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As cross-infection rates in British hospitals hit the headlines, a new report suggests that this may only be part of the problem. Is hospital design hampering patients' recovery and costing too much?Fiona McWilliam investigates

After decades of inactivity, healthcare architecture in the UK is a fast-developing and increasingly dynamic field. Recent years have seen the emergence of a major building programme of privately financed hospitals and hospital refurbishment projects, and the ongoing construction of numerous smaller, and increasingly innovative and well-designed, PPP (Public-Private Partnership) and LIFT (Local Improvement Finance Trust) healthcare buildings.

However, Learning from French Hospital Design, a report published by BDP, suggests that when it comes to hospital design UK architects could learn a lot from their French counterparts. The result of an internal study into the work of Groupe 6 Architectes, one of France's leading architects in hospital design and partly owned by BDP, the report asserts that French hospitals deliver more benefit for less cost than UK hospitals. It claims that French hospitals cost between half and two-thirds as much as UK hospitals per square metre, although it concedes that per-bed costs are similar as the area per bed is much higher in France - with single-bed wards 'used universally'.

The report finds that building services costs in France are less than half those in the UK. 'More ambitious automation and ICT [information and computer technologies] are used in France, ' it states, 'and fabric costs dominate French examples as they plan for natural daylighting and ventilation, and thus generate more gross plan areas than UK and US examples.' It notes too that French contractors 'reportedly' regard UK hospital building notes and technical memoranda as 'excessive in specification'.

Contractor-led detail design in France seems to lie behind much of the economy of means and, while consultants' fees are comparatively high as a percentage, 'many Egan-advocated processes are used'. The benefits of this approach contribute to 'the better outcomes of the French system', the report concludes, with single beds speeding recovery, day-lit plans and good amenities aiding staff well-being, 'and better architecture fostering community pride and user morale'.

French better The design quality of French hospitals is generally high, the report claims, 'while in the UK standards achieved in the past five years have often been disappointing'. In French hospitals, 'generous circulation spines are normal', while 'broad architectural gestures' help generate 'a sense of place'. Fittings costs in France are described as negligible, 'perhaps because of a bias towards moveable furniture'.

Constructional simplicity is said to follow from the French approach: 'French architects have little control of details and do not worry too much about doors, windows, ceilings, etc. Low-cost concrete structure and envelope is put up rapidly with basic techniques.' For all its low cost, the report maintains, 'the French hospital has very sophisticated technology'. It mentions the comparatively generous lift provision, the widespread installation of conveyor and robot delivery systems, ambitious ICT installations and the practice of sterilising 'whole room contents' between patient uses for infection control.

The concept of learning from French hospital design is not a new one, says Richard Burton, inaugural partner of ABK Architects and design adviser to the NHS. 'The French and English have always been close together on this, ' he insists, adding that there has been a great deal of interchange on issues such as planning and cross-infection since the time of Florence Nightingale.

John Cooper, a director with Anshen/ Dyer, is more phlegmatic. 'Hospitals are no different from other building types, all of which are built significantly more cheaply in France than they are in the UK, ' he says.

'The British construction industry compares poorly with its US and European counterparts, which build at much lower rates per square metre - effectively doing for a euro or dollar what we can do for a pound.' No one, claims Cooper, has been able to explain this state of affairs: 'Our view is that this is a historic consequence of the construction industry's organisation as a series of multilayered subcontracts.' Another partial explanation, he suggests, might be a 'continuing legacy of an overly adversarial climate in the construction industry, which persisted throughout the last century'. His hunch is that hospitals as a building type suffer from the attitudes toward their engineering that were formed in the 'command economy' of the old NHS. 'This system could not afford systematic maintenance and compensated by over-investing in the capital costs of the installations in certain key areas, ' he says.

'While hospital briefing does not always encourage design excellence, this is beginning to change, ' Burton wrote earlier this year (AJ 19.2.04). NHS Estates and the public are beginning to focus on the subject through design review panels, he claims, and the fastdeveloping discipline of evidence-based design (EBD) is revealing more about the beneficial effects of design on patients and staff.

It is a fast-developing field, Burton maintains, and as healthcare trusts and design champions become increasingly aware of the practical, psychological and financial advantages of exemplary environments, they might well start favouring bidders who have employed architects of international renown.

This could, presumably, mean appointing architectural firms from outside the UK to design our hospitals, as much as it does UK practices with overseas' experience. One only has to look at the abysmally high cross-infection rates in UK hospitals - and the ongoing and ever-worsening MRSA(Methicillin Resistant Staphylococcus) crisis - to realise that doing things differently can often mean doing them better. So should we be looking at hospital design elsewhere in the world to inform how we design our hospitals in future?

'Oh yes, ' says Burton. 'We should always be willing to learn from overseas.' While slightly less emphatic - noting that there is no perfect hospital anywhere in the world - Richard Mazuch, a design planner, researcher and director with Nightingale Associates, agrees that hospital designers in the UK can learn a great deal from what happens in other countries. Mazuch describes how advanced ICT facilitates the efficient processing of outpatients in Japan; the 'greener solutions' and patient-focus of Scandinavian hospitals, with their abundant use of light penetration and natural ventilation; and the influence of hospitality on the hotel-like environments of US hospitals. Key architectural issues, he says, are: planning, which includes 'avoiding incorrect adjacencies of spaces'; the specification of suitable materials;

and the detailing of these materials - avoiding dirt traps, for example, and installing footoperated washing facilities.

He mentions the well-established use in the US of 'universal rooms'. Larger than the standard single hospital room, universal rooms are designed for flexibility, enabling clinicians to take procedures - from radiography to invasive surgery - to the patient, rather like the increasingly popular LDRP (labour, delivery, recovery and post-partum) rooms in UK maternity units. Less disruptive and ultimately safer for patients than being moved around a hospital, universal rooms are expensive, Mazuch adds, as they require several pieces of specialist equipment including overhead gantries and suspended lighting.

While single-bed wards help with issues such as cross-infection, they make patient observation more difficult for hospital staff and, consequently, more labour intensive - a particularly pertinent issue in non-private hospitals. And generally, Mazuch maintains, the elderly and the very young 'like the opportunity to be together in multiple-bed wards'.

When it comes to infection control, Mazuch adds, management procedures are crucial, and these too can benefit from international exchanges of ideas and practice. He cites as an example the government's decision to consult hospital managers in the Netherlands, where cross-infection rates are relatively low, as part of its efforts to solve the MRSA crisis.

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