A few wrinkles in a great old gem

Theme Hospital was, for many years, among my favourite games. I played that game endlessly when I was younger – that is, I played the first level endlessly. It was easy, it was fun, and I mastered the challenge pretty early on. Having gone back to it now and played further – not the whole game, time being finite, but further – I’ve discovered that there was so much I never really experienced. Theme Hospital is also the first management game I’ve played in a long time with a level-based structure. Is this structure a relic of the past, well left behind, or a forgotten gem of design?

Teaching

Theme Hospital is an interesting case, differing in some ways from the games I’ve already covered. It does offer some amount of explicit teaching – at least, it offers it if you ask. When you start the game, you’re asked if it’s your first time playing. If it is, then you’ll be given a short tutorial when you start playing.

This tutorial covers the basics of the game’s mechanics – you are taught how to build specific rooms, how to place furniture in those rooms and how to hire staff. You’re also set on a good starting path: once you have finished the tutorial, you will have the necessary staff and facilities for the very beginnings of the game. It won’t last long, but it’s a good place to leave you.

The tutorial also – quite cleverly in my opinion – leaves you with a number of things not explicitly explained, but clear enough to be getting on with. A number of rooms are available to build that are never referenced in the tutorial, but are visible from the same menu as those used. It let’s the player know what they should probably try to do next. If you’ve read my analysis for Cities: Skylines and Game Dev Tycoon, you’ll know I’m a big fan of allowing players to explore on their own.

But the game also has a bit of a blunder in terms of teaching. While the core mechanics of building and staff management are shown well, there are a number of options that the player is given at the bottom of the screen – research, finance and staff management amongst others – and not only are these never taught, they are never even referenced. Which is unfortunate, since later on the game they become absolutely essential to use.

My biggest concern is not that the game doesn’t go into detail on all of them. My concern is actually twofold. Firstly, players should have their attention drawn to them, even if no significant explanation is given; secondly, it would be better if screens that weren’t available were greyed out. It’s odd to be able to visit the research screen – and even set research priorities – before research is introduced as a gameplay element.

Still, this error is far from fatal – a little trial and error and I had a handle on the interface, and was ready to start.

Starting complexity

Level 1, of course, has the lowest complexity. You are given only a handful of facilities – GP’s Office and General Diagnosis for diagnosing patients, Psychiatry and the Ward for treating patients, and Pharmacy for addressing specific ailments. Non-medical facilities like toilets are also available (and necessary – please don’t leave patients without toilets). You are also given access to items such as benches and vending machines which are not part of a particular facility, but improve the comfort levels of patients waiting.

That’s really the extent of the complexity in the first level, which is good to begin with. Enough complexity that it takes some effort to manage, but little enough that the player is very unlikely to feel overwhelmed. If you follow the tutorial, the GP’s Office, General Diagnosis and Pharmacy will already be in place by the time you finish the tutorial.

Your goal is also very straightforward: cure ten people and have at least $10 000 in your account. It’s pretty easy too. Money is the main thing you need to manage, but in the first level it really didn’t present much of a challenge for me, and curing ten people once you have the appropriate facilities is quick and straightforward. Once you’ve reached your goal, you are given the option to move on to the next stage, in the form of a letter requesting you to move to a larger hospital. You can decline, but since nothing carries over from one level to the next, there’s very little reason to decline other than to take a few extra moments to enjoy the hospital you’ve built thus far.

Increasing complexity

With each level, the basic goal increases – more people must be cured, and you must have more money. That in itself is a pretty straightforward way to handle increasing complexity. But as with almost any management game, there is more to the increasing complexity than just this.

Certain doctors will have special abilities – a specialisation in psychiatry, for example, or surgery. As the number of diagnosis rooms, clinics and facilities increase, the need for these specialised doctors also increases. In the first and second level, only psychiatry is required for your hospital to run well, but keeping an eye on what specialisations your doctors have, and what new doctors have before hiring, is crucial.

In the second level, you are given access to a new kind of clinic for a condition that was not seen before, and the staff room facility, where staff can rest when they are tired. You will also have more people coming to your hospital, so having seating for waiting patients and adequate toilets is important.

With the third level, the research facilities are introduced, as well as a Surgery Ward. These require doctors specialising in research and surgery. The Surgery Ward is particularly difficult, since it needs two doctors, both with the surgery specialisation. Research itself increases the complexity significantly, since it allows you to spend a doctor’s time to discover new diagnosis, treatments and clinics.

Complexity continues to increase in a variety of ways, but these are not actually the primary form of complexity increase. The complexity mostly increases entirely organically, through one of my favourite methods which I call complexity through scale. That is, the mechanics of the game are mostly static throughout the game, and it is simply time and scale – in this case, the number of patients – that reveal the inherent complexity of those mechanics.

A great example of this can be found in my previous discussion on Cities: Skylines. Traffic is a mechanic that is technically present from the moment you build your first road, but only emerges as something you need to think about as population density increases. Theme Hospital is full of examples of complexity through scale, with existing mechanics slowly being revealed.

For example, it is possible to place benches in your hospital to give patients places to sit while waiting for doctors. When you expect only a few dozen patients, two or three benches will be sufficient for all of them. But as more patients come, you will need more and more benches, each of which takes up space. And without these benches, patients will be forced to stand, and may eventually leave without being helped, which hurts your hospital’s reputation.

Equipment also wears down and eventually breaks with continuous use. This is something you only notice beginning in the third level, and which becomes an increasing problem in later levels. In this case, the scale is twofold: equipment is used on more patients, but there are also many more pieces of equipment available. Breakdowns become inevitable, and you need janitors to fix the equipment. But janitors who are fixing equipment aren’t cleaning floors, and when janitors aren’t cleaning floors they get filthy – fast. You will also almost certainly need more toilets, and have these toilets in more places around your hospital.

Having a single GP’s Office and General Diagnosis will no longer be sufficient with more patients, as is true of the more common treatment facilities. Of course, all of these facilities require more staff, and these staff cost money to hire and employ. Again, these are not new mechanics, but rather new expressions of existing mechanics revealed entirely through scale.

I think complexity through scale is a truly interesting way to approach increasing the complexity of a game, and allows designer to achieve a much sought after property: easy to learn, difficult to master. Because the mechanics themselves do not change significantly, players will very quickly know how to use these mechanics. However the players will constantly have to adapt the way they use these mechanics as the scale increases.

Pace of Progression

The pace of progression is fairly straightforward: each level has a goal, typically to cure a certain number of people, and to have a certain amount of money. In later levels, it is also not uncommon to have to maintain a certain reputation. As should be expected, each level has a progressively more difficult goal, and therefore takes progressively longer. Once the goal is reached, the player is given the opportunity to move on to the next level. You don’t need to move on immediately, but there is very little reason not to.

The levels themselves are laid out on a board game, with a game piece shown moving forward with each level. It’s a nice way to show exactly how far along you are without using numbers. Pictures on the game board also give you a cute image of raising stakes, from minor car crashes to helicopter crashes to natural disasters. How many people you will be seeing, the severity of their diseases, all of these are hinted at by the sequence between the levels.

Feedback

Feedback tends to be pretty straightforward in Theme Hospital: when you cure a patient, you hear cheers. (From the other patients? From an unseen audience? This mystery goes unsolved). If you end up killing a patient, there are boos. Occasionally, a dead patient will be claimed by the Grim Reaper, or will ascend to Heaven. All of this provides pleasantly silly feedback.

There is also a doctor hanging out at the bottom of the screen who will occasionally give extra advice and feedback. And by ‘occasionally’ I mean ‘way too often’. While the feedback is appreciated, a lot of it either tells you about things you can’t currently fix, or things you already know. I found this feedback more frustrating than anything else. I’m not entirely sure how I would tweak it, but it does need tweaking.

Positive Feedback Loop

The positive feedback loop in Theme Hospital is pretty straightforward – the more patients you heal, the better your reputation; the better your reputation, the more people come to your hospital; the more people come to your hospital, the more money you make; the more money you make, the more facilities you can build and staff you can hire to heal more patients. It’s a good loop, and very satisfying when you get into it.

The feedback loop for failure is much weaker, and very easy to recover from. If you get overwhelmed by scale, a number of patients may die, or leave from waiting too long. These things hurt your reputation, which makes it harder to get in more money, and without this money it’s very difficult to build the facilities you need to recover. Fortunately, you can take out fairly large loans at any time, with very few consequences. I ended up in this position a few times, but was always able to pay the loan back very quickly.

All in all, the positive feedback is pretty solid.

Negative Feedback Loop

There is one really solid piece of negative feedback, which is available once you get access to research. If you find out that a patient has a condition that you are either unable to diagnose, or unable to treat, they can be sent to the research centre. At the research centre, they will be… killed… and autopsied. It’s actually kind of grim. However, this gives you a huge amount of progress towards researching the condition the patient at, often immediately giving you what you need for the diagnosis or treatment.

However, people can find out about what you’re doing to these patients, and when they do your reputation will, understandably, suffer. It balances the two aspects of negative feedback well – a failure in the form of inability to treat a patient, leads to success in the form of improved research. At the same time, the success of improved research sometimes leads to the failure of reduced reputation. It’s genuinely quite clever.

Aesthetics

There’s something I haven’t really spoken about before, but it is an important part of design. The aesthetics of a game are often incredibly important, and encompass much more than simply the graphics (although this contributes). Aesthetics can often carry you through parts of a game that are less than ideal. An example of this is Game Dev Tycoon – while the game had some problems, especially in the second half, I ignored these and kept playing. Why? Because the theme of being a game developer appealed to me. This is such a central part of the aesthetics that I overlooked some mechanical faults.

Theme Hospital’s aesthetic can be summed up as charming. Everything in the game looks like toys, there are quirky sounds and voice lines, and all the animations are incredibly charming. The illnesses as well tend to be silly – expanded heads, swollen tongues, invisibility, King Syndrome where the patient believes they are Elvis. They all contribute to the charm.

However, there is also a weird underlying darkness, with people’s tongues being sliced off, patients being killed for research and dead people being dragged to hell. It adds a slight counterpoint to the otherwise sweet aesthetic. Together, these two contribute to a look and feel that elevates it above its mechanics.

Final Thoughts

Theme Hospital is old, there’s no point denying that, and there are places where it shows it wrinkles. The interface especially feels as old as it is. However, the mechanics still hold up today – the strong positive feedback loop, the clever negative feedback loop, charming aesthetics and the complexity through scale are all exceptionally well done. There are some blunders on the teaching front, and I think these lead to more confusion than any other aspect in the game.

I do feel like the level-based progression is very much a relic of its time, and that a modern remake of the game would leave them behind and embrace more organic growth as seen in many city builders. But these are small flaws in an otherwise very good game. Playing it again, I remember why I enjoyed it so much when I was younger, and I do feel like the game still has a lot to teach us today.