Thursday, May 17, 2007

I’ve spent a lot of time over the past month thinking about hospitals. Ever since I was a junior doctor I have been convinced that most hospitals were designed by architects trained in the Central School of Dismal Apartment Block Construction of the Soviet Union. I trained in Belfast, where the new Belfast City Hospital, which was conceived about the same time as I was, finally opened when I was 31. It provides the most perfect case study of how not to design a hospital, ranging from putting the dialysis unit on the top floor but forgetting to check if the water pressure up there would be sufficient or creating acres of underground parking without thinking of where the pipe work would go, so that the clearance was reduced to about 1 metre. The red rectangle in the picture highlights a grey (originally brown) bit that seems to have been put in as an afterthought – as it was. This is the university floor as the original designers overlooked that this was a teaching hospital. Then there was the need to replace all the heating ducts as the contractors forgot to put in portaloos so the builders urinated down the ducts causing them to corrode. I could go on.

Belfast City Hospital
Anyway, a few years ago Judith Healy and I published a book on the future role of the hospital. Our basic premise was that as the world was changing so must hospitals. They should be designed in ways that allows them to adapt flexibly to changing circumstances. Fairly obvious you would think. And of course it is – except to those in charge of the hospital building programme in the UK who happily sign expensive and complex contracts, under the Private Finance Agreement, that make it prohibitively expensive to change even the number of electrical sockets for a period of 30 years.
We also made the fairly radical suggestion that hospitals should be designed in ways that smooth the path of patients through them, so that they do not have to follow complex paths that would defeat an experienced jungle explorer, and that they should promote health.

These are issues we have returned to in a new book that will be published later this year.
This, then, was the reason why a disparate group of people came together in London on the 16th and 17th April. It was the latest of the Observatory’s authors’ workshops, in which those contributing to the book discuss what they are writing with those who make up its likely audience. As always, it was an extremely valuable few days, allowing people from very different backgrounds to understand where each of them is coming from. One of the main challenges, which I am working on, is how to create a system in which about 80% of activity is routine and predictable but the remaining 20% is anything but, and where what you are dealing with is often only clear after you have dealt with it. That should keep me busy for a few weeks!
A week later I was talking about hospitals again, this time at the annual conference of the
European Health Property Network, an organisation that does believe it is possible to build hospitals that actually make you feel better. They are partnering with us on the new book and their members have brought together a series of fascinating case studies from across Europe that give one hope that a better world is possible.
I was asked to set the scene for a debate on planning versus the market (in health care). I tried to be as balanced as possible, noting the great successes of markets compared with, for example, Soviet central planning. But of course the problems arise when you see the market as a panacea for everything, as the current British government does. As a consequence you get bizarre decisions such as that to break up the monopoly that was the perfectly acceptable British Telecom directory enquiries service. The result – dozens of new companies spending millions of pounds to advertise their services, which they then have to recover from far higher charges. Of course they can’t do this openly so they create cost structures that require the user to have a qualification in accountancy to understand them. Others simply cut costs by using voice recognition systems or untrained staff that give you the wrong numbers. A complete disaster. I won’t even begin to talk about the shambles that resulted from privatising the railways.
Unfortunately we never got to the debate. Even those who were meant to be speaking on behalf of the market didn’t do so, quickly conceding the need for planning. A pity as I was rather looking forward to the debate!

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