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Doctors and Architects: Who needs the medicine?

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

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

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

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

Chair: Duane Passman, Partnerships for Health

Speakers:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The following conclusions were made by the panel:

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

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

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