Phase 4 of Great Ormond Street Hospital’s Redevelopment Masterplan, the Children’s Cancer Centre, will be a national resource for children with rare and difficult-to-treat cancers. The centre will be the physical embodiment of the aspiration to improve outcomes for children and will replace the existing frontage buildings on Great Ormond Street. 

This new building on Great Ormond Street provides an opportunity to address the hospital’s relationship with the street and the city beyond it, with the potential for a new, more permeable threshold, (re)integration of the hospital with its community, and a healthier street environment.

Ospedale degli Innocenti, Florence – a case study
The Ospedale degli Innocenti, which faces the Piazza SS Annunziata in Florence, was a source of inspiration for my work at Great Ormond Street Hospital. Commissioned in 1419 and designed by Filippo Brunelleschi, it was originally a Foundling Hospital.¹

The nine-bay loggia facing the piazza provides a covered portico, a sheltered threshold between the piazza and the hospital building. There is a generosity in this architecture, as through the provision of this portico people can sit protected from the elements, whether they’re going to the hospital or not. Market stalls or musicians may choose to set up there. Also, in the piazza is a fountain with access to water.

Internally, there is both a women’s courtyard and a men’s courtyard, spaces which allowed access to fresh air and the opportunity to reflect. Both are surrounded by a covered colonnade, a threshold between inside and outside. The circulation is clear and intuitive, and there is a logic and sense of progression as you move from internal to external spaces. The buildings and spaces in between are able to breathe. There is also a clear awareness of the significance of art.

The facade is made up of nine semi-circular arches springing from columns of the Composite order. The semi-circular windows bring the building down, earthbound, and reflect a revival of the classical style, no longer a pointed arch. In the spandrels of the arches are glazed blue terracotta roundels, with reliefs of babies designed by Andrea della Robbia. 

Many of the frameworks we refer to now when designing the public realm, especially when putting health at the centre of our approach, call on many of the themes that informed buildings of the past such as the Ospedale degli Innocenti. These include:

• open and permeable relationships between institutions and the spaces outside them – in this case, a covered portico providing a generous threshold between the institution and the city, which is open to all;
• the hospital helps define the eastern side of the piazza – its design working and informing both its internal function and external relationship with its surroundings;
• opportunities within the building to experience the outdoors in the form of gardens, courtyards or cloisters – providing fresh air, space for reflection and wellbeing, and opportunity for movement and physical activity;
• art providing identity for the institution, and a positive contribution to health and wellbeing – an acknowledgement of the healing qualities of art;
• water fountain – access to free water as a basic human right (SDG 6: Access to clean water and sanitation) was a given; and
• openings and windows – providing an abundance of daylight and ventilation, and visual awareness of nature and the outdoors.

Background
At the forefront of paediatric care and research, Great Ormond Street Children’s Hospital is one of the most famous children’s hospitals in the world and is located in Bloomsbury, London. Bloomsbury contains some of the best examples of Regency architecture, known for its garden squares and buildings of note, such as the British Museum and Coram’s Fields. The hospital has grown over time and, as a result, is composed of a number of buildings from different periods – some of which are new or recently refurbished, while others are in poor condition. The hospital is carrying out significant buildings works in order to modernise and continue to offer world-class care as a leading children’s hospital, in addition to maximising its estate.

The most recent additions – the Zayed Centre on Guilford Street, and the refurbished Sight and Sound Centre on Queen Square – illustrate that the hospital is becoming more of a campus beyond the island site. Consequently, the routes between the various buildings take on more significance. 

Opportunity
This paper looks at the next significant build project that GOSH is undertaking – a new Children’s Cancer Centre. Great Ormond Street held a competition in 2017 in order to appoint an architect and contractor team for this new facility. It was to be located along Great Ormond Street itself, and would become the new entrance and frontage to the hospital, replacing the current mix of old and new buildings. The competition was won by BDP and Sisk, and is part of Phase 4 of a masterplan affecting the whole GOSH estate. A future Phase 5 will include planned improvements to servicing the hospital, which will be important in relation to the current servicing arrangements along Great Ormond Street. 

The BDP proposal for the Children’s Cancer Centre shows an improved pedestrian experience for Great Ormond Street in a number of ways, including greater activity and visual connection between the hospital and the street; the provision of a cafe and outdoor seating; planting; more accessible surfaces and crossing points; as well as a reduction in width, which should help with safety and access, and create a visually more attractive and stimulating environment.

As the competition entry is developed with respect to the building itself, we’re also working on a vision and brief for the street. The desired outcome is for a health-led and child-friendly approach to the design of the street, which will result in an improved relationship between the hospital and its surrounding community.

Bloomsbury, Camden
GOSH’s location in Bloomsbury and the impact it has on its surroundings are all the more important because it has significant challenges of its own. Despite the reputation Bloomsbury enjoys of being an area full of cultural, educational and intellectual establishments, it is in fact a very mixed area, like many London wards, and scores highly in the Index of Multiple Deprivation criteria. It’s worth noting that in relation to the rest of Camden, the area has a higher percentage of:

• one-person households;
• people over 65 living alone;
• residents who are economically inactive;
• older people living in deprivation;
• adults with a higher increased risk of drinking;
• lower super output areas (LSOAs) (nine), which fall within the 10 per cent most deprived in England; and
• overcrowding.

Alongside these challenging statistics, there is a shortage of access to open space:

• only 14.9 per cent of the land area is defined as public green space (Camden has 24.8 per cent); and
• it has only 11.9 per cent public green space per capita (Camden has 24.5 per cent).

These metrics are of huge significance when discussing the impact that the public realm can have on community cohesion, health and movement. There is much evidence indicating that green space is most beneficial to those experiencing deprivation; indeed, Mitchell and Popham argues that living in areas with green spaces is associated with significantly less income-related health inequality, weakening the effect of deprivation on health.²

The proportion of green space and open space is linked to self-reported levels of health and mental health³ through improving companionship, sense of identity and belonging,⁴ and happiness.⁵

Several frameworks have informed the brief for the public realm, but here we will focus on the three we have found most applicable. These comprise the Clean Air Hospital Framework, the TfL Healthy Streets Framework, and the Urban 95 Toolkit for measuring urban experiences of young children.

Clean Air Hospital Framework
This framework, co-designed by Great Ormond Street Hospital and Global Action Plan, focuses on air pollution, which is particularly harmful to children – as noted by the World Health Organization:

“Children are at greater risk than adults from the many adverse health effects of air pollution, owing to a combination of behavioural, environmental and physiological factors. Children are especially vulnerable during foetal development and in their earliest years while their lungs, organs and brains are still maturing. They breathe faster than adults, taking in more air and, with it, more pollutants. Children live closer to the ground, where some pollutants reach peak concentrations. They may spend much time outside, playing and engaging in physical activity in potentially polluted air.⁶

The framework’s criteria aims to:

• reduce the amount of air pollution directly created by the hospital;
• reduce the amount of air pollution that staff, patients and visitors to the hospital are exposed to; and
• help the hospital increase its impact by mobilising others.

Says the World Health Organization: “Exposure to air pollution can alter children’s trajectory through life, pushing them onto a path of suffering, illness and challenge. But this is preventable. Informed action by health professionals can help reduce the tremendous burden of disease in children caused by exposure to air pollution.⁷

TfL Healthy Streets Framework
The TfL Healthy Streets Framework is the main part of the mayor’s transport strategy for London, and TfL and local authorities are integrating this approach into their plans. The framework uses ten indicators, which reflect key aspects of a healthy street.

Mayor of London Sadiq Khan says in the framework’s guide: “My vision to create ‘Healthy Streets’ aims to reduce traffic, pollution and noise, create more attractive, accessible and people-friendly streets, where everybody can enjoy spending time and being physically active, and ultimately to improve people’s health.”⁸

Urban 95 Toolkit
The Urban 95 Toolkit asks us to put ourselves in the skin of a child who is 95cm tall, and experience the street from this height. In the context of Great Ormond Street, this is especially pertinent, given the large number of children visiting the hospital.

The Urban 95 Quality Criteria looks specifically at caregivers and young children. For small children and their caregivers, the quality of a space is important, as is how connected and accessible it is, what kind of amenities are available, and what kind of interaction between caregivers and young children is supported by the built environment. This tool can be used to research the quality of a public space and how it is experienced by its users, offering potentially deep insights.⁹

The Urban 95 Quality Criteria are split into themes as follows:

• protection: this covers traffic, passive surveillance, as well as protection from the elements and a lively public realm;
• basic needs: here, the fundamentals of air quality, noise, water and food are assessed;
• comfort: themes in this section include accessibility and walkability for children and prams, as well as clear wayfinding;
• interaction: this covers the presence of natural inviting elements, opportunities for interaction, seating, as well as playscapes and interaction with nature at 95cm; and
• connection: this speaks about both flexibility in terms of different activities and programming that may be on offer, and also whether it is accessible, without traffic, and in proximity to amenities and services.

While carrying out the analysis using the different frameworks as a tool, a number of things became apparent. Firstly, both the TfL Healthy Streets and Urban 95 frameworks cover very similar themes, which is perhaps not altogether surprising, although the TfL one is more concise whereas each criterion in the Urban 95 method covers a large number of themes. In addition, the TfL one does not specifically refer to children or a child-focused environment at all. Therefore, in this instance, bearing in mind the motto of the hospital is ‘the child first and always’, the Urban 95 recommendations are important.

Many of the indicators in the Healthy Streets criteria and the Urban 95 themes relate back to the qualities illustrated in the Ospedale degli Innocenti, such as places to stop and rest, shade and shelter, and people feeling relaxed and comfortable with things to see and do.

We also assessed the following frameworks in order to create our brief:

• UN Sustainable Development Goals Strategic Framework;
• Camden 2025; and
• Camden Transport Strategy 2019-2041.

In parallel with using the frameworks above as guidelines, setting out the basis of the desired outcomes, we also analysed the existing situation on Great Ormond Street using a combination of qualitative methods, including observation, interviews, surveys and workshops, as well as looking at the air quality data on the street more closely. 

Observation and site analysis
Currently, Great Ormond Street lacks a clear street identity, partly owing to the fact that on one side it consists of a series of hospital buildings of varying quality, and on the other a beautiful residential Georgian terrace with properties dating back to the early 1700s. The majority of the hospital is still located on the main island site, which can only be accessed from the main entrance on Great Ormond Street and staff entrances on Guilford Street. This has inevitably created an inward-looking hospital, which is difficult to locate because of inconsistent signage and wayfinding, both within the different GOSH hospital buildings and also beyond these from the main tube stations and bus stops in the surrounding area. There is a number of other healthcare institutions immediately adjacent to GOSH, which adds to the confusion.

As is to be expected for a hospital of this scale, it’s highly serviced and subject to arrivals by ambulance, taxi, car, as well as a large number of pedestrians, making it very busy and congested. It suffers also from the main entrance not being visible from either end of Great Ormond Street, making it very difficult to find until you are almost right upon it. Even the journey to it from the nearest tube station, Russell Square, is difficult due to poor wayfinding. The Phase 4 design brief describes it thus:

“Wayfinding from public transport is awkward, and the main entrance difficult to spot, even from Great Ormond St itself. The facade along Great Ormond St is particularly disappointing. It looks institutional and monolithic with almost nothing to suggest it is designed for children.”¹⁰

Half-way along Great Ormond Street, it is crossed by Lambs Conduit Street, an attractive street with shops and cafes on either side, many of which spill out onto the pavement. The similar uses on both sides and scale of the buildings result in a more coherent identity.

Also at this junction, Great Ormond Street continues but becomes residential on both sides. Here, there is an example of guerrilla gardening – some wonderful planting, which is paid for and maintained by a much loved resident, as a response to bins being left outside his property. His positive response to an environmental issue has created a small oasis on this street, from which we could all learn.

Traffic survey
A traffic survey, responded to both by hospital users and the local community, was carried out in 2019 by Sisk to identify traffic concerns. It picked up several themes. 

The main concerns related to traffic – the street is considered congested, noisy, unsafe and often the setting for anger issues in relation to drivers. There is a strong desire to reduce traffic, make it one-way only, and even pedestrianise it. Knock-on effects were identified in relation to the impact that congestion has on air quality. There were also comments about how more planting and trees would improve the street experience, as well as the desire for places to sit, rest and observe.

The travel survey was interesting, as it illustrated that many of the concerns with respect to the street are shared both by hospital staff and patients, as well as the surrounding community. The fact that the different stakeholder groups share a desire for the same improvements is in itself an important step towards the hospital reintegrating itself in its community.

Workshop
We also carried out a workshop with the Young People’s Forum (YPF), which represents young people who are being treated or have been treated at GOSH, aged between 10 and 21. They meet six times a year to discuss what they think the hospital should be taking action on, and they clearly articulated their concerns with respect to the street, with many positive suggestions.

Alongside many young people of their generation, they were very concerned about the climate emergency and had a high expectation that GOSH should be doing everything it can to address this. In terms of the public realm, they were clear, in general terms, about the importance of improving air quality in cities, but they were also very specific with recommendations about paving, drainage, products that absorb carbon dioxide, and case studies to which we should be referring.

Air quality
We are observing and recording the air quality data on the street, measured by the Breathe London monitor on Great Ormond Street. These show consistently high levels of nitrogen dioxide (NO₂) and particulate matter (PM_2.5), often well in excess of World Health Organization guidelines.

Early analysis of air quality on the street during the COVID-19 lockdown period has shown a reduction in NO₂, which is positive, however there has been no noticeable reduction in PM_2.5.

The Breathe London network exhibits variability of PM_2.5 levels, but at this stage there is no clear reduction or evident association with the reduction in traffic.

London experienced pollution episodes from 25 to 27 March and from 8 to 12 April with elevated PM_2.5 levels, which have been captured by the Breathe London network. These increases were likely due to wind blowing in industrial and agricultural pollution from mainland Europe, as well as wood burning for the March episode.¹¹

Given the large number of children who are often unwell travelling along the street to the hospital, alongside the local community, many of whom as highlighted earlier are also vulnerable, improving the air quality is absolutely key.

The frameworks referenced that set out principles – alongside the observational data, traffic survey, YPF workshop, and the air quality analysis carried out to date – have allowed us to identify people’s concerns, describe our vision for the street, and create a brief.

Vision and brief
Our vision for the street is summarised as follows:

• create a suitable and welcoming entrance for the hospital;
• reduce congestion on Great Ormond Street;
• increase greening/nature;
• improve air quality and reduce emissions;
• be play-friendly;
• make the street environment safer;
• make the street more community-friendly for all generations;
• create opportunities to sit, interact and play;
• enhance social and community cohesion;
• make available drinking water;
• focus on sustainable drainage systems – rain gardens; de-pave; sponge city;
• provide shade;
• provide cycling routes; and
• devise adaptive strategies for future streets.

The potential benefits are illustrated in the diagram below. 

Conclusion
The ongoing design development for the new Children’s Cancer Centre needs to be carried out in parallel with the street design, as they both inform one another and their relationship, and interdependencies are key. The frameworks assessed provide a practical step-by-step approach to the creation of a vastly improved public realm for patients, staff and neighbours. The approach also highlights the requirement to understand the viewpoint and experience of a child, both in their journey to the hospital and in the hospital itself.

The health-based approach we’re proposing could reduce congestion, improve air quality, and provide greenery, shelter, water and places to congregate. This, alongside a new hospital frontage, which is open, transparent, permeable and welcoming, could transform the hospital’s relationship with the city, re-integrating it and allowing it to look both outwards and inwards. This would draw on the lessons learnt from the Ospedale degli Innocenti, providing an elevation that speaks and relates to its context, is inviting and open providing an active and transparent frontage, and offers a generous and inviting threshold between building and pavement.

This pandemic has highlighted the value of the outdoors and the public realm for all, in addition to the provision of the basic elements we drew out of our case study, such as light, access to the outdoors, clean air, and the benefits of exercise. These have informed our brief and vision for what we hope will one day become the healthiest hospital street in London.

In the words of Octavia Hill, who wrote widely about the importance of accessible green space to all city dwellers:

“There are indeed many good things in life, which may be unequally apportioned and no such serious loss arise, but the need of quiet, the need of air, the need of exercise, and, I believe, the sight of sky and of things growing, seem human needs, common to all men, and not to be dispensed with without great loss.”¹²

About the author
Magali Thomson is an architect and a public practice associate placed at Great Ormond Street Hospital, where she is project lead for placemaking. She will be leading a transformational approach to public realm as an integral part of the planning process for Great Ormond Street's new Children’s Cancer Centre. She is also studying at the London School of Economics, carrying out an MSc in Cities, which complements her public practice placement, and is a step towards following her passion for equitable cities, especially in relation to children and older people.