How retail and the “non-clinical” layer of hospital projects can contribute to better community health outcomes

Hospitals play a significant role in our communities. The provision of medical and health services is crucial to the health and wellbeing of the community, helping us live longer, and improve our quality of life.

But this isn’t the only thing hospitals can provide.?

Physical health is just one aspect — albeit an important one — of overall health. There are several other social, economic, cultural outcomes that contribute to meaningful metrics of health and wellbeing. Without this holistic view of health, we risk not realising the full opportunity for health improvement of the community.?

A more resilient and sustainable solution requires a rethink about the role of hospitals in our community. Complementing the delivery of clinical medical services — could hospitals also play a greater role in local economies and community wellbeing through improved urban design with retail and other non-typical hospital uses? Could hospitals be the catalyst for the delivery of a greater range of land uses and economic activity within a precinct that improves worker, patient, community wellbeing?

Background

From the 1950’s there was significant population growth in Australia, resulting in the emergence of ‘the suburbs’. This necessitated a significant increase in the delivery of new hospitals as well as the expansion of pre-mid-century hospitals. Like many suburbs and commercial precincts, these hospitals were often developed and expanded in a haphazard and siloed manner with the main consideration being the important provision of acute clinical services and beds. Much less thought was given to retail, public space, urban design and other “non-clinical” elements that could enhance the user, patient and staff experience and deliver additional benefits.

This has resulted in many public and private hospitals and health campuses functioning and feeling similar to corporate office parks and universities. Large inward-facing buildings that don’t integrate with the surrounding streets, have limited access to retail and amenity and have unwelcoming formal landscaped areas that are devoid of people and vibrancy. In an evolving world where there is a greater understanding and emphasis on how public spaces, retail, and amenity can contribute to community health, these older hospitals often no longer meet the contemporary expectations of the community.

The lack of consideration of these non-clinal uses such as retail has also been problematic for staff. In a stressful work environment, exacerbated by the Covid crisis, the need for better hospital environments via public space and retail amenity is crucial to staff’s mental health, and ability to deliver care for patients.?

A 2019 research study published in "Annals of Internal Medicine" found US hospital physicians burnout was leading to absenteeism and staff turnover costing in excess of $7600 per physician annum. This was based on a pre covid study where the burnout rate was estimated at circa 50%. Post covid that rate has increased to nearly 69%. This estimated cost to burnout per physician excluded costs associated with the impact of the quality and efficiency of delivery of health care. In Australia where near two million people are employed in the health sector this poses as a potential significant cost to the Australian health sector.

Opportunity

Hospitals are influential institutions with significant communities of their own in the form of large numbers of employees, clinicians, patients and visitors. When?combined with local residents and workers hospitals are places of significant commercial and social activity. In Australia 10% of GDP is health related, 45% of governments health expenditure is on hospitals, and more 10% of the Australian workforce is employed in the health sector.?With the ever-increasing pressure on government expenditure?can we expand on hospitals’ position in the community in a way that drives increased community outcomes from the existing and forecast government hospital expenditure to ensure wider benefits for the community??

We?know?that?the design and character of hospital and medical buildings, such as biophilic design principles, can directly lead to healthier outcomes and better economic returns. Why? Because they are more pleasant places to be leading to increased visitation and more social and economic opportunities. A survey undertaken by the University of Washington in 2006 found?retail customers judge businesses surrounded by nature and natural features to be worthy of prices between 15% to 25% higher.?

Successful places reflect the needs, aspirations and character of their users and community. They connect emotionally and physically with the community. The community engages and connects with these precincts through the design, the aesthetic, the range of uses, activities, shops, services and amenity. This drives visitation and sense of community.

A more human centric approach to the non-clinical layers of the hospital development process could deliver additional benefits over and above beds and clinical services. A process that considers all users’ “place appetites” including the surrounding community, can deliver improved economic and social benefits for the hospital community. By creating environments that resonate with patients, staff and the local community drives increased visitation and economic activity to create and deliver greater amenity opportunities. This approach to development can deliver a hospital work place experience that can attract and retain the best staff and encourage better care and service, leading to better community health outcomes.?

Connecting people: the role and benefits of retail and public spaces for mental health

Numerous studies identify the link between mental and physical health, nature and social connections between people (Brody 2017;?Ehrenfeld?2019). The research shows that in today’s digital world, physical face-to-face interaction is especially critical in reducing stress and mental health issues such as anxiety and depression.?

Public spaces are essential for facilitating these physical interactions, however public space by itself will not optimise these outcomes. Retail, events or programming, and the design of the public space also plays a critical role in developing human connections. When well-designed public spaces interface with vibrant retail creating a great ground plane, visitation and dwell time increases. This improves the chance of planned and unplanned interactions between people, improving the wellbeing and mental health of the community. Great retail and public spaces can also deliver a range of other economic and social benefits for health precincts. Well designed, curated and programmed retail and public spaces that meets the needs of the community, has potential to deliver the following:?

• Improved staff workplace satisfaction and mental health, reducing staff turnover costs and absenteeism
• Increased visitation and vibrancy generating a?greater sense of community from increased social interactions?
• The ability to attract and retain staff leading to improved patient outcomes
• Improved knowledge sharing between clinicians, researchers, educators and businesses within a health precinct?
• Deeper connections between the hospital and business community assisting in private sector funding?
• The provision of an anchor for broader community economic and social development, delivering a critical population to support a range of other businesses and additional amenity

The Importance of Retail to Realising the Vision & Opportunity

Retail amenity plays an essential role in many developments as it is a major influencer of the ‘place experience’ that can deliver significant economic and social benefits. When the ground plane has been considered in a holistic manner through elements such as pedestrian routes, the micro climate, proximity to other visitation drivers, the retail mix, the lifestyles and needs of the community, and how the design of built form interfaces with the ground plane means the broader community can benefit from better quality and higher performing retail, food, public space and social interactions improving community wellbeing. Imagine a health precinct built around a town square or main street?where people come together to meet, mingle, relax and heal — not just because they have to, but because they want to. It is critical for a place to have numerous reasons for people to visit. A place where patients and public have access to?shops, dining, amenity, services, public spaces, events, and cultural activities that will drive increased visitation and bring the community together.?

Hospitals as Community Anchors

New hospitals are presented with a unique opportunity to plan the hospital as the anchor for a town centre or precinct—a hospital as a ‘heart’ of a precinct. The benefits of vibrant places that deliver a central meeting place with unexpected encounters, amenity, knowledge-sharing and community wellbeing can also deliver significant health benefits to the broader hospital community. Integrated medical and mixed-use precincts with hospital anchors could include a range of layers and experiences such as:

• Improved retail and public spaces including food, beverage and landscaping
• Events?programming such as outdoor cinema, pop-up retail, markets and seasonal events like Halloween and Chinese New Year
• Access to a greater range of quality services?via a mobile hairdressers and grooming services, mobile Service NSW vans and mobile banks?
• Greater variety in commercial offices?including medical suites, research institutes and other commercial businesses that would benefit from proximity to a health precinct and generate increased employment and amenity opportunities
• Short-term accommodation such as hotels, serviced apartments and student accommodation that is connected to the street (as opposed to monolithic campus-style accommodation)

However successful integrated retail and amenity needs more than a ‘build it and they will come’ approach. Firstly, it must consider and respond to the workers, patients and their family’s needs and aspirations. Secondly, it needs to consider the local climate and character, using these to inform the tenancy design, curate best-in-class operators and formulate an attractive economic ecosystem of sustainable rents and incentives. Thirdly, a crucial ‘soft layer’ of event programming such as markets, lunchtime music performances, outdoor cinema, art installations, temporary activations to define the experience of the precinct; to bring it to life.

If these elements are brought together, a precinct can deliver improved social and economic outcomes. When the retail offering, public spaces, amenity and activations are strong enough to attract people from outside the hospital community — it becomes a self-sustaining system where increased visitation and its associated additional income streams are able to fund non-revenue generating amenity to enhance the hospital experience. This model demonstrates the possibility for health facilities to become economic and social hubs in their own right, making them—and their communities—more healthful and resilient overall.

How we get there

Repositioning a hospital precinct as a vibrant economic, social and cultural hub means embarking on a different process in the lead up to development. Some of the shifts include:

• Using a disciplined and human centric development approach to the non-clinical layers of a project.?
• Undertake additional economic, social and user engagement research to better understand the economic and social opportunities from better retail and non-clinical layer of a project.
• Engaging with all internal and external users to understand their lifestyles, needs and aspirations to inform the design, the range retail and amenity, the type and style of events and create a “place” that resonates with them driving increased vibrancy.
• Prepare the retail and non-clinical layer vision and strategy?before?commencement of the master planning phase so the design team can consider the non clinal needs in an integrated approach to ensure the optimum outcome is achieve?
• Development of measurable metrics to assess the social and economic benefits of this new approach
• Consider designing spaces that can accommodate and integrate the retail and other amenity and experiences to meet the needs of the whole community to create activated spaces
• Ensuring spaces design for retail and amenity will succeed in those locations and are not allocated left over space when the clinical needs of the hospital have been designed
• Considering what lessons could be learnt from successful retail precincts where the creation of environments that attract people are essential to their success

Case Study – The Children’s Hospital Westmead Redevelopment

This new approach to considering how the retail, non-clinical uses and the public space could enhance the hospital experience has been adopted by Health Infrastructure and The Sydney Children’s Hospital Network in the approach to the planning for the redevelopment of The Children’s Hospital Westmead. To inform this approach the following research was undertaken:

• Extensive engagement with staff, patients and their families to understand their pain points, needs and aspirations.?
• Economic research to identify the range of non-clinical uses and quantum of retail floor space was supportable.??
• Extensive research on children’s play and other experiences was undertaken and
• Identifying the retail and “place experience” gaps in the local community

This research and understanding of the opportunity has been used to create an industry leading vision and strategy developed by BellRinger and Hoyne with important input from Health Infrastructure NSW, The Sydney Childrens Hospital Network, and PWC. This vision and strategy has informed a design and delivery brief for the retail and “non-clinical uses. This included the tenancy mix, the range of uses and experiences, events, public space design, and ongoing operating models to create industry leading amenity and experiences for the patients, their families and staff.?

The key attributes of the Village Green and retail layer at The Children’s Hospital Westmead includes:

• A grocer.
• Village Green to accommodate a range of day to day activities as well as larger less frequent and seasonal activations.
• A range of different spaces to accommodate a range of groups sizes and ages.
• A children’s play-space.
• External food & beverage interfacing with public spaces to provide respite for staff, patients and their families.
• To provide a public space to be the heart for the local community to facilitate community building and knowledge sharing.

Conclusion

There is huge potential for hospitals and health precincts to become as significant socially and economically in our community as they are medically. A human-centric approach and the economic and social benefits this approach takes have been proven in the commercial sector. With the significant forecast expenditure on hospitals and health facilities, there is an opportunity for hospitals, medical staff, patients, researchers, businesses and the broader community to benefit from this approach. This strategic and proactive approach has the opportunity to alleviate many of the pressures that our health system is facing today — as well as build our collective health, wealth and pride.

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