Patients treated in good surroundings rate their treatment and staff more highly than those seen in old buidlings. Bryan Lawson and Michael Phiri report

Can hospital buildings help to make patients better or do they actually hinder their recovery? A three year project, funded by£150,000 from NHS Estates, is comparing orthopaedic patients treated on a refurbished ward at Poole Hospital with those on a conventional 1960s ward in the same hospital. The research also compares outcomes for psychiatric patients treated at Mill View Hospital, a purpose-built unit in Hove, with those on two wards at Freshfield Mental Health Unit, Brighton General Hospital, located in a Victorian former workhouse.

The project was drawn up by a consortium, comprising NHS Estates, South Downs Health trust, Poole Hospital trust and the school of architecture at Sheffield University. It is chaired by John Wells-Thorpe, an architect and former chair of South Downs Health trust.

We surveyed patients over a period of approximately three months. The two trusts involved prepared data on the patients condition, pattern of referral, treatment and health outcomes. The research team gave the patients a questionnaire just before they left hospital. The sample comprised 273 patients treated at Poole Hospital and 151 patients treated in the units at Hove and at Brighton (South Downs Health trust).

The Poole sample was 55 per cent male and 45 per cent female and half were over 60. Just over half of the South Downs trust sample were between 31 and 50 and the male/female ratio was 57:43 per cent.

Patients were invited to answer a series of questions about several aspects of their hospital stay (see box).

Also, as part of our ongoing research programme, we held focus groups with a range of staff in the two trusts and with professionals specialising in the design of healthcare buildings.

When preparing for this research, a number of people we talked to felt that asking seriously ill patients about their architectural surroundings was a waste of time. Our results, however, suggest they were wrong. The first striking result was how articulate patients can be about the architectural environment and how importantly they regard it. More than a century ago, Florence Nightingale had noted the importance of their surroundings to her patients, and our work confirms this.

1 Patients in the newer buildings expressed more satisfaction with the appearance, layout and overall design of their wards. At Poole Hospital, about 75 per cent of the patients on the new ward gave them the highest possible rating compared with only about 35 per cent on the old ward. At South Downs these figures were both lower, at 45 per cent on the new unit and 15 per cent on the old.

We asked patients detailed questions about environmental aspects - the quality of lighting, temperature, air and noise. Again, in both the newer wards these showed improvements. The data clearly indicates that the newer wards were perceived by patients as significantly improved in spatial and visual terms, but only marginally better in terms of environmental control.

We also asked patients if they thought that the architectural environment had helped to make them feel better. In general, the newer wards again showed higher ratings. At Poole Hospital, this was a significant improvement, with 85 per cent on the newer ward feeling the environment helped them, compared with only 68 per cent on the old ward. Again we saw lower, but comparable, figures of 68 per cent, compared with 39 per cent from the units in South Downs .

We found that patients on the newer wards also gave higher ratings to the treatment they received and the staff who delivered it. These differences were very small at Poole since all patients showed high levels of approval.

But at South Downs 56 per cent of patients in the newer building were pleased with their treatment compared with only 39 per cent in the old buildings. Similarly, doctors, nurses, therapists and ancillary workers at both trusts attracted higher scores from the patients in the newer buildings. None of these improvements are sufficiently large to be statistically significant, but taken together with all our other data, we see a clear overall picture of the patients in the newer buildings being happier in their surroundings.

We also recorded and analysed patient health outcomes for our samples. In terms of length of stay our data is inconclusive at Poole Hospital - patients undergoing operations showed virtually identical average lengths of stay, although patients not undergoing operations were discharged significantly more quickly from the newer ward (6.4 days compared with 8.1 days). But at South Downs the mental health patients treated entirely in the new building were discharged more quickly than those in the old building, with an average reduction of 14 per cent (36.5 days compared with 42.4 days).

Mental health patients in the new unit also spent less time in intensive care than those in the older unit - an average of 3.9 days compared with 13.1 days. But there was also a change of service model and a reduction in the number of intensive care beds which may also have partly contributed to this last result.

The positive effect of good surroundings on patients well-being is also confirmed by staff assessments of their progress.

In the new unit 79 per cent of patients were judged to have made good progress during their stay compared with only 60 per cent on the older wards. The level of verbal outbursts and of threatening behaviour were also judged to have significantly reduced in the new unit (by 24 per cent and 42 per cent respectively). Taken together, all these figures indicate that the atmosphere in the new unit at South Downs was calmer, with fewer serious incidents and patients making better progress.

At Poole, we also looked at medication taken during the patients stay. The data indicates that less analgesic medication was required in the newer ward. Both the number and size of doses of class A controlled pain-killing drugs such as morphine were significantly reduced. By contrast, oral medication of lower-level pain-killing drugs increased slightly on the newer ward. This clearly suggests that lower overall levels of analgesia were used on the newer ward. We are cautious about these figures as standard deviations were rather high, indicating that the data is susceptible to fluctuation through a small number of high-dosage levels.

The idea that our environment can contribute to our well-being is not extraordinary, and yet it has received relatively little attention. Little hard evidence has been gathered, and almost none of it in strictly controlled comparative studies such as this.

In a well-known study, Roger Ulrich gathered data which indicated that patients who have a view through a window from their bed may be discharged earlier than patients who do not.

2 And Peter Scher has summarised suggestions as to the health impact of the hospital environment, which are confirmed by our data.

3 So just what are the environmental factors that contribute to the effects seen in this study? We conducted focus groups with staff in the two trusts involved as well as with design professionals experienced in design for healthcare. We also invited patients in our survey to tell us what mattered to them. A more detailed study is now under way, but some indications are already apparent. For bedridden patients the view from the bed is considered very important and bathroom and associated facilities attracted a great deal of comment from patients. Colour, decoration and pictures were also frequently mentioned. We also heard a great deal of criticism from patients who had been unable to control certain aspects of their environment.