Title: Hotels, factories and places for healing the sick The challenge to planning and design
Pages: 26 - 29
Text: Hotels, factories and places for healing the sick The challenge to planning and design
£68 million will be spent on hospital building in 1965-66. Five million people will be admitted to Britain's hospitals during this time. 30 million out-patients will be treated. Somehow, each pound has to be well spent; each patient needs individual attention. This means a vast planning operation. What is the seat of authority? Whose is the responsibility? What advice is given? And where does it come from?
by R. Gedling
There are some 2,400 hospitals in the National Health Service in England and Wales. Five million people are admitted to them each year, and there are 30 million attendances at out-patient clinics.
The planning of hospital services is undertaken on behalf of the Minister of Health by 15 regional hospital boards appointed by him. The running of the hospitals is undertaken by hospital management committees, appointed by the boards. The teaching hospitals are administered by boards of governors who are the direct agents of the minister.
The ministry seeks to ensure that the resources available for hospital development are distributed between the hospital boards according to their needs, and that the planning of the boards follows a general pattern and is to a broadly similar standard. It is the boards who are responsible for deciding the size and timing of building schemes within the resources which the minister makes available,
and it is they who - employing architects, engineers and quantity surveyors either from their own staff or from private practice provide new premises. In doing so they must, of course, bear in mind the views of the hospital management committees who will administer the new premises when they are completed.
More than a place for healing the sick
Hospitals are not buildings which are erected, have a relatively uninterrupted life, and are then pulled down. The practice of medicine changes, bringing with it new requirements; the change of social pattern may influence design. The hospital building is
becoming more and more complicated. It is a place for healing the sick - and a hotel and a factory, too. Some 40 per cent of the building cost is the cost of mechanical and electrical engineering.
Many of the hospitals inherited by the Health Service in 1948 were in obsolete buildings; about 45 per cent of them were originally erected before 1891, and 21 per cent before 1861. Some £310 million has been spent on hospital development since 1948, and the money being made available for hospital building - £68 million in 1965-66 - is increasing year by year. The size of the hospital building programme depends on the strength of the economy, and the Government has to decide how much of the national resources can be devoted to it rather than to oter development.
The replacing of old buildings, the need to serve an increasing population, the demand for new and up to date equipment -these will always put pressure on whatever resources are available. There is always a need for all concerned to seek and accept economical solutions to their problems. For the designer, there is the task of providing buildings and equipment which will enable those in the hospitals to make available the best service for patients - but not to provide it in so individualistic a way that it is either inflexible or so costly that other essential work has to be postponed.
In the early years of the Health Service, when the hospital building programme was small, the greater part of the resources available for hospital development was spent on adaptation. In order to be able to satisfy Parliament that value was being obtained for the money voted, the ministry examined almost all schemes in detail. With greater experience - and a rising programme - it has been the aim not to criticise plans after they have been prepared but to help the boards in their planning. This guidance is essentially a distillation, made available to all boards, of the most satisfactory features of the schemes which come to the ministry.
Key documents guide designers
The guidance which the ministry makes available to hospital boards, and to architects, engineers and quantity surveyors engaged in hospital work, is given in a number of documents, the key series of which comprises hospital Building Notes. These set out, for each department in the district general hospital, a summary of the functions which that department will discharge; a list of the rooms normally required; a statement of the work to be done and the suggested area for each room; and advice on the engineering requirements and standards that have to be observed in the department.
Attached to each Building Note is an appendix which enables the cost of a department, designed and constructed to the standards described, to be identified: so that clients and designers are able to work within a predetermined and reasonable cost. The financial management of the building programme as a whole is made easier because, once the content of any particular hospital building is fairly clearly defined, it is possible to forecast its cost with a tolerable degree of accuracy.
Each Building Note has its corresponding Equipment Note, which gives guidance on the type, quantity and cost of equipment which will be needed for each department; and this information will be expanded and improved as a number of working groups which are currently studying the design of loose equipment - with a view to rationalisation, variety reduction and design improvement complete their work. There is also a series of Hospital Technical Memoranda, which deal in detail with particular problems of hospital design and provision (eg, hospital electrical services, fire precautions and the planned preventive maintenance of engineering services
Industrialised methods can help
The ministry and the hospital boards have paid considerable attention in the last few years to the application to hospital design and construction of the principles of industrialised building methods. As a basis for this, all hospital design is now linked to the national system of preferred dimensions - is, all dimensions are multiples of 1 inch, 4 inch or 1ft thicknesses.
Some 40 study groups have been set up to examine how building, engineering and equipment components can be standardised, and how these items should be manufactured and supplied. The aim is to reduce design time by lessening the need for architects and engineers to produce detailed drawings of many items which can, with advantage, be repeated; and by enabling them to use standard drawings for a range of components which may ultimately cover perhaps 80 per cent of the content of a hospital building.
The Health Service has been particularly fortunate in that the professional officers of the ministry and the hospital boards have had in this work the most valuable co-operation of a large number of architects, engineers and quantity surveyors in private practice- including most of those with experience of hospital building. Manufacturers also have contributed their expertise to enable specification and design to be linked directly to ease and economy of manufacture.
By linking the processes of specification, ordering, manufacture and supply, we hope to give a greater degree of certainty to all these processes, and so eliminate delay and imprecision. The work of the study groups has already led to the design of a number of components such as doors, storage units, window assemblies, partitions and direction signs; and such additional items as structural members, sanitary fitments, and ceiling and light fittings are now being covered.
Opening out the closed systems
These arrangements may loosen the restrictions imposed by the fact that in this country (as overseas) industrialised building is based on 'closed' systems. Each system is proprietary, and the components which make up a building are specially devised for that system: they are not interchangeable with those of other systems. Our object is to put all hospital building on the same dimensional framework, to make available components which can be used for any building design within that framework, and so to put industrialised building on an 'open' basis any building contractor can use.
Nevertheless, there is a great deal of expertise available in the country among building contractors who have operated 'closed' systems. To take advantage of this, seven of the major building contractors have been invited to be associated with the design of a maternity unit - and if the price is right they will then be asked to go ahead and construct it.
One of the objects of this experiment is to discover which existing building systems can be adapted to the national module, and to the use of the standard components referred to above (it is a condition of the experiment that both should be employed). Results so far show a possibility of 'opening' some of the existing 'closed' systems.
It is important to underline that the minister does not intend to evolve for hospital building a 'building system' as that term is usually interpreted. We start from the assumption that there is nothing intrinsically special about a hospital building (apart from its complexity and the high level of its engineering content), and that we must find ways of gearing the hospital building programme to proved industrialised methods and to the techniques adopted by the most far-sighted builders in the country.
New hospitals on trial
The first results of all this work can now be seen in new hospital buildings, and - more particularly-will be incorporated in those now being planned. They are also brought together in the development projects which the ministry is undertaking in cooperation with regional hospital boards at Walton Hospital, Liverpool (out-patients' department and accident and emergency department), Kingston Hospital (kitchen and dining room) and Greenwich (800-bed complete district general hospital).
In these projects, the ministry's architects are acting as designers to the regional hospital boards concerned, and are applying such of the guidance given in the documents referred to above as seems likely to be permanently valid. But they are also pursuing, in their practical application, lines of development which need further research.
At Walton, for instance, the object was to investigate a number of problems - eg, the use of multi-purpose suites of combined consulting examination rooms, the use of day wards, and the extent to which standardisation and off-site fabrication of building components could contribute to increased speed and reduced costs. A Building Bulletin on Waiting Space and Circulation in Out-Patients' Departments was published in January 1965, partly on the basis of experience on this project.
At Kingston, the aim of the development project was to construct a complete catering unit for an existing hospital and to test the advice on kitchens and dining rooms given in the Building Notes, while allowing for experimental features which may influence the future planning of these departments. Both projects are now under construction.
The project at Greenwich, for the construction of a complete 800-bed hospital, was selected because it represents several of the most important and most difficult problems in hospital design and building - the site is small (approximately seven acres); it is located in a heavily built-up urban area; there is an existing hospital which must be kept in operation throughout new building; and it is subject to severe town planning restrictions in terms of plot ratio and permissible heights.
The broad principles of the design have aroused considerable interest. The emphasis is on easy horizontal circulation in a single, low and completely air-conditioned block. The structural system involves the separation of engineering services in an inter-floor zone for ease of maintenance and flexibility. A prototype structure has been erected at Hither Green Hospital. The project is now at tender stage. The cost control of this unique concept is the same - is, based on Building Note cost allowance - as that of all other types of hospital building, so that the project will test not only novel design concepts but also the flexibility of the ministry's cost control techniques. Looking to the future
How is the ministry's guidance work likely to develop ?
So far, there has been a strong emphasis on the design of specific hospital departments. This will be kept up to date to take account of new developments and the evaluation of completed work. But it is probable that there will be considerably more emphasis on studying the ways in which the various hospital departments may be brought together into a coherent whole. Into this work will be fed the results of the very many studies - there are some 200 in progress - which are being undertaken all over the country on various aspects of the functioning of hospitals.
It seems possible (by taking the ministry's guidance on standards of provision and cost through to its ultimate logical application) that, once the function which a particular hospital building is to perform has been decided and the site selected, a fairly precise cost figure could be attached to any project before the design work is done. This should give more certainty to the designer, and free him from a great deal of the detailed examination he at present has to make after he has gone some way with his work.
There is still too much design that is based on idiosyncrasies which take little account of research or of work already done in the field. There is a need, which the ministry will try to fulfil, to spread more information about good practice; and further reduction in the variety of design solutions is inevitable. The ministry's aim is to standardise components and equipment whenever standardisation can be used to raise quality and reduce cost. To the designer, there will be a continuing challenge to provide the most satisfactory and most economic buildings and equipment to meet user requirements.
R. Gedling has served in the Ministry of Health since 1936, apart from two years at the Cabinet office. He was principal private secretary to the Minister of Health from 1952-55; and has been under-secretary in the hospital and specialist services division of the Ministry of Health, dealing with hospital building, since 1961.