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.

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.

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?

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
phil@gusack.com