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BMA Science & Education

The psychological and social needs of patients
January 2011

BMA Science & Education

Editorial board
A publication from the BMA science and education department and the Board of Science. Chairman, Board of Science Director of Professional Activities Head of Science and Education/Project lead Research and writing Professor Averil Mansfield Professor Vivienne Nathanson Nicky Jayesinghe Grace Foyle

Cover photograph: Shutterstock images. Produced by the BMA marketing and publications department.

© British Medical Association – 2011 all rights reserved. No part of this publication may be reproduced, stored in a retrievable system or transmitted in any form or by any other means that be electrical, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the British Medical Association.

The psychological and social needs of patients

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BMA Science & Education

Board of Science
This report was prepared under the auspices of the Board of Science of the British Medical Association, whose membership for 2010/11 was as follows: Professor Sir Michael Marmot Dr Steve Hajioff Dr Hamish Meldrum Dr David Pickersgill Professor Averil Mansfield Dr Ram Moorthy Mr Philip Belcher Dr Peter Dangerfield Dr Lucy-Jane Davis Professor David Katz Dr Peter Maguire Dr Philip Steaman Dr Andrew Thomson Dr David Wrigley Mr Richard Rawlins Dr Richard Jarvis (Deputy member) (by invitation) President, BMA Chairman, BMA Representative Body Chairman, BMA Council Treasurer, BMA Chairman, Board of Science Deputy Chairman, Board of Science

Approval for publication as a BMA policy report was recommended by BMA Board of Professional Activities on 9 November 2010. Declaration of interest There were no competing interests with anyone involved in the research and writing of this report. For further information about the editorial secretariat or board members please contact the science and education department who hold a record of all declarations of interest: info.science@bma.org.uk

The psychological and social needs of patients

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BMA Science & Education

Introduction
The traditional model of healthcare is a medical model, focussing on the history of illness, investigation into the physiological basis of symptoms, and remedies to return those to normal, followed by measurement of outcomes. The broader wellbeing of the person experiencing illness, and being a patient often for the first time, can be lost within this model. This overly mechanistic view has been recognised for decades as having defects. In general practice in particular Balint and others have described a different approach which considers the patient first as a person, within their family, community and workplace. Known often as a holistic approach this merges readily into modern views of patient-centred care, and of patients as partners in their care. Beyond all this is an additional element; people who become unwell have needs that are social and psychological. Meeting those needs will improve their health and aid recovery. There is a developing evidence base on the psychosocial, and physical costs of not meeting these needs, and on the positive effects of changing the way in which we care, and the environment in which we offer care. This resource was developed following a debate at the BMA’s annual representative meeting (ARM) in 2009. A working group of the Board of Science developed a remit, emphasising that the needs were present, albeit in varying degrees, in all patients. This resource considers the evidence base to help doctors and health care managers consider these important areas when designing and delivering care.

What is health?
The World Health Organisation (WHO) defined health in 1948 as a “state of complete physical, mental and social wellbeing not merely the absence of disease or infirmity”. This coincides closely with the holistic view seeing the patient first as a person within their family, community and workplace, and recognising the positive and negative influences each can have on the person. Helping an ill person back to better health requires due account to be taken of factors other than their physiology and anatomy; meeting psychological, social, spiritual and environmental needs are important. The evidence that environment and other factors affect health can be found below.

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Healthy Lives (February 2010) details the need for social justice. The Marmot Review on health inequalities Fair Society. Copenhagen: World Health Organisation 2 The psychological and social needs of patients . employment and neighbourhood circumstances. The central tenet of the Marmot Review is that avoidable health inequalities are unfair and putting them right is a matter of social justice. They stem from avoidable inequalities in society: of income. Health inequalities are not inevitable and can be significantly reduced.BMA Science & Education The social determinants of health The social determinants of health are sometimes referred to as the causes of the causes. While smoking causes ill health and premature death the social determinants are those factors that persuade or encourage individuals to become smokers. This model demonstrates that there are layers of influence on health that can be modified to improve health. There are many examples of such determinants including tobacco. education. Inequalities present before birth set the scene for poorer health and other outcomes accumulating throughout the life course. and to persist in the smoking habit despite their knowledge of the harm it is doing. psychosocial and political empowerment. These factors are important health inequalities and as well as being causes of the causes of illness may also contribute significantly to poor responses to treatment. Box 1: Factors determining the health of populations 1 Source: Dahlgren and Whitehead (1992) Policies and strategies to promote social equity and health. material. A model of the main determinants of health (see Box 1) highlights some of the key factors determining the health of populations.

This definition lists six dimensions to patient-centred care: • compassion. 6 The psychological and social needs of patients 3 .4 2 The Institute of Medicine defines patient centred care as ‘providing care that is respectful of and responsive to individual patient preferences. relieving fear and anxiety • involvement of family and friends. health states. empathy and responsiveness to needs. While it initially focused on hospitalbased care it also covers outpatient settings. and outcomes. biochemistry or anatomy and deals holistically with the whole patient. values and expressed preferences • coordination and integration • information. One important arena is the face-to-face consultation with a clinician. This moves health care beyond repairing the abnormal physiology.BMA Science & Education What is “the patient experience”? Patient-centred care Patient-centred care is a current descriptor given to the way in which care should be planned and delivered. 5 The Planetree model of patient-centered care is widely replicated. communication and education • physical comfort • emotional support. how they engage and participate in decisions about their care and the values that underpin the management of the health care system. 3. Involvement occurs at many levels – from citizens’ juries to patient participation groups. It recognises what the patient feels. and an important part of quality improvement. Health professionals are increasingly encouraged to involve patients in treatment decisions. It stipulates that health care environments should: • welcome the patient’s family and friends • value human beings over technology • enable patients to fully participate as partners in their own care • provide flexibility to personalise the care of each patient • encourage caregivers to be responsive to patients • foster a connection to nature and beauty. The involvement of patients in healthcare is both a matter of government policy. needs. and values and ensuring that patient values guide all clinical decisions’. recognising patients as experts with a unique knowledge of their own health and their preferences for treatments.

7 No consensus exists about the meaning and concept of ‘need’ in health. whether as a parent. directly and indirectly. 13. spiritual.14. Psychological and social needs of patients also need to be considered and addressed as a part of holistic healthcare delivery. psychological. Most people adjust 16 well to the confines imposed by their illness but a significant proportion find that their emotional and social coping mechanisms are challenged. 12 11 Hospitalisation presents specific stresses over and above those associated with illness. to the lack of privacy and independence and uncertainty about ill-health outcomes. sociology and political literature. The ambition to improve patients’ 4 The psychological and social needs of patients . Needs-oriented theories emphasise the health professional’s role in helping the patient to meet his or her physiological and psychosocial needs. the institution and the wider health system (see Box 2). concepts of need are widely used to define means of treating patients as people. Regardless of the lack of an agreed definition. holistically. regional. People who suffer from physical illness often lose the ability to perform a range of activities which previously maintained their ‘sense of themselves’.9. The European Charter on Environment and Health declares that ‘good health and wellbeing require a clean and harmonious environment in which physical. maintain or restore an acceptable level of social independence or quality of life. as defined by particular care agency or authority’. 2007) The King’s Fund 2009 review Seeing the Person in the Patient examined the factors shaping patients’ experience in hospital and concluded that such experience is shaped. 8. by organisational and human factors interacting in complex ways at four levels: the individual member of staff.15 Becoming physically ill is almost always a stressful experience. the team and clinical micro-system. The environment we live in is fundamental to basic human needs as emphasised in Maslow’s hierarchy of needs. social. The King’s Fund paper looked at how a patient’s experience of being in hospital is influenced by the social processes that create the workings of the health system as a whole. Physical illness can have profound social and emotional consequences. These range from environmental factors such as unfamiliar surroundings. and environmental needs. Traditionally health authorities and other health-related organisations at local. When a patient’s needs are not met it may affect their emotional state. provider or worker. There is no health without mental health. (World Health Organisation.BMA Science & Education Defining psychological and social needs The WHO definition of health cited above indicates that it is not only the physical needs of ill patients that need to be addressed but also their psychological. seeking to achieve levels of health improvement. an acceptable level of social independence and improved quality of life.10 The DH defines need as ‘the requirements of individuals to enable them to achieve. While saving lives and preventing physical deterioration of health are important. and national level set out to provide appropriate services to meet population needs. social and aesthetic factors are all given their due importance’.

These requirements are set out in Tomorrow’s Doctors. Box 2: A framework for the analysis of the factors influencing patients’ experience Source: The Point of Care.BMA Science & Education experience of care will be realised only with the willing cooperation and effort of all staff in direct contact with patients and if the wider organisation provides support and encouragement. 2009 17 Medical education and training Addressing the psychological and social needs of patients should be a theme that runs through all undergraduate and postgraduate curricula. skills and behaviours that medical students should learn while at UK medical school. The General Medical Council (GMC) sets the knowledge. To achieve sustainable change towards patient-centred practice we need to go beyond the teaching of basic communication skills. Patient-centred care is a core part of the vision in this guidance and it places emphasis on the importance of understanding the needs of patients and the need for professionalism in all communication. Teaching ‘patient-centeredness’ is a part of both the undergraduate and postgraduate medical curriculum in the UK. 19.20 18 The psychological and social needs of patients 5 . Addressing the attitudes and barriers to learning such skills is key.

• Discuss adaptation to major life changes. • Apply theoretical frameworks of sociology to explain the varied responses of individuals. the following frameworks are currently in place: Tomorrow’s Doctors (2009) calls on doctors to apply psychological principles. • Explain normal human behaviour at a societal level. • Discuss sociological concepts of health. the course of the disease and the success of treatment. helping to address individual needs. such as bereavement and comparing and contrasting the abnormal adjustments that might occur in these situations. it is also an indicator to the public of what they can expect from doctors. • Discuss psychological aspects of behavioural change and treatment compliance. the course of the disease and the success of treatment − including issues relating to health inequalities. illness and disease. Tomorrow’s Doctors (2009) calls on doctors to apply social science principles. reflecting the importance placed on these skills by the GMC. • Discuss sociological aspects of behavioural change and treatment compliance. method and knowledge to medical practice. 21 6 The psychological and social needs of patients . Relationships based on openness. groups and societies to disease. • Explain psychological factors that contribute to illness. • Explain normal human behaviour at an individual level. Good Medical Practice published by the GMC in 2006 sets out the principles and values on which good practice is founded. illness and disease. the development of longitudinal themes has permitted the introduction of a component devoted to teaching ‘patient-centeredness’. Similar processes are used in other medical schools. groups and societies to disease.BMA Science & Education Example: Problem Based Learning (PBL) medical curriculum – University of Liverpool. • Discuss psychological concepts of health. In delivering patient-centred care. • Apply theoretical frameworks of psychology to explain the varied responses of individuals. In this course. method and knowledge to medical practice. • Explain sociological factors that contribute to illness. the links between occupation and health and the effects of poverty and affluence. trust and good communication will enable a doctor to work in partnership with their patients. • Identify appropriate strategies for managing patients with dependence issues and other demonstrations of self-harm. While the guidance is for doctors. focusing in particular on delivering psychological and social needs of patients.

• make sure. The majority prefer a collaborative approach. • treat each patient as an individual. considerate and honest. Good staff communication helps reduce patient and family anxiety. and respond to their concerns and preferences. The psychological and social needs of patients 7 . promotes better care at home post discharge. 25 24 23 22 a The BMA has a long-standing interest in communication skills. • respond to patients’ questions and keep them informed about the progress of their care. Both are available on the BMA website. in a way they can understand. that arrangements are made to meet patients’ language and communication needs. and the treatment options available to them. ask for and respect their views about their health. Physicians’ communication skills are often the primary reason for patient complaints. This paper was updated in 2004. • support patients in caring for themselves to improve and maintain their health. Good communication is central to overall satisfaction with care across different patient groups. recalled and acted upon by patients. • make sure that patients are informed about how information is shared within teams and among those who will be providing their care. Communication a Effective communication is essential to ensuring that patients’ concerns are understood by those providing care. wherever practical. In January 2003 the BMA’s Board of Medical Education released its publication Communication skills education for doctors: a discussion paper. its likely progression. Informed choice and consent are associated with good psychological outcomes. • encourage patients who have knowledge about their condition to use this when they are making decisions about their care. These skills should be actively maintained throughout a professional career. the information they want or need to know about their condition. • share with patients. Offering choice of treatment and agreeing to patient preference has been found to reduce anxiety and depression. Patients differ in the extent to which they wish to be involved in treatment decisions. and can improve outcomes. Not only are communication skills fundamental to good clinical care but they also facilitate detection of psychological and social problems.BMA Science & Education Good Medical Practice calls on the doctor to: • be polite. • treat patients with dignity. both emotional and behavioural. In February 2010 the BMA produced a signposting resource Developing doctors’ non-clinical skills. advice and treatment is understood. and that relevant information. including associated risks and uncertainties. • listen to patients. • respect patients’ privacy and right to confidentiality.

The report called for wards to address this as a matter of priority. • reducing the incidence of clinical error. Better communication and dialogue by means of reiteration and repetition between doctor and patient has a beneficial effect in terms of promoting better emotional health. Social and psychological needs – in practice Doctors are increasingly aware of the importance of developing good communication skills and of attending to their patients’ psychological and social needs as a part of holistic practice. The doctor is better able to seek the relevant information and recognise the problems of the patient by way of interaction and attentive listening. Patients complained about the lack of daily exercise and the general absence of things to do. Increasingly. 27.28 26 • helping the patient to recall information and comply with treatment instructions thereby • possibly improving patient health and outcomes. Poor communication between professional staff has been identified as an underlying factor for failed communication with patients. examined a total of 69 NHS Trusts and independent sector organisations in mental health services. particularly in the evenings and at weekends. 26 29 • improving the overall quality of care by ensuring that patients’ views and wishes are taken Patient care depends on different communication pathways that include. into account in decision making. As a result. the patient’s problems may be identified more accurately. with measures to ensure that activities and therapies are reviewed regularly so that the provision is appropriate to the current patient and staff mix.BMA Science & Education The benefits of effective communication include: • improving the doctor-patient relationship. doctor to doctor and doctor to manager. doctor to patient. 31 8 The psychological and social needs of patients . resolution of symptoms and pain control. improving patient satisfaction. medical treatment requires different physicians to contribute to the outcome. 30 The GMC in a number of its guidance notes emphasises communication skills as essential for effective care and relationships of trust. The 2006/07 National Audit of Violence report. funded by the Healthcare Commission and managed by the Royal College of Psychiatrists’ Centre for Quality Improvement. Much of the evidence stems from mental health and paediatric care settings. The GMC encourages the acquisition of communication skills from the outset of medical training. The report identified ‘high levels of boredom’ as one of the six main factors contributing to unsafe wards.

novels. Depression. Calman described the use of stories as a means for physicians to establish trusting relationships with patients and to learn valuable lessons from each other. Through poetry. The measured improvements include: • inducing positive physiological and psychological changes in clinical outcomes • reducing drug consumption • shortening length of hospital stay • promoting better doctor-patient relationships • improving mental healthcare. Calman asserts that stories assist in the development of emotional knowledge. cards. Humour has the potential to relieve stress in patients and medical professionals. Creative writing.BMA Science & Education Creating a therapeutic healthcare environment extends beyond the elimination of boredom. fiction or poetry. Specifically citing humor as an important aspect of storytelling. It can also help vulnerable people develop or re-establish social skills in a controlled environment. social interaction. myths. social supports and the accomplishment of task orientated goals. legends. history. Therapeutic recreation can provide patients with an opportunity to improve quality of life through an increased sense of control.xxxii Addressing the psychological and social needs of patients – activity examples Recreational activities Recreational activities (including board games. A study by Van Deurzen Smith in 1997 showed a significant reduction in levels of depression in those patients who were guided to read selected literature. and even altering pain thresholds. bingo) have benefits beyond simply counteracting boredom. the use of writing as a means of expressing feelings and thoughts can have therapeutic value. It can present the opportunity to forget anxiety and pain for a brief period. physiological and psychological functioning. folklore. 35 40 39 38 37 36 35 34 33 The psychological and social needs of patients 9 . or performance. Humour and health The notion that humour and laughter are good for health is not new. Arts and humanities programmes have been shown to have a positive effect on inpatients. especially in regard to sharing of experiences among doctors in training. storytelling and poetry reading The relationship between creative writing and mental wellbeing presents a promising modality for overall patient wellbeing. When doctors share humour with patients. Humour can put both parties at ease in a way that more formal types of communication do not. anxiety and other disorders can leave individuals with social deficits. In mental health. Calman in A study of story telling humour and learning in medicine discussed how humour has value in improving wellbeing. stories are a vital component of all human experience. compared to a control group. they create lines of communication that put patients at ease and which may encourage them to discuss difficult issues.

Perceptions of pain and stress decreased in subjects in an American study who had blood taken in a room with visual arts compared to those in a room with no visual arts. dancing. Drama therapy responds to the deep psychological need of people with dementia to express and understand their own world. music. and myocardial oxygen demand in patients recovering from acute myocardial infarction. improving the quality of life of those patients.lv An investigation of dancing on people with dementia showed that dance-related emotional and functional motor activities were largely preserved. Visual arts have also been shown to help patients manage pain. focusing on handling materials and tools. including reducing the number of falls. supports spontaneous activity and increases physical movement. refining motor skills and practising good hand eye coordination. using both hands. A small-scale controlled study found that daytime exercise helped to reduce daytime agitation and night-time restlessness. helped alleviate the mental and physical effects of stroke. sculpture. cognition and social skills showed a positive effect in alleviating these disabilities. respiratory rate. puppetry. The use of music was found to stimulate emotional and motor responses. A study on premature infants exposed to music. poetry and the art of acting. compared to a control group treated without music. Physical exercise can have a number of health benefits for people with dementia. 56. reported a beneficial effect on weight gain and caloric intake and a significantly reduced length of hospital stay.BMA Science & Education Music There is extensive literature on the effects of music in different healthcare settings. improving mental health 53 52 51 50 49 48 47 46 45 44 43 and improving their mood and confidence. The introduction of social dancing gives patients another way of communicating.57 54 10 The psychological and social needs of patients . Research at Chelsea and Westminster Hospital has shown that chemotherapy patients who were able to view rotating art exhibitions during recovery reported reduced rates of anxiety and depression. specifically lullabies and classical music. painting. At Conquest Hospital in East Sussex weekly art sessions for stroke patients. storytelling. An evaluation of the role of therapeutic theatre for people lacking in communication. 41. The authors stated that this type of activity creates a supportive environment and helps the patient to achieve a state of independence.42 The introduction of music to provide a quiet and restful environment has been found to result in significant reductions in heart rate. Visual art The visual arts have been shown to have a positive impact on patients who engage with them. both for inpatients and for those attending outpatient departments. Active programmes of listening to and performing music have been shown to help the management of patients with Parkinson’s disease. Theatre and drama Theatre and drama are the most integrative of all the arts: they include singing. Dancing Exercise alone improves physical ability and sleep.

concluding that: • patients are sensitive and articulate about their architectural environment • patients make better progress in purpose-designed modern buildings than in older ones • better designed hospitals create an overall improved atmosphere. 63 62 61 This may not always be possible within existing building design. It should ensure that patients are not overcrowded or over concentrated. and can foster the process of recovery. leading to patients with mental health problems being less confrontational and general patients requiring less analgesic medication. with little to do. and are therefore accessible to all persons who wish to use them.BMA Science & Education Singing A study by Clair et al found that singing can be an effective means of eliciting attentional responses in patients in the final stages of dementia. The study emphasized the potential of singing to be used by all types of caregivers: ‘songs are successful facilitators of response even when sung without accompaniment. Singing increases verbal communication. The influence of the immediate environment on their sense of wellbeing and actual recovery was the subject of a 2003 report from NHS Estates. delirium. even in those unresponsive to other types of stimulation in their daily lives. a dining room that is well lit and ventilated and a spacious lobby and corridors and give sufficient attention to natural and artificial lighting. regardless of musical background and training’. elevated blood pressure. marketing and cost. The effects of supportive design are complimentary to the healing effects of drug treatments and other medical technology. 60 Studies have shown that poor design works against the wellbeing of patients and in certain instances can have negative effects on physiological indicators of wellness. Healthcare building design should extend beyond functional efficiency. provide a variety of spaces such as a big day room. 59 58 The physical environment and patient wellbeing Patients can spend many hours in bed or sitting. and increased intake of analgesics. improves their mood and reduces agitation. It should promote wellness by creating physical surroundings that are psychologically supportive. but it should be a consideration in all future builds and renovations. Research has linked poor design to anxiety. 64 The psychological and social needs of patients 11 . The study indicates that the architectural environment can contribute to the treatment of patients and significantly affect their health outcomes. stimulates patients’ collaboration during routine tasks.

71 patients and can heighten blood pressure and heart rate. increased heart and respiration rate. if they are assigned to sunnier rooms rather than rooms that receive less daylight or are always in the shade.BMA Science & Education Examples of environmental hospital design that can be of benefit include: Exposure to daylight Research indicates that exposure to light – daylight or bright. A 2001 study by Benedetti et al found that patients hospitalised for depression stayed an average of 3. endocrine and metabolic functions and insufficient or poorly timed sleep has a negative affect on health and wellbeing. but also for patients with cardiovascular disease or cancer. Research on adults and children has shown that noise is a major cause of sleep deprivation. A Canadian investigation of myocardial infarction patients in an intensive care unit suggested that female patients had shorter stays if their rooms were sited to provide higher daylight exposure. When high performance ceiling tiles were installed in a coronary critical care unit (CCU) in a hospital in Sweden. This strategy is usually ineffective. Reduced noise Studies have documented the negative effects of noise on patient outcomes. Ward layouts and way-finding Ward layouts in older hospitals generally provide long corridors organised around a central nursing station. and worsened sleep.76 74 73 72 Way-finding problems in hospitals are costly and stressful and affect patients who may be unfamiliar with the hospital and are stressed and disorientated. they may get stressed. Lack of adequate sleep results in poor physical and mental function. elevated blood pressure. including shorter and less costly stays. Depression is a serious problem not only for mental health patients.7 fewer days if they were assigned east-facing rooms exposed to morning light. compared to patients in west-facing rooms with less sunlight. Evidence based design (EBD) is an effective solution and involves designing better signage including optimal spacing and location of signage. mortality in both sexes was lower in sunnier rooms than in north-facing rooms. full spectrum artificial light – is effective in reducing depression even for those hospitalised with severe depression. have found that higher noise levels decreased oxygen saturation increasing the need for oxygen support therapy. Several studies focusing on neonatal intensive care units. noise levels declined and patients reported that they were significantly more satisfied with care quality compared to when low performance ceiling tiles were in place. 67 66 65 In the same study. 75. If people get lost. This is worsened as most hospitals have existing complex buildings upon which they impose a signage system. Medical studies have reported that hospitalised patients with depression may have more favourable outcomes. Research has shown that nurses spend much of their time (more than 40 per cent in older UK NHS hospitals) walking up and down halls increasing fatigue and stress and sharply cutting the time available for observing patients and delivering direct care. which raises cortisol levels and lowers immune system functioning. Sleep is important for immune. 68.69 Studies have also shown that noise increases stress in adult 70. 77 12 The psychological and social needs of patients . where medication and charts are located.

Renovating a traditional waiting area in a neurology clinic by making small changes to the general layout. curtains. day rooms. Some believe that the greater sense of ease helps them to recover more quickly. Patients talk about feeling more relaxed and comfortable in same-sex accommodation. 80 79 Women. the better health enjoyed by higher status people was due to their greater social participation and autonomy. improved mood. It can affect a patients’ health at a time when they may already feel vulnerable. noise. Social interaction Patient studies have indicated that social support reduces stress and improves recovery outcomes. and the possibility of other patients overhearing conversations about their condition. the better the health. 85 84 b 82. They are most likely to find mixing ‘not at all acceptable’. and greater reported satisfaction among patients. toilet and washing facilities was a recurrent theme in the responses to the 2008 Royal College of Nursing dignity survey. These worries can disrupt a patient’s recovery. older people and some ethnic minority groups are more likely to worry about being in mixedsex accommodation. colour scheme. including increasing the amount of food consumed by geriatric patients. He labelled this ‘the status syndrome’. Being in mixed-sex hospital accommodation can be difficult for some patients for a variety of personal and cultural reasons. Hospital design can facilitate or hinder access to social interaction. and providing informational material and information displays resulted in more positive environmental appraisals. The psychological and social needs of patients 13 . Older people represent the largest users of NHS services and account for twothirds of NHS hospital admissions. floor covering. and waiting rooms with comfortable movable furniture arranged in small flexible groupings. altered physiological state. 78 Single sex accommodation can dramatically improve how patients feel about their care and help ensure that everyone is treated in privacy with the dignity they deserve.BMA Science & Education Single sex accommodation The importance of single sex accommodation. Studies in psychiatric wards and nursing homes have found that appropriate arrangement of movable seating in dining areas enhances social interaction and also improves eating behaviours. Levels of social interaction can be increased by providing lounges. The most common concerns include physical exposure. Respondents viewed single sex provision as a significant contributing factor to providing dignified care.83 81 b Professor Sir Michael Marmot looked at the social gradient in health concluding that the higher the social position. According to Marmot. being in an embarrassing or sexually threatening situation.

90 89 88 87 86 For information on what is happening in the UK please see Appendix 1 14 The psychological and social needs of patients .BMA Science & Education Nature and hospital gardens Laboratory and clinical studies have shown that viewing nature produces stress recovery. evident in physiological changes. Research has demonstrated that looking at built scenes lacking nature (rooms. Hospital gardens not only provide restorative or calming nature views. compared to days with continuous daytime television programmes. and parking lots) is significantly less effective in fostering restoration and may worsen stress. Visual exposure to nature improves outcomes such as stress and pain. A study of blood donors in a waiting room found that blood pressure and pulse were lower on days when a television played a nature videotape. A study by Whitehouse et al in 2001 indicates that patients and families who use hospital gardens report positive mood changes and reduced stress. but can also reduce stress and improve outcomes through other mechanisms. A study in a Swedish hospital found that heart-surgery patients in intensive care units who were assigned a picture with a landscape scene reported less anxiety/stress and needed less analgesics than a control group. such as in blood pressure and heart activity. including fostering access to social interaction and providing opportunities for positive escape and a sense of control with respect to stressful clinical settings. buildings.

Dignity consists of many overlapping aspects. Improving patients’ experience of care requires the cooperation of both staff and the wider organisation. social and aesthetic factors are all given their due importance. • Health professionals should be encouraged to involve patients in treatment decisions. They should ensure that patients are not overcrowded. Such activities should be regularly reviewed so provision is appropriate to the current patient and staff mix. and outcomes. health states. provide a variety of spaces that are ventilated and spacious. • put measures in place to ensure patients have the option to partake in both recreational and creative therapies. Set out below are key areas for action in helping to address the psychological and social needs of patients. involving respect. This applies not only to hospital settings but also in GP surgeries. • Addressing the psychological and social needs of patients should be a theme that runs through all undergraduate and postgraduate curricula. It is essential that undergraduate and postgraduate students have a good knowledge base and understanding of the basic principles of clinical psychology and medical sociology. The psychological and social needs of patients 15 . Sufficient attention should be given to natural and artificial lighting. This may not always be possible within existing building design. privacy. recognising patients as experts with a unique knowledge of their own health and their preferences for treatments. psychological. autonomy and self-worth. but it should be a consideration in all future builds and renovations. • Dignity in care needs to be considered as an integral part of service provision. • Healthcare organisations should: • ensure that the Planetree model of patient-centred care is applied in healthcare environments: – welcome the patient’s family and friends – value human beings over technology – enable patients to fully participate as partners in their own care – provide flexibility to personalize the care of each patient – encourage caregivers to be responsive to patients – foster a connection to nature and beauty.BMA Science & Education Areas for action As stated in the European Charter on Environment and Health good health and wellbeing require a clean and harmonious environment in which physical. • should promote wellness by creating physical surroundings that are psychologically supportive.

• Effective communication is necessary to ensure that patients’ concerns are understood by those providing care. and difficulties in communicating can have a direct impact on patient care. recalled and acted upon by patients. • Patient-doctor communication relies on effective doctor to doctor and doctor to manager communication.BMA Science & Education • The acquisition of communication skills should be a key feature from the outset of medical training. advice and treatment are understood. 16 The psychological and social needs of patients . medical treatment requires many different physicians to contribute to the outcome. Increasingly. and that relevant information.

access and space). The PEAT programme commenced in 2000 and assessments are undertaken on an annual basis to ensure that standards are being met. The programme initially focused on improving acute hospital environments. It is based on the lessons learned from an academic evaluation of its use. innovation. engineering and construction). It is a benchmarking tool to ensure improvements are made in the non-clinical aspects of patient care. impact (character. citizen satisfaction and internal. 150 teams from 133 NHS Trusts. The toolkit includes references to evidence-based design literature and this is related to the criteria used in the evaluation. food and infection control. • NHS Estates Design Review Panel (DRP) was set up in 2001 to ensure that good design is embedded within the NHS hospital building programme by providing advice. • The NHS ‘Achieving Excellence Design Evaluation Toolkit’ (AEDET) was first published in 2001 to assess and evaluate new healthcare buildings. amenity.xci • In February 2000 the King’s Fund launched its ‘Enhancing the Healing Environment Programme’. was published. space relationships. The latest phases include work to improve environments for care at the end of life and improvements to the environment in which healthcare is delivered to prisoners. Mental health Trust performance ratings include ‘physical environment’ which looks at ‘environmental conditions. before being extended to mental health and primary care settings. The programme encourages and enables nurse-led teams to work in partnership with patients to improve the environment in which they deliver care. To date. guidance and support to the NHS in the form of a design review and subsequent report. such as cleanliness. The Governement are now working with a variety of organisations. highlighting comments and recommendations. It was updated in 2008 and an improved version. • Patient Environment Action Teams (PEAT) is an annual assessment of inpatient healthcare sites in England that have more than 10 beds. PEAT assess cleanliness and other aspects of the patient environment and score hospitals using a five-point scale. service effectiveness. no change needed’) to category ‘X’ (‘nothing but a total rebuild or relocation will suffice’).500 staff and patients have been involved in improving their healthcare environments. external and social environment) and build standard (performance. The assessment results help to highlight areas for improvement and share best practice across healthcare organisations in England. including the architectural The psychological and social needs of patients 17 .BMA Science & Education Appendix 1 What is happening in the UK? • In 2003 the Health Service Journal launched its ‘Fit for Purpose’ campaign ‘demanding urgent action to improve the depressing and dangerous environments in which many service users are still treated’. and location all of which impact on the successful delivery of client care’ and the rating categories range from ‘A’ (‘very satisfactory. The toolkit included 10 sections of questionnaire items that looked at functionality (use. two hospices and five HM prisons across England have joined the programme and more than 1. ‘AEDET Evolution’.

The advice notes were written by a multidisciplinary team of top practitioners in the fields of architecture. It delivers a profile that indicates the strengths and weaknesses of a design or an existing building. whereas by 2003.BMA Science & Education profession. and their architects and design consultants. Their work is based on three main tenets. They complement AEDET using it to create a base template from which a Trust can develop its own specific design briefing requirements. legibility of place. states that in 1995 50 per cent of NHS buildings pre-dated the NHS itself. facilities and staff). 3. engineering. interior appearance. by 2010. to develop their design ideas. company and dignity. views. The ASPECT toolkit addresses eight key headings (privacy. One paper prepared by NHS Estates. 1. ASPECT is designed to be used by those 18 The psychological and social needs of patients . this figure had decreased to 25 per cent. 93 92 • The DH ‘Inspiring Design Excellence and Achievements’ (IDEAs) toolkit is a design tool to aid Trusts. Design can affect health outcomes by reducing length of patient stay. the Royal College of Art and several universities in an attempt to redress the balance in terms of building design and environmental design and safety. comfort and control. For further information on the DBWG Advice please see Appendix 2. It identifies the quality requirements and aspirations that should be taken into consideration. 40 per cent of buildings will be less than 15 years old. IT and the workforce in relation to the design of buildings for healthcare. It works by understanding these activities and the functional and emotional needs of the people involved. IDEAs treats both interior and exterior spaces as ‘places’ where a number of activities commonly take place. The division delivers improved health outcomes through innovative estates and facilities solutions which enable high quality. 94 • The DH A Staff and Patient Environment Calibration Tool (ASPECT) evaluates the quality of design of staff and patient environments in healthcare buildings. nature and outdoors. NHS Estates was formed in April 1991 and abolished in September 2005 when the DH Estates and Facilities Division assumed responsibility for the role. Design can reduce operating costs not only of the building but also the service. architecture. design. 2. engineering and healthcare planning and can be used on every scale of project. safe patient care. • NHS Estates Design Brief Working Group (DBWG) was commissioned to produce an advice note for Trusts involved in or embarking on health buildings. the Design Council. Design contributes to healthcare quality and patient safety. IDEAs is intended to help create aspirations towards good design from the beginning of the process and direct attention towards qualities that otherwise are often lost in highly technical healthcare environments. Within current planning frameworks. it can also affect the wider social community in terms of regeneration and improving social conditions. as it leads to increased retention and efficient working patterns. • The Future Healthcare Network (FHN) is an initiative that has been implemented to focus on planning.

The handbook gives practical ideas for improving the daily experiences and treatment outcomes of acute mental health inpatients. The IAPT Commissioning Toolkit is designed to help PCTs improve or establish stepped care psychological therapies following NICE guidelines. 95 • Accreditation for Acute Inpatient Mental Health Services (AIMS) is a voluntary accreditation from the Royal College of Psychiatrist’s Centre for Quality Improvement that identifies and rewards acute psychiatric wards that have high standards of organisation and patient care. and welcoming can be seen as an essential first step in treatment. The Government is committed to improving access to psychological therapies and in June 2010 announced additional funding to increase services over the next year. It can be used on the plans for new buildings in order to evaluate and compare designs. estates/facilities managers and design champions may find ASPECT helpful.BMA Science & Education involved in the commissioning. Its aim is to inspire excellence in inpatient care. 96 • The Star Wards initiative is a project which works with mental health Trusts to enhance mental health inpatients’ daily experiences and treatment outcomes. It can be used to evaluate existing buildings in order to compare them or understand their strengths and weaknesses. The AIMS accreditation process incorporates elements that research has demonstrated to be effective in bringing about quality improvement. It gives encouragement to identify and prioritise problems and sets achievable targets for change. In particular public and private sector commissioning clients. It brings together a wide range of existing tools and guides and includes positive practice examples throughout. developers. The toolkit is structured around the commissioning cycle and is specifically linked to the World Class Commissioning competencies. • The DH Improving Access to Psychological Therapies (IAPT) Commissioning Toolkit programme aims to help Primary Care Trusts (PCTs) implement the National Institute for Clinical Excellence (NICE) Guidelines for people suffering from depression and anxiety disorders. The Nightingale Project see it as vital to bring life and colour into a hospital or clinic setting to provide a conducive setting for medical and therapeutic work. design teams. To receive a patient in a hospital environment which is pleasant. and a fundamental contribution to the process of recovery. User clients such as patient representatives and members of the general public should also be able to use ASPECT. a large mental health trust with The psychological and social needs of patients 19 . It can be used on ‘imaginary’ buildings in order to set standards for a brief. It is a charitable project that works with Central and North West London NHS Foundation Trust. production and use of healthcare buildings. ASPECT can be used at various stages during the design of healthcare buildings. AIMS has worked in collaboration with the Healthcare Commission to ensure that standards are compatible with those which will be used in the planned improvement review of acute inpatient mental health services. project managers. 97 • The Nightingale Project brightens up the environment in mental health services through art and music. cheerful.

to make the treatment environment more human and more uplifting for both inpatients and outpatients. The Point of Care programme will be piloting Experience Based Design with the Integrated Cancer Centre at Guy’s & St Thomas’ NHS Foundation Trust and King’s College Hospital NHS Foundation Trust. drawing on ideas from design in which users are a central part of the process. – The Royal Free Hampstead NHS Trust is piloting the US Schwartz Center Rounds system. They do this through putting on temporary exhibitions of highquality art in waiting rooms. 98 The Point of Care programme. Patients and staff are partners in the process. which involves a monthly one-hour session for staff from all disciplines to come together and discuss difficult emotional and social issues arising from patient care. involves two practical initiatives to ‘promote compassion in care and improve patients’ experience’. commissioning artists to produce works of art for permanent display in the wards. 99 – Experience Based Design involves patients and staff working together to improve the experience or feel of using services. 20 The psychological and social needs of patients . launched in 2008 by the King’s Fund. and through bringing musicians into hospitals to play live for the patients. The Project began at the South Kensington and Chelsea Mental Health Centre in 1998.BMA Science & Education many sites in the London area. strengthening the link between them. and has since spread to numerous other sites.

Work flows and logistics Work flows and logistics within and between processes should be carefully thought through and optimised. The prime functional requirements of the project Set out: • your operational policies • the operational capacity you seek • relevant future projections. storage. distribution of supplies. staff and visitors. size and location of storage and holding bays should reflect the supply and disposal policy.BMA Science & Education Appendix 2 NHS Estates: Advice to Trusts on the main components of the design brief for healthcare buildings Use The service philosophy and strategy of the Trust Describe the purpose of the building in detail with particular attention to patient and staff needs. and waste disposal should be carefully considered • number. Issues to consider: • clinical. Set out: • your healthcare philosophy and design vision • what effectiveness and efficiency of delivery means for you • your model of care. Issues to consider: Healthcare processes – • departmental workflow should be direct • routes should be as short as possible • inefficient or dangerous cross-flows must be avoided. therapeutic and other services and complex diagnostic and specialist activities should be well integrated so that patients perceive a unified and seamless service • information technology should be used to ensure that information is shared between all providers in a patient-focused manner. The psychological and social needs of patients 21 . The importance and dignity of individuals The design of the building should consistently relate to patients. Logistics – • movements of people.

Security and ease of control Set out the: • security brief • visitor monitoring strategy. critical care unit). including on-site roads for ambulances. motorcycle and bicycle parking requirements. turning circles etc should be safe and convenient • the site design should accommodate public transport access having regard to the proximity or otherwise of public transport stops • car parks. outpatient department.BMA Science & Education Adaptability The building should be designed to be adaptable. Issues to consider: • routes should be clearly marked • roads. public transport. organisational and formal innovations while retaining design coherence • the structural design should enable adaptability and expansion with limited disruption • the possibility of future change and expansion should be built into the design of all M&E systems • space should be allowed for departments to expand (eg operating. service vehicles. to respond to change and to enable expansion. Issues to consider: • the design of the layout. loading docks and entrances should be well lit. Parking for visitors and staff Set out car. technological. Issues to consider: • the layout should include suitable supervision and control points • entrances and departments should be designed to enable ready supervision and security • the layout should maximise passive supervision and overlooking through isovistas. 22 The psychological and social needs of patients . the lighting and Mechanical and Electrical (M&E) controls should be versatile to allow everyday changes of use. Access Access for vehicles Set out access requirements for all vehicles. Issues to consider: • separate access routes should be provided where required • service routes should be clearly sign posted • access and loading bays should be thought through in terms of safety and convenience. and fire appliances. Issues to consider: • drop-off points should be appropriately provided at entrances • sign posting to parking areas should be adequate. access routes. kitchen. widths. Goods and waste disposal vehicle segregation. activity and spaces • the overall design should be capable of accommodating therapeutic. wards.

Issues to consider: • compliance with Firecode with provision for safe horizontal escape routes • free access by fire fighting appliances to the building perimeter. with safe crossings • free from obstacles • pleasantly landscaped • well lit at night.BMA Science & Education External way-finding and sign posting The external way-finding and sign posting strategy should be of high quality and fully integrated into the design solution. and other people with physical or learning disabilities. and impaired sight or hearing • there should be parking spaces reserved and marked for disabled people • parking for disabled people should be provided close to entrances. The psychological and social needs of patients 23 . Integration with fire planning strategy The fire planning strategy should be integrated to allow for ready access and egress. Sign posting – • the sign posting should be an integral part of the way-finding strategy • routes and sign-posting to and from parking areas and public transport points should be clear and obvious. Pedestrian access Issues to consider: Pedestrian routes should be – • obvious • well sign posted • safe from vehicles. Access for all Issues to consider: • pedestrian routes should be suitable for wheelchair users. Issues to consider: External way-finding – • the external appearance and site layout should support intuitive way-finding • distinctive ‘land marks’ eg to signal the main entrance should be incorporated into the design • the hard and soft landscape design should support intuitive way-finding.

storage. etc. Issues to consider in addition to departmental areas: • public and entrance areas • social spaces for patients. staff and public • children’s areas • scope for external franchises and other add-ons • storage • circulation • plant and servicing • exterior terraces.BMA Science & Education Space Functional content and space standards Set out requirements for functional content and space standards. Issues to consider: • the inter-departmental relationships should be convenient and help efficient functioning • there should be clarity about the priority of key relationships • internal relationship within departments (main rooms. Space utilisation Issues to consider: • spaces should be capable of being shared where appropriate – seen as a resource. bays. Privacy. isolation and communality Set out: • requirements of visual and acoustic privacy • requirements for gender segregation • infection control regimes including isolation rooms and beds. allowing patients to communicate with staff when needed. service rooms) should be convenient and help efficient functioning. not personal territory • dual use of circulation space should be exploited where effective eg to encourage informal association and gathering. play areas. Additional issues to consider: • reception areas should enable confidential conversations without embarrassment • the design should help avoid unintended isolation. 24 The psychological and social needs of patients . Adjacencies Set out adjacency matrix indicating appropriate relationships between different functions derived from operational policies.

Titles in the series are viewable from DH Estates & Facilities Division’s publication list and are also downloadable free to the NHS via the DH Estates Knowledge and Information Portal. such as medical gas installations and fire safety requirements. The HTMs are supported by other technical guidance. particularly at business case stages and. The psychological and social needs of patients 25 . HBN recommendations are reflected in the cost guidance promulgated by the Department as a benchmark for demonstrating value for money in business cases. such as the Model Engineering Specifications. They inform project teams about accommodating specific department or service requirements. • The HTM series of publications sets healthcare specific standards for building components such as. A clear vision Issues to consider: • the design should embody a clear and coherent vision confidently communicating its function and aspirations through its physical elements. • The HBN are a series of publications that set the DH’s best practise standards in the planning and design of healthcare facilities. Character and innovation Lifting spirits and helping recovery Issues to consider: • the design of the building should aid therapeutic objectives • the building should engender wellbeing and raise patients’ and visitors’ spirits. avoid blanket statements. as the quality element of Value for Money (VfM ) benchmarks.BMA Science & Education Guidance in Health Building Notes and other good practice documents Set out the guidance to be followed and protocol for departure from it. HTM recommendations are reflected in the cost guidance promulgated by the Department as a benchmark for demonstrating value for money in business cases. They are used in the management of the investment process. they underpin the economic case for investment. Expressing excellence Issues to consider: • the design should express a strong positive image of the health service • the building should raise staff morale. Titles in the series are viewable from DH Estates & Facilities Division’s publication list and are also downloadable free to the NHS via the DH Estates Knowledge and Information Portal. The FIRECODE tiles of the HTM series contain requirements on trusts that are mandatory. windows and sanitary ware and the design and operation of engineering services. List specific Health Building Notes (HBNs) and Health Technical Memoranda (HTMs) to be adhered to.

technique and built form. in conjunction with the building. Issues to consider: • the building should show how good design can improve patients’ and staff’s lives and add value for the Trust over the building’s lifetime. on visitors • how the building is entered in respect of natural points of arrival and local landmarks. Issues to consider: • profile and skyline of the building from a distance and on approach • the shapes the building is made up of • the interplay of light and shade • the relationship of the parts to the whole • coherence of the parts and the whole 26 The psychological and social needs of patients . The value of good design The building should in itself be a demonstration of the value of good design. New knowledge The design should explore with due rigour innovation in practice. Scale and proportion Issues to consider: • the scale should be thought through in relation to adjoining buildings • irrespective of the size of the building the scale should be considered from the point of view of patients. Citizen satisfaction Orientation The building should be designed with its consideration to its orientation. visitors and staff so as to make them welcome Composition The building’s form should be pleasing and well composed. Issues to consider: • sunlight and how it falls on the building • prevailing winds and their effect.BMA Science & Education A stimulating design Issues to consider: • the design should have sufficient variety to stimulate the mind and the senses • users and visitors should feel that the building has a positive character • art should be integrated into the total experience of the building. Issues to consider: • the development should clearly reflect new models of healthcare provision in the design • the design should respond to advanced thinking about architecture and the built environment • where possible the design should develop new and transmissible knowledge about buildings for healthcare.

finishes. Use of art to enhance the healing environment – • art should be an integral part of the design of the interior • the design should make provision for changing art displays • the design should make provision for presentations of the performing arts • the design should make provision where appropriate for art activities to take place for patients and staff. Materials. External materials Issues to consider: • the choice of materials should be on the basis of enhancing the building as a whole • the form and materials should be well detailed • the weathering. The psychological and social needs of patients 27 . textures – • materials and finishes should work with the layout to create a set of varied places with degrees of privacy • finishes. varied and stress reducing environment Issues to consider: The internal environment generally – • the main entrances and reception areas should be pleasant and welcoming • the internal appearance should be calming and non-intimidating • the building should have good acoustics • temperatures should be comfortable in all seasons • the air quality should be fresh. Colour and texture Issues to consider: • colours and textures where used should articulate and enrich the building’s form and enhance its enjoyment. fittings. grilles. flues. refuse bays. plant rooms. Internal environment A pleasant.BMA Science & Education • consistency and attention to detail • the integration of service elements such as rainwater pipes. furniture and notices should be well coordinated and designed to reduce clutter • selection of finishes and materials needs to take account of infection control issues. maintenance and durability of the materials should be thought through.

such as art and sculpture should be incorporated into the design • where repetitious building forms are used thought should be given to avoiding disorientation.BMA Science & Education Light and colour Issues to consider: Light and shade – • light and shade should be used effectively to enhance the perception of three-dimensional space Colour – • the contribution of colour to providing continuity and variety. without daylight or views out of the building. Internal way-finding Issues to consider: • the interior should be integrally designed to support intuitive way-finding • distinctive ‘landmarks’. narrow corridors. staff and public areas with pleasant views. should be avoided • circulation spaces and common areas should be designed as places in their own right – enjoyable rather than utilitarian. Daylight – • daylight should be fully exploited to enhance the experience of patients. staff and public • internal spaces and courtyards should be orientated for optimum sunlight penetration Artificial light – • lighting should be used creatively and sensitively to enhance the use and experience of the interiors. Spatial quality Issues to consider: • there should be a sense of spaciousness with overcrowding avoided • spaces should be experienced as a sequence of attractive places with appropriate degrees of enclosure • long. 28 The psychological and social needs of patients . Views Issues to consider: • there should be special attention to creating patient. stimulation and calmness should be thought through • colour schemes should assist way-finding.

Issues to consider: • the building should be sited and designed with mind to its overall urban (rural) setting • the building should enhance the civic qualities of its setting. The psychological and social needs of patients 290 . should be designed with regard to their therapeutic value • the landscape design should maximise the security of pedestrians and avoid ‘no-go’ areas • the landscaping around the building should contribute to the neighbourhood • the external grounds and gardens should be designed for safety and security. including courtyards. Landscape Design Issues to consider: • hard and soft landscaping.BMA Science & Education Urban and social integration A sense of place The building should create a sense of place. A positive contribution to the community Issues to consider: • the design should promote a sense of belonging to and integration with the neighbourhood and wider community. A good neighbour Issues to consider: • the building’s height. Fit with site Issues to consider: • the building should be well integrated with the site topography • the spaces immediately outside the building should be pleasant • the levels should be designed to be appropriate for entrances and access to outside spaces • thought should be given to making land available for future development and expansion • the design should take advantage of orientation. volume and skyline should relate well to the surrounding environment • in the design thought should be given to what local residents and passers-by will think of the building.

• glare and solar gain should be controlled (eg with louvers and blinds). Passive thermal comfort The design of the building fabric itself should help create thermal comfort conditions. Durability Issues to consider: • the building should be able to withstand wear and tear in use • the finishes should be durable. Issues to consider: • quantity of space with natural/artificial ventilation and/or air conditioning • access by occupants to natural ventilation • control by occupants of heating and ventilation. Air quality Air quality should be fresh for patients. Issues to be considered: • there should be sufficient daylight in each area as required. Issues to consider: • passive summer cooling • minimising solar gain • high thermal insulation • control of infiltration. staff and the public. 30 The psychological and social needs of patients . Operability • the building should be easy to operate.BMA Science & Education Performance Daylight Set out daylight standards to be achieved. Acoustics and noise Issues to consider: • a good acoustic environment to deal with internally generated noise • sufficient sound proofing against external sound to provide comfort internally • adequate sound insulation between rooms • building acoustics to aid communication.

Prefabricated elements in engineering design Consideration should be given to the use of prefabricated elements. Specialist engineering systems Set out brief. requirements and standards to be followed for specialist systems. Issues to consider: • medical gases • fire engineering • emergency generators • batteries • nurse call systems • theatre and other lighting • cold water storage • telephones. Issues to consider: • structural elements • plant pods or pallets • sub-systems • pre-wiring • others as appropriate. Issues to consider: • energy consumption • therapeutic benefits • appropriateness and accessibility of control systems • relative levels of background and task lighting. and in use of resources • local controls should be provided for use by staff and patients • engineering systems should operate quietly.BMA Science & Education Engineering Operational building and engineering management systems and controls Issues to consider: • engineering systems should be flexible. Issues to consider: • structural elements • plant and equipment • lighting fittings and bed-head units • sanitary installations • others as appropriate. The psychological and social needs of patients 31 . Artificial lighting Set out quantitative standards for artificial lighting. efficient and economic in use. Standardised elements in engineering design Consideration should be given to the use of standardised elements.

Set out emergency backup requirements and standards.BMA Science & Education Fire planning strategy A clear fire planning strategy should be incorporated into the design. ventilation and air conditioning systems The heating. Set out thermal and ventilation requirements and performance standards. Issues to consider: • maximising the use of natural ventilation • minimising the use of heating • minimising the use of cooling • surface temperatures of radiators • zoning. Hot water and steam/operational engineering systems Issues to consider: • flexibility and efficiency of engineering systems • economy in use of resources 32 The psychological and social needs of patients . Heating. Emergency backup systems The emergency backup systems should be designed to minimise disruption. Energy and power systems Set out requirements and performance standards. draining and cut-off controls. Issues to consider: • optimising fuel consumption • maximising flexibility. ventilation and air conditioning systems should be logically designed to operate efficiently and provide local control where required. Issues to consider: • medical gases • emergency generators • batteries • nurse call systems • heating • theatre and other lighting • hot water • cold water storage • telephones. Issues to consider: • fire alarm and detection system • high life risks potentially compromised by high fire loads.

Issues to consider: • provision for future phases to be added with minimum disruption to the buildings in use • consistency of phasing with the estate strategy and development control plan • self containment and operational quality for each phase. Set out voice/data/comms brief and standards. Construction Phasing for planning or construction stages Consider whether the project needs to be built in phases. Issues to consider: • flexibility and efficiency • ease of learning • reliability. Issues to consider: • flexibility and efficiency • minimising the use of resources • capacity of the water supply system to provide safe potable drinking water • adequacy of water pressures for clinical processes • leak proofing the drainage system. Robust construction Issues to consider: • junctions between materials and components should be well detailed • components and finishes specified should have sufficient strength and integrity for their functions or locations • sound break out of potential nuisance to neighbours should be dealt with in the design. The psychological and social needs of patients 33 . Maintenance The building should be able to be readily maintained.BMA Science & Education Telecoms and IT systems The telecommunications and data systems should be easy to operate and ‘future proofed’ as far as possible. Issues to consider: • the building should be easy to clean • the construction should be durable • components in the building should be able to be readily cleaned. maintained or replaced when necessary. Water and drainage system Set out requirements and performance standards (refer to specific guidance as appropriate).

higher quality. speed of construction. radiators and hot water systems. sustainability or overall value for money. doors. sustainability or overall value for money.BMA Science & Education Integration of engineering systems. Prefabrication • consideration should be given to the use of prefabricated elements where they promote efficiency. structure and fabric The structure. Considered construction The methods and materials used in the building should be well thought through from the point of view of: • efficiency • impact on neighbours • safety • health. replacement and cleaning of glazing and windows. Issues to consider: • the building should support patients by conveying a feeling of safety and reliability • clinical and other workplaces should be designed for health and safety • the design should provide safe access and working conditions • the following areas (inter alia) should be designed and specified to prevent accidents and to comply with health and safety requirements: stairs and lifts. electrical and water systems should be well coordinated • the IT and communication systems should be well coordinated with other systems. speed of construction. fabric and the engineering systems should be well integrated within themselves and with each other. Standardised elements • consideration should be given to the use of standardised elements where they promote efficiency. maintenance and future expansion • the structural and engineering systems should be well integrated into the design • the mechanical. Health and safety The building should be designed for health and safety in its construction and operation. floors. 34 The psychological and social needs of patients . lighting and cold water systems. Demolition and recycling Consideration should be given in the design to demolition and recyclability. Climate Change Future climate change should be considered in the design of the building. higher quality. Issues to consider: • systems and structure clearly and logically organised for ease of use.

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