Design for Care

The prime minister’s ‘clear plan’ to fix social care is as clear as mud. Cross-party talks to find a political consensus have not happened. The pandemic may explain the government’s behaviour but it cannot excuse it. There was leisure during the crisis to reform the structure of the NHS. Yet there has been no time, apparently, to re-design social care. Covid has cruelly exposed failures in public policy for care. Sadly, some of these have proved fatal. The political adage ‘never let a crisis go to waste’ has not been applied here.

Reports and recommendations come and go. They focus mainly on money. This is understandable. As far back as 2013 there were 29 million Google searches annually for ‘How do I pay for my care?’ The fear of having to sell your home to pay for care has not gone away. The pandemic has merely increased anxiety. Young adults are still afraid they cannot contribute to the cost of caring for frail, elderly parents and relatives.

As the British economy staggers to its feet the political challenge is to find the right balance between additional taxation and private investment. Both will be necessary to fund a national care service adequately. But cabinet ministers fear what happened to prime minister Mrs May. Her 2017 election care plan bombed. It was dubbed the ‘dementia tax’. She lost her job.

If you think social care reform is expensive, consider the political cost of getting it wrong.

But it cannot just be about money, even though the cost (estimated to be between £8 billion – £12 billion annually) is gargantuan. Anxiety also focuses on the quality of care, on who provides it and in what physical circumstances. The current system defies common sense. Why does ‘healthcare’ end, only for ‘care’ to begin? Don’t they overlap in practice? Isn’t dementia (which affects many elderly people) also an illness requiring treatment? Hasn’t the pandemic taught us that hospitals are for people who are ill and which are best avoided if you are not?

The trouble with common-sense is that it is uncommon: healthcare is provided by the NHS and social care is dispensed by local authorities. The money comes from different pots and councils make their own decisions. Not surprisingly, there are wide variations across the country. Improving national standards is likely to remain elusive so long as many care services (including home care services) are subject merely to ‘light touch’ regulation.

As the number of people requiring care rockets, we surely need to work together to design something better as well as calculate its cost. Yet ‘Design Thinking’ hardly suffuses public policy. The civil service and members of parliament are deficient in both scientists and designers. A decade ago, I instigated Design for Care at the Design Council. This programme investigated new services, products and processes in health, social care and well-being. It was intended to be provocative. But it was also premature. It pre-dated the global explosion of digital design, invigilation technologies, modern methods of construction and care-focussed local applications. These can transform services and help improve the performance of care workers. The need is urgent: since Brexit carers are fewer in number and no better paid than before.

Design for care begins (as with all good design) in a spirit of improvement. The design mantra ‘form follows function’ is nonsense. The universal reality is seldom admitted. This is that form follows failure. Observation of what does not work invariably leads to better design. From twisting bridges and inflammable buildings to Apps with glitches, better design learns from gross faults and minor deficiencies. It makes things safer, more intelligible and sometimes (if we are lucky) more beautiful.

Those who are conceiving the proposed national care system in parallel with the current national hospital system should admit the design failures under their noses. They should also reach out to other sectors. Why is housing policy not allied formally to healthcare? Supported living, with care spaces built in, can help reduce hospital admissions on the part of vulnerable adults, especially those with learning disabilities. And why do many new care home buildings and extra care facilities still resemble sealed containers lacking in fresh air and natural light? In the pandemic through which we are still living, surely granting such planning permissions is unconscionable?

Matt Hancock, the health secretary caught in flagrante delicto, promised at the last general election ‘40 new hospitals’ by 2030. No figure has been put on the cost of this programme, which was nonsense then and remains so now. Instead, we know that £2.7bn is to be spent by six hospital trusts by 2025 on ‘refurbishments’ and £100m is ‘seed money’ for hospitals to ‘work up detailed plans’.

If only we knew what the plans were. None has been published. How can the government begin to link health and social care except by a radical re-assessment of current assets? Take healthcare. Since the 1950s the dominant architectural model for hospitals has been the ‘tower on a podium’. This idea was imported from the USA. It is exemplified in the design of St Thomas’ hospital opposite the houses of parliament in London. St Thomas’ is a maze of corridors and wasteful circulation spaces. Their unintelligibility increases as one penetrates to the centre of each floor.

This ‘deep plan’ design model has been repeated everywhere in England. More and more beds were needed in those days because patients stayed for longer. But recovery times have nowadays reduced markedly, while many ‘elective’ or non-urgent procedures can be done on a day-case basis.

The badge of competence we now need for any new hospitals is the opposite of the old model: we should design them to have fewer beds. We still need them to deal effectively with ‘hot’ (that is, surgical) functions and other critical processes that may require admission. But most other activities can be devolved to less expensive premises that more resemble hotels and offices. In this model, a hospital ceases to be a public building which anyone can enter and wander around uninvited.

If only we bothered to look at the good practice that exists. In planning ’40 new hospitals by 2030’ the NHS does not appear to have learned anything from the architect Norman Foster’s outstanding ‘compact’ hospital in Bath for healthcare group Circle. This was completed a decade ago. Today it treats NHS and insured patients alike (the present author declares an interest as a former employee). In this hospital Lord Foster answered brilliantly a fundamental question: why are care and treatments delivered in expensive spaces that depress and crush the spirit?

Just as living is about more than merely existing, so well-being is about more than merely being well. Design for care is not over. It has scarcely begun.