greenspace design for health and wellbeing

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Greenspace design forhealth and well-being

Practice Guide


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Practice Guide

Greenspace design forhealth and well-being

Aileen Shackell and

Robin Walter

Forestry Commission: Edinburgh

sustainable

healthcare

centrefor


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CrownCopyright2012

Youmayre-usethisinformation(notincludinglogos)freeofchargeinanyformatormedium,underthetermsoftheOpenGovernmentLicence.Toviewthislicence,visit:www.nationalarchives.gov.uk/doc/open-government-licenceorwritetotheInformationPolicyTeam,TheNationalArchives,Kew,LondonTW94DU,ore-mail:[email protected].

Firstpublishedin2011byForestryCommission,SilvanHouse,231CorstorphineRoad,EdinburghEH127AT.

ISBN978-0-85538-853-9

Shackell,A.andWalter,R.(2012). Greenspacedesignforhealthandwell-being. ForestryCommissionPracticeGuide. ForestryCommission,Edinburgh.ivi+170pp.

Keywords:greenspace;healinggardens;healthcare;hospitalgardens;NHS;therapeuticlandscapes;trees;woodlands.

FCPG019/FC-GB(KA)/1.75K-ADR/FEB12

Enquiriesrelatingtothispublicationshouldbeaddressedto:

ForestryCommission 231CorstorphineRoad Edinburgh EH127AT

T:01313340303 E:[email protected]

Theauthorscanbecontactedat:

E:[email protected]

E:[email protected]

If you need this publication in an alternative format, for example in large print or in anotherlanguage, please contact the Forestry Commission Diversity Team at the above address.Telephone: 0131 314 6575 or email: [email protected].

Acknowledgements

ThisprojectwasinitiatedbytheCentreforSustainableHealthcareandtheForestryCommission,andsteeredbyanAdvisoryGroup,whosememberswereRogerFrench,SharonHosegood,DianeMillis,MarcusSangsterandRachelStancliffe.Specialthanksareduetothenumerousindividualswhogavesogenerouslyoftheirtimetotheproject,inparticulartothosewhowereinterviewed,tookpartinsitevisits,orcommentedonthetextasitwasproduced.Photographsweretakenbytheprojectteam,unlessstatedotherwise.Researcher:JamesNewmarch.Illustrator:ValerieAlford.CoverillustrationbyRichardCarman.CourtesyofNIHG/LUC.

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Foreword

Green environments are healthy environments. This is the message repeated again and again from healthcare

research that points towards a positive relationship between greenspace and general health. Outdoor environments

can have important restorative qualities that promote recovery from physical and mental stresses. Studies of naturedeficit disorder or nature deprivation suggest that experiences of the outdoors (even views of greenery borrowed

through a hospital window) can have a therapeutic effect on ones social, emotional and mental functioning.

Some outdoor spaces are salutogenic, that is they reduce stress and encourage healthy behaviours. Whilst the

particular reasons for this are not fully understood, various factors may in isolation or combination be important,

including outdoor activity and exercise, natural daylight, stimulation of the senses, and the aesthetic experience. What

we do know is that experiencing these natural environments or helping to care for them can improve the mental

health and well-being of individuals and help to recharge their physical, mental and social capacities.

Nowhere is this relationship with the natural health service more important than around healthcare facilities

particularly across the NHS estate. In supporting health and well-being outcomes National Health Service facilities

should strive to make greater use of existing outdoor spaces by connecting them with the built environment. As we

shift towards a more mutual NHS these largely untapped outdoor spaces should be recognised and utilised as an

important healthcare resource in their own right: hence this guide Greenspace design for health and well-being.

In setting out best practice backed up by case studies this booklet provides a valuable guide to the design of

accessible outdoor healing environments. It is equally applicable to new-build sites and refurbishments. It is relevant

to the full range of healthcare settings, from the smallest health centre to the largest general hospital. It is also relevant

to non-NHS settings such as schools, nursing homes and indeed everywhere where the promotion of health and

well-being is important.

This Practice Guide will assist directors of facilities, estate managers, capital strategic planners, policymakers: in short

everyone interested in health improvement and patient care, whether dealing directly with patients or managing

grounds. By adopting this design guidance, NHS teams will be able to create, transform and revitalise their outdoor

estates with respect to the human experience, encouraging greater use of the outdoors by patients, visitors and staff

alike. These environments will provide a positive distraction from treatment and a therapeutic alternative to hospital

buildings: quiet reflective spaces free from the clinical environment where patients can convalesce and recover in

peaceful surroundings.

Alongside wards, waiting-rooms, and clinical departments, well-designed outdoor spaces are important environments

that provide benefits for everyone. But as well as bringing social benefits, woodland and greenspace initiatives such as

the NHS Forest in England and NHS Greenspace in Scotland can also bring organisational and environmental

benefits too, helping healthcare facilities to meet good corporate citizenship responsibilities and performance measures,

reduce carbon footprints and enhance opportunities for green prescription and outdoor recovery programmes.

By guiding NHS decision makers, Greenspace design for health and well-being will help to harness the full salutogenic

potential of the NHS estate and bring the healing power of nature back into 21st century healthcare provision.

Sir Muir Gray Derek Feeley

Director of the National Knowledge Service and Director-General Health and Social Care

Chief Knowledge Officer to the National Health Service and Chief Executive NHS Scotland

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Introduction 1

Aholisticapproach 1

Benetsofwell-designedoutdoorspaces 1Aguideforpractitioners 1

Why is it important to take healing outdoors? 3

Understandingthebenets 3

Outdoorspacescanhostawiderangeofactivities 3

Whyiscontactwithnaturecalming? 4

Treesandwoodedspaceshaveaparticularroletoplay 5

Healthbenetsofnaturalsettings 6

Healthcare:anartaswellasascience 8

Casestudy1:ArgyllandButePsychiatricHospital,Lochgilphead,Argyll 9

What sort of spaces should we be designing? 11

Designinghealingspaces 11

Creatingahealingenvironmentwiththewidersetting 11

Creatingahealingenvironmentinthebuildingsurroundings 12

Creatingahealingenvironmentingardenspaces 13

Casestudy2:StCatherines,Rotherham,Doncaster,andSouthHumberNHS

FoundationTrust,Yorkshire 14

Designprinciples 17

1.Valuewhatyouhavegot 182.Createspaceswhichfeelspecial 20

3.Maketheoutsideaccessible 22

4.Focusonpeoplesneeds 24

5.Connectwithnature 26

6.Balanceriskwithbenets 28

7.Designforchange 30

Summary 32

Casestudy3:MaggiesCancerCaringCentre,London 33

How do we put the theory into practice? 35

Overcomingthechallenges 35

Privatenanceinitiativeschemes 35

Acutecare 36

Olderpeoplescare 36

Primarycare 37

Casestudy4:CulmValleyIntegratedCentreforHealth,Cullompton,Devon 37

Gettingstarted:theprojectprocesssummarised 39

Stage1:Preparation 40

Stage2:Designandimplementation 41

Stage3:Usingandmaintainingthenewspace 42Stage4:Monitoringandreview 42

Casestudy5:SensoryGarden,theVerwoodOpportunityCentre,Dorset 43

Contents

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Workingwithdesignelements 45

1.Planting 46

2.Trees 48

3.Entrances,pathsandboundariesconnectingthesite 50

4.Sitefurniture 52

5.Art 54

6.Water 56Summary 58

Casestudy6:ChalkhillUnit,PrincessRoyalHospital,HaywardsHeath,Sussex 58

Feelinginspired?Howtogetstarted 60

Further reading and useful sources of information 62

Appendix 1: Researched sites 66

Appendix 2: Sample riskbenet assessment for a community hospital 68

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Introduction

Aholisticapproach

Untilrelativelylateinthe20thcentury,outdoorspacesaroundmosthospitalswereverymuchpartofthehealingenvironment.Gardens,terraces,orchards,meadowsandevenhospitalfarms

wereallcommonplaceandaccessibletopatientsparticularlyintheeldofmentalhealth.But,

astimepassed,thebenetsforpatientsofbeingabletospendtimeoutdoorsinthefreshairhave

beenincreasinglyoverlooked,astheemphasisoncreatingasterileenvironmentindoorshas

developed.Thishasfosteredaviewthatthehealingenvironmentwasrestrictedtotheinsideof

hospitalbuildings,excludingthegardensandotherspacesaroundthem.

ThisGuidefocusesontheoutdoorspacesaroundalltypesofhealthcarefacilities.Itadvocatesa

holisticapproachtotheirdesign,seeingbothindoorandoutdoorgreenspacesasequally

importantforhealthandwell-being.Indoingso,itre-orientatesoutdoorspacesrmlywithinthesphereofpatient-centredcarewiththePlanetreemodelstipulatingthathealthcareenvironments

shouldfosteraconnectiontonatureandbeauty.So,alloutdoorspacesshouldbepartofthe

healingenvironment.

Benetsofwell-designedoutdoorspaces

Peopleareentitledtothebestqualityofcare...attheendofthedaythereasonwhydesignmatters

somuchisthatwehavealimitedamountofresources,andbestpracticereducesthecostofcare.

(ProfessorJuneAndrews,DirectoroftheIrisMurdochDementiaCentre,2010)

Designingoutdoorspacestohaveatherapeuticfunctionrepresentsacost-effectiveapproach.

Suchspacescanimprovepatientoutcomesandleadtoarangeofothercostsavings.Studies

showthatpatientswhoarehappierwiththeirhealthcareenvironmentsareeasiertocarefor,and

returnhomesooner.Evidencealsoindicatesthat,wheretheenvironmentisimproved,betterstaff

retentionresultsincostsavingsinrecruitmentandtraining,withrecruitmentbeingenhancedin

therstplace.ThisGuidewilllookattheevidenceforthisinmoredetail,later.

Therearealsoorganisational,environmentalandsocialbenets.Amorecreativeapproachto

outdoorspace,includingparticipatingininitiativessuchastheNHSForestinEnglandand

GreenspaceinScotland,canhelphealthcarefacilitiesmeetperformancemeasures.Theremay

alsobegainsforthemintermsofsustainabilityandcarbonreduction,especiallyinrelationto

treeandwoodlandplanting.

Aguideforpractitioners

TheKingsFundprogrammeEnhancingtheHealingEnvironment(EHE)hashelpedmanystaff

becomeengagedinprovidingbetterpatientcarethroughimprovedspaces,andthisGuideseeks

tobuildonsomeofthelessonswhichhavebeenlearnt.

Itisapplicabletonew-buildsitesandtorefurbishments,andtothefullrangeofhealthcaresettingsfromthesmallesthealthcentretothelargestacutehospital.Itwillassistsenior

managementteams,thoseengagedwithpolicy,andeveryoneinterestedinimprovingpatient

carewhethertheydealdirectlywithpatients(clinicalstaff,therapists,supportstaff)orfocuson

groundsmanagement(facilitiesandestatemanagers,andpracticemanagers).

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Itisalsorelevanttonon-NHSsettings,forexampleschools,nursinghomes,everywherewhere

thepromotionofhealthandwell-beingisimportant.

Well-designedoutdoorspacesareanintegralpartofthehealingenvironment,alongsidethe

wards,waitingroomsandclinicaldepartments,andprovidebenetsforeveryonepatients,staff

andvisitors.ThisGuidesetsouthow,andwhy,thisisso.

Inspring1994,theplaywrightDennisPotter,nearingtheendofhislife,describedthetree

hecouldseefromhisbedroomwindow.

Theblossomisoutinfullnow...Itsaplumtree,itlookslikeappleblossombutitswhite,and

lookingatit,insteadofsayingOhthatsniceblossom...Iseeitisthewhitest,frothiest,

blossom-iestblossomthatthereevercouldbe...Thingsarebothmoretrivialthantheyever

were,andmoreimportantthantheyeverwere,andthedifferencebetweenthetrivialandthe

importantdoesntseemtomatter.Butthenow-nessofeverythingisabsolutelywondrous...

youhavetoexperienceit,thecomfortofit,thereassurance...(DennisPotter,Interviewwith

MelvynBragg,March1994)

Sensory aspects of the natural environment are especially engaging.

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Understandingthebenefits

Outdoorspaceisanimportantpartofthehealingenvironmentanditcanbeusedforawiderangeofactivities.

Theorieshavebeendevelopedtoexplainthehealthbenetsofnatureandthesehaveledinturntothedevelopmentofevidence-baseddesign.

Treesandwoodedspaceshaveaparticularroletoplayinsupportinghealthandwell-being.

Spendingtimeoutsidecanhelpimprovephysicalhealthandrecoverytimes,andconfersparticularbenetsformentalhealth.

Evidenceisimportant,buthealthcareisanartaswellasascience.

InthisGuide,thetermhealingortherapeuticenvironmentorspacemeansaplacethathas

beendesignedorisusedinawaywhichpromotesthehealingprocess,orhelpstoinstilasenseof

well-being.

Thissectionfocusesonthehealthandwell-beingbenetsfrombeingoutside,thoughthereare

numerousotherenvironmentalandeconomicbenetsassociatedwiththecreationofgood

naturalsettings.

Outdoorspacescanhostawiderangeofactivities

Activitiescanbeactive(includinghelpingwithgardeningorsimplegroundsmaintenance)or

passive(sittingunderatree).Theycanincludewalking,birdwatching,socialisingwithother

patientsandfamily,andevenTaiChi.Playingoutsideisagreatwayforchildrenandyoungpeople

torelaxandletoffsteam,awayfromatiringmedicalenvironment,andtherapeutichorticulture

involvingpracticalgardeningactivitieshasalonghistoryofuse.

Why is it important to take healing outdoors?

Staff and volunteers at a garden party at Helen House, Oxford.

Courtesy:HelenandDo

uglasHouse,Oxford.

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Clinicianscancarryoutone-to-onediscussionsduringwalksaroundthegroundswithpatients.

Walkingsidebysideoutdoorsmightwellfeellessthreateningformanythanfacingsomeone

acrossadesk.

Inapeacefuloutdoorspacepeoplecansometimesmoreeasilystarttocometotermswithbad

news,or,conversely,celebrategoodnews.TheQuietGardenMovementencouragespeopleofall

faiths(andnone)toenjoystillnessandreectioninpeacefulgardenspaces.Thesebecomeoases,

privatespacesforthinking,and,formanypeople,placesofspiritualrefreshmentandsupport.

Whyiscontactwithnaturecalming?

Thegardengivesyouthechancetorelax.Igetlostinthatgarden,suckedintothetreesandthebirds

inthesky.BeforeIwouldseethesethingsbutIdidntconnecttothemitisanotherworldIhave

learnedtoappreciateit,anditdoessomethingtoyou,itsamazing.(Patient,Glasgow

HomoeopathicHospital)

Attentionrestorationtheory(ART)wasdevelopedbyRachelandStephenKaplanintheirbook

Theexperienceofnature:apsychologicalperspective,andsincethenanumberofotherstudies

haveestablishedthatthisalsoholdstrueintermsofmedicaloutcomes.

Attentionrestorationtheoryproposesthatcomparedwithhardindoororurbanenvironments,

naturalenvironmentsaremoreefcientathelpingourbrainstorechargeandresumewhatis

termeddirectattentionorfocusonaparticulartask.Increasedcontactwithnaturerestoresour

brainsfromfatigueandreducesimpulsivebehaviour,irritabilityandaggression.InherpaperonHealingGardensinHospitals,writerandacademicClareCooperMarcusstatesthatnature

engagesattentionwithoutdemandinganyeffort,becauseithastheeffectofawakeningthe

senses,calmingthesenses,reducingstress,andassistingapersontomarshaltheirown

healingresources.

At Harbour House residential home

in Dorset, the front lawn has been

turned into a well-used space by

the addition of croquet hoops.

Residents help themselves to balls

and mallets when ever they want

to play and combine socialising

with staying physically active.

The scent of owers.

Party in the garden.

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Contactwiththeoutdoorscanalsobestimulating,aswellascalming.Theco-ordinatorofthe

CreativeSpacesProjectinCornwall,whichenablespeoplewithdementiatoenjoyoutdoor-

relatedactivities,commentedthat,timeandtimeagainwendthatspendingtimeoutside

increasespeoplescommunicationandstimulatesmemories,peoplejustsparkle.

Thereisagrowingbodyofevidence,muchofitrootedinscienticresearch,thatbeingoutdoors

inanaturalsetting,orevenjustviewingtheoutdoorsfrominside,ishighlybenecialforhealthandwell-being.ThisisincreasinglyinformingthedesignofhealthcarefacilitiesintheUK,inan

approachtermedevidence-baseddesign(EBD).Thisapproachisalsoinformedbyarelatively

neweldofstudy,environmentalpsychology,whichseekstounderstandtheinterrelationship

betweenenvironmentsandhumanbehaviour.

Treesandwoodedspaceshaveaparticularroletoplay

Woodlandsareespeciallyrestorativeenvironments;thesounds,sightsandsmellsinawoodplay

aroleinreducingstressbyprovidinginterestandstimulatingthesenses.

Woodlandsprovidearichsensoryexperience,fromthesubtleshiftsintemperaturethatoccur

betweenareasinheavyshade,andinsunnyglades,tothescentofpineneedlescrushedunder-

foot.Awoodlandsettinghasparticularacousticqualities,meaningthequietestbirdsongis

audible.Theageofveterantreesofteninspiresaweinpeopleandprovidesalinkbetweenthe

past,presentandfuture.Woodlands,andindividualtrees,areseenasrepresentingnature,

particularlyintheurbanenvironment.

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Healthbenetsofnaturalsettings

Thehealingpowerofnature,freshair,sunlightandexercisehaveallbeenafeatureofhealthcare

forcenturies,butthepost-warperiodhasbeencharacterisedbyamoveawayfromnature,and

towardsagreaterrelianceontechnology.Recentdecadeshaveseenareversalofthistrendanda

substantialbodyofevidencenowexists,includingmanyliteraturereviews,whichdemonstrates

thehealthbenetsofcontactwithnature.DetailsofsomeofthesecanbefoundintheFurtherreadingsectionattheendofthispublication.

Asidefromtheobviousopportunitiesforphysicalexercise,whichinthemselveswillbenetmost

people,themainbenetsrelevanttothehealthcareenvironmentcanbesummarisedas:

Reductionofpainandstress

Contactwithnaturecanreducebloodpressure,muscletensionandpulserate,andcanalsohaveasubtleeffectonourexperienceofpain.

Patientsandfamilieswhousehospitalgardenshavereportedpositivemoodchangesandreductioninstress.Evenvisualsettingswherenatureisprominentreducestressandimprove

patientoutcomesespeciallywherestressisaccompaniedbyfeelingsofanxiety.

Areductioninstressinturnenablestheimmunesystemtofunctionmoreeffectively,facilitatingthehealingprocess.

Alleviationofdepression

Depressionisaseriousissuenotonlyforthosewithmentalhealthpatients,butalsoforthosewithcardiovasculardiseaseandcancer.Researchindicatesthatexposuretodaylightis

effectiveinreducingdepression,evenforthosehospitalisedforseveredepression.Simplywalkinginnaturalsettingscanhelpmentalhealthpatientsimproveself-esteem,vigourandmood,andreducetension.

Practicingmindfulnessinanaturalsettingcanbeparticularlybenecalformentalhealth.

View onto garden from the

inside of Chalkhill Unit.

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Reductionofaggressivebehaviour

Restorativecontactwithnaturecanreduceirritabilityandtherebyaggressivebehaviour.Studiesfocusingonolderpeoplewithdementiaandonchildrendiagnosedasbeingontheautisticspectrumhaveshownthatboththesegroupsndcontactwithgardens,andnaturein

general,calming.

Increasedpatientsatisfaction

Thosemostlyconnedindoorsparticularlybenetfrombeingoutsideinthefreshairandsunshine.

Naturalsettingscanenhancetheplayandlearningactivitiesofyoungerpeople.

Improvedrecoveryrates

Studieshavedemonstratedthatpatientswhohavecontactwithnature,evenwherethisis

simplyaviewthroughawindow,recovermorequicklyfromoperativeprocedures.Patientsinintensivecareunitswithmyocardialinfarctionexhibitedshorterstayswhensitedinroomswithhigherdaylightexposure.

Improvedstaffperformanceandretention

Gooddesignofhealthcarefacilitieshasbeenfoundtoimprovestaffperformance,recruitmentandretention.

Post-occupancyevaluationsoftheoutdoorsinUShospitalshaveconsistentlyshownthatthestaffaretheprimaryusersofoutdoorspaces.

The staff garden at Newham

Hospital provides an area for

lunch as well as a venue for

birthday and other celebrations.

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Healthcare:anartaswellasascience

Inmakingthecasefortherapeuticuseofoutdoorspaces,theevidencebaseisimportant.

However,manypeoplealsoseehealthcareasanartaswellasascience,andencourageaccessto

outdoorspacesaspartoftakingamorecreativeapproachtopatientcare.

Thegrowingevidencebaseforthesebenetsisoftensupportedbytheobservationsofclinicians.AtthenewChalkhillUnit,wheretheinteriorisinspiredbyaspectsofthesurroundinglandscape,

stafffeelthatpatientsrecovermorequicklyfromillnessthanwasthecaseintheirprevious

building,whichhadnoaccesstotheoutdoors.

Thisapproachacknowledgesthelimitationsinourunderstandingofthedetailedworkingsof

thehealingprocessandembracestherestorativepowersofnatureevenwhentheevidenceis

onlyanecdotal.

AuserofthegardenatthenewMaggiesCancerCaringCentreinLondonillustratedthiswell.

Thegardenwillallowpeopletobethemselvesandhavetheirownspacewithouthavingtospeakto

anyoneandsometimesthatsmorevaluablethananymedicine:onecantakecouragefrombeingin

agoodplace,breathingincourageandbreathingoutfear.(CathKnox,WestLondon,with

secondarycancer)

At Maggies Centre in London the building is surrounded by quiet, peaceful garden areas.

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Practisingmindfulnessinawoodlandsetting

In2003apartnershipcomprisingReforestingScotland,theNHS,ArgyllGreen

WoodworkersAssociation,theScottishAssociationforMentalHealthandLochgilpheadCommunityCouncilwasformedtorestoreneglectedwoodsnexttotheArgyllandBute

Hospital.Fundswereraisedfromarangeofsources,includingScottishNaturalHeritage,

theScottishMentalHealthDepartment,ForestryCommissionScotlandandLeader.Work

beganin2004andinvolvedmanyusersofmentalhealthservices,disabledpeople,young

people,contractorsandvolunteers.

BlarbuieWoodlandwasopenedasapublicparkin2007,withaccessiblepaths,facilities

andinterpretationforquietrecreationaswellasmoreenergeticwoodlandmanagement

activities.Thereareopportunitiestolearnnewskills,includingnurserywork,forestry,timber

processing,woodworkingandconstruction,andthewoodalsohostsartandmusicprojects.

Keydesignfeatures

Thethresholdarchandsignagewelcomesvisitorsintothewood,indicateswheretheycan

go,andaccessisprovideddirectlyfromthecarpark.Theprojectmakesgooduseof

borrowedlandscape,withspectacularviewsavailablefromthesiteoutacrosstheloch,as

wellasaccesstothehillsbehind.

Case study 1: Argyll and Bute Psychiatric Hospital, Lochgilphead, Argyll.

A wide variety of art and craft activities take place on site out in the fresh air.

Routes through the woods take good advantage of views of the hills and loch.

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Healthbenets

Clinicians view

ForpeoplewhomIrefer,Ithinkalotofthebenetisafeelingofachievementinactually

doingsomeworkinthewoods,seeingthebenetsoftheirwork.Therescertainlythebenetofexercise;theresthebenetoffreshair;theresthebenetofworkingwithothers

onaproject.

Oneparticularthemeisthepromotionofmindfulnessinpatientsappreciatingthe

presentmomentwithoutanxietyaboutthepastorfuture.Formanypatientsinthis

hospitalwithmentalhealthproblems,cultivatingmindfulnessisanessentialskilltolearn.

Cliniciansdescribehowhelpfulthewoodlandsettingwas:

Ithinkwhatsniceaboutthewoodsisthepeacefulnessofwalkingandthebigtreesandthe

nature,andbeinginaplacewhereyoucanpracticemindfulness,awareness.

Peoplehavealotofconcernsandanxieties...maybeyoucouldbeinaquietroominaquiet

ward,butifyouvegotabusyheaditshardtorelaxandbegrounded,soIthinkitdoeshelpto

gooutintoawoodlandarea,andfocusonlike,otherthingslikethenature,likethetrees...

andjusttohelpemptythehead,empty...

Patients view

WellIcomeuphereandIliketojustexperienceonewith...nature.Idoreallyfeeloneness

withnaturewhenIcomeuphere,Ijustsitinthewoodsandjusttalkwiththebirds...Iquite

liketowhistlebacktothemandtheywhistleatmeandIwhistlebackandtheywhistleagain...itsgoodforthewell-being,itsdenitelyimprovedmylife,yeah.

IthinkImalotmorecondentinwhatIdo,andImalotmorecondentinwhatIsayto

people.Itsgoodtomeetalotofpeopleindifferentaspectsinthewoodaswell.

All-weather paths make the wood accessible to a wide range of people, with opportunities for

both quiet solitude and socialising.

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Designinghealingspaces

Allofthedifferentpartsofasitecanhaveatherapeuticpurpose:

thewidersetting;theareasaroundandclosetothebuilding;thegardenspaces.

Theabilitytolocateabuildingtotakeadvantageofaview,ortoarrangeasiteinawaywhich

prioritisespedestrianovervehicleaccess,aretremendousopportunitiesinanydevelopment.

Innewfacilities,thiscanbeplannedfromtheoutset,withthevalueofexternalspacesbeing

recognisedwithinthebusinesscaseforthedevelopmentasawhole.Forexample,atGlasgow

HomoeopathicHospital,thebuildingwasdesignedsothatpatientcarespaceshaveadirectview

andconnectiontonatureandareseparatedfromnoisyareas,whilestaffareasarelocatedtothe

northandeastofthebuildingtoavoiddirectsunlightduringworkinghours.

Improvementofexistingfacilitiesrequiresamoreincrementalapproach,basedonanappraisalof

thesiteasawhole,itsstrengths,weaknessesandopportunities.Evenonthemostchallengingof

sitestherearealwaysimprovementsthatcanbemade,asthesketchexampleswhichfollowshow.

Thinkingaboutthreedifferentaspectsofanysitecanhelpidentifyitspotentialtherapeuticvalue.

Theseaspectsare:

thewidersetting;theareasaroundandclosetothebuilding;gardenspaces.

Astrategyormasterplanwillhelptoensurethatthesethreecategoriesofspaceareallwell

connectedwithpathstomakeacoherentsitelayout.

Creatingahealingenvironmentwiththewidersetting

Carefulthoughtshouldbegivenwhenlocatingnewfacilities,toensurethatthewidersettingis

partofthehealingenvironment.Inthecaseofanexistingbuilding,onemayneedtobecreative

aboutitsuse.

Sometimes,andespeciallyoncrampedurbansites,accesstotheoutdoorsisrestrictedtoaview

ofthewidersettingandinthesesituationsitwillbeessentialtomakethemostofitperhaps

simplyrearrangingadayroomtolookoutofthewindowtothelandscapebeyond.Many

in-patientsmaybeconnedtobedandenjoymentofsunlightandanaturalviewcangreatlyenhancetheirstay,andpossiblyacceleratetheirrecovery.

Onmorespacioussitesitmaybepossibletoconnectwiththesurroundinglandscapebyframing

viewsandlinkingpaths.TheroutearoundSalisburyDistrictHospitalconnectswithnearby

What sort of spaces should we be designing?

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footpaths,andstaffareencouragedtousethispathcircuitintheirbreaks.InScotland,where

thereiswiderpublicaccesstoopenspace,theNHSestatehasgreatpotentialtobecomea

valuableresourceforthewholecommunity.

Creatingahealingenvironmentinthebuildingsurroundings

Thepatientsexperiencestartsoutsidethebuilding,andtheirinitialimpressionofitplaysabigpart

intheirperceptionoftheservice,aswellasinuencingthelevelofstressexperiencedinattending.

Withcarefuldesign,spacesroundthebuildingsuchascarparksandentrancescanandshould

enhancethepatient(orvisitor)experienceconsiderablyeventhoughtheymaynotbe

specicallydesignatedfortherapeuticuse.Well-designedsurroundingsareeasytonegotiate,

meaningthatthejourneyfromsiteentrancetothewardorwaitingroomisaspleasant,well-signedandrelaxedaspossible.

A break away from the ward,

enjoying a chat in the sunshine.

Tree and hedge planting would help make this bleak road on an urban hospital site more of a pedestrianenvironment, rather than one simply focused on trafc and car parking.

Above:Existing view.Right:How the improved areacould look.

Large specimen trees give scale and provide

a better set ting for the taller buildings nearby

Edible hedge of mixed native shrubs

plums; damsons; elder; blackthorn

Cars hidden behind

new hedge planting

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Creatingahealingenvironmentingardenspaces

Gardenspacesarepredominantlynaturalincharacterandcancontainlotsofplanting.They

rangeinscalefromtheverylargetotheverysmall,andfromformalherborphysicgardens,

throughtoorchardsandmoreextensivelawnswithspecimentrees.

Gardenspacesnexttobuildingsofferthegreatesttherapeuticpotential.Proximitytowardsorwaitingroomsisabsolutelyessentialtoencouragenotonlyindependentaccessbutalsostaff-

assistedaccessanurseorplayassistantismuchmorelikelytotakeachildintoagarden

accessedfromthewardthanonethatrequiresatripawayfromit.

Somebuildingshavehiddencourtyardandroofgardenspaces,whichmayhavestrongpotential

intermsofproximityandaccessibility,aslongasthereisadequatesignagewithinthefacilityto

alertpeopletotheirpresence.Thesespacesarealwaysworthexploringasapriorityfor

developmentasahealingenvironment.Moreremoteopenspacesonthesitemaybetoofar

awaytobeeasilyreachedandwellused.

GreatOrmondStreetHospitalislocatedonaveryconstrainedsiteincentralLondon,withalmost

nooutdoorspaceatall,sothenewstaffgardentherewasconstructedontheroof.Thegarden

canbehiredforeventssuchasbirthdaypartiesandshelterfromthewindisprovidedbyglazed

panelswhichstillallowpanoramicviewsoftheLondonskyline.

Great Ormond Street Hospital roof garden

and commemorative inscription to a

previous member of staff.

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Seating against chapel

wall looking onto trees

Birch trees set

in spring bulbsRaised planter with

scented shrubs

Acreativeapproachtoexternalspacesacrossthesite

StCatherinesMentalHealthTrustHeadquartersislocatedinaGradeIIListedbuildingset

inaparklandsiteontheoutskirtsofDoncaster.OriginallythehomeofaVictorian

industrialist,thebuildingissurroundedbyalargenumberofnewerbuildings,offeringa

widerangeofsettingsforthosewithmentalhealthproblems.

Case study 2: St Catherines, Rotherham, Doncaster, and South HumberNHS Foundation Trust, Yorkshire

Adult Mental Health Unit garden.

Courtesy:RDaSHNHSFoundationTrust.

With new seats and some extra planting, this unpromising area outside the chapel could become a Quiet Gardenat Charing Cross Hospital, London.


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Thewidersetting

TheEnvironmentManagerisdevelopingaproposalforopeningupanewfootpathlink

throughthehospitalgrounds,whichwillconnecttheproposedhousingdevelopmentnext

tothesitewithanimportantlocalnaturereserve,PotterickCarr.Thisnewroutewillprovide

acirculargreenwayaswellasawildlifecorridorforthebirdsinthenaturereserve.

Benets:

Biodiversitybenetsforthesiteandthewidersetting.BenetsforthepublicproleoftheTrust.IncreasedpotentialfordevelopingaHealthyWalksprogrammeforthelocalcommunity.

Thebuildingsurrounds

Theparklandischaracterisedbyoutstandingtreesandwoodland.Thisiscurrentlybeingaugmentedbynewplanting,aspartoftheNHSForestinitiative,tohelpscreen

neighbouringdevelopmentandprovideextraprivacyforthoseusingthegrounds.Work

willincludeextendingtheexistingredpathnetwork,whichpatientsusetoidentifysafe

walkingroutesroundthesite.Thenewpathwillalsobeavailableforlocalresidents,as

wellasstaffonsitetherearealreadyseveralgroupsofstaffwhoregularlycomplete

circuitsofthesiteatlunchtime.

New NHS Forest planting will complement existing mature trees and also screen neighbouring

development.

Staff, visitors and certain patient

groups have free access to the

parkland surrounding the

hospital buildings.

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Benets:

Trustbetterintegratedwithinlocalcommunity,resultinginabetterunderstandingofmentalhealthissuesandincreasedaccesstotheTrustsiteforlocalresidents.

Longerwalkingrouteforpatientsandincreaseinexercisebeingtaken.Increasedbiodiversityandamenityfromadditionaltrees.

Thegardenspaces

Thegardenattachedtothenewlow-secureCusworthandBrodsworthwards,andthe

mediumsecurePsychiatricIntensiveCareUnit(PICU)isaccessibleondemandtothe

in-patientsthere.Theimpactofthestandard3mhighfencingenclosingthespaceis

mitigatedbycolourfulherbaceousplantingandthereisplentyofseatingtoencourage

peopletospendtimeoutside.Thehistoricwalledgardennowhousesahorticultural

therapyproject,wherelocalresidentscanbuyplants.

Benets:

Freeaccesstotheoutdoorshelpsrestoreasenseofcontrolforpatients,especiallyimportantforthosedetainedagainsttheirwill.

Anattractiveviewofanaturalenvironmentisbenecialevenforthosewhorarelyventureoutdoors.

TheretailaspectoftheWalledGardenProjectstrengthensconnectionswiththelocalcommunity.

TheEstatesbudgetiscontributingfundsto

theseimprovementsinthegrounds.InitialNHSForestplantingcost5000(with

additionalWoodlandTrustsupport)butan

additional24000isnowbeingaddedtoa

BigLotteryGranttomakeatotalofalmost

250000forasecondphaseofwork.This

willimproveaccesstothewoodlandand

includeengagementwiththelocal

communitytorecruitateamofvolunteers

tocreateandmaintainpaths,assistwith

woodlandmanagementandpotentially

eventransformthesiteintoagreengym.

The historic walled garden houses a social

enterprise project, where service usersdevelop new skills in horticulture, helping

them to return to employment.

Enclosed courtyard, Psychiatric Intensive Care

Unit, Skelbrook Ward.

Courtesy:

RDaSHNHSFoundationTrust.

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Designprinciples

Thedesignprinciplessetoutinthissectionprovideachecklistforanyoneimproving

existingspacesorcreatingnewones:

1. Valuewhatyouhave2. Createplaceswhichfeelspecial

3. Maketheoutsideaccessible

4. Focusonpeoplesneeds

5. Connectwithnature

6.Balanceriskwithbenets

7.Designforchange

Designingoutdoorspacesfortherapeuticpurposesmeansconsideringanumberoffactors.Howwillthespacebeused?Isiteasilyaccessible?Arethereparticularclinicalneedstoconsider?What

abouthealthandsafety?

Thedesignprincipleswhichfollowhavebeendevelopedprimarilytoprovideaframeworkfor

peoplewithoutadesigntraining,tobegintothinkthroughtheelementsofanindividualproject,

andtotacklesomeofthequestionslistedabove.Theyarenotintendedtocovereveryaspectof

design,buttoprovideanintroductiontothesubject.Theyhavebeenformulatedtoreectwhat

ismostimportantandrelevanttohealthcaresettings.

Theprinciplesareintendedforspaceswhichwillhaveapredominantlytherapeuticfunction,and

areapplicabletobothgardenspacesclosetobuildingsandtothefurtherreachesofasite,aswellastonewfacilitiesattheplanningstage,andexistingfacilitiesbeingimproved.

Mostprojectswillrequireinputfromadesignprofessional.Theroleofthedesignerwillbeto

designaschemesothatitistforpurpose.Mostdesignerspreparedetaileddrawingsand

specicationsforthosewhowillactuallyconstructthenewgarden,althoughsomelandscape

gardenersorcontractorsalsoofferadesignandbuildservice.

Itisalwaysadvisabletoemployadesignerwhohashadsomeformaltraininginthiseld,ratherthan

usinganarchitectorinteriordesignerwhomaynothaveexperienceindesigningoutdoorspaces.

Garden designersmaybeabletotacklesmallerspacessuccessfullyandtheycanoftenoffer

particularexpertiseinplantingdesign,whichshouldbeamajorelementinanytherapeuticspace.

Landscape architectsshouldbeemployedonlarger,morecomplexschemes.Thoughtheyshare

manyskillswithgardendesigners,theyareoftenmoreusedtoworkinginthepublicdomainand

cantakefullresponsibilityfordesigningbothhardandsoftlandscapeelements.

Designprofessionalsworkingtocreateatherapeuticoutdoorspaceshouldalsondthedesign

principlesoverleafhelpful.Even someone without any design training who is interested in making

the outdoor space part of the healing environment can help develop a worthwhile project.

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1.Valuewhatyouhave

Healthcarefacilitiesareofteninastateofuxastheydeveloptomeetchanginghealthneeds.

Thereisconstantpressurefornewbuildingsoradditionalcarparks,andevennewhousing,and

openspacemayseemtheobviousplacetoputthem.

TheHippocraticOathFirst,donoharmisagoodguidingprinciplefordevelopingoutdoorspaces.Byvaluingwhatisalreadythere,andunderstandingthebenetsthatopenspaceprovidesmost

importantly,theveryspecialtherapeuticbenets,thecaseforsafeguardingopenspacegrowsstronger.

Howdoyouvaluewhatyouhave?

Tovalueanexistingspaceitisessentialtounderstandtwothings:whatyouvegot,andhowitis

alreadyused.Maybethereisalreadyspaceonthesiteforrecreationbutpeopledonotknow

aboutit,ortheremightbethingsaboutitwhichareputtingpeopleoff,forexamplelitteror

overgrownvegetation.Sometimessomesimplehouse-keepingisallthatisneededtoencourage

peopletouseanarea.

Well-designedfacilitiesarecarefullyplannedtopreserveandenhancekeysitefeaturessuchas

importanttreesorprotectedspecies.Takingamaster-planningapproachandlocatingnew

buildingsfollowingadetailedanalysisandappraisalofthesite,ratherthanlocatingtheminan

opportunisticway,willalwaysgivebetterresults.

Sometimestheopportunitiesarehardtoidentify,asatNinewellsHospital,Dundee.

NinewellsHospitalwaslocatedinanelevatedpositiontotakeadvantageofthepanoramicviews

overtheTayestuary.However,accesstotheoutdoorsforpatientshas,untilnow,beenlimitedto

thesmallfreshairgardenclosetotheentrance.

Alandscapearchitectwasappointedtodevelopamasterplanforthewholesite,withthehelpof

ForestryCommissionScotland.Thesiteappraisalshowedthatoneofthebestopportunitiesfor

accesswasthewoodedparklandtothesouthofthesite.Ithadthepotentialtobeusedbymore

mobilelong-staypatients,aswellasstaffandvisitors,andthesurroundingcommunity.

Theconstructionofanetworkofcycleandfootpathsthroughthehospitalgroundsisnowunder

way.Newseating,restareasandinterpretativeinformationwillencouragegreaterexplorationof

thewoodland,andmakethemostoftheviewsovertheRiverTay.

Aerial view of Ninewells

Hospital in Dundee.

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Thethreerststeps

Step 1: A site appraisal/analysisbyasustainabilitymanagerorfacilitiesmanagementteam,with

theinvolvementofaclinicianwhohasknowledgeofthepotentialbenetsforpatientcare.Where

aretheopportunities?Arethereparticularstrengthsandweaknesses?Inputintothesiteappraisal,

intermsofhealthpromotion,fromtheNHSoreventhelocalauthoritywouldalsobehelpful.

Step 2: TheTrustteamwillneedto set out and adopt a policyregardingtheroleofopenspace

withinthewiderpatientcareenvironment.Supportofseniormanagementteams,includingthe

ChairandChiefExecutive,andthemaintenancestaffisessential.Thepolicyshouldincludethe

businesscasefortherapeuticuseofopenspaceacrossthesite.Cross-referenceshouldbemade

tootherdrivers,suchaslocalTrustorBoardperformancemeasures,andnationalinitiativessuch

astheNHSForestprojectorNHSGreenspaceinScotland.

Step 3:Anaction plantoprioritiseimprovementsandpotentialfundingsources.Atthisstage

additionaldesignsupportfromalandscapearchitectislikelytobeessential,particularlywith

larger-scalespacesormorecomplexsites.

A master plan for the site was prepared by a landscape architect.

New paths around the hospital grounds.

Red squirrels may be returning

to the woods at Ninewells.

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2.Createspaceswhichfeelspecial

Senseofplace

Oneofthemostimportantprinciplesinlandscapedesignisthatdesignshouldalwaysbespecic

toitslocation.Workingwiththesitewillenhancethesenseofplace,andmayevenmakeit

cheapertodevelop.

ThepoetAlexanderPopewroteaboutdesigningwithnatureandsenseofplaceinotherwords,

workwithnature,andworkwiththesite.Thiswillentailanalysingitscharacter,itsstrengthsand

weaknesses,consideringopportunities,celebratingandenhancingthefamiliarinthelocality,and

designingtodelight.Inthiswaythesitewillcomfortandstimulate,beenjoyedandtreasured,and

beaplacewherepeoplewanttospendtime.

Spaceswhichfeellikeplaceswillbewellused

Theaimistocreatespacesthatareplacesintheirownright,withastrongcharacter,whichwillhelptoensurethataspacewillbewellused.InScotland,theGoodPlaces,BetterHealth

frameworkpromotesthehealthbenetsofwell-designedspaces.Itrecognisesthatpoor

environmentsmayfosterhopelessnessandstressanddiscouragehealthybehaviour,whereasthe

creationofpositivephysicalenvironmentsmaynurturebetterhealthandwell-being.

Specialfeaturesshouldbeprotectedandincorporatedinthedesignwherepossible.Trees,

includingfruittrees,areespeciallyhelpfulinestablishingasenseofplace,oftencombininga

distinctiveappearanceorcharacterwithanincreasingsenseofantiquityastheymatureinto

venerablespecimens.

Pine trees at Chalkhill have

inspired the design of the

interiors.

Adding a tree to this dull courtyard will make it feel more like a place, even inviting on a warm autumn evening.

Above:Existing view.

Right:How the improved areacould look.

A specimen tree provides a

new focal point for the

courtyard and makes it feel

like a place in its own right

The new tree should be upright

rather than spreading, to ensure

that views from the windows are

not obscured and the building

still receives plenty of light

Seating helps make the space feel more

inviting and also more likely to be used

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Inruralareasitisimportanttobeawareoflocaldistinctiveness,orwhatmakesthelocality

differentandspecial.Oftenitmeansusingmaterialscharacteristicofthatarea,forexamplestone

pavingorparticularplantssuchasbox,whichgivesBoxHillinSurreyitsname.InShefeldon

theNorthernGeneralHospitalcampus,oldindustrialartefactsareplacedaroundthesiteatkey

locations.Theseprovideinformalmeetingandorientationpoints,andremindeveryonethat

Shefeldisacitywitharichindustrialheritage.

AtthenewSecondRhonddaCommunityHospitalinWales,whichwasbuiltonthesiteofaformer

coal-mine,thelandscapehasbeencarefullydesignedtoreectthecharacterofthesurrounding

landscape.Drystonewallingusedlocallyforeldboundariesfeaturesprominently,andhas

alsobeenusedtocreateseatingspacesinthecourtyards.Slateisusedasasubstituteforgravel

andalsotoformstandingstoneswhichprovidestrongfocalpointsinsomeoftheother

courtyardspaces.

Artworkdesignedinasecondphaseofworktoenhancethecourtyardfeaturesalsohelpstogive

thesespacesadistinctcharacter.

Using local materials will ensure

that outdoor spaces reect the

character of their surroundings.

Courtesy:JamesNewma

rch.

Courtesy:4DLandscapeDesign.

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3.Maketheoutsideaccessible

Anintegratedapproach

Thisapproachintegratesbuildingsandstructureswiththewiderlandscape,ratherthanfocusing

mainlyonbuildingsanddesigningthesitefromtheinsideout.Wherepossible,thismore

strategicapproachispreferabletotacklingexternalareasonagardenbygardenbasis,whichcanonlyinllthespacesleftoveroncethebuildinghasalreadybeendesigned.Well-integratedsites

will,bydenition,beaccessible.

Easyaccess

Alongsidethequalityandproximityofthespace,easyaccessisprobablythemostimportant

factorindeterminingwhetherspaceswillactuallybeused.Designingthebuildingswithregardto

theiroutdoorspaceshouldhelptoensurethatthereisplentyofdirectaccessfrominside,out

intothespaces.AtNewhamUniversityHospitalinLondon,courtyardspacesoffthemaincorridor

provideeasilyaccessiblespacesfortheground-oorcafsandwards.Moremobilepatientsontheupperoorsalsousethesegardens,takingtheliftsorusingthestairstogetthere.

Whereappropriate,wardsshouldbedesignedtoallowbedstobewheeledoutintothesunshine

(rememberingthatsomepatientswillalsoneedtobeinshade).Formanyhospicesthisisa

routinepractice,suchasattheJosephWeldHospice.

Aclearhospitalpolicyonusingoutdoorspaceswillalsohelptogivestaffcondenceto

encouragepatientstogooutsidewhereappropriate.

Formanypeople,andespeciallythoseconnedtobed,beingabletoenjoytheoutdoorsfrom

insideisimportant,andviewsoftreesoragardenshouldbeavailable.Thismeanstakingcarethat

thewindowislowenoughandthebedisorientatedtowardsit.SomeoftheKingsFunds

EnhancingtheHealingEnvironmentprojectshaveinvolvedretro-ttingdoorstomakehardto

reachspacesaccessible.Thisisoftenworthexploringinexistingbuildings.

TheLambethCommunityCareCentreiscleverlyintegratedwithitssetting,andthegardensareseenasanessentialpartofpatientcare.Sun-roomsandbalconiesarepopularwithpatientswho

arenotyetreadytogooutside,butwhostillwanttoenjoythefreshair.Evenpatientsin

wheelchairsontheupperoorscangooutindependently,alongahigh-levelwalkwaywhich

connectsthebalconyareaswiththegarden.

A bed is made ready to be wheeled into the sunshine.

Imagescourtesy:JosephWeldHospice.

The sun room offers a taste of

the outdoors at Lambeth

Community Care Centre.

Courtesy:EdwardCullinanArchitects.

Beds can be wheeled out onto both the balconies and the patios.

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Beingcreative

Someorganisationsandhealthcaresettingsareexperimentingwithdifferentwaysofbringing

natureinside,whereparticularpatientneedsorthedesignofthebuildingmeansaccesstothe

naturalenvironmentislimited.

AtAlderHeyChildrensHospitalinLiverpool,recordedbirdsongisplayedinsomewardsandCDsaregiventopatientswhentheyleavetoassistwiththeirrecoveryathome.

AtDorsetCountyHospitalinDorchester,inthechemotherapyunitwhereinfectioncontrolisahighpriority,livelmistransmittedfromanaturereserverunbytheDorsetWildlifeTrustas

partofthehospitalsRoomWithaViewproject.

Insomeclimates,oronverysmallsites,winter-gardensorconservatoriesmaybethemostsensibleoptionfortherapeuticfunctionssuchasphysiotherapy,especiallyforchildren.

A woodland setting for the new

Childrens Unit at Salisbury

Hospital.

Courtesy:SamBoex/3DSolutions.

An especially creative approach will be needed where outdoor areas are inaccessible: the children here canwatch the pet rabbits playing, through the windows.

Above:Existing view.Left:How the improved areacould look.

Floor to ceiling windows allow good

views in for the smallest visitor

Doors kept locked for this

garden which is inaccessible

to the public

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4.Focusonpeoplesneeds

Insuccessfultherapeuticspaces,meetingpeoplesneedscomesrst,ratherthanthedriveto

reducemaintenancecostsoravoidrisksbeingprioritised.Designersshouldworkcloselywith

people(usergroups,ortheirrepresentatives)tounderstandtheseneeds,ratherthanproceeding

onthebasisofassumptionswhichmightbemistaken.

Inclusivedesign

Animportantgeneralpointisthatspaceswhicharedesignedtohaveatherapeuticfunction

shouldfeelcomfortableandshouldbeplaceswherepeoplefeelsafe,relaxed,atease,andnot

overlookedorconstrained.

Multi-functionalspacessuchasgeneralgardenareasareoftenintendedforawiderangeof

peoplewithwidelydifferingneeds.TheInclusivedesignapproachisparticularlyrelevantfor

thesecateringforspecicneedsinasubtlewaywhichmeansspaces(orstructures)canbe

enjoyedbyallusers,ratherthanbyonespecicusergroup.AccordingtoDavidKamp,aninclusivedesignspecialist,Designconsiderations...areoftensubtledetails,easilyoverlooked

exceptbythosewhoneedthem.

Itmaybethecasethatsomepeoplesrequirementsareconicting.Jasmineplantedinagarden

tohelpalleviatesymptomsofdepressionmightprovetoohighlyscentedforthechemotherapy

patientstrugglingwithnausea.Workingcloselywithpotentialusers(ortheirrepresentatives)will

helpovercomesuchissues.

TheSensoryTrust,basedinCornwall,hasdevelopedtheCreativeSpacesProjectwithCornwall

Care,Cornwallslargestindependentcareprovider.Theprojectaimstoimprovecarehome

gardenssothattheymeetresidentsneeds.Inordertounderstandthese,theTrustrananumberofeventssuchasanoutingtotheEdenProjectledbyyoungpeople,andthedesignworkshop

inthegarden,whereresidentErniewasinvitedtosharehisgardenmemorieswithstaff.

Garden visits and design workshops all help to clarify peoples needs.

Imagescourtesy:Sensor

yTrust.

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Cateringforspecictherapeuticneeds

Insomespaces,thelayoutneedstobequitespecictotheusergroup.Forexample,inamental

healthdevelopment,agardenusedbyelderlypatientswithdementiawillbequitedifferenttoone

usedbyyoungmenwithmentalhealthproblemsrelatedtodrugmisuse.Fundingforgardenspaces

mayalsobeeasiertoprotectwhenthelinkstospecictherapeuticfunctionsaremadeveryclear.

Involvingdisabilityaccessgroupsisessentialtoensurethatallthekeyissuesareaddressed,

especiallywithregardtointelligentandsensitiveinterpretationoftheEqualityAct(2010).Catering

forbroaderequalityanddiversitycommitmentsmayinsomesituationsalsoextendtoaddressing

culturalissues.

AtthenewAlzheimersRespiteCentreinDublin,thegardenisfullysecureandhasbeendesigned

toavoiddeadends,focusinginsteadonaloopsystem.Manyofthepatientswander,and

makingthiswanderingmorepurposefulreducesthelikelihoodofthembecomingstressed.

TheCentreManagerdescribedhowhelpfulthegardenisforresidents:Ifsomeoneisgettingworked

up...youcantakethemoutside,eveninthewinter...thepersonoftencalmsdownmorequicklythan

inside,wherethewallscanfeelveryconning...wehavescentedherbslikelavenderarounddoorways

andweencourageresidentstocrushtheleavesintheirhands,toreleasethescentontotheirskin.

Itshowaspaceisusedthatcounts

Sometimes,alackoffundingorstaffresourcesmeansmakingasmuchaspossibleofanexisting

area.Intheabsenceofanewdesign,encouragingthestafftousetheareamorecreativelymay

enableaspacewhichonthesurfaceseemstohavelittletherapeuticpotentialtomeet

peoplesneeds.TheCreativeSpacesProjectinCornwallintroducedsimpleoutdooractivity

stationsintothegardensofcarehomes,encouragingresidentstospendmoretimeoutdoorsandtoexplorenewareas.AndatWillitonHospitalinSomersetstaff,encouragepatientsoutsideto

re-learnoldskillsinthecaseofonegentlemanwhowasabutterycollector,usingabutterynet!

The garden at the Alzheimers Respite Centre, Dublin, is designed to be secure but also safe and welcoming.

Courtesy:

NickKane.

Scented lavender.

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5.Connectwithnature

Natureliesattheheartofoutdoorspacesforhealthandwell-being.Trees,springtimeowers,

shrubs,birdsong,autumncolours,agentlebreeze,sunshineandrainareallsomuchpartof

everydayexperiencethatitiseasytotakethemforgranted.Forthosewhoareillinhospital

wards,orperhapsanxiousorstressed,theycangreatlyassistthehealingprocess.

Usingnaturalmaterials,andmakingthemostofnaturalelements(earth,wind,water)aswellas

plantingallhelptostimulatethesensesandreconnectpeoplewithnature.Asmallbird-feeding

areaorplantschosentoprovidenectarforbutterieswillgiveeveryonesomethingextratowatch

andanotherreasontogooutside,evenifjustforashortbreak.

Wildlife

Plantedareasarealsomuchmorelikelythanpavedonestoattractbirdsandotherwildlife,which

addextralifeandinteresttoagarden,likethecafcourtyardsketchedbelow.

OneofthereasonsIwantedtoworkattheHomoeopathicHospital,isthebuilding.Itislightandairy

andwelcoming.Thesenseofspaceisextravagantforahospital.Thebestthingaboutworkinghereis

openingthewindowsandlisteningtothebirdssingingasIwork.(CandidaFenton,Librarianat

GlasgowHomoeopathicHospital)

Inschemeswithastrongemphasisonwildlife,itwillbeimportanttomakesurethatnativerather

thanornamentalplantsareused.Thiswillhelptoensurethattheschemebenetslocal

biodiversityasmuchaspossible.Evenmodestimprovementstoaspacetocreateanewgarden

couldhavemajorbenetsforwildlifeinthevicinityandhelpfacilitiesmeettheirlocal

performancetargetsintermsoftheenvironment.

The excitement of meeting a

snail for the rst time.

Courtesy:ChloeEvans-Lippett.

The caf courtyard sketch here shows how a rather dull paved space could easily be turned into a moreinteresting outdoor eating area.


Picnic tables replaced with more

comfortable seating, easier for

those who are less mobile to use

Trees under-planted

with edible herbs

and soft fruit, suchas strawberries

Apple, plum and cherry trees help to soften the space

and create privacy; all growing in light-weight planters

and soil to reduce loading over the roof garden surface

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Forexample,inthesouth-west,plantingasmallareaofDevilsbitscabiousmighthelptoattract

theendangeredmarshfritillarybuttery,apriorityspeciesintheUKBiodiversityActionPlan.

TheWildlifeGardenatTivertonHospitalfocusedonmakingsmall-scalechangestoencourage

wildlife,suchastheintroductionofareasofnativeplanting.Thewholeschemehascostlessthan

1000toimplement(excludingthevalueofvolunteerlabour).

AsurgeonatthehospitalwhoisakeenadvocateofhealinggardensworkedwiththeEstates

Departmenttomakeasterilespacemoreappealingtoawiderangeofbirds,butteriesandbees.

Patientsarenowabletowatchthehedgehogstrundlingaroundthegardenatduskfromtheirbeds.

Therobinsarenestingnowinlastyearsblackbirdnest,andtherearehedgehogsusingthepurpose-

builtnestbox,sosomethingmustberightANDthepatientstellmetheylovethebirds,and

wildowersunderacanopyoftrees.ItreallyisaHealingGarden.(Dr.GavinHaig).

The insect nest-box and hedgehog house are just a few ways in which the garden caters for wildlife.

The Wildlife Garden at Tiverton Hospital.

Wild owers in the new

meadow areas.

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6.Balanceriskwithbenets

Caringforpatientsandkeepingthemsafeisobviouslyakeyobjectiveinhealthcare,alongwith

restoringhealthandwell-being.Therearerisksinvolvedwithaccesstotheoutdoors,forexample

whenpatientsventureoutofthewardintoanadjacentgarden,butthesemustbeweighed

againstthebenetsofexerciseandreconnectingwiththeoutsideworld.

Managingdesignconstraintsconstructively

Mentalhealthsettingscanbeespeciallychallengingfordesigners,butwithagrowing

understandingoftheimportanceofaccesstothenaturalenvironment,manysettingsarenow

providinghighqualityspacesespeciallyimportantinresidentialunitsorwherepeopleare

detainedundertheMentalHealthAct(1983,asamended).

IntheWandsworthRecoveryUnitatSpringeldUniversityHospitalinLondon,thebuilding

wallscreatesecureinternalcourtyardspaceswhicharefreelyaccessible.Here,despitethe

operationalneedforsupervision,acivilisingandhumanesettinghasbeencreatedwhichsupportstherapeuticintervention.

WandsworthRecoveryCentreisarelativelyhighsecuritysettingbutthelayoutoftheoutdoor

areasischaracterisedbydesignqualityratherthanrobustness.Theseatinghereisagoodexample:

sturdy,butwithatactile,softlyundulatingsurfacedesignedinwaywhichradiatescalmness.

Inputfromboththehealthandsafetyandinfectioncontroldepartmentsmaybepartofmaking

surethataspaceissuitabletouse.Theirinputshouldbemanagedconstructively,toavoidtaking

ariskaverseapproachtodesign.Theriskbenetassessment(RBA)process,wherethebenets

ofanactivityordesignareexaminedalongsideanyrisks,isusednowbymanyorganisations

includingtheForestryCommissionasaconstructivewayofmanagingliability.Ithas

governmentsupportthroughtheHealthandSafetyExecutive(HSE).

AtthestrokerehabilitationunitofWillitonCommunityHospital,Somerset,thegardeniswellusedbyin-patientsandtheirfamilies.Allpatientswhoaremobileenoughareallowedintothe

gardenontheirown,andtheyenjoyusingasmallnetworkofpaths,tore-learntheirbalanceand

walkingskills.Theyarealsoallowedaccompaniedaccesstoareasoff-site.

Co

urtesy:DavidButler.

Tactile seating at the Wandsworth Recovery Centre.

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Anexampleofhowthedecision-makingprocessdescribedbelowcouldbedocumentedusinga

riskbenetassessmentprocesscanbefoundinAppendix2.

ThegardensaroundWillitonHospitalinSomersetareunremarkableinappearance,buttheyare

usedcreativelybythetherapiststhere.SeniorOccupationalTherapistSoniaexplains:

Webelieveitsreallyimportanttoallowpatientsthefreedomtoenjoythegardenunsupervised [oncetheyhavebeenassessedasbeingabletomanagewithrelativesafety].Havingthatextrabitof

independencemeansthattheyhavetolearntobemorecondentoutside,whichisanessentialskill

forthemtomasteriftheyaretobedischargedsuccessfully.Sometimes,yes,theydohaveafall,butwe

lookattheseincidentsinaconstructivelightandtheinformationabouthowandwhyithappened

theninformsourtherapyandtreatmentprogrammetoreducethechanceofithappeningagain.

Becausewereinaruralarea,wehavealotoffarmersthrough,anditsespeciallyimportantthatthey

arecondentinamoreinformalsettingnousejustbeingabletowalkontarmac.Sowiththem,

wemighttakethemundersupervisionontothefootpathnexttothegardenandevenoverthestile

andintotheeld,walkingoverroughnewly-ploughedground.Itssoimportantforthemtoknowthat

theycandotheseactivities.

Path leading to surrounding elds fromWilliton Hospital.

Garden, Williton Hospital.

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7.Designforchange

Naturalspacesevolvewithtime

Imagining,designingandcreatinganoutdoorspaceisjustthebeginningaspaceneedstolast

longterm.Spacesdesignedcarefullycanbeenjoyedthroughoutallstagesoftheirlifespan.Thisis

especiallyimportantforschemesincludingtrees,whichwillchangemarkedlyastheygrowthroughestablishmenttomaturity.

Successfulgroundsmaintenanceiswellplannedandadequatelyresourced

Groundsmaintenancecostsshouldbeconsideredfromtheoutset,andsetatalevelwhichstill

allowsthespacetomeetusersneeds.Forexample,pavedareaswouldbecheapertomaintain

thanplantedones,buttheywillneverachievethesametherapeuticbenets.

Well-resourcedgroundsmaintenanceisimportantatanyscale.AtthenewForthValleyRoyal

HospitalatLarbert,StirlingshireaverylargeschemethedeveloperwasobligedbyaPlanningObligationtoendowtheoutdoorspaceswithafundof250,000forrestorationand

maintenance.Atamuchsmallerscale,attheLambethCommunityCareCentreinLondon,the

budgethasbeenstructuredtocoverthecostsofapart-timegardener,withanyadditionalcosts

beingcoveredbyincomeraisedfromplantsales,opentolocalpeople.

Designtoanticipatechangingconditions

Openspacecanbeespeciallyusefulinthecontextofachangingclimate.Treescanbeplantedto

provideshadeinhottersummers,helptomoderatetheeffectsofheavyrainfall,lterairto

improvequality,absorbCO2andsupportbiodiversity,andimprovethebeautyofaplace.They

canevenreducemanagementcosts,comparedwithmowngrass.

Toachievethecarbontargetsitisaimingfor,theNHSmustdesignandmaintainoutdoorspaces

sustainably.TheCentreforSustainableHealthcareisworkingtohelptheNHSbecomemore

sustainableandtheNHSForestinitiative,whichaimstoplantonetreeforeveryemployeeacrosstheNHSestate(andbeyond),isanimportantelementinitsprogramme.Woodlandscreen

planting,suchasthatshownopposite,wouldbeasuitableprojectforthisprogramme.

At Lambeth Community Care

Centre the gardener prunes

shrubs carefully rather than

using a hedge-trimmer.

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AtEnniskilleninNorthernIreland,thenewhospitalisbeingimplementedunderaprivatenance

initiativecontracttohighstandardsofsustainability,withthebestpossibleintegrationofbuilt

developmentandthelandscapeasoneoftheprojectskeyobjectives.

Animportantelementoftheprojectisthereconstructionofwetlandsroundthebuildings,using

surfacewaterrun-offfromroofsandhardsurfaces.Othersustainablesolutionsincludethe

extensiveuseoflocally-grownnativeora,andthecreationofextensivespecies-richmeadowscloseto(andvisiblefrom)thehospitalbuildings.

Introducing larger-scale planting will be possible on more spacious sites and will make them more attractive to staffand visitors, as well as patients. Using native species will also bring wider environmental benets.

Above:Existing view.Left:How the improved areacould look.

Illustration:RichardCarm

an.Courtesy:NIHG/LUC.

Trees can help the NHS

meet sustainability targets

and provide wildlife habitat

A limited amount of meadow grass, where

appropriate, helps reduce frequency of grass-

cutting and improve biodiversity on the site

Improved amenity value of site especially

near to countryside enhances theenvironment for staff, visitors and patients

Atrium view of lough at Enniskillen, Northern Ireland.

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Summary

Thedesignprinciplessetoutabovehavebeendevelopedtoreecttheissuesofmostimportance

withinhealthcaresettings;followingthemwillhelpensurethatthedesignofoutdoorspacesfor

therapeuticuseissuccessful.Theywillprovideagoodoverviewofthekeydesignprinciplesforallthosewhomaylackspecialistexpertise,andwhomaybeinvolvedincommissioningor

developinglandscapeprojects.

MaggiesCentreatCharingCrossHospital,Londonisanexcellentexampleofaschemewhich

placeddesignqualityattheheartoftheproject,andalsoillustratesclearlyseveralofthe

principleslistedabove.

Paediatric courtyard at Enniskillen, Northern Ireland. Linear gardens at Enniskillen, Northern Ireland.

Illustrations:RichardCa

rman.Courtesy:NIHG/LUC.

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Illustratingthedesignprinciples

TherearealreadyanumberofMaggiesCentresthroughouttheUK,usuallydevelopedas

agshipprojectsbyestablisheddesignersworkingonaprobonobasis.AlthoughinthecaseofthisparticularcentreinLondon,wheretheoverallbudgetwasgenerous(fundedby

charitabledonationsandfundraising),therearemanyaspectsoftheprojectthatwouldbe

easilyreplicableonthemoremodestbudgetstypicalofanNHSscheme.

Thereisgrowingevidencetoshowthatthe

emotionalstateofcancerpatients,andthatof

theirfamilyandfriends,caninuencetheircancer

experience,treatmentandrecovery.Researchin

theeldofenvironmentalpsychologyhas

establishedthatourphysicalenvironmentaffects

ourbehaviour,andwell-designedenvironments

suchastheMaggiesCentreinLondonhavebeen

showntoenhancequalityoflifeandapersons

abilitytocopewithstress.

Thegardenillustratesparticulardesignprinciples

mentionedinthisguideveryclearly,asshownin

theimages.

Mostpeoplesaidtheyfeltthattheplantssoftenedthebuildingbutalsothewholeexperience

ofbeingthere.Theplantssimultaneouslycreateasenseofcalmness(soothing)butalsoasense

ofenergypeopleoftentalkaboutbeingfascinatedbythespeedthingsgrowatandtheylook

forwardtoseeingthenextstageintheplantsdevelopment;theresavitalityaboutthebudsopening,andnewleavesunfurling.Forpeoplewithcancer,anythingwhichhelpsthemlook

forwardtothefuturewithasenseofhopeismassivelyhelpful.(Researcher,MaggiesCentre

London,2010).

Case Study 3: Maggies Cancer Caring Centre, London.

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Design for peoples needs: Thesiteradiatescalmnessandtranquillity,whichhelpsrelieve

theanxietyandstressoftenexperiencedbythosewithcancer,andtheirfamiliesand

friends.Therelaxedmoodandeasy,inside-outowhelpmakethecentrefeellikea

sanctuaryinthebusyurbanenvironmentinwhichitsits.

Make the outside accessible:Thelandscapedesignerworkedcloselywiththearchitectandthishashelpedcreateabuildingwhichisfullyintegratedwiththeexternalareas.The

gardensurroundsthebuildingandgrowsthroughitinaseriesofintimateandsensual

spaces.Eachroomhasitsownaccessoutside,andthelargewindowseverywheremake

theoutdoorspacespossibletoappreciateevenonawetwinteryday.

Connect people with nature: plantingenvelopsthewholebuildingandthetreesonce

establishedwillhelpscreenthenoiseandbustleofthesurroundingstreetsandtrafc.

Theplantinghasbeencarefullyplannedtoincludescentedfoliage,andtocreateagood

balanceofintricacyandsimplicityofscale.

Bystimulatingallthesensesandprovidingaconnectiontonatureinanurbanenvironment,

MaggiesLondonwillputallvisitorsintouchwiththishealingpotential(designer).

Cour

tesy:MaggiesLondon.

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Overcomingthechallenges

Eachtypeofhealthcaresettingwillhaveitsownparticularchallengestoovercomein

ordertoprovidetherapeuticoutdoorspaces.Somemethodsofprocurement,suchas

privatenanceinitiativeschemes,alsoneedtobetackledcarefullytoachievethebest

outcomepossible.

Therearemanyexamplesofgoodpracticethroughoutthecountrywherethese

challengeshavebeensuccessfullysolved.

Privatenanceinitiativeschemes

The challenge:ManytypesofNHSfacilityareprocuredunderprivatenanceinitiative(PFI)schemes.

ATrustthatplaceslowvalueonlandscapeattheoutsetrisksseeingthisaspectdiminishedeven

furtherduringdelivery,withproposalserodedbyinevitablecontractualandnancialpressures.

The solution:Whilestronglyfocusedonacost-effectivedesignandconstructionprocess,newPFI

schemescanstilldeliverhighqualitylandscapeswhichcanhaveatherapeuticfunction(andwith

existingschemes,changescanbemadebyvariationtothecontract).

Wherethereisnoexistingguidanceonrequirementsforoutdoorspace,theprocuringauthorityshouldincludetheserequirementsinitsoutputspecication.Bidsshouldplaceemphasison,and

allowpropercostsfor,alandscape-ledapproachsecuredthroughthepreparationofdetailed

proposals,includingagreedlevelsofqualityandprovision,atPreferredBidderstage.The

proposedEnniskillenHospitalexempliesthisprocess.

How do we put the theory into practice?

Enniskillen Hospital, in Northern Ireland, North Spine View.

Illustration:RichardCarm

an.Courtesy:NIHG/LUC.

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Acutecare

The challenge:Wardsarefrequentlyrelocatedinacutehospitalsettings,makinglong-term

planningdifcult,withlittleincentiveforcapitalinvestment.Theremayalsobeaperceptionthat

investinginaccesstotheoutdoorsdoesnotofferagoodreturnwhenmanypatientsaremostly

connedtobed.

The solution: AtSalisburyDistrictHospitalinWiltshire,theArtsManager,togetherwiththe

FacilitiesandEstatesManagementTeam,hasidentiedanumberofspacesforpotential

improvement.Theselieoutsidethehospitalsdevelopmentzone,havepotentialamenityvalue,

andhaveausergroupcloseby.Withastrategynowinplace,improvementscanproceedwith

condenceasfundingbecomesavailable.

Inthehospitalsplansforacourtyardgarden,thespacewillbeaccessiblefromboththeStroke

andOncologyunits.Thesketchbelowshowshowfeaturescanbeincludedtohelppatients

fromtheStrokeUnitimprovetheirmobilityandbalancewhilealsomakinganattractivespace

forotherpeople.

Olderpeoplescare

The challenge:Inolderpeoplescaresettings,therehasbeenatendencyforpeopletospend

muchoftheirtimesittingpassivelyintheTVroom.Staffmaybeunawareofthebenetsforolder

peopleofbeingoutsideand,asaresult,encouragingresidentsoutintothegardenbecomesa

lowpriority.

The solution: TheCreativeSpacesProjectinCornwallcreatesopportunitiesforolderpeoplewith

dementiatoimprovetheirenvironmentsandplayamoreactivepartinsociety.ThelessonslearntarebeingdisseminatedacrossallthepropertiesmanagedbyCornwallCare.

Withinthisproject,theconceptofatimetabledactivitiesprogrammehasbeenreplacedbya

newapproachtoactivitiesthatpromotesindependence.AtTrevarnaCareHomeinStAustell,the

New planting, paths and seating would transform this space for everyone, whether patients, staff or visitors.


Seating areas close to entrances

Shrubs around

the edge make

the garden feel

less over-looked

Existing change in level incorporated within new

circular path using different surfacing materials

Grove of Birch trees helps to dene the

space and create privacy. The trees will

also look attractive from inside the

building, even the upper oors

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gardensarebeingredesignedwiththeresidentsneedsinmindtoenablethemtomaketheirown

choicesaboutwhattheydooutside.

Thegardensarefreelyaccessible,andoutdooractivitystationsconsistingofvisualcuessuchasa

pileofbooksinaquietcorner,oracollectionofgardeningtoolsonaworktable,allhelp

residentstoinitiatetheirownactivities,maintainingtheirindependenceandself-worth.Insites

whereindependentaccesstogardensisdifcult,moreemphasisisplacedongettingresidentsoutandaboutbycoachtotakepartintheday-to-dayactivitiesofthelocalcommunityin

whichtheylive.

Primarycare

The challenge:Inprimarycaresettings,patientsusuallyonlyattendforshortappointments.

The solution: Theremaybescopetodevelopoutdoorspacestoprovideapleasantplacefor

peopletowait,orevenasafocusforactivitieswhichcouldincludethewidercommunity.

AttheCulmValleyIntegratedCentreforHealthinDevon,anewapproachtoprimarycareis

beingtrialled,asdescribedinCasestudy4.

Anewmodelofprimarycareforthe21stcentury

TheCulmValleyCentreisatthecoreofaninnovativenationalself-careprojectsupportedbytheDepartmentofHealth.IncorporatingaconventionalGPsurgeryalongsideanatural

healthcentre,thedesignofthebuildingbothinsideandoutside,andalsoofthegrounds

emphasisesaholisticapproachtohealthcare.Thereisafocusonwellnessratherthan

illness,andafocusonself-care,orprevention,ratherthanonmedication.

Ahealthfacilitatoronthestaffactsasagatewaytoawiderangeoftherapiesincluding

activitieswithastrongsocialorcommunityangle,suchastheGardeningGroup,andthe

CommunityInterestCompany(SustaincareCIC)runsacafinsidethecentre.Thecaf

functionsasasocialhub,andpatientsvisitingtheirdoctor,healthprofessionalorthe

pharmacystopforadrinkandsnackandndnewwaystolookafterthemselvesastheydo.

ThePhysicGardenhas

informationonBritish

medicinalplantsthatcan

begrowninpatients

gardens,andhasabench

wherepatientsandstaff

canspendtimerelaxing

outsideinacalming

environment.

Case Study 4: Culm Valley Integrated Centre for Health, Cullompton, Devon.

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IntheKitchenGardenfoodisgrownforthecaf,toshowpeoplehowfoodgetsfromsoil

toplate,tomodelhowlittlespaceisneededtogrowonesownfood,andtoencourage

theuseofseasonalproduce.

ManypeoplehaveattendedsessionsheldbyherbalistsonMakingmedicinesfromthe

GardenandWinterRemedies.Theworkshopsencouragepeopletotakeresponsibilityfor

theirhealthandarealsosocialevents,givingpeopleachancetomeettheirneighbours

andbuildfriendships.

Imagescourtesy:CulmvalleyCentreforIntegratedHe

alth.

Kitchen garden and produce.

Courtesy:Culmvalley

CentreforIntegratedHealth.

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Gettingstarted:theprojectprocesssummarised

Therearefourmainstagesinthedesigncycle:

1. Preparation.

2. Designandimplementation.3. Usingandmaintainingthenewspace.

4.Monitoringandreview.

Thereviewpartofstage4islikelytoleadbacktostage1again,asfurtherimprovements

continuetobemade.

Timespentongettingtheprocessrightwillhelptoachieveawell-designedandsustainable

outdoorspace.

Mostpeoplethinkoftheprojectprocessasbeinglinear,withabeginningandend.However,a

goodprocessiscyclical,withthenalmonitoringandreviewstageleadingnaturallybacktothe

beginning.Spaceschangeasplantinggrowsandmaturesandonlyregularmonitoringwillidentify

whetherpartsofthelayoutneedtobealteredtoo.

TheKingsFundprogramme,EnhancingtheHealingEnvironment,hasdevelopedasuccessful

modelforteam-basedprojects,ledbyclinicalstaffandcarriedoutinpartnershipwithservice

users,anditisrecommendedthatreadersrefertothis.

At Lyneld Mount Hospital in Bradford, service-users, staff, and relatives all worked together to transform an under-used space, with

funding from the Enhancing the Healing Environment programme.

Courtesy:TheKingsFun

dPhotoLibrary.

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Stage1:PreparationRemember to:

Assembletheclientteam.Developabusinesscase.Makesuresufcientresourceshavebeenallocated.Establishwiderpartnershipswithotheragencies.JointStrategicNeedsAssessmentidentiesthebigpictureintermsofthehealthandwell-beingneedsandinequalitiesofalocal

population,andprojectsshouldbeinformedbythisprocesswherepossible.

Checkplanningorlegislativeobligationsandduties.Surveythewholesite.Developadesignbriefbasedonastrongvisionfortheproject.

Funding

Securingfundingwillbeoneofthemostimportanttasksinthisrststage,whenattemptingimprovementstoanexistingspace.Fundingcancomethroughdonationsandcovenants,legacies

andalsogiftsinkindsuchastheworkbytheSellindgeGardenersAssociationinthegardensof

thePilgrimsHospiceinAshford,Kent.

Fundraisingeventsandevencharityshopsgeneratevaluableincomeforfacilitiesorgroups

registeredwiththeCharitiesCommission,suchashospitalfriendsgroups.Charitablestatuswill

makeiteasiertoapplytogrant-makingtrusts,ofwhichtherearemany,thoughtheircriteriavary

widelyandoftenchangefromyeartoyear.

Fosteringpartnershipswithotherlocalagencies(suchasWildlifeTrusts)orjustbeingawareofthe

localpoliticalclimatemayalsoopenupfundingopportunities.

AtBroomeldHospitalinEssex,anambitiousprogrammeofimprovementstothesurrounding

woodlandwerefundedbyaPlanningObligation,aswellastheForestryCommission'sEnglish

WoodlandGrantScheme,includingaWoodlandAssessmentGrant(WAG),forecologicaland

stakeholdersurvey.OthersourcesoffundingincludedtheChelmsfordBoroughCouncilArts

Fund.Thehospitalcommentedthatarelativelysmallamountofmoneyspentonwoodland

improvementsmadeasignicantimpactinpublicperception.

Therearealargenumberoffundingsourcesforschemeslikethiswhichfocusontreeplanting,

suchasthecampaignTheBigTreePlant.DetailsoftheseareavailablefromtheForestry

CommissionandWoodlandTrust.

Courtesy:EdwardCullinanArchitects.

Event for friends and

supporters of Lambeth

Community Care Centre.

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Stage2:DesignandimplementationRemember to:

Appointadesigner.Landscapegardenersorgardendesignersmaybeabletohelpwithimprovingsmaller-scaleexistingspaces,butprojectswhichareatalargerscalewillneedthesupportofa

landscapearchitect.Landscapearchitectsaretrainedtounderstandandimproveoutdoorspaces,andwillhavethelisteninganddesignskillstoengageinasite-widedesigndialogue.

Briefthedesignerthoroughly.Checkthattheyunderstandinclusivedesign,andhaveexperienceofdesigningfortheparticularusersneedsintheprojectinhand.

Bytheendofthedesignstage,theinitialvisionwillhavebeenhonedbytheteam(includingthe

designer)intothenalproducttheschemewhichistobeconstructed.

Implementationislikelytobeundertakenbyacontractor.However,onsmallerschemesinsome

settings(primarycare,residentialsettings)theremaybeopportunitiesforpatientsorstafftohelpwithelementssuchasplanting.

Courtesy:DFClarkBionmiqueLtd.

Volunteers helping with

implementation work.

Tree planting in Cornwall.

Culm valley centre planting by

patients.

Courtesy:NHSForest.

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Stage3:UsingandmaintainingthenewspaceRemember to:

Organisealauncheventorpublicopening.Thankeveryoneinvolvedintheprojectandpublicisethenewspacetopotentialusers.Takeanyfurtheropportunitiesduringtheyeartoorganisesmalleventsoractivitiesinthenewspaceinvolvingstaff,patientsandvisitors.

Monitorhowthemaintenanceisprogressing,especiallyearlyon.Perhapsthelitterbinsneedemptyingmorefrequently,orthereisextrascopeforpatientorstaffinvolvementinsimple

taskssuchaspickingapplesintheautumn.

Dealwithissuessuchassmokingorlitterconstructively(notbysimplypreventingaccess).Makesureadministrativeandmaintenancestaffareeducatedaboutthevalueofoutdoorspace,andtheimportanceofmaintainingaccessibility,toensurespacesremainunlocked.

Allimprovementswhichleadtospacesbeingusedbymorepeoplewillusuallyresultinincreased

maintenanceneedsandpotentialcosts.

Thesecouldbemetbyndingoutwhetherthelocalhorticulturalcollege,horticulturalsocietyor

largercompanieswithcommunityvolunteeringschemescouldhelp.Also,theWildlifeTrustsand

theBTCV(BritishTrustforConservationVolunteers)havebranchesallovertheUKandwilltake

onavarietyofprojects,especiallyinanaturalorsemi-naturallandscape.

Stage4:MonitoringandreviewRemember to:

Carryoutapost-occupationevaluationstudy,tocheckwhetherthereisanythingaboutthespacethatcouldbeimproved.Knowingwhathasworkedwellalsohasimportantvaluein

termsoflessonstoreplicateelsewhere.

Reviewthespaceannuallytocheckthedevelopmentofthelandscapeasitmatures.Treestakesandtiesmayneedadjustingandsometimesgroupsoftreesneedtobethinnedtogive

betterspecimensthespacetogrow.Itwillalsobeimportanttocheckandmaintainplant

health,especiallyafterperiodsofextremeweather.Continuetocheckweeklythatthenewspacesremainaccessible,andarenotlockedunnecessarily.

TheVerwoodOpportunityCentreProjectdescribedinCasestudy5showshowagoodprocess

resultsinasuccessfulproject.

At Broomeld Hospital in

Essex, special efforts were

made to involve young people

from the local community in

implementing work on site

and in celebrating its

completion.

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Raised beds laid out in the shape of a spiral each focus on a different sense; such as this one

celebrating the sense of Taste.

Awell-plannedspaceforeveryonetoenjoy

In2009staffattheVerwoodOpportunityCentrefoundthattheirclients,peoplewith

physicalandlearningdisabilities,wantedtofeelmoreintegratedwiththelocalcommunityandalsohavethechancetodomeaningfulwork.Thisresultedinthecreationofthe

SensoryGarden,anewwildlife-friendlygardennexttotheOpportunityCentreand

neighbouringCommunityCentre.

Stage1:Preparation

TheSensoryGardenprojectisanexcellentexampleofpartnershipworking:

EastDorsetDistrictCouncildonatedtheland.

DorsetWildlifeTrusthelpedco-ordinatethedesignprocessandagreedtolookafterthemanagementandmaintenance,oncethegardenwascompleted.TheOpportunityCentrepromisedtobuildusageofthespaceintotheirserviceusersdailyactivities.

TheneighbouringCommunityCentreofferedgeneralsupporttotheproject.Privatecompanies,includingalocallandlloperator,providedthefunding.ThelocalEmmanuelSchoolhelpedwiththeplantingduringtheimplementation,aswellassettingupaTuesdaygardeningclub.

Stage2:Designandimplementation

Thegardenislaidoutintheformofaspiral,containingraisedbedsdesignedtoappealtothesenses.Tactilescentedplantingwithawidevarietyoffoliageandleafcolourmakethe

siteequallyattractivetoeveryone.Implementationwascarriedoutbyalocalcontractor

butclientsoftheCentrehelpedwithsmallerelements,suchasmakingthesignsforthe

sensorybeds.Particularattentionwasplacedonmakingthegardeneasilyaccessible.For

example,thepatharoundthegardenwasmadeusingmaterialsenablingwheelchairs,

walkersandpushchairs,tomovefreely.

Case study 5: Sensory Garden, the Verwood Opportunity Centre, Dorset.

Raised beds laid out in the shape of a spiral.

Courtesy:NoelBergin/DorsetWildlifeTrust.

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Stage3:Usingandmaintainingthespace

OvertheyearsusageofthespacehasincreasedandmanyoftheOpportunityCentreclientsnowregularlychoosetospendtimeoutsideintheSensoryGardenratherthan

indoors.ShaneCarter(aserviceuserfromtheCentre),said

Wearereallyabletogetinvolvedwiththegarden,helpingwiththeplants,buildingnest

boxes,eventhesignswerewoodburnedbyus.Itsbeengreattoworkinthisgarden,helpingto

createsomethingforthecommunityandustoenjoy.

TheDorsetWildlifeTrustcontinuestomaintainthesite,monitoringtheplantingcarefully

asitmatures.

Stage4:Monitoringandreview

ProjectevaluationhasdemonstratedthattheSensoryGardenprojecthashelpedpeople

withphysicalandlearningdisabilitiestoengagewiththecommunityandagencies,breaking

downsocialbarriers.NoelBergin,ConservationOfceratDorsetWildlifeTrust,said:

TheideaisthatthedifferentsectionsofthegardenwillbeongoingprojectsfortheOpportunity

Centre,schoolsandothercommunitygroupstolookafter.Hopefully,notonlywillitbeawildlifehavenwithinthetown,butvisitorswillleavewithideasonhowtoimprovetheirown

localareaforwildlife.

Volunteers, staff and service-users all work together in the garden. Being out in the fresh airoften helps de-fuse moments of tension as they arise.

Each raised bed focuses on a different sense; such as this one celebrating the sense of Taste.

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Workingwithdesignelements

Thedesignelementslistedbelowwillallbeusefulincreatingtherapeuticspaces:

1. Planting

2. Trees3. Entrances,pathsandboundaries

4. Sitefurniture

5.Art

6.Water

Developingalayoutbasedonthedesignprinciplessetoutearlierandthinkingthroughthe

practicalitiesofthewholeprojectprocesswillprovideagoodfoundationforanyscheme.

Experienceddesignerswillbeabletocombinethevariouselementssuchasplantingorpaths

skilfully,butitishelpfulforthosebriengthemtohavesomeunderstandingofthesetoo.Inthis

way,aschemecanbecreatedwhichhasasenseofplaceandalsomeetsclinicalandotherneeds.

Themostsuccessfulschemesarethosewheretheclienttakesastrongleadandwherethe

designerandclientworkcloselytogether.

Thissectionprovidesanoverviewofsomeofthemostusefulelementsusedindesigning

outdoorspaces.

Hospice garden, Salisbury Hospital: design elements working in harmony to create a tranquil place

Courtesy:PeterUrsem.

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1.Planting

Plantedspacesformatrulyrestorativeenvironment.Goodqualityplantinghighlightsthepassing

oftheseasons,appealstoallthesenses,helpstoattractwildlife,andprovidessomethingnewand

differenttolookateverydaythroughouttheyear.

VegetablesgrowingintheChildandAdolescentMentalHealthUnitatGreatOrmondStreetHospitalareseenashavingtherapeuticvalueforyoungpeoplewitheatingdisorders.

Lotsofhospitalshaveoutdoorcourtyardspaces,butthosewhicharegardenswithlushplants

ratherthanjustpavedareasarefarmorebenecialtopeopleusingthem.

Justsittinginaplantedareacanbebenecial,butsometimestheextraeffortinvolvedinfocusingonagardeningtaskcanhelprestoreafatiguedortroubledmind.AttheBromleybyBowCentre

inLondontheowerorcuttinggardenisusedforhorticulturaltherapy;thestoryofone

volunteersexperienceisdescribedbelow.

IhadbeenworkingasamentalhealthnurseanddramatherapistintheEastEndforseveralyears

itwasabusyandstressfuljob,butIenjoyedit.Unfortunately,though,Isufferedbullyingand

harassmentatwork,anditaffectedmymentalhealth...Iwasunabletoworkanymoreandwentoff

sick,unwellwithdepression.

InApril2007,myGPsuggestedItryvolunteeringattheBromleybyBowCentre.Initially,Iwasonly

doingafewhoursaweekbut,sinceJanuary2010,Ihavebeenonacontractofemploymentfor35

hoursaweekinthecuttinggarden.Itfeelsgreattobeworkingatthislevelagainaftersomanyyears.

SometimesIcannotbelievehowmuchmylifehaschangedinthelastthreeyears.WhenIwasillI

couldntimaginebeingabletoworkagain.Theworkinvolvedingrowingandnurturingplantsis

amazinglysatisfyingandtherapeutic,butyoudonthavetoworkinagardenorgreenspacetobenet

fromit.Justwalkingthroughaparkcanimproveyourwell-beingandpeaceofmind.(Lisa,member

ofthePoLLENproject,BromleybyBow).

Thingstoremember

Chooseplantstoemphasiseseasonalchange,andbuildanticipationofthingstocomeandallowpeopletonoticethepassageoftimeevergreenschemestendtobelower-maintenancebutwillnotachievethis.

Scentedandbrightlycolouredowersandleavescanbeenjoyedbythosewhoarepartiallysighted,aswellasbeingattractiveforallusers.Senseofsmelliscloselyassociatedwiththe

A rich variety of planting means something new to look at every day.

Vegetables growing at Great

Ormond Street Hospital.

Courtesy:CAMHSUnit,GreatOrmondStreetHospital.

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partofthebraindealingwithmemoryandfeeling,soscentscancallupmemoriesand

powerfulresponsesalmostinstantaneously,whichisparticularlyhelpfulforthosewith

memoryloss.

Shrubsshouldbeprunedcarefullytoemphasisetheirnaturalform.Thiswaythespacewilllookwellcaredforthesubliminalmessagebeingifthegardeniswelllookedafter,Iwillbe....

Food-growingisagoodoption,especiallyifthekitchenstaffcanusewhatisgrown.Inlong-stayorresidentialsettingspeoplewillbeabletoexperienceafullgrowingseason,butevenindaycentrestheycanjoininwithwhateverishappeningatthatpointinthe

horticulturalyear.Agoodactivitiesprogrammecanfocusonfood-growingeatingfruit

crumble,orpaintingcolourfulberries.

At Bromley by Bow Centre, local residents nd that visiting the Flower Garden raises their spirits.

This left-over space between buildings feels bleak and exposed, but with the addition of trees and scented shrubplanting it coul

greenspace design for health and wellbeing

Documents