Beyond the Brief
30 March 2021

BEYOND THE BRIEF: LEVERAGING THE VALUE OF LANDSCAPE – A REVIEW

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As we reached the end of March, saw a glimmer of spring and I think all started to ‘unfurl’ a little, it seemed only fitting that our first AFH community event focused on landscape design.

Often squeezed from the brief on grounds of budget or commissioned almost as an afterthought, landscape has actually played a significant role within the design of healthcare environments throughout history. For many years, it’s been easy to challenge, hard to evaluate and put fear in the heart of infection control!

But times are changing. As we grow ever conscious of the need to address climate change; learn more about the importance of biodiversity and the benefits of biophilia in our homes and workspaces, why wouldn’t we extend this to our healthcare settings?

Add a pandemic to the mix where raised stress levels reduced our ability to connect with people; we reignited our national interest in the outdoors – whether it was gardening and growing your own, or walking, running and cycling – increasingly, we all recognised access to external space as critical to our mental and physical wellbeing.

This session was conceived as a chance to explore not only the history of healthcare landscapes, but also the evidence and the outcomes of projects where landscape has been at the very heart of the design solution.

Joining us for the session were:

  • Jane Findlay, Director, Fira and President, Landscape Institute.
  • Dr Olivia Chapple, GP + Founder, Horatio’s Garden
  • Kwesi Marles, Head of Cancer Environments, Macmillan Cancer Support.
  • Rolf Roscher, Landscape Architect and Director, erz limited.

“The airing courts, pleasure grounds, gardens and field annexed to an asylum, should be of an extent as to afford the patients ample means of exercise and recreation as well as healthful employment out of doors.”
Commissioners in Lunacy

From the ancient greeks with spas and sanatoriums, through roman military hospitals to mediaeval apothecary gardens – engaging with nature has been a key component of health and recovery. The 19th century industrial revolution saw the growth of urban populations and with them, a plethora of public health problems. The solution: pavillion hospitals such as Guys and St. Thomas’s, created with gardens at the heart of the layout and built on the principles of access to light, fresh air and green space.

Open air therapies for diseases such as TB took this one step further, bringing patients outside to aid recovery, but post-war Britain demanded something different. Almost overnight these open, airy pavilion hospitals became the victims of infill – driven by the pressure to provide more diagnostics, car parking and in-patient care.

Thankfully, Roger Ulrich’s research put the focus firmly back on the patient, and the benefits that restorative healthcare environments can bring. The future is brighter – we’re developing a more holistic and biophilic approach that connects the built environment with our shared love and appreciation of nature. Combatting the combined climate and biodiversity crises is pulling us all together, and there are clear financial benefits too:

“By making space for nature in our towns and cities, spending on healthcare could be reduced. Retrofitting urban areas addresses climate emergencies as well as – prevent ill health before it has the chance to occur- creates a saving of circa. £2.1bn every year.”
Jane Findlay, Director Fira + President, Landscape Institute.

Nature is a key tool in our armoury: prevention is better than cure.

RESEARCH, EVIDENCE AND OUTCOMES

Horatio’s Garden and Macmillan Cancer Support are two charities where landscape plays a critical role in patient care. For patients recovering from a spinal injury, the in-patient experience can be anything from 5-months to a year, and the impact of injury ripples across immediate family, work and social groups.

“Bringing nature into the heart of the NHS and building gardens for patients families and hospital staff, allows them to get away from the clinical environment and experience the benefits of all types of nature – flora, fauna, the sound of water, birds, insects – all of which help to improve mental and physical health.”
Dr Olivia Chapple, Founder, Horatio’s Garden

Horatio's Garden, Duke of Cornwall Spinal Treatment Centre, Salisbury
Horatio’s Garden, Duke of Cornwall Spinal Treatment Centre, Salisbury

Three key factors play a part in the design solution:

  1. Gardens are completely flat. Often patients are on beds or newly using wheelchairs, so surfaces are formed with a resin bound aggregate with a tolerance 1 in a 100 – to ensure easy access to all areas of the garden.
  2. All year round beauty. Gardens are intentionally high maintenance gardens – creating year-round interest: something to lift the soul, colour, (mood boosting) smells and scents. Successional apples blossom in the spring and then later in the year, patients can enjoy the taste sensation of picking and eating apples.
  3. Evidence based design. The Horatio’s Garden team used meta analysis from the King’s Fund (2015) to understand how gardens improve healthcare. Key factors include: * Length of stay * Medication use * Blood pressure * Blood glucose *Cortisol levels
    * staff sickness *Relatives’ anxiety *Loneliness *Mood *Wellbeing *Sense of control *Vitamin D *Staff job utilisation *Sleep quality *Fitness levels *Weight loss.

The charity retrofits gardens into underutilised spaces adjacent to spinal injury units within acute hospital settings. Typically between 1,000 and 2,000 square metres in size and developed very much in collaboration with the hospital team (ensuring engagement from the outset), they are jewel spaces – often quirky and colourful but always calm. The impact is palpable.

2020 PATIENT AND STAFF FEEDBACK (Gathered by the University of Oxford)

  • 90% of patients feel wellbeing improved by being in the garden
  • 87% feel mental health was improved (for people with life changing injuries and
    potentially suffering from PTSD.
  • 89% of visitors say they feel they benefit – friends and family are vital and need to feel
    comfortable.
  • 89% of NHS staff feel wellbeing is enhanced. Especially with COVID – getting outside
    in a break makes an enormous difference.
  • Covid – affirms determination to bring more gardens into spinal injury centres.

In much the same way, Macmillan Cancer Support, has always invested in landscape as a core part of their response to helping patients living with cancer.

“People living with cancer spend long periods of time in clinical environments – each patient spends 25 days on average in hospital during the first year of diagnosis. Environments need to affect the all round needs of patients not just medical needs.”
Kwesi Marles, Head of Cancer Environments, Macmillan Cancer Support.

The cancer journey is filled with periods of anxiety; the shock and relief associated with diagnosis, and the demands of dealing with the physical effects of the disease and its treatment. Setting standards for the design of patient environments to support these needs has involved extensive end-user consultation and resulted in the development of a Macmillan Quality Environment Mark (MQEM), with five core principles of quality:

To deliver a place that is:

  • Welcoming and accessible to all
  • Respects privacy and dignity
  • Supports comfort and wellbeing
  • Gives choice and person control
  • Listens to users’ voices.
Macmillan Renton Unit, Hereford
Macmillan Renton Unit, Hereford

The study generated a number of key themes, with peace, privacy, natural light (and shade) all featuring. Calm, therapeutic spaces with seasonal planting , protected from the elements yet connected to the world form the essence of the brief.

“Lots of greenery and nice places to sit and enjoy the surroundings: no noise, no hustle and bustle; quiet but safe. Sometimes it’s nice to have a moment/ tears away from everyone.”
Patient feedback

These core principles are echoed in the brief for the Prince and Princess of Wales Hospital in Glasgow. Designed by Glasgow-based erz limited Director, Rolf Roscher, the concept is driven by the need to create a human scale to all aspects of the building and landscape design. From arriving in the car park, to entering the front door, planting is used to reduce the scale and strip away anxiety before you get to the building.

The design features garden terraces adjacent to bedrooms, accessible courtyards for family and friends to gather and a Lower Garden organised around a central green events space and pond, leading you to 4 seasonal gardens – each their own destination offering patients and families a sensory experience irrespective of the time or duration of their stay.

Prince and Princess of Wales Hospice, Glasgow
Prince and Princess of Wales Hospice, Glasgow

A hill garden provides a wilder, natural space – perfect for discovery and play – and particularly important for children processing challenging situations. A shelter, situated at the highest point creates a room for reflection and an expansive view of the Glasgow skyline.

Key to the design is the reduction of scale (small, human, almost domestic); the concept of destinations (journeys through the landscape) and the proliferation of spaces to sit – alone, as a family, or with friends – both formally and informally which give visitors choice.

A collaborative approach, from the outset, is critical to success. As Rolf notes:

“In Scotland in the NHS over the last 5-10 years there has been a big improvement in terms of the briefing and the outcomes. It makes a huge difference. We’re taking steps towards a more structured, measurable way of looking at [landscape]. Where it’s happened it’s tended to be driven by a well informed project champion.”

Getting your client on board early with the design, is key to the success of a project. Creating the opportunity for engagement – at all levels – from clinical to executive, ensures engagement from the wider team, allows concerns to be addressed (infection control) and ultimately, helps ensure the vision is delivered.

A Jane says,

“My mission is to make landscape like engineering so you can’t do without it.

You can’t do without landscape design otherwise the building won’t function properly and because health and wellbeing and the issues of climate change, biodiversity – are becoming much more measurable.”

It’s an aspiration I think we can all get behind.

Author, Sarah Birkby

With thanks to our panellists:

  • Jane Findlay, Director, Fira and President, Landscape Institute.
  • Dr Olivia Chapple, GP + Founder, Horatio’s Garden
  • Kwesi Marles, Head of Cancer Environments, Macmillan Cancer Support.
  • Rolf Roscher, Landscape Architect and Director, erz limited.

Co-Chairs

Alice Green, AFH Executive Committee + P+HS Architects
Paul Gilligan, AFH Executive Committee + Oberlanders Architects

Executive Team
Helen Young, Executive Coordinator
Sarah Birkby, Programme and Communications Director

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