Transforming care with the power of art

 Health Estate Journal reports on two contrasting presentations, each illustrating art’s significant potential in both creating a first-class 21st Century healthcare environment, and providing patients with a more “holistic” treatment regime.

 In introducing the speakers at the conference, staged by Building Better Healthcare at Savoy Place, London on March 12, conference chair and special advisor on health at CABE (the Commission for Architecture and the Built Environment) Susan Francis got proceedings off to a positive start by telling delegates she was “hugely encouraged by the past decade’s major shift from a general perception that art might actually impact beneficially on the speed of patient recovery to a situation where all the evidence is that it very definitely does”. While art’s positive impact on patient recovery was increasingly being recognised in research studies, as well as by a growing number of medical personnel, the NHS was now, she believed, facing some of its biggest challenges to date in meeting ambitious new patient care standards. The big question against this demanding backdrop was: “What role can art play, going forward, in enhancing the healthcare estate?” The obvious answer was “a very significant one, in improving and, in some cases, transforming, patient and staff environments”. However, art also had a less immediately obvious, but potentially valuable secondary role: while scientists had striven for some years to bring into wider public consciousness the whole issue of climate change, and the contribution individuals and society can take to slow its progress, Susan Francis believed many of the experts’ messages were “still not getting through”. The result was a major opportunity for art, poetry, sculpture, and other art forms, both to heighten public awareness of environmental issues, and, simultaneously, to brighten up medical environments and make a “sometimes subtle, but very often hugely noticeable” impact on patient wellbeing and recovery. As several subsequent presentations attested, many large acute hospitals have seen their environment significantly enhanced and brightened up by artwork – from poetry and photographs, to painting, pottery and sculpture. However, art’s positive impact is now equally being widely felt in the primary care sector. Very much on this theme, GP Dr Sam Everington gave an interesting and detailed address describing the impressive work he and his medical colleagues have undertaken both in bringing artwork into the patient environment, and stimulating the start-up of a number of arts-centred businesses, at the Bromley by Bow Health Centre, a multi-activity centre and now much wider organisation based within one of east London’s most deprived areas that not only houses a busy GP practice (at which he is a partner), but also provides employment, education, arts training, and social enterprise business support, for many local residents.

Established 25 years

A former wood carver, who subsequently became a barrister before moving into medicine as a GP in 1989, Dr Everington began by explaining that the Bromley by Bow Centre as an entity had now been established for some 25 years. Since then, around 100 separate art-related business and community projects had been fostered and subsequently established by the initiatives undertaken there, ranging from stained glass and stone-carving studios to a landscape design business and therapeutic horticulture. The doctor’s key message from the outset was tha for the optimal long-term benefits, 21st Century healthcare must be delivered to patients “holistically”. Doctors should thus not just address individuals’ physical symptoms, but equally must consider the “wider picture”, i.e. their employment, environment, education, and home lives, as well as their spare-time activities and interests, as these all have a major impact on state of mind. It was around such a “whole life” approach that the Bromley by Bow Centre had enjoyed such success in harnessing the power of art to create a medical centre where the quality” of the patient experience “really does come first”. The overall centre’s “journey” had, however, been “quite challenging” at times, requiring both building trust with the local community and, since the Health Centre’s opening in 1997, development of medical policies and practices that effectively address he healthcare needs of a “pretty socially and financially disadvantaged neighbourhood”. For instance, around 50% of children in the surgery’s catchment area malnourished, many of the local houses are “severely overcrowded”, around 30% of the local population does not speak English, and around half of local residents can neither read nor write. On a positive front, and reflecting a message on the therapeutic effects of “green” spaces repeated by many of the day’s other speakers, the Bromley by Bow Health Centre has the inherent advantage of being located close to the proposed site for the 2012 Olympics, and the health centre’s staff have recently concluded a 30-year contract with the local authority to run an adjoining green space called Bob’s Park, significantly improving local residents’ “quality of life”. The centre now also offers patients gardening on prescription using local facilities, as the doctor explained: “Gardening is an activity a sizeable proportion of our inner city patients never otherwise have an opportunity to enjoy, and it has proved hugely therapeutic and very popular with many.”

Patients’ ‘back garden and sitting room’

Via initiatives such as provision of allotment and park space, the whole character and overall ‘feel’ of the practice had been transformed: “It’s now not just a health centre; it’s also patients’ back garden and sitting room.” Within the health centre’s grounds, local enterprises established by the facility built, in 2003, a barn that houses a social enterprise hub. While the project, which was completed in just 18 months, had initially been controversial (“building in a park is anathema to some”), Dr Everington said many of the subsequent landscaping initiatives undertaken in association with the health centre had contributed to a safer, more attractive environment for local people, while the subsequent Beyond the Barn initiative had, to date, guided the launch of 17 successful new social enterprises across the London borough of Tower Hamlets, with a combined turnover of over £100 m. Meanwhile, among the successes born out of the centre, and from a project to clean up the formerly ” shabby, run-down” public space now known as “Bob’s Park”, was a commercial landscape gardening business, Green Dreams, which now not only undertakes such work for the centre itself, but has also won contracts from other London PCTs. One of the things Dr Everington and his medical colleagues rapidly realised on joining the centre was that, “as a medical professional you can end up being quite staid in your approach to patient care”. What was key, he told the conference, was “to start from the patient’s fear perspective” and then, accordingly, consider what particular features of the practice environment, and improvements to the fabric, design, decoration and interior, could help allay these fears. While the entrances and reception areas of many NHS premises were characterised by overt security measures such as screens and barriers, the doctor pointed, during his presentation, to photographs of the attractive waiting area at the Bromley by Bow Health Centre, where large areas are instead devoted to artworks, many by local people. The walls of the reception area display different exhibitions throughout the year, from work by local artists to pieces produced by groups of patients or local children.

Feeling of inclusiveness

 In contrast to a more “traditional” NHS environment, where staff and patients are “segregated”, the practice has also made a deliberate attempt to create a feeling of “inclusiveness. “Our beautiful space is packed with security, but here it’s based on the surgery’s very openness, because we have found that, by giving patients ‘ownership’ of their medical space, they value it more which, in turn, substantially reduces the likelihood of incidents,” said Dr Everington. “Our reception area is not just for doctors, but is just as much a vibrant space for patients, artwork, and our various businesses.” The emphasis on, and success of, integrating art had, he said, led to neighbouring practices seeking to “emulate the formula”. For instance many medical practices in Tower Hamlets were now, he believed, looking to install poetry into their premises, and a number were keen, as at Bromley by Bow, to feature traditional silk screen printing – a popular art form in Bangladesh (where many local residents originate from) – in reception and other public areas. Dr Everington subsequently showed slides of consultation rooms at the centre, many of which feature family and other personal photos on the walls to create an “intimate and welcoming space”. Patients are also encouraged to sit next to their GP rather than, as is more usual, across a table or some distance away facing them. Dr Everington’s view was that widespread NHS PCT adoption of this practice would be “one of the most radical, yet simple, ways of improving the patient experience”.

ECG forms artwork

Another attractive, but in this instance, architectural, feature at the centre which “went against the NHS norm”, was the use of areas of frosted glass as artwork within the building. In one case at Bromley by Bow, local artist Sheenagh McKinlay had turned Dr Everington’s own ECGs into a lead glass window, while the centre also features furniture manufactured by a local enterprise group established by people with learning difficulties. Other art-based and “holistic” initiatives successfully established have included training of budding artists, visits by a professional artist who has not only painted pictures of “healthy” new babies, but also helped reduce the stigma of Downs’ Syndrome for one patient by painting her in front of other children with the condition, the establishment of an Internet café (only around 16% of people in the centre’s catchment area have Internet access at home), and of complementary therapy groups. Dr Everington said features such as the latter were highly important, as were providing patients with the opportunity to try new creative activities, such as hand painting, since all the evidence suggested teaching the unwell new life skills helped them recover, both physically and emotionally. In concluding his presentation the doctor explained that the centre had originally been established “from a dying church” by the Reverend Andrew Mawson, who came to the area as the Minister of the Local United Reform Church in 1984, and, despite the strict teachings of a number of the religions practised locally, had succeeded in “bringing members of diverse and very different communities together within a beautiful space”.

Providing ‘space to talk’

“The health centre here is really all about treating the whole human condition, giving people valuable space to talk, offering consultation and treatment in a comfortable, non-institutional setting, and making them feel included, rather than excluded,” Dr Everington said. “Art and artwork, and the successful integration of a wide range of art skills within the centre, have played a major part.” Today the centre, set around a courtyard and surrounded by a park, works with around 2,000 people every week, “providing a positive, inspiring and welcoming environment”, and “tapping into the arts to build up people’s self-esteem and help them express their creativity”. Dedicated arts spaces include stained glass and stone carving studios, and the centre also runs an arts programme, Art Force, which “aims to engage people in the creative process” via a wide variety of disciplines, including visual arts, creative writing, performance, film, and photography. During the presentation the most striking message to emerge was that the health centre, and indeed the wider Bromley by Bow Centre, were facilities first and foremost designed and built for the patients’ and local residents’ benefit. Interestingly, Dr Everington explained that, on first visiting the centre in 2004, former Health Minister John Reid had asked why there was no NHS logo at the main entrance (a stone arch transported to the site thanks to £20,000 in funding support from the local Tesco store). The GP remembers retorting that incorporating such a feature could have sent patients the “wrong” message: “This is Government -owned property”, whereas the facility’s whole ethos was, he stressed, very much based on the centre being “owned” by the local community, a feeling that the extensive incorporation of locally-produced artwork undoubtedly helps reinforce.

Low cost, but high quality refurbishment

In a contrasting, but equally interesting presentation on the benefits of art in healthcare, Sarah Waller, programme director for the King’s Fund’s “Enhancing the Healing Environment” (EHE) programme, described the considerable achievements to date of the programme, which has been running since 2000, and seeks to improve patient environments through high quality, but generally lowcost, refurbishment schemes via close liaison between clinical staff and service users, with the majority of the refurbishment and redesign projects backed by Department of Health grant funding. (The King’s Fund itself was established by Edward VII during the time he was Prince of Wales). Sarah Waller said that, while art and design were helping improve patient environments in many NHS hospital buildings, and indeed there was now evidence from over 4,000 research studies that a good environment can aid recovery from numerous illnesses, the environment confronting many sick people and their relatives /friends on arriving in hospital was, she felt, still “far from ideal for the 21st Century”. She said: “Imagine you’re entering a hospital in a nervous, frightened state for an examination or investigation and are immediately faced with poor signage, soulless corridors, ceilings with tiles missing, uncared for gardens, messages on boards not updated for months, or even years, dirty lift buttons, and so on. It would make you wonder whether, if this is how the hospital cares for its environment, then how is it going to care for me?”

‘Terrible clutter’

Based on visits to many hospitals, a significant number of which King’s Fund initiatives have subsequently helped improve, Sarah Waller showed delegates slides illustrating, (as just a few examples) bathrooms not fit for use, including one apparently incorporating a fire exit also used as a thoroughfare for staff, “terrible clutter”, a drip pole holding up curtains, areas it would be “nigh on impossible” for disabled people to access, and “very poor strip lighting”. She said: “How often do we really stop to properly think what effect this has both on patients, and on staff morale?” The King’s Fund speaker went on to describe the “excellent collaboration” between King’s Fund project teams and clinical, nursing and estates staff, which she said had led to the transformation of unattractive, dingy and, “frankly, in some cases, downright depressing”, hospital environments since the establishment of the Enhancing the Healing Environment programme (The Prince of Wales played a key role in the EHE programme’s launch). Project teams now typically, she explained, received around £30,000- £40,000 in grant funding for improvement projects and, as Sarah Waller’s “before and after” slides clearly showed, even this relatively modest financial input can result in dramatic enhancements to patient, staff, waiting, reception, and even mortuary viewing, areas. To encourage development of the optimal design when revamping existing premises, she explained that project teams were provided with a development programme which included some residential elements so that they can learn both the most effective way to use the available funding, and to harness the creative skills and capabilities of the various team members. While projects that effect significant physical improvements to properties are the major focuses of EHE funding, the programme also encourages use of performing arts strategies “in suitable environments”. Sarah Waller said the EHE team had already worked with 150 teams and around 20 hospices, with 20-30 new improvement projects earmarked for the rest of this year, and a similar number identified for 2010.

AEDET evaluation

 In gauging the degree of success achieved in the projects she explained that members of the EHE teams are encouraged to evaluate their schemes, and that many use the Department of Health’s “Achieving Excellence Design Evaluation Toolkit” (AEDET), now widely also employed by NHS Trusts, not only to manage their design requirements from initial proposals to post-project evaluation, but also for subsequent design reviews. Accessible online at: www.dh.gov.uk/en/ Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/ DH_082089, the AEDET guidance sets out key criteria covering issues ranging from how “positively” a building contributes to its locality, to “whether it has a human scale and feels welcoming”. Overall, Sarah Waller went on to explain, the EHE programme has three overarching outcomes: it “transforms environments”, “develops people and their skills”, and “enables organisations to review and improve care delivery”. The slides subsequently shown illustrated how effectively EHE projects had transformed a wide range of healthcare environments, in many cases environments that cried out for renovation and a radical re-design to make them “fit-for-purpose” for 21st Century patient care. The many examples cited included an emergency admission acute ward at Whitehaven Hospital in Cumbria where, without physically changing the space, the team deployed light and colour, and “considerably decluttered” the environment by creating new office space away from the main entrance, in the process enhancing both the ward and associated areas, and improving the security and confidentiality of patient records. The stated purpose of the project (for the North Cumbria Acute Hospitals NHS Trust) was to make the emergency admission ward entrance area and day room more welcoming for patients, and create a better staff working environment. Previous lack of space had seen the entrance area used as a workspace for ward clerks, meaning patients often mistook them for receptionists. New seating, flooring and artworks, including a stained glass window created with the help of two local schools, “transformed” the area, which now also includes a patient dining area. The stained glass window replaced a wall between the ward and day room, bringing in significant extra light.

Benefits of calm

The highly beneficial effects of a calm, relaxing, bright, light and airy environment on those suffering from mental health problems had, Sarah Waller said, been recognised for some time. In an excellent example of an EHE project involving a mental health facility, a team identified and helped create new seating areas, water features and sculptural works as the major element of a transformation of overgrown, and underutilised, gardens on each side of a busy corridor in the Park House unit at North Manchester General Hospital. The unit is the oldest building used to care for patients with mental health needs on the site. The EHE project saw the gardens planted to ensure interest throughout the year, with small animal sculptures created by service users contributing to the scheme, and special chairs manufactured and installed that provide comfortable seating, but equally shelter from the sun and rain. The building’s first floor corridor was also repainted, and is now hung with colourful plastic cones; their colour changes as one walks from one end of the corridor to the other. The cones present no ligature risk, as they “simply drop” should an individual place any load on them. Another interesting project, whose impact was clearly evident from “before and after” slides during the presentation, involved the provision of a new reception and waiting area at the St Anne’s Centre, St Leonard’s-on-Sea in East Sussex, operated by the Sussex Partnership NHS Trust. Here the goal was to create a welcoming, reassuring first impression for their older patients and visitors who attend for outpatient appointments, to visit the day centre and the outpatient wards.

Confusion eliminated

Although the facilities had been redecorated relatively recently, the orientation of the reception desk was described as so “confusing” that many visitors and patients initially walked straight past it. The main corridor, although full of light, sloped down to the wards, whose entrance doors were not well lit, creating a “somewhat intimidating” entrance to the inpatient facilities. Meanwhile, the large corridor windows, some obscured by bright yellow radiators, looked onto a garden dominated by an old bus shelter used as a smoking area. The team commissioned a designer to develop a scheme informed by consultation with a wide range of patients, staff and visitors from St Anne’s. As a result, the reception desk was reorientated to enable staff to see those approaching the entrance, new lighting was installed throughout, with special emphasis on lighting the ward entrances, while flooring now incorporates “ageappropriate “signage,. The corridor radiators, now painted white, no longer distract from the view of the garden. The team also created a semi-screened area at the top of the corridor, where people can wait close to the entrance, with a “soft, gentle colour scheme” of greens and yellows selected, reflected in the glass partitions and windows to the adjoining day hospital. Patients that attend the day centre also made a tile plaque that commemorates the project and reflects local history and landmarks. In many cases, Sarah Waller explained, changes brought about by EHE projects “had not cost much”, but had had a “huge impact” in making residents and staff feel better. An EHE team project which had both enhanced the patient/staff environment and improved safety and security had seen the waiting area for the A&E Department at Hillingdon Hospital in London, previously “pretty dingy and uninspiring”, transformed via the installation of new curved, concretebased seating with soft seats, and the incorporation of specially commissioned mosaics on walls and ceilings.

‘Encouraging ownership’

Sarah Waller said the project team had worked closely with the building’s occupiers to get them to encourage both staff and service users to take “ownership” to ensure that the interior, previously prone to vandalism, gets damaged less, adding: “When time and trouble is taken to make effective changes to a building’s interior the evidence is generally that people tend to respect the property and facilities more.” Illustrating the “considerable creativity which can result from different project team members’ ideas”, her presentation also described a sharply contrasting, but equally successful, artist-led project at the Child Development Centre operated by Rotherham Primary Care Trust at Rotherham District General Hospital, involving a refurbishment of the unit’s reception and waiting areas. Here toys that had previously caused considerable clutter and made the floor difficult to clean are now incorporated alongside other artwork within the walls while, at the press of the button, artwork changes. Remodelling was also undertaken to create separate office and clinic areas, and to ensure all areas met Disability Discrimination Act requirements, and a new heating system installed. The project’s overall goal – to provide a relaxed area for children to play in and help minimise parental anxiety – was felt to have been successfully realised. One area where Sarah Waller said there was growing evidence of the importance of the environment on patient care was dementia care. In an EHE project at the Mental Health Unit at Kidderminster Hospital in Worcestershire clearly demonstrating such benefits, where excellent PEAT scores on cleanliness at the hospital’s Witley Ward had, unfortunately, coincided with “such shiny floors that elderly patients would not walk on them”, an “extraordinarily different environment” had been created. She explained: “Here the project team opened up a really beautiful space for people to sit in (prior to the project an initial survey of patients, staff and visitors had described the reception area as “dull and drab”), with an open nurses’ station (this used to be in a closed office) and the installation of stained glass artwork, created by a local glass artist. With lack of natural light, a poor colour scheme and a “clinical atmosphere” all singled out for criticism in the pre-project survey, a new “spring-themed” colour palette of neutrals, browns and greens was implemented, while the removal of the staff office and changing facilities had “opened up the entrance area and created a lighter, brighter space”. To enhance patient privacy, clear glass windows between the day area and reception were replaced with the specially commissioned stained glass, with glass panels also used at the ward entrance, and to decorate other seating areas, and the main lounges refurbished. Lighting was upgraded, and colouredback- lit panels inserted into the ceiling of the main reception area to add further light, while the whole of the ward corridor was painted, and a different flower pictures hung by each bedroom to help patients identify their room. Meanwhile, to “support reminisce work”, black and white photographs were hung in the corridors, and glass shelves full of historical items placed in the reception area.

Energetic play areas

Slides showing another, entirely different project undertaken at Fant Oast, Maidstone in Kent (an inpatient facility for youngsters with mental health needs aged between 12 and 17), demonstrated how new hard landscaping, bricks, flagstones and design of borders, had been conceived to blend with the circularshaped oast building, while in “energetic play areas” strong wooden play equipment was provided, and the grass reinforced to ensure robustness. Each area of planting in the garden was given a particular focus, with individual plants and herbs, while the “central creative area” includes a tipi, already reportedly well-used for small group work, and a curved wall, to be used as a backdrop for performances. The wall’s reverse side is intended to be an “evolving artwork” that the young people can contribute to on being discharged. In the building’s interior, meanwhile, four-part glazed doors lead from the lounge to a terraced area for socialising and eating outdoors, with shade provided by large parasols and in an area where a wicker seat, woven on-site, curves around the base of a tree. The EHE team says the project led to many “new partnerships” with the local community, with a volunteer weekend, for instance, seeing over 70 people coming in to assist with planting. In concluding her address, Sarah Waller discussed the importance of artwork to end of life care and, for instance, its potential impact in mortuary patient viewing rooms, where she said that “for as little as £3,000 in many instances you can totally transform the environment”. Such transformation was, she said, especially important for the bereaved, with study evidence clearly demonstrating that the memories individuals have of loved ones who have died can be strongly influenced by the last environment in which they saw the person.

Board backing essential

She concluded her presentation by emphasising both how important it was for Trust boards to continue to back EHE and other similar projects, and the value of continuing development of a network of people who had been involved in the projects “to take forward learning and experience to other projects in the future”. (Further information about the King’s Fund EHE programme can be found at www.kingsfund.org.uk) The theme of taking forward the lessons learned from successful artwork installations across a wide range of hospital and other healthcare facilities to inform new projects recurred in many of the day’s presentations, being a key focus of the joint Ixia/Willis Newson presentation looking at a project which is seeing guidance developed for commissioners of artwork in future new healthcare facilities.