VIRTUE OUT OF NECESSITY:

REFLECTIONS ON COVID-19, DESIGN AND THE NHS

Paul Murphy, Director of Paul Murphy Architects, June 2020.

As we have struggled to adjust to the present Covid-19 crisis and start to consider what the short, medium and long term impacts will mean for personal and professional lives, I have been fascinated to observe how the NHS has restructured to deliver its services in the midst of the pandemic. I have worked as an architect in the healthcare sector for over twenty-five years and this crisis has offered time to reflect on how improved strategic design of healthcare facilities could transform the NHS.

This article looks at the current context, collaboration with healthcare industry, pop up hospitals. the flexible use of facilities, technology and the wider ramifications of Covid 19 in the context of the climate emergency and impact on the built environment.

The NHS: Current Context:

By way of setting the context for this discussion, this is how the NHS is currently operating:

• The NHS is the largest UK employer and the fifth largest employer globally (behind the US Department of Defence, China’s People’s Liberation Army, Walmart and MacDonald’s) employing some 1.5m people across acute, community and primary care settings (Nuffield Trust)
• Across NHS hospital, community and primary care settings, there are around 150,000 doctors in total and over 320,000 nurses and midwives, representing only just over a third of the total workforce. The remaining two thirds reflects the multi-disciplinary nature of the NHS, with its reliance on others such as health care scientists, physiotherapists and occupational therapists and support staff (Nuffield Trust).
• The Department of Health manages a budget of around £125 billion. £113 billion of this goes to NHS England and around £84 billion of this sum is managed by the Clinical Commissioning Groups responsible for commissioning healthcare services (Kings Fund/National Audit Office 2019).
• In England, there are currently 207 Clinical Commissioning Groups comprising 10,135 acute non-specialist trusts (including 84 foundation trusts); 17 acute specialist trusts (including 16 foundation trusts); 54 mental health trusts (including 42 foundation trusts); 35 community providers (11 NHS trusts, 6 foundation trusts, 17 social enterprises and 1 limited company)- (NHS Confederation)
• Healthcare spending in the UK as a percentage of GDP has remained stable between 2012-2020, representing around 7.2% of GDP (The Health Foundation 2019). This represents the lowest growth over a nine-year period since the inception of the NHS. Other sources quote nearer to 8.5% of GDP.
• In comparison to other countries with highly developed healthcare systems, the spend relative to GDP in the Netherlands, Germany, France and Sweden hovers around 11%, whilst Greece, Portugal, Italy, Austria and Finland are reported to spend around 9% of GDP.
• The healthcare spend per person in these developed systems point to a possible correlation in success of response to containing the pandemic in their respective countries. In 2018, the Organisation for Economic Corporation and Development calculated the average spend globally was $4000 per person. The UK spends $4070, with France and Italy spending a similar $4965 and $3428, respectively. Whereas Norway spends $6187 and Germany $5986; both countries have been lauded on their governments and healthcare’s response to the crisis (OECD 2018).

The impact of Covid-19 has shone a spotlight on the fragmentation of healthcare delivery in the UK, from the issue of inadequate stocks and procurement of PPE through to the seemingly forgotten social care provision for the elderly and those suffering from mental health conditions. The array of organisations involved in managing and delivering healthcare is bewildering. It is difficult to comprehend how they all work together to create a truly integrated care system.
So, what has the NHS response been so far? And will the emergency practices temporarily put in place result in long term alterations to the way healthcare is delivered in England?
If so, how can we plan for a better future, with a more efficient, effective NHS, and what role do architecture and design play in creating these solutions?

Increased collaboration with the wider healthcare sector

The speed and range of the response from the healthcare sector and wider manufacturing industry within the UK has been striking. Who would have thought the Royal Mint were able to swiftly move from printing money, to 4,000 rudimentary visors a day? And four Formula 1 teams (Mercedes, McLaren, Red Bull and Williams) were working with University College London, to develop and manufacture 20,000 ventilators for use in Intensive Care Units. Many organisations, including architects and those associated with the sector, have been designing and making their own PPE for wider public use, including using their in-house 3D printing machines to make plastic visors. This response is not limited to the UK, nor just the manufacturing sector. Academia has also turned their attention to PPE, for example, across the pond, the Massachusetts Institute of Technology has developed a disposable face shield that is made from a single piece of plastic, which can be mass-produced and shipped flat pieces of plastic and be folded into a three-dimensional structure when needed.

Moving forward, how can this innovation be best harnessed to improve our healthcare facilities and delivery of healthcare systems?

Examples of such pioneering already exist: during an Architects for Health study visit to the Hospital Clinic in Barcelona a few years ago, we witnessed the hospital positively driving innovative research in conjunction with focussed support from the healthcare industry, whereby they were piloting a new form of operating theatre. Here, healthcare specialists were approached to respond to a specific brief, rather than the hospital procuring kit developed by the specialist. A new approach was taken to create a safer, cleaner and more efficient operating theatre: In order to reduce the risk of infection, aid cleaning and minimise tripping over dangling cables and the like, carefully positioned telescopic floor mounted service poles served mobile equipment, eliminating traditional overhead kit. Specialist LED lighting and cameras are arranged in a series of ceiling mounted domes, all controlled remotely via a handheld tablet; and a cleaning regime uses a gas pumped into the theatre when required. All wall and ceiling surfaces feature a seamless “solid state” material for ease of cleaning.

As we emerge from the pandemic, collaborations such as this, combined with lesson learnt during the crisis, will be more important than ever.

Pop-Up Hospitals

Legislation has recently been passed in the UK to allow temporary healthcare facilities to be constructed to address the potential overload of our strained hospital settings. In the UK, “Nightingale” field hospitals have been set up in London, Cardiff, Birmingham, Manchester, Glasgow and Jersey. Thanks to a simple design template, the use of a flexible “kit of parts” derived from exhibition technology, and the organisational and logistical support from the Army, these overflow centres have been constructed over a matter of weeks. This is a remarkably short time, especially when compared to how long a normal healthcare project may take to be delivered from initial business case to completion.

In addition to floating hospitals, modular units including shipping containers are being used as temporary ICU facilities. Turin Airport, for example, has been repurposed as a Covid centre featuring tailored shipping containers. Whilst these are useful temporary solutions to an immediate problem, careful thought needs to be given in relation to longer term strategic planning. Often the danger in a hospital setting is that they often become permanent fixtures which can compromise future development of the healthcare estate and add little to either a sense of place or a well-planned setting for improved healthcare and wellbeing.

Given that it is highly likely we will face further pandemics in the future, it is probable that short term temporary solutions become the standard response in dealing with such crises and capacity within existing hospitals, whereas in new build facilities there is the opportunity to reconsider how we strategically plan and design for such events.

Would the continued use of these or similar centres provide a viable alternative to our normal understanding of a hospital? Or will Covid-19 underpin a different approach to how we brief, plan and design our facilities to allow for either a flex of service or easy adaptation or re-appropriation of space to cater for emergencies?

Flexible use of facilities

It is clear that in addressing the Covid-19 crisis, hospitals have rapidly adapted their facilities to cope with the surge of acute patients requiring either intensive or high dependency care. This appears partly to have been accomplished by appropriating certain spaces and prioritising bed spaces and surgical procedures. In the UK some 25,000 “non-essential” bed spaces were cleared in anticipation of the need for Covid bed spaces.

Zoning of acute hospital spaces is not a new phenomenon. For example, emergency departments (A&E) already segregate patients presenting with “minor” and “major” cases, along with separate triage settings and specialist resuscitation areas for critical cases. Well designed and flexible departments can assist with aiding staff manage, zone and flex the peaks and troughs of the service and perhaps this may lead to a review of how critical care units are arranged.

In some hospitals during the crisis, operating theatres and recovery spaces have been turned into Intensive Care Units, as non- essential planned surgeries have been postponed and increased capacity for critical and high dependency cases expanded through taking over other ward spaces. Given the need for increased space in critical care settings and the requirement for “don and doff”/scrub areas, this is no mean achievement.

Whilst the new NHS Covid 19 Ward design guide was published in April 2020, it will helpful to understand how the recommendations were translated in practice. For example, it will be interesting to learn whether single bedded wards have been helpful in mitigating the spread of the virus within the hospital and whether this will lead to an increase in single bedded wards. The impact on mechanical air systems on infection control to reduce the spread of airborne disease may also need to be reviewed and whether oxygen supplies are extended to standard wards in anticipation of surge requirements.

Research into evidence-based design in recent years has linked improved patient recovery to better designed spaces with views and connectivity to the outside world, as well as the use of artwork in hospitals aiding recovery. Anecdotal evidence during the current crisis suggested that critical care patients recovered more quickly when taken out to an internal courtyard garden, with one patient recalling how the impact of fresh air and aromas of the garden helped to speed his recovery. Could this hail a return to the early modernist sanatoriums (e.g. Alvar Aalto’s Paimo Sanitorium) extolling natural light and fresh air rather than all fully enclosed technical spaces?

In response to the Ebola crisis in Rwanda, the new Butaro District Hospital deploys high ceilings with natural cross ventilation to mitigate airborne disease, with perimeter corridors and patient beds located in the centre of the open wards offering views out. Wards also feature ultraviolet germicidal irradiation lamps (UGVI) which deactivate microbes as air is drawn upwards. This example demonstrates both spatial and technological responses to a particular crisis.

As a way of easing the pressure and reducing the risk of infection from within hospitals dealing with so many infectious cases, non-emergency visits have been sensibly rescheduled with specific cases taking priority and specialist hubs being established to deal with particular healthcare needs. For example in London, specialist “Covid Free” Cancer Hubs have been established to allow patients to continue their essential treatment, as well as the transfer of surgical procedures to relieve the pressure on general hospitals and have these undertaken in a “safer” environment.

In another interesting development, community facilities have been re-appropriated for novel healthcare use. Tottenham Hotspur FC have set up a key worker Covid-19 testing site within the basement car park of their flagship stadium, in addition to creating a maternity clinic in the Club’s medical suite allowing mothers-to-be, anxious about contracting the virus due to their increased risk, to be able to attend clinic in a non-hospital setting.

In another example of repurposing an existing facility, Opposite Office has proposed reconfiguring the unopened Berlin Brandenburg Airport into a Covid 19 super hospital.

Could this lead to a rethinking of what constitutes an acute hospital, for example, which outpatient functions could be performed outside the normal hospital envelope? Relocating non-emergency activities could release pressure on space within hospitals for the more acute functions but would need to be carefully balanced so as not to further fragment services and resources.

In re-imagining the healthcare estate of the future, are these innovations which should be incorporated into the re-planning of existing hospitals and inform those new hospital developments allegedly coming down the track?

Is the aphorism “Long life, loose fit, low energy” more relevant than ever?

Remote Consultations and increased use of technology

The impact of social distancing has resulted in the first line of interaction with the NHS -the GP -being curtailed, leading to consultation by phone or email. However, there has also been an increase in the use of virtual consultations using on-line video conferencing. Whilst this has been mooted for many years, it appears to have had little traction to date in the UK, apart from its use where a patient distance to a GP surgery is restrictive or patients do not have internet access. Various IT specialists already offer have fairly sophisticated systems to allow GP’s to carry out remote consultations, and with the ongoing restrictions on social distancing and travel, one imagines this will become a very useful technological tool as we move forwards.

This forms part of the current NHS Long Term Plan to revolutionise General Practice. The aim is that “online consultations implemented inclusively, as part of a comprehensive primary care service, can enhance the experience of care for patients and support general practice in managing time and workloads, improving both access and sustainability. The pressures on general practice are immense. To realise this unique opportunity, commissioners must work with their practices and primary care networks (PCNs) to invest in digital technology and infrastructure, while supporting the transformation of service delivery”. (NHS England On Line Consultations in Primary Care Toolkit, September 2019).

In tandem with this, mobile apps are being developed for use in the UK to assist with the tracing of suspected coronavirus cases. Whilst these appear to have been successful in South Korea, Taiwan and Hong Kong, they are still being trialled in the UK.

Will the crisis of Covid-19 become an opportunity to improve the technology supporting our healthcare systems? Satya Nadella, CEO of Microsoft the software giant, stated they have “seen two years’ worth of digital transformation happen in two months”.

In the immediate future it is clear that remote consultations will continue for all non-essential appointments, limiting face to face contact, supported by digital technology such as mobile apps and remote tests and I suspect we will see a blended approach as we ease out of the lockdown, depending upon individual circumstances and level of acuity.

Covid-19 and Climate Change

Lenin said, “there are decades when nothing happens and there are weeks when decades happen”. As we have had to adapt at great speed to this pandemic, perhaps a positive outcome of will be an urgent, collective and joined up approach to how we protect our environment and design our cities in responsible and sustainable way.

2019 saw an unprecedented focus on the environment and climate change, with the language used to describe it moving from “global warming” to “global heating” and “climate crisis”. Manifested in the monthly Friday lunchtime demonstrations initiated by Greta Thunberg, as well as the Extinction Rebellion protests, addressing climate change was brought sharply into focus. Ironically this culminated in the British Government failing to meet its own climate targets, set out in UK law, in its attempt to get a third runway at Heathrow and perhaps seemed to reflect the collective perception as it appeared the public began to think harder about the need to travel via one of the most polluting methods of travel.

Various scientific reports have pointed out that the biggest threat to human health is the continued human destruction of natural habitats and the risk of novel viruses arising from greater interaction with animals. It is argued that zoonotic diseases are apparently responsible over 2 billion cases of human illness and over 2 million human deaths each year, including from Ebola, Mers, HIV, bovine TB, rabies and leptospirosis. Some 142 viruses are known to have been transmitted from animals to humans and in a recent article published by the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES) they stated “rampant deforestation, uncontrolled expansion of agriculture, intensive farming, mining and infrastructure development, as well as the exploitation of wild species have created ‘perfect storm’ for the spillover of diseases.”

Research is already underway to examine the impact of air pollution on the spread of coronavirus and whether low lying air particles assist in the virus concentrating the spread between humans. In Italy, 78% of reported deaths have been attributed to those areas with poor air quality in the northern industrial cities. With both carbon dioxide and nitrous oxide levels dropping markedly across the world, will this pandemic act as a catalyst to review how far we can go in reducing carbon emissions and creating a cleaner environment with better air quality in our towns and cities? In turn could this lead to less reliance on mechanical air systems in some of our buildings?

To make sense of where this is all heading, the causal link between global issues and individual actions is clear:

• Will the Covid-19 crisis seriously inform how we inhabit the planet and drive global policy on how we use the precious resources on earth?
• As traffic levels reduced to 1955 levels during the peak of the pandemic, will we rely less on the car in the future, even though in the short-term travel on public transport may be less popular due to fear of a second spike of infection?
• As we all get use to remote working and become adept at using Zoom, Microsoft Teams etc, will we need to travel as much to attend those “oh so” important meetings?
• How do we adapt healthcare settings, schools, hotels and restaurants, industry and workplace to adjust to social distance guidelines in the absence of a vaccine?

As designers, whilst we have limited capacity to influence what policies other countries pursue in terms of climate change, the environment and loss of bio diversity, we can make a difference through doing all we can to conserve the use of natural materials in construction, reduce carbon emissions and pursue a net zero carbon agenda for all new buildings. By thinking about buildings as long-term assets and part of the “Circular Economy”, we can reduce waste and improve recycling and retrofit existing buildings to save energy, make buildings more efficient and conserve materials. For our part as a practice, we have committed to this and have signed up to the RIBA Climate Challenge where, in addition to our ongoing sustainable design approaches, we will be seeking to track the zero-carbon process more closely.

Whilst the nation’s approach to coming out of lockdown will be inevitably be tentative and phased, each small step will make a difference, in the same way that if we make incremental changes to the way we design our buildings and healthcare facilities can make a significant improvement to the way we deliver healthcare and create truly sustainable buildings for the future.

So, as architects and designers can we use this crisis as an opportunity to help build a better future?
I think we can.

“We desperately need designers to help organize the environment and products to help keep the correct focus on a patient, and reduce distraction,” said Dr Sam Smith, a clinical physician at Massachusetts General Hospital in Boston.

“We need designers at every turn, but they are so infrequently consulted,” he added. “In the end, most physicians burn out early because, in part, we are lacking well designed cognitive and physical spaces to help process the information smoothly.”

Paul Murphy
Director of Paul Murphy Architects

June 2020.