Viewpoint: Phil Gusack on Roger Ulrich’s Personal Observations About Health Care Buildings in the UK

Viewpoint: Phil Gusack on Prof Roger Ulrich: Personal Observations About Health Care Buildings in the UK

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