Designing the hospital of the future

The build­ing of the first NHS Nightin­gale hos­pi­tal in just nine days last year showed what is pos­si­ble in a pan­dem­ic. It was a remark­able achieve­ment. Natal­ie For­rest, who led the Lon­don ini­tia­tive, is now over­see­ing the build­ing of 48 new NHS hos­pi­tals, which is the biggest such pro­gramme since the 1960s. The cost could reach £24 bil­lion.   

A for­mer nurse, For­rest rose to promi­nence after super­vis­ing the four-year rebuild­ing of Chase Farm Hos­pi­tal, Lon­don, where she was chief exec­u­tive and direc­tor of nurs­ing. Her new chal­lenge is one of the most daunt­ing in the NHS.  

Few build­ings are more com­plex and cost­ly than hos­pi­tals. In his book, Anato­my of a Hos­pi­tal, Julian Ash­ley says that a large provin­cial hos­pi­tal includes some ten mil­lion bricks (enough for 900 homes), 12,000 rooms, two-and-a-half miles of cor­ri­dors and a floor area totalling 55 acres, not to men­tion a daz­zling array of med­ical tech­nol­o­gy. 

Small won­der that build­ing hos­pi­tals can take up to ten years or more. But For­rest is com­mit­ted to deliv­er­ing prime min­is­ter Boris Johnson’s hos­pi­tal build­ing pro­gramme by 2030. Will she make it? Some pun­dits say it is impos­si­ble. They point to the NHS’s infa­mous record for not meet­ing con­struc­tion dead­lines and going mil­lions of pounds over bud­get per project. 

For exam­ple, last year the Nation­al Audit Office report­ed that the Roy­al Liv­er­pool Hos­pi­tal was due for com­ple­tion in 2022, more than five years late. The cost of the pri­vate finance ini­tia­tive had risen by more than 40 per cent, from £739 mil­lion to £1.06 bil­lion.  

The hos­pi­tal build­ing pro­gramme was announced before the pan­dem­ic. The gov­ern­ment pro­pos­al to restrict pay to nurs­es and oth­er NHS staff to 1 per cent has gen­er­at­ed spec­u­la­tion that the squeeze on spend­ing may also affect the hos­pi­tal bud­get. 

For­rest will need the same kind of man­age­r­i­al flair and steely deter­mi­na­tion as shown by Flo­rence Nightin­gale to trans­form nurs­ing if she is to ensure Johnson’s hos­pi­tal pro­gramme does not go the same way as his Riv­er Thames Gar­den Bridge project cost­ing £53 mil­lion and his abort­ed plans for an air­port in the Thames Estu­ary on so-called Boris Island.  

So what can we expect? Pre­pare for sur­pris­es. Board­ed-up depart­ment stores in your local shop­ping cen­tre may give way to com­mu­ni­ty hos­pi­tals dou­bling up as com­mu­ni­ty cen­tres with shops, cafés, clubs and patient groups.

Influ­en­tial bod­ies such as the Health Foun­da­tion, which spends £30 mil­lion a year to improve health and health­care, believes that open­ing NHS build­ings and land for pub­lic use can help to bring com­mu­ni­ties togeth­er.  

“The great advan­tage of shop­ping cen­tres as loca­tions for com­mu­ni­ty hos­pi­tals is they have good trans­port links,” says Christo­pher Shaw, chair of Archi­tects for Health and the founder of the prac­tice Med­ical Archi­tec­ture. Repur­pos­ing exist­ing premis­es may also be cheap­er than build­ing new ones. 

For­rest says: “We have the oppor­tu­ni­ty to trail blaze.” Imag­i­na­tion is a mag­ic pre­scrip­tion. For exam­ple, the Roy­al Children’s Hos­pi­tal in Mel­bourne has a meerkat zoo to bright­en the lives of seri­ous­ly ill chil­dren.

Shaw envis­ages future hos­pi­tals resem­bling high-tech, air traf­fic con­trol cen­tres, with “con­trollers” mon­i­tor­ing hun­dreds of patients at home. Before coro­n­avirus, the NHS had a poor track record in adopt­ing dig­i­tal tech­nol­o­gy. The pan­dem­ic has spawned a rev­o­lu­tion.

So-called vir­tu­al wards will be as much a part of tomorrow’s hos­pi­tals as x‑ray machines and scan­ners are of today’s. Enabling patients to have hos­pi­tal care in the com­fort and safe­ty of their own homes, vir­tu­al care took off when COVID patients at home began mea­sur­ing their oxy­gen lev­els and heart rates with fin­ger-tip oxime­ters. Clin­i­cal teams checked in with them sev­er­al times a day. 

Vir­tu­al care stopped the pan­dem­ic from over­whelm­ing hos­pi­tals. The British Med­ical Jour­nal described how the West Hert­ford­shire Hos­pi­tals NHS Trust in Wat­ford man­aged around 1,200 patients at home. Near­ly 400 were mon­i­tored ini­tial­ly through phone calls, sav­ing 300 bed days over three weeks at the height of the pan­dem­ic. 

Patients then fed into an app their tem­per­a­tures, heart and res­pi­ra­to­ry rates and oxy­gen lev­els. This enabled the num­ber of patients mon­i­tored from home to more than dou­ble. Extend­ing vir­tu­al care after the pan­dem­ic should reduce the need for hos­pi­tal beds and, most impor­tant­ly, anx­i­ety among patients. 

Addi­tion­al ward space may allow a cor­re­spond­ing­ly big increase in sin­gle-bed rooms. Sin­gle rooms could account for up to 70 per cent of patient accom­mo­da­tion in new hos­pi­tals. Pri­va­cy and dig­ni­ty are regard­ed as a high pri­or­i­ty. but sin­gle rooms can be lone­ly places. For­rest says: “It’s a mat­ter of strik­ing the right bal­ance and recog­nis­ing the impor­tance of patient choice.” 

Sin­gle rooms, vir­tu­al wards and out-patient tele­phone con­sul­ta­tions, which are increas­ing­ly com­mon, should reduce hos­pi­tal acquired infec­tions (HAIs). It may seem iron­ic that, of all build­ings, hos­pi­tals are “unhealthy”, but about 5,000 patients a year in Eng­land alone die from HAIs. Treat­ing the esti­mat­ed 100,000 HAI cas­es that occur year­ly costs as much as £1 bil­lion. 

How­ev­er, healthy hos­pi­tals are about far more than infec­tion con­trol. Land­mark research by Pro­fes­sor Roger Ulrich, of the Chalmers Uni­ver­si­ty of Tech­nol­o­gy, Swe­den, high­light­ed how nature, gar­dens and art can reduce pain, stress and health­care costs. He found that 23 sur­gi­cal patients in rooms with a win­dow look­ing out on a nat­ur­al scene had short­er hos­pi­tal stays and took few­er potent pain killers than 23 matched patients in rooms fac­ing brick walls. Ulrich’s research has impact­ed the design of bil­lions of dol­lars of hos­pi­tal con­struc­tion.  

But while what is envi­ron­men­tal­ly best for patients has been recog­nised, NHS staff have been severe­ly neglect­ed. For­rest says: “The last 12 months have shone a spot­light on how impor­tant rest facil­i­ties are to our staff.” Doc­tors on breaks were recent­ly charged for blan­kets and had to rest on office floors. Oth­ers have had to rest in their cars in car parks for which they had to pay.  

One of Forrest’s biggest chal­lenges will be future-proof­ing. The pace of med­ical change is such that many new hos­pi­tals are out­dat­ed even before open­ing day. Tomorrow’s hos­pi­tals will be mul­ti-func­tion­al. For exam­ple, there will be med­ical gas capac­i­ty in all clin­i­cal areas in case of emer­gen­cies such as anoth­er pan­dem­ic. Design will enable four-bed­ded bays to be con­vert­ed into two sin­gle rooms and vice ver­sa. In addi­tion, wher­ev­er pos­si­ble, build­ings will be designed so they can be extend­ed by going either up or side­ways.  

What con­sti­tutes a “good” or “beau­ti­ful” design? For­rest con­cludes: “We are open to all design con­cepts so long as we can repeat them. If we were to spend a lot of mon­ey on bespoke hos­pi­tals, we may miss an oppor­tu­ni­ty to stream­line the pro­gramme and get as much val­ue for mon­ey as pos­si­ble. 

“We want to estab­lish tem­plates, but we will learn, refine and improve as we go along. One of our main aims is to short­en the con­struc­tion process. This is essen­tial if we are to com­plete the pro­gramme on time.

“The focus must be on func­tion­al­i­ty. It would be won­der­ful if we could cre­ate beau­ti­ful-look­ing hos­pi­tals, but we must ensure they give us the func­tion they were designed to deliv­er. That in itself is beau­ti­ful.”