Case Study

University Hospitals Plymouth (UHP) NHS Trust is the largest hospital in the South West Peninsula, providing comprehensive secondary and tertiary healthcare and we are the region’s Major Trauma Centre.  We offer a full range of general hospital services to around 450,000 people in Plymouth, North and East Cornwall and South and West Devon, including maternity services, paediatrics and a full range of diagnostic, medical and surgical sub-specialties.  UHP has one of the busiest Critical Care Units in the country admitting over 3000 adult patients per year across Neuro, Cardiac and General Intensive care. In addition, we are tertiary centre for neonatal care, providing intensive care for over 300 neonatal infants and their families per year. The Trust also has an integrated Ministry of Defence Hospital Unit which has a staff of approximately 250 military personnel who work within a variety of posts from lead doctors to trainee medical assistants.

The population is characterised by its diversity – the rural and the urban, the wealthy and pockets of deprivation, and wide variance in health and life expectancy. Population ageing is a recognised national trend, but is exacerbated locally by the drift of younger people out of the area and older people in.  The proportion of our population aged 85 or over is growing ahead of the national average by approximately 10 years, giving Plymouth the opportunity to innovate on behalf the nation in services for the elderly.

We work within a network of other hospitals to offer a range of specialist services.

Facilitating fresh air therapy for inpatient settings is exceptionally challenging, particularly for those receiving intensive care.  Using a patient led, co-design process UHP created a Secret Garden which provides a fully equipped, all weather, outside space to enable all patients and their loved ones to experience the sensory and psychological benefits of a fresh air space.

The garden provides outdoor space for neonatal, paediatric and adult patients. For our neonatal patients this may be their first experience of the external environment, and for their families, the only opportunity to capture memories in a non-hospitalised space. This unique garden offers a private space to spend time with loved ones, engage with functional rehabilitation, make memories, engage in animal assisted activities and supports end-of-life care.  We believe we are the only acute inpatient fresh air space offering this provision in the UK, providing personalised end-of-life care for all inpatients.

This space is for everyone – including our amazing staff.  We host events, teaching, staff yoga, meetings and a space for rest and recuperation.  It is a haven for all. The real impact of the garden lies in its legacy: national guidance, clinical research in practice, memories for patients, loved ones and our teams.

A patient story was the foundation for the Secret Garden Space, and please see videos. The space was identified in the summer of 2019 and was refurbished by volunteers from clinical teams in ICU that summer.  Including moving 5 tonnes of wet soil by hand on the wettest day of the year!

We opened the space on Christmas eve in 2019 and started the design process with procurement of architecture support.  Co-design was a fundamental anchor within the project.  Patients loved ones and colleagues all working collaboratively to both design and fundraise.  We managed to raise the £750000 to build the garden from 2019 – 2022.

During the COVID pandemic we were able to use the space for staff and patients, and we were fortunate to receive and install plants from a show garden from RHS Chelsea 3 days before lock down.  COVID was a turning point for us, it allowed end of life care in a fresh air space to be considered for inpatients due to infection and prevention regulations.

The garden build took nearly 12 months (scheduled to be 4) and went over budget.  Beset with challenges, financial blips and new expert knowledge of building regulations.  As the first ICU bed space built in a garden, the challenge was set for the estates, procurement, mechanical and electrical engineering teams, who were exceptional throughout. Delivering medical gases into non-clinical spaces, ensuring appropriate air flow, infection and prevention control measures and delivering a sustainable, environmentally friendly design within budget, was an opportunity for a new style (and level) of collaborative working.

Since opening formally in 2022 we have supported over 5000 patients, loved ones and staff to feel the benefits of fresh air therapy.  Its unique design and innovative utilisation make it a hub for holistic therapy and care in a very busy hospital.  A space that has supported patients irrespective of age, and a space that proves when teams unite amazing things can happen.

Our feedback:

“Time in the garden meant she existed outside of NICU, to actually be a person…. The wind through her hair and the sun on her face. It was lovely and just meant everything to us” A parent.

“It allowed us just for a moment to be a normal family, to have a normal Christmas experience with our 5 year old.  He loved the therapy ponies!” A long term ICU patient.

“Technically whilst daunting to move such an unstable, critically ill infant, a concerted multi-professional effort, facilitated by specially designed, external electrical & gas supplies enabled baby R and her family to safely enjoy their precious time outdoors together, whilst safely maintaining full multi-organ intensive care” Dr Alex Allwood NICU Consultant.

“I love eating lunch in our garden, its just to peaceful to be away from the ward” ICU nurse.

“It means so much that I can see my dog – I have been in hospital for 6 months” A Ward Patient.

National guidance has been developed in partnership with the Intensive Care Society (see additional evidence) to formalise the processes and risk assessment for fresh air therapy for both transfer and end-of-life care. The plan is to extend that formal guidance into neonatology, paediatrics, adult inpatients and end of life care for non-ICU patients. Currently Standard Operating Procedures (SOP) have been developed within each area to support the safe transfer of patients. We are also collating research evidence to explore the impact of the garden and a post occupancy utilisation review.

In addition, we actively gather and respond to feedback from those who have used the garden to optimise the benefits it offers. All feedback will be incorporated into our work with the Royal Horticultural Society to create a national blueprint for hospital gardens.  It is our aspiration that the story of our secret garden inspires other centres and starts a quiet revolution of the importance of fresh air therapy.

The secret garden is unique and innovative, and its success is attributed to the inclusivity, engagement and collaboration of teams throughout its development. This alongside its inception with a core patient co-design process, has resulted in an outside space which offers care for all patients and loved ones.

It has provided for the first time, an outdoor space for neonatal intensive care patients, and their families/carers, to experience the benefits of fresh air. In collaboration with adult ITU and healthcare professionals from across the MDT, the transfer of the infant to the secret garden was judiciously planned and facilitated, enabling the family to experience a private, sensory environment, away from neonatal intensive care. For this infant and family, it was their first and only opportunity to create outdoor memories.  The success of the event impacted positively on both the family and staff, captured within feedback given, and fuelled an aspiration to offer the experience to all our service users.  To ensure this became a safe, feasible and realistic option, a Standard Operating Policy (SOP) was created.

To date three families of infants receiving neonatal ICU care, have benefitted from spending time in the Secret Garden. Two of these were to create personalised end-of-life experiences and another to reunite a family whose parent required ICU. These loved one’s experiences are being translated into an academic piece of work as they are keen to share their experience, in the hope it becomes a possibility for families throughout the UK. In addition, the healthcare professionals involved felt an enormous sense of achievement and satisfaction in being able to support the families wishes.

The feedback and suggestions received from family and staff, enables us to evolve and optimise our processes and the garden, to support future episodes of care both within our organisation and nationally.

• Amazing things can be achieved with collaborative teamwork and a shared desire to reach an end goal which benefits all patients.
• Outdoor provision of ICU can be challenging but is feasible and offers measurable benefits.
• It provides a less clinical environment for healing and care interventions.
• Management of patient risk is achieved through preparation and collaboration of the MDT.
• The environment can be personalised to suit any population of patients, loved ones and carers.
• For some families this may be their only opportunity to spend outdoors together.
• Fresh air spaces offer staff a place for privacy, quiet reflection and calm amongst a challenging clinical environment.