The current approach to delivering hospital infrastructure needs ‘a fundamental reset’, favouring a more-effective model of system-wide integration, according to the Westminster think tank, Reform.

As part of its Reimagining Health workstream, Reform has embarked on a new project to outline a vision for hospitals within a health system that is re-orientated towards prevention and early intervention.

The Hospital of the Future proposes a fundamental reset in the approach to secondary care, providing a long-term vision with a new, revitalised model fit for the 21st Century.

And reform has now published the first in a series of papers diagnosing the problems experienced by hospitals today.

This will be followed by a series of papers outlining a detailed programme of reform to reimagine hospitals for the future.

The paper poses the view that a focus on the need for more resource is the wrong approach without consideration of whether the right resources are being deployed to meet the type of demand.

The model of secondary care, it says, is not changing with the nature of demand.

Furthermore, it should be viewed as a service, not just a building.

Reform aims to challenge how the physical hospital building can change and how the same level of care can be provided outside of the traditional hospital.

And it acknowledges that rethinking the division of care in a hospital raises fundamental questions about economies of scale, as well as logistical concerns about services, facilities, and rotas.

It also points out that patient flow within hospitals needs a ‘fundamental reset’, and promises to explore a more-effective model of system-wide integration, the role of management and flow co-ordination, as well as the technology infrastructure needed to enhance this.

The paper states: “There are severe problems facing hospitals in the immediate term: financial deficits in NHS trusts, a reliance on locum working, outdated equipment, and a growing maintenance backlog, to name a few.

“But, underlying these short-term problems, is a profound set of structural questions as to how a hospital fundamentally operates and whether this is the right model.

“This framing paper will diagnose the problems in hospitals today – what they are, why they exist, and the long-term prognosis.”

Economies of scale

The paper says that, since the creation of the hospital, the logic of the physical hospital building has always been that it enables substantial economies of scale.

These arise from being able to achieve high levels of utilisation of specialist capacity, both human and technical. For example, health systems have high fixed infrastructure costs, in that they must pay for diagnostic and operating theatre equipment as well as hospital beds and staff. These high costs become substantially more cost efficient the larger the patient base that uses them.

Thus, the core logic of hospitals is that they provide a range of services that draw on economies of scale, providing different forms of care to high volumes of patients using the same underlying infrastructure base.

The paper states: “With this said, it is still not clear what the optimal size and scope of a hospital is if it is to make the most use of its available expertise, infrastructure, and equipment.

“Hospitals that are too large can depart from the optimal level of efficiency and exhibit diseconomies of scale.

“But, at the other end of the scale, small hospitals might be inefficient because the fixed infrastructural and administrative costs are shared across too small a caseload.

“How hospitals achieve economies of scale is also evolving. Many large regional hub hospitals are seeking to increase volumes in specialised services to deliver high-quality care affordably, while smaller hospitals are forming networks to invest in infrastructure, share back office costs, and retain staff who want to undertake a range of clinical work.”

Barriers to change

Problems which need addressing, according to the report, include poor understanding of patient flow; hospitals being internally incoherent and fragmented; a bias towards specialism within the workforce; poor integration between primary, secondary, and social care; insufficient management; complicated funding models; and an absence of communication and technological infrastructure.

Low capital investment is also cited.

The paper states: “Over the past 15 years, levels of capital investment have grown dramatically, but this is partially to compensate for the fact that from 2014-15 to 2019-20, funds from capital budgets were transferred to support day-to-day spending and relieve the growing pressures in the NHS.

“The dire state of NHS England’s hospital estates contributes to poor secondary care productivity.

“In 2023-24, the cost to resolve the backlog of maintenance for all ‘risky’ NHS England buildings was estimated to be just over £13.75bn.

“Worryingly, over 55% of those costs would be needed just to tackle high-risk and significant-risk building issues.”

It adds: “There are numerous negative consequences, for patients and staff, resulting from poor NHS hospital estates.

“Perhaps, most obviously, shut or disused facilities caused by unsafe buildings or unusable equipment reduces the capacity of secondary care.

“Broken lifts, unfit-for-use or outdated equipment, and finding workarounds for estate issues causes major inefficiencies, similarly reducing secondary care capacity.”

Hospitals of the future

In its vision for the future, the paper reimagines hospitals as if they were being designed from scratch today, posing four questions:

• How should the patient journey through the hospital change?
• How would hospitals interact with the rest of the healthcare system?
• How would the entire configuration and location of secondary care services look different?
• How would this change the scale, clinical portfolio, workforce, infrastructure, and funding model of secondary care?

It concludes: “Policymakers have paid lip service to prevention for decades, but realising the prevention ambition will always be unachievable if there is not a coherent plan for what the role of the hospital is, and how it can achieve this.

“Otherwise, the modus operandi that has existed for decades – a hospital-centric health system – will continue, draining resource out of the health service and forcing costs to increase in perpetuity.

“As the healthcare landscape continues to evolve, the pressure to overhaul hospital systems will only intensify.

“The decisions made today will shape the future of healthcare delivery, and with mounting pressure on the system, the imperative for reform has never been more obvious.”