Notes on the Design of Hospitals and their Clinical Organisation: Whitepaper by Andy Black

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UK-based Andy Black is a consultant in strategic healthcare planning and offers an alternative to the established patterns of hospital design he has witnessed in his career. Below is an extract of his report.

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I am under no internal pressure to persuade you to agree with the concepts set out here; but if you are involved in hospital planning, I would be pleased if it made you rehearse the philosophy of patient care that underpins your current approach to the design of tomorrow’s hospital.
Firstly, we might see that the simple imperative to give each patient back their dignity and comfort has opened up a new way of managing their clinical care both individually and as the collective body of inpatients of the day.
The great majority of acutely ill citizens in today’s (and tomorrow’s) hospitals are older with more complex amalgams of morbidity, family and social issues. If a wide definition is used; to include depression, dementia and delerium - then a very significant proportion will also have mental health issues. The traditional organisation and design of the acute hospital is making life difficult when it should be doing the opposite.
What are the the great failures of today’s hospitals? The increasing difficulty of matching patients’ generalised needs to the growing specialisation of healthcare professionals.
Perhaps the most difficult job for any employee today is the personal care of a frail elderly demented person. To smell and clean up their faeces, change the urine soaked bed; wipe their bum, wash their genitals, ears, hair, teeth. Cope with their disinhibited anger and occasional abuse.
The assumption that valuing this work at or around the minimum wage is a fair basis for high standards. Then assigning an army of higher paid inspectors to police the consequences. The repeated failure to introduce information systems that work as well as we can easily imagine that they could.
The arcane and convoluted approval and planning processes of our autistic state bureaucracies have delivered us a whole new generation of UK hospitals that were out of date on the day that they were opened.
A good start would be to burn all the official ‘planning guidance’ and talk to your mother, friend or relative who is in hospital with a complex condition. From there, think it through from the beginning, anew.
The hospital and its host city
By far the most important decision in planning a major hospital is “where to site it?” In the UK, the sponsor of the project is usually the existing hospital and the hospital community reserves this important decision to itself. More often than should be, the new hospital is built on the same site as the old one. Consultation with the general population and the civic authorities has more the dynamic of the sell-job than a genuine search for external inspiration.
I am struck by the answer given by a longstanding CEO of one of the largest city hospitals in the UK when asked what was the most important role of his hospital.
“Probably the most useful role of the [prestigious city-based hospital] is to provide employment and opportunity to a city where jobs are scarce.”
The relationship between a large metro hospital and its host city is layered and important. In an earlier work we saw nine aspects to it, as shown opposite. For the major academic hospitals, I believe that separate ‘healthcare planning’ has led to an impoverished image of the hospital as something separated from its urban host.
A better approach might be to put all major hospital projects firmly into a civic planning arena.
Why?
If a major new hospital is planned as a civic asset rather than part of the national health network, then perhaps the integration of housing, education, culture, transport and commerce can be explored?
Why not embed housing, culture and leisure in the project? A large hospital campus at night can be a depressingly soul-less expanse of empty accommodation. Thousands of staff have to commute daily from housing areas - undoubtedly some of them would take up the opportunity of living and working in the same community - if those opportunities were for exciting and convivial homes. Why couldn’t a senior clinician walk a short distance to meet his or her children from school when working late that evening? Or pop home to have lunch with a friend or partner? Why is the hospital cafeteria there but not an array of bars, cafes and restaurants? Why is the hospital cordoned from the city?
Ghettoed.
Here is another way of approaching the elements of hospital space: a simple hierarchy [ed: which Black details in his whitepaper, viewable on our website]

• Therapeutic space


• Immediate supporting space


• Blue space


• Green space


• Circulation


• Plant and closed spaces

This is a deliberate return to basic principles and requires a departure from traditional hospital planning. It undoubtedly takes us into more difficult discussions.
If those traditional planning processes were producing high quality new hospitals that were good value for money and environmentally sustainable, then this might be an unnecessary distraction.
My perspective is that they are not: we are getting obsolete duplicates of the industrial/efficient hospital paradigm. Worse, the overstatement of space needs against fixed levels of affordability delivers buildings that are mediocre in their materials and build standards as well as poorly conceived.
Worse yet, it all seems to take a very long time.
This is an extract of Andy Black’s whitepaper Notes on the Design of Hospitals and their Clinical Organisation. You can  the paper in full here: Andy Black, Durrow, Whitepaper (1)

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“This short paper sets out my personal observations based upon four decades of working in the hospital world. It is (I hope) a radical prospectus for the design of a very different hospital with a different approach to the organisation of clinical practice.”

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Andy Black
E andy@durrow.org.uk
Andy Black is based in the United Kingdom and known as an independent thinker in healthcare planning. His main focus is now on the organisation of acute care and the managed introduction of innovation into healthcare practice. He has been a consistent champion of the concept of the hypermodern local acute hospital and the local emergency unit in the face of a strong NHS consensus for centralisation in bigger units. His later work has examined the Academic Medical Campus of the future and its relationship with its host city. Andy is chairman of Durrow which is an international healthcare strategic consultancy active across public and private sectors.