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The future of the NHS depends on how we design for birth, death and everything in between


Paul Finch’s letter from London: There has been little attention paid to converting parts of homes into space where the ill can lead a civilised existence

Visiting a major London teaching hospital recently, we were told it was not possible to use the striking staircase that runs up the hospital atrium because of ‘health and safety’.

Apparently some poor soul had taken a dive from one of the landings and now only staff can use it. I asked whether it would still be open to visitors if a member of staff had been the diver, but was met with a blank look.

This story might be a metaphor for how we discuss the NHS and the relationship between supplier and users. I remember with some fondness my student years when I spent each holiday working as a porter at Westminster Hospital (now converted to luxury apartments).

All human life was there, and it was my first introduction to both birth (as a theatre porter at a couple of caesareans) and to death (helping prepare bodies for visits by relatives).

Technology has changed, but the hospital atmosphere, and that relationship between the system and its consumers, has remained pretty constant. Now, as then, for both patients and visitors, the human interaction with nurses and doctors is crucial and the medical kit taken for granted.

There still seems to be huge admiration for the NHS as an idea and as a principled approach to equality of healthcare, but grumbles persist about the details of delivery on the ground. This is not helped by the mind-numbing mantra that the NHS is ‘free at the point of delivery’, when that is also true of private healthcare paid for by insurance.

The challenges facing the NHS, however, have little to do with the detail of who does what and whether it is better to, for example, contract out cleaning. The big picture is about demographics and funding. Given the welcome but unnerving fact that the proportion of the population comprising old people is rising, the success of the NHS is guaranteeing that care of the elderly increases substantially, simply because we can keep people alive longer today.

No matter that the NHS spends most money on most people in the last 18 months of their life; it would be politically impossible to deny people treatment when they have paid for it all their working lives via National Insurance, the world’s biggest Ponzi scheme (there is no record of the money you and your employers have paid in).

Curiously, how to treat older people so that they enjoy a decent life during their final few weeks has attracted little discussion in relation to architecture. Maggie’s Centres are a magnificent example of an initiative to change both attitudes and physical environments for cancer sufferers, but they are noticeable for being an exception.

You might have thought that hospices would by now have been given more attention, as a civilized half-way house in the final days, when most people say they would rather be at home than in hospital. But then, nor has there been much attention paid to converting parts of homes and apartments into decent spaces where the ill can lead a reasonably civilized existence.

Instead we have focussed on massive centralised megastructures that the PFI hospital programme has largely comprised, producing buildings that are in some ways inferior to 19th century precedents. Tomorrow’s medicine is about home treatment and miniaturisation of technology.

This is a far cry from the current debate about the future of the NHS; but like its buildings, that will need to be determined through a process of design.


Readers' comments (2)

  • You are correct, insurance paid health cover is in a sense 'free' at the point of delivery, provided you can afford the premiums. That is a big 'provided that'. It makes the comment both unpleasant and ignorant. The USA spends 16%of GPD on health and the UK 8%. Their health is governed by the charges made by the insurance companies. Do you really want that here? With all the hardship and unpleasantness that follows. Do you want to see people saving up for a heart operation?

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  • That was meant to be GDP of course.

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