Getting better

Health systems around the world are under increasing pressure, but the problems they face are not incurable. Alexandra Pratt reports

Even in the depths of a recession, healthcare remains an essential cost. But it is a sector that has undergone massive changes – in funding, governance and patient expectations. Globally, health reform is a hot topic everywhere from the US to China.

Lifestyle, consumer demand and the huge boom in technology and pharmaceuticals all affect how we design, build and use healthcare systems. But it is demographics and, in particular, the ageing population of 
the developed world, that has the most significant impact.

In the UK, the Office of National Statistics records that the number of over 65s has risen by 1.5m in the past 25 years, while the number of over 85s has doubled in the same period and will do so again by 2033.

The US Department of Health predicts that 16% of its population will be over 65 by 2020, something that will influence clinical 
research and care.

As Conor Ellis, head of health at EC Harris explains, “there is a growth in what we are clinically able to do… [but] demand will 
outstrip supply.” In terms of what will need to be built, Ellis predicts that “even allowing for care at home, more [people] will end up in nursing homes in the next few years.”

There have been a range of responses 
to this situation. One of the more innovative can be seen at the BRE Watford Innovation Park, where the Willmott Dixon Community Healthcare Campus (see below) uses sophisticated technology to monitor 
patients remotely in their homes, thereby reducing trips to stretched facilities. Other features include self diagnostics 
and a ‘smart’ reception with self check-in.

This is the kind of patient-centred, integrated facility many hope will be the healthcare 
of the future. Reconfiguration of existing facilities will also be a feature of future development, according to Paul Coomber, head of public health at Davis Langdon.


We will move “away from new build towards communities… integrated care… and smaller facilities. The days when we said ’let’s just build big’ are gone.”

Spatial consequences
Across the Atlantic, US President Obama’s proposed healthcare reform agenda will provide a huge shake-up to medical care, too. “We’re hoping to see a more outcomes- based healthcare system,” explains Randy Guillot of OWPP/Cannon Design Guillot, “but that will have spatial consequences.”

At the recently completed Advocate Lutheran General Hospital, designed by Guillot (see below), it is all about flexibility for future growth and adaptability, with column free interiors, inpatient floors laid out in ‘pods’ 
using a universal floor plate design, and modular designs in areas such as operating rooms that will make the hospital “easier to reconfigure over time.”

Designing for growth and adaptive technology is one thing, but how is it to be paid for, particularly in countries where public funding of health has been hit by the recession?

“The healthcare systems in place need to 
be refined in future,” says Ingrid Hulshoff, portfolio manager at ING Real Estate in the Netherlands, “due to a lack of income (mainly 
in tax and insurance), which will decrease because there are fewer in the labour force and more in need of services. There will be 
a gap between income and cost.”

This is certainly the case in the UK, where a recent report by the King’s Fund, Windmill 2009; NHS Response to the Financial Storm, suggests that the combination of rising demand and expectations, the recession and the end of the planned funding increases by the UK Government in 2011, will lead to a considerable funding gap of between £21bn to £40bn.

Paul Coomber says health foundation trusts will have to look to the market for resources, while Conor Ellis believes planners will have to re-think the affordability of capital projects and the responsiveness 
of buildings. “We’ve gone for quality, not the functional approach,” he says, “and as a result our hospitals are the most expensive in Europe.”

Biggest changes
Some of the biggest changes in the sector have been in procurement, with PPP, PFI 
and government funding mechanisms, such as LIFT and ProCure 21, changing how healthcare infrastructure has been delivered 
in recent years.

ProCure 21 was introduced 
for publicly funded NHS capital schemes and offers fast-tracked projects through partnering with one of a small number of suppliers who agree a guaranteed maximum price before construction begins. More than £4bn of NHS schemes have been delivered, 97% of which were on time and 
on budget.

With the arrival of ProCure 21+ this year, however, Coomber says there will be less flow-through of work, with 12 providers down to six, and not so much work generated through capital expenditure. “A number of clients believe there is better value through competitive tendering.”

With the Government deficit adding to the pressure of demands already being made on the NHS, the King’s Fund suggests that new partnerships will be needed, and this isn’t the time for the private sector to be dissuaded from getting involved.

This is something that has already been embraced in the healthcare real estate sector in Europe, where Hulshoff is responsible for alternative investment funds.

Regulations are changing to allow private capital into the sector, providing excellent opportunities for investment through new business models, 
such as sale and lease back transactions and off-balance real estate investments.

The consequences of the credit crunch have been the same as in other real estate sectors, but Hulshoff says he can see a turning point now. “Banks are willing to finance again and investors are very interested.”

Healthcare is an attractive investment 
as it has little correlation with economic growth, consumer spending, or business confidence. It also offers stable incomes, with low volatility and low risks. It is, however, “an emerging market”, admits Hulshoff.

There are a few property healthcare funds, but most of them have a single country investment strategy or no core strategy. The markets vary considerably, too. While Germany “is the most mature”, fundamentals are also important: “Italians, for example, would not put parents in a home.”

Too large
Over in the US, Guillot explains that they are “in a period of uncertainty” and “right-sizing, as things have gotten too large and ambitious.”

The two main types of healthcare clients 
in the US, academic medical centres 
and the not-for-profit sector, have both struggled to find the capital for projects, 
as the bond market has “all but ground 
to a halt” as a result of the credit crunch.

Furthermore, capital campaigns had previously been stalled for some time while administrators waited to see if the reforms were to be passed by Congress. Elsewhere, finance is not always a problem.

The Turkish government has recently invested in a 600,000 sq m, six hospital medical campus (see below) – it is the first stage 
in the government’s ‘re-imagination’ of the public healthcare system.

In India, charitable funds from the Anil Agarwal Foundation have financed the construction of the new 500-bed world-class Vedanta Teaching Hospital, due to open in 2011 (below). Its location in the poor and remote area of Puri in Orissa will, 
it is hoped, also create a significant boost 
to the regional economy.

Perhaps unsurprisingly, it is China that is experiencing the largest investment in healthcare infrastructure and services. The combination of a massive population of 1.3bn, and vast levels of industrial 
pollution the World Bank defines as a ‘significant health hazard’, translates into real pressure on medical services.

In response, 
the Chinese government has now started 
a three-year health reform programme that 
will eventually see 90% of the population covered by medical insurance. To accommodate this, 850bn yuan (£77bn) is to be spent building an astonishing 30,000 
hospitals – an incredible 986 of which were completed in the first six months of 2009.

A further 5,000 hospitals, 3,700 community health centres and 11,000 health stations will also be regenerated, retrofitted and upgraded to modern health care standards. In Singapore, the new £73m National Heart Centre (see below) is aiming to set a green benchmark in healthcare development.

It is one of several new projects that are focusing on sustainability and it is using eco friendly materials that are energy efficient in manufacture and self-cleansing.

In India, Vedanta’s sustainable features include storm-water management (vital for
 the July-October monsoon season) and water conservation, the sourcing and use of local materials, landscaping with local plants and 
a green roof.

Permeable pavements
Some of these features are similar to 
Guillot’s Advocate Lutheran hospital, which 
has been awarded ‘gold’ under the LEED program (akin to BREEAM in the UK) for 
its eco features, which include permeable pavements for dealing with waste water and green a roof.

Perhaps some of the most striking sustainable new healthcare buildings have been in the UK.

The Viking Day Unit 
(see below) in Margate (financed, unusually, by staff fundraising) is a £1.1m project designed by Nightingale Associates, which exceeds NHS best practice guidelines and features dense materials to retain heat, 
low energy lighting, with untreated larch and zinc cladding.

The same company also designed the Alltwen Community Hospital, a similar project in Wales (see p.21), which boasts bio fuel heating, an internal winter garden and rainwater harvesting.

All of the new sustainable projects seek to go one step beyond what is environmentally friendly, and make a direct link between environmental benefits and health benefits, 
for patients and staff alike.

At the Singapore Heart Centre, that includes striking internal gardens across one side of the high-rise structure, with most developments featuring internal and external open spaces, improved natural daylight and ventilation.

Recent findings published in the Perkins and Will Research Journal (Spring 2009) recognise the link between the environment and patient health, not just in terms of more sun, but through inspirational design that is free 
of toxic materials, water balanced and with 
zero waste.

This new trend in healthcare design is supported by a report by Dr William Bird (Natural Thinking RSPB, 2007), who found that contact with nature benefits mental 
health and post-operative care, as well 
combating modern lifestyle problems, 
including obesity, stress and inactivity.


He found that a more carefully designed hospital environment could bring financial benefits, in terms of savings through faster recuperation. His conclusions were in part based on earlier research (Gardens in Health Care Facilities by Cooper, Marcus and Barnes, 1995; Science magazine, Ulrich, RS, 1984.) which supported the positive effects of a natural environment and found that patients suffered increased stress from windowless rooms and artificial lighting.

Buildings such as the Singapore Heart Centre recognise the potential significance 
of future medical technology advances in 
their flexible design, but technology issues 
are also important for surveyors working in 
the sector.

“Healthcare projects have quite a high mechanical and electrical services content, especially for example in operating theatres and medical gases,” explains Coomber. “Medical buildings are highly serviced, and 
[you need] a thorough understanding before going through procurement.”

Yet it’s not just about understanding clinical planning and co-ordination – healthcare is a marketplace with its own standards and requirements that surveyors need to be 
familiar with.

Learning curve
“There’s a steep learning curve for those new entrants who don’t have experience in healthcare,” says Coomber. “You need to learn rapidly to have credibility when 
talking to NHS people… and a thorough understanding of how their market works, 
how their business performs.”

He sees little opportunity in the UK at the moment. “In the last six months, there have been new entrants to the market, recognising that commercial retail has gone down,” he says. “My feeling is, though, that it’s saturated with players already.”

In fact, Coomber warns, it is becoming so competitive that the profession could be devalued by people bidding at ridiculous rates that can’t deliver a decent service.

It seems that in the recession stricken, publicly funded UK healthcare market, the building boom of the past few years will soon reduce to a trickle, and with it opportunities 
for the profession.

This is balanced out, thankfully, by burgeoning new and restructured markets overseas, especially in the Far East and in Europe. “Where do I see opportunity,” asks Hulshoff, “everywhere!”

US healthcare reform

The US spends approx. £2.26tn on healthcare annually – but around 46m people (or 15.3% of the population) are believed to be uninsured.

The current healthcare debate centres on the recently passed Affordable Health Care for America Act and the Patient Protection and Affordable Care Act, and concerns such questions as if there’s a fundamental right to healthcare, who should have access to it and to what level of quality.

Those in favour of universal healthcare say that the large number of uninsured US citizens create direct and hidden costs shared by all, and extending coverage would cover costs and raise quality. Opponents to reform argue that this would impinge on their personal freedom.

National Heart Centre, Singapore
Split into two ‘fronts’, the 9-storey, 35,000 sq m National Heart Centre’s environment has been designed by ONG&ONG in collaboration with Broadway Maylan to reflect the needs of patients, staff and visitors.

The main approach, which houses medical facilities, is quiet and formal, while the garden front at the other end serves as a healing park and waiting area. To be completed in 2013 for the Singapore Ministry of Health, the facility aims to set a precedent for sustainable heart-related healthcare development.

Alltwen Community Hospital, Porthmadog, Wales, UK
Ysbyty Alltwen is a highly sustainable community hospital that’s been integrated into its setting on the edge of Snowdonia National Park in Wales. Local materials such as stone, render and timber were used in construction of the 30-bed building, which also maximises outside views for the natural environment to aid patient therapy.

Etlik Health Campus, Ankara, Turkey

Located just outside Turkey’s capital, the vast 600,000 sq m Etlik Health Campus, designed by Cannon Design & NKY, will contain 2,600 beds across six hospitals and is the first large-scale project in the Ministry of Health’s ‘re-imagination’ of the public health system.

The general hospital, cardiovascular, neurosciences, children’s, women’s and oncology facilities will be connected by a shared diagnostic and treatment base.

Advocate Lutheran General 
Hospital, Illinois, USA
One of only a handful of hospitals in the 
US to achieve LEED Gold certification, the 192-bed Advocate Lutheran utilises mechanical and electrical systems to reduce energy use by 21%. The building’s green roof provides insulation and retains 50% of water during average rainfall, which is then filtered to 31,000 on-site plants within a ground-level rain garden.

Vedanta University Teaching Hospital, Puri, India
The Anil Agarwal Foundation has a plan to develop the rural area of Puri into a global centre of medical education that would be on par with Harvard and Oxford. As part 
of this, the Vedanta University Teaching Hospital, designed by Perkins + Will, would serve as a regional hub for critical medical research into conditions such as diabetes and heart disease.

Viking Day Unit, Margate, UK
Using a plan arrangement that maximises the number of rooms with natural daylight and ventilation, the Viking Day Unit keeps energy consumption at a reduced level. A showcase for sustainable design in healthcare, the scheme is the product of 11 years of fundraising by the staff.

Willmott Dixon Community Healthcare Campus, Watford, UK
Created as a prototype local healthcare facility, this innovative campus removes the everyday usual waiting room and introduces an airport-style self check-in for patients, who can then enter a ‘self-diagnosis pod’ that checks weight, body mass index and blood pressure. Medicine is then dispensed from a robotic pharmacy, which also features a touch screen Healthpoint for information on conditions and treatments.