HEALTHCARE PLANNING
Care providers prefer large, concentrated facilities to maintain critical mass of expertise and a high level of connectivity between clinicians
Care receivers prefer locally accessible provision by
someone whose name they know
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 community- based 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 Distance
Figure 1: The information-access paradox – the facility clustering that gives staff the best information provides poor access for the patient, while the clustering that gives patients good access provides poor information sharing among professionals, and undermines the quality of care.
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 co- location 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
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
28 Health Estate Journal April 2023
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.
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