THERE are three things in life we need that cost you money. Your life, health and family. However you work it through, we pay for these things.

So we all want the best from them and for them. Everything else, when you break it down isn't a need, but a want. Bermuda is about to make a major long-term capital investment in the future of the island's health.

The proposed plans for those developments have attracted enough criticism that a period of reflection and feedback has been offered. The present hospital has to go: but what to put in its place is now up for serious questioning.

Other than to say that the proposed plan is an answer to the wrong question, I'm going to argue that all Bermudians take the chance available to stand back and take a real look at what's actually required here.

A hospital is not a set of buildings, or a piece of land. It's a place where medicine happens. It's a place where we care for our sick, our disabled and our infirm, where we give birth to our babies, support our children's development and care for our old people to help them live a dignified old age. The delivery of quality health service to everyone on the island is the bottom line here.

The present plan is offering an either/or choice, that in reality is neither here nor there.

Let me put it bluntly. There is no need to build a hospital. As such.

What's required is a new infrastructure to bring Bermudian health services into the 21st century. A hospital ? as the set of buildings, is only that ? an infrastructure, that allows everything that needs to happen, happen.

At a time when most of the West's better health services are moving away from large, monolithic institutions to decentralised services, maybe the whole thing needs to be looked at afresh.

A health service has to do two things: maintain and develop the health of the general population, and provide effective intervention during times of individual and general health crisis. There's a real opportunity here to create something new, Bermuda-focused, cost-effective and health-effective.

The only reason we used to build these kinds of places is that we needed to have all the different expertises together in one place, and because big institutions offered economies of scale.

That's not true any more. We need a new model here. Nowadays, big institutions have high overheads, are energy intensive, cost a lot to run, and more than anything else, just aren't very "intelligent" for the consumers of the services they provide.

No matter the calibre of the individuals, large institutions are slow to respond to real need, and are divorced from their communities by the bureaucracy they require. They are very expensive things, and like the situation here, their scale forces difficult either/or choices on us.

So . . . what's the alternative ?

Here's one. I'm not going to go into the details of how, where and when this happens, but just at this stage outline how it might look in overview. The island creates a number of walk-in care/emergency community health centres, one or two per parish, but roughly one per 5,000 ? 10,000 population, say.

These are staffed by a multi-disciplinary team of doctors, paramedics, nursing, physio, psychological, family and social services offering full individual and family care services. They would offer a full range of services up to and including minor ops/casualty, short stay care on one side, long-term care and family/social support services on an other, and community health services and education on an other.

Each of these would be the first port-of-call for any health service user. Some of what I'm talking about already exists, at least in embryonic form ? the clinics at either end of the island being a case in point.

I'm not going to make any premature statement as to the financing of any of this, except to say that there are some very good examples round the world about how to create very cost-effective health economies.

These would feed into maybe four-six major intensive / specialised care units spread throughout the island. What each of these would be in practice is open to debate as this point. Obvious examples would be a maternity / women's heath place, perhaps a conjoint geriatric / paediatric unit (many of the health management problems are similar, and where this has been tried both groups have benefited hugely from it), but really I think this is up to the health professionals and the general Bermudian population to get to grips with (there may be a case for creating a core service unit on the old hospital site, for instance).

While each of these would have a core specialisation, each would be capable of handling any critical health situation in modern, sophisticated team based medical terms.

Looking at things this way your capital costs both drop remarkably ? and the running costs can do the same. There are brownfield / vacant sites all over the island which are economically viable, and spaces of sufficient size, and proximity to major population centres, to make this decentralised approach a cost-effective option.

Rather than destroying the heart of the Botanical Gardens, I would turn the thing on its head and make each of these sites a completely "green" area. Even if a core group of services were kept at the original hospital site, this kind of plan would release a LOT of land for the kind of social and affordable housing the island so desperately needs. It's all about choice.

But my central point is that taking this approach would free up a lot of very central land that could be put to great purpose for everyone on the island. It would also mean there would never be any "transitions" issues about moving from the old hospital to the new system.

There are two major costs in health services. Human beings and energy. To put that in perspective, you're looking at about 50 per cent staff costs and about 30 per cent on energy.

I can't decide whether it's a shame or interesting that the development of the hospital and the Sustainable Development debate should happen to come to prominence about the same time. A lot of profitable thought could go into using the whole hospital redevelopment as a model for Sustainable Development throughout the island.

Low/zero-carbon renewable energy technologies are cost effective in terms of capital outlay versus energy return over time. Once the investment is paid for, the energy is basically free. Listen to what that means. The second highest cost in your health system is reduced to zero within ten years maximum. The only thing that is holding people back individually is the present high capital cost of installation.

That really should not be an issue here. An integral part of the overall design of the new health service provision should be a zero-carbon, fully sustainable, fully integrated energy production and delivery system.

Using integrated micro-generation technology as the basis for the energy system in the kind of distributed health service I've discussed will deliver the energy requirements of that service at a vastly lower rate than the island is now paying. In terms of global warming, I know Bermuda's place in the scheme of things is low, but at absolute levels, the island has one of the highest carbon footprints of any population in the world. It would be nice to be at the forefront of saying - this is how you change that, and offer better services to your people at the same time.

The other thing the island needs to do is get its act together in free/low-cost high-speed internet, which would allow the kind of system I've outlined to work together fully in real time, thereby meeting all possible criticisms about increased management overheads, comms costs and so on.

This kind of system would not only allow Bermuda to know in real time exactly how the service was operating, but, for instance, allow hi-speed video conferencing of medical expertise, and generally open up the island's health services to all kinds of high tech stuff that just isn't available on the island.

Exactly what that network should be and what it might look like is another story for another time. None of this stuff is cutting edge in itself. It's all about how you put things together in new ways. In doing so, you free up a lot of land, capital, and energy dependency, and you get a sophisticated, community-based, lowered cost, but most of all sustainable health system in return.

There's a model for decentralised systems which is just begging to be used in Bermuda. Moving on from internet / communications, I'd argue that this decentralised network model lies at the heart of the whole future of Bermuda's successful development, and should be at the heart of the SD plan.

Whether you're talking about economics, politics, communications, agriculture, health care, energy systems, the island needs to move away from old monolithic, top-down systems to open distributed networks.

Bermuda has some time to get this right. There is no need to be railroaded into a solution for a problem whose time has passed. Once the Government releases the figures relating to the hospital redevelopment, all interested stakeholders could contribute to a process whereby Bermuda gets the health services it deserves, and meet its needs well into this century.