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7/29/2019 Greenspace Design for Health and Wellbeing
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Greenspace design forhealth and well-being
Practice Guide
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Practice Guide
Greenspace design forhealth and well-being
Aileen Shackell and
Robin Walter
Forestry Commission: Edinburgh
sustainable
healthcare
centrefor
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CrownCopyright2012
Youmayre-usethisinformation(notincludinglogos)freeofchargeinanyformatormedium,underthetermsoftheOpenGovernmentLicence.Toviewthislicence,visit:www.nationalarchives.gov.uk/doc/open-government-licenceorwritetotheInformationPolicyTeam,TheNationalArchives,Kew,LondonTW94DU,ore-mail:[email protected].
Firstpublishedin2011byForestryCommission,SilvanHouse,231CorstorphineRoad,EdinburghEH127AT.
ISBN978-0-85538-853-9
Shackell,A.andWalter,R.(2012). Greenspacedesignforhealthandwell-being. ForestryCommissionPracticeGuide. ForestryCommission,Edinburgh.ivi+170pp.
Keywords:greenspace;healinggardens;healthcare;hospitalgardens;NHS;therapeuticlandscapes;trees;woodlands.
FCPG019/FC-GB(KA)/1.75K-ADR/FEB12
Enquiriesrelatingtothispublicationshouldbeaddressedto:
ForestryCommission 231CorstorphineRoad Edinburgh EH127AT
T:01313340303 E:[email protected]
Theauthorscanbecontactedat:
If you need this publication in an alternative format, for example in large print or in anotherlanguage, please contact the Forestry Commission Diversity Team at the above address.Telephone: 0131 314 6575 or email: [email protected].
Acknowledgements
ThisprojectwasinitiatedbytheCentreforSustainableHealthcareandtheForestryCommission,andsteeredbyanAdvisoryGroup,whosememberswereRogerFrench,SharonHosegood,DianeMillis,MarcusSangsterandRachelStancliffe.Specialthanksareduetothenumerousindividualswhogavesogenerouslyoftheirtimetotheproject,inparticulartothosewhowereinterviewed,tookpartinsitevisits,orcommentedonthetextasitwasproduced.Photographsweretakenbytheprojectteam,unlessstatedotherwise.Researcher:JamesNewmarch.Illustrator:ValerieAlford.CoverillustrationbyRichardCarman.CourtesyofNIHG/LUC.
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Foreword
Green environments are healthy environments. This is the message repeated again and again from healthcare
research that points towards a positive relationship between greenspace and general health. Outdoor environments
can have important restorative qualities that promote recovery from physical and mental stresses. Studies of naturedeficit disorder or nature deprivation suggest that experiences of the outdoors (even views of greenery borrowed
through a hospital window) can have a therapeutic effect on ones social, emotional and mental functioning.
Some outdoor spaces are salutogenic, that is they reduce stress and encourage healthy behaviours. Whilst the
particular reasons for this are not fully understood, various factors may in isolation or combination be important,
including outdoor activity and exercise, natural daylight, stimulation of the senses, and the aesthetic experience. What
we do know is that experiencing these natural environments or helping to care for them can improve the mental
health and well-being of individuals and help to recharge their physical, mental and social capacities.
Nowhere is this relationship with the natural health service more important than around healthcare facilities
particularly across the NHS estate. In supporting health and well-being outcomes National Health Service facilities
should strive to make greater use of existing outdoor spaces by connecting them with the built environment. As we
shift towards a more mutual NHS these largely untapped outdoor spaces should be recognised and utilised as an
important healthcare resource in their own right: hence this guide Greenspace design for health and well-being.
In setting out best practice backed up by case studies this booklet provides a valuable guide to the design of
accessible outdoor healing environments. It is equally applicable to new-build sites and refurbishments. It is relevant
to the full range of healthcare settings, from the smallest health centre to the largest general hospital. It is also relevant
to non-NHS settings such as schools, nursing homes and indeed everywhere where the promotion of health and
well-being is important.
This Practice Guide will assist directors of facilities, estate managers, capital strategic planners, policymakers: in short
everyone interested in health improvement and patient care, whether dealing directly with patients or managing
grounds. By adopting this design guidance, NHS teams will be able to create, transform and revitalise their outdoor
estates with respect to the human experience, encouraging greater use of the outdoors by patients, visitors and staff
alike. These environments will provide a positive distraction from treatment and a therapeutic alternative to hospital
buildings: quiet reflective spaces free from the clinical environment where patients can convalesce and recover in
peaceful surroundings.
Alongside wards, waiting-rooms, and clinical departments, well-designed outdoor spaces are important environments
that provide benefits for everyone. But as well as bringing social benefits, woodland and greenspace initiatives such as
the NHS Forest in England and NHS Greenspace in Scotland can also bring organisational and environmental
benefits too, helping healthcare facilities to meet good corporate citizenship responsibilities and performance measures,
reduce carbon footprints and enhance opportunities for green prescription and outdoor recovery programmes.
By guiding NHS decision makers, Greenspace design for health and well-being will help to harness the full salutogenic
potential of the NHS estate and bring the healing power of nature back into 21st century healthcare provision.
Sir Muir Gray Derek Feeley
Director of the National Knowledge Service and Director-General Health and Social Care
Chief Knowledge Officer to the National Health Service and Chief Executive NHS Scotland
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Introduction 1
Aholisticapproach 1
Benetsofwell-designedoutdoorspaces 1Aguideforpractitioners 1
Why is it important to take healing outdoors? 3
Understandingthebenets 3
Outdoorspacescanhostawiderangeofactivities 3
Whyiscontactwithnaturecalming? 4
Treesandwoodedspaceshaveaparticularroletoplay 5
Healthbenetsofnaturalsettings 6
Healthcare:anartaswellasascience 8
Casestudy1:ArgyllandButePsychiatricHospital,Lochgilphead,Argyll 9
What sort of spaces should we be designing? 11
Designinghealingspaces 11
Creatingahealingenvironmentwiththewidersetting 11
Creatingahealingenvironmentinthebuildingsurroundings 12
Creatingahealingenvironmentingardenspaces 13
Casestudy2:StCatherines,Rotherham,Doncaster,andSouthHumberNHS
FoundationTrust,Yorkshire 14
Designprinciples 17
1.Valuewhatyouhavegot 182.Createspaceswhichfeelspecial 20
3.Maketheoutsideaccessible 22
4.Focusonpeoplesneeds 24
5.Connectwithnature 26
6.Balanceriskwithbenets 28
7.Designforchange 30
Summary 32
Casestudy3:MaggiesCancerCaringCentre,London 33
How do we put the theory into practice? 35
Overcomingthechallenges 35
Privatenanceinitiativeschemes 35
Acutecare 36
Olderpeoplescare 36
Primarycare 37
Casestudy4:CulmValleyIntegratedCentreforHealth,Cullompton,Devon 37
Gettingstarted:theprojectprocesssummarised 39
Stage1:Preparation 40
Stage2:Designandimplementation 41
Stage3:Usingandmaintainingthenewspace 42Stage4:Monitoringandreview 42
Casestudy5:SensoryGarden,theVerwoodOpportunityCentre,Dorset 43
Contents
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Workingwithdesignelements 45
1.Planting 46
2.Trees 48
3.Entrances,pathsandboundariesconnectingthesite 50
4.Sitefurniture 52
5.Art 54
6.Water 56Summary 58
Casestudy6:ChalkhillUnit,PrincessRoyalHospital,HaywardsHeath,Sussex 58
Feelinginspired?Howtogetstarted 60
Further reading and useful sources of information 62
Appendix 1: Researched sites 66
Appendix 2: Sample riskbenet assessment for a community hospital 68
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Introduction
Aholisticapproach
Untilrelativelylateinthe20thcentury,outdoorspacesaroundmosthospitalswereverymuchpartofthehealingenvironment.Gardens,terraces,orchards,meadowsandevenhospitalfarms
wereallcommonplaceandaccessibletopatientsparticularlyintheeldofmentalhealth.But,
astimepassed,thebenetsforpatientsofbeingabletospendtimeoutdoorsinthefreshairhave
beenincreasinglyoverlooked,astheemphasisoncreatingasterileenvironmentindoorshas
developed.Thishasfosteredaviewthatthehealingenvironmentwasrestrictedtotheinsideof
hospitalbuildings,excludingthegardensandotherspacesaroundthem.
ThisGuidefocusesontheoutdoorspacesaroundalltypesofhealthcarefacilities.Itadvocatesa
holisticapproachtotheirdesign,seeingbothindoorandoutdoorgreenspacesasequally
importantforhealthandwell-being.Indoingso,itre-orientatesoutdoorspacesrmlywithinthesphereofpatient-centredcarewiththePlanetreemodelstipulatingthathealthcareenvironments
shouldfosteraconnectiontonatureandbeauty.So,alloutdoorspacesshouldbepartofthe
healingenvironment.
Benetsofwell-designedoutdoorspaces
Peopleareentitledtothebestqualityofcare...attheendofthedaythereasonwhydesignmatters
somuchisthatwehavealimitedamountofresources,andbestpracticereducesthecostofcare.
(ProfessorJuneAndrews,DirectoroftheIrisMurdochDementiaCentre,2010)
Designingoutdoorspacestohaveatherapeuticfunctionrepresentsacost-effectiveapproach.
Suchspacescanimprovepatientoutcomesandleadtoarangeofothercostsavings.Studies
showthatpatientswhoarehappierwiththeirhealthcareenvironmentsareeasiertocarefor,and
returnhomesooner.Evidencealsoindicatesthat,wheretheenvironmentisimproved,betterstaff
retentionresultsincostsavingsinrecruitmentandtraining,withrecruitmentbeingenhancedin
therstplace.ThisGuidewilllookattheevidenceforthisinmoredetail,later.
Therearealsoorganisational,environmentalandsocialbenets.Amorecreativeapproachto
outdoorspace,includingparticipatingininitiativessuchastheNHSForestinEnglandand
GreenspaceinScotland,canhelphealthcarefacilitiesmeetperformancemeasures.Theremay
alsobegainsforthemintermsofsustainabilityandcarbonreduction,especiallyinrelationto
treeandwoodlandplanting.
Aguideforpractitioners
TheKingsFundprogrammeEnhancingtheHealingEnvironment(EHE)hashelpedmanystaff
becomeengagedinprovidingbetterpatientcarethroughimprovedspaces,andthisGuideseeks
tobuildonsomeofthelessonswhichhavebeenlearnt.
Itisapplicabletonew-buildsitesandtorefurbishments,andtothefullrangeofhealthcaresettingsfromthesmallesthealthcentretothelargestacutehospital.Itwillassistsenior
managementteams,thoseengagedwithpolicy,andeveryoneinterestedinimprovingpatient
carewhethertheydealdirectlywithpatients(clinicalstaff,therapists,supportstaff)orfocuson
groundsmanagement(facilitiesandestatemanagers,andpracticemanagers).
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Itisalsorelevanttonon-NHSsettings,forexampleschools,nursinghomes,everywherewhere
thepromotionofhealthandwell-beingisimportant.
Well-designedoutdoorspacesareanintegralpartofthehealingenvironment,alongsidethe
wards,waitingroomsandclinicaldepartments,andprovidebenetsforeveryonepatients,staff
andvisitors.ThisGuidesetsouthow,andwhy,thisisso.
Inspring1994,theplaywrightDennisPotter,nearingtheendofhislife,describedthetree
hecouldseefromhisbedroomwindow.
Theblossomisoutinfullnow...Itsaplumtree,itlookslikeappleblossombutitswhite,and
lookingatit,insteadofsayingOhthatsniceblossom...Iseeitisthewhitest,frothiest,
blossom-iestblossomthatthereevercouldbe...Thingsarebothmoretrivialthantheyever
were,andmoreimportantthantheyeverwere,andthedifferencebetweenthetrivialandthe
importantdoesntseemtomatter.Butthenow-nessofeverythingisabsolutelywondrous...
youhavetoexperienceit,thecomfortofit,thereassurance...(DennisPotter,Interviewwith
MelvynBragg,March1994)
Sensory aspects of the natural environment are especially engaging.
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Understandingthebenefits
Outdoorspaceisanimportantpartofthehealingenvironmentanditcanbeusedforawiderangeofactivities.
Theorieshavebeendevelopedtoexplainthehealthbenetsofnatureandthesehaveledinturntothedevelopmentofevidence-baseddesign.
Treesandwoodedspaceshaveaparticularroletoplayinsupportinghealthandwell-being.
Spendingtimeoutsidecanhelpimprovephysicalhealthandrecoverytimes,andconfersparticularbenetsformentalhealth.
Evidenceisimportant,buthealthcareisanartaswellasascience.
InthisGuide,thetermhealingortherapeuticenvironmentorspacemeansaplacethathas
beendesignedorisusedinawaywhichpromotesthehealingprocess,orhelpstoinstilasenseof
well-being.
Thissectionfocusesonthehealthandwell-beingbenetsfrombeingoutside,thoughthereare
numerousotherenvironmentalandeconomicbenetsassociatedwiththecreationofgood
naturalsettings.
Outdoorspacescanhostawiderangeofactivities
Activitiescanbeactive(includinghelpingwithgardeningorsimplegroundsmaintenance)or
passive(sittingunderatree).Theycanincludewalking,birdwatching,socialisingwithother
patientsandfamily,andevenTaiChi.Playingoutsideisagreatwayforchildrenandyoungpeople
torelaxandletoffsteam,awayfromatiringmedicalenvironment,andtherapeutichorticulture
involvingpracticalgardeningactivitieshasalonghistoryofuse.
Why is it important to take healing outdoors?
Staff and volunteers at a garden party at Helen House, Oxford.
Courtesy:HelenandDo
uglasHouse,Oxford.
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Clinicianscancarryoutone-to-onediscussionsduringwalksaroundthegroundswithpatients.
Walkingsidebysideoutdoorsmightwellfeellessthreateningformanythanfacingsomeone
acrossadesk.
Inapeacefuloutdoorspacepeoplecansometimesmoreeasilystarttocometotermswithbad
news,or,conversely,celebrategoodnews.TheQuietGardenMovementencouragespeopleofall
faiths(andnone)toenjoystillnessandreectioninpeacefulgardenspaces.Thesebecomeoases,
privatespacesforthinking,and,formanypeople,placesofspiritualrefreshmentandsupport.
Whyiscontactwithnaturecalming?
Thegardengivesyouthechancetorelax.Igetlostinthatgarden,suckedintothetreesandthebirds
inthesky.BeforeIwouldseethesethingsbutIdidntconnecttothemitisanotherworldIhave
learnedtoappreciateit,anditdoessomethingtoyou,itsamazing.(Patient,Glasgow
HomoeopathicHospital)
Attentionrestorationtheory(ART)wasdevelopedbyRachelandStephenKaplanintheirbook
Theexperienceofnature:apsychologicalperspective,andsincethenanumberofotherstudies
haveestablishedthatthisalsoholdstrueintermsofmedicaloutcomes.
Attentionrestorationtheoryproposesthatcomparedwithhardindoororurbanenvironments,
naturalenvironmentsaremoreefcientathelpingourbrainstorechargeandresumewhatis
termeddirectattentionorfocusonaparticulartask.Increasedcontactwithnaturerestoresour
brainsfromfatigueandreducesimpulsivebehaviour,irritabilityandaggression.InherpaperonHealingGardensinHospitals,writerandacademicClareCooperMarcusstatesthatnature
engagesattentionwithoutdemandinganyeffort,becauseithastheeffectofawakeningthe
senses,calmingthesenses,reducingstress,andassistingapersontomarshaltheirown
healingresources.
At Harbour House residential home
in Dorset, the front lawn has been
turned into a well-used space by
the addition of croquet hoops.
Residents help themselves to balls
and mallets when ever they want
to play and combine socialising
with staying physically active.
The scent of owers.
Party in the garden.
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Contactwiththeoutdoorscanalsobestimulating,aswellascalming.Theco-ordinatorofthe
CreativeSpacesProjectinCornwall,whichenablespeoplewithdementiatoenjoyoutdoor-
relatedactivities,commentedthat,timeandtimeagainwendthatspendingtimeoutside
increasespeoplescommunicationandstimulatesmemories,peoplejustsparkle.
Thereisagrowingbodyofevidence,muchofitrootedinscienticresearch,thatbeingoutdoors
inanaturalsetting,orevenjustviewingtheoutdoorsfrominside,ishighlybenecialforhealthandwell-being.ThisisincreasinglyinformingthedesignofhealthcarefacilitiesintheUK,inan
approachtermedevidence-baseddesign(EBD).Thisapproachisalsoinformedbyarelatively
neweldofstudy,environmentalpsychology,whichseekstounderstandtheinterrelationship
betweenenvironmentsandhumanbehaviour.
Treesandwoodedspaceshaveaparticularroletoplay
Woodlandsareespeciallyrestorativeenvironments;thesounds,sightsandsmellsinawoodplay
aroleinreducingstressbyprovidinginterestandstimulatingthesenses.
Woodlandsprovidearichsensoryexperience,fromthesubtleshiftsintemperaturethatoccur
betweenareasinheavyshade,andinsunnyglades,tothescentofpineneedlescrushedunder-
foot.Awoodlandsettinghasparticularacousticqualities,meaningthequietestbirdsongis
audible.Theageofveterantreesofteninspiresaweinpeopleandprovidesalinkbetweenthe
past,presentandfuture.Woodlands,andindividualtrees,areseenasrepresentingnature,
particularlyintheurbanenvironment.
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Healthbenetsofnaturalsettings
Thehealingpowerofnature,freshair,sunlightandexercisehaveallbeenafeatureofhealthcare
forcenturies,butthepost-warperiodhasbeencharacterisedbyamoveawayfromnature,and
towardsagreaterrelianceontechnology.Recentdecadeshaveseenareversalofthistrendanda
substantialbodyofevidencenowexists,includingmanyliteraturereviews,whichdemonstrates
thehealthbenetsofcontactwithnature.DetailsofsomeofthesecanbefoundintheFurtherreadingsectionattheendofthispublication.
Asidefromtheobviousopportunitiesforphysicalexercise,whichinthemselveswillbenetmost
people,themainbenetsrelevanttothehealthcareenvironmentcanbesummarisedas:
Reductionofpainandstress
Contactwithnaturecanreducebloodpressure,muscletensionandpulserate,andcanalsohaveasubtleeffectonourexperienceofpain.
Patientsandfamilieswhousehospitalgardenshavereportedpositivemoodchangesandreductioninstress.Evenvisualsettingswherenatureisprominentreducestressandimprove
patientoutcomesespeciallywherestressisaccompaniedbyfeelingsofanxiety.
Areductioninstressinturnenablestheimmunesystemtofunctionmoreeffectively,facilitatingthehealingprocess.
Alleviationofdepression
Depressionisaseriousissuenotonlyforthosewithmentalhealthpatients,butalsoforthosewithcardiovasculardiseaseandcancer.Researchindicatesthatexposuretodaylightis
effectiveinreducingdepression,evenforthosehospitalisedforseveredepression.Simplywalkinginnaturalsettingscanhelpmentalhealthpatientsimproveself-esteem,vigourandmood,andreducetension.
Practicingmindfulnessinanaturalsettingcanbeparticularlybenecalformentalhealth.
View onto garden from the
inside of Chalkhill Unit.
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Reductionofaggressivebehaviour
Restorativecontactwithnaturecanreduceirritabilityandtherebyaggressivebehaviour.Studiesfocusingonolderpeoplewithdementiaandonchildrendiagnosedasbeingontheautisticspectrumhaveshownthatboththesegroupsndcontactwithgardens,andnaturein
general,calming.
Increasedpatientsatisfaction
Thosemostlyconnedindoorsparticularlybenetfrombeingoutsideinthefreshairandsunshine.
Naturalsettingscanenhancetheplayandlearningactivitiesofyoungerpeople.
Improvedrecoveryrates
Studieshavedemonstratedthatpatientswhohavecontactwithnature,evenwherethisis
simplyaviewthroughawindow,recovermorequicklyfromoperativeprocedures.Patientsinintensivecareunitswithmyocardialinfarctionexhibitedshorterstayswhensitedinroomswithhigherdaylightexposure.
Improvedstaffperformanceandretention
Gooddesignofhealthcarefacilitieshasbeenfoundtoimprovestaffperformance,recruitmentandretention.
Post-occupancyevaluationsoftheoutdoorsinUShospitalshaveconsistentlyshownthatthestaffaretheprimaryusersofoutdoorspaces.
The staff garden at Newham
Hospital provides an area for
lunch as well as a venue for
birthday and other celebrations.
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Healthcare:anartaswellasascience
Inmakingthecasefortherapeuticuseofoutdoorspaces,theevidencebaseisimportant.
However,manypeoplealsoseehealthcareasanartaswellasascience,andencourageaccessto
outdoorspacesaspartoftakingamorecreativeapproachtopatientcare.
Thegrowingevidencebaseforthesebenetsisoftensupportedbytheobservationsofclinicians.AtthenewChalkhillUnit,wheretheinteriorisinspiredbyaspectsofthesurroundinglandscape,
stafffeelthatpatientsrecovermorequicklyfromillnessthanwasthecaseintheirprevious
building,whichhadnoaccesstotheoutdoors.
Thisapproachacknowledgesthelimitationsinourunderstandingofthedetailedworkingsof
thehealingprocessandembracestherestorativepowersofnatureevenwhentheevidenceis
onlyanecdotal.
AuserofthegardenatthenewMaggiesCancerCaringCentreinLondonillustratedthiswell.
Thegardenwillallowpeopletobethemselvesandhavetheirownspacewithouthavingtospeakto
anyoneandsometimesthatsmorevaluablethananymedicine:onecantakecouragefrombeingin
agoodplace,breathingincourageandbreathingoutfear.(CathKnox,WestLondon,with
secondarycancer)
At Maggies Centre in London the building is surrounded by quiet, peaceful garden areas.
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Practisingmindfulnessinawoodlandsetting
In2003apartnershipcomprisingReforestingScotland,theNHS,ArgyllGreen
WoodworkersAssociation,theScottishAssociationforMentalHealthandLochgilpheadCommunityCouncilwasformedtorestoreneglectedwoodsnexttotheArgyllandBute
Hospital.Fundswereraisedfromarangeofsources,includingScottishNaturalHeritage,
theScottishMentalHealthDepartment,ForestryCommissionScotlandandLeader.Work
beganin2004andinvolvedmanyusersofmentalhealthservices,disabledpeople,young
people,contractorsandvolunteers.
BlarbuieWoodlandwasopenedasapublicparkin2007,withaccessiblepaths,facilities
andinterpretationforquietrecreationaswellasmoreenergeticwoodlandmanagement
activities.Thereareopportunitiestolearnnewskills,includingnurserywork,forestry,timber
processing,woodworkingandconstruction,andthewoodalsohostsartandmusicprojects.
Keydesignfeatures
Thethresholdarchandsignagewelcomesvisitorsintothewood,indicateswheretheycan
go,andaccessisprovideddirectlyfromthecarpark.Theprojectmakesgooduseof
borrowedlandscape,withspectacularviewsavailablefromthesiteoutacrosstheloch,as
wellasaccesstothehillsbehind.
Case study 1: Argyll and Bute Psychiatric Hospital, Lochgilphead, Argyll.
A wide variety of art and craft activities take place on site out in the fresh air.
Routes through the woods take good advantage of views of the hills and loch.
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Healthbenets
Clinicians view
ForpeoplewhomIrefer,Ithinkalotofthebenetisafeelingofachievementinactually
doingsomeworkinthewoods,seeingthebenetsoftheirwork.Therescertainlythebenetofexercise;theresthebenetoffreshair;theresthebenetofworkingwithothers
onaproject.
Oneparticularthemeisthepromotionofmindfulnessinpatientsappreciatingthe
presentmomentwithoutanxietyaboutthepastorfuture.Formanypatientsinthis
hospitalwithmentalhealthproblems,cultivatingmindfulnessisanessentialskilltolearn.
Cliniciansdescribehowhelpfulthewoodlandsettingwas:
Ithinkwhatsniceaboutthewoodsisthepeacefulnessofwalkingandthebigtreesandthe
nature,andbeinginaplacewhereyoucanpracticemindfulness,awareness.
Peoplehavealotofconcernsandanxieties...maybeyoucouldbeinaquietroominaquiet
ward,butifyouvegotabusyheaditshardtorelaxandbegrounded,soIthinkitdoeshelpto
gooutintoawoodlandarea,andfocusonlike,otherthingslikethenature,likethetrees...
andjusttohelpemptythehead,empty...
Patients view
WellIcomeuphereandIliketojustexperienceonewith...nature.Idoreallyfeeloneness
withnaturewhenIcomeuphere,Ijustsitinthewoodsandjusttalkwiththebirds...Iquite
liketowhistlebacktothemandtheywhistleatmeandIwhistlebackandtheywhistleagain...itsgoodforthewell-being,itsdenitelyimprovedmylife,yeah.
IthinkImalotmorecondentinwhatIdo,andImalotmorecondentinwhatIsayto
people.Itsgoodtomeetalotofpeopleindifferentaspectsinthewoodaswell.
All-weather paths make the wood accessible to a wide range of people, with opportunities for
both quiet solitude and socialising.
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Designinghealingspaces
Allofthedifferentpartsofasitecanhaveatherapeuticpurpose:
thewidersetting;theareasaroundandclosetothebuilding;thegardenspaces.
Theabilitytolocateabuildingtotakeadvantageofaview,ortoarrangeasiteinawaywhich
prioritisespedestrianovervehicleaccess,aretremendousopportunitiesinanydevelopment.
Innewfacilities,thiscanbeplannedfromtheoutset,withthevalueofexternalspacesbeing
recognisedwithinthebusinesscaseforthedevelopmentasawhole.Forexample,atGlasgow
HomoeopathicHospital,thebuildingwasdesignedsothatpatientcarespaceshaveadirectview
andconnectiontonatureandareseparatedfromnoisyareas,whilestaffareasarelocatedtothe
northandeastofthebuildingtoavoiddirectsunlightduringworkinghours.
Improvementofexistingfacilitiesrequiresamoreincrementalapproach,basedonanappraisalof
thesiteasawhole,itsstrengths,weaknessesandopportunities.Evenonthemostchallengingof
sitestherearealwaysimprovementsthatcanbemade,asthesketchexampleswhichfollowshow.
Thinkingaboutthreedifferentaspectsofanysitecanhelpidentifyitspotentialtherapeuticvalue.
Theseaspectsare:
thewidersetting;theareasaroundandclosetothebuilding;gardenspaces.
Astrategyormasterplanwillhelptoensurethatthesethreecategoriesofspaceareallwell
connectedwithpathstomakeacoherentsitelayout.
Creatingahealingenvironmentwiththewidersetting
Carefulthoughtshouldbegivenwhenlocatingnewfacilities,toensurethatthewidersettingis
partofthehealingenvironment.Inthecaseofanexistingbuilding,onemayneedtobecreative
aboutitsuse.
Sometimes,andespeciallyoncrampedurbansites,accesstotheoutdoorsisrestrictedtoaview
ofthewidersettingandinthesesituationsitwillbeessentialtomakethemostofitperhaps
simplyrearrangingadayroomtolookoutofthewindowtothelandscapebeyond.Many
in-patientsmaybeconnedtobedandenjoymentofsunlightandanaturalviewcangreatlyenhancetheirstay,andpossiblyacceleratetheirrecovery.
Onmorespacioussitesitmaybepossibletoconnectwiththesurroundinglandscapebyframing
viewsandlinkingpaths.TheroutearoundSalisburyDistrictHospitalconnectswithnearby
What sort of spaces should we be designing?
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footpaths,andstaffareencouragedtousethispathcircuitintheirbreaks.InScotland,where
thereiswiderpublicaccesstoopenspace,theNHSestatehasgreatpotentialtobecomea
valuableresourceforthewholecommunity.
Creatingahealingenvironmentinthebuildingsurroundings
Thepatientsexperiencestartsoutsidethebuilding,andtheirinitialimpressionofitplaysabigpart
intheirperceptionoftheservice,aswellasinuencingthelevelofstressexperiencedinattending.
Withcarefuldesign,spacesroundthebuildingsuchascarparksandentrancescanandshould
enhancethepatient(orvisitor)experienceconsiderablyeventhoughtheymaynotbe
specicallydesignatedfortherapeuticuse.Well-designedsurroundingsareeasytonegotiate,
meaningthatthejourneyfromsiteentrancetothewardorwaitingroomisaspleasant,well-signedandrelaxedaspossible.
A break away from the ward,
enjoying a chat in the sunshine.
Tree and hedge planting would help make this bleak road on an urban hospital site more of a pedestrianenvironment, rather than one simply focused on trafc and car parking.
Above:Existing view.Right:How the improved areacould look.
Large specimen trees give scale and provide
a better set ting for the taller buildings nearby
Edible hedge of mixed native shrubs
plums; damsons; elder; blackthorn
Cars hidden behind
new hedge planting
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Creatingahealingenvironmentingardenspaces
Gardenspacesarepredominantlynaturalincharacterandcancontainlotsofplanting.They
rangeinscalefromtheverylargetotheverysmall,andfromformalherborphysicgardens,
throughtoorchardsandmoreextensivelawnswithspecimentrees.
Gardenspacesnexttobuildingsofferthegreatesttherapeuticpotential.Proximitytowardsorwaitingroomsisabsolutelyessentialtoencouragenotonlyindependentaccessbutalsostaff-
assistedaccessanurseorplayassistantismuchmorelikelytotakeachildintoagarden
accessedfromthewardthanonethatrequiresatripawayfromit.
Somebuildingshavehiddencourtyardandroofgardenspaces,whichmayhavestrongpotential
intermsofproximityandaccessibility,aslongasthereisadequatesignagewithinthefacilityto
alertpeopletotheirpresence.Thesespacesarealwaysworthexploringasapriorityfor
developmentasahealingenvironment.Moreremoteopenspacesonthesitemaybetoofar
awaytobeeasilyreachedandwellused.
GreatOrmondStreetHospitalislocatedonaveryconstrainedsiteincentralLondon,withalmost
nooutdoorspaceatall,sothenewstaffgardentherewasconstructedontheroof.Thegarden
canbehiredforeventssuchasbirthdaypartiesandshelterfromthewindisprovidedbyglazed
panelswhichstillallowpanoramicviewsoftheLondonskyline.
Great Ormond Street Hospital roof garden
and commemorative inscription to a
previous member of staff.
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Seating against chapel
wall looking onto trees
Birch trees set
in spring bulbsRaised planter with
scented shrubs
Acreativeapproachtoexternalspacesacrossthesite
StCatherinesMentalHealthTrustHeadquartersislocatedinaGradeIIListedbuildingset
inaparklandsiteontheoutskirtsofDoncaster.OriginallythehomeofaVictorian
industrialist,thebuildingissurroundedbyalargenumberofnewerbuildings,offeringa
widerangeofsettingsforthosewithmentalhealthproblems.
Case study 2: St Catherines, Rotherham, Doncaster, and South HumberNHS Foundation Trust, Yorkshire
Adult Mental Health Unit garden.
Courtesy:RDaSHNHSFoundationTrust.
With new seats and some extra planting, this unpromising area outside the chapel could become a Quiet Gardenat Charing Cross Hospital, London.
Above:Existing view.Right:How the improved areacould look.
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Thewidersetting
TheEnvironmentManagerisdevelopingaproposalforopeningupanewfootpathlink
throughthehospitalgrounds,whichwillconnecttheproposedhousingdevelopmentnext
tothesitewithanimportantlocalnaturereserve,PotterickCarr.Thisnewroutewillprovide
acirculargreenwayaswellasawildlifecorridorforthebirdsinthenaturereserve.
Benets:
Biodiversitybenetsforthesiteandthewidersetting.BenetsforthepublicproleoftheTrust.IncreasedpotentialfordevelopingaHealthyWalksprogrammeforthelocalcommunity.
Thebuildingsurrounds
Theparklandischaracterisedbyoutstandingtreesandwoodland.Thisiscurrentlybeingaugmentedbynewplanting,aspartoftheNHSForestinitiative,tohelpscreen
neighbouringdevelopmentandprovideextraprivacyforthoseusingthegrounds.Work
willincludeextendingtheexistingredpathnetwork,whichpatientsusetoidentifysafe
walkingroutesroundthesite.Thenewpathwillalsobeavailableforlocalresidents,as
wellasstaffonsitetherearealreadyseveralgroupsofstaffwhoregularlycomplete
circuitsofthesiteatlunchtime.
New NHS Forest planting will complement existing mature trees and also screen neighbouring
development.
Staff, visitors and certain patient
groups have free access to the
parkland surrounding the
hospital buildings.
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Benets:
Trustbetterintegratedwithinlocalcommunity,resultinginabetterunderstandingofmentalhealthissuesandincreasedaccesstotheTrustsiteforlocalresidents.
Longerwalkingrouteforpatientsandincreaseinexercisebeingtaken.Increasedbiodiversityandamenityfromadditionaltrees.
Thegardenspaces
Thegardenattachedtothenewlow-secureCusworthandBrodsworthwards,andthe
mediumsecurePsychiatricIntensiveCareUnit(PICU)isaccessibleondemandtothe
in-patientsthere.Theimpactofthestandard3mhighfencingenclosingthespaceis
mitigatedbycolourfulherbaceousplantingandthereisplentyofseatingtoencourage
peopletospendtimeoutside.Thehistoricwalledgardennowhousesahorticultural
therapyproject,wherelocalresidentscanbuyplants.
Benets:
Freeaccesstotheoutdoorshelpsrestoreasenseofcontrolforpatients,especiallyimportantforthosedetainedagainsttheirwill.
Anattractiveviewofanaturalenvironmentisbenecialevenforthosewhorarelyventureoutdoors.
TheretailaspectoftheWalledGardenProjectstrengthensconnectionswiththelocalcommunity.
TheEstatesbudgetiscontributingfundsto
theseimprovementsinthegrounds.InitialNHSForestplantingcost5000(with
additionalWoodlandTrustsupport)butan
additional24000isnowbeingaddedtoa
BigLotteryGranttomakeatotalofalmost
250000forasecondphaseofwork.This
willimproveaccesstothewoodlandand
includeengagementwiththelocal
communitytorecruitateamofvolunteers
tocreateandmaintainpaths,assistwith
woodlandmanagementandpotentially
eventransformthesiteintoagreengym.
The historic walled garden houses a social
enterprise project, where service usersdevelop new skills in horticulture, helping
them to return to employment.
Enclosed courtyard, Psychiatric Intensive Care
Unit, Skelbrook Ward.
Courtesy:
RDaSHNHSFoundationTrust.
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Designprinciples
Thedesignprinciplessetoutinthissectionprovideachecklistforanyoneimproving
existingspacesorcreatingnewones:
1. Valuewhatyouhave2. Createplaceswhichfeelspecial
3. Maketheoutsideaccessible
4. Focusonpeoplesneeds
5. Connectwithnature
6.Balanceriskwithbenets
7.Designforchange
Designingoutdoorspacesfortherapeuticpurposesmeansconsideringanumberoffactors.Howwillthespacebeused?Isiteasilyaccessible?Arethereparticularclinicalneedstoconsider?What
abouthealthandsafety?
Thedesignprincipleswhichfollowhavebeendevelopedprimarilytoprovideaframeworkfor
peoplewithoutadesigntraining,tobegintothinkthroughtheelementsofanindividualproject,
andtotacklesomeofthequestionslistedabove.Theyarenotintendedtocovereveryaspectof
design,buttoprovideanintroductiontothesubject.Theyhavebeenformulatedtoreectwhat
ismostimportantandrelevanttohealthcaresettings.
Theprinciplesareintendedforspaceswhichwillhaveapredominantlytherapeuticfunction,and
areapplicabletobothgardenspacesclosetobuildingsandtothefurtherreachesofasite,aswellastonewfacilitiesattheplanningstage,andexistingfacilitiesbeingimproved.
Mostprojectswillrequireinputfromadesignprofessional.Theroleofthedesignerwillbeto
designaschemesothatitistforpurpose.Mostdesignerspreparedetaileddrawingsand
specicationsforthosewhowillactuallyconstructthenewgarden,althoughsomelandscape
gardenersorcontractorsalsoofferadesignandbuildservice.
Itisalwaysadvisabletoemployadesignerwhohashadsomeformaltraininginthiseld,ratherthan
usinganarchitectorinteriordesignerwhomaynothaveexperienceindesigningoutdoorspaces.
Garden designersmaybeabletotacklesmallerspacessuccessfullyandtheycanoftenoffer
particularexpertiseinplantingdesign,whichshouldbeamajorelementinanytherapeuticspace.
Landscape architectsshouldbeemployedonlarger,morecomplexschemes.Thoughtheyshare
manyskillswithgardendesigners,theyareoftenmoreusedtoworkinginthepublicdomainand
cantakefullresponsibilityfordesigningbothhardandsoftlandscapeelements.
Designprofessionalsworkingtocreateatherapeuticoutdoorspaceshouldalsondthedesign
principlesoverleafhelpful.Even someone without any design training who is interested in making
the outdoor space part of the healing environment can help develop a worthwhile project.
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1.Valuewhatyouhave
Healthcarefacilitiesareofteninastateofuxastheydeveloptomeetchanginghealthneeds.
Thereisconstantpressurefornewbuildingsoradditionalcarparks,andevennewhousing,and
openspacemayseemtheobviousplacetoputthem.
TheHippocraticOathFirst,donoharmisagoodguidingprinciplefordevelopingoutdoorspaces.Byvaluingwhatisalreadythere,andunderstandingthebenetsthatopenspaceprovidesmost
importantly,theveryspecialtherapeuticbenets,thecaseforsafeguardingopenspacegrowsstronger.
Howdoyouvaluewhatyouhave?
Tovalueanexistingspaceitisessentialtounderstandtwothings:whatyouvegot,andhowitis
alreadyused.Maybethereisalreadyspaceonthesiteforrecreationbutpeopledonotknow
aboutit,ortheremightbethingsaboutitwhichareputtingpeopleoff,forexamplelitteror
overgrownvegetation.Sometimessomesimplehouse-keepingisallthatisneededtoencourage
peopletouseanarea.
Well-designedfacilitiesarecarefullyplannedtopreserveandenhancekeysitefeaturessuchas
importanttreesorprotectedspecies.Takingamaster-planningapproachandlocatingnew
buildingsfollowingadetailedanalysisandappraisalofthesite,ratherthanlocatingtheminan
opportunisticway,willalwaysgivebetterresults.
Sometimestheopportunitiesarehardtoidentify,asatNinewellsHospital,Dundee.
NinewellsHospitalwaslocatedinanelevatedpositiontotakeadvantageofthepanoramicviews
overtheTayestuary.However,accesstotheoutdoorsforpatientshas,untilnow,beenlimitedto
thesmallfreshairgardenclosetotheentrance.
Alandscapearchitectwasappointedtodevelopamasterplanforthewholesite,withthehelpof
ForestryCommissionScotland.Thesiteappraisalshowedthatoneofthebestopportunitiesfor
accesswasthewoodedparklandtothesouthofthesite.Ithadthepotentialtobeusedbymore
mobilelong-staypatients,aswellasstaffandvisitors,andthesurroundingcommunity.
Theconstructionofanetworkofcycleandfootpathsthroughthehospitalgroundsisnowunder
way.Newseating,restareasandinterpretativeinformationwillencouragegreaterexplorationof
thewoodland,andmakethemostoftheviewsovertheRiverTay.
Aerial view of Ninewells
Hospital in Dundee.
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Thethreerststeps
Step 1: A site appraisal/analysisbyasustainabilitymanagerorfacilitiesmanagementteam,with
theinvolvementofaclinicianwhohasknowledgeofthepotentialbenetsforpatientcare.Where
aretheopportunities?Arethereparticularstrengthsandweaknesses?Inputintothesiteappraisal,
intermsofhealthpromotion,fromtheNHSoreventhelocalauthoritywouldalsobehelpful.
Step 2: TheTrustteamwillneedto set out and adopt a policyregardingtheroleofopenspace
withinthewiderpatientcareenvironment.Supportofseniormanagementteams,includingthe
ChairandChiefExecutive,andthemaintenancestaffisessential.Thepolicyshouldincludethe
businesscasefortherapeuticuseofopenspaceacrossthesite.Cross-referenceshouldbemade
tootherdrivers,suchaslocalTrustorBoardperformancemeasures,andnationalinitiativessuch
astheNHSForestprojectorNHSGreenspaceinScotland.
Step 3:Anaction plantoprioritiseimprovementsandpotentialfundingsources.Atthisstage
additionaldesignsupportfromalandscapearchitectislikelytobeessential,particularlywith
larger-scalespacesormorecomplexsites.
A master plan for the site was prepared by a landscape architect.
New paths around the hospital grounds.
Red squirrels may be returning
to the woods at Ninewells.
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2.Createspaceswhichfeelspecial
Senseofplace
Oneofthemostimportantprinciplesinlandscapedesignisthatdesignshouldalwaysbespecic
toitslocation.Workingwiththesitewillenhancethesenseofplace,andmayevenmakeit
cheapertodevelop.
ThepoetAlexanderPopewroteaboutdesigningwithnatureandsenseofplaceinotherwords,
workwithnature,andworkwiththesite.Thiswillentailanalysingitscharacter,itsstrengthsand
weaknesses,consideringopportunities,celebratingandenhancingthefamiliarinthelocality,and
designingtodelight.Inthiswaythesitewillcomfortandstimulate,beenjoyedandtreasured,and
beaplacewherepeoplewanttospendtime.
Spaceswhichfeellikeplaceswillbewellused
Theaimistocreatespacesthatareplacesintheirownright,withastrongcharacter,whichwillhelptoensurethataspacewillbewellused.InScotland,theGoodPlaces,BetterHealth
frameworkpromotesthehealthbenetsofwell-designedspaces.Itrecognisesthatpoor
environmentsmayfosterhopelessnessandstressanddiscouragehealthybehaviour,whereasthe
creationofpositivephysicalenvironmentsmaynurturebetterhealthandwell-being.
Specialfeaturesshouldbeprotectedandincorporatedinthedesignwherepossible.Trees,
includingfruittrees,areespeciallyhelpfulinestablishingasenseofplace,oftencombininga
distinctiveappearanceorcharacterwithanincreasingsenseofantiquityastheymatureinto
venerablespecimens.
Pine trees at Chalkhill have
inspired the design of the
interiors.
Adding a tree to this dull courtyard will make it feel more like a place, even inviting on a warm autumn evening.
Above:Existing view.
Right:How the improved areacould look.
A specimen tree provides a
new focal point for the
courtyard and makes it feel
like a place in its own right
The new tree should be upright
rather than spreading, to ensure
that views from the windows are
not obscured and the building
still receives plenty of light
Seating helps make the space feel more
inviting and also more likely to be used
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Inruralareasitisimportanttobeawareoflocaldistinctiveness,orwhatmakesthelocality
differentandspecial.Oftenitmeansusingmaterialscharacteristicofthatarea,forexamplestone
pavingorparticularplantssuchasbox,whichgivesBoxHillinSurreyitsname.InShefeldon
theNorthernGeneralHospitalcampus,oldindustrialartefactsareplacedaroundthesiteatkey
locations.Theseprovideinformalmeetingandorientationpoints,andremindeveryonethat
Shefeldisacitywitharichindustrialheritage.
AtthenewSecondRhonddaCommunityHospitalinWales,whichwasbuiltonthesiteofaformer
coal-mine,thelandscapehasbeencarefullydesignedtoreectthecharacterofthesurrounding
landscape.Drystonewallingusedlocallyforeldboundariesfeaturesprominently,andhas
alsobeenusedtocreateseatingspacesinthecourtyards.Slateisusedasasubstituteforgravel
andalsotoformstandingstoneswhichprovidestrongfocalpointsinsomeoftheother
courtyardspaces.
Artworkdesignedinasecondphaseofworktoenhancethecourtyardfeaturesalsohelpstogive
thesespacesadistinctcharacter.
Using local materials will ensure
that outdoor spaces reect the
character of their surroundings.
Courtesy:JamesNewma
rch.
Courtesy:4DLandscapeDesign.
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3.Maketheoutsideaccessible
Anintegratedapproach
Thisapproachintegratesbuildingsandstructureswiththewiderlandscape,ratherthanfocusing
mainlyonbuildingsanddesigningthesitefromtheinsideout.Wherepossible,thismore
strategicapproachispreferabletotacklingexternalareasonagardenbygardenbasis,whichcanonlyinllthespacesleftoveroncethebuildinghasalreadybeendesigned.Well-integratedsites
will,bydenition,beaccessible.
Easyaccess
Alongsidethequalityandproximityofthespace,easyaccessisprobablythemostimportant
factorindeterminingwhetherspaceswillactuallybeused.Designingthebuildingswithregardto
theiroutdoorspaceshouldhelptoensurethatthereisplentyofdirectaccessfrominside,out
intothespaces.AtNewhamUniversityHospitalinLondon,courtyardspacesoffthemaincorridor
provideeasilyaccessiblespacesfortheground-oorcafsandwards.Moremobilepatientsontheupperoorsalsousethesegardens,takingtheliftsorusingthestairstogetthere.
Whereappropriate,wardsshouldbedesignedtoallowbedstobewheeledoutintothesunshine
(rememberingthatsomepatientswillalsoneedtobeinshade).Formanyhospicesthisisa
routinepractice,suchasattheJosephWeldHospice.
Aclearhospitalpolicyonusingoutdoorspaceswillalsohelptogivestaffcondenceto
encouragepatientstogooutsidewhereappropriate.
Formanypeople,andespeciallythoseconnedtobed,beingabletoenjoytheoutdoorsfrom
insideisimportant,andviewsoftreesoragardenshouldbeavailable.Thismeanstakingcarethat
thewindowislowenoughandthebedisorientatedtowardsit.SomeoftheKingsFunds
EnhancingtheHealingEnvironmentprojectshaveinvolvedretro-ttingdoorstomakehardto
reachspacesaccessible.Thisisoftenworthexploringinexistingbuildings.
TheLambethCommunityCareCentreiscleverlyintegratedwithitssetting,andthegardensareseenasanessentialpartofpatientcare.Sun-roomsandbalconiesarepopularwithpatientswho
arenotyetreadytogooutside,butwhostillwanttoenjoythefreshair.Evenpatientsin
wheelchairsontheupperoorscangooutindependently,alongahigh-levelwalkwaywhich
connectsthebalconyareaswiththegarden.
A bed is made ready to be wheeled into the sunshine.
Imagescourtesy:JosephWeldHospice.
The sun room offers a taste of
the outdoors at Lambeth
Community Care Centre.
Courtesy:EdwardCullinanArchitects.
Beds can be wheeled out onto both the balconies and the patios.
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Beingcreative
Someorganisationsandhealthcaresettingsareexperimentingwithdifferentwaysofbringing
natureinside,whereparticularpatientneedsorthedesignofthebuildingmeansaccesstothe
naturalenvironmentislimited.
AtAlderHeyChildrensHospitalinLiverpool,recordedbirdsongisplayedinsomewardsandCDsaregiventopatientswhentheyleavetoassistwiththeirrecoveryathome.
AtDorsetCountyHospitalinDorchester,inthechemotherapyunitwhereinfectioncontrolisahighpriority,livelmistransmittedfromanaturereserverunbytheDorsetWildlifeTrustas
partofthehospitalsRoomWithaViewproject.
Insomeclimates,oronverysmallsites,winter-gardensorconservatoriesmaybethemostsensibleoptionfortherapeuticfunctionssuchasphysiotherapy,especiallyforchildren.
A woodland setting for the new
Childrens Unit at Salisbury
Hospital.
Courtesy:SamBoex/3DSolutions.
An especially creative approach will be needed where outdoor areas are inaccessible: the children here canwatch the pet rabbits playing, through the windows.
Above:Existing view.Left:How the improved areacould look.
Floor to ceiling windows allow good
views in for the smallest visitor
Doors kept locked for this
garden which is inaccessible
to the public
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4.Focusonpeoplesneeds
Insuccessfultherapeuticspaces,meetingpeoplesneedscomesrst,ratherthanthedriveto
reducemaintenancecostsoravoidrisksbeingprioritised.Designersshouldworkcloselywith
people(usergroups,ortheirrepresentatives)tounderstandtheseneeds,ratherthanproceeding
onthebasisofassumptionswhichmightbemistaken.
Inclusivedesign
Animportantgeneralpointisthatspaceswhicharedesignedtohaveatherapeuticfunction
shouldfeelcomfortableandshouldbeplaceswherepeoplefeelsafe,relaxed,atease,andnot
overlookedorconstrained.
Multi-functionalspacessuchasgeneralgardenareasareoftenintendedforawiderangeof
peoplewithwidelydifferingneeds.TheInclusivedesignapproachisparticularlyrelevantfor
thesecateringforspecicneedsinasubtlewaywhichmeansspaces(orstructures)canbe
enjoyedbyallusers,ratherthanbyonespecicusergroup.AccordingtoDavidKamp,aninclusivedesignspecialist,Designconsiderations...areoftensubtledetails,easilyoverlooked
exceptbythosewhoneedthem.
Itmaybethecasethatsomepeoplesrequirementsareconicting.Jasmineplantedinagarden
tohelpalleviatesymptomsofdepressionmightprovetoohighlyscentedforthechemotherapy
patientstrugglingwithnausea.Workingcloselywithpotentialusers(ortheirrepresentatives)will
helpovercomesuchissues.
TheSensoryTrust,basedinCornwall,hasdevelopedtheCreativeSpacesProjectwithCornwall
Care,Cornwallslargestindependentcareprovider.Theprojectaimstoimprovecarehome
gardenssothattheymeetresidentsneeds.Inordertounderstandthese,theTrustrananumberofeventssuchasanoutingtotheEdenProjectledbyyoungpeople,andthedesignworkshop
inthegarden,whereresidentErniewasinvitedtosharehisgardenmemorieswithstaff.
Garden visits and design workshops all help to clarify peoples needs.
Imagescourtesy:Sensor
yTrust.
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Cateringforspecictherapeuticneeds
Insomespaces,thelayoutneedstobequitespecictotheusergroup.Forexample,inamental
healthdevelopment,agardenusedbyelderlypatientswithdementiawillbequitedifferenttoone
usedbyyoungmenwithmentalhealthproblemsrelatedtodrugmisuse.Fundingforgardenspaces
mayalsobeeasiertoprotectwhenthelinkstospecictherapeuticfunctionsaremadeveryclear.
Involvingdisabilityaccessgroupsisessentialtoensurethatallthekeyissuesareaddressed,
especiallywithregardtointelligentandsensitiveinterpretationoftheEqualityAct(2010).Catering
forbroaderequalityanddiversitycommitmentsmayinsomesituationsalsoextendtoaddressing
culturalissues.
AtthenewAlzheimersRespiteCentreinDublin,thegardenisfullysecureandhasbeendesigned
toavoiddeadends,focusinginsteadonaloopsystem.Manyofthepatientswander,and
makingthiswanderingmorepurposefulreducesthelikelihoodofthembecomingstressed.
TheCentreManagerdescribedhowhelpfulthegardenisforresidents:Ifsomeoneisgettingworked
up...youcantakethemoutside,eveninthewinter...thepersonoftencalmsdownmorequicklythan
inside,wherethewallscanfeelveryconning...wehavescentedherbslikelavenderarounddoorways
andweencourageresidentstocrushtheleavesintheirhands,toreleasethescentontotheirskin.
Itshowaspaceisusedthatcounts
Sometimes,alackoffundingorstaffresourcesmeansmakingasmuchaspossibleofanexisting
area.Intheabsenceofanewdesign,encouragingthestafftousetheareamorecreativelymay
enableaspacewhichonthesurfaceseemstohavelittletherapeuticpotentialtomeet
peoplesneeds.TheCreativeSpacesProjectinCornwallintroducedsimpleoutdooractivity
stationsintothegardensofcarehomes,encouragingresidentstospendmoretimeoutdoorsandtoexplorenewareas.AndatWillitonHospitalinSomersetstaff,encouragepatientsoutsideto
re-learnoldskillsinthecaseofonegentlemanwhowasabutterycollector,usingabutterynet!
The garden at the Alzheimers Respite Centre, Dublin, is designed to be secure but also safe and welcoming.
Courtesy:
NickKane.
Scented lavender.
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5.Connectwithnature
Natureliesattheheartofoutdoorspacesforhealthandwell-being.Trees,springtimeowers,
shrubs,birdsong,autumncolours,agentlebreeze,sunshineandrainareallsomuchpartof
everydayexperiencethatitiseasytotakethemforgranted.Forthosewhoareillinhospital
wards,orperhapsanxiousorstressed,theycangreatlyassistthehealingprocess.
Usingnaturalmaterials,andmakingthemostofnaturalelements(earth,wind,water)aswellas
plantingallhelptostimulatethesensesandreconnectpeoplewithnature.Asmallbird-feeding
areaorplantschosentoprovidenectarforbutterieswillgiveeveryonesomethingextratowatch
andanotherreasontogooutside,evenifjustforashortbreak.
Wildlife
Plantedareasarealsomuchmorelikelythanpavedonestoattractbirdsandotherwildlife,which
addextralifeandinteresttoagarden,likethecafcourtyardsketchedbelow.
OneofthereasonsIwantedtoworkattheHomoeopathicHospital,isthebuilding.Itislightandairy
andwelcoming.Thesenseofspaceisextravagantforahospital.Thebestthingaboutworkinghereis
openingthewindowsandlisteningtothebirdssingingasIwork.(CandidaFenton,Librarianat
GlasgowHomoeopathicHospital)
Inschemeswithastrongemphasisonwildlife,itwillbeimportanttomakesurethatnativerather
thanornamentalplantsareused.Thiswillhelptoensurethattheschemebenetslocal
biodiversityasmuchaspossible.Evenmodestimprovementstoaspacetocreateanewgarden
couldhavemajorbenetsforwildlifeinthevicinityandhelpfacilitiesmeettheirlocal
performancetargetsintermsoftheenvironment.
The excitement of meeting a
snail for the rst time.
Courtesy:ChloeEvans-Lippett.
The caf courtyard sketch here shows how a rather dull paved space could easily be turned into a moreinteresting outdoor eating area.
Above:Existing view.Right:How the improved areacould look.
Picnic tables replaced with more
comfortable seating, easier for
those who are less mobile to use
Trees under-planted
with edible herbs
and soft fruit, suchas strawberries
Apple, plum and cherry trees help to soften the space
and create privacy; all growing in light-weight planters
and soil to reduce loading over the roof garden surface
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Forexample,inthesouth-west,plantingasmallareaofDevilsbitscabiousmighthelptoattract
theendangeredmarshfritillarybuttery,apriorityspeciesintheUKBiodiversityActionPlan.
TheWildlifeGardenatTivertonHospitalfocusedonmakingsmall-scalechangestoencourage
wildlife,suchastheintroductionofareasofnativeplanting.Thewholeschemehascostlessthan
1000toimplement(excludingthevalueofvolunteerlabour).
AsurgeonatthehospitalwhoisakeenadvocateofhealinggardensworkedwiththeEstates
Departmenttomakeasterilespacemoreappealingtoawiderangeofbirds,butteriesandbees.
Patientsarenowabletowatchthehedgehogstrundlingaroundthegardenatduskfromtheirbeds.
Therobinsarenestingnowinlastyearsblackbirdnest,andtherearehedgehogsusingthepurpose-
builtnestbox,sosomethingmustberightANDthepatientstellmetheylovethebirds,and
wildowersunderacanopyoftrees.ItreallyisaHealingGarden.(Dr.GavinHaig).
The insect nest-box and hedgehog house are just a few ways in which the garden caters for wildlife.
The Wildlife Garden at Tiverton Hospital.
Wild owers in the new
meadow areas.
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6.Balanceriskwithbenets
Caringforpatientsandkeepingthemsafeisobviouslyakeyobjectiveinhealthcare,alongwith
restoringhealthandwell-being.Therearerisksinvolvedwithaccesstotheoutdoors,forexample
whenpatientsventureoutofthewardintoanadjacentgarden,butthesemustbeweighed
againstthebenetsofexerciseandreconnectingwiththeoutsideworld.
Managingdesignconstraintsconstructively
Mentalhealthsettingscanbeespeciallychallengingfordesigners,butwithagrowing
understandingoftheimportanceofaccesstothenaturalenvironment,manysettingsarenow
providinghighqualityspacesespeciallyimportantinresidentialunitsorwherepeopleare
detainedundertheMentalHealthAct(1983,asamended).
IntheWandsworthRecoveryUnitatSpringeldUniversityHospitalinLondon,thebuilding
wallscreatesecureinternalcourtyardspaceswhicharefreelyaccessible.Here,despitethe
operationalneedforsupervision,acivilisingandhumanesettinghasbeencreatedwhichsupportstherapeuticintervention.
WandsworthRecoveryCentreisarelativelyhighsecuritysettingbutthelayoutoftheoutdoor
areasischaracterisedbydesignqualityratherthanrobustness.Theseatinghereisagoodexample:
sturdy,butwithatactile,softlyundulatingsurfacedesignedinwaywhichradiatescalmness.
Inputfromboththehealthandsafetyandinfectioncontroldepartmentsmaybepartofmaking
surethataspaceissuitabletouse.Theirinputshouldbemanagedconstructively,toavoidtaking
ariskaverseapproachtodesign.Theriskbenetassessment(RBA)process,wherethebenets
ofanactivityordesignareexaminedalongsideanyrisks,isusednowbymanyorganisations
includingtheForestryCommissionasaconstructivewayofmanagingliability.Ithas
governmentsupportthroughtheHealthandSafetyExecutive(HSE).
AtthestrokerehabilitationunitofWillitonCommunityHospital,Somerset,thegardeniswellusedbyin-patientsandtheirfamilies.Allpatientswhoaremobileenoughareallowedintothe
gardenontheirown,andtheyenjoyusingasmallnetworkofpaths,tore-learntheirbalanceand
walkingskills.Theyarealsoallowedaccompaniedaccesstoareasoff-site.
Co
urtesy:DavidButler.
Tactile seating at the Wandsworth Recovery Centre.
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Anexampleofhowthedecision-makingprocessdescribedbelowcouldbedocumentedusinga
riskbenetassessmentprocesscanbefoundinAppendix2.
ThegardensaroundWillitonHospitalinSomersetareunremarkableinappearance,buttheyare
usedcreativelybythetherapiststhere.SeniorOccupationalTherapistSoniaexplains:
Webelieveitsreallyimportanttoallowpatientsthefreedomtoenjoythegardenunsupervised [oncetheyhavebeenassessedasbeingabletomanagewithrelativesafety].Havingthatextrabitof
independencemeansthattheyhavetolearntobemorecondentoutside,whichisanessentialskill
forthemtomasteriftheyaretobedischargedsuccessfully.Sometimes,yes,theydohaveafall,butwe
lookattheseincidentsinaconstructivelightandtheinformationabouthowandwhyithappened
theninformsourtherapyandtreatmentprogrammetoreducethechanceofithappeningagain.
Becausewereinaruralarea,wehavealotoffarmersthrough,anditsespeciallyimportantthatthey
arecondentinamoreinformalsettingnousejustbeingabletowalkontarmac.Sowiththem,
wemighttakethemundersupervisionontothefootpathnexttothegardenandevenoverthestile
andintotheeld,walkingoverroughnewly-ploughedground.Itssoimportantforthemtoknowthat
theycandotheseactivities.
Path leading to surrounding elds fromWilliton Hospital.
Garden, Williton Hospital.
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7.Designforchange
Naturalspacesevolvewithtime
Imagining,designingandcreatinganoutdoorspaceisjustthebeginningaspaceneedstolast
longterm.Spacesdesignedcarefullycanbeenjoyedthroughoutallstagesoftheirlifespan.Thisis
especiallyimportantforschemesincludingtrees,whichwillchangemarkedlyastheygrowthroughestablishmenttomaturity.
Successfulgroundsmaintenanceiswellplannedandadequatelyresourced
Groundsmaintenancecostsshouldbeconsideredfromtheoutset,andsetatalevelwhichstill
allowsthespacetomeetusersneeds.Forexample,pavedareaswouldbecheapertomaintain
thanplantedones,buttheywillneverachievethesametherapeuticbenets.
Well-resourcedgroundsmaintenanceisimportantatanyscale.AtthenewForthValleyRoyal
HospitalatLarbert,StirlingshireaverylargeschemethedeveloperwasobligedbyaPlanningObligationtoendowtheoutdoorspaceswithafundof250,000forrestorationand
maintenance.Atamuchsmallerscale,attheLambethCommunityCareCentreinLondon,the
budgethasbeenstructuredtocoverthecostsofapart-timegardener,withanyadditionalcosts
beingcoveredbyincomeraisedfromplantsales,opentolocalpeople.
Designtoanticipatechangingconditions
Openspacecanbeespeciallyusefulinthecontextofachangingclimate.Treescanbeplantedto
provideshadeinhottersummers,helptomoderatetheeffectsofheavyrainfall,lterairto
improvequality,absorbCO2andsupportbiodiversity,andimprovethebeautyofaplace.They
canevenreducemanagementcosts,comparedwithmowngrass.
Toachievethecarbontargetsitisaimingfor,theNHSmustdesignandmaintainoutdoorspaces
sustainably.TheCentreforSustainableHealthcareisworkingtohelptheNHSbecomemore
sustainableandtheNHSForestinitiative,whichaimstoplantonetreeforeveryemployeeacrosstheNHSestate(andbeyond),isanimportantelementinitsprogramme.Woodlandscreen
planting,suchasthatshownopposite,wouldbeasuitableprojectforthisprogramme.
At Lambeth Community Care
Centre the gardener prunes
shrubs carefully rather than
using a hedge-trimmer.
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AtEnniskilleninNorthernIreland,thenewhospitalisbeingimplementedunderaprivatenance
initiativecontracttohighstandardsofsustainability,withthebestpossibleintegrationofbuilt
developmentandthelandscapeasoneoftheprojectskeyobjectives.
Animportantelementoftheprojectisthereconstructionofwetlandsroundthebuildings,using
surfacewaterrun-offfromroofsandhardsurfaces.Othersustainablesolutionsincludethe
extensiveuseoflocally-grownnativeora,andthecreationofextensivespecies-richmeadowscloseto(andvisiblefrom)thehospitalbuildings.
Introducing larger-scale planting will be possible on more spacious sites and will make them more attractive to staffand visitors, as well as patients. Using native species will also bring wider environmental benets.
Above:Existing view.Left:How the improved areacould look.
Illustration:RichardCarm
an.Courtesy:NIHG/LUC.
Trees can help the NHS
meet sustainability targets
and provide wildlife habitat
A limited amount of meadow grass, where
appropriate, helps reduce frequency of grass-
cutting and improve biodiversity on the site
Improved amenity value of site especially
near to countryside enhances theenvironment for staff, visitors and patients
Atrium view of lough at Enniskillen, Northern Ireland.
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Summary
Thedesignprinciplessetoutabovehavebeendevelopedtoreecttheissuesofmostimportance
withinhealthcaresettings;followingthemwillhelpensurethatthedesignofoutdoorspacesfor
therapeuticuseissuccessful.Theywillprovideagoodoverviewofthekeydesignprinciplesforallthosewhomaylackspecialistexpertise,andwhomaybeinvolvedincommissioningor
developinglandscapeprojects.
MaggiesCentreatCharingCrossHospital,Londonisanexcellentexampleofaschemewhich
placeddesignqualityattheheartoftheproject,andalsoillustratesclearlyseveralofthe
principleslistedabove.
Paediatric courtyard at Enniskillen, Northern Ireland. Linear gardens at Enniskillen, Northern Ireland.
Illustrations:RichardCa
rman.Courtesy:NIHG/LUC.
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Illustratingthedesignprinciples
TherearealreadyanumberofMaggiesCentresthroughouttheUK,usuallydevelopedas
agshipprojectsbyestablisheddesignersworkingonaprobonobasis.AlthoughinthecaseofthisparticularcentreinLondon,wheretheoverallbudgetwasgenerous(fundedby
charitabledonationsandfundraising),therearemanyaspectsoftheprojectthatwouldbe
easilyreplicableonthemoremodestbudgetstypicalofanNHSscheme.
Thereisgrowingevidencetoshowthatthe
emotionalstateofcancerpatients,andthatof
theirfamilyandfriends,caninuencetheircancer
experience,treatmentandrecovery.Researchin
theeldofenvironmentalpsychologyhas
establishedthatourphysicalenvironmentaffects
ourbehaviour,andwell-designedenvironments
suchastheMaggiesCentreinLondonhavebeen
showntoenhancequalityoflifeandapersons
abilitytocopewithstress.
Thegardenillustratesparticulardesignprinciples
mentionedinthisguideveryclearly,asshownin
theimages.
Mostpeoplesaidtheyfeltthattheplantssoftenedthebuildingbutalsothewholeexperience
ofbeingthere.Theplantssimultaneouslycreateasenseofcalmness(soothing)butalsoasense
ofenergypeopleoftentalkaboutbeingfascinatedbythespeedthingsgrowatandtheylook
forwardtoseeingthenextstageintheplantsdevelopment;theresavitalityaboutthebudsopening,andnewleavesunfurling.Forpeoplewithcancer,anythingwhichhelpsthemlook
forwardtothefuturewithasenseofhopeismassivelyhelpful.(Researcher,MaggiesCentre
London,2010).
Case Study 3: Maggies Cancer Caring Centre, London.
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Design for peoples needs: Thesiteradiatescalmnessandtranquillity,whichhelpsrelieve
theanxietyandstressoftenexperiencedbythosewithcancer,andtheirfamiliesand
friends.Therelaxedmoodandeasy,inside-outowhelpmakethecentrefeellikea
sanctuaryinthebusyurbanenvironmentinwhichitsits.
Make the outside accessible:Thelandscapedesignerworkedcloselywiththearchitectandthishashelpedcreateabuildingwhichisfullyintegratedwiththeexternalareas.The
gardensurroundsthebuildingandgrowsthroughitinaseriesofintimateandsensual
spaces.Eachroomhasitsownaccessoutside,andthelargewindowseverywheremake
theoutdoorspacespossibletoappreciateevenonawetwinteryday.
Connect people with nature: plantingenvelopsthewholebuildingandthetreesonce
establishedwillhelpscreenthenoiseandbustleofthesurroundingstreetsandtrafc.
Theplantinghasbeencarefullyplannedtoincludescentedfoliage,andtocreateagood
balanceofintricacyandsimplicityofscale.
Bystimulatingallthesensesandprovidingaconnectiontonatureinanurbanenvironment,
MaggiesLondonwillputallvisitorsintouchwiththishealingpotential(designer).
Cour
tesy:MaggiesLondon.
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Overcomingthechallenges
Eachtypeofhealthcaresettingwillhaveitsownparticularchallengestoovercomein
ordertoprovidetherapeuticoutdoorspaces.Somemethodsofprocurement,suchas
privatenanceinitiativeschemes,alsoneedtobetackledcarefullytoachievethebest
outcomepossible.
Therearemanyexamplesofgoodpracticethroughoutthecountrywherethese
challengeshavebeensuccessfullysolved.
Privatenanceinitiativeschemes
The challenge:ManytypesofNHSfacilityareprocuredunderprivatenanceinitiative(PFI)schemes.
ATrustthatplaceslowvalueonlandscapeattheoutsetrisksseeingthisaspectdiminishedeven
furtherduringdelivery,withproposalserodedbyinevitablecontractualandnancialpressures.
The solution:Whilestronglyfocusedonacost-effectivedesignandconstructionprocess,newPFI
schemescanstilldeliverhighqualitylandscapeswhichcanhaveatherapeuticfunction(andwith
existingschemes,changescanbemadebyvariationtothecontract).
Wherethereisnoexistingguidanceonrequirementsforoutdoorspace,theprocuringauthorityshouldincludetheserequirementsinitsoutputspecication.Bidsshouldplaceemphasison,and
allowpropercostsfor,alandscape-ledapproachsecuredthroughthepreparationofdetailed
proposals,includingagreedlevelsofqualityandprovision,atPreferredBidderstage.The
proposedEnniskillenHospitalexempliesthisprocess.
How do we put the theory into practice?
Enniskillen Hospital, in Northern Ireland, North Spine View.
Illustration:RichardCarm
an.Courtesy:NIHG/LUC.
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Acutecare
The challenge:Wardsarefrequentlyrelocatedinacutehospitalsettings,makinglong-term
planningdifcult,withlittleincentiveforcapitalinvestment.Theremayalsobeaperceptionthat
investinginaccesstotheoutdoorsdoesnotofferagoodreturnwhenmanypatientsaremostly
connedtobed.
The solution: AtSalisburyDistrictHospitalinWiltshire,theArtsManager,togetherwiththe
FacilitiesandEstatesManagementTeam,hasidentiedanumberofspacesforpotential
improvement.Theselieoutsidethehospitalsdevelopmentzone,havepotentialamenityvalue,
andhaveausergroupcloseby.Withastrategynowinplace,improvementscanproceedwith
condenceasfundingbecomesavailable.
Inthehospitalsplansforacourtyardgarden,thespacewillbeaccessiblefromboththeStroke
andOncologyunits.Thesketchbelowshowshowfeaturescanbeincludedtohelppatients
fromtheStrokeUnitimprovetheirmobilityandbalancewhilealsomakinganattractivespace
forotherpeople.
Olderpeoplescare
The challenge:Inolderpeoplescaresettings,therehasbeenatendencyforpeopletospend
muchoftheirtimesittingpassivelyintheTVroom.Staffmaybeunawareofthebenetsforolder
peopleofbeingoutsideand,asaresult,encouragingresidentsoutintothegardenbecomesa
lowpriority.
The solution: TheCreativeSpacesProjectinCornwallcreatesopportunitiesforolderpeoplewith
dementiatoimprovetheirenvironmentsandplayamoreactivepartinsociety.ThelessonslearntarebeingdisseminatedacrossallthepropertiesmanagedbyCornwallCare.
Withinthisproject,theconceptofatimetabledactivitiesprogrammehasbeenreplacedbya
newapproachtoactivitiesthatpromotesindependence.AtTrevarnaCareHomeinStAustell,the
New planting, paths and seating would transform this space for everyone, whether patients, staff or visitors.
Above:Existing view.Right:How the improved areacould look.
Seating areas close to entrances
Shrubs around
the edge make
the garden feel
less over-looked
Existing change in level incorporated within new
circular path using different surfacing materials
Grove of Birch trees helps to dene the
space and create privacy. The trees will
also look attractive from inside the
building, even the upper oors
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gardensarebeingredesignedwiththeresidentsneedsinmindtoenablethemtomaketheirown
choicesaboutwhattheydooutside.
Thegardensarefreelyaccessible,andoutdooractivitystationsconsistingofvisualcuessuchasa
pileofbooksinaquietcorner,oracollectionofgardeningtoolsonaworktable,allhelp
residentstoinitiatetheirownactivities,maintainingtheirindependenceandself-worth.Insites
whereindependentaccesstogardensisdifcult,moreemphasisisplacedongettingresidentsoutandaboutbycoachtotakepartintheday-to-dayactivitiesofthelocalcommunityin
whichtheylive.
Primarycare
The challenge:Inprimarycaresettings,patientsusuallyonlyattendforshortappointments.
The solution: Theremaybescopetodevelopoutdoorspacestoprovideapleasantplacefor
peopletowait,orevenasafocusforactivitieswhichcouldincludethewidercommunity.
AttheCulmValleyIntegratedCentreforHealthinDevon,anewapproachtoprimarycareis
beingtrialled,asdescribedinCasestudy4.
Anewmodelofprimarycareforthe21stcentury
TheCulmValleyCentreisatthecoreofaninnovativenationalself-careprojectsupportedbytheDepartmentofHealth.IncorporatingaconventionalGPsurgeryalongsideanatural
healthcentre,thedesignofthebuildingbothinsideandoutside,andalsoofthegrounds
emphasisesaholisticapproachtohealthcare.Thereisafocusonwellnessratherthan
illness,andafocusonself-care,orprevention,ratherthanonmedication.
Ahealthfacilitatoronthestaffactsasagatewaytoawiderangeoftherapiesincluding
activitieswithastrongsocialorcommunityangle,suchastheGardeningGroup,andthe
CommunityInterestCompany(SustaincareCIC)runsacafinsidethecentre.Thecaf
functionsasasocialhub,andpatientsvisitingtheirdoctor,healthprofessionalorthe
pharmacystopforadrinkandsnackandndnewwaystolookafterthemselvesastheydo.
ThePhysicGardenhas
informationonBritish
medicinalplantsthatcan
begrowninpatients
gardens,andhasabench
wherepatientsandstaff
canspendtimerelaxing
outsideinacalming
environment.
Case Study 4: Culm Valley Integrated Centre for Health, Cullompton, Devon.
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IntheKitchenGardenfoodisgrownforthecaf,toshowpeoplehowfoodgetsfromsoil
toplate,tomodelhowlittlespaceisneededtogrowonesownfood,andtoencourage
theuseofseasonalproduce.
ManypeoplehaveattendedsessionsheldbyherbalistsonMakingmedicinesfromthe
GardenandWinterRemedies.Theworkshopsencouragepeopletotakeresponsibilityfor
theirhealthandarealsosocialevents,givingpeopleachancetomeettheirneighbours
andbuildfriendships.
Imagescourtesy:CulmvalleyCentreforIntegratedHe
alth.
Kitchen garden and produce.
Courtesy:Culmvalley
CentreforIntegratedHealth.
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Gettingstarted:theprojectprocesssummarised
Therearefourmainstagesinthedesigncycle:
1. Preparation.
2. Designandimplementation.3. Usingandmaintainingthenewspace.
4.Monitoringandreview.
Thereviewpartofstage4islikelytoleadbacktostage1again,asfurtherimprovements
continuetobemade.
Timespentongettingtheprocessrightwillhelptoachieveawell-designedandsustainable
outdoorspace.
Mostpeoplethinkoftheprojectprocessasbeinglinear,withabeginningandend.However,a
goodprocessiscyclical,withthenalmonitoringandreviewstageleadingnaturallybacktothe
beginning.Spaceschangeasplantinggrowsandmaturesandonlyregularmonitoringwillidentify
whetherpartsofthelayoutneedtobealteredtoo.
TheKingsFundprogramme,EnhancingtheHealingEnvironment,hasdevelopedasuccessful
modelforteam-basedprojects,ledbyclinicalstaffandcarriedoutinpartnershipwithservice
users,anditisrecommendedthatreadersrefertothis.
At Lyneld Mount Hospital in Bradford, service-users, staff, and relatives all worked together to transform an under-used space, with
funding from the Enhancing the Healing Environment programme.
Courtesy:TheKingsFun
dPhotoLibrary.
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Stage1:PreparationRemember to:
Assembletheclientteam.Developabusinesscase.Makesuresufcientresourceshavebeenallocated.Establishwiderpartnershipswithotheragencies.JointStrategicNeedsAssessmentidentiesthebigpictureintermsofthehealthandwell-beingneedsandinequalitiesofalocal
population,andprojectsshouldbeinformedbythisprocesswherepossible.
Checkplanningorlegislativeobligationsandduties.Surveythewholesite.Developadesignbriefbasedonastrongvisionfortheproject.
Funding
Securingfundingwillbeoneofthemostimportanttasksinthisrststage,whenattemptingimprovementstoanexistingspace.Fundingcancomethroughdonationsandcovenants,legacies
andalsogiftsinkindsuchastheworkbytheSellindgeGardenersAssociationinthegardensof
thePilgrimsHospiceinAshford,Kent.
Fundraisingeventsandevencharityshopsgeneratevaluableincomeforfacilitiesorgroups
registeredwiththeCharitiesCommission,suchashospitalfriendsgroups.Charitablestatuswill
makeiteasiertoapplytogrant-makingtrusts,ofwhichtherearemany,thoughtheircriteriavary
widelyandoftenchangefromyeartoyear.
Fosteringpartnershipswithotherlocalagencies(suchasWildlifeTrusts)orjustbeingawareofthe
localpoliticalclimatemayalsoopenupfundingopportunities.
AtBroomeldHospitalinEssex,anambitiousprogrammeofimprovementstothesurrounding
woodlandwerefundedbyaPlanningObligation,aswellastheForestryCommission'sEnglish
WoodlandGrantScheme,includingaWoodlandAssessmentGrant(WAG),forecologicaland
stakeholdersurvey.OthersourcesoffundingincludedtheChelmsfordBoroughCouncilArts
Fund.Thehospitalcommentedthatarelativelysmallamountofmoneyspentonwoodland
improvementsmadeasignicantimpactinpublicperception.
Therearealargenumberoffundingsourcesforschemeslikethiswhichfocusontreeplanting,
suchasthecampaignTheBigTreePlant.DetailsoftheseareavailablefromtheForestry
CommissionandWoodlandTrust.
Courtesy:EdwardCullinanArchitects.
Event for friends and
supporters of Lambeth
Community Care Centre.
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Stage2:DesignandimplementationRemember to:
Appointadesigner.Landscapegardenersorgardendesignersmaybeabletohelpwithimprovingsmaller-scaleexistingspaces,butprojectswhichareatalargerscalewillneedthesupportofa
landscapearchitect.Landscapearchitectsaretrainedtounderstandandimproveoutdoorspaces,andwillhavethelisteninganddesignskillstoengageinasite-widedesigndialogue.
Briefthedesignerthoroughly.Checkthattheyunderstandinclusivedesign,andhaveexperienceofdesigningfortheparticularusersneedsintheprojectinhand.
Bytheendofthedesignstage,theinitialvisionwillhavebeenhonedbytheteam(includingthe
designer)intothenalproducttheschemewhichistobeconstructed.
Implementationislikelytobeundertakenbyacontractor.However,onsmallerschemesinsome
settings(primarycare,residentialsettings)theremaybeopportunitiesforpatientsorstafftohelpwithelementssuchasplanting.
Courtesy:DFClarkBionmiqueLtd.
Volunteers helping with
implementation work.
Tree planting in Cornwall.
Culm valley centre planting by
patients.
Courtesy:NHSForest.
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Stage3:UsingandmaintainingthenewspaceRemember to:
Organisealauncheventorpublicopening.Thankeveryoneinvolvedintheprojectandpublicisethenewspacetopotentialusers.Takeanyfurtheropportunitiesduringtheyeartoorganisesmalleventsoractivitiesinthenewspaceinvolvingstaff,patientsandvisitors.
Monitorhowthemaintenanceisprogressing,especiallyearlyon.Perhapsthelitterbinsneedemptyingmorefrequently,orthereisextrascopeforpatientorstaffinvolvementinsimple
taskssuchaspickingapplesintheautumn.
Dealwithissuessuchassmokingorlitterconstructively(notbysimplypreventingaccess).Makesureadministrativeandmaintenancestaffareeducatedaboutthevalueofoutdoorspace,andtheimportanceofmaintainingaccessibility,toensurespacesremainunlocked.
Allimprovementswhichleadtospacesbeingusedbymorepeoplewillusuallyresultinincreased
maintenanceneedsandpotentialcosts.
Thesecouldbemetbyndingoutwhetherthelocalhorticulturalcollege,horticulturalsocietyor
largercompanieswithcommunityvolunteeringschemescouldhelp.Also,theWildlifeTrustsand
theBTCV(BritishTrustforConservationVolunteers)havebranchesallovertheUKandwilltake
onavarietyofprojects,especiallyinanaturalorsemi-naturallandscape.
Stage4:MonitoringandreviewRemember to:
Carryoutapost-occupationevaluationstudy,tocheckwhetherthereisanythingaboutthespacethatcouldbeimproved.Knowingwhathasworkedwellalsohasimportantvaluein
termsoflessonstoreplicateelsewhere.
Reviewthespaceannuallytocheckthedevelopmentofthelandscapeasitmatures.Treestakesandtiesmayneedadjustingandsometimesgroupsoftreesneedtobethinnedtogive
betterspecimensthespacetogrow.Itwillalsobeimportanttocheckandmaintainplant
health,especiallyafterperiodsofextremeweather.Continuetocheckweeklythatthenewspacesremainaccessible,andarenotlockedunnecessarily.
TheVerwoodOpportunityCentreProjectdescribedinCasestudy5showshowagoodprocess
resultsinasuccessfulproject.
At Broomeld Hospital in
Essex, special efforts were
made to involve young people
from the local community in
implementing work on site
and in celebrating its
completion.
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Raised beds laid out in the shape of a spiral each focus on a different sense; such as this one
celebrating the sense of Taste.
Awell-plannedspaceforeveryonetoenjoy
In2009staffattheVerwoodOpportunityCentrefoundthattheirclients,peoplewith
physicalandlearningdisabilities,wantedtofeelmoreintegratedwiththelocalcommunityandalsohavethechancetodomeaningfulwork.Thisresultedinthecreationofthe
SensoryGarden,anewwildlife-friendlygardennexttotheOpportunityCentreand
neighbouringCommunityCentre.
Stage1:Preparation
TheSensoryGardenprojectisanexcellentexampleofpartnershipworking:
EastDorsetDistrictCouncildonatedtheland.
DorsetWildlifeTrusthelpedco-ordinatethedesignprocessandagreedtolookafterthemanagementandmaintenance,oncethegardenwascompleted.TheOpportunityCentrepromisedtobuildusageofthespaceintotheirserviceusersdailyactivities.
TheneighbouringCommunityCentreofferedgeneralsupporttotheproject.Privatecompanies,includingalocallandlloperator,providedthefunding.ThelocalEmmanuelSchoolhelpedwiththeplantingduringtheimplementation,aswellassettingupaTuesdaygardeningclub.
Stage2:Designandimplementation
Thegardenislaidoutintheformofaspiral,containingraisedbedsdesignedtoappealtothesenses.Tactilescentedplantingwithawidevarietyoffoliageandleafcolourmakethe
siteequallyattractivetoeveryone.Implementationwascarriedoutbyalocalcontractor
butclientsoftheCentrehelpedwithsmallerelements,suchasmakingthesignsforthe
sensorybeds.Particularattentionwasplacedonmakingthegardeneasilyaccessible.For
example,thepatharoundthegardenwasmadeusingmaterialsenablingwheelchairs,
walkersandpushchairs,tomovefreely.
Case study 5: Sensory Garden, the Verwood Opportunity Centre, Dorset.
Raised beds laid out in the shape of a spiral.
Courtesy:NoelBergin/DorsetWildlifeTrust.
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Stage3:Usingandmaintainingthespace
OvertheyearsusageofthespacehasincreasedandmanyoftheOpportunityCentreclientsnowregularlychoosetospendtimeoutsideintheSensoryGardenratherthan
indoors.ShaneCarter(aserviceuserfromtheCentre),said
Wearereallyabletogetinvolvedwiththegarden,helpingwiththeplants,buildingnest
boxes,eventhesignswerewoodburnedbyus.Itsbeengreattoworkinthisgarden,helpingto
createsomethingforthecommunityandustoenjoy.
TheDorsetWildlifeTrustcontinuestomaintainthesite,monitoringtheplantingcarefully
asitmatures.
Stage4:Monitoringandreview
ProjectevaluationhasdemonstratedthattheSensoryGardenprojecthashelpedpeople
withphysicalandlearningdisabilitiestoengagewiththecommunityandagencies,breaking
downsocialbarriers.NoelBergin,ConservationOfceratDorsetWildlifeTrust,said:
TheideaisthatthedifferentsectionsofthegardenwillbeongoingprojectsfortheOpportunity
Centre,schoolsandothercommunitygroupstolookafter.Hopefully,notonlywillitbeawildlifehavenwithinthetown,butvisitorswillleavewithideasonhowtoimprovetheirown
localareaforwildlife.
Volunteers, staff and service-users all work together in the garden. Being out in the fresh airoften helps de-fuse moments of tension as they arise.
Each raised bed focuses on a different sense; such as this one celebrating the sense of Taste.
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Workingwithdesignelements
Thedesignelementslistedbelowwillallbeusefulincreatingtherapeuticspaces:
1. Planting
2. Trees3. Entrances,pathsandboundaries
4. Sitefurniture
5.Art
6.Water
Developingalayoutbasedonthedesignprinciplessetoutearlierandthinkingthroughthe
practicalitiesofthewholeprojectprocesswillprovideagoodfoundationforanyscheme.
Experienceddesignerswillbeabletocombinethevariouselementssuchasplantingorpaths
skilfully,butitishelpfulforthosebriengthemtohavesomeunderstandingofthesetoo.Inthis
way,aschemecanbecreatedwhichhasasenseofplaceandalsomeetsclinicalandotherneeds.
Themostsuccessfulschemesarethosewheretheclienttakesastrongleadandwherethe
designerandclientworkcloselytogether.
Thissectionprovidesanoverviewofsomeofthemostusefulelementsusedindesigning
outdoorspaces.
Hospice garden, Salisbury Hospital: design elements working in harmony to create a tranquil place
Courtesy:PeterUrsem.
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1.Planting
Plantedspacesformatrulyrestorativeenvironment.Goodqualityplantinghighlightsthepassing
oftheseasons,appealstoallthesenses,helpstoattractwildlife,andprovidessomethingnewand
differenttolookateverydaythroughouttheyear.
VegetablesgrowingintheChildandAdolescentMentalHealthUnitatGreatOrmondStreetHospitalareseenashavingtherapeuticvalueforyoungpeoplewitheatingdisorders.
Lotsofhospitalshaveoutdoorcourtyardspaces,butthosewhicharegardenswithlushplants
ratherthanjustpavedareasarefarmorebenecialtopeopleusingthem.
Justsittinginaplantedareacanbebenecial,butsometimestheextraeffortinvolvedinfocusingonagardeningtaskcanhelprestoreafatiguedortroubledmind.AttheBromleybyBowCentre
inLondontheowerorcuttinggardenisusedforhorticulturaltherapy;thestoryofone
volunteersexperienceisdescribedbelow.
IhadbeenworkingasamentalhealthnurseanddramatherapistintheEastEndforseveralyears
itwasabusyandstressfuljob,butIenjoyedit.Unfortunately,though,Isufferedbullyingand
harassmentatwork,anditaffectedmymentalhealth...Iwasunabletoworkanymoreandwentoff
sick,unwellwithdepression.
InApril2007,myGPsuggestedItryvolunteeringattheBromleybyBowCentre.Initially,Iwasonly
doingafewhoursaweekbut,sinceJanuary2010,Ihavebeenonacontractofemploymentfor35
hoursaweekinthecuttinggarden.Itfeelsgreattobeworkingatthislevelagainaftersomanyyears.
SometimesIcannotbelievehowmuchmylifehaschangedinthelastthreeyears.WhenIwasillI
couldntimaginebeingabletoworkagain.Theworkinvolvedingrowingandnurturingplantsis
amazinglysatisfyingandtherapeutic,butyoudonthavetoworkinagardenorgreenspacetobenet
fromit.Justwalkingthroughaparkcanimproveyourwell-beingandpeaceofmind.(Lisa,member
ofthePoLLENproject,BromleybyBow).
Thingstoremember
Chooseplantstoemphasiseseasonalchange,andbuildanticipationofthingstocomeandallowpeopletonoticethepassageoftimeevergreenschemestendtobelower-maintenancebutwillnotachievethis.
Scentedandbrightlycolouredowersandleavescanbeenjoyedbythosewhoarepartiallysighted,aswellasbeingattractiveforallusers.Senseofsmelliscloselyassociatedwiththe
A rich variety of planting means something new to look at every day.
Vegetables growing at Great
Ormond Street Hospital.
Courtesy:CAMHSUnit,GreatOrmondStreetHospital.
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partofthebraindealingwithmemoryandfeeling,soscentscancallupmemoriesand
powerfulresponsesalmostinstantaneously,whichisparticularlyhelpfulforthosewith
memoryloss.
Shrubsshouldbeprunedcarefullytoemphasisetheirnaturalform.Thiswaythespacewilllookwellcaredforthesubliminalmessagebeingifthegardeniswelllookedafter,Iwillbe....
Food-growingisagoodoption,especiallyifthekitchenstaffcanusewhatisgrown.Inlong-stayorresidentialsettingspeoplewillbeabletoexperienceafullgrowingseason,butevenindaycentrestheycanjoininwithwhateverishappeningatthatpointinthe
horticulturalyear.Agoodactivitiesprogrammecanfocusonfood-growingeatingfruit
crumble,orpaintingcolourfulberries.
At Bromley by Bow Centre, local residents nd that visiting the Flower Garden raises their spirits.
This left-over space between buildings feels bleak and exposed, but with the addition of trees and scented shrubplanting it coul