LESSONS FROM BOTH SIDES OF THE POND
Healthcare architecture firms that have designed projects in both the United States and the United Kingdom know that, along with the differences in cultures and health economics systems, each country's healthcare system has advantages and disadvantages. In this introduction to a three-part series comparing the two countries’ approaches to large-scale planning and design, I want to explore where what we have learned in one culture might be applied in the other. In some cases, the United States seems to lead; in others, the United Kingdom does.
The first lesson we can share from this is that architects must care about issues that extend beyond their buildings if they are to be effective as designers—that is, we can't operate outside society's larger influences. In healthcare we have an interest in organizational culture, clinical outcomes, patient satisfaction, technologies, economics, and politics. But we also have to ask ourselves: How do we, as designers, have an impact on the larger issues?
In the United States, how can design be used to improve financial performance, healthcare quality, efficiency, and safety? Can we convince healthcare providers that architecture and design are legitimate therapeutic modalities? In the United Kingdom, how can design make a difference in the country's competitive, privately financed procurement system? Can we convince healthcare providers in both countries that architecture and design are legitimate therapeutic modalities?
The two countries ration care in various ways. Neither country has enough money to do all that is desired; both are looking for the maximum value from capital expenditures. Both countries need to better understand the relationship between capital and operating costs, which are too often considered separately, each having different managers exercising responsibility and authority.
With health insurance for government employees, veterans, active military personnel, and seniors under Medicare and Medicaid, the U.S. government is subsidizing healthcare for one-fourth of the population. Who pays for the uninsured is less clear. The U.S. Census Bureau estimated that 43.6 million people in the United States lacked health insurance in 2002. When these individuals need emergency care (because they often won't get preventive care), some form of government subsidy might pay for it (perhaps at the county level). As a result, even though the United States doesn't have a single-payer system or a National Health Service (NHS), federal and local governments are responsible for a significant percentage of the population.
Direct comparisons begin to develop the story. Public expenditures on healthcare were 6.9% of the gross domestic product (GDP) in the United States and 6.4% in the United Kingdom in 2002. Even more telling is that total 2002 expenditures on healthcare, as expressed as a percentage of the GDP, were 14.9% in the United States and 7.7% in the United Kingdom. The statistics for morbidity and mortality are roughly the same in both countries.
The interest in using design to give hospitals a competitive edge has a longer provenance in the United States, but the United Kingdom has a distinguished history of strategic thinking about systemic and strategic design for hospitals. Indeed, I believe that the high-level, strategic thinking of U.K. architect John Weeks in the 1960s and 1970s has not been surpassed in either country. In the United Kingdom, however, patients have to wait to be treated for elective conditions, often for months, although the NHS has been making a determined effort to reduce waiting periods. Hospital replacement is the challenge in the United Kingdom, while growth is the challenge for America's $1.4 trillion health system between now and 2010. In both countries, demand for inpatient and ambulatory care services will rise steadily in the decade ahead, driven by demographics, consumerism, and technology.
Design for an Uncertain Future
In both countries we are designing for modalities of care and technologies that do not yet exist. In the United States, we are designing for healthcare delivery systems that may not yet exist, while in the United Kingdom the delivery systems are relatively stable. The key to preparing for the uncertain future will be to design for the universal rather than the unique. Therefore, healthcare architects are developing several strategies, including concepts of site zoning, open-ended planning, universal space programming, and “landbanking.”
Both the United States and the United Kingdom are experiencing tremendous growth in hospital construction. Continued U.S. hospital growth is uncertain, however, because of constantly changing demographic, economic, and political conditions throughout the country. An additional complicating factor in California is State Senate Bill 1953, which requires all licensed general acute care hospitals to comply with the Alquist Hospital Facilities Seismic Safety Act by several key dates: 2008, 2013, or 2030, depending on the level of risk involved and the planned date for completion of a full replacement project.
Across the entire United States, healthcare facilities have aging buildings, many funded through the Hill-Burton Act of the 1950s. Large numbers of baby boomers are growing older and bringing high expectations. Initially, however, the economic uncertainty of the early 1990s, combined with a belief that new technologies in outpatient services would greatly reduce inpatient bed demand, stalled the growing demand for new construction. Today's surge in construction is addressing pent-up demand, but healthcare providers are also competing for a very focused market: physicians. For the most part, consumers don't select hospitals, their doctors do—although this may be changing, with hospitals more and more trying to reach consumers directly.
In the United Kingdom, the building stock is even older, much of it dating from the Victorian era and the makeshift reconstruction following World War II. In a recent shift in policy, the NHS has redesigned the system to give hospitals, in the form of Public Trusts, more autonomy than they had previously. This greater decentralization has helped spawn a building boom, with the stated intents of increasing efficiencies, reducing waiting lists, and increasing patient satisfaction. The underlying belief is that the private sector, rather than the government, will be more innovative and efficient in the use of capital and operational expenses to further these purposes.
The demand in both countries will continue to grow, but we can't be certain how the hospital of the future will look. Three of the most promising facility design improvements are single-occupancy patient rooms, readily available hand-hygiene stations, and acuity-adaptable patient rooms.
Statistical evidence shows that single-occupancy patient rooms improve health. Transfers because of roommate incompatibility become unnecessary, lowering the risk for medication errors and patient falls. Single occupancy also helps eliminate the transmission of germs between patients sharing the same bathroom; as a result, infection rates drop. Single-bed rooms also improve caregiver/patient communication, increase occupancy because of operational efficiency, and allow for more flexible planning. Within the building, improved air-filtration systems, patient transportation protocols that separate patients from sources of potential infection, and separation of “clean” and “dirty” areas on patient floors can all enhance patient health. It must be noted, however, that although the percentage of single-bed rooms is growing in the United Kingdom, four-bed wards are still being designed there, in part because of the belief that they are cheaper to build and staff, and that they are more appropriate for certain patients.
Acuity-adaptable rooms mean that patients with changing medical requirements do not have to move to new rooms. These standardized rooms are designed with space dimensions and services that can accommodate a wide variety of patient conditions and needs during various stages of illness and recuperation. Two hospitals in Indiana, Ball Memorial Hospital in Muncie and Clarian Methodist Hospital in Indianapolis, have statistics showing that acuity-adapted rooms and other related innovations have reduced patient transfers and the quality- and safety-related problems that accompany them.
Severe shortages in nursing staff in both countries make employee retention urgent, which in turn raises the importance of efficient and flexible facility organization and a quality environment in which to work. Good design can greatly reduce wasted movement and unnecessarily lengthy trips to obtain supplies or move patients, and it can increase the amount of time nurses have for patient care. Environmental amenities are also important to attracting scarce labor resources.
Another important strategy for building in flexibility for an uncertain future is landbanking—the practice of acquiring land without any immediate plans, in anticipation of future replacement construction. In the United Kingdom, the goal of long-term flexibility is often difficult to achieve because the government's Private Finance Initiative (PFI) System, while innovative, tends to focus on the near-term financial goals of local trusts and the private consortia that build hospitals.
PFI: Where Public and Private Sectors Meet
Ironically, when it comes to drawing on private investment to build the country's hospital infrastructure, the United Kingdom is further along than the United States. The British have accomplished this with PFI. Created in 1992, the initiative allows the government to contract with private consortia to finance, design, build, operate, and manage public infrastructure projects. The private entity leases the building back to the public institution for 25 to 30 years, after which the facility becomes publicly owned.
The government benefits from PFI because it can spread out the risks as well as the payment for large public-sector projects over the long term, while the private entity pays the capital construction costs. Healthcare projects are the most challenging to carry off successfully using PFI, because they require a great deal of interaction with a variety of clients and user groups, and because they must be designed to accommodate a high degree of change over the span of the contract. The NHS has given its regional trusts the responsibility of leading the PFI process for each project, assembling the technical teams, preparing project specifications, demonstrating the project's viability, and preparing and managing the bidding process. The U.K. government has committed itself to using PFI for large healthcare projects, generally those costing more than £100 million, and has established other public-private partnerships for smaller projects.
In the United States, we are facing a significant capital shortage as we go from estimated healthcare expenditures of $15 billion to $30 billion a year over the next decade. If we decide to tap into the entrepreneurial private sector for those funds and allow hospitals to concentrate their resources on their core competencies, the government at federal or state levels will need to guarantee the process, much as federal insurance guarantees bank deposits and some home loans.
Despite our technologic advances, the high rate of medical errors in the United States has resulted in increased malpractice insurance costs. Both the United States and the United Kingdom have been studying ways to improve performance, in part by using evidence-based design. The Pebble Project in the United States is one such initiative. Sponsored by The Center for Health Design in partnership with various healthcare institutions, the project documents how improvements to the built environment enhance patient care, increase donations, improve staff retention, raise market share, and result in better financial performance. Ongoing research is investigating the design effects in a number of other areas—such as providing patients with stronger connections to nature, more control of their environment, better social support, and positive diversions—and reducing environmental stressors such as noise. Studies have sought to evaluate the healing impact of factors such as room size and scale, privacy, lighting, colors of walls and furnishings, patterns in walls and fabrics, air and ventilation management, art, music, and the design of windows and the views available through them.
In line with error reduction, evidence-based design also emphasizes the design of safer buildings, which includes improvements in both operations and systems. Recent improvements, such as computerized physician order entry and bar code verification technology, have already shown dramatic reductions in record-keeping errors. These kinds of innovations are happening in both the United States and the United Kingdom.
Waste and Energy Management
Hospitals consume huge amounts of energy and produce a great deal of waste. Much of that waste is hazardous and contaminated. The disposal of all kinds of waste costs money and leaves institutions open to risk and liability. A new technology is being tested in the United States that safely converts waste into hydrogen to feed fuel cells in a hospital's central utility plant, with no measurable greenhouse gas emission. The steam generated by this process would be used for sterilization, laundry, space heating, and electricity generation. The fuel cells would provide a highly reliable power source for the hospital, backed up by traditional sources for an uninterruptible supply. The payback period is anticipated to be less than five years. Following further testing and implementation, this kind of system could be used by hospitals throughout the world.
Each country or culture will tend to view its own healthcare system as superior. In the United States we often hear that our healthcare system provides better services and more innovation. The British, however, are dismayed that the United States does not provide healthcare for all its citizens. But the real situation is more nuanced. The United Kingdom, with government backing, has entered into a true public-private scheme to develop hospitals. In the United States, federal and local governments are already committed to providing health insurance for well over 25% of Americans. Each country has made advances that the other has not. Let's share them. One day, it is possible that our systems may become more similar than we expect. HD
Future articles in this series will develop the issues in large-scale planning introduced in this article, which will confront both countries for years to come.