1 Background

The infrastructure that supports built health systems require significant levels of finance. Decisions associated with the physical scale, scope and distribution of services across health systems is critical [1,2,3] and directly impacts a range of issues from quality, safety and workforce to patient flow, equipment location and access. However, the quality of built health system evidence is rarely seen as a key factor in improving outcomes [4], quality [5] or hospital performance [6, 7]. Over time, evidence to inform such decisions has been fragmented into different formats, sources and levels of access [8,9,10,11,12,13,14,15]. Therefore, standard ways are required to interpret the methodological and interdisciplinary variations when undertaking systematic literature reviews to support built health system infrastructure reconfiguration. This article presents a new built health system review framework that will help decision makers to assimilate evidence when (a) developing infrastructure capital budgets and designing input specifications (e.g. questioning how infrastructure will increase productivity, reduce harm, drive innovation or increase sustainable resilience), (b) agreeing infrastructure performance outputs (e.g. questioning how infrastructure will advance experience, build human capital, support prevention or increase access) and (c) prioritising specific infrastructure health outcomes (e.g. questioning how infrastructure will promote health and create wellbeing).

Healthcare systems, and hence evidence of how they are built, must be kept up to date to meet current and future health challenges. This requires continuous discovery to identify efficiencies, service innovations and new ways to build resilience [14, 16,17,18]. However, disciplinary boundaries give rise to methodological, interdisciplinary and theoretical issues, necessitating an ongoing process of interpretation. There is interdisciplinary evidence from domains as diverse as economics, evidence-based medicine and design, and issues ranging from how patients access care along a pathway of interventions, to implementation of innovations in telecare, telehealth and eHealth [19], reconfiguration of urgent care services in community settings [20,21,22], and divestment from outdated assets. Unsurprisingly, with such a diverse evidence base, whole-systems reconfiguration evidence is seldom adequately integrated into capital investment planning and built health system policy.

In this article, we examine five literature review studies that have informed healthcare infrastructure reconfiguration policy. We investigate the application of scoping, systematic, rapid, realistic and narrative reviews to understand their impact, and compare their methods, benefits and limitations. The findings highlight the interdisciplinary nature of the evidence and suggest how such evidence may contribute to both theory [23, 24] and policy [25].

1.1 Need for built health system reconfiguration evidence

We must consider what is meant by evidence and how it is used to inform decisions on built health system infrastructure. A systematic review uses systematic, reproducible, transparent methods to identify, select, critically appraise and analyse data from all available research pertaining to a clearly formulated question [26]. Systematic reviews of healthcare systems typically focus narrowly on a specific place (e.g. school, environment, neighbourhood), setting, building type or characteristic [27,28,29,30,31], and on a range of health outcomes (e.g. health, obesity, harm or physical function) for a specific population group (e.g. students, obese patients, middle-aged to older adults). These studies into public health clearly identify what is known, the quality of that information, and what is not known. However, systematic reviews of built healthcare system reconfiguration are rare. In the building of hospitals for example practical guidelines and expert opinions are more prominent in influencing policy and practice. It is accepted that evidence varies in quality and credibility [32,33,34], ranging from expert opinions and best practices that perhaps lack scrutiny, to more measurable evidence in terms of its influence on outcomes. What constitutes evidence on infrastructure reconfiguration is much debated, and across all levels of decision making there may be manufactured recommendations, implicitly biased toward self-interest or commissioners’ preferences.

In order to enhance the evidence associated with built health system reconfiguration policy, we address the methodological, interdisciplinary and theoretical challenges of systematic reviews of healthcare reconfiguration. This requires an interdisciplinary and integrative process [35] for agreeing actions based on diverse evidence bases, capabilities and methodologies. In addition to impact [36, 37] there is a need for co-production of evidence to support whole-system reconfiguration [14, 38,39,40,41] to mediate multiple competing interests [42, 43].

1.2 Use of built health system reconfiguration evidence to inform policymaking

To translate the literature into built health system reconfiguration policy there is a need to encourage the flow of knowledge to move away from a ‘decide–announce–defend’ approach to policy decisions [44, 45]. This requires collectively agreeing what constitutes ‘good’ evidence [46,47,48] and understanding its messy and complex nature [49]. This requires interpretation, because ‘good science, even when it is well packaged and accessible, does not guarantee good policy’ [50]. A literature review must respond to structural and capability changes [51] and co-evolve over a longer term [52]. In this process, researchers may act as intermediaries (e.g. preparing, briefing, presenting), translators (e.g. formatting, simplifying for the audience, contextualising), brokers (e.g. playing an active role in decision making, using the evidence, co-producing or advising on its use) or system-level facilitators (e.g. innovating, changing conceptual understandings, establishing further funding or new support networks).

In the context of built health system reconfiguration, the process of evidence creation and use is fragmented by the complexity of existing built healthcare systems and configurations. This requires a facilitated flow of knowledge across research and policy environments [53,54,55], and the rigorous analyses of goals, strategy and policy design and implementation [56] to respond to context [57,58,59].

Policy formulation on built health system reconfiguration may begin by asking ‘how do we achieve the desired policy outcome?’ However, the scope of this question is ‘big’, ‘holistic’ and integrative, involving many steps, interventions, conditions and interacting solutions [50] that allude to scientific methods and causal demonstration. Policymakers must establish evidence hierarchies and understand levels of caution in recommendations [32]. For example, Stetler [60] defines levels of evidence and Pati [61] do this in relation to healthcare built infrastructure design. To ameliorate overreliance on less trustworthy sources, a homogeneous built health system reconfiguration evidence base is needed [62]. Evidence provides decision makers with more ‘deliberate’ guidelines and forces the use of so-called ‘best available’ resources and methods [33]. This requires translation and effort, as non-scientific internal sources are often more readily available and accepted [63].

1.3 Methodological challenges in achieving a homogeneous evidence base

There are methodological problems in integrating built health system reconfiguration evidence for use by policymakers. Scholars are therefore central to facilitating co-production in the interplay between evidence and policy, to address methodological challenges by drawing comparisons across multi-level [27, 28] and multi-intervention [29, 64] healthcare settings. For example, in agreeing resource commitments to infrastructural investments in urgent and emergency care, policymakers will often need to consider evidence from multiple settings and interventions. These settings may be major trauma centres, emergency departments, GP-led urgent treatment centres, minor injury units or nurse-led walk-in centres. Local contexts vary significantly with differing demography and health needs. Furthermore, alternative interventions may be employed across these settings. For example, urgent and emergency care demand management may require less investment in infrastructure. Diversions using telephone services, paramedics, direct referrals or other out-of-hospital interventions (e.g. for the elderly or those with chronic conditions) will not need investment in secondary-care settings, but may require investments elsewhere. Alternatively, policymakers may choose to address ED triaging, fast-tracking or waiting times, or set targets for discharge, point-of-care testing, ICU capacity or bed management. Without homogeneous evidence on built health system reconfiguration, it is almost impossible for policymakers to understand whole-system infrastructure investment decisions and use the most appropriate local, regional or national evidence. This article examines how multi-level, multi-setting and multi-interventional built health system reconfiguration policy might best be supported. This requires us to synthesise the evidence and use various approaches to reviewing it [14, 32, 41, 65,66,67,68], and to design research [69], build frameworks and establish methods for systematic evidence reviews [70, 71].

1.4 Evidence review types and processes

In this section, we classify the various types of evidence-based literature review and identify ways in which evidence can be simplified for use. Then we propose a new framework using questions to support evidence-based policy. Given the heterogeneity of evidence on reconfiguration, it is critical to select a review design that facilitates integration of the various interdisciplinary sources, including quantitative, experimental and systematic approaches and more pragmatic reviews [69, 72, 73] and to learn about the merits and limitations of their use and capabilities required to deliver them [74].

Irrespective of its source, evidence must be deemed credible if it is to have any influence. However, expert opinions and views on the robustness of research designs are likely to differ, raising the need for interdisciplinary research [75] and theorisation [76]. In the field of evidence-based policy [65], Pawson [77] prioritises the process of evidence review and use during the design phase [62, 78, 79], and highlights a need for evidence that is context-specific, stakeholder-relevant and explicit about the evidence-use community [80]. Furthermore, the cost-effectiveness of impacts, such as return on investment, and incentives must be agreed [80].

Miller and Jones-Harris [81] link the suitability of study methodologies with the types of question being asked. They outline an alternative evidence framework based on eight categories of questions typical in clinical practice [82,83,84]. Simplifying evidence into pathways provides a useful means to integrate it with patient care and classify its strength. Such an approach may provide a conceptual basis for structuring the evidence on built health system reconfiguration, by revealing intrinsic links between the built environment of healthcare (physical building sites, buildings, departments and rooms) and health gains in the healthcare system or in the population more broadly.

1.4.1 Evidence-based literature review study design and policy impact

The research design of five evidence-based built health system literature reviews are now described. Each had various infrastructure reconfiguration impacts and Appendix 1 contains a fuller description of the outcomes of these studies. Figure 1 illustrates emergent interactions between policy, literature review evidence and built health system reconfiguration interventions and theory development.

Fig. 1
figure 1

Interface between policy, literature review evidence, health and infrastructure interventions and theory development

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In literature review Study A, an interdisciplinary and integrated approach was taken to the development of Department for Health policy, informed by the literature, and this effective empirical investigation drove a new clinical intervention relating to dementia. Critical to this review was an interactive and abductive approach to evidence and impact co-production. Literature review Study B indirectly informed hospital lending policy in an Investment Bank. The literature review commissioning process was relatively linear, with few clinical interventions specified and limited measurable impacts. Literature review Study C directly influenced a National department for healthcare facilities, and involved interdisciplinary working and translation into policy and practice. Literature reviews D and E were performed for academic purposes and so indirectly impacted policy and deductively narrowed the literature sources based on specific methodological grounds.

Having described the literature review study design and its influence on impact, the next sections summarise the various literature reviews method types, which were dependent on the research questions and policy need [72]. Definitions of the systematic, scoping, rapid, realistic, narrative review types are contained in Appendix 2.

1.4.2 Study A: realistic review of dementia-friendly environment reconfiguration

This realistic review was focused on a specific intervention—dementia, using and creating evidence by combining literature and primary data collection. The review supported a £50 million ‘Improving the environment of care for people with dementia’ programme, which custom-designed care facilities in health and social care environments for people with dementia. A multi-method research methodology was adopted, using a rapid literature review as a basis for creating an evaluation tool, which was then used to analyse 115 nationally coordinated pilot projects [85]. The review considered the expert opinions of policymakers, architects, social scientists and dementia and clinical stakeholders, and led to the co-production of a new national standard [86] on dementia-friendly health and social care environments.

Many international sources were reviewed, including research articles, reports, and government and non-governmental codes of practice [15], with the intention of enabling consistent measurement of expected outcomes [87, 88]. The aim was to understand how design of the built environment might mitigate the escalating costs of dementia care. The results were enriched with primary data collected to understand built-environment interventions and their costs [15].

This realistic review revealed opportunities for interdisciplinary and integrated evidence-based built health system reconfiguration, and supported the development of costed policy support tools.

1.4.3 Study B: narrative review of infrastructural investment to support health gains

This narrative review provided evidence of the contribution of investments in built health systems to health gains, with particular reference to hospitals. The review team, which included a healthcare planner, an economist, an investor and social scientists, worked together to select literature and build a logic between the fields of evidence. The review was descriptive and user-friendly to enable funders to understand the evidence, and drew together various fragmentary evidence, including from economic infrastructure investment appraisals, evidence-based medicine and design.

A review of 25 systematic reviews, a PubMed keyword search (revealing 521 additional publications), a cited reference search (producing an additional 211 cited articles), and a subjective quality evaluation, resulting in the selection of 160 studies for full review.

Although evidence from the various sources was not directly comparable, and some sources were outdated, the results revealed a need to develop a more generic health-gain measure and a future-oriented view on capital investment scenarios. This narrative review highlighted the importance of establishing a theoretical framework that would provide a strong integrative basis for subsequent research.

1.4.4 Study C: rapid evidence review of reconfiguration of operating theatre design and engineering

This rapid review summarised and synthesised research evidence to support national repeatability in operating theatre engineering and design. A research team, which included a building services engineer, an architect, a procurement specialist and a social scientist, conducted a comprehensive and systematised review. They examined academic and grey literature on the design of operating theatre suites for both emergency and elective use, and how this related to patient outcomes since 2000.

The review followed Centre for Review Dissemination guidance as far as possible [73], relating to identification of the research question and search strategy, the selection of studies, quality assessment, extraction and synthesis, with expert journal searches of BMJ and HERD. The search resulted in the identification of 147 articles that appeared to be relevant based on their title and abstract. Following more detailed examination, 55 were discarded either because they focused entirely on medical and surgical practices, or because they were guidance notes for patients. Much of the literature related to surgical operating-room procedures written by medical staff, with very few on architectural or building design. Of the latter, the majority concerned environmental studies, including heating, ventilation and air conditioning (HVAC). Terminologies and care models differed significantly between countries.

This rapid review revealed a complex array of product engineering solutions providing potential evidence for infrastructure reconfiguration, and highlighted the need for generalisation across the reconfiguration evidence to enable policymakers to make sense of the complex fields.

1.4.5 Study D: systematic review of specific clinical built health system evidence for reconfiguration

This systematic review was conducted to explore the impact of built health systems infrastructure investment on costs, patients’ health and staff experiences, to inform regional responses to national policy changes. It was limited to reconfigurations of services relating to A&E, mental health, cancer and stroke, which were receiving significant capital investment. A specific search strategy was developed to collect data from seven databases for the period 2011–2019. Quantitative and qualitative evidence was synthesised and organised to identify clusters of literature.

The evidence compiled from this systematic review provided indicative evidence, although the search strategy looked for direct causalities. Rationalising quantitative and observational studies based on their methodological quality [89,90,91] simplified the review process, but perhaps removed nuances and more generalisable findings. The exclusion of pre-2011 studies contributed to the fragmented and heterogeneous nature of the evidence. This systematic review also revealed fragmentation of the built health system infrastructure reconfiguration evidence across various clinical fields and interventions.

1.4.6 Study E: scoping review of discipline-specific studies supporting built health system infrastructure reconfiguration

This scoping review was organised to understand the need for interdisciplinary evidence in policymaking when prioritising annual capital funding for new-build schemes and hospital upgrades. The evidence was categorised into four place-specific levels: whole-system, building, department and room. Abstracts from 543 studies were reviewed, including economic and quantitative analyses, formal evaluations, qualitative studies and simulations. At the whole healthcare system reconfiguration level, 54 studies involved economic, qualitative and NHS service reviews. Reconfiguration at the scale of hospital buildings was supported by 235 disciplinary studies, including economic, post-occupancy, qualitative and simulation evidence from a wide range of fields. At the hospital department scale, 110 studies involved economic, post-occupancy, qualitative, service review and simulation research. At the room scale, 106 studies drew qualitative, quantitative, simulation and review evidence from diverse domains, including ergonomics and social sciences. Table 1 details the disciplinary domains.

Table 1 Nature of the interdisciplinary evidence on built health system infrastructure reconfiguration
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This scoping review revealed the interdisciplinary and heterogeneous nature of the reconfiguration evidence, and the complex array of settings and places that must be taken into account when providing evidence to support policy on built health system infrastructure reconfiguration design. It showed the influence of diverse scientific disciplines and their fragmentation across settings, and the criticality of establishing a common framework for evidence-based policy decision making in relation to built health system infrastructure reconfiguration.

2 Discussion

The evidence base for built health system infrastructure reconfiguration policy must be developed to deliver policy impacts. However, first we must address evidence co-production and its methodological, interdisciplinary and theoretical challenges.

2.1 Conceptualising a new theoretical foundation for built health system infrastructure reconfiguration

There is a need for a more homogeneous basis for evidence-based policy on built health system infrastructure reconfiguration. Figure 2 shows components of the healthcare reconfiguration evidence that emerged from the five literature reviews. It sets out high-level policy questions to be addressed (relating to wellbeing and health outcomes), potential performance output strategies (relating to public health, access or human capital) and infrastructural capital, design and engineering inputs. The problem of attributing causality to particular evidence in order to inform policy is well-known [92], as is the very basis of causality [93], however studies A to E contributed to our understanding of how the built health system can reduce harm, drive innovation, use its physical infrastructure assets efficiently and productively, and improve patients’ experience. Ultimately, the purpose of built health system infrastructure is to enhance wellbeing and promote health, so its roles in building human capital, supporting prevention and improving access must be prioritised.

Fig. 2
figure 2

Proposed evidence co-production framework for homogeneous built health system infrastructure reconfiguration

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This evidence-based framework allows evidence to be ‘un-packed’ and ‘re-packed’ during policy formation [94]. We need a homogeneous basis for built health system infrastructure reconfiguration evidence [76, 95] and we must design critical research, which moves beyond a fragmented intervention-led approach [23, 64, 76, 96], and provides a means to generalise, weigh and integrate evidence to support built health system infrastructure reconfiguration. This framework will focus interdisciplinary attention on the evidence, and challenge gaps between those who generate scientific evidence and the practitioners who must use it [81]. Questions can be used to evaluate the status of evidence on interdisciplinary built health system infrastructure reconfiguration (see Appendix 3). Taking each question in turn, evidence of harm is most prevalent and shows a direct causality on outcomes, although it is fragmented across disciplines, specialties and specific building and room types. Place-based evidence on built health system infrastructure for prevention (e.g. health-screening centres, diagnostic clinics and institutes of exercise medicine), equitable access (e.g. number of in-patient beds per 10,000 population or MRIs per million persons) and capability distribution (e.g. staffing of nurse-led walk-in centres versus polyclinics or GP-led emergency department triage) is perhaps more limited and requires associative (rather than causal) interpretation. Evidence on performance, productivity and experience is of moderate quality and is highly dependent on the context and purpose of individual studies. This shows the importance of classifying built health system infrastructure reconfiguration evidence more rigorously, asking questions about the evidence required and its quality.

2.2 Selection of review type and impact

Literature review studies A and C were part of a social process of learning that built sense between researchers, policymakers and wider stakeholders (e.g. to create a ‘web of influence’[97]). But perhaps could not claim to have been entirely independent or neutral [52, 98, 99], unlike systematic and scoping reviews (Literature reviews Studies D and E). Each review had different impacts, as shown in Table 2. Study A created an evolving process of learning, and built sense through a process of review that drew together actors across organisational levels and stakeholders. In contrast, in Study B there was a separation between the evidence and its use in influencing lending for hospitals. Study C involved an interdisciplinary research team operating as broker for a policymaker who translated and co-curated the evidence. This resulted in an ongoing process of interdisciplinary learning, and the researchers and policymakers subsequently developed, won and delivered a funded research proposal and extended the network of impacts. In contrast, Study D and E were independent reviews.

Table 2 Comparison of studies’ impacts on built health system infrastructure reconfiguration policy
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Further comparing these five studies reveals that each has specific benefits (Table 3). But that these are dependent on the context, purpose and involvement of the various research, expert and stakeholder teams [74]. The scoping literature review identified the size and nature of the evidence base but, perhaps because of the systematic approach to data extraction, quality and synthesis methods, may have excluded intuitively relevant literature. Rapid, realistic and narrative literature review designs achieved a spread of built health system infrastructure reconfiguration evidence and effectively utilised strategies such as expert opinions, expert tools and news analysis methods, although these may be viewed as less credible than other types of review.

Table 3 Comparison of review type and weighting of built health system infrastructure reconfiguration evidence
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Decision makers’ need for rapid and efficient synthesis of the evidence (e.g. co-produced, useful and accessible) must be balanced against the time and resources required for rigorous systematic reviews [100]. Therefore, it is critical to use such reviews appropriately.

2.3 Multi-stakeholder co-production of evidence-based policy

According to Baldwin et al. [101] the best policy outcome will involve multiple institutions and instruments. One such instrument is the evidence provided by systematic literature review. This is ‘smart regulation’ [13] for built health system infrastructure reconfiguration. We have shown that a reflexive and adaptive approach will see evidence, and action (decision making and interventions) proceed simultaneously [102] to create adaptive evidence and policy [102]. There are important lessons on how evidence and intervention co-emerge in the social practice of health system infrastructure reconfiguration, and how evidence-making and intervention proceed through dialogue, incorporating multiple forms of evidence and expertise, and resulting in more mutually beneficial evidence creation, capture and use. We reflect on the ways to bring academics who perform systematic literature review together with those who deliver healthcare output performance (health systems regulators and providers), those who can best judge outcomes (patients and public health professionals) and those who develop design standards and specifications (usually consultants and private infrastructure providers) -see Fig. 2 (right label).

2.4 Methodological, interdisciplinary and theoretical implications of selecting a systematic review

Co-producers must understand the methodological issues when designing the comprehensiveness of a literature review. We shed light on the nature of review methods and their use to inform evidence-based policy in built health system infrastructure reconfiguration. Co-production of evidence is critical; however, key methodological, interdisciplinary and theoretical decisions must be taken when co-producing a review. Choices of the nature of the evidence and review type (e.g. heterogeneous versus homogeneous), between the substantive setting and the evidence nature (e.g. interpretation versus specificity), and between review type and substantive setting (e.g. exploration versus impact) must be carefully considered. Scholarship plays a key role in the co-production of evidence synthesis as a knowledge broker across different disciplinary perspectives.

Various scientific enquiry and review types will be required to focus policymakers on directed, closed review questions that test specific variables derived from clear hypotheses, in addition to more interpretative and open-ended reviews to simplify complex literature for use by policymakers [103,104,105]. Together, review co-producers must ‘carve out’, and address ‘tensions’ and manage the dynamic ‘flux’ in a vast and scattered literature [106] to enable it to be directly applied and ‘adjusted’ to practice and policy [105].

3 Conclusions

There is a need to build a homogeneous evidence base for built health system infrastructure reconfiguration. An enduring problem is the many fields, numerous types of evidence and different disciplinary ways of looking at the evidence. We provide a generalised theoretical starting point for future literature reviews. We pose specific questions that will make evidence useful for policymakers and those seeking to deliver infrastructure reconfiguration. Such as how can reconfiguration improve health promotion, access, prevention, human capital development, patient experience, productivity and reduce harms?

Due to the rapid-shifting and complex nature of built health system infrastructure reconfiguration, a range of review types and interdisciplinary interpretative understanding is needed. We have shown how we might bring together evidence from across healthcare settings (such as acute hospitals versus community hospitals, walk-in centres versus expanded A&E departments) and incorporating multiple interventions and institutional perspectives to make policy decision.

Given recent policy and major investments in the reconfiguration of built health system infrastructure, the need for an evidence base is clear. In this article, we have weighed evidence types and methods, and have asked what review approaches should be used to inform healthcare infrastructure reconfiguration policy. The impact of this evidence will be the assurance that healthcare infrastructure investment will improve health outcomes.