With the NHS having celebrated its 75th anniversary earlier this year, Graham Harris, Principal, and Neil Evans, Associate Principal, at Arcadis, look back at some of the major changes in healthcare provision and buildings over the period, and forward to some of the key steps – including increasing digitalisation and ‘embedding healthcare deeper into the fabric of communities’ – that they believe will help ensure a resilient service, able to cope with changing demographics and demands, in the future.
The ground-breaking NHS marked an incredible 75 years of service on 5 July this year. It has long been a source of tremendous pride for the UK, and – as the world’s first free-at-the-point-of-use healthcare service available to all citizens – set a new standard and blueprint followed by other nations for their own health services. In the three quarters of a century since, the transformation of healthcare – and how we think of healthcare facilities – has been vast. This has gone hand in hand with how we design and build healthcare buildings, which has evolved accordingly to meet changes in the macro landscape, impacting priorities and needs. Architecture and design practitioners have started considering in greater detail than ever before the impact these buildings and facilities have on the staff, patients, and visitors, who use them. They are finding more creative ways to mirror these considerations when updating and maintaining buildings to ensure that they are modern, climate-friendly, energyefficient, digitally connected, appealing, comforting, and better embedded into their local communities. Crucially, this sets them up for longevity and agility to best serve the principles behind the NHS.
The Government has a two-pronged priority – to prevent illness, while simultaneously strengthening public health. We have learned some hard lessons from the COVID-19 pandemic, which put the NHS under enormous strain, and served to highlight where improvements are needed to make our health system fit for purpose in a new era. How can good design complement these efforts and shape the future of our NHS?
When it was launched in 1948, the NHS faced a very particular set of pressures, including a much smaller budget and fewer nurses and doctors, as well as a post-war baby boom to contend with. Back then, the country was acclimatising after the Second World War, rationing was still in force for certain products, and the focus was very much on socio-economic recovery. There were different kinds of healthcare issues and requirements and, just as advancements in the medical field have seen significant leaps forward over the last 75 years, the way we live has also shifted substantially
Figures from the Office for National Statistics (ONS) show that people are living an average of 13 years longer today than when the NHS was established. ONS data also reveals that infant mortality has reduced significantly. In 1948 there were 34.5 infant deaths per 1,000 live births, compared with 3.7 in recent years. Amazing breakthroughs in medicine, including new vaccinations coming into effect that have wiped out polio, for instance, have been a real boon for public health.
A contrasting workforce picture
According to NHS Digital, a year after the inception of the NHS, there were just over 68,000 nurses in NHS hospitals in England and Wales, and 11,735 doctors and consultants. An extremely contrasting picture to 2022, with 350,600 nurses and 132,900 doctors, with a total NHS workforce of 1.3 million. However, we face multiple new challenges today. Health and social care services are under pressure and struggling with a multi-billion-pound funding shortfall, affected by economic uncertainty resulting from energy price hikes, inflation, and rising interest rates, the massive hit from the coronavirus, and other factors. Life expectancy dipped for the first time in 40 years during the pandemic, and many are still being treated for longer-term complications arising from the virus.
Despite the surge in healthcare employees over time, patient numbers have grown too, translating into ongoing, acute staff shortages. It is estimated that, unless appropriate industry and policy interventions are made, by 2030/1 the NHS will have a gap of approximately 140,600 nurses. As demand for services continues to exceed available resources, waiting lists reached another record high, jumping to a backlog of almost 7.5 million by May this year.
Additionally, as awareness around the climate crisis has increased, the NHS committed to achieving Net Zero by 2040 with the goal of becoming the first ever Net Zero carbon national health system. The NHS contributes 4% of the nation’s carbon emissions and is, among other things, seeking to slash the environmental footprint associated with its buildings and facilities. It has published its Net Zero Building Standard, which sets out guidance on a greener future for the NHS, but getting there requires overcoming several complicated roadblocks at once. Public health and the health of the planet are, after all, inherently linked, so it is critical to find ways to support the sector’s green agenda.
Preventing us ‘tipping into crisis’
The NHS has served us well for so long, and, now that it is under intensifying pressure, we cannot take it for granted. At Arcadis, we believe we all have a responsibility to prevent the situation from tipping into crisis, and this means closer collaboration across both industry and government to do everything possible to make the NHS robust and futureready. Architecture and design can play a huge role here, by embracing innovative approaches to deliver smarter spaces tailored to society’s needs – with longevity, sustainability, and wellbeing, front of mind
It is important to remember that the meaning of high-quality healthcare extends beyond hospitals, and must be seamlessly interwoven into all areas of life to have the greatest benefits. Over time, there has been encouraging progress when it comes to embedding healthcare deeper into the fabric of communities. In fact, the total number of NHS hospital beds in England has fallen from 480,000 in 1948 to around 140,000 at present, with the much reduced number due to better provision of care in communities. ‘Prevention is better than cure’ is an age-old maxim that still holds true, and should be the underlying message of any strategic decision-making when delivering healthcare environments in a community setting.
To minimise the burden on the NHS, the first step is to shift some processes out of hospitals (barring major procedures and treatments) that can be just as effectively, if not more so, supplied at local level. Boosting more easily accessible, preventative outpatient care can cut the length and frequency of inpatient stays, and create a more sustainable care model for the future. Further, it would have a beneficial impact on the environmental footprint of healthcare facilities by lessening the over-reliance on hospitals.
Integrating the provision of high-quality healthcare into communities can also go a long way to eliminating existing health inequalities in the UK, where a so-called ‘postcode lottery’ still persists. Conditions are not caught as early or treated as quickly in economically deprived areas, ultimately meaning a lower life expectancy for the most disadvantaged in society. The Health Foundation finds that people living in more deprived areas, on average, have more diagnosed illnesses – with cardiovascular disease, COPD, diabetes, depression, chronic pain, and alcohol issues accounting for 64% of the conditions in the most deprived decile (as opposed to 49% in the least deprived)
There is a pressing need to safeguard all communities by ensuring a fairer distribution of quality services, and access to equitable healthcare. An excerpt from the former Minister of Health Aneurin Bevan’s speech, made during the second reading of the NHS Bill in 1946, set out the original intention and ethos for the NHS: ‘It is available to the whole population, and not only is it available to the whole population freely, but it is intended, through the health service, to generalise the best health advice and treatment…. [It] will place this country in the forefront of all countries of the world in medical services. I believe it will lift the shadow from millions of homes. It will keep very many people alive who might otherwise be dead. It will relieve suffering. It will produce higher standards for the medical profession. It will be a great contribution towards the wellbeing of the common people of Great Britain.’ It is crucial that we enable the NHS to keep to these objectives
Arcadis strives to reimagine what healthcare design can look like, and the key common thread across a number of our stand-out projects is that they look beyond the purely functional to deliver multi-faceted, integrated healthcare and community benefits. The multi-service Gorton Community Hub in Manchester, for instance, is the city’s first facility to combine a complementary mix of health and community features that include NHS services, a job centre, adult education services, and a public library. England’s Index of Multiple Deprivation areas lists Gorton in the bottom 1%, and co-locating all of these services in one place can contribute to breaking the cycle of deprivation, and position the region for a thriving future by generating skills and job opportunities as a catalyst for growth. Moreover, deprivation can directly correlate with poor mental health, thereby adding even more pressure to primary care in the area. So, it is vital to take a forward-looking approach by improving early diagnosis and access to effective help for the predominant conditions affecting Gorton, with depression and dementia high on the list.
We also worked on delivering the Bevan Health and Wellbeing Centre in Tredegar, Wales, comprising outpatient clinics, a pharmacy, and two GP surgeries, offering a route to a variety of health and social care staff. Creating this accessible ‘super surgery’ addresses some of the biggest challenges that were felt locally previously, such as a lack of community-facing care staff, insufficient wellbeing-related services, and outdated GP surgeries. The community was also experiencing high levels of deprivation, which again corresponded with worsening health overall.
Supporting staff retention
The project team wanted to create an environment that is attractive, collaborative, and efficient – not only for people accessing the services, but also for existing and prospective healthcare professionals, to support staff retention. To that end, we introduced a unique ‘social stair’ concept to link the floors within the centre and encourage interaction between clinical and community teams. The design also connects the centre to the historic park and grounds at nearby Bedwellty House, to provide patients with an active wellbeing landscape. The interior will also include artwork that documents the significance of Tredegar as part of the heritage of the NHS, as it is the birth place of Aneurin Bevan, who was also MP for Tredegar, and discussed the formation of the NHS at Bedwellty.
There is encouraging progress at policy level to reorganise the NHS to ensure it is ready to meet the needs of today and tomorrow, with the introduction of the Health and Care Bill in 2021, which received Royal Assent in April 2022. In a February 2021 policy paper, Integration and innovation: working together to improve health and social care for all, outlining its proposals, the government stated that ‘we are living through the greatest challenge our health and care system has ever faced’, and stressed the importance of shaping a health system that is ‘better able to serve people in a fast-changing world’, taking on board some of the lessons from the pandemic
The government has set its focus on preventing physical and mental illness, and providing earlier and faster intervention where necessary. The subsequent Health and Care Act heralds some of the most sweeping reforms in years to deliver the best possible care and solve some of the most complex health problems that society is facing today. This will be achieved through an approach that combines more integrated health systems, closer partnerships between the NHS and government, and better connected health, social care, and public services locally, to improve health and wellbeing and offset health inequalities.
Re-thinking healthcare design choices
The upshot is that we need to re-think healthcare design choices to adhere to population needs and priorities based on in-depth understanding. For example, we cannot overlook the fact that the UK is undergoing a mental health crisis, as a growing percentage of young people, especially, is struggling. Last year, it was found that 22 % of young people (aged 17-24) and 18% of children (7-16) were likely to have a mental disorder, and this shows no sign of slowing. It is for this reason that early diagnosis and intervention have never been more crucial to set young people up for a healthier and happier life.
As designers, we need to take a holistic approach to deliver the right mix of facilities that can make people feel more at ease and able to speak about mental health more openly, removing any stigma that may be associated with it, and overcoming the barriers to asking for help. This means delving beyond bricks and mortar to understand how building occupants react to various surroundings, what feelings are evoked, and, therefore what thoughtful design touches can actively promote more positive feelings and healing. By finding the right balance between the functional and therapeutic, these kinds of environments can help accelerate recovery.
Pears Maudsley Centre
When Arcadis delivered the new Pears Maudsley Centre for Children and Young People in Denmark Hill for the South London and Maudsley NHS Foundation Trust, we gave careful consideration to these facets. We harnessed innovative design measures to provide a welcoming, comforting, open-plan, green, light, and airy healthcare setting that can respond to the diverse physical, mental, and emotional needs of young people. Through extensive stakeholder engagement and consultation with service-users throughout the process, we could assess the real lived experience of the people for whom we were designing. This included an emotional mapping exercise to analyse their feelings about healthcare facilities to deliver a wellbeing-led space that would positively impact their healing journey. For example, a ‘green spine’ allows building users to easily access landscaped terraces and rooftop gardens to enjoy the well-known advantages of nature and fresh air on health and wellbeing. Replacing the formerly 1930s, cramped and overly clinical spaces, another great feature of the centre is that it brings together treatment and research in one place, cultivating a unified and collaborative hub at the forefront of mental healthcare
One major factor to take into account when designing for the future of the NHS is the demographic shift taking place in the UK, which has a growing – and ageing – population. Forecasts suggest that in 50 years there will be 8.6 million additional citizens above the age of 65. This adds urgency to ensuring that health and social systems are well prepared and agile enough to put in place the types of care provision that will be needed. As people get older, they may be affected by several conditions at once, such as diabetes or underlying dementia. Care homes, which already incorporate a good level of dementia-friendly design, can provide valuable learnings for all other health facilities. One of these is the power of salutogenic design, which flips the traditional approach by focusing on creating environments that support health and wellbeing instead of focusing solely on treating illness. It is more proactive than reactive in promoting health and wellness.
Similarly, spaces should actively alleviate anxiety, given that many find healthcare settings, by their nature, to be stressful and worry-inducing environments. Not only do healthcare facilities need to cater to a wide range of complex healthcare needs, but must also be silently supportive and sensesensitive by design. We should configure them in a way that allows busy staff to manage stress too
Looking ahead at the development of the UK’s healthcare system, many of the trends influencing it are interlinked, and must be approached in parallel for a successful and comprehensive solution that truly stands the test of time. As mentioned previously, healthcare facilities are already transitioning, and will continue to do so, towards less institutional design and more calming spaces that can support healing. This can be achieved via a variety of design techniques, including maximising ventilation and natural light for airy, bright, warm, and comforting places that move away from dark, constricted corridors, and towards a flexible range of communal and private areas. Similarly, noise reduction measures, softer textures and furnishings, along with carefully chosen colour palettes and art, can deliver a beautiful and relaxing aesthetic.
Leading on from that, outdoor spaces and biophilic design will remain invaluable to creating the healthcare buildings of the future. Much evidence and academic research point to green spaces, particularly in urban environments, having a considerable positive impact on physical and psychological wellbeing, feelings of motivation, cognitive function, and rehabilitation. How we design and build all healthcare spaces must take this into account going forward. Biophilic design principles can also mean using natural materials where possible, or creating connections between internal and external environments (including depictions of nature through the use of art and colour). Stakeholder engagement should also play a central role from the earliest stages of any project, to enable patient-led, humancentric design to reflect service-users’ needs and wants
Dyson Cancer Centre
Encompassing all of these and other factors, our team is working on the new Dyson Cancer Centre at the Royal United Hospital in Bath, a scheme that effectively demonstrates how the NHS Trust estate has evolved over time, and how it is successfully adapting to the current and future landscape. Focused on the user experience, the centre provides a therapeutic, nurturing healthcare setting, and brings the majority of cancer services – oncology, chemotherapy, radiotherapy, and research departments, plus a dedicated pharmacy – under one roof to expedite and bolster the provision of fully integrated, seamless care that makes it much easier for people to access the full spectrum of services they might need in a supportive environment.
Bringing state-of-the-art research facilities into the fold will add tremendous value, as teams can collaborate to conduct and analyse trials, and work together to potentially discover the clinical breakthroughs of the future. The entrance area is also home to a new Macmillan Wellbeing Hub, a space for patients and their families to relax, and receive advice, or emotional support, in a non-clinical and peaceful environment. When embarking on the design strategy for the centre, we worked closely with all relevant and interested parties, including patients, community members, and employees. A three-storey glass atrium welcomes visitors at the entrance, and floods the area with natural light and a sense of openness, complemented by an intuitive and clear wayfinding strategy to accommodate different accessibility needs and ages. The interior design and art approach, meanwhile, was inspired by biophilia, with an overarching theme of ‘Land, Water, and Sky’ implemented throughout to create an uplifting background and reiterate that vital human connection to nature.
As already covered, smaller health centres and hubs will become increasingly prevalent in the make-up of our communities, and can be replicated nationwide to aid with pre-vetting, diagnosis, and taking some of the mounting pressure away from hospitals. It also feeds into the UK’s Live Longer Better initiative, whose goal is to increase life expectancy and allow people to live in a healthier and more fulfilling way for longer, shortening the time towards the end of life during which they may otherwise have been overwhelmingly dependent on constant care. Research conducted by the programme finds that, while an ageing population undoubtedly brings sizeable implications for healthcare, this can be turned around. By taking action now, it argues that is actually possible to prevent or delay dementia and frailty, lower the risk of falls, and cut the need for long-term care by £45 m per million of the population for each year of life expectancy.
Innovations in digital technology
Next, many innovations in digital technology will underpin the ongoing transformation of healthcare, by improving efficiencies with the help of data analytics and the provision of real-time healthcare and signifiers that are not currently available (for instance, people receiving mobile phone alerts prompting them to take action). While the process of ramping up the digital capabilities of the NHS has been called ‘too slow’ by an independent expert panel, largely due to inadequate support or funding, we are likely to see real movement in the coming years as the service works to solve legacy and data silo roadblocks, and aggregate all patient records in a unique repository for better, faster communications, care, and diagnosis.
The emergence of more tech-enabled and data-led health monitoring tools will inform a holistic approach to community healthcare, with intelligent digital platforms attuned to biomarkers that can easily become part of everyday life. Monitors for heart, blood pressure, and blood sugar, are already available, with new innovation coming through – such as WC sensors that monitor urine automatically and upload the data for real-time evaluation. This can be especially useful for those who are at a higher risk of certain diseases.
Decarbonising the estate
Last but by no means least, decarbonisation of the estate and decreasing embodied carbon will only grow in urgency in the light of the UK’s wider Net Zero targets. The government has plans for 40 new hospitals but, to attain some more immediate gains, we should take a retrofit-first approach, and begin by addressing inefficiencies in existing buildings, which can be modernised to minimise their heavy climate implications, improve energy performance, reduce emissions, and generate operational and cost savings. The hope is for a smarter, rather than an ever-expanding, estate
It is promising to see that hospitals are shifting from fossil fuels towards renewable energy sources, exploring onsite energy generation through PV and more. Intelligent and sustainable design, construction, and materials choices, are becoming early-stage considerations in new developments. Technology will be a key enabler of a sustainable estate, bringing capabilities to undertake accurate energy monitoring for insights into how the NHS uses its buildings, and where meaningful changes can be made. Design, too, will increasingly be enhanced by digitalisation from the start to gain clearer visibility of the entire lifecycle of buildings
When the NHS was born, it opened the door to a completely unprecedented universal care model, as every medical discipline joined together under one nationwide umbrella. That same sense of collaboration and innovation should now inspire us to stay true to the vision of the NHS, and keep delivering on that by ensuring greater resilience and capacity for the provision of the best possible care
At a time of higher-than-ever demand, and a stretched NHS, good design can go a long way towards empowering the health sector to reach its aims, and turbocharging it for the coming generations. We must continue pushing boundaries in traditional healthcare design to solve current issues, meet new demands, and support the NHS in the next 75 years – and far beyond.
Neil Evans
Neil Evans, Associate Principal at Arcadis, is a qualified architect with a long history of designing for healthcare, particularly specialist acute developments and schemes undertaken in challenging ‘live’ environments. Working within various procurement routes such as ProCure22 and Frameworks Scotland, he is skilled at effectively managing stakeholder engagement and working collaboratively with project teams, championing best practice and innovation
. Successful recent projects delivered under his direction include the Eye Centre at Golden Jubilee Hospital, Clydebank, Huddersfield Royal Infirmary Emergency Department, and Ysbyty Glan Clwyd Neonatal Centre. He has designed for a wide variety of patient groups and clinical departments, becoming one of the practice’s specialists in operating theatre design, while also working extensively at strategic development stages, having prepared masterplans for phased development works at Antrim Hospital, Wrightington Hospital, and the Royal Liverpool University Hospital. He has been a Studio Principal since 2006.
Graham Harris
Graham Harris, Principal at Arcadis, is an experienced architect and project director with over 25 years’ experience delivering all aspects of the project lifecycle. He is particularly strong at developing and challenging NHS briefings, helping to realise projects through innovative stakeholder consultation processes. He joined Arcadis A&U (as Nightingale Associates) in 1998, and over the past 25 years has played an active role in growing the business’s healthcare portfolio, ensuring improved standards in architectural output and efficient working methods, including BIM. He currently leads the UK Healthcare team. Successful recent projects delivered under his direction include the new Douglas Bennett House for South London and Maudsley, and the Pears Maudsley Centre for Children and Young People