Wolfson Economics Prize 2021

Lord Wolfson writes in his opening statement that “all too many hospitals are now outdated”. This is undoubtedly true, not just for Britain but for the whole world. What makes this particularly alarming is that the great majority of the buildings he refers to are clearly less than one hundred years old. This is particularly relevant now when a minimum lifespan of one hundred years is becoming generally accepted in Europe for a new structure to be granted building permission. The thinking behind this is based on eliminating all eventualities that would further accelerate climate change and instead promote solutions that would support the development of various circular economy based processes. Clearly we can no longer afford to build what Cor Wagenaar has called “built catastrophes”, major public buildings that are often outdated by the time they are taken into use.

In ancient Greece, the equivalents to the hospitals of our time were the Asclepieions. They were based on a holistic concept that we can still learn from today. In the Asclepieions, the latest scientific evidence, obviously modest in comparison to what we have today, was combined with drug therapy and dietary disciplines, as well as physical and mental exercise. As a product of the development of the Asclepieions came the ethical rules formulated by Hippocrates, which are still in use and followed everywhere today. Let us take the idea of a modern Asclepieion as the backbone of the narrative to be followed on these pages.

Patient Experience

The French architect René Gutton wrote, as early as 1979, that a hospital can transform a patient into a vegetable in two weeks, not because of shortcomings in medical techniques but because of the conception of space. In order to achieve the desired therapeutic effect he called for a network of spaces where the patient could “meet, live, love, be greeted, celebrate, dream, inhabit, move, sleep, look, communicate, be recognised, place oneself, cure oneself, participate, work, act, eat and drink, create, develop one’s faculties, be integrated, contemplate, walk around, admire, feel useful and learn”. Gutton’s list could almost be seen as a design guide and checklist of activities for a modern Asclepieion. With his colleagues in Athens, Professor Dimitrios Sotiris has, ever since he tried to create one for the Olympic Games in 2004, pursued the dream of establishing one.

Patient-centred care has finally become more than just a politically-correct slogan. Multidisciplinary cooperation beyond the limits of the wards has become commonplace, and many other trends that relatively recently would have been deemed too expensive and too complicated due to the new approaches and new thinking required of the medical staff are now widely in use in order to promote genuine patient-centredness.

We are, on these pages, primarily concerned with the architecture of hospitals, that is, how architects can contribute to the improvement of the patient experience as well as the wellbeing of staff. Many Evidence-Based Design (henceforth EBD) studies have relatively little to do with architecture. Some of the studied issues do, however, undoubtedly improve the comfort of the patient (better food, better entertainment devices, personally controllable lighting etc), and are thus of great value. They are nevertheless more about programming, prioritisation and resources than about architectural design. Many frequently published EBD studies also apply only to wealthy western countries at one given moment, which means that they are lacking on three very important counts, i.e. social, cultural and historical.

The concept of patient-centred care also includes patient empowerment, allowing the patients stronger control over their personal space. The patients are now, in most new hospitals, able to control the room temperature, lighting conditions, as well as the tv-programmes and internet on their screen in a private room. In hospitals such as Zuyderland (previously known as Orbis) Medical Centre in Sittard, Netherlands, the patient can further control the level of privacy vis-à-vis the central corridor or “living room” by regulating the louvre system in the glazed partition wall and choosing freely how open or closed they want the glazed sliding door between the private bedroom and the more public area outside.

A progressive recent idea is that the front line hospital staff undergo retraining at colleges for hotels and tourism in order to learn how to deal with the guests/ patients. In Zuyderland, there are actually two distinct groups of staff, those with a clinical (hospital) training and those with training in the hospitality business. There are very good reasons for this to become a norm, people doing what they are best at.

The quality of food in hospitals has been a frequent subject of discussion lately but still remains a problem in most countries. However, in some Dutch hospitals (such as Deventer by GAF Architects – a hospital with more Modern Asclepieion features than most) the in-patients can choose between three different menus at every meal – “traditional home cooking”, “vegan” and “ethnic”. Alternatively, they can use one of the three good restaurants in the public areas of the hospital that also serve the surrounding communities.

The Zuyderland wards are designed so that the spacious central corridor becomes the communal living room, which has a 24/7 buffet table for the patients to serve themselves snacks at their leisure. The main hot meals can be served at tables in this area as well, and eating in bed is discouraged. The central corridor, as well as being the living room for the patients, is also where the nursing staff perform administrative duties, sitting on comfortable sofas with their laptops. It is also used for the rehabilitation of the patients. Rehabilitation now takes place everywhere with only a small number of spaces actually earmarked for that function. This strong global trend has led to rehabilitation no longer happening out of sight in tiny cubicles in hospital basements, but openly everywhere, both indoors and outdoors.

 

One should no longer talk only about patient-centredness but also about visitor-centredness. The patients in the wards as well as their personal visitors, family and friends, will remain the main focus, but all visitors should be seen as important. This includes everyone seeking health or social services of any kind, as well as people from the surrounding communities dropping in at the restaurants, cafés, shops and art exhibitions. Students and researchers in the knowledge centres, as well as entertainers, such as clowns, who are there to contribute to the creation of a healing environment, are all important groups. Just as it was in the original Asclepieions!

The more our future hospital starts to look and feel like an Asclepieion, or, alternatively, a modern version of the Nightingale pavilion hospital, the more central these questions become. The number of visitors who are strictly speaking not “patients”, will grow in these urban hubs, which provide many more reasons for people to drop by than happens in our existing hospitals today. Future accommodation schedules, as well as urban (zoning) plans, should make allowance for this and all buildings for cure and care should be seen as multifunctional hybrids.

The role of art as an important element in hospitals has been a major talking point for some time. It has become an easy “healing environment – wash” when designing and building new hospitals. A percentage of the budget is set aside for art and the “experts” decide what kind of art it should be spent on. The results are often unsatisfactory. Art in hospitals should be used in the same way as art is used in cities, to provide highlights, as well as help in placemaking and wayfinding. It should not, as is often unfortunately the case, used as random stick-on applications, or to cover up ugly appliances.

Popular notions about the nature of “healing” art often lead to second rate results. On the contrary, art created for hospitals should be anything but neutral and meaningless. There are historical examples of powerful works in old and new hospitals by great artists as diverse as Rogier van der Weyden, Piero della Francesca, Andrea and Luca Della Robbia, El Greco, Isaac Grünewald, Henry Moore, Naum Gabo and Anthony Gormley. As can be seen from these names, diverse yes, but never neutral nor meaningless. From the time of the Asclepieions, good hospitals have, also in this respect, presented the best that the surrounding community has had to offer.

The results of the most convincing and frequently quoted evidence-based research show that the correlation between the patient experience, clinical outcomes, as well as staff wellbeing and productivity, are so closely knit together that the link between all these aspects is undeniable. Thus, more or less the same solutions apply to all three headlines, the most important one being the quality of the architecture. According to Vitruvius, good architecture is all about “commodity, firmness and delight”. Maybe now, in the 21st century, we could, when talking about hospitals, start using the words “functional, technically sound, and beautiful”.

Clinical Outcomes

Evidence-based design literature should be carefully vetted. The most relevant results are of essential importance and everyone designing, implementing and financing new hospitals should treat them as second nature. The rest should either be taken with a pinch of salt or ignored altogether. Studies exist where this job (separating the valuable from the irrelevant) has already been done for us.

A lot of the existing EBD literature is very ethnocentric. Many of the researchers involved have found it surprisingly difficult to grasp that people from different cultures react differently to most issues and thus the outcomes cannot be treated as universal truths. This problem is at its most evident when the research deals with reactions to music, art, and colour, all popular subjects in the evidence-based design market. About a decade ago, when the architects of the new University Hospital in Oslo were asked which colour theory they used for their interiors, the answer was that from the many which they could have picked, they chose the one that best served their architectural ambitions. At the time this was seen as a somewhat flippant and certainly “unscientific” reply. Today, when people have become more aware of the cultural factors involved, the reaction would probably be different.

The most significant studies are those that prove that a certain way of doing something can produce savings in the long run. These are some of the few concrete tools that an architects can use if they want to convince those that are paying to produce better hospitals than before. These gains, presented as actual sums of money, have not featured in these studies until fairly recently. Some of the issues for which plenty of convincing material exists, are listed in BOX 1.

 

The AHRQ (Agency for Healthcare Research and Quality) in the US reported in 2018 on new EDB results that emphasise the importance of this research. Costs due to patients falling exceed 30 billion and hospital-acquired infections cost 10 billion dollars per year in the US. Medication errors cost an average of 5.6 million dollars per hospital annually. Strong proof exists that these costs can be dramatically reduced by design-related methods (single rooms, standardisation etc). These are the results that matter, because they provide convincing arguments for higher architectural quality.

One essential question related to the improvement of clinical outcomes and other issues covered in this text is the way accommodation schedules/room programmes are built up. These should no longer be composed by experts whose prime (and often only) concerns are ergonomics and economics. Architects and interior designers should always be involved in this work together with the users. The schedules should always be flexible enough to adapt to a variety of functional concepts and structural grids. They should never become a straightjacket forced on the designers and the users. It is never known how the functional requirements of a hospital will change during its lifetime which is why flexibility (see BOX 2 for related terminology) should always come first. It can never be sustainable to provide small rooms of slightly different sizes in long rows (11 sq.m, 12 sq.m, 14 sq.m., 10 sq.m., 12 sq.m., 13 sq.m., etc).

 

 

Staff Wellbeing and Productivity

This section, perhaps more than any other, is about architectural quality as we have known it since the days of Vitruvius. A truly patient-centred hospital, as well as a staff-centred hospital, must be technically and functionally sound. Logistics without logic, floorplans that do not function, work environments that make you want to leave – such a building cannot possibly be good architecture regardless of how “beautiful” it might seem. With hospitals, just as with any other building type, it is very difficult to reach the highest qualitative standards if you do not understand why so many present or recent hospitals get nowhere near that level. You need to be aware of what has been happening around you, not just in your own limited circles, but everywhere. Lessons learnt from recent history are important and can be very inspiring, particularly if there are helpful social and cultural reference points to help you along. This process does, however, gain more weight when you go deeper into history.

 

Why are there still things we can learn from the Asclepieions? Because so much of what we value today, and which is amply supported by EBD material, was part of the essence of those institutions. They can be seen as the original wellness campuses. The buildings were future-proof because of their generic character. They were shallow-framed, which allowed for easy natural ventilation and optimal daylight conditions. All these are characteristics that we should regard as starting points in our new facilities.

What can we still learn from the pavilion period? The original justification for breaking the hospital up into smaller units was connected to the growing awareness, largely thanks to Florence Nightingale, of questions related to hygiene. Since the Asclepieions, the pavilion hospitals became, after a very long break, the next examples of real health campuses, which were mostly situated in or very near city cores.

If tuberculosis had not become a major medical emergency throughout the world during the early decades of the 20th century, the development of our hospitals may have worked out quite differently. As it was, the new buildings were now thrown out of the cities to areas with ample fresh air and sunshine, the only cure for that particular ailment at the time. The good news was that some of the best architects then got involved in hospital design. Sanatoria designed by architects such as Alvar Aalto in Finland, Richard Döcker in Germany, Jan Duiker and Bernard Bijvoet in the Netherlands and Tony Garnier, Paul Abraham and Henry-Jacques Le Même in France represented some of the most exciting, appropriate and influential buildings of the 1920s and 1930s. The secret was largely the close cooperation between these innovative and open- minded architects and enlightened progressive doctors, as well as engineers who represented the best expertise in the fast developing fields of building technology and industrial production. Another aspect all these professionals had in common was social consciousness combined with a highly developed sense of responsibility towards humankind.

The architects of that period found themselves at the centre and the avant- garde of the architectural debate. What we need now is our contemporaries to achieve a similar position. There have been some promising signs around the world during the past decade or so, but high quality has certainly not established itself sufficiently to become the kind of norm it needs to be. There have been too many backward steps following some promising forward ones. Often this has been due to the fact that both the public and the private sectors have, for different reasons, been unable to control their procurement methods in ways that would support these aims. We will get back to this in the final section of this document.

The hospitals that have caused us the biggest problems and have to some extent become symbols of what a hospital should not be like are many of the ones built in the 1960s and 1970s. Many of these are becoming or have already become obsolete. We must, however, not forget that this era has with good reason also been called the “heroic era” of hospital design. Many of the issues which are now in the forefront of the debate have their roots in the discussions that started over half a century ago. The pioneers of flexibility, modularity and future-proofing (Eberhard Zeidler, Perkins and Will, Weber Brand & Partner, etc) developed technical innovations such as interstitial space (technical floors between the different levels of the hospital), plug-on applications and prefabricated spatial units. These ideas are all now seen as potentially useful tools for solving a variety of problems and some have become standard solutions under certain specific circumstances. The amount of research and experimental design that went on in those decades was akin to that of the era of the sanatoria, but unfortunately, during the 80s and 90s, this development slowed down and have not improved since. Issues such as climate change have shown that major changes are required. The international community has accepted the long overdue wake-up call and is slowly beginning to react to the new challenges. The fact that hospitals are far too often already obsolete before they have been taken into use has also finally been recognised as a major problem.

 

The achievements of the “heroic era” included the notion that staff should be involved in the design process of new hospitals. This democratisation of the decision-making processes was a major step forward and has in many countries continued to be a key element of the design process. When staff wellbeing and productivity are discussed, the Asclepieions and the modern pavilions make a better point of departure than most others. Almost by definition, challenges presented by having to cover long distances along corridors with no daylight or views can easily be avoided, while easy access to internal courtyards, green roofs, greenery and the surrounding gardens can be secured.

Connection to the wider Health and Social Care Infrastructure

This overview aims at covering not only health and social care services, but also the interplay between the health care unit with the wider community surrounding its facilities. The hospital should be an active participant within the community while providing the tools for a perfect modern work environment and first-class clinical outcomes. This would ideally include active and continuous cooperation with landscape designers and gardeners, chefs, artists, actors, musicians, librarians, experts in inter-cultural communication, and, obviously, a large variety of wellbeing professionals. Again, very much as one would expect a modern Asclepeion to function.

In the early years of this Millennium, the Nuffield Trust and other organisations were advocating concepts such as Health Kiosks, Drop-in Centres, Healthy Living Centres, Resource Centres and Community Hospitals, a kind of decentralisation of services, all in the name of Patient Centred Care. “Medical villages” were recommended as a way to improve the patient experience without actually decentralising the services. This meant breaking what was usually a very large institution, physically into smaller units but remaining located basically in the same place. There are some good examples of both these approaches, but the feeling is that patient-centred care has, in the last couple of decades, become a buzzword which is still bandied about, while some of the original ideas have had to give way to budgetary “realities”.

 

Specialist care centres were another innovative idea that emerged during this same period. These were health care units which only provided secondary and tertiary care and were preferably located in central urban sites. In 2004, Bouwcollege organised an international idea competition under the heading “Future Hospital – competitive and healing”. Ton Venhoeven’s winning example of a prototype hot hospital, named Core Hospital, was a unit housing all the core functions, all those that demanded the largest amount of sophisticated technology and had often in the past proven to be the bottlenecks in the function of hospitals. By showing that a prototype of a certain size could be placed on central sites in almost any major city, a new concept was created which has unfortunately not yet become commonplace. This version of promoting patient-centredness by having the essential services within easy reach of the majority of urban dwellers was also a strong reminder that it was time to bring hospitals back to where people lived, worked, did their shopping, and participated in cultural events. The era of the tuberculosis sanatoria when hospitals were thrown out “into the bush” had, after all, ended over half a century earlier. This approach also made a welcome change at a time when some people in Britain, at least half-seriously, came to the conclusion that the most economical way to deal with secondary and tertiary healthcare in England was to concentrate all of it in one giant edifice somewhere in the vicinity of Leeds.

There are already good examples of interesting new hospitals (Paris, Lyon, Madrid) that have been built in central urban locations in big cities. Robert Wischer, among others, has written about the necessity of giving hospitals back their role and status as significant public institutions, comparable to city halls, railway stations, concert halls, theatres and museums. It is a shame that most of them have now been far too long totally ignored the community they should be part of. The re-introduction of hospitals as urban landmarks has fortunately recently become a regular feature in the discourse. It seems clear that this will gradually have an effect on the location of healthcare facilities, their spread within the communities and their role in these ever growing “de-specialised” cities. It seems inevitable that the final death blows to the “zoned city” are imminent and will lead to ever increasing hybridisation. Pandemics will help to accelerate this trend, since people are getting increasingly used to performing a new kind of double role, where the role and the location are no longer connected.

Boundaries between functions are getting blurred, and building typologies are likely to go through a total overhaul within the next few decades. What will the healthy city look like in the future? How will the concept of health be expressed in the cityscape? It is certainly likely that its physical expressions will bear more resemblance to the Asclepieions and the pavilion hospitals than to the giant monoblocks that have unfortunately become the symbol for healthcare buildings in the wealthy countries of the world. It has been said that as a building type, the planning of a hospital is the closest akin to the planning of a city. Leon Battista Alberti wrote, in 1450: “The city is like a great house, and the house in its turn a small city”.

 

Alberti’s countrymen and contemporaries designed some important hospitals in very urban locations. Brunelleschi’s Foundling Hospital in Florence, Filarete’s Ospedale Maggiore in Milan, and the Ospedale de Santi Giovanni e Paolo in Venice, are all significant features of major city centre piazzas. They are also excellent examples of sustainable, adaptable and modular architecture.

Another, more recent architectural movement that can be said to possess those qualities, possibly even more convincingly than their Renaissance counterparts, is the one created by the “Mat builders” of Team 10, dominated by figures such as Allison and Peter Smithson, Giancarlo di Carlo, Aldo van Eyck, Herman Herzberger, Jakob Bakema and Candilis, Josic & Woods. Team 10 criticised the CIAM for separating urbanism and architecture. Good hospitals are indeed like small cities, probably more so than any other building type. Le Corbusier and his right hand Guillermo Jullian de la Fuente saw a hospital as a perfect playground for applying the Mat approach. Their proposal for the Venice hospital is an interesting model mainly because the grain it presents in its Mat feels like a perfect continuation of the urban grain of Venice and as such is very different from all other hospitals planned for urban areas in those years. It also responds well to the principles of the Asclepieions. Modern Mats are closely related to the modular, flexible and adaptable floor plans of ancient Greece and the Italian Renaissance.

The French architects Jourda and Perraudin have taken the Mat idea one step further and created a three-dimensional prototype in the Mont-Cenis Academy in Herne, Germany. Lessons could be learnt from this approach, particularly if we presume that, in the future, centralised facilities will still dominate our health care services. A collection of 3D Mats of varying proportions might well be the answer for our future “health care hubs”. They could form easily recognisable ensembles where the parts fit together in a logical way and the “hub” becomes a natural part of the way that the urban structure functions.

 

Conclusions

What next – past errors that should be eliminated and replaced by – what?

“Hospitals are built catastrophes, anonymous institutional complexes run by vast bureaucracies and totally unfit for purpose they were designed for,” wrote the influential and frequently-quoted Dutch art historian Cor Wagenaar, in 2005. Ten years later he wrote about the “re-emergence of hospitals in the avant-garde of architecture”. He was probably referring to some positive examples that had appeared in his home country and also in France and Spain. Looking at the situation today, it must be said that in spite of the good work and fine goals set by several relevant health organisations in Europe and the United States, progress has been slow. Similarly, the important work done by specialised programmes and courses in renowned academic institutions around the world has not gained as much weight as perhaps was hoped for. (A list of these organisations and universities can be found in Section 6 ACKNOWLEDGEMENTS)

 

The Nuffield Trust, in its publications (2000-2001) on how future health care environments should function, came up with a number of visions which still today feel relevant and regularly appear in discussions about where we are going. Many of them are closely related to the concepts that appear in the four headlines forming the guidelines for the compilation of this document. This shows that much of the thinking that took place around the turn of the millennium has, when confronted by political, ideological and economic debates, not led to concrete results. The lack of improvement is certainly not due to the “design architects” or the medical specialists, and most certainly not the users – the staff and the patients.

A frequently-quoted prediction of how future hospitals will look in the future has recently been that they will look like luxury hotels. This prediction might on some levels still be valid, but on the other hand, the idea that the image of a luxury hotel is worth striving towards, now seems outdated. Once again, all this has very little to do with architecture. A hospital should not be a hotel that pretends to be a home, with technological devices hidden in mock mahogany wardrobes. Too much attention has probably been given to superficial issues.

The “for me, just now” attitude should finally be banned from hospital design. Fixed schedules of accommodation, lack of flexibility of the design process and the forced inclusion of short-sighted visions have dominated the decision- making processes for too long. The “specialist architects” are also partially to blame because their success has largely been due to doing exactly what their clients ask them to do. As a result of this, unrealistic time tables are adhered to, as well as unrealistic budgets. But just as artists do their worst work when they do what they are asked to do (such as “healing” artworks for hospitals) architects also do their worst work when they are told exactly what to do.

The strength of modular thinking and future-proof solutions can be found in Greek classical architecture. Asclepieions could become market halls or government offices when new needs arose. The floor plans of Renaissance buildings were at the same time extremely orderly and extremely flexible. Brunelleschi’s system of modular design is an absolute treasure trove of ideas, inventiveness and beauty. His hospital in Florence, Ospedale degli Innocenti, is still one of the most beautiful buildings of its kind and it functioned as a hospital for more than 400 years. Future hospitals must, as buildings, become more generic again.

We live in an ecological, cultural and economic global environment where it is no longer sufficient to recognise the necessity for recycling our building stock. We should now also pursue ways to secure a circular economy as a tool for safeguarding the welfare of our planet and our communities. The rationalisation and adaptability of everything we build must become a primary challenge. A circular economy requires that buildings can be used for many purposes and can adapt to new situations. All kinds of hybrid solutions are thus called for. In many countries, gaining building permission now requires that any building must be shown to last for at least 100 years. If a building has, for some good reason, to be moved elsewhere, the structural frame should be designed for ease of dismantling, removing and erecting at a new locality. The design process should thus also include plans for different scenarios.

 

The importance of flexible accommodation schedules/room programmes has already been touched upon earlier in this document. An equally important issue is the ratio between the net and the gross areas, i.e., how much floor area could/ should be added on to the bottom line when the net sizes of all the programmed spaces are added up. The ratio should obviously be higher in areas where the general public moves about and where the clients/patients wait. Designers are often pressurised into minimising this ratio which has become a major reason for the lack of qualitative progress. This attitude is, once again, very short sighted. It obviously helps to minimise the capital (investment) cost, which unfortunately most of the time is the overriding consideration. The accruing compensation in the shape of savings in the running costs, more flexibility, better daylight conditions and views, the ease of achieving intuitive wayfinding, far too often does not receive the value it deserves (see BOX 3 for sobering figures by Bouwcollege, still as relevant as they were in 2005).

From now on, much more emphasis should be put on placemaking, location as near home as possible, therapeutic environments, contribution to place
and community, sustainability (social, cultural, economic and environmental), adaptability (life cycles), telemedicine and other information technology, green roofs (and walls) as well as easily approachable healing gardens.

(See BOX 4 for other issues that should always be remembered from now on)

How should Architectural Services be procured?

It is interesting to note how many of the hospital buildings that are considered to be among the very best have been the first effort in the field by its architect. Recent examples include Pritzker prize winners Herzog & de Meuron, Rafael Moneo and Toyo Ito. Very many of these buildings have been winners in open or invitational design competitions. The time frame spans from the Baroque period to the period of Pavilion Hospitals and through Early Modernism to the last couple of decades. Add to this the fact that none of these listed winners had ever designed a hospital before taking part in the competition in question, then the case for only using “specialist” architects for hospital projects is not very convincing. (See BOX 5 for competition winners)

 

Maggie Centres have greatly helped to improve the architectural image of healthcare buildings. The organisation has used only the very best architects, such as Ted Cullinan, Foster and Partners, Frank Gehry, Piers Gough, Kisho Kurokawa, Richard Murphy, OMA, Page and Park, Richard Rogers and Snöhetta, many of them again being newcomers to the health care scene. These architects have shown to their colleagues that branching out to health care can be worthwhile and this bodes well for the future. It is not only patients who need psycho-oncological support that benefit from the positive effects that these centres can produce. The easy access to all the aspects designed to make the users feel better, information about their problems, help with stress management, entertainment and pleasant social contacts are all features that should be available in all buildings designed for cure and care.

It is clear that any team involved in the design of a hospital needs members with previous experience of hospitals. This is undeniable, but in which role and at what level? Something has been lost if, in the discourse about who should design hospitals, it has become commonplace to divide architects into two categories – “specialists” and “design architects”. The former group consists of people who have been in charge of designing the great majority of hospitals everywhere in the recent past. The latter are those referred to earlier, the competition winners and first-timers who have produced hospitals that have been published in the architectural media. When hearing the expression “design architects”, most of us cringe and wonder who those architects are that do not design. In spite of this, the use of the term continues. Groups formed to take part in a competitive tendering process like to include a “design architect” in order to gain a few more points in the quality stakes.

In order to procure design services, architectural design competitions are the best method, and the very best are completely open competitions that any qualified architect or student can enter anonymously. Limited invitational competitions, with no “specialists” in the main roles, are the second best. The Cognacq-Jay competition in Paris, which was won by Toyo Ito, is a good example of an invitational competition in which the client body actually did not want to invite anyone with previous hospital design experience. Recently, Dezeen reported that Office for Metropolitan Architecture (the Netherlands) had been commissioned to design hospitals in France and Qatar precisely because they had never done one before (although they had designed the Maggie Centre in Glasgow!)

 

Whatever the future brings, there will still be buildings or groups of buildings, large or small, in the service of health care, that will be designed by architects. In order to secure the best possible results, the highest possible quality for the buildings run by people who look after our health and wellbeing, there remains one obvious point cannot be over-emphasised. We will have to find the best possible architects to do it for us. As stated previously, in this millennium some of the best architects in the world have produced some very good hospitals and the young generation has shown a growing interest in a field that was earlier seen as the domain of so-called “specialists”. Lately this trend has again slowed down in many countries and good examples are not as common as they were 10 years ago. This has a lot to do with the over-zealous procurement processes, which in many countries makes it inevitable that the best architects are rarely commissioned.

Examples of the prowess of the best method, architectural competitions, abound. Not only do these competitions usually lead to excellent results and in the best case to revolutionary and ground-breaking solutions, but they are also an important catalyst for the continuing education of architects and engineers. A huge array of sometimes brilliant ideas are presented in open competitions. Most of them will never see the light of day, and they will never be published or exhibited anywhere. They do, however, make up an enormous bank of potential innovations and a treasure trove for research.

If a client body, whether public, private or third sector, considers an open competition too time consuming, expensive and/or cumbersome to arrange, smaller limited invitational competitions are the next best method. As discussed earlier, it is important to pick the right competitors. The main criteria should be that all are first class award-winning professionals. The choice should never be based on how many thousands of square metres of hospital the candidates have previously produced. Quality, not quantity, should always come first.

If conventional procurement methods are used, i.e., competitive tenders according to EU or other local regulations, candidates quoting the lowest price should never be given preference. The fee should in fact never be a deciding factor at all, but should be a figure predetermined by the client after careful research into recent, comparable, high quality projects. The choice of architect should in these cases be determined entirely on the quality of the applicant’s reference projects, which should not necessarily be hospitals. The aim should be to attract better architects, to make hospital design a desirable subject again, to break the stronghold of mediocre “specialists”, who simply concentrate on satisfying the (predominantly) financial aims of their clients and/or business partners.

 

How should the plans be implemented?

One reason for the lack of genuine progress in many parts of Europe and the rest of the wealthy parts of the world, is a series of unfortunate experiments. These have aimed at saving public money through different kinds of financing mechanisms, various ways in which the partnership of public and private funding has been explored. Some successful examples may exist, but on the whole the results are at best mediocre. Public sector procurement processes (both for realisation and design) should be rethought completely. The present ones are more reminiscent of buying short-lived commodities that can be thrown away when you tire of them, rather than investing in something valuable and sustainable. Where different variations of PPP/PFI modes of procurement are still in use, marginal savings in capital costs are often preferred although it would be wiser to invest in solutions which would lead to savings in long term running costs.

The PFI (Private Finance Initiative) method (created in Britain by John Major’s government and expanded by Tony Blair’s government), has been heavily criticised for the mediocrity of the results. In 2018, a public enquiry?? declared the experiment a failure. A total of 127 PFI hospitals were built (total bill – 13 billion pounds) and few of them reached the quality that should have been expected. Many of them also ended up costing more than they would if traditional procurement methods had been used. The field is, in many parts of Europe, still dominated by methods that do not lead to good results. The PFI scandal in England unfortunately did not attract sufficient negative publicity to stop the spread of this trend elsewhere in Europe. Various “alliance” type arrangements have proved to not serve the demands of the welfare state in the best possible way. This has become obvious, for instance, in the Nordic countries in the last few years.

The developers and contractors involved have, in all these arrangements, generally shown a distaste for renovation and refurbishment. The same can be said about the reluctance to tackle any sites in slightly more complicated urban situations and involving hybrids of any kind. Commercially more viable outlying greenfield or brownfield sites have thus dominated, paving the way for yet another disappointing wave of new hospitals being produced at a distance from where people live and work. It is thus surprising that variations of the same theme still appear, particularly since different observers have frequently shown that no money is saved through these partnerships. The public sector can borrow money more cheaply than the private one and these various constructs also tend to lead to higher total costs because of the considerable return of capital that the private sector is supposed to produce.

In these situations the designers of these projects appear to be responsible primarily to the contractor, rather than to the bodies that are their actual clients, the hospital administration, the staff and the patients. Both the designers, usually led by “specialist” architects, and the contractors are often very large multi-national players. Even if it should be obvious that no party should be given the chance to water down the fundamentals of the welfare state in order to satisfy their own profit margin requirements, this often seems to remain the principal aim.

Third sector clients (hospitals in the Netherlands and in some specific cases also elsewhere) have an easier time. As opposed to the public bodies, they do not have to adhere to EU or national competition laws. They can choose who they want. Most Dutch hospitals are owned by non-profit third sector organisations or non-profit private companies. As their choices are less restricted by legislation than in most European countries, the results have tended to be more forward-looking, genuinely patient-centred, and of a higher architectural standard.

So what will this result in – what will future hospitals be like?

There is really little point in going too deeply into what the perfect hospital, the most functional, healing and beautiful, should be like, if we continue procuring them in ways that have become common in many countries. Thus, the strong recommendation and an overriding priority is to first create fool- proof systems that secure the services of the best possible designers and other experts, some whom will represent specialisations that today we know little about.

It is clear that the future growth of that portion of health care investments which is earmarked for prevention and health promotion will have an effect on the physical spatial facilities of hospitals. A facility that mainly provides information, support, surveillance and prevention will look different from today’s models that are dominated by hotels (wards), office blocks (outpatients departments) and factories (hot floors). The modern Asclepieion (with features of 19th century Nightingale variations thrown in) again raises its hand and reminds us of its existence.

A group of idealistic Greek medical specialists and historians in Athens has kept the idea of modern Asclepieions alive for a couple of decades but their efforts at spreading the word have not been a huge success. As far as we know, the idea hit some headlines only once, thanks to the now defunct Netherlands Board for Hospital Facilities (Bouwcollege) that used to organise international competitions under the theme “Future Hospital” early in this Millennium. In the 2004 edition of this competition, one of the winning entries was heavily influenced by Asclepieion ideology.

The “core” part of the modern Asclepieion could be a hospital providing acute and elective care with 24 hrs emergency and general acute care programmes, and would be centrally located within the community it serves. The ground floors of the hospital buildings would connect directly to the urban activities surrounding the complex. They would contain restaurants, cafes, shops, art galleries and installations, as well as links to sports activities in the open areas of the sites and gardens (outdoor events, sculpture gardens, vegetable gardens used by the restaurants, etc).

In order to humanise the built environment and to avoid overpowering and massive sizes of the buildings themselves, the best features of the pavilion period would be taken into consideration in addition to following the lessons learnt from the ancient Asclepieions. These pavilions were a direct product of Florence Nightingale’s ground-breaking thinking about hygiene, thinking that has been an inspiration in some of the better recently completed hospital projects.

Pavilion type hospitals can be divided up into sections in different ways. The most commonly used and probably also the most economical way is: 1. Diagnostic centre, 2. Consultation and outpatients centre, 3. Treatment centre, 4. Nursing centre, 5. Logistics centre, and 6. Knowledge and expertise centre. A simplified version of this model is shown in BOX 6, which also presents a view (courtesy of Bouwcollege) on how the total floor area of a hospital is divided up between the different sections.

The division presented in BOX 6 is useful because it presumes that certain important features that have an impact on investment costs can be controlled. This way of producing modern pavilion hospitals has in France been called “the debundling system”. It is clear that the requirements related to the structural grid, the floor to floor heights, the amount of space reserved for technical installations etc., are quite different in the “Hot Hospital” (surgery, ICUs, radiology) from what they need to be for the “office” (out-patient clinics), and that considerable savings can be made through optimising the dimensioning of the different pavilions. Another division, the one presented in BOX 7, which is based on clinical entities, is a particularly expensive one because of the need to repeat many of the most expensive items on the hospital “shopping list”. For this typology to work in a satisfactory fashion, all pavilions need their own separate “hot” units. One successful example of this can be found in Trondheim, Norway.

Whichever of these classifications were used, it would be logical, and probably necessary, to provide additional, more “contemporary” separate buildings for such functions as the day hospital and day surgery facilities, a rehabilitation centre, a family building for births and post-natal care, as well as for general paediatrics.

Will we see a resurrection of the asclepieion, or will developments lead us
in a different direction, one in which the recent trend towards centralisation
is reversed and hospitals are “everywhere” as parts of hybrid complexes in all types of urban conglomerations? Whatever happens it is difficult to imagine that all the paradoxes that surround hospitals today would have been eliminated. Hospitals will still have to be smaller to be more humane, and larger to make more economic sense. They will have to be more open in their spatial arrangements, while providing better control of spreading infections. They will have to be more open to the surrounding community while at the same time providing better security. Or will information technology, and everything that comes with it, develop to such an extent and at such a pace that all these paradoxes will no longer be of any significance. In any case, matters will hopefully already have developed in a direction where the death knell of an idea such as “one giant hospital somewhere in the vicinity of Leeds” has already sounded.

 

As far as the composition of the modern pavilion complex is concerned, all other factors except investment costs, speak against the “debundling model” in which all pavilions are tailor-made for their initial use. A better choice is a model in which all the pavilions are basically identical as far as their dimensioning and technical solutions are concerned. For this to become commonplace, we do need a new approach to budgeting, and the decision-making bodies must learn to put running costs first when choosing between different alternatives. Everyone involved must also finally accept the fact that the expected lifespan of a hospital must be increased considerably.

Another reason for preferring the generic model is the continuing development of the heaviest and technically most awkward elements housed in the “hot hospital”. The latest versions of an MRI scanner contain only seven litres of fluid helium, as opposed to more than 1000 litres in the models still in use everywhere. The character of the equipment that sets the standards for the dimensioning of the most demanding parts of the hospital will keep changing dramatically and it will be possible to house “hot” functions, such as radiology, in quite ordinary buildings.

The buildings of a modern asclepieion or a modern collection of Nightingale pavilions, although separate and free-standing, would need to be connected to each other for logistic reasons and a network of tracks, either underground or on overhead bridges, would have to be provided for the automated vehicles, with their storage trolleys, that would generally take care of the logistics.

All buildings would use the same structural module as well as the same mechanical, electrical and IT systems. Narrow building masses throughout would guarantee the maximisation of daylight and provide good conditions for the use of various high-tech controlled hybrid natural ventilation techniques.

In addition to the problems we are accustomed to, we now also have the necessity for designers and builders to demonstrate their knowledge and realisation of the principles of the circular economy (materials re-usable after the change of use of a building) – hospitals must not become the worst culprits because of the function they serve – on the contrary, they should become positive examples.

The future could be that modern asclepieions, or pavilion-type complexes in an urban setting inspired by the ideas of the asclepieion, will dominate. Alternatively, the development might lead towards decentralised models in which much smaller units are scattered around and served by self-driving “ambulances” that take people to those units most appropriate for their particular complaints and problems.

 

With an improvement in the methods used for procuring architectural services, we can hope to see hospitals that represent the kind of quality that this important built place that looks after us all, deserves. This is especially the case in a welfare state were the infrastructure for health and wellbeing is based on the money of the taxpayers. Many leading designers have already (re)discovered hospitals as buildings that present unique design challenges. No other building type has such a direct impact on the quality of life of the people who rely on the services it provides. Only the very best expertise, not only in the cure and care they provide, but also in creating the best possible physical surroundings to cater for it, is good enough for hospitals.

It is clear that technological developments will completely redefine the way health care is procured, perceived and delivered. All this will also have an impact on how hospitals will look in the future. Will decentralisation or further centralisation be the direction we are going? Or maybe there will be both alternatives with decentralisation being the stronger trend and centralisation really only used to cover the provision of tertiary care in the latest state-of-the- art, large-scale facilities. An ever-increasing emphasis on health promotion and other salutogenic approaches will probably lead to hospitals being increasingly like health care hubs. Whichever way things develop, the future models will be more reminiscent of the Asclepieions and the pavilion hospitals than any of the more monolithic typologies. Architecture will certainly still play an important role and we will still need the best possible architects and engineers to design hospitals, preferably commissioned through design competitions.

The Venice Architecture Biennale in 2000, curated by Massimiliano Fuksas, had as its motto “Less Aesthetics, more Ethics”. These two words have not been in the forefront when discussing hospitals. It should, however, be clear to anyone that not putting sufficient emphasis on aesthetic matters in hospital design, inevitably leads to unethical outcomes. But, in the end, no matter what our future hospitals will look like, they will certainly still always be “places” – and it is the architects who have the essential skills as place makers.

 

Acknowledgements

Iwould like to thank the following people, some for their writings, others for their lectures and many also for inspiring private conversations:

Tom Avermaete • Aaron Betsky • Paul Boluijt • Jerome Brunet • Paolo Brescia John Cole • Jean-Bernard Cremnitzer • Jonathan Erskine • Daniela Fondi • Peter Fröst • Roelof Gortemaker • Philip Gusack • René Gutton • Philipp Meuser • Bas Molenaar • Tony Monk Yasushi Nagasawa • Christine Nickl-Weller • Lawrence Nield • Anne Noble • Pierre Riboulet • Magnus Rönn • Hashim Sarkis • Dimitrios Sotiriou • Abram de Swaan • Roger Ulrich • Erkki Vauramo • Ton Venhoeven • Stephen Verdeber • Cor Wagenaar • Robert Wischer • Eberhard Zeidler • Peter Zumthor

The following organisations have provided useful material during the years:

  • ENAH European Network Architecture for Health
  • EuHPN European Health Property Network
  • European Observatory on Health Systems and Policies (WHO Europe)
  • GUPHA Global University Programmes in Healthcare Architecture (UIAPublic Health Group)
  • Netherlands Board for Hospital Facilities (Bouwcollege)
  • The Nuffield Trust (UK)
  • AAH Academy of Architecture for Health (AIA/USA)
  • AHRQ Agency for Healthcare Research and Quality (USA)
  • Center for Health Design (USA)As have these universities with their programmes on health care architecture:
  • CVA Centre for Healthcare Architecture, Chalmers University of Technology, Gothenburg
  • EBD Cluster, Architecture for Health Department, Technische Universität, Berlin
  • MARU Medical Architecture Research Unit, South Bank University, London
  • School of Health Sciences, University of Athens
  • SOTERA Research Institute for Healthcare Facilities, Aalto University,Helsinki
  • CHSD Centre for Health Systems and Design, Texas A & M University,College Station
  • Institute for Healthcare Delivery Design, University of Illinois, Chicago
  • MS Design and Health, Georgia Tech, Atlanta

 

And very special thanks go to:

Marcus Vitruvius Pollio (75BC – 15BC): De Architectura – libri decem (Ten Books on Architecture)
Leon Battista Alberti (1404 – 1472): De Re Aedificatoria (On the Art of Building)