An Architects for Health Event held on Thursday 17 April 2008 at The Kings Fund, London

The purpose of the presentation/debate was to explore the issues and problems associated with the treatment and care of older people in an environment designed and operated with a younger population in mind.

There where four presentations with differing views and experience of looking after, or promoting the care of, older people in hospital.

Context

• Recognition of the special needs of the patient who may have dementia or limited physical capability and whose mental or physical well being must be addressed at the same time as medical or surgical treatment
• Discussion and comparison of the merits or disadvantages of single rooms with multi-bed spaces – C of I, privacy, dignity, loneliness, fear, depression compared with companionship, shared care, stimulation etc.
• Problems of mixed wards and inappropriate behaviour
• Space standards – social spaces, storage.
• Difficulties with and the precautions to be taken with the treatment of the older patient and their physical requirements.

Chair

Professor Russell Jones General Practice Principal of Chorleywood Health Centre. Director of the UKeHealth Association, and an Associate Professor, Department of Information Systems and Computing at Brunel University
http://www.chorleywood.org

Speakers

Ann Noble Chair of Architects for Health
http://www.architectsforhealth.com

Dr Graham Lister Sociologist and Economist, senior associate of the Judge Business School, Cambridge and a visiting professor at London South Bank University & Rosemary Glanville Head of the Medical Architecture Research Unit (MARU), London South Bank University
http://www.jbs.cam.ac.uk/research/associates/listerg.html
http://www.phonebook.lsbu.ac.uk/php4/person.php?id=1200

Judith Torrington Reader in Architecture, School of Architecture of the University of Sheffield. Judith is a researcher specialising in the design of living environments for older people, with a special interest in design for people with dementia. Her research focus is on the contribution design can make to well-being and a good quality of life. She has developed several tools for the evaluation of older people’s living environments
http://sheffield.ac.uk/architecture/people/staffpages/j_torrington.html

Dr Mike Gill Medical Director of the Newham University Hospital NHS Trust since 2002 and a Consultant Geriatrician in the Trust since 1989
http://www.newhamuniversityhospital.nhs.uk

Richard Smith Vice President and Chairman of The Royal College of Ophthalmologists Professional Standards Committee
http://www.rcophth.ac.uk/standards

The Reform Club, 104-105 Pall Mall, London, SW1Y 5EW
28 February 2008 – 6.00pm for 6.30pm start

“This House believes that better architecture will result when architects reclaim their position as leaders of the Design Team, and lead the integration of engineering into the building design process.”

Review of Event by Peter Scher

CHAIR: Chris Gilmour, of HBG Construction

Chris is an Architect and Marketing Director of HBG UK, one of the largest construction companies in the UK turning over £1billion per year and a leader in the delivery of major projects in both the public and private sectors. HBG is the UK arm of BAM the sixth largest construction services and property group in Europe.

He has over 35 years experience in the industry particularly in the commercial, retail, education and health sectors and has particular responsibility for the Education and Health teams within HBG.

He is a Director of BE the leading industry reform group in collaborative working as well as a Director of the BCO.

www.hbgc.co.uk

SUPPORTING THE MOTION

John Cooper, of Anshen & Alllen

John Cooper has been a Director of Anshen & Allen since 2001 and has led a number of ambulatory care and larger acute hospital projects, including the recently completed St. James’ University Hospital in Leeds, the largest cancer centre in Europe.

He has recently been the architectural director-in-charge of a number of large PPP bids, including the Royal Children’s Hospital, Melbourne, and the New Hospital Pembury for the Maidstone & Tunbridge Wells NHS Trust, which will be the first 100% single bed NHS hospital in the UK.

www.anshen.com

Jaime Bishop, of Steffian Bradley

Jaime Bishop completed his education at The Royal College of Art, after previously studying at University of Bath and TU Delft.

He has worked at Tectus and Coda before moving to Steffian Bradley Architects where he is an Associate Director.

Over the last six years Jaime has gained expert knowledge of healthcare design particularly primary care design and multiple tenancy regeneration projects typified by the LIFT program. Most recently Jaime was a primary designer for the new £151 million Walsall Manor Hospital PFI.

www.steffian.co.uk

OPPOSING THE MOTION:

Phil Nedin, of Arup

Phil, is a chartered mechanical engineer, leader of ARUP global healthcare business and building services group in Cardiff, UK, and President of the UK Institute of Healthcare Engineering and Estates Management (IHEEM).

He has a wide experience of working on healthcare facilities in both project management and technical advisory roles. Sustainability and developing low-energy alternatives are key drivers in his work.

His particular area of expertise is working on an integrated approach to create optimum therapeutic environments in the design of healthcare facilities.

www.arup.com

Chris Shaw, of MAAP Architects

Christopher Shaw is a registered architect with 25 years experience. In 1991, Christopher became a founding director of MAAP Architects.

Much of his recent energy has been directed towards business development. He speaks regularly on the design of environments for mental health and acute hospital care as well as acting as professional advisor to NHS Trusts.

www.medicalarchitecture.com

The Event was sponsored by: hbg

14th ANNUAL REFORM CLUB DEBATE – 28th February 2008

The annual Debate is one of the many innovative and valuable initiatives of Ray Moss, our organisation’s founding Chair. Ann Noble, the present Chair, opened this year’s event by congratulating Ray on his Award for Lifetime Achievement, an honour bestowed for the first time at the 2007 celebration of Building Better Healthcare. Her congratulations were warmly endorsed and applauded by the house. As it turned out this was the high point of the evening.

The formal debate is a game of words between two sides for a participating ‘house’, played according to well-established rules and under the control of the chairman, an official referee. A predetermined ‘motion’ is set for one side to propose and for the other to oppose in speeches to persuade the house to agree. The members of the house join in and then decide the game in a vote at the end. The quality of the game depends on the wording of the motion and the skill and determination of the players.

Many previous Reform Club Debates have examined important contemporary controversies, providing members with informed arguments by expert advocates in passionate verbal contests. HBG Construction sponsored the event this year and the motion proposed that “this house believes that better architecture will result when architects reclaim their position as leaders of the Design Team, and lead the integration of engineering into the building design process.” Chris Gilmour, A Director of HBG Construction, chaired the debate which was opened by John Cooper of Anshen and Allen proposing the motion. Opposing it was Phil Nedin of Arup UK. The seconders were Jaime Bishop of Stefian Bradley for the motion and Chris Shaw of MAAP against. About seven members contributed from the floor of the house eliciting some further responses from the platform.

The topics of design team “leadership” and “the integration of engineering” have been debated in architecture and construction circles for as long as I can remember with no notable outcome or clarity. As for “better architecture”, the term has no meaning that we could ever agree to debate. All the platform speakers are successful in practice and it was clear that they all shared the same values for architecture and the construction process. John Cooper made a good advocate for architects, drawing on extensive and well-analysed experience in a characteristically amusing chat. Phil Nedin, from an impressive engineering background, was also very sound and balanced in his argument. I could not discern any real disagreement between them or any need to vote one way or the other.

From the floor of the house Phil Gusack made his usual attempt to enliven the debate by bringing up “PFI” and “American business models” but to no avail. There were some forty people attending and since most were architects and already sure supporters of the motion the vote was a foregone conclusion. There were 28 for, seven against and four abstentions. But as a game it was the equivalent of a practice knock-up within the football club.

Peter Scher
March 2008

Presented by Architects for Health on Thursday 29 November 2007 at the RIBA, 66 Portland Place, London.

Both professions share lengthy formal courses of qualification – both are populated by dedicated and hardworking individuals, who work long hours for uncertain reward. Both professions come under fire for failing to live up to the challenges of change in the health service.

In our separate ways, architects and doctors dream of new futures for the service and believe them to be worthy. In reality, when service developments result in new buildings, architects and doctors seldom share their visions and passions. The process seems to get in the way.

Sunand Prasad, President of the RIBA, will welcome guests for the evening.

Chair: Duane Passman, Partnerships for Health

Speakers:

• Dr Charles Gutteridge, Medical Director, Barts and the London NHS Trust
• Andrew Barraclough, Director, HOK Architects
• Dr Frances Raphael, Consultant Psychiatrist, Springfield University Hospital NHS Trust
• Mungo Smith, MAAP Architects

The speakers will share their experiences of working with their opposite numbers – doctors with architects and vice versa. In progressing positively to pursue better outcomes, what is it that doctors expect from architects and what do architects expect from doctors.

Report on the Event by David Andrews of LSI Architects LLP (London, Norwich):

Dr Ann Noble opened the evening by stressing how important it is that AfH does more with other disciplines, as was to be the focus of this event.

Sunand Prasad extended a warm welcome to the non-architects and clinicians in the audience, who numbered a significant proportion. His opening statement recounted how learning with doctors could have powerful results, as witnessed on a recent Belfast project which involved a memorable healing process in Ireland!

Duane Passman noted how his background as an astrophysicist led to a personal reaction to the statement that ‘it’s not rocket science’ when used by the NHS. He reiterated the need to engage in discussions between professions about what has gone well and where there might be common ground for improvement – in the context of their being lots of work to do, with the ongoing shift in focus of healthcare delivery towards the community sector.

Dr Charles Gutteridge revealed his background as an anthropologist. He noted that his aim at Barts and the London was to influence the way his organisation works by encouraging the consultant body to engage in the formulation of local health policies. Reference was made to a book he inherited upon his appointment, which contained a history of Barts, along with an early diagram for the proposed demolition and redevelopment. This showed that thinking on the current redevelopment project could be seen to have first started in 1925 and has only recently resolved the different ways of working between the two sites. On joining the organisation in 2002 the current project had been in the 3rd version of a PFI scheme involving two bidders and a challenging planning context. The process involved doctors at the frontline of planning layouts and patient pathways, with resulting changes to the design to achieve fitness-for-purpose. However, the question was posed as to whether this will be a reflection of East London?

Andrew Barraclough qualified as an architect at a young age. He noted how the training for both professions involved a similar timespan but resulted in a diversity of output which was extreme, as though the two professions were differently wired. He saw the doctor’s education as being deep and narrow, with the architect’s shallow and broad. He commented that the process of arriving at a finished building was not a simple one and the way architects consulted often involved user groups which were too large and made up of the wrong people, rarely involving doctors and with a reliance on senior nursing staff, with the key issues generally not fully understood by all participants. Andrew’s message was to encourage openness to new ideas, rather than an institutional reluctance to change, as more frequently experienced.

Frances Raphael introduced herself as a jobbing psychiatrist with three experiences;

• Seeing St Stephens flattened and the Chelsea & Westminster built in its place
• Being presented with a new building and being told you’re moving to a pretty good facility
• Involvement on a project with Mungo for a new inpatient facility at Springfield

From these experiences she drew out that the architect needs to bear in mind where the doctor is coming from, often without any background knowledge of what is going on. She saw that the input from doctors and nurses is more generally concerned with practical issues, with the potential to feel that the outcome is one of compromise. Frances concluded that the process was inherently difficult, with uncertainty regarding the context and nature of the engagement by the doctors and nurses.

Mungo Smith described his first project working for a small practice with a Trust which was losing its beds to the community. He cited how at this time the doctors involved in the project were radical in their wholistic perspective of healthcare. Seeing this struggle within another profession has rubbed off on him with regards to carrying passion and commitment over the years. He described how when he arrived at MARU he met a social worker called Paul Rooney who was convinced that the way forward for mental health was to get out of large and into small community facilities. This was seen to be swimming against the tide at that time. Mungo’s closing point was made that there generally aren’t many people within the health environment looking at alternative models, due to the day-to-day reality of under-funding and lack of resources, and that the cross-over between architect and doctor is difficult, with the medical profession not trained in spatial relationships.

A lively session of questions and debate followed which covered issues including the following:

• Differences in doctors and architects education and training with regards to their experience of receiving positive and negative criticism, with doctors not having to face studio critiques of their work!
• Both doctors and architects sharing humanitarian values in a system which doesn’t necessarily support these aims, with problems of hanging on to ‘a bigger idea’ in the face of the system and its constraints.
• The ‘patient centred environment’ having had a focus on functionality in the past, but the emergence of more generic solutions now leading to an increasing focus on quality, with attention to daylight, ventilation, views, way finding and better spaces etc.
• What lessons are learned and how are these lessons passed on to others? There have recently been some good post project evaluations, though improvements in the process are needed to change the current culture of blame.
• PFI – a system in perfect balance, with output dependant on input and, in particular, the quality of the brief. A benchmark of ‘getting better buildings than we were before’ could be seen as a fairly low aspiration.
• The question of compatibility of the current management culture in the delivery of ‘the best’ in terms of health buildings and the message from the NHS to Trusts to ‘look out not up’.
• Who talks to who and when? The trend for less contact between architects and doctors over the years, with a plea to utilise the collective capacity with the room to direct this process.
• Pebble projects initiated in the USA with the aim of disseminating research and development on projects, with a ripple effect. The first pebble project in the UK is under consideration in Kent.
• Inconsistency in standard terms of reference for those involved in the process, with NHS directives at a detailed level rather than addressing the fundamental differences in approach by Trusts across the country. A national understanding?
• Pro and cons of smaller units versus larger projects, with challenges faced in delivering high quality large scale facilities, though equal challenges in effectively ‘joining-up’ healthcare at the small scale. Can the hospital experience be anything other than the equivalent of travelling by jumbo jet, functional yet never wholly enjoyable?

The following conclusions were made by the panel:

• Mungo; Design has to be the ideal, not today’s reality, and those involved in the process need to remain vigilant with a consumer’s hat on.
• Charles; We need to develop management structures to deliver clinical excellence and should also consider developing the AfH website as a social networking tool.
• Frances; In engaging doctors there needs to be a decision as to how to engage
• Andrew; There is an irony in that consistency removes innovation, and with no natural leader it should remain the architects responsibility to try and impact change

Duane concluded the session by reflecting on the importance of transparency to allow interaction between professionals.

Report by David Andrews of LSI Architects LLP (London, Norwich)
www.LSIarchitects.co.uk

Exhibition Stand
16 and 17 October 2007

Presenation at The Building Design Partnership 20 September 2007
A presentation on the Switzerland Study Tour that AfH organised in July 2007. Five buildings were visited: REHAB Basel, a centre for paraplegia and craniocerebral injury trauma patients; University Hospital of Basel; CasaVita Kannenfeld, a Nursing Home in Basel; INO – University Hospital in Berne; and Women’s Hospital in Berne.

Speakers: Karin Imoberdorf of Itten + Brechbuhl Architects AG, Karin is our invited speaker for the evening and will be talking about the Swiss Health Care System and the INO University Hospital, Claudia Bloom of Avanti Architects, Susan Francis of CABE – Commission for Architecture and the Built Environment, Mungo Smith of MAAP Architects, and Nigel Greenhill of Greenhill Jenner Architects.

20 September 2007

The RIBA (Royal Institute of British Architects) in London.

Five visits where arranged: Rehabilitation Clinic, Basle; University Hospital, Basle; Nursing Home, Kannenfeld; INO University Hospital, Berne; and Women’s Hospital, Berne.
The visit was arranged through the co-operation of Karin Imoberdorf of Itten + Brechbuhl AG and was led for AfH by Claudia Bloom.
11 to 13 July 2007

Architects for Health where invited to exhibit at the Design and Health Congress in Glasgow.
27 to 30 June 2007

Operating Theatres of the Future was the title of an Architects for Health Event that took place at The RIBA, 66 Portland Place, London, on Thursday 31 May 2007

Chairman: Mike Sury, FRCA – Consultant Paediatric Anaesthetist, Great Ormond Street Hospital London, Honorary Senior Lecturer Portex Unit Institute of Child Health. Email: surym@gosh.nhs.uk

Speakers

“The Future of Surgery” – Professor Erik Fosse, professor and director of the Interventional Centre of Rehabilitation of the University Hospital of Oslo, Norway. Erik Fosse is specialised in general surgery and cardiothoracic surgery. He is professor and director of the Interventional Centre which is a research and development department at Rikshospitalet University hospital in Oslo. The department develops new treatment strategies based on advanced imaging technology and work closely with industry to develop and validate new technological solutions for surgical intervention and patient monitoring. http://www.ivs.no

“Surgical Work Places” – Andrew Walters of Maquet – Surgical Workplaces. Andrew is the Product Manager of Modular Theatre Systems of Maquet and will be talking on the Modular OR-System VARIOP, and the benefits that the company’s approach offers to surgical workplaces. http://www.maquet.com

” A recent case Study: The Barn Theatre at the Royal Liverpool and Broadgreen University Hospitals” – John Knape, Northern Regional Director of Nightingale Associates. John has throughout his career specialised in the design of healthcare facilities. He led Nightingale Associates’ team responsible for the design of the recently completed £70m Broadgreen Hospital Development, delivered through ‘ProCure 21′, which includes an innovative ‘Barn’ Operating Theatre. John will be talking about the reasons why he adopted the ‘Barn’ theatre solution and the perceived advantages from a surgical perspective (prior to occupation) before talking about the construction. http://www.nightingaleassociates.com

Contribution

Donal O’Donoghue, Divisional Director for Medical Surgery at The Royal Liverpool and Broadgreen University Hospitals, NHS Trust
John Davidson, John Davidson is a consultant Orthopaedic surgeon and Clinical Director of the Royal Liverpool and Broadgreen University Hospitals NHS Trust. John specialises in Joint replacement, specifically in knees and hips. He sits on International Advisory Boards for developing new technologies in surgery and is a frequent faculty member at international meetings on surgical technique and practice.
Donal and John will talk about how the ‘Barn’ theatre concept was considered and taken up by their team and the ‘Barn’ theatre in use – how it operates (i.e. the patient journey), whether it has met the surgeon’s expectations, infection rates, effects on staff morale, good/bad features and what they would want to have done differently if doing the scheme again. http://www.rlbuht.nhs.uk

Sponsor MAQUET

It was a stroke of brilliance by Architects for Health to hold this meeting only two weeks after the absorbing and uplifting meeting on Hospices. This one was quite as absorbing but hardly uplifting.

Professor Erik Fosse, Director of the Interventional Research Centre at Oslo’s Rijkshospitalet, presented a thorough and penetrating review of recent innovations in medical technology. This will furnish our professional discourse with an impressively advanced vocabulary – mulitmodal image guidance, telemanipulators, focused ultrasound, ‘Pathfinder’ robots and so on.

The purposes of the Interventional Research Centre are to develop new procedures and treatment strategies, to compare them with existing ones and to study the social and economic consequences. Non-invasive procedures and ‘Keyhole’ techniques are increasingly replacing conventional surgery. Day surgery and early discharge require patient follow-up to move to primary care.

Professor Fosse described the transformations already evident in surgery in terms of a change from a handicraft to an industrial culture. “You become what you do,” he said: cardiologists become cardiac surgeons, radiologists perform more complex procedures, surgeons become computerised and engineers, mathematicians and physicists enter the theatre now. Under seven headings Professor Fosse tabulated the differences between the handicraft and industrial cultures -
“ownership” – from individual to corporate
“product development” – from integrated to separated
“knowledge transfer – from personal to explicit
“collaboration” – from interdisciplinary to cross-disciplinary
“review” – from individual to evidence-based
“value” – from procedure to product-based
“treatment” – from tailor-made to standardised.

In considering surgery (or intervention as we must now call it) in isolation from health care, and for those who see “healthcare” as an “industry” delivering a “product” this analogy has some relevance. In answer to a question from Ann Noble, Chair of Architects for Health, Professor Fosse said that the handicraft tradition in which ownership, knowledge transfer, review, value and treatment were controlled by the expert consultant clinician and his/her team has become too expensive. “Hospitals are being run as corporations” and “it is only a matter of time before corporations take over medical education”.

The meeting was expertly chaired by Michael Sury, Consultant Paediatric Anaesthetist at Great Ormond Street. He asked about the barriers to change and Professor Fosse said they were “resources, which are very expensive” and the “challenge to existing human power structures”.

“Toys for the boys” are indeed very, very expensive but individual human care for sick, anxious and fearful patients is priceless. It never came up at this meeting while it had been the central theme of Hospices.

The well-attended meeting was generously sponsored by Maquet and Andrew Walters their Product Manager gave a clear and informative presentation of the Modular Operating Room System, VARIOP. John Knape of Nightingale Associates and John Davidson and Donal O’Donoghue, Clinicians of the Royal Liverpool and Broadgreen University NHS Trust, completed the session describing the well-known ‘Barn’ theatre there.

Peter Scher
June 2007

Hospices was the title of an Architects for Health Event that took place at The King’s Fund, Cavendish Square, London, on Thursday 17 May 2007.

Hospices are special buildings, not only because they are for special groups of people but also because the approach to design and the means of procurement frequently falls outside the public sector and thereby creates opportunities for new and different designs. Undoubtedly the wider health sector can learn from them.

Chair: Mr Simon Henderson from Macmillan Cancer Support.

Introduction to the Modern Hospice Movement;
Dr Nigel Sykes, Medical Director of St Christopher’s Hospice

Robin House Children’s Hospice, Balloch, GIA Design Award 2006, Winner
Sarah Murphy of Gareth Hoskins Architects

Evidence based design and impact; St Gemma’s Hospice, Leeds; Marie Curie Hospice, Glasgow; St Patrick’s Hospital and Mary Mount Hospice, Cork.
Ian Clarke of Jane Darbyshire & David Kendall Ltd

Enhancing the Healing Environment Programme for End of Life Care
Mura Mullan of Jane Darbyshire & David Kendall Ltd

Hospices are not very numerous or conspicuous and, as far as I can recall, they have not been the topic of any previous Architects for Health event. This gap was filled at a completely absorbing meeting chaired by Simon Henderson of Macmillan Cancer Support. The first excellent and authoritative presentation was given by Dr Nigel Sykes, Medical Director of St Christopher’s Hospice, with a succinct account of the development and of the present position of the hospice concept. His most striking message was that “hospice” is not a building type it is a concept of care. Palliative care as it has come to be called – formally defined, in fact, by the WHO – can be delivered at home, in a hospital or in a hospice. Some 80% of hospice beds are in the voluntary sector and all care is free, but with the NHS providing only 28% of funding.

Sarah Murphy of Gareth Hopkins Architects then presented the design of Robin House, the second children’s hospice to be opened in Scotland. It was completed in 2005 at a beautiful site to the west of Glasgow near the southern end of Loch Lomond. Showing design sketches alongside photographs of the completed building vividly demonstrated the designers’ care in understanding the users’ needs and in collaborating to realise them.

The firm of Jane Darbyshire & David Kendall Ltd has long been involved in hospice designs. St Oswald’s, Gosforth, received an RIBA Award in 1980. Ian Clarke’s presentation on Evidence based design and impact was a very thoughtful and illuminating analysis of the interaction of hospice users and the designed environment. His understanding applies, indeed, to the design of all health care facilities and derives from the clear patient-focused approach of Roger Ulrich and others. He regards “intangibles”, “soft issues” and suchlike vague excuses for arbitrary design as misnomers. Our work should be to eliminate the stress, anxiety, depression or boredom that can be brought on by the designed environment. It can be done.

Ian demonstrated this approach in the practice’s excellent designs for St Gemma’s Hospice, Leeds, the Marie Curie Hospice, Glasgow and, in collaboration with Scott Tallon Walker, the Mary Mount Hospice in Cork. The latter design is a very sensitive solution to an unusually difficult brief – 130 hospice beds on a steeply sloped, north-facing site.

The final presentation, by Mura Mullan, also of Jane Darbyshire & David Kendall Ltd, was both moving and inspiring. It was for a single room at the existing Marie Curie Hospice in Glasgow. This was one of the projects of the King’s Fund “Enhancing the Healing Environment Programme”. It was a classic “before and after” demonstration of how a small amount of money and an incalculably large amount of enthusiasm and commitment by users and designers can transform the culture as well as the environment for care.

An interesting discussion followed these presentations held at the King’s Fund and some very valuable insights were gained by the appreciative members.

Peter Scher
May 2007