Hospital gardens are making a comebackBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5627 (Published 07 December 2017) Cite this as: BMJ 2017;359:j5627
Visitors to London’s Great Ormond Street Hospital may be in for a lovely surprise. Those who venture past the Peter Pan statue at the entrance, through the busy corridors, and into the middle of the hospital will eventually discover a little garden, secreted away from the hustle and bustle. Built on an abandoned boilerhouse roof, it is now a small retreat—quiet, peaceful, and sheltered. It is surrounded by bushes and shrubbery on all sides, with an open wooden pavilion at one end. It is overlooked by hospital wards, but when you stand in the middle of the garden you don’t feel as if you are in a hospital.
What may be a surprise today was rather more the norm in the past: Florence Nightingale was a champion of outdoor spaces, and in the 19th century hospital gardens were an important part of the therapeutic regimen. It was only after the second world war, and with the birth of the NHS, that they started to disappear. Hospitals were built for clinical effectiveness and had to house numerous specialist units, as well as provide ever more car parking spaces. The cost of managing a garden was hard to justify, and gardens were easy to write off.1
But now, hospital gardens are making a comeback, and a growing number of hospitals across the UK benefit from gardens built specifically as a therapeutic space for patients.
Horatio’s Garden is perhaps one of the best known hospital gardens. Horatio Chapple had the idea for the garden when he was volunteering at the Duke of Cornwall spinal treatment centre at Salisbury District Hospital. Wondering at the lack of outdoor space for patients, he decided to conduct some research. What he found was that patients wanted a change from the clinical environment of the wards—to somewhere “beautiful,” with colour, flowers, wildlife, and running water, where they could temporarily return to “normal life.” The staff, on the other hand, thought that the garden should be a “rehabilitation tool,” with different surfaces, slopes, curves, and steps to help patients recovering from spinal injuries to practise moving with walking aids or in wheelchairs.
In August 2011 Horatio was killed by a polar bear while on expedition in Norway. His parents, both doctors, decided to make his vision a reality. They focused on what the patients wanted and built a garden they could access safely: a place for patients to find space and privacy, time to recover, and come to terms with what are often life changing injuries. Many patients take their first steps outside hospital here. The garden is full of hardy perennials, giving it colour throughout the year (fig 1). It also gives inpatients a sense of the seasons, and of time passing—something that can be lost inside a clinical ward. Patients report that the garden helps to them feel that they are making progress.
In a recent survey, 100% of participants (30 patients) said that the garden improved their sense of wellbeing. It gave them a space to reflect, a sense of community, a support network and good company, and somewhere to go and meet other people experiencing the same challenges. Patients can take their visitors to this private space, away from the busy wards. Doctors have noticed that the atmosphere on the wards has become calmer since the garden was built, which has alleviated some of the stresses and pressures of being in hospital. Many of the patients said it restored their sense of identity—according to one: “You can see the earth, and you can see sky overhead, and just all these things are so much part of the life that I had before.”
The success of the garden has led to a second Horatio’s Garden built in Glasgow, and building is under way for a third one at Stoke Mandeville Hospital. Fundraising has started for a further two gardens.
“If I died and were born again and worked all my life I wouldn’t be able to pay back everything that Horatio’s Garden has done for me.”—From patient survey
Aberdeen Royal Infirmary
Aberdeen Royal Infirmary’s therapeutic roof garden has been in use since 2016 and was formally opened by the Queen. Unlike other hospital gardens, it is officially designated as clinical space. Before it was built, the only green space in the hospital was outside the front entrance. The roof garden is open 24 hours a day, and floodlit after dark. Staff can take a fully ventilated intensive care patient into the garden, with full resuscitation and monitoring equipment. A sanctuary alongside the garden features a large panoramic window, so that in poor weather, patients can still look out. Reverend James Falconer, healthcare chaplain at the hospital for 25 years and one of the driving forces behind the garden, says that for patients the garden “can make a significant difference in recovery and sense of wellbeing.” One patient told him: “It is the one thing that keeps me going.” The staff have noticed that, after spending time in the garden, patients may work more positively with physiotherapists, for example, and are more engaged with their care. The garden was also noted as an area of good practice and a valuable resource for patients receiving extracorporeal membrane oxygenation (ECMO) treatment and their families in a recent NHS England review.
The therapeutic benefits of hospital gardens are just as valuable for relatives and visitors of patients. The Oasis at Wansbeck Hospital—built in 2010—was one of the first places to recognise this. Pioneering at the time, it is not only a garden but also includes a separate suite of rooms specifically designated for families of patients receiving end of life care. Relatives have somewhere to go and can even stay overnight if they need to. The Oasis is designed to feel like a living space that opens out onto a garden, rather than a hospital. It has proved so popular that other hospitals in Northumbria NHS Trust have since replicated the idea.
St Margaret’s, Epping
Gardens are therapeutic for patients with dementia, a finding that is supported by strong evidence.2 Sarah Croot, a consultant occupational therapist specialising in dementia and frailty services, described how she uses gardening as a therapeutic medium at St Margaret’s Hospital, Epping. Gardening is an “excellent activity that can be used in so many ways.” Not only is the outdoor space beneficial in itself, but gardening with patients can have a tremendous impact. This is particularly true for patients with dementia, even when it is quite advanced, as gardening can trigger old memories and skills. Patients are “now in the role of working in the garden,” which may trigger happy memories. They grow fruit and vegetables that they then eat in the hospital, and enjoy the wildlife in the garden. The garden provides an element of sensory stimulation—with different sounds, perfumes, and textures—and a pleasurable environment
What all these gardens have in common is that they are charitably or privately funded. They were built and are maintained thanks to the energy, support, and resourcefulness of volunteers. In order to fund Horatio’s Garden, “a lot of cupcakes were sold, and marathons run,” said Victoria Holton, the garden’s executive trustee. “No one is going to spend money on a garden when we need an x-ray machine,” said Fraser Smith, consultant general and colorectal surgeon at Royal Liverpool University Hospital and garden enthusiast. Scarce NHS funds are rightly focused on clinical needs. Nevertheless, gardens are increasingly recognised as a valuable resource. The King’s Fund recently set out “a wide range of recommendations that we believe will help to integrate the benefits of gardens into the mainstream of health policy,” and clinical commissioning groups are prescribing gardening to patients, as they believe it can save them money in the long run.2
Crucially, however, if we want to continue to build gardens, we need space. The Naylor report recently outlined plans to sell off NHS land to raise money to invest in patient care.3 The gardens discussed here were built on rooftops, in small spaces, or on previously unused land—that may be a prime opportunity for planners.
The benefits of hospital gardens are not limited to patients. Some hospitals, such as Great Ormond Street Hospital, already have gardens that are specifically designated for staff, and the Royal Aberdeen Infirmary is looking to build a new staff garden. Gardens and gardening are also being included in community care. The Lambeth GP Food Co-op has set up 11 food growing gardens in GP surgeries across the London Borough of Lambeth and in King's College Hospital. The gardens are run by patients, healthcare workers, and volunteers.
Hospital gardens are clearly having a revival—and the evidence for their benefits is incontrovertible. Learning from the past to take us into the future?
A patient’s perspective
Lyn Farrugia's 12 year old daughter, Gabriella, is being treated at Great Ormond Street Hospital (GOSH) for juvenile dermatomyositis.
Before the garden opened
When Gabriella was first admitted (and for several weeks after), I was in a state of complete shock. I couldn't leave her at the beginning because she was too ill, but then, even when she was in physio and school, I didn't feel able to leave the hospital—nothing felt safe, and I felt I had to be in the building at all times. The furthest I got to outside was to sit by the Peter Pan statue right outside the front entrance. When I eventually did venture out, I realised the seasons had changed, and I had missed it. To have had a garden within the hospital would have allowed me to still be close to Gabriella, but to have been able to feel the sun on my face or the rain on my skin—things that make you feel alive, but that you completely take for granted.
Where we stayed in the oldest part of the hospital there was no communal area for parents. You see each other in the kitchen and talk over a snatched cup of tea. This is fine, but when times are hard and you want to cry, scream, be angry, shout, there is nowhere to go. A garden would have given me somewhere to go, when times were tough and I needed time out.
There were times when I didn't want to be in the real world and watch everyone going about their normal lives, when our lives had been so traumatised. I missed the smells of being outside, watching the birds, listening to the wind. A tranquil space, where you can just “be” and not have to make any decisions or think about anything is very rare in hospital, and it is probably the thing you need most.”
Since the garden opened
The Morgan Stanley Garden (fig 2) has made such a difference to my daughter and myself. We now come to GOSH every month, for two days of infusions. Gabriella can leave the ward room for an hour of physio and then she is back on a bed, having six hours of drug infusions, where she can't move at all.
We don’t have a chance to leave the hospital, but my daughter always asks to sit in the garden before treatment. It is a really important part of her GOSH stay now, the ability to just sit somewhere so tranquil and beautiful which is only one minute from our ward.
When Gabriella is in physio, I always sit in the garden, just absorbing the serenity. You can’t hear any hospital noises, and you can remember what the real world is like—it sounds overdramatic, but when your life revolves around hospital visits and medication, that sense of normality is desperately needed.
Thanks to Fraser Smith, Brenda Longstaff, Clare Hickman, Reverand James Falconer, Sarah Croot, Victoria Holton, and Andrew Willard.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed