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Typology: Hospitals

Ancient civilisation advocated letting the wider world’s healing power flow through the body and mind, but the industrialisation of healthcare isolated patients from these larger contexts. From city centres to sylvan settings, today’s hospitals must reintegrate the public realm into the healing process

The origins of the hospital as a type are far from the city, but the typology of the city has played a large part in shaping the modern hospital. Paradoxically, from the middle of the last century the design of city hospitals has generally ignored the urban fabric in which they are set, making only the minimum essential logistical connections. Now with advance in the understanding of environments for healing and a greater appreciation of the role and value of networks of urban public space, architects and co-designers need to rediscover and re-cast the typology of hospitals and healthcare settings generally to enact a potent integration with the city.

The architectural genealogy of hospitals starts in the ancient world. The temples of Askelpios in Epidaurus and Kos in Greece (around 500BC), where the sick came to be diagnosed and healed, placed faith in the power of sacred settings and ritual. Ancient Roman hospitals on the other hand were developed for military purposes with plans based on barracks. These two traditions – the military and the religious – are consistent threads in the development of hospitals right up to the 20th century. They have parallels today in the sometimes competing, and sometimes complementary, ideas of a hospital as an efficient mechanism for delivering treatment and a hospital as a place for healing.

For the ancient Greeks, healing was in the lap of the gods, specifically Asklepios (shown here in his temple at Epidarus in the Peloponnese)For the ancient Greeks, healing was in the lap of the gods, specifically Asklepios (shown here in his temple at Epidarus in the Peloponnese)

The word hospital comes from the Latin hospitium or a guest-house and originally denoted a shelter for the needy, which later transmuted into a place where the sick could recuperate. At the end of the 18th century in the course of planning the post-fire replacement of the Hôtel Dieu hospital in Paris, French physicians and architects conjectured on the way the accommodation of the sick was arranged for maximum ventilation that would improve health and recovery.

The Revolution delayed the rebuilding of the Hôtel Dieu but several others were designed and built on what came to be known as the ‘pavilion’ typology. Wards were arranged in narrow depth rectangular blocks linked by a corridor, which might also have other rooms off. This idea was taken up in the UK in the mid 19th century, most notably through the passionate advocacy of Florence Nightingale, and became standard with advances focused on improving ventilation, for example by adjusting the cross sectional proportions and separation of the blocks, and introducing updrafts through chimneys and fireplaces.

The great advances of science-based medicine in the 20th century were reflected in hospital design by the domination of a particularly fervent variety of functionalism. Medical and surgical processes came to be considered virtually deterministic as regards building form; even though they change frequently in response to technological and clinical developments. Perhaps because the smooth flow of these processes can literally be a matter of life or death, medical architecture has escaped the critique of functionalism that began in the 1950s and which by the end of the 1960s had shattered the consensus around the International Style.

It is to be expected that hospitals are unlikely to be prime subjects for the experiments of the avant-garde; however, the opposite came to dominate the design of hospitals, with a few exceptions such as the work of Powell and Moya whose radical domestic scale designs for ward blocks at Wexham Park (1955–66), for example, were designed for the patient’s experience without neglecting clinical imperatives.

The Hotel Dieu, Paris. 1830The Hotel Dieu, Paris. 1830

In the main, hospital architects the world over adopted an earnest and conservative approach focusing on the efficient accommodation of processes at the cost of making living places or meaningful form. This functionalist approach gave rise to half a dozen distinct typologies to add to the hitherto dominant pavilion or finger plan invented in France in the 18th century and advocated by Florence Nightingale.

In-patient wards had formed the largest element of a hospital’s plan and volume, but now there was a need to orchestrate four principal and equally important elements of a hospital, namely the outpatient & diagnostic departments, the operating theatres, the wards (or nursing units) and the servicing and circulation. These typologies – for example the street, the monoblock, the podium with tower or block(s), the campus, the atrium – can be seen in modern hospitals all round the world in various pure and hybrid interpretations.

The emergence in the 1960s of ‘patient centred medicine’ turned the attention of hospital architects in the US and UK to the idea of ‘patient centred design’. The UK Department of Health – which at that time had several hundred architects – held a seminar with this title in 1971, but it was not until the 1980s that an exploration really began of what makes for a better sensory experience for people, such as the quality of space, light, acoustics and finishes and how we can reduce stress through making buildings pleasant to approach and easier to navigate, in contrast with the notorious anomie of endless hospital corridors.

The Hospital de St Pau in Barcelona, 1901-30 by Luis Domench i MontanerThe Hospital de St Pau in Barcelona, 1901-30 by Luis Domench i Montaner

The resultant concern to create healing environments suggests a kind of a return to Epidaurus if less numinous. But Epidaurus was all about connecting with the wider world and letting its healing power flow through the body and mind even as the individual focused inward. What the modern hospital typology lacks is that connection, save for a preference for a good view if possible. The benefit of a view has been validated by research such as famous paper of 1984 by Roger Ulrich which showed that patients with a bedside window looking out to a natural setting recovered more quickly.

Until the advent of motorised transport, hospitals tended to be sited where populations were concentrated, and the prototypes of the modern hospital as briefly described above emerged with 18th and 19th century urbanisation. From mid 20th century there has been a preference to locate hospitals on green field sites where possible, away from town centres, giving freedom for layout design and responding to an underlying belief that has been present since the phenomenon of the transmission of infection began to be understood; the belief that the ill should be kept away from the well, not least for their own good in a leafy open air setting.

The desirability and inevitability of universal car use was not questioned until recently while the rising cost of urban land has encouraged the centrifugal trend. Where urban sites were used or re-used, modern hospitals were designed as hermetic entities. A reciprocal spatial engagement with the civic realm has simply not been on the agenda. And yet hospitals are in themselves as large as many settlements and even small towns.

Alvar Aalto's TB Sanatorium in Paimio, 1932Alvar Aalto’s TB Sanatorium in Paimio, 1932

Their design, in terms of legibility of layout, the hierarchy of the parts and the capacity for growth and change, owes much to the city as a paradigm, most evidently in the ubiquity of the ‘hospital street’ – the ‘main artery’, to reverse the metaphoric reference. They contain shops, schools, libraries and places of worship and have their own security apparatus. They have a greater number of well people than ill people. Furthermore, as well-considered extensions to the urban realm they have great potential as agents of regeneration, helping to increase economic activity in the neighbourhood.

That is not to underestimate the design challenge in the integration of the hospital and the city. Like any building with a private realm, and so intensely private at that, there will be limits to such integration. The sheer size of the hospital and the requirements of privacy create a problem of the long blank edge to the street, and the every tightening noose of security increasingly compromises permeability. However, these are problems the city itself faces. In the creative resolution of the tension between the mechanistic and the holistic, through design imagination and rigour, the city and hospital planning have much to exchange.

There is a rich typology in architectural history showing a layered engagement of the hospital and the city. The first building of the Italian Renaissance, as taught in schools of architecture, Filippo Brunelleschi’s Ospedale degli Innocenti in Florence (1419) forms one side of a city square the other sides of which were added in imitation of Brunelleschi’s loggia. While not strictly a hospital, more a refuge or asylum for orphans, the building is generically similar containing most of the elements of a hospital.

Filippo Brunelleschi's Ospedale degli Innocenti, Florence, 1419Filippo Brunelleschi’s Ospedale degli Innocenti, Florence, 1419

English hospitals of the 18th and 19th centuries, like St Bartholomew’s Hospital, Guy’s Hospital and Leeds General Infirmary, have powerful civic presences and display an elegant and functional continuity with the urban public realm. They do so not only through a self-confident architectural language, but also through the creation of urban space usable by citizens not necessarily on hospital business.

This is a two-way transaction: the public space of the city benefits from the hospital, and the patients, visitors and staff have a hugely richer set of options on hand. St Bartholomew’s Hospital, the oldest in London, was founded in the 12th century and its central courtyard (1732–69) by James Gibb is perhaps the finest example of the engagement of rehabilitation and recovery within the life of the city. Almost until the end of the 20th century, patients would be wheeled out in their beds to take the air and sun in the square, a through urban route, watching the world go by.

The Hôtel-Dieu in Paris was founded even earlier and has been through many incarnations in the prominent civic position it has occupied for many centuries next to Notre-Dame on the Île de la Cité. The current building is a classic of the 19th-century city hospital with a pavilion typology organised around a long court which opens from the cathedral square. The pavilion ends appear rhythmically on the side streets, prominent and noble in form.

Before designing Leeds General Infirmary (1863-69) the architect George Gilbert Scott with the Chief Physician Dr Charles Chadwick toured the best hospitals of Europe. He used the pavilion plan advocated by Florence Nightingale and earlier used at St Thomas’s London but adapted it to create street edges much as of other public buildings.

Leeds

Leeds General Infirmary by George Gilbert Scott, 1863-69

The Hospital de St Pau in Barcelona (1901-1930) designed by Lluís Domènech i Montaner has perhaps the most uplifting and convivial of public spaces held within hospital precincts. Were it not for the discreet signs it would be impossible to know that the central space, around which most of the rather beautiful buildings are set, was not simply another of the city’s fine public plazas. It was until very recently a fully functioning hospital now partially converted to a cultural centre.

The Modern Movement in architecture made some notable contributions to hospital typology, for example Alvar Aalto’s Tuberculosis Sanatorium at Paimio or Johannes Duiker’s Zonestraal sanatorium. But Le Corbusier’s unrealised Venice Hospital (1963) stands out as the one truly visionary modern conception of a hospital responding to the city and its possibilities. In his design the building is segmented and woven into the Venetian urban fabric of canals and roads in a subtle and sophisticated way.

With the exception of the windowless in-patient wards on the roof (Corb thought that recovery required a level of introspection that warranted a view only of the sky) this was a radical humanist essay in designing the hospital as a continuation of the urban fabric, a series of linked squares, with routes connecting to the city and a vertical layering of functions.

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Le Corbusier’s unrealised Venice Hospital, Elevation, 1963

Le Corbusier's unrealised Venice Hospital, Plan, 1963
Le Corbusier’s unrealised Venice Hospital, Plan, 1963

 

Case Studies

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AZ Groeninge Hospital, Baumschlager Eberle, Kortrijk, Belgium

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St Olav’s Hospital, Narud Stokke Wiig Architects, Trondheim’s Norwayb

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Hospital de la Santa Creu i Sant Pau, Bonell & Gill Arquitectes, Barcelona, Spain

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Centre Hospitalier Louis-Daniel Beauperthuy, SCAU, Pointe-Noire, Guadeloupe

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Medisch Centrum Rijnmond-Zuid, Wiegerinck Architecten, Rotterdam, The Netherlands

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Riviera-Chablais Hospital, Groupe-6, Rennaz, Switzerland

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QEII Hospital, Penoyre & Prasad, Welwyn Garden City, Herts, UK

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Livsrum Cancer Hospital, Effekt Architecture with Hoffmann and Lyngkilde, Næstved, Denmark

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