A review of Ken Worpole, Modern Hospice Design: The Architecture of Palliative and Social Care, London and New York: Routledge, (Second edition, 2024), 188 pp., 50 ills., £32.99. ISBN 978-1-032-30813-5.
Until you have experienced hospices and hospice care at home, as patient, relative or friend, and lived, however briefly, to tell the tale, you cannot fully appreciate what a wonderful, caring service they offer. In a contemporary climate in which the National Health Service is battered, belittled, underfunded, dysfunctional, beset by inade- quate information systems, short-staffing, over-regulation and a culture of concealment, able to carry on at all only through the determination of dedicated doctors and nurses, it is immensely reassuring to find an aspect of the health service which still works, partly NHS-funded, partly local authority, partly through donors and heroic fundraising by enthusiastic supporters.
Here in the modern hospice is Atul Gawande’s Being Mortal (London, 2014) rendered in brick and stone. His ground-breaking book offered a probing critique of the American (and indeed also British) medical-isation of end-of-life care which is not care at all
but treatment to prolong life, often in a manner inimical to the desires of recipients or relatives.
The hospice movement does not do that: hospices are anti-medicalisation. Gawande’s insight was to ask the patient towards the end of life what they want. The answer often is not increasing doses of pain relief to prolong a merely passive existence. It is to make the best, with palliative care, of the time still available.
Hospices do this, emphasising ‘symptom control, pain control and the emotional and spiritual wellbeing of patients and their friends and families’ (30).
Ken Worpole here recounts the development of the hospice movement in a history which often reads like an official report with bullet points.
He is a wonderfully well-informed and sensitive advocate who has been engaged with this subject for twenty years, listing thirty-two hospices and other palliative care centres visited between 2005 and 2022.
This book should be a standard design guide for all architects, local authority planners and others, as well as ourselves, the potential users
of the services provided, hoping for sympathy and support as we limp on towards our conclusions, panting on alongside Samuel Beckett’s Malone, perhaps ‘to the Transfiguration, not to speak of the Assumption’.
This is a new, updated and enlarged edition of a book first published in 2009, designed to take note of new conditions of social care at a time when the over 65s make up 18% of the United Kingdom population, a figure set to rise to 25% by 2046: ‘how to care for people in infirmity in old age is now a major public policy concern across the world’ (6).
Hospices, of which there are now about 240 in the UK, the first being at Sydenham in 1967, along with the 27 Maggie’s Cancer Care Centres also considered in this book, are hybrid spaces, blending the determinedly ordinary elements of home with the inevitable accoutrements of the collective, distancing themselves consciously and effectively from the familiarly bleak long-corridored environment of the general hospital – the humane size, scale and landscape setting of hospices and Maggie’s Centres inevitably gives them an inbuilt advantage over hospitals designed to accommodate hundreds of patients where notwithstanding the notion that recovery is the aim and mortality a failure, the majority of deaths will occur.
In England and Wales in 2018, Worpole reports, 47% of deaths occurred in hospitals, 23.5% at home, 22% in care homes and 5.7% in hospices (leaving a small percentage undesignated). Quoting the Ombudsman report Dying without Dignity, that of the half a million people who die in England each year, three-quarters of those deaths are expected, Worpole takes the peculiarly optimistic view that ‘death rarely arrives “out of the blue”’ (7), but surely 125,000 unexpected deaths is a far from inconsiderable figure with potentially devastating impact individually and socially.
Unlike Maggie’s Centres, which privilege architectural statements by leading practitioners, hospices have a ‘studied neutrality’, a ‘lack of richness of meaning or sense of occasion’ (33), the hope no doubt being, in Worpole’s view, that deliberate neutrality will enable users to shape and colour the building to the ethos they feel works best.
This absence of architectural drama and occasion is perhaps understandable in a multi-cultural society in which different faiths have differing attitudes to death and the afterlife and its celebration or commemoration: best to remain neutrally on the architectural safe side perhaps, adopting a vernacular, neo Neo-Georgian or blandly modernist style, or combinations thereof.
Worpole relates the complex history of the modern hospice movement, setting it in a chart (47) in the context of buildings designed for the arrangement and regulation of society: monasteries, hostels, almshouses, hospitals, hospices, asylums, prisons, health farms and retirement
villages. The majority of people treated by hospices are out-patients in their homes or day patients.
Worpole has found in his extensive survey that for every twenty in-patient beds, there might be 100 day patients and up to 500 other patients in their own homes. So hospices are moving from being ‘an end destination or place of terminal care to an active care and treatment centre at the heart of the community’ and, moreover ‘a model of social sustainability’ with volunteers running charity shops, undertaking day-to-day activities with patients and families, maintaining gardens and fund-raising (51).
The development of the architectural design brief for the hospice is considered at length and a number of case studies are cited. In the author’s
view hospice design has benefitted from the sharing of good practice but too little attention has been paid to post-occupancy evaluation. This
is unsurprising – evaluation seldom commands the same enthusiasm as inception and seldom has the same urgency as realisation; once it’s done, it’s done and the creators move on.
The hospice is a complex building type requiring a balance between medical observation and privacy, accommodating the needs of patients, visitors, staff and volunteers. Sometimes requirements are in conflict – it is for example easier to maintain surveillance on a ward than on a private room but this comes at the cost of a loss of privacy for the patient. In an open ward it is easier for nursing staff and indeed other
patients to raise the alarm if one of their number is in difficulty.
There is a necessary trade-off between the potential intimacy and privacy of the architectural space and the need for observation as well as for potentially intrusive, clearly non-domestic medical aids such as hoists. How the room is viewed by its primary occupant is an important and often overlooked consideration.
Worpole refers to the patient lying prone (supine is more likely): after a period of illness, Alvar Aalto was able to inform his innovative design of the Paimio Tuberculosis Sanatorium in Finland (1929-33) through his experience of horizontality, realising that rooms tend to be designed for the upright user rather than the person lying flat whose eyes are drawn consistently to the electric light fitting as if permanently in the dentist’s chair.
As well as the form of the building and the disposition of the rooms, there is the question of location. Worpole provides a useful table of the
advantages and disadvantages of the inner-city and the rural, contrasting accessibility, tranquility, distance from medical services, familiarity of
surroundings, staff retention, costs of land and so on.
There is no simple answer to the question of the ideal location, or indeed ideal form. Four exemplary case studies are used to inform the
discussion through demonstrating and illustrating the diversity in contemporary care provision: a new hospice in Eastbourne, St Wilfrid’s, with twenty bedrooms and a distinguishing ‘street’ open to all; Lark Hill Retirement Village, Nottingham, now the largest in Europe with 327 one- and two-bedroom apartments; the Appleby Blue Almshouse in South London, completed in 2023 in which the residents are encouraged to remain active in the community; and the new non-residential Maggie’s Cancer Care Centre in Southampton with an integral garden –
Worpole later devotes a whole chapter to the long history of attaching gardens to places of healing and spiritual care, citing Sarah Price, the landscape architect at Maggie’s Southampton who has avoided fixed or static elements, preferring ‘trees, plants and shrubs which emphasise flow, change, shifting patterns of light, the impious movement and sound of small birds, and the shock and drama of sudden rainfall or strong winds’ (154).
Worpole’s fine book concludes with a chapter on ‘The evening land’: how can design ‘shape a sense of privileged ritual and ethos’? (163). Hospices offer ‘as much as a quality of space … a quality of time’ (174) – recalling T. S. Eliot: ‘at the still point of the turning world’. Although hospices are no longer places of inevitable no return − there are day patients and there are home visits – they remain places where many will die so there is a need for a secular architecture ‘rich in presence and a sense of occasion’ (170), providing a setting for spatial and temporal harmony in which we might hope (in Worpole’s closing phrase), ‘everything that matters and mattered in life is gathered in’ (175).
JOHN BOLD
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This review is republished here with kind permission of author John Bold and The Journal of Historic Buildings and Places, vol 04, 2025.
Ken Worpole (born 1944) is a British writer and social historian whose many books include works of literary criticism, architectural history, and landscape aesthetics, and was one of the editors of the 2001 United Nations Centre for Human Settlements (UNCHS) report, The State of the World’s Cities. In 2005, The Independent newspaper stated that: “For many years, Ken Worpole has been one of the shrewdest and sharpest observers of the English social landscape”. In 2014, ICON Review similarly observed that “For well over 40 years Ken Worpole has been one of the most eloquent and forward thinking writers in Britain”.
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