Shopping centre pop-up shows way forward for NHS

The challenges to the infrastructure of healthcare throughout lockdown have been immense. Not only have hospitals been pressured for resources but waiting lists for non-Covid treatments have grown. A multi-department effort from across The Bartlett, including senior healthcare professionals, architects, designers and spatial analysts, has ended with one of the top eye hospitals in the world opening a diagnostic hub for eyecare in a shopping centre in north London. Using ingenuity and flair, the team has brought urgently needed tests, normally only administered in hospitals, to where the public is.

Ophthalmology is the busiest outpatient specialty in the National Health Service, more than trauma or orthopaedics. One of the key conditions that this service treats is glaucoma – a nerve condition which, if left untreated, can lead to blindness. Indeed, glaucoma is the most common cause of irreversible blindness worldwide. One million visits to the NHS annually are caused by treatments for it and the sheer scale can cause problems.

According to Professor Paul Foster, Professor of Glaucoma Studies, UCL Institute of Ophthalmology, despite Moorfields Eye Hospital being one of the best specialist hospitals in the country, the process for glaucoma testing is fragmentary with patients called in and out of different testing areas in different parts of the hospital, each with their own waiting areas. “Although this capacity crisis was a problem before the pandemic, the caseload of consultants has grown inexorably after it,” he says.

To address this rise, Moorfields Eye Hospital set up a clinic in a repurposed waiting area in its main site near Old Street Station. It was created with a linear flow pattern: waiting areas followed by an examination area, with station after station for specialised tests including optical coherence tomography scans, eye pressure measurements and visual field testing. Later, a larger clinic was set up in a building adjacent to Moorfields, in Cayton Street, although the spatial layout was more ad hoc in this expanded clinic.

This allowed medics to shorten the length of visit from 2 hours to 45 minutes. Before the pandemic it provided 10% of the clinical capacity of Moorfields Eye Hospital. To try and address the backlog created by the pandemic, Hoxton Hub was opened in February 2021 with an even clearer linear flow pattern embedded in the layout. It was at this point that Professor Kerstin Sailer from The Bartlett School of Architecture became involved: observing the care practices and flow of patients through those clinics.

“We were interested as architects in layout and design – how were the spaces performing?” Sailer confirms. “In Cayton Street, the examination stations are dotted around two open plan rooms. At the Hoxton Hub you can see the linear plan put into the arrangement; three linear rows of examinations one after the other.” Sailer and her team charted how each patient went through the system in each clinic. It wasn’t easy to make exact comparisons as the Hoxton Hub was not as well attended, but it was clear that there were huge variations in the duration of patient visits at Cayton Street with longer waiting times occurring during busy evening hours. The organisation of the stations was not optimal and the visual separation between the two rooms meant that clinicians couldn’t see what was happening at other stations.

The next evolutionary stage in exploring how the healthcare system design could be improved was at Brent Cross Shopping Centre, in an unused retail unit. Following analysis of usage patterns at the Cayton Street and Hoxton Hub sites, two check-in points were created and the order of the stations was altered. The autorefractors were placed first. These were followed by additional visual field analysers, six in this case, as this test often takes the longest. The Brent Cross clinic combines the advantages of Cayton Street with the pooling of certain resources, and the linear progression of the Hoxton Hub. The Brent Cross clinic was launched in September 2021 and continues to be tweaked and evaluated by the team.

Professor Duncan Wilson from The Bartlett’s Centre for Advanced Spatial Analysis is exploring how Internet of Things technologies can be used to support continuous monitoring of the environment. As a first step the company Ubisense set up a real-time location system (RTLS) using ultra-wideband. A series of beacons were positioned around the interior and lightweight polycarbonate tags were worn by both staff and visitors. The software on the server took 4,000 readings per second to calculate exactly where the tags, and hence those wearing them, were. This allowed Ubisense to ensure that there were no lags or stumbling points in the flow of patients through the system. The Brent Cross Shopping Centre became a real-time experiment in spatial analysis as well as the provider of high-quality diagnosis.

But how to create a design that could be adapted following feedback from the location system? Professor Peter Scully, Technical Director of The Bartlett Manufacturing and Design Exchange, explains that this was a flexible walling system. “The initial plan for the layout is based on a 3-metre grid,” he says. “This grid allows for an overall system understanding with flexible walls, to allow anyone to reconfigure the design, not just an architect or a manufacturer. Following ongoing testing, the design can be perfected. Anyone can easily reconfigure the walls and re-integrate the services.”

The design process involved an investigation of standard supply materials. Scully says: “We had a conversation with Moorfields very early on and we asked: can we use this as a vehicle to shape supply markets or supply thinking around sustainability?” What might be considered a standard architectural walling system is in fact a means of efficiently adapting the space to the feedback from analysis of the RTLS output. Where are the hold-ups? Do more of a certain kind of station need to be added? These are just some of the questions that spatial design can quickly address.

Professor Grant Mill at The Bartlett School of Sustainable Construction says: “If we get quicker diagnoses in this setting, patients can go home and manage their condition much more effectively. If they aren’t diagnosed, then those patients will move into higher acuity settings, they will move into hospital settings and require more care, more informal care, more care in nursing homes. The important thing for us as infrastructure professionals is to think about how we work with intelligent, advanced clients, to help them quickly diagnose and move patients effectively through the system.”

Dr Hari Javaram, Consultant Ophthalmic Surgeon at Moorfields is proud of what the team have achieved. He says: “The Government is sending clear messages that diagnostic hubs are the future and here to stay. We at Moorfields are ideally placed to lead the development of this new healthcare environment as the unique “clinical efficiency laboratory” gives us unique capacity to research how these hubs work best. Through this process we have managed to build a state-of-the-art eye clinic inside of a shopping centre.”

Authors

• Professor Kerstin Sailer
• Professor Grant Mills
• Professor Duncan Wilson
• Professor Peter Scully

The Bartlett Review 2021