Opening The Debate

Unfortunately I wasn’t able to attend the AfH event on 30th November 2006 at the new Libeskind Lecture Space at the London Metropolitan University, and indeed was doubly distressed for as I am keenly interested in the topic of architectural education in general, and post-graduate specialist training and research in particular and was moved to establish MARU because of strong feelings in this area.

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This is a brief note responding to what I understand to be a suggestion that architecture schools should “teach” medical buildings, and that they are at present ignoring them. [AfH Event 30 November 2006]

I assume that to teach a building type, it would be necessary to give students a good deal of technical information about the contents of the building type, and a set of operating rules about hierarchies of importance, functional connectivities, space standards, etc. To do so, however, would simply be to burden students with information whose long (and even short) term obsolescence is guaranteed.

Architectural education is rather in the business of helping students to understand the design process, and to begin to work out for themselves a method of taking a set of complex requirements, including a site, and to see them as an opportunity for formal invention. The constraints and requirements are not to be learned, but to be used as a basis for design hypotheses.

This is a difficult and partly mysterious process that requires many years of practice before the designer can embark with confidence and sophistication on the road starting with a client briefing and ending with a building.

Most design problems in architecture school must be resolved in something like six weeks, and must therefore be based upon a brief whose level of complexity is appropriate for that time scale.

The hope of any architecture school is to help its students understand both the need and the pleasures of designing buildings which resolve the functional requirements stated in the brief, understand what constitutes a truly integrated building in which all systems support that resolution, and have a sense of the importance of detailing the building in support of that set of ideas.

The school should actively discourage students from trying to pick up a specific way of responding to a particular building type. Such an ability will quickly become obsolete when any of the requirements change. Any good architect should, with time to do some basic research, and a competent set of parallel consultants, be able to do a good job on any building type, and will actually do it better for having fewer preconceptions.

If my recent exposure to LIFT projects is anything to go on, there is a crying need for well trained architects not only to design fully integrated buildings, but to carry their design intentions through to the details of the building, and make it a complete visual and tactile experience.

M J Long
November 2006

Long & Kentish Architects

AfH Preface
With rare exception, healthcare facility planning and design is not taught in schools of architecture in the UK. This absence on the curricula has a direct effect on the perception that students, staff and the profession have of the skill base and competences which flow into practice.
Holloway Road, London, November 2006

Congratulations to AfH decision makers for booking this seminar on Healthcare building design education into Daniel Libeskind’s rather devilish tin tsunami. Now dubbed London Metropolitan University (LMU), AfH oldies still think of it as the Northern Poly , original home of Professor Raymond Moss’s Medical Architecture Research Unit (MARU) that once had a related to the Department of Health Architects Department as the Enigma code-breakers had once had with the Admiralty. Libeskind’s building is as good an example as any in London of the diverse trajectories that architects have pursued in the last thirty years, and begs two questions: (1) has hospital design changed dramatically and (b) what has happened in hospital design education over the same period? And it answers a third question: that the Bilbao Effect does not always happen. Hiring an enfant terrible architect to produce an enfant sauvage building has done nothing to regenerate the degenerate Holloway Road.

Jewish Museum, Berlin, Daniel Libeskind, 1989-99
According to Doris Saatchi, who visited Libeskind’s Berlin Jewish Museum before anything went on display, the experience evoked by the demonic power of the building moved her to tears. People cry in British hospitals, old and new too, but with the exception of John Weeks’ New Brutalist Northwick Park (1962-6), whatever it is that moves people to tears, it is not the power of the architecture. Because, despite massive funding increases and the launch of the 100 new hospital programme nine years ago, public confidence in the National Health Service is at an all-time low.

I have put the idea of a hospital design implant into architecture curricula to a dozen old friends who teach architecture, and they all recoiled from it. Hospitals are lumped together with shopping centres, hypermarkets, prisons, logistics centres, anything military and anything nuclear as either too technically complicated and/or diabolical – potential contaminants to schools and students’ minds. The study of architecture was never supposed to be celebrate grunge building but nor was it supposed to discriminate against buildings by type.

Gower Street, London, 1961
British architectural education had its big bang in 1961. The RIBA Oxford Conference redefined architecture as a professional rather than vocational subject, to be studied in universities rather than art schools. It was sex change surgery. Heavy doses of masculine science were injected and the Beaux Arts womb removed. Richard Llewelyn Davies, who led the surgical team, took the Chair at London University’s Bartlett School the same year. The mantra that form follows function was a modernist battle cry in the war against the past, against decoration, but it was not a road map. There are no instructions on the package. Exorcising the Beaux Arts drove design dialogue into hiding and left a vacuum at the very core of the curriculum. Students don’t just enrol to learn about architecture: they also assume they will learn how to design it. Llewelyn Davies’ theology, initially proposed in 19561 as ‘Endless Architecture’, maturing over ten years to be proposed by John Weeks’ as ‘Indeterminate Architecture’, was ‘the ideology of a design process – it was supposed to be methodically empirical and culturally neutral. He owed something to Gropius and a lot to post-war reform. But Llewelyn Davies may have had a soft spot for Sherlock Holmes too – “If you eliminate the impossible whatever remains however improbable has to be the truth.”

I received a far more considered opinion from Professor David Dunster, a Llewelyn Davies’ student in the mid-sixties: ‘He (Ll D) could neither design nor draw, John Weeks was fabulous at both. Together they tried to rid architectural design of the personal…As a student at the Bartlett we were not encouraged to use the library precisely because that would reintroduce the idea of copying other modernists, and thus reintroduce the Beaux Arts by the back door.’

Abercromby Square, Liverpool, 1969
My own experience at Liverpool University (1967-70) was a mix of disbelief that the curriculum virtually prevented dialogue about active contemporary architects, that the faculty were so uptight that not one of them could serve as a role model. Worst of all, I was frog-marched through relentless structural and heat loss calculations – the horror I thought I had escaped after O levels. We did not know much about architecture but that did not mean we were incapable of aesthetic rapture: like a million others we debated the respective merits of other devils – Keith Richards and Jimi Hendrix. We knew other clerics with newer lyrics and so, without thinking about the inevitable consequences, I persuaded Professor Robert Gardner Medwin to suspend the weekly visiting lecture series and let me spend the money on a one-shot three-day rally we called 2000+, bringing Cedric Price, Archigram, Richard Rogers, Martin Pawley to the dark side of the moon. 47 of us entered the school in 1967, and only half made it to the end of the third year on time. I was not one of them.

Tottenham Court Road, London, 1971
For three years (1971-74) I lived a double life: office hours in Euston Tower, playing a minor part in the Department of Health Harness team, evenings at the Architectural Association (AA) where I was a student of Peter Cook and Ron Herron.

The AA was famous for its agnosticism, Its casual approach to building science. All this was supercharged by the newly elected Chairman, Alvin Boyarsky. He ran the school, not as nutrition scientist, but as master chef, and the AA was his hell’s kitchen! At Liverpool, as at the Bartlett, they said good architecture was a matter of firmness, commodity and delight, but at the AA we saw it was more a matter of means, motive and opportunity, just like murder. To RIBA inquisitors Boyarsky was Llewelyn Davies’ Moriarty, and to many architects in practice, AA graduates were the devil’s disciples.

Nowadays the demarcation is more blurred. I asked Peter Cook, once an AA student, then its foremost Unit Master, to sum things up. By the time he was appointed to head the Bartlett, Llewelyn Davies fundamentalism had faded to grey, and Cook said the reason he got the job was to shake things up. Now in constant demand as a visiting critic, he said that although many schools are less rigid the relationship between classroom and studio is still unpredictable and competitive, and there are very marked differences between schools – classroom versus studio, diligence versus inspiration, theory versus practice. What is the best way? If he knows, he will not say. And so the last word goes to Reyner Banham: his posthumous essay ‘Black Box’ does not say that design cannot be taught, but does say that it is learned by socialization in tribal gatherings.

Jazz is the teacher but Funk is the preacher

My overriding impression of DoH at that time is the contrast between the enormous scale of the Harness programme (70 massive standardized general hospitals, of which only five were built) and the modesty of the people working on it. Euston Tower was awash with space stands, dimensional grids, activity data and performance specs. But the thing that hooked me was that Harness was column-free and its concrete skeleton would use 15m pre-cast concrete trusses, so drawn in cross-section it would somewhat resemble the exciting imagery from Cedric Price, Archigram, Ezra Ehrenkrantz, Norman Foster and Piano and Rogers, all seemingly transfixed by the silhouette of tower cranes against full moon.

Although DoH and the trussmeisters had a common book – Banham’s The Architecture of the Well Tempered Environment – they never met. Nothing would drag the diligent DoH sports jackets down Tottenham Court Road to the satanic temptations at the AA. And, to be fair, all the young dudes at the AA turned down all my invitations to check out what was being plotted in the DoH’s dark tower.

Holloway Road, London, November 30th, 2006
Make what you like of Libeskind’s Orion stories, or the Batman’s Cape version, but you can’t deny this is smashing building, brilliantly detailed – check the soffit of the overhang at the south end. If you have ever wrestled with the problem of reconciling sloping cladding and in-situ concrete, and I have, then you will appreciate the practical limitations of formwork and re-bar placement. The facts as given on Libeskind’s web site, are equally impressive: £2 million for 1,000 gross sq metres IN three years is surely enough to the ‘never-mind-the-quality-feel-the-width’ brigade. It should also stop the ‘young architects can’t do details’ brigade in their tracks. It will be interesting to see what The Architecture Foundation gets from its competition winner, Zaha Hadid, for the same money. There is, however, one glaring but correctable problem – the projection screen, standard format, Euclid upstaging Orion.

The Seminar
Seminar Chairman Robin Nicholson, ’68 Robin Hood defying the Baron Llewelyn Davies, now Lancelot at the Cullinan round table, has an appetite for new alchemies, and opened proceedings with a report Obesogenity. (whatever it is, it must be big) He scares me. My appetite is for food! Its a good way to relax an audience of architects not sure whether to align their spinal columns perpendicular to the horizontal floor or parallel to a leaning wall. We are, after all, in the belly of Orion, Libeskind’s blind beast.

Mr Nicholson first announced two papers had been received offering informed opinion on architectural education, one from M J Long and the other from Professor Raymond Moss, since neither could attend. I also asked Paul Mercer, AfH Secretary, who drafted the preface, to elaborate. The full texts follow as addenda to this essay. Long and Moss view the objective of undergraduate curriculua is to provide students with intrinsic skills and the intricacies of design as generic process that they can then apply to wherever their career paths take them. They both urge extreme caution.

Professor George Mann, who has been leading the healthcare design programme at Texas A&M University for 40 years, says ‘Just do it!’ Mann runs courses at undergraduate, postgraduate and full research levels, being home base of Dr Roger Ulrich and his Evidence-Based design rangers. He set out his stall in a recent issue of Healthcare Design magazine ‘Why schools of architecture should be more like architectural firms—and vice versa.’

When Mann says ‘Just Do It’ it is the US context of the relentless hospital construction market completely deregulated by Ronald Reagan and. Now, as Mann says: ‘Hospitals are free to go broke!’ This is a crucial relevant observation, unfortunately not explored. Instead, he skirted over 40 years of finding students for his courses, jobs for his graduates and staff for his alumni. Whatever population explosion, Chinese Economy and ;Indian middle-class ‘ mean to us here on the Holloway Road, to Mann they mean more work for hospital architects.

In 2004, Architects Newspaper asked the Deans of the fifteen schools in the north-eastern United States about their schools and the state of architectural education. Only CCNY’s George Ranalli New York said that the curriculum must reflect social needs. In this range, Mann is Bono, not Yoko Ono!

Ake Wiklund, after a long career in healthcare design, was appointed by Sweden’s Health Ministry as a Professor at Chalmers Technical University, in Gothenburg about five years ago. Many people have assumed that rye crisp, clogs and Abba prove the Swedes are not just easy going but thoughtless. This is dead wrong. Sweden messed up in Poland in 1655, reversed, parked in its own space, shifted to neutral, but never switched off. Sweden’s approach to homeland security is the last word in vertical integration. It has Saab Viggen fighters to ward off Soviet Bears, and its own subs to patrol the Baltic. And not content that it has achieved the highest life expectancy with the lowest hospital bed per capita ratio in Europe, it decided to insure against any future shortage of hospital architects by a pre-emptive educational launch. Professor Wiklund is their Dr Strangelove.

Bas Molenaar is a Director of EGM Architects in Holland and has been part-time Professor at the Eindhoven Technical University for two years. Holland has enjoyed high brand values in recent decades, arguably eclipsing Sweden as a clean easy-going place where everything works. Holland spends a lot on healthcare and you can live long and prosper there too. The rise and rise of high profile Dutch architects is a whole phenomena yet to be fully understood, but, in my experience, it must have something to do with great Dutch clients. Molenaar’s account of his first offering to his students: Placebo Hospital, ‘assume the equipment doesn’t work but the staff are all very happy and design a good place for people to regain theory health may lead young AfH members, whose entire experience to date has been defined by DoH potato-cuts and PFI voodoo, to imagine these classes meet, not in Eindhoven, but in Amsterdam coffee shops.

Current British efforts at Sheffield University’s Live Projects unit were [resented by Leo Care. This is, in my view, a viable option, especially if students are confused by ephemeral studio discourse. When they get the blues some real-life hands-on can help their self-esteem. It is a complicated subject on its own, but it cannot be the tail that wags the dog.

Audience reaction centred on the viability of the idea within British schools as they are now. As in the NHS, a lot now hangs on consumer choice, the consumers being the students. My impression is that some AfH members find this disturbingly permissive, not because they are authoritarian, but because they cannot see the logic of deliberate denial. In other words, because we need better healthcare design, we must do something positive to attract students who may, eventually, help raise the game. To which the resistant faculty repeat that until the game is raised, students will opt for the safety of higher cultural ground. Don’t blame them: I heard not one comment from anyone present about Libeskind’s Orion. There we were in something so provocative. So much for all our talk about environmental sensitivity throughout the year. What can it say to our visitors from academia?

In a week that saw four public protest marches against NHS job cuts, leaked papers revealing other Ministers’ have privately warned Health Secretary Patricia Hewitt, what everyone else has known since she took up her post, that her handling of NHS reform is as controversial and counterproductive as Tony Blair’s misadventures in Iraq. And, as if this wasn’t enough to put faculties off healthcare, Chancellor Gordon Brown told the House of Commons he is upping spending on schools. In these circumstances architectural professors who need to fill their design studios, but want to tackle a building type of unquestioned social benefit, now have every reason to opt for education and practically no reason to opt for healthcare.

If we are to continue the debate, and there are good reasons to persevere, we as practitioners and employers stop pontificating about what we think the schools should be doing. Nor can we blame schools if we hire disappointing staff. Candour is everything. How do we handle our side of the de facto apprenticeship? Are our offices creative hot-houses or high-end call centres? Do we hire good thinkers or good CAD monkeys? Do we mentor or a devil seeking sympathy?

A lot of decoding needs to be done. The common jargon – architecture, process, research – is volatile and flammable – handle with care. If we want to offer our experience and expertise we need to CAT scan the way we do things here and now so we can carefully remove the malignant effects of PFI and the tissue that has been damaged by prolonged dependence on DoH standards and guidance. We need to study the basic anatomy of our craft before we can safely donate bits of it to the schools who are incubating the stem cells. Our purpose is to contribute to the education of students so that they can whatever they like with it. We will have to be vigilant – any suggestion that we are planning a covert breeding programme for young hospital architects and I, for one, will try to pull the plug.

Postgraduate level is an altogether different proposition but any speculation has to take account of the current location and orientation of MARU. It has rewritten its website and now has much more to do with facility delivery within current DoH procedural and procurement regimes. It may be the realpolitik but is it still architecture?

It is entirely possible that the Howard Goodman Fellowship research into adaptability at Imperial College is the only serious healthcare building design work being done now, and this is retrospective. If AfH members are doing serious R+D, they are keeping quiet about it. We are, I believe, dangerously close to losing the knowledge about the design concepts and building technologies that were what made hospital design vibrant and relevant. With great affection and respect I know the surviving pioneers are an endangered species. Soon, the only reference to their work will be 50 Years of Ideas, a slim summary out of print, out of sight, out of mind.

The most important change in operating context is likely to be Gordon Brown’s move into 10 Downing Street. As Prime Minister he will finally hand over budgetary policy ll find it easier to U-turn if expedient. And Brown will finally have to explain the countless cock-ups in NHS reform, just as Blair has had to step in to cover for the hapless Ms Hewitt. Next year we may have sympathy for the devil.

Merry Christmas

Phil Gusack
phil@gusack.com

With thanks to:
David Dunster, Roscoe Professor of Architecture, Liverpool University
Sam Gathercole, Histoiran and writer, Roehampton Institute
Professor Peter Cook
Nicholas Boyarsky
Professor Raymond Moss
Professor George Mann
Professor Ake Wiklund
Professor Bas Molenaar
M J Long
Paul Mercer
Georgeanne Burns

Professor Raymond Moss

MBE Ph.D RIBA

Ann Noble
Chair, Architects for Health

14 November 2006

HEALTHCARE FACILITY EDUCATION
OPENING THE DEBATE

Thank you for the ‘Notice of Meeting’ for the AGM. As you may understand, I am very sorry that I will not be able to attend but I have to be in Derbyshire.

Indeed I am doubly distressed for, as I think you know, I am keenly interested in the topic of architectural education in general and post-graduate specialist training and research in particular and was moved to establish MARU because of strong feelings in this area.

That said I have to add that I think that the debate you propose is being opened on the wrong note. By this I mean that there are critical flaws in the education of architects that override teaching healthcare facility planning in one or other of the schools of architecture, as currently structured.

The general and generalist level of undergraduate education may have something to commend it, teaching the basics of design and construction, brief building and so on. Indeed some hold that it is arguably better not to have had any previous experience of a particular building type, but to come to it with a fresh, and enquiring mind.

Much more to the point is to ask whether the basics are being taught properly in order that the products of our schools of architecture are equipped adequately to progress in whichever facet of modern professional practice they choose to work in. And perhaps more importantly to regain their seat at the top table where the big decisions are made rather than just becoming more effective and efficient in what I call the ‘no clout’ department.

In my view, one of the important reasons why architects have lost their seat on the board is that the ‘basics’ are not being taught as well as they might even if they are taught at all. Key subjects now are accurate cost forecasting, both building and whole life; designing to reduce operating costs (systems engineering); informed site appraisal; sustainability; design for continuous Achange; creative brief building etc etc.For a large variety of reasons architectural education has let slip some of these subjects and this accompanied by a growing belief that we do not need to design to suit the materials any more but we use or develop materials which do what we want them to do has led to the development of the ‘concept’ which can be anything from what somebody thinks the building might actually look like to what somebody would like the building to look like.

This trend is not particular to architectural training but is noticeable also in product design and fashion.

So I would like to suggest that if it is considered desirable to create interest in; develop knowledge of; be aware of developments internationally and generally influence the future of things, that we should not be imposing the odd design programme on random schools of architecture but developing centres for the study of health design to which people with a genuine and long lasting interest in the subject can look as well as schools of architecture for whom the Centre can run credible programmes either in the school or at the Centre.

In my view it is a question of doing things professionally to prepare architects to play their role fully at all levels of health planning and design – including the ‘clout’ department.

ray(at)rmoss(dot)fsnet(dot)co(dot)uk

M J Long

AIA RIBA

Medical Buildings and Schools of Architecture

This is a brief note responding to what I understand to be a suggestion that architecture schools should “teach” medical buildings, and that they are at present ignoring them.

I assume that to teach a building type, it would be necessary to give students a good deal of technical information about the contents of the building type, and a set of operating rules about hierarchies of importance, functional connectivities, space standards, etc. To do so, however, would simply be to burden students with information whose long (and even short) term obsolescence is guaranteed.

Architectural education is rather in the business of helping students to understand the design process, and to begin to work out for themselves a method of taking a set of complex requirements, including a site, and to see them as an opportunity for formal invention. The constraints and requirements are not to be learned, but to be used as a basis for design hypotheses.

This is a difficult and partly mysterious process that requires many years of practice before the designer can embark with confidence and sophistication on the road starting with a client briefing and ending with a building.

Most design problems in architecture school must be resolved in something like six weeks, and must therefore be based upon a brief whose level of complexity is appropriate for that time scale.

The hope of any architecture school is to help its students understand both the need and the pleasures of designing buildings which resolve the functional requirements stated in the brief, understand what constitutes a truly integrated building in which all systems support that resolution, and have a sense of the importance of detailing the building in support of that set of ideas.

The school should actively discourage students from trying to pick up a specific way of responding to a particular building type. Such an ability will quickly become obsolete when any of the requirements change. Any good architect should, with time to do some basic research, and a competent set of parallel consultants, be able to do a good job on any building type, and will actually do it better for having fewer preconceptions.

If my recent exposure to LIFT projects is anything to go on, there is a crying need for well trained architects not only to design fully integrated buildings, but to carry their design intentions through to the details of the building, and make it a complete visual and tactile experience.

m(dot)j(dot)long(at)longkentish(dot)com

Paul Mercer

RIBA

My views on the subject are simple. Architecture and design are taught at a very large number of undergraduate schools in the UK and very few have any part of the curriculum which addresses healthcare design and planning. Why is this when we know that there are schools overseas which have extensive programmes (as evidenced by the overseas speakers on the night)?

Healthcare design is considered by many to be “too hard” to teach at undergraduate level and “highly specialised” to the extent that it is clearly being ignored by many schools of architecture. We need to debunk the ignorant and inform educators about the real status and value of teaching healthcare, which tends even in the ‘real’ world to get bundled into one big parcel as if all healthcare design is somehow difficult and the same.

I suspect the most poignant comment on the night was the suggestion that lecturers and studio teachers are most often the source of the problem in that they have blind spots. Maybe AfH should offer to become involved in undergraduate studios, workshops, crits, and design exercises and so on
- although I haven’t worked out yet how we guarantee that the people we ask to be involved will actually be able to deliver a good quality product to the schools nor how AfH can benefit from this except by increasing its already good name. AfH needs to generate some ££ out of what it does as well as being considered a soft touch for loads of free time and input.

paul(dot)mercer(at)tangramarchitects(dot)co(dot)uk

200,000 years after his ancestors stood up and wandered out of the rainforest and onto the savannah, man discovered the caves at Lascaux, central France, and decided they were a perfect machine for living. It was the birth of the European lifestyle – man as hunter-decorator. 17,000 years later, thanks to low-budget airlines, the French countryside is more popular than ever. And for almost all of that time walls were not only used to keep the undesirable out, but also the only sensible place to hang pictures. Then, suddenly, the first world war exploded across Europe. The blast split the DNA of art and architecture forever. Each mutates, recombines and mutates again, according to its own internal codes and ambitions. In twenty years the modernists changed everything, architecture was reinvented and walls and the art on them went out the window.

The propaganda for the brave new world played up notions about the integration of art in architecture. Opening the Weimar Bauhaus in 1919, Walter Gropius proclaimed ‘Let us create the new building of the future, which will embrace architecture and sculpture and painting in one unity and which will one day rise toward heaven from the hands of a million workers like the crystal symbol of the new faith.’ Very Wagner, very vague and not verifiable. Thee modernist photo album we have all studied shows one iconic composition after another with flat roofs, huge glazing and unadorned white walls; only precisely positioned signature chairs save us from the embarrassment of mistaking a Corb for a Breuer. The mood is monastic. Our reaction is reverence. Art is there all right, but it is the art of the architect.

Whether it was President Dwight D. Eisenhower forcing Britain and France out of Suez, or Rock Around The Clock driving British audiences to tear cinema seats out so they had room to jive, 1956 was obviously the tipping point in the ascendancy of American culture over Britain. And what America had was born-again Mies van der Rohe, his pre-war ambition that his was the true German architecture washed clean on his Atlantic crossing. His 1951 house for Dr Edith Farnsworth reached the apogee of transparency. He had done for architecture what another immigrant, Werner von Braun, had done for aviation: rendered human occupants and their art objects obsolete while producing objects of unprecedented precision and timeless beauty.

The British reaction was recorded by Reyner Banham’s 1966 book New Brutalism1. It covers the story of architects in post second world war Britain, their participation with artists in The Independent Group, their gatherings at the ICA, then in Dover Street, and their collaborations in the This is Tomorrow exhibition at The Whitechapel in 1956. The most memorable work, Richard Hamilton’s collage ‘Just what is it that makes today’s homes so different, so appealing?’ is a clear marker that whatever the real context that artists now worked in, and it was definitely not, (nor had it ever really been) a unity with architecture. Banham, a diarist as much as a historian, charts the splits between neo Swedish brick detailers, new brutalist concrete shapers and the agent provocateurs – Cedric Price and Archigram, each a search for a way round the scary glamour and extravagance of Mies, just as the spaceship tries to get round the monolith in Kubrick’s 2001. In Black Box2, his poignant parting shot, Banham sees architecture as a sort of self-perpetuating tribalism, primary concerned with its own ambitions, adhering to its own rituals and rites of passage, ready to sacrifice whatever sciences and arts that do not fit in. He concludes: ‘… many students will have heard something which I personally heard at that time, the blunt directive: “Don’t bother with all that environmental stuff, just get on with the architecture!”

If any further proof that architecture occupies a position that Banham called ‘cultural privilege’ is needed, we need only look at the perversity in art museums and galleries in recent decades. Exquisite torsos hooked on the hyperbolic steroids of critical acclaim. What else are the architects – Wright in Manhattan, Gehry in Bilbao, Hadid in Cincinnati, Cook in Graz – saying to artists? ‘ Now follow that!’

As British political aspirations arced from James Keir Hardie’s real Labour Party to Tony Blair’s New Labour, British belief in the institution of the marriage of art and architecture has arced from William Morris to Tessa Jowell, Secretary of State for Culture, Media and Sport, which encourages civil partnerships and cohabitation as well. Ms Jowell is self-designated Government Design Champion3: she is also chief match-maker. Her dating agencies include The Arts Council (now receiving £455 million and distributing £410 million a year) and CABE (now receiving £12 million, or 200 Prescott homes a year). Regarding CABE, she said ‘The difference that good architectural design can make to improve the lives of ordinary people and to deliver ‘liveability’ is at the heart of CABE’s work.’ Good news for the ‘ordinary people, since they’re the ones who have spent billions on lottery tickets that helped reboot British architects after the last property market crash.

With no constitutional clarity such as French fraternite or the American pursuit of happiness, New Labour ideology now ranges from form foreign imperialism to domestic empiricism. Jowell’s rationale is that culture, lisle sport, is good for our health. And the Arts Council has dutifully commissioned Your Health and the Arts by Dr Joy Windsor. It is a superb example of evidence-based research that has been imported from Texas A & M. As AfH members know all too well, Texas Professor Roger Ulrich’s advisory role at the Department of Health has sidelined British hospital experts as Billy Graham sidelined British clergy. Dr Windsor’s work may be encapsulated as follows:

1. Hypothesis: art is good for your health;
2. Conclusion: art is good for your health;
3. Methodology: 2,500 telephone interview

Nagging questions:

1. How many calls were made to people out at Tate Mod?
2. How many calls were made to people out at hospital A&E?
3. How many calls were made to people who went to Tate Mod, where they ere hit by runaway buggies and ended up in hospital A&E?

Personally I am all for art in hospitals, surely the most appropriate place for (say) Gilbert and George’s Fundamental Paintings such as Spit and Piss. Bad taste? No more than the lung x-ray look-alikes’ that Vital Arts recently hung in the Barts outpatient waiting area. Its not quite as crass as you might think, because it is too dark to really see it for what it really is. AfH member LeAnn Barber, who runs Contemporary Art Projects, tells me bad lighting is a bigger problem than getting Trust’s to sign on and, she says, fresher brighter uplighting doesn’t help if it depends on wall-mounted fixtures that, by definition, spoil the view.

With these many issues in mind, I was very pleased to attend the LAHF seminar4 and see presentations of two new-build architect-artist collaborations. The first of these is at the Moorfields International Children’s Eye Centre presented by Architect Sunand Prasad, art consultant Isabel Vasseur and artist Alison Turnbull. In a DoH Procure 21 contractual arrangement, Prasad had the room to manoeuvre to bring an artist in to the team. Isabel Vasseur organized the shortlist. Prasad’s team had already designed extensive south-facing glazing that would be shaded by large horizontal louvres. This was Turnbull’s blank canvas, which she would transform beyond the mere prosthetic. I have to admit I did not really follow her account of her private work method but I do appreciate that it is there. No matter: the end result, raises the building from corporate to delicate. It is not an eyelid, it is an eyelash. No mascara required.

The second project is the Gloucestershire Royal Hospital (GRH) a PFI scheme, presented by Architect Claudia Bloom and art consultant Jane Wills. The idea was Wills who was contracted by the Trust. Their discreet observations suggest Le Carre tradecraft, the PFI contractor being the baddies. Wills organized 20 custommade pieces and raised funds from seven sources totalling £325,000. From her description I think they range from Blue Peter to science show, the general intention appearing to be distraction of the nervous by enlivenment of the interior.

The problem here is really very little to do with these collaborations and much more to do with my unrealistic expectation of some sort of emotional disagreement. No I didn’t think an artist, enraged by a philistine PFI contractor, was going to cut an ear off in protest. Even in Hoxton Square, Britart’s Harley Street and/or London’s West Broadway, where East London’s estimated 10,000 artists meet, when someone asks if the empty seat at my café table is free, and I quip’ Sorry, I’m waiting for Tristan Tzara,’ they don’t get it. The history of art over the last 100 years is surely one of provocation, but if I can’t find it in Hackney I’m never going to find it at this seminar because LAHF is not there to investigate the aesthetic constraints of therapeutic art – it exists to promote the business for artists in the hospital building boom.

If it is possible to extrapolate any trend from only two projects, it is that the market makers – the art consultants will expand market share working with Primary Care and Hospital Trusts but won’t have much luck with PFI. Even before Claudia Bloom’s discreet remarks about the GRH experience, I had resigned myself to the fact that the blue paint on the site fencing now encasing large chunks at Barts is as much art that the Skanska Innisfree gangmasters will pay for. It’s a different story on the fences on the numerous office and apartment blocks, decorated with marketing graphics, they do impart some information. But then Barts is a pre-let, so why spend the krpne? Come on Skanska and come on HOK too. It will soon be Christmas.

It would be ungrateful and holier than thou to suggest that AfH occupies higher moral ground than LAHF. LAHF may be getting an Arts Council bung, but AfH ranks are swelled by PFI. The point is that AfH thrives on diversity and tolerates its discontents. Hopefully it will put the questions about therapeutic art to further test. Its not a matter if evidence, because you know perfectly well that the evidence submitted by Joy Windsor, Roger Ulrich et al does not prove anything beyond reasonable doubt. The bigger questions are:

1. Is artwork intended to be therapeutic really art?
2. Is artwork made for specifically to go in or on a building art decoration?

If we learn anything from Simon Schama’s stunning films on the Power of Art5, it is that art is powerful when artists do what they want, not what we want.

Phil Gusack
phil@gusack.com
21.11.2006

Footnotes:

1. New Brutalism, Reyner Banham, pub Architectural Press, Nov 1966 ISBN: 0851394604
2. A Critic Writes: Essays by Reyner Banham (Centennial Books) by Reyner Banham, Paul Barker (Editor), Sutherland Lyall (Editor), Cedric Price (Editor. The article originally appeared in ‘New Statesman and Society’ , 12 Oct 1990, pp 22-25. In the foreword Peter Hall writes about this; “The posthumous 1990 piece is particularly significant, not simply because it was his swan song, but because he knew it was and wrote it that way”
3. AJ 100 Breakfast Club, London, 02/02/2006
4. http://www.architectsforhealth.com/library/integratedartinhealthcarefacilities.html
5. http://www.bbc.co.uk/arts/powerofart/intro.shtml

Bipolar mental healthcare planning and passive-aggressive design in the NHS

A review of the Architects for Health seminar ‘Context, Challenge and Creativity : Designing for Acute Mental Healthcare’ on 21 September 2006 at the King’s Fund, London.

Context

Current developments in British mental healthcare still show traces of their medieval origins. Scrolling through the Mental Health Timeline ¹ reveals a saga of myths, beliefs, theories, investigations, Royal Commissions, legislation and, more recently, government guidance. Its a 700-year story of protecting of normalcy and segregation of the afflicted so they can be properly cared for, treated and, perhaps, cured. The route taken has been paved with good intentions, but the navigation has been by trial and error. Who went on trial and who made the errors are obviously matters for the Royal Colleges, not Architects for Health (AfH).

New developments in acute (inpatient) mental healthcare have been largely overshadowed by the 100-hospital building boom, so this seminar was organized to bring AfH members up to date. Broadly speaking the trend is towards smaller less ‘institutional’ projects within the community. MHU treatment is non-invasive, and there are no surgical, imaging, laboratory and sterile supply departments. The parameters for good MHU design were presented by Andrew Simpson ², one of that rare breed of end-user client who takes the game out of the box, confident that the beancounters won’t value-engineer William Morris down to Laura Ashley. His criteria, coincidentally elaborated in Mind’s recent publication entitled ‘Building Solutions’ ¹¹ include the need for safety, privacy, comfort, dignity, and the importance of gradients of intimacy (as propounded by Christopher Alexander ³ sixties Design Methods guru). There are, of course, detailed complications arising from the ergonomics of suicide – hooks are a no no. On the other hand, surveillance and safety are simplified by cctv and electronic gizmos. The consensus is that MHU;s are more like hotels than hospitals. This is not quite true: the balance between privacy and observation means they are like hotels in East Germany!

Ward concepts by Devereux

En-suite room concepts by Broadway Malyan

Challenges

Three schemes were presented:

1. Springfield Village, a phased campus of inward focussed square donuts by Mungo Smith and MAAP ^4,7
2. Queen Mary’s Hospital MHU, a 2-storey rooftop addition to a general hospital, by Nic Allen and Devereux Architects ^5,8
3. Woodhaven MHU, a single-storey pavilion in a park by Doug Attrill and Broadway Malyan. ^6,9

Springfield is a fascinating regeneration plan to weave new mental healthcare, commercial and residential building into a new urban fabric. Nonetheless, If we accept that smaller, less institutional and community settings are the overarching parameters, these schemes present unmistakeable signs of systemic bipolarity. Having raised our expectations, Mr Simpson owes it to his architects to explain to us why:

• If smaller really is better, why will Springfield’s modest Phase A eventually be surrounded on three sides by a complete mental health campus, big and, inevitably institutional?
• If less institutional is better, isn’t Queen Mary’s a lame duck from the start?

And Simpson’s counterparts should explain why, if being in the community is critical to recovery regimes, how can they achieve this in the green and pleasant lands at Woodhaven?

Trusts are in a hell of a bind. Struggling to stay afloat in the new internal healthcare market, praying that patient choice doesn’t mean patient flight, torn between tariffs and targets. And however adept Trusts may be at resource planning and facility planning – and these are not now nor have they ever been the same thing – Trusts simply don’t have the muscle or agility to buy into town centres or the overheated residential property markets. As an agent told me, ‘If they’re afraid of the big dogs they’ll have to stay on the veranda!’ The veranda is, inevitably, a Trust’s own property, usually the grounds of the asylum that is to be replaced.

Shifting healthcare of all kinds into the community is one of Secretary Hewitt’s main rally cries these days. CABE thinks it jolly important too. And I think it is too. every time I walk past the brand new retail units near the bus stops, on my way to my GP who hides in the obscurity of the side street. Getting GP’s to offer more. Stay open, and appear hygienic let alone into locations that positively contribute to the officially desired vibrant high street still seems beyond our reach. Unless and until our borough planning departments can find the staff to draw up town centre and neighbourhood plans and design briefs, the fate of community healthcare will be in the hands of property developers. They would love to have healthcare tenants – great covenant, planning gain and a great match with retail because they have different and therefore non-competitive parking peaks. We need less rhetoric, joined-up procedures and some clout to make this real. But if they were to try, my guess is that we would not only get mental healthcare closer to the community, but it would have to be smaller and less institutional too.

Whether a Trust decides it can’t relocate into the community or not, or that it will bring the community closer to it’s MHU’s, which is what Springfield is all about, architects will always be challenged by prior strategic decisions that compromise design options. But like anyone else the architect is only the true hero under fire. But they also have to contend with the medieval dilemma of loyalty to both church and state – today, however, the state bares it’s soul in the church of private finance. Challenge the Hospital Building Note gospels or the 4,500 stone tablets of the Activity Data Base and you can expect the inquisition, Spanish, Swedish or French. It is not only that the money-lenders are back in the temple, but also the fact that planning, briefing and commissioning is now in the hands of tens of thousands of born-again internal market converts.

Creativity

After a year nibbling at salads AfH has finally got back to the meat and potatoes of real building design. What the three schemes show is that it is possible to run the DoH gauntlet and still produce diverse, indeed opposing, design solutions to roughly the same brief. Table One gives the architects’ answers to a short questionnaire I sent them after the seminar. It is a snapshot only, a handy reference when comparing their plans.

The main elements in these schemes are en-suite single-patient rooms (red), group activity areas (yellow), and a variety of offices and consultation rooms (lavender) and one exam / treatment room built to conform with DoH ADB XO 104 – electric shock treatment. ECT may not be medieval in origin but it is without doubt medieval in effect: no matter how benign the MHU décor may be, with or without William Morris touches. Patients must surely know that, just as uncooperative or hysterical residents are called to a chat with Big Brother, they too can be taken on the long walk to hell. ECT is still current. Statistics show that the administration of ECT is really a matter of psychiatrist preference, not patient condition. The question is whether interior design can ever mitigate incipient terror.

It takes one kind of creativity to win a healthcare project, another to design within the parameters, another again to again to make an environment that maintains the pretence that there is no electric hell. I suspect many MHU designers would counter this by asking what they can possibly do to reduce the anxieties of a resident population with such diverse perceptions, obsessions and compulsions, chilled out or hopped up.

It was interesting to hear John Wells-Thorp stress the importance of environmental cognition theories. This, and Andrew Simpson’s citation of Alexander’s Pattern Language, suggests that interest in the way the built environment is perceived is still strong, despite the rise of evidence-only dogma. This is great news because in the big brash world of PFI general hospitals, design theory has been dumbed down to the wow factor.
Woodhaven by Braodway Malyon

Woodhaven by Braodway Malyon

Queen Mary’s by Devereux

Queen Mary’s by Devereux Whether anyone comes forward with a design version of the double helix that allows us to analyze and predict design meaning remains to be seen. Meanwhile, there is a growing body of knowledge to dip into. For instance, a couple of speakers at the seminar said that colour is subjective. I refer them to CHER ¹⁰ who offer a CD on this subject for $35.00. Another speaker said they tried to stick to natural ventilation throughout their schemes, yet Building Solutions ¹¹ reports that MHU patients’ number one complaint is that it is usually too hot and smell too bad, and they can’t do anything to about it, a chilling reminder that good therapeutic environments depend on good science, not just arts and crafts.

Obviously site conditions have had a huge influence on the way a similar brief, encapsulating a similar concept of care, has been translated into designs. Springfield is the latest version of a quadrangle concept that MAAP has been reinventing in a succession of schemes for around fifteen years.

At Springfield itself the urban density of the masterplan and a sloping site have lead to back-to-back quads further complicated by steps in cross-section. The end product appears to exceed the net-to-gross benchmarks, not by accident but because MAAP have lobbied long and hard about the functional merits and therapeutic benefits of their plans.

Queen Mary’s, Devereux had to add the MHU onto the rooftop of a bigger scheme they were already designing. Fitting it all in has meant a tight squeeze, aggravated by the decision to keep it well inboard from the parapet. As I understand it, it was for reasons of privacy and discretion.

At first glance the plan is a potentially confusing labyrinth – the sort of plan that needs lots of signage – but it is in reality a series of gated communities where wanderers will find access denied.

The plan at Woodhaven, a pavilion on a park, is an essay in angular invention, origami on a grand scale, and it’s two internal courts are incidental to the main aim of maxing the views out.

Springfield Design sketches by MAAP

Ospedale Degli Inocenti Florence 1419 by Filippo Brunelleschi Are the differences alone result in different patient recovery outcomes? One of these days we’ll get some post-occupancy evaluation that may show how one works better than the other. It is a marvellous case study for someone like Roger Ulrich to bring CSI Miami into the MHU. Here and now, however, are some observations on the architecture as it has been presented, and a few questions:

Woodhaven is a great example of expressive composition, achieving a rousing crescendo in volume, in every sense. It is extrovert and unapologetically a building that happens to house an MHU.

By accident of siting and because of striking design Woodhaven is a piece of real estate that could, if circumstances were ever to change, be sold off. Re-use is a serious matter for everyone except DoH.

DoH assume that (a) today’s new hospitals will still be in great nick in thirty years time and (b) they will continue to be used for the same purposes in sixty years from now. They approve plans without exit strategies. What are they thinking?

If Woodhaven expresses it’s function in form, what does Queen Mary’s tell us? The general hospital is in safe British brick with discreet residential windows, while the supposedly less institutional MHU is proto-modem white with glass block and the over sailing flat roof comes with modish retro holes. If anyone still has a copy of ‘Ad-hocism: The Case for Improvisation’ ¹² it must be Devereux. Yes, form follows function, but not because they are stapled together.

Finally, back to Springfield: quadrangles are as old as any of our civilizations, but for hospital architects the iconic image must be Brunelleschi’s Ospedale Degli Innocenti. ¹³ It incorporates a colonnaded single-loaded corridor – a perfect place for a contemplative stroll – which creates the gradient in intimacy between the surrounding building and the central piazzetta. The centre must be different. It should be a delight. Creating such a space and then filling most of it in, is a victory for the mundane. Winning dispensations on size, and cost, only makes the mundane bigger. Why why why do I start thinking CLASP? Wow may be dumbed-down but it is still something. The point In architecture is spatial foreplay, penetration and climax. That’s why we build courtyards and why we put fountains in them.

Phil Gusack
phil@gusack.com

1. http://www.mdx.ac.uk – page no longer available
2. Director of Planning at the South West London and St. George’s Mental Health NHS Trust
3. http://www.patternlanguage.com
4. http://www.medicalarchitecture.com
5. http://www.devereux.co.uk
6. http://www.broadwaymalyan.com
7. http://www.swlstg-tr.nhs.uk
8. http://www.nhs.uk – page no longer available
9. http://www.hantspt.nhs.uk – page no longer available
10. http://www.cheresearch.org
11. http://www.mind.org.uk
12. Charles Jencks and Nathan Silver, 1972 (ISBN: 0385016174)
13. http://www.bluffton.edu – page no longer available

Yuli Toh’s review of Value of Landscaping on Health; Facts, Therapy, and Inspiration from UK and Japan, an Event presented by Architects for Health in association with The Daiwa Anglo-Japanese Foundation

Architects for Health’s June Event titled The Value of Landscaping on Health; Facts, Therapy and Inspiration from UK and Japan, co-hosted by the Daiwa Anglo-Japanese Foundation, gave an insight into landscape design through the personal experiences of five invited speakers. The topics and points of view were diverse, intimately presented and engaging.

The speakers were Dr Clare Hickman (Art and History University of Bristol), Jane Stoneham (Sensory Trust), Rose Moore (Blackthorn Trust), David Buck (David Buck Landscape Architects) and Takashi Sawano (Japanese Floral and Garden Designer) – their biographies given separately. Jeremy Barraud, Director of Programmes (Daiwa Anglo-Japanese Foundation) introduced the Foundation and their programme of events; this year on the theme of Demographic Change. Jeremy welcomed the speakers and members and Ann Noble, Chair (AfH) thanked the Foundation for their support of this Event.

The presentations gave different perspectives on the powerful role of landscape as a social and therapeutic tool. The speakers revealed examples of its value, both qualitative and quantifiable. However, the collective realisation that emerged from the evening was how under-valued and neglected this aspect of healthcare design is today.

Dr Clare Hickman was the opening speaker who guided us in a re-examination of our not so distant past and what we appear to have known but lost sometime during the last 200 years; the garden, as a part of a private mental asylum, “was just what they did”. Clare shared with us a privileged resume of her thesis and of her prize-winning essay on Brislington House, Bristol. Brislington House, founded by Dr Fox, was an early institution that pioneered moral therapy and treatment, a shift from physical restraint. It was a mild regime, believing that the patient suffered mis-association and thus there was hope for recovery. The landscape and location of the asylum was very important, as it was a part of the therapeutic regime, including open-air entertainments, exercise and gardening. The asylum building’s windows looked onto walled ‘airing courts’, to literally take the air, which were intensively landscaped with contemporary designs of the day such as snail mounts. But patients were able to see beyond the walls to the wider landscape and were encouraged to go out to physically interact with it. A stroll round this aesthetically designed landscape took one past ferns, grotto, battery summer house (rustic shelter), stones, picturesque Swiss cottage, farm and cliff top walk. By the mid nineteenth century, the asylum is to “command an extensive view” (Isaac Ray) and what you see you can also walk in. By 1872, a public asylum like the City and County Asylum, Hereford, spent money on impressive gardens. Clare’s well illustrated talk engendered from the audience at Q&A many observations on how the present day equivalent institutions are but a poor shadow of the visions and application of our Victorian past.

Our second speaker was Jane Stoneham from the Sensory Trust, where they believe people have a basic fundamental need to connect with the external environment. There are groups in society with no easy access to this, for many reasons such as lack of transport and money or disability, or an emotional disengagement with the outdoors due to lack of confidence, fear or not feeling they belong there. Jane shows an image of a girl with a dog on a patch of grass surrounded by tarmac and with a backdrop of high-rise tenement blocks. It is a bleak but sadly common sight. Landscape has certainly dropped off the agenda, since the nineteenth century. Yet GPs prescribe fresh air as part of healthy living programmes and, with demographic change, our older selves will need landscapes to evolve in response.

So, how do we get that back on the agenda? How do we prove that landscape is good for people? Jane directs us to evidence based research available, including Human Well-being, Natural Landscapes and Wildlife in Urban Areas, a Review by CLE Rohde and AD Kendle, published by English Nature Science. Also, others such as Rachel Hind, Roger Ulrich and even Jamie Oliver in a different context, have shown that evidence exists and have got the issue out for public discussion. Where landscape was an integral part of design, people got better faster and that equated to savings. Jane went on to give examples of many ways to use the landscape; how a park was not used until residents were consulted and allowed BBQs into the evenings, perfect for large family gatherings; how OAPs went on extreme rambling trips; to sitting in Kings Garden, Copenhagen with its spectacular block planting of herbaceous material and good details throughout (that is high capital spend but maintenance low) and to a sensory garden in Osaka, Japan with its xylophone on a bridge.

Jane in her own designs considered therapy within the familiar garden, but the challenge is to translate high maintenance designs into low. She also used conservatories and other transitional spaces, where the indoor and outdoor start and finish was blurred. Hospital gardens also have the physiotherapy element tied-in. In a Cornwall community, when the gardens were in decline the people themselves declined and with the renewal of the gardens they also felt vibrant. Jane concludes by giving the Eden Project as an example of the renewal of a place made successful by bringing people into it, to be a part of it and showing them that change is not scary and can be good.

Rose Moore is a gardener and understands the garden in its most intimate way. She says, “The work is the therapy”. She has been sharing this insight and work with others at the Blackthorn Trust for the last 14 years. Rose explained the idea is to engage with the healthy part of the person and “leave the ill one out of it for a while”. The prescribed work means the patient is a not passive recipient of therapy and the work, from gardening, garden produce, cooking and baking to crafts is all based on nature. The work engages with a group and the wider community, so the patient can forget “how am I?” for a while; “the grace of self-forgetting”. Rose would like architects to think of the garden as having a space and time dimension (that buildings being finite do not have). Nature has her objective laws of ’cause and effect’ and her cycles and rhythms. Although a medical doctor taking medicine away from just drugs started the Blackthorn Trust, Rose does not describe themselves as therapists (though later she concedes to being grassroots therapists). She loves gardening and the cook loves cooking, and with others they provide a secure, safe physical environment for those with chronic or terminal illness. They work with people of all ages, some with mental health challenges, including 16-19 year old who may be excluded from school, to become more balanced and move away from the extremities, through reconnecting with nature. They inherited, from what was the headquarters of the maintenance team of the old hospital, some greenhouses, underground rainwater tanks and a lot of neglected ground. Rose presented images of the work gone into creating the “chaotic but beautiful vegetable field”; the 24hours sponsored dig in the beginning to the harvesting of several metric tons of organic produce annually. The produce ranges from potatoes to herbs, bread baked daily, chutneys and jams. They also run a café open to the public. Rose was interested to hear Clare talk of the nineteenth century therapeutic gardens and felt their work at the Trust had “come full circle”.

David Buck’s talk was titled East of the Sun West of the Moon, named after a Japanese song, presenting ‘cultural coordinates’ in Japanese landscapes. David’s own built work is an exploration of ways to reconfigure traditional Japanese landscapes, which were private and religious spaces such as the temple and shrine, into secular and public contemporary spaces. He was studying at Kobe University at the time of the 1995 earthquake, an event that showed him how nature, trees and open spaces survived and could protect buildings and people and was formative in a positive way to his design for a campus park. Although he claimed it was difficult to prepare for this short talk referring to 2000 years of history, he gave us an accessible presentation using elegant slides of his completed urban park paired with images of fragments of traditional Japanese gardens and representations of gardens, while explaining its traditional significance and his re-interpretation. A folding screen carries a symbolic stylised image of nature, while the self-referential gardens are a series of interlinked spaces with no centre, nor perspective. There is no distinction between us (people) and nature and we are at the centre of nature. A hidden logic or sequence exists. We can enter a space visually, such as a rock garden in Kyoto. Surface patterns are boundary-less and precision in placement of objects can achieve continuity yet on-going change. A most memorable image is of a simple sand mound out-scaled by tall-forested mountains – yet it dominated the space. These are some of the thoughts and visions David evoked in his talk, taking the audience to a strange land yet always bringing them back to a present day application. He stressed that his urban park was a “forum for people to enjoy the changing seasons of nature”. He closed his talk with a quote from jazz pianist Bill Evans “the further you look into the future the further you see into the past”.

Takashi Sawano followed with his talk titled Japanese Gardens in the UK – “why are Japanese gardens therapeutic?” He sought to create a feeling of calm, silence and the “slowing of the senses”. He based his talk on his experiences of implementing two Japanese gardens within the UK and, to an almost disbelieving audience, within NHS premises! The first garden is on a quarter acre in the grounds of the North East London Mental Health Trust NHS mental hospital. Takashi involved all in the making with the “ceremony for the garden”. The ground-breaking ceremony was followed by the naming and tree planting ceremony. He explained to staff, patients, visitors and construction workers that “making was not just physical but important mental way too”. The design of this compact garden was in the form of yin and yo, with 50 cherry trees outside. The patients volunteered to become part of its making, and since, in much of the on-going maintenance. The second garden is in Scotland on 4 acres. Here, he involved school children and the non abled. He used water for depth, movement and sound, such that the blind can touch and the deaf can hear. The dry garden, Takashi explains, is a philosophical mental way of garden, where a rock is an island in a sea of sand, giving calm and peace. The flowering cherry trees are ‘calling’ to the people from early to late spring. Only a short section of wall make up the boundary, the remaining formed of beech trees. The garden is now nearing its 5-year ceremony. Takashi gave his answer to “why are Japanese gardens therapeutic?” by referring to Sakuteiki-Visions of the Japanese Garden. It was written 1000 years ago and remains the ‘bible’ of Japanese design. Takashi designs to the natural ways, nature being his teacher and master, always with and in nature.

During The Question and Answer Section, Takashi answered that Goodmays was mostly funded by a private donation from an individual doctor, with the NHS providing the site within its grounds, 50 tons of top soil and 4 gardeners. The project cost approx £50,000, with design done voluntarily. Maintenance cost is about £2000 per year but with most of the work done by the patients. Takashi chose the site, from 3 he was given, for its possibilities in the spiritual way.

Jeremy asked about the possibilities at The Royal London Hospital, Whitechapel. Opportunities for the creation of roof gardens and small spaces were discussed.

Ann Noble made an observation that today the site location of a hospital is not seen as prime importance for consideration, unlike the examples Clare gave, where getting the site right was vitally important. Jane, for example, has experienced a project sited in woodland where there was pressure to cut the trees down.

Rose was asked why their work was not common knowledge. Rose stated that they have been visited by Prince Charles, community groups, and NHS personnel but not much by planners and designers. They have been called a ‘blueprint’ but Rose asked rhetorically could something, implemented by people who care so much, be repeated. Their work is based on anthroposophical medicine and therapy, with the gardening and farming inspired by those ideas.

A. Murray observed that the NHS is very poor at passing round good practice, as there is no system for doing it.

Jeremy Barraud thanked the speakers for showing us a historical perspective, the social roles, an experience in Japan and implementation in the UK of the value of landscaping on health.

Yuli Toh – Toh Shimazaki Architecture

Conference held on 28 June 2006

Nobody interested in design should pass up a chance to go to an event at Denys Lasdun’s marvelous Royal College of Physicians [RCP] in Regents Park. Unlike many newer landmarks RCP looks better during the day than at night. Those of us at Wilmington’s conference on PFI Hospitals had the added bonus of spending all day in the sheer spatial delight of the council chamber. Originally a Tory formula but now New Labour’s turbo on the engine of UK plc, private finance initiatives have been dismissed by critics as a giant national credit card: buy now pay later. The end that justifies the means is government’s target of 100 new hospitals by 2010.

When my interests first returned to hospital design last year, I was completely out of touch. I finished my last hospital project in 1981. I went to an Architects for Health seminar at the RIBA assuming I would see exciting new applications and new interpretations of the ideas and methods that I had worked on in London, San Francisco and New York. I assumed too that the exchange of ideas across the Atlantic was bound to have increased since many A-list global design firms have thriving offices in London. Instead I was startled to learn that both Northwick Park and Greenwich DGH, the flagships of two completely different ways of accommodating growth and change, were slated for demolition. Margaret Thatcher, I soon learned, had axed funding, cast Howard Goodman’s team out of Euston Tower and , in effect, burned their books.

From the start NHS hospital building was tough going. With the best of intentions, architects still took years and years to design hospitals and contractors, with other intentions, took forever to build them. Invariably they claimed enormous extras. In 1997, I imagine, elderly Treasury mandarins warned Gordon Brown about the bad old days when planning took longer than the lifetime of the government which meant government couldn’t really get much done. What I don’t know is what the mandarins thought about Goodman’s Best-Buy, Harness and Nucleus programmes. Nor do I know if any of this was ever tabled for discussion. If anyone does know, please email.

Anyway this is my take on why Treasury not only insists on PFI but also on contractor-led design-build. It’s an extension of Tony Blair’s ‘tough on the causes of’ rhetoric: an ASBO for architects. No Scottish Parliaments in healthcare!

It’s hard to establish an informed independent overview. At AfH and CABE events I hear architects complain about the rules of the game – they can’t talk to end-users, DoH Activity Data is archaic, and creativity rarely survives the truth-drug of the Comparator. But after 35 years I know that no matter where they work or what they work on, architects always say the kitchen is too hot. Today, however, they are outnumbered by delegates from the public sector. We are addressed on a wide range of topics that illustrate the dark side of development: project credit ratings, consortia contracts, senior debt options and the workings of the Freedom of Information Act. It slowly dawns on me that, after a twenty-year funding drought, and the empowerment of countless trusts / fragmentation of responsibility, the 100-hospital deluge is largely in the hands of first-time buyers.

To complicate matters further, only a few weeks ago new Health Minister Andy Burton who 72 hours earlier had been in charge of design [?] at that other exemplar of numeracy, the Home Office, declared official endorsement of patient safety, patient-focused care and single-patient rooms. On that occasion, the ecclesiastical and academic hybrid architecture of the House of Commons was the perfect place to receive the gospel according to Ulrich. Having realized it no longer had a hospital design experience base, DoH has decided that it’s contribution will now be evidence-based. What I want to know is how many of the100 hospitals are open, on-site or beyond the point of no return, and if schemes now on the drawing board are being designed to be flexible superstructures to facilitate change, which is what we had been doing 35 years ago.

So, as hidden skylights splashed the afternoon sunshine on the flowing council chamber walls, and delegates began to slip away, I put my questions. Ironically, however, it was really my mention of Ulrich that set the cat among the pigeons. Wait ’till DoH launches SHAPE. This is a clinical planning methodology now being developed and my guess is it will present radical new ideas that will shakeup the parts of hospitals that Ulrich cannot reach. Ominously not one person still at the conference said they were actually working on projects that were ‘future-proof’. Is the future of the 100 new hospitals orange, or is it black?

phil@gusack.com

Presented by Architects for Health at Building Design Partnership, 16 Brewhouse Yard, Clerkenwell, London on 16 March 2006.

What was you thinkin’?

Patricia Hewitt took over as Secretary of State for Health from John Reid in May 2005. He moved to Defence. Now, in his flak-jacket, he patrols the far-flung outposts, his mission: to bash local warlords into line and force them to reform. In charge of the NHS, Hewitt’s mission is the same. But has she got the bottle? The one thing she can’t do is tell any of the leaders of the 640 Hospital Trusts, regardless of their managerial skills, that one of them will be fired! If only she had Sir Alan. In my serotonin-boosted imagination Mrs Hewitt and Sir Alan make a good team, Lady Penelope and Parker digitally remastered. But who is Brains? Could it be the guru of ‘Evidence-Based Design’ Professor Roger S. Ulrich PhD? He’s been air-lifted from Texas Agriculture and Mining University to advise the Department of Health. As a result Ulrich has more access and influence on UK hospital design than anyone since 1973 – the heyday of Euston Power – when Howard Goodman ran DHSS Architects, Ceri Davies managed the Harness roll-out and Ray Moss ran MARU. Some of the science may seem, in retrospect, a bit dodgy but transparency and optimism prevailed.

Architects for Health, forged in the embers of Thatcher’s DHSS kristalnacht, acutely aware of Ulrich’s Whitehall Travelcard, finally pinned him down and he presented some of his current advisory activities to them at BDP’s former bierkeller in March this year. Ulrich presents the intricate details of his impressive research portfolio on his web site so to keep it short I am only listing 28 of his published articles:

1. Visual landscape preference: A model and application
2. Visual landscapes and psychological well-being.
3. Psychophysiological approaches to landscape visibility.
4. Benefits of passive experiences with plants.
5. Natural versus urban scenes: Some psychophysiological effects.
6. Psychological and recreational functions of a residential park.
7. View through a window may influence recovery from surgery.
8. The psychological benefits of plants.
9. Human responses to vegetation and landscapes.
10. Recovery from stress during exposure to everyday outdoor environments.
11. Effects of hospital environments on patient well-being
12. The role of trees in human well-being and health.
13. Psychophysiological indicators of leisure consequences:Stress reducing effects of leisure in natural settings.
14. Wellness by design: Psychologically supportive patient surroundings.
15. Aesthetic and control dimensions of health facility design: The case of hemodialysis units.
16. Stress recovery during exposure to natural and urban environments.
17. Effects of health facility interior design on wellness:inhold.
18. How design impacts wellness. Healthcare
19. Health benefits and costs of urban trees.
20. Expanding the boundaries of architectural knowledge.
21. Sensation seeking and reactions to nature paintings.
22. Experimental approaches to the study of people – plant relationships
23. Improving medical outcomes with environmental design
24. Methods for strengthening arts/health research.
25. The view from the road: Implications for stress recovery and immunization.
26. Effects of environmental simulations and television on blood donor stress
27. Effects of viewing nature in intensive care on recovery from brain impairment following heart surgery.
28. A stress reduction perspective on restorative environments.

His presentation was comprehensive, compelling and, like the venue, 100% irony-free. To introduce Evidence-Based Design he explained that medication demands and recovery times of inpatients who had nice views and good early morning sunshine was lower and faster compared with those patients that did not. If this evidence proves that sunrise is better for you than sunset, it might explain why Miami is more fun than Malibu. Sceptics who point out that Florence Nightingale first realized the importance of daylight, but in fact what Ulrich has shown is that half the beds in Nightingale wards are substandard or, not as beneficial as they might have been had they also faced east, all other things being equal. Which demonstrates one of the first law of design research: the closer research is to a commonly held belief, the greater the web of caveats needed to defend the research.

Here in the corridors of power Ulrich is campaigning for the single-patient room. It’s the key to patient-focussed care regimes that render the traditional recovery-stepdown-icu-acute ward configurations obsolete. Iit is better for recovering patients, is easier to manage and as a result, is cheaper to run. Having experienced a number of shared rooms over the last few years, and having only survived thanks to my secret stash of hypnotics and a well charged Walkman, I will support anything that puts an end to sharing. As things stand now, however, many architects complain that their PFI gang masters are unwilling to consider long-term costs and that their insistence on construction budgets is harsh, inflexible and dictates massive compromise. What does Ulrich suggest? Keep trying! I think it would be useful to add something the late James Stirling used to say: ‘…any architect worth his salt must resort to animal cunning…’ Another problem, according to Ulrich, is that many senior members of the medical fraternities voice negative opinions about the single-patient room without any evidence. He’s got every right to be frustrated considering that, thanks to trench-fighters like Mungo Smith and Diana Bass, single rooms were officially approved in HBN 4 nearly ten years ago. So, Roger, welcome to Britain.

In every TV courtroom drama there comes a point when the expert witness blurts out a personal opinion. The vigilant lawyer objects but the damage is done. So I am happy to hear Ulrich promoting single rooms, morning sunshine, more gardens and more art but where is his evidence to support his opinion that PFI is ‘probably OK?’ Obviously he hasn’t been comparing numbers with Dr Allyson Pollack at UCL whose research findings are that PFI only costs more. Nor do I believe he has examined the methodologies applied by Trusts to match resources to health care needs in general and to compile project briefs in particular. If many Trusts are struggling to balance their budgets and, according to the first New Labour Health Secretary Frank Dobson’s revelations that trusts spent at least £50 million last year on management consultancy fees to help them do this, does Ulrich really believe they have the know-how to plan facilities? Does he realize that although there is some post-graduate research work there hasn’t been any international level training in hospital planning and design available in theUK for years? If Ulrich accuses the medical establishment of superstition, doesn’t he realize the science in which PFI projects are built on is really only alchemy?

What Ulrich does give us is the mantra of Patient Safety, and it is surely revitalizing at a time when Lady Penelope only moves when Downing Street jerks her strings and such DH architects as there are the last of the summer wine. He expects Trust reimbursement based on successful medical outcomes, because, whatever the wider consequences, it is the missing link in his scheme of things. The logic of rewarding success would power the investment in all things that improve patient safety, but since this reduces operating costs, the investment in safety is also cheaper in the long run. With it we can design on the basis of life-cycle costs. We could shred the dreaded Comparator and send it’s enforcers to rehab.

There’s no doubt that Evidence-Based Design research is increasingly popular. Perhaps it fills the intellectual vacuum that has existed since adaptability, building systems, long-life loose-fit low-energy and modular standardization were thrown on Thatcher’s bonfire. Moreover many hospital architects in the UK are far too comfortable within the confines of their parochial specialism. My proposition is that there’s a lot to learn about planning, design and construction and fitting-out big adaptable shell-and core superstructures from commercial projects, based on my design experience – hospitals in the US, offices and shopping centres in the UK and Europe, is usually dismissed. Maybe I’m too exuberant or, maybe they are too demoralized. Yet technical evolution in the private sector has been spontaneous, is well-researched and delivers the ‘wow’ factor under time and cost controls as rigorous as any UK hospital project, with or without PFI rules of engagement. Undress Bluewater, for example, and you’ll find a regimented cost-efficient column grid, 5.5 or 6.00m floor to floor heights that enables all electro-mechanical systems to support every conceivable user need in any location. Do any of the PFI hospitals offer similar adaptability?

It’s too early to tell what influence Ulrich will have at DH, but I’m sure he can only add weight to new flexibility set out in last month’s White Paper. I am also sure he is prompting some serious rethinking in AfH circles: we have to revise our agenda to promote Patient Safety, and I’m sure many members will be wondering if we are researching the right things in the best way. With 400 members AfH should not underestimate it’s own potential and it can, if it wishes, take the next step and change from a PFI-fixated talk shop into a pressure group committed to the right things in the best ways. Design Research is not the exclusive preserve of those who have sinecures. We need new ideas, new cooperation, new funding whether from Gordon Brown, Patricia Hewitt, Skanska, Siemens or Glaxo. We should be lobbying for a Health Design Academy and it needs to be on site. I favour at St Barts, amid the rebuild, near halfway between the marvels of St Paul’s and the machinations of the Smithfield meat market. If the Architecture Foundation can wangle a £2 million Zaha Hadid new-build AfH can try too.

Why now? First, because we have an explicit professional responsibility and an implicit moral imperative. We have to re-engage in every aspect of the UK’s health-care delivery system. Second, because it is in our health buildings that over 1 million medical, nursing technical, support and administrative staff struggle to heal another 1 million people every week. And third, because it costs UK taxpayers £5 billion a year to combat cross infection. It’s the hospital war on terrorism, in which MRSA is the Al-Qaeda of bacteria! At over 20 MRSA deaths per million population the evidence proves you are safer without a flak-jacket in a back-alley in Basra than you are in a British hospital bed. As the Apprentices boss would say: ‘So you didn’t do any research and you just followed orders? What was you thinkin’? You’re fired!’

phil@gusack.com

Corridors of
Power

University College Hospital, London

Euston Tower, London

London, 17 June 2005

I take the lift to the top floor of the RIBA. The last time I’d made it past the bookshop off the main entrance was in 1997 when I handed my CV in to the Appointments Bureau but they took one look and said I was just too old. This time I’m going to ‘City Hospitals’, a seminar organized by Architects For Health. Surely this time I won’t be the only oldie.

During the intermission I discover the roof terrace. Across the rooftops there’s a clear view of Llewellyn-Davies’ creamy tower that is the new University of London Hospital at the top of Gower Street. A degree or two west there is Euston Tower, 30 stories of standard-issue curtain wall, once the Department of Health and Social Security Architects and where, thirty years ago, I was a very minor player on the Harness team. It’s a moment of profound nostalgia. But more is to come.

The seminar itself is, like most I have sat through for the last forty years, without serious bite. The trouble is that no matter how intriguing the title or topical the theme, most architects revert to their default settings: adrenaline-free graphics and apologetic narratives. The fact is that after years or even decades of perseverance Dyer and Llewellyn-Davies have designed buildings that are, in the final analysis, much more important than any art gallery or Prada shop. But I am not suggesting that should be exempt from examination and diagnosis. Nor did Ray Moss.

I hadn’t seen Ray Moss since my time in Euston Tower, but as everyone in the hospital design business knows, he was too bright to forget. His response to the presentations of the evening cut to the chase. Thirty five years ago their were two big ideas in British hospital design, both proposed as ways to facilitate growth and change that were the undoing of [arguably] all hospitals. The DHSS idea – long-span deepplan compact and low-rise – was prototyped in Greenwich. Llewellyn-Davies, Weeks, Forrestier and Bor proposed an architecture of indeterminacy in which, in theory, the only fixed element would be a multi-level corridor, departments and wards being attached or, in theory, detached as needed. This was prototyped at Northwick Park. For Ray Moss the real issue is that to this day no study has been made to see which idea worked best. It’s too late now because both are about to be demolished.

Liverpool, June 1970

My undergraduate days have been cut short. Having borrowed the School of Architecture’s brand new video equipment [Sony black and white half-inch reel-to-reel only just portable if someone else can carry the monitor, camera, tripod and extension cables] I end up helping organize a campus sit-in rather than just shooting it.

Along with nine prominent student activists I am expelled. On condition I don’t talk politics I go to work for Victor Basil at Holford’s. He hands me over to a stoic Welshman somewhere in the deeper recesses of the office. Our mission: to revise the door schedules. Our technology: well worn Gillette blades to scrape the India ink off the tracing paper and a well worn thumbnail that’s to burnish the tracing paper before stenciling the revision. It was a way of life. After a month I went AWOL.
The Harness system prototype, DHSS, 1972

Dudley District General Hospital, 1972

London, October 1971

Friends of friends ask me to help them do a job nobody wants to do. I report to Room 503, Euston Tower. Senior Architect Geoff Mayers sets the scene. Government plans for replacement of Britain’s antique hospital stock had been adopted from the Bonham-Carter report that had concluded that the UK needed at least 70 new 1,000-bed general hospitals, each to serve 300,000 people. Without new procedures and technology DHSS doesn’t stand a chance. [Yes, I was thinking, there wouldn’t be enough thumbnails.] The DHSS solution was Harness, an integrated briefing, planning and construction system using standardized department plans in standardized 15 x 15 meter clear-span modules. I was dispatched to Greenwich to see what had happened to the partitions when the long span structure deflected. Many had split. You could see through the cracks into the room next door. I return to base and the task of writing performance specifications for Harness partitions, doors, ceilings and floors. Somehow I managed to spin a three-month contract into two-and-a half years.

VA Hospital Building System, 1972

McMaster University Medical Centre, Hamilton, Ontario

London, April 1974

With the Harness specs finally finished I write my history thesis for my AA Diploma. It’s a history of hospital design theories. I skip through the middle ages as fast as I can: In my version of events it only gets interesting in the Crimea. My main thrust was to set out the pros and cons of the prevailing theories about design for growth and change. I place Llewellyn-Davies and Northwick Park in the red corner and Agron and Ehrenkrantz’s building system for the US Veterans Administration in the blue. I am very prejudiced. First, I had been virtually sponsored by the Harness team. Second, I had gone to Hamilton, Ontario and toured Craig, Zeidler and Strong’s McMaster University Medical Centre. In all the ways I thought were important it blew unbuilt untried untested Harness and the spartan road-to-nowhere of Northwick Park right out of the ring.

Third, I’d met George Agron at a Harness workshop, and he was touting the work his team had already tried and tested in the US.

If McMaster and the VA system made sense, I Argued then something was wrong with Northwick Park and Harness. I drew my thesis to its close with almost undiluted Agron propaganda:

1. Real ability to accommodate growth and change requires full-height interstitial service floors, not crawlspace;
2. Enormous clear spans aren’t really worth it – columns in common-sense places don’t really screw plans up;
3. Compact low-rise configurations are quantifiably more efficient than any other.

Veterans Hospital, Loma Linda, CA

San Francisco, July 1974

I got my Diploma and flew here to join Agron’s team at Stone, Marracini and Patterson on Fisherman’s Wharf. Like DHSS they only do health facilities. Unlike DHSS they do everything from soup to nuts – master planning, functional programming, design, construction documents, equipment specs and construction management. 120 staff coming from 35 countries. Architects and technicians of course, but health planners, nurses, former state administrators and two computer programmers who had to rent time on a mainframe in a James Bond lab downtown.

My mission here is to rescue Agron’s latest research for the VA. What he’d told us back in England about compact configurations being more efficient wasn’t the whole truth. He was convinced but the research hadn’t come up with a working tool to prove it. It had taken them a year to compile a database of 99% of all interdepartmental traffic, people and materials. It was a shoebox of punched cards and it was sitting on my drawing board. The next step was to survey the growing array of machinery that was being sold to America’s 7,000 hospitals. Besides elevators there were dumbwaiters carrying robotic carts, massive pneumatic tubes that would suck bundles of laundry and selfpropelled tote-boxes that rode on monorails. And then we had to write the code and debug the programme. It took another year, a lot of it at night alone with the mainframe praying that our punch cards would take the punishment. We flew to Washington with the shoeboxes on our knees. We presented it, demonstrated it and explained it over and over again but at the end of the week, the VA’s head of research admitted that he barely had enough clout to persuade other architects to use the building system, and that our new-fangled programme could only be offered if the architects they commissioned volunteered to try it.

Back at Fisherman’s Wharf there was good news. Our first full-blown use of the building system, a 400-bed VA Hospital in Loma Linda, a town out on the eastern edge of greater Los Angeles was on site and was starting to accelerate ahead of its construction schedule. We went to see why.

The rationale for the full-height interstitial floor was that it could be subdivided into distribution zones to simplify the installation, maintenance and rearrangement of the maze of ducts, pipes and cables. In the semi-desert of Loma Linda the contractor decided to leave the cladding to the interstitial floors ‘till last. Sections of duct are stacked round the perimeter and are being raised into position by fork-lifts. In some places the entire mechanical and electrical first-fix is complete before the rooms below. In the end the 30-month construction schedule is completed in only 18! Agron’s instincts about compact lowrise are now vindicated by results that no Senator or Congressman can fail to grasp.

King Khalid Eye Hospital, Saudi Arabia, 1878

Hackensack Community Hospital, New Jersey, 1981

Washington DC, July 1976

We have teamed up with Chi Systems, a group of industrial engineers who work as management consultants, and we’ve been selected by DHEW to produce technical procedures and guidelines that the US Government intends to introduce to try to improve facility planning and cut soaring costs. It’s a three-year project. Around the table each firm has fielded its top planners, epidemiologists and functional programmers all brandishing NASA style calculators that use RPN – reverse Polish notation. I reckon that’s what they’re speaking too. I’m only there because I wrote the proposal. I interrupt the RPN and ask if they’ll get around to hospital design in the next hour or so as I want to get some non-conditioned air. They laugh. ‘Next hour Phil’ says Chi Systems efficiency expert, ‘we won’t get that ‘till next year!

New York City, June 1979

Believing that that there may be more to architecture than the height of an interstitial floor I had gone east and joined Ezra Ehrenkrantz who had made the cover of Time magazine because of his innovations in school building in the sixties. He too was working the VA. Somehow he had acquired a mini computer about the size of a desk. My assignment was to start it up every morning. It took half-an-hour. It was loaded with two databases: one was the complete US Census and the other the complete American Hospital Association annual statistics for over 7,000 hospitals. Very simply the computer would compare the two and figure out what a hospital in any given location would need to serve its catchment area. The VA was impressed. Unfortunately for us they were so excited by the Loma Linda pace of design and construction that they rushed to award contracts for all the hospitals they would ever need. I realized that if I was ever going to get anything built I’d have to go undercover into the mainstream where somebody even more junior would do the thumbnail stuff.

Isadore and Zachary Rosenfield, a family business, had been designing hospitals in and around New York for decades. Maybe they never heard of interstitial space but they know all the hospital managers. They know they need to cut costs and. In the field, this means cutting staff. So Zachary has come up with a ward plan that allows them to do just that. Hackensack Hospital is in suburban New Jersey. It’s where the Soprano family dysfunctions. It has approved Zachary’s sketches for a $25 million expansion. My job is to get it drawn, approved, tendered and built ASAP. We work in an unholy alliance with construction managers. It is ‘fasttrack’ all right – in month six we are on site, by month twelve the entire basement is ready for second fix and all 22 tender packages have been awarded. After eight years of theory and one of practice it was now time for something completely different.

University Medical Centre, Warsaw, c1978

Above: What they wore and what they where

Below: The stuff that dreams are made of

London, 26 June, 2005

It’s 10.00 pm on the hottest night of the year. I’m in the London Chest Hospital and I’m here to sleep. The size S ward coordinator [Sister?] has finally managed to stretch a web of elastic belts round my XXXL body that feed data about the expansion and contraction of chest and stomach into an electronic device on my chest. Her exertions create a moment of intimacy. She tapes another sensor to my finger and drapes some plastic tubing under my nostrils and says goodnight. All this kit is to see if I get enough oxygen when I sleep. Sleep? Oxygen? I need a cigarette! But eventually the Zolopicine and John Grisham book on tape do their job and I close my eyes. To sleep perchance to meditate on the realties of hospitals as I now know they are as compared with the ways we thought they should be.

For me this is only the latest step in a regime of diagnosis and treatment that started five years ago in Poland. This is the seventh hospital I’ve been in since then. All of them have obviously grown and changed despite the fact that none were designed to do so. When it first started I found myself in a Meccano bed with a tube from my arm connected to an upside-down bottle of Absolut. The old man in the other bed slept on. I could hear the clatter of clogs and squeaking sneakers ascending and receding in the corridor outside. Once I remembered how, thirty years ago in San Francisco, when the term ‘postoccupancy evaluation’ was something we all thought we needed to do but never did, we got a young architect to do a 2-day stint as an inpatient. He reported that overhead fluorescents were glaringly bright, but he never said anything about the sound track. Listening to the foot traffic became my way of constructing a map of my outside world and from that I could extrapolate a rationale for my place in it. And so I began to reconsider the design ideas that I had promoted in my history thesis when John Weeks, Ceri Davies and George Agron were contenders.

Duty of Care

My father was a GP in Sunderland, most of his patients worked in the shipyards and coalmines. He always made visits. I’d sit in the Jowett Javelin tuning to Radio Luxembourg. He would disappear for what seemed like ages. One day I asked why it took so long. He said it took two minutes to attend to the patient, five to lecture them on the importance of their kids’ education and five more to hunt for the tablets he’d prescribed but they hadn’t taken which he would then wash down the sink. He said his job was to get them better with or without their cooperation. Hospital architects face a similar challenge.

The Best Medicine

The day after they told my Father he had only a few months left to live I went to see him. He was in Ryhope General, an old red-brick maze where he had attended many if his own patients over the years. He insisted I get him into a wheelchair and directed me to push him to a nurses changing room. The nurses knew him well. ‘Don’t mind us,’ he said, as he lit his John Player Special. On the way back he told me the sign of a good hospital was the laughter of the nurses.
‘And how are we feeling today?’

Silence of the Lambs

Even when they are designing for much less traumatized occupants, private homes for example, architects struggle to make their designs ‘fit for purpose’. How much tougher to do this for occupants who are overworked and underpaid or else in pain, shock or fear?

Size Counts

Contrary to what I used to think, corridor length does not make or break a hospital but corridor width can and does. Take a walk down your local gentrified or regenerated high street or a shopping centre and you will see the sort of thing our hospitals ought to embrace. Width allows improvisation.

Art for Pete’s Sake

Art on the walls may or may not be good art but it’s a good way to stop the viral spread of advisory notices and posters that invariably festoon our hospital corridors and waiting areas. Notice boards are nonsense. OK so you have to be careful where you put the Damien Hirst [not in Accident and Emergency] but if we flock in our millions to museums and galleries we should accept there is more to it than an easy way out of dreary decoration.

Landlord and Tenants

Hospital architects probably don’t have much to learn from Las Vegas but they should learn from shopping centers. These days an 8.0 x 8.0 meter column grid supporting 300mm slabs at 6.0 meter floor-to-floor heights is the international norm. They are shell-and core jobs. Landlords offer the floor space and the guarantee that it will be clear up to 4.5 meters. The landlord reserves the right to run ducts and pipes above. Tenants can choose whether or not to install ceilings. Landlords guarantee to supply hvac, water, electricity etc., all on a per square meter basis. It allows for endless change. Large shops can mutate into a series of boutiques and small shops can be turned into big restaurants. It’s more or less what Agron developed for the VA but without the interstitial construction and without the rhetoric. It’s what DHSS set out to do 35 years ago but without the mantra of A, B and C sheets, the technical notes and guidelines and all the other paraphernalia of briefing about which we can only reasonably conclude that without it all the end-products could have been worse. More bluntly, is Barnet General what we’ve been waiting for?
St Bartholomews Hospital, London, 2005

My Favorite Hospital

Last year, my first back in Britain after 16 years abroad, I had the misfortune of being referred to the unlovely inconvenient Barnet General where clinic receptionists social graces and building roof configuration are all pseudo Victorian. Thankfully I moved to Hackney and to St Barts.

What a setting. I walk through Smithfield meat market and past the Plague mound. Barts is a medieval labyrinth of buildings, extensions and additions, built around a small town square. A fountain splashes away in the centre. By all theories of hospital design this cannot work. And I have to admit that, at the beginning, with only a fraction of my optic nerves still working, it was very difficult to find my way around. But it was not impossible. To my eyes the buildings round the square all looked the same so I memorized the positions where the consultants park their cars. Inside I discovered Dr Jamie Cavanagh and his team in the Hematology Clinic and Nurse Carol Willock and her team in Bodley Scott day unit.

At long last I have found the people who will stop at nothing to get me better. Now I know why, in 1945, a soldier who was a patient of my Father came back to Sunderland from North Africa and before he went home he brought his doctor a pineapple.

Phil Gusack, London, July 2005
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