Industry experts gathered recently to discuss the benefits of natural and artificial light on the creation of truly-supportive healthcare environments

Healthcare designers need to ‘be brave and challenge the status quo’ in order to create more-supportive environments for patients and staff, according to participants in an industry roundtable event focusing on the impact of natural and artificial lighting on wellbeing and productivity.

Organised by independent lighting specialist, Atrium, the discussion, chaired by Healthcare Property editor, Jo Makosinski, brought together a panel of experts from across academia, architecture and design, and industry to discuss how to better harness the benefits of light to create healthcare environments that actively contribute to, and promote, healing.

And they revealed that current approaches often focus on pathogenesis – the development of disease – rather than salutogenesis, where the emphasis is on creating health and healing through more-structured and better-informed design approaches.

We are now interested in the process of the interaction of light with biology in a rather fundamental way, and we have only realised there’s been a problem over the last couple of decades because we’ve removed most of the solar spectrum from our everyday lives

They also called for a shift from environmental sustainability – which they fear is stifling progression – to ‘human sustainability’, together with more-creative thinking around legislation.

Offering an academic view was Robert Fosbury, an Honorary Professor at the University College London (UCL) Institute of Ophthalmology, who has led extensive studies and analysis on the interaction of light with life.

He drew comparisons with how plants use photosynthesis to transform light energy into chemical energy and the potential impact of improved natural and artificial lighting on the wellbeing of humans.

Light is life

He said: “A long time ago we knew that sunlight was healthy. Florence Nightingale, for example, was perfectly aware of the fact that to heal patients you needed to wheel them out in the sunshine, and on her list of the most-important medical functions you could offer patients, top was fresh air and daylight.

“Now, in the era of Big Pharma, we’ve forgotten this and we’re just starting to rediscover it, to realise that actually we need sunlight to metabolise and it allows us to be much healthier. It’s blindingly obvious in a sense.

We’ve gone backwards, at least by 100 years, if not more, and have reduced our understanding of light rather unintelligently to just the visible element

“We are recovering from a phase in human life on Earth which has lasted for about the last 50 years, where we’ve gradually moved away from thermal lighting via things that are hot – tungsten filaments, oil lamps, gas lamps, fires, campfires, candles, etc.

“All of those things produced the light that allowed us to see, but they also allowed us to metabolise properly.

“Since we’ve taken those away, starting with fluorescent tubes and then going onto white LEDs and so on, our level of public health has deteriorated, and I don’t think anyone would dispute that we’re less healthy now than we were 20-30 years ago.

“We are now interested in the process of the interaction of light with biology in a rather fundamental way, and we have only realised there’s been a problem over the last couple of decades because we’ve removed most of the solar spectrum from our everyday lives.

“As far as I’m concerned, we have to resuscitate the sunlight.”

A step backwards

Ulysse Dormoy, CEO of Atrium, added: “In the past 35 years working in the lighting industry I have seen the shift from analogue to digital and we are now starting to realise what the potential impact might be of having made that shift.

“We’ve gone backwards, at least by 100 years, if not more, and have reduced our understanding of light rather unintelligently to just the visible element.”

And Tye Farrow, founding partner of Farrow Partners, a world-renowned advocate and thought leader for health-promoting architecture, said: “One of the greatest mysteries in the study of people is how do we stay healthy and to thrive.

“And we have such a pathogenic point of view.

“We need to start viewing architecture, not by what it is, but what it does and what is can do is its ability to cause health.

“The problem is there is very little evidence and we need to enthuse and teach people.”

Karen van Creveld, founder of Karen van Creveld Lighting Design, argued that the issue lay with how healthcare projects are specified and costed, with the focus fixed on environmental sustainability.

She said: “I think the danger that we’ve seen is that a lot of the science gets selectively filtered into how it can then be monetised and rolled out and a lot of the actual meaning gets lost.

“There is this idea in simplistic terms that LED is good and everything else is bad because it’s perhaps more energy hungry; it’s more costly, etc.

“I think the danger is in how the science is then translated into application for better outcomes.”

We always get caught in cheap is best – it always comes down to money. We want to produce the minimum functional light as possible, so we talk about levels of light; we don’t talk about quality of light

Farrow added: “We look at capital cost, not always the impact on operating costs.

“The building is to hold people and when we spend money we need to look at the exponential impact on people and creativity, social interaction, learning, etc.

“I fundamentally believe we need to find a new path forward where placemaking is seen as a health-generating system.”

Representing the architecture and design community at the roundtable were Phil Clarke, senior principal design manager at Mott MacDonald; Sophie Crocker, architect and health design researcher at White Arkitekter; and Negar Mihanyar, partner at Hawkins Brown Architects.

While they claimed the design community was aware of the importance of sunlight, and the positive impact artificial lighting solutions can have on the wellbeing of all building occupants, they cited several barriers to more-widespread adoption.

Money talks

Mihanyar said the UK market could learn a lot from their overseas counterparts, stating: “Often when clients are briefing us on their ambitions, it’s to replicate an existing facility, but I think there’s a huge amount to learn from Scandinavia and other countries, which are far further advanced in terms of their thinking about healthcare and healing environments and health creation, rather than just trying to remedy an illness or something that someone’s in hospital for.

“Once you’ve got all the foundations right, absolutely we need to think very carefully about how we light the interior spaces to make sure they are very patient centric and staff wellbeing is as important as patient wellbeing.”

Clarke added: “I’m a little bit disappointed that we’ve not really evolved much, so that’s why I’m very passionate about change and about improving the experience.

“We always get caught in cheap is best – it always comes down to money. We want to produce the minimum functional light as possible, so we talk about levels of light; we don’t talk about quality of light.

“For me, I’m sure if the financial teams of the world did a study and really understood the actual cost comparison between treating people with drugs instead of treating people with daylight, things would be better.

“It’s bonkers and I don’t understand why we aren’t doing it.

“It’s about educating the people making the choice between cost and value.”

A major stumbling block to using natural daylight and artificial light in a more-impactful way, they said, was the growing focus on sustainability and carbon reduction.

I think we need to start talking about the human sustainability perspective, especially now that we know the science and that light is more than just a visual aspect for human health

Dormoy said: “Projects are being driven predominantly through an environmental, or a planetary, sustainability agenda.

“I think we need to start talking about the human sustainability perspective, especially now that we know the science and that light is more than just a visual aspect for human health.

“This is not a technological problem; it is a legislative problem. We are so focused on sustainability metrics that we’re not actually joining the dots and working out the impact at the end.

“There must be a huge energy cost in the production of pharmaceuticals, but we still target the physical environment for cost reductions.”

Healthier environments

The panel agreed that the key to future design best practice was to firstly ensure the building itself was designed to be inherently carbon efficient. This means considering orientation and the use of, and type and size of, windows which will let in natural, health-enhancing sunlight.

But, with many hospitals by their nature a labyrinth of long corridors and deep floorplans, the discussion went on to determine the potential need for, and benefits of, artificial light sources – particularly a focus on broad-spectrum, and particularly infrared, lighting.

Fosbury said: “Can artificial light provide what sunlight does? Yes. I think it can – if it is used intelligently.

“It has to be used with care, and I think it varies whether you’re talking about ultraviolet light, for instance, which we all need, but we have to be a little bit careful about; or infrared light, which we need, but we don’t have to be so careful about. We have to realise though that we will have to pay a little bit more for that infrared light.

“However, the gains that we could get from producing it, and giving it, would hugely, hugely outweigh the costs of providing it.

“We are trying to recover from all the stupidities of illuminating everyone with white LEDs and are trying to restore the status quo from 50 years ago in lighting.

“We just want to make it more natural.

“To create healthy lighting in a healthcare environment I think is legislatively perhaps difficult, but if you were to go into an intensive care unit in a hospital with all these LED downlighters, take every third one out and put a tungsten halogen spotlight in instead, I guarantee that the outcomes would be incredibly positive. And it would cost nothing. You would maybe have to change the temperature control units on the thermostat, but it’s so simple.”

Dormoy said the cost of keeping a patient in an intensive care unit (ICU) was around £2,000 a day and cited a study carried out in Chile which revealed that intervention using infrared lighting could reduce patients’ length of stay in ICU by 30%.

Back to nature

“Through design we can harness different aspects of nature to create environments that are not super hot, but are actually beneficial,” he said.

“And then, technologically, we can introduce infrared LED into a light source of 850 nanometers, which you’re not going to see, but you’re going to potentially benefit from it.”

“However, not every LED is born equal. Quality comes at price and the value engineering process goes against almost every aspect of a healthy anthem.

“If you’re buying cheap, your LEDs are not going to be particularly good.

“I think we have to push for quality every time to try and shift the balance back towards human sustainability.”

We struggle to negotiate as legislation and guidance doesn’t really feel like it’s allowing that navigation of what is good design, what is safe design, or what is energy efficient design?

Designers also want to see updates and improvements to Healthcare Building Notes (HBNs) and Health Technical Memoranda (HTMs), which are religiously adhered to by most healthcare designers and specifiers, but, according to the panel, are not holistic in their approach.

Crocker said: “Where we hit a wall is actually the HTMs.

“As an architect I am told you need this Colour Rendering Index (CRI) so that, for example, doctors can see skin tone correctly, and this is all extremely important, but when we try and say we don’t just need white light in these spaces, maybe in the waiting areas or patient rooms we should have more adaptability, we get hit.

“We struggle to negotiate as legislation and guidance doesn’t really feel like it’s allowing that navigation of what is good design, what is safe design, or what is energy efficient design?

She added that, specifically in UK healthcare projects there is also a ‘complete disconnect’ between CapEx and OpEx.

True value

She said: “We can say, ‘hey if we put in a bigger window here, your staff will be healthier and they will come to work more often and they will want to stay working here’ or ‘your patients will recover faster’. But they will just say ‘this is how much money we have. I can’t get more money’, or even ‘I need to spend less money’.

“We need clients to brief us in a way that will allow these creative solutions and we need to be looking at metrics for holistic human health criteria, or improvement in staff productivity.

“We can do something more creative, but I think better client briefing would help us a lot.”

Having heard all the evidence today, the takeaway for me as a designer is to be brave, to take risks, and to challenge the status quo more across the work we do in the sector to help our clients make more-informed decisions with solid evidence-based design

Clarke adds: “For me, it’s about the education of the people making the choice between cost and value.

“True value is understanding how we use light and lighting, rather than just saying, ‘well we’ve got this chunk of money for lighting and this chunk of money for heating’.

“Who is actually making those decisions? Are they truly-informed decisions? Are they educated decisions?

“We’ve got Utopia and then we’ve got somewhere in the middle.

“We know that blue light can get rid of jaundice, etc, so, for me, the bottom line is it’s all about educating the client and the financial team to understand the cost analysis and what is benefit. What gives true value?”

Concluding the debate, Mihanyar said: “Having heard all the evidence today, the takeaway for me as a designer is to be brave, to take risks, and to challenge the status quo more across the work we do in the sector to help our clients make more-informed decisions with solid evidence-based design.

“And I will think more about the full spectrum of light and how can we bring as much of that into planning our hospitals.”