As the impact of climate change continues to unfold globally, extreme weather is here to stay – whether in the form of new temperature highs and lows, precipitation patterns, flooding, storms, or wind. The UK experienced its warmest year ever in 2022, highlighted by the red weather warning issued in the summer as a result of recordbreaking 40 °C heat. The year before, a series of heatwaves claimed 1,634 lives – one of the highest numbers since the Heatwave Plan for England was launched in 2014. There are also occurrences of serious flooding that are causing damage and disruption to many communities nationwide.
Worsening conditions anticipated
Worryingly, experts are anticipating that conditions will continue to worsen, leading to even higher potential mortality rates. According to a Met Office report, UK Climate Projections: Headline Findings, published in August 2022, current climate change trends will lead to drier, hotter summers, and wetter, warmer winters across the UK – with temperatures during the summer months likely to be 3.8 °C to 6.8 °C higher by 2070. Incrementally increasing temperatures and other extreme weather episodes will start to have an even greater impact on public health, and will take a bigger toll – both operationally and financially – on the health system itself. The extremes of last summer demonstrated the severe associated risks of heat, which are especially acute for the most vulnerable in society, including older adults, people with disabilities, and those recovering in hospital.
Healthcare facilities need to effectively withstand and mitigate against the hazards of these extreme climate-related changes, while continuing to provide uninterrupted and high-quality healthcare services. The problem is that our cities, and the buildings within them, were designed around historic average UK weather patterns, leaving them ill-prepared to deal with unpredictable weather. In fact, UK property is in far worse condition than that of many of its European neighbours, with poor-quality buildings accounting for considerable heat loss or heat gain (see Figure 1). This is likely due to building standards that have specified lower-performing insulation based on more temperate conditions, and which do not provide resilience to climate change.
Healthcare buildings’ impact on the environment
Another key consideration is the big impact that healthcare buildings have on the environment. Globally, healthcare systems are responsible for around 4.6% of all greenhouse gas emissions (GHGs), providing a good opportunity for a combined effort to reduce GHGs and increase climate resilience. To create resilient healthcare facilities, we now need to design for extremes, rather than for the averages. To quote guidance from the World Health Organization in its 2020 publication, WHO Guidance for ClimateResilient and Environmentally Sustainable Health Care Facilities, ‘climate resilient healthcare facilities are those that are capable to anticipate, respond to, cope with, recover from, and adapt to, climaterelated shocks and stress, so as to bring ongoing and sustained healthcare to their target populations, despite an unstable climate’. We can take it a step further, and say that real climate resilience means not only adapting our buildings to the emerging risks of climate change, but also not contributing negatively to that change in the first place. Designers need to take an innovative, multi-faceted approach to healthcare developments to ensure that they are sustainable and energy-efficient for their entire lifecycles, and make a positive impact on their surroundings, as well as create healing, safe spaces
Improving health in the community
Design interventions at the building, healthcare campus, and indeed city level, can all make a significant difference, all while having the wider benefit of improving health within the community, and taking pressure off an NHS in crisis. Healthcare facilities designed today will experience dramatically different climate conditions to such buildings developed in the past. It comes down to incorporating forward-thinking measures to ensure the long-term adaptability of facilities that will benefit both people and the planet. For continuity of services, even at times of extreme weather events, we must consider design decisions from a macro as well as a micro perspective, from masterplanning and urban greening, to optimising infrastructure, right down to the position of everything in the streetscape, including bus stops or trees. In healthcare buildings, a host of measures can be considered – from the use of water for cooling purposes, to ‘smart technology’ and much more. This is all crucial for the safeguarding of communities and urban health.
Principal challenges faced by healthcare facilities
Healthcare buildings are perhaps uniquely complex, as they are designed to accommodate a vast array of services in one place to meet various medical needs – from waiting areas and patient rooms, to critical-care units and operating rooms, many of which hold intricate specialist equipment. It is important to understand and effectively prepare for the various additional challenges emerging from climate change, not just in terms of the environment and its health impacts, but also as regards organising healthcare facilities themselves to avoid disruption to critical services, costly damage, and any trickle-down effects on patients, employees, and communities
One of the biggest climate-associated risks is heat, which brings with it the threat of heat exhaustion, heatstroke, dehydration, overheating, and other complications for buildings’ occupants. In 2020 and 2021, NHS Digital records reveal that more than 4,000 overheating incidents occurred. For some, excessive heat can be life-threatening. Within a clinical setting, it is imperative for patients to have a temperature-controlled, stable environment to aid rest and recovery to the maximum, as well as support the wellbeing of everyone in the building (including in terms of better comfort and productivity for staff). However, regulating temperatures in a sustainable way will be almost impossible unless we design facilities based on the future, rather than the past or present.
Warming weather and increased temperature fluctuations lead to higher operational costs in the form of rising energy costs, along with increased pressure on mechanical equipment, or the need to acquire additional equipment to supplement cooling requirements. Without proper ventilation, these factors can also increase the chances of airborne transmission of infections or contaminants.
Higher than usual demand for cooling
Higher than usual demand for cooling during periods of extreme heat can also overwhelm the grid, and interrupt the provision of services and patient care – a risk that can not only affect the ability to maintain an appropriately comfortable interior temperature, but also lead to severe ramifications in a fast-paced healthcare setting. One way to counteract this, and to avoid dangerous outages, is to have a reliable back-up source of power, ideally from renewable energy such as wind or solar. Renewable energy has the extra advantage of helping to reduce the operational energy usage of the building and boost energy efficiency. In addition, it is a great way to utilise extreme weather (heat or wind), and transform it into a positive for the environment
Global temperature changes can lead to weather pattern changes of all types. Prolonged extreme winds and rainfall can cause extensive damage to a building’s foundation or structural integrity. Insufficient capacity in local stormwater drainage systems can cause rainwater to overflow, adding to the impacts felt by the healthcare system, with flooding threatening the sanitation of healthcare environments, not to mention the negative impact on expensive equipment, as well as the mental health of patients and staff.
Combating the urban ‘heat island’ effect
If we look at the issues through a wider lens, at a city level, it’s clear that population growth and rising urbanisation present difficulties of their own. WHO estimates show that over 55% of the population worldwide lives in urban areas, a percentage that is forecast to grow to 68% by as soon as 2050 and not stop there. Urban locations are likely to experience hotter temperatures, given their high density of buildings and people, and a higher ratio of paved roads, leading to the so-called ‘urban heat island effect’ – whereby major cities are warmer than their surrounding regions due to their predisposition to heat retention. The shift towards harder road surfaces in the typical city streetscape leads to more reflectivity, and consequently amplifies the heat further.
Reducing the urban heat island
A number of measures can be taken to reduce the urban heat island effect; most notably the use of trees to increase external shade and encourage a cooler micro-climate. A recent study by ETH Zurich University showed that trees cool the land surface temperature of cities by up to 12 °C. Material and colour choices can also make a tangible difference in heat retention, and reflectivity of rooftops and road surfaces. However, the most vital measure is to add natural infrastructure wherever possible, something we will explore in fuller detail below.
With all these challenges comes the opportunity to be proactive about addressing climate change risks and enhancing the resilience of urban health facilities. So, what are some of the shortand long-term solutions that can help
Resilient design strategies
Assessing the main hazards and potential risks early in the planning and design process helps to frame the primary considerations that the project team(s) must address before any work begins on site. It is the only way to ensure that appropriate measures can be incorporated in the best way possible to suit the particular needs of a building, its occupants, and its surroundings.
Flexible, responsive heating and cooling solutions can help buildings handle temperature fluctuations, and deliver optimum thermal comfort and safety for occupants. Another key decision is how to leave facilities in the best position to respond fast to climate-related disruptions with minimal impact on clinical operations. Ideally, priority should be given to Passive House design solutions as a way of lowering a building’s carbon footprint. Passive buildings can effectively moderate their own energy use, meaning that during milder conditions, they can eliminate the need for mechanical heating or cooling. Buildings with high-performance insulation make it easier to rely more on natural ventilation, which can be supplemented with the addition of low-carbon solutions such as air source pumps.
Flexibility built in
Other factors to bear in mind include designing and constructing the facility’s main infrastructure – such as the pipe network – to be able to be amended and re-sized accordingly to cope with future conditions, and allocating adequate space for future upgrades in various mechanical rooms
The orientation of the building itself – along with the positioning and shading of windows – of course go a long way toward reducing the overall demand for cooling or heating. Subsequently, this means less pressure on the mechanical systems, and enhanced energy efficiency. The greatest step towards decarbonising a building during extreme weather is to decrease its space heating and cooling demand as much as possible through innovative Passive design strategies. The use of white roofs can reduce the impact of heat even more. For the surrounding landscape, we can capitalise on the natural environment by installing sustainable urban drainage systems (SUDS) to prevent instances of flooding.
By identifying all of the most important design considerations and challenges early in the design phase, it is possible to avoid additional costs down the line. An area growing in popularity is how to incorporate more alternative energy sources by design, such as allocating sufficient space for PV panels to generate energy for heating or cooling. In fact, several UK NHS Trusts are actively exploring investments in new energy technology, including planning how to integrate solar panels to help power their healthcare facilities more efficiently
Using water and plants to regulate indoor temperatures
Urban greening is a fantastic and proven way of mitigating against heat, and should sit at the heart of any thoughtful placemaking or landscape strategy. It is required by many planning authorities, and indeed highlighted by the Greater London Authority in the London Plan as a fundamental part of any new development – with green roofs and walls, tree planting, and sustainable drainage, all contributing to a more appealing, environmentallyfriendly, and cooler city. The same elements can be applied to healthcare buildings through biophilic design and high-quality landscaping.
Apart from their well-documented cooling properties, plants can drive biodiversity, provide shade and shelter from the elements, and lessen heat reflectivity, with the bonus of also helping to reduce the urban heat island effects of a city more widely. Greenery positioned by the entrance or in any outdoor space throughout healthcare buildings improves local air quality considerably, while creating attractive social gathering spaces that promote wellbeing for patients, staff, and visitors.
Pears Maudsley Centre
At Arcadis IBI, we are using a combination of these methods at our Pears Maudsley Centre for Children and Young People for the South London and Maudsley NHS Foundation Trust. Here, green- (planted) and blue- (water-retaining) roofs, biodiverse walls, coupled with smarter and more sustainable nature-based drainage systems, will help to create a truly futureproof building that harnesses the power of nature to the utmost to deliver multiple benefits at once.
Water features can play a vital role in thermal comfort. For example, during periods of high temperatures, evaporating water has been used for centuries as a natural air-conditioner. There are manifold co-benefits of going ‘green’, or indeed ‘blue’ (water), in our healthcare infrastructure. Studies have demonstrated time and again how access to natural elements can promote better health and wellbeing, as well as offset climate change.
Patients in ‘greener’ hospitals, which feature green roofs, walls, or biophilic features, have been known to heal faster, while plant-covered uninsulated roofs have been shown to reduce the need to cool a building by 33% during warm weather.
Reduced anxiety and lower pollution
Ample greenery can help reduce feelings of anxiety, tackle air pollution, and create spaces for refuge, reflection, or socialising, for a better sense of cohesion and connectivity. Water, too, can positively contribute to air filtration, mask outside noise and, together with greenery, manage carbon sequestration in the landscape, as well as add an appealing aesthetic element to what can traditionally be a fairly clinical environment. A good example can be found in our work on the redevelopment of Barnsley in Yorkshire and its new The Glass Works Square, where water is used to shape the size of the town’s newest public space, to control how it is used, and help with acoustic masking, natural air-conditioning, and air quality – as rows of water jets effectively block out particulates. The jets can reconfigure the public space to meet changing demands at different times of the day or week, with controls to alter the flow of water to open or close routes
Data and technology can add value
Turning to innovation in the form of fast-advancing smart technology, and becoming more data-led, can result in some of the quickest wins when it comes to making meaningful improvements to a building’s operational efficiency and longterm resilience, as well as to the urban built environment as a whole. Sensors are becoming more prevalent in our streetscape, gathering accurate insights on a wide range of elements – including rainfall, temperature, air quality, and more. In Canada, Arcadis IBI has delivered a ‘smart tree’ project, which included programmable LED lighting, tree health sensors, and air-quality monitors, soil sensors, and the opportunity for a remote dashboard or 5G distribution.
In a healthcare setting, smart technology can generate real-time feedback to allow the building’s systems to operate in a more tailored and efficient way. Facilities managers can assess their building’s current environmental footprint and energy performance through data analytics, and use it to establish a baseline against which to make future improvements and meet sustainability targets
. For hospital buildings, in particular, becoming more digitally enabled and ‘connected’ means that every single space can be used to its fullest potential in a way that best meets the needs of its intended function. Sensors can measure metrics like the proportion of a day a room is in use, with the lighting and cooling timed accordingly. Additionally, artificial intelligence-based weather prediction analytics technology will only grow in its capabilities, and could provide a vital advance warning of extreme weather to enable staff to conduct adequate risk assessment and quickly implement mitigation plans.
For existing healthcare estates, where refurbishment is the only option, we need to do the best we can to optimise the environment and its performance, so that it remains adaptable and fit for the future. Technology in the form of ‘digital twins’ and parametric modelling can be a gamechanging tool here. Creating a digital ‘virtual twin’ of a hospital building allows modelling of an almost unlimited number of scenarios, while using the processing power of the computer to optimise design and planning solutions.
Looking forward
With climate issues continuing to evolve, and global temperatures and weather becoming more unstable, we must transform our approach to designing healthcare facilities and infrastructure. To action change will take a collaborative effort from all estates and construction practitioners, together with a fresh and creative approach to design that takes account of a much wider scope of risks and potential eventualities. Only then will we ensure that our healthcare facilities can protect the health of their patients, become environmentally sustainable, and guard against future climate shocks. Furthermore, collaborative action towards climate resilience can solve some of the challenges facing our urban areas to support healthy communities, healthy buildings, and a healthy planet.
Geoff Southern
Geoff Southern, associate director, Buildings, and Out-of-hospital Care lead (UK) for Arcadis IBI Group, is currently responsible for leading the design of healthcare, science, workplace, residential, and mixed-use schemes for the business.
He has academic and professional qualifications in architecture and landscape architecture, working on projects in both the private and the public sector. Being dual-qualified brings significant benefits to feasibility and capacity studies, especially as an early contributor to place-making. His work embeds evidence-based research such as:
NHS England’s Healthy New Towns placemaking principles.
The ‘4 Labs 4 Cities’ research project to examine how architecture, environmental leadership, and smart technology, can help us re-think the modern campus configuration.
NHS strategic transformation programmes (services and estates).
The New Economics Foundation’s ‘5 Ways to Wellbeing’.
HAPPI-informed residential for seniors and in-care environments.