Over one and a half years and 1,200 pages later, the much touted Hospital Estate Master Plan Comprehensive Review has been completed and made public for the community to consider.

At its core the Review concludes the existing King Edward VII Memorial Hospital and the Mid Atlantic Wellness Institute are at the end of their natural lives and will need to be totally replaced by no later than the end of 2012.

Eighty five percent of the medical equipment at KEMH will have to be replaced in only six years, the Review says, while at the MAWI the figure is closer to 95 percent.

The proposals contained in the Review are wide-ranging and undeniably radical ? urging significant alterations and improvements both to the physical infrastructure of healthcare provision in Bermuda as well as the mentality which surrounds it.

A comprehensive business plan will be drawn up in the near future and until that time, no indication has been given as to how much the scheme is going to cost or where the funding will come from.

"What we are looking for here is the total integration of healthcare provision into the community ? getting to a system which offers the best care to the entire population in the most efficient manner possible," said leading design and architectural consultant Ron McIntyre who headed the project team.

"At present there is far too much strain placed on one central hospital and our vision for the future of healthcare in Bermuda centres on the creation of a decentralised health delivery model."

To achieve this, the Review recommends the construction of:

A new, 150-bed main hospital in the central parishes, designed to accommodate modern medical technology at all levels

Three large clinics ("Campuses of Care") located in the eastern, central and western areas of the Island.

These COC's will operate in conjunction with local GPs to ensure nobody in need of medical attention is left unattended at any time, day or night, and that the much-publicised pressure on the main hospital's Emergency Department is somewhat alleviated.

They will also boast facilities for the mentally challenged and additional continuing care wards where those recovering from disease or operations will be sent, to take further stress away from the main "acute care" hospital.

The exact location of the eastern and western COC's has yet to be determined, although it is understood the central facility will be built on the current MAWI site which is owned by the Bermuda Hospitals Board (BHB) and possesses considerable land for expansion.

But undoubtedly the hottest and most divisive topic to be debated in the near future will be the potential location of the new hospital.

From the outset the Review concludes that merely renovating the inside of the current hospital's shell is not an option given the very specific spatial requirements of a 21st century hospital.

As Mr. McIntyre questioned: "Do you really want to build your new state-of-the-art hospital in a building which will be around 60 years old?

"The Review of the existing facilities determined that the renovation of the existing buildings was not feasible to meet the long-term needs of healthcare in Bermuda."

From that premise therefore, and under direction from the BHB to look at all conceivable options, the project team ultimately settled on six possible sites: Pembroke Marsh, Government House, the Arboretum, the Botanical Gardens, the MAWI and the current KEMH land.

Pembroke Marsh was soon discarded given widely-held concerns over building a large hospital on land-fill, as well as the area's poor access routes, particularly from the West End.

Government House was struck off the list almost immediately because of its poor accessibility and the obvious political ramifications.

With four sites left and taking the Foot of the Lane moorings near Trimingham Hill roundabout as a rough centre point on a map of the Island, the project team drew a circle with a 1,000 metre radius from that spot to see which of the remaining viable locations fell within the critical central area ? leaving only the Arboretum, the Botanical Gardens and the current KEMH site as the possible options.

Any site outside of that 1,000 metre range is a non-starter in terms of adequate access, they concluded.

The team anticipated the deluge of environmental objections to building a hospital on green open space and pointed out that the decision over where to build would ultimately rest with Government. All along, they argue, their job has been to present the available options to the public for their perusal ? while they were at pains to stress that they have left no potential site unconsidered in exercising their expert judgment.

"It is up to the people of Bermuda to decide what their priorities are," said Mr. McIntyre. "We have come up with the only three viable sites and I would like to stress that we do not have a definitive opinion on any of them. Sometimes when we have done this in the past there is one site that stands out above the rest and the decision is straightforward. This is not the case in Bermuda and all three sites have a number of strengths and weaknesses which the community has to consider. What cost is the community prepared to bear? If the preservation of open space is deemed more important than healthcare, then the current KEMH site is the option. But as I've made clear in my presentations, there would be many logistical difficulties with building a brand new hospital around 30 feet from the old one. The cost will also be higher and it would not be finished until several years after the critical deadline. Can you afford to wait? That is a question the community will have to wrestle with."

While the current KEMH does boast good access routes, there would be major disruption to the operating hospital during the construction phase, including noise, dust and underground vibrations which would prevent the use of certain medical equipment at various times of day. The current parking problem at KEMH would become worse while part of the Botanical Gardens and the adjacent riding arena would have to be acquired in order to accommodate the massive influx of construction equipment, materials and labourers.

The cost of building a new hospital at the KEMH site would be considerably higher than at the other two sites and the structure would not be completed until around 2017 or later.

The Review does acknowledge that many physicians and healthcare agencies have located themselves in and around the area of Point Finger Road in order to be close to the hospital and that relocating the facility elsewhere would represent an inconvenience. Under the Review's second site proposal, 35 percent of the Botanical Gardens could be built upon, requiring the destruction and relocation of the gardens themselves and the 20 or so buildings which make up the various Government Departments, Show Halls and the riding arena ? all of which will add to the cost.

Although the construction site would be close to the existing hospital, there would be little in the way of disruption to its operation while the redundant hospital could later be bulldozed and converted into a public park. The hospital should also be completed within the eight year timeframe laid down in the Review.

Meanwhile, under current site plans, a new hospital at the Arboretum would be built into the hill at the back of the property, leaving approximately 70 percent of the land unaffected. The BHB would then hand over the equivalent amount of land at the KEMH site lost at the Arboretum to Government, for possible conversion into a park so there is no net loss of open space.

However, the decision over what to do with the newly acquired land will sit entirely with Government, and there is no guarantee as yet that the land will not be put to some other use.

While the project team does not deny there will be some disruption to the Arboretum as a whole while the four-year construction phase is ongoing, there can be no doubt it represents the most convenient site on which to build and deliver a first-class new hospital at the lowest available cost ? possibly by as early as 2010. On the other side of the equation, one of Bermuda's most cherished wildernesses would be permanently compromised if the plans are given the go-ahead.

Residents of the area might also object to having yet another major facility in an area which also includes the National Sports Centre, Prospect Police Headquarters and CedarBridge Academy. But if instructed to build at either the Arboretum or the Botanical Gardens, Mr. McIntyre revealed, incorporating a hospital into the natural environment with plenty of green space would be a top priority for them ? buttressing his point by highlighting the conclusions of a recent study published in the United Kingdom Medical Journal.

"In that report, the findings were that the greatest impacts on medical outcomes in terms of patient recovery in the future will come not from medicine or technology but from the physical environment," he said.

"It has been shown that if a patient feels comfortable and at ease in a tranquil setting, he is much more likely to fully recover in a much quicker time. If we were told to build the hospital in either the Botanical Gardens or the Arboretum, incorporating the natural environment into the structure would be a fundamental part of the plans."

Other conclusions and recommendations ? among many others ? contained in the lengthy Review include:

An increase in the number of educational scholarships and publicity campaigns to encourage more Bermudians to work in the healthcare industry

The drastic improvement of staff housing to attract better foreign workers to the Island. In the face of stiff competition from other jurisdictions and a global shortage in healthcare professionals, Bermuda needs to do all it can to remain competitive. The best will not be attracted by the mediocre housing facilities which currently exist

The promotion of a change in mindset from one of "reactive" treatment to proactive health (Wellness). Successful campaigns to promote healthier lifestyles ultimately mean a healthier populace and reduced medical costs

The use of more sophisticated digital technology to overcome the Island's isolation. Major advances in medical technology in recent years make it possible for specialists in other countries to make diagnoses via the Internet and other means

Ensure all newly-built facilities are easily accessible and possess adequate parking