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The prime minister's wife builds a new hospital

Rinckside 2019; 30,6: 17-20.

he he history of hospital planning and construction is an interesting subject of study. It reflects not only changes in medicine, new insights and discoveries, but also social, political and financial trends.

Until the 19th century, the traditional hospital was commonly little more than a place of custody of the severely sick, basically care homes, first and foremost for members of the military, built in the style of barrack-blocks — most often three-floor red brickwork buildings with hundreds, even thousands of beds.

The view that only the supply of fresh air could eliminate “hospital fever” led to a pavilion building style that originated in France and England.

Since the beginning of the 20th century, the introduction of operating rooms with a sterile environment, chemical laboratories, and special departments for x-ray diagnostics required a new functional building style with one single building complex, the general hospital style, collecting everything under one roof.

Among the first general hospitals created in this manner in Europe was Södersjukhuset in Stockholm. It opened in 1944 and was then one of the world's most modern hospitals. It was designed by two of the leading hospital architects, Hjalmar Cederström and Hermann Imhäuser. They placed their emphasis on three perspectives: bodily, spiritual and economic. The design of the patient rooms was spacious and bright.

Roger Ulrich, Professor of Architecture at Chalmers University of Technology in Sweden and at Texas A&M University, was one of the first to research how hospital buildings can affect patients. In 1984, he noted that patients looking out of their room into nature recovered faster and required less painkillers: “Reducing stress, and distracting patients from their internal focus or their obsession on their own pain, reduces the pain [1].”

In other words, good hospital design can make people get better more quickly. Doctors and paramedical personnel are also thankful for good hospital design and administration.

When Florence Nightingale viewed with skepticism the dreadful hospitals of her times, she did not recommend shutting them down; she suggested that they were improved.

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Good hospital design can make people get better more quickly.

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    Stockholm’s best known hospital abroad is the Karolinska, the teaching hospital of Karolinska Institute. The Nobel Assembly at the Karolinska Institute awards the Nobel Prize in Physiology or Medicine. Some 20 years ago some administrators and politicians decided that Karolinska Institute should get a new world-renowned centerpiece hospital. Hardly anybody else thought it was needed; it would have been more practical and far cheaper to update the existing hospital. Clearly, there was no solid determination of need.

The county council of Stockholm proposed a public-private partnership to finance, construct and run the new hospital — an approach that was developed for the profit-oriented health care in the United States, had not been tried in Sweden earlier but already failed in Great Britain [2]. The vision was of a specialized hospital with deeper ties between clinical care and research.

The minister of finance Anders Borg had the responsible county official Filippa Reinfeldt contacted to drop this idea. She said that this was a matter of political principle and refused. Borg then talked to her husband, prime minister ‎Fredrik Reinfeldt, to have him change the deal. Unfortunately, that happened to be the end of his intervention; the Reinfeldt couple had just decided to get a divorce.

Although Stockholm was offered an interest-free loan from the Bank of Sweden, the project was awarded to a consortium consisting of a big Swedish construction company and a British investment firm. There was no competition. The consortium needed to get the loans on the private market place. The entire deal was shrouded in secrecy. The agreement itself was designated as ‘confidential’ both before and after it was signed.

In an independent review of the entirety of the project the University of Stockholm clearly denounced this procedure:

"… Several related matters were covered by secrecy … not only [were] certain actors excluded … but [this] also affected the possibilities for accountability … [3].”

The side effects of such mega-projects were well described in an article published in 2017 about mega-projects in Valencia, Spain:

"The mechanisms used to implement mega-projects — including both exceptionality measures and privatisation of management through the creation of semi-public delivery bodies — result in a lack of transparency and democratic control, which in turn lead to more authoritative and privatised forms of decision-making … Mega-projects — through their focus on expertise and technocracy and a populist politics and discourse constructed around them — play a crucial role in the erosion of democracy … [4].”

    Built in the ungainly “modern” style of an insurance administration building of the 1960s and 1970s to the outside and not taking into account the necessary functionality of a general hospital in the inside, one has the feeling that the planners and architects in charge were on the apprentice level. Their lack of expertise is evident. They perfectly fulfilled the general prejudice of incompetent architects: first, the buildings are eyesores; second, they are built without consultation of people in the know; third and worst, they don’t accomplish the functions required.

Before the start of the construction, during the building period and after the project was finished neither the county council nor the companies involved chose to follow essential and professional recommendations. There was also no competitive pro­cure­ment.

One revealing example is radiology. In dozens of committee meetings the radiologists suggested and worked out, for instance, a united radiology department with cooperation and localization close to pathology. Then the consultants came and divided radiology into five to seven separate units depending on what is included. These units are practicing in about 15 different locations. No co-localization or cooperation with pathology existed, apparently the consultants nearly forgot to plan a department of pathology.

The old hospital had a lot of expensive and fairly new equipment. Little was reused and moved to the new hospital. It is said that the old equipment colors did not match the new examination rooms. New equipment for all of radiology was tendered for and only one company offer could be accepted. Philips won and was guaranteed to deliver 40% of all equipment. The rest Philips had to buy from Siemens, GE, Toshiba and others. This procurement system is, politely put, unconventional.

When faced with the new structure, the professor of radiology decided to step down. No new professor of radiology has been appointed. A large number of experienced and highly specialized radiologists left and are expected to be compensated for by more residents.

    The building project culminated in disaster. The planners, architects and builders of this apocalyptic hospital failed the people for whom this hospital was built: patients and those who take care of them. It was a completely mismanaged and, for the taxpayer, an extremely costly political and financial experiment. The final expenses more than quadrupled to approximately 6 billion euros.

Not only in the diagnostic imaging units, but all over the building, there were no blinds on the windows. Thus, in some instances, the glass fronts had to be covered with paper by the employees.

In 2014, Fillipa Reinfeldt, now ex-wife of the now ex-prime minister was clearly fond of the idea that passers-by could look straight into the hospital: “People on the sidewalks will see the staff run with severely ill in the glass corridors above them. It's pretty cool [5].” Gaping is not a socially appropriate behavior. Such a statement reveals a total lack of due diligence, dutifulness and sense of responsibility. Reinfeldt didn’t belong on the position she had.

    With the opening of the new hospital a new health care management model was to be implemented: value-based care. The Boston Consulting Group was in charge of this mega-project. The company promised that it would revolutionize the entire health care system and make Karolinska a global pioneer. The objective of value-based health care is to align physician and hospital profit and loss with cost, quality, and outcome measures — based on outcome studies [6]. Performance of examinations and treatment should be standardized. However, quantification of medicine is nearly impossible because medicine is not an exact science. In which unit do you measure “I am feeling well”?

This idea is based on a simplistic view of medicine and health. All people are the same, they suffer from one single disease when they need medical assistance. They will be diagnosed and treated in the same way. Multi-diseased, difficult-to-treat patients who do not give quick results will then not be high priority. They do not fit into the required setting of treatment pathways, into the assembly line of the medical factory.

After the misfit building this was the second disaster of the New Karolinska, another dysfunctional social utopia. The ideas of the Boston Consulting Group were doomed to fail. Any completely new, untried and untested approach should be implemented by people with knowledge and experience and grow organically over years.

The consequence of the introduction of the new system has been described in a more than 400-page book about the scandal. According to the authors Anna Gustafsson and Lisa Röstlund [7] the new system operates at very low speed; proven routines are gone. Medical employees are leaving the already understaffed hospital. Members of the staff often do not have time to eat or go to the toilet. Qualified doctors and nurses say they are unable to do more, but the number of managers grew by 30 percent and the health care staff is increasingly devoting time to filling out forms. There is an atmosphere of suppressed fear and anger, but people don’t speak up; they fear reprisals and to be bullied.

The two authors also reproach politicians and management that they do not abide by the law and responsibility necessary in health care. When moving into New Karolinska, 350 children had been waiting for surgery for more than 90 days. Almost a year later, 800 children were queuing up. Pancreatic cancer patients will be operated in Germany and Denmark within 14 days, in Sweden, the limit is raised to 36 days — a limit that Stockholm County could only manage in every third case in 2017. Several people with cancer died because Karolinska did not have time for them — and the hospital refuses to take help from elsewhere.

One central theme of “the hospital of the future” was that the routines were to be so effective that waiting rooms for patients and their families were not needed. However, as the patient flow tends to vary substantially, service capacity needs to be able to take care of the peaks, which leaves a lot of "air" in the system at other times. This high capacity was not acceptable; thus, the reality is that there are patients waiting but there are no waiting rooms. As the three main elevator shafts with 30 elevators have huge marble halls around them, these halls are gradually being transformed into primitive waiting areas.

The consulting company BCG also decided that no one of the hospital’s medical staff needed a permanent office. Whoever needs an office for a couple of hours has to sign up in advance; the computer in the room will allow to access one’s personal “cloud” account. Everything, including patient reports, was to be run through this cloud which did not function and had to be replaced.

More so, one’s clothes are still to be left in the old hospital, since no wardrobes are available. Thus, every day begins and ends with a 15-minutes walk between the old and the new hospital. There is some unprotected shelf-space for “old-fashioned” books, but most doctors use that space for outdoor clothes. As one employee put it sarcastically: “This is of course ideal for the research work at this world-renowned university hospital.”

The new hospital buildings are failures of urban planning, without harmony, not inspired by local tradition, not places of meaning, and disconnected from human nature and concerns. They are also expensive to fix, and there is a lot to fix if you don’t want to tear them down.

Other complains include “horrible” and “evil” colors all over the hospital such as strong orange, brown, even black walls, the color of mourning. The entire building has a sterile atmosphere without any soul. The obligatory pieces of art show frightening motives. They are not appropriate for a hospital.

    New Karolinska is one of or even the most expensive hospital ever built in the world. It suffered from three consecutive disasters: The catastrophic building, the hoax of value-based medicine, and, finally, these failures unfortunately rubbing off on the reputation of the Karolinska Institute.

However, this project is an outstanding example to learn from.

   P.S. The whole story reminds one of another project of utmost prestige, that of the flagship of the Swedish navy, the Vasa. During its maiden voyage on 10 August 1628 the ship sank after sailing about a mile.

The ship was built on the orders of the King of Sweden Gustav II Adolph at the navy yard in Stockholm under a contract with private entrepreneurs. Upon completion it was one of the most powerfully armed vessels in the world. However, Vasa was dangerously unstable and top-heavy with too much weight in the upper structure of the hull. Despite this lack of stability it was launched and capsized immediately.

An inquiry by the Swedish Privy Council to find those responsible for the disaster came to nothing, in the end no one was punished.

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References

1. Ulrich RS. View through a window may influence recovery from surgery. Science 1984; 224: 420-421. DOI: 10.1126/science.6143402
2 Rinck PA. US-healthcare – the price of it all. Rinckside 2013; 24,8: 15-16.
3. Stockholms Universitet. Sundström G. LS 2016-1186 Framtidens universitetssjukhus. Beslut om Nya Karolinska Solna. Delrapport 2. 2019-03-15. 9.
4. Tarazona Vento A. Mega-project meltdown: Post-politics, neoliberal urban regeneration and Valencia’s fiscal crisis. Urban Studies. 2017; 54: 68-84.
5. "Folk på trottoarerna kommer att se personalen springa med svårt sjuka i glaskorridorerna ovanför dem. Det är ganska häftigt." Filippa Reinfeldt: Varför ska man gnälla? (Why should you whine?) Dagens Nyheter, Stockholm. 12 April 2014.
6. Rinck PA. New, improved radiology demands better analysis. Rinckside 2002; 13,3: 9-11.
7. Gustafsson A, Röstlund L. Konsulterna. Kampen om Karolinska – Consultants. The fight for Karolinska (in Swedish). Stockholm: Mondial Publishers, 2019. ISBN 978-91-88671-91-2.

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Citation: Rinck PA. The prime minister's wife builds a new hospital. Rinckside 2019; 30,6: 17-20.

A digest version of this column was published as:
What's gone wrong at the Karolinska?
Aunt Minnie Europe. Maverinck. 7 August 2019.

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