Rethink: How will Covid-19 affect healthcare design?

The Covid-19 crisis response in hospitals, GP surgeries and care homes has left its mark, from infection control to remote consultations. Below, we ask four specialist architects to make their predictions for the future of healthcare design

The UK has paid a heavy human cost for Covid-19, not to mention a social and economic one, but it would have been higher without the exemplary response of the NHS, which was able to rapidly prepare staff and adapt facilities and processes to handle an unprecedented influx of patients.

The question now is, what lessons can be learnt for the future design of hospitals, as well as other healthcare buildings? Do we need to adapt and refurbish in preparation for a second, third or fourth wave of infections? What will the longer term impact be on building typologies and layouts, strategic planning and investment?

As the outbreak subsides and spaces used to deal with coronavirus are handed back, new protective measures and triage points may be required to separate the infected from the ‘healthy’.

The sudden growth of phone and video consultation could in future free up space for diagnostics and treatment, while office staff work remotely and occasionally access business lounge-type environments on site.

Care homes across the UK were devastated by Covid-19, a situation exacerbated by the fact many are densely populated with residents forced to share bathrooms where infections can spread. Should minimum standards be made more fit for purpose and conducive to health and wellbeing?

These new design considerations and how new models of healthcare are delivered are set against a backdrop of an ageing health building infrastructure that’s ill-suited to meet the demands of a growing population, a changing workforce and new technologies. And it is important to the public. A poll by Policy Exchange ahead of a call for evidence on the future of building hospitals showed that 81% of respondents put it at in the top three priorities from government infrastructure projects, with younger respondents emphasising the importance of light and green spaces.

Christopher Shaw, chair of Architects for Health and senior director of Medical Architecture, which helped the NHS prepare new standards for the emergency changes to hospital facilities, comments: ‘Demand on primary care practices has increased in line with the population in the UK, but despite their being the first port of call in the NHS the infrastructure is mostly awful and the practice model is starting to creak and crumble… We need to see specialist hospitals consolidate skills into larger buildings that serve much larger populations, like the European super hospitals. Walk 20 minutes in any direction in London today and you hit a hospital; those will have to go.’

Prime minister Boris Johnson revealed plans last year to build 40 new hospitals, but in reality just six will be upgraded by 2025, while 21 others will get seed funding to develop plans for upgrades. Critics have claimed this fails to acknowledge the scale of the challenge and the overhaul required.

Many architects working in healthcare will now be taking stock to consider what it means to design for a world far removed from the one that existed just four months ago. Here, four of them share their views.

Andrew Smith, principal and head of healthcare at BDP

BDP developed designs for most of the Nightingale surge hospitals in England, which are effectively an insurance policy against a second wave of Covid-19 infections. The facilities are temporary, so unless the virus disappears, or a 100% effective vaccine is made available, the UK is going to have to get to the point where the NHS can deal with Covid patients alongside traditional healthcare as normal services resume. It may be necessary to consolidate coronavirus needs into existing hospitals, with strategies including refurbishment, reusing outpatient space or some new build.

In the past the UK had isolation hospitals on city outskirts used to treat things like TB and other infectious diseases. It isn’t acceptable to construct these types of buildings any more, partly because the sites don’t exist, and partly because communities would object to having them on their doorstep. Hospitals will therefore need to adapt functionally to deal with the virus, and public perception will need to improve so they are considered safe.

One idea being developed is streamlining patients in existing hospitals. Admissions areas may need to expand to become triage points where infected people are separated from others to reduce the likelihood of infection. A Green Zone would be a clean zone where you can be reasonably certain that nobody is infected, a Blue Zone is where Covid-infected patients are sent and an Amber Zone is where the state of the patient is unknown.

There is an opportunity to exploit the innovative processes developed to help the NHS respond to Covid-19. There has been talk of virtual outpatient and doctors’ appointments for years; the crisis made that necessary and the widespread availability of wi-fi and video conferencing platforms made it possible.

If hospitals require less outpatient space, layouts could be reconfigured to increase diagnostic and treatment space. With more bed space, discrete areas could be created for Covid patients, which would help infection control and allow the rest of the hospital to carry on normally.

The need to adapt hospitals for social distancing is less of a concern as spaces are typically large. The ability to reconfigure to new needs is also embedded: for a long time we’ve tried to design hospitals on the basis of standardization and flexibility so equipment can be changed rather than having to demolish walls.

The NHS is fantastic value for money compared with other health systems around the world. If there is a public appetite to spend more on health, political parties may respond to that.

Danielle Swann, associate at Glancy Nicholls Architect s

It is a tragedy what has happened in care homes during the pandemic. The crisis has really highlighted the flaws in traditional care homes and their inherent inflexibility to adequately respond in terms of the physical environment and care and management strategies.

Physical distancing is incredibly difficult to achieve in a care setting, mainly because it makes physically caring for a vulnerable resident almost impossible. It can also have a negative impact on their mental well being.

However, there are several examples of best practice design in the sector, which illustrate how high quality environments that support the wellbeing and safety of residents can also create an optimum environment to deal with a pandemic.

We’ve designed a number of care homes for Derbyshire County Council that naturally lend themselves to the effective management of an outbreak, including the Meadow View scheme in Matlock, which won an RIBA Regional Award in 2018, and a new facility in Belper that’s being used as a temporary Covid-19 isolation unit before the official opening.

A focus on smaller ‘households’, comprising eight to 10 residents and four to five staff during the day, is key and contrasts with traditional care homes that tend to have much higher staff to resident ratio, making social distancing incredibly difficult.

We try to ensure that all residents have their own en-suite bathrooms, which reduces the risk of cross contamination. Corridors are 2.5m wide, so people can comfortably pass each other. There are a range of flexible shared spaces, including smaller breakout spaces along corridors, increasing opportunities to physically distance if necessary.

Layout planning is really important to ensure that households can be accessed by staff and visitors without having to walk through another household. This is about carefully managing adjacencies and progressive privacy lines coming in from the outside.

It has been heartbreaking to see media coverage of families having to stand in gardens to communicate with residents through closed windows. For someone with dementia this can be really confusing and upsetting. In future, care homes could provide safe ways for families to visit and spend time with their loved ones, for example separate spaces in gardens that families can reach without having to go through the main building.

The crisis has highlighted how the risk of infection is reduced outside and there is already a mountain of evidence that shows how access to external space has a positive effect on health and wellbeing – it should be championed on every care home project.

There’s no doubt that coronavirus is influencing current thinking among care home clients and the situation offers an opportunity to raise the game for design and quality of care.

We need to promote an expansion, or an overhaul, of the national minimum standards for care home regulations to drive forward quality design. The current standards were last updated in 2006 and only require a minimum of one bathroom per eight residents, which is one aspect that should be revisited.

The main barrier to reform is funding. Social care has been chronically underfunded for years and needs sustained investment and resourcing from central government. This could drastically improve people’s quality of life and dignity and ultimately help reduce the strain on the NHS.

Christopher Shaw, chair of the 500-strong Architects for Health group, founder and senior director of Medical Architecture

Pandemics aren’t new and we have known for a while about the major threat to aspects of the UK’s health infrastructure. The problem is the 2016 testing of Britain’s pandemic readiness became obscured by short term contingency planning around Operation Yellow Hammer [for a no-deal Brexit] and was never resolved.

As the first wave of infections starts to become more easily managed, we can see a few things more clearly. Britain has a very low number of acute hospital beds per head of population and since 1961 the numbers have dramatically reduced to a point where, alongside Sweden, we have the least in Europe. About 15,000 more ICU beds are required to match European norms, although Scotland in a slightly better position than the rest of the UK.

Fantastically committed work was done by architects, engineers and contractors in building surge hospitals, but they weren’t terribly useful, and the NHS workforce proved itself capable of managing, treating and caring for very ill patients in acute hospitals. We learnt that the workforce could be used more efficiently and effectively by reusing, extending and densifying the existing hospital estate.

Before Covid, 3-5% of GP consultations were by phone or video conference, now it is 50-70%. The transformation talked about for years happened overnight. It seems to work and the public appears happy with it.

That has implications for schedules of accommodation. You can imagine a big push for the remote management of healthcare and more advanced devices, with health centres becoming more like air traffic control centres for the local population.

In terms of acute care hospitals, the hot core isn’t likely to change. Operating theatres are already designed to tackle disease transmission and are heavily engineered with the separation of flows, and of clean and dirty materials.

Pressures on gender separation and for different acuities in wards has led to increasing numbers of individual bedrooms. Around 70% of beds in a new hospital are single bedrooms and the push for separation is likely to continue in the wake of coronavirus.

Hospitals incorporate lots of office space and staff, many of whom now work remotely. The challenge for a massive organisation like the NHS, which is the fourth biggest employer in the world, is how to maintain a sense of belonging for high value staff.

We need to move towards business lounge type environments where people can drop in and drop out, where they can feel part of a enviable place to be employed.
Many of these ideas are nascent, we’re still trying to deal with the problems in front of us. The UK is embarking on a major cycle of health infrastructure investment at a time of economic downturn. We need to reboot our ideas in a similar fashion to the 1961 NHS hospital plan, which is not something that’s going to happen instantly.

The health service has come out of a period where clinical planning was predicated on a five-year forward view, we need long term horizons, investments and structures when talking about the kind of infrastructure changes required.

Charlotte Ruben, architect and partner at White Arkitekter in Sweden

Hospitals are the most complex buildings in society and environments that people inhabit during the most vulnerable moments in life. These buildings represent huge investments so a future-proofing agenda must be highly valued at all stages.

Assessment of our recently commissioned projects in Stockholm – Karolinska University Hospital in Solna and Huddinge Hospital – has highlighted some design features that proved successful during the peak weeks of the pandemic. These include adaptivity, flexibility and humanity, with a healing and attractive environment for patients and staff that is sustainable over time.

The Huddinge case study is fascinating: in just 10 days 23 operating theatres were transformed into 64 intensive care units able to accommodate three patients in each theatre, in a light and safe environment. This was impressive action in the face of the pandemic.

The pandemic will of course also influence the patient experience outside of hospitals. The digital revolution is here to stay, but what will solutions for telemedicine and mobile healthcare units, that bridge the gap between the patient’s home and the healthcare provider, ultimately look like and how will they work?

In the longer term I think we will be increasingly looking at hospital, pandemics and digital technologies together in relation to reinventing whole health landscapes: how should we be envisioning mobile units and primary care satellite pods that take the emphasis and pressure off the hospital? How can we redesign homes so that certain medical interventions are possible there? How can we use limited financial resources in the best way for society? These are the kinds of questions we’re focusing on now at White – it’s a widening of the focus from hospital design to healthcare design.

For more on architecture and the coronavirus and to see more ideas for rethinking our built environment see here.

Illustration by Jason Lyon.