An innovative healthcare project in Hull was driven by a desire to integrate health and social care options for the elderly beyond the city to the wider UK. Roseanne Field reports
According to 2017 data there were approximately 11.8 million people aged 65 and over in the UK – and it’s been predicted that by 2050 that number could reach 19 million. In turn, hospital admissions are also steadily increasing year-on-year, with many being elderly people relying on continuing care. NHS Hull Clinical Commissioning Group (CCG) therefore identified a gap in provision, and a vision to offer an alternative service for elderly patients in need of care, but not necessarily a hospital bed. In 2013, they approached LIFT company Citycare and NHS health planners Community Health Partnerships to work with them on a new integrated care solution to fill that gap. Medical Architecture, a practice whose name gives away their exclusive healthcare specialism, were approached by Citycare to attend a competitive interview for what would be the Jean Bishop Integrated Care Centre (ICC) – named after a much-loved local fundraiser. The centre is located in East Hull which, explains practice director and senior architect Paul Yeomans, has one of the highest levels of hospital admissions across the city, and an average life expectancy below the national average. It was therefore natural that this location was chosen for the ICC, which is hoped to be the first in a series of “care hubs” as Yeomans describes them. “The overall vision was to respond to emerging national thinking around the idea of integrating health and social care,” he says.
An alternative approach
Integrated care, says Yeomans, is about “delivering joined-up support for those with long term conditions, rather than the episodic support at times of crisis that acute hospitals are geared towards.” Although other integrated care provision already exists within England – based around different NHS organisations working together – the Jean Bishop ICC is “based on the earlier thinking, but goes much further,” says Yeomans. One obvious example is the fact that the building also houses a fire station. This unusual mix was the result of mutually aligned needs: Humber Fire and Rescue Service (HFRS) needed a new facility and the ICC was the perfect opportunity to showcase how such public services can work together and provide added value. “The ability to share facilities with health partners made sense,” comments Paul Yeomans. Chris Blacksell, chief fire officer for HFRS explains further: “We recognised that the people we were working with to try and prevent them having fires and other emergencies, were the same people our health colleagues were working with.” As a result of being located in the centre, fire service staff are able not only to ‘educate’ patients on fire safety, they also provide a falls response team. As well as the fire service, the centre houses geriatricians, GPs, advanced nurse practitioners, pharmacists, therapists – physio and occupational – as well as social services and the voluntary sector. “You don’t normally see all these team members when you go to an outpatients appointment,” says consultant physician in elderly care at the centre, Dr Dan Harman. “We’re trying to deliver care in a different way to keep people as independent as possible for as long as possible.” The centre has facilities for undertaking blood tests, x-rays and CT scans. Describing the primary aims of the project – beyond increasing the area’s average life expectancy – Yeomans says the client wanted to “reduce admissions to hospital via a community based integrations and assessment approach, and reduce the length of stay of episodes through availability of reablement services.” As well as the key health-related drivers, they were also mindful of tackling social isolation and security issues the elderly often face. “We want to improve quality of life,” he explains.
A design challenge
Designing a building that was, in certain respects, the first of its kind, was always going to prove challenging. But what made this even more testing for the practice was that they were designing the building with no specific end-user in mind. The CCG works with partners – including GPs, NHS trusts and the local authority – on staffing. However, “at the time of briefing,” explains Yeomans, “the CCG hadn’t commissioned the services that would be going into the centre, so the design team couldn’t engage with the staff that would eventually use the building”. They worked with key stakeholders within organisations likely to end up involved, but naturally, “their input was necessarily informal and detached.” Additionally, along with the CCG and Citycare, they analysed data to ensure they were optimising space provision, while catering for the expected population. It was, says Yeomans, through this “careful planning” that they achieved an 18 per cent reduction in floor space compared to conventional hospital standards. He credits this as being key in the project gaining business case approval. This also naturally proves more beneficial to the patients in this setting, he says, “getting away from the ‘miles and miles’ of hospital corridors and keeping the building at a friendly scale – hard to quantify, but an important consideration.” It also encourages the integration of the services through shared office and social spaces. Working with the various stakeholders also required a great deal of thought. “Planning meetings required care, political adeptness and sensitivity to differing and often conflicting organisational objectives,” says Yeomans. “At each stage we were able to present data; reasonable benchmarking that helped the commissioning team to develop a sustainable shared vision for the project.” This data covered a variety of areas including 3D modelling, sketches, workshops and reports. The other tricky aspect to navigate was keeping costs down. Fixed at £7.5m, Yeomans explains that the budget “was reasonably tight for the amount of accommodation needed, plus the extended gestation of the design.” However, obeying this constraint was actually another factor in seeing the project get underway. “The cost, based on the floor area, was an important driver towards getting the project off the ground, giving the existing health services in Hull confidence to sign up to the new model,” says Yeomans.
A thoughtful layout
It was important to Medical Architecture that the building had the right look and feel in order to steer clear of the more traditional institutional aesthetics. “Reducing the ‘hospital’ feel was important,” says Yeomans, giving the example of entering through a cafe space “which is convenient for waiting between consultations and helpful for orientation within the building.” The ICC was intentionally built in an area with a high older adult population so that the services would be “on their doorstep”. Says Yeomans, “A visit to hospital is a traumatic experience, so the easy access was one way to reduce the stress of engaging with the health service.” The architects had to ensure the building itself was fully accessible, and could be easily navigated by its elderly patients. The simplest way to ensure easy access for all patients – including wheelchair users and those arriving on hospital beds – was to locate all services they would need on the ground floor. The building is arranged, in a “pinwheel formation” around the reception/cafe area. “By organising the welcoming point at the heart of the low rise building, all the clinical and support functions are nearby and accessible,” he says. This layout means a patient can attend a planned consultation, during which necessary tests are taken. The analysis can then take place elsewhere, and results can be ready the same day. When a wait is necessary, “comfortable and convenient” waiting areas are available – also beneficial to any carers who may be accompanying patients. “This process might take several visits over a period of weeks in a hospital setting, but can be dealt with in a day at the Jean Bishop ICC,” Yeomans explains. The practice also employed “thoughtful internal finishes” to help with navigation. Says Yeomans, these “address colour contrast/dementia issues, but are also part of a robust wayfinding strategy that assists the visitor to find their way into the building, but just as importantly, find their way out.” The fire station is attached to the building, located in its own space at one end – a conscious decision so emergency vehicle access wasn’t affected by patients visiting the centre, and vice versa. It also made sense from a design point of view explains Yeomans: “If the HFRS business case didn’t receive approval, there would be minimal redesign as the service wasn’t embedded at the heart of the building.” Although not integrated with the rest of the centre, the fire service still has access to shared facilities. “The aim is that the fire services get involved in the therapies wing,” Yeomans says.
Upon entering the building, patients are “immediately able to see out to the central courtyard,” Yeomans says, adding it’s “a very important factor”. As well as offering views out, this use of glass allows lots of natural light in. Rooflights also let further daylight into spaces. “The therapeutic and non-institutional character of the design is immediately apparent,” says Yeomans. “The planning logic of interspersing clinical and public spaces fosters a sense of reassurance and wellbeing. This is central to the experience of patients, staff and visitors.” To reinforce the idea of wellbeing, the practice made a conscious effort to reduce “the clutter of hospital fittings that often get fitted as standard – wall protection ‘rub rails’ for example,” says Yeomans. “By omitting these and concentrating on handrails we went a long way to getting away from the hospital feel.” Bespoke fitted furniture has been included in the reception and consultation areas, to “drop a note of solid quality into key spaces.” Generous ceiling heights also played an important part in giving the building a less institutional feel, but these heights fluctuated due to necessary servicing and access requirements above the ceiling in places. “We strove to get the head space and daylighting where we felt it was most needed, in the deep plan waiting spaces for example,” he says. The centre includes a variety of community spaces, including rooms which can be booked by local community groups. This, Yeomans says, forms an important part of the patient experience. In these spaces they’re able to share advice with one another, helping address the social issues of loneliness and isolation. “People coming and going and recognising faces is an important part of the ethos,” he says. Other design considerations included grouping services to create integrated panel systems (IPS) – enclosures that sit behind washbasins, normally housing pipework. These are fitted with access panels, so they can also be used for storage of items such as patients’ belongings, helping keep rooms tidy while preventing pipework from being a “utilitarian intrusion”. The centre is naturally ventilated as much as possible, although some treatment rooms required some from of mechanical ventilation. The centre has achieved a BREEAM Excellent rating, thanks to the design’s ‘fabric first’ approach, as well as elements including PV panels, LED lighting, and a sustainable urban drainage system. The building has also been designed with flexibility in mind to adapt to changing healthcare needs. The accommodation can be “changed easily as services develop,” says Yeomans, and “occupancy zoning” allows for certain parts of the centre to remain open when necessary while others are closed. Overall, due to the tight budget, Yeomans admits “there is no great innovation at detail level”. He explains further: “The emphasis is on doing simple things well and getting the patient environment right.” Despite the limitations, the building has a clean, modern look, punctuated by a couple of features such as yellow-framed oriel windows, which help “communicate a structure and order to the linear form”. The modern theme is further enforced through the use of glazing in doors and screens.
Since opening in May this year, the centre has reportedly been very well received and has already made significant contributions towards reducing NHS costs and admissions. Alan Johnson, former health secretary and current independent chair for Citycare gave his view that this type of facility is the future: “I think this is something the rest of the country will be looking at very carefully”. Looking forward, the centre hopes to reduced unplanned hospital admissions by up to 20 per cent, which is projected to save the NHS £5.8m a year. “Overcrowding shows how acute hospitals deal well with trauma and episodic treatment, but are poorly suited for complex and continuing care of an elderly population,” says Yeomans. “There is a broad consensus in the NHS that a new class of infrastructure is needed, and the Jean Bishop ICC sets that new direction.”