Birmingham Heartlands Hospital

For the well being of staff, patients and visitors, Birmingham Heartland’s Hospital realised it needed to understand the causes of crime in its Accident and Emergency department so that measures could be put in place to reduce the crime risk. But to design a solution that would work, it needed to understand the extent of the problem.

As part of the Safer Hospitals Project managed by the Home Office Scientific Development Branch (HOSDB), a treasury funded initiative funded within the Invest to Save Budget scheme, Birmingham Heartlands Hospital undertook a project to reduce crime and fear of crime in its Accident and Emergency department through the application of integrated systems and innovative technology.

Intelligent Space Partnership (ISP) was asked to evaluate the risk of crime occurring in A&E due to its physical design. Elspeth Duxbury, ISP Director says: “It is important to consider the movement of people when looking at crime risk because movement rates influence the occurrence of antisocial incidents.”

In particular, the risk of crime is influenced by:

• The number of people present
• The ways in which people are enabled or restricted in their movements through the environment
• The restrictions or opportunities afforded by the immediate environment.

But taking a design approach to making its working environment crime proof took some getting used to at Heartlands.

ISP was called in because crime levels in the A&E department were rising, particularly violent crimes against staff. In 2002 there were over 700 crime incidents recorded, which was 73% higher than in 2001. Nearly 60% of all recorded crimes occurred in the ward where patients were treated and where emergency cases were brought in to by ambulance.

ISP did two different sorts of design surveys. Firstly, for 12 hours on 19 May 2003 an ISP researcher observed how staff, visitors and patients moved around the A&E department. They counted the number and type of people coming into and out of each of the external entrances and tracked the routes that people took through the department. 

The research started to explain why crimes were happening where they were. “Almost all crimes were occurring in the major injuries ward, Maitland, which is the last place that you want it to,” says Duxbury and after looking at the map of the department with entry counts and well-used routes drawn on it, it was clear that the majority of people came into the building by the wrong entrance and that from there they were guided by natural light and people traffic and the appearance of a medical looking area, towards Maitland.

The spatial analysis also revealed that:

• The patient entrance was less prominent than the paramedic entrance, which had a large canopy over it
• The natural wayfinding was poor. People were drawn by light and activity to the wrong areas
• Signage was not obvious or clear. In fact there was a red sign advertising the A&E department pedestrian entrance. Red sounds good right? But not in this context. It was positioned on a red brick wall so had no stand out
• People entering through the correct entrance came face to face with a wall and a sign pointing them one way to reception when it appeared the medical attention they might need could be found in another direction. There was no immediate eye contact possible with a member of staff

Duxbury explains how these problems affected crime levels: “Difficulties in wayfinding may exacerbate the stress that patients or visitors are already experiencing,” and this may increase the risk of aggressive crimes happening.

ISP also used its visibility modelling software to calculate how far a person could see from any point in a public space. Visibility is one of the most important ways to deter says ISP, because:

• The risk and fear of crime may increase as the level of surveillance decreases
• Artificial surveillance has the potential to provide evidence during a crime to enable appropriate intervention or after a crime occurs to help a conviction
• People are more likely to witness crimes, incidents or disturbances if the location is highly populated or overlooked.

Pictures of the data the visibility model and the researcher had compiled were vital to explaining the ISP process to the hospital. They showed that the department’s layout had a definite impact on the likelihood of crime happening. In areas that couldn't be seen easily by staff, crimes were more likely to occur. The pictures also helped the team decide on what design changes needed to be made, which would include:

• The removal of signage from the paramedic entrance, as paramedics know where to go so they did not require signs
• A new foyer incorporating illuminated signage to indicate to patients and visitors that this is the entrance
• A new reception area design that would address questions raised by ISPs surveillance modelling like how far could staff members see if they were sitting behind the reception desk and where would they need to be to see people entering through the ambulance doors or through the right entrance? It designed out crime by promoting levels of natural surveillance. The reception desk was relocated to face the patient’s entrance, walls were replaced with transparent screens so receptionists could see people entering and those in the waiting area.

Now these design changes have been made they have “provided an 80% reduction in trouble and staff are very much happier and feel very much more secure,” says Bleetman, who stresses that the mapping exercise and design changes were supplemented by staff training, more CCTV and access controls.

When ISP spent another day mapping how A&E was used by staff, visitors and patients they observed that the design measures were having the desired affect on how people moved around the department, and as the department was more in control of where staff, patients and visitors were, its crime levels had dropped.

There were more people taking the desired route round the department, fewer patients and visitors wondering through the Maitland ward and 88% of people using the correct entrance to the department. The total use of the paramedic entrance had been reduced by 55%.

This led to a dramatic reduction in the levels of aggressive incidents between 2003 and 2005, after design work had been completed. In 2003, there were on average 13 aggressive incidents reported each month. This decreased to just 5 a month in 2005.