The JCA leadership has been engaged in changing health care architecture for fifteen years. Our emphasis has moved from ambulatory care and single bed accommodation to looking at more fundamental changes in the design of acute facilities.
There is growing consensus about the strategic directions for hospital development in England and Wales. Its pyramidal form is well known. Vertical care pathways will define healthcare by service provision and not primarily by location. Specialist care will be increasingly concentrated in a limited number of tertiary hospitals. The migration of services from acute hospitals into primary or community settings will continue and will undoubtedly accelerate if we can achieve the integration of health and social services. As a consequence the size and content – and perhaps location – of what were called district general hospitals will change fundamentally. Surprisingly there is very little discussion within the NHS about what these might be. We have named their successors the new model hospitals and the nearest we have come to defining these is in the New Cumberland Hospital project at Whitehaven. Our model is based on the NatFed report from 2007 by Davies, O’Riordan, Morgan and Powell. Its central thesis is:
• A high-quality acute service can be provided or maintained at a local level (target catchment area of 200,000 to 250,000) with support from a specialist network.
• This local acute service only makes sense if it is combined with local primary care and community services to form a single integrated whole. Specialist teams and primary care would, therefore, be working hand in hand as part of a combined service.
• Local health services need to be restructured to create new cross-community teams with the freedom and appropriate incentives to deliver quality services. This means the disbanding and restructuring of traditional departments such as A&E and specialty-based wards.
• Piecing these local services together systematically is the most important task facing the health service, and should drive how specialist networks are put together, rather than the other way around.
This provides a smaller more integrated physical model described in the diagrams below.
This process is undoubtedly happening much more slowly in this time of austerity. However, any discussion about the physical requirements of hospitals should take place within this specific context. If not, we risk repeating the mistakes made in previous recessions when ill-considered and opportunistic short term developments bequeathed us some of the poorest buildings in the NHS estate.