Healthcare Property Under the Microscope

Published in

Pi Labs Insights

23 min readJan 27, 2021

In a sector where outdated practices are quite literally a matter of life or death, national healthcare providers must drastically improve their understanding of the properties they own and operate if it they are serious about building long term resilience.

Existing facilities are not fit for purpose

If 2020 has taught us one thing, it’s that the current global healthcare capacity is critically low. Hospitals have become overwhelmed with COVID-19 patients, forcing long delays, or worse, the cancellation of regular routine check-ups and operations, while primary healthcare does not yet have the ability to absorb patient spill over. While many will turn towards imminent vaccination as a medium-term solution, how to add long term resilience and much needed capacity to the healthcare sector is not so obvious. Against the backdrop of mass media attention in global drug development, it seems one integral part of healthcare provision has so far been largely overlooked: Real Estate.

“Most healthcare providers have significant investments in real estate and facilities, yet these assets are often overlooked as a necessary cost of doing business.” [1]

80% of health care is delivered in primary care environments. A figure which has likely increased as a result of COVID-19, with more than 52% of 7,000 UK GPs reporting that since the pandemic started they have had to provide more patient care that would normally be delivered in hospitals, mostly from unequipped premises, leading to undue delay and unsatisfactory outcomes[2].Despite these startling figures, very little is known about the design of primary care spaces, with most architectural studies choosing to focus on hospitals[3].

Recent patient survey results[4] suggest that confidentiality in most GP surgeries is a key issue, particularly the risk of being overheard at the reception desk or when telephoning practices. 58% of respondents felt that there was not enough space at their practice to allow reasonable privacy, while 40% stated that their GP practice was a poor environment that made them feel anxious or stressed. While in the UK, it is reported that 50% of GP practices have seen no investment in their premises in the last decade, leading to 40% of GP’s revealing that their premises are not fit for purpose and 80% of GP’s fearing that their facilities will not be fit to cope with future demand[5].

Accordingly, more than 15.4m general practice appointments are being wasted each year because patients do not turn up and fail to warn surgeries that they will not be attending. This accounts for 5% of all appointments being missed, without enough notice to invite other patients. Just under half of these, 7.2m are with family doctors, adding up to more than 1.2 million GP hours wasted each year — the equivalent of over 600 GPs working full time for a year. With each appointment costing an average of £30, this puts the total cost to the NHS at more than £216m pounds on top of the disruption for staff and fellow patients[6].

If the UK government is serious about its recent announcement to facilitate the expansion of GP practice teams and improving access to more patient services in primary care through in-person or tech enabled delivery[7], there is an urgent need to turn towards PropTech to do so effectively and efficiently. However, despite the amazing modular construction feats of the Chinese, assembling a temporary hospital in Wuhan in only two weeks in response to pandemic induced demand[8], it is not enough to simply build more, especially as government budgets around the world begin to tighten through post-COVID-19 fiscal policy. The industry must look to build better, while upgrading and better utilising the existing primary care stock.

PropTech and patient satisfaction

There is a large body of research suggesting that bright, comfortable and well-designed healthcare premises reduce anxiety, promote healing and have a positive effect on patients and staff[9]. It is somewhat worrying then, that so many GP buildings are perceived inadequate and lacking in a comfortable environment for patients. In a recent survey, an overwhelming majority of patients believe that their experience within GP surgeries could be improved through better internal design[10]. Most notably, these design features include environmental factors such as air quality and temperature, as well as the quality of amenities and optimal layout. These are four areas currently being targeted by novel PropTech solutions.

Figure 1: Patient suggested GP surgery improvements (n=611)

Studies have found that perceived quality of care is greater for waiting rooms that were nicely furnished, well-lighted, contained artwork, and are warm in appearance versus waiting rooms that had outdated furnishings, were dark, contained no artwork or poor quality reproductions, and were cold in appearance[11]. These factors are all easily optimised through the use of virtual staging software during the design stage of any new project, such as offered by start-up Propster. Their proprietary algorithm is able to set up the most suitable configuration of any space within only a couple of minutes. Based on various parameters such as location, budget and demographics, their platform allows users to create a product and service selection to better meet consumer needs and market standards.

Perceived quality of care is also linked to indoor air quality, affected by particles in the air, chemical pollutants, and environmental contaminants. While there is no way to keep a common area like a waiting room 100% germ-free, there are ways to boost the air quality, reducing the impact of waiting time on the patients overall perception of care quality[12]. Additionally, research cites decreased incidence of infection are directly related to filtration of indoor air and laminar airflow, while air quality has also been successfully associated with several self-reported symptoms of medical staff, such as a dry skin, fatigue, nasal inflammation and ocular symptoms[13].

Start-up 720 Degrees combine artificial intelligence (AI), indoor environmental quality data and measurements of organisational behavioural in order to improve the indoor environment. Their cloud platform is able to recognise whether indoor climate and air quality targets are met, delivering real time insights on how ambient conditions, occupants and property systems are affecting the quality of the indoor environment, and automatically adjusting systems to optimise outcomes.

In fact, the optimal performance of a buildings heating, ventilation, air conditioning and lighting systems has also been proven to positively impact the wellbeing, satisfaction and productivity of its occupants[14]. With high performing buildings holding further financial benefit to occupants through reduced employee absenteeism due to sickness and an increased retention rate, leading to fewer lost working hours spent re-training new staff[15]. While the ability of PropTech to aid in energy management highly aligns with the NHS commitment to becoming the world’s first net zero carbon health system. However, as with all legacy real estate, this will be no easy task, as NHS properties are one of the biggest contributors to carbon emissions. generating almost one-fifth (18%) of all emissions from non-domestic buildings in the UK, at a cost of £600m, before factoring in excess carbon emission, the impact of fossil fuel and excess water usage[16].

This is an area targeted by Demand Logic, who are automating the delivery of optimal indoor environmental conditions. Their smart building management optimisation platform provides live data intelligence on how a building is operating in real time, in particular the Heating, Ventilation and Air-Conditioning (HVAC) systems, utility meters and any internal environmental sensors, such as those used for temperature, CO2, air-quality, humidity and occupancy. This not only improves the delivery of patient and staff comfort, but has the added benefits of both a reduction in energy demand and the predictive maintenance of any malfunctioning systems.

“As a hypothetical example, if a health system successfully implemented cost-containment measures (utility controls, contract re-negotiations, or other measures) to reduce real estate operating expenses by only $0.50 per square foot across a one million square foot real estate portfolio, they could save $500,000 annually. Consider the impact over a 10-year time period: $5 million in savings. Straight to the bottom line and available for reinvestment in other healthcare services — physician alignment, technology, or new facility development.” [17]

The promise of predictive and efficient maintenance is especially pertinent considering that the 2017 Naylor Review of NHS property and estates was explicit in highlighting the estate’s maintenance shortcomings. The report cited a 9% rise in backlog maintenance between 2014/15 and 2015/16, totalling around £5bn in works required, with £1.5bn of this in London. While no equivalent national data is collected on the maintenance of the privately owned primary care estate representing approximately 5000 GP practices, the Naylor Review suspects that its age and condition is no better than those 1500 GP practices owned by NHS provider trusts[18]. In some cases, maintenance costs have soared so high that GP surgeries have become financially unviable and had to close all together[19].

Plentific are one PropTech start-up who help overcome this issue, offering hassle free maintenance booking. Working with landlords, Plentific transforms how they deliver repairs and maintenance services through a powerful marketplace SaaS platform that empowers landlords and property managers to launch and manage their own fully flexible contractor supply chain. In a similar vein MediShout offer staff a quick and simple platform for instantly reporting equipment malfunctions to the managers who can solve these issues, allowing staff members to operate more efficiently and therefore provide better patient care.

PropTech and provision efficiency

The focus on staff efficiency is perhaps one of the more overlooked features in GP surgery design. In fact, in general, medical staff are less satisfied than patients with spatial layout, thermal, air, acoustical and visual quality of their surroundings[20]. When these statistics are added to the latest workforce figures from NHS Digital, which show the number of full-time equivalent GPs in England is continuing to fall — dropping by 651, from 28,256 to 27,605, between June 2019 and June 2020, with a third of practices in London currently carrying GP vacancies and two-fifths with impending retirements[21] - then never has there been a more pressing time to focus on the wellbeing and efficiency of those who work in GP practice, prolonging the life of existing physicians, while attracting and retaining new talent.

Research into the layouts of medical buildings find that those with high intelligibility (the degree to which what can be seen and experienced locally in the system allows the large–scale system to be learnt without conscious efforts) tend to have shorter duration of activities and conversations, more democratic work culture, higher rated teamwork and communication and consequently better quality of care[22]. Time saved walking is translated into more time spent on patient-care activities and interaction with family members[23]. Workplace design that reflects a closer alignment of work patterns and the physical setting has been shown to improve workflow and reduce waiting times, as well as increase patient satisfaction with the service[24].

Figure 2: Example of intelligible (top) and unintelligible (bottom) patterns.

Start-up Archilyse offer a tool for 3D floorplan optimisation, allowing for a greater understanding of how the design of any space impacts the social experiences which take place within. Their data has previously been applied to assessment of medical facility quality by researchers at the University College London[25]. While new concepts coming from the office market also have a clear healthcare use case. Bright Spaces 3D virtual staging tool offers occupiers online tours that resemble live visits and provide the opportunity to interact with multiple fit-out proposals in order to identify optimal internal design prior to any significant capital expenditures.

“Data obtained through computational and statistical tools promises to revolutionise the way we understand our work environments as well as the design and policy decisions that emerge from them.” [26]

However, the pace of developments in the HealthTech sector means that even more satisfactory and efficient in person care may soon itself become outdated.

The GP surgery of the future

Time and time again, access to GP surgeries and availability of appointments ranks as the biggest patient dissatisfaction with current healthcare provision[27]. Average UK waiting times for non-urgent GP appointments have grown from 12.8 days in 2016 to 14.8 days in 2019[28]. While even once inside the GP surgery, long wait times are a key source of patient misery with 30% of patients in the US having walked away from an appointment because of a long wait and 20% having changed doctors due to wait times[29]. While this statistic may not be directly transferrable to the UK, it is no secret that in surgery wait times are also a major issue.

Figure 3: Reasons for dissatisfaction with the NHS (n=2926)

We have already highlighted how wait times can become an altogether more pleasurable experience, directly impacting the perceived quality of care. However, technology now exists which aims to eliminate any patient waiting time at all.

Apps like QLess are able to give patients an estimated wait time prior to their arrival. It even allows patients to join a virtual queue which updates them on their position, giving them the option to spend their wait time somewhere more desirable. Patients can also alert staff remotely if they are running late. While such apps are a great step in the right direction, the real disruption to patient wait times will come from the advances in telemedicine and remote diagnosis, rapidly becoming normalised due to the coronavirus pandemic.

The ongoing global crisis forced healthcare institutions and regulatory bodies to turn to alternative ways of providing healthcare while limiting exposure to the virus. Both the CDC and WHO are advocating for telemedicine to monitor patients and reduce risks of them spreading the virus by traveling to hospitals. Over 70% of GP consultations in England were carried out face-to-face prior to the COVID outbreak; within weeks the figure was 23% [30].

“By deploying advanced telehealth solutions, physicians are expanding their reach, even if quarantined, with the ability to remotely examine and diagnose more patients in a shorter amount of time, minimising the number of patients entering medical facilities” [31]

It comes as no surprise then that HealthTech drew around $10bn of US and European VC investment in the first three quarters of 2020, compared to $8.8bn in the same period last year. With 42% of this funding going into ‘alternative care’ — a categorisation that includes services like telemedicine and mental health platforms[32]. This sector will only grow with data revealing that while before the pandemic only one in ten US patients used telemedicine service[33], this number has doubled during the last 9 months[34], with seven in ten people who used a telehealth service saying they would continue to do so[35]. Additionally, 94% of people who sampled telehealth, in the form of synchronous virtual visits, for the first time during COVID reported satisfaction with the ease and convenience and expressed interest in other modes of virtual care, such as digital monitoring and at-home lab testing[36].

Figure 4: HealthTech saw increased investment due to COVID-19

This comes as great news for already overstretched hospitals and GP surgeries, as findings suggest that 71% of emergency room visits are unnecessary and avoidable. 42% of these required immediate attention for conditions that could have been safely treated in a primary care setting, 24% did not require immediate attention and 6% required emergency care that could have been avoided with appropriate primary care[37]. It is clear that upwards of 30% of all A&E visits could be reduced by the rollout of an effective, technology based, remote primary care strategy. Just as important, analysis of 14 US hospitals with telemedicine services found that patient wait times reduced by 6 minutes on average when compared to those facilities that didn’t use telemedicine[38].

“Telehealth technology allows doctors and specialists to spend less time transitioning between patients and more importantly, the ability to offer care during off-hours, Telehealth solutions can prevent late arrivals and no shows, eliminate time needed to travel to the office visit, and improve the efficiencies of documenting patient information” [39]

While most of the recent growth in telehealth has been around virtual visits, its potential lies in connecting longitudinal data across the entire patient journey — from wearables and remote monitoring devices and self-care apps to the electronic healthcare system record of care[40]. The improved efficiency of documentation offered by telehealth consultation will only further enhance the efficiency at outdated practices where studies show that for every hour physicians spend face-to-face with patients, 2 additional hours are spent on updating electronic health records and desk work within the clinic day[41].

However, critics warn of primary care physician burn out through the increased use of telehealth consultations, where in surveys fielded over the past few years, a third or more of physicians regularly report symptoms of burnout[42], while more than half say those symptoms have increased since the onset of the current public health crisis[43] – even more reason to focus on our earlier smart building determinants of staff satisfaction. While wellness technologies such as Thrive Reset are using neuroscience findings which show that humans can course-correct from stress in 60 to 90 seconds to readily integrate with video call technologies to provide a sense of respite and calm between meetings[44].

Regardless of these teething problems, it’s clear that the inevitable en-masse roll out of new HealthTech over the next decade will have a huge impact on how and where primary healthcare is delivered. This will drastically impact the functions that the existing real estate and digital infrastructure stock will have to fulfil.

It has been well documented that fully remote GP practises won’t be in anyone’s best interest[45]. However, where this sweet spot between in person and remotely administered primary care, and those procedures which are outsourced from hospitals to primary care is, has yet to be revealed. But one thing is for sure, it’ll certainly be a lot different from how it is now, with the NHS announcing their ambition for every patient will have the right to be offered digital-first primary care by 2023/24[46].

Case Study — Assura’s surgery of the future concept

A 2015 public poll revealed the following choices for what the vision for General Practice in the future might look like: weekend access (58%), digital reception areas (50%), Wi-Fi connections for patients (42%), other health services onsite (31%), 24 hour a day appointment slots (33%), ability to consult with specialists through a web or video link (29%)[47]. These very much align with The Royal College of Practitioners ‘Vision for General Practise’ in which 3000 medical professionals and patients outlined what they believed to be the future of healthcare in 2030[48]. It comes as no surprise then, that these are all aspects being targeted by UK Healthcare REIT, Assura’s ‘surgery of the future’ concept:

The building will be designed around both remote video consulting and face-to-face appointments, incorporating point-of-care diagnostics so patients make fewer journeys for further tests. Digital media throughout the building will help staff share information and patients to feel calm. Patients will also be able to access NHS health apps on tablets, while a ‘check out’ screen will automatically send their appointment and prescription details to mobile devices[49].

“In the coming decades, surgery building design will have to reflect the way primary care is using technology. As elements like remote consultation and point of care diagnostics become more familiar, they will change the way GPs and their teams use their space. There’s huge opportunity for the building design to work with technology to help teams to be flexible. This specific design wouldn’t work everywhere: primary care premises must be right for the communities they serve. But many of the principles reflect the experiences the NHS wants us all to have as patients.” [50]

However, at present, this very much remains a concept, and one solely targeted at new build projects. While great for highlighting the ability of new technologies, it does little to address the underperformance of the existing stock, where it stands to reason that very few primary healthcare facilities are utilising PropTech in any capacity. PropTech that we have shown is able to optimise building layout, waiting room design, staff efficiency, patient satisfaction, maintenance schedules, waiting times, and remote consultation, all leading to enhanced healthcare provision, reducing the overall burden on the NHS, and ultimately, the tax-payer.

This problem is not one of owner or occupier will, or a lack of availability of beneficial solutions, but one of financial incentive, rooted in an outdated valuation practice, which monetises a GP surgery based on the size of the plot and not on the quality of care it is able to provide.

The valuation paradox

The current financial model through which primary care is being supplied clearly isn’t working. In fact, 502 GP practices have had to close in the UK over the past 5 years, forcing 2 million patients to find a new primary healthcare provider[51].

Figure 5: Number of UK GP closures and patients effected, 2013–2019

The largest cost in a facility’s lifecycle is staffing, operations and maintenance, followed by construction, equipment and furnishings. The smallest percentage of cost is planning and design, but these arguably have the largest impact on how well the whole facility operates, contributing to the overall cost-effectiveness and ROI[52].

More than ever, healthcare designers are responsible for crafting environments that provide quantifiable improvements in organisational effectiveness and patient outcomes and satisfaction. A cornerstone of this practice is evidence-based design, characterised by the use and generation of scientific evidence in order to support decision-making for more predictable outcomes. An evidence-based healthcare design should result in demonstrated improvements in the organisation’s clinical outcomes, economic performance, productivity, and/or customer satisfaction[53].

However, as we have shown, currently very little evidence exists that offers a direct link between the inclusion of PropTech or HealthTech and staff or patient outcomes, despite an overwhelming wealth of indirect and anecdotal evidence which has been presented throughout this case study. In fact, the rent reimbursement mechanism has been in place for 70 years since the NHS was founded in 1948, and yet despite the advances in healthcare provision in this time, the principle has remained unchanged by any of the 19 consecutive governments since[54]. As a result, the NHS district valuer does not place a financial value on the inclusion of digital building technologies into their GP rental reimbursement model.

Figure 6: A typical GP rent reimbursement structure

The lack of financial value attached to potentially beneficial technology is creating a split incentive problem. This is defined as a circumstance in which the flow of investments and benefits are not properly rationed among the parties to a transaction, impairing investment decisions[55].Put plainly, a GP is not incentivised to spend money on PropTech as they will not be reimbursed via the current NHS model, and a landlord is not incentivised to input such technologies as they are unable to charge a higher rent. Yet all the while, the inclusion of these technologies will improve patient outcomes and staff efficiency, saving the NHS money and providing a clear and immediate ROI. In fact, this is a point noted by the NHS themselves in their June 2019, General Practise Policy Review:

“Although the NHS is responsible for reimbursing the [rental and operational] costs, it is not able to directly influence cost incurred and there is no actual incentive within the system for GPs to drive costs down or seek cheaper alternatives where such costs are within their control” [56]

The much needed innovation adoption is further stifled by the 20 year lease terms accepted by tenants, creating a low incentive for landlords to modernise premises to ensure occupier retention, and the lack of available substitutes for both GPs and patients who may be disgruntled with their healthcare premises, but unable to access any alternative. Unfortunately for PropTech, this is unlikely to change, as the long leases backed by public sector tenants provide bond like security that underpins the investment rationale into the sector and any shortening of lease terms would likely mean even lower levels of investment.

To further highlight this paradoxical issue, lets revisit our earlier example of the GP surgery of the future. This tech enabled building will be able to increase the efficiency of staff and quality of care provided to patients. It will operate with lower maintenance cost and require less energy, saving further time and money. As the digital infrastructure of this building has been delivered to a modern standard, it is able to roll out a telehealth consultation programme which further increases the efficiency and catchment area of the care provided. It also allows a GP surgery to reduce the space required for waiting rooms, as there are fewer patient delays and less in person visits. The value generated to the NHS from such a smart building would be exponentially more than its analogue counterparts. However, as this premises has now reduced in size and is servicing fewer in person patients, the outdated valuation metrics used by the district valuer means that the NHS would actually be reimbursing this premises less, not more.

It seems ridiculous that in this day and age, with all the modern data available, that the current healthcare system still values a building based on where it is, and not on what it actually does. Never has this outdated practice been more greatly highlighted than the recent high profile Babylon case:

Babylon, which runs a digital-first service GP at Hand, enabling people to access GP consultations 24/7 on their smartphone, bid for rent reimbursement totalling £400,000 for two London sites. This figure amounted to only 40% of the average cost per patient which conventional practices in London are reimbursed. However, for the third year in a row, this claim was rejected as the costs of this telehealth service had not been factored into the local district’s financial plan, neither were the sites included in their estates development plan for future funding.

Paul Bate, Babylon’s Manging Director, spoke of the issue:

“Three years on we’re still in a position where, despite a lot of sound policy and statements publicly about supporting tech firms and supporting innovation, we’re disadvantaged compared to all other practices because we don’t receive the reimbursement. We’re concerned that the message being sent is that a digital-first provider like ourselves can have no guarantee or confidence that they will be reimbursed on a like-for-like basis with other practices.” [57]

In fact, this valuation paradox is not a problem unique to healthcare, with industry bodies such as the RICS[58] and Liquid Real Estate Inonvation[59] calling for an overhaul to the standard ‘red book’ method of valuation to include more technology enabled, social indicators of asset performance. However, in a sector such as healthcare, where an update to current practices is quite literally a case of life or death, these emerging valuation principles should be applied as a matter of priority.

This is a view shared by the aforementioned Naylor Review, which suggests that the NHS consider linking GP payments to the quality of facilities and greater use of fit-for-purpose standards[60], as well as the Kings Fund, whose report ‘Clicks and Mortar’[61] calls for technology and the NHS estate to be brought together as part of wider plans for change, developing an overarching vision for how health and care will be delivered in the future and being clear about the role of technology and the estate in delivering it.

This was something hinted at prior to the pandemic as the NHS sought industry consultation regarding how to reimburse digital first primary care[62], primarily regarding amendments to the out-of-area registration payment and new patient premiums paid to those GPs who are able to provide a wider and comprehensive digital catchment offering. However, whether any change occurs is yet to be seen.

Building healthcare resilience

A recent report from the Royal College of GPs, General practice in a post Covid world, called for further commitments to digital technology to enable remote monitoring, digital consultations, flexible working and better sharing of data[63]. If the future of primary healthcare is patient centred and tech driven, then there is a need for new indicators of a GP surgery success to be incorporated into its valuation decision, so that those ‘smart buildings’, better able to provide a higher quality of care, are accurately rewarded, while ensuring that a more satisfactory equilibrium level of remote versus physical consulting in primary careis established.

Accreditations of buildings ability to meet these changing standards already exist, such as WiredScore, which targets the quality of digital infrastructure in any given asset, and the WELL Building Standard, which incorporates measurements of lighting, access to good food and water, fitness facilities, and clean air, promoting the wellbeing of occupants[64]. In the office market, there is now evidence that assets achieving these ratings are able to fetch a rental premium[65]. However, studies of more traditional healthcare accreditations in the US find that accredited buildings often perform worse than non-accredited buildings in perceived patient care and warn that the emerging data should add some caution to the excitement that accreditation alone will offer that assurance of high-quality care[66].

“Accrediting bodies should focus on those processes and structural factors that have been convincingly shown to be associated with good outcomes. The current approach leaves too much room for focusing on things that aren’t important, often leading to a lot of work but not better care. If we change the way we approach accreditation, we can ensure that we are actually providing quality care for all.” [67]

While there are huge ethical considerations which make defining and measuring the “success” of any healthcare premises extremely hazardous, the NHS currently publish a league table of all GP surgeries in the UK based on their annual patient survey[68]. This data could be combined with publicly available, GDPR compliant data sets, such as the total number of patients cared for, the percentage of missed and cancelled appointments per year and, dare I say it, hyper-local health statistics, all normalised across population demographics, catchment area, and the number of GPs registered at each premises, for example. This would give a good indication of those surgeries operating with both high quality and high efficiency as a basis for accreditation.

Perhaps once the current dust settles and the future of in person vs remotely administered primary care becomes clearer, new NHS valuation practices may emerge. In anticipation, we believe that the NHS should get one step ahead, using these available data to commission an independent report into the real estate specific design and amenities across this sample of ranked GP surgeries, in order to begin to identify those features which warrant additional attention at valuation. Such understanding would help to design a system able to accurately reimburse GPs, and ultimately the landlords, of these premises for installing technology that is essential for improving the quality of healthcare they are able to provide.

The result would not only be improved patient satisfaction, staff efficiency and landlord return, but it would also reduce the long term cost to the NHS while offloading the strain on their struggling hospital infrastructure. Indeed, if the NHS is serious about building healthcare resilience, it first needs to correctly value the technology in its properties which are best able to provide just that.

References

1. https://www.realtytrustgroup.com/healthcare-real-estate-optimization/

2. https://www.gponline.com/hospital-tasks-dumped-half-gps-covid-19-creates-tsunami-extra-work/article/1687310#:~:text=COVID%2D19-,Hospital%20tasks%20dumped%20on%20over%20half%20of%20GPs%20as%20COVID,creates%20'tsunami%20of%20extra%20work'&text=GPs%20are%20facing%20a%20'tsunami,hospitals%2C%20the%20BMA%20has%20warned

3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2441527/

4. https://www.necsu.nhs.uk/wp-content/uploads/2019/03/2019-01-PatientsViewsOnMakingBestUseOfGPPremises.pdf

5. https://placetech.net/analysis/invest-in-tech-to-protect-the-nhs/

6. https://www.england.nhs.uk/2019/01/missed-gp-appointments-costing-nhs-millions/

7. https://placetech.net/analysis/invest-in-tech-to-protect-the-nhs/

8. https://news.sky.com/story/coronavirus-chinese-hospital-built-in-two-weeks-is-to-close-after-last-patients-leave-11973367

9.https://www.healthdesign.org/system/files/Ulrich_Role%20of%20Physical_2004.pdf

10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2441527/

11.https://www.sciencedirect.com/science/article/abs/pii/S0272494402902744