Doctors' orders: healthcare architecture, too often a functionalist response to short-term budgeting, should increasingly be based on the wealth of evidence about how patients respond to different physical environments.

What sort of hospitals do we want in the twenty-first century, how might they differ from those of the recent past, and why would we change them? In March 2002, AR carried an article on evidence-based design which showed that certain environments would help patients recover more quickly, using fewer drug treatments. That sort of research continues, and continues to confirm what every patient knows: that physical environment has an effect on the way you feel; and as every doctor knows, the way you feel has an effect on your state of both mind and health. The dilemma for designers, both generalists and specialists, is how to synthesise the increasing body of knowledge about the relationship between design and well-being with the requirements of those who commission hospitals. It is all very well saying that every patient should have their own room with their own nurse and (to exaggerate) their own personal physician on call twenty-four hours a day. Life is not like that. But how close would it be possible to come to the civilised environment for patient, staff and visitor without incurring costs disproportionate to the improvements achieved?

Britain's National Health Service, one of the world's biggest organisations with a nursing staff of 365 000, has been reviewing this in the light of the extraordinary programme of healthcare building now under way, with 100 new hospitals likely to be completed in the next five years. It has had the benefit of advice from Professor Roger Ulrich, currently on sabbatical from the US and working with NHS Estates, who has been a pioneer in this field for many years. At a recent UK conference (1) the professor and his British architectural ally Richard Burton outlined the attributes of what he and fellow researchers, medical, architectural and financial, have dubbed the 'Fable Hospital', a composite of recently completed or upgraded hospitals where evidence-based design principles have been employed. (2)

Such a composite would include a series of elements which, in combination, would produce a building which is safer, patient-focused, family-friendly, cost-sensitive and offering high levels of staff amenity. Specifically, Fable would have oversized single rooms with dedicated space for patient, family and staff activities; sufficient capacity for in-room procedures; and maximised daylight exposure. Acuity rooms would be standardised in shape, size and technology-friendly headwall, eliminating the need to move patients as their conditions change. Bathrooms would have double-door access to help carers and staff assist patients on foot, in wheelchairs or in bed. Decentralised, barrier-free nursing stations would place nurses in close proximity to patients and supplies, most stored nearby. Alcohol-rub hand hygiene dispensers would be located at the bedside of each patient room to reduce staff-to-patient pathogens. Filters would be used to improve filtration of outside air and eliminate re-circulated air.

In respect of softer environmental issues, the new model hospital would include peaceful environments with artwork displays, space to listen to piano music (apparently more soothing than other sorts), and gardens with fountains and benches. Noise-reduction measures would include sound-absorbing floors and ceilings and wireless communication systems. Patient education centres would be created on each floor giving patients and relatives a greater understanding of illness. On the staff front, support facilities would include a staff-only cafeteria, windowed break rooms with outside access, and a health club.

This composite picture represents an architectural and product design response to patient-based or evidence-based design: the question inevitably asked is in relation to the robustness of the evidence. Roger Ulrich and others scoured the academic world for research papers in the field, finding more than 600 relevant to their quest. (3) They posit the design equivalent of evidence-based medicine, that repeated use with repeated successful results means a causal link. They acknowledge the difficulty to identify the impact of single elements within a complex system like hospital care, but the impressive weight of evidence they cite makes it imperative that any architect working on healthcare projects digests the conclusions they have reached. The conclusions will make uncomfortable reading for those health procurers and designers wedded to the primacy of the ward over single rooms (except in the case of children's hospitals, where the reverse seems to be true), and for those institutions where hygiene arrangements in a world of cross-infection are inadequate. There is no excuse for the latter, and the research about what happens if the facts are ignored is there too.

In the US, of course, the threat of litigation concentrates the minds of health administrators, and sets pulses racing among hospital finance directors. Can it really be true that additional spending to produce better, safer hospitals can result in paybacks of only 12 months, excluding any savings, as a result of less litigation? Ulrich cites the work of Professor Leonard Berry and others (2) which shows just this: in their Fable Hospital model, the hypothetical initial construction cost of $240 million was increased by $12 million to take account of the enhanced facilities outlined above. Financial appraisals carried out by hospital CEOs suggested that the additional costs would be recovered in year one, and that savings would accrue from that time on. This would sound extraordinary, and possibly fantastical, were it not for the fact that the financial models have been checked by professionals with no aesthetic axe to grind.

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Professor Ulrich sees a potential new era for healthcare design as the result of research findings, in relation both to design strategies that can improve healthcare performance, and to financial analysis suggesting that it makes absolute economic sense to make the necessary initial investment in order to achieve more cost-effective health outcomes, and more 'profitable' buildings over time. The knowledge base established should, he suggests, empower architects, and help design aspirations to mesh more closely with the views and needs of clinicians. Ulrich hopes healthcare architecture may emerge from its traditional role as an architectural by way to taking a more prominent position.

'Which hospital would you like to be in?' is not necessarily a relevant question, it depends on where you live and the attitude to health of society and government. But it is a question that can be researched where there is any element of choice, and it may be that the popularity of hospitals with generous bed spaces, calm environments, access to open air and so on, will prove by their take-up that they should be examples to follow. It seems curious that consumerist attitudes should stop at the hospital door.

There is another aspect to this subject which is little discussed: the way hospitals deal with the dying (in the UK nearly 60 per cent of people die in them). A report for NHS Estates (4) raises issues which relate strongly to the work of Ulrich and his colleagues. Patients and relatives need even more the calming environments that good design can bring about. The behaviour of staff, and the training given, are crucial in this area, but design has an important part to play in giving comfort to the individual patient, for example by making the incorporation of personal possessions into their room easy, to more general considerations of where facilities are located (mortuary, viewing rooms, bereavement counselling spaces).

The world of hospitals is one where specialisms rule, as they must. In the creation of new hospitals, there is the risk that one set of specialists interacts with another, to the exclusion of those wider considerations which affect patients, visitors and staff as ordinary individuals, rather than as players in the unending drama that is hospital life. The message of the buildings in the following pages is that architecture in the round, which takes account of spiritual and psychological needs as much as the strictly medical, is what can make a life-enhancing difference.

1 'Transforming the Environment; practical lesson in creating the environment for care'; NHS conference, Harrogate, March 2005.

2 'The business case for better buildings', Leonard L. Berry et al, published in Frontiers of Health Services Management, 2004.

3 'The role of the physical environment in the hospital of the twenty-first century: a once-in-a-lifetime opportunity', Roger Ulrich et al, report to the Centre for Health Design, September 2004.

4 'Improving the patient experience--A place to die with dignity: creating a supportive environment', report for NHS Estates by its Design Brief Working Group, chaired by Richard Burton.