Greenspace design for health and well being

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Greenspace design for health and well-being

Practice Guide

Practice Guide

Greenspace design forhealth and well-being

Aileen Shackell andRobin Walter

Forestry Commission: Edinburgh

sustainablehealthcare

centre for

inspire • empower • transform


centre for

© CrownCopyright2012

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

Firstpublishedin2011byForestryCommission,SilvanHouse,231CorstorphineRoad,EdinburghEH127AT.

ISBN978-0-85538-853-9

Shackell,A.andWalter,R.(2012). Greenspacedesignforhealthandwell-being. ForestryCommissionPracticeGuide. ForestryCommission,Edinburgh.i–vi+1–70pp.

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

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

Enquiriesrelatingtothispublicationshouldbeaddressedto:

ForestryCommission 231CorstorphineRoad Edinburgh EH127AT

T:01313340303 E:[email protected]

Theauthorscanbecontactedat:

E:[email protected] E:[email protected]

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

Acknowledgements

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

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Foreword

‘Green environments are healthy environments’. This is the message repeated again and again from healthcare research that points towards a positive relationship between greenspace and general health. Outdoor environments can have important restorative qualities that promote recovery from physical and mental stresses. Studies of ‘nature deficit disorder’ or ‘nature deprivation’ suggest that experiences of the outdoors (even views of greenery ‘borrowed’ through a hospital window) can have a therapeutic effect on ones’ social, emotional and mental functioning.

Some outdoor spaces are ‘salutogenic’, that is they reduce stress and encourage healthy behaviours. Whilst the particular reasons for this are not fully understood, various factors may – in isolation or combination – be important, including outdoor activity and exercise, natural daylight, stimulation of the senses, and the aesthetic experience. What we do know is that experiencing these natural environments – or helping to care for them – can improve the mental health and well-being of individuals and help to recharge their physical, mental and social capacities.

Nowhere is this relationship with the ‘natural health service’ more important than around healthcare facilities – particularly across the NHS estate. In supporting health and well-being outcomes National Health Service facilities should strive to make greater use of existing outdoor spaces by connecting them with the built environment. As we shift towards a more mutual NHS these largely untapped outdoor spaces should be recognised and utilised as an important healthcare resource in their own right: hence this guide Greenspace design for health and well-being.

In setting out best practice – backed up by case studies – this booklet provides a valuable guide to the design of accessible outdoor healing environments. It is equally applicable to new-build sites and refurbishments. It is relevant to the full range of healthcare settings, from the smallest health centre to the largest general hospital. It is also relevant to non-NHS settings such as schools, nursing homes and indeed everywhere where the promotion of health and well-being is important.

This Practice Guide will assist directors of facilities, estate managers, capital strategic planners, policymakers: in short everyone interested in health improvement and patient care, whether dealing directly with patients or managing grounds. By adopting this design guidance, NHS teams will be able to create, transform and revitalise their outdoor estates with respect to the human experience, encouraging greater use of the outdoors by patients, visitors and staff alike. These environments will provide a positive distraction from treatment and a therapeutic alternative to hospital buildings: quiet reflective spaces free from the clinical environment where patients can convalesce and recover in peaceful surroundings.

Alongside wards, waiting-rooms, and clinical departments, well-designed outdoor spaces are important environments that provide benefits for everyone. But as well as bringing social benefits, woodland and greenspace initiatives such as the NHS Forest in England and NHS Greenspace in Scotland can also bring organisational and environmental benefits too, helping healthcare facilities to meet good corporate citizenship responsibilities and performance measures, reduce carbon footprints and enhance opportunities for green prescription and outdoor recovery programmes.

By guiding NHS decision makers, Greenspace design for health and well-being will help to harness the full salutogenic potential of the NHS estate and bring the healing power of nature back into 21st century healthcare provision.

Sir Muir Gray Derek Feeley Director of the National Knowledge Service and Director-General Health and Social Care Chief Knowledge Officer to the National Health Service and Chief Executive NHS Scotland

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Introduction 1Aholisticapproach 1Benefitsofwell-designedoutdoorspaces 1Aguideforpractitioners 1

Why is it important to take healing outdoors? 3Understandingthebenefits 3

Outdoorspacescanhostawiderangeofactivities 3Whyiscontactwithnaturecalming? 4Treesandwoodedspaceshaveaparticularroletoplay 5Healthbenefitsofnaturalsettings 6Healthcare:anartaswellasascience 8Casestudy1:ArgyllandButePsychiatricHospital,Lochgilphead,Argyll 9

What sort of spaces should we be designing? 11Designinghealingspaces 11

Creatingahealingenvironmentwiththewidersetting 11Creatingahealingenvironmentinthebuildingsurroundings 12Creatingahealingenvironmentingardenspaces 13Casestudy2:StCatherine’s,Rotherham,Doncaster,andSouthHumberNHSFoundationTrust,Yorkshire 14

Designprinciples 171.Valuewhatyouhavegot 182.Createspaceswhichfeelspecial 203.Maketheoutsideaccessible 224.Focusonpeople’sneeds 245.Connectwithnature 266.Balanceriskwithbenefits 287.Designforchange 30Summary 32Casestudy3:Maggie’sCancerCaringCentre,London 33

How do we put the theory into practice? 35Overcomingthechallenges 35

Privatefinanceinitiativeschemes 35Acutecare 36Olderpeople’scare 36Primarycare 37Casestudy4:CulmValleyIntegratedCentreforHealth,Cullompton,Devon 37

Gettingstarted:theprojectprocesssummarised 39Stage1:Preparation 40Stage2:Designandimplementation 41Stage3:Usingandmaintainingthenewspace 42Stage4:Monitoringandreview 42Casestudy5:SensoryGarden,theVerwoodOpportunityCentre,Dorset 43

Contents

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Workingwithdesignelements 451.Planting 462.Trees 483.Entrances,pathsandboundaries–connectingthesite 504.Sitefurniture 525.Art 546.Water 56Summary 58Casestudy6:ChalkhillUnit,PrincessRoyalHospital,HaywardsHeath,Sussex 58

Feelinginspired?Howtogetstarted 60

Further reading and useful sources of information 62

Appendix 1: Researched sites 66

Appendix 2: Sample risk–benefit assessment for a community hospital 68

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Introduction

Aholisticapproach

Untilrelativelylateinthe20thcentury,outdoorspacesaroundmosthospitalswereverymuchpartofthehealingenvironment.Gardens,terraces,orchards,meadowsandevenhospitalfarmswereallcommonplaceandaccessibletopatients–particularlyinthefieldofmentalhealth.But,astimepassed,thebenefitsforpatientsofbeingabletospendtimeoutdoorsinthefreshairhavebeenincreasinglyoverlooked,astheemphasisoncreatingasterileenvironmentindoorshasdeveloped.Thishasfosteredaviewthatthehealingenvironmentwasrestrictedtotheinsideofhospitalbuildings,excludingthegardensandotherspacesaroundthem.

ThisGuidefocusesontheoutdoorspacesaroundalltypesofhealthcarefacilities.Itadvocatesaholisticapproachtotheirdesign,seeingbothindoorandoutdoorgreenspacesasequallyimportantforhealthandwell-being.Indoingso,itre-orientatesoutdoorspacesfirmlywithinthesphereofpatient-centredcare–withthe‘Planetreemodel’stipulatingthathealthcareenvironmentsshould‘fosteraconnectiontonatureandbeauty’.So,alloutdoorspacesshouldbepartofthehealingenvironment.

Benefitsofwell-designedoutdoorspaces

‘Peopleareentitledtothebestqualityofcare...attheendofthedaythereasonwhydesignmatterssomuchisthatwehavealimitedamountofresources,andbestpracticereducesthecostofcare.’(ProfessorJuneAndrews,DirectoroftheIrisMurdochDementiaCentre,2010)

Designingoutdoorspacestohaveatherapeuticfunctionrepresentsacost-effectiveapproach.Suchspacescanimprovepatientoutcomesandleadtoarangeofothercostsavings.Studiesshowthatpatientswhoarehappierwiththeirhealthcareenvironmentsareeasiertocarefor,andreturnhomesooner.Evidencealsoindicatesthat,wheretheenvironmentisimproved,betterstaffretentionresultsincostsavingsinrecruitmentandtraining,withrecruitmentbeingenhancedinthefirstplace.ThisGuidewilllookattheevidenceforthisinmoredetail,later.

Therearealsoorganisational,environmentalandsocialbenefits.Amorecreativeapproachtooutdoorspace,includingparticipatingininitiativessuchastheNHSForestinEnglandandGreenspaceinScotland,canhelphealthcarefacilitiesmeetperformancemeasures.Theremayalsobegainsforthemintermsofsustainabilityandcarbonreduction,especiallyinrelationtotreeandwoodlandplanting.

Aguideforpractitioners

TheKingsFundprogramme‘EnhancingtheHealingEnvironment’(EHE)hashelpedmanystaffbecomeengagedinprovidingbetterpatientcarethroughimprovedspaces,andthisGuideseekstobuildonsomeofthelessonswhichhavebeenlearnt.

Itisapplicabletonew-buildsitesandtorefurbishments,andtothefullrangeofhealthcaresettings–fromthesmallesthealthcentretothelargestacutehospital.Itwillassistseniormanagementteams,thoseengagedwithpolicy,andeveryoneinterestedinimprovingpatientcare–whethertheydealdirectlywithpatients(clinicalstaff,therapists,supportstaff )orfocusongroundsmanagement(facilitiesandestatemanagers,andpracticemanagers).

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Itisalsorelevanttonon-NHSsettings,forexampleschools,nursinghomes,everywherewherethepromotionofhealthandwell-beingisimportant.

Well-designedoutdoorspacesareanintegralpartofthehealingenvironment,alongsidethewards,waitingroomsandclinicaldepartments,andprovidebenefitsforeveryone–patients,staffandvisitors.ThisGuidesetsouthow,andwhy,thisisso.

Inspring1994,theplaywrightDennisPotter,nearingtheendofhislife,describedthetreehecouldseefromhisbedroomwindow.

‘Theblossomisoutinfullnow...It’saplumtree,itlookslikeappleblossombutit’swhite,andlookingatit,insteadofsaying“Ohthat’sniceblossom”...Iseeitisthewhitest,frothiest,blossom-iestblossomthatthereevercouldbe...Thingsarebothmoretrivialthantheyeverwere,andmoreimportantthantheyeverwere,andthedifferencebetweenthetrivialandtheimportantdoesn’tseemtomatter.Butthenow-nessofeverythingisabsolutelywondrous...youhavetoexperienceit,thecomfortofit,thereassurance...’(DennisPotter,InterviewwithMelvynBragg,March1994)

Sensory aspects of the natural environment are especially engaging.

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Understandingthebenefits

•Outdoorspaceisanimportantpartofthehealingenvironmentanditcanbeusedforawiderangeofactivities.

•Theorieshavebeendevelopedtoexplainthehealthbenefitsofnatureandthesehaveledinturntothedevelopmentofevidence-baseddesign.

•Treesandwoodedspaceshaveaparticularroletoplayinsupportinghealthandwell-being.

•Spendingtimeoutsidecanhelpimprovephysicalhealthandrecoverytimes,andconfersparticularbenefitsformentalhealth.

•Evidenceisimportant,buthealthcareisanartaswellasascience.

InthisGuide,theterm‘healing’or‘therapeutic’environmentorspacemeansaplacethathasbeendesignedorisusedinawaywhichpromotesthehealingprocess,orhelpstoinstilasenseofwell-being.

Thissectionfocusesonthehealthandwell-beingbenefitsfrombeingoutside,thoughtherearenumerousotherenvironmentalandeconomicbenefitsassociatedwiththecreationofgoodnaturalsettings.

Outdoorspacescanhostawiderangeofactivities

Activitiescanbeactive(includinghelpingwithgardeningorsimplegroundsmaintenance)orpassive(sittingunderatree).Theycanincludewalking,birdwatching,socialisingwithotherpatientsandfamily,andevenTaiChi.Playingoutsideisagreatwayforchildrenandyoungpeopletorelaxandletoffsteam,awayfromatiringmedicalenvironment,andtherapeutichorticultureinvolvingpracticalgardeningactivitieshasalonghistoryofuse.

Why is it important to take healing outdoors?

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

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Clinicianscancarryoutone-to-onediscussionsduringwalksaroundthegroundswithpatients.Walkingsidebysideoutdoorsmightwellfeellessthreateningformanythanfacingsomeoneacrossadesk.

Inapeacefuloutdoorspacepeoplecansometimesmoreeasilystartto‘cometoterms’withbadnews,or,conversely,celebrategoodnews.TheQuietGardenMovementencouragespeopleofallfaiths(andnone)toenjoystillnessandreflectioninpeacefulgardenspaces.Thesebecomeoases,privatespacesforthinking,and,formanypeople,placesofspiritualrefreshmentandsupport.

Whyiscontactwithnaturecalming?

‘Thegardengivesyouthechancetorelax.Igetlostinthatgarden,suckedintothetreesandthebirdsinthesky.BeforeIwouldseethesethingsbutIdidn’tconnecttothem–itisanotherworld–Ihavelearnedtoappreciateit,anditdoessomethingtoyou,it’samazing.’(Patient,GlasgowHomoeopathicHospital)

Attentionrestorationtheory(ART)wasdevelopedbyRachelandStephenKaplanintheirbookTheexperienceofnature:apsychologicalperspective,andsincethenanumberofotherstudieshaveestablishedthatthisalsoholdstrueintermsofmedicaloutcomes.

Attentionrestorationtheoryproposesthatcomparedwith‘hard’indoororurbanenvironments,naturalenvironmentsaremoreefficientathelpingourbrainstorechargeandresumewhatistermed‘directattention’orfocusonaparticulartask.Increasedcontactwithnaturerestoresourbrainsfromfatigueandreducesimpulsivebehaviour,irritabilityandaggression.InherpaperonHealingGardensinHospitals,writerandacademicClareCooperMarcusstatesthatnatureengagesattentionwithoutdemandinganyeffort,becauseithastheeffectof‘awakeningthesenses,calmingthesenses,reducingstress,andassistingapersontomarshaltheirownhealingresources’.

At Harbour House residential home in Dorset, the front lawn has been turned into a well-used space by the addition of croquet hoops. Residents help themselves to balls and mallets when ever they want to play and combine socialising with staying physically active.

The scent of flowers.

Party in the garden.

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Contactwiththeoutdoorscanalsobestimulating,aswellascalming.Theco-ordinatoroftheCreativeSpacesProjectinCornwall,whichenablespeoplewithdementiatoenjoyoutdoor-relatedactivities,commentedthat,‘timeandtimeagainwefindthatspendingtimeoutsideincreasespeople’scommunicationandstimulatesmemories,peoplejustsparkle’.

Thereisagrowingbodyofevidence,muchofitrootedinscientificresearch,thatbeingoutdoorsinanaturalsetting,orevenjustviewingtheoutdoorsfrominside,ishighlybeneficialforhealthandwell-being.ThisisincreasinglyinformingthedesignofhealthcarefacilitiesintheUK,inanapproachtermedevidence-baseddesign(EBD).Thisapproachisalsoinformedbyarelativelynewfieldofstudy,environmentalpsychology,whichseekstounderstandtheinterrelationshipbetweenenvironmentsandhumanbehaviour.

Treesandwoodedspaceshaveaparticularroletoplay

Woodlandsareespeciallyrestorativeenvironments;thesounds,sightsandsmellsinawoodplayaroleinreducingstressbyprovidinginterestandstimulatingthesenses.

Woodlandsprovidearichsensoryexperience,fromthesubtleshiftsintemperaturethatoccurbetweenareasinheavyshade,andinsunnyglades,tothescentofpineneedlescrushedunder-foot.Awoodlandsettinghasparticularacousticqualities,meaningthequietestbirdsongisaudible.Theageofveterantreesofteninspiresaweinpeopleandprovidesalinkbetweenthepast,presentandfuture.Woodlands,andindividualtrees,areseenasrepresentingnature,particularlyintheurbanenvironment.

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Healthbenefitsofnaturalsettings

Thehealingpowerofnature,freshair,sunlightandexercisehaveallbeenafeatureofhealthcareforcenturies,butthepost-warperiodhasbeencharacterisedbyamoveawayfromnature,andtowardsagreaterrelianceontechnology.Recentdecadeshaveseenareversalofthistrendandasubstantialbodyofevidencenowexists,includingmanyliteraturereviews,whichdemonstratesthehealthbenefitsofcontactwithnature.DetailsofsomeofthesecanbefoundintheFurtherreadingsectionattheendofthispublication.

Asidefromtheobviousopportunitiesforphysicalexercise,whichinthemselveswillbenefitmostpeople,themainbenefitsrelevanttothehealthcareenvironmentcanbesummarisedas:

Reductionofpainandstress

•Contactwithnaturecanreducebloodpressure,muscletensionandpulserate,andcanalsohaveasubtleeffectonourexperienceofpain.

•Patientsandfamilieswhousehospitalgardenshavereportedpositivemoodchangesandreductioninstress.Evenvisualsettingswhere‘nature’isprominentreducestressandimprovepatientoutcomes–especiallywherestressisaccompaniedbyfeelingsofanxiety.

•Areductioninstressinturnenablestheimmunesystemtofunctionmoreeffectively,facilitatingthehealingprocess.

Alleviationofdepression

•Depressionisaseriousissuenotonlyforthosewithmentalhealthpatients,butalsoforthosewithcardiovasculardiseaseandcancer.Researchindicatesthatexposuretodaylightiseffectiveinreducingdepression,evenforthosehospitalisedforseveredepression.

•Simplywalkinginnaturalsettingscanhelpmentalhealthpatientsimproveself-esteem,vigourandmood,andreducetension.

•Practicing‘mindfulness’inanaturalsettingcanbeparticularlybeneficalformentalhealth.

View onto garden from the inside of Chalkhill Unit.

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Reductionofaggressivebehaviour

•Restorativecontactwithnaturecanreduceirritabilityandtherebyaggressivebehaviour.

•Studiesfocusingonolderpeoplewithdementiaandonchildrendiagnosedasbeingontheautisticspectrumhaveshownthatboththesegroupsfindcontactwithgardens,andnatureingeneral,calming.

Increasedpatientsatisfaction

•Thosemostlyconfinedindoorsparticularlybenefitfrombeingoutsideinthefreshairandsunshine.

•Naturalsettingscanenhancetheplayandlearningactivitiesofyoungerpeople.

Improvedrecoveryrates

•Studieshavedemonstratedthatpatientswhohavecontactwithnature,evenwherethisissimplyaviewthroughawindow,recovermorequicklyfromoperativeprocedures.

•Patientsinintensivecareunitswithmyocardialinfarctionexhibitedshorterstayswhensitedinroomswithhigherdaylightexposure.

Improvedstaffperformanceandretention

•Gooddesignofhealthcarefacilitieshasbeenfoundtoimprovestaffperformance,recruitmentandretention.

•Post-occupancyevaluationsoftheoutdoorsinUShospitalshaveconsistentlyshownthatthestaffaretheprimaryusersofoutdoorspaces.

The staff garden at Newham Hospital provides an area for lunch as well as a venue for birthday and other celebrations.

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Healthcare:anartaswellasascience

Inmakingthecasefortherapeuticuseofoutdoorspaces,theevidencebaseisimportant.However,manypeoplealsoseehealthcareasanartaswellasascience,andencourageaccesstooutdoorspacesaspartoftakingamorecreativeapproachtopatientcare.

Thegrowingevidencebaseforthesebenefitsisoftensupportedbytheobservationsofclinicians.AtthenewChalkhillUnit,wheretheinteriorisinspiredbyaspectsofthesurroundinglandscape,stafffeelthatpatientsrecovermorequicklyfromillnessthanwasthecaseintheirpreviousbuilding,whichhadnoaccesstotheoutdoors.

Thisapproachacknowledgesthelimitationsinourunderstandingofthedetailedworkingsofthehealingprocessandembracestherestorativepowersofnature–evenwhentheevidenceisonlyanecdotal.

AuserofthegardenatthenewMaggie’sCancerCaringCentreinLondonillustratedthiswell.

‘Thegardenwillallowpeopletobethemselvesandhavetheirownspacewithouthavingtospeaktoanyoneandsometimesthat’smorevaluablethananymedicine:onecantakecouragefrombeinginagoodplace,breathingincourageandbreathingoutfear.’(CathKnox,WestLondon,withsecondarycancer)

At Maggie’s Centre in London the building is surrounded by quiet, peaceful garden areas.

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Practisingmindfulnessinawoodlandsetting

In2003apartnershipcomprisingReforestingScotland,theNHS,ArgyllGreenWoodworkers’Association,theScottishAssociationforMentalHealthandLochgilpheadCommunityCouncilwasformedtorestoreneglectedwoodsnexttotheArgyllandButeHospital.Fundswereraisedfromarangeofsources,includingScottishNaturalHeritage,theScottishMentalHealthDepartment,ForestryCommissionScotlandandLeader.Workbeganin2004andinvolvedmanyusersofmentalhealthservices,disabledpeople,youngpeople,contractorsandvolunteers.

BlarbuieWoodlandwasopenedasapublicparkin2007,withaccessiblepaths,facilitiesandinterpretationforquietrecreationaswellasmoreenergeticwoodlandmanagementactivities.Thereareopportunitiestolearnnewskills,includingnurserywork,forestry,timberprocessing,woodworkingandconstruction,andthewoodalsohostsartandmusicprojects.

Keydesignfeatures

Thethresholdarchandsignagewelcomesvisitorsintothewood,indicateswheretheycango,andaccessisprovideddirectlyfromthecarpark.Theprojectmakesgooduseof‘borrowedlandscape’,withspectacularviewsavailablefromthesiteoutacrosstheloch,aswellasaccesstothehillsbehind.

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

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

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

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Healthbenefits

Clinicians’ view

‘ForpeoplewhomIrefer,Ithinkalotofthebenefitisafeelingofachievementinactuallydoingsomeworkinthewoods,seeingthebenefitsoftheirwork.There’scertainlythebenefitofexercise;there’sthebenefitoffreshair;there’sthebenefitofworkingwithothersonaproject.’

Oneparticularthemeisthepromotionof‘mindfulness’inpatients–appreciatingthepresentmomentwithoutanxietyaboutthepastorfuture.Formanypatientsinthishospitalwithmentalhealthproblems,cultivatingmindfulnessisanessentialskilltolearn.Cliniciansdescribehowhelpfulthewoodlandsettingwas:

‘Ithinkwhat’sniceaboutthewoodsisthepeacefulnessofwalkingandthebigtreesandthenature,andbeinginaplacewhereyoucanpracticemindfulness,awareness.

Peoplehavealotofconcernsandanxieties...maybeyoucouldbeinaquietroominaquietward,butifyou’vegotabusyheadit’shardtorelaxandbegrounded,soIthinkitdoeshelptogooutintoawoodlandarea,andfocusonlike,otherthingslikethenature,likethetrees...andjusttohelpemptythehead,empty...’

Patient’s view

‘WellIcomeuphereandIliketojustexperienceonewith...nature.IdoreallyfeelonenesswithnaturewhenIcomeuphere,Ijustsitinthewoodsandjusttalkwiththebirds...IquiteliketowhistlebacktothemandtheywhistleatmeandIwhistlebackandtheywhistleagain...it’sgoodforthewell-being,it’sdefinitelyimprovedmylife,yeah.

IthinkI’malotmoreconfidentinwhatIdo,andI’malotmoreconfidentinwhatIsaytopeople.It’sgoodtomeetalotofpeopleindifferentaspectsinthewoodaswell.’

All-weather paths make the wood accessible to a wide range of people, with opportunities for both quiet solitude and socialising.

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Designinghealingspaces

Allofthedifferentpartsofasitecanhaveatherapeuticpurpose:

•thewidersetting;

•theareasaroundandclosetothebuilding;

•thegardenspaces.

Theabilitytolocateabuildingtotakeadvantageofaview,ortoarrangeasiteinawaywhichprioritisespedestrianovervehicleaccess,aretremendousopportunitiesinanydevelopment.

Innewfacilities,thiscanbeplannedfromtheoutset,withthevalueofexternalspacesbeingrecognisedwithinthebusinesscaseforthedevelopmentasawhole.Forexample,atGlasgowHomoeopathicHospital,thebuildingwasdesignedsothat‘patientcare’spaceshaveadirectviewandconnectiontonatureandareseparatedfromnoisyareas,whilestaffareasarelocatedtothenorthandeastofthebuildingtoavoiddirectsunlightduringworkinghours.

Improvementofexistingfacilitiesrequiresamoreincrementalapproach,basedonanappraisalofthesiteasawhole,itsstrengths,weaknessesandopportunities.Evenonthemostchallengingofsitestherearealwaysimprovementsthatcanbemade,asthesketchexampleswhichfollowshow.

Thinkingaboutthreedifferentaspectsofanysitecanhelpidentifyitspotentialtherapeuticvalue.Theseaspectsare:

•thewidersetting;

•theareasaroundandclosetothebuilding;

•gardenspaces.

Astrategyormasterplanwillhelptoensurethatthesethreecategoriesofspaceareallwellconnectedwithpathstomakeacoherentsitelayout.

Creatingahealingenvironmentwiththewidersetting

Carefulthoughtshouldbegivenwhenlocatingnewfacilities,toensurethatthewidersettingispartofthehealingenvironment.Inthecaseofanexistingbuilding,onemayneedtobecreativeaboutitsuse.

Sometimes,andespeciallyoncrampedurbansites,accesstotheoutdoorsisrestrictedtoaviewofthewidersettingandinthesesituationsitwillbeessentialtomakethemostofit–perhapssimplyrearrangingadayroomtolookoutofthewindowtothelandscapebeyond.Manyin-patientsmaybeconfinedtobedandenjoymentofsunlightandanaturalviewcangreatlyenhancetheirstay,andpossiblyacceleratetheirrecovery.

Onmorespacioussitesitmaybepossibletoconnectwiththesurroundinglandscapebyframingviewsandlinkingpaths.TheroutearoundSalisburyDistrictHospitalconnectswithnearby

What sort of spaces should we be designing?

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footpaths,andstaffareencouragedtousethispathcircuitintheirbreaks.InScotland,wherethereiswiderpublicaccesstoopenspace,theNHSestatehasgreatpotentialtobecomeavaluableresourceforthewholecommunity.

Creatingahealingenvironmentinthebuildingsurroundings

Thepatient’sexperiencestartsoutsidethebuilding,andtheirinitialimpressionofitplaysabigpartintheirperceptionoftheservice,aswellasinfluencingthelevelofstressexperiencedinattending.

Withcarefuldesign,spacesroundthebuildingsuchascarparksandentrancescanandshouldenhancethepatient(orvisitor)experienceconsiderably–eventhoughtheymaynotbespecificallydesignatedfortherapeuticuse.Well-designedsurroundingsareeasytonegotiate,meaningthatthejourneyfromsiteentrancetothewardorwaitingroomisaspleasant,well-signedandrelaxedaspossible.

A break away from the ward, enjoying a chat in the sunshine.

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

Above:Existing view.Right:How the improved area could look.

Large specimen trees give scale and provide a better setting for the taller buildings nearby

Edible hedge of mixed native shrubs – plums; damsons; elder; blackthorn

Cars hidden behind new hedge planting

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Creatingahealingenvironmentingardenspaces

Gardenspacesarepredominantlynaturalincharacterandcancontainlotsofplanting.Theyrangeinscalefromtheverylargetotheverysmall,andfromformalherborphysicgardens,throughtoorchardsandmoreextensivelawnswithspecimentrees.

Gardenspacesnexttobuildingsofferthegreatesttherapeuticpotential.Proximitytowardsorwaitingroomsisabsolutelyessentialtoencouragenotonlyindependentaccessbutalsostaff-assistedaccess–anurseorplayassistantismuchmorelikelytotakeachildintoagardenaccessedfromthewardthanonethatrequiresatripawayfromit.

Somebuildingshavehiddencourtyardandroofgardenspaces,whichmayhavestrongpotentialintermsofproximityandaccessibility,aslongasthereisadequatesignagewithinthefacilitytoalertpeopletotheirpresence.Thesespacesarealwaysworthexploringasapriorityfordevelopmentasahealingenvironment.Moreremoteopenspacesonthesitemaybetoofarawaytobeeasilyreachedandwellused.

GreatOrmondStreetHospitalislocatedonaveryconstrainedsiteincentralLondon,withalmostnooutdoorspaceatall,sothenewstaffgardentherewasconstructedontheroof.ThegardencanbehiredforeventssuchasbirthdaypartiesandshelterfromthewindisprovidedbyglazedpanelswhichstillallowpanoramicviewsoftheLondonskyline.

Great Ormond Street Hospital roof garden and commemorative inscription to a previous member of staff.

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Seating against chapel wall looking onto trees

Birch trees set in spring bulbs Raised planter with

scented shrubs

Acreativeapproachtoexternalspacesacrossthesite

StCatherine’sMentalHealthTrustHeadquartersislocatedinaGradeIIListedbuildingsetinaparklandsiteontheoutskirtsofDoncaster.OriginallythehomeofaVictorianindustrialist,thebuildingissurroundedbyalargenumberofnewerbuildings,offeringawiderangeofsettingsforthosewithmentalhealthproblems.

Case study 2: St Catherine’s, Rotherham, Doncaster, and South Humber NHS Foundation Trust, Yorkshire

Adult Mental Health Unit garden.

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


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Thewidersetting

TheEnvironmentManagerisdevelopingaproposalforopeningupanewfootpathlinkthroughthehospitalgrounds,whichwillconnecttheproposedhousingdevelopmentnexttothesitewithanimportantlocalnaturereserve,PotterickCarr.Thisnewroutewillprovideacircular‘greenway’aswellasawildlifecorridorforthebirdsinthenaturereserve.

Benefits:

•Biodiversitybenefitsforthesiteandthewidersetting.

•BenefitsforthepublicprofileoftheTrust.

•IncreasedpotentialfordevelopingaHealthyWalksprogrammeforthelocalcommunity.

Thebuildingsurrounds

Theparklandischaracterisedbyoutstandingtreesandwoodland.Thisiscurrentlybeingaugmentedbynewplanting,aspartoftheNHSForestinitiative,tohelpscreenneighbouringdevelopmentandprovideextraprivacyforthoseusingthegrounds.Workwillincludeextendingtheexisting‘redpathnetwork’,whichpatientsusetoidentifysafewalkingroutesroundthesite.Thenewpathwillalsobeavailableforlocalresidents,aswellasstaffonsite–therearealreadyseveralgroupsofstaffwhoregularlycompletecircuitsofthesiteatlunchtime.

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

Staff, visitors and certain patient groups have free access to the parkland surrounding the hospital buildings.

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Benefits:

•Trustbetterintegratedwithinlocalcommunity,resultinginabetterunderstandingofmentalhealthissuesandincreasedaccesstotheTrustsiteforlocalresidents.

•Longerwalkingrouteforpatientsandincreaseinexercisebeingtaken.

•Increasedbiodiversityandamenityfromadditionaltrees.

Thegardenspaces

Thegardenattachedtothenewlow-secureCusworthandBrodsworthwards,andthemedium–securePsychiatricIntensiveCareUnit(PICU)isaccessible‘ondemand’tothein-patientsthere.Theimpactofthestandard3mhighfencingenclosingthespaceismitigatedbycolourfulherbaceousplantingandthereisplentyofseatingtoencouragepeopletospendtimeoutside.Thehistoricwalledgardennowhousesahorticulturaltherapyproject,wherelocalresidentscanbuyplants.

Benefits:

•Freeaccesstotheoutdoorshelpsrestoreasenseofcontrolforpatients,especiallyimportantforthosedetainedagainsttheirwill.

•Anattractiveviewofanaturalenvironmentisbeneficialevenforthosewhorarelyventureoutdoors.

•TheretailaspectoftheWalledGardenProjectstrengthensconnectionswiththelocalcommunity.

TheEstatesbudgetiscontributingfundstotheseimprovementsinthegrounds.InitialNHSForestplantingcost£5000(withadditionalWoodlandTrustsupport)butanadditional£24000isnowbeingaddedtoaBigLotteryGranttomakeatotalofalmost£250000forasecondphaseofwork.Thiswillimproveaccesstothewoodlandandincludeengagementwiththelocalcommunitytorecruitateamofvolunteerstocreateandmaintainpaths,assistwithwoodlandmanagementandpotentiallyeventransformthesiteintoa‘greengym’.

The historic walled garden houses a social enterprise project, where service users develop new skills in horticulture, helping them to return to employment.

Enclosed courtyard, Psychiatric Intensive Care Unit, Skelbrook Ward.

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Designprinciples

Thedesignprinciplessetoutinthissectionprovideachecklistforanyoneimprovingexistingspacesorcreatingnewones:

1. Valuewhatyouhave2. Createplaceswhichfeelspecial3. Maketheoutsideaccessible4. Focusonpeople’sneeds5. Connectwithnature6.Balanceriskwithbenefits7.Designforchange

Designingoutdoorspacesfortherapeuticpurposesmeansconsideringanumberoffactors.Howwillthespacebeused?Isiteasilyaccessible?Arethereparticularclinicalneedstoconsider?Whatabouthealthandsafety?

Thedesignprincipleswhichfollowhavebeendevelopedprimarilytoprovideaframeworkforpeoplewithoutadesigntraining,tobegintothinkthroughtheelementsofanindividualproject,andtotacklesomeofthequestionslistedabove.Theyarenotintendedtocovereveryaspectofdesign,buttoprovideanintroductiontothesubject.Theyhavebeenformulatedtoreflectwhatismostimportantandrelevanttohealthcaresettings.

Theprinciplesareintendedforspaceswhichwillhaveapredominantlytherapeuticfunction,andareapplicabletobothgardenspacesclosetobuildingsandtothefurtherreachesofasite,aswellastonewfacilitiesattheplanningstage,andexistingfacilitiesbeingimproved.

Mostprojectswillrequireinputfromadesignprofessional.Theroleofthedesignerwillbetodesignaschemesothatitisfitforpurpose.Mostdesignerspreparedetaileddrawingsandspecificationsforthosewhowillactuallyconstructthenewgarden,althoughsomelandscapegardenersorcontractorsalsooffera‘designandbuild’service.

Itisalwaysadvisabletoemployadesignerwhohashadsomeformaltraininginthisfield,ratherthanusinganarchitectorinteriordesignerwhomaynothaveexperienceindesigningoutdoorspaces.

Garden designersmaybeabletotacklesmallerspacessuccessfullyandtheycanoftenofferparticularexpertiseinplantingdesign,whichshouldbeamajorelementinanytherapeuticspace.Landscape architectsshouldbeemployedonlarger,morecomplexschemes.Thoughtheysharemanyskillswithgardendesigners,theyareoftenmoreusedtoworkinginthepublicdomainandcantakefullresponsibilityfordesigningbothhardandsoftlandscapeelements.

Designprofessionalsworkingtocreatea‘therapeuticoutdoorspace’shouldalsofindthedesignprinciplesoverleafhelpful.Even someone without any design training who is interested in making the outdoor space part of the healing environment can help develop a worthwhile project.

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1.Valuewhatyouhave

Healthcarefacilitiesareofteninastateoffluxastheydeveloptomeetchanginghealthneeds.Thereisconstantpressurefornewbuildingsoradditionalcarparks,andevennewhousing,andopenspacemayseemtheobviousplacetoputthem.

TheHippocraticOath‘First,donoharm’isagoodguidingprinciplefordevelopingoutdoorspaces.Byvaluingwhatisalreadythere,andunderstandingthebenefitsthatopenspaceprovides–mostimportantly,theveryspecialtherapeuticbenefits,thecaseforsafeguardingopenspacegrowsstronger.

Howdoyou‘value’whatyouhave?

Tovalueanexistingspaceitisessentialtounderstandtwothings:whatyou’vegot,andhowitisalreadyused.Maybethereisalreadyspaceonthesiteforrecreationbutpeopledonotknowaboutit,ortheremightbethingsaboutitwhichareputtingpeopleoff,forexamplelitterorovergrownvegetation.Sometimessomesimplehouse-keepingisallthatisneededtoencouragepeopletouseanarea.

Well-designedfacilitiesarecarefullyplannedtopreserveandenhancekeysitefeaturessuchasimportanttreesorprotectedspecies.Takingamaster-planningapproachandlocatingnewbuildingsfollowingadetailedanalysisandappraisalofthesite,ratherthanlocatingtheminanopportunisticway,willalwaysgivebetterresults.

Sometimestheopportunitiesarehardtoidentify,asatNinewellsHospital,Dundee.

NinewellsHospitalwaslocatedinanelevatedpositiontotakeadvantageofthepanoramicviewsovertheTayestuary.However,accesstotheoutdoorsforpatientshas,untilnow,beenlimitedtothesmall‘freshair’gardenclosetotheentrance.

Alandscapearchitectwasappointedtodevelopamasterplanforthewholesite,withthehelpofForestryCommissionScotland.Thesiteappraisalshowedthatoneofthebestopportunitiesforaccesswasthewoodedparklandtothesouthofthesite.Ithadthepotentialtobeusedbymoremobilelong-staypatients,aswellasstaffandvisitors,andthesurroundingcommunity.

Theconstructionofanetworkofcycleandfootpathsthroughthehospitalgroundsisnowunderway.Newseating,restareasandinterpretativeinformationwillencouragegreaterexplorationofthewoodland,andmakethemostoftheviewsovertheRiverTay.

Aerial view of Ninewells Hospital in Dundee.

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Thethreefirststeps

Step 1: A site appraisal/analysisbyasustainabilitymanagerorfacilitiesmanagementteam,withtheinvolvementofaclinicianwhohasknowledgeofthepotentialbenefitsforpatientcare.Wherearetheopportunities?Arethereparticularstrengthsandweaknesses?Inputintothesiteappraisal,intermsofhealthpromotion,fromtheNHSoreventhelocalauthoritywouldalsobehelpful.

Step 2: TheTrustteamwillneedtoset out and adopt a policyregardingtheroleofopenspacewithinthewiderpatientcareenvironment.Supportofseniormanagementteams,includingtheChairandChiefExecutive,andthemaintenancestaffisessential.Thepolicyshouldincludethebusinesscasefortherapeuticuseofopenspaceacrossthesite.Cross-referenceshouldbemadetootherdrivers,suchaslocalTrustorBoardperformancemeasures,andnationalinitiativessuchastheNHSForestprojectorNHSGreenspaceinScotland.

Step 3:Anaction plantoprioritiseimprovementsandpotentialfundingsources.Atthisstageadditionaldesignsupportfromalandscapearchitectislikelytobeessential,particularlywithlarger-scalespacesormorecomplexsites.

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

New paths around the hospital grounds.

Red squirrels may be returning to the woods at Ninewells.

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2.Createspaceswhichfeelspecial

Senseofplace

Oneofthemostimportantprinciplesinlandscapedesignisthatdesignshouldalwaysbespecifictoitslocation.Workingwiththesitewillenhancethesenseofplace,andmayevenmakeitcheapertodevelop.

ThepoetAlexanderPopewroteaboutdesigningwithnatureand‘senseofplace’–inotherwords,workwithnature,andworkwiththesite.Thiswillentailanalysingitscharacter,itsstrengthsandweaknesses,consideringopportunities,celebratingandenhancingthefamiliarinthelocality,anddesigningtodelight.Inthiswaythesitewillcomfortandstimulate,beenjoyedandtreasured,andbeaplacewherepeoplewanttospendtime.

Spaceswhichfeellike‘places’willbewellused

Theaimistocreatespacesthatareplacesintheirownright,withastrongcharacter,whichwillhelptoensurethataspacewillbewellused.InScotland,the‘GoodPlaces,BetterHealth’frameworkpromotesthehealthbenefitsofwell-designedspaces.Itrecognisesthatpoorenvironmentsmayfosterhopelessnessandstressanddiscouragehealthybehaviour,whereasthecreationofpositivephysicalenvironmentsmaynurturebetterhealthandwell-being.

Specialfeaturesshouldbeprotectedandincorporatedinthedesignwherepossible.Trees,includingfruittrees,areespeciallyhelpfulinestablishingasenseofplace,oftencombiningadistinctiveappearanceorcharacterwithanincreasingsenseofantiquityastheymatureintovenerablespecimens.

Pine trees at Chalkhill have inspired the design of the interiors.

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


A specimen tree provides a new focal point for the courtyard and makes it feel like a place in its own right

The new tree should be upright rather than spreading, to ensure that views from the windows are not obscured and the building still receives plenty of light

Seating helps make the space feel more inviting and also more likely to be used

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Inruralareasitisimportanttobeawareof‘localdistinctiveness’,orwhatmakesthelocalitydifferentandspecial.Oftenitmeansusingmaterialscharacteristicofthatarea,forexamplestonepavingorparticularplants–suchasbox,whichgivesBoxHillinSurreyitsname.InSheffieldontheNorthernGeneralHospitalcampus,oldindustrialartefactsareplacedaroundthesiteatkeylocations.Theseprovideinformalmeetingandorientationpoints,andremindeveryonethatSheffieldisacitywitharichindustrialheritage.

AtthenewSecondRhonddaCommunityHospitalinWales,whichwasbuiltonthesiteofaformercoal-mine,thelandscapehasbeencarefullydesignedtoreflectthecharacterofthesurroundinglandscape.Drystonewalling–usedlocallyforfieldboundaries–featuresprominently,andhasalsobeenusedtocreateseatingspacesinthecourtyards.Slateisusedasasubstituteforgravelandalsotoform‘standingstones’whichprovidestrongfocalpointsinsomeoftheothercourtyardspaces.

Artworkdesignedinasecondphaseofworktoenhancethecourtyardfeaturesalsohelpstogivethesespacesadistinctcharacter.

Using local materials will ensure that outdoor spaces reflect the character of their surroundings.

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3.Maketheoutsideaccessible

Anintegratedapproach

Thisapproachintegratesbuildingsandstructureswiththewiderlandscape,ratherthanfocusingmainlyonbuildingsanddesigningthesite‘fromtheinsideout’.Wherepossible,thismorestrategicapproachispreferabletotacklingexternalareasona‘gardenbygardenbasis’,whichcanonlyinfillthespacesleftoveroncethebuildinghasalreadybeendesigned.Well-integratedsiteswill,bydefinition,beaccessible.

Easyaccess

Alongsidethequalityandproximityofthespace,easyaccessisprobablythemostimportantfactorindeterminingwhetherspaceswillactuallybeused.Designingthebuildingswithregardtotheiroutdoorspaceshouldhelptoensurethatthereisplentyofdirectaccessfrominside,outintothespaces.AtNewhamUniversityHospitalinLondon,courtyardspacesoffthemaincorridorprovideeasilyaccessiblespacesfortheground-floorcafésandwards.Moremobilepatientsontheupperfloorsalsousethesegardens,takingtheliftsorusingthestairstogetthere.

Whereappropriate,wardsshouldbedesignedtoallowbedstobewheeledoutintothesunshine(rememberingthatsomepatientswillalsoneedtobeinshade).Formanyhospicesthisisaroutinepractice,suchasattheJosephWeldHospice.

Aclearhospitalpolicyonusingoutdoorspaceswillalsohelptogivestaffconfidencetoencouragepatientstogooutsidewhereappropriate.

Formanypeople,andespeciallythoseconfinedtobed,beingabletoenjoytheoutdoorsfrominsideisimportant,andviewsoftreesoragardenshouldbeavailable.Thismeanstakingcarethatthewindowislowenoughandthebedisorientatedtowardsit.SomeoftheKingsFund’s‘EnhancingtheHealingEnvironment’projectshaveinvolvedretro-fittingdoorstomake‘hardtoreach’spacesaccessible.Thisisoftenworthexploringinexistingbuildings.

TheLambethCommunityCareCentreiscleverlyintegratedwithitssetting,andthegardensareseenasanessentialpartofpatientcare.Sun-roomsandbalconiesarepopularwithpatientswhoarenotyetreadytogooutside,butwhostillwanttoenjoythefreshair.Evenpatientsinwheelchairsontheupperfloorscangooutindependently,alongahigh-levelwalkwaywhichconnectsthebalconyareaswiththegarden.

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

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The sun room offers a taste of the outdoors at Lambeth Community Care Centre.

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

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Beingcreative

Someorganisationsandhealthcaresettingsareexperimentingwithdifferentwaysofbringingnatureinside,whereparticularpatientneedsorthedesignofthebuildingmeansaccesstothenaturalenvironmentislimited.

•AtAlderHeyChildren’sHospitalinLiverpool,recordedbirdsongisplayedinsomewardsandCDsaregiventopatientswhentheyleavetoassistwiththeirrecoveryathome.

•AtDorsetCountyHospitalinDorchester,inthechemotherapyunitwhereinfectioncontrolisahighpriority,livefilmistransmittedfromanaturereserverunbytheDorsetWildlifeTrustaspartofthehospital’s‘RoomWithaView’project.

•Insomeclimates,oronverysmallsites,‘winter-gardens’orconservatoriesmaybethemostsensibleoptionfortherapeuticfunctionssuchasphysiotherapy,especiallyforchildren.

A ‘woodland setting’ for the new Children’s Unit at Salisbury Hospital.

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

Above:Existing view.Left:How the improved area could look.

Floor to ceiling windows allow good views in for the smallest visitor

Doors kept locked for this garden which is inaccessible to the public

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4.Focusonpeople’sneeds

Insuccessfultherapeuticspaces,meetingpeople’sneedscomesfirst,ratherthanthedrivetoreducemaintenancecostsoravoidrisksbeingprioritised.Designersshouldworkcloselywithpeople(usergroups,ortheirrepresentatives)tounderstandtheseneeds,ratherthanproceedingonthebasisofassumptions–whichmightbemistaken.

Inclusivedesign

Animportantgeneralpointisthatspaceswhicharedesignedtohaveatherapeuticfunctionshouldfeelcomfortableandshouldbeplaceswherepeoplefeelsafe,relaxed,atease,andnotoverlookedorconstrained.

Multi-functionalspacessuchasgeneralgardenareasareoftenintendedforawiderangeofpeoplewithwidelydifferingneeds.The‘Inclusivedesign’approachisparticularlyrelevantforthese–cateringforspecificneedsinasubtlewaywhichmeansspaces(orstructures)canbeenjoyedbyallusers,ratherthanbyonespecificusergroup.AccordingtoDavidKamp,aninclusivedesignspecialist,‘Designconsiderations...areoftensubtledetails,easilyoverlookedexceptbythosewhoneedthem’.

Itmaybethecasethatsomepeople’srequirementsareconflicting.Jasmineplantedinagardentohelpalleviatesymptomsofdepressionmightprovetoohighlyscentedforthechemotherapypatientstrugglingwithnausea.Workingcloselywithpotentialusers(ortheirrepresentatives)willhelpovercomesuchissues.

TheSensoryTrust,basedinCornwall,hasdevelopedtheCreativeSpacesProjectwithCornwallCare,Cornwall’slargestindependentcareprovider.Theprojectaimstoimprovecarehomegardenssothattheymeetresidents’needs.Inordertounderstandthese,theTrustrananumberofevents–suchasanoutingtotheEdenProjectledbyyoungpeople,andthe‘designworkshop’inthegarden,whereresidentErniewasinvitedtosharehisgardenmemorieswithstaff.

Garden visits and design ‘workshops’ all help to clarify people’s needs.

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Cateringforspecifictherapeuticneeds

Insomespaces,thelayoutneedstobequitespecifictotheusergroup.Forexample,inamentalhealthdevelopment,agardenusedbyelderlypatientswithdementiawillbequitedifferenttooneusedbyyoungmenwithmentalhealthproblemsrelatedtodrugmisuse.Fundingforgardenspacesmayalsobeeasiertoprotectwhenthelinkstospecifictherapeuticfunctionsaremadeveryclear.

Involvingdisabilityaccessgroupsisessentialtoensurethatallthekeyissuesareaddressed,especiallywithregardtointelligentandsensitiveinterpretationoftheEqualityAct(2010).Cateringforbroaderequalityanddiversitycommitmentsmayinsomesituationsalsoextendtoaddressingculturalissues.

AtthenewAlzheimer’sRespiteCentreinDublin,thegardenisfullysecureandhasbeendesignedtoavoid‘dead’ends’,focusinginsteadonaloopsystem.Manyofthepatientswander,andmakingthiswanderingmorepurposefulreducesthelikelihoodofthembecomingstressed.

TheCentreManagerdescribedhowhelpfulthegardenisforresidents:Ifsomeoneisgettingworkedup...youcantakethemoutside,eveninthewinter...thepersonoftencalmsdownmorequicklythaninside,wherethewallscanfeelveryconfining...wehavescentedherbslikelavenderarounddoorwaysandweencourageresidentstocrushtheleavesintheirhands,toreleasethescentontotheirskin.

It’showaspaceisusedthatcounts

Sometimes,alackoffundingorstaffresourcesmeansmakingasmuchaspossibleofanexistingarea.Intheabsenceofanewdesign,encouragingthestafftousetheareamorecreativelymayenableaspace–whichonthesurfaceseemstohavelittletherapeuticpotential–tomeetpeople’sneeds.TheCreativeSpacesProjectinCornwallintroducedsimpleoutdoor‘activitystations’intothegardensofcarehomes,encouragingresidentstospendmoretimeoutdoorsandtoexplorenewareas.AndatWillitonHospitalinSomersetstaff,encouragepatientsoutsidetore-learnoldskills–inthecaseofonegentlemanwhowasabutterflycollector,usingabutterflynet!

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

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Scented lavender.

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5.Connectwithnature

Natureliesattheheartofoutdoorspacesforhealthandwell-being.Trees,springtimeflowers,shrubs,birdsong,autumncolours,agentlebreeze,sunshineandrainareallsomuchpartofeverydayexperiencethatitiseasytotakethemforgranted.Forthosewhoareillinhospitalwards,orperhapsanxiousorstressed,theycangreatlyassistthehealingprocess.

Usingnaturalmaterials,andmakingthemostofnatural‘elements’(earth,wind,water)aswellasplantingallhelptostimulatethesensesandreconnectpeoplewithnature.Asmallbird-feedingareaorplantschosentoprovidenectarforbutterflieswillgiveeveryonesomethingextratowatchandanotherreasontogooutside,evenifjustforashortbreak.

Wildlife

Plantedareasarealsomuchmorelikelythanpavedonestoattractbirdsandotherwildlife,whichaddextralifeandinteresttoagarden,likethecafécourtyardsketchedbelow.

‘OneofthereasonsIwantedtoworkattheHomoeopathicHospital,isthebuilding.Itislightandairyandwelcoming.Thesenseofspaceisextravagantforahospital.ThebestthingaboutworkinghereisopeningthewindowsandlisteningtothebirdssingingasIwork.’(CandidaFenton,LibrarianatGlasgowHomoeopathicHospital)

Inschemeswithastrongemphasisonwildlife,itwillbeimportanttomakesurethat‘native’ratherthanornamentalplantsareused.Thiswillhelptoensurethattheschemebenefitslocalbiodiversityasmuchaspossible.Evenmodestimprovementstoaspacetocreateanewgardencouldhavemajorbenefitsforwildlifeinthevicinityandhelpfacilitiesmeettheirlocalperformancetargetsintermsoftheenvironment.

The excitement of meeting a snail for the first time.

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


Picnic tables replaced with more comfortable seating, easier for those who are less mobile to use

Trees under-planted with edible herbs and soft fruit, such as strawberries

Apple, plum and cherry trees help to soften the space and create privacy; all growing in light-weight planters and soil to reduce loading over the roof garden surface

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Forexample,inthesouth-west,plantingasmallareaofDevil’sbitscabiousmighthelptoattracttheendangeredmarshfritillarybutterfly,apriorityspeciesintheUKBiodiversityActionPlan.

TheWildlifeGardenatTivertonHospitalfocusedonmakingsmall-scalechangestoencouragewildlife,suchastheintroductionofareasofnativeplanting.Thewholeschemehascostlessthan£1000toimplement(excludingthevalueofvolunteerlabour).

Asurgeonatthehospitalwhoisakeenadvocateof‘healinggardens’workedwiththeEstatesDepartmenttomakeasterilespacemoreappealingtoawiderangeofbirds,butterfliesandbees.Patientsarenowabletowatchthehedgehogstrundlingaroundthegardenatduskfromtheirbeds.

‘Therobinsarenestingnowinlastyear’sblackbirdnest,andtherearehedgehogsusingthepurpose-builtnestbox,sosomethingmustberightANDthepatientstellmetheylovethebirds,andwildflowersunderacanopyoftrees.ItreallyisaHealingGarden.’(Dr.GavinHaig).

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

The Wildlife Garden at Tiverton Hospital.

Wild flowers in the new meadow areas.

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6.Balanceriskwithbenefits

Caringforpatientsandkeepingthemsafeisobviouslyakeyobjectiveinhealthcare,alongwithrestoringhealthandwell-being.Therearerisksinvolvedwithaccesstotheoutdoors,forexamplewhenpatientsventureoutofthewardintoanadjacentgarden,butthesemustbeweighedagainstthebenefitsofexerciseandreconnectingwiththeoutsideworld.

Managingdesignconstraintsconstructively

Mentalhealthsettingscanbeespeciallychallengingfordesigners,butwithagrowingunderstandingoftheimportanceofaccesstothenaturalenvironment,manysettingsarenowprovidinghighqualityspaces–especiallyimportantinresidentialunitsorwherepeoplearedetainedundertheMentalHealthAct(1983,asamended).

IntheWandsworthRecoveryUnitatSpringfieldUniversityHospitalinLondon,thebuildingwallscreatesecureinternalcourtyardspaceswhicharefreelyaccessible.Here,despitetheoperationalneedforsupervision,acivilisingandhumanesettinghasbeencreatedwhichsupportstherapeuticintervention.

WandsworthRecoveryCentreisarelativelyhighsecuritysettingbutthelayoutoftheoutdoorareasischaracterisedbydesignqualityratherthan‘robustness’.Theseatinghereisagoodexample:sturdy,butwithatactile,softlyundulatingsurfacedesignedinwaywhichradiatescalmness.

Inputfromboththehealthandsafetyandinfectioncontroldepartmentsmaybepartofmakingsurethataspaceissuitabletouse.Theirinputshouldbemanagedconstructively,toavoidtakinga‘riskaverse’approachtodesign.Therisk–benefitassessment(RBA)process,wherethebenefitsofanactivityordesignareexaminedalongsideanyrisks,isusednowbymanyorganisations–includingtheForestryCommission–asaconstructivewayofmanagingliability.IthasgovernmentsupportthroughtheHealthandSafetyExecutive(HSE).

AtthestrokerehabilitationunitofWillitonCommunityHospital,Somerset,thegardeniswellusedbyin-patientsandtheirfamilies.Allpatientswhoaremobileenoughareallowedintothegardenontheirown,andtheyenjoyusingasmallnetworkofpaths,tore-learntheirbalanceandwalkingskills.Theyarealsoallowedaccompaniedaccesstoareasoff-site.

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Tactile seating at the Wandsworth Recovery Centre.

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Anexampleofhowthedecision-makingprocessdescribedbelowcouldbedocumentedusingarisk–benefitassessmentprocesscanbefoundinAppendix2.

ThegardensaroundWillitonHospitalinSomersetareunremarkableinappearance,buttheyareusedcreativelybythetherapiststhere.SeniorOccupationalTherapistSoniaexplains:

‘Webelieveit’sreallyimportanttoallowpatientsthefreedomtoenjoythegardenunsupervised[oncetheyhavebeenassessedasbeingabletomanagewithrelativesafety].Havingthatextrabitofindependencemeansthattheyhavetolearntobemoreconfidentoutside,whichisanessentialskillforthemtomasteriftheyaretobedischargedsuccessfully.Sometimes,yes,theydohaveafall,butwelookattheseincidentsinaconstructivelightandtheinformationabouthowandwhyithappenedtheninformsourtherapyandtreatmentprogrammetoreducethechanceofithappeningagain.

Becausewe’reinaruralarea,wehavealotoffarmersthrough,andit’sespeciallyimportantthattheyareconfidentinamore‘informal’setting–nousejustbeingabletowalkontarmac.Sowiththem,wemighttakethemundersupervisionontothefootpathnexttothegardenandevenoverthestileandintothefield,walkingoverroughnewly-ploughedground.It’ssoimportantforthemtoknowthattheycandotheseactivities.’

Path leading to surrounding fields from Williton Hospital.

Garden, Williton Hospital.

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7.Designforchange

Naturalspacesevolvewithtime

Imagining,designingandcreatinganoutdoorspaceisjustthebeginning–aspaceneedstolastlongterm.Spacesdesignedcarefullycanbeenjoyedthroughoutallstagesoftheirlifespan.Thisisespeciallyimportantforschemesincludingtrees,whichwillchangemarkedlyastheygrowthroughestablishmenttomaturity.

Successfulgroundsmaintenanceiswellplannedandadequatelyresourced

Groundsmaintenancecostsshouldbeconsideredfromtheoutset,andsetatalevelwhichstillallowsthespacetomeetusers’needs.Forexample,pavedareaswouldbecheapertomaintainthanplantedones,buttheywillneverachievethesametherapeuticbenefits.

Well-resourcedgroundsmaintenanceisimportantatanyscale.AtthenewForthValleyRoyalHospitalatLarbert,Stirlingshire–averylargescheme–thedeveloperwasobligedbyaPlanningObligationtoendowtheoutdoorspaceswithafundof£250,000forrestorationandmaintenance.Atamuchsmallerscale,attheLambethCommunityCareCentreinLondon,thebudgethasbeenstructuredtocoverthecostsofapart-timegardener,withanyadditionalcostsbeingcoveredbyincomeraisedfromplantsales,opentolocalpeople.

Designtoanticipatechangingconditions

Openspacecanbeespeciallyusefulinthecontextofachangingclimate.Treescanbeplantedtoprovideshadeinhottersummers,helptomoderatetheeffectsofheavyrainfall,filterairtoimprovequality,absorbCO2andsupportbiodiversity,andimprovethebeautyofaplace.Theycanevenreducemanagementcosts,comparedwithmowngrass.

Toachievethecarbontargetsitisaimingfor,theNHSmustdesignandmaintainoutdoorspacessustainably.TheCentreforSustainableHealthcareisworkingtohelptheNHSbecomemoresustainableandtheNHSForestinitiative,whichaimstoplantonetreeforeveryemployeeacrosstheNHSestate(andbeyond),isanimportantelementinitsprogramme.Woodlandscreenplanting,suchasthatshownopposite,wouldbeasuitableprojectforthisprogramme.

At Lambeth Community Care Centre the gardener prunes shrubs carefully rather than using a hedge-trimmer.

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AtEnniskilleninNorthernIreland,thenewhospitalisbeingimplementedunderaprivatefinanceinitiativecontracttohighstandardsofsustainability,withthebestpossibleintegrationofbuiltdevelopmentandthelandscapeasoneoftheproject’skeyobjectives.

Animportantelementoftheprojectisthereconstructionofwetlandsroundthebuildings,usingsurfacewaterrun-offfromroofsandhardsurfaces.Othersustainablesolutionsincludetheextensiveuseoflocally-grownnativeflora,andthecreationofextensivespecies-richmeadowscloseto(andvisiblefrom)thehospitalbuildings.

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


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Trees can help the NHS meet sustainability targets and provide wildlife habitat

A limited amount of meadow grass, where appropriate, helps reduce frequency of grass-cutting and improve biodiversity on the site

Improved amenity value of site – especially near to countryside – enhances the environment for staff, visitors and patients

Atrium view of lough at Enniskillen, Northern Ireland.

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Summary

Thedesignprinciplessetoutabovehavebeendevelopedtoreflecttheissuesofmostimportancewithinhealthcaresettings;followingthemwillhelpensurethatthedesignofoutdoorspacesfortherapeuticuseissuccessful.Theywillprovideagoodoverviewofthekeydesignprinciplesforallthosewhomaylackspecialistexpertise,andwhomaybeinvolvedincommissioningordevelopinglandscapeprojects.

Maggie’sCentreatCharingCrossHospital,Londonisanexcellentexampleofaschemewhichplaceddesignqualityattheheartoftheproject,andalsoillustratesclearlyseveraloftheprincipleslistedabove.

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

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Illustratingthedesignprinciples

TherearealreadyanumberofMaggie’sCentresthroughouttheUK,usuallydevelopedasflagshipprojectsbyestablisheddesignersworkingona‘probono’basis.AlthoughinthecaseofthisparticularcentreinLondon,wheretheoverallbudgetwasgenerous(fundedbycharitabledonationsandfundraising),therearemanyaspectsoftheprojectthatwouldbeeasilyreplicableonthemoremodestbudgetstypicalofanNHSscheme.

Thereisgrowingevidencetoshowthattheemotionalstateofcancerpatients,andthatoftheirfamilyandfriends,caninfluencetheircancerexperience,treatmentandrecovery.Researchinthefieldofenvironmentalpsychologyhasestablishedthatourphysicalenvironmentaffectsourbehaviour,andwell-designedenvironmentssuchastheMaggie’sCentreinLondonhavebeenshowntoenhancequalityoflifeandaperson’sabilitytocopewithstress.

Thegardenillustratesparticulardesignprinciplesmentionedinthisguideveryclearly,asshownintheimages.

‘Mostpeoplesaidtheyfeltthattheplantssoftenedthebuildingbutalsothewholeexperienceofbeingthere.Theplantssimultaneouslycreateasenseofcalmness(soothing)butalsoasenseofenergy–peopleoftentalkaboutbeingfascinatedbythespeedthingsgrowatandtheylookforwardtoseeingthenextstageintheplant’sdevelopment;there’savitalityaboutthebudsopening,andnewleavesunfurling.Forpeoplewithcancer,anythingwhichhelpsthemlookforwardtothefuturewithasenseofhopeismassivelyhelpful.’(Researcher,Maggie’sCentreLondon,2010).

Case Study 3: Maggie’s Cancer Caring Centre, London.

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Design for people’s needs: Thesiteradiatescalmnessandtranquillity,whichhelpsrelievetheanxietyandstressoftenexperiencedbythosewithcancer,andtheirfamiliesandfriends.Therelaxedmoodandeasy,inside-outflowhelpmakethecentrefeellikeasanctuaryinthebusyurbanenvironmentinwhichitsits.

Make the outside accessible:Thelandscapedesignerworkedcloselywiththearchitectandthishashelpedcreateabuildingwhichisfullyintegratedwiththeexternalareas.Thegardensurroundsthebuildingandgrowsthroughitinaseriesofintimateandsensualspaces.Eachroomhasitsownaccessoutside,andthelargewindowseverywheremaketheoutdoorspacespossibletoappreciateevenonawetwinteryday.

Connect people with nature: plantingenvelopsthewholebuildingandthetrees–onceestablished–willhelpscreenthenoiseandbustleofthesurroundingstreetsandtraffic.Theplantinghasbeencarefullyplannedtoincludescentedfoliage,andtocreateagoodbalanceofintricacyandsimplicityofscale.

‘Bystimulatingallthesensesandprovidingaconnectiontonatureinanurbanenvironment,Maggie’sLondonwillputallvisitorsintouchwiththishealingpotential’(designer).

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Overcomingthechallenges

Eachtypeofhealthcaresettingwillhaveitsownparticularchallengestoovercomeinordertoprovidetherapeuticoutdoorspaces.Somemethodsofprocurement,suchasprivatefinanceinitiativeschemes,alsoneedtobetackledcarefullytoachievethebestoutcomepossible.

Therearemanyexamplesofgoodpracticethroughoutthecountrywherethesechallengeshavebeensuccessfullysolved.

Privatefinanceinitiativeschemes

The challenge:ManytypesofNHSfacilityareprocuredunderprivatefinanceinitiative(PFI)schemes.ATrustthatplaceslowvalueonlandscapeattheoutsetrisksseeingthisaspectdiminishedevenfurtherduringdelivery,withproposalserodedbyinevitablecontractualandfinancialpressures.

The solution:Whilestronglyfocusedonacost-effectivedesignandconstructionprocess,newPFIschemescanstilldeliverhighqualitylandscapeswhichcanhaveatherapeuticfunction(andwithexistingschemes,changescanbemadebyvariationtothecontract).

Wherethereisnoexistingguidanceonrequirementsforoutdoorspace,theprocuringauthorityshouldincludetheserequirementsinitsoutputspecification.Bidsshouldplaceemphasison,andallowpropercostsfor,alandscape-ledapproachsecuredthroughthepreparationofdetailedproposals,includingagreedlevelsofqualityandprovision,atPreferredBidderstage.TheproposedEnniskillenHospitalexemplifiesthisprocess.

How do we put the theory into practice?

Enniskillen Hospital, in Northern Ireland, North Spine View.

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Acutecare

The challenge:Wardsarefrequentlyrelocatedinacutehospitalsettings,makinglong-termplanningdifficult,withlittleincentiveforcapitalinvestment.Theremayalsobeaperceptionthatinvestinginaccesstotheoutdoorsdoesnotofferagoodreturnwhenmanypatientsaremostlyconfinedtobed.

The solution: AtSalisburyDistrictHospitalinWiltshire,theArtsManager,togetherwiththeFacilitiesandEstatesManagementTeam,hasidentifiedanumberofspacesforpotentialimprovement.Theselieoutsidethehospital’s‘developmentzone’,havepotentialamenityvalue,andhaveausergroupcloseby.Withastrategynowinplace,improvementscanproceedwithconfidenceasfundingbecomesavailable.

Inthehospital’splansforacourtyardgarden,thespacewillbeaccessiblefromboththeStrokeandOncologyunits.ThesketchbelowshowshowfeaturescanbeincludedtohelppatientsfromtheStrokeUnitimprovetheirmobilityandbalancewhilealsomakinganattractivespaceforotherpeople.

Olderpeople’scare

The challenge: Inolderpeople’scaresettings,therehasbeenatendencyforpeopletospendmuchoftheirtimesittingpassivelyintheTVroom.Staffmaybeunawareofthebenefitsforolderpeopleofbeingoutsideand,asaresult,encouragingresidentsoutintothegardenbecomesalowpriority.

The solution: TheCreativeSpacesProjectinCornwallcreatesopportunitiesforolderpeoplewithdementiatoimprovetheirenvironmentsandplayamoreactivepartinsociety.ThelessonslearntarebeingdisseminatedacrossallthepropertiesmanagedbyCornwallCare.

Withinthisproject,theconceptofatimetabled‘activitiesprogramme’hasbeenreplacedbyanewapproachtoactivitiesthatpromotesindependence.AtTrevarnaCareHomeinStAustell,the

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


Seating areas close to entrances

Shrubs around the edge make the garden feel less over-looked

Existing change in level incorporated within new circular path using different surfacing materials

Grove of Birch trees helps to define the space and create privacy. The trees will also look attractive from inside the building, even the upper floors

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gardensarebeingredesignedwiththeresidents’needsinmindtoenablethemtomaketheirownchoicesaboutwhattheydooutside.

Thegardensarefreelyaccessible,andoutdoor‘activitystations’consistingofvisualcuessuchasapileofbooksinaquietcorner,oracollectionofgardeningtoolsona‘work’table,allhelpresidentstoinitiatetheirownactivities,maintainingtheirindependenceandself-worth.Insiteswhereindependentaccesstogardensisdifficult,moreemphasisisplacedongettingresidentsoutandaboutbycoach–totakepartintheday-to-dayactivitiesofthelocalcommunityinwhichtheylive.

Primarycare

The challenge:Inprimarycaresettings,patientsusuallyonlyattendforshortappointments.

The solution: Theremaybescopetodevelopoutdoorspacestoprovideapleasantplaceforpeopletowait,orevenasafocusforactivitieswhichcouldincludethewidercommunity.

AttheCulmValleyIntegratedCentreforHealthinDevon,anewapproachtoprimarycareisbeingtrialled,asdescribedinCasestudy4.

Anewmodelofprimarycareforthe21stcentury

TheCulmValleyCentreisatthecoreofaninnovativenationalself-careprojectsupportedbytheDepartmentofHealth.IncorporatingaconventionalGPsurgeryalongsideanaturalhealthcentre,thedesignofthebuilding–bothinsideandoutside,andalsoofthegrounds–emphasisesaholisticapproachtohealthcare.Thereisafocuson‘wellness’ratherthanillness,andafocusonself-care,orprevention,ratherthanonmedication.

Ahealthfacilitatoronthestaffactsasagatewaytoawiderangeoftherapiesincludingactivitieswithastrongsocialorcommunityangle,suchastheGardeningGroup,andtheCommunityInterestCompany(SustaincareCIC)runsacaféinsidethecentre.Thecaféfunctionsasasocialhub,andpatientsvisitingtheirdoctor,healthprofessionalorthepharmacystopforadrinkandsnackandfindnewwaystolookafterthemselvesastheydo.

ThePhysicGardenhasinformationonBritishmedicinalplantsthatcanbegrowninpatients’gardens,andhasabenchwherepatientsandstaffcanspendtimerelaxingoutsideinacalmingenvironment.

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

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IntheKitchenGardenfoodisgrownforthecafé,toshowpeoplehowfoodgetsfromsoiltoplate,tomodelhowlittlespaceisneededtogrowone’sownfood,andtoencouragetheuseofseasonalproduce.

Manypeoplehaveattendedsessionsheldbyherbalistson‘MakingmedicinesfromtheGarden’and‘WinterRemedies’.Theworkshopsencouragepeopletotakeresponsibilityfortheirhealthandarealsosocialevents,givingpeopleachancetomeettheirneighboursandbuildfriendships.

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Gettingstarted:theprojectprocesssummarised

Therearefourmainstagesinthedesigncycle:

1. Preparation.2. Designandimplementation.3. Usingandmaintainingthenewspace.4. Monitoringandreview.

The‘review’partofstage4islikelytoleadbacktostage1again,asfurtherimprovementscontinuetobemade.

Timespentongettingtheprocessrightwillhelptoachieveawell-designedandsustainableoutdoorspace.

Mostpeoplethinkoftheprojectprocessasbeinglinear,withabeginningandend.However,agoodprocessiscyclical,withthefinalmonitoringandreviewstageleadingnaturallybacktothebeginning.Spaceschangeasplantinggrowsandmaturesandonlyregularmonitoringwillidentifywhetherpartsofthelayoutneedtobealteredtoo.

TheKing’sFundprogramme,‘EnhancingtheHealingEnvironment’,hasdevelopedasuccessfulmodelfor‘team-based’projects,ledbyclinicalstaffandcarriedoutinpartnershipwithserviceusers,anditisrecommendedthatreadersrefertothis.

At Lynfield Mount Hospital in Bradford, service-users, staff, and relatives all worked together to transform an under-used space, with funding from the ‘Enhancing the Healing Environment’ programme.

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Stage1:PreparationRemember to:

•Assembletheclientteam.

•Developabusinesscase.

•Makesuresufficientresourceshavebeenallocated.

•Establishwiderpartnershipswithotheragencies.JointStrategicNeedsAssessmentidentifies‘thebigpicture’intermsofthehealthandwell-beingneedsandinequalitiesofalocalpopulation,andprojectsshouldbeinformedbythisprocesswherepossible.

•Checkplanningorlegislativeobligationsandduties.

•Surveythewholesite.

•Developadesignbriefbasedonastrong‘vision’fortheproject.

Funding

Securingfundingwillbeoneofthemostimportanttasksinthisfirststage,whenattemptingimprovementstoanexistingspace.Fundingcancomethroughdonationsandcovenants,legaciesandalso‘giftsinkind’–suchastheworkbytheSellindgeGardeners’AssociationinthegardensofthePilgrimsHospiceinAshford,Kent.

FundraisingeventsandevencharityshopsgeneratevaluableincomeforfacilitiesorgroupsregisteredwiththeCharitiesCommission,suchashospital‘friends’groups.Charitablestatuswillmakeiteasiertoapplytogrant-makingtrusts,ofwhichtherearemany,thoughtheircriteriavarywidelyandoftenchangefromyeartoyear.

Fosteringpartnershipswithotherlocalagencies(suchasWildlifeTrusts)orjustbeingawareofthelocalpoliticalclimatemayalsoopenupfundingopportunities.

AtBroomfieldHospitalinEssex,anambitiousprogrammeofimprovementstothesurroundingwoodlandwerefundedbyaPlanningObligation,aswellastheForestryCommission'sEnglishWoodlandGrantScheme,includingaWoodlandAssessmentGrant(WAG),forecologicalandstakeholdersurvey.OthersourcesoffundingincludedtheChelmsfordBoroughCouncilArtsFund.Thehospitalcommentedthatarelativelysmallamountofmoneyspentonwoodlandimprovementsmadeasignificantimpactinpublicperception.

Therearealargenumberoffundingsourcesforschemeslikethiswhichfocusontreeplanting,suchasthecampaignTheBigTreePlant.DetailsoftheseareavailablefromtheForestryCommissionandWoodlandTrust.

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Event for friends and supporters of Lambeth Community Care Centre.

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Stage2:DesignandimplementationRemember to:

•Appointadesigner.Landscapegardenersorgardendesignersmaybeabletohelpwithimprovingsmaller-scaleexistingspaces,butprojectswhichareatalargerscalewillneedthesupportofalandscapearchitect.Landscapearchitectsaretrainedtounderstandandimproveoutdoorspaces,andwillhavethelisteninganddesignskillstoengageinasite-widedesigndialogue.

•Briefthedesignerthoroughly.

•Checkthattheyunderstandinclusivedesign,andhaveexperienceofdesigningfortheparticularusers’needsintheprojectinhand.

Bytheendofthedesignstage,theinitial‘vision’willhavebeenhonedbytheteam(includingthedesigner)intothefinal‘product’–theschemewhichistobeconstructed.

Implementationislikelytobeundertakenbyacontractor.However,onsmallerschemesinsomesettings(primarycare,residentialsettings)theremaybeopportunitiesforpatientsorstafftohelpwithelementssuchasplanting.

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Volunteers helping with implementation work.

Tree planting in Cornwall.

Culm valley centre planting by patients.

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Stage3:UsingandmaintainingthenewspaceRemember to:

•Organisealauncheventorpublicopening.

•Thankeveryoneinvolvedintheprojectandpublicisethenewspacetopotentialusers.

•Takeanyfurtheropportunitiesduringtheyeartoorganisesmalleventsoractivitiesinthenewspaceinvolvingstaff,patientsandvisitors.

•Monitorhowthemaintenanceisprogressing,especiallyearlyon.Perhapsthelitterbinsneedemptyingmorefrequently,orthereisextrascopeforpatientorstaffinvolvementinsimpletaskssuchaspickingapplesintheautumn.

•Dealwithissuessuchassmokingorlitterconstructively(notbysimplypreventingaccess).

•Makesureadministrativeandmaintenancestaffareeducatedaboutthevalueofoutdoorspace,andtheimportanceofmaintainingaccessibility,toensurespacesremainunlocked.

Allimprovementswhichleadtospacesbeingusedbymorepeoplewillusuallyresultinincreasedmaintenanceneedsandpotentialcosts.

Thesecouldbemetbyfindingoutwhetherthelocalhorticulturalcollege,horticulturalsocietyorlargercompanieswithcommunityvolunteeringschemescouldhelp.Also,theWildlifeTrustsandtheBTCV(BritishTrustforConservationVolunteers)havebranchesallovertheUKandwilltakeonavarietyofprojects,especiallyinanaturalorsemi-naturallandscape.

Stage4:MonitoringandreviewRemember to:

•Carryoutapost-occupationevaluationstudy,tocheckwhetherthereisanythingaboutthespacethatcouldbeimproved.Knowingwhathasworkedwellalsohasimportantvalueintermsoflessonstoreplicateelsewhere.

•Reviewthespaceannuallytocheckthedevelopmentofthelandscapeasitmatures.Treestakesandtiesmayneedadjustingandsometimesgroupsoftreesneedtobethinnedtogivebetterspecimensthespacetogrow.Itwillalsobeimportanttocheckandmaintainplanthealth,especiallyafterperiodsofextremeweather.

•Continuetocheckweeklythatthenewspacesremainaccessible,andarenotlockedunnecessarily.

TheVerwoodOpportunityCentreProjectdescribedinCasestudy5showshowagoodprocessresultsinasuccessfulproject.

At Broomfield Hospital in Essex, special efforts were made to involve young people from the local community in implementing work on site and in celebrating its completion.

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

Awell-plannedspaceforeveryonetoenjoy

In2009staffattheVerwoodOpportunityCentrefoundthattheirclients,peoplewithphysicalandlearningdisabilities,wantedtofeelmoreintegratedwiththelocalcommunityandalsohavethechancetodomeaningfulwork.ThisresultedinthecreationoftheSensoryGarden,anewwildlife-friendlygardennexttotheOpportunityCentreandneighbouringCommunityCentre.

Stage1:Preparation

TheSensoryGardenprojectisanexcellentexampleofpartnershipworking:

•EastDorsetDistrictCouncildonatedtheland.

•DorsetWildlifeTrusthelpedco-ordinatethedesignprocessandagreedtolookafterthemanagementandmaintenance,oncethegardenwascompleted.

•TheOpportunityCentrepromisedtobuildusageofthespaceintotheirserviceusers’dailyactivities.

•TheneighbouringCommunityCentreofferedgeneralsupporttotheproject.

•Privatecompanies,includingalocallandfilloperator,providedthefunding.

•ThelocalEmmanuelSchoolhelpedwiththeplantingduringtheimplementation,aswellassettingupaTuesdaygardeningclub.

Stage2:Designandimplementation

Thegardenislaidoutintheformofaspiral,containingraisedbedsdesignedtoappealtothesenses.Tactilescentedplantingwithawidevarietyoffoliageandleafcolourmakethesiteequallyattractivetoeveryone.ImplementationwascarriedoutbyalocalcontractorbutclientsoftheCentrehelpedwithsmallerelements,suchasmakingthesignsforthesensorybeds.Particularattentionwasplacedonmakingthegardeneasilyaccessible.Forexample,thepatharoundthegardenwasmadeusingmaterialsenablingwheelchairs,walkersandpushchairs,tomovefreely.

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

Raised beds laid out in the shape of a spiral.

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Stage3:Usingandmaintainingthespace

OvertheyearsusageofthespacehasincreasedandmanyoftheOpportunityCentreclientsnowregularlychoosetospendtimeoutsideintheSensoryGardenratherthanindoors.ShaneCarter(aserviceuserfromtheCentre),said

‘Wearereallyabletogetinvolvedwiththegarden,helpingwiththeplants,buildingnestboxes,eventhesignswerewoodburnedbyus.It’sbeengreattoworkinthisgarden,helpingtocreatesomethingforthecommunityandustoenjoy’.

TheDorsetWildlifeTrustcontinuestomaintainthesite,monitoringtheplantingcarefullyasitmatures.

Stage4:Monitoringandreview

ProjectevaluationhasdemonstratedthattheSensoryGardenprojecthashelpedpeoplewithphysicalandlearningdisabilitiestoengagewiththecommunityandagencies,breakingdownsocialbarriers.NoelBergin,ConservationOfficeratDorsetWildlifeTrust,said:

‘TheideaisthatthedifferentsectionsofthegardenwillbeongoingprojectsfortheOpportunityCentre,schoolsandothercommunitygroupstolookafter.Hopefully,notonlywillitbeawildlifehavenwithinthetown,butvisitorswillleavewithideasonhowtoimprovetheirownlocalareaforwildlife’.

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

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

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Workingwithdesignelements

Thedesignelementslistedbelowwillallbeusefulincreatingtherapeuticspaces:

1. Planting2. Trees3. Entrances,pathsandboundaries4. Sitefurniture5. Art6. Water

Developingalayoutbasedonthedesignprinciplessetoutearlierandthinkingthroughthepracticalitiesofthewholeprojectprocesswillprovideagoodfoundationforanyscheme.

Experienceddesignerswillbeabletocombinethevariouselementssuchasplantingorpathsskilfully,butitishelpfulforthosebriefingthemtohavesomeunderstandingofthesetoo.Inthisway,aschemecanbecreatedwhichhasasenseofplaceandalsomeetsclinicalandotherneeds.Themostsuccessfulschemesarethosewheretheclienttakesastrongleadandwherethedesignerandclientworkcloselytogether.

Thissectionprovidesanoverviewofsomeofthemostusefulelementsusedindesigningoutdoorspaces.

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

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1.Planting

Plantedspacesformatrulyrestorativeenvironment.Goodqualityplantinghighlightsthepassingoftheseasons,appealstoallthesenses,helpstoattractwildlife,andprovidessomethingnewanddifferenttolookateverydaythroughouttheyear.

VegetablesgrowingintheChildandAdolescentMentalHealthUnitatGreatOrmondStreetHospitalareseenashavingtherapeuticvalueforyoungpeoplewitheatingdisorders.

Lotsofhospitalshaveoutdoorcourtyardspaces,butthosewhicharegardenswithlushplantsratherthanjustpavedareasarefarmorebeneficialtopeopleusingthem.

Justsittinginaplantedareacanbebeneficial,butsometimestheextraeffortinvolvedinfocusingonagardeningtaskcanhelprestoreafatiguedortroubledmind.AttheBromleybyBowCentreinLondontheflowerorcuttinggardenisusedforhorticulturaltherapy;thestoryofonevolunteer’sexperienceisdescribedbelow.

‘IhadbeenworkingasamentalhealthnurseanddramatherapistintheEastEndforseveralyears–itwasabusyandstressfuljob,butIenjoyedit.Unfortunately,though,Isufferedbullyingandharassmentatwork,anditaffectedmymentalhealth...Iwasunabletoworkanymoreandwentoffsick,unwellwithdepression.

InApril2007,myGPsuggestedItryvolunteeringattheBromleybyBowCentre.Initially,Iwasonlydoingafewhoursaweekbut,sinceJanuary2010,Ihavebeenonacontractofemploymentfor35hoursaweekinthecuttinggarden.Itfeelsgreattobeworkingatthislevelagainaftersomanyyears.SometimesIcannotbelievehowmuchmylifehaschangedinthelastthreeyears.WhenIwasillIcouldn’timaginebeingabletoworkagain.Theworkinvolvedingrowingandnurturingplantsisamazinglysatisfyingandtherapeutic,butyoudon’thavetoworkinagardenorgreenspacetobenefitfromit.Justwalkingthroughaparkcanimproveyourwell-beingandpeaceofmind.’(Lisa,memberofthePoLLENproject,BromleybyBow).

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•Chooseplantstoemphasiseseasonalchange,andbuildanticipationofthingstocomeandallowpeopletonoticethepassageoftime–evergreenschemestendtobelower-maintenancebutwillnotachievethis.

•Scentedandbrightlycolouredflowersandleavescanbeenjoyedbythosewhoarepartiallysighted,aswellasbeingattractiveforallusers.Senseofsmelliscloselyassociatedwiththe

A rich variety of planting means something new to look at every day.Vegetables growing at Great Ormond Street Hospital.

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partofthebraindealingwithmemoryandfeeling,soscentscancallupmemoriesandpowerfulresponsesalmostinstantaneously,whichisparticularlyhelpfulforthosewithmemoryloss.

•Shrubsshouldbeprunedcarefullytoemphasisetheirnaturalform.Thiswaythespacewilllookwellcaredfor–thesubliminalmessagebeing‘ifthegardeniswelllookedafter,Iwillbe...’.

•Food-growingisagoodoption,especiallyifthekitchenstaffcanusewhatisgrown.Inlong-stayorresidentialsettingspeoplewillbeabletoexperienceafullgrowingseason,butevenindaycentrestheycanjoininwithwhateverishappeningatthatpointinthehorticulturalyear.Agoodactivitiesprogrammecanfocusonfood-growing–eatingfruitcrumble,orpaintingcolourfulberries.

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

This left-over space between buildings feels bleak and exposed, but with the addition of trees and scented shrub planting it could become a space to relax in, between appointments or after a visit.


Archway creates a pretty entrance and helps separate the garden from the road

Lavender hedge along the lawn for butterflies and bees

Low maintenance rosemary hedge encloses the space and makes it feel more private

An arbour at the rear planted with jasmine to lift the spirits

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2.Trees

Treeshaveaspecialplaceinthedesignofoutdoorspacesandtheymakedistinctiveplaceswhichendure.Theyarealiveanddynamic,withenormouspresence–ofteninspiringastrongemotionalresponseinpeople,suchasthesinglemagnoliatreeinblossom,atSalisburyDistrictHospital.

Nativetreesareespeciallygoodforwildlife.Treescanalsohelpscreenunsightlyviewsornoisytraffic–important,whennoiseisoftenseenasreducingthetherapeuticvalueofaspace.Theyalsohelptodefinespaces.

Largecanopytreesofalltypesprovideshadeinsummerandshelterinwinter.TheNHSHeatwavePlanisupdatedannuallyandacknowledgestheroletreescanplayinmodifyingclimateand,inparticular,reducingairtemperatures.

Evensittingunderasolitarytreecanprovideausefulhealingspace.

‘IworkedforyearsintheMentalHealthservicesinTaunton...whenwemovedtothenewoffices,wehadasmallareaofgrasswithabenchunderalargeoverhangingtree.Therewaspressuretomakethisareaintoacarparkbutwesuccessfullyresistedthis,becausewefeltitwassoimportanttohavethispieceofnaturalspace.

At Salisbury District Hospital there is space in the small courtyard for a single specimen Magnolia, laden with flowers every spring.

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Thereweretimeswhenparticularclientscouldnotcopewithcomingintothebuildingandsessionstookplaceoutside.Irememberoneyoungmanwhowasunwell,verydistressedandalsoangry.Foratimehecalledtoseehisworkeratleastonceaday.Inthereceptionareahecauseddisruptiontoothersandhisworkertooktomeetinghimoutsideonthebench,wheretheclientdidnotfeelsohemmedin.’(Formermentalhealthservicesworker,Taunton)

TheNHSForestplanstoplantonetreeforeveryNHSemployee,aspartofthelong-termaimtomaketheNHSmoresustainable.Theplantingschemescanbeassmallasasinglefruittreeoraslargeasanewpieceofwoodland.Individualspecimentreesofferhighvisualimpact,soareoftenespeciallyusefulfortighturbansiteswherespaceformoreextensiveareasofplantingmaynotbeavailable.

Onlargersiteswoodlandplantingforbiomassboilersmayhelpsaveenergycosts.

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•Planttherighttreeintherightplace.Treesgrow!

•Aplantingstrategywillensurethatnewtrees,includingcommemorativeones,canbelocatedwheretheywillhelptocreateattractiveandusablespaces.

•Fruittreescanbeusefulforsmallerspacesandoffergoodseasonalinterest.Orchardplantingmayalsobeagoodwaytomakeshort-termuseofasitewhichisearmarkedinthelong-termforre-development.AttheRoyalEdinburghHospital,staffharvestfruitfromtheiroldorchardforpatients.

•Inhighsecuritymentalhealthsettings,treescanbeplantedinareaswheretherewillbeaccessundersupervision.Treeplantingcanbeusedtosoftenandscreenunsightlysecurityfences.

•Somepeoplefinddarkwoodlandoppressive;havingopensunnygladesandgenerouspathswillincreasethewoodlandflowersandenhancethesensoryaspectsofbeinginawoodedspace.

Whether it’s glowing autumn leaves or the spring sun lighting up a pussy willow catkin, each in their own way help to transport the visitor away from stress and anxiety.

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3.Entrances,pathsandboundaries–connectingthesite

Gatewaysandentrancesprovideimportantcuesforpeople–theysay‘comein,you’rewelcomehere’.Timespentonplanningacomprehensivenetworkofconnectingpaths,andondevelopinganappropriatespecificationandthenmakingsuretheyareproperlyconstructed,willhelpcreateasitewherepeoplecanmoreeasilyfindtheirwayaround.

Everyone,andespeciallythosewithcirculatoryandrespiratoryproblems,benefitsfromexercise–andmoreinterestingrouteswillprovidemoreofanincentive.Signpostingcanindicatethedistancecoveredandcaloriesused.

Pathsurfacesshouldbechosentoreflectthecontext,with‘softer’materialsforaninformalsetting.Primaryroutesshouldbedesignedtoalloweveryoneaccess,includingthosewithrestrictedmobility,butmanypeoplewanttoexperiencethenaturalenvironmentwithallthatimpliesanddonotexpecteasyaccesseverywhere.

Walkingcanitselfbetherapeutic,andthecontemplativeapproachtowalkingusedintheLabyrinthGardenatthePilgrim’sHospiceinCanterburyisonewhichmanypeopleofallfaiths(andnone)findhelpful.Theslow,steady,regularwalkingpacetunesinwiththeheart-beatandthishelpsinduceacalmerframeofmindandoften,asaresult,aloweringofbloodpressure.

Well designed entrances make people feel welcome as they arrive.

At St.Catherine’s in Doncaster, in-patients who have access to the grounds know they can safely walk along the red tarmac paths.

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‘Eachpersonfindstheirownwayroundthelabyrinthandthereisnorightandwrongway.Inwalking,theanalyticalleftsideofthebraingiveswaytothemoreintuitiverighthandsideandweareledbythepathawayfromstressfulthoughtsintostillness.’(LizzieHopthrow,Chaplain,PilgrimsHospice)

Boundariesdonotneedtobeoppressiveandthreatening,butcancontainandencloselikecomfortingarms.Thesecanincludenaturalboundariessuchaslandformorchangesoflevel,plantedboundariessuchashedges,andtraditionalwalls.Boundariesareanimportantpartofthesitedesignandshouldbechosentocomplementandenhancethesite.

For‘secure’boundaries,finemeshfencingismorevisuallypermeablethanverticalrailingsandfeelslessrestricting.Thevisualimpactoftallfencingcanbereduced,ifnecessary,byplantingoneitherside.

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•Makesurethatentrancesarewideenoughforthosewithspecialmobilityrequirements,andthatatactileelementisincludedtoindicatethethresholdtothosewithsightimpairment.Usingarangeofsurfacingmaterialscanalsohelpthosewhoaresightimpaired.

•PathdesignshouldgenerallyfollowtheAccessibilityStandardsdevelopedbytheFieldfareTrustaspartoftheBTCountrysideforAllproject,thoughitmaybeappropriatetodivergefromtheseinsomesituations.

•Wheelchairorscooteruserswillneedsufficientlywidepathswithawell-compactedsurface,shallowgradients,andlevelaccessfromthebuilding.

•Specialcolouredortexturedsurfacingcanhelpsomeusersfindtheirwayroundasiteindependently.SuchsurfacinghasbeenusedatStCatherine’sHospital,Doncaster.

Pilgrim’s Hospice, Canterbury: The Labyrinth garden.

Fine mesh fence at St. Catherine’s, Doncaster.

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4.Sitefurniture

Sitefurnitureincludesthefree-standingelementswhich‘furnish’asite–forexampleseating,litterbins,lightingandsigns.Goodsitefurnitureshouldbechosenandlocatedtomeettheparticularneedsofthoseusingthespace.Forexample,theheightanddepthofseatscanmakeabigdifferencetohowusabletheyarebypeoplewithspecificneeds:dotheyneedtohavearms,oraback-rest,oraretheyjusta‘perch’?

Sitefurnitureisusuallyincludedinitiallyforfunctionalreasons,butcarefuldesigncanaddanextradimension–helpingcreateitemsfullofcharacterwhichprovideextrainterestinaspace.Thefurniturecanalsoenhancethe‘senseofplace’–veryimportantinsettingswherepeopleareeffectivelyconfined,eitherbytheirownfrailtyorillness,orforothers’safety.

Bespokeitemshelpspacesfeellessinstitutional.Theymaybemorecostlybutcanbetailoredtotheirlocationandtousers’specificneeds,somayactuallyofferbettervalueformoney.Somebespokeitemscanbeverysimple–attheRoyalEdinburghHospitalin-patientspaintedflower-potsbyhandtocheerupthepatioandseatingareas.

Infacilitiesusedbychildrenandyoungpeopleitisvitallyimportanttocaterforplay–includingbothnaturalfeaturesthatcanbeplayedwith(suchassand,waterandgrassmounds)andpurpose-builtplayequipmentwhereappropriate(suchastheseating,chosenspeciallyforeachsite).Childrenwithimpairedmobilitystillliketoenjoythesameactivitiesasable-bodiedchildren,and,forsome,climbingnetsinaplayspacewillprovideamoreenjoyablewayofstrengtheningmusclesthanphysiotherapyindoors.

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•Remembertoincludeshadingandshelter–helpingpeopletocopewithphotosensitivityorjusttoavoidashowerofrain.

•Allowspacenexttoaseatforawheelchairorelectricscooter.Wheelchairusersandthosewhofinditdifficulttobenddownalsobenefitfrom‘raised’features,whichshouldbedesignedtoappealtootherstoo(e.g.bydesigningtheedgesothatitmakesaninformalseat).

•Insomeresidentialsettings(e.g.incarehomes)whereresidentsmaywanttousethespaceintheevenings,lightingwillhelpensurethespaceisbothattractivetolookatfrominside,andalsosafetouseafterdark.

Signs are often the first thing people see and designing them so they look friendly will help make everyone relax and feel welcome.

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Woven hazel tree seat at Fant Oast Unit, Kent.

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•Signsneedtobeapproachableandwelcoming.Theabilitytomakeaninformedchoice(e.g.tofolloworavoidaroutewithrough,bumpypaths)iscrucial,andappropriatesignsatthebeginningofrouteshelpthischoicetobemade.

•Seatingshouldbeplacedwheresomeonewouldactuallywanttosit–enclosedtotherear;withsomethingattractivetolookat,andoffthepathtoavoidobstructingotherpeople.

•Seatingshouldpreferablybewoodenwitharmsandbacks(notsteelorconcrete),butcanalsobeanartworkinitsownright,liketheexampleabove.

Seating for Hereford County Hospital.

Seating and lighting café courtyard, Newham Hospital.

In the park behind Bromley by Bow Health Centre, a large sheep doubles as a seat and a sculpture, and at Fant Oast in Maidstone, a Tipi makes a good social space.

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5.Art

Artinhealthcaresettingshelpstoprovideaplaceof‘respite’foreveryone.

Artcanprovideafocalpointforaspaceandhelpsengagetheattention.Asabespokeitemitmayhaveparticularandunusualtactileorsensoryqualities;itcanoffersurprise,encouragereflection,andevenprovidehumour.Italsohelpstomakeaspacefeellessinstitutional.Goodquality,carefullylocatedartworkscangreatlyenhanceahealthcaresettingandprovideanincentivebothtoventureoutsideandtospendmoretimeoutsidewhenyougetthere.

Theexperienceofartsmanagerssuggeststhatmorepeoplerespondpositivelytoartworkwhichisrepresentationalratherthanabstract,whereconventionalskillisinevidence,andinparticularwhereimagesofnatureareconcerned.However,moreabstractworkcanalsoprovokeinterestandpositiveresponses–suchastheworkoutsidethechapelatDorsetCountyHospital,basedonthesymbolismofthecircle,andconsideredespeciallyappropriateforthisnon-denominationalspace.

Actuallycreatingartcanbeanotherformoffocusedengagementorpurposefulactivity,likegardening–perhapsitiseventheadultequivalentofchildren’splay.Insomesettingsartistsworkwithpatientsandevenstaff,oftenoutdoors,tocreateitemsthatcanbeexhibitedinsideoroutsidethebuilding.

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•Artworksshouldrespondtotheopportunitiesofaspecificsite.Byreflectingwhatmakesaspacespecial,theirworkwillenhancethe‘senseofplace’.Artcanalsobeespeciallyhelpfulinurbanareas,addingcharacterwhereasenseofplacemaybelessapparent.

•Inspaceswhichareeasilyaccessibleandthereforehavestrongpotentialfortherapeuticbenefits,artworksshouldbedesignedsoastocreateinviting,habitablespacesandtosupportandencourageaccess.

•Somespacesmightbeinaccessiblebutarestilloverlookedbywardsandcorridorsabove.Theseofferspecialopportunitiestoinstallartworkthatmightnotbesuitableforpubliclyaccessibleareas.

Reminiscent of seed-pods, this artwork adds extra interest to an inaccessible hospital courtyard.C

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DorsetCountyHospital(DCH)inDorchesteremploysarttohelphumanisetheoutdoorspaces,makingthehospitalfeellessinstitutional.

Theartworksprovideusefulorientationpointsinwhatisquiteacomplexsitearrangedoverdifferentlevels.

Theyalsohelptocreateadistinctcharacterforeachgardenareaandaddextrainteresttospaceswhichmightbetooshadytospendverylongin,orwhichareinaccessibleanddesignedtobeviewedonlyfrominsidethebuilding.

Outsideoneofthemainentrances,thiskineticstructuredancesunpredictablytotheDorsetseabreezes.Theartworktransformsasmallspaceinaheavilytraffickedareaintosomewherepleasanttositandalsohelpsnewvisitorsorientatethemselvesastheyarriveonsite.

Dorset County Hospital.

There is a dazzlingly wide variety of art at DCH, from temporary installations such as the willow sculptures shown here, to this little dog above by Elizabeth Frink, a former patient at the hospital.

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6.Water

Thesoundofrunningwaterorthesightofafrogpoisedmotionlessatthepond’sedgecanprovideafocusforagardenspaceallyearround,withthesensoryqualitiesappealingtopeopleofallagesandabilities.Evena‘bubble’fountainisinvitingtothetouch,andasthesedonotusuallyinvolveareasofdeeperwater,mayraisefewerhealthandsafetyissues.

‘Ilikesittinginthegarden,Iwaswatchingtheblackbirdwashinghimselfinthefountaintoday,firstoneleg,thentheother,thenhiswings,hishead!Ohitdoesgivemealaugh...’(ResidentatHarbourHouseResidentialHome,Bridport,2010)

AtSpringfieldUniversityHospitalinLondon,stafffindithelpfultotakepatientsoutintotheextensivegrounds,whichincludeafish-pond,asdescribedbelowbytheActivitiesWorker:

‘PatientKwasdeaf,hadlearningdifficultiesandamentalhealthproblemrelatedtobehaviourissues.Aresidentialplacewasbeingsoughtwhichcouldmeethisneeds,butbecauseofhisbehaviouritwasdifficulttoplacehimanywhere...

PatientKlikedtowatchthefishandtofeedthem,andasawayofbuildinguparelationshipwithhimhewasoftenescortedtothegardensoastofeedthefish.Hewasawarethathewouldnotbe

Resident at Harbour House Residential Home, Bridport.

Formal fountain and fishpond, Springfield Hospital.

Frog in wildlife pond.

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takenouttothegardentofeedthefishifhisbehaviourwasnotundercontrol,andhebegantomodifyhisbehavioursoastobeabletobetakenouttofeedthefish.Overtimearapportwasbuiltupwithhimsothathewasabletoteachsomeofthestafftosignsoastocommunicatebetterwithhim.Hisbehaviourimprovedsomuchthataspecialistresidentialplacewasfoundforhim,andwhichhewasacceptedfor.’

Eventhosewhoareprofoundlydisabledcanappreciatethesprayofwaterontheirskin,asatTheChildren’sTrustinTadworth,Surrey.

‘OursensoryfountainhasbeenagreateducationaltoolforthelearnersatTheSchoolforProfoundEducation.Ithasanincredibleamountofmulti-sensorybenefits,fromthesightofthewaterarchingverticallyoverthetopofthelearnerastheywalkorarepushedintheirwheelchairalongthepathbetweenthetwojet-streams...

Thewatercanrespondtotheirvoices/vocalisationsastheycommunicateusingthe‘talkie’flowerswhichprojecttheirsoundsacrossthefountain...thefountainisaverysocialspace–classeshavebeenheldthere,musicmakingsessions,aswellasteddybears’picnics!Itisalsoidealasacalmingareaforanylearnerneedingabitoftimeout.’(SteveSnook,Teacher,SchoolforProfoundEducation)

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•Pondsshouldbedesignedforeitherwildlifeorfish–notboth.

•Thesoundofwatercanbeveryusefulinmaskingnoise,whichhasbeenproventohaveaverynegativeimpactontheperceivedtherapeuticvalueofaspace.

•Waterfeaturesshouldalsobedesignedassimplyaspossibletokeepmaintenancecostsdownandreducewaterusage.

•Peopleoftenassumethatrunningwaterissuitablefordrinking,soifthefeatureiseasilyaccessibleand/orunsupervised,watershouldbefedfromthemainssupply.

•OutbreaksofLegionnaires’diseaseareusuallyassociatedwithcoolingtowers,evaporativecondensersandhotandcoldwatersystems.Theriskofcontractingthediseasefrommostornamentalwaterfeaturessuchaspondsorfountainsislikelytobelowandcanbeminimisedbydesign(e.g.byavoidingthepresenceofshallow,stagnantwater).Aspecificassessmentofriskwillberequired,takingintoaccounttheactualdesignandlocationofthefeature(Legionnaires’disease:aguideforemployers,HSE).

Interactive fountains at The Children’s Trust, Surrey.

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Summary

Allofthedesignelementsdescribedabovehavethepotentialtoaddanewdimensionandextrainteresttospacesdesignedforatherapeuticpurpose.TheChalkhillUnitinSussexincludesmanyofthedesignelementsmentionedaboveandrepresentsahighlycreativeapproachtodesignofbothinternalandexternalspacesonthesite.

TheChalkhillUnitcatersforchildrenandyoungpeoplewithacutementalhealthproblems,andhasbeendesignedtoreflectnature,usingthesurroundingsiteasapalette.Membersofstaffareconvincedthatthenewunitishelpingtospeedtherecoveryoftheyoungsters,astheyappeartoberecoveringmorequicklythansimilarpatientsdidintheformerbuilding.

Theprocessinvolvedcollaborationbetweenarchitects,interiordesignersandlandscapearchitectstocreateafacilitywithafeelingofsafetybutalsofreedomandtranquillity.

Workshopswereconductedwiththosewhoweregoingtousethenewbuilding,toexploretheirattitudestothemes,imagesandcolours.Theyoungsterschosenatureasthegeneralthemeforboththeinteriorandtheoutsidespacesandgardens,astheyfeltthatwoodlandandseasidewereplacestheywantedtobe.Woodlandwasusedasanimportantunifyingdesignelement;forexample,thedesignofthecarpets,curtainsandwallcoveringswasbasedonapatternofleaves.

Designelements

Trees and planting:TheoriginalnativepineheathlandenclosesthesitetothenorthandthereareexpansiveviewsouttothesouththroughthepinestowardstheSouthDowns.Pinetreesclosetothebuildinghavebeenpreserved;theglassentrancedoorsareetchedwithimagesofthesametrees.Neatminiaturepinesgiveacrisptidyminiaturelandscapetothefrontentrance,andwithinthegardens,theplantingisredolentofseasidewithgrassydune-lovingplants.

Entrances, paths and boundaries: Gatesandboundariesarefunctional,attractiveandoftenwooden,makingthemfeelnaturalandlessintrusive.Pathwaysaresimple,eithertarmacordecking,withlargetimberedwoodenseatingandtablessuchasyouwouldfindattheseaside.

Site furniture:Withintheinnercourtyard,thethemeofnaturecontinues.Thereisawoodenboardwalkrunningalonginfrontofjungle-likeplantingoflarge-leaved,exoticplants,leadingtoabeach.Ingoldenconcretethereareripplesjustliketheripplesinsandonasea-sweptshore.Hugerocksprovideseating.

The surrounding pine trees are visible from everywhere on the site and have influenced the design of the interiors in particular.

Case Study 6: Chalkhill Unit, Princess Royal Hospital, Haywards Heath, Sussex.

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Art and water:Impressedintothesandareimagesofleavesandseacreatures.Theyaresubtleandtakesomefinding.Athree-dimensionalceramicmuralofstreams,animalsandplantsaddscolourandarichtexturetoawall.Onerockhasbeendrilledandpipedtoprovideasafe’wetrock‘waterfeature.Ithelpstocreateanintricatefantasylandscapewithtinytreasurestobediscoveredbyquietexploration.

Alltheelementsofthisunit,throughcarefulconsultationanddesign,combinetoprovideakindof‘escape’fortheinhabitantsoftheunit,whoareoftenconfinedinmorewaysthanone.Theirfunctionwastoactasaportalintoanetherealworldthroughwhichthechildren’smindscouldwander,unboundbytiresomerealities.

Surfaces imprinted with leaves and other objects from the natural world act as reminders of the seaside, and reward curiosity by inviting exploration.

The garden areas are designed with a quiet simplicity which creates a calm, peaceful atmosphere. Natural materials predominate, creating tactile surfaces.

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Feelinginspired?Howtogetstarted!

Whydesignahealingenvironment?ThiswillindicateyourObjectives.

•Aretherespecificpeoplewhowouldbenefit,suchasstrokeormentalhealthpatients?

•Improvementstothestaffworkingenvironment?

•Makingthesitemoreinvitingandaccessibletothewidercommunity?

Whereisyouropenspace?ThiswillindicateyourpotentialResource.

•Walkaroundyoursite,exploretheperimeter,courtyards,carparksandroofspaces.

•Findasiteplanandannotateopenspaces.

•Geta‘bird’s-eye’view,withonlineaerialmappingtools.

Whatisalreadythereinyouropenspace?ThiswillindicateitscurrentValue.

•Isitpavedorplanted?Arethereanytreesorotherinterestingfeaturesofnote?

•Isit‘openaccess’orlocked,andarethereaccessroutesthroughyourspace?

•Isitnexttowardsoroffices,orspecificservices?

•Isitaplacewherepeopleliketogatherorisitnormallyempty?

Whoisinterested,orcouldbeengaged?ThiswillindicateyourTeam.

•Thinkofmedicalandancillarystaffwhomightuseopenspaces.

•Thinkofpatientgroupswhowouldbecapableofparticipating,visitorsandfriendsgroups.

•Supportoftheseniormanagementteam,andthefacilitiesorestatesmanagers,willbeessentialfortheprojecttosucceed.

Howdoyoubegin?ThiswillindicateyourPlan.

•UseyourlocalStrategicHealthNeedsAssessmentasaleverforimplementinggreenspace/treeplantingproposals.

•Getyourteamtogetherandbrainstormwhatcouldbedone.

•Considersourcesoffunding.

•Seewhatotherplacesaredoing,visittheNHSForestwebsite.

•Makesureyoucommunicateyourideastoyourcolleaguesandthewiderpublic.

Whenwillithappen?ThiswillindicateyourTimetable.

•Youdonothavetodoitallinonego:considerphasinginmanageableblocks.

•Startwiththeeasybits,maybebird-boxesorplantingsomebeds.

•Tidyingupthelitterimmediatelymakesaplacelookmorecaredfor.

•Simply‘signing’existingopenspaces,sopeopleknowwheretheyare,andwhattheyarecalled,wouldhelptomakethemostofwhatyoualreadyhave.

Gettingstartedmightbeassimpleasplantingafewfruittrees,orsomebulbs,orallowingsomeofthegrasstogrowalittlelonger.Anexampleofapossibleprojectlikethisisshownopposite.

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Improving an area on a hospital or health centre site needn’t be complicated or expensive. This scheme would include some new cherry trees and bulb planting, along with a reduction in frequency of mowing to allow the bulbs time to flower and to establish.

Before and after of improved hospital area.

Seat now looks onto trees rather than just other buildings

Close-mown grass verge makes the area look well cared for

Trees could be set in longer meadow grass, with bulbs

Flowering cherry trees chosen for spring blossom and autumn colour as well as fruit for the birds

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ForestryCommissionpublications

–A marvellous opportunity for children to learn: A participatory evaluation of Forest School in England and Wales(FCRP009)

FororderinginformationanddetailsofthisandotherForestryCommissionpublications,visittheonlinepublicationscatalogueatwww.forestry.gov.uk/publications

ForestryCommissionwebsites

– Forinformationonthe case for trees in development and the urban environment:www.forestry.gov.uk/thecasefortrees

– Forresearchinformationonthesocial aspects of forestry: www.forestry.gov.uk/fr/peopleandtrees

Thefollowingreportsareavailabletoviewanddownloadfromthiswebsite:

•Treesandwoodlands,nature’shealthservice

•UrbanhealthandhealthinequalitiesandtheroleofurbanforestryinBritain:areview

•Asortofmagicalplace:people’sexperienceofwoodlandsinnorthwestandsoutheastEngland

Otherpublications

BritishMedicalAssociation– The psychological and social needs of patients, 2011

BTCV– Green gym national evaluation report, 2008

CABE– Future health, sustainable places for health and wellbeing, 2009– The role of hospital design in the recruitment, retention and performance of NHS nurses

in England, 2004– The value of public space, 2004

DepartmentofHealth– Heatwave Plan for England, 2010– NHS health and well-being: Boorman Review, 2009

FacultyofPublicHealth– Great Outdoors: how our Natural Health Service uses green space to improve wellbeing, 2010

ForumfortheFuture– The health system in 2025, a vision of health and sustainability in England, 2009

HealthandSafetyExecutive– Legionnaires’ Disease: a guide for employers, 2006

Further reading and useful sources of information

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HealthResearchForum– Sunlight Robbery: Vitamin D and Public Health, 2010

King’sFund– Enhancing the Healing Environment, a guide for NHS trusts, 2004– Improving the patient experience, celebrating achievement: Enhancing the Healing

Environment Programme 2003–2005 – Improving the patient experience, sharing success in mental health & learning disabilities,

2008

MIND– Ecotherapy – the green agenda for mental health, 2007

NHS– Saving carbon, improving health – update, 2010. Sustainable Development Unit.– The architectural healthcare environment and its effects on patient health outcomes, 2004

RSPB– Natural thinking: investigating the links between the natural environment, biodiversity and

mental health, 2007– Natural Fit: can green space and biodiversity increase levels of physical activity? 2004

ScottishNaturalHeritage– Health and the natural heritage – the evidence base, 2009

SustainableDevelopmentCommission– Health, place and nature: how outdoor environments influence health and wellbeing –

a knowledge base, 2008

TheCenterforHealthDesign– A visual reference for evidence-based design, 2008

TheScottishGovernment– Good places, better health, 2008

TreesandDesignActionGroup– No trees no future, 2010

USDepartmentofAgriculture,ForestService,NorthernResearchStation– Restorative commons: creating health and well-being through urban landscapes, 2009

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beinginyoungadultsandthelong-termeffectsofchildhoodplayexperience.Endofprojectreport.CJCCONSULTING(2005).Economicbenefitsofaccessiblegreenspacesforphysicalandmental

health:scopingstudy.FinalreportfortheForestryCommission.COOPERMARCUS,C.(2005).Healinggardensinhospitals.In:C.Wagenaared.Thearchitectureof

hospitals.NAiPublishers,Rotterdam.

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COOPERMARCUS,C.andBARNES,M.(1999).EvaluationsofsixChicagohospitalgardensforHitchcockDesigns.Un-published.

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PARK,B.,TSUNETSUGU,Y.,KASETANI,T.,KAGAWA,T.andMIYAZAKI,Y.(2010).ThephysiologicaleffectsofShinrin-yoku(takingintheforestatmosphereorforestbathing):evidencefromfieldexperimentsin24forestsacrossJapan.EnvironmentalHealth&PreventiveMedicine,15 (1),18–26.

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WHITEHOUSE,S.,VARNI,J.W.,SEID,M.,COOPERMARCUS,C.,ENSBERG,M.J.,andJACOBS,J.R.(2001).Evaluatingachildren’shospitalgardenenvironment:utilizationandconsumersatisfaction.JournalofEnvironmentalPsychology,21 (3),301–14.

Websites

– Architecture+DesignScotland:www.ads.org.uk– ArtCare,Salisbury:www.artcare.salisbury.nhs.uk– BiodiversityActionPlan(UK):www.jncc.defra.gov.uk– BuildingBetterHeathcare(providesthehealthcarebuildingcommunitywiththelatestnews,

andguidanceonhealthcareestatesandfacilities): www.bbhealthcare.co.uk– BTCV(BritishTrustforConservationVolunteers):www.btcv.org – CentreforSustainableHealthcare:www.sustainablehealthcare.org.uk– DesignCouncil(forinformationonCommissionforArchitectureandtheBuiltEnvironment,

CABE):www.designcouncil.org.uk – EnhancingtheHealingEnvironment: www.enhancingthehealingenvironment.org.uk– FieldfareTrust(promotingcountrysideaccessfordisabledpeople,andtheAccessforAll

Standards):www.fieldfare.org.uk– ForestryCommission:www.forestry.gov.uk– ForestryResearch:www.forestry.gov.uk/forestresearch– GlasgowHomoeopathicHospital: www.ghh.info– GreenspaceScotland:www.greenspacescotland.org.uk– InformeDesign(evidence-baseddesigntool):www.informedesign.umn.edu– KIDS(workswithdisabledchildren,youngpeopleandtheirfamilies):www.kids.org.uk– LivingMedicine(workingtoconnectpeopleandplantsforhealth): www.livingmedicine.org– MaggiesCancerCaringCentres:www.maggiescentres.org– NHSForest:www.nhsforest.org– OPENspace(researchcentreforinclusiveaccesstooutdoorenvironments):

www.openspace.eca.ac.uk– Outdoors&HealthNetwork:www.outdoorshealthnetwork.co.uk– PeckhamExperiment(astudyintothenatureofhealth):www.thephf.org– Planetree(anorganisationfacilitatingeffortstocreatepatientcentredcareinhealing

environments):www.planetree.org– QuietGardenMovement:www.quietgarden.org– ReforestingScotland(networkinvolvedinrestoringScotland’sforestcoverandculture):

www.reforestingscotland.org– SensoryTrust(creatinginclusiveenvironments):www.sensorytrust.org.uk– SocialCareInstituteforExcellence(anindependentcharityimprovingthelivesofpeoplewho

usecareservicesbysharingknowledgeaboutwhatworks):www.scie.org.uk– TheBigTreePlant:http://thebigtreeplant.direct.gov.uk– TherapeuticLandscapesNetwork:www.healinglandscapes.org– TheWildlifeTrusts:www.wildlifetrusts.org– WalkingforHealth: www.wfh.naturalengland.org.uk– WoodlandTrust:www.woodlandtrust.org.uk– WorldHealthDesign(subscriptionbasedjournalandwebresource,promotingexcellencein

thefieldofdesignandhealth):www.worldhealthdesign.com

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AlderHeyChildren’sHospital,LiverpoolArgyllandButeHospital,Lochgilphead,Argyll

BromleybyBowCentre,LondonBroomfieldHospital,Chelmsford,EssexCastleHillHospitalandOncologyUnit,HullChalkhillUnit,PrincessRoyalHospital,WestSussexChelseaandWestminsterHospital,LondonCreativeSpacesProject,Cornwall(CornwallCare)CulmValleyIntegratedCentreforHealth,DevonDorsetCountyHospital,DorsetEnniskillenHospital,CountyofFermanagh,NorthernIrelandFantOastAdolescentUnit,KentForthValleyRoyalHospital,StirlingshireGlasgowHomoeopathicHospital(GartnavelGeneralHospitalsite),GlasgowGreatOrmondStreetHospital,LondonHarbourHouseResidentialHome,DorsetHelen&DouglasHouse,OxfordHerefordCountyHospital,HerefordHullRoyalInfirmary,HullJosephWeldHospice,DorsetLambethCommunityCareCentre,LondonMaggie’sCancerCaringCentre,CharingCrossHospital,LondonMaggie’sCancerCaringCentre,OxfordMaggie’sNorthEast,NewcastleNewhamUniversityHospital,LondonNinewellsHospital,DundeeNorthernGeneralHospital,SheffieldOrchardRespiteCentre,Blackrock,Co.Dublin

PilgrimsHospice,Ashford,KentPilgrimsHospice,Canterbury,KentPilgrimsHospice,Thanet,KentPulrossCentre,LondonQueenElizabethHospital,Woolwich,London

RoyalEdinburghHospital,EdinburghRoyalHallamshireHospital,Sheffield

Appendix 1 – Researched sites

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SalisburyDistrictHospital,Wiltshire

SchoolforProfoundEducation,TheChildren’sTrust,SurreySecondRhonddaHospital,Llwynypia,WalesSpringfieldUniversityHospital,LondonStCatherine’s,Rotherham,Doncaster,andSouthHumberNHSFoundationTrust,YorkshireTheChildren’sTrust,SurreyTivertonandDistrictHospital,DevonTodmordenHealthCentre,LancashireTrevarnaCareHome,CornwallVerwoodOpportunityCentre,DorsetWandsworthRecoveryCentre,SpringfieldUniversityHospital,LondonWarnefordMeadow,OxfordWhitfieldRuralActivityCentre,DorsetWillitonCommunityHospital,Somerset

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Should patients with dementia be allowed free access to the garden?

Issue Commentary Evidence

Health benefits

• Greater mental stimulation from access to outdoors helps delay further mental deterioration

• Continuing practice in walking over different surfaces and textures prolongs mobility

• Access to sunshine increases manufacture by body of Vitamin D and this has consequential beneficial effects with regard to other conditions

• Everyday experience and observation

• Medical literature

Risks • Risk of falls• Risk of minor injuries• Lesser risk of more serious injuries, for example

long bone fractures• Risk of claims, litigation and loss of reputation

• Everyday experience and observation

• Information about claims from colleagues and professional networks

Expert views • Health and safety department have inspected site and found it to be free from obvious trip hazards

• Positive attitudes from occupational therapy and physiotherapy staff

• Health and safety department report on site

• Interviews with occupational therapy and physiotherapy staff

Relevant local factors

• Garden is completely visible from main building and in full view of the staff inside

• Sightlines and staff rotas have all been checked

Options and their costs

Pros and cons

• Continue to allow free access for all who are physically mobile enough

• Cordon off part of the garden for those who are most frail to use

• Stop access completely for the most frail• Financial costs of any action will be low

• Sectioning off garden may have negative impacts for other users

• Removing access will have major dis-benefits for health of key patient group

• Maintaining free access will help the occupational therapy team continue to make full and accurate assessments of patients’ capabilities

• No new information – pros and cons to be discussed and weighed up

Precedents / comparisons

• The Foundation Trust has other sites where this type of free access has worked successfully for this patient group

• Trust management

Risk-benefit judgement

• In general benefits greatly outweigh risks; however, the risks need to be managed

• Ensure all staff are aware of access regime and the need to be aware of patients’ movements

• Most vulnerable patients to be identified and staff to be made aware of these as they will be monitored more closely than others

Implementing judgement locally

• Consider publicising the decision within Trust newsletter

• Make policy clear to all staff and to families of patients

• Support will be needed from the Trust

Appendix 2 – Sample risk-benefit assessment for a community hospital

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Notesanddesignideas

69

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The guidance set out in this Practice Guide represents a step forward in our thinking about

the benefits of the outdoors for health and well-being. It aims to inspire everyone involved

with outdoor spaces in healthcare settings to think how they could be used for therapeutic

purposes. Focusing on outdoor spaces across the NHS estate, the guidance is relevant to

the full range of facilities, from the largest hospital to the smallest health centre. It also has

a wider application wherever health and well-being is important, for example in places

such as care homes and special schools. The Guide has been designed to be accessible to a

non-technical audience, and will be of interest to those engaged with policy, and everyone

interested in improving patient care – whether they deal directly with patients, or focus

on grounds management. It will act as a good introduction for those new to the field, but

many professionals already working in ‘therapeutic landscapes’ will also find it of interest.

This Practice Guide introduces the principles and practical methods for collecting, storing

and propagating from seed a wide range of woody species commonly grown in the British

Isles. It is aimed partly at anyone interested in raising a relatively small number of plants,

and partly at commercial growers – as a useful reference but without the legal aspects. The

Guide begins with information on flowering and fruit development, and recommendations

for small–scale collecting, handling and processing. It then provides detailed advice on

storage, dormancy and pretreatment methods for over 100 woody species. It gives

suggestions of ‘things to try’ to hasten dormancy breakage in the most time consuming and

dormant species. The Guide concludes with some tips on sowing seeds and raising seedlings.

231 Corstorphine RoadEdinburghEH12 7AT

www.forestry.gov.uk£13.50


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Greenspace design for health and well being