Global perspectives on the future of healthcare design
By Sarah Wesseler
October 9, 2013
In the last few decades, rapid advances in both medical and consumer technologies have created revolutionary possibilities for every aspect of healthcare, from prevention to diagnosis to treatment and beyond. From DNA-based preventative care to digital appointments with doctors thousands of miles away, the future holds enormous potential for improving longevity and quality of life for people around the world.
This dynamic creates significant challenges for designers working to shape environments that will meet healthcare needs both today and in the future. I spoke with Arup experts from around the globe — Phil Nedin, who heads the firm’s global healthcare business from London; Bill Scrantom, the Los Angeles-based healthcare leader for North and South America; and Katie Wood, who recently relocated from Australia to Toronto to build the Canadian practice — to learn more.
In your view, what are the biggest changes facing healthcare?
Phil: There are a few fundamental issues that we’ve got to come to terms with. First, we’ve got two generations of healthcare. We can look into the future and think about when the population is all digitally literate, when we can do all the preventative stuff and monitoring at home, telemedicine and all of that. That becomes the bedrock of our healthcare systems.
We’re backing the digital horse to do lots of things, which almost takes us to a lost generation: the elderly. The elderly have longevity, but they’re not really digitally literate. The next generation, the 40-year-olds and younger, suffers more from lifestyle diseases — cardiovascular disease, diabetes particularly; incredibly difficult stuff to deal with — and may not have the longevity. But they have the digital skills.
We know that healthcare’s expensive, but I’m suggesting that it’s only expensive because we’ve got to keep two systems running at the moment.
Katie: And then the effect on the actual hospital buildings due to this shift to digital medicine will be quite profound.
Phil: Absolutely right.
Bill: If you think of today’s hospital bed tower as being made up of lower-acuity medical surgical beds and higher-acuity intensive-care unit (ICU) beds, in the future lower-acuity beds won’t really be needed. Those will be your bedroom. And hospitals will become super-acute hospitals; basically ICU hospitals.
Phil: I agree. You’ve only got to look at the way the occupancy has changed. In the mid ’70s, the average time in hospital (in the UK) was 11.5 days. It’s now 3.5. And one of the reasons for that is that all the diagnostics are now done before you step foot in the hospital. They know exactly what’s wrong and they know exactly what they’re going to do.
I think it’s going to get even more interesting than that. Look at technology and science, molecular biology and what that can offer. There’s this issue about DNA screening at birth. You know what you’re going to be prone to get. That’s not meant to frighten anybody, because we know lifestyle factors, the nurture, now overwhelms the nature. Noncommunicable diseases are now overtaking communicable diseases.
But molecular biology techniques and nano — so they can put a little camera in you — are evolving fast. Even now, we’ve got slowly dissipating drug regimes that people can implant on themselves. I mean, that’s going to be a different world in terms of diagnostics.
Bill: And treatment, because all those drugs are made to be way more targeted — little robot drugs inside your system that are only looking for the problem area and attacking only it.
Phil: Yeah, it’s all very much more targeted. We’re working on a number of proton beam centers, cyclotrons, and this technique makes the destruction of tumors far more accurate than it’s ever been before. The collateral damage which is normally associated with the treatment of a tumor won’t happen with this technique.
Katie: Proton beam therapy, that’s a good example. Those installations are just huge: really technical, complex, specialist buildings. But a lot of the other treatments which might have been performed in an acute surgery environment are now moving to consulting rooms and not needing an enormous amount of surgery or equipment. So you’ve got a huge split between the specialists and the sort of stuff that can happen in a primary environment.
Phil: There are some forms of chemotherapy that can be taken at home.
Healthcare costs are rising inexorably across the world. How do you think governments should respond?
Phil: I’m struggling with this a bit, because I happen to think that the funding of healthcare is a shared responsibility. It’s my responsibility as an individual to look after myself in an average sort of way. I don’t have to be a super athlete, but neither do I have to be chronically obese.
I also believe, however, that the government has a massive role to play, because it is the government that needs a healthy workforce. Otherwise they aren’t going to have a healthy economy. If you extract the numbers on chronically ill populations, you could come out of it with a view that it’s the biggest threat facing Western civilization, because many people are not able to go to work, or at least do a meaningful day’s work, because they’re chronically ill right at the key part of their working life. So what happens then? If the individual is less than effective and efficient, suddenly it’s going to dawn on the government that it’s their responsibility maybe to keep a healthy workforce. So I struggle when they try to bat the responsibility back to the individual.
I’ve done some figures, and when politicians talk to us about percentages of GDP of healthcare costs and X billions of dollars — to the man in the street who they want to be responsible for looking after his or her health, it’s meaningless, absolutely meaningless. What that person wants to hear is that their individual health budget for the year in the UK is £2,450. That’s what they have. So if they want to go out on a Saturday night and get drunk in the city center and they fall over and break an ankle, they’ve got to understand that if an ambulance comes to pick them up they’ve just lost £750, and if they spend a night in hospital it’s £600 a night, and if they have an X-ray it costs £140.
So if people have to take responsibility, they need more information. And they’re not having it. We’re having politicians’ and economists’ financial-speak, and it doesn’t do the man in the street any good whatsoever.
If you extract the numbers on chronically ill populations, you could come out of it with a view that it’s the biggest threat facing Western civilization
Bill: I totally agree, but the one-to-one relationship in terms of healthcare costs for a single individual is not evident in the US either. As you were talking, Phil, I was envisioning that you go into the hospital and literally, when you walk in to get an MRI there’s a big price tag, “X number of dollars for this procedure,” posted over the door.
The trend in US healthcare is to create the exact opposite. Because of another part of healthcare reform, we’re trying to make hospitals as hospitable as possible. Part of the reimbursement equation for hospitals moving forward has everything to do with patient satisfaction. So when you walk in the door, you need to go, “Wow, I feel good about this place, it’s clean, it’s beautiful, everyone’s so nice, I’m confident that I’m going to get good healthcare.” I give you high rankings and that helps you with your reimbursement. I feel that if you treated them like a commodity and posted costs on everything, they’d say “That was such an insensitive experience; I’m going to mark these guys low.” And then economically the hospital just hurt itself.
There’s been a lot of controversy in New York around people accusing Bloomberg of implementing a nanny state by banning large soft drinks and the like. Is this an effective means to improve population health?
Phil: Well, my view is that we’re completely misinformed. We’ve been moved by governments, the US government and UK government, from saturated fats to carbohydrates. Carbohydrates are sugars, and some of those sugars are pretty damn deadly. Corn syrup, for example, is disastrous — it’s almost a poison. And yet we’re putting it in everything, because it’s cheap. But yet we never talk about sugar. All the stuff that we’re told about is about the fats.
Over the years, the food production has moved from the farmyard to the factory. We are now eating stuff that has very little resemblance to anything off the tree or grown in the ground. And it really isn’t good enough. So when we look at nanny states, I’m with Bloomberg, because I think he’s got his finger right on the pulse.
Bill: The difference, obviously, is that in the United States the government is not the healthcare provider. So your point about being uninformed — we’re possibly even less informed in the United States. A great number of issues beyond the individual create cost in our system. As an example, many people come in to our hospitals with no insurance at all, but with serious health problems related to lifestyle choices, and they’re taxing the system. So population health is huge in the United States, as is resolution of immigration issues. Here, potentially, it’s even harder to rationalize the connection between behavior and healthcare costs for the individual.
Katie: What do you think of the move to create organizations that are responsible for population health outcomes?
Bill: You mean accountable care organizations (ACO)?
Katie: Yes, so there’s an alliance between the care provider and the health insurer, looking at someone’s total health. So they’re motivated to keep people out of the healthcare system.
Bill: Yeah, they’re financially motivated to do so. Basically, in the United States healthcare reform is very closely modeled after Kaiser Permanente. Kaiser Permanente is a healthcare insurer and a provider. Their motto is “Thrive,” and the ad campaign is all about wellness: you know, “Come to us, we’re all about living a healthy lifestyle.” Because their goal is to collect your membership dues and never see you. They want you to be healthy and stay the heck away from their hospitals because you cost them money when you show up, both on the insurance side as well as on the provider side. It’s win-win. So the accountable care organization concept is to get other private entities to form similar relationships with one another to emulate that concept that Kaiser created.
But the interesting thing about the concept of the accountable care organization is that, in the States, who your insurance company is can change. For the most part your insurance is tied to your employer, and when your employer negotiates a new deal then they’re going to all of a sudden be tied to another ACO. Which means you’ll be tied to a different set of hospitals. I’m not sure how a group plan for a company with offices across the country will work.
Katie, what have you noticed about Canada and how it relates to other countries since you’ve been there?
Katie: As with other countries, I think that there’s also a need to establish a stronger link between people’s use of healthcare and their understanding of the cost of it in Canada.
And then when it comes to the buildings, there could be more study into the cost of the infrastructure and how it relates to the costs of delivering healthcare over the longer term — whole-of-life value for money. This is particularly important because we have an enormous amount of P3s, so we’re tying ourselves up over the long term to a load of infrastructure.
Bill: My favorite version of P3, these massive long-term investment strategies, is when there’s an operational component and it’s not just a design/build/finance strategy. Then there’s a lot of attention paid to the efficiencies of the building and making sure the building is going to be cost-effective to operate. And there should be.
But the real cost is in the care. We simulate energy and the operations costs of the building, but who’s simulating the cost of care?
Katie: A lot of the time people just take a set of assumptions about how we deliver care now and translate them into a functional program and a schedule of accommodations and don’t think about what’s happening in the future. Which is difficult to do, admittedly. And then what we end up is a built environment which supports a model of care which is probably from five years ago before the thing’s even opened.
How do we build for the future?
Phil: Once you start thinking about this stuff deeply you realize that the low-hanging fruit in healthcare design is gone. And this doesn’t do us a lot of good, as Arup. You cannot now just go out, design a hospital, get our fees, watch it being built, and be satisfied with that as a thought leader. You have to ask yourself, what are the socioeconoimic impacts of this? How does this fit in with future healthcare developments? Have I designed a hospital flexibly so that in 10 years’ time, if it were not a hospital, it could be something else? What could it be?
You cannot now just go out, design a hospital, get our fees, watch it being built, and be satisfied with that as a thought leader
Bill: Healthcare continues to face the baby boomer effect. And it is daunting, but temporary. You were talking about the two generations and the two groups of care that we have to deal with — I completely agree. But there’s a crazy transition that we have to deal with because of the baby boomers. So the weird thing is that we really do have to build hospitals, clinics, ambulatory care centers and everything else to deal with what we’ve got in front of us, because it is an onslaught. And then have a plan so that you can deflect the building into other useful structures in the future, absolutely.
Phil: And that is exactly what I’m hoping to communicate. We think we’re building for the future, but actually we’re not. For example, if you look at the different forms of acute hospitals, one of the popular forms is the podium and bed tower. In its time, that was a very, very popular form of building. But I am not aware of any podium and bed tower hospital that’s ever been converted to anything else. And if we start losing beds, then the only thing they really put in those spare floors is offices, and there’s only so many offices you can put in there. So to design a state-of-the-art hospital, we now say ok, low-rise hospital street, pavilions off the street with diagnostic and treatment on one side, bed areas on the other side. But it can be difficult to change traditional ideas of what a hospital building is.
Bill: A lot of the issues too have to do with land availability. Densification drives the vertical approach of towers upon a platform. There’s often just not enough land to pull something else off.
I do think that that there is an attempt to incorporate penetrations and break up the mass of the podium in these scenarios. It’s really being driven by the concept of driving natural light into the facility, making it a better healing environment, making it more energy efficient. And maybe that helps it to be more adaptable to different building types, too.
Do clients typically push back against these kinds of ideas?
Katie: There’s not pushback as such, but everything our clients deal with has got a whole load of constraints and motivators that can be counter to thinking about the long term. And they’re struggling with it.
So as designers in this field, how do you think you can make a difference? Is it about more advocacy? What can we do if the clients aren’t interested in or able to adopt our recommendations?
Katie: The approach we take is to always advise a client by thinking about the overall project in the context of their business going forward. We don’t just jump straight into the technical issues; we give them balanced advice about the overall things so they can make the best decision with the information available.
Phil: That’s absolutely right. Arup has developed a sustainable model for healthcare design: whole-life cost rather than first cost, changing clinical need rather than current need, low carbon rather than high carbon, innovation rather than prescriptive codes and guidelines, and therapeutic rather than clinical efficiency.
Katie: But even in our business-as-usual design we still look to take an integrated approach, which is so important in health facilities. Even if we’re only doing one discipline, we still focus on how that discipline interfaces with the rest of the design of a complex health facility.
As we’ve heard, hospitals are getting more and more acute, more and more technically complex. So that approach is absolutely vital. Even in a business-as-usual situation we can’t go on with the architect and each group of engineers in their own little silos.
Bill: On the States side right now, healthcare reform is all about efficiency. We’re focused on clinical efficiency, but also on building efficiency, building operations efficiency. So we’re able to start integrating some really great life-cycle strategies into the building. Our approach is resonating with clients.
Hospitals are getting more and more acute, more and more technically complex
Katie: Here’s another interesting thought to throw in the mix. Lean design has become a popular buzzword in healthcare, and I think that engineers in particular are extremely well-equipped to actually deliver lean designs. I’m quite excited about that.
Phil: We think broader than just engineers and engineering at Arup.
The solutions that we’re seeking at the moment are becoming more and more complicated, and don’t just center around bricks and mortar. They’re a lot wider than that. The new generation of engineers that want to get involved in healthcare, they have to be pretty well read, and they have to be interested in the socioeconomic issues of providing healthcare for the masses and the implications on economies if they don’t.