Hospital-less cities: dream or possible reality?

By Nick Gordge

Over 18 million additional health workers will be needed by 2030 if we want to meet the health workforce requirements of the Sustainable Development Goals and Universal Health Coverage targets. Think about it: 18 million more in 9 years.

Globally, hospitals and health services are under increasing pressure due to growing demand related to population increases. Treatment of chronic illnesses, increasing elective surgery, and life enhancing treatments have seen a surge in hospitalisations.

But what if we lived in a world where there were no hospitals?

Is it just an absurd notion to dream of hospital-less cities?

Current healthcare systems are designed and operated around pathogenic intervention – people get sick and injured, we identify what is causing the illness and we treat it. But is it possible to prevent people being sick in the first place? Enter salutogenics.

Salutogenic thinking is about focusing first on creating wellness, moving towards preventative measures, rather than relying on reactive processes to manage illness outcomes. Introduced by Aaron Antonovsky in 1979, the model suggests that life experiences contribute to shaping a person’s sense of coherence, and someone who has a strong sense of coherence will be able to cope with stressors successfully. It focuses on the origins of health, instead of disease.

What if we take a salutogenic design approach to all aspects of how we live and work ‒ from buildings and places, to transport infrastructure and everyday products? Would the idea of a hospital-less city be wishful thinking or a possibility? And if it’s a possibility, what would it take to achieve it?

Healthier spaces, healthier society

By 2050, it is projected that 68 per cent of the world’s population will live in urban areas. This urban transition is an opportunity to focus on creating healthy cities. Every aspect of the built environment can take salutogenics into account to minimise harm for people’s health and promote wellness.

Studies have shown that being surrounded by natural stimuli – clean air, natural sounds, plants and water – reduces stress, strengthens the immune system, lowers blood pressure, and has even been proven to reduce Type 2 diabetes and cardiovascular disease.

Designing salutogenic urban environments is about encouraging exercise, stress management, nutrition and social inclusion. This could include ensuring that public transportation is designed to encourage spending more time outdoors, focusing on access to commuting options that incorporate physical activity – walking, riding or scooting, for example.

While urban design has already caught onto the effect of green and blue spaces on public health within our metropolitan environments, imagine if this ‘well-being first’ thinking reached into how we approach infrastructure and transportation.

Can we design infrastructure and public transportation systems that incentivize more physical activity?

Can housing developments be designed and built to include the wide range of features that promote wellness, such as access to communal gardens and fresh-food markets? How can existing housing stock be improved to address wellness needs?

Salutogenics in action

Denmark has spent the last 20 years reducing the number of hospitals it has from 98 to 32 and has emerged as a global healthcare leader.

While hospitals will always be a necessary element of how we care for people’s health – births, genetic conditions, emergency traumas and various other conditions require medical attention and facilities – creating more salutogenic environments has the potential to significantly reduce the need for hospitalisations. That will make a huge difference.

One shining example of this transformation is the Khoo Teck Puat Hospital in Singapore, which has been designed to promote restoration and healing by integrating proven wellness elements.

Opened in 2010, the unique hospital facility looks and feels nothing like a hospital. The doors and windows are wide, maximum airflow and natural light was prioritised in design, and narrow, sterile hallways are replaced with outdoor walkways brimming with lush, native foliage. The green roof and communal gardens attract wildlife, replacing the clinical sounds of the hospital ward with birdsong. And it works.

Healthy, sustainable economies

At present, healthcare services cost billions of dollars every year. One of the biggest issues facing countries worldwide is the unsustainable growth in the cost of delivering healthcare infrastructure.

By creating spaces that facilitate healthier lifestyles, we will ultimately create healthier economies, too.

A recent World Health Organisation paper reports that global health spending is increasing by 3.9 per cent every year since 2000. Despite this investment, health outcomes in many countries aren’t improving.

In Australia, over AUD 4 billion is spent every year on potentially preventable hospitalisations, including conditions that could be prevented via vaccination, and chronic and acute conditions that are caused by lifestyle – unhealthy eating, sedentary routines and stress caused by a lack of work-life balance.

In the UK, the government recently increased the budget for the NHS by GBP 36 billion over three years, and NHS directors say this isn’t enough!

Rather than spending budgets on treating avoidable illness, what if we invested in greater well-being in much the same way that governments are investing in climate change? Can we reduce spending in healthcare and improve health outcomes by creating healthier towns and cities, thereby reducing the need for reactive healthcare services?

Transforming the health and care ecosystem

While we will always require a space for medical care, the way our healthcare system functions, and how we use it, could transform completely if the design of our living and working ecosystem took a salutogenic approach.

Within the healthcare sector, different approaches to services are already beginning to transpire. Examples of this transformation include an increased focus on decentralised service: pathology services are no longer strictly confined to hospital spaces, specialist facilities are more distributed and telehealth appointments are now very common, allowing people to access health advice from home.

By integrating nature and technology, agriculture and community living, infrastructure and lifestyle, salutogenic thinking can help us to design cities that are automatic enablers of health – future cities where avoiding illness is central to how people live.

The ecosystem approach requires a higher order of critical thinking, collaboration and co-design between politicians, governments, professions, industries, developers and communities, whereby a well-being lens is applied to every aspect of urban development, seeking health equity in outcomes. Cities will be designed to enable the entire community to achieve optimal health – physically and mentally.

To achieve this will require huge strength of character for leaders within our communities, and for them to have diverse life experiences and characteristics to be representative of the population they represent. They will need to break free of the tribal bonds, which they inherently associate with and learn to develop focal questions that address the fundamentals of wellness, before committing to investing in any particular notion or idea.

Taking the Auckland Light Rail proposal as an example from New Zealand, it would be very easy for people to view this as a transport infrastructure project. However, the need for light rail is predicated on one of the solutions to the city’s housing shortage, with ‘infill’ housing being built in an existing suburban area.

So, light rail is actually about improving the liveability of these increasingly dense multiple suburbs, and catering to community needs. It’s about creating communities that are safe, socially cohesive, inclusive and environmentally sustainable.

Taking a health equity lens to the proposal at the conceptual stage can provide broader benefits for the greater good of the community. But was salutogenics considered when deciding to encourage infill housing?

Only time will tell whether the outcomes desired will be delivered. (