 | ARCHITECTURE AND THE HOSPITAL Light and shade, walls and space, civic and social values. Sarita Chand argues that in the complex and fast-changing world of contemporary healthcare, hospitals need the qualities that architecture can bring more than ever.
|
|
Sketch for the galleria at the New Children’s Hospital, Westmead, by Bligh Voller Nield.
|
Photograph of the galleria at the New Children’s Hospital.
|
|
|
The issue of the design of health buildings in Australia is a vexed one. The health
landscape is littered with buildings of the 1960s and 70s – eight to ten floors of
narrow ward floors stacked vertically on a podium accommodating diagnostic and
treatment service. The majority of hospital building programs are in fact
redevelopments of existing buildings, such as these, with some new bits stuck on. The
decision to develop thus is driven by imperatives of the health dollar (ever shrinking),
location (ideally wherever they currently stand), community concerns (don’t want to
lose their hospital) and, more often than not, political gain (health is always an emotive
voter issue). Whatever the motive, the strategy of redeveloping existing hospitals has
inherent problems because the buildings of yesterday are simply not able to deliver
today’s clinical services. For one or more of the reasons mentioned above, decision
makers shy away from starting anew and therefore very few hospitals are being
designed for greenfields sites. The real tragedy is that even these few lucky ones are,
by and large, inept physical manifestations of functional health planning diagrams with
little or no regard to an appropriate architecture or to site and context issues.
The reasons behind this sorry state of affairs are not hard to diagnose. Even with
the best design intentions in the world, architects get overwhelmed by the sheer
complexity and “hard” functional issues of a hospital brief. The process of hospital
planning, onerous enough as it is, is further burdened by multi-layered management
systems and convoluted hybrid procurement systems concentrated entirely on process
rather than on the eventual product. But these issues, daunting in themselves, are not
the only reasons for the unacceptable state of much hospital architecture. The real
issue, in my opinion, is that little value is attached to the architectural quality of the
hospital – to amenities such as natural light, views, wayfinding devices and public
spaces. Instead, process-driven managers, under the guise of cost rationalisation,
drive their obsession with statistics – area-per-bed, room areas, circulation
percentages and so on – to such a level that they become the main criteria for the
assessment of hospital design.
Although there is no doubt that the functional order is paramount in hospital
buildings, designs driven entirely by the requirements of functional planning will
produce layouts with convoluted, confusing circulation patterns. Architects, in an
attempt to gain a market edge and win large projects, are getting themselves into a
“health specialist” corner. This is not necessarily a bad thing. However, it is certainly a
cause for concern when “specialisation” only embraces the technical knowledge of
clinical functions and processes specific to healthcare, and does not include expertise in
the resolution of the essential elements of architecture – light and shade, walls and
space. This imbalance is often addressed by offering an association of two architectural
practices – one for “health planning” and the other for “architectural design”. This is a
dangerous situation; time and time again it has produced inept architecture, with
“architectural” facades slapped on to clumsy internal layouts and cosmetically enhanced
foyers as a token of “good design”.
Even in a functional sense, current hospital design does not respond adequately to
changing clinical work practices. At best, some lukewarm attempts are made in a few
areas, but the overall hospital building is still laid out in traditional configurations
responding to outmoded models of care. In the current world of healthcare delivery it is
simply not enough to tweak the edges of old typologies. Design responses must embrace
all parts and aspects of the hospital. If the delivery of health services has changed
radically, the buildings that dispense them also have to change. The new hospital will
have to have a new form and structure. It will have to be a different monster – not only in
terms of its form and layout, but also its physical fabric, circulation patterns, engineering
services and structure. It must provide a seamless integration of clinical requirements
with building planning and design issues. Established clinical practices have had to
revise their approaches to meet new demands, and hospital designers must also develop
new approaches to respond to these demands.
Changes in clinical practices, brought about by shortages of money and skilled staff,
demand enhanced efficiencies in the processing of patients. The process is greatly
helped and made safer if key departments are co-located. Small footprints prevent
appropriate adjacencies and therefore impose penalties in terms of clinical safety, staff
efficiencies and transportation costs. An efficient hospital for the future will require floors
with large footprints – say 6,000 to 8,000 square metres per floor, depending on the
size of the facility. One sensible design response to facilitate modern health care delivery
is to have a fat, squat building rather than a thin, tall one. “Fat” footprints will need clever
spatial resolutions for the introduction of natural light and cognitive wayfinding devices.
“Smarter” patient processing has been made possible, to a large degree, by the
advent and rapid development of information technology and management. Responses
by architects and engineers to its implementation are at present limited to the provision
of communication cupboards and fibre-optic cabling. This is largely because users
themselves have not fully come to terms with the comprehensive use of new technology.
The impact of communication and electronic technology, when fully unleashed, will be a
significant driver of the physical design of hospitals. In the recent past, comparisons
have been made to other buildings that process people, such as airports. Though some
analogies can be drawn in terms of movement patterns and the dispensation of
information, clearly health facilities need their own model, tailored to their own special
requirements – the need for patient privacy being just one example.
Advances in technology and new drugs are generating radically different ways of
diagnosing and treating diseases, leading to the treatment of patients in non-hospital
settings located within primary care centres or even at home. The hospital is therefore
left with the responsibility of delivering highly acute clinical services to the very sick,
catering to patients and relatives at their most vulnerable. At the same time it has to
house intimidating technology and equipment, operated by a staff that is under
considerable stress due to the very nature of its work. The parameters for an appropriate
environment for each of these hospital users are contradictory. It is not hard to see why
hospitals are the most complex of all building types to design – the design has to
respond adequately to disparate criteria.
In the zeal for providing appropriate amenities for patients, it is often forgotten that
the facility is also a workplace. The need to provide “break out” spaces for stressed,
overworked staff seems obvious, but it is a fact that, even if such spaces are included in
early briefs, that are often deleted during the inevitable cost cutting sessions that follow.
The new hospital must be a workplace for the new clinical culture – a dedepartmentalised
workplace, devoid of traditional hierarchical real estate symbolism.
Cellular offices arranged in rabbit-warren-type configurations do not encourage the
interaction necessary for the blurring of department boundaries so necessary for the
dispensing of modern healthcare.
Courtyards/landscaped areas and other spaces for both formal and informal
interaction between staff, patients, relatives and visitors must also be included in initial
briefs as therapeutic areas and their integrity must be defended through the design
process. The unfortunate tendency for such spaces to be “managed out” during costcutting
sessions can be rectified if they are included in preliminary design briefs on
which the project budget is based.
Perhaps the ambivalence in dealing appropriately with the design of hospitals lies in
the inability of society to deal with the sick – do we include them in the normal patterns
of life, or to segregate them at the periphery? Particular attitudes influence not only the
internal layout and appearance of hospitals, but also their relationship to the city. Until
the nineteenth century hospitals were pavilion-type structures quarantined away from
city centres, as their primary purpose was to alleviate the sufferings of infectious
patients. The early twentieth century saw the advent of clinical advancements such as
radiology and anaesthesia, which allowed the emphasis to shift from “looking after the
sick” to “treating the sick”. The parallel inventions of lifts and mechanical airconditioning
in the building industry allowed the vertical stacking of patient
accommodation atop podiums. Having steered away from the earlier image of a building
housing infectious people, hospitals were now brought closer to habitation and
recognised as key civic buildings with an important role in society.
Recent changes in the delivery of health services, with the emphasis placed
squarely on community health, preventive medicine and ambulatory care, have made the
hospital’s relationship with the city less isolationist and more enmeshed with the urban
fabric. An opportunity exists to once again recast the role of health buildings within the
built fabric of the community, bestowing on them an appropriate level of social
significance and the civic importance that is their due. Perhaps then a greater value will
also be placed on their architectural merit. The architecture of the hospital must not get
subsumed by technical and bureaucratic demands; architects have a responsibility to
show that a balance can be struck between the clinical demands of healthcare and a
humane architecture.
Society deserves no less.
Sarita Chand is a principal of Bligh Voller Nield
|
|
