I spent more of last year than I would have liked in hospitals. Once you become ill and enter the system for treatment, a general assumption seems to descend that your time doesn’t really matter any more. You have placed yourself in their hands and you subject yourself to humiliating, boring and often painful rituals in which you become in effect powerless. You are supposed to know it is for your own good so you subject yourself.
It is an extremely peculiar situation in which you feel suddenly physically vulnerable at the exact time you are most traumatised. Days seem to go by in plastic stacking seats and sticky easy chairs, waiting in claustrophobic booths, perched on the edge of benches and beds, always waiting for blood tests, for nurses, for doctors, for results.
The bad news was given to me in a room the size of a Photo-me booth, with my wife and myself leaning precariously against a day-bed and a bunch of doctors lined up against the wall about a foot away looking morose.
During a gruelling but not unbearable course of chemotherapy and a major operation I had a little too much time to observe and think about the spaces I was in, the furniture I was on and an architecture that can seem, when you begin to think about it, very little thought about.
After months of exams and scans, of being passed into and under huge, incomprehensible machines, and after a deluge of blood tests, form filling and drug taking I lay, for almost a fortnight, in the well-equipped ward of a big, relatively new hospital with sweeping views over the rooftops of London and an impressive barrage of grand, generous public art. And I couldn’t see any of it. For most of my stay my world was contained between two, non-matching flowery PVC curtains. The art was in the public areas, the atriums and the corridors, so that everyone who came to see me told me how lucky I was to be in such a lovely hospital, with such a good view and all that art.
A year before, my wife gave birth in the same hospital. She was in a ward of about the same size but more tightly packed, as perspex cots were squeezed between the beds. Exhausted, the crying of new-borns kept her awake all night. This is how we embark on that momentous and emotional event in our lives, the birth of a child.
Hospitals are where we celebrate our most intimate and touching but also our most harrowing and emotional moments. They should be among the most important and profoundly symbolic spaces we inhabit yet instead they are largely the result of dim bureaucratic decisions, penny-pinching, unquestioned orthodoxy and, at best, average planning and architecture.
Neither is the private sector immune, even if its buildings do have nicer colour schemes and private wards. Anyway, many private patients find they end up in the National Health Service when really serious illness hits.
Now is the time, with the biggest hospital building programme since the foundation of the NHS under way, to be debating the healing power of architecture and experimenting with the case for space. Just how much difference can architecture make to health?
It is an intriguing question and one that is probably unanswerable. The scientifically ideal experiment, to take a thousand patients in varying states of illness and put half in decrepit cesspits while the other half wallow in spacious, well-designed luxury would be both unethical and so obvious in its outcome that we hardly need bother. Yet surely that’s the point? Healthy or sick, we would all rather be in well-designed, light, clean, beautiful spaces enjoying a cocktail of privacy, views and fresh air.
Much detailed research has been done recently on office accommodation; on the effects of architecture on staff, on performance and on profit. In every instance it could be shown that workers respond positively to decent architecture and that as a direct consequence they feel happier, are able to work harder and more productively and, here’s the headline, profits rise. Ergo office developers are now hiring the finest international architects to lure in the customers, to give their new developments an architectural unique sales point.
Hospitals on the other hand, which are extraordinarily specialist and complex structures compared with even the most sophisticated offices, are being left to contractors, with architects reduced to relatively impotent members of a larger private finance initiative consortium. The architects I have talked to tell me that architectural quality is pushed to the peripheries and where it appears it is used sparingly in the design of atria or lobbies or some extravagant façade treatment to give the hospital a public face, a purely cosmetic exercise to show where some of that almost incomprehensible sum of money might have gone. The government is building hundreds of new hospitals, only a handful of which have any architectural value.
The argument against decent public architecture is one of cost. It is true that hospital buildings are hugely expensive to construct, far more so than offices, housing or even luxury hotels. But they are even more staggeringly expensive to run. Compared with the day-to-day costs of running a hospital, the capital expenditure is piffling, yet it is at this stage, and this stage only, that the opportunity arises to do something with the building itself.
One fundamental problem with the whole process is the brief. Doctors and nurses have been excluded from the process and, as bureaucrats take on more power, they become seen almost as a nuisance, an obstruction. Managers like to communicate with other managers. While
some regional offices of the NHS had built up formidable reputations as bodies of expertise and design capability since their foundation in the idealistic postwar period, these were dispersed during the outsourcing and reorganisation of the Thatcher years, leaving local trusts with little knowledge of how to formulate the critical brief without which good architecture is virtually unachievable. Specialist architects are still around, some still making efforts to design good buildings, but they are scarce, stressed and often unconsulted.
The basic problems are obvious. Patients would like private rooms, now standard in France, for instance. The argument is that private rooms would cost too much. In fact they don’t cost significantly more, as the costs of hospital construction are embodied largely in the complex services and specialist equipment. Furthermore, the development of drug-resistant superbugs would seem a powerful incentive to the provision of individual rooms.
The rationale behind communal wards was visibility and ease of response. The traditional Nightingale ward of 36 beds was created by the Lady of the Lamp herself, a big unit in which a small number of stretched staff could survey the patients efficiently and relatively comprehensively. The size of the wards shrank but the principle of communal space stayed the same and remained guided by the need for vigilance and surveillance. But the reduction of ward sizes actually led to a reduction in privacy. Just as there is a kind of anonymity in a crowd, there is a kind of privacy in a big room. This disappears in a space containing six or eight beds. Everyone and all their visitors remain constantly audible, if not visible.
The only control over privacy levels that patients are given – and that only at certain times – is the PVC curtain, the drawing of which means that the nurses lose visual contact with the other patients anyway so everyone may as well be in a private room.
But perhaps the reason people want a private room most of all (whether they admit it or not) is an en-suite bathroom. People like their own bathrooms, particularly when they are infirm or prone to infection.
It is these mundane details and the prosaic components of the building with which we interact that are so crucial, from beds and bedside tables to easy chairs.
Why can every US car and every UK multiplex cinema seat have a cup holder but hospital furniture cannot? In most hospitals, even new ones, the feel is of a neglected nursing home. Furniture and fittings are mismatched and seemingly random. Efficiency and function do not necessitate bland and institutional. All these elements need to be addressed by manufacturers, specifiers and product designers.
Then there are windows and views. While it is not possible to position every hospital in the sylvan sublime, research has consistently shown that a view of trees or landscape can aid healing. The construction of courtyards and internal gardens is an architecturally fine solution that aids ventilation and light and allows patients access to fresh air without leaving the embrace of the institution.
One figure bringing architecture into the debate is the influential critic Charles Jencks, whose wife, Maggie, died of cancer. Her widower has made it a mission to commission, in her memory, an extraordinary cross section of the world’s architectural greats to build “Maggie’s Centres”, buildings that serve as nonclinical support centres for cancer patients and their families.
Jencks gave Frank Gehry (architect of the Bilbao Guggenheim) his first UK commission for a sculptural Maggie’s Centre in Dundee. Zaha Hadid is building a centre in Fife, Daniel Libeskind (the increasingly sidelined architect of Ground Zero in New York) is at work in Cambridge and Richard Rogers is about to start building the first Maggie’s Centre in London.
Jencks’s achievement is a scintillating and extremely worthwhile experiment in the role of architecture in healing but it is slightly peripheral – these are non-clinical centres not subject to the rigorous demands of large hospitals. It is also entirely due to his charm, influence and the memory of his wife that these trophy architects (I say that in the nicest possible way) become involved in these schemes. Health trusts are unlikely to be employing starchitects to construct their brand spanking new super-hospitals under the Private Finance Initiative.
This is, of course, ironic. Rogers’s monumental Terminal Five scheme at London’s Heathrow airport, to use one hugely complex example, is on budget and on time, unlike so many hospital schemes.
There is nothing new in the idea of architecture as a healing aid. Historically, hospital buildings have played an important role in defining a city, in expressing the philanthropy of royalty, clergy or wealthy patrons and in using art, architecture and design to inspire, or at least make dying a bit less traumatic.
Foundling and leper hospitals in the west date back at least to the sixth century and were first attached to churches and cathedrals. By the middle ages grand infirmaries had become not only a religious injunction but a source of great pride for the orders that usually established and tended them.
In the Renaissance the greatest architects were employed from Filarete’s delicate Ospedale Maggiore in Milan to Enrique Etas’s Hospital Real at Santiago Compostella and stunning Hospital de la Santa Cruz in Toledo that kicked off the 15th century in spectacular style.
The following century saw the construction of Paris’s Hôtel des Invalides and two of London’s finest public buildings, Sir Christopher Wren’s Chelsea and Greenwich Royal Naval hospitals.
Hospitals also became a key proving ground for radical modernism. Their very public and humanitarian agenda of health and efficiency perfectly suited the ideals of the new movement. The motifs of modernism; clean, unadorned surfaces, rational planning, generous natural light and ventilation, and lots of white rapidly became de rigueur.
More than anything the architects of modernism were fascinated by the sanatorium, a building type dedicated solely to the healing power of place. Josef Hoffmann’s Secessionist Purkersdorf Sanatorium (1903) outside Vienna and Alvar Aalto’s extraordinary Paimio Sanatorium in Finland (1929) are among the most significant products of the movement’s history. The tradition has been upheld by Herzog and de Meuron, the Swiss architects of London’s Tate Modern and almost certainly the finest architects working today. Their recently completed Rehab centre for spinal cord and brain injuries – which has to deal with the traumas of the recently and profoundly disabled – just outside their home town of Basel, is one of the most heartening and touching buildings I have seen.
Its modest timber façades give way to a series of delicate courtyards, each subtly different in colour and foliage, which make the building easily navigable and bring light into its core. Rooms for bedridden new paraplegics feature transparent domes in the ceilings affording views of the constantly changing sky to those who would otherwise be looking at nothing but the ceiling.
Britain too has its history of a radical architecture for health. Berthold Lubetkin’s still-functioning 1938 Finsbury Health Centre (slogan: “nothing is too good for the ordinary people”) is a much-admired experiment in light and space dropped into the slum fabric of one of London’s poorest boroughs. It looks like an alien object now, inserted into a sea of pastiche housing and quaint streets; it is hard to imagine what an impact it must have had in those drab inter-war years.
From that position of radicalism, from a period in which research and the pushing of intellectual, constructional and aesthetic boundaries was taken for granted, we find ourselves in an era in which hospital design is seen as a Meccano amalgamation of standard components and high-tech machinery, the building reduced to an envelope and a series of anonymous spaces demarcated by their label on a plan and the skeleton requirement to house a certain quantity of equipment and services.
Accessible city centre sites are being sold off for development while new amalgamated super-hospitals are being built like out-of-town malls in dreary, ill-defined locations with neither the benefits of the rural or the urban. While the old hospitals and asylums are developed into lofts, the unique opportunity to use this astonishing programme of architectural construction to give coherence and civic and public character to our increasingly privatised cities is being lost.
I remember designing a house at architecture school and one of my tutors telling me it looked like a hospital. I was delighted. I could think of no greater paragon of functionalism, of cleanliness and light, and sheer, unadulterated practicality.
I should love hospitals but instead during my treatment I found my heart sinking each day as I pined for the view that was just beyond my reach, for the natural light blotted out by those flowery curtains, for furniture that should have been as elegant as the tubular, modernist archetypes with which I’ve populated my flat.
Our culture is increasingly informed by what have become known as non-places – malls, car-parks, airports, cloned high streets, grindingly dull offices. These are spaces and places that reduce us all to zombies, shopping, travelling and working beneath fluorescent strips that suck the life out of us.
In hospitals both the sick and their relatives are at their most vulnerable. Putting them in buildings that are at best bland and ill-considered, at worst ugly and actually harmful is the design relationship of a placebo to a proven drug.
There are some signs of the recognition of the importance of design in health. The Evelina Children’s Hospital, opened earlier this year at London’s Guys and St Thomas’s, designed by Hopkins Architects, is an extremely visible structure culminating in a glass roof over its capacious atrium. It is atypical but nevertheless an example of what can be achieved. Kids were consulted throughout the process and everything, even the design of nurses outfits, was considered.
If any buildings deserve the full attention of architects, product-designers and artists, then those buildings are hospitals, which should be among the finest, most thoughtful and most affecting spaces we encounter. These are buildings that we, as an ageing population, will be spending much more time in. This is our chance to get them right.
Edwin Heathcote is the FT’s architecture critic. He would like to acknowledge the help of Ann Nobel of Ann Nobel Architects with this article