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Is it time to rethink the acute hospital?

Rosemary Glanville
1 January, 2008  

The District General Hospital model for hospital care in the UK was devised in the 1960s. Since then, technological advances in diagnosis and treatment and social changes in demography have begun to redesign the processes of care delivery. So, has the time come for the DGH model to change?

Rosemary Glanville
BArchLond RIBA
Head of MARU
(Medical Architecture Research Unit)
London South Bank University
UK

In 2000, the Nuffield Trust and RIBA sponsored the Medical Architecture Research Unit (MARU) study Building a 2020 vision: future healthcare environments,1 which set out a blueprint for future health facilities. This took account of three agendas. First, the health agenda of a better patient experience, better access to care and more emphasis on privacy and dignity. Secondly, the built environment agenda of better public ­buildings and design quality. And finally, the sustainability agenda, which includes green transport. It is becoming increasingly important that these separate agendas become joined up.

Settings for care
Taking account of the growing cascade of care pouring out of hospitals and into settings closer to people’s homes, MARU proposed four settings for future care: home, primary and social, community and specialist. This model is reinforced by the recent white paper that proposes to provide for a further tranche of inpatients in community settings.
One driver of such change is technological advancement. For example, changes in anaesthetics are allowing increasing levels of day surgery, and imaging technology advancement is allowing acquisition to be separated from reporting. Reinforcing this rationale is the fact that many patients do not need the high-technology environment of the hospital for more routine interventions but prefer to receive care in settings closer to home.
Demographic change is another driver. Two characteristics of an ageing population are slower recovery from acute episodes and increasing chronic disease. The former requires rehabilitation and the latter long-term management. But neither is now so suitably accommodated for in an acute hospital.
There has been a move in the UK towards managed clinical networks for a geographical catchment area, providing levels of care according to the complexity of equipment and skills in relation to service need. The most developed of these are the cancer network organisations. These are arranged as patient pathways from primary care to complex care, with chemotherapy at cancer units and radiotherapy at cancer centres. In providing very complex equipment and installations a balance must be established between patient access and efficiencies of scale.
 
But what is left in the hospital?
The UK District General Hospital (DGH) was a sophisticated hospital model developed in the 1960s for an earlier hospital building programme. It proposed a future of multispecialty hospitals sharing the growing range of diagnostic and treatment facilities, with superspecialties at selected hospitals. Each hospital would serve population groups of about 250,000 with 600–800 beds, providing 3.3 acute beds per 1,000 population. Care was either residential (inpatient) or nonresidential (outpatient) with shared diagnostic and treatment facilities, underpinned by a range of support services such as sterile ­supplies, catering and laundry. Access from primary care was, as now, by a system of referral to individual ­specialists. This model has evolved until today without a radical rethink of the principles behind it.
What are our European neighbours doing?

New models of hospital care can be seen which are accommodated in new settings and require a new built environment response.
Fourth-age hospital in Paris  In central Paris there is a fourth-age hospital providing ­services for the over-80s, with outpatients in all relevant specialities, diagnostics, rehabilitation services and medium-stay beds with a rehabilitation stepdown. There are also long-stay beds run by a pensions organisation. There is a local kitchen serving “French” food and a staff restaurant, which is thought to aid staff retention.
The new Karolinska Hospital in Stockholm  The Swedes agree that new technology and treatments demand new infrastructure and new units or buildings. They believe that building new hospitals on existing sites for highly specialised care will help develop a physical closeness between the patient and scientific research. The hospital will have 500 beds and a 500-bed patients’ hotel and be networked with other hospitals in the region. The masterplan concept is to create links to the city of Stockholm, new businesses (particularly around ­biosciences), new residential zones and the airport.
Dutch core hospitals  A care process that rigorously appraises what has to take place in or outside the hospital can help to shift the provision of care as close to the home as possible. It is proposed that only very acute and high-technology aspects of care will be provided for in Dutch core hospitals. All noncore services will take place offsite in local office blocks or in larger centres supporting a group of facilities. The new hospital will require only a small footprint and so can be built on a city-centre site. The network organisation will include smaller centres in neighbourhoods around the core for elective outpatient care, rehabilitation and the management of chronic care.

Settings for care in the UK – the home
We are not short of technical capability to monitor patients in their own homes, whether for vital signs, falls, accidents or real-time drug delivery. But who will create the monitored structure and ­intervention plan needed to support home care? Two years ago it was thought that purpose-built homes with cabling infrastructure were the future. But new wireless technology means that monitoring can now be put in place anywhere. The next constraint will be space. Will nursing care, assisted bathing and wheelchair use be possible in new homes?
Primary and social care  Access to primary care is now supported by NHS Direct, a telephone advice system and, increasingly, “walk-in” pharmacy consulting in a more private space than the shop ­counter. Primary care is now delivered through nurse practitioners as well as GPs, and more specific care through a new brand of GP with a special interest (GPwSI). Service expansion has spread to triage and urgent care, minor surgery and treatments, and diagnostics. Increasingly, specialist services, such as dental, sexual health, minor surgery, mental health and rehabilitation, are located in primary and social care. Alongside these developments, information services and the idea of the “expert patient” have started to merge into community and social spaces.
Our health, our care, our say2  This 2006 white paper is proposing a new generation of modern community hospitals. Such hospitals are to serve about 100,000 people, with specialist outpatient clinics and diagnostic services as “one-stop shops” with test results and diagnosis in the same session. A huge part of elective surgery will be carried out as day cases and planned short stays in inpatient acute care beds without critical care support. Other inpatient and day care will be “stepdown care” for recover closer to home supported by intensive rehabilitation services.
Hospital confusion  So where does that leave the hospital? Currently, private finance initiative (PFI) hospitals are planned on the basis of Trust development, not from a patient pathway perspective or by reappraising the hospital’s role. Elements of the hospital are being cherry picked in order to develop standalone diagnostic and treatment centres (DTCs) and independent sector treatment centres (ISTCs). There is a growing debate as to how many emergency centres for serious accidents and trauma care are needed.
Developing a new model for specialist care in the UK  MARU suggests a return to first principles, taking the financial analogy of zero-based budgeting, to establish a new balance of specialist skills, specialist equipment and specialist environments which need to be located in a high-technology environment for the delivery of complex care. This could take place for planned or emergency pathways and may include complex care for patients with multiple conditions and low-volume case types.
Different levels of specialisation in any of these three aspects could be arranged through managed clinical networks which can trade off a balance between ease of patient access and centralised provision of very specialist services and equipment for complex care. Distributed networks of care based on a network rather than an institution can respond to existing services, service gaps and local geography, planned from a holistic area-wide perspective. Models for specialist care units could then be
developed, ensuring they deliver viable packages of care.
Support services  All facilities along the pathway will require both clinical and other support services. Automated near-patient testing and image acquisition will go to distributed services. More complex processing such as pathology and sterile supply reprocessing will serve a range of facilities at different levels on the pathways (see Figure 1). These could be provided in standalone centres in a factory-type space.
Different care settings can be provided in environments with different levels of engineering ­technology. The home is the place for care with instant retrofit installations. Primary and social care can be provided in flexible and repeatable spaces. Local community hospitals will require clinical ­environments adapted to the new models and a clearer understanding of their role. Core specialist care will require highly engineered environments.

References
RU. Building a 2020 vision: future healthcare environments. London: MARU; 2001.
2. Department of Health. Our health, our care, our say. White paper.
London: DH; 2006.