Design and Health World Health Design

Dialogue: The shift left

The financial crisis could quicken the movement of services from acute to community settings, and design has a critical role to play, John Cole tells Marc Sansom.

Three projects from Northern Ireland were awarded commendations in the Design & Health International Awards this year. John Cole, chief estates officer of Northern Ireland’s Department of Health, Social Services and Public Safety and chair of the European Healthcare Property Network gives his views on procurement, design quality and the contribution research can make to improving healthcare environments.

Marc Sansom: How does design quality improve patient outcomes?

The team from Altnagelvin Area Hospital, designed by HLM Architects, with Health Minister Michael McGimpsey, receiving their Design & Health award

John Cole:
I think all of us intuitively feel that our environment has a major impact on our outlook, our approach to work, our interactions with others, our energy levels and our moods. There is an increasing body of work that provides research-based evidence to support our intuition in this regard and which demonstrates the potential for our built environment to have both positive and negative impacts on those who are ill and on the effectiveness of the healing process in different environments. In health facilities where many users are there because they already have a health problem, it would seem only right that those of us charged with creating the facilities have a responsibility to ensure that, to paraphrase Florence Nightingale, they should do no harm to service users. Poor design quality can be detrimental to healing yet frequently, there is evidence of insufficient focus or recognition by health service clients and design teams on eliminating the negative aspects of poor design, e.g. inadequate space standards, limited natural light, poor ventilation, oppressive interiors, design that facilitates spread of infection or patient accidents. Not only should we eliminate poor design but it is our responsibility to ensure that we optimise the benefits of good design by creating true healing environments to support significantly better patient outcomes and major economies over the lifetime of a facility.

MS: How important is the application of research and evidence to the improvement of healthcare buildings?

JC: Many of the difficulties associated with the lack of consistent high quality design in health facilities are due to:
1) the lack of awareness of some clients and designers of the direct connection between the quality of design input and patient outcomes and
2) the inability to make the case for what are often relatively small amounts of additional capital investment required to deliver high levels of design excellence.
In the debate between architects and directors of finance it is often difficult to demonstrate bottom-line benefits which would justify any additional capital expenditure required because of the lack of relevant evidence. Unfortunately the architectural profession is not renowned for its structured research or for sharing knowledge, the latter partly because of the competitive nature of their work. It is therefore critical that organisations like the Academy actively promote and support research and dissemination of knowledge in these key areas.

We need to be able to deliver evidence-based design. To do so we need to be able to ensure that our knowledge base is as current as possible so we can constantly review and update our design approaches to reflect emerging findings.

MS: Which procurement models have been successful in recent years?

JC: The answer to this question could fill several books but I will seek to focus on what to me are a few key principles which are central to my own approach and which can be incorporated into any of the current procurement models to deliver design excellence. Good design quality is facilitated by:
  • a clear understanding by the client of what is required expressed in a comprehensive brief;
  • a culture promoting the value of design which is actively and continuously maintained within the project environment and is shared with all participants;
  • a clear articulation of the quality objectives for the project against which all proposals are measured and a firm resistance to accepting anything less;
  • a budget for the project which is commensurate with the content and quality of the scheme required;
  • selection of design and construction teams on, primarily, quality criteria;
  • an ongoing direct relationship and iterative interaction between the creative design team and the real client for the building;
  • independent external expert design reviews at key stages to ensure that the required quality is being delivered
  • understanding the difference between the ‘what’ and the ‘how’ and not letting the ‘how’ compromise the ‘what’;
  • viewing the incorporation of art and landscaping as essential elements in the design of health buildings;
  • a focus on learning and continuous improvement; and
  • a little passion.

MS: What advice would you give to governments and health clients assessing procurement models for healthcare buildings?

John Cole (left) and Northern Ireland Health Minister, Michael McGimpsey presenting Design & Health International Award commendations to the Knockbreda Centre, the Bluestone Unit, Craigavon Area Hospital and Altnagelvin Area Hospital

Start off with a strategic vision of the type of health service you wish to provide and avoid the pressure to give way to short termism. Health facilities can only be effective if they are responding to a coherent service vision. Articulate that service vision into a design vision.

Invest in becoming an informed client able to interface from a position of strength and knowledge with private sector design, construction and service organisations. Procurement is only effective if you are an intelligent customer.

Select only the highest quality designers and contractors and build longer term partnerships with these organisations with incentives for success but dependent for their ongoing existence on continuing high levels of performance.

As a client, never delegate the responsibility to others to determine what quality of facilities you will receive. Maintain effective ownership of decisions on the design quality of projects through close involvement of key client representatives.

MS: What key factors set the three award winning projects apart as international benchmarks in design quality?

JC: In organisational terms the issues that were key to success in these projects were having the right culture, the right processes, the right resources and the right people and then, most importantly, putting at the centre of the design philosophy the optimisation of the quality of experience of the service user. In relation to more specific design matters, key elements in these buildings, and equally found in others developed by Health Estates, are:
  • relating the building to its context;
  • investing in public space in the buildings as well as functional space;
  • optimising the use of natural daylight and views from the building;
  • eliminating unnecessary corridors;
  • facilitating natural wayfinding;
  • sensitive lighting design;
  • attention to detailed design and material, fittings and furniture choice;
  • creating human scale and non-intimidating design;
  • ensuring that clinical requirements are properly integrated within the overall design approach and do not visually overwhelm; and
  • the incorporation of art and landscaping.

MS: What design factors can improve the patient and staff experience?

JC: Successful buildings should convey a sense of the level of thought that has gone into the design to enhance the experience of staff and patients in using the building. Good buildings engender pride and a sense of ownership by staff, users and the local community.

Too many health buildings feel like large intimidating machines that are processing all who enter. Healing environments must be softer and less relentless. The creation of a series of small occasional places which are comfortable and have views out to facilitate conversations or to allow people to withdraw for a time are highly valued. Art and landscaping are particularly important in bringing human scale to buildings.

MS: How do we balance the need for carbon reduction against the patient experience?

JC: Sustainable development is a fundamental requirement of all buildings. Health buildings, particularly those providing more complex services, will have unavoidable high energy needs related to these services but in all other aspects of their design they should be exemplars for low-energy sustainable design solutions. In every project there are compromises.

Architecture is the art of managing conflicting requirements to create a solution that appears to satisfy them all. Sustainable design solutions are more likely to provide an improved patient experience than those which ignore sustainable design principles.

Design teams must use their creativity to rise to the challenge of meeting the new standards that will contribute to reducing the impact of climate change. In this regard it is even more essential that best practice solutions are shared.

MS: As healthcare costs rise, what role can design play in promoting the role of preventative public health strategies?

JC: In Northern Ireland the focus of our health strategy is on health promotion, illness prevention, greater personal responsibility for health, earlier diagnoses and interventions and better management of chronic diseases outside the acute sector.

The recognition that health problems are often the result of unhealthy lifestyles, poor diet, inadequate exercise and stress resulting from financial, legal, housing, relationship and employment problems requires a more proactive and cross-sectoral approach from a range of government agencies.

As a result, there has been a significant shift in the type and nature of health facilities that are currently being built in Northern Ireland. There is much more investment in community and primary care facilities and, where possible, we are seeking to link these health facilities with other facilities like leisure centres, swimming pools, libraries and community advisory services, which together provide for a more holistic response to the health and well-being of the local community. This is leading to a new typology of building which presents new challenges and opportunities to demonstrate the benefit of high quality design. A good recent example in Northern Ireland is the Grove Health and Well-being Centre in Belfast that combines a wide range of services that are synergistic in this way.

It is difficult to predict the whole-life cost benefits to be achieved by ‘the shift left’, as this movement of services from the acute setting to community setting is known. Kaiser Permanente in the US has adopted a similar approach to the management of the health of their members and achieved financial results and economies which support this direction of travel. The principal benefits in terms of dramatically improved quality of life for major sections of the population, if achieved, cannot however be measured in simply monetary terms.

MS: What does the future of healthcare infrastructure development look like over the next ten years?

JC: I would predict a number of consequences of the global recession, cuts in public spending and less access to capital, including:
  • significantly lower levels of capital investment as governments seek to reduce national debts incurred as a result of the financial crisis;
  • more considered regional strategic development plans with more demanding tests; to justify individual capital investment decisions
  • rationalisation of acute hospital services into fewer but larger ‘centres of excellence’;
  • incremental modular developments providing a series of high-value focused but flexible ‘small-bang’ solutions rather than the ‘bigbang’ developments of new hospital complexes. This incremental approach will allow organisations to take better account of the rapidly evolving models of healthcare, ‘the shift left’ and the potential of information technology to transform how and where services are delivered;
  • innovative system and facility design skills being focused on and seen as a potential facilitator of revenue efficiencies in the cost of delivering healthcare services; and
  • the continued development of locality-based primary and community polyclinic facilities, providing a growing range of diagnostic and treatment services which were previously only available in hospital settings, combined with a focus on lifestyle change and health promotion through cross-sectoral multi-agency co-located facilities.
Marc Sansom is the editorial director of World Health Design

John Cole
1973-5 BSc (Arch) / DAAS Queens University, Belfast
1976 Registered Architect
1993-2007 Member of RIBA Council
2008 Chairman of European Health Property Network
2002-2009 Chief Executive, Health Estates Agency Northern Ireland
2009 Chief Estates Officer, Department of Health, Social Services and Public Safety

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