Clinical engagement key in reducing waiting lists

The current Government has pledged to reduce NHS waiting lists within this Parliament. Consequently, there is now greater need than ever for space for delivering care. We know that we need the views of clinicians to ensure that healthcare buildings will meet their needs. However, clinicians’ time is more constrained than ever, as a result of the new commitment to reducing waiting times, which comes on top of a period of ‘COVID recovery’ under the last Government.

In this article we explore how we can make one aspect of a new healthcare development more effective and efficient — clinical engagement. We bring an innovative ‘Experts Network’i approach to clinical engagement, that requires less time from hospital staff, gets the information and buy-in needed for a new development, and is a better experience for staff. Streamlining clinical engagement and making the process more targeted, efficient, and enjoyable, is one way of ensuring that we have better facilities and more engaged frontline staff.

Demand outstripping supply

Demand for healthcare was outstripping supply even before the COVID-19 pandemic, and has now reached unprecedented levels. The NHS ‘elective backlog’ is currently around 7.5 million cases, or over 6 million people waiting for procedures.¹ In response, the Government has said that reducing the length of these waiting lists is central to its health policy. It has committed to clear all waits of over 18 weeks (currently around three million people) within five years.

To help achieve this ambitious aim, in last year’s Autumn Budget the Chancellor announced additional funding for the NHS — £22.6 bn revenue and £3.1 bn in capital funding. While the New Hospital Programme is being finalised, the additional capital funding indicates recognition that additional capacity, in the form of hospitals and other healthcare facilities, is needed.

Healthcare facilities, and particularly hospitals, are complex, and need to be designed to support a breadth of functions — the Department of Health’s Health Building Notes (HBNs) include design guidance for 25 different types of spaces within a hospital.² Not only do hospital buildings have to accommodate a wide range of complex functions, but the layout also matters. The positioning of rooms and areas in relation to each other can make a difference to the quality of care and in optimising delivery.

The global trend towards considering healthcare needs in the broadest sense, and addressing the root causes of ill health — increasingly reflected in NHS policy, add another layer of complexity when it comes to hospital design. The design of hospitals, and indeed all healthcare facilities, should not only ‘promote healing’,³ but should also support people to live healthily.

Furthermore, the hospital building needs to be designed to work for now, and — equally — to be fit for the future, as well as to support technological and social change. UK Government guidance on capital investments requires a 60-year investment appraisal on new buildings.⁴ While the guidance applies to all UK Government-funded buildings, ensuring that a project is ‘future-proof’ is particularly challenging for healthcare, which is a rapidly evolving sector.

Elective care issues during the pandemic

During the COVID-19 pandemic we learned many things — including that hospitals were unable to deliver elective care when there was a rapidly spreading airborne infection. There may well be another pandemic within a 60-year period,⁵ so future-proofing design means we need to consider ‘megatrends’ and understand the implications of major unforeseen shocks on the workings of a hospital. Architects and the wider design team have created designs that meet the needs of the day while striving to allow for flexibility for the future. Whatever the architectural design strategy — whether to design for a specific set of functions, or for an unknown future requirement, what is clear is that we need to hear, understand, play back, and test, with those who use the buildings. ‘Clinical engagement’ is therefore key when developing investment cases and designing new healthcare buildings.

Two areas with major room for improvement

The Nuffield Trust’s report, Lessons learned from the last hospital building programme and lessons for the next,⁶ argues that the two areas of the end-to-end capital project process where we can do much better are (1) approvals and (2) quality of design. Both can be significantly improved by smarter, and more targeted, involvement of clinicians. That clinical engagement matters is backed up by a study in the British Journal of Nursing which shows that clinical engagement in procurement has a positive impact on take-up of products and eventually savings.⁷

Getting the right clinical input, at the right time, is vitally important when developing a new facility. Utilising an Expert Network allows for this to be done in a way that is more effective and efficient, with the following benefits:

• Crucially, we differentiate between clinical input and clinical engagement. Clinical input is needed to address specific questions, and is provided by specialists who may not be employees of the hospital. Our ‘Experts Network’ provides specialist input, where it is appropriate. In contrast, clinical engagement is with people who work within that organisation.
• While we still need senior level sign-up from the start, where specific clinical input is needed, this can often be obtained more efficiently from our Experts Network.ⁱ
• Drawing on external experts to provide clinical input has a particular advantage at the early stages of a project, when funding may be uncertain. It means we avoid taking up unnecessary staff time and creating uncertainty and concern amongst hospital staff. It also enables us to rapidly use specific knowledge and current best practice, and deliver more value for money, including exploring the latest clinical models.
• One-off clinical input, in the form of very specific questions from external experts, is also helpful at later stages of the design and construction phase, including specialist equipping, which is often overlooked.

Report on the PFI hospital programme

The Nuffield Trust report on PFI hospitals from the 1990s to early 2000s states that, despite clinical engagement, ‘there was a lack of knowledge about the clinical models available’.

Due to the current demands on staff we recognise that not all clinicians can or want to step away from their busy, intellectually and emotionally demanding day jobs to support a capital project. We believe that identifying engaged and committed Trust staff is essential, however, and supporting them with external specialists via our Experts Network enhances the engagement process for everyone involved. To rapidly obtain the input needed by designers and other technical professionals, and to do it efficiently, Experts Network clinicians:

• are fully qualified and experienced — that is a given;
• have a set of shared values, and exhibit highly collaborative behaviours;
• bring a base level of understanding of capital projects.ⁱⁱ

Curious and receptive to change

The people in our Experts Network are all passionate about improving healthcare; they are curious, interested, and respect others’ expertise; they are open to change, new ideas, and perspectives. Our Experts Network consists of specialists across the full spectrum of healthcare professionals — from strategists through to individual clinical specialisms, all intrinsically integrated with significant capital projects.

In terms of ways of working, our Experts Network are collaborative, friendly, and approachable; they are prepared to share their expertise and experience, and they are honest, independent, and courageous. The last point is particularly important, as external clinicians may be needed to provide constructive clinical challenge, and this is not an easy thing to do. While it’s arguable that all clinicians should adhere to these values and behaviours, this is something our experts sign up to.

While external clinicians’ input is highly effective, particularly at the very early stages of a project, local engagement — with clinicians who are employees of the hospital being (re)developed — is also critical, especially when it has a clear purpose and is carefully managed. In contrast to clinical input, clinical engagement serves a different purpose. Engagement with the hospital’s clinicians is about providing more than answers to designers and engineers’ questions. It is to ensure that the development supports delivery of the Trust and system’s wider strategy, which may include moving to different models of care, and to ‘socialise’ the idea of the new development, i.e. to disseminate information about the development across the workforce, and help communicate how the project enables the hospital and the wider system’s overall strategy.

This is not to say that clinical engagement with a hospital’s clinical staff is not an opportunity to obtain expert input. Rather, the input obtained during this type of engagement is about the hospital staff’s ways of working and preferences, specific to their site, and in relation to other local services within their particular health and care system.

With the traditional approach to clinical engagement, staff have reported that the experience is unsatisfactory, and that the outcomes often don’t quite meet their needs, but why is this? For many reasons, key being often that the right questions are framed in a manner unfamiliar to the client which they find difficult to interpret and respond to, leading to the information shared being sub-optimal, and the engagement stressful for all concerned. Moreover, with clinicians’ time now more pressured, securing Trust staff time to develop future models of care and the associated built environment is harder, and — when provided — staff can be distracted with the ‘fire-fighting’ of the day.

With the drive for increased productivity, NHS consultants are seeing a reduction in the number of ‘Supporting Professional Activities’ (SPAs) in their job plans. The BMA recommends that consultants have 2.5 ‘PAs’ (Programmed Activity; 1 PA is around 4 hours) per week, for all work that is not direct care delivery, which includes revalidation, appraisal, study, research, and supporting projects. Yet consultants are increasingly only allowed 1.5 PAs per week (six hours) for non-care delivery, which — according to the BMA — will only cover revalidation and appraisal-related activity,⁸ leaving no time in their working week for, say, supporting a new buildings project.

Consultant workforce shortage

The BMA has also highlighted the issue of consultant workforce shortage. In a recent report, it states that ‘Prior to the COVID-19 pandemic the NHS workforce faced a perfect storm of consultants choosing to retire earlier, a significant proportion approaching retirement age, and a growing trend of younger doctors walking away from a career in the NHS’. Post-pandemic, pressures on the workforce are even more acute.

For these reasons, clinical engagement will become more challenging, so we only undertake this with hospital staff after we have obtained clinical input. The clinical engagement is tailored to the teams’ specific needs and outputs, deployed proportionately and flexibly depending on the scale and time pressures of any particular scheme. It will typically include the following:

‘Prep’ and post-workshop: Depending on the size of the scheme, and the availability of staff time, we hold a launch workshop, which gives everyone contextual information, sets expectations, and starts to bring together the individuals involved in the team. Before each session, we send a short reminder email which sets out the purpose of the session and what clinicians need to think about beforehand. After the session, we send a short write-up of ‘what we heard’, and how this information will be used.

Align with ‘transformation team’: During the early stages of engagement we work with directors of Strategy/Transformation Team or equivalent and ensure that we understand the wider vision for the hospital and workforce, potential implications for models of care, and what that means for the use of the new development.

Planning and timing: Recognising that clinical sessions are likely to be booked at least six weeks in advance and cannot be cancelled, we plan well ahead, and flex to enable everyone invited to participate. We work with the hospital team to identify a rota coordinator, or equivalent, who can support the planning. We ensure that diary time is blocked, and ask hospital administrators to ensure that there are no clashes with clinical sessions. We then send reminders prior to the session to workshop participants and the rota coordinator.

Alternatively, we offer online and in-person sessions, and let the client team lead on this. Some clinicians prefer an online session, as it’s easier to fit in, but others welcome an in-person session, particularly when their work is done in-person.

As part of our planning, we ensure that everyone is well briefed. This involves sharing information about location, logistics, and what questions to expect, well in advance. Additionally, as part of the pre-engagement briefing, we ensure that we iron out existing operational issues, so they don’t take over a workshop.

We build on information we have obtained from our Experts Network to ensure that workshop and interview questions are informed and highly targeted. This also helps to counter a degree of (understandable) scepticism. Most clinicians will either have been involved in a previous building project, or will know a colleague who has, which hasn’t been realised. We are very mindful of this, and ensure that we do not ask questions of hospital staff that are not absolutely essential.

For any specialty, we ask a question in three stages:
(1) What’s needed now?, (2) What is likely to be needed in the future?, and (3) Recap both sets of answers, and allow further thinking time for future requirements. The Nuffield Trust report referenced earlier states that ‘Planning for the new buildings often did not fully consider the emergence of new diseases or possible changes in disease management drugs, technology, or the labour market’. To address this, we feel it is imperative that specialists are actively guided and supported to think about future developments, as well as current needs. So, having a senior facilitator, who knows the sector well, is vital.

Crystal ball gazing a significant challenge

Asking people to think decades into the future is a huge ask, and a difficult one. Particularly when people have been working in sub-optimal facilities, often they simply want an improved version of what they have. To generate ideas and to get buy-in to significant change, we use prompts and exemplars. Where it is feasible, we take clinicians out of their day-to-day environment. This is an opportunity to show them a completely different working environment, and take them away — temporarily — from their day-to-day work pressures.

In any session, we provide information on the end-to-end process of a capital project. We explain key guidance we are working within, e.g. ‘Better Business Case’, who is involved, and give an indication of timescales. We also alert the team early that timescales can change, and why that may happen. While all of this may seem obvious to those of us who work on capital projects, it is a very different type of work, with different challenges, for clinicians. The better they understand the context, the richer the conversation.

Share what we have learned: At the early stages of any new development, we share our national and international experience and insights with the hospital team at the outset, and during our clinical engagement.

Make it a two-way discussion: Clinical engagement workshops involve highly experienced experts, who have extensive experience. Staff are more likely to engage with experienced facilitators where they feel they are learning as well as sharing their expertise. We ensure that facilitators bring their knowledge of capital projects and examples from other projects that they have been involved with. A more interesting workshop means we get more genuine engagement. Experienced facilitators are also adept at drawing in individuals who may be quieter or reluctant to speak in a group. Sometimes, the most helpful and detailed insights can come from more junior members of a team.

Constructive clinical challenge: Clinicians tend to come from the perspective of getting what is best for their patients, so often engage with capital projects with a ‘lobbying’ mindset. Where we and clients feel it is helpful, we test these views with the right specialists from our Experts Network. A structured, facilitated discussion between in-house hospital staff and external specialists will derive a more robust view of clinical needs.

Using a mix of input from the Experts Network and highly targeted clinical engagement is more efficient and cost-effective overall than a traditional approach to a new hospital development.

Pressures on frontline staff time are not going to reduce in the foreseeable future, yet the need to build new facilities is greater than ever. An Experts Network approach means that, overall, clinical engagement is faster, and provides better quality information. The input we obtain from the Experts Network and local clinical engagement are then used by the multi-specialist team, including, but not limited to, strategists, financial modellers, clinicians, and healthcare planners and architects, to ensure that the business case is both robust, and a solution that exceeds expectations.

Lengthy planning process

Historically, the planning process alone for large-scale NHS hospital projects has taken between five and eight years. Bringing in more targeted, focused clinical expertise, using external as well as in-house clinicians, is one way to make new healthcare capital projects more efficient and optimise clinicians’ input. This approach leads to standardised clinical engagement, in line with standardisation across the construction industry:

• by only using engagement when necessary;
• by having highly targeted questions, and
• by drawing on our Experts Network for one-off input.

We will cut engagement and pre-construction time, and bring clinical benefits. While this article focuses principally on ‘clinical’ engagement, we are aware that there are many more staff groups who are critical to the effective running of a hospital, and whose experiences and insights are vital when developing a new facility. The principles of the Expert Network apply equally when discussing their needs and requirements.

References

1 NHS backlog data analysis. British Medical Association,
10 January 2025. https://tinyurl.com/4jj7hem3

2 HBN 00-01: General design guidance for healthcare buildings. Department of Health. 20 March 2013. https://tinyurl.com/kb5c9yvt

3 Callister R. Key principles transforming healthcare architecture and design. Urbanist Architecture. 26 September 2024. https://tinyurl.com/vveeueux

4 The Green Book (2022). Updated 16 May 2024. HM Treasury. https://tinyurl.com/38kjtzan

5 Joi P. New study suggests risk of extreme pandemics like COVID-19 could increase threefold in coming decades. Gavi The Vaccine Alliance. 5 September 2022. https://tinyurl.com/2xabt4au

6 Edwards N. Lessons from the last hospital building programme, and recommendations for the next. Nuffield Trust. 16 July 2020. https://tinyurl.com/yc7b3epz

7 Moses C. Effect of clinical engagement on value, standardisation, decision-making and savings in NHS product procurement. Br J Nurs 4 April 2024; 33(7):326-336.
https://tinyurl.com/39unuy9v

8 Consultant working patterns. A BAPM Report. British Association of Perinatal Medicine. November 2023. https://tinyurl.com/5e3d7sum

Further reading

i Symbi Consulting has an ‘Experts Network’ of hospital consultants, social workers, pharmacists. and clinical and care specialists. Smriti Singh said: “We use the term ‘experts’ as these specialists have a number of areas of expertise in addition to their clinical or care specialism, e.g. an ED Consultant whose areas of expertise include emergency medicine and hospital flow.

ii Building blocks for clinicians course 2024. Great Ormond Street Learning Academy. https://tinyurl.com/pup7kd8k