Operating Theatres On the Road
The antithesis of PFI 'monuments,' mobile operating units are part of a global move to create flexible, responsive facilities, says Graham Cooper HD September 2005.
As the growth of less invasive procedures reduces length of stay in hospitals, the focus of operational policy will shift more from inpatient to ambulant care, and from a curative ethos to greater user involvement. Preferences for more flexible care nearer to the home will take healthcare beyond the walls of existing facilities. The patient pathway with the central infirmary at its heart appears outmoded and is unlikely to cope with new 18 week waiting targets and increased expectations for the NHS to become a health-enhancing, preventative service. Instead of building icons to clinical might, policy makers are now promoting a more agile and responsive strategy to solve access challenges and blockages in throughput. According to the recent report 'Global Hospitals in the year of 2050,'1 future healthcare facilities will be smaller, supported by sophisticated communication and transportation systems. With miniaturised and improved digital technology healthcare is increasingly capable of being localised nearer to users.
Developments in telemedicine give great potential for flexibility and mobility leading to greater effectiveness in managing queues and capacity challenges. As we learn to adapt telecommunications to patient pathways, institutions will dissolve into the community. In place of the mainstream general hospital come a network of local services - walk-in and one-stop primary care centres, healthy living education centres, and online consultations. Hospital will be the last resort. A plank of this new structure is a more responsive ambulance service with "super" paramedics able to treat or via mobile telecommunications. The modern hospital is a resource for the treatment of diseases and maintaining wellness locally. Infections and injuries however occur at any place or time and health facilities must be able to deal with sudden surges in demand. In the wake of major emergencies, coupled with the worldwide chronic shortages of health services, especially in remote areas, building permanent hospitals is unrealistic. However, across the world the potential for mobile clinical facilities is increasing and dispatching such hardware is becoming more feasible.
The historical precedent for taking clinical expertise nearer to 'the scene' is the field hospital, the classic example of which is Isambard Brunel's prefabricated hospital for the Crimea. Designed, shipped and assembled at Renkioi in 1855, within nine months of opening it had reached its capacity of 1000 beds. This historic ancestor of the modern modular building is the star of a conference being held by MARU and the Florence Nightingale Museum at Guy's Hospital in October2. The statistics for the contemporary version - the mobile treatment centre - are, in their own way, no less impressive.
Mobile Treatment Centres
Whilst hospital staff are overstretched, existing day surgery facilities are reported to be insufficiently supported, undermining performance. Figures for the first quarter of this year demonstrate nearly 22000 operations were cancelled at short notice for non-clinical reasons. Drafting in privately operated mobile units to 'cherry pick' minor operations and reduce waiting lists is however a controversial means of reducing NHS waiting time targets. Criticised as privatisation through the back door, some describe it as innovation driven by new market potential, resulting from shortcomings in existing provision.
The Government is committed to a diverse economy, in partnership with private health providers. Last year then health minister John Reid announced a total of 80 such fast track units would be operational by the end of 2005. A further step outside the hospital perimeter, mobile centres, it is predicted, will eventually provide elective surgery (such as cataract, hip and knee) for a quarter of a million patients a year. Mobile theatres have already been used to perform 36,000 procedures; a considerable dent in the waiting list. Infections and injuries occur at any place or time and health facilities must be able to deal with sudden surges in demand In the Vanguard
The opportunity has been seized by Vanguard Healthcare, which supplies mobile facilities across the country. The firm was acquired last autumn by Nuffield Hospitals, the UK's largest independent hospital group, which promotes mobiles as a means to work closer to health authorities.
The Department of Health has commissioned Vanguard to provide mobile facilities for a twin national cataract programme in the north and south. Each 'chain' provides consultation, with patients assessed and booked into the mobile operating theatre the following week. The units commenced work in February 2004 and by July this year they had delivered more than 15,000 successful cataract procedures.
Working in the units, Netcare (incidentally the largest private healthcare provider in Africa), is claimed to be able to perform cataract operations 10% cheaper than those carried out by the NHS. Such benchmarks may be indicative of a significant deficiency in the existing system, but conversely the franchise has no long term responsibilities for R&D or training.
First-hand experience as a carer can testify to alarming waits of up to three years between an optician's referral and final completion at the regional eye centre. Compare this with the patient at the visiting surgery who was diagnosed in May last year and the second eye satisfactorily completed early in the new year.
With 35,000 minor operations undertaken since it launched in 1999, Vanguard Health Care solutions claims to be the leading player in the world. Director of planning and development Steve Hudson is responsible for formulating the clinical configurations and accommodation layouts. He believes the bright white containers provide a safe and reassuring clinical atmosphere. To encourage hygiene surfaces are coated with impact-resistant coach paint.
Unlike hospitals, incubating infections along their acres of corridors and ceiling voids, to ease carriage and cleaning the trailers are designed to be easily cleared of all furniture and equipment. The general clinical domain is compact and confined, offering high specification dust-free ventilation. Within the theatres themselves the ceiling offers structural support, air conditioning and lighting conforming to HTM regulations. To allow for the application of various types of orthopaedic hip or knee surgery and simple endoscopies, laminar air flow rooms have been introduced to the latest models (see plan, p22).
Vanguard is currently commissioning a new unit each month from specialist UK vehicle manufacturer Smith & Bentley. Steve Hudson describes three particular areas of technical innovation; expandable trailers, high clinical integrity with laminar flow theatres and the introduction of 'healthports' (see below). The 30 ton mobile vehicles are able to be stationed at any location where it is possible to manoeuvre a 19 m trailer, eg a sports arena or supermarket car park. They are however more likely to be found within the healthcare envelope, on hospital sites with sufficient level space and access to water, drainage, power and telecommunications.
There are two means of transportation - the original trailer-mounted mobile and the latest modular version. The trailer-mounted theatre model arrives and parks like any other articulated lorry. The cab is quickly discharged and the unit sides open to give access to a combined anaesthetic, surgery and a three bay recovery space. The sections are hydraulically activated, expanding along a slide-out channel to a width of 8.5 m.
The modular version arrives on a low loader, before dropping hydraulic legs and expanding laterally. The modular carriage can offer a range of interfaced services including the single consultation-assessment or operating theatre format, and the twin configurations of the visiting day surgery. Unfolded and bolted together the full modular day surgery suite provides 130 m2 floor space.
Mobile treatment centres are normally delivered overnight and installed ready for a 7 am start the following morning. Vanguard currently has a fleet of 22 mobiles including six with Netcare.
The applications for long-distance flexible treatment networks have already been exploited overseas. It has been calculated that two such units can be loaded onto a transport aircraft and delivered virtually anywhere around the globe within 24 hours. The Australian armed forces are currently trialing a unit in the Solomon Islands, which has an operational temperature of a constant 18ºC compared with over 36ºC in the surrounding jungle.
The South African 'instant visiting hospital', which consists of an operating theatre linked to a mobile eight-bed recovery unit, can carry out 20 to 25 procedures per day. A separate dedicated staff performs 1000 cataracts per month and 45000 over five years.
Visiting a mobile for minor surgery doesn't impact on the user's perceptions in the same way as entering a normal hospital environment
Vanguard's director of strategy Gary King describes a healthport as low-cost, fast-build accommodation designed to enable the NHS to meet its day surgery targets, regardless of location. Utilising off-site manufactured construction the healthport is assembled in six weeks, containing recovery wards, nurse station, patient changing, toilets and other facilities.
Taking the ethos of an 'airport hub,' the healthport incorporates docking bays for mobile units, which allows roving theatres to attach themselves seamlessly to the building. According to Gary King, "It's hugely cost-effective because the NHS does not have to pay for permanent additional theatres and Vanguard can bring in other operators' MRI, CT or x-ray diagnostic mobiles as required."
He points out that a healthport has an average lifespan of some five years. Not only may they be sited within communities that have long day surgery waiting times but they can easily be relocated. To accomplish this programme a new generation of airport-style surgery centres are planned, the pilot of which opened adjacent to Plymouth's Derriford Hospital in 2004.
Waiting times were the catalyst for a group of surgeons at Derriford to formulate the healthport day surgery strategy and to raise the initial funding. The principle was to provide a streamlined locally-based service which was responsive to the changing surgical demands of the community as well as to generally increase capacity. The consultants contacted Vanguard, raised 50% of the funding, and now jointly own the building with the Plymouth Nuffield Hospital. With the capacity to dock two mobiles the Tamar Surgery Healthport also contains two consulting rooms and a recovery ward with eight loungers. A consumer survey revealed very high levels of patient satisfaction with the service provided.
Vanguard is currently in talks with PCTs and NHS trusts in other areas, using its selling points of a significant investment in the fleet and healthports' ability to be quickly sited. planning applications have been submitted for ports near Colchester, and at Nuffield's HQ in Surbiton, with further enquiries having been made in the West Country, Lancashire and Cumbria.
Offering scope for process redesign, the inherent flexibility of the 'visiting treatment centre' provides adaptability, and new ways supplementing care alongside the hospital. The director of access policy, development and capacity at the Department of Health, Bob Ricketts, speaking to chartered accountants in June, warned about building expensive inflexible monuments with long term leases, and advised against fitting health services around buildings rather than vice versa. He was urging NHS managers to fundamentally rethink about how today's hospitals will work in the future: "I've seen some awfully grand PFI schemes that are starting to give us a real problem in our capacity mapping".
He added: "Some private providers are putting up good, cheap and cheerful builds that will only last five years, which is fine because you cannot estimate day surgery in 20 years' time. Build for five years, possibly 10, and really focus on human resources solutions."
Mobiles are achieving impressive figures, but they are considered only medium-term solutions to shortages in staff and resources within the NHS. Their economic advantage is the delivery of dedicated clinical service at reduced rates, direct to populations without permanent provision. A cost-effective pathway the mainstream system struggles to match. An additional design aspect is that visiting a mobile for minor surgery doesn't impact on the user's perceptions in the same way as entering a major hospital.
However, how is the wellness of the community encouraged and sustained following the mobile's departure? It is clearly undesirable in the longer term to parachute in extra surgeons of differing standards with minimal accountability. The challenge for the mobile operators is enlisting local taxpayers' support and involvement. Self-contained surgeries have the potential to bring clinical excellence physically closer, but it is the healthports that hold the key to the hearts and minds of the community.
Like a trailer camp for 'para-surgeons,' mobile facilities offer to supercede the aggregated detritus of short-term accommodation with increased versatility. However although the recovery wards may have windows, in future further thought must be given to how the very 'clinical' mobile centres might incorporate aesthetic qualities. A departure point may be to apply the healthport branding metaphor and consider how airline operators attempt to pacify and aid passenger confidence using design.
1 Global Universities Programme for Health care Architecture, GUPHA Tokyo, December 2004.
2 'Lessons From Renkioi' Conference and Anniversary Exhibition (organised by MARU and the Florence Nightingale Museum), to be held at Guys and St Thomas' NHS Trust on Friday October 7th 2005 from 10.00 am. The event is sponsored by Amec.
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