Beyond Walls

ROYAL HOSPITAL FOR CHILDREN AND YOUNG PEOPLE, DEPARTMENT OF CLINICAL NEUROSCIENCES AND CHILD & ADOLESCENT MENTAL HEALTH SERVICES, EDINBURGH

Publication Authors: Gill and Chris Fremantle with Tom Littlewood

Published By:

NHS Lothian Core Team:

Ginkgo Projects Ltd on behalf of NHS Lothian

Janice MacKenzie, Project Clinical Director, NHS Lothian

Sorrel Cosens, Capital Planning Project Manager, NHS Lothian

Mary Murchie, Charge Nurse, DCN Outpatient Department

Margaret McEwan, Play Services Co-ordinator, Play Specialists and Play Assistants Manager

CONTENTS

New hospital buildings are once in a lifetime opportunities. We build them to enable better services, incorporate new technologies and new thinking about what it means to care for patients and their families and carers.

NHS Lothian’s Royal Hospital for Children and Young People (RHCYP), the Department of Clinical Neurosciences (DCN), and Child and Adolescent Mental Health Service (CAMHS) all have significant histories and, in moving to a new shared building, the ambition has been to create a new chapter.

The integration of art and therapeutic design supporting patients in their pathway through healthcare is an important aspect of NHS Lothian’s expectation for many prospective building projects. This ambition is shared with two key funders of the Beyond Walls programme, Edinburgh and NHS Lothian Charity and Edinburgh Children’s Hospital Charity (ECHC).

Beyond Walls curator and producer Tom Littlewood of Ginkgo Projects Ltd formed a programme that focussed on supporting the patient journey through enhancing wayfinding, designing for dignity, personalisation and distraction.

The programme also provided time and space for artists to work through a fellowship and residency programme.

The sections in this publication explore the ways that the art and therapeutic design has been developed from the perspective of NHS clinical, nursing and allied health professional staff together with the perspective of the artists and designers. We hope that the combination of voices provides a rounded understanding of this ambitious and innovative project.

In addition, there are two essays articulating the perspectives of the key stakeholders, Susan Grant on behalf of Edinburgh and Lothians Health Foundation, and Roslyn Neely for Edinburgh Children’s Hospital Charity. These highlight why art and therapeutic design are considered important elements of healthcare.

More than 40 individuals and teams – graphic, textile, furniture and lighting designers, artists, sculptors, illustrators, printmakers, writers, composers, film makers, animators, theatre directors and digital programmers – have contributed to 26 projects to create Beyond Walls for the new NHS Lothian Hospital forming one of the largest art in healthcare programmes in the UK.

The New Building

The major new building at Little France is shared by two distinct acute services, the Department of Clinical Neuroscience (DCN) and the Royal Hospital for Children and Young People (RHCYP). In addition, it also includes a Child and Adolescent Mental Health Service (CAMHS) with its own unique needs. All three services have strong identities and proud stories. Maintaining the sense of individuality whilst ensuring efficient use of shared services is central to the design of the building.

The new building supports modern up to date healthcare across all three services, and brings physical and mental healthcare together within the building.

There are common themes relevant to the building for all patients:

• patients are at the centre of the new hospital and all the processes within it

• the building design suppor ts families as they care for their children/young people and adults in the healing process

• physical and mental health facilities are on the same site

• each service within the building has its own identity within an integrated clinical facility, providing appropriate and discrete environments for all patients: children; young people; and adult patients, each with their own clear visual and spatial identity

• patient pathways for both patient groups are separate wherever possible

• 60% of the 233 beds are ensuite single rooms providing both privacy and supporting infection control

• the building is spacious, light, colourful and comforting and does not feel like an institution

The Art and Therapeutic Design programme, Beyond Walls, was founded on support for promoting the experience of patients as they navigate the physical and emotional experience of arrival, waiting, treatment and staying in hospital. Susan Grant commented, “It’s a fantastic showcase in terms of the physical outcomes, but also in reflecting what’s possible with very generous funding support and a commitment from genuinely engaged staff members.”

Key Stakeholders

NHS Lothian Charity has an ongoing commitment to the use of art and therapeutic design through its Tonic Arts programme, to achieve its overarching aim, ‘longer lives, better lived.’ Edinburgh Children’s Hospital Charity (ECHC) - aims to put the child first: Roslyn Neely comments, “We exist to transform the experiences of children in hospital so they can be a child first and a patient second.”

NHS Lothian, in committing to the role of art and therapeutic design to support the patient pathway, recognised the importance of integration within the building from the outset. Janice MacKenzie, NHS Lothian Project Team Clinical Director, and Sorrel Cosens NHS Project Team Project Manager provided the core vision and support to enable the formation and delivery of Beyond Walls.

Janice MacKenzie said of NHS Lothian’s ambitions, “We were clear we didn’t want the building to just be like any other hospital and we were very clear that we didn’t want the art to just be for the Children’s Hospital. Everyone on the team could see the benefit of the art work in all its different guises in the existing hospital and we wanted it not to be the same but better.”

Our Approach

Ginkgo Projects worked for both NHS Lothian and for the main building contractor, Multiplex Construction Europe Ltd to curate and develop the Beyond Walls programme. Each project went through a staged approval process overseen by a multi-disciplinary Steering Group. The programme was directly procured through Ginkgo which allowed for space within the commissioning process for artists and designers to work flexibly with fabricators. Early selection of designer and artist teams allowed for an integrated approach to embed proposals with the design of the building.

Key to the curatorial approach beyond the positioning of commissioning within keys points of the patient pathway was the opportunity to draw in the city and build new partnerships to promote and reflect the social and cultural aspects of the city which the hospital serves. Focus was placed on a people led approach embedding co-creative and participatory practice building relationships between artists and designers with staff and communities. It also served to promote the value of a placebased approach to leverage local and regional cultural resources and partnerships for the benefit of all participants.

Scale and Focus

Art and therapeutic design enriches more than 30% of the rooms in the building.

The programme draws on the substantial evidence of the role of therapeutic design and art to:

• reduce patient stress through enhancing wayfinding

• de-institutionalise spaces to support patient dignity

• improve recovery times

• reduce the requirement for pain-relief medication

• increase staff retention rates

Beyond Walls supports and promotes a sense of identity and distinctiveness within the hospital environment. Each project was developed within the guiding principles:

• creating a positive healing environment focusing on user experience

• recognising the importance of cultural context and cultivating community links

• integrating the role of the artist and designer into the design and working life of the hospital

• upholding artistic quality and contemporary practice.

Publication Structure

We have spoken to many staff and have, wherever possible, brought together the voices of NHS clinical and support staff with the voices of artists and designers to provide the clearest sense of how the programme is focused on patients, families and carers through the following four chapters.

The Way Through addresses wayfinding, a key challenge in healthcare environments, and a specific cause of stress and anxiety for patients, families and carers. Providing effective wayfinding is, as with all healthcare, a multi-disciplinary challenge involving the NHS, architects, wayfinding signage designers, and artists. Art provides several important aspects of wayfinding including building on the building colour scheme adding pattern and texture at key points, commissioning unique landmarks, and connecting the building with its wider context.

Wonder draws out the multifaceted use of distraction. Distraction has traditionally been associated with children’s services, and in this project the benefits to service delivery of distraction have been extended to specific aspects of adult services. Distraction is widely understood to be a vital aspect 8

of the patient pathway, particularly in the context of treatment and also in relation to staying and waiting in hospital.

I am not a Number explores how artists and designers have helped shape dignity and personalisation, the complement to distraction, and a vital aspect of a caring environment. This case study focuses on the design process for challenging spaces including the Child and Adolescent Mental Health Service, the Child Protection Unit, the Spiritual Care and Bereavement Suites as well as Interview Rooms across the Hospital. The engagement process, driven by co-creative approaches from the various artists and designers, has shaped not only the look and feel, but more fundamentally the ways in which these different areas meet the needs of patients, families and carers.

Time & Space opens up the work undertaken by artists and designers through the Residencies and Fellowships programme. Artists worked with Mental Health Service users, but also with clinicians in the Department of Clinical Neurosciences interested in smell and trying to build awareness of Functional Neurological Disorders.

Artists and designers involved in this aspect of Beyond Walls were not asked to deliver any installed work in the new building, but rather to open up and connect with new communities and audiences. Throughout the Case Studies we have highlighted the impact and benefit of the cocreative approaches of artists and designers, clarifying the needs of patients, families and carers and resulting in funders allocating additional funds. Rather than profiling each project in detail, we have focussed on showcasing the key benefits to patients and staff of working with artists in the creation of a therapeutic environment within the provisioning of a complex building with complex service needs.

We very much hope that our placebased and people-led approach is reflected in the resulting high quality final work. We hope that the approach provides evidence to support the case for the normalisation of working to create therapeutic environments over the coming years.

Key Collaborators

Spine Wall and Main Entrances: Peter Marigold, Artist

Christina Liddell, Dance Instructor

Evan Glass, Patient

Peter Keston, DCN Consultant

Atrium Vestibules: ELFA / Kevan Shaw Lighting Design

Wall Graphics:

Claire Hope, Artist

Alison Unsworth, Lead Artist

Rachel Duckhouse, Artist

David Galletly, Artist

Natasha Russell, Artist

Andy Illingwor th, Interior Designer, HLM Architects

Sanctuary Stained Glass: Emma Butler-Cole Aiken, Artist

Old to New:

Kate Ive, Artist

Joachim King, Designer and Maker

Ruth Honeybone, Manager, NHS Lothian’s Archive

Why wayfinding works.

‘Would you tell me, please, which way I ought to go from here?’

‘That depends a good deal on where you want to get to,’ said the Cat.

Alice in Wonderland, Lewis Carroll

We have all felt lost at some time, whether that’s physically or mentally. It might be that we were stressed, distracted, excited or something as simple as not being able to spot a sign. Finding your way around a hospital as a patient, carer or family member can seem a bit scary, bewildering, exciting or just over-whelming.

The patient’s pathway is the key inspiration of Beyond Walls. Everything is focussed on making the experience of visiting or staying in the new Children’s Hospital, CAMHS and DCN as positive as possible.

In this chapter on Wayfinding we review several projects that seek to lessen patient stress by supporting patients and visitors to find their way through the building. Sometimes quirky, always interesting, the art and therapeutic design exists to make the various

journeys that countless numbers of people will undertake as smooth and as easy as possible.

The Spine Wall is a 180 metre long glass reinforced concrete wall that acts as a backbone to the building, flowing directly into the main atrium from both external approaches.

As Peter Marigold explains, “The design for The Spine Wall features three-dimensional skin textures taken from one representative from each of the three Services.”

Peter always knew he wanted explore how to create such a huge artwork without it feeling overwhelming. “I wanted to investigate textures and shapes of skin at microscopic levels and how these seem both utterly familiar and yet equally mysterious.

I chose skin samples of patients and staff because I also wanted to reverse the idea that the hospital is simply a container of humans, but instead the building is created by the people who inhabit it. In this case, the skin of the occupants wraps around the building between all parts of the hospital flowing into the landscape outside.”

Peter ran casting and impression making workshops to explore the evolving themes. As he says “There were lots of different people involved in lots of different ways. They weren’t about working on the artwork directly but they did provide a taster of what I was thinking about, so we worked with microscopes and textures, modelling and casting. They were fun and everyone was really enthusiastic. In the end three volunteers’ skin samples were used.”

Sorrel Cosens said, “One of the things that came through loud and clear from staff moving out of the existing sites was that there is a real love for the buildings and their history, so they were very keen to develop something physical that could be a new identity. This is really why and how The Spine Wall came about.”

It also helped the staff understand the benefits of the Beyond Walls programme. As Tom Littlewood, explains, “Clinical Directors were working alongside DCN staff and patients. The artist-led workshops started to open people’s minds about the role artists could play in what is a major intervention in the building.”

With such a large-scale work there were many technical challenges. Peter Marigold said, “We went through a lot of samples of differing depths in order to get

it right. The wall looks different depending on the various lighting effects and we also had to have a balance between an approach that would work outside as well as inside.

What I wanted was that sense of scale. It’s huge but when you’re standing right next to it you might well think it’s just texture. You might not be sure if it’s stone or mineral. I’m hoping that your relationship with it will be different, depending on where you are standing and what part of the wall you’re seeing.

I wanted it to be characterful without being obvious. It’s the idea of skin but without identity. It could be any one of us. The patterns of skin are staggered and scattered across the space. Only coming together to form complete images in certain key areas. I’ll leave you to discover where they are. Hopefully a double-take

played out over a long period of time.”

Kevan and artist Claire Hope were responsible for the Atrium vestibules which the Spine Wall links. The two glass entrances, one at each end of the Atrium, form both a physical connection and colour ‘place’ marker. Kevan and Claire felt that embedding the entrance and exit experience in people’s memories could “help to reduce two potential moments of stress in an individual’s day by simplifying a journey.”

One of the aims NHS Lothian felt was that each part of the building should have its own identity and that the patient pathways for both patient groups would be separate wherever possible.

You can see the distinct colour of the vestibules from across the Atrium and from most levels

internally: a simple visual cue on a patient or visitor’s journey. The new Children’s Hospital entrance is bright blue and orange and the DCN entrance is green and purple. Claire Hope used abstract, transparent colour washes which are both a wayfinding tool but are also relaxing and very striking. She described the space as being about the, “play of daylight on the transparent paintings” with a “natural sense of time and location as the colours, shades and shadows shift across the hours. By overlaying artificial light in the evenings, the dynamic changes to that of a beacon in the landscape - a full body experience” that offers “a moment of calm.”

The attention to detail to ensure a clear pathway is at the heart of this building and carried on through the use of light and colour at the DCN entrance through to the Service.

The green of the vestibule is picked up and carried on as a visual clue with the same green continuing in wall-mounted lightboxes, providing a guiding stream of colour and leading you to DCN Outpatients reception.

Another way the DCN entrance is differentiated is the large artwork stretching up three floors. Peter Marigold, working with clinicians from the Department developed this from a patient’s angiogram. The staff were very engaged in what the visuals in the Atrium and in particular ‘their’ entrance would be like. Sorrel Cosens said, “The staff are rightly proud of what they do and seeing that exhibited in a different way, though art, has been a really new experience for them.”

At the RHCYP entrance Peter created a large-scale, wall-based work that captures the movement derived from a therapeutic dance

session held at Musselburgh Primary Care Centre. The looping shapes track each of the participant’s movements -one is the young patient Evan Glass, the other dance instructor Christina Liddell. These movements were at first interpreted by the artist using motion tracking technology and then loosely translated by hand. Photographs superimposed onto the abstract forms differentiate the colours of the two dancers in motion. Peter wanted the artwork to reflect the happy and playful interaction between the patient and dancer through an abstracted form.

Colour is an integral part of the Wayfinding techniques used throughout the hospital as part of interior design, signage as well as art and design. It enhances identity, creates a memorable pathway, and a more relaxing and

pleasant environment for patients and their visitors, and, of course, the staff.

As interior designer Andy Illingworth explained, “I was obviously very keen to understand what the Art and Therapeutic Design involved and how this would integrate with our overall concept for the hospital and also what sort of areas it would affect. It was important to make sure it coordinated with existing services and existing architectural interior elements of the building.”

Andy continued, “It helped that Ginkgo were involved very early in the bid stage of the project and they understood what we were trying to do and vice versa from the outset. In some cases, the projects could stand alone but in others they had to consider the whole hospital. For example, the Wayfinding Graphics had to tie in

with the colour scheme for the different hospital areas. Their areas of expertise and the artists who had been appointed could take a theme that we’d identified and dedicate a lot of time and extra research into taking it to that next level of enhancement. For us it might be a concept idea but looking at it from an artist’s point of view means a different approach.”

That ‘different approach’ was created by a team of three artists Rachel Duckhouse; David Galletly and Natasha Russell, supported by Lead Artist Alison Unsworth. As Andy Illingworth pointed out earlier, as a major project providing visual clues to support the patient pathway, it had to also connect with the existing colour palette and themes which HLM had introduced.

The Wayfinding Graphics team had a lot of freedom to come up with new, interesting and quirky interventions at approximately two hundred locations and which, as Alison Unsworth says, “supports the patient journey throughout the hospital, provides patient and visitor distraction, helps create a sense of place and identity and creates links with the surrounding city community.”

Creating the links with the community meant getting out and hearing what people thought. “We did a lot of engagement work before we started. We had a workshop at the National Museum of Scotland where we asked people to describe and draw on luggage labels what they thought should be included in the graphics.”

David and Natasha spent significant time at the old Hospital

working with play staff, children and young adults. “It was important to be on the ward and play areas and doing drawing activities to get feedback about the interests and context. We also did the same in the waiting areas in DCN with each artist working on various activities so that we could chat to people about what interested them, for example, memories and reminiscences of the local area.”

“The Wall Graphics you will see around the hospital for Wayfinding are split into three groups,” explains Lead Artist Alison Unsworth. “The first group is in the main public corridors created by Rachel Duckhouse. As a person moves through the public corridors on each floor there will be ten to fifteen Graphics locations with the idea that they are a series of linked images and you will remember the last one you saw as you spot the

next one at a junction ahead creating a visual ‘trail of breadcrumbs.’ They draw on HLM’s colour scheme with accent colours to give a visual ‘pop’. They are in linear strips and are made of different shapes. There are cubes on the ground floor, chevrons on the first and second floors and hexagons on the third and fourth floors.” These patterns and colours are subtly replicated around signs as an extra visual Wayfinding clue.

Rachel takes one shape as a motif and plays with it in different patterns. Rachel is a printmaker and she hand-prints so a lot of the shapes are linocuts or are printed directly from materials. For example, on the first (rural) floor they are printed directly from wood capturing the grain. She made a whole range of printed patterns, scanned them to make digital files and created lots of different combinations of shapes.

It was very important for Rachel that you could see these were hand-made and not digitally altered for size or shape so there will be little random marks or misalignments to add ‘life’ and interest. Where a line is made up of multiple shapes, for example hexagons, she’ll also has a floating hexagon that looks like it’s jumped up to the ceiling or fallen down to the floor. The odd chevron will look like it’s decided to be a boomerang, and cubes will pile up like unfinished walls. All these quirky details add both interest and help with working out and remembering where you are.

The second group is the next step on the patient journey and is when you enter each ward, the corridors within them and the nursing stations and reception desks. These are by David Galletly and Natasha Russell. David’s work relates well to the colour scheme

for each floor as his work is black line drawings with a ‘spot’ colour which are hand drawn, scanned into the computer and then manipulated further. Like all the other artists, however, it’s important that there are slight imperfections and quirks. David used HLM’s conceptual idea, so on the ground (urban) floor, he drew the Edinburgh cityscapes with playful elements, like giants or ice-cream sundaes. With Wayfinding it can be something as simple as giving a ‘hand’ to find the right way! However, he kept his own quirky style, so on the first (rural) floor there are trees with lots of leaves, but with parts of buildings popping up from underneath them, reminding you that the Ground Floor is below you. The stairwells between floors depict mixed themes as a visual reminder of which floors you are between.

Natasha Russell works through printmaking, painting and drawing through illustration. Like David she used HLM’s conceptual scheme so, for example, on the second (lochs) floor there are islands in the Firth of Forth and people swimming. On the fourth (mountain) floor there are wonderful mounds that could be, “Huge Hills, Hairy Heads or Hopping Hummocks?”

Some journeys in hospital are ones where it is vitally important that they are as stress-free and dignified as possible. Emma Butler-Cole Aiken was commissioned to lead the design of the stained-glass which appears outside the new Bereavement Suite. She had previously designed and made the Sanctuary stained glass window for the old Hospital in 1997, a place she knew well as she had spent a lot of time there in the nineties. “My daughter was

being treated for kidney failure following an e-coli infection and it was a worrying time for our family. When creating the original window, I tried to remember how I felt at that time, and what I would have liked to look at. That’s when I came up with the idea of a beautiful tree tunnel with light at the end as a symbol of hope.”

In the new commission Emma again used nature as her inspiration with the design being based on one of the trees on the right-hand side of the old window. The theme is the cycle of life: green shoots and healthy leaves; weathered branches bearing the weight and finally the inevitability of decay. The old stained-glass window has been much loved over the years and so she has created a new window using traditional techniques and colours to bring a memory of the old alongside the beauty of the new.

The importance of remembering and honouring the old whilst celebrating the new is at the forefront of Old to New by Kate Ive, a series of portals placed at key points within corridor spaces.

The project aims to share the identity, history, and stories of the three institutions as they undergo a transition from their original sites to the new building at Little France.

Kate said, “I really enjoyed doing the project, it was fascinating. I loved tapping into these unique nuggets of history and information and representing it in the works. During my research I met with a range of people in the Children’s Hospital and heard the hopes for the new buildings. In DCN I was meeting neurosurgeons and saw some of the technology they use. Both groups were excited by the opportunity to have their input

heard and reflected back in the artwork.

It was clear through all the stories I got from the staff how important their everyday workspaces and the history in the buildings was to them. For example, I engraved one of the outside perspex discs from the Norman Dott designed domeshaped operating theatres and it’s gone into an artwork because the neuroscientists are very attached to those spaces.

I was commissioned to make artworks to go into wall mounted lightbox cabinets throughout the hospital. Eight are in the new Children’s Hospital; two in CAMHS and eight in DCN, plus one double sided wall-mounted cabinet in a waiting room in the Neuroscience Outpatients Waiting Area which is a technological feat by the cabinet maker Joachim King. It’s viewable from the waiting room and the

walkway. The artwork is more three-dimensional because we had more space. It relates to Neuroscience Imaging and is a polarized artwork. The artwork is completely clear but it uses filtered light to change colour. You can spin a knob on the glass and that changes the filtering of the light and hence the colours seen in the artwork. The shape of the artwork symbolises the brain and there are little arrows hand cut into the glass. I also was lucky enough to get to spend time in the NHS Lothian Archives. I was given a lot of help by the team there and I used it to get a sense of the different Departments I was working with.”

Ruth Honeybone, who manages NHS Lothian’s Archive based at the University of Edinburgh, was one of a team who helped Kate and others. “The Archive holds significant collections that relate

to the hospitals moving to Little France. This primary source material was used by artists and researchers who wanted to draw on the history of the buildings and the past experiences of both patients and staff. Our role was to introduce the potential of the Archive and help narrow down what material might be of most interest. That’s what we do for most researchers, but what was intriguing in this context was watching the artists take this initial shared starting point in their own direction. Seeing how the stories stored within the Archive were absorbed into the work of these artists was fascinating – they have created a connection with the past through new pieces that will be enjoyed now and in the future.”

Kate found the Archive fascinating. “I asked for a lot of books! I looked at the history. One of the pieces

in the new Children’s Hospital was informed by my finding that, when rickets was still prevalent, the old Hospital had a Sunlight Department where they used to treat the children. The piece is lots of pairs of sunglasses. The lenses are engraved with facts about the Sunlight Department. Plus, the medical advice that, with care, it’s good for us to get out in the sunshine and fresh air. There are also mountain scenes and sailboats to represent a healthy, active outdoor life. Another big thing that came out of working in the Archive was that there were lots of sources of inspiration to make the wall mounted cabinets circular rather than a traditional shape.

It’s been such a fun and interesting project and I have loved making pieces that relate to the history and stories from the various departments but that also

celebrate their future. For example, I created a piece about the history and future of bone setting. It’s called ‘Sticks and Stones’. and is outside the Plaster Suite. It’s filled with representations of the types of treatments through history, like wooden splints, through bandaging, then pinning, to the future where 3-D printing might be used.

Each of the artworks is unique in approach and treatment. I worked with the staff and thought about the location and tried to pick themes and materials that were relevant. A number of people have said they thought they were all made by different artists! I wanted each one to be dependent on where it was going and who it was going there for.

I know staff will see them all the time and patients and visitors may well be spending long periods of time at the hospital. I wanted to

create pieces that won’t disappear into the background and so I’ve tried to put a lot of fine and hidden details into the background. That way people will be able to see things that they didn’t see before.”

Conclusion

NHS Guidance says,

“The wayfinding process is fundamentally problem-solving and is affected by many factors.... People’s perception of the environment, the wayfinding information available, their ability to orientate themselves spatially and the cognitive and decisionmaking processes they go through all affect how successfully they find their way.”

The basic principles of wayfinding according to Jan Carpman’s ‘Design that Cares’ are:

• Knowing where you are

• Knowing your destination

• Knowing how to get there

• Knowing when you have arrived

• Getting back out

The reprovisioning has provided NHS Lothian with a significant opportunity to modernise service delivery, and wayfinding is critical to the efficiencies being sought. To deliver this required HLM’s design for the building to focus on the patient pathways through treatment and care involving multiple different hospital departments. Beyond Walls contributes to this multi-layered approach to wayfinding through a number of complementary elements. Fundamental to Ginkgo’s approach has been both the focus on the Patient Pathway and draw the cultural assets of the city and region into the new building –a place-based approach.

The Spine Wall both marks the Atrium out as a distinctive space and leads visitors into the building,

almost as an outstretched hand connecting the point you come onto the campus through to the reception desks and onwards. The texture is organic and brings a human element into the clinical environment.

The Atrium vestibules are designed to be accessible. Bright colours allow them to both be easy to see and memorable. These two projects are the first examples of landmarking which runs through the building.

The Wayfinding Graphics integrate into the overall architectural design as well as the signage. Rachel Duckhouse’s ‘trail of breadcrumbs’ accentuates the designation of different levels of the hospital as different layers of the landscape with associated colour palettes.

This particular element represents an innovative use of the art programme to animate and strengthen the memorability of the colour and signage. The use of graphics in Waiting Areas to reinforce patient and visitor under-standing of where they are in the building, drawing attention to the important locations.

Finally, the Old to New project provides ‘Landmarks’ at key points throughout the building across all three services. Landmarks are specifically identified in NHS Scotland guidance as an important part of supporting the patient pathway.

In an environment where corridors and entrances, as well as signage, are all standardised, things that only appear once, placed at significant locations are useful.

They signal ‘when you’ve got there’ as well as giving staff a specific reference point – ‘keep going until you see a porthole full of sunglasses’. Involving staff and connecting to memorable aspects of the various histories means that these are unique points of interest. They meet practical wayfinding needs as well as the high-level objective of fostering pride in the history of healthcare in NHS Lothian.

Problem-solving approaches are important but there is another level – sense-making. Ginkgo’s ‘place-based’ approach directly strengthens the practical wayfinding and also contributes to making sense of the building by drawing on the resources of the City and region.

This takes the form of reimagining of the Scott Monument as a rocket

in the new Children’s Hospital waiting area (the Pod) through to details such as the Orkney Chairs in waiting areas. NHS Lothian named the wards after castles, and the trees used in the Wall Graphics are all indigenous to Scotland.

Humanising, accentuating, providing unique reference points, and placing the building in the City, are some of the things art and therapeutic design can do to reduce the stress for patients and visitors, and help staff too.

THE SPINE WALL

Peter Marigold

A 180 metre long glass reinforced concrete artwork running through the building guiding people into the main atrium from both external pedestrian approaches. The design depicts skin textures cast from one patient or staff member from each service.

Let’s reverse the idea that the hospital is simply a container of humans, but instead the building is created by the people who inhabit it. In this case, the skin of the occupants wraps around the building between all parts of the hospital flowing into the landscape outside. It’s the idea of skin but without identity. It could

be any one of us.

Peter Marigold, Artist

ELFA / Kevan Shaw Lighting

Design and artist Claire Hope

Abstract, transparent colour washes which are both a wayfinding tool but are also relaxing and a very striking way to welcome visitors at each entrance to the atrium.

VESTIBULES

EFLA / KSLD and Claire Hope

ATRIUM WALL GRAPHICS

Peter Marigold

DCN entrance: A large scale image based on a recovering patient’s angiogram developed through collaboration with Peter Keston.

ATRIUM WALL GRAPHICS

Peter Marigold

RHCYP entrance: A dynamic work that captures the movement derived from a therapeutic dance session held at Musselburgh Primary Care Centre. The looping shapes track each of the participant’s movements. One is the young patient Evan Glass, the other dance instructor Christina Liddell.

STAINED GLASS PANEL BEREAVEMENT SUITE

Emma Butler-Cole Aiken

A representation and development of existing work at the old hospital. This new design is based on the cycle of life: green shoots and healthy leaves; weathered branches bearing the weight and finally the inevitability of decay.

OLD TO NEW

Kate Ive

A series of portals placed at key points within corridor spaces. Each explores the identity, history and stories of the institutions as they transition from their original sites to the new building at Little France.

“I wanted to create pieces that won’t disappear into the background and so I’ve tried to put a lot of fine and hidden details into the background. That way people will be able to see things that they didn’t see before.”

Kate Ive

WALL GRAPHICS

Alison Unsworth

David Galletly

Rachel Duckhouse

Natasha Russell

A series of over 200 artworks throughout the whole building focussing on main corridors, reception, waiting and treatment rooms providing waymarking and distraction

Printmaker Rachel Duckhouse created playful designs that articulate the main corridors at key decision points.

RECEPTION DESKS

Reception desks throughout the building are enhanced through narratives developed by David Galletly and Natasha Russell

Natasha Russell’s intricate illustrations inhabit both reception desks and walls.

It was important to be on the ward and play areas and doing drawing activities to get feedback about the interests andcontext. We also did the same in the waiting areas in DCN with each artist working on various activities so that we could chat to people about what interested them, for example memories and reminiscences of the local area.

David Galletly

Alison Unsworth created graphic puzzles within treatment rooms and waiting areas based on five different types of objects: drinking straws, patterned paper bags, lolly sticks, bus tickets and revision/ index cards.

Key Collaborators

Interview Rooms, Sitting Rooms, Dress for the Weather, Andy Campbell and Matt McKenna, Architects

Waiting Areas, Adolescent Shared Daniel Ruther ford, Manager of the Children’s Hospital Charity Drop-in

Facilities and The Hub: Centre (The Hub)

Bespoke Atelier, Design Studio

Sanctuary and Sue Lawty, Artist

Bereavement Suites: Lucy Harwood, Ginkgo Projects

Child Protection Unit Dr Lindsay Logie, Consultant Paediatrician

CAMHS:

Annie Campbell

James Christian, Projects Office, Architect

James Leadbitter, Madlove

Alison Unsworth, Ginkgo Projects

Gwyneth Bruce, Head of Occupational Therapy in CAMHS

Why Patient Dignity and Personalisation are at the heart of Beyond Walls.

Before you examine the body of a patient, be patient to learn their story.

The Maxims of Medicine, Suzy Kassem

Being seen as an individual allows us to articulate how we can feel lost and vulnerable. Being treated with dignity and being allowed to personalise a clinical space goes a long way to making us feel like a human being rather than an illness. We most need kindness, calm and support when we are at our lowest ebb, feeling desperately worried and frantically seeking answers.

This chapter reviews work in spaces used for the some of the most challenging and difficult aspects of the work that goes on in the hospital including child protection, spiritual care and bereavement, as well as less challenging, but no less important aspects such as staying and waiting. The issue of dignity has both physical and mental dimensions and is critical to a hospital that has the range of services including the new

Children’s Hospital, CAMHS as well as DCN.

There are many ways Beyond Walls has brought a concern for dignity to the new Hospital, not least in addressing the eighteen Interview Rooms where difficult conversations take place and hard decisions are made.

Sorrel Cosens explained why these were included, “We hear such horrible stories of people who are being given the worst news of their life and what really resonates with them, when they revisit the memory, is they were sitting on a hard, plastic chair and there was a bulb that was broken.

I really think that Interview Rooms should ideally be invisible, in a very reassuring and comforting way. It’s a very traumatic time and Interview Rooms should be about giving people the time and space to think about what they’ve been

told, then compose themselves before carrying on. It’s about giving them a bit of dignity.”

Mary Murchie agreed, “It’s little things that make the difference, but they are so important. Things like changes in the lighting, comfortable furniture and a less clinical feeling to the space, but just having the space for an Interview Room where you can have a private, possibly distressing talk is such a huge bonus.”

Dress for the Weather enhanced the rooms in subtle ways. “We changed the brighter clinical lighting to softer down-lighting which is concealed behind pelmets running around ceiling. We also created mood-lighting with wall lamps. We felt it was important to work with real materials: stone, concrete, metal and wood. We added metal tables with Jesmonite tops to create

a sense of order in the room. Jesmonite is a concrete substitute and we used it to create a terrazzo style with stones that were picked up on a series of engagement walks around Lothian with patients and families. The tables have two levels because this is something staff flagged as being important. There’s a high part for staff making notes and a lower part for the family. This makes the space less like a consultation and more natural and comfortable.”

The attributes that might well seem ‘invisible’ are invaluable at enhancing patient dignity. Sorrel Cosens adds that one of the things she likes the most about the new Interview Rooms are the, “little design features. For example, Dress for the Weather proposed putting a mirror in so people can brush their hair, wipe their eyes and just check their appearance before they go back to their

loved one’s bedside or leave the hospital.”

The Sanctuary in the new hospital is a multi-functional space where patient dignity is central to its identity. Sue Lawty designed a space for patients, staff and visitors of all faith communities and none, with spaces for reflecting, celebrating, and for communal activity. The spaces Sue Lawty designed provide a main space for prayer, meditation and reflection, an interview room, and courtyard which allows for movement between inside and out.

Lucy Harwood explains, “We had some initial meetings with staff from the Bereavement Services and the Spiritual Care Department. What was emphasised in these discussions was that the feeling and quality of the space was more important than specific art works. Sue Lawty quickly picked up that

the biggest impact we could have was on the building itself. We worked with HLM to change the shape of the spaces to a curved wall so the route through the space was calmer. The lighting and colour palate are soft and Sue focused on natural materials, with beautiful wooden floors and benches.

There is a wall of glass that both provides natural light, which is known to be therapeutic, and also looks out onto the courtyard. The flooring and lighting in the Sanctuary were designed to draw the eye to the outside space which people will be free to enjoy or to sit inside and admire the view if the weather is bad.”

The courtyard can be seen from a number of places in the building, including one of the two Bereavement suites, also enhanced by Sue Lawty. The

other suite in the Emergency Department also has a small private garden, allowing families the dignity of a peaceful place to start to come to terms with the news.

Another challenging area in the new Hospital is the Child Protection Unit, called the Acorn Suite. Dr Lindsay Logie explained that the work they do has particular requirements. “We cover the whole of Lothian and carry out medical examinations of children when there are concerns about physical abuse, sexual abuse, neglect and, as a by-product, emotional abuse.

In the new Acorn Suite we will be able to have a dedicated room, which means less traffic, making it far easier to keep it as forensically clean as possible. One of our main discussions right at the beginning about having

this suite was about making the space both suitable as a Child Protection Unit but also ‘child friendly’. I was also keen to take into consideration the teenagers we see as part of that discussion. I don’t want it to just be about the younger children. I wanted everyone to be catered for and for the space to seem as friendly as possible.

Part of that is the furnishings, which are very comfortable, and that the curtains around the private area have an acorn design which is echoed in the ceiling tiles. We had chosen the name Acorn a long while ago. We wanted something attractive but both gender neutral and not age specific. Dress for the Weather picked up on that, and there are brightly coloured oak patterns. It looks less clinical whilst still allowing us to do our job. It was so helpful being able to engage

with them early on. We felt listened to and able to explain what we need from the space, not just for the children but from a staff viewpoint too. It’s a complex process and to have a well organised, friendly space is very beneficial.

We also have a distraction module with a docking station for a tablet. This allows children to control the lights. I wanted a background distraction that will allow children to be able to relax but not be too immersive as we need them to listen to instructions and questions.

NHS Lothian will be doing other work with sexual assault and young people outwith the new Hospital and so my hope is that the Acorn Suite will be able to be a learning tool for the future about how to make children feel safe.”

The Hub provides a domesticspace for child and adolescent patients and their families to relax in. Sorrel Cosens described the Hub as, “A space where they can play games, go on the internet and Skype their friends.

Sometimes it’s something as simple as being able to make a coffee for themselves that makes all the difference. People spend a lot to time in hospital: waiting for news or deciding next steps. There is shared decision-making to be done and providing people with privacy and spaces to do that is a luxury we haven’t had in the old hospital.”

Daniel Rutherford agreed about the need for a domestic setting, but also added that there is a requirement for flexibility of space to provide a more diverse selection of opportunities.

“The services we offer at the moment may well change because it’s an ongoing process of consultation and the developing needs of the children, young people and their families. I think having the Hub will affect the way we work. The opportunity to offer more specific support will be an enhancement. For example, we’ve got a social youth group on a Monday evening now where before there wasn’t a non conditionspecific youth group. This provides a really nice social opportunity for young people who may otherwise have been quite isolated.”

Dress for the Weather, said, “We visited the original Drop-in centre, overlooking the Meadows. We wanted to take as much of the quality and vibe of that into the new Hub. There was a danger that the kids are so attached to the Drop-in centre that they might feel a bit unsettled, so we

aimed at creating both a sense of connection and a space which was really sociable. That meant thinking about the layout and getting away from the hospital environment.

Our understanding of how children and families used the previous space was one of the drivers for us to provide an inter-connected flow and flexibility. It now looks like a domestic kitchen, dining room and living room. We enlarged the kitchen space and designed a new kitchen that is the first thing to greet you on arrival because the parents said that the old Dropin centre it was very welcoming that the kettle was always on. We also created a breakfast bar overlooking the kitchen with bar stools, as well as having tables so everyone can have somewhere to sit. Next door is much more ‘kid friendly’, and the sliding door can be kept open to keep a casual eye

on things but it can also be closed for privacy.

Flanking both rooms are ply-lined storage spaces, where all the workshops materials can be tidied away. We wanted to make the most of the space so they also drop down to become benches, a dining or computer table, or TV cabinet units. They serve quite a functional purpose but we worked with textile designers Bespoke Atelier to develop a pattern of animals from the zoo and plants from amongst other places the Meadows. Bespoke Atelier developed the design with young people in a series of workshops.

Dress for the Weather designed the Shared Adolescent Spaces. “If the Hub is about parents and family time, then we really wanted to make sure the Adolescent spaces were about the older kids breaking away and having their

own space. One of the things we did was to talk to them about what kinds of rooms they wanted. We took some of the adolescent patients for lunch in a couple of cafes in Edinburgh that have the kind of interiors we thought they might like and talked about how they might like and want to use the space. What came across as being important to them was colour, vibrancy and sociability but also spaces where you can tuck yourself away. They wanted the rooms, one for studying and one for being social, to be theirs.”

One of the key aims for bringing departments together in the new hospital was that physical and mental health facilities are on the same site. The new CAMHS is the amalgamation of two units which have been in different parts of the City up to this point.

One of the challenges for Projects Office was to make sure both the younger children and the adolescents felt represented whilst creating a cohesive feel to the Department as a whole.

“Prior to and since our appointment for this project we’ve been working with Madlove, an artist-led project whose big aim is crowd-sourced ideas in order to come up with designs for good mental health. We worked with James Leadbitter of Madlove who shaped the workshops programme.

We took a part of the established Madlove workshop process which encourages participants to talk quite broadly about environments and what makes us feel good. We explored the sensorial side of smells, touch, texture and things we like to look at with the staff, children and young people in

CAMHS. That bespoke workshop process was very much key to our approach to the project.”

Gwyneth Bruce felt that engagement process was instrumental in making the young people feel a part of the creative process. “We had lots of fantastic workshops about what the teens and primary age children hoped the Unit would be like. Projects Office worked with the staff and young people around what kind of colours and environment they found calming and soothing and the sorts of places they felt comfortable in. That was when the theme of the sea and the coast and seaside came through. Many people talked about how the colours and the images of the coast were things that they found uplifting and calming and so that’s the ideas that Projects Office have used as the basis

of their design which has been amazing.

We wanted our young people to think about the new hospital and have a sense of preparing for it, so we had them creating designs that could be integrated into the soft furnishings and table-tops. They took time looking at objects at The National Museum of Scotland who were at the time exploring what makes a sense of home, and then created prints which are going to be used. Although the specific young people who made them won’t be there, it’s really important that it brings the young people’s voices and history into it. It made this process not just for them, but about them.”

James Christian agreed that this was vital to how the process was shaped. “The brief stressed the opportunity for personalisation of spaces, so we thought a lot

about how individual identity can be taken into account within the design process.

We dealt with this in bedroom spaces by creating a piece of furniture which is a ‘safe’ wall board that allows the young person to bring their own belongings from home and personalise the space. They can bring decorative items like photographs and small objects so they don’t have to suffer from bare clinical walls. We were very fortunate that the bedroom brief did expand quite considerably, thanks to extra funding from the Children’s Hospital Charity. This additional support was in response to some of the things we fed back to them from the workshops with young people. We had a particularly illuminating conversation with the parent of a teenage inpatient being treated for her very severe anorexia. She’d been in the unit some time

and the parent talked about the difficulty of having nowhere to sit comfortably in the room and just talk. From a very early stage we had the desire to facilitate normal conversation in the bedrooms. It was great that the charities really wanted to go that extra mile to personalise the space. We created, in some of the rooms, an upholstered bench window seat which can be pulled out so that it, combined with a desk chair, enables more natural seating arrangements for conversation. They also have a television on the wall, bespoke furniture including a desk and seating, curtains and colour on the walls with the ambition to create a much more dignified environment.

We were keen to incorporate seating into some of the other spaces that might be used for visiting families. In the Games Room we created a seat in a nook

and that, combined with the moveable furniture, allowed those corners to be used more naturally for visits. One of the things we were told in engagement was that often the young person will not admit that they are very unwell and so it was important that although the rooms weren’t sterile, the space had to communicate comfort but not a ‘home.’ We used quite bold colour schemes to strike a balance between the clinical and domestic.

Throughout the space we also had to balance comfort and privacy with safety.” Gwyneth Bruce agreed this was vital. “The real challenge about creating this Unit is that it would be easy to make it ultra-safe, but if it looks too clinical then it’s not at all ‘young people friendly.’ We wanted to use good colours and scenes of the coast and the seaside and all of the things that the young people

said gave them a lift, but at the same time we had to make sure that things were safe and people could see that support was around them. I think Projects Office have done an amazing job. They brought someone along who facilitated things and they’d obviously put a lot of planning and thought. They seem to have really listened and very thoughtfully gone away and created amazing furnishings and décor. They’ve clearly kept in their heads all the staff have said about the importance of being able to look after the young people in this very vulnerable time in their lives.”

James Christian continued, “In the Dining Room space and the Inpatient open space we have allowed for private booths that staff can still monitor and keep people safe. In all of the design for Mental Health work we undertake we are keen to explore ideas of privacy. That can range

from solitary spaces where people can feel that they are alone; intimate spaces where you might have a conversation with a couple of people; and group open spaces where activities take place and there is more action. With group spaces we always try to create opportunities where someone can retreat from the action. In the Inpatient Open Space there’s a central table and seating for activities, but the storage wall has a recess in it so you can observe the activities taking place but not feel you have to be part of it if you are feeling overwhelmed.

The Inpatients Open Space is quite large, and we wanted to make it as friendly as possible. In every workshop we undertook about the places that make people feel good, there was an overriding theme of the coast. There is also, in one of the original buildings, a very important artwork of a lighthouse

which is a memorial to a member of staff. So we were able to take these two ideas and combine them in a strategy for the unit. That memorial lighthouse is now one of these retreat spaces. The lighthouse anchors the space and provides privacy but the windows are angled so that the staff can ensure patient safety as well.

The sea and coastal theme continues throughout the space but we wanted to give each age group their own sense of identity. The adolescent spaces are offshore with slightly stronger colours. The ‘under eleven’ spaces, the Rainbow Unit, references East Coast Scotland seaside towns with brighter colours. We’ve designed the artwork in the circulation spaces to pick up on the coastal themes. We use the lighthouse motif throughout along with seaside buildings. In the young people’s

spaces and the main waiting area the lighthouse leads the boats into the shore, emphasizing safety and protection.

It’s a challenge designing for a Mental Health environment, but what we did learn was to take forward the lessons from engagement and be ambitious about what we wanted to achieve.

Conclusion

Dignity and personalisation is a complex and multifacetted challenge – fundamentally it is at the heart of developments such as ‘realistic medicine’ and person-centred care. The evidence for the impact of personalised and respectful care by health professionals is substantial and this can be demonstrated through environments as well. Art and Therapeutic Design can make a significant contribution,

but the challenges cannot be underestimated. Through this thread of work for the new Hospital we have seen how artists and designers can deinstitutionalise aspects of the healthcare environment, even in some of the most challenging areas such as CAMHS, the Child Protection Unit, Bereavement Suites, and Interview Rooms. This has to be done without compromising safety or in some cases forensic requirements. The approach taken throughout has focused on understanding the needs of users through engagement and co-creation. The significance of this is highlighted by the way that the principle funder, the Children’s Hospital Charity, listened to the feedback from the workshops focused on the CAMHS and substantially increased funding to enable a more comprehensive approach to the needs of users.

This focused on simple domestic needs such as a place for visiting family to sit in a bedroom or have a cup of tea together, or for the kitchen area to be the welcoming face of the Hub. These domestic aspects significantly change the experience of the hospital.

The co-creative approach generated many aspects of the aesthetic, such as the seaside theme, but it also ensured that the functionality was informed by users. Dignity doesn’t just mean de-institutionalising the look and feel of the spaces – it means putting the needs of the patient, their families and carers at the heart of the design.

De-institutionalisation is one of the key ways to affect perceptions of healthcare, and is achieved through effective interior design. Most often the spaces that will make a difference are non-clinical spaces – places where people

wait and meet with clinical and nursing staff. Making these spaces more ‘human’ through use of different colours, patterns, types of furniture as well as with artworks has a significant impact. The converse, as noted by Sorrel Cosens above, is abiding memories receiving bad news sitting on a hard plastic chair or standing in a corridor. The ambition that she goes on to articulate, that these spaces go unnoticed, invisible, is perhaps the clearest statement of the challenge for art and design.

and their families.

THE HUB Dress for the Weather

A flexible meeting, dining and work space for young people

We worked with textile designers Bespoke Atelier to develop a pattern of animals from the zoo and plants from amongst other places the Meadows. Bespoke Atelier developed the design with young people in a series of workshops.

Andy Campbell, Dress for the Weather

INTERVIEW ROOMS

Dress for the Weather

A series of Interview rooms located around the building designed with hand crafted elements, furniture and controllable lighting.

It’s little things that make the difference, but they are so important. Things like changes in the lighting, comfortable furniture and a less clinical feeling to the space, but just having the space for an Interview Room where you can have a private, possibly distressing talk is such a huge bonus.

Charge Nurse, DCN Outpatient Department

SHARED ADOLESCENT SPACES

Dress for the Weather

Two spaces, one for socialising and one for study have been designed as vibrant, colourful spaces in discussion with teenagers.

CHILD AND ADOLESCENT MENTAL HEATH UNIT Projects Office

A bold and vibrant enhancement of social, dining, work, bedroom and courtyard spaces based on a coastal theme providing for dignity and personalisation.

People talked about how the colours and the images of coast were things that they found uplifting and calming.

Projects Office

ACORN ROOMS

Dress for the Weather

Two rooms forming part of the Child Protection Unit designed to enhance privacy and distraction

THE SANCTUARY AND BEREAVEMENT SUITES

Sue Lawty with Ginkgo

The non-denominational spaces

Sue Lawty designed provide a main space for prayer, meditation and reflection, an interview room, and courtyard which allows for movement between inside and out.

The flooring and lighting in the Sanctuary were designed to draw the eye to the outside space which people will be free to enjoy or to sit inside and admire the view if the weather is bad.

Lucy Harwood

Key Collaborators

Restaurant:

Emma Varley, Artist

Multi-Sensory Design & Distraction: Alex Hamilton, Lead Artist

Oli Mival, UX Research & Design

Derek Kemp, Audio Visual Consultant

Helen Fisher, Communications Consultant

Yulia Kovanova, Curator

Film makers: Nim Jethwa, Jack Lockhart, Kris Kubik, Tracey Fearnehough & Holger Mohaupt

Tony Kimera, Occupational Therapist

Radiology:

Alison Unsworth, Project Manager

David Galletly, Artist

Sarah-Jane Selway, Radiographer

Multi-Sensory Room: Southpaw, Multi-sensory equipment provider

The Pod & RHCYP Waiting Daniel & William Warren with Alex Fitzsimmons, Designers & Dining Areas: Emily Hogar th, Artist

Guy Bishop, Ar tist

Touzie Tyke, Animation Studio

DCN waiting & sitting rooms

Dress for the Weather (Matt McKenna & Andy Campbell) & RHCYP sitting rooms: Catherine McDerment, Lead Occupational Therapist/Children & Young People Strategic Lead

References:

Kaplan Attention Restoration Theory

Belfiore & Bennett, Social Impact of the Arts

Debajyoti Pati, writing on Positive Distractions in Healthcare Design (2008 Report from Cornell)

Effective Distraction Techniques and their Therapeutic Effects.

Wonder (noun)

A feeling of amazement and admiration, caused by something beautiful,remarkable, or unfamiliar.

Wonder (verb)

Desire to know something; feel curious.

In a hospital setting distraction is a very useful therapeutic tool. Beyond Walls demonstrates a plethora of distraction techniques. These range from artworks to contemplate whilst you have a cup of tea through to works developed in close collaboration with Clinicians, Nurses, Radiologists and Therapists to take a patient’s attention in a very specific way during treatment or in the process of rehabilitation.

On the fourth floor is Emma Varley’s ‘Garden of Dreams’. It’s situated in the restaurant which is open to all and provides the chance for a moment of whimsy, reflection, calm and yes, sitting over a meal or a drink and just dreaming.

As Emma says, “The work unfolds over six large scale light boxes which are a re-interpretation of the existing stained glass from the

old Children’s hospital. The final artworks are real and imagined; snapshots of a wider landscape captured in portrait format to emphasise elements of strata linking to the local Lothian environment. Scottish flora and fauna dominate each scene, the hare perched up high keeps watch over the Scottish meadows whilst being observed by the sun. A view over Loch and Glen with a spring rabbit and swan who observe a single weed bearing its intricate root system, referencing energy and power echoed by wind turbines and the moon. A stag and eagle look towards the mountains protected by the Willow pattern plate – a reference to dining, storytelling, love and escapism.”

As with all the projects, engagement was an important part of the process. Emma says “Creative engagement with the patients inspired ideas

of escapism, developing around stained glass and the intensity of light as projected colour. Using an overhead projector, we explored light collages, placing coloured glass, translucent papers, found and personal objects on the surface to create ‘dream-scapes’.”

Yet distraction, in therapeutic terms, can be much more than an escape. In the Multi-Sensory Design project there is a range of distractions to specifically aid treatment as well as rehabilitation. This is a example of taking something that already has a proven track record within the old Hospital and building on it for the benefit of all patients within the new hospital.

The ‘Secret Garden’ in the old Hospital was an art installation designed to engage children for therapeutic purposes. As Catherine McDerment says,

“The Secret Garden was a ‘first generation’ interactive distraction commissioned with funding from the Children’s Hospital Charity about ten years ago and designed by Falling Cat with a lot of engagement with children and staff. What we wanted was the ability to add more diversity and the ability for the system to grow and adapt. The ambitions for the possibilities of the new system came from the great success of The Secret Garden. The staff knew what worked well and knew what they wanted to improve, adapt and add.”

As the new system will be part of the combined hospital, it was important that all the Departments were brought on board for the planning stage. Engagement with DCN was particularly relevant because Secret Garden had been part of the old Children’s hospital.

Janice MacKenzie said, “One of the successes we’re building upon is the Multi-Sensory work for therapy, both in Children’s and in DCN. I think, initially, DCN were a bit sceptical that there would be any benefit for their patients. However, it was, to use the cliche, ‘the journey’ the Therapists went on to actually see the real benefits and how it could be adapted for their patients.”

Alex Hamilton, Lead Artist on Multi-Sensory Design and Distraction agrees completely.

“A lot of our initial consideration about this project came from the existing Secret Garden programme. This was a very early use of this technology and we were excited to develop the Multi-Sensory Design and Distraction programme as the next steps in the cutting-edge future for these therapeutic techniques. It also meant that a lot of staff were immediately

involved and on board as they had confidence in the technology and were excited to explore and help us push the boundaries to give the best patient experience possible. The Therapists and Support Staff were incredibly generous with their expertise about what would be beneficial for all the variety of patients, their needs and particular challenges.

The brief identified a need for digital media being projected and used in a variety of different ways to engage patients, providing entertainment, exercise and as part of a recovery programme. I and the team (Oli Mival, Derek Kemp and Helen Fisher) created the programme for three Therapy Rooms, two in the new Children’s Hospital, and one in DCN, as well as forty-six Treatment Rooms. We had a lot of engagement with the staff. We wanted the programme to be an addition to the existing ‘tool

kit’ rather than being seen as a replacement. The main focus was to enhance the patient experience and help the staff do the best job possible.

The Therapy Rooms have three projectors. One of the projectors is set up to project onto the largest wall on any of the three rooms and will draw imagery from the film library. It’s there to produce a more calming, relaxed environment.

The other two projectors are set up to allow much more sophisticated, interactive Apps to be presented on another wall. There is a camera to catch a patient’s movement and translate that into different games and exercises to encourage correct posture, movement and exercises but in a fun, distracting way. The last projector will project onto the floor to allow other types of interaction. This will allow the staff to work with whatever particular

needs the patient has. For example, in DCN, with the help and advice of many members of staff including Tony Kimera, the set up will address the particular practical needs within patient recovery such as learning to walk again. This projector will allow the patient to feel as if they are engaging in everyday situationslike walking through a shopping mall or garden centre; climbing steps to get onto a bus; or navigating around furniture in different rooms at home.

Each Treatment Room has a laser projector projecting imagery from the film library onto the wall or ceiling, depending on which way the patient needs to be positioned.

The Film Times contains three strands of commissioning curated by Yulia Kovanova and Alison Unsworth.

Film Times

Strand One: Commissions for Artists and Filmmakers

Kris Kubik produced four 5min films using wildlife footage, including footage of birds in a coastal landscape, footage of bees and other insects and close up footage of birds. The films are suitable for multiple age groups. Whilst some focus on creating an atmosphere of calmness and relaxation, others are fun and playful, with some surprises and vivid colours.

Nim Jethwa spent 11 days filming in locations across Edinburgh to film content which he edited to create the film ‘A Little Edinburgh’.

Jack Lockhart created four 10-minute films, from collaged video, photographs, painting and animations of the beach. Three

films are designed for young children aged 0-5, and one is designed for a broader age range including adults. A character encounters kites, boats and sea animals during the first three films. The fourth is a relaxing film using beach and seascape imagery and a soundtrack of wave sounds.

Holger Mohaupt and Tracey Fearnehough worked with Jupiter Artland to run a series of workshops for a group of 6-8 children aged between 7 and 11 years old within the Jupiter Artland setting, exploring the themes of water, breath and wind, things that grow, animals and light.

Strand Two: Commissions for Creative Curators

Matt Lloyd, Director of Glasgow Short Film Festival, selected a series of short animations from

GSFF’s Family Animation Programme, intended to relax, focus or engage patients. He also produced a series of short films using content from ‘Everything’ a game created by Irish animator David OReilly.

Adam Castle, Curator, ran an open call for film submissions for the film library through Edinburgh Artist Moving Image Festival networks and received more than 400 submissions. He selected a number of these films along with a curation of other short films around the functions of focus, relax and engage.

Strand Three: Open Submission

Just under 50 film submissions were received from an open call. Staff and/or patients at RHCYP and DCN were invited to be involved in the selection of a wide range of content and creative approaches.

The films are grouped through an accessible interface as:

• Relax - feel less stressed about procedures;

• Engage - be ready to listen and follow instructions; and

• Focus - keep a particular part of the body still.

This is a bespoke very nuanced system which will continue to grow and adapt whilst allowing staff to choose options which will best suit a particular situation for an individual patient.

The other important aspect of the Multi-Sensory Design and Distraction was the provision of storage in order to provide a calming, therapeutic workspace. We utilized the expertise of Interior Designer Paula Murray to create storage that would allow all the clutter of vital equipment to be tidied away.”

Another area where distraction is a useful therapeutic tool is the multi-sensory room which was developed by Southpaw. A multi-sensory room is a controlled environment which is specifically designed for Sensory Therapy. Sensory experiences can include touch, movement, body position, vision, smell, taste, sound and the pull of gravity. Depending on the particular needs for each patient, it will be adjusted to be as soothing or stimulating as required.

One of the great strengths of Beyond Walls is the multi-layered, nuanced approach to the four themes of Wayfinding, Distraction, Personalisation and Dignity. For NHS Lothian and the Funders it was always vital that the programme was integrated into the fabric of the new build and always had the patient at the heart. Janice MacKenzie NHS Lothian Project

Clinical Director said, “We want the Art and Therapeutic Design to deliver a building which is special and very memorable to people. That it would be a nice place for patients and their families to be and for staff to work in which didn’t feel like a hospital.” This integrated approach means that although projects have been highlighted in one chapter they will often have aspects of another.

This is the case with the Wall Graphics work of Alison Unsworth and some of the work of David Galletly. Alison’s work can be seen in waiting rooms and treatment rooms within the various departments. Alison explained that for her distraction is all about the context and environment of the particular room. “My Wall Graphics are all picture puzzles with five different types of objects: drinking straws, patterned paper bags, lolly sticks, bus tickets and revision/

index cards. I created a type of picture Sudoko, with gaps for you to work out. There are different ways you can engage with them. You can look at it carefully to work out the puzzle, you can then expand the pattern. You can draw or make it. You can also create your own ideas. For example, I made Origami objects out of bus tickets, and then hand drew them. I have very happy personal memories of sitting with my Gran whilst we waited for my sister who was taking part in competitions. She taught me how to make Origami boats with nothing but a packet of lottery tickets. As an experienced artist I’ve worked a lot in gallery education and with school children and often the most amazing results you can get with groups are when you limit them to one item. I wanted to create graphics for the hospital waiting rooms that people could join in with by using what they might

have in their pockets.”

David Galletly’s work is more focused on distraction techniques for various interventions and treatments. Sarah-Jane Selway talked about how early engagement and an open dialogue between staff and artist can produce exactly what a department is looking for in terms of therapeutic distraction.

“I got involved because radiology needed artwork for all its rooms. I became quite active in making that happen and then working with the artist to develop it. Early engagement is vital so that the artist can get a better understanding of how we use each room and tune into what our requirements were going to be. For us the art on the walls is really an essential tool. We use it all the time. Firstly, it’s a way to get a child into the room and making them comfortable. Secondly, it

disguises quite intimidating pieces of equipment like CT scanners. Having the opportunity to work closely with an artist and explaining all the uses we have for art was great. It has resulted in something very specific to the requirements of each room. It’s going to be exciting to use now.

We did a walk-through of the Department and David took loads of notes. He was all about the details. It’s so important that we get it right because it makes it so much easier for the child to not be scared, to understand exactly what the staff need them to do. This means we can get through the treatment as quickly as possible. For example, in the General X-ray room a child might need to be in different positions. So something interesting or curious to get them to look in a specific direction, something which grasps the child’s attention, is ideal. We can

tell them stories and get them to look for specific things. David has also managed to provide us three illustrated breathing instructions next to the chest x-ray so that a child can learn how to take a big breath. They are very specifically designed and helpful.

In the Fluoroscopy room a child will generally be lying on their back with interventional procedures which are not pleasant. So, we worked with David to design images for the ceiling tiles and all the artwork is high up, like birds on telegraph poles.

In Ultrasound we’ve interesting graphics with moving parts, so we’ve got a video running and they see a story happening. Ultrasound is quite a dimly lit room so having something moving and attractive which they can still see whilst they’re having their procedures is so good. When I showed David

the CT scanner, I explained that it’s large, intimidating and frightening for a child to come into this and the way we generally encourage children is to describe it as looking and sounding a bit like a washing machine. So, our CT is going to be designed as a washing machine with tops and pants flying around!

David has also managed to link all the rooms together so that we have an identity through Radiology. Different characters will reappear so that children can come back for multiple scans and that curiosity of finding familiar characters will be fun for them. It will make Radiology a friendlier place. For example, the Nuclear Medicine scanner is going to be an Edinburgh bus with characters from other rooms in it. It’s amazing and I’m really looking forward to seeing it all happen. Having the opportunity to work closely with

David, including the exact positioning of the graphics, is a great opportunity.

Art is the key to all that, making it a bit more friendly, familiar, and fun. These graphics will be tools for us to work with and make our job easier.”

Distraction is used in waiting areas, social spaces, treatment rooms and also on wards. The Bedside Environment project, with Derek Kemp, Alison Unsworth and Lucy Harwood developing creative content, delivers on both distraction and also personalisation.

It is a hugely ambitious project which provides the majority of patients with an enhanced entertainment system and more control over their immediate environment. Patients have access to both the entertainment systems that are a part of everyday life

including on-demand TV, gaming, etc., Single rooms have a small tablet for personal viewing and surfing the internet. In multibedrooms there is a larger arm-mounted tablet for personal viewing and entertainment, as well as a smartTV for shared viewing.

Alison Unsworth talked about the goals and challenges of curating the creative content for such an all-encompassing project. “When a patient picks up a tablet there is a bespoke user interface with folders. One of the first things is the Welcome App and this provides all the practical information they will need for their stay in hospital. We commissioned Neu, a design agency, to work on the interface. I’ve been curating a selection of Apps where the content is based on the themes of ‘Play,’ ‘Read,’ ‘Listen,’ ‘Watch’ and ‘Relax/ wellbeing.’

There is one major aspect of

hospital life that has yet to be addressed in this section and that’s the amount of time spent in Waiting Rooms – whether as patients or as visitors. It’s for waiting for news, for treatments, or visits with families and friends.

Debajyoti Pati, writing on Positive Distractions in Healthcare Design, states, “When people refer to their ‘healthcare experience,’ they typically (and correctly) note their experiences in the examination, treatment, and recovery rooms as well as interactions with the caregivers and support staff.

However, it is common knowledge that a sizable proportion of a patient’s and the accompanying family members’ time is spent waiting.”

A 2008 report from Cornell University further articulated the potential association between the

quality of the waiting environment, the perceived waiting experience, and the overall healthcare experience. Sets of independently collected data on environmental attractiveness and a host of perception measures from actual patients in six clinic waiting areas demonstrated significant correlations between the attractiveness of the physical environment and perceived waiting time, perceived care quality, level of anxiety, and quality of interaction with staff.

Beyond Walls has been able to enhance waiting areas throughout the new hospital, creating spaces that are more comfortable, entertaining and visually pleasing. Daniel and William Warren along with Alex Fitzsimmons worked on the Main Childrens’ waiting area, known as ‘the Pod’, as well as other linked play, dining and waiting areas across the new

Children’s Hospital. This is a major creative intervention at the heart of the patient pathway. The Warrens explained that the first phase of research and engagement was incredibly important, “in order to get some principles of what the project should be and, equally important, what it shouldn’t be. It was really important to listen.” said Daniel.

William felt the same. “When we first got the brief, it was about play and we were to come up with ideas for the children enjoy in the environment. We quickly realized that the fun element of it wasn’t meant to be boisterous, physical play because that’s not appropriate for the environment. The focus is instead on imaginative play and engaging interest. We talked about journeys of the imagination. Some children don’t want to be social and just want to feel safe in the environment and

that has to be balanced with those who do want to have fun.

There’s also the reality that we were designing for two groups: we were designing for children and their families, but we were also designing for staff. We wanted to make things more fun for families but also easier for the staff working in the environment. Some workshops were spent talking to kids, but we also made sure that we talked a lot to the staff. In particular, we talked to the Play Team about how they worked in the space. Some things, like a ‘train table’ we designed, related to a train set they already had. But quite a lot of what they needed was to help the kids relax, with a mix of socializing and ‘alone’ space.

The challenge was to fire the imagination, give children the opportunities to read, hide or

just sit and look at murals and graphics. There are lots of references to the city centre and the idea of moving the ‘city’ out to Little France was to give a sense of where the old hospital came from. We wanted people to recognize the landmarks but in a slightly peculiar way - one of the tasks we gave the children was to re-imagine and draw an Edinburgh landmark - so the Scott monument is a space rocket and the Balmoral monument has teacups on the top of the hill. These ideas come through beautifully in Emily Hogarth’s illustrations, so things are recognizable, but differentlike a piece of cake or a birdcage.” This particular aspect is a clear example of Ginkgo’s overall cultural planning approach.

The Warrens went on to say, “The digital project in ‘the Pod’ has been really excellent to develop. The idea is to augment reality and

add another layer of imagination on top. We commissioned software developer Touzie Tyke and now you can control a dragon character and make it fly around the waiting area. The space rocket will take off. There will be balloons floating around which, when you pop them, explode into a cloud of glitter. Birds fly and a steam train with animals in it travels across the real bridge spanning the space on an upper level. These are controlled by touch screens at child height, scattered around the space, with the interactions being suitable for different ages.

It’s a large space so we wanted to make it organised and manageable. It’s important that parents and children know where to go and that the staff can find them! There are “arches” with illustrations by Emily Hogarth that are almost like stage flats and they break the space up into the three colour-

coded waiting areas but also house the digital surprises. There are also tiny little peepholes with installations by Guy Bishop, like the Penguin Parade for the children to find on their own.”

The Warrens designed families of furniture for play and dining areas. There is a herd of Deer stools where the head is a writing and drawing space and the body is a seat. There is also a big, flat upholstered footstool that looks a little like a Galapagos tortoise. “We made a design based on an Orkney chair, with a woven back and a large hood, which acts like a little cave that a child can get in. People will know where you are but you’re suddenly not in a huge, echoing space. There are obviously lots of sofas and other seats where people can sit as family groups but this adds something special for the children.”

The staff are clear that this

definitely adds something special for the children. Margaret McEwan is clear about why that is. “With all the equipment, the art works and everything, there’s always been joint and mutual decisions. We were always giving feedback and were always involved in anything that involved the children. It was easy for the Play Staff to arrange for groups of children in the hospital to give lots of feedback. We facilitated workshops for the artists to come in and meet them so the artists had a feel for what the children and young people wanted.

The Warrens were fantastic at the engagement process. It’s not always easy to engage children but they literally got down to the children’s level, if the children were on the floor then so were the artists. Sometimes it took a while for the children to join in from the sides but they did when they

realized it was fun.

I love the way that Emily Hogarth’s illustrations are carried on throughout the hospital. There are the illustrations in ‘the Pod’ but there’s other wee things, like the films we’re using for distraction. I was involved before they chose the artist and her images really stood out. We loved them and the children and adults are going to love them too because they’re not to childish and they have lots of talking points.

The ‘mini worlds’ in the arches by Guy Bishop are amazing! You look through that tiny window and there is so much happening. You just don’t expect it. If it excited the adults, then you can imagine how exciting it will be for the children to discover it for themselves. It’s amazing how they’ve created it. It’s captivating.”

One of the things that stands out

is how much the early engagement with the staff and patients makes a difference both to how well the projects are integrated and how much difference they will make in the lives of patients, staff and visitors. As Margaret McEwan points out successful distraction is a mixture of both the immediate ‘wow’ and the little every-day details that you will notice over time. Sometimes, however, it’s the ‘invisible’ that makes that difference. Glasgow based design team Dress for the Weather (Matt McKenna and Andy Campbell) spent a lot of time thinking about how people really use space and how they might make the necessary waiting more natural.

“We wanted it to be more like a sitting room rather than a waiting room, so within the main waiting room there are four or five sitting groups with a lounge set-up: some are sitting around a TV; some will

be better for a private chat in a booth; and others will be perfect for people who like to read a book. There are also ‘distraction benches’ with gently undulating lights make you feel like you are sitting in front of a fire.

Understanding what people want from the space is key. Yet, the most important thing of all is something you won’t be aware of as you relax in this new space and that’s the time spent engaging with patients and a huge number of clinical staff, nursing staff, therapists and patients to make sure that the chairs were safe, strong, robust and just the right height for the particular needs of DCN Outpatients. It’s all the little things adding together.”

One of those expert members of staff is Mary Murchie. She feels that an important part of her work on the Art and Therapeutic

Steering Group was, “Representing lots of patients groups from all over as far as the Borders and Aberdeen.” She’s clear that engagement is vital. “I wanted to get across the challenges our clients have with mobility so that it was important that chairs were measured so that they could do the job. And that the décor wasn’t too distracting because some of our clients have epilepsy. I wanted to make sure they understood the importance of practicalities.”

This practicality was also the aim for Dress for the Weather in the new Children’s Hospital Sitting Rooms where, “people might be waiting while loved ones were having an operation. They might be there for a few hours so these are spaces that have to be comfortable and enjoyable to be in.”

Distraction plays a number of different roles within the new hospital. It is a catchall term being used to talk about all the different ways Beyond Walls is working to direct and re-direct the attention of patients, families and carers to facilitate their journey through the hospital.

The process of bringing together DCN with the new Children’s Hospital and CAMHS has offered challenges, but it has also presented the opportunity for aspects of distraction normally associated with children’s services to be developed for the adult context. Historically distraction has been considered to be one of the less positive characteristics of art. In ‘The Social Impact of the Arts’ (2008) the authors point out that art can distract us from ‘worthier matters.’ But in this case, it is precisely this function, of art’s ability to direct our attention, that

is being utilised for the benefit of people on their journeys through healthcare.

There are many different forms of useful distraction within the new hospital, some in order to make treatments go quickly and others to help pass the time whilst waiting. All of these are focused by the Patient Pathway, from large and small waiting areas, through the bedside environment to treatment and therapy rooms. In every case artists and designers have worked closely with staff and consulted as extensively as possible with patients. This engagement means that the various interventions are tried and tested from the outset. They have been thought about in terms of repeat visits and long stays.

The articulation offered by the Multi-Sensory Design and Distraction project in terms of

‘relax,’ ‘engage,’ or ‘focus’ is helpful in understanding the specific form of distraction that might be relevant.

Underlying this is valuable theory about effective distraction and its relationship with ‘attention’ provided by Rachel and Stephen Kaplan (1989). At various times we will be asked to give attention, whether that is part of a therapy session, or when meeting with medical, nursing or support staff. At other times we might have our attention focused on our own or our loved one’s health. Giving our attention is tiring. Distractions can form a moment for us to recover our energy. Attention Restoration Theory argues that distractions are an important part of recovering our ability to give attention. Our examples of projects delivering distraction in the new hospital demonstrate the importance of collaboration

between healthcare professionals and art and design professionals, based on mutual respect and the sharing of challenges.

This needs to be combined with effective user involvement but is actually more accurately described as co-creation. Co-creation assumes that everyone involved is contributing to the development, that everyone is an expert in their own lives. Professionals might have expertise in particular processes and techniques and this needs to be brought to bear on the challenges of lived experience. But the users’ experience of healthcare is of equal importance and needs to frame and help shape interventions. It is after all the patient’s pathway.

In the context of healthcare, distraction and dignity are complementary qualities which both enhance the patient pathway

in different ways. We discuss projects focused by Dignity and Personalisation in I am not a Number.

DCN WAITING AREAS

Dress for the Weather

Spaces spread through out the department offering arrange of crafted environments for distraction during waiting.

People might be waiting while loved ones were having an operation. They might be there for a few hours so

these

are spaces that have to be comfortable and enjoyable to be in.

Dress for the Weather

THE POD AND WAITING AREAS THROUGHOUT RHCYP

Daniel and William Warren

A major commission for the RHCYP main outpatients waiting area with the theme extended to waiting and dining areas.

The graphics by Emily Hogarth provide a strong linking theme running through all spaces.

The challenge was to fire the imagination, give children the opportunities to read, hide or just sit and look at murals and graphics. There are lots of references to the city centre and the idea of moving the ‘city’ out to Little France was to give a sense of where the old hospital came from.

William Warren

The ‘mini worlds’ in the arches by Guy Bishop are amazing! You look through that window and there is so much happening. You just don’t expect it.

Margaret McEwan

RHCYP WAITING & DINING AREAS

William and Daniel Warren

A series of spaces located throughout the building providing distraction, respite and a chance to relax.

RADIOLOGY

David Galletly

Equipment and walls form a background for scenes transformation of the everyday.

Different characters will reappear so that children can come back for multiple scans and that curiosity of finding familiar characters will befun for them. It will make Radiology a friendlier place.

Sarah-Jane Selway

MULTISENSORY ROOM

Southpaw

Multisensory room for Sensory Therapy

RESTAURANT: GARDEN OF DREAMS

Emma Varley

Series of six light boxes which are a re-interpretation of the existing stained glass from the old Children’s hospital. The work is composed of real and imagined views of a wider landscape to emphasise elements of strata linking to the Lothian environment.

Picture Sudoku by Alison Unsworth based on folded bus tickets.

MULTI-SENSORY DESIGN AND DISTRACTION

Alex Hamilton, Oli Mival and Derek Kemp

Forty six treatment rooms with projectors installed to suit patient viewing positions. Production of Film Times a curated library of short films for distraction based helping to relax, focus or engage patients. Three therapy rooms with interactive digital therapy projected installation.

Left column: Nim Jethway.

Middle column: (top image): Kris Kubik. (middle and bottom image): Holger Mohaupt and Tracey Fearnehough.

Right column: Jack Lockhart.

Key Collaborators

Artist Residencies:

Jeremy Weller, Theatre Director

Hans K Clausen, Visual Artist with Kjersti Sletteland, Ceramicist & Jenny Fagan

Doneil MacLeod, Practice Mental Health Nurse

Creative Research Artists Fellows: Susana Cámara Leret

Alex Menzies with Florence To

Gavin Inglis

Mentoring Residencies:

Curator:

Sven Werner

Stacey Hunter

Jack King-Spooner

Mark Daniels, New Media Scotland

Dr Peter Keston, Neuroradiologist

Joy Milne, the woman who can smell Parkinson’s

Alison Williams, Ar tist & Researcher

Jon Stone, Professor of Neurology

Fellowships and Residencies.

Unless you try to do something beyond what you have already mastered, you will never grow.

Ralph Waldo Emerson

The Beyond Walls Residencies and Fellowships provided a counter balance to the building based programme through creating opportunities for artists to work over two years with staff, researchers, communities and city organisations to explore the interrelationships between healthcare and culture. Ginkgo’s Director Tom Littlewood said that, “This was an opportunity for the hospital to develop a relationship with the city as a new resource.” This is very much part of the ‘place-based’ approach taken by Ginkgo which creates connections between the new hospital, city cultural organisations and the hospital charities.

The Residencies were focused on specific communities within the City, and the Fellowships on research and working practices in DCN. Both the Residencies and Fellowships opened up the Art

and Therapeutic Design programme to wider audiences.

The Fellowships were curated by Mark Daniels.

Artist Residencies

The two long-term Residencies were awarded to Jeremy Weller, theatre director, and Hans K Clausen, visual artist. Their focus was on working within communities and in particular for Jeremy, people who might normally be overlooked.

Jeremy Weller, the Artistic Director of Grassmarket Projects, a theatre and film company, focused on the co-creation of a new play Where it Hurts. This was performed by both NHS staff and people normally considered to be ‘hard to reach.’ It focused on their longstanding issues of addictions, poverty, depression and suicide attempts. The play ran, to critical acclaim, for three weeks at Summerhall

Arts Centre as part of the Edinburgh Festival Fringe. The theatre newspaper The Stage rated it as ‘5 stars’ praising it for ‘authentic voices on mental health issues.’ Jeremy said, “The brief wanted to explore the ‘hard to reach’ communities’ experiences of accessing the NHS. It was a novel thing to do because noone is really asking this but when you speak to the NHS staff, they love that question because they are very front-facing on that issue.”

Jeremy went on to explain that he has, “More than twenty years of experience of collaborating with, usually, untrained individuals to help them create performances. The people I worked with in Where it Hurts feel marginalised and excluded. They kept asking me who would be interested in seeing them perform. My role was to nurture and to help them. I don’t tell them what to say. I ask them

what they want to say and work out how to do it. I see it as going on a journey together and we see where we end up. As an artist I’m interested in giving voice and shape to their unique and raw experiences.”

Doneil MacLeod explained how he connected with Jeremy. “I work within a GP Practice. I deliver Mental Health Care including Psychotherapy. I work in Primary Care which is outside of the Hospital development however, we would have patients referred to us, mostly through A&E and sometimes through Inpatients. I was asked to speak to Jeremy about how NHS Lothian approaches Health Inequalities at the extreme end because I work at the homeless level.”

Jeremy said that most of the people were recruited from drop-in centres. “I was inundated. There

could be twenty of these projects. The need is overwhelming. The stories from the edge of society tell us more than those from the middle of society. The residency gave me the time to engage and nurture.”

Doneil agreed. “It was a very careful and thought-out process and it surprised me how it would even over-take Jeremy sometimes. That artistic process reminded me of psychotherapy - it’s something that evolves and sometimes you don’t know how, but you have to be open to it. What the whole process with Jeremy allowed was to ask the potentially frightening question of, “Who cares?”. It was an exhilarating process to delve into the nitty-gritty of how we engage in that dialogue. The energy from the people involved was amazing. It lit a huge spark and I would love to collaborate with Jeremy further to give more

people to have the chance for their voices to be heard and for a different dialogue about care to be created.”

That’s certainly something Jeremy would want to pursue. “The people said that the process made them feel amazing. More confident. More able to face life because of the performance and how they were made to feel, validated by the audience reaction. It was quite a shattering experience for them all to see how the work we did together had achieved such praise and interest. I have no doubt that the NHS could do 20 more of these projects as part of the future of Art and Therapeutic Design.”

Hans K Clausen’s residency focussed initially on forming new relationships with the community surrounding the hospital at Little France. Hans said, “I am primarily interested in how the stuff that we

come into contact with every day has a language I can use in the visual art world. I want to have a dialogue with people by using and manipulating objects - squeezing the meaning out of them.

As Resident Artist I was given the time and space to look at the processes within the existing hospital community and what happened as it went through a time of transition. I produced a collaborative piece (on many levels) that captured a sense of the community both on a personal level and the idea of people becoming part of a community.

Staff, patients, relatives and visitors would be given a piece of raw porcelain clay, asked to stop for a moment, take a few deep breaths, gather their thoughts and squeeze. We fired the clay and this has resulted in a collection of over 600 unique sculptural objects,

referred to as ‘Hospital Impressions’, each the result of one person grasping the pliable material for a moment. Hans worked with Kjersti Sletteland, an expert ceramicist, and poet Jenni Fagan.

Mary Murchie was involved in the project and liked that it was, “Very inclusive, very tactile and involved lots of patients.”

Hans explained, “I was involved in a lot of engagement. I had the luxury of just being able to spend time observing and shadowing activities throughout the hospital, listening in to staff meetings, sitting in the cafe and observing members of the public. It’s all about partnerships and relationships - between professionals and patients - little fleeting moments. You sometimes see a patient walking in one of those gowns and you think, ‘Poor

soul,’ but they have an NHS wristband on and they are part of the hospital, part of a department, part of a ward and they are a person. You just scratch the surface of this fairly anonymous hospital community and underneath is a person with a life.

The residency was one of these types of projects where it is both incredibly simple and yet complex. I was inspired by a DCN nurse telling me about the importance of holding someone’s hand when they were dying. Touch is so vital. After the residency I was invited to take part in an artists’ medal making course at Edinburgh Sculpture Workshop and the piece I made was based on this project. I wanted to focus on touch, what you hold in your hand or who you are holding.

I got my parents to squeeze a piece of porcelain between their hands, one on either side of the porcelain so as they flattened it, they put their imprint on the surface. I created a medal from it with the inscription, ‘We are able to hold and to be held.’

It was also important to me that the Hospital Impressions pieces have an anatomical quality to them but they can also remind you of childhood; the first day at school playing with the plasticine. Squeezing the clay was very primal. One elderly woman at a workshop was reminded of early childhood, loss and grief. It was very powerful.

It’s been interesting how many people have talked about our choice to use porcelain. Sometimes you make a piece of work and retrospectively it becomes far meaningful in a direction you hadn’t foreseen. My decision to work in porcelain, with the help of Kjersti Sletteland, was two-fold: I wanted to use something that was precious and I wanted people to feel the resistance when they squeezed, almost like the feeling of a stress ball. The porcelain we used was the most expensive because what we were capturing was of value. It also had a pristine quality to it when it was fired that reminded us of the association of clinical materials and cleanliness and sterile environments.

the shrinkage distorts that a little in the same way our memories are slightly distorted by time and context.

When we exhibited at the Edinburgh Arts Festival in the Anatomical Museum, we strung up all the pieces so that they were connected. Like fingerprints, the pieces look the same from a distance but they are all different when you get close up.

When you fire porcelain, it shrinks a bit more than other types of clay. This was a positive thing for me because I wanted this to be capturing a moment, like a memory, but we know that a moment is never preserved perfectly in the memory. The artefact you look at is the space from inside somebody’s hand but

One other thing about porcelain is that when we suspended them, not only did they have the anatomical quality of vertebrae but also had a sense of fragility because they were just hanging from very fine silk thread. They made a beautiful chiming noise which reminded people of the clinking of china on a tea trolley as it makes its way through the wards. I liked the fact that this serious piece of work that works

on so many levels can still have a touch of levity.

I am really excited and determined to work out how the Hospital Impressions pieces could be seen in different contexts, especially a hospital environment. I think there could be something with movement, working with music and drama therapists. It’s been very rewarding to explore the ideas and meanings of being held, holding and touch.”

Research Fellowships

The Fellowships were undertaken by Susana Cámara Leret, Alex Menzies and Gavin Inglis. The aim was to promote and highlight the research interests and working practices found in DCN. The Fellowships sought to build relationships between artists, staff and external research partners to demonstrate best practice and contribute to dialogues about the benefits of creative practice in

clinical environments. There were also three Mentoring Residencies with Sven Werner, Stacey Hunter and Jack King-Spooner.

Mark Daniels explained, “A couple of years before, I’d worked with the Scottish Government on Project Ginsberg which was an ‘ecosystem of assets’ to help people understand the triggers in respect of mental health and wellness. They supported my work as a curator by investing in the Alt-W Fund which allowed us to work with a variety of different creative practitioners and contribute to that ‘asset eco-system’.

So, the opportunity of curating the Fellowships and Mentoring Residencies within DCN continued the trajectory of working with a different spectrum of practitioners. As a curator, working with Susana, Alex and Gavin, I wanted to understand how they liked to

work, how I could best support them. Obviously, engagement was important. I didn’t want the artists to be in a vacuum, connecting with the outside audience is important.

We set up a space in the City Arts Centre to support the Fellowships and subsequent Mentoring Residencies, as well as having a space to connect with other Beyond Walls projects. The audience at the City Arts Centre is quite interesting because it’s a mix of local and international. We had an exhibition there called The Re(a)d Bed. We had done a European-wide call for the three Fellowships, but we also had three month-long Mentoring Residencies where I brought in Sven Werner, Stacey Hunter and Jack KingSpooner. I thought they would benefit from having some time and resources to make something happen. It provided us with some

very focused, definitive outcomes for the exhibition.”

The Re(a)d Bed exhibition included work from the three Fellows and the three Mentoring Residencies as well as material from the NHS and City Archives. This combination offered a rich mix of responses to the experience of healthcare.

Mark commented, “Stacey has a particular interest in self-image and identity within a healthcare environment. She curated work about the personal items we surround ourselves with when we want to ‘feel our best’. The central idea was the dressing table or vanity unit.

Sven continued his Observer Cinema project with an installation and audio work about a man who realizes he can inhabit hidden space (this was also shown at the Royal Scottish Academy for the

Society of Scottish Artists exhibition).

Jack made a work that looked at hope and false hope within wellbeing, focused on Victorian spiritualism and Scottish witchcraft. Although quite dark in tone, his fortune telling booth was very family-friendly!

This exhibition was, for me, a definite highlight. It showed what a dedicated Mentoring Residency with dedicated support and resources can produce and what effect it can have on a practitioner’s career. It led to interesting pieces from the mentees as well as further commissions and opportunities for them.

We introduced the Fellows to a public audience at an event called The Art of Neuroscience at the National Museum of Scotland as

part of the Edinburgh International Science Festival. Susana’s ongoing collaborative project, Thought Collider, was featured at the Edinburgh Arts’ Festival. All of the Fellows produced work for the Edinburgh International Science Festival and the International Book Festival. This provided a chance for collaboration and a way to build the holistic feel that we wanted this programme to have. Plus, Susana was able to re-visit some of that at the Royal Botanic Gardens, Edinburgh where she collaborated with Gavin. Alex did a series of monthly concerts at the City Arts Centre called Other Mind Music.

This programme gave the artists the opportunity to reflect on their practice and explore ideas within a healthcare context - this is unparalleled. I am already seeing the beneficial effects of being able to give time and resources

and I would strive to do this again if the opportunity arose. I am indebted to the Health Foundation for the opportunity. Everyone has gone above and beyond what was expected of them with this opportunity and it’s really quite beautiful.”

With the Fellowships, each artist approached what was a very open brief regarding involvement with DCN very differently.

Susana Cámara Leret was the Design Fellow and has worked across art and design for the past ten years. She said, “My interest is in the overlap between science, art and technology. A lot of the work I develop is done in collaboration with research institutes and academics within the various disciplines. I explore the questions of what health is and how we deal with illness, especially chronic illness. I’m

particularly interested in exploring these questions in relation to organoleptic properties (acting on, or involving the use of, the sense organs). I have worked with smells and the link to memory previously and carried this on during the Fellowship.

I wanted to explore the issue that care is something that exists ‘beyond walls’. With my work on smell molecules, I was exploring how people related to them in and outside the hospital environment. The collaboration with the NeuroRadiology team in DCN resulted from an anecdote. They told me how they insert a glue-like substance into the brain. They do this in stroke sufferers because it blocks the knot causing the problem in the arterial vein. It redirects the blood from the problem area. The patient’s body metabolizes the compound which affects the smell of their breath.

Dr Peter Keston said he thought it smelled like artichokes and one of the nurses can’t eat asparagus at home because it makes her feel as if she’s back on the ward!

It’s this connection, what I call a ‘hyperlink’, between smells and memories or associations which allows for lateral thinking in a way I find fascinating. You might be smelling the same molecule but your reaction might be completely different to someone else because you have your own specific ‘paired’ memories and emotions. These are completely dependent on context and environment.

What fascinates me is that each smell is composed of combinations of molecules, meaning that one particular molecule can be found in many different smells in completely different contexts. The molecule released on the patients’ breath is

shared with seaweed, bacteria, algae and lots of vegetables when you cook them. The NeuroRadiology team call it the ‘onyx’ smell because the glue has a contrasting black colour in the imagery.

I was able to follow one of these procedures and I collected both the breath of the patient and the radiologist. I used balloons. I then used these breaths to create a series of glass vials. I’m interested in creating some kind of reflection of the breath or smell, a way to see the invisible, so I’m developing metal stands to hold the vials and provide a reflection of the glass.

The molecule expressed in the breath is the same one produced by the Titan Arum or Corpse Flower when it mimics rotten flesh. I went to see it bloom at the Edinburgh Botanic Gardens. Fortuitously, I was part of an

art-science symposium with Joy Milne, the woman who can smell Parkinson’s, and Alison Williams, artist and researcher who has Parkinson’s.

I was introduced to Joy by Dr Tilo Kunath at the Centre for Regenerative Medicine because I’ve been exploring the smell of Parkinson’s as part of the Fellowship. Joy and I immediately connected and we would do smelling exercises. There was a BBC documentary called The Woman who can Smell Parkinson’s about Joy and there’s a moment where I’m featured doing smelling exercises at the City Arts Centre.

Through Joy I met Alison and that took the work into a completely new direction. Joy can tell what stage the disease is by the different scent and by the time it reaches level 5 she can no longer smell the person, only the

disease. We discussed the idea of ‘body talk’ and how the body communicates through the senses. Alison was keen to try and lessen the effect of the symptoms through diet and exercise. I provided a hospital suit and Alison wore this when she exercised. We cut up the suit and, with the help of Matthew Pauley at Herriot-Watt University, distilled the sweat. I liked the idea of exploring what remains and what’s left behindis what we distilled Alison, the Parkinson’s or both?

We came up with the idea of Three Suits, one suit representing the traditional medical process, the second representing the process of fragmentation and distilling we did, and finally the last one where Alison and Joy took control of the process. Joy embroidered her perception of the five levels of Parkinson’s onto the suit. Alison embroidered her

narrative about the disease but she turned the suit round so that the back became the front, like a symbol of her trying to control her own body. These suits became like a ‘platform’ or shared framework where we could discuss and explore. It was the experience of a patient who is living through the progression of the disease and a person who can decipher that progression through smell, but who was also the carer for her husband who died of the disease. It was the unofficial story which does not appear in the casenotes.”

Alex Menzies was the Music Fellow. He is a composer, producer and artist. Where Susana had very specific areas she wanted to consider, Alex liked the fact that the brief allowed him to consider the therapeutic effects of music and music therapy in a wider context. He says, “It was really

nice to be able to approach the Fellowship with a wide-angle lens as it meant I was able to consider all the different ways that music and health interact within history and within different cultures.

There were a lot of workshops where I and the other Fellows presented our research findings. For my section at the Edinburgh International Book Festival, for example, I presented a selection of music representing various approaches to altering consciousness. This included the sound of gongs and bells from Tibet, a Zar ritual from Egypt, Sufi Ney music from Iran, drumming from the Congo and shamanic chanting from Peru. It also included modern examples such as binaural tones, techno and psycho-acoustic manipulation by Ryoji Ikeda. I also did a lot of work looking at how clinical research is finding links between

particular sounds, paces and rhythms. I was really interested in discovering about the therapeutic use of sound in medicine, seeing it in real-life examples, because that seemed to be the most useful thing I could do with the Fellowship. Neurological Music Therapy is covers things like stroke rehabilitation using the pace of a sound. What I really liked about these things was that it empowers patients, allowing them to feel that they can be an active part of their own treatment.” Alex created an album Eirini Pt1 which can be found on Bandcamp: https:// alexmenzies.bandcamp.com/ album/eirini-pt-i

Gavin Inglis was the Language and Cognition Fellow and is a writer with a background in Computer Science, Artificial Intelligence and Interactive Narratives. He explained how he

used his previous experience to explore the possibilities offered by the Fellowship. “The brief was to ‘mark the transition’ and do something constructive for patients and the building. I knew I wanted to do a lot of engagement, amongst other things there was a neuroscience evening at the Edinburgh International Book Festival. The other two Fellows Susana, Alex and I all did some pieces at it. I had a new piece of interactive fiction where someone was strapped up to an EEG [An electroencephalogram]. EEG is a test used to find problems related to electrical activity of the brain. An EEG tracks and records brain wave patterns. Small metal discs with thin wires (electrodes) are placed on the scalp, and then send signals to a computer to record the results. The twist was that the EEG was making the decisions. I think it was probably the first time at the Book Festival

where they had brains being ‘read’ live on stage!

For the cognition side of it I built a piece of Artificial Intelligence that digested the work of particular authors and wrote new pieces in their style. It’s kind of spooky how neural nets can do that these days.

I had audience members reading pieces supposedly by Jane Austen, Conan Doyle, and HP Lovecraft. I also collaborated with Susana on a piece where the story was accompanied by smells. She broke down the components of the smell produced by the Corpse Flower which was blooming at the Royal Botanical Gardens Edinburgh and I wrote a story about a break-up where the components were the accompaniments. The floral scents and the real ’stink’ of the Corpse Flower produced the ups and downs of the relationship. When we met up later and did another

session with different smells, the story took a different direction.

As someone interested in interactive texts, I found that really fascinating. For the audience at the Book Festival it added a whole new interactive layer. One minute they were scratching things in a bag and sniffing it and then next minute Susana has a cauldron on stage with a fan blowing the smells out to the audience. These were not meant to be informational per se but they were highly entertaining and a good way of raising the profile of the hospital as a whole and DCN specifically.

I went to a lot of meetings at the hospital and talked to lots of staff. I was fairly open-minded about what I was going to do. I spoke to someone who mentioned the field of Functional Neurological Disorders (FND) and suggested it might be something I would be

interested in. Everyone who works in this field knows about Professor of Neurology Jon Stone, who has spent the last twenty years researching Functional Neurological Disorders. When I approached him with my idea of a graphic novel about FND he was very helpful and approachable.

I wanted to do something therapeutic and something that would last longer than the Fellowship. My understanding of FND is that some of the suffering that patients go through is about not understanding what is wrong with them. The body doesn’t seem to be working properly and they don’t know why, often they go to a GP who doesn’t know what it is and they get passed around from place to place. FNDs can have a terrible effect on their life. If you can’t go to work and your doctor can’t tell you what’s wrong with

you, the suffering just increases. As part of my research I went to a conference at the Assembly Rooms about FND.”

Professor Stone says that FND is the “second most common reason someone sees a neurologist. The peak age for onset is eighteen, although it can occur at any age.” FND is when someone has neurological symptoms, such as limb weakness, numbness, fits or blackouts. These are due to a problem with the functioning of the nervous system rather than because of damage or a structural disease of the nervous system. You can’t see FND on a scan but it is real, and not imaginary.

He goes onto to explain, “It’s a very hidden, stigmatised disorder, although people are changing their attitudes and behaviours and developing better treatment,

which might include physiotherapy or psychological therapy. The condition is at the interface between neurology and psychiatry. It’s a disorder of the nervous system functioning where psychological factors can be very important but might not be. The patient ends up in neurology because the symptoms appear to be epilepsy or a stroke. It was the case in the past that patients might be told there was nothing wrong with them. In Gavin’s graphic novel a character presenting with a type of FND called a dissociative seizure to the ambulance services is questioned by the paramedic. We now diagnose FND using the positive features of the episode. So, for example, the character in Gavin’s work has her eyes closed when having a dissociative seizure whereas with an epileptic fit their eyes would be open. With FND related leg weakness, if the patient

is distracted, they can move their leg better, something we share with them to improve understanding and treatment. For someone with a seizure this would probably be through psychological therapy and for FND mobility problems the first port of call would usually be physiotherapy.

I made a website for patients with FND called www.neurosymptoms. org which Gavin used as part of his research. [There are also two patient-led websites: www. fndaction.org.uk and www. fndhope.org.uk] Gavin’s graphic novel is an accessible format to help people get their head round a difficult topic. It can take a long time to understand it and having someone’s battles and frustrations with their FND be represented is appealing. Hopefully patients with FND will identify with it and not feel alone. We have to normalize this condition and use multiple

methods and help people understand it.”

Gavin agrees. “I wanted to create the graphic novel because it’s easily accessible with a mixture of text and striking images. The images are produced by the very talented artist Fin Cramb. I write the text and do the lettering. I very much hope it will also raise awareness and be therapeutic because it will allow people to gain some understanding of what they have and the challenges they face. It will initially be available online but the plan is to produce it as a physical thing. As an art form, it’s something that takes a lot of time to get right. For example, we went into DCN and saw an MRI because one of my characters has a scan. The central character has dissociative attacks but there are so many different symptoms of FND. I really needed Professor Stone’s guidance and expertise

as well as the website www.neurosymptoms.org he runs. He always puts the needs of the patient first and I hope, with his help, I’ve produced something that does that too.

Conclusion

The Residencies and Fellowships provided a catalyst for new partnerships and working relationships to be nurtured; it also provided artists and designers with time and space for ‘blue sky’ thinking evolving their working practice. Most importantly, it enabled artists to collaborate with staff and patients to reflect the conditions, treatments and research practices of the services, as well as their hopes and fears.

The different approaches highlight some of the range of forms of collaboration that are used in the arts. From Susana Cámara Leret’s work with individuals researching

and living with Parkinson’s; through Hans K Clausen involving more than 600 people in a simple physical act; to Jeremy Weller providing a platform for Mental Health Service Users to tell their stories. Gavin Inglis’ project can be understood as illustrating the science of Functional Neurological Disorders in support of suffers, their families and carers where Alex Menzies is creating new music.

We started with Jeremy Weller’s work with individuals accessing mental health services, using theatre as a means to enable them to tell their story. Hans K Clausen’s 600 porcelain pieces, each made by someone squeezing the raw material, offers a completely different approach to enabling individuals to make a mark.

The Fellowships enabled artists to engage a broad public in neuro-

science using the City Arts Centre as a base and the International Science, Art and Book Festivals as platforms. The Re(a)d Bed exhibition and Festival events opened a dialogue enabling City inhabitants and visitors to understand aspects of the DCN services moving to the new hospital in ways not normally featuring in mainstream cultural programming.

The three Fellows each explored very different aspects of the work of DCN, from the role of smell in our lives and our health, through the therapeutic role of music in health, to the ways that art and design can support public awareness and communicate specific information regarding a particular condition. In every case the artists and designers developed close collaborative relationships with specialists.

We might read the Fellowships in particular in the context of art science collaboration (sometimes called SciArt). The outcomes of art science collaboration can be the illustration of expert knowledge to open this up to more general understanding. Other outcomes can be enabling scientists and researchers to see their practices in new lights, temporarily freeing them from strictures of their disciplines to reflect on the wider significance of their work.

In terms of illustration, approaches such as graphic novels use storytelling to evoke personal experience. Science tends to seek general truths and to ensure that treatments work on as many people as possible, so refocusing back onto the singular is not normally within the repertoire of researchers’ skills. Evoking individual human experience in

ways large numbers of people can relate to is a particular skill of the arts. This can be achieved through more literal and more indirect or elliptical approaches translating technical knowledge into quite different material forms, such as capturing the breath of those living with Parkinson’s in glass vials.

These sorts of collaborations take time because artists, scientists, clinicians and communities need to develop trust. People need to learn about each other’s’ forms of expertise. This is often through learning each other’s specialist words (whether that is technical terminology or a local dialect). This process is sometimes imagined as a triple helix (artist, scientist, community). Understanding and trust develops through this process.

The Residencies and Fellowships programme and its public face

through exhibitions and festival events is unusual in the context of a public art development for a hospital and its value cannot be measured in the practical terms of the other elements of Beyond Walls. Creating a dialogue with the City and opening up aspects of the New Hospital, whether that is in relation to the experience of Mental Health Services or Clinical Neurosciences, brings the vital work of the various services in the building to wider public understanding. This place-based approach helped the new hospital to be part of the City even before it opened, and drew attention to some of the more specialist services. Edinburgh’s particular reputation for Festivals made these natural partners for the project. The value of that cannot be underestimated and complements the value of other contributions of art and design to the building.

Fellowships.

MUSIC FELLOWSHIP

Alex Menzies

Other Mind music workshop and performance at the CityArts Centre using EEG

LANGUAGE AND COGNITION FELLOWSHIP

Gavin Inglis

Gavin Inglis presenting at a neuroscience evening as part of the Edinburgh International Book Festival.

Graphic novel promoting wider recognition of FND in collaboration with Professor Jon Stone and illustrated by Fin Cramb

I wanted to do something therapeutic and something that would last longer than the Fellowship.

Gavin Inglis

DESIGN FELLOWSHIP

Susana Cámara Leret

The Smell of Onyx: Aspirations is a series of hand blown glass vessels containing the breath of patients who have undergone embolization treatment for Arteriovenous Malformations (AVMs) of the brain and spinal cord at City Arts Centre, Edinburgh

I wanted to explore the issue that care is something that exists beyond walls. With my work on smell molecules, I was exploring how people related to them in and outside the hospital environment

Susana Cámara Leret

TALKING BODIES

Susana Cámara Leret

Event at Royal Botanic Garden, Edinburgh with Joy Milne and Alison Williams.

RE(A)D BED EXHIBITION

Above: The residency by mentee artist Stacey Hunter explored the depersonalising effect of clinical environments on patient experience. Her installation explored ideas of the ‘dressing table’ and ‘vanity unit’. The residency then considered the accoutrements we surround ourselves with to communicate or sustain our ‘best self’.

Right: Florence To (working with Alex Menzies) presented OCM_01, a digital animation for Sedition, that visualises a tangible sense of gravity and the psychological effects of being in a full dome environment. This relates to an exploration of the Dott Theatres.

Residencies.

ARTIST RESIDENCY

Hans Clausen

‘Hospital Impressions’

It was also important to me that the Hospital Impressions pieces have an anatomical quality to them but they can also remind you of childhood; the first day at school playing with the plasticine. Squeezing the clay was very primal.

Hans Clausen

Left to right: (Top and bottom) Clay workshops with staff, patients and visitors.

Exhibition as part of the Edinburgh Arts Festival in the Anatomical Museum.

Bottom right: Hospital Impressions seminar at the City

ARTIST RESIDENCY

Jeremy Weller

‘Where it hurts’

What the whole process with Jeremy allowed was to ask the potentially frightening question of, “Who cares?” and it was an exhilarating process to delve into the nittygritty of how we engage in that dialogue.

Doneil MacLeod

A FUNDER PERSPECTIVE -

EDINBURGH CHILDREN’S HOSPITAL CHARITY

Alice in Wonderland, Lewis Carroll

A Funder’s PerspectiveEdinburgh Children’s Hospital Charity

The hospital is looking wonderful. It is so refreshing to see the building has been designed with young people in mind, listening to the needs of children and young people and the parents/ carers that support them is so important - it is clear that this has been central to the design. It’s wonderful to see the work of ECHC and how much they have contributed to making the hospital a friendly and welcoming building.

Edinburgh Children’s Hospital Charity (ECHC) believes that nothing should get in the way of being a child. We exist to transform the lives of children and young people in hospital so they can be a child first and a patient second.

As a result of what we do children and young people’s lives are less interrupted by illness. They are less scared of hospital and have a positive experience. Their families are better supported and comforted; and children and young people have an improved experience of health-care in hospital and in their community.

ECHC carries out a number of activities to make this difference to young lives. This includes running The Hub, a child, youth and family support service, unique in a children’s hospital setting anywhere in the UK; funding a volunteer service; running the

children’s hospital shop; and supporting the work of the Play and Family Support teams. Most relevant to the new children’s hospital, however, was our work as a grant giver, our strategic desire to increase our activities relating to children and young people’s mental health and wellbeing; and our innovative Arts Programme, delivering a broad programme of participatory arts workshops.

Our Grants Programme, encourages applications from NHS staff members to provide funds for projects, equipment, distractions and enhancements over and above that which the NHS can provide. NHS Lothian project staff had the foresight, right from the start, to appreciate the importance of integrating art and therapeutic design into the new hospital.

Our interest in this area, of arts in healthcare and the impact of

surroundings on a child or young person’s sense of value, engagement with treatment and speed of recovery, meant we were immediately keen to fund such an ambitious project. Our previous enhancements to NHS facilities had not been on this scale and the project allowed us to be bold and set the bar at the level we’d like all enhancements to aspire to.

‘The Sick Kids’ had been in operation since the mid-1890s. The Victorian sandstone building had long been outgrown and the need for a new facility was obvious. That said, the building was an Edinburgh institution with generations of families with their own ‘sick kids’ story. It was important that the heart and soul of this well-loved building be transplanted to the new, along with the sense of community so important to those who knew the building well. Moving to a building

with no thought to art and environment would have led to those important aspects being instantly lost. The ability of the Art and Therapeutic Design (ATD Beyond Walls) Programme to inject a personality and character into the new building was an important aspect for ECHC, as we knew this would matter to those who visited.

The initial request for funding the ATD project came as seven grant applications from ‘welcome and wayfinding’ to ‘play and waiting’. The funding request from NHSL was made through our Grants Application process and this ensured that the project case for support had to be made in line with the Charity’s outcomes. The projects were always about the difference being made for babies, children, young people and their families. For the Charity, it is a lovely bonus that the ATD

programme is hailed as the largest, integrated project of its kind in a healthcare setting in the UK but our first priority at all times was about the impact for children, young people and those that care for them.

From the start of the project and throughout, the Charity has had representation on the ATD Steering Group. This has involved the Charity’s representatives being involved in all stages from briefing to installation. The Charity has been able to influence the outcomes for each project, ensuring that they have children and young people at the heart. All projects needed to have some obvious positive outcomes for children, be that anxiety reduction, engaging them in play, distracting them from a procedure or calming and soothing their parents at difficult times. Throughout the project, the Charity had the

privileged position of representing those who would benefit. In one discussion, for example, about waiting areas, there were some clearly differing views as to how much ‘fun’ a waiting area should be when NHS staff need children to leave that space for their appointment. The Charity (and the hospital play team) were able to make certain that ‘fun’ came to be viewed as importantly as clinical need or infection control compliance.

One of the key successes of Beyond Walls has been the involvement of children, young people and their families in the design process. The Charity is their voice and no-one is better placed to give that perspective.

The involvement of current hospital and healthcare visitors gave us the best chance of getting the final design right. Written into every

project brief was the condition that each design team must demonstrate significant user engagement. This led to design teams being well informed and thoughtful about the spaces which they were creating. Engagement activities included a series of arts workshops which involved children trying everything from screenprinting to sculpture.

The engagement process allowed potential disagreements to be quickly solved. When the adult professionals around a table began to dispute the appropriateness of artwork or designs, this could very quickly be resolved by the play team ‘surveying’ children and young people in the hospital. Similarly, prototype furniture was tried out in the wards and the ECHC Hub and feedback led to some significant changes of thinking by designers and makers. Involving and listening to

staff was crucial too, not just in getting the final spaces right for their many uses but to get buy-in from a team potentially anxious about the move and concerned about the artistic approach to a clinical environment.

ECHC works with around 35 partners at any one time in the delivery of our Arts Programme and Hub service, and in joint fundraising ventures. The Charity is used to a collaborative approach although the number of stakeholders involved in this project was larger than we would normally sit around one table with. Like all projects, the key to success lies first and foremost in sharing the same goal.

All stakeholders had the shared vision of creating a world class children’s hospital which provided excellence in clinical care in a sensitively designed environment.

Although each person around the table may have come at the goal from a different angle, the single aim kept us on track throughout. The creativity which Beyond Walls stimulated led to a culture of problem-solving and can-do willingness around the table.

Our initial commitment of £2.9 million rose to over £3.1 million as more parts of the building were identified as benefitting from extending the ATD programme. These included the Child Protection Unit and Radiology. All of ECHC’s funds are raised from charitable donations from a range of sources including individuals, fundraising events, sports challenges, trusts, companies and legacies. The project allowed us to approach supporters with a once in a lifetime chance to fund the enhancement of the city’s new children’s hospital. Many of those who provided the funds for

Beyond Walls were families who wished to donate in memory or in celebration of their own child. All understood the difference that could be made by applying an arts approach to what might otherwise be a clinical, daunting building.

The thoroughness and rigour of Beyond Walls has meant that we have avoided situations where funders have felt the need to dictate how ‘their’ rooms should look. We have asked funders to trust that design, colour, look, feel are all being considered through engagement with those who will be on the receiving end of this. The involvement of children and young people has given reassurance to funders that the project is well thought out from a beneficiary’s perspective. Being able to outline the process that the artists, designers and makers have gone through and to have been allowed up close to the project has

allowed the Charity to speak to funders confidently and with knowledge.

This is not always the case for fundraisers of projects they have never seen or are not so closely involved in. This has led to funders feeling engaged even throughout the delays to the build.

The risk to a Charity of a capital appeal is that once a brand new, shiny hospital opens it is seen as ‘job done’. The message to funders throughout this project has been that the Beyond Walls enhancements mark only the start of a longer term commitment by the Charity to arts, therapeutic environment and holistic supports. Some funders have funded not only the initial enhancement of the space they’re funding but have committed to ongoing funding. One company was so impressed by Beyond Walls that

they are funding three years’ salary for a new member of Arts Team staff to allow us to deliver our Arts Programme seven days per week. Other funders are gifting toys, books and games to fill the playrooms and waiting areas for which they’ve funded the enhancement.

The new hospital gives us a (very colourful) canvas to continue our broad range of engagement, distraction and supportive projects. The first funders shown around the project have been visibly astounded by the sheer scale of the project and we’ve yet to show someone the Pod and not have their first reaction be ‘wow’. ECHC supporters have helped create a truly special building, on a different level to other healthcare facilities.

For the Charity, it has been a privilege to represent the views of children, young people and families, ensuring their involvement in design but also to link up

supporters with projects they feel passionate about giving to.

This project is our first of many commitments to the new Royal Hospital for Children and Young People, and CAMHS and we look forward to now bringing the building to life with arts, activities and a range of supports for all who find themselves having to visit this special place.

Roslyn Neely Chief Executive

Edinburgh Children’s Hospital Charity

A Funder - Programmer’s Perspective - Edinburgh & Lothians Health Foundation

The art contributes to a feeling that we care about patients and their surroundings. It provides a focal point and gives inspiration to patients and families to look at things from a different angle, helping them manage the extremely challenging events in their lives.

NHS Lothian Charge Nurse

Both the Art and Therapeutic Design Programme and NHS Lothian Charity’s Tonic Arts programme work to enhance the patient experience by improving the healthcare environment and enriching the patient’s stay, asking:

How can this patient’s day be brightened?

How can this environment be made better?

How can the experience of treatment be improved?

Beyond Walls has used creativity in all its forms to find joyful, innovative ways to answer these questions.

NHS Lothian’s official charity, NHS Lothian Charity, invests in projects which promote better physical and mental health and wellbeing across the patient community. We work

through our Tonic Arts programme to collaborate with NHS colleagues and wider partners to support a diverse range of activities which go above and beyond standard health services, from clinical research to innovative equipment; peer support projects to family engagement; community gardens to diverse therapeutic activity for priority patient groups.

The charity manages a programme of funds and grants built from donations, legacies and investments, often donated for use in specific NHS Lothian wards, departments or hospitals. Looking to enhance NHS provision, but not substitute it, staff propose a diversity of projects, from the small-scale funding of dementia cafe sessions to the large-scale enhancement of patient wifi. Alongside this, the charity has identified key priorities for delivery, appointing specialist leads and

commissioning strategies for the areas of Arts, Greenspace, Staff Wellbeing and Volunteering. There is much established international evidence that confirms the role creativity plays within the healthcare context, saving resources and improving patient experience by reducing the need for pain medication, shortening length of stay, reducing anxiety and depression and improving patient and staff morale. Recognising this, Trustees appointed an Arts Manager and approved an Arts in Health and Wellbeing Strategy.

At a similar time, the delivery of an arts strategy was included as part of the brief for the building of the new Royal Hospital for Children and Young People, Department of Clinical Neurosciences and Children and Adolescent Mental Health Services, next to the existing Royal Infirmary of Edinburgh.

This reflected NHS Lothian’s ambition to embrace a ‘Percent for Art’ approach in all its major new-build schemes. The winning tender from Integrated Health Solutions Lothian included public arts agency Ginkgo Projects. Following a consultation and development period and subsequent request from the NHSL project team to fund the enhancement of a range of interior and exterior spaces and patient play and entertainment, NHS Lothian Charity Trustees agreed a £2M commitment to co-fund the holistic Beyond Walls programme.

That the NHS Lothian Charity Arts Strategy and this programme coincided was a timely development. Firstly, it was recognised that here was a flag ship hospital with a number of important patient groups, including the young, the elderly and those at their most vulnerable

who would sometimes be resident for long periods of time. Secondly, Beyond Walls mirrored the NHS Lothian Charity Arts in Health and Wellbeing Strategy in scale and ambition.

The NHS Tonic Arts Programme works to improve and support the health and wellbeing of staff, patients and visitors through the provision of high quality arts and creativity, to conserve the artistic assets of NHS Lothian and to foster a culture in which the benefits of the arts and the skills of the artist are valued across the service.

Strategic management of the programme is provided by NHS Lothian Charity, with each project delivered in partnership with artists, arts project managers and agencies, third sector organisations and national bodies. The programme is overseen by an Arts Advisory

Group of Trustees, NHS staff and Arts Specialists.

Patient representatives, volunteers and staff are all central to the development of projects, advising on suitability of artwork and activity. As patient benefit is central to our activity, projects are often developed with patients, for patients. Collaboration with colleagues including those in Volunteering, Nursing, Occupational Therapies, Activity Coordination, Operations, Facilities, Estates and Capital Planning, is essential to our delivery.

The diverse programme includes:

• the management and provision of an art collection of over 2500 works, managed in collaboration with the Royal Scottish Academy.

• a changing programme of diverse exhibitions in devoted spaces across all main hospital sites.

• a thriving participatory and live arts programme of artist residencies, workshops, events and concerts for priority longstay patient groups – particularly those in Mental Health and Medicine for the Elderly ser vices - delivered both in-house and in partnership with specialist arts organisations, such Artlink, Music in Hospitals and Care and Generation Arts. Over 800 sessions were delivered last year across NHS Lothian, with over 8000 patients and staff.

• a programme of high-quality art and integrated design commissions for new healthcare builds and large-scale refurbishments, enhancing greenspaces, interior spatial

designs and enhancing elements of buildings. Current projects include the redevelopment of services at the Royal Edinburgh Hospital, the building of East Lothian Community Hospital, the Edinburgh Haematology Centre at the Western General Hospital and a series of Community Health Centres across Edinburgh.

The vision for Beyond Walls echoed our wider programme aims in many ways. The benefits to patient experience have shaped the programme structure from the outset. Enhancing Arrival and Wayfinding bring clear practical benefits, along with the enlivening and making unique of spaces for staff and patients. Similarly, Personalisation & Distraction projects have tailored the design of spaces for particular patient groups and individual needs. Alongside interior design schemes, bed-

side and therapy room spaces have been enhanced with a library of bespoke digital animations and films. The presence of Gingko ensured a quality of project management from an organisation with significant experience of working within NHS contexts, and the guarantee of employing professional artists with engagement and people skills.

The emphasis on patient and staff inclusion in each commission brief was central to the programme and the development of programmable exhibition spaces enable us to provide engagement and distraction for patients and visitors, allowing for an escape from the intensive hospital experience.

The process was a collaborative one throughout, with a steering group of Project Managers, Clinical staff, Play Specialists, Therapists, Charity Directors and Arts

Managers meeting every six weeks for the full five year duration of the project. This enabled a wide range of informed voices to shape the project and allowed NHS Lothian Charity to contribute an arts specialist voice to compliment the patient and clinical voices. Such contribution allows us to fund these projects knowing that we’ll be able to ensure suitable, patientfocused artistic quality throughout.

People are often intrigued as to how the artists are appointed on projects like this. Each project had a publicly advertised brief and application process – not unlike a job or tender submission process but with stunning visuals. The applications were then shortlisted by Ginkgo and interviews took place, with presentations from the artists to a sub-group of arts managers, project managers and relevant clinical staff and patient representatives. Appointed artists

then started to collaborate with department staff to identify the needs of the commission. They ran extensive workshops with staff, patients and public groups to gather opinion and content for the artworks. As the project progressed, each artist produced concept and ultimately final designs, all going through various stages of refinement for comment, revision and approval; ensuring every drawing, every piece of artwork, every item of furniture; every animation was suitable for its destination.

Particularly important for NHS Lothian Charity was the support of ‘Artist-Led Durational’ projects in the programme, where commissioned artists, writers, designers and theatre producers worked with staff and patients in current settings. This meant that not only would the ATD programme result in permanent commissions

for the building, but that more intensive engagement projects would take place, developing a sense of ownership for the new build, bringing out the unique identities of the relative departments and showcasing their work within the NHS community and wider city context. The aim of the residency programme was to focus on building creative engagement within the Little France community - the site of the new hospital and the existing Royal infirmary – and connect with minority groups across Edinburgh. New cultural relationships were also built as a result of collaborative residency and fellowship outcomes being showcased across the city in the Edinburgh Festivals and beyond.

So what lessons have we learnt in undertaking this and similar programmes?

Have vision

• be ambitious. It ’s amazing what we’ve managed to achieve.

• be bold and fully commit to the programme, taking stylistic risks and avoiding ‘the bland’.

• have fun with it. Healthcare environments can accommodate – and indeed welcome – the whimsical or the amusing. It softens the clinical.

Look elsewhere

• learn from the documented evidence showing the benefits of the arts in healthcare environments.

• visit other project examples and see what they have done well and what materials have longevity.

Collaborate

• keep the patient and staff

groups in mind at all times throughout commissioning and ensure their voices are heard.

• use diverse participatory activity to engage groups throughout the project.

• ensure you have sufficient interest and capacity from NHS Capital Planning project managers, architects and the construction company to deliver the project. We were very lucky on this project to have the ATD built into the project brief and to have great capacity and enthusiasm in the NHS team.

• engage all partners early in the process - get funders, arts managers and artists involved as early as possible to collaborate with the build project team.

• form a project steering group with staff and patients from all areas with a clear remit and agreed methods for design sign off. This is important with numerous partners and diverse

voices around the table. You want the programme to be guided by those who know the context. You don’t want to design by committee.

• decide clear communications routes. There can be multiple chains of communication between patients and staff, managers, funders, construction companies, engineers, artists and arts managers. You need this process to be as simple as possible whilst allowing for everyone to be able to contribute their areas of expertise.

Engage professional arts specialists

• Staff can fear that this means working with people who will alienate participants or encourage a ‘high art’ approach. Not so! There are plenty of creatives who are down to earth and encourage participation and dialogue.

• ensure patient and staff inclusion is par t of each commission brief and where possible commission artists with public engagement at the centre of their practice. Appoint a good specialist arts producer to curate and project manage the programme. If they have knowledge of the healthcare environment, all the better. Be prepared to be a mediator between them and the NHS if this is a new area of work for them, as this is a unique environment.

Get the right artists

• ensure you commission artists who work in a range of styles. Everyone has different tastes and age ranges have varied needs.

• have multiple approaches to ‘procurement’ – develop different sorts of briefs for different types of project.

• encourage the appointed artists to deliver the project in the same way that they would normally. There is a tendency for artists to think that they need to alter or water down their usual working practice or style. You have engaged them on the project based on their existing work and taking on the comments of others doesn’t need to dilute this.

Be flexible

• be prepared for changes and delays. With the luxury of a new build project comes many elements which are outwith your control.

• the priority business of healthcare comes first. These are public buildings. There will be technical and practical restrictions, for good reasons.

Think long term

• consider the longevity of

materials and placement.

• agree maintenance responsibilities and be aware that an ongoing budget may well be required.

• think about the spaces and resources you can provide for ongoing participatory and exhibition programming.

• develop a culture of valuing the benefits that the arts can bring to health and wellbeing within your organisation.

Finally, always return to the original question

• how will this benefit the patient?

Beyond Walls brings playful distraction and fun for all ages. It provides entertainment. It helps people navigate a large public building. It provides identity to and encourages ownership of distinct services. It brings decorative enhancement and colour to a clinical environment.

It creates calming spaces for contemplation or private conversations. However, perhaps the most important reason of all for supporting and delivering such programmes – and often the hardest reason to articulate –is to reflect back the humanity of the hospital and its inhabitants. Where people are removed from their familiar home environments, at their most vulnerable, sometimes in pain, by necessity being categorised by their condition, in many ways the most important achievement of this programme is to provide a reminder of what it is to be wonderfully, imperfectly, colourfully human.’

‘Art helps us access and express parts of ourselves that are often unavailable to other forms of human interaction. It flies below the radar, delivering nourishment for our soul. A world without art is an inhuman world. Making and consuming art lifts our spirits and keeps us sane. Art, like science and religion, helps us make meaning from our lives, and to make meaning is to make us feel better.’

Grayson Perry Creative Health: The Arts for Health and Wellbeing

All-Party Parliamentary Group on Arts, Health & Wellbeing Inquiry Report 2017

Susan Grant, Arts Manager, Edinburgh & Lothians Health Foundation.

CREDITS

We would like to thank all artists, staff, designers and fabricators who have helped to realise this ambitious project for patients, staff and visitors.

Core Ginkgo Projects team

Tom Littlewood

Lucy Harwood

Annabel Mansell

Janeanne Gilchrist

Alison Unsworth

www.ginkgoprojects.co.uk

For further information please email Tom Littlewood tom@ginkgoprojects.co.uk

Graphic design

Ian Richards

www.heavyobject.co.uk

Photography

Ross Campbell:

Page: 81, 82, 85, 86, 109, 138, 140, 141, 144 top, 145, 170, 180, 181

Mark Daniels:

Page: 116, 117

French and Tye:

Page: 89, 90, 92, 93, 94, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105

Kate Ive:

Page: 44, all apart from top right

Peter Marigold:

Page: 29, 38 bottom

Rob McDougall:

Page: 147, 148, 149, 150, 154 top left, 154 bottom right, 155 middle right, 155 bottom left, 155 top right, 156, 157, 158

Chris Scott:

Page: 49 top right, 59 top right, bottom right, 108, 154 top right, 162 top left, 162 bottom left, 167, 168, 169, 173, 176, 177, 203, 204, 205, 207, 211, 212, 213, 214, 215, 221, 222, 223, 224, 225, 227, 228, 229, 231

Shannon Tofts:

Page: 27, 30, 32, 33, 36, 38 top, 39, 40, 41, 42, 44 top right, 46, 48, 49 apart from top right, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 77, 78, 87, 111, 112, 113, 115, 117, 137, 142, 144 bottom, 151, 152, 154 middle left, 154 middle right, 154 bottom left, 155 top left, 155 middle left, 155 bottom right, 159, 161, 163, 164, 165, 171, 172, 174