There is no easy fix for all the issues that our health system is facing in the wake of the pandemic, but innovative solutions that help to create capacity and allow more efficient working are key to facilitating the recovery process.
An article published in the British Journal of Healthcare Management suggests mobile or modular healthcare facilities, which provide flexible and cost-effective spaces to expand services without sacrificing care quality, may be the solution to both the patient care and building maintenance backlogs within the NHS. But the issue is not specific to the UK – Australia is facing similar challenges with inflated waiting lists and healthcare inequalities affecting parts of the country.
The need for capacity
Capacity is becoming an increasingly pressing problem for healthcare services. The Nuffield Trust has estimated that in the UK alone, the equivalent of 22 new hospitals with 800 beds each will be needed by 2027 to accommodate population growth and a rising proportion of older people.
Although the situation may not be quite as dire in Australia, our population is both ageing and increasing. This has a number of implications; not only are older people more likely to live with multiple long-term conditions, evidence has also shown that hospital bed occupancy increases at the end of life, with up to 55% of lifetime bed occupancy occurring in the last year of life.
Right now, the most urgent need stems from the fact that the Australian healthcare system continues to be disrupted by the COVID-19 pandemic. At the time of writing, figures suggest that in Victoria there are almost 67,000 people on the elective surgery waiting list in Victoria, with the wait for hip and knee replacements generally between two and three years. As well as being distressing for the individual, this delay in surgery can lead to an increased risks of falls, fractures and other adverse events, which can result in increased pressure on healthcare services.
Even more worrying, an article in ‘the Age’ suggested that urgent category-one elective surgeries have also been postponed because of the increasing shortage of beds in Victorian hospitals and the need to make room for COVID-19 patients. Diagnostic services have also been impacted negatively; new estimates from the Victorian Cancer Registry reportedly show almost 3500 cancers were missed between April last year and mid-August this year, half of which were for prostate cancer.
With the COVID-19 pandemic exacerbating the backlog, there is an urgent need for innovative solutions to increase capacity in hospitals. Currently, Australia arguably lacks a long-term, ‘future proof’ health infrastructure plan but with patient backlogs mounting, a more flexible approach to creating and configuring space in the healthcare sector is needed.
What are flexible healthcare facilities?
Modular health facilities are constructed from individual, largely prefabricated modules that are then installed on to a site to create a single structure, or series of structures. They can be used as stand-alone facilities on a particular hospital site, attached to an existing hospital building or used in conjunction with a mobile facility (a so-called mixed-modality solution).
With appropriate maintenance, both modular and mobile facilities can last up to 60 years. However, there are several key differences between mobile and modular facilities, as shown in the table. Crucially, modular facilities can be designed specifically for the particular healthcare function they are required for, while mobile facilities can be moved between different locations in line with variations in demand.
Modular building methods have been used in social housing and education for several decades, including in structures such as the famous Burj Al Arab Tower in Dubai, as a faster and more cost-effective way of creating space. In a healthcare context, they have typically been used to increase capacity in times of high demand or to provide space to continue services while an existing building is being renovated or refurbished. The healthcare field is well-suited to modular design, as facilities usually include functional elements that have clear pre-existing procedures and standards, which allows for clear planning along the whole supply chain.
The COVID-19 pandemic has highlighted the role that modular facilities can play in healthcare, with rapidly constructed triage and isolation units making headlines in early 2020. As stand-alone buildings, modular facilities can allow patients who test positive for the virus to be kept entirely separate from the main hospital building. A more sophisticated modular ward was subsequently built in in Singapore to treat confirmed or highly suspected COVID-19 patients. The large modular ward situated just outside of the main hospital was fitted with high-specification air filtering, oxygen supplies and air conditioning, while one module was customised with lead shielding to allow X-rays to be performed. In the period of one month, around 1,500 patients were treated in the facility, with no breaches of infection prevention and control measures, thanks to the practical, bespoke layout of the building.
Using a similar approach, a cataract surgical unit at Stoke Mandeville in the UK installed a modular unit to act as a COVID-free zone, allowing the surgical team to become one of the first services to re-start elective procedures after the initial pause during lockdown. Since then, many other hospitals have followed suit. In Brisbane, Australia, the installation of a mixed-modality colonoscopy unit is allowing 6,600 extra screening procedures to be performed per year, facilitating faster detection of one of the country’s most common cancers.
The benefits of flexible healthcare solutions
Several studies and reports have emphasised the importance of flexibility in healthcare infrastructure and spaces. Healthcare technology, clinical practice and policy can develop very quickly, so building projects that take many years are at risk of being out of date before they are even finished. The rapid adoption of healthcare technology during the COVID-19 pandemic further highlighted this need for greater flexibility.
State governments and healthcare providers are increasingly looking to create more flexible facilities to meet fluctuating capacity demands and deliver integrated care. Modular facilities are a potential solution for this, as they can be developed far more quickly than traditional, bricks and mortar buildings, while mobile operating theatres can be moved between locations according to demand.
For example, the construction of four modular operating theatres, a ward and support hub recently built at Queen Mary’s Hospital in South-West London, UK, took only 12–14 weeks from commission to completion and receiving first patients. This was possible, in part, because modular facilities need less in terms of groundworks and other enabling works, and those works that are needed can be undertaken at the same time as the off-site construction of the modules.
Flexible, mobile or modular facilities can also be removed or repurposed when demand shifts. For example, the modular COVID-19 ward in Singapore has now been repurposed to treat patients with other infectious conditions. This provides more flexibility when making planning decisions as it is possible to measure the value for money over a shorter period of time. Furthermore, fast project delivery is crucial to success in infrastructure construction and expansion, both in terms of cost saving and risk reduction.
This flexibility could be a crucial asset in dealing with treatment backlogs. Modular or mobile healthcare facilities can be operational within a matter of weeks – meaning extra capacity to address waiting list backlogs can be made available with the appropriate level of urgency. Then, if demand decreases, increases or changes, the modular facilities can be either removed or repurposed.
Quality and value
A key element of a modular facility is that the majority of construction takes place off site. Once ready, the facility will be delivered to the site, installed and tested for quality so that the health service is left with a completed building that is ready to use immediately. Building infrastructure in a factory environment typically allows for better quality control and more efficient use of labour and resources than would be the case with on-site building.
Some providers of modular facilities, such as Q-bital Healthcare Solutions, also offer leasing contracts that include regular quality standard testing, maintenance and full facilities management packages. This means that trusts have set costs that they can budget for, without needing to factor in extra, unknown maintenance costs. These designs are also compliant with health technical memoranda meaning that hospital staff can trust in the appropriateness and safety of the facilities.
In terms of the construction process, modular builds can also improve efficiency. A US study found that a modular, pre-fabricated construction approach resulted in time savings of 45%, cost savings of 16% and an increase in productivity of 30%. These cost savings are continued after construction is complete, as temporary modular facilities can prevent services needing to resort to outsourcing to the private sector.
Enhanced patient and staff experience
A common misconception about modular facilities is that they are less comfortable or customisable than a traditional hospital building. In fact, given the limitations often placed on older hospital buildings, the opposite is often true. Although the earlier models of modular building used in the 20th century were often relatively basic, more recent models are made to be bright, airy and spacious, with many options for customisation or even bespoke design.
In an earlier review of modular diagnostic laboratories in Mali and Zambia, it was found that, despite some initial misgivings, almost all of the users were converted after entering the modular facilities. Similarly, in a study from 2019 of three hospitals that had used modular facilities in Finland, the authors found both staff and patients had commented favourably on the amount of natural light let into the modular units compared to the main building. In interviews with staff members, one manager who worked across multiple sites states that the hospital’s modular unit was the only facility about which they had never had a complaint about comfort.
The ability to standardise modular facilities can be a significant benefit, as it means that the layout and storage of equipment in each room can be the same, making it easier for staff to work in different rooms. These studies, alongside anecdotal evidence from healthcare staff, suggest that modular facilities are just as, if not more, comfortable and easy to use as traditional healthcare buildings.
Healthcare services contribute a significant amount of global carbon emissions; if the healthcare sector were a country, it would have the fifth highest carbon emissions in the world, along with a large amount of waste material. Because of their flexible nature, modular healthcare facilities can help to facilitate a more circular economy—a regenerative closed loop that prevents waste and promotes optimisation of physical, financial and human resources. By repurposing modular or mobile facilities according to need, health providers can avoid waste and cater their buildings to fit patient needs.
Off-site prefabrication is also believed to reduce construction waste and facilitate better building insulation, improving energy efficiency. This is in addition to the reduction in emissions from transporting building materials to the hospital site, as well as the noise pollution and disruption to local communities that often occurs during long on-site building projects.
Many of the issues that were already affecting the healthcare system – such as patient backlogs – have been exacerbated to unprecedented levels as a result of the COVID-19 pandemic. However, innovative solutions that can help to create capacity and allow more efficient working are key to facilitating the recovery process, as well as improves and prepares it for future challenges.
There is also substantial potential to address healthcare inequalities, by facilitating greater cohesion between services and local provision of both diagnostics and treatment, allowing patients to access care closer to home. Achieving this requires better integration between primary, secondary, tertiary and social care services, and it can also have major implications on existing physical infrastructure. A flexible modular or mobile facility could solve the immediate challenges.
In summary, there are a number of benefits to modular and mobile healthcare facilities, including greater flexibility, faster delivery, enhanced patient and staff experience, cost-effectiveness and a reduced environmental impact. Healthcare services experiencing capacity issues should seriously consider modular or mixed-modality facilities as an effective means of increasing capacity and/or continuing services during periods of change.