plan includes follow-up telehealth appointments with his GP.

While accepting that such a world may be beyond the realm of possibility, McGuire suggested some elements should and could be part of a far more efficient health system. Top of the list, he argued, is the way the built environment sector does business – moving from what he sees as an old-fashioned model to become partners or advisors rather than contractors. Another important principle is to design systems around people to make the process easy to navigate, and placing more control of their health and healthcare in their own hands.

“What I want is better scheduling, minimal or zero wait, a single room, and planned discharge. That would be enough for me,” he said, adding that designing the health system, rather than buildings, around these patient experiences and outcomes, along with a regional focus, should deliver better performance.

Reverting to the aviation sector, he pointed out that for every plane in the sky, its engines are monitored by someone on the ground. If a problem occurs, an alert is triggered, and maintenance crews are ready to fix the problem as soon as the plane is back on the ground. This level of efficiency, McGuire suggested, is something to which healthcare should be striving.

Using the data to gain efficiencies

Following on from McGuire, Oliver Hawes, Mott MacDonald’s head of smart infrastructure, agreed that “there’s a huge opportunity to act on the lessons learned from other industries”, before describing how data processing and analytics in regard to asset management and infrastructure have the power to unlock social, economic and environmental value.

“Data is everywhere, but insights are not,” he said. “And this forces us to look at some new ways of thinking.”

A major area of work reflecting a new way of thinking is the creation of a digital twin of infrastructure, and considering how this approach might be applied to the healthcare ecosystem. A digital twin is defined as a realistic representation of assets, processes or systems in a built or natural environment. Data is extracted from the physical twin, inputted into the digital representation and provides informed insights, leading to better decisions and applying interventions to the physical twin, with the aim of  realising improved outcomes. 

Hawes described a project in Auckland, New Zealand, where Mott MacDonald worked with a number of local partners to collect multiple data streams to measure the performance of the city’s wastewater infrastructure; for example, flow centres, rainfall data, tidal information, and water quality and temperature. Collating this data in the Cloud generated around a billion data points daily, which could be analysed to predict the water quality at 84 beaches. This is then relayed with a wealth of other safety information to the public – for example, through the site Safeswim.org.nz.

The social story from this project is equally powerful, with the public engaged to ask probing questions, leading to an approximate 70-per-cent vote in favour to increase wastewater investment by NZ$400m. This generated an economic benefit in better protection of the public from reduced exposure to waterborne disease.

Occupancy, safety and customer experience 

Running through some numbers in healthcare, Hawes suggested that the NHS needs to achieve six minutes of efficiency on a 10-hour shift to save £1.3bn a year. “That could be as simple as the porter’s wheelchair that wasn’t in the right place, now being where it should be,” he said.

He went on to outline some thoughts on enabling smart infrastructure in healthcare by looking at the areas of occupancy, safety and customer experience. 

“Occupancy can include effective space management through occupancy monitoring, analytics to maximise the use of operating theatres and facilities, and smart tags on assets and people to improve traceability and productivity,” said Hawes. “Safety can include using data effectively to reduce safety incidents through pattern recognition, machine learning, and active notification tools to ensure antibacterial procedures are upheld. And customer experience can include smart wayfinding and interactive maps, as well as patient journey mapping from first contact to discharge, and looking at zero wait times.”

The key, added Hawes, is to unlock the real value in existing and new data, in order to create a more sustainable and healthy environment with better use of resources. 

In a world of physical constraints but digital abundance, it makes sense that the latter should do most of the leg work in this regard. If technology can be applied in ways that enhance the physical realm and existing system processes to generate improved outcomes, then hope may not only remain healthcare’s most important commodity but may also serve to release it from the burden of unfulfilled expectation.