Many of New Zealand’s hospitals need major remedial work, have poor seismic ratings or other compliance risks or fall short in their ability to support modern-day models of care. Photo / 123rf
Many of New Zealand’s hospitals need major remedial work, have poor seismic ratings or other compliance risks or fall short in their ability to support modern-day models of care. Photo / 123rf
Opinion by Chris Thom
Chris Thom is a principal at leading New Zealand health architecture firm Chow:Hill. He has worked in this sector almost exclusively for over two decades and has contributed to a number of international hospital projects as well as to healthcare facilities in New Zealand.
THE FACTS
Te Whatu Ora’s buildings average 47 years old, requiring major remedial work and seismic upgrades.
A projected shortfall of 4900 hospital beds by 2043 highlights growing demand and infrastructure challenges.
Health design emphasises resilience, cultural diversity, and adaptability to advances in medical technology.
As reported by the Government earlier this year, the average age of buildings operated by Te Whatu Ora: Health New Zealand is 47 years.
Many of these require major remedial work to avoid service disruption, have poor seismic ratings or other compliance risks, and/or are otherwise compromised intheir ability to support modern models of care.
This is in the context of growing demand from an ageing population, and advances in medical technology creating increasing expectations. The current deficit of public hospital beds is 500, with a projected shortfall by 2043 of 4900, a 45% increase on the present 11,000.
Health New Zealand is increasing the emphasis on value and cost-effectiveness in its infrastructure investments. Alternative procurement models are being considered, such as design-build or public-private partnerships.
Economies are also being sought through the standardisation of components; however, care is required in this, otherwise the standard applied may not be appropriate. For example, not all operating theatres need to be sized and serviced for complex cardiac surgery.
Conversely, some rooms may need to be fitted out to a higher level than currently needed, to allow some flexibility for future changes in use and technology. Allowance is also needed for improvement in standards over time, and innovation.
There is a growing awareness that the built environment can enhance human experience and facilitate healing. Biophilic design utilises the healing properties of connection to nature, through well designed greenery within the facility, or access to wider views beyond.
Research has shown that patient outcomes are improved when they are in single rooms with their own ensuite, with a lower risk of infection transmission, increased privacy and dignity, and greater ability for whānau to be part of the care process.
Health facilities should reflect New Zealand’s growing cultural diversity, while addressing the commitments made to Māori in the Treaty of Waitangi. A bicultural approach has begun to result in greater engagement and partnership, and the weaving of cultural themes and concepts appropriate to local communities into the design of hospitals.
Events such as the Canterbury and Kaikōura earthquakes have led to a greater emphasis on resilience in health facilities, both in the protection of life during the event, and the ability to bring them back into full use rapidly.
New Zealand’s research into seismic action on structures is world-leading, as are the innovative responses of designers, such as base isolation and low-damage design.
Fire also constitutes a significant risk in hospitals, as many of their occupants have little or no ability to self-evacuate. Generally, a staged evacuation approach is adopted, with a greater degree of protection and separation to allow staff to move patients away from danger. Health New Zealand has recently worked with fire engineers and other designers to develop a detailed set of guidelines for the design of fire protection in health facilities.
In the Covid-19 pandemic, there was a rapid response by facility managers and engineers to compartmentalise spaces and improve isolation and filtering in air-conditioning systems. This raises questions as to the level of preparedness that should be designed into new buildings in anticipation of future events. Should hospitals be designed with sufficient flexibility to accommodate a large cohort of patients in a crisis, or can we allow for this by the rapid installation of temporary facilities?
The average age of Te Whatu Ora buildings is 47. Photo / Alex Cairns
Advances in pharmaceuticals, diagnostics and surgical technology are improving outcomes, but are also leading to significant increases in per capita health expenditure. Tele-health enables more self-testing by patients and remote consultations and should allow for more people to receive care in their own homes.
Innovations such as tele-ICU and robotic surgery are already allowing for clinical expertise to be harnessed remotely. All these will have an impact on the type, scale and design of health facilities.
Changes in medical technology and models of care will also continue to result in hospital buildings needing to be modified, and the challenge for designers is to make them as adaptable as possible, without detracting from their initial function and affordability. Retrofitting existing buildings that are often designed for one specific situation is likely to be a particular challenge in future, as their replacement becomes increasingly unaffordable.
Hospitals are heavy users of resources and energy, both in their construction and operation. By incorporating on-site energy generation, using photovoltaic solar panels for example, health facilities can reduce their net energy demand while improving their resilience to natural disasters.
Their external envelope needs to be carefully considered, as glass and aluminium require large quantities of energy to produce, and windows create significant thermal bridges in the building envelope. Therefore, their size and location need to be carefully considered to ensure that outlook and natural light are optimised, while their environmental impact is minimised.
New Zealand has extensive forests, and timber has been extensively used in the construction of smaller-scale hospital buildings. Innovative ways are being developed to use it as the structure for larger-scale commercial and residential buildings, and these could be adopted in hospitals as well. Water is becoming increasingly scarce, even in areas where it was once abundant, and consideration should be given to capture, treatment and reuse.
Health facilities generate significant quantities of waste, and this has increased significantly over recent years as items including personal protective equipment, medical implements, curtains and bedpans have been made disposable. This has certainly aided infection control, but more sustainable options do need to be considered.
Facilities make up just one component of a complex and dynamic health system, which will continue to rely on dedicated, skilled and adequately resourced clinicians. They often continue to “make do” in challenging conditions. Improving their working environments should assist in the retention and recruitment of staff, while enhancing patient care.
Health design will almost certainly remain one of the most technically demanding areas for architects and engineers, and one of the most rewarding, as designers work with clinicians and other stakeholders to create environments to best serve people in their greatest hours of need.
Chris Thom’s new book Health Design in New Zealand: Te whaihanga o ngā whare hauora o Aotearoa chronicles the evolution of healthcare architecture from the 1830s to the present day (published by Massey University Press, RRP: $75.00)
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