Bright Lights: London Healthcare
A look at the current drivers of health facilities strategy in London, as embodied in three current schemes of merit by Graham Cooper HD March 2006
At a time when the practice of health care is changing at a pace we find the largest ever capital investment with considerable changes in provision and procurement. With a million NHS visitors per week and an evolving emphasis from institutional care through the NHS reforms to consumer choice, the outlook is both intriguing and challenging. To make sense of these emerging developments nowhere are the effects more evident than in London, with its 'critical mass' of relevant factors. The health sector is the largest employer in the city but a third of hospitals are built before the NHS was introduced, - 10% are Victorian and are incapable of meeting current demands.
The recent Capital Health exhibition held at the Building Centre1 was a unique opportunity to take stock of care in London at a critical point in UK health provision. Looking ahead into the new century, the exhibition also provided an opportunity to reflect upon historical developments in medical care, a complex picture of prestige teaching hospitals and pioneering social programmes. The exhibition showcased a breadth of opportunities and innovation not witnessed since the heroic days of the 1960s when the NHS was advocating district general hospitals with a thousand beds. In the wake of the latest waves of PFI, LIFTS and independent projects, were the decommissioning of two health facility icons at the Northwick Park and Greenwich. With their progressive concepts of "indeterminate architecture" and interstitial spaces they were once heralded to be "future-proofed", but both are now threatened with demolition. The institutions began to crumble following Irvine Gottman's revealing findings that it was the institutionalisation itself which prevented recovery. Since the Sixties the number of psychiatric hospitals, for instance, has fallen dramatically from 130 by half with much shorter stays and an average size of 320 beds. In the intervening 30 years there has of course been considerable societal and economic change, not least the oil crisis, the development of digital technology and information networks. With the need to address hospital acquired infection and climate change, it is clear the appetite for mass hospitalisation as depositories for illness is out of favour. Some trusts like UCLH and Royal London are still perpetuating monuments to clinical might but for most, health infrastructure is in the process of rational de-construction and building networks. Now it is a matter of mobilising health resources taking care nearer to home.
The drive to reconfigure care and modernise facilities in the capital is made possible by an inflow of public and private finance which is predicted to reach £9 billion over the next ten years. As a result health care construction in the capital is happening at an unprecedented rate, but potential sites are scarce and much of the development is taking place within existing and constrained surroundings. Often there is a desire to conserve heritage and encourage a familiarity for place within the existing urban fabric. Many are in the civic realm which contribute to the public consciousness and at the same time create a sense of shared experience. Whilst there remains a significant role for emergency and critical care, with new methods of minimal-invasive surgery 70% of procedures can be achieved without the need for an overnight stay. To provide an improved patient orientated service many of the less acute services are being devolved back into the community. Facilities which were previously separate are being merged or networked to a single locally based service.
Across the city there is a surge of interesting new health building types, buildings which are multi-functional and which incorporate a diversity of related programmes. Understandably the needs of children attracts special attention with playful and creative expression, so leading edge services now try to keep children out of unnecessary stays in hospital.
Three exemplary schemes encapsulate many of these drivers. The Lewisham Children and Young People's Centre is the first one-stop children's care centre in NHS, the providers and mix of social and health service carers working closely together within the community. Once conveniently hidden within asylums around the outskirts of Greater London, mental illness is increasingly being addressed amongst the population at large. Integrating mental health into the community, the "Springfield Village" development values its green space and natural context, whilst planning to keep in scale with the grain of the neighbourhood. Adding a further tier of specialised care will be the London Maggie's Centre, which is navigating a gap in cancer care provision and advocating an educational route for encouraging patients in emotional turmoil to deal positively with the trials of the disease.
Lewisham Child and Young People's Centre
Due for completion in April, the Lewisham Child and Young People's Centre2 hosts a variety of health and social services. Following a seven year gestation period and business plan which recognising users benefits when providers work closely together the centre won an open CABE design competition which included architects with no health care experience. Establishing a precedent for the NHS it provides a combination of education, mental health and outreach services for youngsters up to 18 years. Architects van Heyningen and Hawarth proposed an inspiring landmark which would provide an opportunity to landscape and add to existing trees along Rushey Green the Catford High Road. A community building in daily use it accommodates different groups from babies to young adults, with 20% of facilities dedicated to children and adolescent mental health services CAMS.
The site looks to accommodate a U-shaped footprint offering a central garden inter-relating to the streetscape and enabling the five storey building to be naturally lit and ventilated. It features a private garden in conversation with the outside high street from over a transparent screen. Occupying the heart of the building the garden offers human scale at street level and a threshold space orientating visitors through the primary circulation. The aim is to welcome and to lift the spirits, not to intimidate but to provide security, privacy and dignity. Child centred the service should provide a calming ambience, both visually and acoustically, in a place where staff enjoy working. The intention is for simple legibility, so the receptionist can point the way, the circulation single loaded onto the garden. The ground floor contains the main waiting and spaces of differing character, a soft room for the infants and AV lounge for the teenagers. Overlooking the garden the first floor contains CAMS and Child Health, the second to top levels provide shared private space, presenting a simple building which in future if appropriate will be easily transferable.
At Tooting Bec the Springfield University Hospital accommodating over 300 people is one of the largest and few remaining 19th century mental health institutes still in use. The grounds are expansive and the existing buildings are no longer fit for delivering modern mental health care services. In its role as site developer the South West London & St George's Mental Health NHS Trust has commissioned Urban Strategies Inc to produce a masterplan which will make best use of its land assets.
It is clear the appetite for mass hospitalalisation is out of favour
It is the first step in a rolling 10 year programme to realise the vision of mental healthcare and suburban regeneration in south London. The trust's commitment of introducing new facilities, supporting social inclusion and accessibility, is underpinned by the proposed masterplan. The plan aims to decrease the effects of stigma by a mixture of additional uses that bring people and vitality to the site, blurring the boundaries between care and daily activities. These include a variety of residential options, commercial enterprises, social functions and public spaces. By integrating mental health care into the Springfield Village the principle is to enhance the character of place by preserving the heritage buildings and establishing a logical framework of streets. To provide improved access, cycling and pedestrian movement and to introduce trees to enhance the open spaces and views offered by the site.
During planning consultation from clinical carers and nursing staff through to patients and the local residents is vital in the successful development of the service. The healthcare facilities will be concentrated into two small clusters of dedicated units which function as an integral part of the village environment. The new mental health units designed by MAAP Architects will be housed within templates up to four-storeys high across the sloping site. They accommodate various clinical disciplines within set footprints. Individual units are defined by a ring of perimeter accommodation, protecting the private courtyards. Natural daylight and sunshine penetrates the blocks, and allows internal views across outdoor spaces. The outer elevations deal with privacy issues by means of oblique bay windows with a composite of translucent and transparent glazing. En-suite single bedrooms are arranged with outward views and access to each bed area is possible from two directions. Day activity and living areas are placed at the centre of the units with direct access to secured external gardens. The external terraces are adjacent to circulation and activity spaces so that privacy in bed areas is maintained and staff can easily observe on an informal basis. The first phase containing eighteen acute beds, ten intensive care suites, an outpatients and community team section goes for full planning approval in January and is scheduled for completion in 2008. This pilot scheme will test the masterplan's integrity, and its future capacity to achieve best value from the remainder of the development.
Complementing the mainstream path the scheme for a Maggie's Centre at Charing Cross Hospital will provide a facility for a service that offers patients diagnosed with cancer respect, comfort and emotional support. Due to open at the end of the year, the centre designed by Architects Richard Rogers Partnership will be the Maggie's headquarters. The object is to carve space and time in a calm atmosphere which lower stress levels, establishing a frame of mind and mood to lift the spirits and identify a map to remission. The design ethos is to create inspiring buildings of distinction, human scale and sympathetic to the particular needs of the user. Maggie's Centres represent a a dramatic shift from the grim impersonal and utilitarian throughput to celebrate each centre as a distinctive entity in its own right. The brief is consistent but flexible to challenge designers to take risks, the main constraint being the architects own limitations. As the culture in each city varies the outcome is pluralistic, dependant on the locality and the individual design teams. The architecture, art and gardens are essential and all pervasive in transforming outlook from "will I live into the will to live".
As according to leading RRP architect Ivan Harbour3 Hammersmith was inspired by Maggie's fondness of Chinese landscape architecture there is a continuity of space fusing outside to inside connecting the user's experience. The building is bathed in landscape with an earthy perimeter wall offering protection from the hostile Goldhawk Road surroundings. Small courtyards formed between interiors and enclosure surrounded by trees filter noise and pollution, whilst providing a leafy backdrop. An introverted oasis the landscape softens the atmosphere and the garden designed by Dan Pearson arrives at the discrete side entrance. A large floating canopy denies views of the oppressive Charing Cross tower and instead allows canyons of daylight to stream through the roof lights. A spiral route leads to the kitchen stove hub, a quality open communal space within the double height central core at the heart of the building. At the corners, quiet one to one sitting rooms for private consultation and contemplation. Designed by local but leading architects, rather than an anonymous support centre the London Maggie's is a beacon of hope.
In co-founder Charles Jenck's opinion3 these are exciting times for healthcare designers as hospitals begin to mutate into new types of form. He believes good architecture can make a significant contribution, not in the sixties utopian sense but is powerful if appreciated by users and those who support the ethos. Patients only require intensive clinical services for an hour or so during the period of sustained treatment, the rest of the time they yearn for a more homely and civilised setting. There is a groundswell of grass root resistance to the top down paternalistic dictates of the past.
As the status of public health and NHS is once again elevated up the political agenda we appear to be experiencing a paradigm shift in the delivery of care. Discharge of responsibility is occurring from centrally distributed welfare to an era driven by the specific needs for individual care, informed choice and access to information. As the health service enters a new chapter instead of institutional conformity, we are entering a competitive phase of identity branding and signature design. Despite the promotional and marketing orientation, until there is evidence of their fit-for-purpose qualities, the success of trophy projects cannot be predetermined.
With continual change in health provision there is a need for capital planning to loosen up, otherwise if too prescriptive and not whole-life it will be redundant before schemes reach completion. Disrespecting the broader urban design context at macro and micro level is likely to create isolated and alienating estates. The challenge is to rationalise the resources to reflect the changing public health demands of the community and choices in the way health services are delivered. To have access to buildings which reflect humanity and the changing patterns of healthcare; to create appealing, but sympathetic environments which inherently make people get better.
Graham Cooper is a designer, and the co-curator for the Capital Health exhibition produced by the Building Centre Trust in October 2005.
1 'Networks of Care and the Lewisham Childrens Centre', Joanna van Heyningen Optimising Design Seminar November 2004.
2 'The design of the London Maggies Centre in Hammersmith' Ivan Harbour The Healing Space Seminar, London October 2004.
3 'Introducing the concepts of the Maggie's Centre' Charles Jencks. The Healing Space Seminar, 2005.
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