Designing the hospital of the future

With 48 new NHS hospitals set to be built in the coming years, there is an opportunity to rethink how they are designed and used to maximise patient comfort and service provision

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.”