Design and Health World Health Design

Dialogue: Advanced Warning System

From left: Chris Liddle, Lord Crisp and Prof Per Gunnar Svensson debate the importance of
'early health, not late disease'

Nigel Crisp and Chris Liddle go head to head and agree that global human health requires a research-based approach to design that supports the concept of ‘early health, not late disease’.

Leadership is many things but most of all, in the words of management theorist John Adair, it is the manifestation of practical wisdom, consisting of a powerful blend of intelligence, experience and goodness. Upon meeting Lord Nigel Crisp (right), my deep impression was of a character who not only possesses these special traits in abundance, but has also earned the right through thoughtful professional endeavour and an alert political radar, to deploy them on issues of global significance.

What leadership is not is indifference. Each time I meet with leading social architect Chris Liddle (below), I am reminded of Elie Wiesel’s millennium address on the ‘perils of indifference’. It is an accusation that could never be thrown at Liddle, whose passion, enthusiasm and desire to make positive changes through the medium of design sets him apart.

As I walked back past the UK’s Houses of Parliament following my appointment with Crisp and Liddle, I considered how the dynamism of their relationship might unfurl in architectural or health management form and, at the same time, began to understand a little more about the power of an interdisciplinary approach.

Lord Crisp: "The most pressing needs in developing countries are for balanced and integrated health systems."

Crisp consults to Liddle’s firm, HLM Architects, but as a description it does little to reflect the real value of their relationship, which is defined by a shared passion for improving human health and well-being. But they share much more too, not least an understanding that health is a global issue that requires local delivery. Since leaving the NHS in early 2006, a cornerstone of Crisp’s work has been as a government consultant on issues of international health development, which included a report published last year on Global Health Partnerships and the UK contribution to health in developing countries1.

Health statistics show a stark contrast between the developed and the developing world (Figure 1) and Crisp says that cultural, economic and political differences must be considered in decisions about how local health systems are organised and what services are delivered. “The most pressing needs in developing countries are for balanced and integrated health systems with an emphasis on public health and primary care, not hospitals and tertiary care, although these have their place.

Providing healthcare to a needy population with an average total expenditure (public and private) of $36 a person each year – and a range going down to around $5-$10 in parts of Africa and India – is very different from providing for an affluent population in a developed country. “There are also cultural issues – things are done very differently in different countries. You simply cannot apply UK methods and behaviours. This is not about giving people a UK product, but about a process of working together to meet a need.”

There are some common issues too, however, that Crisp says characterise the economic, social and physical interdependencies of a globalising world, upon which national health systems and policies in the 21st century should be founded. In particular, he identifies three core themes: early health, not late disease; patient and public involvement; and knowledge, evidence and standards.

Early health, not late disease
The concept of ‘early health, not late disease’, says Crisp, encapsulates public health, health promotion and educational concerns. With the management of symptom-based, advanced diseases reported to consume 70-80% of healthcare resources, Crisp says it is an approach that makes economic as well as clinical sense: “The earlier you can tackle a problem, preferably before it starts – and that’s about stopping smoking rather than dealing with cancer – not only are the patient’s chances better, but the costs are also reduced.”

He points out, however, that there is nothing new in this theory. “If you study Florence Nightingale’s prescriptions for health in India, where she spent 30 years of her life working, she said, ‘you need to sort out the land tenure issues; you need clean water; and you need to get on top of the economic issues, as well as focusing on the clinical issues’.”

Liddle: "Health is no longer just about hospitals. We need to think of the world
as a joined-up system."

Our thinking needs to consider the entire social and economic sphere, agrees Liddle, and not just healthcare. “Health is no longer just about hospitals. It’s about how primary care plays a much greater role at the front end in our schools and in the community, and how cross-sector design projects can deliver this.”

“We need to think about the world as a joined up system – about education and health systems, rather than schools and hospitals,” says Crisp.” In the UK, there are some excellent examples of sensible health screening of children in schools that breaks out from a mindset that confines healthcare provision to the hospital setting.”

He adds, however, that the importance of an effective interface between health and education is a lesson we can learn from the developing world. “It’s a case of designing fit-for-purpose health systems based around the patient’s needs,” adds Crisp. “If you look at what children die of in Africa, an immunisation programme based in a primary and community care setting is far more effective than a brand new modern hospital.”

Involvement and participation
“We’ve moved from a world where we did things to and for people, to a world where we do things with people, or they are doing it for themselves,” says Crisp. “The creation of health is a shared responsibility. Diabetes patients receive two hours of care a year from health professionals and 60 hours a year from themselves, but if they don’t take their jabs, the professional aspect isn’t worth doing.”

Central to this idea in healthcare is the concept of the patient journey, which is a critical paradigm change in healthcare planning from the technically-driven perspective of clinical pathways. “The patient journey is an approach that is based on the idea that patients will require care from more than one place, service or health worker,” explains Crisp. “Care may be received from the GP, the acute sector and tertiary care.”

From an architectural perspective, it’s about how you design the physical environment to respond to, facilitate and support the patient journey, says Liddle. “And it’s not only about medical services, it’s the whole hub-and-spoke environment of social services, schools and the community.”

One of the tools Liddle uses to involve end users are patient and prisoner reference groups in the design of healthcare and custodial facilities. “It’s a great responsibility to try and make a place that people will enjoy as a positive experience, and it’s a great comfort as a designer to listen to people talk about their personal experience of being in a hospital or a prison. I firmly believe that, as designers, the closer we can get to the point of activity, the better architecture we will create.”

Lord Crisp: "Health systems need to create the evidence through the task of research and evaluation."

Knowledge, evidence and standards

The third core theme common to all health systems, says Crisp, is the development and practical application of knowledge, evidence and standards. “We live in a world where there is so much knowledge available. In many parts of the world, we come across similar projects with excellent results but one of the most striking things was the lack of learning from each other. While evaluations are being done, there appeared to be no means for the systemic and rigorous spread of good practice.”

Health systems, adds Crisp, need to consider within a global context how to firstly “create the evidence through the task of research and evaluation” and, secondly and equally as important, how to disseminate and “make the evidence available in ways that people can use, as a means of sharing and learning from each other across national, institutional and language barriers”.

How you derive the evidence from a rigourous approach to research is the key, says Liddle: “People often shy away from research, believing it to lack a foundation in reality. We need to demystify the value of research-based design, because there’s a lot further to go if we can build on what we already know. Our patient and prisoner reference groups generate many interesting design ideas that we believe will work, but where can we try them out? Where is the space for research-based design?”

Crisp adds that dissemination of knowledge and evidence is also about how people learn. “Everybody likes to reinvent their own wheel. In the NHS, we introduced a programme that targeted accident and emergency departments to see and discharge patients within four hours.

Liddle: "We need to demystify the value of research, and build on what we know."

But the patterns of use in a large teaching hospital are very different from those in a small district general hospital, so we invited five different A&E departments to report back to each other on how they addressed the same problem of reducing waiting times in a process that we called ‘assisted-wheel reinvention’. The result was they learnt faster, reinventing their own wheel more quickly.”

An interdisciplinary approach to research-based design, stresses Liddle, can be a foundation for how we make places that support health and well-being. But, says Crisp, there is still a big issue about raising the importance of design, particularly within health management. “Why should I pay attention to the value of design? There is still an argument that needs to be won to engage thought leaders and decision-makers, about the economic as well as the clinical value of good design. Because, that’s what we’re in the health business for – quality and value for money.”

Marc Sansom is editorial director of World Health Design


1. Crisp N. Global Health Partnerships: The UK contribution to health in developing countries. London: Central Office of Information; 2007.

Lord Nigel Crisp
1986 General Manager for Learning Disabilities in East Berkshire 1988 General Manager and Chief Executive of Heatherwood and Wexham Park Hospitals
1993 Chief Executive of the Oxford Radcliffe Hospital
1997 Appointed South Thames Regional Director of the NHS Executive
1999 Appointed London Regional Director
2000 Appointed Chief Executive of the NHS and Permanent Secretary at the Department of Health
2003 Received Knight Commander of the Order of the Bath (KC)
2006 Awarded Life Peerage

Christopher Liddle BA (Hons 1st Class) dip ARCH(dist) RIBA ARIAS FFB
1969-76 Educated at Sheffield University
1976-78 Architect, Roth & Partners
1978-80 Design architect, Jack Bonnington Partnership
1980-82 Chief Architect, Hassall Homes
1982 Associate, HLM Architects
1994 Partner, HLM Architects
1999-08 Chairman, HLM Architects
1969-02 International Lecturer - Architecture & Design
1989-08 International speaker PFI/PPP
1984-08 Recipient of Civic Trust, RIBA, Conservation and Urban Re-generation Awards


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