Back to the future
A better balance between function and the creation of patient, staff and visitor well-being through the environment is the future of hospital design in the UK, writes Marc Sansom, a director of the International Academy for Design & Health
Little has changed and everything has changed. Few today, for example, would challenge the definition of Roman architect Vitruvius, who suggested that the principal qualities of well-designed buildings were ‘commodity, firmness and delight’.
Buildings should be fit for purpose and should work (commodity); they should be well-built and sustainable (firmness); and they should have an impact on the human sensory experience (delight).
The value of design in this context is often misunderstood, however, with a preference for perceiving its contribution in the realm of the aesthetic, without consideration of its criticality to function. In reality, the three criteria set out by Vitruvius are so intertwined within the design process, that only poor architecture and poor buildings will result from a failure to consider each aspect equally within a design response.
It is perhaps regrettable, therefore, as the president of the Royal Institute of British Architects, Sunand Prasad has suggested, that, “the efficient accommodation of processes rather than the making of places has continued to dominate the design of hospitals”.
A focus on function is, of course, an understandable approach in hospital design where the effective operation of medical and surgical processes is so often a matter of life and death, which Prasad naturally accepts.
But, by questioning the “miserable ‘either/or’ doctrine” that suggests that good architecture is at odds with the “implacable demand of optimising clinical adjacency”, Prasad is at the fore of an emerging movement that is trying to reinvent healthcare architecture as a humanistic experience, at the centre of which is patient, staff and visitor wellbeing.
It is an idea that finds clarity in the thoughts of the late Aaron Antonovsky, who developed a list of factors, which contribute to healthy, or ‘salutogenic’, design.
Salutogenes, Antonovsky said, help individuals to maintain and improve their health by focusing on the causes of health rather than the causes of disease, which is the focus of the pathogenic approach to healthcare adopted by modern society.
Central to these ideas is the human need for a ‘sense of coherence’ in the physical environment – a key influence on an individual’s coping strategies and ability to deal with stress.
The three fundamental components in the concept of a sense of coherence are comprehensibility, manageability and meaningfulness. Comprehensibility is concerned with understanding our environment and how it relates to our every day experience.
Manageability relates to a sense that we have the resources around us to cope with different scenarios. And meaningfulness is the perception that life has meaning and that our problems are worth resolving.
If an individual has a high level of all of these factors, they are more able to manage stress and achieve better health. In the hospital context, it can be applied to both patients, staff and visitors.
But it is surprising how often little energy is spent on ensuring that the physical environment is optimal for an individual’s health and well-being.
Enter an older hospital and you may find yourself becoming more and more anxious as you try to find your way down endless corridors, trying to understand signs that are difficult to interpret.
In contrast, the best new hospitals convey a sense of calm, with gardens, water features, natural daylight and works of art. These all help to make the hospital experience comprehensible, manageable and meaningful, says Professor Alan Dilani, director-general of the International Academy for Design & Health.
Taking these ideas a step further, environmental psychologist Judith Heerwagen has created a framework for salutogenic design, which identifies the following factors as key to a healthy building:
Social cohesion, the provision of both formal and informal meeting points – including places that can promote both spontaneous interaction and social support;
Personal control, the ability to regulate lighting, daylight, sound, temperature and access to private rooms; and restoration and relaxation – quiet rooms, access to nature and other means that allow the brain to restore itself and re-energise.
The concept of creating optimum environments for supporting the healing process has increasing validity, explained Richard Mazuch, research director at Nightingale Associates speaking at the recent HEFMA annual meeting.
International studies, explains Mazuch, demonstrate that “elements of the environment – such as lighting, colour, aroma, views, art, modulation of space and form, manipulation of scale, proportion and rhythm, sound, texture and materials, ease and flow of movement through space and time, indoor and outdoor plantscaping – can have a powerful healing and therapeutic benefit on patients.”
The environment is perceived through the main sensory receptors, of which there are a minimum of 21, according to recent research.
By employing ‘sense- sensitive’ design principles, says Mazuch, clinicians and hospital designers can navigate more easily and with greater skill through the emotion, feelings, sentiments and sensations of patients, by understanding better the relationship between the sensory experience of the patient and their environment.
Mazuch has been the driving force behind the ground-breaking H-Pod project, which has applied this knowledge-base to create optimum healing environments for a range of conditions and therapies, including: neonatal; labour, breastfeeding, MRI/CAT; cardiac; burns / palliative care; seasonal affective disorder (SAD); bipolar depression; headache; dementia; oncology; chemotherapy; phlebotomy; intensive therapy; energising; and calming.
Extensive research in the US, for example, has shown that the optimum healing environment for neonates needs to mimic that of a uterus or womb in terms of temperature, light and other key factors.
The outcome of the H-Pod project, suggests Mazuch, will be the development of a ‘design prescription’, that defines the optimum conditions for healing processes within individual departments and rooms that are specific to the needs of individual patients and their medical condition.
In practice, he envisages that this could mean smart cards, linked to building management systems, could be used to deliver the optimum environment, ensuring the right levels of light, colour and temperature.
Some of the most innovative and award-winning examples of buildings that reflect these ideas have been the projects of Penoyre & Prasad.
Greg Penoyre, speaking on the same platform as Mazuch at the recent Hefma event, explained how current trends were to focus on ‘people’ rather than ‘function’.
The key drivers, he explained, are increased patient knowledge, self-care and patient choice combined with radical advances in technology and the medical sciences, all of which are helping to shift care into the community.
Designed to minimise ‘institutionalism’, Penoyre & Prasad buildings, such as the award-winning Richard Desmond Children’s Eye Centre at the Moorfields Eye Hospital and The Arches Community Treatment and Care Centre, Belfast, are characterised, in their own words, by a smooth integration of people, time and place, through an understanding of purpose, construction, context, art, care, learning and limits.
In practice, says Penoyre, rapid change within the UK healthcare system will mean a need for greater flexibility in the healthcare estate, with more openended briefs, a focus on whole life value, adaptable designs, sustainable solutions and increased quality.
The values of ‘commodity, firmness and delight’, however, informed by current thinking on salutogenic health and sense-sensitive design within the context of people, time and place, remain an unchanging and durable force for the future design of our healthcare estate and its buildings.
REFERENCES
1 Prasad, Sunand, 2008. Changing Hospital Architecture. RIBA Publishing, London, pp2-3.
2 Dilani, Prof Alan. 2006. International Hospital Federation Reference Book 2006/07, p57.
3 Penoyre & Prasad, 2007, ‘transformations the architecture of penoyre & prasad’, Black Dog Publishing, London.
