Health and efficiency
The government Green Paper, 'Our Healthier Nation', published earlier this year1 sets out a number of innovative ideas for the future of the nhs. Much of the work was based on a renewed interest in primary health care and its refocus on a holistic approach. The concept that mind, body and spirit each play a part in our overall well-being is once again being recognised as important after the high-technology solutions of the post- war period led simply to bottomless pits of finance and bureaucracy.
By advocating primary care groups the medical service will be placing the patient first, and organising health care increasingly at a local level, with the provision of specialist services for population groupings of 100,000, bringing together 50 gp practices of varying size for each pcg. Pilot studies and research programmes are testing these ideas and we can expect trial exercises very shortly on the implications for primary care buildings. A variety of procurement routes are likely to be tested, including the involvement of the private sector. This will create development opportunities on sites no longer required, and design challenges for briefs still being written.
But how will architects respond to this opportunity? Over 600 practices include experience of gp surgeries on their returns to the client's advisory service at the riba, and over the last decade the primary health-care sector has been a rich vein for sensitive architect/client relationships, resulting in many successful buildings with satisfied users. Until now designs have been based on the doctors' 'red book', a bureaucratic schedule of areas, spaces, and cost limits which is a microcosm of the way in which most health sector buildings have been procured over the last 30 or 40 years. The revisions of last October will offer greater flexibility to architects.
It had been believed that the great detail of design guide data and briefing documents leaves the architect free to produce better-quality buildings. However, all too often it meant a protracted gestation period with restricted opportunities for architects to achieve delight and freshness in a building type where patients need more help than usual to make them feel good. Perhaps it is surprising how many well designed surgeries have been built.
The new primary care group buildings will need to be flexible, long-life, low-energy, loose-fit structures. They will also need to be responsive, taking a lead from other sectors such as higher education (there are several excellent learning resource centres), and commercial, where space planning techniques have developed attitudes to flexibility and building economy which could transfer to the health sector.
The renewed interest in the holistic approach to health care will improve locally established links between doctors and the other social services. Health visitors and district nurses became part of a gp's team some years ago, but social services duties, including the responsibility for mental health, have remained with local authorities. This will change as the new relationships unfold over the next few years.
pcg's will require more specialised facilities, and these may be provided either by new centres, or by additional facilities at a strategic existing gp's premises. You could describe these facilities as a re-invention of the urban cottage hospital, or a 'polyclinic', a word once used to describe the Finsbury Health Centre. A modern example can be found in the recently completed polyclinic at Hove by Nightingale Associates.
At a riba seminar earlier this year, the minister with responsibility for primary health care buildings, Alan Milburn, said that there will be a need for 1000 health centres in the community near patients' homes, with an expansion of intermediate care through these facilities. He forecast the forging of new partnerships with the private sector and the batching of projects to create larger development opportunities, both using pfi as a procurement route.
Increasingly the government, as principal client, is recognising the importance of high-quality design, reflecting a greater awareness of the importance of good design by a number of large national clients. The Millennium Commission, the Arts Council, English Partnerships, and the Higher Education Council all have introduced guidelines and procedures to appraise design standards. The nhs has produced 'Better by Design'2 which sets out a checklist of design pointers. This could usefully form the basis of a compulsory quality test for new primary health care buildings, in conjunction with the self-appraisal questionnaire in 'Environments for Quality Care'3.
Surely this represents an almost unprecedented opportunity for architects to capitalise on by clients' wish to see buildings well designed. Architects have the opportunity to work with clients directly, with doctors, patients, and other users of primary health care buildings, and to respond positively with design ideas, rather than proceed along the more tortuous route of satisfying health managers.
New technologies will also set new design challenges. 'Wires for Health' will introduce accurate, clear and credible websites on a variety of health issues to all schools and colleges in the country, according to the government's green paper. Patient-focused electronic diagnosis will allow gps to communicate with consultants instantly from consulting rooms, and early diagnosis gives better prognosis.
The West End Resource Centre in Newcastle upon Tyne has launched a new attitude towards fitness for life with, alongside the traditional gp practice excellent exercise, fitness and community leisure facilities. This approach of combining preventative medicine with encouraging of physical fitness is setting new standards for the integration of health and social workers.
The National Primary Care and Research Development Centre in Manchester has undertaken a study of 10 innovative projects4. What is clear from the results of the study is that there is an opportunity for architects in the new wave of projects which will flow out of policy changes in the nhs. The opportunity afforded by the recognition that architect-led design teams can bring a fresh approach to a more rounded philosophy for health in the community should not be missed. Architects' pivotal role in the quality of the next generation of primary health buildings could bring rich rewards to a wide range of practices over the next few years - if they ask the right questions, explore the design process and use their skills as design-orientated team leaders.
1 'Our Healthier Nation, A Contract for Health' (Cm 3852, Feb 1998). London: The Stationery Office.
2. nhs Estates (1994). Better by Design: Pursuit of excellence in healthcare buildings, London, HMSO.
3. nhs Estates (1994). Environments for Quality Care, London, HMSO. The Wideopen Medical Centre by the Geoffrey Purves Partnership is included in this publication as one of a number of exemplar GP surgeries.
4. Bailey J, Glendinning C and Gould H (1997). Better Buildings for Better Services: Innovative Developments in primary Care, Oxford: Radcliffe Medical Press.
Geoffrey Purves is senior partner of Geoffrey Purves Partnership which has designed more than 25 doctors' surgeries over the last 10 years. He is researching a PhD on quality control in the design of primary health- care facilities.