Speaking at last October’s Healthcare Estates 2023 conference, Suzanne MacCormick, an experienced healthcare planner at healthcare consultancy, Spencer Harrison, discussed how getting the sensory aspects of healthcare facilities right plays a critical part in providing the optimal care environment and speeding recovery. While the importance of – for example – selecting the right colours, and providing sufficient light air, and quiet, is well-proven through numerous studies, in some hospitals, these elements are still not being adequately factored in, she told delegates. HEJ editor, Jonathan Baillie, reports.
Suzanne MacCormick’s keynote address in an early afternoon conference slot on 10 October formed the second ‘half’ of a two-part Health & Social Care Planning session; in the first Natalie Forrest, Senior Responsible Owner at the New Hospital Programme (NHP), updated delegates on progress with the planned construction of 40 new hospitals across England. The former nurse and hospital CEO/COO also explained the principles behind, and anticipated benefits of, the NHP team’s Hospital 2.0 initiative; its aim is to enable many more of the new hospitals required to be built concurrently – by speeding up the planning process, increasing use of standardised components, and harnessing Modern Methods of Construction (see pages 57-61 for a full report).
Clinical planning background
Suzanne MacCormick is a clinical planner who works with healthcare leaders globally, and also has a clinical practice, working with patients ‘to achieve lifechanging behavioural and emotional change, and optimum health and wellbeing outcomes’. Her current research is in the neuro-plasticity of the brain, and she is particularly interested in ‘the power of the subconscious mind on overall mental and physical health, and how our built environment impacts this’.
She began her presentation, ‘Building for excellent outcomes’, by emphasising that today’s healthcare buildings must not only meet numerous different standards – including those around Net Zero carbon, but must also be easily navigable, ‘totally accessible’, easy to maintain, improve outcomes, and be affordable and sustainable – ‘quite a big ask’. Addressing the topic both from a healthcare planner’s perspective, and through the lens of her clinical work and research, she said her presentation would consider the topic, ‘How we achieve excellence in outcomes’ in designing new healthcare buildings. Many delegates would be familiar with Winston Churchill’s saying: ‘We shape our buildings, and thereafter they shape us’, but her question was: ‘When we’re designing those buildings, how much thought do we actually give to the impact they have on us once built?”
Crediting IHEEM as a Professional Engineering Institute that provides ‘expert and valuable guidance and opportunities’ for engineers and Estate managers, ‘always leading to excellence’, she explained that the Institute now has a Strategic Estates Management Advisory Platform (‘SEMAP’) – on which she represents healthcare planning, and which would be holding a workshop immediately following her presentation. “So,” Suzanne MacCormick said, “we know IHEEM’s purpose, but what is the NHS’s raison d’être? It’s to improve our health and wellbeing, support us to keep mentally and physically well, and help us get better when we’re ill. In its constitution, the NHS aspires to the highest standards of excellence and professionalism, to provide the best value for taxpayers’ money, and to be sustainable. However, critically – and I know we’re discussing buildings today – the NHS puts patients at the heart of everything else. So, to ensure world-class health, the NHS says it does all of this to ensure that the population has the staff and facilities the service needs for the future.”
Opportunity or catastrophe?
This brought her back to what constitutes excellence in the healthcare arena. Her presentation would, she said, consider ‘excellence and excellent outcomes, what they are, and how we can all work together to achieve them’. To demonstrate how fundamental access to the right expertise is in achieving ‘excellence’ in healthcare planning and design, she used a hypothetical scenario, “Imagine,” she told delegates, “that instead of being here in this conference hall, we’re all on a plane going somewhere we’ve really wanted to go for some time. So, we’re all buckled up in our seats, and the captain announces: ‘Good afternoon, this is your captain speaking. Today, we’ll be flying to Bermuda, where the sun is shining brightly, and the temperature is currently 29 degrees. We’ll be flying at 31,000 feet, with a journey time of seven hours, 15 minutes, and landing at 3:30 pm local time. However, I won’t be flying the plane today; instead, Jane, the head of cabin crew for 20 years, who knows this aeroplane inside out, will be your pilot. She really knows how to look after her clients, has travelled many thousands of miles serving passengers from across the world, and knows all there is to know about planes. So, Jane, over to you.’
“How would you feel about this?,” Suzanne MacCormick asked delegates. “Personally, I would be straight off the plane. Jane is no doubt a critical part of the in-flight experience, but not flying the plane. Similarly, a critical part of delivering excellence in healthcare planning and design is recognising that there are specific roles for specific people, and it is the quality of the interface between the various professionals that makes the excellence happen.”
She added: “I’m now going to look at this both from my clinical perspective, working with our behavioural neurology, and from a healthcare planner’s standpoint. What we know about buildings,” she continued, “is that they absolutely can cause constraints and make us feel good, or indeed bad. On their own they don’t solve health problems; it’s the processes, flows, ergonomics, and the ‘soft’ things around them that make the difference. As part of a complex design team delivering healthcare buildings, I want to really nail down what credence we give to the impact of that environment on us, our wellness, recovery, and staff’s ability to perform. So, whether it’s working within the estate, or staying in hospital as a patient, what is the impact of that environment on our health?”
Healthcare planning, Suzanne MacCormick, stressed, was ‘absolutely clinically-led’. She elaborated: “The clinical model comes before anything; even before Stage Zero – what is it you want to achieve? We develop the clinical model around which we can develop excellence in design – based around excellence in flow and delivery. Once we have the model, our service needs emerge, and we can then properly understand the resources required.”
With an ageing population, more people living into their 80s, and more multiple comorbidities, the aim shouldn’t, she argued, be to bring all these people into hospital if they can remain well in their own environment. “So,” she said, “it shouldn’t always be about the estate. Healthcare clinical planning is about keeping people well, which should lead the agenda. As healthcare planners, we ask the existential questions to determine not just where the healthcare provider is on its journey, but also its goals, and how it plans to achieve them. Our job is to be the objective friend in perhaps challenging some of the standard ways you’ve done things, so that maybe you can be better prepared for the future.”
This approach, Suzanne MacCormick explained, harnesses ‘the seven flows of healthcare’ (see page 34). She said: “When planning a new healthcare building, patients should be at the centre of your considerations, with patient flows, and excellence in clinical delivery, the vital elements.” Nevertheless, a detailed understanding of the importance of ‘the other flows’, and how the building needed to be designed and shaped to facilitate efficiency and excellence, were also key. She continued: “The other key elements include the staff, and what they need within the space; how medicines come onto site, and reach the point of delivery, plus the equipment, and the process for replacing it. We then need to similarly consider ‘supplies’ and ‘information’.” Information was not, however, purely about paper or digital information, she stressed: “ ‘How do things get from one place to another?’ and ‘How do you notify somebody of something?’ ” There were then visitors to consider – not just those visiting the sick, but anyone else entering the healthcare space. These ‘seven flows’ were, she said, healthcare planners’ ‘bedrock for doing things really well design-wise’. She added: “We then work hand in glove with architects to ensure that all these elements are addressed. I’d emphasise, however, that ‘one size definitely does not fit all’.”
Different demographics, resources, and finances
Every demographic was also different, as was every NHS Trust – in terms of its finances and organisational structure, while healthcare needs varied considerably from location to location, as did the available resources, workforce, and skills.
Suzanne MacCormick’s next focus was human factors, and ‘the power of the subconscious mind’. She explained: “Human factors are the cognitive, social, cultural, physical, and emotional factors that make up our complete experience – in healthcare settings as a patient, a staff member, or a visitor. All these affect how we feel, and on every building project I’ve worked on in the past 30 years, I’ve factored them all in.
“So, from a clinical perspective,” Suzanne MacCormick added, “we can enhance clinical performance – via understanding the effect of teamwork, tasks, equipment, workspace, culture, and organisation, and the impact all this has on our human behaviour, our abilities, and how we apply them in a clinical setting. These are things we should never miss; it’s about recognising that our buildings shape us. The subconscious mind is infinitely more powerful than the conscious one, and all behaviour, once learned, is done subconsciously.”
Some actions naturally ‘hardwired in’
Suzanne MacCormick said this factor meant we can anticipate the outcome of things, with the brain building its neural pathways, resulting in certain reactions and actions effectively being ‘hardwired’ – and thus undertaken subconsciously. She asked delegates: “Do you remember first learning to tie your shoelaces? As a small child it’s a very complicated task, but once you’ve done it, you don’t spend the rest of your life thinking about how. You do it subconsciously. Then,” she continued,” there’s learning to open a door. Fascinating when you are two years’ old, but you very quickly learn there are handles you push down, or round knobs you turn – so you don’t feel challenged every time – unless, of course, modern architecture steps in and messes with your hardwired programmes. Then,” the speaker said, “you think ‘Wrong door’, and you’re snapped back into reality, and must use the other door. What we thus want, as designers of healthcare buildings, is to give that best experience, which is really easy to do
“Now,” she continued, “I want to look briefly at two elements of design that impact us at a subconscious level in our pre-frontal cortex and amygdala – the parts of the brain that affect our emotions. We’ve all heard about Biophilia, and our human connections to nature, but I only want to focus on three elements today: air, light, and colours, and how they impact us – both subconsciously and at a cellular level. So,” Suzanne MacCormick said, “we hear regularly about Biophilia and our visual connection with nature – plants, patterns, and all the associated fractals, and then there are natural materials, minerals, and so on. All these stimulate elements of us – even if it’s just a synthesised view, such as a green picture of a field, and make us feel connected to nature.”
There was also, she explained, our ‘non-visual’ connection with nature, ‘often undervalued at a design level’. She said: “This is where it affects our other senses, such as sound, touch, smell, and taste, to remind us of that connection. In fact, the presence of water alone can be incredibly calming, and impacts us at a non-rhythmic, sensory stimuli level. You then have wind and air – important because thermal airflow variability really impacts us at a cellular level, i.e. on how we recover from ill health and feel well. There are also dynamic and diffuse lights, both of which subconsciously impact recovery.”
‘Numerous’ healthcare studies on the impact of light and air had, she noted, shown that patients exposed more to natural light often experienced less pain. She added: “We also know that even in an ICU, when a patient might be comatose, with real sunlight and fresh air, their recovery at a cellular level is much quicker.”
Florence Nightingale had recognised the importance of air and light; hence the Nightingale wards no longer used ‘because we’ve moved on to things like privacy and dignity’. “With that privacy and dignity, however, “Suzanne MacCormick asked, “have we lost sight of the benefits of light and air? In fact, there is plenty of empirical research proving that surgical peak patients exposed to greater sunlight require 22% fewer pain relief medications. This resulted – in the studies we looked at – in a 21% reduction in drug budgets. More importantly, the patient experience was so much better, because sunlight and air literally heal us at a cellular level.”
An ‘indoor species’
Humans had, by now, become an ‘indoor species’, with many of the offices and other spaces we occupy almost devoid of air and light. The speaker said: “In many meeting rooms, open the door, and it literally breathes air back into the room and invigorates you, getting oxygen to the brain, and you feel a lot more alive. It also increases serotonin levels.”
On the impact of colour, Suzanne MacCormick had recently worked with ‘a wonderful architect,’ who had told her ‘Everything about colour is rubbish.’ She said: “I’m going to challenge that – so, for example, we know yellow makes babies cry more, and patients far more irritable, and gives clinicians migraines and headaches. I’m not talking about looking at swatches, or the colour of a jacket, but rather the experiential thing we get subconsciously on walking into that coloured environment.
“Orange environments can make you feel nauseous, while green can make you vomit, and is really bad from a clinician’s perspective, because – as ladies here may know – when you get red and blotchy you use green base foundation to remove the red. As a clinician, however, you don’t want red colouring removed from the patient, because you want to see the first sign of a raised temperature, for example – so colours are really vital.”
Colour quadrants
Showing a slide of a circular colour spectrum (see page 36), the speaker explained that all the ‘negative’ colours – especially greens and yellows – sat in the top right quadrant. “Conversely,” she explained, “the calming colours that make us feel good – such as blues and pinks – sit at the bottom left, while we avoid shades of red (shown in the 8 o’clock – 10 o’clock portion of the spectrum) because they make us angry and scared. Isn’t it interesting that there’s a distinct line running horizontally across the centre of this spectrum separating the colours that that make us feel good or ‘bad’ subconsciously? Why do we use the colours in the top half?”
Reinforcing her point about the impact of different colours on patients, and indeed staff, Suzanne MacCormick drew on an anecdote. Showing a slide of part of a hospital interior, she said: “Building a new single-bedded extension to a hospital, we used this (purple) palette. All the nurses had expressed their reluctance to work in the environment, saying they preferred large wards. At our open day, however, every single nurse walked in, commented on the ‘great’ environment, and signed up to work there – because we got the colour right.”
Alongside their impact on mood and wellbeing, different colours could improve wayfinding, a point again demonstrated via slides showing hospital environments. She said of one particularly well-signed environment: “Here, patients would arrive, look at the coloured wayfinding signs, and get to the required treatment location quickly and easily. They’d then wonder how they got there, but would also mention how easily navigable the building was. That’s because – at a subconscious level – you pick up a colour a million times quicker than you get to a sign to read it. Your brain thus takes you where you want to go. Why aren’t we doing more of this?”
Switching focus, Suzanne MacCormick showed a slide of several HTM and HBN documents, and said: “We have a plethora of standards that are so out of date and inaccurate they do not deliver clinical excellence, yet we have to use them. I want to challenge this. I really believe we’ve thrown the baby out with the bathwater. This room is full of experts who really know how to deliver excellence, and clinicians who know how to deliver great clinical care. A healthcare building really isn’t about the bricks and mortar; it’s about delivering excellent patient outcomes.” The speaker said many of the audience would have experienced buildings around the world characterised by excellence in structures, engineering, and aesthetics, and would ‘know how they make us feel’. She said: “And when we feel better as humans, we get well as humans. So, we know – innately and experientially – about excellence.”
Summing up, she said: “Building for excellence is about building for optimal experience and wellness – for everyone working in a building, and every patient. Do the wrong thing and we cause cognitive overload. So, we know we can use colours that calm, nurture, heal, and make us feel better. We also know we can develop acoustics that really help minimise noise, and help us subliminally feel better, and wayfinding and colours that subconsciously help us get to our destination
“Similarly, provide rest areas that link to nature, greenery, and health, and have fresh air and light that ensure healing, boost mood, lower heart rate, and increase energy levels, and we can eliminate the pressure cooker effect buildings can have. Finally – on people – we need to ensure we rely on teamwork; i.e. not just the individual roles that make up a building programme. So, an architect working hand in glove with the clinical planner, who in turn works with the clinical teams to get the right thing, meet the right challenges, and get the right results and skills at the right time. Interestingly and very perceptively,” Suzanne MacCormick said, “Einstein noted that that ‘Excellence is doing a common thing in an uncommon way’. Perhaps that should be our mantra?
“Our buildings undoubtedly shape and impact us,” she concluded. “So let’s build for health and wellbeing to improve those health outcomes.” This closed the second part of an interesting session, and, having thanked both speakers, the session’s chair, Paul Fenton, invited the audience to put any questions to Natalie Forrest and Suzanne MacCormick.
Audience questions
The first question centered on how the New Hospital Programme team would address the six years Natalie Forrest had explained that it takes, on average, to get the business case for a new healthcare facility approved. She said: “This is definitely a work in progress – because there are so many agencies involved in putting together a business case – but we’ve set ourselves a challenge to cut the period to two and a half years.”
Another delegate asked whether – with MMC a key route for delivering the new hospitals, there was a sufficient pipeline of such schemes for MMC contractors to justify investing in large factories to deliver them. Natalie Forrest said: “Yes, absolutely; 40 hospitals to start with, but earlier this year we secured a rolling programme of investment into the NHS. It’s thus not just about the 40 hospitals. One of the objectives is to build that capability within the system, so we can keep going. Those familiar with our estate will know there aren’t just 40 hospitals needing to be built – so, absolutely, there is a pipeline.”
Natalie Forrest was then asked what lessons had been taken from the ‘industrialised construction’ operated in the 1960s with high-rise blocks? She replied: “Well, as Suzanne said, I think it’s key that ‘no one size fits all’ – and high-rise buildings are not environments we particularly want to build hospitals in. There will be some, but what is key is to take and implement all the learning around fire compliance, and the many new standards being put in place. We recognise we need to advance, and we have different expectations. With highrise facilities particularly, fire safety is the biggest priority.”
A senior representative from the Design in Mental Health Network was particularly interested in the role of co-production, and asked both speakers about working with people with lived experience.
Natalie Forrest said: “I’ll answer first – on what we’re doing in the New Hospital Programme. Everything Suzanne spoke about resonated with this work, because many of you will be aware that I’m a nurse, and have worked in these facilities for 35 years, so I understand what makes a difference to the workforce and patients. Suzanne’s right; we must take into account the human factor, and we have a whole team whose sole purpose is to engage with patients, the public, and staff, to understand what their needs are, and enhance both the patient experience and clinical outcomes. We absolutely have to do that.”
She continued: “Regardless of specialty, it’s the same principle of co-design, while none of the new schemes we are working on will get a ‘one-size-fits all’ hospital. We are developing the clinical standards with Trusts and the Royal Colleges, but the project teams will put together the components in the way that works best for them and the services they’re delivering.” Suzanne MacCormick added: “It’s really important to understand how people feel, but also to know that facts and feelings aren’t the same thing, which is why working with patients is so critical. It’s also about asking the right questions of both staff and patients, and then aligning that with all the other design intelligence and expertise.”
Work with ‘important new stakeholders’
Natalie Forrest was then asked what, if anything, the NHP central team can do to help Trusts ‘work well with important new stakeholders’, such as Integrated Care Boards. She replied: “I’d love to help everyone do everything, but I can’t, and it’s important to recognise that the Integrated Care Systems are now maturing, and have that responsibility, and indeed some of my NHP team colleagues and I participated last week in East of England events with the Integrated Care Systems in the region only last week.”
She continued: “We rely on healthcare planners to understand how to translate that into what we need. As regards models of care and moving care closer to home, we have a responsibility to build the right-sized hospital. This includes recognising if a particular hospital might need to be smaller, but that if so, we might then need to provide other facilities locally elsewhere. What we can’t do is build these hospitals on a wing and a prayer; we have to be sure those shifts in care models are going to be realised.”
Here Paul Fenton asked a question, explaining that at a recent Public Accounts Committee meeting, the National Medical Director of NHS England, Professor Steven Powis, had mentioned the experience gained from international learning around COVID, and what had been learned from clinical practices. Paul Fenton’s question was: “Why are we not – or indeed if we are, where is it being demonstrated – learning from estates and building designs from the international sector? We know that TAHPI (an international specialist in health planning, architecture, and technology), for instance, is working across 32 countries doing some massive billion dollar projects in 20 of those, and that the business has international facilities guidance, and a Health Facilities Briefing System. So, when we talk about standardisation in a building design, and everything Hospital 2.0 is trying to deliver, have we taken any of that learning from our international colleagues, and fed that into the New Hospital Programme?”
Natalie Forrest said: “Yes – absolutely. We talk to colleagues across the world on a continuous basis. Australia, Canada, and our Scandinavian colleagues, are doing a lot of hospital building. What’s key is to understand the different context they’re building in, and feed the learning into the Programme. Expertise is coming from all over the world.” The same speaker was asked when the first outputs of Hospital 2.0 would be seen. Natalie Forrest replied: “We have already issued many of the clinical standards with the Trusts we are working with, but it’ll be late spring 2024 when we have a product we feel has enough components for us to share widely with our NHP schemes. What’s key, though, is to keep testing and learning from the standards we have, and making them better. We work alongside our NHSE colleagues to ensure we’re integrated with all of their thinking, so that if we agree a new standard, we’re all agreed on the approach. We must also ensure that standards are continually updated, although the process does take considerable though and collaboration.”
Another delegate asked how the NHP team was addressing staff wellbeing in the new hospital designs. Natalie Forrest responded: “This is why it has been great presenting with Suzanne, because she’s discussed the human factor. We also learned a huge amount during COVID about the impact of the environment on our staff. So, as well as talking about clinical standards for patients, we’ll be setting new standards for staff.
The last question, for Suzanne MacCormick, was around elements such as single beds, views of nature, and use of colour. The delegate’s view was that ‘much of this stuff’ – i.e. the elements shown in studies to aid recovery, had been developed by Roger Ulrich ‘20-30 years ago’, and were thus already well established. He asked: “Hospitals everywhere are designing using these principles; do they really need to be brought into the UK – which seems to have been dragged kicking and screaming to single bedrooms – now?”
A ‘lone voice’?
Suzanne MacCormick replied: “I guess your question is: ‘Why aren’t we doing all this already?’, and indeed I have the same question. On every project I work on, I will bring in all of the elements I have discussed, but sometimes I feel like a lone voice. My clinical expertise is in psychology, but these things are not just something we’ve created. Psychology has come from study of man, and we’ve created the models through knowing that this is how humans work. So we know all of these things, and need to do embed them into the normal way of doing things. Take colour, and the reason I put it on a spectrum is because it’s really clear the colours that work the best in healthcare settings, so why are we using the others?”
She added: “I recently visited a new hospital with an orange reception, yellow walls, and a green Paediatric Department, where even the nurses felt ill. In fact the day the new ED opened, they closed it, because it was yellow and green, and was causing these kinds of problems. I’d also emphasise that as healthcare planners, we’re ‘for life, not just for Christmas’, i.e. we need to be brought in at Stage Zero, and involved all the way through projects.”
Here, Paul Fenton thanked both the session’s speakers, and the audience, adding: “I’d just like to mention the terrific work that IHEEM’s Strategic Estates Management Advisory Panel is doing looking at healthcare planning, and health system planning, and everything that Suzanne was talking about is absolutely crucial. It’s also a plea to you, Natalie, that you allow the work that IHEEM and its members are doing to be very much part of the New Hospital Programme.”