A tidal wave of government debt-funded cash is about to break over England, particularly, in neighbourhoods that voted Conservative for the first time in 2019. £4.6 billion alone is going into building six new large hospitals and upgrading another twenty.
We’ve had flash floods of government largesse before. They can magnify poor-thinking as well as improvements. The fortune spent on destroying Victorian streets and building utopian housing estates in post-war Britain created many places that are, objectively, less successful neighbourhoods than the streets they replaced. The evidence on the success of the Blair-era New Deal for Communities is mixed.
Many of the proudest buildings in England’s towns and cities are civic buildings erected with public funds, particularly in the nineteenth century. Sadly, the public buildings built in the last generations are, in comparison, crude, short term and tacky: unworthy to be placed alongside their forebearers. The workhorse of project delivery most recently, the Private Finance Initiative (PFI), certainly did not sully itself with anything as hard to measure as human pride or civic dignity. Compare the (old) Liverpool Royal Infirmary with the (new) Royal Liverpool Hospital. Or the Royal London Hospital, Whitechapel as was with as is.
Somehow, somewhere, we have lost not just the ability but even the desire to create public buildings of comprehensible beauty, civil dignity and transparent moral worth. The issue was starkly highlighted by the evidence that one architect gave the Building Better Building Beautiful Commission last year:
“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.”
This is ridiculous. A hospital is a noble building designed for a noble purpose. It should not be built to look disposable and cheap.
A remarkable study found that patients in older wards with large windows were less susceptible to infection than those in modern wards
Patients recover more quickly in green and beautiful surroundings. And doctors and nurses work more effectively in such surroundings too. Increasingly robust data on environmental psychology, and patient wellbeing find that hospitals that are calming and green, restful and beautiful inside and out are better for both patients and for those who care for them. One remarkable study, for example, found that patients in older wards with large windows were less susceptible to infection than those in modern wards.
The importance of a palliative environment was obvious to our forefathers. Across time and culture many hospitals strived to create calming environments for their patients and to reflect a sense of their important purpose to their neighbours, whether at the Al Mansur Qalawun complex in Cairo, the Hospital de Santa Cruz, Chile, or the former Exe Vale Hospital in Exminster.
This remained the case during the nineteenth century with the expansion of modern scientific medicine based on empirical observation. During the twentieth century, however, this principle was gradually abandoned. The readily measurable functionality of the hospital took precedence.
Not only did this change profoundly affect the aesthetic nature of the buildings, it also negatively and needlessly affected the quality of care – despite the huge advances made scientific healthcare. In striving for readily provable efficacy we forgot that humans are not machines. As Professor Roger Ulrich, one of the pioneers of the study on how hospitals influence their patients’ health, 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.”
Sadly, Professor Ulrich is right. Evidence is piling-up that overly industrial environments just aren’t good for us. Forty per cent of British hospital patients are bothered by noise at night, according to in-patient surveys. And this in turn has negative health effects. It’s the same for doctors. As one doctor working in Charing Cross Hospital (built in 1973) told Create Streets,“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.”
Medicine and cleanliness are vital to recovery. But so are restful, reassuring and beautiful places
The Government intends to create six large new hospitals, to be delivered by 2025. So what should we do?
Put simply, we should have the confidence to learn from the past as well as from the present. Obviously, hospitals should have the latest equipment. But if we want them to be as good as they can be we will need to treat patients and health professionals as humans not as robots. Medicine and cleanliness are vital to recovery. But so are restful, reassuring and beautiful places.
The Khoo Teck Puat Hospital in Singapore, for example, isn’t just mucking around with a few pot plants. Space and flora are integral to its environment. There are 15 gardens across the grounds, over 700 species of native plant and a continuous green view for patients and staff. “I felt so relaxed” said one patient.
New hospitals should have gardens that patients can see and use (perhaps as partly covered courtyards or cloisters), wards with windows – not just piped air – and interiors and exteriors which have dignity and variety in a pattern not just “spreadsheet architecture.” They should be calm and quiet. They should be human in scale and visually both coherent and complex – by which I mean there is much for the eye to digest and enjoy, from the detail of the ornament, to the window surround, to the variety in a pattern and near symmetry of the overall façade. Studies are very consistent about the type of façade that most of us prefer. We like detail to look at, but we don’t like chaos. Patients should find the place they find themselves in attractive. Yet, a hospital that was all these things would not last five minutes in any public sector procurement process.
As Create Streets argues in its latest briefing paper on improving hospital design, to change this grim reality, the government will need to state clearly in the aims of the procurement process that gardens, beauty and popular support from the local population are key elements of the design brief. This should involve polling on local design preferences and making use of the emerging “science of place” on the likely impact of different designs on patients’ health.
It is right that the government is parsimonious with taxpayers’ money. 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. 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. Otherwise we can “build, build, build” for ever, whilst only going around in circles.
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