Sicker by design

Until recently, when they had the opportunity to build or alter hospitals, health trusts were guided by a dozen or so experienced architectural firms and a dossier of Health Building Notes and Hospital Technical Memoranda. The overriding twin priorities in this accumulation of guidance were functionality and cost, and no wonder, given the job hospitals must do and the publicly accountable way in which they are funded.

But things are changing. The NHS is beginning to perceive that hospitals do their job better if they respect normal human sensibilities: in other words, if they are nice places to be. Humane design is shouldering its way up the NHS Estates agenda, propelled by CABE and fuelled by a growing body of evidence.

It looks like the supply chain will have to respond, whether firms are attached to one of the dozen consortia appointed under ProCure21 to deliver publicly funded projects, or whether they are bidding for larger PFI jobs. ProCure21 consortia could face design reviews, and PFI bidders will face trusts that will be appointing on the basis of revised design criteria.

Let's face it: hospitals are crummy places. Granted, they represent fantastic design achievements in their own way. They facilitate an amazing flow of people and goods and they house highly advanced technology. But in most cases you don't feel good there. Windowless corridors, noise, startling smells, claustrophobia – the NHS is beginning to squirm with the realisation that patients don't have to take it anymore, and that these things are counterproductive.

"Hospitals are like body workshops," says Thomas Saunders, author of The Boiled Frog Syndrome (Wiley-Academy, 2002). "They're high-tech laboratories for machinery and equipment."

For Saunders, horrible hospitals are a symptom of the arrogance of conventional medicine. "Doctors think it's all up to them," he said. "Their model is cut it off, stitch it up, administer a dose and stick you in a bed. The word 'healing' is almost alien to them. A patient's self-healing ability is totally ignored."

Nurses also agree hospitals can be unhealthy. "Having to walk along miles of corridors everyday and care for patients in airless, poorly designed wards… is not conducive to a quick recovery for patients," said Beverly Malone, general secretary of the Royal College of Nursing.

Until recently, the evidence linking environment to recovery has been scant or scattered. In 1984 Roger Ulrich, a Texan architectural psychologist, was able to show that a view from a window aided recovery after surgery.

In this country the groundbreaker is considered to be Professor Bryan Lawson, Dean of Architecture at University of Sheffield who, with Dr Michael Phiri, was able to compare patients' progress in new and old wards in hospitals near Brighton. They found that, in a newly refurbished ward, patients not undergoing operations went home on average two days earlier than their counterparts on an old 1960s ward. They also consumed less Class A pain-relieving drugs, and staff recorded 24% fewer verbal outbursts and incidents of threatening behaviour. Lawson surveyed mental patients as well. Here the results were starker. Patients in a newer facility went home six days earlier than counterparts in a older facility that used to be a Victorian workhouse. Life in the newer facility was calmer, too. This was a three-year study, with results published last year.

Lawson and Phiri are gathering a database of evidence from around the world that shows how environmental factors assist the healing process.

CABE is also putting pressure on the NHS through its Healthy Hospitals campaign. The point of this is to build a popular head of steam in support of "nicer" hospitals. CABE encouraged four teams of designers and architects to submit schemes that blow the hospital mould apart. The public will vote on the one it likes best. The results will be announced this month.

High-concept healthcare
The schemes show that designers are pretty eager to think outside the box. One team attacked the notion that you need a waiting room. They wrote: "It is highly stressful to wait in a room filled with lots of other anxious people, bored, uncomfortable, desperate for information and attention."

They suggest hospitals be more like town centres, with shops, work spaces, art, libraries and other services so you can get on with life while waiting. Bleeping wristbands could tell you when to turn up for the appointment. Other teams expand on this theme, saying hospitals should be viewed as prime development spaces, attracting, as they do, all sorts of people.

There is a bit of blue-sky thinking here, but CABE feels it's justified on one hand to encourage the public to demand better design and on the other to help architects escape the strictures that attended hospital design in the past.

NHS Estates has responded quite vigorously to the pressure from CABE and from other quarters, notably the government and the Prince of Wales. It set up the Centre for Healthcare Architecture and Design (CHAD), a kind of internal design watchdog. It has appointed "design champions" at the majority of local trusts. It oversees design review panels for major projects, which are bit like travelling courts that pass judgement on projects' design. It has also commissioned advice notes for trusts on sensitive design and published a tool for measuring design quality, called AEDAT, short for Achieving Excellence Design Evaluation Toolkit.

Nobody wants to design bad hospitals. But nobody wants to be undercut

Professor Bryan Lawson

Bryan Lawson is involved at this level. In conjunction with Balfour Beatty, architects Building Design Partnership (BDP) and the NHS Estates, Lawson is working on a questionnaire that will score major hospital designs on the environment they provide to patients and staff. Has the room got a window? Does the window give a view of sky and ground? Can you see what's going on outside? Research suggests that this helps people feel better.

Ideally, Lawson would like to see trusts around the country use this tool to help them choose the right consortium for a major project. This, he believes, would help create a level playing field in what is a very competitive market. "Nobody wants to design a bad hospital but nobody wants to be undercut on the price, either. This would give bidding consortia some form of protection." The questionnaire is due for release imminently. It's called ASPECT, an acronym for A Staff, Patient Calibration Tool.

But tools, champions and initiatives do not equal policy. While there is a significant will to push holistic design, the NHS has limited control. Which design gets the nod is generally down to the individual trust. They need to be educated to develop a proper brief and to use the tools. While the design review panels are influential, they do not have veto power.

"In one way there is no such thing as the NHS," Lawson said. "It's more like an industry of hundreds, maybe thousands of organisations. NHS Estates is just one of those organisations. And it's not in the final loop on design."

Lawson sees this as a potential barrier to coherently raising holistic design standards. Among the 400-plus health trusts in the UK, there are likely to be many people inexperienced in procuring large healthcare projects, in part because there has not been a healthcare building boom since the 1960s. "These are not clients like BAA or Marks & Spencer," he said. "And yet here we are in the middle of a massive building programme, possibly the biggest period of public sector procurement ever undertaken."

He's not against PFI, but says it doesn't always help holistic design. For instance, under PFI, trusts have to undergo a public sector comparator design, which is intended to demonstrate that the private sector can produce better value than the public sector. This process involves commissioning an initial design that forms the basis of deciding the scope of the project. Architects know it will most likely not be built, and Lawson suggests this can fail to motivate them to design inspirationally. He says the scene is then set at a relatively low level.

Mike Nightingale, chairman of Nightingale Associates, advised the government on this issue back in 1994. He agrees that PFI can pose problems but maintains it can get better at promoting good design.

"When PFI first started, the main pressure was economic," he said. "What won early contracts was good banking. But now good design has become a powerful tool for contractors."

Into account
Sunand Prasad, an architect and CABE commissioner, believes that a significant barrier lies in simple accounting. Sure, he says, sunny rooms may increase patient throughput, but by precisely how much? And how do you turn that into a whole-life-cost calculation? It may be common sense that pleasant surroundings help nurses nurse better and encourage patients to go home sooner but PFI bidders prefer exact return-on-investment calculations.

Nightingale insists that holistic design doesn't necessarily have to cost more money. His firm is developing a technique called emotional mapping, which is really just imagining how patients would feel and responding to it. "Take A&E. What do you feel there? Fear. Stress. It helps if you have nice colours, nice smells, privacy. It also helps if you were able to find the place, park the car and were met with a smile."

He admits that good design takes time, and that the PFI process hasn't allowed much for this in the past. But Nightingale believes the supply chain can help by taking a genuine interest in design. "The worst trait is when contractors are all luvvy duvvy during the bidding and then turn into design and build contractors right after, using old-style conflict to cut costs."

However, in PFI, contractors face enormous pressure from the funders to maximise return on investment, so they cannot take all the blame.

Blame aside, the health trusts need the private sector. Right now the world of healthcare construction resembles the Wild West. The pace of building work is feverish, while trusts are being asked to rewrite basic design rules: 23 hospitals are currently under construction and another 15 are about to start. The government plans to build nearly 60 new hospitals by 2010.

Susan Francis is an architectural advisor to the Future Healthcare Network and the NHS Confederation. She needs help moving away from the old hospital blueprint, but recognises it's a tough job and one in which the design community will need encouragement. Back in the 1970s the government wanted rational, repeatable designs for hospitals to achieve cost predictability and to accommodate the vast technical complexity hospitals represent.