The evolution of global healthcare models requires a profound rethinking of healthcare infrastructures as an opportunity to interpret the multiple instances that are transforming contemporary paradigms at a social, economic, and environmental level. The global challenges of our time — such as ageing population, inclusive design, Artificial Intelligence, and climate change and urbanisation, may find synthesis and balance in the ‘architectural project’, which has precise sustainable objectives, both in terms of individual projects and on a system level.
The recently concluded United Nations Conference on Climate Change (COP28) saw a unique moment in history, with 123 countries signing a declaration to ‘put health at the centre of climate action’, and support the development of climate-resilient, sustainable, and equitable health systems. In line with the so-called ‘One Health’ approach, sustainability, and practical actions to tackle climate change, are strictly related to health.
Climate change is a global phenomenon that countries around the world are seeking to address — due to its negative impact on the natural environment and, consequently, on humankind. It has been identified ‘as potentially the greatest health challenge of the twenty-first century’,1 as it contributes to the increase in non-communicable diseases (NCDs), and facilitates the spread of new infectious diseases, which in turn devastate the healthcare sector and its infrastructure. By causing an increase in both recurrence, and harshness of, extreme weather events, climate change also exerts a direct negative impact on health, provoking injury and illnesses. Rising air pollution alters the patterns of vector-, food- and waterborne diseases, and global warming also has mediated effects on social and human systems — including malnutrition, occupational heat stress, and mental illness, as well as increasing the rate of population displacement. This, in turn, slows economic growth, and further increases poverty. The effects of global warming are particularly relevant to the most vulnerable populations, such as those with pre-existing medical conditions, the poor, children, and the elderly. They have also been found to affect the middle- and low-income populations.2
A form of social architecture
The hospital is the social architecture that best interprets these transformations. It accompanies significant demographic, technological, and epidemiological evolutions, and condenses them in a key physical space, contributing to global health through the creation of healthier, more efficient, and comfortable systems.
The hospital is a ‘city within the city’, where multiple functions are co-located in a single but complex infrastructure experienced by users with different, and sometimes conflicting, needs. Against this backdrop, it is important to duly consider how sustainable such a facility is; doing so tends to highlight how the previous obsessive focus on widespread technological solutions, rather than a human-orientated approach, the lack of significant investment, and remarkable managerial complexity, have contributed to a slowdown in the research on the architectural, morpho-typological, and construction aspects of these infrastructures. In particular, given an optimal lifecycle of around 50 years, it is estimated that the majority of European hospitals are obsolete and poorly suited to contemporary organisational models. This obsolescence arises from the inability of excessively rigid organisations to promptly support the changes necessary in the light of evolving processes and technologies, which also contribute to an increase in the net design and construction time. The need to keep up with rapid innovation while complying with stringent safety, hygiene, and system redundancy requirements, makes the hospital an energy-intensive infrastructure — functioning 24 hours per day, seven days a week — with extremely high consumption (over double that of a commercial building).
Ushering in a new era for hospital design
For these reasons, the focus of hospital design in the near future will need to be filtered through the strategies of the Next Generation Hospital, in keeping with precise sustainability requirements. Sustainability should be considered as a holistic concept encompassing environmental, social, energy, economic, and organisational issues. In the healthcare sector, as underlined by European Union’s One Health approach, in addition to involving access to care and the digitalisation of processes and risk management, it also relates to the relationship between people and the healthcare environment from an architectural standpoint. It is estimated that if the healthcare sector was a country, it would be the world’s fifth largest polluter. The recent report of the EU Expert Advisory Group of the Partnership for Health System Sustainability and Resilience (PHSSR) highlights a strong reciprocity between environmental sustainability and health systems.
On the one hand, healthcare systems — through their activities, infrastructure, and resource use — contribute to approximately 5.2% of global greenhouse gases, with far-reaching implications for air and water quality, climate change, and biodiversity loss. Meanwhile, the risks posed by climate change — including heatwave-related illnesses and rising mortality rates, are leading to an ever-increasing burden on healthcare systems, particularly with regards to chronic and non-communicable diseases.
Sustainability must therefore be addressed in the healthcare environment not just from a medical, but also from an architectural standpoint. Through correct sizing of spaces and the use of decarbonisation technologies, hospital design can create wellbeing for people and improve quality of life by contributing to sustainable policies orientated towards the Sustainable Development Goals (SDGs) and the definition of the right ESG (Environment, Social, Governance) profile of the healthcare organisation at large.
Meta-design models and frameworks are thus needed to help decision-makers, policymakers, contracting authorities, and designers, identify the correct sizing, functional, and spatial relationships, as well as the sustainability performance requirements that the hospital of the future must possess. It is also necessary to identify performance monitoring indicators (KPIs) for each thematic area, to shape a new generation of hospitals that are functional, sustainable, digital, safe, inclusive, and deeply embedded in their territory, and able to meet the healthcare needs of the future. The Next Generation Hospital project, developed by the Politecnico di Milano Joint Research Partnership in Healthcare Infrastructures, goes in this direction, and establishes a framework for decision-makers for the use of policies on hospital design. Drawing on the 2023 World Health Organization report titled ‘Hospitals of the future. A technical brief on re-thinking the architecture of hospitals’, the aim of the Next Generation Hospital project is to develop sustainable healthcare facilities that remain modern and up-to-date throughout their lifecycle.
To be classified as ‘Next Generation, a hospital must be located on a site that encourages urban renewal and is well connected to surrounding healthcare facilities, creating a regional health network. This is key to attracting investment, whether active or passive, to accommodate the needs of the hospital and its functions. Such an initiative, in other words, facilitates the creation of new infrastructure, as in the case of the New Karolinska Solna Hospital (see Fig. 1) in Sweden, a facility designed by architects, White Arkitekter. A new tube station was built next to the hospital, to enable sustainable travel to the area. In addition, the use of public arts in the facility not only provided relief for users, but also helped make the space more attractive, and in turn encouraged users to explore the surroundings.3 The location of medical facilities is, indeed, vital for sustainability, from both an ecological and an economic perspective, as it encourages new investments and the development of infrastructure that helps to reduce carbon footprint.4
Green is the colour of healing
Just as location is essential to the Next Generation Hospital, so is the availability of space to create ‘green’ areas, which are key when it comes to sustainability and health. Not only do green spaces contribute to mitigating the urban heat island effect, but they also help absorb the carbon released into the atmosphere. Moreover, they make the surroundings more attractive, and act as places of refuge for users, with studies finding that access to greenery helps calm users, reducing stress and anxiety,5 which can be abundant in hospital environments.6 Green spaces also help the healing process. Even a simple visual connection to plants has therapeutic properties, as it decreases patient recovery time,7 and helps patients leave the hospital feeling calmer and less anxious. Many hospitals thus now look to incorporate green spaces in a variety of ways. The Santa Fe de Bogotá Foundation (Fig. 2) in Colombia, for instance, created an indoor solarium/greenspace (Fig. 3) on the ninth floor, adjacent to the inpatient area, to support recovery and clean the air. It was found that both patients and staff responded positively to the space, resulting in shorter recovery times and a reduction in anxiety.7
The multiple benefits of modular design
A report released by the World Health Organization titled ‘Operational framework for building climate resilient health systems’, stated that health should be resilient, which ‘relates to the capacity of the system itself to cope with and manage health risks in a way that the essential functions, identity, and structure of health systems are maintained’. This type of resilience can only be achieved through modular design, which leverages prefabricated construction. Modular design allows any changes to be quickly implemented, and adaptation of the system to meet any needs that may arise, including in emergency situations. The Sammy Ofer Heart Building (Fig. 4), designed by Sharon Architects and Ranni Ziss Architects, is a great example. Thanks to its modular design, the hospital is able to convert its parking garage into an intensive care unit in as little as 72 hours. The building itself contains plenty of buffer space that can be used for different purposes depending on what is necessary to deliver optimal care. Even spaces requiring independent ventilation systems can be built rapidly, as the mechanical systems are also modular.
Modular design also allows the development of a healthcare system that is not only resilient, but also environmentally responsible through the reuse of materials. As D. Campbell-Lendrum et al explained, ‘to ensure economic and environmental sustainability [the healthcare system] should also support the shift towards a circular economy in health (and in society generally), through rethinking models of care — including optimising the use of telemedicine, minimising consumption and wastage, and making more sustainable purchasing decisions’.1 The Martini Hospital (Fig. 5) in the Netherlands, designed by Burger Grunstra Architecten, exemplifies these ideas with its industrial, flexible, and demountable building system (IFD), which harnesses a unique assembly system to mount and dismount pieces of the building with ease. The facility’s modular design, along with the IFD system, unlocks advanced flexibility.7 The building is expected to be used as a hospital for 40 years, at which point the government may choose to change its function and turn it into an office space, a shopping mall, or even housing.8 Without modular design, it would be impossible to achieve true sustainability, as medical infrastructures would be too ‘rigid’ to adapt to and address the changes that the medicine of the future might hold, or to adapt to unforeseen circumstances, including extreme climatic events. To be fully sustainable, a facility should serve the community to which it belongs right up to the end of its lifecycle.
Unlocking the power of AI
It is essential that hospitals keep up to date with the disruptive technological advancements of our time, and use Artificial Intelligence (AI) to its fullest capacity. AI-powered systems can help streamline a range of processes, including patient management, making the delivery of healthcare services far more efficient. The adoption of these technologies has already begun, with medical call centres empowering doctors to connect with patients and provide consultation remotely, relieving hospitals of high volumes of patients. Among the facilities that are making the most of AI, the Jacobs Medical Center (Fig. 6) in San Diego, California, designed by CannonDesign, and the aforementioned New Karolinska Solna (Fig. 1), designed by White Arkiteketer, stand out.
These hospitals have introduced private rooms that capitalise on digital technologies to enable patients to customise their space and maximise comfort from their bed. The same rooms also favour the use of interdisciplinary examination and medical tools that allow multiple specialists to visit patients, eliminating the need for them to travel to different parts of the hospital. The New Karolinska Solna also leverages pneumatic tubes and AI-powered robotic carts that transport supplies via a dedicated elevator system, with no disruption to other hospital activities. The use of drone delivery services is expected to become more widespread in the near future, as more and more facilities begin adopting the technology.
Advanced technologies, notably AI, are becoming integral to the healthcare industry, facilitating a smarter use of resources, and improving sustainability.
It’s worth highlighting that the hospital of the future will operate on the basis of reducing its energy consumption with the aim of reaching Net Zero. This can be achieved by using both passive and active sustainable design technologies and strategies. The former, comprising greenery and shading devices, help to reduce carbon and heat gain from the sun, specifically during the summer months. This technique is employed by the Santa Fe de Bogotá Foundation (Fig. 2), with its indoor greenspace/solarium and the unique brick pattern of its façade, which serves as a passive filter, controlling the amount of sun rays that enter depending on the space, and, ultimately, the amount of heat gain.
The New Karolinska Solna (Fig. 1), on the other hand, relies on more active systems and technologies. It uses a ‘combination of district heating, remote cooling, a separate geothermal plan, plus recycled energy from ventilation air’,3 to achieve LEED Gold certification, with 99.7% of its energy drawn from renewable sources. Healthcare facilities should adopt a combination of passive and active sustainable design techniques to reduce their carbon footprint and tackle the challenge of climate change effectively.
A holistic approach to the hospital of the future
The hospital of the future will need to achieve the objectives of sustainable development in full to guarantee health alongside social, economic, and environmental sustainability. This will see numerous aspects of the architectural design — from the building components to the integrated management and design criteria — being applied from an early stage and supported by advanced digitalisation tools.
The sustainability of building systems will be increasingly determined by a wide range of factors. Energy consumption, alternative energy sources, thermal comfort, use of water, waste management, ventilation systems and lighting efficiency, air quality, materials and construction techniques, will all play a part. On a broader scale, smart choices — in terms of location, aiming to reduce land consumption while maximising the potential of existing infrastructural areas, will be critical to promoting sustainability and urban regeneration strategies. Sustainability should ultimately be assessed holistically, through the implementation of models based on scientific evidence and robust methodologies.
From the location study, accessibility and functional design, to the presence of greenery, safety, and resilience strategies, hospital design is tasked with the development of innovative strategies through a comparison between the latest scientific literature and notable best practice cases from around the world. Innovation can only occur when there is continuous synergy between research, training, and technological transfer. This is key to shaping cutting-edge, inclusive, and sustainable care spaces that benefit from an evidence-based approach of a multidisciplinary nature. Intrinsic to the hospital of the future is a firm commitment to facing the most complex social, environmental, and organisational sustainability challenges.
Professor Capolongo
Stefano Capolongo is Full Professor in Hospital Design and Urban Health at Politecnico di Milano, where he is also director of the Department of Architecture, Built Environment and Construction Engineering (DABC). He has a PhD in Public Health from the University of Milano. He is President of the Urban Public Health Section of the European Public Health Association (EUPHA), Scientific coordinator of the Design & Health Lab and of the Joint Research Partnership Healthcare Infrastructures (JRP HI) at Politecnico di Milano, and General Secretariat of CNETO (Italian Center for Hospital Building and Design). Prof. Capolongo is the scientist responsible for the World Health Organization’s report, ‘Hospitals of the future’, and the Working Group, ‘Hospitals and Social-sanitary Facilities’ of the Italian Standards Body (UNI). His research interests include the health and sustainability of the built environment, hospital building and design, and f inance in public health and social architecture.
References
1 Campbell-Lendrum D, Neville T, Schweizer C, Neira M. Climate change and health: Three grand challenges. Nature Medicine 2023 29(7):1631—8.
2 Shumake-Guillemot J, Villalobos-Prats E, Campbell-Lendrum D. Operational framework for building climate resilient health systems. Geneva, World Health Organization, 2015.
3 New Karolinska Solna Hospital [Internet]. 2023]. https://tinyurl.com/ysuhk65t
4 World Health Organization (WHO). Hospitals of the future: a technical brief on re-thinking the architecture of hospitals. Report number: WHO/EURO:2023-7525-47292-69380, 2023. 22 May 2023. https://tinyurl.com/2we93mvx
5 Wark R, Galvin A. Design Guide for Health Space, Places and Precincts. New South Wales: Government Architect New South Wales Health Infrastructure; 2023.
6 Sagredo R. Santa Fe de Bogotá Foundation / el equipo de mazzanti [Internet]. ArchDaily. https://tinyurl.com/bddbssk8
7 Burger Grunstra Architecten, Rob Hoekstra · New Martini Hospital in Groningen [Internet]. 2007. https://tinyurl.com/nwk3kd4v
8 Martini Hospital by Dutch Hospital Design [Internet]. 2013. https://tinyurl.com/27pvxmuh
Other sources
Brambilla A, Rebecchi A, Capolongo S. Evidence Based Hospital Design. A literature review of the recent publications about the EBD impact of built environment on hospital occupants’ and organizational outcomes. Ann Ig 2019; Mar-Apr; 31(2): 165-180.
Capolongo S, Gola M, Brambilla A, Morganti A, Mosca EI, Barach P. COVID-19 and Healthcare Facilities: a Decalogue of Design Strategies for Resilient Hospitals. Acta Biomed 2020 Jul 20; 91(9-S):50-60.
Brambilla A, Capolongo S. Healthy and Sustainable Hospital Evaluation — A Review of POE Tools for Hospital Assessment in an Evidence-Based Design Framework. Buildings 2019; 9 (76). https://doi.org/10.3390/buildings9040076
Partnership for Health System Sustainability and Resilience (PHSSR). A Stitch in Time: Early Intervention to Tackle Europe’s NCD Crisis. The Partnership for Health System Sustainability and Resilience. November 2023. Accessible at https://www.phssr.org/reports
Jacobs Medical Center at UCSD health [Internet]. 2016. https://www.cannondesign.com/work/ucsd-jacobs-medical-center
Sammy Ofer heart building — ziss architects [Internet]. 2012. Available from: https://ranniziss.com/Sammy-Ofer-Heart-Building
Capolongo S, Sianesi. JRP Health Infrastructures Annual Report 2022. The Next Generation Hospital. Politecnico di Mialno; 2022.