Words by Stephen McGrath
“The good news is that for the first time in history, most people alive now can expect to be around well into their sixties. The challenge is that increasing longevity coupled with lower birth rates means a smaller global workforce will have to support a much larger elderly population”
You are old. You wake up, in your own bed, and look up at the camera on the ceiling, which has been looking down at you all night. You find its presence reassuring. Another day begins. While your smartphone takes your blood pressure, a companion robot brings in breakfast, together with your various meds. You know you should get up. You have physiotherapy exercises to do on your games console. And you know the clinic will be analyzing your every move …
A scene from 2050? Perhaps, but it could also be much sooner. Care for older people is evolving rapidly, in response to an impending crisis in demand. The good news is that for the first time in history, most people alive now can expect to be around well into their sixties. The challenge is that increasing longevity coupled with lower birth rates means a smaller global workforce will have to support a much larger elderly population. Health and social care will be on the frontline. As the World Health Organization (WHO) has pointed out, older people have complex health needs, often with multiple chronic conditions and geriatric syndromes, and most health services are ill-prepared to cope.
This poses tough questions for governments and healthcare providers across the globe, especially as rising expectations coincide with pressure on funding and fewer resources to go round. The answers promise to challenge not only established models of healthcare provision but the way in which cities are planned and, perhaps most fundamentally, the distinction between care environments and our own homes.
Forever young: the rise of the over-60s
In 2016, the post-war babyboomer generation began to turn 70. In the longer term, the WHO estimates that the number of over-60s will more than double between 2015 and 2050, to 22% of the global population. In all major areas, apart from Africa, at least a quarter of the population will be in this age group. Advanced economies such as Japan and Germany are worst affected — by 2060, one-third of Germans will be over 65, while Japan’s population is set to drop from 127 million to 87 million, of whom almost 40% will be 65 or older. China too is on the edge of a demographic cliff, with its working-age population set to peak in 2020.
The WHO points out that this collective ageing is also happening much faster than in the past: France had almost 150 years to adapt as its proportion of over-60s rose from 10% to 20%, but countries such as Brazil, China and India will have little more than 20. And there is little evidence that older people today are any healthier than their parents: over the last 30 years, there has been a slight decline in the proportion of older people in high-income countries who need help with basic activities, but little change in the prevalence of less severe limitations in functioning.
An obvious first step is to improve the efficiency of hospital operations, so that a smaller workforce can look after a larger number of patients, while lowering costs. Minimizing walking distances, maximizing patient visibility and reducing energy use are already important considerations for the designers of healthcare buildings. But advances in information technology could remove the need for staff to walk between departments at all, while enabling much more detailed patient monitoring and cutting energy bills dramatically.
One of the most exciting developments in hospital design is all but invisible to patients, but it is set to revolutionise care over the coming decades. Healthcare buildings contain many systems, spanning everything from light control and fire alarms to hospital administration, nurse call and heart monitoring, but they are typically separate and unable to communicate with each other. So, what if there was a single communications platform that united all of these systems? Medical staff and facilities managers would be able to extract the information they needed far more quickly, while other tasks could be automated completely. The data harvested from such a system could also be used to improve everything from user experience to waiting times to buildings’ energy efficiency.
“You’d go to the hospital but you wouldn’t have to go to the admin desk — your smartphone would tell them you’re in the building”Rick Rome, WSP
“You’d go to the hospital but you wouldn’t have to go to the admin desk because your smartphone would tell them that you’re in the building,” says Rick Rome, mechanical engineer and executive vice president at WSP’s specialist healthcare division in Dallas. “They would send you a message to tell you that you’re going to be in room 502 on the fifth floor. So you go straight to your room and the nurse meets you. On a screen in your room, it will list all of your caregivers and all of your procedures for the next three days. They’ll already know your blood pressure because it’s been on your Fitbit prior to your arrival. So you’ve just eliminated two or three steps in the process.” Meanwhile, the thermostat in room 502 has been automatically adjusted when you entered the building so that it’s a comfortable temperature: “That’s improving the energy efficiency of the hospital too because you’re not air-conditioning rooms that aren’t occupied yet.”
This might sound futuristic but Rome’s team has already implemented limited versions of it on projects including Dell Children’s Medical Center in Dallas, the first LEED Platinum hospital in the world. “We tied the patient check-in system with the energy management and the lighting control systems, and it works really well.” They are now developing the concept further, at the cutting-edge University of Texas hospital in Austin, and a new 150,000m2 hospital in China.
“The ultimate goal is to improve the efficiency of the hospital and improve the efficiency of the caregiver, so they don’t have to spend as much time on administration,” Rome says. “It all comes through one system and it’s at their fingertips. So if a caregiver is currently, say, 65% efficient, the goal would be to improve that efficiency to 85%.”
But the future of senior healthcare is not limited to hospitals: large, consolidated facilities will be unable to fulfill the care needs of ageing societies on their own. Instead, the focus is shifting towards a decentralized model, in which a much greater proportion of care is provided from smaller, primary care facilities such as walk-in clinics or freestanding emergency departments — the latter will have the facilities to treat more acute illnesses and injuries than a conventional clinic, but without large wards or radiology departments.
This will mean a community-planning approach, where care and wellbeing are integrated throughout a wider urban area. It’s a radical break with the past, says Marco Buccini, a healthcare planner and architect with over 28 years of experience in Canadian healthcare. “It means not thinking of hospitals as these isolated institutions that are there when you’re sick. Instead of just building a hospital, now there’s a real focus on integrated campuses, where you may have wellness clinics and medical clinics on a site, as well as residential senior care. Often a lot of those people get stuck in hospitals — it’s not the proper design response and it’s costing more and more.” Buccini’s vision is to build a “medical ecosystem” comprising many elements, including care homes, doctors’ clinics, regular housing, a hospital and an outpatient facility. These campuses would be designed in such a way that you couldn’t differentiate a hospital or a research facility from any of the other buildings: “These buildings used to be designed around the doctors and administrators, but now they’re being designed around what the patient needs.”
Then there are what Doug Lacy, vice president at WSP in Dallas, describes as “progressional age of life facilities” — a model that resembles a leisure resort as much as a medical centre. “In the US, nursing homes were for a long time just for the last stage of life,” he says. “But now we’re seeing that the ageing population want a nicer place, so they’re much more hospitality-oriented.” Such facilities offer general life activities — office space, restaurants, shops, hotels, apartments — but with healthcare services added on.
The changing age profile of society is driving architects and developers to consider new ways of living that work better for people not only when they are dependent on medical care, but for the lengthening window when they may be retired but still relatively healthy. When he turned 40, architect Matthias Hollwich started exploring how society and architecture could make the later part of life fulfilling and happy. He has just published the results in New Aging: Live Smarter Now to Live Better Forever. Some 90% of Americans want to age at home, but only a fraction are able to do so, he points out. “This is why we have to start a revolution, and redesign our cities and buildings to allow all of us to live the life we want, all life long.
“We have to start a revolution, and redesign our cities and buildings to allow all of us to live the life we want, all life long”Matthias Hollwich, Hollwich Kusher
We have to facilitate social interaction, because 50% of nursing home inhabitants are there because of social deficits. We have to provide opportunities for informal exercise — running upstairs extends your life expectancy by six minutes — and empower post-retirement work. We need ‘stealth care’: healthcare without the stigma. Longevity is one of today’s megatrends. It is time to address it from all angles.” His practice, Hollwich Kushner, first explored these ideas in 2011 with the BOOM masterplan concept, designed for the gay community, and combining high-design health, sports and entertainment facilities with lofts, apartments and houses set in a pedestrian-friendly landscape. Its latest prototype is Skyler, a tower that embodies the New Aging principles. It offers multigenerational living for 1,000 people, and includes not only homes but healthcare, shared workspaces and places for socializing.
Multigenerational living and social interaction was also at the heart of the winner of the Future Experimental Project award at the 2015 World Architecture Festival. Homefarm Cyberjaya is a collaboration between Singapore-based SPARK Architects and healthcare provider HSC, to be developed on a 6.5ha site in Cyberjaya, Malaysia. As well as a medical centre, the 200,000m2 project includes six residential towers that double as vertical farms, around a productive garden and farm. Residents will be able to participate in growing food, while cloud-based technology embedded in the residential units will monitor their vital signs.
“The world’s ageing population is changing and so must the way we think about the architecture that supports this section of our community,” says SPARK director Stephen Pimbley. “Those entering retirement age are generally mentally and physically healthy. This is a new typology for residential living that seeks to retain the older generation with a supportive cross-sectional community rather than isolating them from it.”
With its vertical farm, Homefarm achieves something that many higher-density models struggle to offer: proximity to nature. A growing body of evidence shows that this is the basis of better physical and mental health. “Green spaces and immersion in nature have positive effects on a wide range of parameters, such as cognitive abilities, stress and cardiovascular health,” says Simon Secher, a consulting psychologist based in Denmark who advises architects on this subject. More than 2,000 studies have shown a correlation between physical surroundings, such as the inflow of natural light and green views from hospital beds, and patient recovery, he adds. For example, in a 2008 study, patients recovering from abdominal surgery were randomly assigned to rooms with or without plants. The group with plants experienced less pain, fatigue and anxiety, and had lower blood pressure and heart rates.
Giving patients access to greenery is hardest in places where space is at a premium. Hong Kong is an acute case — its 65-plus demographic is expected to double to 31% of the population within the next 20 years. But as one of the most densely occupied places on Earth, the only way to meet demand for healthcare facilities is to build tall.
“We read articles about new hospitals elsewhere in the world, where there is a lot of interaction with external spaces and greenery,” says Vivien Mak, a specialist in healthcare architecture at Hong Kong-based consultant P&T. “We try to create better spaces that relieve stress for patients and staff, and where they can get more daylight, more access to outdoor areas, more gallery space and communal spaces. But here we are very packed, so that limits what we can do.”
One answer is to create a kind of vertical campus, containing many of the same spaces you would find in a horizontal one. Earlier this year, P&T completed Gleneagles Hospital, where landscaped flat roofs connect treatment zones and patient ward towers.
“We expect there to be an app for everything, so why wouldn't healthcare use the same technology to become part of our daily lives?”Simon Kydd, WSP
The logical end point of decentralization is to provide as much care as possible in the home. In many developed countries, telehealth services that provide a virtual link between patients and doctors are already making tentative steps into the mainstream. These hold the promise of supporting people to stay at home, rather than going into hospital or residential care. According to UK telehealth provider Appello, postponing entry into care for one year saves £26,000 (US$32,000) in non-care costs.
Such solutions do rely on a good-quality broadband infrastructure being in place to start with. Sweden is one of the world’s best connected countries, currently working towards giving 90% of its citizens a 100MB internet connection by 2020. Municipalities are now looking to capitalize on this, with digital homecare solutions that include assistive robots, smart cameras and Facetime-like video capabilities. “If you look at the cost of homecare, it’s expected to increase by 20-25% in Sweden from now to 2020,” says Christian Wictorin, manager of smart city solutions at WSP. “They are asking, how can we make this work for society?” The economic case is persuasive: ITC firm Acreo estimates that countrywide adoption would cut 53 billion kronor (US$8.2 million) from the country’s care bill by 2020. Understandably, this initially met with strong resistance from caregivers and families, suspicious that homecare is being replaced with digital services and perhaps unsettled by the idea of “Big Brother” style surveillance. But users themselves quickly adapt, says Wictorin: “It’s a big barrier before they have tested it. They say, ‘Ah, we don’t want a camera looking at us.’ But when we do evaluation afterwards, we discover that the patients find it much less intrusive than having someone that comes to them at night-time, with a key that can open their door. They actually think cameras are better.”
Another example of pioneering telecare is being trialled at the University of Manchester in the UK. Mira Rehab is a remote physiotherapy software that uses a Microsoft Kinect motion-sensor camera to transform exercises into interactive video games. By gamifying the exercises, the patient is kept motivated throughout the therapy and the clinical staff can monitor their progress remotely. “This is not intended to replace physiotherapists or practitioners, it’s to supplement them,” says Emma Stanmore, a lecturer in nursing who is leading the NHS-backed project. “Traditionally, people come to a clinic to see a physiotherapist, or the physiotherapist goes to their home, but they can’t go that often and it’s time-limited. With Mira, the physiotherapist assesses the person and decides what they need, but they are then able to remotely monitor how they’re doing, in comparison to, say, giving them a leaflet.”
Older people can be fearful of the technology, but Stanmore has found that they respond positively if they’re provided with training and given enough time to get to grips with it. Although it’s early days, feedback from patients indicates that it is already promoting independence: “One lady gave up driving two years ago and she’s now starting again. That’s life-changing for her.”
There are many digital solutions that attempt to engage patients in their own health, from wearable fitness trackers to myriad smartphone apps that monitor heart rates, blood sugar or sleep cycles, remind people when to take their medication, or simply encourage them to follow healthy eating plans or to drink enough water. “We’re becoming a culture that expects there to be an app for everything, so why wouldn’t healthcare use the same sort of technology to become part of our daily lives?” points out Simon Kydd, global lead for healthcare for WSP. Mobile technology should also improve diagnoses: “It enables long-term measurements of the body’s activity, rather than relying only on measurements taken in an anxious state at the hospital.”
For now, the majority of telehealth services make it easier for patients and their human doctors to communicate. But in the future, it’s likely that artificial intelligence will be involved at some point in the process. There are many start-ups now seeking to harness the mighty data-processing power of computers to develop new drugs or identify patterns in diagnoses. The French division of SoftBank Robotics has even developed a 140cm-tall humanoid robot called Romeo, intended to be “a genuine personal assistant and companion”, who will help with daily tasks, and learn users’ behaviour so that they can identify unusual patterns.
All of this will comprise a major transformation in healthcare, which will inevitably meet resistance and raise questions of data protection, privacy and the appropriate role of robot carers. But society has already demonstrated great capacity to adapt to technological change. And given the scale of the demographic challenge facing societies around the world, we can’t afford to dismiss possible solutions in any field, from more connected buildings to new social models and technologies. “There’s no magic bullet but we’re going to have to leverage technology to ensure that our ageing population can receive the care that they need,” as Michael Witecki, a senior healthcare engineer based at WSP’s innovation centre in Boulder, Colorado, puts it. “We can’t build fast enough, we can’t afford to keep building, and we don’t have enough doctors.”