A&DS Design Champion Gareth Hoskins’ contribution to a Holyrood Magazine special on the NHS at 60.
Florence Nightingale knew, and we intuitively understand, that people feel, respond and act better in environments that are humane and optimistic. So why is it that many of our hospitals and healthcare buildings are such awful places?
Of course there are numerous issues we can point to, such as inherited estates, the vagaries of capital funding, not to mention advancements in treatment and changing healthcare models, which have contributed to the piecemeal development of the healthcare estate. But there is now a dawning realisation that the NHS cannot continue to function effectively in campuses developed in this manner.
The way we design buildings to house our public services is a reflection of the service we expect to provide, and this is particularly true in healthcare. From the imposing and magnificent buildings of the Victorian era that said ‘matron, or indeed patron, knew best’ and that patients were fortunate subjects of a philanthropic act, through the hospitals of the 1960s – machines for healing organised strictly around doctors’ requirements, where the patient was an object to be processed efficiently through the system – the attitude of the service to the patient has pervaded the built form. A medically centred design ethos has persisted into modern times; for example the project manager who showed the Cross Party Group on Architecture and the Built Environment around a new hospital proudly announced that the organising principle of the building was that Consultants should walk the shortest distance possible to save wasting their valuable time. Some would still question what is wrong with this.
However, the publication of the Scottish Government Health Directorate’s (SGHD) “Better Health Better Care” (BHBC) Action Plan firmly sets aside such paternalistic approaches in favour of the concept of ‘mutuality’. BHBC defines mutuality as an organisation that is designed to serve its own members, to gather people around a common sense of purpose. A ‘mutual’ NHS would see the public as partners and owners, therefore directing, rather than passively receiving, the service. This fundamentally challenges the attitudes described above and requires us to consider whether our current estate supports or obstructs the delivery of this new model. If the fundamental pretext is that the patient’s personal experience is core, then few, if any, of our hospitals meet this standard. Whilst a desire for ‘patient focused’ environments is not new, the high level influence of BHBC may provide the impetus to embed and fully realise this ambition.
Architecture and Design Scotland (A&DS) has been working with the SGHD and NHSScotland for almost two years in a formal programme of work engaging with both policy development and the delivery of new hospital and community care buildings. Through this work we’ve started to see recognition, supported by research, that the design of the built environment influences more than simply the efficiency of the staff. General place-making features such as views, privacy and the opportunity to decide aspects of your environment (to be in a private or more social space, to control light, heat and noise) have been linked to reduced treatment times (of 14% to 21%), lowered patient stress levels, lowered perceived pain levels and reduced need for analgesia. Access to pleasant courtyards and garden spaces was found to be significant both for staff and patients as a positive escape, providing respite and social support.
Within the SGHD the drive for better designed buildings and external spaces has resulted in a Policy on Design Quality for NHSScotland and the backing of Dr Kevin Woods (Director General Health | Chief Executive NHS Scotland) for our publication ‘Masterplanning Health’. This guide encourages health boards to strategically plan the long-term, sustainable development of their campuses to provide places that are flexible, adaptable, welcoming, easy to get to and move around and have external spaces of identity and utility – thus providing long term value. However, there is still significant work to be done before we can say that the NHS is fully addressing the challenges set in BHBC.
Despite both research and policy advocating the benefits of good design, we still see many projects developed where the brief is a series of treatment rooms and key adjacencies, with no requirements for the qualities of space that the patients and staff will occupy. Budgets are then set on the basis of these rooms and a circulation allowance that is sufficient only for a maze of internalised, soulless corridors – artificially lit and ventilated irrespective of the sustainability agenda and rising fuel costs. Rarely is there briefing for the nature of the places and routes around the building that determine our initial impression, or the gardens and playspaces that are high priorities for patients and their carers. Often there is minimal involvement of patients, carers and the wider public in the briefing and design process for fear of raising expectations above what can be delivered.
Buildings developed solely on this short-termist basis perpetuate the piecemeal development that stifles the delivery of a well planned service. Whilst being poor environments for users, they also miss the opportunity to deliver a wider benefit and, as such, comprehensively fail to deliver value. The development of a hospital or health centre, like a school or any other public building, is a major event in the life of a community and can be used to impact more than the size and arrangement of treatment rooms. Such investment has the potential to demonstrate the value placed on local communities; assist regeneration; and build environments that encourage healthier lifestyles by, for instance, prioritising pedestrian access over cars and providing green places in which to rest or play.
However, things are not all black; there are client bodies trying to move this agenda forward and some improvements and successes are being delivered. But even these enlightened and motivated clients can do better, if assisted and supported in their aims. There are a few simple steps which must be made if the NHS is going to deliver on BHBC.
Establish a culture where the built estate is viewed as integral to service delivery. Estate departments are often viewed as entirely secondary to the service: at best providing the tools clinicians request, at worst struggling to keep pace with maintenance and safety. Sadly the action plan for BHBC reinforces this view as the only direct mention of the built estate is in carbon management. A properly resourced and supported estates strategy is needed to provide the environment that supports human interaction and wellbeing.
Understand how a high quality environment can improve the service and develop the ethos and skills needed to deliver it. Most Health Boards now have Design Champions who need to be supported in this role both by the political culture within the Board and by estates staff with the skills to take forward the Champion’s lead.
Plan procurement routes to deliver the widest benefit. Too frequently we see Outline Business Cases (OBC) developed without any considered view of the implications of building on the chosen site. Boards, and those charged with approving business cases, should insist on early design feasibility studies (pre-OBC) to test the opportunities and constraints of alternative sites, and alternative site strategies. This will inform the development of an appropriate and realistic budget, thus saving waste in redesign at a later stage when it is found that the budget, brief and site do not tally.
Allow time at the right time; a successful design is the result of an intelligent and creative synthesis of many, often conflicting, demands and this process requires an investment of time and skill on the part of both the designer and the client. Both clients (including clinicians and, in a mutual NHS, the public) and the designers consider time spent exploring and testing alternatives as invaluable in developing an understanding of priorities and opportunities so that the final design is of long term value. This crucial dialogue should be programmed rather than curtailed due to the imposition of artificial (often political) deadlines.
Demonstrate commitment to a quality outcome. The public client needs to direct the market more strongly towards high quality solutions. This is done by setting an aspirational brief, ascribing a high weighting to the ability to deliver a well designed outcome in the bidding process, and having the confidence to make a selection on this basis.
Recently Chief Medical Officer Dr Harry Burns lectured on the biological consequences of living in adverse circumstances – the physiological changes that occur in humans living with hopelessness that have a direct and detrimental effect on our health. He challenged all those working in the design and building industries to develop ‘supportive environments’ – environments that promote social interactions and make it easier to make healthy choices – even suggesting that this could be the ‘vaccine for the twenty-first century’. Scotland has the design talent to do this: it is time for the health sector client to lead the way, to engender the attitudes and implement the processes needed to make these aspirations a reality.