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By 2015 our 1970s Wishaw Health Centre was no longer fit for purpose: too small with too few consulting rooms, no space for greatly expanded primary care.
Since joining my practice in 1988 consultant numbers in our local district general hospital have increased by a factor of five, but acute beds decreased by a third and long-stay beds in psychiatry and geriatrics almost completely closed with their patients now cared for in community settings. Also during this time undergraduate and general practice postgraduate teaching and training have moved into community settings. Our old building was simply inadequate for our increased clinical and teaching workload.
The number of GPs in Wishaw Health Centre has remained the same since 1988. However, we now have three practice nurses instead of one, and treble the number of receptionists, administrators, and IT staff. We now teach students from two Scottish medical schools (Glasgow and Dundee), with Edinburgh to follow, and have billets for an FY2 and two specialist general practice trainees (ST1 and ST3). We have an annual postgraduate trainee from the American University of Beirut, Lebanon, and in 2016 will have visiting trainees from Japan and Ireland. In 2016 we welcome our first pharmacist in training.
Our old building was also host to important community nursing services: district nurses, treatment room nurses, health visitors, community psychiatric nurses, midwives, and podiatry and physiotherapy care. All working in an out-of-date clinical environment. Other secondary care services with a strong role in community health care — psychiatry, community dentistry, community paediatrics — were scattered about the town in cramped and ageing premises. As were other public services: housing, our municipal bank, social services, and the Citizens Advice Bureau. Also unfit for purpose was our 1970s Wishaw Library, a sad replacement for Wishaw’s finest Edwardian structure, the old library, lost in a catastrophic fire in 1968.
A new Scottish Government funding model, the Hub programme, is dependent on public agencies working together on a single site. Wishaw, as outlined before, was ripe for just such an approach. The new building was therefore planned as a joint undertaking between NHS Lanarkshire and North Lanarkshire Council, our local authority.
Two important early decisions. One, to build on an accessible central site in the heart of the community that the building will serve. Fortunately the site of the old library, swiftly demolished, exactly fulfilled that role. Two, design the new building to a high specification, commissioning the Royal Institute of British Architects (RIBA) award-winning Scottish architects Reiach and Hall (R&H).1 Serendipitously, R&H’s senior partner in charge of Houldsworth, Andy Law, is one of Europe’s most thoughtful commentators on the role of good architecture in healthcare provision.2
The new Houldsworth Centre opened in mid-August 2015, on time and on budget.
Now my practice has space, light, and boosted morale. We have three consulting rooms dedicated to teaching. Our consulting rooms themselves, the very beating heart of general practice, where doctor meets patient, are generously proportioned and immaculately finished. There are glorious views to west and south for over 50 miles.
Inevitably, there are some teething problems. The fire alarms are overly sensitive. The lifts are underwhelming, too small and too slow: memo to five-storey health centre designers, apply the specification for a luxury hotel, nothing less will do. And of course you can’t please every user every time. How to respond to a complaint that the new building is ‘Too big, too bright, and too new’?
But what compensations. Popping downstairs to solve a late Friday psychiatric emergency with a quick face-to-face chat with a psychiatric nurse. Finding a consultant older-age psychiatrist drinking coffee with a colleague, ostensibly sorting out a patient’s complex medication, ‘but mainly to enjoy the view’. A crocodile of primary school children lining up in the foyer to visit the library. Scuttling down the side of the building on a filthy Scottish winter’s evening past a roomful of children making music. Leaving an evening surgery to go downstairs with colleagues to discuss modern democratic politics (with Owen Jones as it happened).3 The lovely airy ground floor café, so busy and successful that they supply free smallie eats and coffee for our postgrad visitors (in the last month from China and Lebanon). The setting sun picking out the spire of Glasgow University, 20 miles west north west.
Clinicians and architects need to talk to each other directly. The design of the public spaces within our new building, then our waiting areas, and, most importantly, our consulting rooms, matters. Waiting to see the doctor is less nerve-wracking in a lovely sunlit space with a distant view. Early plans for consulting rooms followed a hospital out-patient template, with the examination couch as High Altar. But, after input from GPs, our rooms are re-focused around our desk and the surrounding furniture, where doctor meets patient/children/relatives and students. I have a cheap and cheerful bright yellow Ikea sofa and less cubic metreage for clinical waste. It works, triumphantly. By way of contrast, our local psychiatrists were less involved, and their spaces are smaller, darker, and pokier, facing into the building rather than out.
Similarly, clinicians and architects are natural allies. We can support each other against the forces of mediocrity: the financials; the scrupulously clean but bleak hands of infection control who view a potted plant as latent vector for bubonic plague; the Health Board formula crunchers who do not understand that primary care is a team sport with a need for team space.
Our new Houldsworth Centre is what investing in primary care can mean in reality, beyond vacuous electioneering. A building that clearly values and celebrates integrated public services.
The Houldsworth Centre will inspire a new generation of young doctors to plump for a career in general practice. In Lanarkshire general practice. Every town should have one.
Arriving in Wishaw by train involves an undistinguished walk up Hill Street from the station. Crossing the junction with Main Street, however, one reaches a commanding, central position high up in the town. An important site given over to a key public building: the new health centre doesn’t disappoint or waste this opportunity.
An immediate impression is that the building, combined with the associated urban realm around it, is already exerting a powerful and positive influence on this central part of the town. This is in part a consequence of the fundamental decision to build high but also with more subtle decisions in the restrained (some might say severe) proportions and material palette. Siting these community facilities at the heart of the town is in itself an endorsement of their value, and the quality and presence of the building only enhances their potential for civic and civilising influence. Big plus points for all this, with the exception of the ubiquitous and grubby NHS signage outside.
The health centre wins a watch for the quality of its consultation rooms. All things being equal, convex spaces are almost always more comfortable places to be in, allowing more flexibility of use and a more relaxed and sociable arrangement of furniture. Here the rooms are exactly square and the ceilings are in good proportion. A very generous window is fitted with a good low sill, just above desk height. This fills the room with light and a neatly detailed louvred opening permits safe and straightforward natural ventilation. Taking up much of the wall opposite the door, the window offers a panoramic view of the town and the landscape beyond to those entering the room; another benefit of the decisions to build high and on this site.
All these moves were doubtless hard-fought with the purser and will have had a cost attached to them; less obvious but significantly so the wider rooms, which make corridors a bit less efficient. All will have had to be traded against savings elsewhere, wherever possible constructively. Therein one of the key skills of the architect: bargaining and prioritising, standing vigil over the items that will make or break a good building. Here the vigil has indeed been stood and the resulting well-proportioned, naturally lit and aired spaces, often with a fine view, are simply a delight to be in.
Having won this battle, the consulting room, appropriately, takes centre stage. As a well-detailed, three-dimensional nugget it is adopted as a fundamental building block of the health centre. An understated but nevertheless powerful and pervasive celebration of the primary human encounter it is there to give place to — that between a patient and their doctor. Bravo!
Neither stairs nor lifts are obvious at ground floor and the stairs are not easy to spot on any floor. Both seem rather utilitarian; the face of the lifts is somewhat clinical, and the interior of the main staircase looks more like a large fire escape. Was the payback exacted here?
When a building is multistorey, its vertical connections need to work very fluidly for it to be navigable and feel like a working ‘whole’, perhaps especially important in a building type seeking to be open, disarming, and accessible. The beauty of the taller building is that in principle it can be more compact: no long corridors are needed, confusing or institutional. The danger is the segregation of the different floor; 20 seconds in a lift can quite quickly achieve more disassociation of people and place than time spent in a corridor.
The atria — one with a glazed roof, the other open to allow a planted space — are superb visual and spatial assets pouring light and air deep into the heart of the building (another battle won). They become a linchpin of the organisation, offering reference points by which visitors orientate themselves, and a sense of connection and shared purpose among the groups of people who work there. As such they go a long way to overcoming that potential segregation between floors but how much stronger this would be if a physical linkage were also found there.
There are barely sufficient resources currently invested in the procurement of public sector healthcare buildings to cover all the bases. Things are run on an extremely tight budget. The architect as lead consultant, along with the wider design team and stakeholders, will have had to make high-level priority decisions, not just concerning the detailed refinement or finesse of the building but also some of its fundamental architectural attributes.