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Just what the doctor ordered

What issues need to be taken into account to design a humane hospital environment? And how difficult can it be?

'Alex-Li Tandem, like everybody, held hospitals in the highest, purest dread and loathing.To come in with a bump and leave with the baby - this is the only grace available in a hospital.

Other than that, there is only pain.The concentration of pain.Hospitals are unique in this concentration.There are no areas in the world dedicated to the concentration of pleasurethere are no buildings dedicated to laughter, friendship or love.They'd probably be pretty gruesome if they existed, but would they smell of decay's argument with disinfectant? Would people walk through the hallways weeping? Would the shops sell only flowers and slippers and mints? Would the beds (so ominous this! ) have wheels?'

The Autograph Man, Zadie Smith,2002 Just over two years ago, NHS Estates asked ABK Partner (and now Design Advisor to NHS Estates) Richard Burton to chair a group known as the Design Brief Working Group (DBWG).The initiation of the group is an indication of the increasing importance being placed upon the design of the therapeutic environment. Its members include medical planners and doctors, engineers and design consultants, and its role is to bring together and examine a range of issues relating to the increased humanisation of the healthcare environment.

The group's first paper, 'Advice' (available from NHS Estates), is aimed at members of NHS Trusts or those in a position to influence the chain of events at the outset of a project.Perhaps most crucially, 'Advice' re-emphasises the importance of the quality of the briefing process to the success of building in the healthcare sector, in particular asking for more 'design thinking time' at the earliest stages of the strategic brief. The second project, to be published shortly, looks at the issues involved in the use of the deep plan in healthcare buildings.

Multiple partners

The issues involved in the current healthcare design debate are varied and complex: from the impact of changing medical practise on the design of the healthcare environment to the difficulties met by smaller, younger practices in moving into healthcare design. From the multiple personalities of the healthcare client (patient, staff, Trust and so on), to the difficulties brought about by the complexity of estates'provision and contractual processes in this sector.High on the healthcare agenda is how to communicate to those in a position to make a difference to the value of good design to the healing environment, to the therapeutic recovery of the patient, and the performance of the nursing staff.

Susan Francis, design lead at the Future Healthcare Network (which is described as 'providing an intelligent learning organisation to share ideas and develop optimal concepts to inform future investment'), says: 'Medical advances are moving fast, meaning that changes in service provision are taking place. But this is happening alongside a paradigm shift from taskorientated design that organises and arranges for the medical profession, to a more patientcentred model. It's no longer enough for the emphasis in healthcare buildings to be placed on functionality; the experience of the patient is important.'

The National Health Service is now more than 50 years old; what we are working with now is a large quantity of old building stock and the largest healthcare building programme for a generation, through which the government aims to build 100 new hospitals by 2010.

Patients are a virtue

In 2000, the NHS Plan introduced the notion of the 'patient environment'.

A new idea then, it is common parlance now, and the ways in which a well-designed patient environment impacts positively on nursing staff, as well as vice-versa, is now also being recognised.Overall, many of the issues involved in healthcare architecture and design are becoming very familiar, certainly among architects and designers, and are beginning to be unpacked very productively.

However, it is fair to say that design has played a marginal role in the healthcare industry for many decades. Inevitably, the focus of attention has been on clinical matters; what is going on now is linking the clinical with the designed environment. There is an increased understanding that well-designed spaces work across all sectors and many of the current conversations in the healthcare sector are fundamentally common sense; the sheer scale of investment and the speed of the building programme means that it is the urgency of the situation that is important.

A number of key organisations and individuals have been raising the stakes for healthcare design and architecture, consistently lifting the standard of debate about the impact that design quality can have on the healthcare environment: The King's Fund, the Nuffield Trust, the Future Hospitals Network, Sheffield University to name but a few. CABE, already working within the healthcare sector through its enabling programme, will launch its 'Healthy Hospitals' campaign shortly, which, through a range of activities, will further raise the stakes and take the debate into the public arena.

The NHS Estates Design Champions programme has placed an individual with sole responsibility for design quality within each Trust, while a range of tools and guidance from NHS Estates is available to those who are involved in healthcare procurement. For example, the 'AEDET' (Achieving Excellence Design Evaluation Toolkit) unpacks the components of design excellence - functionality, impact and build standards.

What is needed is to be able to continue to counter the view still so often aired that design input is costly and that any investment in design is investment wasted. Quality of space and light, use of materials, the use of form, texture, scale and proportion are all tools of the architect, which in so many other sectors are brought into play unquestioned but that in healthcare are still too often viewed as superfluous extravagance.

Relative values

The DBWG is currently looking at the way healthcare buildings deal with issues around dying and death, perhaps the most emotive and personal area of healthcare. Though the work is in progress, one of the key messages emerging is that none of us can guess how another will react when faced by the long-term illness or the death of a loved one, so that, whatever knowledge and understanding we may have of cultural or religious difference, in an already difficult and painful situation, we should not try to second-guess reaction. Instead, as architects, designers and clients, we should design for the possibility of a range of responses, rather than prescribing behaviour.

This area is one of the best ways in which to demonstrate how the designed environment can impact on patients, their relatives and on the staff who care for them.While clinical functionality in this area will always remain crucial, the importance of the designed environment cannot be underestimated.

Medical practice is likely to continue to develop, and clinical adjacencies and technical factors will continue to dictate form and layout up to a point, but those involved in the sector need to continue the endeavour, which says that design quality is absolutely not superfluous and is neglected at all our costs.

'There is no good reason why we should not have good, humane and efficient design in our health buildings. Indeed, quite the opposite.We now have every reason to demand it and have it, ' says Burton.'We have outstanding architects and designers and we have the essential understanding of the benefits of a good environment to the healing process. We know from experience its value to the community.With the visit of Roger Ulrich to NHS Estates in June this year, there is now a major movement to expand 'evidencebased design'as a way to underpin the emerging benefits of design on the patient, the staff and visitors.'

Kate Trant of KT Projects is contactable at katetrant@ktprojects. demon. co. uk

THE DESIGN BRIEF WORKING GROUP

Richard Burton (chair), John Ellis, Ray Moss, Ronnie Pollock, Jane Priestman, Peter Senior, Vijay Taheem, Kate Trant and John Worthington

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