Why one-size-fits-all rural healthcare hubs will fail: a look at scale and design choices

Treating rural healthcare the same as urban healthcare is a recipe for disaster. However, assuming one rural model fits all is just as flawed. This is what Francis Gallagher from HKS Architects has learned from his years working in healthcare architecture.

The Community Regional Director at HKS is renowned for his work on the New Hospital Programme’s £900m Midland Metropolitan University Hospital design, but the prominent architect is keen to emphasise that rural healthcare is its own challenge.

The UK’s healthcare system has traditionally been centralised, urban, hospital-led care. The NHS’s 10-Year Plan aims to change this and decentralise care closer to communities. This is particularly applicable for rural areas where accessing specific care and services is a challenge. People in these areas often have to travel long distances to hospitals, with limited public transport options. GPs are generally the only community-based option for healthcare in rural areas, and normally only provide limited services. 

This creates a binary system, driving traffic toward acute hospitals even when the patient’s needs are not acute. But with no intermediate option beyond the GP, this is patients’ only option.

With all this in mind, Gallagher thinks the metric of success for reform to rural healthcare would be “how much pressure we can take off of acute hospitals”. He explains that the new vision is somewhere in between the two, but where is the cutoff?

Is it a GP? A GP plus? Are we doing minor procedures? Diagnostics?

The GP+ concept

Gallagher argues that in many rural settings, the current model leads to escalation by default: “you better go to A&E,” because facilities lack capability. The GP+ concept aims to increase service capabilities where possible, as well as extend opening hours, in order to address this.

Where the “line is drawn” is where facility planning and design come into play. Trusts and estates need to be very clear about the exact limitations of a facility from the outset, in order to create a successful endeavour. “Is it a GP? A GP plus? Are we doing minor procedures? Diagnostics?” These are all good questions for planners to ask themselves. A clear service definition will inform good design, as well as patient and staff experience.

To inform where this “line” is placed, the planners should examine what the local needs are and what will realistically take pressure off of acute hospitals in that area. Gallagher thinks planners should “understand where the weakness in services are and respond to that”. He gives the example that if the closest acute hospital is a cancer care specialist, there is no need, and local care shouldn’t duplicate it. These issues especially come into play when planners fall into the “idealised model trap”. “Just because it worked somewhere, doesn’t mean it will work elsewhere,” Gallagher hammers home.

For example, a large elderly care day centre offering social activities, physiotherapy, and meals might thrive in a rural market town in Devon, where there’s a moderately concentrated older population and good road links to nearby villages. It can attract enough attendees to justify full-time staff and varied programmes. In contrast, in the Highlands of Scotland, where older residents are widely scattered, attendance may be low, making a smaller, flexible model, such as a mobile day services visiting individual villages, a more practical solution.

“Critical mass" is important for staffing reasons

Size matters, but location does too

One of the big decisions that needs to be made early on in a project is the size. Once you have decided on the services needed inside, this can be a great indicator. In many cases, Gallagher suggests these hubs may need to reach around 25,000–30,000 sqm to achieve viability. This way, you get all of the normal GP and support services, but also some real specialisms. 

This size also creates what Gallagher calls “critical mass”. This critical mass is important for