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HOSPITALS: THE RIGHT DESIGN TREATMENT

FOCUS ON: HEALTHCARE

The architecture of NHS hospitals and prisons has much in common - both institutions are places where a small number of people do unpleasant things to a large number of people, even if ostensibly for their benefit. On entering a hospital, patients, just like prisoners, hand over their clothes and are given a number and a uniform. Their possessions are listed and taken away, and they lose control of their life for the duration of their stay. To emphasise this humiliation and loss of power they will probably be subjected to 'an intimate examination' as well.

The dehumanisation of patients in hospitals is to some extent inevitable and necessary - an individual patient cannot very well decide at what time he or she might like to have their operation, for instance - and, to an extent, the staff need to be insulated and detached from their patients' suffering if they are to function effectively.

Power, however, corrupts, and just as clinical staff must meet the challenge of balancing compassion with detachment, so too must hospital architects and the committees that commission them. Indeed it is in many ways more difficult for architects and NHS managers to meet this challenge than it is for clinical staff, because they are remote from the day-to-day reality of treating ill people.

In other words, when designing a hospital, it is easy to forget the underlying reality - that they are places of intense stress, suffering and often great sadness. This failure is often compounded by two further factors: failure to appreciate the identity of mind and matter; and a failure to appreciate the true nature of modern, hospital medicine - the question of care as opposed to cure.

In the 17th century Descartes famously declared that mind and matter were separate entities. There has always been a tendency in scientific medicine for doctors to divide symptoms and illnesses into 'physical' and 'psychological' categories.

'Physical' problems can be analysed and treated, and one might even extend some cautious sympathy to the patient with the problem, because it is not his or her 'fault'. But problems that cannot be explained on a 'physical' basis are dismissed as deserving little sympathy or attention.

We now know from modern neuroscience that this division between mind and matter is false, and there is a growing body of evidence that states of mind have a great impact on disease. But it is a division that has led to a neglect of good environmental design in hospitals. As early as 1859, Florence Nightingale pointed out Descartes' mistake when, in her Notes on Nursing, she wrote: 'By form, by colour, by light? they have an actual physical effect.'

Florence Nightingale had a large and very beneficial inuence on hospital design, with her emphasis on the importance of daylight, fresh air and colour (even though it was based on the mistaken miasmatic theory of disease, which reasoned that infections were spread by foul vapours).

With the development of elevators, wide structural spans, air conditioning and deep-plan design, Florence Nightingale's lesson has had to be learned all over again.

A common criticism of doctors is that they tend to see patients as assemblages of diseased organs and fail to care for the patient 'as a whole' - in other words, that they neglect the emotional, psychological and social causes and consequences of their patients' illnesses. A very similar criticism can be made of most of the hospitals built in this country over the past few decades and in particular during the PFI boom of recent years.

Hospitals have been built as assemblies of functional modules - an outpatient block, a ward block, a theatre block - with little understanding of the fact that successful hospitals are as much communities that deliver care for chronic illnesses as factories that cure acute ones. If form does indeed follow function, the form of a hospital will be profoundly different if its primary function is seen by its designers as one of care rather than simply cure.

There are two major reasons for the importance of making a distinction between care and cure. Firstly, many of the illnesses treated in modern hospitals are incurable. Diseases such as cancer, diabetes and the consequences of ageing are treated in hospitals, but not cured. All the simple, curable conditions are dealt with by GPs in the community or on a day-case basis in hospitals.

Most medical treatments are at least unpleasant and often worse - but the pain, discomfort and fear that most of us experience in hospitals when we are patients is easy to accept if we can hope that the treatment will cure us forever. If the treatment is only palliative, the way in which it is delivered becomes increasingly important, because the unpleasantness of the treatment has to be balanced against the intended benefit.

Secondly, there is an increasing body of evidence which suggests that the effectiveness of treatment for many illnesses is profoundly inuenced by the design of the environment in which it is delivered - so-called EvidenceBased Design. This growing field of research was started more or less single-handedly by Professor Roger Ulrich of A&M University in Texas. His first publication, in 1986, showed that patients left hospital more quickly and required fewer analgesics after gall bladder surgery if their room had a view of a tree as opposed to a car park. There is now a growing body of research from Ulrich and others showing similar benefits of a good environment: morning daylight reducing depression; carpets reducing patient falls (not because they are less slippery than vinyl, but because relatives stay longer and there is therefore more supervision of patients than the nurses can provide); re-admission rates to an acute coronary care unit with further cardiac problems reduced by sound-absorbing ceiling tiles.

If doctors have traditionally neglected the patient 'as a whole', hospital architects and their clients have neglected hospitals 'as a whole'. A good, well-designed hospital is more than the sum of its functional modules. The space between modules - waiting rooms, corridors, interview rooms, offices, canteens - as well as the modules themselves is of critical importance. A successful hospital is one where:

patients and their families feel that they are cared for as individuals;

curable illnesses are cured and treatable illnesses treated, with low rates of hospital-acquired infections and complications;

patients can sleep undisturbed at night;

patients have a stimulating unstressful daytime setting;

there are high staff-retention rates; and there is effective communication between patients and staff.

Many of these goals are most likely to be achieved by single rooms - a commodity that is universal in private hospitals but one that the NHS has been very slow to take up. Research has shown that single rooms lead to far lower hospital-acquired infection rates and, contrary to the suspicions of many hospital staff, do not require larger numbers of nurses.

Patients obviously sleep better in single rooms and have greater dignity and privacy.

If single rooms are, on the whole, of benefit to patients, the size of hospitals is a major opposing force. Many factors are forcing NHS hospitals to become larger and larger: the European Working Directive and cost-cutting to name but two. NHS founder Nye Bevan famously stated that he 'would rather die in the cold altruism of a large hospital than die in a gush of sympathy in a small one.' There is certainly a need for a 'critical mass' in medicine to permit the accumulation of experience and training, but it does not follow that 'bigger is better'. Any working doctor will tell you that there are huge dis-economies of scale with large hospitals; staff work less effectively, there is less effective communication, and institutional jealousies and rivalries develop.

If the move to large hospitals and the closure of smaller, local hospitals cannot be resisted, architects will face increasing difficulties trying to design humane buildings; yet good design is probably the main weapon against the alienation and inefficiency that comes with large hospitals.

One solution, which management will resist on grounds of cost, is 'patientcentred' design. Instead of one gigantic outpatient department, each clinical department should have its own outpatient department, operating theatres and an X-ray department. The hospital, in other words, should be decentralised, with different departments taking the form of independent villages within a city. It is no coincidence that in the private sector, which tells us to some extent what patients really want, there are no really large hospitals.

Being a patient in hospital is like being a soldier at war;

boring 95 per cent of the time, terrifying for 5 per cent.

A successful hospital is one where patients are not suffering the stress of having nothing to do and nowhere to go.

Early mobilisation is an important part of modern medicine, reducing, for instance, the risk of deep vein thrombosis and chest infections.

Windows with views and well-designed corridors with immediate access to gardens, nature and daylight, are all areas where good architectural design will have as great an impact on patient well-being as the engineering of air-handling and operating theatres.

It is well-known - but not sufficiently well-known in the NHS - that the capital cost of a new building is only 5 to 6 per cent of the lifetime cost of running it. Most of the lifetime cost is staffing costs and there are compelling long-term economic arguments for building hospitals that will attract high-quality staff and retain them. An experienced secretary or staff nurse who stays in a post for several years is many times cheaper - and more effective - than an army of short-term agency staff and locums. Good office spaces and good team rooms, coffee rooms and canteens, should be a vital part of a successful hospital.

The profound truth that the key to designing a successful building is an informed client is particularly difficult to apply to hospitals - not just because of the complex, technical challenges they present, but because the architect is faced by the problem of deciding who the real client might be: the patient, the clinical staff or the hospital management.

To make matters worse, most large hospitals are deeply dysfunctional institutions with complex political rivalries among managers and clinical staff. Doctors tend to be argumentative and selfimportant, and, as a result of the rise of managerialism with the NHS reforms of recent years, there is little effective leadership. For example, on average, an NHS Trust chief executive stays in post less than four years.

The membership of the committee that plans the initial design of a hospital will probably have changed completely by the time the building is commissioned. To make matters worse, the great majority of patients, doctors and managers have relatively little understanding of the impact of design on patient well-being and staff motivation.

What, then, should the poor architect do? A new hospital will not be welldesigned and successful if the senior management - in particular the chief executive - have no interest in or commitment to good design and little appreciation of the fact that it saves money. They will need to have their eyes opened. When designs are being drawn up, it is absolutely essential that the design team visits good examples of welldesigned hospitals (such as Hexham in Northumberland, the Rikshospital in Oslo and several in the US) and good examples of badly designed ones (of which, alas, there are many in this country). It is the duty of the architect to educate the client as to what is possible.

There is nothing inevitable about bad design.

Henry Marsh is one of the UK's leading neurosurgeons at St George's Hospital, London

MORNING LIGHT AND DEPRESSION Bipolar patients suffering from depression who stay in east-facing rooms stayed an average of 3.67 days less in hospital than those in westfacing rooms.

Benedetti, Colombo, Barbini, Campori & Smeraldi, 200 LENGTH OF STAY Female patients in cardiac intensive care stayed for a shorter time in sunny rooms than those in dull rooms. Mortality was higher for those in dull rooms for both sexes.

Beauchemin & Hays 1998 REDUCING BACK PAIN Using soft floor surfaces reduces lower back discomfort for workers who spend large amounts of time on their feet.

Redfern and Chan, 2000 Source: www. healthdesign. org

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