Progressive Paediatrics

2020 forced rapid changes in technology, social engagement, networks of care and working practices. We caught up with Benedict Zucchi,chair of architecture,to find out how design for specialist paediatric and complex care requires agility, creativity and practicality.

Dublin Children's Hospital

Healthcare design is becoming a niche profession as we continue to respond to the specific needs of patients. What do you see as the biggest changes in hospital design, especially given the events of the last year?

In today’s healthcare sector there are two counter-tendencies at work: one of greater specialisation, with dedicated hospitals devoted, for example, to emergency care, cancer or children, and the other to a more flexible provision of services, either through adaptable estates or adopting a hub and spoke model with greater emphasis on dispersed smaller-scale community facilities. This last trend is being accelerated by the pandemic which has proven the potential of telemedicine and thus the viability of a more decentralised approach to patient care. We have helped a number of Trusts to develop estate masterplans with the express aim of incorporating buildings that can be adapted to different uses or leased to other organisations as an income stream. Hand in hand with this, urban hospital sites are consciously shedding their image as healthcare silos to achieve a better mix of uses, including spaces for learning, research, retail, senior living and community activities.

Alder Hey Children's Health Park

How does architecture influence the construction of children’s hospitals and what makes them distinct from a general hospital?

Architecture has a hugely significant role to play in transcending the merely utilitarian to produce an environment that is intrinsically therapeutic and can contribute to the healing process through its physical qualities. Key to this is breaking down the scale of what are often very large buildings into visually distinct elements; even more important in a children’s hospital where more than half the patients are under the age of ten. Child and family-centred identity is the overriding principle at the heart of paediatric models of care, from their external form and scale through to the quality of the buildings’ public spaces, bedrooms, interior finishes, play and learning spaces. Central to this challenge is accommodating the broad age range of patients - from toddlers through to older teenagers - in ways that avoid the Disneyesque and have a timeless appeal, not just to the patients but also to families, staff and visitors.

How do you introduce light, views, outdoor space and biophilic design for young patients?

The integration of landscape is vital for a welcoming ambience that helps to distract children and destress family visits. For example, as one approaches the new Alder Hey Children's Hospital, the first impression is of a gentle grassy knoll rising out of Springfield Park, its scale no higher than the existing trees. Its hilly, undulating profile makes the new building instantly recognisable.

Central to our concept was giving the majority of rooms (for children and staff) park views and ensuring that gardens and terraces are accessible to all, so that one can step outside very easily from all parts of the hospital within a secure environment.

This integration with the park in crosssection is further reinforced by the building’s plan form. This is composed of three open ‘fingers’ that radiate out from the atrium concourse that forms the public hub. These fingers of clinical space alternate with gardens, intertwining building and landscape like two hands embracing.

The long elevations of the fingers are orientated broadly north-south, which is ideal for passive energy design, ensuring good daylighting, ventilation and views to all patient areas, particularly the wards on the upper two storeys. This passive design approach, together with the green roofs and a number of active engineering systems, ensures that we contain the hospital’s energy consumption and CO2 emissions.

This emphasis on landscape integration continues in our design for the New Children’s Hospital in Dublin, currently under construction, which incorporates one of Europe’s largest ever green roofs, destined to become a very distinctive presence on the Dublin skyline.

How important is user engagement in the design process and how do we maximise feedback?

In all hospital projects, engaging meaningfully with patients is a challenge. In a paediatric hospital the challenge is even greater because this group encompasses such a broad age range (from neonates, toddlers and children through to young adults) and includes parents and relatives. Our experience suggests there is no single prescription for successful engagement but rather we tailor an approach to each project.

A concept that people can identify with is fundamental, but it must be flexible enough to respond to comment. If participation is to be meaningful, the design must be able to evolve, sometimes quite radically, without undermining the overall integrity of the selected concept and the project’s momentum. To address this, our concepts follow what might be called an urban design approach, breaking down the scale of the hospital into a series of smaller elements associated with different departments, or ‘buildings within the building’. At Dublin’s New Children’s Hospital for example, the wards are housed within a distinct oval building wrapped around a large central garden. This early design decision meant that the ward layout could be refined progressively with users over a two-year engagement process without hindering the parallel process of engagement with other departments.

How do you design a hospital environment that emotionally supports the child and their family through the patient journey?

We design places that feel welcoming and memorable whilst preserving a reassuring feeling of familiarity for those who need regular or constant care. By challenging preconceptions we can be creative with inspiring outcomes; our designs are fun, surprising and decidedly non-institutional, without resorting to cliché. At Alder Hey Hospital in Liverpool we played with scale in an Alice in Wonderland way, altering perspectives to appear deceptively small and acquiring affectionate nicknames, like Hobbit Hill. Our concept is faithful to the Trust’s vision of a children’s health park, which has a much more profound and universal appeal, related to landscape, ecology and healthy living.

How do we design for diverse but specific patient requirements and ensure hospitals remain flexible enough for change or future public health crises?

Standardisation of key rooms is essential. We have identified about 20 rooms which typically account for more than 80% of a hospital’s clinical requirements. Over several years we have perfected a standard single bedroom typology which we believe offers the optimum balance between what are often competing priorities. Placing bathrooms in a back to back arrangement between the bedrooms, as opposed to the typical hotelstyle arrangement, has a number of advantages: it gives patients unimpeded views to the outside, maximising daylight and fresh air; full width sliding glass doors to the corridor benefit staff observation and allow families and patients to connect visually with the life of the ward, preserving something of the sociability of the old multi-bed wards; but interstitial blinds within the doors also give them the choice of complete privacy.

What does the industry need to build major hospitals with the necessary knowhow and infrastructure to deal with acute public health issues?

Healthcare knowhow within the construction industry is already very mature, having benefitted from the very high level of investment made in new hospitals in the UK over the last 20 years. Addressing acute public health issues, however, is not simply a question of building more capacity. Equally important is the inclusion of flexible features that allow hospitals to be adapted quickly when required; for example, by making single bedrooms the norm so that infectious patients can be contained and rooms can be quickly converted for higher acuity cases. If car parks are designed with medical gas and electrical infrastructure, as in many other countries, they can be used for beds in field hospital mode.

Great Ormond Street Hospital

Hospitals are complicated buildings that require technical and programmatic considerations. How do we balance this with the need for creative space, materiality, form and identity?

This may sound paradoxical but the key is not to become too expert! Critical perspective, or a certain detachment, is important to bring a fresh pair of eyes to challenges and avoid overly formulaic solutions. Our first designs for children’s hospitals benefitted most from our extensive experience of designing schools. Although there is much in common between all hospital clients or different clinical specialisms, successful places, like successful teams, draw their strength from the particular culture and aspirations of a group of people. It is our role as architects to use our broader experience of hospital design to resolve requirements through specific creative solutions. This not only addresses the important issue of identity but also acts as the spur to innovation through meaningful engagement.