Over the past 20 years enormous changes in policy and procedures have affected the NHS estate. Since the establishment of NHS trusts in 1991 and the 'Care in the Community' initiative, many hospital services have either merged, closed or relocated. This has led to the sale of many of the older hospital sites, including up to 150 large psychiatric hospitals with their historic buildings and landscapes. Many of these have now been converted successfully to residential uses.

The NHS estate includes many specialised types of hospital, for example those designed specifically for the treatment of infectious diseases (such as tuberculosis) or mental illness, as well as former workhouses and country houses adapted for hospital use. Research carried out by the former Royal Commission on Historical Monuments in England (RCHME) has resulted in two publications on the architectural history of hospitals and workhouses².

In recent years increasing attention has been given to hospital landscapes, most of which were conceived as a therapeutic environment for the treatment of mental illness. Seven of these have been registered through inclusion on the English Heritage Register of Parks and Gardens of Special Historic Interest in England. (See "Landscapes for the mind and body", p11.) A study of the European hospital heritage is being undertaken in the framework of the Culture 2000 programme. This project brings together the United Kingdom and six other countries³.

The process of hospital closures and disposals is inherently complex and prone to controversy. Too often, over the past two decades, closures have been characterised by delays, uncertainties and a lack of consensus between the various parties involved, particularly between local planning authorities and the NHS. Time and resources have been wasted by leaving buildings empty, unmaintained and prey to vandalism, while the planning situation has remained unresolved. Many sound historic buildings have been needlessly demolished and the setting of those that remain has frequently been damaged by unsympathetic development in their grounds⁴. In the worst cases historic buildings have been abandoned and their settings irreversibly compromised by insensitive modern development, for example at St John's Bracebridge Heath, a Grade II former psychiatric hospital on the outskirts of Lincoln.

The priority for NHS Estates, NHS trusts and their planning advisers is to optimise the development value of surplus hospital sites; however, in doing so they are expected to take note of government guidance', which states that, in the sale of public assets with heritage value, maximisation of receipts should not be the overriding objective. Non-financial and wider regeneration benefits including environmental, cultural and long-term economic impacts also need to be taken into account. However, in many cases the inherent quality and attractiveness of listed buildings enhances their disposal value.

The challenge is to reconcile all these competing agendas, optimising the potential of the site while protecting its environmental and heritage value, yet without excessive delays in the planning process or resorting to public inquiry. The 70-day public inquiry in 1998 relating to development proposals at the former Claybury Hospital at Chigwell in Essex was found by all parties concerned to be a wasteful and frustrating process. This experience has demonstrated the importance of seeking to work in a partnership which involves the NHS, the local planning authority, English Heritage and, in some cases, the NHS's preferred developer, where the latter has been selected in advance of planning permission being granted.

The current emphasis in planning policy on socalled 'brownfield sites' is giving a helpful impetus to the reuse of hospital sites. However, this does not give carte blanche for developers to build all over sites where these include open land. Planning policy guidance note (PPG 3) on housing, issued last year, clarifies this issue. It includes the proviso that "where the footprint of a building only occupies a proportion of a site of which the remainder is open land (such as at an airfield or a hospital) the whole site should not normally be developed to the boundary of the curtilage. The local planning authority should make a judgement about site layout in this context, bearing in mind other planning considerations, such as policies for the protection of open space and playing fields or development in the countryside, how the site relates to the surrounding area, and requirements for on-site open space, buffer strips, landscaped areas etc."A growing number of developers have experience of the risks and opportunities in converting historic hospitals, and an increasing number of exemplar schemes demonstrate how hospital sites can be creatively adapted for new uses in a commercially successful way.

Despite the delays in the planning process at Claybury Hospital, this site, now known as 'Repton Park', has been successfully developed by Crest Homes. The main elements of the original 'echelon' plan have been converted to residential use, and new housing development is being introduced in some areas of the surrounding landscape. Schemes such as this demonstrate that former psychiatric hospitals that once carried a stigma in the local community can be transformed into highly sought-after locations.

Other successful examples of conversions to residential use include the St Nickolas's Hospital in Great Yarmouth (built as the Royal Naval Hospital between 1809 and 1811) and the Royal Herbert at Woolwich, which is of particular importance as the prototype pavilion plan hospital. The Dreadnought Seaman's hospital at Greenwich (dating from the 1770s) has found new use as part of the University of Greenwich. And in a highly imaginative and unconventional design, the Judge Institute of Management Studies at Cambridge has been created by adapting part of the old Addenbrooks Hospital.

In some cases, old hospitals have been adapted and refurbished for continuing use in the health service, for example University College Hospital in Gower Street, London. The old Royal Infirmary in Liverpool, also designed by Alfred Waterhouse, has been adapted to provide accommodation for a number of health and medicine -related uses, following a period of 15 years when it lay empty.

Guidance for NHS Trusts on the handling of disposals is contained in Historic Buildings and the Health Service⁷ and in the Estatecode produced by NHS Estates⁸. Although NHS Trusts are not government bodies as such, they are required by the Estatecode to follow the guidance on the disposal of historic buildings published by the Department for Culture, Media and Sport⁵. The following are key points of good practice to aid the process of disposal:

• The use of planning briefs that are shaped by extensive public consultation.
• Public consultation and participation in the planning process, for example through open days and community planning exercises.
• The use of conservation plans which examine the significance of sites in terms of their history, architecture, archaeology, designed landscape and natural environment.
• Planning disposals to ensure that a future for the site has been secured before the buildings are vacated.
• An holistic approach to sites, particularly in those cases where hospitals stand in a designed landscape. In the past the sale of such sites in a piecemeal manner has proven highly damaging to the setting of historic buildings.
• The use of planning agreements to ensure that heritage assets are secured and repaired to an agreed standard before completion of any enabling development⁶.
• Adopting innovative methods of sale, particularly joint ventures between the NHS and a selected private partner which allow development value to be shared by both parties.

The handling of disposals is the subject of a current National Audit Office study on managing surplus property in the NHS. This has examined the strategic framework within which disposal activity takes place and the mechanics of the disposal process.

In a move towards a greater emphasis on partnership and dialogue, English Heritage and NHS Estates maintain regular liaison through the Historic Hospitals Working Group. This was responsible for drafting the 1995 guidance note Historic Buildings and the Health Service⁷, a practical guide for all levels of NHS management as well as local authorities, developers, architects and other professionals.

One of the purposes of the group is to promote guidance and training for the staff of both organisations. This resulted in the conference at Lincoln in May 2000 'Health vs Heritage', organised jointly by English Heritage and NHS Estates.

For the future it is essential that there is a continuing dialogue between all parties involved in the disposal and reuse of surplus hospitals. Local planning authorities have a key role in ensuring a successful transition for historic hospital sites to new uses, by setting a clear planning framework and ensuring that development is carried out without damage to the historic environment.