Hugo Owen is a researcher at Create Streets. Prior to that he worked for a volume house builder.
The Health and Social Care Secretary, Matt Hancock, has made it clear that the largest hospital building programme in a generation will be a key part of the post-COVID infrastructure investment. The Government intends to invest £2.8 billion in the construction of six large new hospitals, to be delivered by 2025. What should they look like?
This is not a dilettante question. Increasingly robust data on environmental psychology, patient wellbeing, and public health, demonstrates that hospitals which are calming and green, restful and beautiful inside and out, are better for patients (they recover more quickly in beautiful and green surroundings), better for people who work in hospitals (people work more effectively in places they find beautiful) and even better for civic pride – which is good for all of us.
The importance of what hospitals look like inside and out is something we’ve instinctively known for millennia across all different cultures and climates. From the early Islamic hospitals such as the Qawaloon complex in Cairo to the healing temples (Asclepeions) in Ancient Greece, their moral mission and social significance was encapsulated in expressions of architectural beauty.
During the twentieth century, however, this principle was gradually abandoned. Instead of proclaiming their high moral purpose to their surroundings, hospitals’ measurable functionality and cost became an architectural feature in itself, transforming the hospital as a building type.
Not only did this profoundly affect the aesthetic nature of the buildings, it also negatively affected the quality of care – despite the wider advances made in scientific healthcare. In striving for readily provable efficacy, we forgot that humans are not machines. We threw out the baby with the bathwater. As one of the pioneers of the study of hospital’s effect on their patients’ health, Professor Roger Ulrich, put it: ‘This desire for functional efficiency, together with the pathogenic conception of disease and health, has helped to produce healthcare facilities with environments starkly institutional, stressful, and detrimental to care quality.’
Somehow, somewhere, we have lost not just the ability but even the desire to create public buildings of beauty and moral worth. Rather than the two jostling for superiority, as it had done to create, for example, the ‘cure porch’ in America, modern hospital design, like modern architecture, denounced the ideal altogether. Evidence from one architect for the Building Better Building Beautiful Commission last year highlighted the extent of the problem: “I was working on a Private Finance Initiative project ten years ago, and we were told by the contractor to put in a more expensive material that looked cheaper, because there was real sensitivity about anything in the NHS looking expensive.”
Not only are we the richest society to ever live, but we are the most advanced in our understanding about what environments we react best too. Nevertheless, we choose to turn our back on beauty, scared by the very concept of the word.
The hospital building programme surfaces this debate once again. Do we really want to follow on from where the PFI programme left off? You only need to look as far as the Royal London Hospital or the Royal Liverpool University Hospital for your answer.
Create Streets’ recent research note, Why we should build beautiful hospitals, argues for a complete rethink of how we design and create hospitals, remembering that patients are humans not ‘machines for getting better’ and drawing upon both the past and the latest research for answers to the future. How can we create places that patients, staff, and communities can cherish and in which they can flourish? The evidence suggests some key themes.
Firstly, we should create gardens that patients and staff can see and use. Hospitals with ready access to green space (think beautiful internal courtyards) alleviate stress, improve job satisfaction and improve recovery times. For example, a carefully controlled study found that gallbladder surgery patients assigned to a room with a window view of a garden or natural setting had shorter postoperative hospital stays as compared to patients in similar rooms with windows facing a brick building wall. Despite this, concepts such as Horatio’s Garden still remain one-offs rather than mainstays in the UK. You only have to look as far as Singapore to see how it should be done. The Khoo Teck Puat Hospital in Singapore integrates greenery into design at a monumental level. It has 15 onsite gardens with over 700 species of native plant.
Secondly we should create hospital with large windows, not just piped air. One doctor working in Charing Cross Hospital (built in 1973) told us:
“There were some days when I felt physically unwell just from being in the hot stuffy doctors’ room with no window, no air, and horrible smells.”
The advances in artificial ventilation models means that windows are no longer irreplaceable. Yet a range of studies now show that large windows and high ceilings are normally more successful at lowering infection rates and levels of harmful bacteria, than expensively and artificially ventilated rooms – one study found a differential of 28 per cent. And that’s not to mention the wider benefits. Research by the Department of Neuropsychiatric Sciences at the University of Milan found that patients with bipolar disorder assigned to brighter, east-facing rooms with morning sunlight had hospital stays nearly four days shorter than those with west-facing rooms.
Hospital should have variety in a pattern. Too many modern hospital layouts are bland and sterile. Not only are all the rooms the same but the corridors that lead to them and the doorways that give entrance to them are normally undifferentiated. The sensory and aesthetic experiences of patients are not held to be crucial to their treatment for or recovery from illness. However, the evidence suggests that this is a mistake. Studies suggest that environments that lack positive distractions causes patients to focus increasingly on their own worries, fears or pain.
We should also create calmer and quieter environments. In the UK, 40 per cent of hospital patients are bothered by noise at night, according to in-patient surveys. This is far too high and provably bad for them.
I could go on. If we design places with human scale, coherence, and complexity with variety in a pattern, and some symmetry, we are designing places that most people prefer and find more settling. That is better for all of us, and for neighbourhoods than huge anonymous boxes. This should not be a top down approach however. Throughout, public engagement, citizen involvement in scheme selection and data on local preferences should underpin the process to avoid some of the major errors of the last 50 years in public sector procurement.
2020 has retaught us of the importance of where we live and spend our time in sickness and in health.
It is right that the government is parsimonious with public money. It is the tax-payers’, not theirs. Nevertheless, it is possible to be penny wise and pound foolish. Many public sector procurement processes over-emphasise short term cost and under-emphasise lifetime costs. Few if any none properly factor in the long-term financial benefits of creating beautiful restful environments in which patients and staff can thrive and in which a local community can take pride. This should change.