Introduction 

At the beginning of the Covid 19 pandemic, in March 2020, the UCL’s Bartlett Real Estate Institute considered the impact of Covid on the built environment. ‘This pandemic will change people, the economy and society in ways we can’t yet imagine,’ the report stated. ‘We could be at a crossroads in history of the same significance as the Black Death and the two world wars.  Like it or not, it really is time to rethink real estate.’

Written over three years later, this article will address the long-term impacts of the global pandemic on the future provision of healthcare real estate. The immediate impact (the provision of Nightingale Hospitals, structural changes required to enable social distancing and the impact of the Coronavirus Act 2020 in enabling shorter term solutions) is well known; so this article looks ahead, at the way in which planning and designing for the health sector is changing. 

Increased demand 

Prior to the Covid pandemic, the report The Lancet Countdown on health and climate change stated that outbreaks of infectious disease were likely to become more frequent, as the world becomes more connected and rising global temperatures create more favourable conditions for the transmission of disease. And as a 2020 report by WSP, Hospitals After COVID-19: How Do We Design For An Uncertain Future? states, around the world work is already underway to review building regulations and standards, not only on hospital buildings but the guidelines that govern their operations too. As an example of this, in the last year it was reported that China planned to add more than 28,000 new beds, while India anticipates capacity for a further 24,000 according to [link].

And here in the UK at the height of the pandemic, the then prime minister Boris Johnson promised to build 40 new hospitals – and immediately received criticism that such a number failed to acknowledge the scale of the challenge and the overhaul required.

The Covid pandemic thew into sharp focus the UK’s undersupply of necessary facilities.  As Stephen Cousins states in Rethink: How will Covid-19 affect healthcare design? (The RIBA Journal 24 June 2020), ‘Britain has a very low number of acute hospital beds per head of population and since 1961 the numbers have dramatically reduced to a point where, alongside Sweden, we have the least in Europe. About 15,000 more ICU beds are required to match European norms.’

A 2022 poll by Policy Exchange ahead of a call for evidence on the future of building hospitals showed that 81% of respondents put new, modern healthcare building in the top three priorities required of Government infrastructure.

Standalone facilities

One of the major changes in healthcare facilities is the move towards standalone bespoke units, which responds to a need at the height of the pandemic (and one which remains a concern within the population at large), to avoid cross-contamination especially where ‘vulnerable’ patients are concerned. 

Carter Jonas has been involved in several such schemes, including Barking Community Hospital and a community diagnostic centre for West Middlesex Hospitals. 

In June 2023 Carter Jonas achieved planning consent for a brand new Community Diagnostic Centre for Barking, Havering and Redbridge University Hospitals NHS Trust. The 0.1 ha site has been host to the Barking Community Hospital for over 100 years and during that time has seen various redevelopments and additions. This application is the latest addition to increase outpatient capacity. It will provide clinical spaces for the use of cardiology, respiratory, pathology, physiological measurement, MRI/CT control and procedure rooms.   

Patient backlogs have been well documented recently and it is felt that this new approach in healthcare design can go some way to addressing it. Outpatient facilities such as this offer a highly efficient throughput of patients without risk of disruption via unplanned cases or a need to redesign existing facilities. 

Community 

Another significant benefit of these facilities is their integration of healthcare within the community.

During multiple Covid lockdowns, the unpredicted and urgent need for adaptation led to individuals uniting to form resilient communities. Compounded by the working from home revolution, the importance of local and ‘hyper-local’ communities was intensified and the ‘15 minute neighbourhood’ – a concept which until recently had had little practical impact - was found to function naturally in towns and cities. 

The principles of this concept - neighbourliness, support for local businesses and sustainable travel – have now become central to the masterplanning of large-scale new communities and the function of existing communities. 

And although the 15-minute neighbourhood and its association with low-traffic neighbourhoods has come into contention recently, the increased importance of community is clearly here to say. 

Research carried out by Place Alliance considered 2,510 individual views of lockdown experiences and confirmed that people’s sense of community had changed significantly. Specifically, ‘respondents reflected on a period in which people seemed friendlier…and in which they had more time for…family, exercise, the garden, neighbours and the community.’ 

Planning legislation responded quickly to the renewed appreciation of local community centres, while simultaneously addressing the ongoing ‘perfect storm’ that has battered the high street for many years.  

In 2020, amendments to the Town and Country Planning (Use Classes) Order allowed for greater change of use between use classes, creating the all-encompassing Class E. This allows for change of use between a wide range of ‘commercial, business and services’ without the need for a full planning application. It covers shops, office buildings, research and development facilities, clinics, health centres, creches, day nurseries, day centres, gyms and most indoor recreations. As a result, a soft play centre may now convert to a surgery, a retail unit facility to a research or a day nursery to a dentist, under Permitted Development Rights.

This change not only benefits local residents but helps protect the future of our high streets and town centres. It has proven that the high street location of healthcare occupants (which are less dependent on economic cycles than shops, cafés and other leisure services) is an important component in revitalising high streets at a time of economic uncertainty. As an example of this, Carter Jonas’ Leeds office recently used permitted development rights to position a breast screening service in Wakefield town centre, which was positively supported by Wakefield Council and was well attended by the local community. 

PropTech

A positive outcome of a crisis, be it a war or a pandemic, is invariably the expedited adoption of emerging technology. This is abundantly clear in the health sector post-Covid. 

Before Covid [link], 3-5% of GP consultations were conducted by phone or video conference. Immediately following the requirement to lockdown in March 2020, that number soared and remains at now it is 50-70%. This, like remote working or contactless banking, was then an ongoing but very gradual transformation which picked up a considerable pace, literally overnight. 

Similarly, the growing demand for ‘touch-free’ services which arose from a fear of cross-contamination has impacted the design of healthcare facilities. Coupled with a need to embrace both energy efficiency and net zero, a more sophisticated approach to lighting, heating and cooling, and other building systems now involves variable (often voice-activated) controls and the use of sensors has allowed buildings to function more efficiently. 

Many waiting rooms now incorporate digital patient management tools for check-ins, smoother operation of triage systems, and real-time locating systems for better patient management.

Another technology also in its infancy at the start of the pandemic was 3D visualisation. Its use has benefitted the design of new health facilities, enabling healthcare trusts to test out new facilities virtually as part of the design process: both operationally but also in terms of everything from infection control and social distancing to lighting and environmental factors. A more collaborative approach, this enables adaptations and improvements to be implemented before a project goes to site.

But while healthcare premises will always remain important, technology is enabling traditional hospital work to take place elsewhere. According to Spyglass Consulting Group [link], 88% of US healthcare providers are investing in remote patient monitoring of chronic conditions, relieving demand for outpatient services.

Telemedicine (from patient consultations, self-monitoring and online prescribing to digital operating theatres, robotics and artificial intelligence) will invariably impact on facility sizes – as the evolution of community diagnostic centres has shown. Compared to land, bricks and mortar, technology (especially over the long term) is relatively cheap and efficient. 

Technology and processes are changing so fast that adaptability has never been more crucial. This will impact on decisions to locate heavy machinery such as CAT and MRI scanners, and the caballing and tracking systems needed to provide specific services. 

Pandemic preparedness

As Unicel Architectural reports [link], global pandemics were previously once-in-a-century events, but due to climate change, a more connected world, and the continued rise of zoonotic diseases, most experts predict that large-scale pandemics are likely to be more common in the future. The changes to healthcare facilities as described above are vital in reducing the impact of the inevitable next pandemic.  

However, considerations about facility design must take into account that the next pandemic may not be airborne, as Covid was. Ebola, for example, is spread by surface contact. Again, flexibility is all-important. 

Even before the pandemic, there was a growing recognition that buildings generally needed to be more flexible, as technological change far outpaces a typical development cycle. 

The continued growth in ambulatory care will be key to this. These facilities are well placed to provide faster surge capacity, with fewer disruptions, than temporary hospitals and those currently being designed take account of this increased need for flexibility. 

Conclusion 

In addition to those mentioned, there are many ways in which healthcare design has been impacted by Covid: improvements to air filtration and air exchanges; layout of corridors to support visitor flow and social distancing; the use of outside spaces, perhaps to incorporate visitation pods, and importantly the provision of adequate facilities to support and motivate staff – vital in addressing the undersupply of healthcare workers which is feared to reach 18 million health by 2030. 

The Covid pandemic has unquestionably expedited change in healthcare: not solely in how healthcare settings respond to a pandemic but how they respond to secondary change – to technology, lifestyle and economic factors. Policy is shifting, but social change is shifting faster: hence the priority for agility in all aspects of healthcare facilities. 
 

Charlotte Hutchinson, Associate Partner, Carter Jonas (London)