Viewpoint: Sympathy for the Devil

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Opening the Debate on adding healthcare design into architectural education
Architects for Health seminar
London Metropolitan University, 30.11.2006

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

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

Addendum One

Professor Raymond Moss


Ann Noble
Chair, Architects for Health

14 November 2006


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.


Addendum Two

M J Long


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.


Addendum Three

Paul Mercer


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.



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