Why Do Our Hospitals Look Like Boxes?
Paul Mui 梅鉅川
When I worked on hospital projects, I found myself always having to answer questions, Most common was whether I had any recommendations for good surgeons or specialists. But closely following was ‘Why do our hospitals look like boxes?’ Answering the first question was easy; the latter required far more effort.
New Norm of Building Form
From my perspective, healthcare architecture has much in common with other building typologies, particularly in the way its common building forms change over time, often for pragmatic reasons.
Before switching to the healthcare sector, I worked for a while on transport projects. Nearly all the airport concourses and train stations I worked on had a common form: a long span roof hovering over a series of hub-like accommodations. In the last 20 years, this type of pavilion form has dominated our transportation terminal design. A pioneering example of this approach is London’s Stansted Airport, which opened in 1991. Its Norman Foster-designed terminal placed its baggage-handling system in the basement in order to create a vast open interior space and so allow the concourse to have unobstructed sightlines for operation and passenger orientation.¹ This plan was a direct response to new demands in the aviation business in the 1990s, among them a large increase in passenger volume and needs for improved baggage handling and better airport security.
Towards a Big Box
Hospitals have undergone a similar evolution, albeit one shaped by different forces. Looking at Hong Kong’s hospitals built in the 1980s, we can see that they are mostly based on a campus approach, with each faculty occupying its own individual building. Between the buildings are public spaces such as open plazas, gardens and cafés. Buildings are connected by podiums, covered walkways and open-air bridges.
Prince of Wales Hospital, completed in 1984, and Tuen Mun Hospital, completed in 1986, both followed a similar master-planning approach with clusters of building blocks separated by open spaces. Each building block or wing was designated to one or a similar group of clinical specialists.
Since the 1980s, medical treatments and clinical operations have moved on. Whether you agree with Mies van der Rohe’s ‘Form follows function’ principle or not, hospital planning has had to develop to meet these changes. Disease treatments today tend to be more complex than before, often requiring the collaboration of multiple specialists, so making building flexibility a priority.² Large floorplates are preferred over finger-like footprints or clusters of blocks, while vertical travel is minimised in order to ease the logistics involved in moving hospital beds and equipment from one place to another.
In a hype-dense city like Hong Kong, many development projects inevitably have to be carried out in-situ. What makes this particularly challenging is the absence of decanting accommodation facilities due to a lack of vacant land on site. Off-site decanting facilities are also constrained due to many of clinical services having to be physically connected to the operating hospital. One ironic result of this problem is even bigger hospital blocks.
Nearly all architecture serves a programme. However, some building typologies are less forgiving of their operational requirements than others – notably those, such as hospitals, which address matters of life and death.
A project’s absolute operational needs are almost always determined by its core accommodation, or ‘holy grail.’ As core accommodations are fundamental to users’ operations and normally cannot be altered easily, they usually are subject to a series of non-negotiable conditions. Although the design of these core accommodations will be the highest priority in any scheme, with the rest of the supporting space planned around them, it is often in these peripheral areas where an architect has most freedom to explore –options such as how best to handle daylight, ventilation and visual connections.
American avant-garde architect Frank Gehry once said that after taking into account all the constraints of building, he was only left with 15% freedom to make art.³ When we examine the floor plan of the Walt Disney Concert Hall, one of Gehry’s masterpieces, we see a lot of boxes. The biggest one at the centre is the auditorium. Behind that one are many others housing other core needs, such as rehearsal rooms, green rooms and performers’ amenities. Gehry’s architecture is not manifested in those boxes. Rather, his 15% of art appears in the space between them, and the way he filled those voids, corners and gaps with daylight, air and circulation. Instead of trying to mess with the holy grail, Gehry’s architecture happened in the negative spaces, leaving the concert hall’s core accommodations in peace.
Our healthcare facilities may not need as much art as the Walt Disney Concert Hall, and certainly, I am not implying that our hospitals should be turned into extravagant architectural showpieces. However, the lesson learnt from Gehry is that we should always exercise our 15% of freedom to bear in mind the needs of people. For a moment, we can put aside clinical performance and mechanical efficiency and look at our hospital design from the viewpoint of the patients, staff and public who will use them.
When we design a clinical space, operational needs will inevitably take priority. Engineering considerations such as air exchange rates, logistic flows, vibration tolerances and lux levels have to be taken into account, much as acoustic performance and sight lines take priority in a recital hall. But when we design non-clinical spaces, such as foyers, lobbies, patient waiting halls and canteens, architectural considerations such as daylight, natural ventilation and greenery should take first place. Where clinical space is for treatment, non-clinical space is for healing. If we see healing as equally important as treatment, the same effort should be put into designing non-clinical spaces as clinical ones.
Five Measures to Fill the Gaps
Once we have found our 15% freedom for our architecture, what can we do with it? For an urban hospital, we normally have the following space available for our canvas: ground planes, podiums, balconies, courtyards, atriums, sky gardens, rooftops and bridges. These elements typically are not subject to demanding operational requirements. If we can make good use of them with our creativity, our future hospitals will no longer look as they have done up to now. Around the world, hospital architects are making good architecture by injecting their creativity into these spaces.
Seijo Kinoshita Hospital designed by Japanese architect Kengo Kuma is an interesting example of how landscape can be integrated into a hospital environment. Instead of internalising its plan around clinical facilities, Kuma centred the hospital around landscaped courtyard gardens. Common spaces and patient rooms are connected to nature at different levels and well lit by daylight. The courtyard gives a natural sense of orientation for people in the building, unlike in traditional hospitals, where wayfinding usually relies solely on signage systems.
Lady Cilento Children Hospital designed by Brisbane architect Conrad Gargett is a clever example of how sky gardens can be used in a hospital building. This teaching hospital challenges the conventional model of podium and tower configuration, resulting in a sculpted mid-rise building covered with gardens and landscaped roof terraces.
For many hospitalised patients, a mild walk with fresh air helps their healing. Balconies attached to wards can provide convenient outdoor areas where patients can stretch out and stressed clinicians and other staff can enjoy a break. Balconies can also function as shading for the ward behind.
Atriums are common architectural elements that facilitate interactions and orientate circulation. Many of our local hospitals have atrium spaces. For me, the success of an atrium relies on two factors. First, whether it is connected to a skylight above, either vertically or diagonally. And second, whether it is surrounded by open corridors rather than closed windows. Perth Children Hospital in Australia is a good example of a hospital atrium. Its daylight-flooded atrium connects all of the hospital’s eight floors with corridors that as well as allowing access to parts of the building also serve as form gathering spaces.
In our city, we see podiums everywhere. Some are less popular than others – especially those that are unsheltered. Open piazzas similar to those found in Italy do not work with Hong Kong’s weather. The most successful podium spaces have multiple layers of canopies, bridges, vegetation and furniture to provide shade – as is the case with Singapore’s Khoo Teck Puat Hospital.
Beyond Efficient Boxes
None of the projects described above are comparable in size to the hospitals we are now building in Hong Kong. In order to catch up with the medical demands of our aging population, we undoubtedly we have to go big. Yet, as a designer, I believe size does not matter when it comes to architectural quality. All measures can still be adopted as long as we can find and use our 15% of freedom. With the ten-year hospital redevelopment plans currently in place, Hong Kong will definitely be a major new testing ground in setting the world’s new norms of hospital building.⁴ As well as developing efficient clinical boxes, I hope we will also be able to show the fruits of the freedom we enjoy.
Paul Mui is the director of BREADstudio Ltd and an Adjunct Assistant Professor at the Department of Architecture, University of Hong Kong.
¹ Menno Hubregtse (2020), Wayfinding, Consumption, and Air Terminal Design, New York: Routledge.
² Hospital Authority (2016), ‘Clinical Services plan for the Kowloon Central Cluster’. Available at https://www.ha.org.hk/haho/ho/ap/CSP-KCC_2.pdf (accessed 16 October 2020).
³ Masterclass (nd), ‘Design Obstacles’. Available at https://www.masterclass.com/classes/frank-gehry-teaches-design-and-architecture/chapters/design-obstacles (accessed 16 October 2020).
⁴ Hospital Authority (2016), ‘10-Year Hospital Development Plan’. Available at http://www32.ha.org.hk/capitalworksprojects/en/Others/Ten-Year-Hospital-Development-Plan.html (accessed 16 October 2020).
Fig.1 Aerial view of Prince of Wales Hospital (Credit: Prince of Wales Hospital)
Fig.2 Project images from left to right, credit:
1) Toru Hiraiwa
2) kgbo Wikimedia
3) Adam Mørk
4) Shannon McGrath
All 5 massing diagrams by BREADstudio