Dispensing with the proviso....

For a long time healthcare architecture has been seen as the poor relation of other building types; a field of design endeavour that’s struggled to provide as uplifting environments as those created for other human activities. A new health centre or hospital that was the best of its type would be pronounced ‘good, for health’.

But recent healthcare developments are competing with the best of any sector and winning! The Alex, a children’s hospital in Brighton by BDP was, in 2008, the first healthcare building to win the Prime Minister’s Better Public Buildings Award. This month, the Maggie’s Cancer Caring Centre in London, by Rogers Stirk Harbour + Partners, won the coveted RIBA Stirling Prize. The shortlist of just six buildings also included the Kentish Town Health Centre by AHMM - this building was noteable on the list as only one commissioned within tight UK public sector budgets. Elsewhere, Stobhill Hospital in Glasgow, by Reiach and Hall, won the Architecture Grand Prix at the Roses Design Awards against competition from around the UK.

There is no proviso on the achievement of these buildings. They are good architecture; they are good... for your health.

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Skills Shortage

As Simon Foxwell points out in his peace for the RIBA Journal this month, the modern public sector client is advised by a myriad of design experts - both employed directly by the client and indirectly by advisory bodies and through the planning system - very few of whom design the final scheme. He estimates that more that 15 architects will play a part in a BSF (Building Schools for the Future) project before it gets to the Planning stage.

I’m clear that most clients expect architects to draw for their supper and do not always see the value of external advisors questioning the work of their architects... I certainly have some sympathy for this if the employment of the advisors is reducing the budget for the designers and builders to do the real work. The reaction of the development’s designers, as one might expect, is infinitely varied.... In general the response is positive: seeing advisors as either preparing the ground for a better project; as fresh eyes on a design helping them get the best outcome, or providing comfort to the client or planning authority on the merits of the scheme. Indeed, I was surprised to lobbied by a pair of architects (not usually known for breaking out in violent agreement) that I should be on the judging panel for designer’s appointments to all NHSScotland projects.... However others are less comfortable with the involvement of other design professionals in an advisory role, particularly if the advice provided questions their proposals.

For these reasons clients often look for the advisors to be unquestionably superior to the employed design team, either to ensure that the advice provided is authoritative or that their design team take heed of the advice...

...personally, I’d prefer the best design hand to be holding the pencil...

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INTRODUCING..

... A Vision of Health ...

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This is the culmination of 3 years work, and represents the embodiment of the NHSScotland's future development agenda.

Big news is that an assessment of design quality is being made part of the business-case approvals process - i.e. the decision to spend is linked to the quality of the proposed development!

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Launched by Nicola Sturgeon MSP you can download it now.

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I'll let you into a secret...

....not all architects are great designers.

As in all walks of life, different people bring different gifts...

...many architects will design you a building by drawing simply what you ask of them, but probably little more. They will do this with great technical competency. They may have great skill in detailing or be wonderful at brief development, but they are not great designers.
...others will design something good if you let them, encourage them and even give them a wee push now and again.
...but a very few are pure alchemists and, almost without fail, will create a thing of beauty. These designers however are not always great communicators, some can hardly speak without pen and paper on which to sketch their thoughts...

So what sort of client are you? Do you want a basic box that does not leak but neither does it uplift your spirits? Will you encourage a team with potential to get a happy result? Or are you ready to have your preconceptions challenged? As one of my design champions said when presented with a scheme that was unexpected but with some potential ‘ just because we’ve always bought a hoover, it shouldn’t mean we can’t consider a dyson...’

The trick as a client is to be able to distinguish between the talents on offer and build a team that has all the skills you need, as they are all valuable. Some architect’s firms have a balance of these skills, others are dominated by one. It’s so much down to the people you get – so make sure you know who you’re buying.

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Creativity and Certainty

I’ve been working on mapping design into the business case process; a process defined for NHSScotland by nearly 200 pages of text. A process that seeks to quantify and analyse and in doing so to narrow down the range of possibilities to one certainty that best fits the initial aim. It is a linear and rigorous process. Design, or more specifically creativity, is often seen by clients as dangerous in this – an unpredictable spark that cannot be relied upon either to arrive or to be helpful if it does. An uncontrollable element, advocated by ‘maverics’ that probably hold their own artistic interests above those of the project.

This perception is often reinforced by designers. I once attended an interview where we were asked how we would guarantee a good design. My colleague responded that developing a good design was like throwing a double six, and the trick was to throw one sooner rather than later. You can imagine we didn’t get the job. Architectural education – the act of sketching furiously, waiting for the muse of inspiration to bless your hand, and the subsequent examination of the design by ritual criticism and demolition – does not equip Architects to describe their thinking and their value in a way that clients can understand and find comfort in. Some of the good designers I’ve worked with recently almost distrust the ability to describe design in such terms, feeling that it’s probably more possible for those who cannot themselves design.

However designing is very much like the business case process – first you imagine what you are looking to achieve and test that this is possible. You then move on to sketching a limited number of possible worlds that, to varying degrees, will house and support your needs. By analysing these and making choices you narrow the options down to the world that you will build. You get the best result by using skill and a wee spark of creativity to make every element work hard to deliver more than one part of your vision.

The apparently opposite poles - of clients needs for certainty and the designers talent for creativity - are not so far apart. As with economics, or the business case process, design is... the intelligent application of a scarce resource.

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Protective measures

The design of a new public building is a human endeavour, the result of which effects many people – as such it is often complex to progress, to keep all interested parties happy with the progress, and to communicate the intent of the project. However, for someone outwith the delivery team it is remarkably simple to form an impression of the project – a perception of how good it will be and what it will mean to us. As with any human endeavour what most people respond to is an honest intent; the recognition in response to what is done, said and - in the case of new building designs - drawn that the people in control are seeking a truly beneficial outcome.

Three years of working with the public sector clients has shown me this honest intent is much more prevalent than I’d dared to hope. So why is the public impression so different? Could it be the habit of approaching public servants with suspicion (both of their motives and competency) is, in part, causing just the secrecy, bureaucracy and defensive engagement that engenders these suspicions. Our attitudes and actions are, in part, the cause of the defensive stance taken by many public officials....

Though somewhat contrary to current media preoccupations, I do wonder if process and accountability at any cost produces real value... One of my recent ‘heros’ pondered, after a soul sapping procurement process, if it would not have been possible to cut out 80% of the process (and with that the cost) and only loose 20% of the auditability... A bit of trust, respect and an honest and open intent in both directions - seeing the fellow human - could get us much further.

A cautionary quote comes to mind “argue for your limitations and sure enough they’re yours”.....

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NEW PUBLICATION

A+DS publishes 'Case Notes : Client Leadership'

This publication celebrates the clients behind some of the most successful healthcare buildings recently established in the United Kingdom and learns lessons from their hard work and leadership. Each client has delivered award-winning buildings, places that lift the human spirit and support our wellbeing; healthcare facilities that embody the ethos of the NHS and offer its users an ‘Architecture of Hope'. Copies can be found here

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What price excellence?

Achieving excellence in the private sector can and often does bring rewards; the opportunity to charge a premium for your product, to sell more or build a market advantage. For the individuals involved it can mean a monetary reward in addition to the recognition of a job well done. But it is not so everywhere...

For some in the public sector, achieving excellence is to attract attention that is not wholly welcome (some particularly close scrutiny for example) and presents greater difficulty in the future to demonstrate the incremental improvements that are the staple sign of good performance. For the individuals involved it probably does not bring greater remuneration but, almost undoubtedly, triggers additional work as people flood in to see how it was achieved.

People working in the public sector are generally more motivated by the benefits they produce for others than the financial return for themselves. Therefore to motivate these people to produce excellence we must, as a minimum, value the impact of their work on others and reduce the cost they pay for having produced this benefit.

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A shot in the arm...

Having worked in all three sectors I can testify that they each have their own frustrations and barriers to achievement. However the public sector, perhaps due to size and complexity, can make those barriers look insurmountable. Factor in procedures and structures that channel concentration and energy towards meeting the detail rather than the spirit of the issue and you’re a good way towards a culture where independence (and personal responsibility) of thought and action can be viewed as a high risk business. Even free thinkers such as MPs have been known to blame the system rather than their part in operating, or taking advantage of, it....

So it was a real boost today to go to a talk by someone who takes the core intent of the public sector and makes the system (in his case a PPP system) work to deliver on that promise. Richard Glenn, a project manager of nearly 30 new hospital buildings and now Project Lead for Alderhey Children’s Health Park, takes a transformational view of hospital developments. What I mean by this is that he tackles these complex projects by taking a real leadership role that not only keeps the ‘future patient’ clearly in focus but also seeks to transform clinical practice, aspiration and stakeholder perceptions through the development of the brief and the design.

At a previous project, ‘the Alex’ in Brighton, he brought together two groups – a children’s board and a group of what he calls his ‘young turks’ (clinicians who will go on to be senior staff members during the life of the new hospital) – to influence the development of the project and, in doing so, to form the basis of the culture and operation of the new service. Through this enthusiastic and honest engagement (which necessarily included frank discussions where ideas could not be realised) with these key groups the project achieved what many re-provisions struggle to – to transfer the affection and loyalty of the hospital community, and with them the broader public, from their previous magnificent, dilapidated and overstretched Victorian pile to a new home elsewhere in the city.

At Alderhey he has used design based tools such as ‘Enquiry by Design’ to engage the whole local community in planning changes that will effect local parkland, play spaces and pedestrian routes. In doing so the project has developed broad community support and a momentum of its own which, to paraphrase, would require a very brave politician to stop!

Richard’s mode of leadership is not one of lock-down, top-down control but rather to establish an environment where others feel they can make a difference. This is not to say that he abandons personal responsibility but that he sees that responsibility as being the person that clears away barriers; and having now heard him speak with some candour I can imaging the sheer force of personality that is employed to do this. This then gives space for those people responsible for making the hospital work to concentrate on what really matters – the creation of a joyous and optimistic place for children and young people.

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Who trains the trainers?

Now as a person whose job it is to advise people this is a interesting issue for me to talk about, but a fair few times recently I’ve been to training events where the experts brought more barriers than solutions. The two that stand out relate to experts in the judicious management of a development project...

Ever the optimist, I’d thought that experts in procurement law and project management might have a view on how to achieve a better outcome from the processes.... but when asked about incorporating, benchmarking and assessing the potential quality of the product both shied away and exhorted an auditable concentration on various readily measureable elements that have no lasting benefit for the building owners and users. One such expert enticingly offered up a wee workshop on determining “customer quality expectations (CQE)” - those factors that determine what the project needs to achieve - and defining the “acceptability criteria” that reflect these. Great stuff if he hadn’t then refused to address the primary CQE as he could not see a numerical way of defining it!

In both my recent disappointments the expert’s focus was avoiding claims, not getting a result you’d actually want; one which is worth the effort and expense. With such messages being relayed across the country it’s no wonder that overstretched and underappreciated people often choose simply to follow the advice given in the training their leaders have bought and paid for. ..

Perhaps, instead of helping client bodies gain the confidence to value what they aspire to, we should instead be training the trainers not to undermine what good clients have set out to do...

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Only human....

Firstly let me introduce one of my colleagues – Sam. No he's not the guy in the picture, but a fellow blogger.... By reading across the blogs that I’ve provided links to at the top of my page you’ll get a good feel for the type and complexity of issues we tackle in improving the built environment in Scotland.

In Sam’s piece on measuring design there’s a critical element of measurement that’s missed – the fact that those doing the measurement, and selecting the scheme or the team, are human. Despite our best endeavours and the most rigorous and objective, even soulless, selection processes; at some point the client must choose the work of one human being over another and that choice is influenced by the confidence and comfort the client has in the team they select.

Though seemingly against current conceptions of a fair process this element of measurement which we do subconsciously, and even unwillingly, can bring benefits. The most successful projects often happen where there’s a meeting of minds – a client and a designer who share a vision and can work skilfully together towards realising it. Clients often attribute the success the project to just such relationships “they knew how to really listen to us and understood what we wanted” . The soft skills to work through a project, to develop and maintain a constructive dialogue, are much prized by clients. However they’re not often an explicit part of the measurement they undertake.

From seeing a number of bidding processes from both sides over the past years two things have become clear to me.

• Client teams should make explicit how much they value ‘soft-skills’ in the selection process and rank them in relation to the design skills that are needed to translate an understanding of the client’s requirements into a successful or even a great outcome... “they not only delivered what we asked for, but also many things we didn’t know we hoped for”.


• Designers with the skills to deliver a great environment sometimes need to work on their communication skills. To come across as difficult is often to force clients to make up their mind between someone who may deliver a great building, but looks to be a pain to work with, and another team who listens attentively and reflects back to them their hopes and desires.
  

Given such a choice it’s hard for many clients – even if they can see a clear differentiation in the design potential on offer - to bite the bullet and take the higher hassle choice in the hope of a better outcome - they’re only human...

Ironically, a tool designed for measurement, AEDET (the NHS's toolkit for measuring design quality), has been shown to have a greater value in facilitating a constructive dialogue between client and designer. One of NHSScotland’s Design Champions, Dennis O’Keeffe of NHS Fife, showed in his recent research project that the true value of AEDET is in bringing people together to talk about what they need the building to do and how the design can realise that. This work-shopping contributed more to the quality of the outcome than using AEDET solely as a measurement tool.

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Fat in the system

The planning stystem grew from the realisation that the built environment – the size and proximity of houses and their relation to sources of pollution – affects public health.

Watching ‘the hospital’ last night brought home the epidemic we’re facing as our children become increasingly obese; and the impact this is having on the NHS – the increased workload on staff who are tasked with helping. But there are hidden implications too – hospitals are having to plan to build wider doors and stronger beds and hoists to deal with the new field of bariatrics - the science of obesity. Despite the pressures for apparently easy fixes the NHS cannot offer a gastric band to everyone – and many of us would not want to live out our lives without a proper meal – so can planning help us out of this public health problem too?

Well the way we’ve built our towns – with suburbs a car’s drive from anywhere – has clearly been a significant contributor to this growing problem. We now have to have special initiatives to encourage children to walk to school, where once it was the obvious and probably only option. We need special festivals to reclaim the streets and change a traffic island into a place to meet and socialise. Once children would have played there daily...

How we build is a reflection of how we want to live. It influences - for better or worse - how we feel about ourselves and the life choices we feel are open to us. Our built environment is again determining how well, and how long, we live. But don’t take my word for it – the Chief Medical Officer for Scotland, Dr Harry Burns, has called on the development industry to tackle these issues and be the “vaccine for the 21st century” .

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To Dream...

As a motorbike rider, universally known within the Health Service as an ‘organ donor’, I’ve a vested interest in the NHS working really well. As an architect, I fundamentally believe that the design of our health estate can help our nurses and doctors in their work and help me feel better when I have to go there, and I’m happy to say that the NHS in Scotland believe this too.

But travelling the country - those conversations you have on the train or in a taxi - I’m often met by a feeling that nice hospitals are just for those who go private or even that nice buildings get in the way of clinical function. One person argued with me the length of the country that we shouldn’t be spending money on new hospitals, but on the drugs that offer hope to many...

This is the false dilemma that faces NHS Boards commissioning new facilities. They know that much of the old estate is getting in the way of modern care – of moving the service closer to the community; they understand how the built environment effects the morale and motivation of clinical staff and the wellbeing of patients, and that better, more efficient buildings can free up resources to use directly in patient care. However the development of a new hospital or health centre is not always greeted by the public as a welcome opportunity, but with the defence of the old and a suspicion that the board will waste money and take too long... all attention turns to cost and programme.

In this apparent dilemma is where my heroes work, seeking ‘the impossible dream’. Day in, day out, they work to consult and keep happy a myriad of stakeholders, political masters, auditors and advisors who all want to see their interests given prominence through the procurement, in an audited and accountable fashion – under constant press and public scrutiny – within a system that one such hero described as ‘treacle’. In such an environment some struggle to deliver a place that will offer hope – but some struggle on to do this for us. They do not get the sympathy the public reserve for nurses and doctors, in fact they’re often overlooked. But today I offer them a wee (borrowed) tribute – inspired by my love of bikes – “to dream the impossible dream”

The flip side of this is we need more heroes. Audit Scotland’s recent report identified a shortfall of estates professionals that is looking like worsening as many retire. Perhaps as many architects and other building professionals are joining the dole queues, some might want to take up the role of hero in a sector that’s investing in real change.

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