Design and Health World Health Design

Book Review: Investing in Hospitals of the Future

Investing in Hospitals of the Future
Bernd Rechel, Stephen Wright, Nigel Edwards, Barrie Dowdeswell, Martin McKee
World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2009
Price: $40/CHF40 or free download at

Although this book has its focus mainly on Europe, the issues discussed within it have worldwide applications, and it is particularly relevant for health economic planners in emerging economies who wish to avoid some of the mistakes made by developed countries. Bite-sized chapters with clear headings and well-argued points make what is a very meaty tome, with lots of serious data, a very enjoyable and satisfying read.

The opening chapter presents a masterful overview of health planning trends and their consequences on hospital design. One somewhat obvious but important conclusion is that the almost impossible task of accurately predicting the outcome of evolving technical innovation and advances in information and communication technology (ICT) can only be mitigated by increasingly flexible hospital design.

The need for a sea-change in the management of long-term care – away from clinician-led, hospital-centred service into a multi-professional community-based model of care – is a refreshing recurring theme in the book. The evidence gathered on “getting capital investment right” demonstrates an alarming lack of long-term strategic thinking in favour of tactical (and often politically-driven) decisions, resulting in an unacceptably high proportion of project failures, particularly high in the implementation of health-related ICT projects.

Market competition in Europe is not well developed, probably because most countries have a tradition of universal access, equal treatment and a fair distribution of the financial burden. Although some recognise the potential for improving efficiencies, this book advocates much more focused research on what works and what doesn’t.

The excellent chapter on life-cycle economics clearly describes the vital relationship between the different functional components of hospitals – ‘hot floor’ (diagnostic and treatment), hotel (wards), offi ce (outpatients) and factory (labs, CSSD etc) and how their very different life-cycle and adaptability characteristics profoundly affect forward planning. I have rarely seen a more compelling financial rationale for investing in building design quality to ensure initial capital investment is sufficient to benefit from long-term life-cycle economies.

It is surprising, and somewhat alarming, that although 20-30% of costs in a hospital can be attributed to facilities management (FM), there is apparently very little empirical evidence in Europe as to how this money is actually spent. The idea advocated here – of a flexible mechanism that tracts FM costs to specific medical services to enable payment to providers to be linked to particular patient treatments, rather than, for example, general cleaning – has great potential.

A really inspiring chapter on the economic and community impact of local health spending highlights the importance of healthcare as a catalyst for regeneration in deprived settings and as a universal tool for community empowerment, including in wealthy areas. Again, these ideas are hugely relevant outside Europe.

The chapter on sustainable design for health gives a wholly convincing summary of the importance of social, economic and environmental sustainability by clearly describing the considerable challenges facing designers as the critical phases of climate change increasingly manifest themselves. The need for governments, worldwide, to evolve their building standards and finally act on the need to make the necessary capital investments to facilitate whole-life savings is argued very well.

The book’s concluding message is a heartfelt plea to embrace future flexibility. The need to improve flexibility is seen as a key lesson and needs to be applied in the widest possible manner, incorporating all aspects of the hospital system, including the scale and scope of facilities, architectural design and supporting infrastructure.

Mike Nightingale is an architect and founder of Nightingale Associates

©2018 All Rights Reserved. Website Design Graphic Evidence