SUPER GREEN - the International Academy of Design and Health

StandpointEach year, many billions of euros are spent on capital investment projects in the health sectoracross Europe, and this amount is likely to increase in the coming years, as many countriesface a backlog of maintenance and refurbishment.Nowhere is the need greater than in Central and Eastern Europe, where levels of capitalinvestment have been particularly low over the last 30-40 years.When funds become available to address the long-standing lack of capital investment – forexample through structural funds for new EU member states or the oil boom that countries likeRussia or Kazakhstan are experiencing – there is a real danger that resources are not spent in themost effective and sustainable way. Before rushing into building new facilities, there are some keylessons to be learnt from capital investment in Europe.What should precede any capital projects, is a comprehensive analysis of health needs and howthese needs should be translated into services and appropriate facilities. Long gone are the dayswhen hospital beds were seen as an indicatorof a good healthcare system, such as under theSoviet Union, which placed great emphasis on alarge number of hospital beds and physicians.Health facilities should not be perceivedmainly in terms of buildings, beds or specialties,but rather from the perspective of the patientswho are treated in them and the processesdelivered by the health professionals who spendtheir working lives in them.This approach entails going beyond the singlehealth facility and taking account of the wholetrajectory of care. Far too often, capacity planningin the health sector fails to move beyond hospitalsand does not take account of the overall healthneeds of the population and the spectrum ofhealth services required to meet those needs.Health facilities also often continue to be used beyond their functional lifespan and refl ect outdated patterns of care – such as thelarge number of tuberculosis hospitals throughout the former Soviet Union that are at odds with modern approaches to tuberculosistreatment. Flexibility must encompass all aspects of health facilities, including their scale and scope, architectural design, supportinginfrastructure, services to be provided, relationships with the rest of the health system, revenue fi nancing, and sources of capitalinvestment. Paradoxically, in a few countries, policy is moving in the opposite direction – the Private Finance Initiative in the UK involvescontracts, which are specifi ed in great detail for the lifetime of a project, usually around 30 years, with very little scope for change.Effective capital investment requires intelligent fi nancing mechanisms, both for services and capital. In terms of services, resourceallocation should reward outcomes rather than capacityThe cost, risksand value of capitalhave largely beenignored acrossEuropeLearningthe lessonSuccessful capital projects in Europe require much morethan good architectural solutions, healing design andenvironmental sustainability, claims Bernd Recheland provide a smooth patient journey across differentlevels of care. With regard to capital, the cost, risks andvalue of capital have largely been ignored across Europe,with investment and revenue costs belonging to differentstreams, removing any incentive for hospital managers tomanage assets effi ciently. This traditional split is graduallyeroding in many European countries, as hospitals areincreasingly becoming responsible for their capital assets.It is abundantly clear that successful capital projectsrequire much more than good architectural solutions, healing design and environmental sustainability. Theywill need to be based on an assessment of health needs, comprehensive capacity planning, a whole systemsperspective, systematised care pathways, anticipated fl exibility and intelligent fi nancing solutions. None of thecountries in Europe has perfect solutions for all these issues and those involved in planning major capital projectsare well advised to try and ensure the long-term effectiveness and sustainability of anticipated health facilities.Bernd Rechel is a lecturer at the London School of Hygiene & Tropical Medicine and a researcher at theEuropean Observatory on Health Systems and Policies. He will be presenting a paper on ‘Hospitals of theFuture: Improving the Effectiveness of Health Capital Investment’ at Healthcare Infrastructure 2008: BuildingBetter Healthcare in the Community on 2 December at the Savoy Place in London. For more information onthis event, which is endorsed by the International Academy for Design & Health, see p6.WORLD HEALTH DESIGN | October 2008 13