When the Architects Leave: Maintaining artwork in the hospital environment
A new hospital opens, filled with striking works of public art commissioned from contemporary artists. Along with imaginative architecture and modern interior design, the artwork transforms the patient’s encounter with the hospital environment from an unpleasant but necessary process to an experience that could even be described as uplifting.
Impressive photographs appear in the national and trade press, triggering the familiar debate about whether money spent on the arts is somehow diverting funds from essential medical services. In fact, huge efforts have been made for this transformation to happen, with substantial funds raised from outside the NHS as well as the consultation and involvement of staff, patients and service users.
It all looks great on the day the photos are taken. But what happens two years, five years, and ten years down the line? This information sheet considers the particular challenges of maintaining artwork in the hospital environment in the light of the experiences of curators / arts co-ordinators at six NHS Trusts in the UK.
Proof of the benefits
Arts programmes in British hospitals started in the 1970s and gained impetus from the wave of new hospital building under Private Finance Initiative (PFI) and other investment programmes from the 1990s onwards. There are now many examples of hospital buildings like the imaginary one above, with impressive public art features that were commissioned at the time they were opened.
As well as conventional examples of sculpture placed outside buildings and in central atria, art features have been incorporated into hospital flooring, walls, ceilings, and have been used to enhance courtyard and garden areas. A wide range of artists have been commissioned, working in media ranging from the traditional to the contemporary including ceramics, wood carving, painting, textiles and the moving image.
In addition to humanising the environment, artworks can act as effective landmarks in a large, complex building, helping patients, visitors and even staff to navigate around it.
Research has shown many benefits to patients, staff and visitors resulting from the presence of artwork in hospitals. These include softening impersonal clinical buildings and therefore reducing the anxiety of patients using them; improving recovery times from surgery and decreasing the need to prescribe anti-depressants and analgesic drugs.  The incorporation of art has been shown to reduce violence and even to improve staff retention rates. 
Hospitals are public buildings and their main purpose is the delivery of healthcare, not the display of art. The maintenance of artwork in the hospital environment invariably comes second to other demands and pressures. Without champions, it has the potential to become dirty, broken, poorly sited and potentially an embarrassment to the artist and funder.
These issues are not unique to arts in healthcare and are found to some extent in all environments in which art is not the primary purpose of the organisation: artworks in airports and schools, for example. However, the difference for arts programmes in hospitals is that they operate at the juncture of two highly politicised areas: public art and healthcare; therefore the issues are magnified. They are also subject to huge expectations: art isn’t just there to make the buildings more attractive, but to actually make people better.
The hospital building programme is slowing down and the political climate in healthcare is volatile. The media debate focuses on financial deficits, affordability of new drugs and perennial issues such as infection control, privacy and dignity (e.g. mixed wards) and staffing. Much media coverage of hospital arts programmes has highlighted commissioning of sculpture for large central London teaching hospitals and parliamentary questions about expenditure have been asked. 
This information sheet is based on interviews with arts co-ordinators / curators at six different NHS Trusts in the UK. It aims to give some practical insights into the challenges they face in maintaining their public art works and the solutions that have been adopted. Programmes are not identified by name because the issues discussed affect all hospitals with public art a greater or lesser extent.
The interviewees were responsible for a wide variety of art collections containing everything from works designed specially for children to major works of contemporary sculpture. Some had been responsible for collections for more than a decade and were experts in contemporary art; others were relative newcomers to hospital arts and/or visual art curation. Despite the variety in their collections, some common themes emerged.
Public art can have a limited lifespan, but the contracts for PFI hospital buildings may last 30 years or more. Where Trusts are not locked into long PFI contracts, buildings frequently change strikingly in use and appearance over the years as they are redecorated, reconfigured, sold or knocked down. Therefore, site-specific commissioned artwork is always at risk of becoming redundant even before issues of wear and tear are taken into account. Artwork that is integrated into the fabric of the building is particularly vulnerable to changes of use.
Much of the artwork in one PFI building investigated was built into the fabric e.g. windows, walls, floors. An agreement had been made that if there was damage to an artwork then the PFI consortium would bear the cost of a basic replacement (depending on whose fault the damage was). For instance, a piece of stained glass would be replaced with a plain glass window; decorative flooring with plain vinyl flooring etc. It would be up to the arts committee to find funds to replace the artwork element if they felt this was worth doing.
However, Jane Willis notes in her useful arts and health guide for NHS Estates, that the usual cause of loss of hospital art is that “works are removed from walls during redecoration or building works and then not replaced.”  This, at least, is unlikely to happen to integrated work.
Interviewees mentioned a number of commissioned works that had proved difficult to maintain in the hospital environment – for example artworks had been encroached on by developments such as shops, or parts had broken off. Problems with works with moving parts or that were intended for the public to operate were a particular issue. One project was spending nearly £2,000 a year just maintaining clocks. One co-ordinator had been quoted £15,000 to make an artwork function as it was originally supposed to.
Several of the interviewees had had to decommission an artwork or would have liked the freedom to do so. Examples included a ceiling work in glass that buckled after high summer temperatures; the curator responsible had provided maintenance schedules to the hospital over a period of years but no maintenance had been carried out. The artist had voiced doubts about the safety of the work.
Issues with water and light
A commission that included water had developed a number of issues including algae, leakage and corrosion. The work had been designed and manufactured by students who had since graduated and moved on, so it was not possible to go back to them to resolve these problems.
Another hospital reported that a water feature had been out of operation for some time due to concerns about legionella. The infection control team required testing of the water several times annually, and the charge to do this would have been £5-6k, which was unaffordable. This problem was eventually solved through a sponsorship in kind deal with a chemicals company.
In a project where artworks had been placed in a large glass atrium, the natural ventilation and high light levels were causing works to fade, and the curator was monitoring the situation with light meters and advice from a professional conservator.
High levels of ambient light had also caused difficulties for another project involving video projection, while an artwork using flickering fluorescent light had been switched off after complaints about headaches.
A number of those interviewed felt projects had been over-ambitious for their setting: “they thought they could design an all-singing, all dancing thing that would defy the laws of gravity.” Sometimes installations had omitted to give thought to future maintenance: as a result, artwork applied directly to a wall was simply painted around in a different colour.
Most felt that a realistic expectation for site-specific work in hospital was that it would last five to ten years. One person interviewed had written into artist contracts a specific right for the hospital to remove artwork that was no longer suitable or in a fit condition to justify its retention.
One co-ordinator commented that although the impact of designs e.g. of flooring and gardens had been diluted in use to some extent, because they were strong schemes they continued to have an impact.
Who does the maintenance?
Hospital facilities / estates departments face a number of ongoing challenges regarding budgets, staffing and backlog maintenance, before art is added into the mix. One interviewee described them as ‘the Cinderella directorate’. At the same time, public expectations are rising as to the condition and presentation of hospital buildings. All NHS hospitals are now subject to regular Patient Environment Action Team (PEAT) inspections and the condition of artwork is noted and commented on.
Most of the people interviewed were using external contractors to do everything from installation to specialist cleaning and repairs rather than relying on help from facilities. This was easier for the programmes which had dedicated maintenance budgets, and those tended to occur in the Trusts which had significant charitable funds and / or a scheme specifically raising money for the arts programme. Other Trusts were struggling to keep artworks in an acceptable state. One particular issue is that where artwork is placed in a PFI environment, unless it has been written into output specifications at an early stage of negotiations, it will not be included in building and maintenance contracts.
“I won’t commission artwork without identifying a budget to maintain it; it’s not responsible. But I’m aware we’re in a fortunate financial position here.”
Artists had often been involved in helping to solve problems that later arose with their commissioned works. For instance, in one project an artist had provided advice and specialist technicians to fix damage to an artwork caused by hospital building works. However, other artists had proved uninterested, or impossible to contact when problems arose. It was clear from the interviews that it is critical to sort out problems that arise with artwork as soon as possible after it is installed; the longer issues have been in existence, the harder it is to fix them.
Calling in the big guns
All the curators had at times faced problems that could not be solved by them alone. An artist-designed work in hard landscaping had been threatened with paving over to make space for a car park. The funder’s architect wrote to the press to recommend against altering the design, and this recommendation was accepted.
One interviewee explained that it was essential for arts programmes to have the support of senior staff within the organisation.
“You’ve got to think strategically, and make requirements about budgets and commitments on behalf of your Trust. You must have relationships with key decision-makers – they will be the high level advocates for the art in your Trust. With them, you can integrate maintenance and repairs into existing systems; without them, you will struggle to get things done at a grassroots level.”
Co-ordinators were struggling with issues arising from communication and record keeping. Two programmes had no inventory and another had only a partial one. Another, in contrast, had spent years undertaking the mammoth task of noting, photographing and security marking thousands of works.
Commissioned works sometimes had no associated contracts or maintenance schedules, so it was not clear where responsibility lay if things went wrong. One curator had received no schedules for any of the commissioned works in the building.
Another programme had developed a system of annual cleaning of the major artworks, with a five year review on selected works which were deemed vulnerable e.g. exposed canvas, textiles etc. This programme had a contingency fund for any urgent repairs.
“Windows in hospital may only be cleaned annually, so artwork is not likely to be cleaned frequently. Designs must be sustainable and practical. You have to be realistic.”
Recommendations for good practice
- When commissioning or designing work, consider whether/how it could be moved in future e.g. consider placement, fixings, modular construction, not painting directly on walls, etc. Murals are particularly vulnerable in the hospital environment.
- Think carefully before including water, electricity or moving parts and beware of false economies such as using cheaper materials that will have to be replaced more frequently.
- Ask commissioned artists to provide a maintenance schedule; spell out clearly in contracts what each side’s responsibility is as regards installation and issues that arise, particularly in the first year (see examples of maintenance schedules). Contracts may offer artists first refusal on any repairs or alterations that become necessary.
- Maintenance of artwork should be considered from the start of a commission as there may be ongoing revenue costs.
- Enlist colleagues and volunteers in keeping an eye on the collection and reporting any problems, so they come to attention sooner rather than later.
- Make regular checks – at least annually – on the condition of artworks and then prioritise repairs and maintenance.
- Good record-keeping and labelling is essential and helps to avoid problems if key personnel move on. All programmes should have an inventory, which can be a simple spreadsheet and a digital photograph of every artwork.
- In the case of major difficulty such as the possible loss of a commissioned work, professionals from outside the Trust – architects, policymakers, funders – may be taken more seriously than the arts co-ordinator/curator or even the Trust’s own directors and non-execs.
When the architects leave, the patients arrive. The many high quality examples of commissioned artwork contribute hugely to a welcoming and supportive hospital environment in the UK. Many problems can be avoided if artists’ briefs and contracts are sufficiently comprehensive and realistic about suitability and appropriateness of work.
However, even with effective planning at the commissioning stage and an adequate maintenance budget, keeping artwork in an acceptable condition over a period of years is challenging. Arts programmes should monitor the condition of their artwork and aim for good relationships with key decision makers inside their Trust. Action can then be taken to deal with any problems before they become too large and complex to fix.
1. Report B(9705) Commissioned by NHS Estates: A Comparative Study of the Impact of Environmental Design upon Hospital Patients and Staff, Dr Phil Leather, Diane Beale & Laura Lee, Institute of Work, Health & Organisations, University of Nottingham, February 2000.
2. A Study of the Effects of Visual and Performing Arts in Health Care at Chelsea & Westminster Hospital 1999 – 2002 by Dr Rosalia Lelchuk Staricoff, Jane P. Duncan and Melissa Wright.
3. Steve Webb, the Liberal Democrat MP for Northavon, Gloucestershire asked the following question in September 2006: To ask the Secretary of State for Health how much was spent on hospital art in each of the last five years (a) in total and (b) broken down by region.
4. NHS Estates, The art of good health: A practical handbook (2002), p21.See full reference below.
The Conservation Register
The Conservation Register is a service provided by the Institute of Conservation which lists information on accredited conservator-restorers in the UK and Ireland. It includes a search feature to find a local conservator-restorer, guidance on choosing and working with a conservator and tips on caring for art and decorative features of buildings.
Willis, Jane, Improving the patient experience: The art of good health – a practical handbook, NHS Estates, TSO 2002, ISBN 0113224990 contains advice on managing art collections in the hospital environment. Part of this publication relating to the Private Finance Initiative is reproduced here by kind permission of NHS Estates.
Example artwork maintenance schedules:
© Josie Aston 2007
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