Design and Health World Health Design

Community care: Gateways to health

Community Hospital of the Monterey Peninsula (CHOMP)
A number of outstanding community care buildings are drawing attention to the power of architecture to communicate more inclusive and enlightened services and inspire the surrounding populations. Veronica Simpson reports.

Community healthcare should, in an ideal world, be an opportunity for unrivalled creativity. One would think that the necessity for bespoke and differentiated responses, both in the services provided and the design of the buildings that house them, would galvanise and promote creativity in architecture, as well as service concepts, but that is sadly rarely the case. It is only when there are visionary individuals involved, or teams of individuals who have a strong concept of what their community needs and what modern architecture can do to fulfil those needs, that truly remarkable buildings and facilities result.

A handful of outstanding community projects have inspired ambitious projects across the globe in terms of the range of services they provide and the impact these have had on their communities. One is the Bromley by Bow Centre in east London, a GP centre which has grown to house its own art workshops, supports local entrepreneurs and small businesses with space and mentoring, and offers a vast network of classes and community groups at one or more of its idiosyncratically designed buildings (all of this stemming from the vision of resident GP Dr Sam Everington).

In the US, the groundbreaking Codman Square Health Center, in Dorchester, Massachusetts, promotes a culture of health and well-being within its urban and impoverished community through youth programmes, after-school computer technology classes for kids, weight loss and fitness programs for overweight teens, adult education and financial health services (driven and supported by its CEO Bill Walczak).

It was a visit to Codman Square that inspired John Cole, chief estates officer at the Northern Ireland Department of Health, Social Services and Public Safety, to reframe all his region’s disparate health service offices into a streamlined, multi-disciplinary, holistic framework. But Cole, a former architect, knew that these schemes would be even more effective if they harnessed the power of modern architecture.

Thanks to Belfast’s enlightened healthcare and architecture policies, a family of community healthcare buildings is being created that will serve its citizens well into the new millennium. These buildings have become a regional, national – and even international, following a slew of awards – benchmark for high-quality public design, thanks to Cole’s visionary policies.

Faced, in 1998 with a £10m bill for repairs from what was then the South and East Belfast Trust (SEBT), Cole and his team took a good look at the 42 individual facilities scattered around the city and decided, after visiting a couple of inspiring community care centres in Minneapolis and Massachusetts, to do a complete reorganisation. The buildings have been replaced with three community care and treatment centres (CCTCs), funded entirely by the sale of the 42 existing buildings.

These new buildings represent a radical change in community healthcare provision. Says Cole: “We wanted to provide everything people needed in one building – a one-stop shop, or gateway to health.”

The centres combine a holistic array of social and healthcare services, including children’s services, podiatry, chiropody, physiotherapy, dentistry and Citizens Advice Bureaux, with or without GP services. In order to flush out the most creative architectural and social solutions, Cole launched a design competition, with competing architects briefed to make right what he felt was wrong with so many health service spaces – among them, the proliferation of “dull, dead spaces”, poor clarity, confusing signage and wayfinding, a lack of natural lighting or ventilation and too many “double-loaded corridors with low ceilings and artificial lights”. Projects were awarded under his visionary procurement process, ‘performance-related partnering’ (PRP), which groups projects in clusters; good practice on the part of the construction and design teams on the first completed project – relating to design and build standards, not just budgets – results in their being awarded the remaining work.

Penoyre + Prasad won the first competition, in conjunction with Belfast-based Todd Architects (see Placemaker, p14-15). Its first three buildings are now up and running – The Arches, The Bradbury and the 2009 Design and Health International Academy Award-winner Knockbreda – and have been joined by a fourth, the recently opened Carlisle Centre, part of North and West Belfast NHS Trust, which P+P/Todd won at a later date.

Kentish Town Health Centre, London
Design champion and GP Roy MacGregor selected Allford Hall Monaghan Morris (AHMM) as architects of his new community vision through a RIBA-led design competition in 2002. Surrounded by fine 19th-century residential buildings, it faced local opposition as well as many bureaucratic, funding and logistical battles before the building was completed late 2008. A design inspired by the ‘Jenga’ woodblock game sees the impact of this huge building reduced by three stacked and cantilevered storeys, broken up by small terraces and balconies. Space and light flows along a three-storey central atrium ‘street’, off which all treatment rooms flow. Frequent viewing points into and from the building improve legibility and wayfinding. Boldly coloured and playful graphics along the interior and exterior walls, high-quality furnishings and fine art complete a sophisticated and welcoming scheme.

Infused with respect and care
There are common principles of design manifest throughout these buildings, though each has its own character, responding to the sites’ geographical and demographic constraints. Dominant in each is a central three- or four-storey atrium which welcomes visitors, feeds light into the heart of the building and helps to clarify circulation and wayfinding.

Low-slung, open reception desks are immediately visible from the entrance, with attractive and comfortable seating areas and greenery nearby. The buildings feature generous staff quarters, with rooftop cafes/canteens, lounge areas and expansive views onto the city.

Inspired use of highlight colours and artwork also creates a strong and pleasing identity to the buildings – 1% of the total project budget is given over to specific and commissioned artwork.

On visiting these CCTCs, some of them four years into their full occupancy, what is striking is how well they’ve been maintained. Cole is unsurprised by the continued care: “I think if you give people something that shows that kind of care and respect, they treat it accordingly.”

This degree of care and respect extends to staff consideration and consultation throughout the process. Staff were encouraged to “view space as a resource, not as territory” in order to help facilitate the very different methods of working that the new buildings require, including hot-desking and crossdisciplinary collaboration. The results speak for themselves, Cole concludes: “The staff clubs and terraces are well used.

Staff are now working very effectively in multi-disciplinary teams. It has hugely improved accessibility and understanding of how the services work.”

There are now five of these CCTCs completed in Belfast, including The Grove, a combined library, health and leisure centre (designed by Avanti Architects, with Kennedy Fitzgerald). Fortytwo are planned over the next 10 years across the five Northern Ireland healthcare trusts, for each of whom an architect team has been appointed. In addition to those already mentioned, the teams include: Edinburgh-based Richard Murphy Architects and Belfast’s RPP (Robinson Patterson); Keppie Architects and Gareth Hoskins Architects; and Todd Architects with Hall Black Douglas.

Due to the structure of their healthcare systems, the US and the UK seem to lead the way in community care innovation, says Phil Astley at London’s Medical Architecture Research Unit, though he complains that too often these projects are clinically rather than socially driven and seldom does the architecture measure up to the ambitions. However, few would deny that the presence of a growing number of architecturally outstanding community projects either side of the Atlantic are raising the bar in terms of public perception of what these places should look like, as well as what they can achieve for their community.

Harlem Hospital Center
Client: New York City Health & Hospitals Corp
Architects: HOK
Project cost: US$249 million
Area: 150,000sq ft/13,935sqm
Completion: September 2009

Harlem Hospital Center is technically a city hospital, but it is in the truest sense a community hospital, specialising in areas such as diabetes, heart disease and paediatrics. HOK masterplanned and designed a new 150,000 sq ft patient wing which uses art, light and colour in order to engage the community. The expansion of the facility involved the replacement of most of the beds and diagnostic imaging equipment. The plan integrates inpatient emergency room and outpatient services under one roof in the new Patient Pavilion. Its most outstanding design feature is the wraparound mural projected onto the exterior.

In the US, HOK has recently completed three very diverse community projects. The newly completed Harlem Hospital Center is, in the truest sense, a community hospital, serving its population of often disenfranchised and impoverished New Yorkers in a way that is intended to motivate and inspire its community (see case study).

HOK’s Patsy Trine says: “In this community there is a lack of trust in institutions. But many of the diseases that are prevalent in the community can be prevented or easily treated without hospital stays or invasive procedures. We wanted to get the community to see it as a place where they want to go in order to stay well.”

HOK’s masterstroke was to photograph, and then display via huge blown-up projections across the façade of the building, a series of murals created for the hospital in the 1940s through the Works Progress Administration’s Federal Art Project (during its eight-year existence, the WPA created over 500 murals solely for New York’s public hospitals).

The response of the community to its new healthcare building has been overwhelmingly positive.

Community Hospital of the Monterey Peninsula (CHOMP), California
Client: Community Hospital Foundation
Architect: HOK (Los Angeles office)
Cost: US$170 million
Area: 290,000sq ft / 26,942sqm (200,000 sq ft new, 90,000 sq ft renovation)
Schedule: South Pavilion completed October 2006; Forest Pavilion Feb 2007; Renovation due May 2010

On the other side of the country, an expansion at the Community Hospital of the Monterey Peninsula (CHOMP) saw HOK adding to an original building by Edward Durell Stone and seamlessly blending the new patient wing and diagnostic centre with the original. Says Trine: “This is one of the most beautiful hospitals in one of the most beautiful locations we’ve ever done. This was a client that told us they didn’t care about cost and they didn’t care about certain operational requirements that we usually need to focus on in healthcare. Their focus was all about embracing patients in a healing environment from the moment they walk into there.”

The third of HOK’s recent community projects takes a leap into the future. For Methodist Stone Oak community hospital in San Antonio, Texas, the client asked HOK to design the facility of the future. HOK responded by creating a canted, ‘same-handed’ patient bedroom which minimises the distance between bed and bath to reduce the risk of falls; HOK also designed a ‘wraparound’ patient grab rail that further secures in-room safety.

Enlightened clients and the need to stand out from the competition are increasingly common in the US healthcare system. Less typical in many parts of Europe, there are still areas of outstanding innovation. One such project, the Ravelo clinic in Lanzarote, winner of this year’s Design and Health International Academy Awards Judges’ Special Prize, ticks almost every box with its bold and yet welcoming design, its treatment of natural light and harnessing of stunning views to maximise the inhabitant’s enjoyment of spaces within and beyond the building.

Well-designed social circulation spaces enhance wayfinding at London's Waldron Health Centre

In the UK, this sector has seen some of the most creative architectural solutions of any healthcare stream, with stunning recent examples including Buschow Henley’s Waldron Health Centre in Lewisham (winner of Best Primary Care design at the Building Better Healthcare (BBH) Awards 2008) and Edward Cullinen Architects’ Stonebridge Hilliside Hub. The Waldron Health Centre achieves maximum legibility and impact through a cleverly arranged series of social circulation spaces that help to define the journey from waiting room to clinic. Stonebridge, meanwhile, marks the culmination of a 14-year long regeneration project for an economically and socially challenged part of North West London.

A threestorey mixed-use building, its two ‘wings’ accommodate a health centre and a retail unit, both topped with mixed-tenure residential units and fused together by a central community facility aimed at education and integration. GP and design evangelist Dr Jacques Mizan (see Standpoint, p15), however, feels that too many still end up as “boxes with lots of rooms in them”.

“The challenge about being creative with community healthcare buildings,” he says, “is that first you need a creative client, and the clients are usually GPs and healthcare teams who really don’t have a clue about healthcare design...Secondly, the market of architects and contractors is dominated by a few names. They have got a formula that kind of works. Faced with a client who doesn’t know what they are after, they will deliver the safe option. Occasionally you get someone who bucks the trend.” Mizan is a great admirer of Penoyre + Prasad’s work, for example.

Kentish Town Health Centre, London
Client: Camden & Islington Community Solutions, Camden Primary Care Trust, NHS
Architect: Allford Hall Monaghan Morris
Cost: £10.1 million
Area: interior 3,432sqm, external landscape area and car parking 1,332sqm
Procurement: Local Improvement Finance Trust (LIFT)
Completion: December 2008
Main contractor: Morgan Ashurst
Consultant: Sonnemann Toon Architects

Mizan is also a huge fan of what Dr Roy MacGregor has achieved with Kentish Town Health Centre (see above and right). MacGregor’s radical notions included banishing all paperwork and making the whole surgery digital (one of only two healthcare buildings in the UK to do so yet, he says), creating a central ‘hot-desking’ workspace for all staff and making all ‘surgery’ spaces and offices non-proprietorial.

Doors are numbered, painted with black magnetic paint and each member of staff has his or her name on a magnetic strip, which attaches to the door when they’re in residence. Staff belongings are tidied away at the end of the day and stashed in a central shelving system.

One of the key platforms of MacGregor’s new centre is the provision of employment and welfare advice. “For every £10,000 we spend on providing welfare advice, we increase the income of the population by £100,000. Last year we spent £50,000 and captured £498,000 uplift in income for attendees,” he says.

Mizan concludes: “To get a building like this you need a real champion who has got the vision, the energy and space within his brief to get where he wants. He has looked at how people work, then looked at how people should work, and tried to create a building that fits the new model. This building may well help the cause. It’s been nominated for enough awards now for people to sit up and take notice of what happens when you challenge the notion of territorial space.”

Veronica Simpson is an architectural writer

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