The World Architecture Festival in Barcelona and research projects in Finland, Spain, Denmark and Italy into the design of future health services may not at first seem to have very much in common ..... and what do these topics share with the reform of the banking sector and next-generation fibre networks?

Art & Work

The interplay of the built environment and societal development is a theme that has long been a staple of presentations by urban regenerators, landscape architects, property developers and architectural practices.  The beneficial impacts of art have also been extensively researched in healthcare circles.

There may not always be a positive correlation between design aspirations and achievements but there is more than enough solid evidence to show that the art of place-making can have beneficial repercussions across all aspects of work and life.

In this respect the interconnectedness of things - and their impacts across aspects of society that are conventionally considered in isolation (and the challenges faced by innovators seeking investment and support) - reflects the very same trans-sectoral themes that are beginning to be accepted in policy areas such as utility infrastructure investment in digital access.  Economic fundamentalists may see these impacts as lying outwith their narrow focus but the values of the so-called ‘externalities’ often vastly exceed the costs and returns conventionally recognized at the core of each project.

At the recent World Architecture Festival in Barcelona, the British architect Will Alsop OBE made an impassioned plea for for rejection of the notion that art and architecture were separate disciplines.  His approach seems in some respects like a return to the sensibilities of the Arts & Craft movement and ‘the artistic house’ of pre-war architects like H M Baillie-Scott.

At the same event an international art consultant, Alex Heath, more-often called upon for post-design supplementary or remedial work, described art projects in hospitals that led to reductions in patient hospitalization periods, lower levels of trauma for clinicians and a much reduced use of analgesics.  Similar benefits were illustrated in educational outreach programmes to engage local communities in development projects that would otherwise have been seen only to benefit outsiders.

These and many other architectural practitioners, especially those engaged in urban regeneration, understand the need to garner the widest possible support from across communities - building plausible investment cases through the aggregation of multiple concurrent benefits that would in isolation seem insignificant.

And yet, despite this wealth of experience (and plain common sense) the treatment of innovative proposals by corporate or public planning processes (and policy makers) remains to a large extent locked in narrowly defined regimes of cost justification rather than value creation.

This departmentalized ‘silo-thinking’ convenience is remarkably resistant to open-minded discovery - and a very long way from Will Alsop’s designed determination to resist agendas.  Disentangling ideologies (and economic fundamentalism) from the comforts of departmental convenience is in many ways as difficult as separating the banking functions into its constituent and conflicting components (clearing and casino) or the traditional ‘vertically-integrated’ compacts of digital access and applications services.  Only when the needs and functionality of each individual component are re-discovered is it possible to reconstruct or re-meld innovative relationships between them and add in new components.

Granton sur Mer

This re-melding of motivations and desires can be illustrated by the imaginative and societally-led Granton sur Mer project in Edinburgh.  The community-based voluntary group JUMP (Joined Up Master Planning) has a focus on revival of cultural activity in various parts of Edinburgh’s wider waterfront setting.

Within a short bus ride from central Edinburgh but in many ways a world apart, the challenge is to not treat the scheme’s diverse elements as individual projects but to coordinate these into a larger vision of cultural-led area regeneration.

The complexities of public and private site ownerships, a web of partnerships with widely different priorities and a local community only sporadically engaged in matters of planning, art and design, calls out for patient long-term leadership.  The leadership challenge demands an ability to tease out the benefits for various constituencies and then articulate these appropriately without losing the grass-roots ‘contra-plan‘ approach that reflects a history of local activist resistance to poor quality developer-led projects.

These tensions are not impossible to resolve but, as in so many projects, it takes time and very careful development of relationships.  To keep fresh thinking alive, a course must be steered between perceived authority and a more-subversive approach.   Whilst perhaps not immediately obvious, these place-making challenges map almost perfectly onto those faced by designers of future community health services.

Healthier Communities

Health services in all countries are under pressure - not just from the current consequences of economic recession but also from demographic trends and rapid increases in preventible ‘lifestyle diseases’ triggered, for example, by obesity, smoking and physical inactivity.

Across Europe it is estimated that 77% of the overall disease burden is accounted for by disorders related to lifestyle.  70% of strokes and colon cancers, 80% of coronary heart disease and 90% of Type II diabetes could, in theory, be prevented by better maintenance of healthy lifestyles.

We may be bombarded with health promotion information but, like planning and policy regimes, we seem not to be making a very good job of taking this advice.  And despite a considerable focus on better (more efficient) methods of healthcare delivery, the scale of the challenge is such that more-sustainable innovative solutions are required.  To resolve these issues we need to move beyond marginal improvements (‘doing the same things differently’) towards ‘doing very different things’.

This innovative approach requires new relationships between citizens and their healthcare professionals.  In contrast to long-established dependencies, where health issues are only addressed in reaction to illness, the new approach places citizens as ‘co-producers’ of their health and well-being.

It is still early days for a thorough working through of a transformational approach driven not just by economic necessity but by a stronger focus on ‘quality of life’ issues.  Whereas previous attempts to ‘modernize’ healthcare practice have been driven by cost-saving ‘efficiency’ objectives, the new approach looks to ‘value creation’ with a ‘Service-Dominant logic’. This shift, however, needs vastly greater societal engagement and educational effort.

Waiting in the wings for these innovative needs to be more-widely recognized are researchers probing the potential for new ‘management models’ for primary care and disease prevention.  This work requires a very clear understanding of individuals’ motivations (or lack of them) for their own well-being and identifying ways of triggering and incentivizing more appropriate behaviours.

Not surprisingly the research directions being explored include ideas drawn from the experience of novel digital applications.  Our increasingly digitally-mediated world will inevitably demand better (more open and flexible) local infrastructure provisions and a determined effort to overcome the digital divisions where the least-connected citizens are amongst the heaviest consumers of public services.

In the healthcare environment a key aspect of this work is beginning to look like a teasing apart of the roles of GP’s into their utility and services components in order that they can be re-melded (or, in techno-speak, ‘mashed up’) with a variety of other service components to produce innovative and personalized solutions.

Indeed, as research work has progressed it has become increasingly clear that the promotion of well-being and avoidance of preventable diseases may not be part of any conventional healthcare system.  The researchers in the recent EU Preve project ask, ‘whether we discuss primary prevention as an activity that belongs to the healthcare system or whether we focus on life-style management outside of the healthcare regime?’

This questioning of organizational ‘ownership’ is similar to the views expressed in the recent report from the UN Broadband Commission for Digital Development - a trans-sector approach that is recommended for developing nations as part of the UN’s Millennium Development Goals.  If the case for investment in utility broadband access infrastructure has very little to do with Telco’s then it follows that the same quest for transformational innovation demands much the same reconstruction of how we envisage healthcare provision.

We should all be indebted to the research authors of ‘The Spirit Level’ for highlighting the dire consequences of societal inequalities.  Predictable resistance and knee-jerk reactions to the obvious (often politically uncomfortable) messages around income inequalities and higher levels of distributive taxation are perhaps better answered by paying greater attention to those elements of infrastructure where innovation has been constrained and less-wealthy citizens have not yet been enabled to develop or play a greater part within their own communities.

In discussion last week with researchers at one of Italy’s foremost medical sciences institutions they cited the complexity of the organization of many different specialist faculties as the main factor inhibiting their work.  ‘Real’ breakthroughs’, complained one, ‘only seem to be triggered when we meet specialists from other faculties in the cafe!’  Even in the cleverest of communities it needs the fusion of many different voices and the meeting of many different minds to spark great ideas.

So whether we are making work-places workable, or place-making within culture-led urban developments, or finding fresh approaches to individuals as co-producers of their well-being, or determined driving of banking reform, or realization of the need for digital infrastructure investments to enable a myriad of new locally-relevant service innovations, we are, ultimately, talking about the health and well-being of communities.

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Readers of this editorial also read 'Innovation - the road less travelled?' and 'Disconnected Health?'.

The author attended the World Architecture Festival and the Art & Work Awards in Barcelona and subsequently attended advisory group workshops for the EU FP7 ‘Preve’ project.

This editorial was written for the WAF and Preve communities and as a discussion document for the 'Granton sur Mer' project in Edinburgh, Scotland.