Dutch Courage

Utretch Academisch Zickenhuis Utrecht (AZU)

The new market culture calls on health service professionals to broaden their horizons and improve the public image of NHS hospitals. The Dutch could provide a useful source of inspiration, reports Graham Cooper HD October 1990

Encouraging noises are coming from down the corridors of power about improving the quality and appearance of healthcare buildings. The introduction of an internal market into the NHS, with hospitals competing for patients, means that managers are starting to concern themselves with the public image of their hospitals. Over the years hospitals have developed away from the public eye, in isolation from the lives of the people they serve. Planning decisions have been made from the perspective of services and treatment, and the public realm has been undervalued and consequently, has suffered from neglect. The new market culture, with its emphasis on 'customer satisfaction', and ministers' rhetoric about ,sprucing up' old buildings, will raise the public image of hospitals, and could have a profound effect on hospital design. Low staff morale and recruitment problems in the NHS also call for an upgrading of the hospital environment to attract staff, as well as patients, and this requires a more holistic approach to health care design. How do hospital managers respond to these demands, and where can they go to see examples of good quality public domains in hospitals? Recently, as representatives from the Medical Architecture Research Unit, we had the pleasure of visiting two new mega teaching hospitals in Holland: the enormous Academisch Medisch (AMC) near Amsterdam, completed some four years ago; and the Academisch Zickenhuis in Utrecht (AZU), completed last year. The appearance and quality of interiors in these Dutch hospitals far transcends anything the UK has to offer, and should offer some useful lessons.

AMSTERDAM.The AMC is strategically well positioned for easy access to a busy suburban station and motorway south of Amsterdam, and is one of the largest buildings in Europe. It is an uncompromising, well ordered, concrete and steel building, containing 1,150 beds, 19 operating theatres and serving over 10000 users per day. The approach to the main entrance, although hard landscaped throughout, is biased towards the pedestrian, and vehicles are kept well out the way at the lower service level. Once inside, the visitor is surprised at the spaciousness of the public squares and streets, which are arranged in a simple grid pattern. Reminiscent of large shopping arcades, these generous public spaces are a further development of a planning concept used for the Mackenzie Centre University Hospital in Edmonton, Canada, where extremes in climate encourage the use of large indoor complexes and shopping malls. The atmosphere in the AMC is stimulating and cheerful, with different colours and materials emphasising the building structure, and punctuating and distinguishing different zones of the hospital. Plenty of daylight is admitted through the transparent arcade roofs, and streetlamps provide illumination at night. Information desks are yellow and easily recognised, and street furniture and signage is clear and of an appropriate scale. Along the main streets there are shops selling books and flowers, banks, a hairdressers and a post office. A pavement cafe stages musical and dance events. The architects, Duintjer, Istha, Kramer van Willegen have introduced subtle contrasts into the main circulation areas, using round the smooth materials. In the grand hall, industrial materials predominate, such as cast concrete, paving slabs, glass blocks and steel. Hospital departments have a more intimate feel, and feature highly finished joinery, upholstered seating and materials with highly tactile qualities. An outstanding civilising feature of the hospital is the AMC kunst collectie, which must be the largest modern art collection in the world to be assembled under a hospital roof. This was financed through the 'percent rule', whereby a percentage allocation of the total building construction cost goes towards art embellishment (in this case one quarter of one percent of one billion guilders, or approximately £1.25 million). The collection comprises over 4 000 works, and these were carefully chosen by the art committee under the discerning eye of physician ProfessorW H Brummellkamp (a distinguished art collector) and the resident art historian Dr Elmyra M H van Dooren.

Three thousand of these pictures are on permanent loan from the Government Beeldende Kunstenaars Regeling BKR scheme which has art mountains of works by contemporary Dutch artists, stored away in warehouses. A hefty 390-page colour catalogue has recently been published as a testament to this considerable collection. The works have been arranged into 15 categories according to artistic styles, from abstract-expressionism to 'new wild paintings'. They represent a significant collection of post-war Dutch art, including a highly valued painted relief hung in the outpatients department by the Cobra artist Karel Appel.

Less successful, but still providing varied and surprising landmarks are the commissioned built-in art features. UTRECHT Our second place of call, the new Academisch Zickenhuis Utrecht (AZU), is a 900-bed hospital, which has clearly benefited from the experience gained at the AMC in Amsterdam. A massive building with three main blocks separated by glazed arcades, the AZU has a dazzling white exterior. It is situated to the east of Utrecht, close to a major motorway interception, and has its own bus station.

The planning is based on 'controlled decentralisation', and provides seven main centres of service, with decisions on patient care being taken as close as possible to the place of treatment. Everything revolves around the needs of the patient, referred to as the 'client'. Just as customers give direction to a company's strategy, so the clients give direction to a hospital's method of operation. As patients in the Netherlands divide equally into state health service and private insurance, tremendous effort has been put into the hospital's 'up-front' services.

On arrival, in addition to an attractive information desk, there is a patient services bureau and a patients' library. The main circulation is concentrated along five naturally-lit, wide streets. These contain a range of retail units, small restaurants, a coffee bar piazza, and a floating arena within a surprisingly elaborate covered courtyard. The sign-boards and signs are clear, large, economically distributed, and well nested.

As well as offering direct circulation, the main streets are planned as generous public spaces, with informal seating areas and planting. The circulation on the upper floors is provided along galleries, enabling the daylight to penetrate deep into the top lit atrium spaces.

As in the AMC, the structural detail is conspicuous and punctuates the spaces. The building's external finishes are continued inside the walls of the main streets and their robust nature adds consistency and texture to the building surfaces. In contrast, the detailing and furnishings with which people come directly into contact, are of a high visual and tactile quality.

The art features at the AZU are predominantly site-specific com- missions, specially produced for the different types of public spaces within the hospital. The problem of echo, produced by highly finished hard materials in large spaces, has been elegantly resolved by the use of acoustic panels. The sculptor, Herman Knijer, has cleverly hung clusters of acoustic panels, arranged in formal groups, in the three main arcades. These panels not only fulfil the duty of noise reduction, they are visually pleasing and spatially interact with the deep hallways.

Artist Maria van Elk was commissioned to provide floor decorations in the outpatients department, and she was evidently aware of the spatial potential offered by deep multi-floored rooms. Her low-key, hard-edged geometric designs, seen from above, sit very comfortably in the waiting areas.

At the AZU 18 artists were involved in a range of successful projects, all of which have been positioned in strategic places as part of the 'Percent for art' scheme. The first thing a visitor sees inside the building is artist Mart van Schijndel's information desk. This is designed to he welcoming and has its own canopy, integral flooring, planting, and polychromatic desk. The asymmetrical sculptured desk handsomely incorporates two video display units.

As the UK health service goes through radical changes, and as customer choice and quality of service are put high on the hospital manager's agenda, there is much to learn from the AMC and AZU in Holland - particularly if the emphasis is on front-of-house presentation to ensure that the patients' first contact with the hospital is pleasant and reassuring.

This article was written by Graham Cooper of the Medical Architecture Research Unit at the Polytechnic of North London, following a recent trip to Holland with colleague and architect Mungo Smith. MARU is currently engaged in preliminary studies concerning the upgrading of public space in a number of UK hospitals, and has been commissioned by the DoH to produce a study of Nucleus hospital main entrance areas.

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