Primary Care Centres

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Primary Care Centres a guide to health care design Second Edition

Geoffrey Purves

OXFORD AMSTERDAM BOSTON LONDON NEW YORK PARISSAN DIEGO SAN FRANCISCO SINGAPORE SYDNEY TOKYO

Architectural PressArchitectural Press is an imprint of Elsevier

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First edition 2002

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09 10 11 12 13 10 9 8 7 6 5 4 3 2 1

v Contents

Foreword vii

Acknowledgements viii

Executive summary ix

Chapter 1 Introduction 1

Chapter 2 An outline review of the main issues (including a summary of the approach to designing health buildings) 5

Chapter 3 International comparisons 17

Chapter 4 Political framework 28

Chapter 5 Approach to brie ng 35

Chapter 6 Design development/measurement of design quality 51

Chapter 7 Holistic care 73

Chapter 8 Art in health 79

Chapter 9 Case studies 83

Chapter 10 The next steps 168

Bibliography 175

Further reading 178

Acronyms 184

Appendix A: Colour images 185

Index 195

vi

A. LIFT 1. Community Health Centre 89 Purves Ash LLP

2. Vale Drive Primary Care Resource Centre 94

Murphy Philipps Architects

3. Chelmsley Wood and Woodgate Valley Primary Care Centres 97

One Creative Environments Ltd

4. The Vermuyden Centre 101 P HS Architects

B. Northern Ireland 1. The Bradbury Centre 110 Penoyre & Prasad LLP with Todd

Architects

2. The Arches Centre 113 Penoyre & Prasad LLP

3. The Grove Well Being Centre 114 Kennedy FitzGerald and Associates

with Avanti Architects Limited

4. Portadown CCTC 119 Avanti Architects Limited with Kennedy Fitzgerald and Associates

C. Scotland 1. Robin House 122 Gareth Hoskins

Case studies

2. Conan Doyle Medical Centre 126 Richard Murphy Architects

3. Community Centre for Health, Partick 128

Gareth Hoskins

D. Community care centres 1. Grassroots in Memorial Park 134 Eger Architects

2. The Oak Tree Centre 137 macmon chartered architects

3. Washington Primary Care Centre 144 P HS Architects

4. Rothbury Community Hospital 145 Mackellar Architecture Limited

E. Special interest buildings 1. Clinical Education Centre 151 Richard Murphy Architects

2. The Richard Desmond Childrens Eye Centre 154

One Creative Environments Ltd

3. The Breast Care Centre, St Bartholomews Hospital 160

Greenhill Jenner Architects

4. Kaleidoscope Children and Young Peoples Centre 161

van Heyningen and Haward Architects

vii

Foreword

It is remarkable how rapidly thinking and development can advance in any specialty in just a few years. When the rst edition of this book appeared, I noted that health care buildings needed to change and adapt to the changes in the way services were being delivered. They needed to present patients and the public with a new vision of health, in the same way that practitioners were trying to think more of the needs of the person behind an illness. This volume shows just how much has been accomplished and how expe-rience from different parts of the country and the world can inspire and how practical learning can occur.

I also noted that at the heart of all health service architec-tural developments a focus on patients and the staff involved needed to be retained, and that the architect was part of a large team with the vision of improving patient care and well-being. Once again, this is a key part of this book.

My own interests in the arts and health are represented, re ecting again on an important development in patient care. This area has developed substantially over the last ten years with the visual arts and architecture becoming more

prominent. This, together with the chapter on holistic care, puts patients where they matter, at the centre of the proc-ess. The major case studies provide a rich seam to mine for re ection and fresh thinking.

In the rst edition, I also noted that as a schoolboy I had always wanted to be an architect, perhaps because Charles Rennie MacIntosh had been a pupil at the same school before me. If things had been different and I had chosen architecture as a profession, I hope I might have written such a book as this, bringing together as it does many of my own professional medical interests in patient care, the arts, and my passion for space and buildings.

A few words from CRM say it all:

Reason informed by emotion, expressed in beauty, ele-vated by earnestness, lightened by humour; that is the ideal that should guide all artists.

Professor Sir Kenneth Calman Chancellor, University of Glasgow

viii

Acknowledgements

Since Healthy Living Centres was published in 2002, many changes have occurred in the governments approach to the provision of primary health care services. I am therefore pleased to have this opportunity to re-examine some of the issues which have emerged concerning the design of doc-tors surgeries, and the increasing demands placed on these buildings. Patients are increasingly seeing the provision of health care services from the point of view of being a con-sumer and are expecting higher standards of environmental design.

My practice, Purves Ash LLP a result of the merger of the Geoffrey Purves Partnership with David Ash Partnership in 2003 has continued to work in the primary health care sector and I would like to thank my colleagues for their support. I have been able to draw on their ideas which has allowed me to develop my research and follow the changes in academic thinking as we have designed buildings using new procurement routes such as LIFT. Much of the new material for this book is also included in my PhD thesis The Design of Primary Health Care Buildings (awarded by Newcastle University, March 2009) and I would like to thank my supervisors Prof Andrew Ballantyne and Dr Peter Kellett for their guidance and helpful comments.

The production of this book would not have been pos-sible without the encouragement, support and tolerance of the editorial staff at Architectural Press. I would also like to thank Sharon Brown who has helped coordinate and check all the illustrations and copyright issues as well as spending many hours dealing with my revisions to the text. Every effort has been made to contact the copyright hold-ers for their permission to reproduce material in this book. However, I would be grateful to hear from any copyright holder who is not acknowledged so that any errors or omis-sions can be corrected in any future editions of this book. This publication was completed at an exciting time for architecture in the health sector and I am sure that many opportunities will unfold during the next few years as new government policies give direction to procurement routes and the development of professional employment contracts with the medical profession.

The case studies illustrate the high standard of work that can be achieved and I would like to thank all of the archi-tects who have provided detailed information about their projects which are illustrated in this book.

Finally, I would like to thank my wife, Ann, for her sup-port and encouragement to complete this project.

ix

Executive summary

Introduction

History can be written at any magni cation. One can write the history of the universe on a single page, or the lifecycle of a may y in forty volumes.

(Davies, 1997, p. 1)

Norman Davies uses this description to justify his broad sweep of European history and offers an alternative approach to the modern compulsion to know more and more about less and less (p. 1).

This study of primary care health in the UK, its evolu-tion and framework lls a slot at a particular time (2008) and seeks to explain the background, and highlight some in uences during a number of key periods in history. It also identi es several factors and makes recommenda-tions about how the design of primary health care buildings should be undertaken in the future, including how the med-ical profession should be engaged in that process.

The speci c contribution of this book lies in two areas of primary care architecture.

1. The importance of the brief in an architectural commis-sion and the need to set out the ethos for design qual-ity using tools such as design quality indicators and evidence-based design principles.

2. An examination of the procurement systems which need to become more exible, with different structures of pri-vately nanced providers. This implies changes to the contractual employment conditions for doctors.

The following summary of key factors includes issues identi ed by other research studies. The introductions and conclusions for each chapter more speci cally set out my own ndings.

1 Relationship between doctor and patient

From earliest times (before 3000 BC) the health and well-being of a person have been subject to a close relationship between two people the patient and the doctor. This rela-tionship can be traced through many civilisations and remains constant even as the development of knowledge about the body has increased. The Greeks paid close attention to the workings of the body as well as spiritual well-being. The Romans advanced aspects of care through the develop-ment of rest houses where the quality of life was seen as a vital component in recovery from ill health. These ideas con-tinued to be re ned in both the East and West with Islamic in uences coming together with Renaissance intellectualism in Italy during the 15th and 16th centuries.

Eighteenth-century Britain saw the development of wealth and civic responsibility evolve into charitable giv-ing with the formation of the early hospitals in London and elsewhere in England. These well-meaning philanthropic ideals began to institutionalise health care, and although Florence Nightingale made huge strides by recognising some important issues in nursing standards the growth of Victorian Britain saw health care of variable quality. Technical standards in surgery gave rise to some barbaric practices. It was not until the early 20th century, when Lord Dawson attempted to focus attention again on primary care, and health services were provided within the com-munity, that the signi cance of the patient as an individual was re-established. These far-reaching ideas were lost in the race to create the welfare state, a concept that was at the centre of political debate during the rst half of the last century. The rst 50 years of the NHS (the second half of the last century) saw the development of a bureaucratic system, dominated by the provision of health services for all, but implemented from the standpoint of the provider rather than the patient.

Executive summary

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Conclusions

2.1 The brief for a primary care health facility should adopt a holistic approach and should be cognisant of the bene ts that art, music and good food can bring to a sense of well-being.

2.2 Mental well-being is about being content and a brief should be written that re ects this ethos.

2.3 A building should have a high-quality local environ-ment. Not only should the internal spaces be designed for calmness and humanity but the external space and its relationship to the urban fabric of the neighbour-hood should be accessible and welcoming.

2.4 A healthy place is somewhere people can enjoy living and can go about their daily lives free from stress; this leads to healthy lifestyles and healthy people.

2.5 Health care buildings should be integrated with the community.

2.6 Primary care buildings should contribute to a sense of place.

3 Therapeutic bene ts

Early civilisations understood in a largely non-scienti c way that religious and spiritual issues were important to mans well-being. This can be seen from the close relation-ship between a patient and their doctor, a pattern which can be traced over many centuries. As scienti c knowl-edge increased, based on sound research, there was an increasing tendency to assume that health problems could be resolved by purely physical and technical interventions. From the Renaissance onwards, but particularly during the 19th century, medical practitioners became increas-ingly assertive on account of their technical expertise. This continued throughout the 20th century and until very recently the assumption was that medical advances would nd solutions to all problems. Clearly, there are outstand-ing success stories which are continuing to unfold, such as the search for advanced techniques to treat all cancers, the latest DNA research and the possibility of genetic manip-ulation of the human body in a way which could not have been envisaged only a few years ago. The apparently expo-nential growth of scienti c discovery is now balanced, how-ever, by an understanding that we must look again at the provision of health care, how it is nanced and the bene ts that can be accrued from understanding some of the thera-peutic bene ts, physical and spiritual, known to the early civilisations.

Therefore, architectural research into evidence-based design is giving substance and factual data to support the environmental bene ts to which previous generations have responded intuitively.

By the end of the 20th century the NHS was struggling to survive, unable to meet the escalating costs of medical care amidst a political climate of uncertainty about what to do next. The introduction of the NHS Plan 2000 was the begin-ning of a refocusing on patient-centred care and already (by 2008) the government is gaining con dence in promoting the importance of patient power and showing increased con -dence in being prepared to take on the entrenched attitudes of the medical profession. There is renewed interest in re-establishing a strong patient/doctor relationship as the core of medical care, but also a recognition that the quality of the environment and a sense of place are vital to provide a social framework in which individuals can thrive in terms of both mind and body.

Conclusions

1.1 Everyone should have the freedom to choose their own doctor in the UK (or even in Europe and beyond).

1.2 Doctors should provide exible services that are con-venient for the patient (e.g. surgery hours should be appropriate to the locality).

1.3 Service standards should be comparable with other service industries (e.g. complaints procedures).

1.4 Patient care must be focused on giving priority to the patients needs (patient power).

1.5 The NHS should continue to develop electronic services for easy record-keeping and other communication sys-tems and investigative procedures.

1.6 Primary care services should continue to be based in the community with specialist services based on locally accessible community hospitals.

2 Cultural issues

As with the patient/doctor relationship, issues of spiritual-ity have been interwoven with health care from the earliest recorded times. Overlapping with religious principles, the concept of healing the soul has always remained an impor-tant component in the overall well-being of mankind. The Renaissance saw many strands of mental health coming together with recognition that the quality of the environ-ment, and therefore architecture, played a signi cant role in creating human settlements that were conducive to good health. These philosophical strands extended to other disci-plines including music and art.

Some of these issues are understood by the brie ng documentation prepared for the design of hospices. The brief for a hospice starts out with the objective of creating a place that is most calming to someone who is physically ill. The conventional approach to the design of NHS build-ings, including doctors surgeries, has rarely recognised the signi cance of these factors.

Executive summary

xi

Conclusions

3.1 The ethos of buildings should be welcoming and friendly.

3.2 Lessons should be learnt from the design of hospices, particularly the way in which architectural briefs are written.

3.3 Therapeutic bene ts the technical solutions need to be incorporated into design solutions for such issues as good lighting, sound insulation, views to the natural world, and a wide range of other design issues leading to accessible and friendly environments.

3.4 The quality of life should be central to the brief of any primary care facility.

4 Architecture

The power of architecture to in uence a persons well-being has been recognised for centuries. The design of Egyptian temples was recognised as contributing to the spiritual-ity of a place and the Greek and Roman civilisations clearly understood the bene cial effects of well-designed buildings as healthy places to live. More recently, the ability of archi-tecture to contribute to a sense of well-being is known not only philosophically but also technically through the develop-ment of environmental standards for buildings. The brief is the starting-point for a well-designed building and for health care buildings the ethos must be set out if a successful build-ing is to result. In the twentieth century, these ideas were recognised by Lord Dawson when he launched his ideas for health care buildings. Sadly, many of these concepts were lost after the NHS was set up, as bureaucratic systems and mas-sive administrative structures were put into place to manage the nations health buildings estate.

Conclusions

4.1 Architects should have more training in health buildings.

4.2 The brief is crucially important and should set out the ethos for health buildings.

4.3 Architectural design should be driven by quality not function and cost.

4.4 The government should encourage and facilitate the procurement of buildings in the health sector from a range of other providers.

4.5 Private nance should be introduced to the provision of primary care buildings to a greater extent than exists at present.

4.6 Innovation should be encouraged so that different design ideas are explored depending on the scale of the building and its locality.

5 Professional services

Architects should be given the opportunity to create places within the health sector by responding to local needs and with greater exibility in setting briefs. They should be designing buildings for various organisations who have become additional providers of GP facilities in the UK.

Doctors need to be made more accountable to the marketplace. There should be a change from the contractual relationship between the government and GPs with the intro-duction of exible employment packages via other providers, although these must be controlled by the government.

Patients should have a choice of GP, not just based on where they live, and the government should continue to develop community services as part of an integrated primary care pack-age including doctors, ambulance services, paramedic serv-ices, nursing and mental health services. All of these services could be under the umbrella of community-based structures. The existing PCTs should be encouraged to develop their pro-curement policies to generate a variety of building types.

Conclusions

5.1 Doctors should be exposed to the marketplace and understand that patients have the power to demand the service they require. This will give greater choice for patients, and lead to a wider range of types of serv-ice. A range of contractual arrangements covering the employment of doctors should be developed by the pri-vate sector.

5.2 These services should be available at times and in places convenient to patients, not just the doctors.

5.3 Individuals should be free to choose the type of GP service they require. For example, do they continue to use a traditional GP or would they prefer to use other providers such as supermarkets or other high street based providers? Alternatively, private GP services could also be available.

5.4 Architects should be encouraged to provide innovative design solutions for alternative providers. The gov-ernment should ensure that procurement routes are simpli ed; for example, the current system of LIFT is causing substantial delays and delivering buildings very inef ciently.

5.5 The government should be more exible in buying pri-mary care health services.

5.6 Buildings should be designed to a high quality and this factor must come before functionality and cost.

Summary

I would like to end this Executive Summary by identifying three key areas that should be considered when primary health care buildings are designed in the future.

Executive summary

xii

enter the marketplace. New contractual arrangements for doctors should be encouraged. Greater patient freedom will also bring the need for greater personal responsibility and the government is introducing schemes to encourage self-help with appropriate guidance. The continuing develop-ment of electronic records will help to speed up this process.

3 The design of primary health care buildings

With a range of providers, greater expectations of patients about the quality of buildings, and better briefs being given to architects, the range of health care buildings in the future should be more responsive to local needs. They will be responding to an increasing volume of evidence-based design criteria, which will bring therapeutic bene ts to the buildings users. Increasingly, designers should look beyond the imme-diate constraints of the individual building to examine how a primary health care building ts into the urban environment. Government policy will encourage the cross-fertilisation of ideas between urban planning and the generation of healthy places. There will also be an increasing awareness that well-designed places bring a sense of well-being for both mind and body.

1 Political in uences and the governments role in shaping health policies in the future

I have argued that the retention of the original NHS prin-ciples of free care available to all should remain the central tenet for government health policy in the UK. Elsewhere in the world (for example, in the USA) the escalating costs of an insurance-based national health structure are making it increasingly dif cult to afford. The contractual arrange-ments between the government and GPs, however, do require further change. The government has introduced new contractual arrangements and is encouraging the crea-tion of new primary care providers, but the power of the BMA should be reduced.

2 Patient power

The government is using the phrase patient power and this re ects the increasing trend of patients wishing to access medical services as consumers in the market economy. This also is the way in which individuals access most other per-sonal services. We can anticipate the evolution of new pat-terns of health care in the UK as more GP service providers

1 Introduction

Historically, there has been a long tradition of a strong rela-tionship between patient and doctor. This evolved over an extended period from the care exercised in the mercy tem-ples of early civilisations to the holistic treatments that were found in the monastic hospitals founded in the Middle Ages.

The rapid advancement of knowledge, and its wide dis-semination through the printed book invented during the Renaissance, saw the commencement of a scienti c approach to medical treatment. By the mid 19th century there was a greater understanding of disease and Florence Nightingale introduced major changes in the way nursing was carried out.

The Dawson Report (1920) advocated primary care policies based on local services by the GP. At the same time, political and social pressures led to the forma-tion of the welfare state and the creation of the National Health Service (NHS) (1948). The Royal College of General Practitioners was not formed until 1952. General Practitioners (GPs) at that time (mid 20th century) did not have an in uential position in the medical hierarchy. This developed into a pattern of control in the NHS which focused on ever more ambitious plans for large, technologi-cally advanced hospitals during the second half of the 20th century. In turn, this culminated in the failure to deliver services on time and within budget giving rise to wide-rang-ing reviews on the structure of the NHS. In line with other major government spending (e.g. education) it became clear that tax revenues could not continue to rise inde -nitely to service the ambitions of increasingly ambitious and technologically advanced hospitals.

Due to nancial pressures and social changes, giving more power to individuals as consumers, the NHS had to change to re ect these realities. Hence, private capital was introduced and health policies have been focused on provid-ing patient focused care. Services are now examined in rela-tion to convenience and the ability for medical care to be provided in the community. Community hospitals are being built re ecting considerable similarity to cottage hospitals, many of which were closed with great speed in the 1980s.

Ambulance services are also being redeployed on com-munity needs and increasingly being linked to medical facil-ities (GP practices and community hospitals, particularly in rural areas) once again re ecting similarity to the recom-mendations of the Dawson Report of 1920.

The advantages of a primary led health service are also reinforced by the successful policies found in develop-ing countries. As young doctors have the means to work throughout the world often taking a gap year before or after their medical training, they see the successful results of primary health care services operating in poor countries.

The changing pattern of health care is beginning to re-establish the importance of the relationship between doctor and patient. Patient focused care returns power and in uence to the individual who is able to exercise greater control over the medical interventions advocated for their body.

Today, we are at an exciting point in the evolution of health care facilities with a wide diversity of options depending on a variety of political, social and economic pressures. However, each solution is striving to give appeal to the customer and with this comes the realisation that the medical facilities need to compete with each other in a market economy. The unexpected conclusion is that the NHS, although giving universal access to high quality medi-cal services, did not provide a convenient or patient focused service.

The government is grappling with the challenge of pro-viding consistent and high quality technical competence, but in a manner which responds and re ects the needs and aspirations of the patient rather than the convenience of the medical and administrative staff of the NHS. The architectural design quality of new buildings is therefore of greater importance today than it has been for nearly a cen-tury. The therapeutic bene ts of good design are now rec-ognised in both the large hospitals under construction using the PFI (Private Finance Initiative) procurement route and the wider variety of small health buildings being procured using a variety of nancial models.

1

Primary Care Centres

2

playgrounds that have closed in recent years, and the fact that few children now cycle to school as a result of parents citing health and safety problems. There has been a reduc-tion in competitive sports in schools, which brings greater risks for developing diabetes, various cancers and cardio-vascular problems (heart attacks and strokes).

However, there is now a greater understanding that well-designed buildings can have a positive effect on health outcomes. There has also been a growth in the area of evi-dence-based design and an increase in the number of research papers that point to the advantages that can be achieved.

Review of historical bureaucracy and procedures for building procurement

The NHS is the last of the large nationalised industries to come under the spotlight of privatisation. Steel, coal, the rail-ways, electricity and gas were all privatised many years ago but the NHS is continuing to go through a painful process of change. Although the government is committed to the reten-tion of the NHS as a public service, the funding of services will include an increasing percentage of private nance. This will be particularly evident in the provision and nancing of new buildings, including those in the primary care sector.

There had been a philosophy of tight economic planning in the post-war period, which the public had accepted. The bene ts of nationalisation and the welfare state had signif-icantly outweighed the shortcomings now coming under the spotlight. The new NHS Plan re ects some of these chang-ing attitudes, in particular the in uence of information technology and the importance of consumerism or putting the patient rst.

The NHS has not been customer focused. Historically, the perception (even if legally incorrect) was that the customer (i.e. the patient) had few rights and the attitude was often along the lines of arent you lucky to have a free service . Although the government recognises the need for change, this will not happen overnight. Investment cannot take place instantly, and there will be a decade of changes as the new initiatives begin to be implemented.

This does raise the question of striking a balance between political in uence and power and the responsibility for the delivery of high quality medical services.

Other countries have made greater strides in the intro-duction of joint venture agreements between public and private nance for their health programmes. Obviously, the American health sector has long been driven by a competi-tive market economy and is dominated by a two-tier serv-ice largely nanced by insurance. There is a safety net for those without health insurance but it is regarded by most as a backstop position. The best doctors and the best equip-ment are found in the private sector.

More meaningful comparisons can be found on the other side of the Channel, in France. Some in the medical profes-sion regard the French system as superior to the British NHS Health Scheme. Certainly, there are many reports of excellent

The starting point for good architecture is always rooted in the quality of the brief. It has been said many times before, and in many different ways, but the time spent by an architect understanding the aspirations of a client, and thoroughly digesting the spatial requirements that a build-ing is expected to meet, is invariably time well spent. This functional analysis will develop into the architectural form of a building re ecting the ethos of the client. The design must also be capable of being executed within the permit-ted budget. These three tenets underpin the philosophical expression of rmness, commodity and delight, which have been restated more recently as built quality, functionality and impact and are the bases of the design quality indi-cator (DQI). This methodology is part of the evaluation tool developed by CABE (Commission for Architecture and the Built Environment) to assess the design quality of a building. This is never more important than with health buildings. However, health building present a particularly complex set of relationships between the medical staff and the patients who visit the building because many will be anx-ious, or indeed stressed. This provides an opportunity for the therapeutic bene ts of a high quality building to con-tribute to the sense of well-being sought after for patients.

The rst edition of this book, Healthy Living Centres , pub-lished in 2002 concentrated on the relationship between the architect and the doctor. This second edition develops these themes and re ects the rapidly changing climate in the pro-curement methods and attitudes towards primary health care buildings that have evolved and are continuing to change. In particular, the approach to primary health care buildings is more readily identi ed with community-based initiatives. The NHS Plan 2000 underpinned the political will to focus attention on patient centred care. The NHS Plan 2000 had also set a new agenda to reinvigorate the NHS service, not just in patient care, but also the governments move to pri-vatise investment in capital projects, which has changed the basis for nancing new buildings. New primary care build-ings involve a wide range of skills and activities and the solutions being designed include community uses. Indeed, primary care centres can be seen as community resource buildings, re ecting the demands of a particular locality in areas such as social services, related medical services such as physiotherapy, dentistry, podiatry and pharmacy as well as preventive health initiatives such as leisure and tness clubs, caf s with healthy food options, libraries and computer cen-tres. These activities place an emphasis on encouraging a healthy mind and body as well as providing diagnostic serv-ices for those people who have become ill.

The government has provided additional nance, which in the nancial year 2004 2005 reached 78 billion and is continuing to climb. By 2008 the annual expenditure had exceeded 100 billion.

Contraindications, which make the advances in health care more demanding, are linked to the nations seden-tary lifestyle. This leads to a tendency for greater obes-ity and lack of tness, and critics of current government policy point to such factors as the large number of school

Introduction

3

health services being available in France, such as a patient visiting a GP in the morning, having a consultant undertake tests and further examination in the afternoon, and results being delivered the same evening. This may lead to some interesting unexpected developments. Medical politics in the UK has evolved as a process of the BMA (British Medical Association) acting like a trade union in its negotiations with its employer (the government). Perhaps inadvertently, doctors have not given suf cient attention to directing their discussions to the customer (their patients). Architects went through these same traumas 20 years ago when the Thatcher government turned the spotlight on the perceived restrictive practices of the architectural profession at the beginning of the 1980s. Mandatory fee scales for architects were abolished, and architects were thrown into the cauldron of the competi-tive open marketplace. Today, doctors nd themselves at the centre of public interest, receiving wide publicity for those doctors who have strayed outside their professional bounda-ries with a series of damaging court cases and public expos s.

The government is taking the initiative, and doctors are caught between the demands of a vociferous and articulate public and an employer adopting an uncompromising stance towards conditions of contract and expectations of the qual-ity of service. Nevertheless, new contracts of employment for general practitioners appear to be more advantageous to doctors than was envisaged by their employers (the government).

Medical services will also become increasingly interna-tional. Already, along the south coast of England, people are crossing the Channel to seek medical advice, and it is expected that this trend will increase in popularity. Obviously, many people also come to the UK for highly specialised treatment, but for initial consultations with a GP consumers are likely to become more demanding, more selective, and more likely to ask for second opinions. It can be argued that this may lead to a privatisation of GP services, similar to GP services before the introduction of the NHS. Already, there is evidence that in our more af uent suburbs, personal recommendation between patients is creating a network of preferred GPs who are perceived to have specialist knowl-edge in certain areas. Patients are saying Lets go and see Dr A Ive heard he is very good with knees. Patients are increasingly able and willing to pay for a second opinion. However, the privatisation of GP services, should this trend develop, will be heavily in uenced by the pharmaceuti-cal industry. It is dif cult to predict how the pharmaceu-tical industry will react if, for example, the supply of drugs through the NHS was to begin to decline and an increasing percentage of medication was prescribed by doctors pri-vately. At present, if doctors leave the contractual arrange-ments between themselves and the NHS, they are no longer able to give patients the bene t of subsidised medication.

Further speculation invites consideration of whether the privatisation of GP services will be taken over by large com-mercial organisations, rather than left as a network of indi-vidual private practitioners as in the pre-NHS situation. Not that long ago every high street had a privately run opticians

shop. Now, the market is dominated by a handful of large commercial organisations that employ large numbers of opticians within national networks of shops. There are those in the retail trade who have already spotted the opportunity for providing pharmacy services and the next step may be GP services, within their retailing empires. How convenient it would become, when doing the weekly shop, to see a GP at the local supermarket, particularly if this could be done at a time convenient to the patient. Already, many super-markets are operating 24 hours a day.

Time remains a crucial component of the cost effec-tiveness of GP services. The personal consultation period between a patient and their GP remains a vital interface for that initial consultation. There are examples of bad doctors (in medical terms) who are popular with patients because of their personal charisma. There are even examples of doctors hauled before the Disciplinary Committee of their profes-sional organisations who bring their own patients as wit-nesses to support their defence. Time spent with a patient is crucial if a sympathetic, healing environment is to be engen-dered. For example, in the Mayo Clinic in the USA, con-sultants see on average four cases during a morning session, but in a typical NHS hospital a consultants caseload for a morning session is more likely to be 20 patients. For GPs, the national average consultation period in the UK is eight minutes all too short if a meaningful rapport is to be developed between doctor and patient and those subtle tell-tale signs are to be identi ed from a patients unhurried description of their concerns.

Intuitively, therefore, one is led to believe that build-ings in the future for primary health care services need to be friendly, non-threatening, and full of old fashioned con-cepts of comfort, light, cleanliness, warmth and friendliness. They should be relaxing, accessible, community-based facil-ities, which patients are keen to make full use of to pop in for a chat or to ask a nurse or a pharmacist or a social worker for advice.

Why has the NHS concentrated on time and cost parameters for health building procurement?

Until recently, the governments approach to nancing health care facilities, in line with all government spending, has been based largely on negotiating lowest cost tenders within annual spending budgets. This tended to down-grade the consideration of whole-life costs, and it is only lately that the Treasury has begun to promote best value as the basis for selecting successful bidders for government contracts.

Inevitably, this led to an approach within the NHS bureaucracy to concentrate on setting targets for different sizes of GP surgeries and offering guidance on the space standards that would be acceptable. This approach created a cultural background to the provision of buildings encap-sulated within the framework of the Red Book . Standards

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doctors who have invested in their premises, and may have substantial loans outstanding against their property, may nd that there is little alternative use for their bricks and mortar should they be interested in moving on to more exciting ex-ible facilities under the umbrella of a coordinated housing, social services, and health programme. A question of equity values, the approach of district valuers and rental calcula-tions, and alternative resale values will all need to be consid-ered and it may be that the government will need to devise some systems to ensure that the problems of negative equity do not sti e development of health care services. These problems are likely to be greatest in those areas most in need. It is in those areas where property values are likely to be lowest, and the need for alternative combined resources may be greatest.

At the time of writing (July 2008), the NHS is celebrating its 60th anniversary and the government has just published Lord Darzis review of health services. In future, the health service will be judged on quality and it will be interesting to see if the aspirations set out in the Darzi Report are ful lled in the years ahead. Much has been spent on dubious pay settlements to health workers, particularly GPs, and now the recommendations include the expectation that patients will bene t from private sector competition in primary care contracts. The key founding principles for the NHS remain rmly intact but how the new expectations for the quality of patient care are paid for remains the critical challenge for government health policies over the next few years.

The emphasis is now rmly on primary care services and architects have an exciting opportunity to shape the success of GP surgeries by the skills they bring to providing innova-tive and popular designs for buildings in the future.

were set for accommodation, maximum allowances were set down for professional fees and cost limits were estab-lished. These principles were developed over many years resulting in a well-established set of procedures with which doctors needed to comply to improve or redevelop their premises. The environmental quality of these buildings was given scant attention. The philosophy regarding design was essentially that the administrators of NHS funds would establish a framework of requirements and set cost limits in the belief that this would leave designers free to interpret, in an imaginative way, the built form.

Fortunately, because of the relatively short timescale between inception and completion for primary health care buildings, and the personal rapport between doctors and architects, many successful small surgeries have been com-pleted over the last decade. However, there are many more of these buildings that could have been even better. There could have been more encouragement from NHS Estates to the doctors under their contract to build facilities that were more exible, more responsive to their patients requirements and more likely to offer better value to the community.

Functionality has been a key test of previous appraisal systems, a process devised by the administrators or service providers with negligible attempts to ask patients what they wanted.

The new NHS Plan recognises the importance of putting patients rst, and an exciting period lies ahead as new approaches to satisfying consumer demands begin to be developed and implemented. This is very good news indeed for patients, doctors and architects.

The legacy of the previous approach to procuring health buildings does create some problems for the future. Those

5 An outline review of the main issues (including a summary of the approach to designing health buildings)

Until the advent of scienti c discovery led to the develop-ment of a technical base for medical practice, healing rem-edies relied on a holistic approach based on healthy living and the quality of life. Early civilisations in Egypt, from the third millennium BC, the ancient Greek communities from c. 1000 BC onwards and the Roman Empire spanning a few centuries before and after the birth of Christ all left evi-dence of their interest in medicine and the importance that it played in their philosophies and faiths.

Early papyri from the Nile region of Egypt provide infor-mation about injuries and wounds. The most important papyri are the Edwin Smith Papyrus (1600 BC) and the Ebers papyrus (c. 1550 BC) found at Thebes. The literature is wide including Porter (1999, pp. 47, 48) and Walsh (2006).

The Egyptians believed well-being was endangered by earthly and supernatural forces was associated with correct living, being at peace with the gods, spirits and the dead; illness was a matter of imbalance which could be restored to equilibrium by supplication, spells and rituals. (Porter, 1999, p. 49)

The Egyptians used a considerable number of remedies and physicians held clinics in the temples. Similar customs prevailed in Greece and the sick resorted to the temple of Asclepius where they spent the night ( incubatio ) in the hope of receiving directions from the god through dreams which the priests interpreted. They were run by priests and patients were encouraged to bathe, sleep and meditate.

The importance of the relationship between medicine and philosophy is implicit in a holistic approach to life advocated by the ancient Greeks. One examination of these concepts (Van der Eijk, 2005) draws out the signi cance of spirit and the reluctance to adopt the materialist position that reduces mental phenomena completely to processes in matter. Many of us, instinctively, seem to prefer to think of body and mind as distinct but interacting on each other. 1

Greek philosophers praised health as one of the great-est blessings of life and this approach was exempli ed in the Hippocratic Oath. Writers such as Empedocles, Plato, Aristotle and the Stoics took a great interest in medical top-ics such as the nature of health and the causes of disease, phenomena such as respiration, old age, sleep and dreams, mental and psychosomatic illnesses such as epilepsy and melancholy, and questions of embryology, reproduction, fertility and sterility.

Aristotle wrote, how shall a doctor or a general who has had a vision of Very Form become thereby a better doctor or general? As a matter of fact it does not appear that the doctor makes a study even of health in the abstract. What he studies is the health of the human subject or rather of a particular patient. For it is on such a patient that he exercises his skill (Thompson, 1953, p. 35). This is an early indica-tion of the importance of the patient, which in 20th century medicine was obscured by the framework and systems of

2

1 Prof. P. van der Eijk, lecture notes, 20 April 2005, Newcastle University.

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and, further, from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not in connection with it, I see or hear in the life of men, which ought not to be spo-ken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!

This translation, quoted by Calman (1998, p. 218), is ascribed to Francis Adams.

The Hippocratic Oath was updated by the Geneva Convention (adopted on 12 August 1949 and brought into force on 21 October 1950). The Declaration of Helsinki developed by the World Medical Association sets out the ethical principles for the medical community regarding human experimentation. It was originally adopted in June 1964 and distinguishes between therapeutic and non-therapeutic research. The Declaration made informed consent a cen-tral requirement for ethical research and is important in the history of research ethics as the rst signi cant effort of the modern medical community to regulate itself. The development of regulations was stimulated by the expo-sure, by whistleblowers such as H.K. Beecher (1904 76) in the United States and M.H. Pappworth (1910 94) in Britain (Porter, 1999, p. 651), of unethical procedures being performed on vulnerable patients such as the men-tally ill. There were other shocking examples including the Tuskegee (Alabama) experiment started by the US Public Heath Service in 1932 which deprived black men of proper treatment for syphilis. The Second World War focused attention on the German medical scientists who conducted programmes of human experimentation (including Dr Josef Mengele, camp doctor at Auschwitz). Other human experi-mentation took place in Japan where biological weapons were developed.

The Hippocratic Oath is clouded by questions of academic authenticity; many versions exist and the library at Alexandra houses a collection of texts. However, Hippocratic medicine was also to win a name for being patient-centred rather than disease-orientated (Porter, 1999, p. 56).

Several parts of the Oath have been removed or reworded over the years as the social, religious and political importance of medicine has changed. Modern medical eth-ics have also addressed the historic dif culties of the Oath on issues such as abortion, con dentiality, surgery and the teaching of men but not women.

A hospital was a place of hospitality (Latin: hospes , a guest; hence hospitalis , hospitable; hospitum , a guest house or guest room). With almost no technical knowledge as we know it today (but a long tradition of faith, wisdom and experience by practice and observation) health care was also associated with religion, music, poetry, the arts and good food. The lack of scienti c knowledge as we understand it put reliance on the natural healing process which is today

health care only to re-emerge as a key factor in the present day philosophy of health care, now referred to as patient centred or patient focused care (NHS Plan, 2000).

Plato also examined the holistic nature of health and the importance of mind and body in maintaining a sense of well-being.

For with a view to health and disease and virtue and vice, there is no symmetry or want of symmetry greater than that of the soul to the body that we should not move the body without the soul or the soul without the body, and thus they will aid one another, and be healthy and well balanced. (Jowett, 1999, pp. 1213, 1214)

More recently, Scruton (1994, pp. 210, 211) reminds us that once again it is Descartes who set the agenda for mod-ern philosophy, arguing for a real distinction between mind and body in particular, thought does not belong to the essence of body. I therefore clearly and distinctly per-ceive that the mind is essentially distinct from the body and therefore in principle separable from it.

We can see that for over 5000 years there has been interest in exploring the relationship between a renewed awareness that technical and scienti c medical expertise continues to be in uenced by the state of the human mind and our sense of well-being. New techniques to meas-ure environmental conditions are being developed so that emotional and spiritual factors can be evaluated. These are broadly included in the term evidence-based design .

The Hippocratic Oath has survived from its Greek ori-gins when health care was viewed within a natural and totally holistic framework.

I swear by Apollo the physician, and Aescuplapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgement, I will keep this Oath and this stipulation to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring on the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my sons, and those of my teachers, but to none others. I will follow that system or regiment which, according to my ability and judgement, I consider for the bene t of my patients, and abstain from whatever is deleterious and mischie-vous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practise my Art. I will not cut persons labouring under the stone, but will leave this to be done by men who are practition-ers of this work. Into whatever houses I enter, I will go into them for the bene t of the sick, and will abstain from every voluntary act of mischief and corruption;

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receiving greater attention than ever before as an alterna-tive approach to modern high technology medicine.

The Romans incorporated both a scienti c and mytho-logical approach to medicine and health care. They adopted much of the Greeks scienti c data concerning medicine. Primarily, the teachings of Hippocrates (460 384 BC) gave the Romans a holistic look at medicine and the treatment of illnesses and diseases.

Instead of the Greek method of simply observing the symptoms and recording them in order to treat the patient, the Romans also included many prayers and offerings to the gods. Almost all the Roman gods had healing powers. This led to an eclectic medical system but despite this lack of focus the Romans enjoyed relatively good health for sev-eral reasons. The availability of fresh water prevented many diseases associated with standing water, and hygiene led to good health. The Roman baths became a part of life and kept germs and bacteria under control. Finally, the drain-age system took old wastewater away from the population and prevented many illnesses and infections. The Romans also tried, whenever practical, to boil medical tools and pre-vent using them on more than one patient without clean-ing. Health care was largely personal between the physician and the patient although in large households there were slave physicians caring for their sick fellows in valetudinaria(hospitals). The adoption of Christianity as the state reli-gion of the Roman Empire gave an expansion of the provi-sion of care, but not just for the sick.

Galen (131 201 AD) was a prominent physician in the ancient world and worked diligently to expand medical knowledge. He pursued Hippocrates methods of observa-tion and research by dissecting and studying human anat-omy. Thanks to him, doctors for centuries afterward had at least a basic knowledge of practical medicine. In the Roman army, buildings were set aside for treating the sick and wounded. A standard military hospital plan evolved, with individual cells off a long corridor, a large top-lit hall, latrines and baths (Porter, 1999, p. 78).

In England, the Venerable Bede (c. 672 735) was aware of the need to meld healing and holiness. Although Northumberland lay on the northern edge of the civilised world at that time, Bede and his monks possessed many med-ical writings. His in uence is being carefully researched and recorded at Bedes World in Jarrow ( www.bedesworld.co.uk ).

The Islamic world was also developing medical practice and built up a high standard of care between the 8th and 12th centuries AD. There are records of hospitals in Sri Lanka, India, Baghdad, Damascus, Cairo and throughout Persia.

The birth of the healing arts with Hippocrates was cor-rupted by the Medieval (Porter, 2000, p. 189). This is traced by the entry in Chambers Cyclopdia (1738).

At length, however, they [Galens errors] were purged out and exploded by two different means: principally indeed by the restoration of the pure discipline of Hippocrates in France; and then also by the experiments and discoveries

of alchymists and anatomists; till at length this immortal Harvey overturning, by his demonstrations, the whole theory of the ancients, laid a new and certain basis of the science. Since his time, Medicine is become free from the tyranny of any sect, and is improved by sure discoveries in anatomy, chymistry, physics, botany, mechanics, etc. 2

The Enlightenment brought scienti c analysis to the fore-front of academic study, although by the middle of the eight-een century, however, strict mechanism was being judged incapable of accounting for the full complexities of living phenomena, especially properties like growth and reproduc-tion (Porter, 2000, p. 139).

Thus, the study of holistic forms of medicine is part of a process of reverting to care in the community, and is begin-ning to take precedence again over the institutionalised treatment of the ill, which has been prevalent during the last 200 years. Indeed, it is a fundamental aspect of current UK government health policy and part of the principle of patient focused care (NHS Plan, 2000). These ideas had also begun to in uence policy in the USA some years ear-lier (in the 1990s). Based on a system of payment for medi-cal services by insurance policies it was convenient to the patient and cost effective for the provider of health services to locate facilities within, or close to, residential areas.

It is only comparatively recently that the focus has returned to care in the community. As medical invention and technology become further sophisticated so technology itself can begin to break away from hospital buildings and move into the community. Therefore the hospital no longer needs to be the focus of health care.

This is also re ected in the world-wide economic crisis in the funding of large hospital programmes and the enor-mous expense of hospital technology which encourages providers towards the low tech form of treatment. Have we therefore come full circle? (Valins and Salter, 1996, p. 4)

Although the rituals and belief systems of the ancient civilisations are not being revived, the philosophical issues between the mind and the bodys physical condition have par-allels that remain as valid today as they were 2000 years ago.

The same authors suggest a chronological split for the nature of caring in the Western world as shown in Figure 2.1 .

2 Ephrain Chambers, Cyclop dia , 2nd edn (1738 [1728]), Vol. ii, unpaginated, Medicine.

Years01800

2000 and beyond18002000

Care takes place at home or in the community Care takes place in medical institutions Care takes place at home or in the community

0 1800 2000

(Valins and Salter, 1996, p. 4 )

Figure 2.1 Chronology for the place of care

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2. The Medieval describes the Catholic Churchs provision of monastic hospitals built on the edges of villages and cities. These hospitals were the origins of the modern medical centre (p. 11).

(500 1500: largely in Italy and Western Europe)

3. The Renaissance period saw the development of archi-tecturally planned buildings with symmetrical, axial plans and formal facades. Many of these were constructed in response to the declining standards of hygiene that saw the spread of disease and plagues throughout parts of Europe including Britain (Londons Bethlehem Hospital, 1676, also known as Bedlam).

(1500 1850)

4. The Nightingale phase saw functional ward designs emerge from dealing with casualties of the Crimean War during the 1850s. For the rst time we see concerns for high levels of natural light to be introduced to wards for the bene t of patients. She emphasized function above form some two decades before the phrase form follows function was coined by Chicago architect Louis Sullivan to epitomize the new epoch of modern architecture (p. 11).

(British Empire 1850s and later than that)

5. The Minimalist Megahospital is a phrase used to describe the evolution of large high-tech hospitals. These were developed in response to the complex scienti c medical technologies that dominated health care in the 20th century. Particularly in the USA, where health care is insurance based (compared to the UK NHS system), this led to huge, self-contained mothership medical centres (p. 14). However, they were to become anachronisms when they opened in an era of a restructured healthcare system soon to be refo-cused on community-based managed care. These hospitals therefore symbolized to critics everything wrong with the healthcare system in advanced industrialized nations (p. 14). They have become outdated as health care has reverted to a predominantly community-based structure re ecting the 21st century preoccupation with patient focused care. Developing from about 1990, ideas are fast changing: the information age is profoundly in uencing how we de ne health and how we care for ourselves (pp. 14, 15).

(20th century mainly USA)

6. The Virtual Healthscope anticipates a more exible and open system for health care. New computer technologies are permitting health care solutions that offer greater choice, exibility and accessibility for everybody.

A concise history of medical buildings is Lorenzo DallOlios essay Origin and development of health-care facilities ( Materia , 38, August 2002, pp. 20 27). It emphasises the importance of the Hippocratic doctrine in attempting

It could be argued that the rst period (0 1800 AD) should be extended to 3500 BC 1800 AD.

Although valid in wealthy, industrialised and technologically advanced societies this analysis would not be representative of countries where home and community care may be all that is available to the great majority of the population. Hospitals may be many miles away and very limited in medical skills and facilities.

The World Health Organisation (WHO) see below has adopted policies which support locally based primary healthservices. Patient demand for convenience encourages this policy in Western countries together with the natural pref-erence for people to be treated at, or close to, their home rather than in a large institutionalised building.

These trends are likely to provide new opportunities for the design of specialist buildings, to provide sophisticated day-care treatment located within the localities they serve, thereby reducing the demand for highly expensive capital-intensive hospitals (although some will continue to be required for research and complex medical conditions).

The historical pattern of health care has been reviewed by several authors. Verderber and Fine (2000) in HealthcareArchitecture in an Era of Radical Transformation identify six periods in the history of health architecture that capture key developments through the centuries (p. 10).

The following quotations chart the six categories of health care identi ed by the authors. They trace the range of com-munity facilities that were available, the links to wellness and the development of a range of architectural solutions to accommodate the services provided. As medical knowledge increased so did the complexity of the built environment. Until about the 1850s, surgery could be performed in a variety of settings but steadily it became focused and inter-dependent with hospitals. This development of Victorian technical mastery led towards the concentration of medical expertise in hugely expensive and technologically sophisti-cated hospitals that continued throughout the 20th century. For many reasons, society (in the UK and other leading industrialised countries) has changed its approach to the provision of health care facilities. The emphasis has moved from large complex hospitals (although some of these will continue to be required as centres of technical excellence) to a pattern of smaller, community-based facilities.

1. The Ancient period follows the development of wellness care by the Greeks and the importance the Roman army put on military hospitals near the front lines throughout their Empire in both Europe and the Middle East. Nature and the afterlife played a role in the healing process although the earliest in rmaries were operated in conjunc-tion with wellness and spiritual treatment centres. Wellness care was developed by the Greeks between 1000 BC and AD 100. The private room rst appeared nearly three thousand years ago in the Greek Asclepion (p.10).

(up to 500 AD or thereabouts: the Greek and Roman Empires)

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to go beyond the medicine of the priesthood in favour of clinical study of the patient (p. 20). He goes on to say, the dual roots, secular and religious, of medical theory and prac-tice conditioned for centuries the entire hospital and welfare system as well as the overall organization of health care (p. 20). More recently, DallOlio identi es Powell and Moyas design in 1962 for Wexham Hospital at Slough as perhaps the clearest attempt to design a hospital for patients, con-sidering their needs, the psychological implications of eve-rything that concerns the patients wellbeing, through a high quality environmental and architectural context (pp. 25, 26). The essay concludes with the following summation of policy:

The humanization of the hospital thus seems to be the primary objective of the research conducted in recent years, humanization that has to do with quality and even with the vivacity of interiors, nishes, materials and colors, that calls for the addition of new functions and spaces, for both patients and personnel, and for the visitors shops, caf s, indoor gardens, meeting points, libraries and, lastly, breaking down the historic isolation of this type of struc-ture, considers it fundamentally important to insert the hospital in the life processes of the city. (p. 27)

The idea that health care buildings should be enjoyed and include works of art has historical antecedents. This approach is being developed by many architects who are designing health care buildings today after the austerity, nancial restraint and practical approach to the design of health care buildings during the early years of the NHS.

That the arts can be therapeutic is an idea that emerged in the 1980s and Sir Kenneth Calman, a former chief medi-cal of cer of the UK, used the phrase when writing in 2001 that embracing the arts and humanities with health and medicine was an idea whose time had come (lecture, University of Durham, July 2001).

Art in health buildings is usually thought of as a recent phenomenon and it is certainly true that there has been considerable interest, and awareness of the bene ts, in recent years (Haldane and Loppert, 1999; Waller and Finn, 2004; NHS Estates, 2002) . However, the Victorians deco-rated their public buildings, including hospitals, with paint-ings and sculpture celebrating great personal achievements. Proud of their nancial and technical progress, benefactors were recorded for posterity by these self-indulgent acts of artistic patronage. A typical example is the entrance area of the Royal Victoria In rmary, Newcastle upon Tyne. Known as the Peacock Hall, it is a richly decorated space with inlaid timber panelling. Plaques, portraits and busts com-memorate people important to the institution including

Portrait of Robert Stephenson (1805 1899) Portrait of Shute Barrington, Bishop of Hexham

(1734 1826) Bust of Thomas Emerson Headlam (1777 1864), physi-

cian to the Newcastle In rmary 1805 1840

Plaque recording the of cial opening of the RVI on 11 July 1906 by King Edward VII commemorating the Diamond Jubilee of Queen Victorias reign. Also men-tioned are the contractors, funding committee and the architects (Lister Newcombe and Percy Adams).

This tradition of recording signi cant people has been continued with a small brass plaque commemorating that Ludwig Wittgenstein, philosopher, worked at the hospital from April 1943 to February 1944. This legacy is still with us, often exercising the minds of todays administrators as to the best way to incorporate these works in new hospital buildings.

A historical anecdote illustrates how art was beginning to be associated with health. The story is that Nijinsky was taken ill during a visit to London in 1912 with Dyaghilevs Ballets Russes and was taken to St Stephens In rmary, a Victorian workhouse-turned-hospital on the site of the Chelsea and Westminster Hospital. On his recovery three days later he apparently performed LApr s-midi dune fauneand Dyaghilev had distributed gold sovereigns to patients and staff (Loppert, 1999). He obviously felt that this per-formance would help the other patients as well as being a thank you for the improvement in his own condition.

Susan Loppert, in charge of the arts programme at the Chelsea and Westminster Hospital, has developed a track record of integrating public awareness of cultural issues into a healing environment. Music, opera and the visual arts all have an important part to play in raising the envi-ronmental quality of the building for those who visit it. The hospital is now an important research centre (under the direction of Dr Rosalia Staricoff) for examining and quan-tifying therapeutic bene ts and patient outcomes resulting from environmental factors.

Art is seen not only as honouring the great and the good but as enhancing public enjoyment; indeed it can be argued that art in health care environments should be con-ceived not just as an adornment to a building or a space but integral with the design of the environment as a whole. This approach and the potential importance of art and good design to hospital patients are summed up by Linda Moss in her study of Arts and Healthcare :

The arts offer an important area in which the con icts of the modern hospital provision can be partially resolved, or at least mediated. The arts are a human intervention, expressive of human emotion and response to experi-ence. Their presence in the hospital can raise the pro le of the human aspects of health care without infringing upon its clinical ef ciency. (Moss, 1988)

Others have promoted the importance of integrating art into the design of the building as a whole (including Leichak Staricoff et al ., 2001; Francis, 2003; McDonald, 2002).

I have argued (Purves, 2002) that quantifying the cost bene ts of the intangible qualities of art presents todays designers with considerable obstacles. These dif culties

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the dominant Newtonian light and optical theories of his time, but also with the entire Enlightenment methodology of reductive science (retrieved from http://en.wikipedia.org/wiki/Theory_of_Colours , accessed 29/1/06). Colour has an extraordinary power to move us emotionally and design-ers have long recognised its importance to the design proc-ess. Other ways of sensing colour via hearing, taste and smell have also been reported ( http://midwest-facilitators.net/downloads/mfn 1999 1025 frank vodvarka.pdf, accessed 30/1/06). John Ruskin, writing in The Stones of Venice , which he started in 1849, said:

We have seen that all great art is the work of the whole living creature, body and soul, and chie y of the soul. (Ruskin, 2001, p. 319)

Exhibited at the Academy in 1840, Turners painting Slavers Throwing Overboard the Dead and Dying Typhoon Coming On re ects the great sunset blaze on a heaving sea.

Romantic images are contrasted with the scienti c work of Darwin and others during a period of great intellectual energy.

Nightingale addressed the necessity of healing relation-ships with patients and family and with colleagues. Having travelled in Europe as a young woman with her family, she was exposed to a wide range of views and opinions and she thought that nurses were well positioned to create a new vision of healing that integrates relation-centred care into all aspects of the health care system. She saw that a persons well-being was not just physical health but also psychologi-cal and spiritual health. By understanding that the environ-ment was central to her concept of good nursing practice, she looked for ways in which the environment could be modi ed to improve conditions so that natural healing could occur. This had developed from her empirical obser-vation that poor or dif cult environments led to poor health and disease. In contrast to this holistic approach to health, Brunel had developed a modular hospital for casualties of the Crimean War. In Brunels design he placed empha-sis on the environment, particularly lighting, ventilation, drainage, colour and cleanliness, and the resulting hospital was found to provide a healthier environment, with better recovery rates than the other British hospitals Florence Nightingale was aware of Brunels design concept and the improved infection rates, and this in uenced her future thinking (Glanville, 2005, p. 1).

Florence Nightingale had this intuitive foresight of thera-peutic bene ts in health care nearly 150 years ago. Writing in her Notes on Nursing: what it is and what it is not in 1859 she recorded:

The effect in sickness of beautiful objects, of variety of objects, and especially of brilliancy of colour is hardly at all appreciated. Such cravings are usually called the fancies of patients. And often doubtless patients have fancies , as e.g. when they desire two contradictions. But much more often, their (so called) fancies are the

may be put into perspective if the concept of quality is not divided into tangible and intangible bene ts. Our percep-tion of intangible bene ts is categorised thus only because the factors involved are more dif cult to quantify. With more research, perhaps meaningful conclusions will be able to be drawn and the mysteries of concepts such as welcom-ing , relaxing and calm will be given quanti able char-acteristics for the architect to manipulate. In this way, the control of environmental qualities will emerge as the future path to improving patient outcomes by offering therapeutic bene ts. Today, we are seeking scienti c evidence. There is growing awareness of the need for more research and over the next few years, our intuitive instincts will be tested and challenged by the results of the research being carried out by Ulrich and others known as evidence-based design .

A study funded by NHS Estates (where I was a member of the research team) examined the role of art in a new hos-pital in the North East of England and suggests that there might be an additional cultural role for art in hospitals, and for hospital buildings (Macnaughton et al ., 2005 to be published in the International Journal of Cultural Policy ). This work has been developed and Macnaughton considers the wider evidence for the changing role of art in hospitals, the history behind it and places the idea within an aesthetic framework. She says:

that the art can be seen to have a wider role within hospitals than purely that of providing a therapeutic environment , has implications for arts and design plan-ning and for the kinds of question asked in researching and evaluation current hospital arts and design pro-grammes For this synergy between hospitals and artists to work, artists do have to have some further potential professional bene t from displaying their works in these locations and information is essential to this process.

From the research point of view theories about art and design in hospital spaces have not yet caught up with the idea that hospitals may be being used as a cul-tural resource in this way. The questions asked in the new evidence-based healthcare design movement (led by Ulrich) are entirely related to either clinical effective-ness or cost effectiveness. The evidence presented here suggests that the functions of hospitals are expanding to provide a social and cultural resource for their com-munities, although this is not necessarily uppermost in the minds of most day-to-day hospital users. Clearly the main focus for art and designs must be their impact upon patients and upon the NHS purse. However, it would be interesting in the future to extend research questions to look at the impact of arts programmes on the wider communities served by those NHS hospitals which are increasingly seeing them as part of their role.

The perceptiveness of Florence Nightingales observa-tions should be considered in the context of other views being expressed at the time. Goethes Theory of Colourswas an example of holistic science and parted radically with

An outline review of the main issues (including a summary of the approach to designing health buildings)

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most valuable indications of what is necessary for their recovery. And it would be well if nurses would watch these (so called) fancies closely I shall never forget the rapture of fever patients over a bunch of bright-coloured owers. I remember (in my own case) a nosegay of wild owers being sent me, and from that moment recovery becoming more rapid. (p. 58)

Going on she expanded on her views of the connection between mind and body in the healing process:

This is no fancy. People say the effect is only on the mind. It is no such thing. The effect is on the body, too. Little as we know about the way in which we are affected by form, by colour, and light, we do know this, that they have an actual physical effect. Variety of form and brilliancy of colour in the objects presented to patients are actual means of recov-ery. But it must be slow variety e.g. if you show a patient ten or twelve engravings successively, ten-to-one he does not become cold and faint, or feverish, or even sick; but hang one up opposite him, one on each successive day, or week, or month, and he will revel in the variety. (p. 59)

Perhaps even the more recent research examining the recovery time for patients which compared patients looking at a brick wall compared to looking at natural landscape (Ulrich, 1984) was anticipated by Florence Nightingales observations:

The fact is, that these painful impressions are far bet-ter dismissed by a real laugh, if you can excite one by books or conversation, than by any direct reasoning; or if the patient is too weak to laugh, some impression from nature is what he wants. I have mentioned the cruelty of letting him stare at a dead wall. In many diseases, espe-cially in convalescence from fever, that wall will appear to make all sorts of faces at him; now owers never do this. Form, colour, will free your patient from his painful ideas better than any argument. (p. 60)

He was a workman had not in his composition a sin-gle grain of what is called enthusiasm for nature but he was desperate to see once more out of a window .

Yet the consequence in none of their minds, so far as I know, was the conviction that the craving for variety in the starving eye, is just as desperate as that of food in the starving stomach, and tempts the famishing creature in either case to steal for its satisfaction. No other word will express it but desperation . And it sets the seal of ignorance and stupidity just as much on the governors and attendants of the sick if they do not provide the sick-bed with a view of some kind, as if they did not provide the hospital with a kitchen. (p. 61)

And long before todays view that blue is a colour induc-ing coolness and depression and that red suggests warmth and invigoration she had recorded:

No one who has watched the sick can doubt the fact, that some feel stimulus from looking at scarlet owers, exhaustion from looking at deep blue, etc. (p. 62)

International position

World Health Organisation (WHO) The fact that health care is of great concern to all nations is re ected by the existence of the World Health Organisation. At the World Health Assembly in 1977 a commitment was made to the attainment by all citizens of the world by the year 2000 of a level of health that will per-mit them to lead a socially useful and economically produc-tive life (World Health Organisation, 1979). A joint World Health Organisation/UNICEF Conference at Alma-Ata in 1978 declared that primary health care was the most prom-ising vehicle for attaining the target of health for all by the year 2000 as part of overall development and in the spirit of social justice (World Health Organisation, 1978).

This approach (since 1978) has had an impact on the planning, building and operation of health care facilities. It is therefore important, in order to avoid mistakes, to con-sider carefully what should be the place of these activities in a health system based on primary health care and what are the constraints to be overcome.

This is further developed by Kleczkowski and Pibouleau, the editors of a World Health Organisation document pub-lished in 1983 (Kleczkowski and Pibouleau, 1983) . They identify that the role of the hospital in the primary health care context will inevitably change, and argue that it is dif- cult to predict the full extent of that change until the pri-mary health care programmes have become more rmly established. Many developing countries are staking large investments in vast national networks of health care facili-ties, and the success or failure of their planning, building and operation is an issue of high priority.

They state that architects are frequently not involved in formulating the building brief when decisions require relat-ing to the size and scope of facilities and to their general standard of construction and equipment are being made . At the design and production stage, an excess of project loads lead to a general lowering of professional standards and the easy adoption of ad-hoc designs as standard solu-tions. In achieving the goal of health for all through the medium of health systems oriented towards primary health care, there needs to be a fundamental rearrangement of building and equipment priorities involving completely new building types, design approaches, methods of construction, uses of material and modes of implementation.

USA the early days for primary health care In the USA, more literature is available on the evolution of the primary health care facility and its development over the last 50 years. During the 1950s, there was considerable

Primary Care Centres

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importance of proper nutrition, exercise and the risks asso-ciated with alcoholism, drug abuse, and smoking is perhaps the most effective weapon in the battle against disease. Health education centres as agents to hospitals and other health service agencies have sprung up recently in store fronts and shopping centres, making sound information accessible to the community. Future social, economic, and political considerations will change the character of health delivery systems considerably. Good medical care is now considered the right of all citizens, rather than the privi-lege of a few. In addition, we have increased longevity, so more elderly persons will be around to need medical care. These two factors demand a comprehensive health plan-ning system co-ordinated on a nation-wide basis.

From the stand point of economics, prevention of ill-ness is more economical than disability and disease. (Malkin, 1982, p. viii)

Early NHS policy

Functionality and cost The NHS Estates procurement policy was based until recently on the Capital Investment Manual, which required a business case approach to justify new investment. This led to a position where design quality was understood to be represented by functionality. Design quality was assessed by its functional suitability. That methodology was enshrined in their Estate Code document that set out a ve-facet analysis process:

Space utilisation Functional suitability Energy ef ciency Statutory standards (compliance) Physical condition.

These factors were used as a basis for design quality evaluation. This is done by subdividing each category into four sections from fully compliant (e.g. new building) to below an acceptable standard. With this background, an assessment of design quality does not include qualitative issues, or an assessment of the desired ethos of a building. The criteria set out in the analysis process do not include emotional responses such as pleasantness or calmness or indeed any suggestion of therapeutic value . However, the problem remains that even if appropriate categories of patient satisfaction were included there would be dif cul-ties in measuring or placing values on these factors. Design quality had to be based on quanti able data.

The tests of functionality were set against cost targets established by the Treasury. Over the rst 50 years of the NHS, management of the health budget for physical assets (buildings) was based on annual targets that provided little incentive to consider lifecycle costs or to allow for the development of value-for-money concepts.

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