Healing Environment: Without and within, The

Scher, Peter

The Healing Environment: Without and within Ed. Deborah Kirklin and Ruth Richardson Pub. Royal College of Physicians, London. Price £15.99.

To healthcare architects, designers and arts professionals healing environments are the patients’ physical surroundings – buildings and their external spaces, equipment, furniture, decor, art works ansd so on. But to doctors, nurses, therapists and other healthcare workers the healing environment also embraces personal and social interactions and the conscious and unconscious processes – ‘within’ as well as the surroundings ‘without.’

This book, which succeeds the RCP’s excellent Medical Humanities: a practical introduction from the same editors (see HD june 2001), is about these two understandings of the healing environment. Of the four pieces specific to healthcare art and architecture three summarise projects which have also featured in HD. John Wells-Thorpe sets out the research by Lawson and Phiri (HD March 2002), Rosalia Staricoff and Susan Loppert the Chelsea and Westminster Hospital investigations (HDJune 2001) and Jane Duncan her art project for the hydrotherapy unit there (HD February 2001 ). The last of these is described and illustrated well in the book and looks very impressive, although the attempt at evaluation is disappointing. The other two set out to show that architecture and the arts affect clinical outcomes but, with the exception of the trials of music within specific hospital departments, the results do not impress. For example, at Poole Hospital Wells-Thorpe reports that 72% of patients gave a refurbished ward the highest rating they could for overall appearance whereas in an unrefurbished ward the figure was only 37%. This is associated with a shorter lengths of stay and reduced analgesic medication for patients in the refurbished ward. A clinician would need to examine the data very closely before accepting that these outcomes were solely and directly due to the appearance and design the refurbished ward.

The Chelsea and Westminster opinion survey asked an apparently self-selected sample whether, for example, they noticed the works of art and whether they enjoyed them, on a scale of one to ten. But which ones? They were also asked whether they felt the overall surroundings eased their stress levels. How does each different person assess their own stress level as affected by his or her surroundings? The authors also claim, without citing any data, that staging performances of La Boheme and La Traviata prove that the subject of death and dying can be broached by hospital arts programmes.

Unless their methodology and full data are exposed to critical assessment those who claim to do research in architecture and the arts cannot expect to convince sceptical clinical staff to accept their ‘proof.’ I am a believer and need no persuading of the value of high-quality architecture and the arts; I also have the highest admiration for the arts programme at Chelsea and Westminster Hospital, inspired by the late Howard Goodman’s commission to Arts for Health to join the design team at the very inception of the new building to create it. The message has now been received in the NHS and it is rare to find a healthcare facility without an arts project. What is still in very short supply is rigorous, independent research and evaluation of the wonderful range of arts in healthcare that we already have.

Ruth Richardson, art historian and co-editor of the book provides a digested history of hospital design. This is marred by her fatuous comparison between Chelsea and Westminster Hospital’s interior (“a modern incarnation of a great mediaeval cathedral”!) and the old St Stephen’s Hospital which she knew only by its exterior (“massive, dark, daunting”) in the 1960s. She seems not to have noticed the 1960s redevelopment beside it in the Fulham Road; this decent, if unspectacular design was physically neglected and then demolished to make way for the Chelsea and Westminster Hospital, whose fourth-rate exterior has no merit at all (see HD February 1993).

The six contributions by physicians and therapists, mainly about the environment ‘within,’ are altogether more convincing. From the viewpoints of patients and healthcare professionals the boundary between the environment within and the environment without is difficult to plot. Michael Anderson’s exposition of the work of MAPS in Stockport demonstrates impressive outcomes for both patients and community as a result of using the arts in mental healthcare. Professor Roger Higgs’ paper, The Medical Paradigm: Changing Landscapes, could hardly be bettered as an account of the realities of experiencing and treating illness. His sensitive understanding and his vision were profoundly important for the inception and realisation of the Lambeth Community Care Centre, a model of local secondary care, and a respected building.

Do not be put off by the dark cover illustration (a Madonna and decapitated Child) as the book is worth reading for these two sections alone. They illuminate the heartening developments in healthcare that are possible when the understanding of illness extends beyond the narrow biomedical model.

Peter Scher

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