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Healing architecture

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DOI: 10.1080/17533010903488517

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Healing architecture
Bryan Lawsona
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The School of Architecture, University of Sheffield, Sheffield, UK

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To cite this Article Lawson, Bryan(2010) 'Healing architecture', Arts & Health, 2: 2, 95 — 108
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 Arts & Health
Vol. 2, No. 2, September 2010, 95–108

Healing architecture
Bryan Lawson*

The School of Architecture, University of Sheffield, Sheffield, UK

The value of a new evidence-based design approach to healthcare architecture is

described and the range of evidence available introduced. The paper then focuses on
the challenge of applying empirical research knowledge to a creative design process.
Examples are given of the results of such an approach and of how we can develop
design tools to transfer complex scientific knowledge into a “designerly way of
knowing”.
Keywords: evidence-based design; architecture; creativity; design knowledge; design
research; design tools
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The Research Evidence

The last couple of decades have seen a major development of research into the impact
of architectural design on the success of healthcare environments (Lawson, 2004a).
We maintain a database of such research for the Department of Health in the UK and are
now aware of around 1000 relevant items of research focusing on but not exclusive to
hospitals. The evidence suggests factors under the control of architects that can make
significant differences to patient satisfaction, quality of life, treatment times, levels of
medication, displayed aggression, sleep patterns, and compliance with regimes among
many other similar factors. Studies range in size and scope. Some are multi-factorial and
some much more parametric. Some concentrate on specific factors, such Roger Ulrich’s
seminal paper that demonstrated the effect of views on the rate of recovery from surgery
(Ulrich, 1984). Some are small and little more than anecdotal, while others are major
longitudinal controlled investigations, such as Lawson and Phiri’s work at two UK
hospitals (Lawson & Phiri, 2003).
A study by Berry et al. using data from the USA and building on the work of Roger
Ulrich suggested that only a relatively small additional capital cost might be needed in
order to achieve a very substantial chunk of the benefits this research identifies. A
theoretical 300-bed hospital, dubbed Fable, was imagined on a typical suburban site
(Berry et al., 2004). Extra items suggested by the research included larger private, acuity-
adaptable en-suite rooms with large windows for better views, decentralized nurse
stations, more art and community space, better technical air-handling plant and noise
control facilities, and so on. Financial analysis suggested that around 5% additional capital
cost might be required, but the research indicates operational savings returning around the
same sum annually.
Lawson and Phiri (2000), reviewing all the evidence, suggested that the operational
savings that could reasonably be expected from an evidence-based design approach might

*Email: b.lawson@sheffield.ac.uk

ISSN 1753-3015 print/ISSN 1753-3023 online

q 2010 Taylor & Francis
DOI: 10.1080/17533010903488517
http://www.informaworld.com
 96 B. Lawson

be in the region of 20% annually compared with much of the existing British National
Health Service (NHS) building stock. They also showed that recurrent costs of major
hospitals typically exceed the capital cost during the second year of operation. An
evidence-based approach then has the potential simultaneously to improve the quality of
patient experience and, in many cases, health outcomes, while also saving time and costs.
The overall pattern of the evidence will be discussed later in this paper. However, this
body of research demands a fundamental shift in our attitudes towards the design of
healthcare environments especially for those working in the public sector. The research
emphasizes the patient experience and requires us to create places of healing rather
than machines for treating. There is now a significant body of knowledge that can no
longer be ignored in the design of new healthcare facilities and the management
and upgrading of existing ones (Lawson, 2002); the subject is served by a refereed
journal of high standing, Health Environments Research and Design Journal (HERD).
Perhaps more significantly, the introduction of the Evidence-based Design Accreditation
and Certification Programme (EDAC) by the Center for Health Design in the USA
allows both architects and their clients to study and gain accreditation in the field (Harris
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et al., 2008). All this suggests that evidence-based design is now becoming established,
with the healthcare sector leading the way. The publication of accessible and compre-
hensive books suggests that it also becoming mainstream (Cama & Zimring, 2009;
Malkin, 2008).

Evidence-based Design
So we might perhaps be tempted to think that the problem is solved and that all new
healthcare buildings will achieve these benefits. Unfortunately this is far from being the
case, and there are a number of obstacles still in our way, some of which have tended to
prove rather intractable. The evidence suggests that to achieve these benefits, designs will
need to increase in quality. So far, in the case of publicly funded healthcare buildings, most
design guidance has tended to concentrate on compliance with some minimum standards.
Moreover, the public-sector guidance, especially in the UK, focuses on the issue very
much from a staff and treatment perspective. The research evidence suggests that we need
a more patient-focused experiential perspective. This approach therefore suggests a new
departure in focusing on ways to drive up quality in relation to the evidence and to be
creative and imaginative about ways of meeting the demands of the evidence through
design and management.
Such an approach also requires a fundamental shift in terms of thinking about life-
cycle costing rather than keeping capital and revenue costs in separate pockets. It might be
thought that recent building procurement innovations such as the Private Public
Partnerships (PPP) might help towards this end. Under such schemes the private sector
funds and builds the hospital, taking the risks and introducing innovation. The public purse
then effectively agrees to pay rental to the private developer for a period of years, typically
around 30. However, under the UK system at least, any benefits that accrue in savings on
the medical operation such as reduced treatment times would not reflect in profit to the
private developer. Thus the incentives assumed to be in PPP arrangements are in reality
largely not effective in driving us towards an evidence-based design approach. Developers
remain more likely to win the contract by keeping the capital costs low. Alternative forms
of PPP are possible in which the private sector bids competitively on design quality against
a fixed and predetermined cost, but these have so far not been widely used and have many
other problems associated with them.
 Arts & Health 97

Here, however, we are more interested in another set of obstacles to the introduction of
evidence-based design. They are the fundamental core problems of combining scientific
evidence with a creative and designerly approach to architecture. Indeed, this very notion
of combining scientific knowledge with artistic knowledge is at the very core of the
Society for Arts in Healthcare and consequently this journal. To understand these
problems we need to review the latest understanding of how and why designers such as
architects go about their tasks.

Design Research
The field of design research is relatively new to the academic world, having only really
been in a form that could be described as mature for around half a century. The early work
in the field was done in a social and ideological context of a greater belief in the power of
science and technology than we might accept today. There was a feeling around that
architects in particular were creating huge chunks of our public domain and were not doing
this in a proper open and scientific way. As a consequence, much of that work was an
attempt to tell designers how they should think rather than understand how they might
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think (Jones, 1966). At that time, the field might have easily been described as “design
methodology” rather than design research (Jones & Thornley, 1963).
Today the field is itself more rigorous and is largely populated by work that examines
scientifically how and why designers work the way they do, as well as using that evidence
to help support them in terms of both education and practical tools (Lawson, 1997). It is
difficult to sum this idea up in a better way than has been done by one of the most eminent
workers in the field, Nigel Cross. In a paper in the leading journal in the field, Nigel coined
the phrase “a designerly way of knowing” (Cross, 1982). The direct implication of this
idea is that designers might indeed “know” in a way that is distinct to their profession, and
this might be different to other more commonly understood ways of knowing such as
science. This is now widely accepted across the field, and we now understand far more
about those designerly ways of knowing as a result of far more research (Lawson, 2004b).
As the field has matured, it has also become able to study not just students and ordinary
designers but the most creative and able designers alive today. As a result, we now have a
better understanding of what might distinguish the best from the crowd and what it takes to
think at the highest levels of design performance (Lawson & Dorst, 2009).
Architecture is actually a design field in which artistic processes and ways of knowing are
combined with more technical engineering and scientific knowledge. Buildings must not
only look and feel beautiful, but they must be constructable and structurally stable. It has long
been the case that the physical sciences have impacted significantly on the way we design
buildings to create comfortable environments. More recently, we have rightly increased our
empirical and theoretical knowledge about how to design them to be more sustainable. So
theory and science are not new to architecture. However, evidence-based design, which seeks
to exploit empirical knowledge about human behaviour, is rather more problematic, since it
deals with the fundamental organization and creation of space that lies at the heart of the
architectural design process. This really does result in a collision of artistic and scientific
ways of knowing. Three key reasons why this is difficult will be explored here and we might
describe them as “solution-focused approach”, “episodic knowledge”, and “integration”.

Solution-focused Approach
Architects tend to use what is generally described as a solution-focused approach to their
work along with most designers in similar areas (Lawson, 2006). By this is meant that they
 98 B. Lawson

do not work from some deep analysis of a problem through some theoretical procedure
towards a solution. Rather, they tend to come up with ideas about possible solutions and
then through a process of evaluating those solutions abandon, modify, recombine and
generally progress to an idea that seems to marry problem and solution together. Lawson’s
study of famous architects includes looking at the process used by Robert Venturi when
working on his high-profile extension to the National Gallery in Trafalgar Square in
London. The first two drawings done on this job were both sketches on menus, one in the
nearby Savoy Grill and one on the plane returning home from his first visit to the site. Both
these sketches show ideas about the plan and main elevation of the building that are
remarkably prescient of the built design (Lawson, 1994).
To the uninitiated, such a process may seem very odd, even chaotic, but it is in fact a
highly adapted response to a number of fundamental characteristics of design problems.
These are of a kind first described by Simon (1973) as “wicked”. Such problems can never
be fully described, are seldom made totally explicit, and do not usually have optimal
solutions. We now generally describe the design process as one in which problem and
solution emerge together rather than one necessarily preceding the other (Lawson & Dorst,
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2009). For example, clients can rarely tell you what the problem is at the outset, but during
the process may become quite explicit about a requirement, wish or need that they had
either forgotten in the brief or not even realized was important to them. In the case of
healthcare buildings, there are many stakeholders involved, many of whom may have little
or no voice in the formal briefing process. Uncovering their needs and wishes is as much a
creative part of designing as making architectural form.

Episodic Knowledge
Unlike most sciences, architecture does not have some overarching theory that enables its
practitioners to move reliably from problems to solutions. It is not like civil engineering,
where loads can be analysed and calculations used to size the members of a structure. Of
course, architecture has used sets of rules that might be called styles to help generate form
and composition. Some writers do refer to their own “architectural theory”, but mostly
these are personal guiding principles rather than comprehensive or widely accepted
rational theories. For this reason architects are very heavily dependent on what we might
call episodic rather than theoretical knowledge. In simple terms, they know a lot about
solutions. They have studied other designs and even the ways form has evolved in nature.
They might use paintings, sculptures and even films and books as useful inspirational
material. Architects often describe such knowledge as “precedent” and thus seem to work
in a way similar to lawyers who seek to prove a case based on precedents that the law
might be expected to follow. However, architects are not seeking to follow precedent, but
rather to use it flexibly and creatively (Goldschmidt, 1998). A few years ago when I was
designing a small shelter in my garden I had just been to Bali (online Figure 1). There I had
seen the way the workers in the rice fields had constructed “pondoks” or pavilions in which
to shelter from the hot tropical midday sun. I had also studied the extraordinary temples
that sit so beautifully in the dramatic hillsides and the wonderful way that the traditional
Balinese house combines indoor and outdoor space. All these things impacted on the
design of my own pondok, which would undoubtedly have looked quite different had I just
returned from a different culture, country and continent. We value architecture that has
such qualities. We may want to introduce evidence-based design to our healthcare
buildings, but we do not want them to become standardized solutions independent of
place, culture and raw creative innovation.
 Arts & Health 99

Integration
Finally here we need to look at the very integratedness of architecture. To explore this, we
might turn to one of the most famous buildings in the world from the twentieth century,
Sydney Opera House (Figure 1). This building is special because it has become so well
loved, memorable and symbolic. It represents the unique place in which it belongs, Sydney
Harbour, a new culturally progressive Australia, the time it was built and many other ideas.
It is fascinating not just as a product but also as a process that has been well documented
and teaches us many lessons about designing.
The most characteristic and recognizable features of this extraordinary piece of
architecture are the great curved concrete shells that soar over a comparatively plain
rectilinear podium. These shells simultaneously perform many tasks for their architect,
Utzon. They create a magnificent composition sitting perfectly on Bennelong Peninsula
jutting out into the very heart of Sydney Harbour. They act as a perfect counterfoil to the
famous bridge against which they are so often photographed for that reason. They subtly
reflect the sails of the myriad of small yachts that often surround building. Of course, they
also house the great spaces of the opera auditorium, concert hall, the smaller restaurant and
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the public domain. They create opportunities for solving the tricky problems of threading
services through such a complex and demanding set of volumes. They offer a structural
system that is self-explanatory, efficient and beautiful when exposed.
How can one mind arrive at a single device that simultaneously does so much on so
many levels? In truth, the sails perform far better in some of their tasks than others. They
leave spaces that have poor acoustics, although that is not really Utzon’s fault. They insult
and discriminate against the disabled. They make life hell for stagehands; ridiculously, the
public approach is from the stage end of the opera house. But of course it is this very thing
that results in the wonderful glazed bars and lounges that hang right over the water in the
centre of the harbour, making the interval a celebratory experience in its own right. It is
well known that Utzon designed the sails before he knew how to build or even draw them,
and this was one of the factors that would drive the initial contractor to financial ruin. And
yet we forgive the building all these inadequacies because it is so magnificent in so many
other ways.

Figure 1. Sydney Opera House with its Famous Concrete Shells.

 100 B. Lawson

Incorporating Evidence into Design Processes

In terms of evidence-based design, this poses some tricky problems for us. Research
evidence tends to be parametric and about individual issues such as natural lighting, views,
access to nature and so on. Generally, design guidance is typically similarly divided up
into sizes, dimensions and other features of a building. Solving one problem at a time and
trying to optimize in each case is unlikely to result in architecture of the quality produced
by Jorn Utzon, and it certainly will not create healing places. Good architects work much
more holistically, striving to find a limited number of ideas that simultaneously solve
many problems. Once done, such design is not something that can easily be taken apart and
tinkered with.
I have recently been part of a team winning a major new hospital, Southmead in
Bristol, UK. This will be developed by Carillion and has been designed by BDP
Architects. The design is quite revolutionary for the UK National Health Service and will
be very largely built using single rooms rather than multiple shared wards (Figure 2). In
arriving at the design for these rooms, every millimetre was accounted for and the location
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and design of all the items simultaneously addresses the clinical agenda along with issues
of privacy and dignity, as well as views outside, minimizing the risk of falls and cross-
infection, allowing for easy maintenance, and so on. To achieve this integrated solution,
minute changes in location and angles of walls had to be explored representing months of
intense and creative design work. And yet, still someone might come along with a new
piece of evidence and want one feature moving or adjusting. Such a move is highly likely
to unravel the whole design in such a cost-sensitive solution. But this is just the sort of
thing that frequently happens in such complex projects. Late in the day, a new consultant is
appointed in the hospital with different ideas, a new regulation is introduced, some new
standard set, a key supplier goes out of business, or more likely than all these, some
additional late cost savings are required. The perfectly integrated architectural solution is a
very delicate flower.

Figure 2. Bristol Southmead Hospital – The Design for Single-room Wards.

 Arts & Health 101

An excellent example of creative integration in design can be found in the remarkable

Evelina Children’s Hospital created by Hopkins Architects. Evelina is part of the Guys and
Thomas Hospital sitting on a tightly packed site right against the River Thames in London
directly opposite the Houses of Parliament. It was inevitable on such a site that the design
would be multi-storey, so that posed additional problems of way-finding. A key idea in the
solution of these problems was to integrate art and architecture. Each floor was given an
ecological theme ranging from “Ocean” up through “Arctic” and “Forest” to “Savannah”
and “Mountain” to “Sky”. Each of these has a distinctive and appropriate colour and its
own set of natural creatures. The colours are used to distinguish the spaces at each level
and the creatures inspire motifs used in the surface materials. Particularly clever is the way
creatures are used in the flooring to help way-finding within a ward or department. Whole
creatures such as butterflies are to be found at the major arrival point and then
progressively dissected as you go further in (see Figure 3). Eventually a child might find
perhaps one wing under the bed. To get back to the main arrival point, you put the creature
back together. This brilliant application of art-based thinking is simultaneously
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distracting, light-hearted, educational, attractive and effective. This is no simple-minded

signage system or crude pattern of lines along a floor. It delightfully permeates the whole
building with the creatures themselves all making another appearance in sculpture outside
the building.

Figure 3. Evelina Children’s Hospital, London – The Creative Integration of Art and Architecture.
 102 B. Lawson

Design Tools
So what does all this research suggest in terms of the way we should design, build and run
our hospitals and other healthcare buildings? Those involved in the briefing, specifying,
commissioning and design of healthcare environments are unlikely to find time or have the
expertise to read a thousand items of original research. For this reason an overall picture is
needed, not in terms of the causal factors and theories, but couched largely in terms of the
design considerations and direction needed to achieve the results suggested by the
research. In simple terms, clients and architects want to know roughly what sort of things
they should do, what features of buildings they should control or elaborate, what sorts of
qualities of environment they need to produce (Lawson, 2005).

ASPECT
To this end, Lawson and Phiri have analysed the research evidence and produced a tool
known as ASPECT (A Staff and Patient Environment Calibration Tool). ASPECT has now
been widely used in the UK and Ireland as well as Australia, Malaysia, New Zealand and
Singapore. It is publically available on the UK’s Department of Health Website. It relies
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on grouping the evidence under eight main headings (Lawson, 2007).

Privacy, company and dignity. Design to give patients privacy, dignity and company.
Design to enable them to be alone and to be with others when they wish to. Design to
enable them to control their levels of privacy. Such a simple rule can be applied to the
obvious setting of an acute hospital bed space, but it can also be applied to a waiting space
in a primary care building.

Views. Design to give patients, staff and visitors views out of buildings. The evidence
about such things is not just woolly expressions of niceness. We know that patients who
have views out actually recover more quickly. We think we understand many of the
mechanisms that bring this about. Daylight is actually good for us. It results in chemical
changes in our bodies that enable our self-healing systems to operate more effectively.
Some of the research here is remarkably detailed, even suggesting that there are
differences between having morning as opposed to afternoon sunlight. Again, this
principle can be applied sensibly across a wide spectrum of healthcare settings.
Commonsense tells us that patients waiting at a clinic where they may be concerned about
some test results might benefit most from a calming view. On the other hand patients in
more long-term care may benefit more from views that are interesting and stimulating.

Nature and outdoors. Design to give patients, visitors and staff contact with nature. Ideally
and in the right climate, this may be a matter of physical access. Views of nature are
known to be therapeutic. Internal planting and even pictures can help significantly where
gaining access to outdoors is not possible or sensible.

Comfort and control. Give all building occupants environmental comfort and, most
importantly, control over that comfort. This most obviously involves heat and light.
However, it also includes sound. Hospitals are notoriously noisy places. Some of Roger
Ulrich’s research has shown that patients in a cardiac unit had their heart rates significantly
reduced by decreasing background sound levels (Blomkvist, Eriksen, Theorell, Ulrich, &
Rasmanis, 2005). Organizing space to reduce noise transmission and provide acoustic
 Arts & Health 103

privacy calls for some fundamental architectural strategies. Visual barriers are simpler,
cheaper and more moveable than acoustic ones, which must be heavy and sealed. Giving
patients bedhead controls of lights, blinds and curtains and doors is really very cheap to do
and remarkably effective in reducing stress levels.

Legibility of place. Create places that have spatial legibility. That is to say, make places
people understand and can find their way around in. We move around using our own
mental map of the world. Places that are confusing prevent us from building that map and
add to stress levels. Design so that there is some hierarchy of space, so that public and
private places are clearly demarked, so that entrances and ways out are obvious, so that
different parts of buildings have different qualities.

Interior appearance. Make places that people will spend time in feel homely, light and
airy, with a variety of colours and textures. Design them to look clean, tidy and cared for.
Use art to provide distraction. This may be paintings on the walls, but it can also be
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sculpture and even the nature of the spaces themselves. However, it can also be
performance. Chelsea and Westminster Hospital has famously shown and measured the
value of this (Staricoff, Duncan, Wright, Loppert, & Scott, 2001).

Facilities and staff. The final two ASPECT headings are slightly different. Under facilities
we can find all those issues that evidence suggests are important but are not really so much
characteristics of the buildings as their contents; the presence of televisions, vending
machines, and so on. Since the consequences of these have different significance when
designing, they are usefully located together. Finally, the staff category; while all spaces in
healthcare buildings are used both by patients and staff, some are reserved specifically for
staff use. It is evidence about the qualities and facilities of such spaces that come under this
category.

Healing Architecture
The research clearly indicates that if we can design our healthcare architecture on these
principles the outcomes for patients, their quality of experience and the satisfaction and
effectiveness of staff are all likely to improve significantly. Moreover, these effects can be
cost-effective if we observe whole life-cycle costing. However, what the simplified
explanations above indicate is that such an approach requires significant changes to our
briefing and designing processes and values. The factors we have identified above require
architects to have a fairly deep understanding of what we might call the social psychology
of space. Many of them require an organisation of place that respects what I have called
the “language of space” (Lawson, 2001). There is not room to elaborate in detail here, but
such ideas are now fairly well developed theoretically and deal with how space can be
used to bring people together or keep them apart, how it can give people a sense of privacy
even in public, how it can enable people to feel in control even in shared spaces. It needs an
appreciation of the role the environment plays in meeting our fundamental psychological
needs such as stimulation, security and identity. All this requires an approach to the design
and organisation of space that does not treat it, as so much architecture does, as an abstract
geometrical construct, but as a social and psychological one. Although many of these ideas
have been around for some time, much of architectural practice still seems oblivious to
them. Indeed, it turns out to be the case that the features of architecture that often dominate
 104 B. Lawson

debate among the cognoscenti are often not those that impact most fundamentally on the
quality of life of the people who inhabit them.
But it is not just the architects who need to change. Design in this kind of field invariably
involves the resolution of conflicting demands. Most obviously here, for example, what
might be good for a patient is not necessarily good for a nurse. If we take the design
principles of healing architecture as listed above, then many of them can be seen to be in
conflict with other demands. The principle of company, privacy and dignity inevitably leads
to an arrangement of space that might make overall surveillance of patients by staff less
straightforward. The principle of creating views out of buildings is in conflict architecturally
with a principle of clinical adjacency that has dominated much recent healthcare design.
This latter example is all the more problematic since it may not always be apparent to
the client and the architect may not always be able to articulate this clearly or not be
involved in the briefing stage in a role that allows such a conflict to be debated and
resolved. The principle of clinical adjacency is in itself a perfectly reasonable and
desirable one. Busy clinical and ancillary staff should have to walk no further than is
absolutely necessary in the course of an often hectic schedule. The architectural result
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of such a principle being allowed to dominate the generation of form is that we arrive at
deep-plan buildings with internal rooms and many patients located well away from
windows. In specifying clinical adjacency as being desirable, however, those who brief
architects may not appreciate the consequences and if they did might want to re-evaluate
their position.
This therefore suggests a process of briefing that is itself interactive and in fact part of
the design process. As we saw earlier in this paper, current thinking suggests that problem
and solution emerge together in a good design process rather than one totally preceding the
other. Many of our healthcare buildings are built through procurement processes that
conspire against such an approach. The PPI method of procurement (private finance
initiative (PFI) in the UK) is such an example. Here a series of contractor/developers
compete by producing alternative designs that the client must eventually chose between.
Inevitably in such a process it is difficult both logistically and legally for the client to
interact with all the parties as intensively as the design process demands. By the time one
consortium is chosen to construct the hospital or primary care building, the design is too
far developed to enable proper reconsideration.

Inspiring Design Excellence and Achievements

This leads us to turn our thinking to how we can facilitate this process of interactive briefing
and design to create healing architecture. To this end, we have designed a new tool known as
IDEAs (Inspiring Design Excellence and Achievements). IDEAs is a web-based tool that is
intended to assist in the discussion between client and architect about the qualitative issues
in designing healthcare buildings based largely on research evidence and contemporary best
practice. It breaks away from the conventional approach of defining large numbers of room
types that all have predefined requirements and performance specifications. Instead, at its
highest level, it offers a much simpler analysis of what people are trying to do in healthcare
environments. It lists a range of activities that between them account for the vast majority of
what people do in hospitals, health centres and the like. It does not, however, attempt to deal
with highly medicalized or specialized spaces such as operating theatres, nor does it
deal with technical behind the scenes areas such as laundries. IDEAs activities include:
Arriving at a site, a building or department; Bathing; Bed rest; Circulating (moving
around complex buildings); Consulting (including examining and treating); Shopping
 Arts & Health 105

(including refreshments, retail and banking); Sanctuary (pastoral and counselling places
including outdoors); Socializing; Waiting (large, small, and very short span waiting places).
IDEAs1 explores each of these activities in two main interactive windows (online
Figure 2). The first window is called “design challenges and considerations”. This shows a
“pictogram” for each of the sub-types or variants of activity. This pictogram is a sort of
cartoon; an idealized drawing that effectively acts as graphical shorthand for all the major
features that one might expect to see in such a place. The window then lists the challenges.
These are essentially the kinds of things people want to do, are likely to do and need in this
place. Many of these things are seen in several of our main activities. For example. when
“arriving” people need to “move”, “find” and “wait”. But of course moving and finding are
also constituents of “circulating”. Not only does the window explore these challenges but
also the “considerations”. Considerations are made up of the things architects can
manipulate. They include, for example, light, views, scale, materials and colours. So
IDEAs allows us to explore how the research evidence links challenges and considerations
in an interactive and graphical way.
The second main window in IDEAs shows “precedents”, or what others have done that
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seems to work quite well and gives exemplars of successful design. This is where IDEAs
differs from the usual sort of design portfolio that is often used as precedent. Each example
comes under one of the main activity headings and the features of that example that are
being cited as exemplary are related closely only to those issues. No buildings are perfect,
and it is quite likely that any building will have good as well as not so good features.
Showing designs listed by building project is thus not helpful to those who do not have an
architectural background and may find it difficult to disentangle the strengths and
weaknesses. One single feature of a room may be good from some points of view and yet
quite unsuccessful from other points of view. Just like Utzon’s sails at Sydney Opera House.
The main point of IDEAs then is to provide a communication channel between all the
stakeholders in a healthcare setting. In particular the clients, users and architects can discuss
the challenges, considerations and admired precedents, and from this arrive at a brief that is
likely to show the benefits of evidence-based design while leaving room for the creative
innovation of an individual architect and allowing for any local peculiarities. So often we find
that the briefs for healthcare buildings are so full of all the quantitative stuff, floor areas, sizes
of things, numbers of pieces of equipment, temperature levels and so on. Sadly, such briefs
can often be relatively mute about the big issues discussed in IDEAs such as views, dignity,
finding your way around, making places feel your own, and so on. It is such things that we
find time and time again in the research evidence that make real differences to people in
healthcare settings. IDEAs represents an attempt to move us away from seeing the
hospital as a machine for treating people and towards a place for healing. In doing so it also
aims to restore architecture to its historic role as essentially an activity of making good
places. It shares its objectives with the well-known Pebble Project initiative started by
the Center for Health Design in which good practice is disseminated by the building of
real examples.

What Can Be Done to Our Existing Hospitals?

Although so far this paper has tended to concentrate on the design of new buildings, in
reality the process of replacing our healthcare estate is inevitably a slow one. Many
patients will continue to be treated in buildings that are old and increasingly unsuitable for
their purpose, and staff will struggle with that, especially in the public sector. So what can
be done to bring evidence-based design to help ameliorate this condition?
 106 B. Lawson

To begin with, ASPECT can be used to evaluate an existing building. This facilitates a
reasonably objective and unemotional common assessment of where the building
currently fails most. From this, users can play with IDEAs to get inspiration for things that
might be done. I have run many such projects, but one which will help make the point here
is a large fairly modern hospital in a part of Dublin known as Tallaght. A large group of
interested stakeholders representing all parts of the hospital identified a number of possible
projects in a workshop. From these, two were selected as likely to have the biggest impact
and be most feasible.
The first of these, already completed, was to address the chronic way-finding problems
up and down the very long hospital street that runs the whole length of the site. This largely
featureless and directionless corridor was the source of frequent confusion, with visitors
unable to decide which way to go to get out once they returned to it from a department. So
the task was to create some interest on a long walk and give a sense of direction. Sarah
Dobbs, then acting as arts officer, curated a permanent exhibition of archived material
arranged to go back in time as you penetrated deeper into the hospital. This was also
mounted on only one side of the street and gave two clues to the direction of the street.
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Along the street were three points at which it widened out and these were then named after
the original founding hospitals to create landmarks that could be used for giving directions.
The hospital also had a large atrium offering huge unrealized potential. Unfortunately
patients and other visitors could spend little time in it. A large amount of space was taken
up with planting and water features, there was little room for some rather unimaginative
seating and patients were directed on into the depths of the outpatient department to sit in
often unlit, internal and dull waiting spaces. We worked with the hospital to release the
potential first by introducing a simple patient bleep that they would be given on arrival and
which would sound some 10 minutes before their actual (as opposed to scheduled)
appointment time. Our architects under the imaginative direction of John Handley at RKD,
Dublin then worked with me to create a completely new place (Figure 4). By moving a few
toilets we could also connect these spaces to the outdoors and provide garden access.

Figure 4. Tallaght Hospital, Dublin – An Integrated Solution to Patient Arrival and Waiting.
 Arts & Health 107

The idea here was similar to that now seen in many airline business class lounges but
pioneered by British Airways. Using different attractions, furniture and arrangements you
create a series of places, each having its own character and implied behaviour. Somewhere
quiet to relax, somewhere to get refreshments, somewhere to sit and be entertained by
performers, an area specifically designed with children in mind, and so on.
The important lesson that this scheme teaches us is perhaps one of the most central to
this whole paper. In order for healthcare environments to become truly healing and part of
the service, they must be designed in harmony with the care models and procedures
themselves. Three things unlocked the massive potential at Tallaght hospital. They are the
application of evidence-based design, the creative and innovative approach of good
architects, and a willingness to re-think the way patients and staff are organized. These
three must come together to achieve the benefits of an evidence-based design approach.
Finally, it is important to recognize that although the examples and arguments used here
largely discuss hospital environments, the evidence, techniques and principles apply to all
healthcare environments. For example, CABE have recently published a major report
evaluating the UK NHS programme of rebuilding primary care facilities (LIFT). They use
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a modified version of ASPECT to demonstrate a rather disappointing failure to exploit

evidence-based design, perhaps for the reasons discussed in this paper (CABE, 2008).
I have deliberately given this paper a slightly ambiguous title: healing architecture.
There is now a huge amount of evidence that, based on empirical findings and done well,
architecture can help to heal. However, perhaps we can also interpret the title another way.
In recent years, contemporary architecture has gone through periods of detachment from its
public and become less than popular. Strangely, this probably started with the Modern
Movement that was really inspired by an essentially social programme and human agenda.
More recently, much architecture has become somewhat arbitrary and inconsequential. The
possibility, however, that architecture can again have the lofty purpose of making places so
well that people feel better is surely one that we should all celebrate. To make this happen,
however, we need enlightened clients as well as talented architects and excellent research.
We need those clients to see the buildings used for healthcare as part of the service, rather
than some necessary expenditure that is essentially separate from it. Those who commission
our healthcare estates need to connect capital and revenue expenditure to facilitate this
process in imaginative new ways. Hopefully the tools we have begun to develop will assist
in the process of clients and architects not only understanding what the research evidence
says but also understanding each other and collaborating as they need to do.

Supplementary Material
Additional figures referred to in this article are available online at http://dx.doi.org/
10.1080/17533010903488517.

Acknowledgements
Kind permission has been granted to publish illustrations as follows.
. Figure 2: Carillion and BDP Architects, Sheffield, UK.
. Figure 3: Hopkins Architects, London, UK and Paul Tyagi, architectural and interior
photography (paul@ptpa.demon.co.uk).
. Figure 4: RKD Architects, Dublin, Ireland.
 108 B. Lawson

Note
1. ASPECT and IDEAs referred to in the text can be found at: http://www.dh.gov.uk/en/
Managingyourorganisation/Estatesandfacilitiesmanagement/Designandcosting/DH_4122853.
The CABE report can be found at: http://www.cabe.org.uk/publications.

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