- Good afternoon and welcome to the Architecture for Health Lecture Series.

My name is Ray Pentecost and we're glad to have you with us today.

We're continuing our semester-long emphasis on international aspects of practice, in particular healthcare architecture and health design for health architecture.

Our guest today is joining us from the UK.

So let me give you a brief introduction.

I had the pleasure of meeting our guest speaker today, John Cooper, during some of my international work with an organization based out of Sweden.

And we became acquainted and have been able to stay in touch now over many, many years, a relationship which has led me to having a great deal of respect for our speaker.

And so it's a special treat to have his voice in the studio today.

John Cooper has been practicing now for some 37-plus years as an architect, and more recently, I want to tell you about the recent history and why he is such a valuable voice to this event today.

John set up JCA in 2009 and his practice has done work in, are you ready, listen up, in the UK, Ireland, Switzerland, South Africa, Iceland, Australia, Kashmir, and Palestine.

Now, that's enough to give him an international perspective and that's what we're seeking for this lecture series.

He's led government report panels and provided peer review on major projects in the UK, Ireland, Australia.

He clearly brings to this conversation an international perspective, and that's what we were seeking.

He's a regular speaker at conferences in the UK and overseas, written for lots of major architectural journals.

He chaired Architecture for Health, Architects for Health in the UK from 2009 to '14.

Still active with that group, by the way.

And he's currently the program director for the annual European Health Design Congress.

I was recently in London for that event.

John led in many of those discussions and panel activities, and if you were there, you know this, but if you weren't, I wanna let you in.

John is one of the more masterful managers of panel discussions and group discussions that I have ever witnessed.

I really was struck, and I've told John this.

This is not something out of school.

I've told John what a wonderful job I thought he did.

And that comes because he understands the subject matter and he knows how to lead those discussions and offer the leading questions.

So with no further ado, John Cooper.

Please help me welcome him.

(audience applauding) - Unmute me.

Ah, I'm now unmute.

Good afternoon.

It's an absolute pleasure to be here in London.

It's a very mild autumn night.

Now it's dark outside and I'm gonna talk for 40 minutes on working abroad.

Okay.

Oh, why is that?

As Ray said, it's very interesting what Ray said.

It's as though my life flashed before me.

It's really quite worrying, but here I am, of an all-too-elderly an age.

Working abroad.

The blue dots are places where we've been paid to do some work albeit build buildings in all of those places.

And the green dots are where we've bid for work and have proved to be unsuccessful.

But there's a fair degree of coverage of the world there.

I'm not gonna dwell on, you can look at our website to see the sort of work which we do.

Needless to say, I've designed a lot of health hospitals, healthcare buildings, laboratories, and other such buildings.

The one on the top left was very interesting.

We were the only non-USA finalist in the Kaiser Permanente Small Hospital Competition, oh, 10 years ago, and it's a long way to go to San Diego for a 45-minute presentation.

We weren't successful, but I got to see the Salk Institute at La Jolla and that made that very much worthwhile.

Right, what I'm gonna do, these are today's topics.

I don't like reading out a PowerPoint and you can all read, so that's really what I'm gonna cover, and if there's a recording of this, you could go back and see what the framework for this presentation is.

Right, I think that those of us in the UK and those of us in the US of A are good travelers.

I think we, wherever I go in the world, there's somebody from the States and there's somebody from the UK, and I think we do that well.

We're helped because we both have a strong soft power culture in that I think the world pretty much knows quite a lot about UK culture, American culture, popular culture, and that in film, television, advertising, architecture, and the creative arts, we are the preeminent, dare I say it.

Having said which, we should be wary in a way in that in the UK, let us not forget we had an empire of some consequence.

And you can, it's a very political thing, you can argue that it was a good thing for a number of countries, but equally, you can argue that it was brutal, in some cases racist.

And there are a number of places in which it is remembered and not remembered with a great deal of fondness.

Similarly, it has to be said, and let's be honest, in the States that you have a legacy of intervention in a number of countries in which governments have been toppled and interventions have been made, so that we both have a dark side, if you like, to our presence in the world.

Whether or not, I'm not being a politician here, both Johnson and Trump are very popular, were very popular in both countries, but they don't travel very well, actually, if you go abroad.

Having said which, our preeminence in science and our experience in healthcare more than trumps that so that wherever you will go in the world, I believe that you will have a strong hand in any discussions, presentations, or bids that you make because there's an awful lot of evidence behind whatever it is you are going to propose, present, or design.

I think it's very important to look at what is the healthcare context at the moment.

You can see from this slide that the call for papers for next year's European Healthcare Design Congress have gone out, and this year the strap line, the headline, is Fault Lines and Front Lines, in that it's quite clear that climate change, flood, drought, fire, moving climates, moving people, and moving animals, moving insects, moving diseases, is making the whole of the world a less, or a more volatile place, and that, too, so that is a real issue.

And also that the pandemic, COVID, has reminded us that communicable disease has had a triumphant return and is more than likely to strike again.

So it's a very volatile world within which, those are the strap lines, the sort of six key areas that we talk about and have talked about for the last six years are all to do with planetary health and population health, where you manage health systems, and the traditional pyramid of the sort of base as home and pinnacle as tertiary hospital is now inverting, and I'll come to that in a moment.

Obviously, we've got to do climate-smart healthcare and I think that the thing which I've been interested in most of my time as a healthcare architect is to re-humanize healthcare architectures as much as we can be and base it on wellbeing, identity, and dignity, as much as technical...

I take technical expertise for granted, should I say, that we should know what we're doing.

And the paradigm shifts of the last 15 years are the climate crisis, are the digital revolution, which in a way COVID catalyzed.

You know, it's said in 10 weeks things changed more than they had in 10 years.

And that all of these things need to get built into the architecture which we practice and which we can demonstrate and present abroad.

And in a way, this is, and on the left is 20th century medicine, where you have the base, which is home, and then the top, which is tertiary healthcare.

And then in a way you can invert that in the information age, where we would like as much self-care to take place as possible, enabled by digital means of managing and healthcare communicating, and that there are networks, again, enabled by social media, to enable us to support ourselves, going through to obviously community, secondary, and tertiary care.

I mean, it's a bit of a polemical diagram, if you like, but I think, too, we must also acknowledge that the relationship between the patient and the clinician is changing and has changed.

Also, we have to address climate change.

We have to create a circular economy in which we minimize the amount of carbon in a building, in the building of the building, in the running of the building, and the repurposing of that building.

And currently we're working on a project in Wales, in the UK, where we've got a very, very low carbon content.

We're using timber.

We're using materials like hempcrete, lime plaster, breathable paint to maximize wellbeing and minimize carbon in that building.

And I think that wherever you work in the world now, that has to be an essential part of what you do.

And what's interesting is that, it has to be said, in the past that the architect, with or without a black cloak, would create a diagram for a building, and then at some stage down the road, the engineers would become involved in a call and response way.

You can't do that anymore.

In a low-carbon design economy, the engineering and the construction of a building have to be considered as integral parts of any diagram, I would suggest.

And, you know, we've got architecture and then we've got landscape architecture, and I would suggest that they are as one, and the added value, certainly in healthcare, that a proper and a real embrace of nature is a fantastic thing that adds value to the design of a building, and, again, is an international value.

And I would, this is a provocative slide, if you like.

On the left is, I can't remember where this is.

It's in the States.

It's a new building.

You may or may not know it.

I've forgotten who designed it.

And you have on the right the Renzo Piano, one of the three hospitals they're designing for Greece.

And to be honest, if I had to present one of these to a prospective client, there's no doubt I would present the building on the right, the healing, the Renzo Piano building.

The one on the left is to a certain extent mechanistic.

It's on a freeway.

It's kind of quite hard-edged, angular, mechanistic, as I said.

Whereas the integration of nature, the low rise, obviously the solar roof makes the one on the right immediately, for varying reasons, a more interesting proposition.

And I was appalled at the Congress, which I helped to organize, that this building won last year's Big Hospital of the Year award.

I think it's everything that I find old-fashioned about hospital design.

It's assertive.

It says that the hospital is a machine and that you become subjugated to that machine.

I would say it's quite a foreboding building.

And I find those squiggly things on the left-hand side to alleviate the really rather tedious nature of the elevations.

Appalling, plus the fact that as in all plinth and, you know, the matchbox on the muffin, the ward blocks above patient towers, above the plinth, it's very difficult to reuse this building as anything other than a hospital.

You could make it a conference center, but I doubt it would work.

It's eminently not really reusable.

And one of the interesting things from, well, I'll come on to that in a moment.

I was talking a moment ago about people taking it for granted that if you're invited to work in the developing world, or even the developed world, or certainly the developed world, it's taken for granted that if you're pitching for a healthcare project or you're discussing it, that your expertise is taken for granted.

They've gone onto LinkedIn, they've gone onto your website, they've looked at it, they've talked to people.

They wouldn't have come to you if you hadn't got a degree of knowledge.

To which extent, they're not looking for the assertion of knowledge.

They're looking for a wise and talented partner who has the knowledge to take them further.

And what was interesting in Rwanda, which is a strange country in which to work...

I have to say, Kigali, which is its capital, is the greenest, cleanest, safest city I've been to in the developing world.

It really surprised me.

There are obvious downsides to Rwanda, but it's as though a country, as you know, there was an awful genocide there, had looked into hell and decided they didn't really want to be there and kind of reformed themselves.

What they were interested in is leapfrogging 20th century medicine.

In the image on the left is a drone, which is delivering pharmaceutical drugs to outlying districts because the roads aren't very good.

75% of Rwandans have mobile phones and they're banking on these.

There's some health insurance on these.

So they're looking at ways in which they can leapfrog the investment in large-scale bricks and mortar to create a network that will be inherently cheaper and more appropriate for a society such as theirs.

So lesson one, I mean this is the boring bit, if you like, if you're gonna work abroad, you've got to make sure you know where the country is that you're gonna work in.

You've got to have done your homework: the economy, the commissioning culture, and good and bad points.

If you are in healthcare, and this is a lecture which is about designing healthcare buildings, what's very interesting is that clinical cultures differ from country to country, and in so doing, the design solutions for those clinical cultures differ.

In the States, you can have hospitals with carpets, ceramic tiling in the bathrooms.

Neither of those are considered appropriate in the UK, although ceramic tiling is, I mean, I won't go into that, but for instance, the design of theater design is very different all over the world and each country thinks they've got the best sort of solution, and they all differ, and they all have good points and bad points.

So there are no absolutes, and therefore it's unwise to assert that there are absolutes, because they're not, that's not always the case.

There are some social, cultural absolutes, which I'll come to.

Talk to people who've worked there, obviously, and realize that there are significant risks to working abroad.

We've just about to start a project with a wonderful firm of architects in the UK.

We partner with everybody 'cause we do front-end work.

And they had three large projects in Russia and, of course, you know, the Ukraine invasion, those go up in smoke, you know, and everything changes.

Several architectural practices I know quite well went bankrupt as a consequence of bad debts from working in various places in the world.

So there are risks involved.

I remember, before Ireland joined the EU, we were doing a project in Ireland, and the Irish punt, their pound, went down in value against the pound so that the fee, which was in punts, meant that basically all the profit was wiped out sort of on day one of the project because of this currency shift.

The most important thing when you're working abroad is to have a local partner who's the right one.

That's essential.

And it's essential that you know there's a responsibility matrix, which is a sort of rather stodgy word.

What often happens in healthcare architecture, and I know that in the States, virtually all projects are delivered in collaboration, you often get the design architect and the healthcare architect.

Now, if you're like me, you think you can do both, which may, well, I think I can, (chuckles) I hope that you all think you can, but that leads to friction.

So both parties need to know what they're going to get out of a project.

And that takes, that refers both to international partners and to local partners.

Always try and get paid in dollars.

I always try to get paid in pounds.

And where there is a risk, get an upfront payment.

Then you're not subject to currency variation and a whole heap of things.

And if you're a small/medium practice, doing currency hedging and stuff is really quite complicated.

So if you can get paid in your currency, that's a great thing, and the standard form of contract.

Okay, second lesson, which is avoid cultural imperialism.

In 2009, with Sheppard Robson, we won the international competition for the Nelson Mandela Children's Hospital, and after we started working for them, they told us why we had been selected over the other three shortlisted firms.

And it was actually, the first one was quite simple.

The other three told them what they needed and we asked them what they wanted.

Sounds kind of obvious, really, and especially when you're working in a post-apartheid country, you know, that's the sort of courtesy which they wanted to be afforded.

But it wasn't merely that.

It was that I didn't know whether there was such a thing as a South African architecture with regard to a modern style/form of architecture which was particular or specific to the country.

But if you gave them a building that had universal qualities, and in this case, we tried to do a building, there's the site plan on the bottom right, that I'd call it skinny, that it was, and you can see the ward blocks in the diagram above, it could be described in terms of children scale, in terms of family scale.

There was a linear garden at the center of it.

And again, children and gardens is a no-brainer, and of course, the fingers enclosed a set of gardens.

But also, the form of the building enabled it to maximize passive energy and minimize carbon.

And when you put all that together, you had a story, and it's a sort of crude and rather sort of embarrassing thing to say, but a good building always has a good story.

And I always ask people who I'm working with, "Can you put on a sheet of A4 paper or a single screen on your computer, a building that somebody can understand?

", in other words, a diagram that explains what this building is all about.

And I think that's a critical thing when you're working abroad.

Now, the next one is (chuckles) read the room.

A hospital we're doing in Wales, there were two practices bidding for the final design.

And one of them, the one that lost, had a very earnest but nonetheless inexperienced interior design architect who presented all their interior designs, and she couldn't read the room.

She was talking about "your Welsh textiles" and your this, and daffodils, which is the national flower of Wales, and of course everybody in Wales knows this.

You don't play back to people what they already know because you unwittingly patronize them.

So if you are making cultural references, make sure that they're oblique or quite sophisticated, I would suggest.

Now, returning to the notion of contextual architecture is a kind of crazy project that we won in Palestine.

That's a view from the site.

I mean, there's that hymn, "There is a green hill far away, outside the city wall."

Well, it's a brown hill, really, in Ramallah.

Ramallah is very interesting.

It's the capital of Palestine, if you observe Palestine.

So there's a lot of geography.

There's a lot of politics.

It's quite high up.

Its climate isn't that hot, isn't that cold.

There are many political issues which make it a difficult place in which to work.

But nonetheless, it was absolutely fascinating and I loved every minute of it.

The site was outside the city of Ramallah, and what's amazing, because of the containment in the West Bank, the land in Ramallah is almost as expensive as land in London, which I found extraordinary.

And we had a very small site.

As you can see, these were two options at a very early station in the design, with the land falling away on either side.

And again, we applied our usual sort of methodology.

We don't normally like going up this high, but there was no way we could avoid that.

So the ambulatory center is the part in green, facing south.

Because this was a cancer center, all those facilities in which the clinicians work on the kind of patient's backstory, if you like, were at the front, creating a kind of active shield so that you didn't need to pull the blinds, because there weren't any naked patients there, putting it crudely.

And then the two wings, excuse me, I'm just getting a bit raucous, the two wings at the back were designed in such a way that you could stack wards on theaters, on imaging, on endoscopy, on everything, other than the radiotherapy, which is the bit in the middle.

And again, it worked upon there being an atrium, bottom left, and there being two sets of lifts, those which took you to the wards.

So you came out of these lifts into a winter garden and turned left or right, and you can see obviously there are two wings on either side, so that that was an interesting story because you didn't need wayfinding.

As soon as you got into the lifts, all you needed to do was know you're on one, two, three, four, five, six, seventh floor, and then you'd either turn left or right.

The ambulatory had another set of lifts, and you would take these lifts and then you'd walk along a dalek corridor into waiting rooms which dispersed you.

So one of our things we try to do in all the projects we do, is to get you from the front door to your clinical destination in daylight, albeit if it was a lift, you're not in daylight there.

But again, it's a very simple way of moving people around the building.

Oh, and I'd forgotten that bit, and then you go into chemotherapy like that.

And what you then get is an incredible amount of daylight penetration, obviously, the yellow bit.

Some of that's a bit mendacious, to be honest, but something like that.

Now, what should a building in Palestine look like?

Well, what they have got, which is quite marvelous, is huge quantities of stone, and stone is a material which is wonderful to work with and is local.

There's no, you know, it's locally hewn, therefore there are a few travel miles involved in it.

We thought this was a wonderful way of looking at the way in which we could design this building.

And so our first designs were really kind of very monumental, a lot of shading.

So that's the south-facing facade.

You get a lot of shading on the windows.

And we presented this to the client.

Now, the client had seen the neighboring building, which is in Amman, and said this is what it should be: lots of glass.

Now, in a climate where, albeit it never gets that hot, nonetheless, there's an awful lot of sun, it's not the greatest material to use with regard to carbon, and so there was quite a lot of discussion there.

And (chuckles) then we had a meeting and the client, who's actually now the prime minister of Palestine, said, "Your design doesn't look like a hospital."

And we said, "Fantastic.

That's what we are trying to do 'cause most people don't like the look of most hospitals."

And he said, "No, no, no, I want a hospital."

So there was a very long discussion and this was the compromise, which I think is far less successful than the previous image, but that's me.

And probably with, okay, we're trying to shape the glazing, but anyway.

That's what the interesting tensions there are in what is modern, what is to be seen as the latest, you know, where, in fact, an indigenous architecture is sort of frowned on because it's not international enough, and those are very interesting discussions to be had with clients.

Now, the awful truth is, we got to tender, and then they abandoned the project, although they'd excavated this hole, which is extraordinary.

I mean, it's the biggest hole I've ever been responsible for, and it wasn't even finished.

I think there was another level to go down.

So what was the outcome?

Well, the outcome, you know, the downside was it never got built.

There was a degree of chaos in the project management and we lost money, not that much.

And I would suggest that if you do work in a developing country, if you really want to work there, we lost money because the program extended to twice what it had originally been and they didn't accept there should be any more payment.

But you need to actually make sure that if something goes wrong, you have the wherewithal to actually cover it.

But what did we get out of it?

Well, the wonderful thing on all three projects I'm gonna show is that because there was a respect for us as healthcare strategists as well as architects, we wrote the brief for them, and there was a brief, but it was really very, on all three, there was a brief but it wasn't very specific.

We developed the brief with them, developed the functional content, schedule of accommodation, helped them to shape the project, and in so doing, there's a lot of learning in a practice that that does.

We added to our knowledge base.

We worked in a fascinating, strange country and met some amazing physicians, and we got to see Petra.

And when you get to my age, things like Petra, you're petrified, and I'm sorry, it's a bad joke, that they're gonna be a disappointment, but when they're much better than you even thought they were gonna be, I mean, that was worth quite a lot in itself.

Now, I'm going to go off-piste, if you like, and I'm just seeing how much, oh, when do, right, I think I'll speed up.

Right, now, contextual issues.

How do you provide a better base for designing for different cultures?

I would suggest that the building on the left has far more clues as to what one might do than the building on the right.

But I'll leave you to debate that.

I believe that architecture in itself can assist in healing, that it can be an adjunct to and a support for medicine, and that there are spaces in which we just naturally are reassured, calmed, healed.

I remember taking a very, very fractious two-year-old daughter who'd had enough of Florence in 38 degrees, and she was getting very ratty indeed.

And we finally ended up in the Pazzi Chapel in Santa Croce, and within 30 seconds of entering it, she'd completely calmed down.

The space had cast its spell, and without sort of BS, I honestly believe that to be the case.

The most extraordinary hospital I know, and for those of you who study healthcare architecture you may well know this, on the left, is the Khoo Teck Puat in Singapore.

That forest, that jungle is a hospital, and what it is, is a set of buildings, which in themselves are fairly mechanistic, standard, quite high-rise, but everywhere there is this lush planting and it supports 40 birds and 60 butterflies, many fish, and a whole heap of things.

It's quite extraordinary.

So you can create healing spaces.

And this is a standard, or I'm gonna say standard, it's actually from a building I've been to, which my erstwhile practice designed in the States.

I think it's in, can't remember, I think it's in Oregon.

Anyway, this may well be an effective way of setting out an OR floor, but when you put a football pitch on it, you realize that the sheer scale of it is beginning to be, in my opinion, inhuman, that nobody really has much access to daylight, and that it becomes a mechanistic place in which to work and maybe not an ideal solution to the design of a workplace.

Right, why am I showing you this?

As you can see, the jaunty little fellow on the right is me, my grandmother is in the middle, and my great-grandfather, whom obviously I never met, is on the left, and you can see the timeline there.

So this is about how young modern medicine is.

Now, my grandmother told me a story about the Lancashire Cotton Famine.

It was 15 years before she was born, but it was in a formative part for her father's life.

Now, why was there a famine in 1862?

Well, what was happening elsewhere in the world?

The answer was the American Civil War and that for once capital and labor in the UK collaborated and there was an embargo, as you probably know, on Confederate cotton.

So they had to re-source, and the mills closed for a number of weeks, and, as my grandmother said, "Mill owner and mill-hand alike were on gruel."

Now, there is only one in interlocutor between me and the American Civil War, which is my grandmother telling me stories of her father.

Now, I know I'm an old man, but even in, you know, I was 13 when this photograph was taken.

The bottom-right man, William Casby, it's a famous photo, was born a slave.

So that shows you how near the past is.

And there's a reason why I'm saying this.

I also find it quite extraordinary, and there's Frank Lloyd Wright, your great architect, the great architect, he was, I think, 14 years old when Jesse James got shot and he was still alive when Elvis recorded "Hound Dog," "Heartbreak Hotel," and "Love Me Tender," and those are all the presidents along the top, and I challenge you after this to name each and every one of them.

I can only go back to Teddy, I think.

But what that, if you look at the timeline then of modern medicine, you'll see those three people, me, my grandmother, and my great-grandfather, actually, modern medicine is very, very young.

And if you go up to the First World War, medicine didn't really have a great effect on curing.

It was, curative powers were fairly minimal until you got diagnostics and the pharmaceuticals, which make such a difference now.

So if you were Florence Nightingale, and that's going way back to '59, 1859, she wrote a book called "Notes on Hospitals," and it's really as though, how would you design a hospital, that medicine was of little value in healing people.

So the only things you had were nursing, which she basically invented as a profession, and the patient environment, and these were the only two healing agents.

And what I find extraordinary is that when you read that, I won't bother to read it out, you can read that on the right, it's a very good pattern book for how to design healthcare buildings.

And she based her observations on the building on the left, which is perhaps the best pavilion hospital.

It's in Paris, Lariboisiere, and it's very simple.

You've got a cloister.

You've got a set of pavilions, which are separated by a chassis around a central courtyard.

Wayfinding is a cinch 'cause you can intuitively navigate.

The buildings are of an urban scale, three stories, high floor to floors.

I'm not suggesting for one moment that this is a model in architectural terms what a hospital be, but it is in conceptual terms.

The spaces between the pavilions are twice as wide as the heights of the building for passive engineering.

But more importantly, it's actually, if any of you have come to London and taken the Eurostar to Paris, you'll have ended up at the Gare du Nord, which is here.

Here is the Lariboisiere, but you'll see that it's part of a much wider urban grain, so it's an inherent, intrinsic part of the city.

And when you put these two next to each other, I know it's unfair, but there are many hospitals that look like this corridor on the right, and the one on the left is so fabulously better.

And when you do, as I have done, a number of patient surveys, many patients will describe a hospital as a set of sort of labyrinthine corridors in which they have difficulty in finding where they're going.

You know, and this corridor doesn't have light, doesn't have grace, doesn't have, it's hospital land.

So if you're going to interest people in whichever country you're gonna work in, you need what I would describe as absolutes, which are not... And the absolutes are getting to places in daylight, having a chassis which enables the various wings to be plugged in and out and changed as time goes by, a place which celebrates both the patient, the staff, and the visitor.

It's not a building I've done.

It's a building in Bristol.

And also that first impressions are incredibly important.

My thesis is, and you may well think I'm nuts, that when you buy a flat or an apartment, you probably spend less time in deciding whether you're gonna buy it or not than you would on a pair of trousers, in that you walk in and you go, "This is for me."

And you'll go through days of mortgage finding and all the rest of that nonsense, but the initial impression is extraordinarily important.

And here's a little lesson, too, for working abroad.

We did the wayfinding with these glass chandeliers, I guess you'd call them, which are opposite lifts.

So you go to the green lift and you go to level two, three, or four.

But I was doing this in Ireland on a project, which, I'm pleased to say, this was (indistinct) which we won.

And I was saying, "Well, you know, we'll have these colored devices, such as these, and we'll have a red and a blue," and this guy just kicked me under the table.

Of course, if you're working in Ireland, asserting the UK's colors of the national flag is actually not a very clever thing to do, so it was rapidly orange and green.

So again, kind of beware of local susceptibilities.

The other lesson is that, and it's really kind of crude, US and UK architects will probably be phased out on projects abroad when they get to the producing the construction drawings, to a certain extent because unfortunately we cost a great deal more per hour than the local architects.

So it's incredibly important that you develop a scheme which has a very strong diagram, which can actually withstand all the budget cuts and compromises which come along.

This is actually the scheme that was built for the Mandela, because the problem was we didn't know what the site was really like until we got there, which was after we'd interviewed for the competition.

And the scheme we'd done didn't...

It's a very steeply sloping site, so we had to reorganize it.

We maintained the notion of there being a garden through which you progressed and that these buildings would step down.

And it had the very nice thing on the slope.

If you came in, it was a three-story building, you came in on the middle floor, so you went upstairs to bed, the entrance level was diagnostics, and then you went downstairs to have things done to you.

So again, there was something nice there and the very straightforward plan form.

And you could get the social spaces actually off this gallery, which ran down, and then there would be terraces on.

Very simple.

We had a wonderful set of arguments and discussions about single bedrooms, which they didn't think that they could have, but got quite a few of them through, which was wonderful.

The one on the left is what we wanted the central space to be.

The one on the right is sort of what it became, which is still pretty good.

But the local architects were really engaged in the detailed elevations.

And I absolutely, there's a sort of Louis Kahn quality to these, which I love.

It's very simple, straightforward.

It fits the urban grain.

These are the ends of the blocks, which were the social spaces, and then you had just the fabric of the wards in the middle.

It sits very happily.

It integrates landscape beautifully and there's very lush gardens, and we could have fun with the principal part.

So choose a diagram that will withstand, I mean, I went to the opening and we hadn't seen it for 18 months.

Actually, I had briefly, and I was full of trepidation and it was, "Oh, actually it's fine.

Good."

And finally, I don't whether I'm, I think I'm running to time, we were asked to do a building in Switzerland.

It was quite extraordinary in that I got a call on my cell phone when I was on holiday in Italy, and they said, "We want you to do some work for us."

And they just bought, it's a family wealth fund, actually, putting it crudely, who'd bought the hospital and somebody had recommended us, and I said, "Well, when do you want us to interview for it?"

And they went, "No, no, no, you got the gig," which is very odd.

Only time it's ever happened.

But again, we had, bizarrely, earned the client's trust, but we had to maintain it.

And they asked us to, it's in Geneva, there, that's Lake Geneva, that was the original building, which is this trefoil, and they wanted us to put a second phase there.

And it was assumed that the existing entrance, which is here, would remain, and you walk through the existing hospital to get to the new wing, which was down here.

And they employed us to write the brief, do the functional content schedule of accommodation, I think with McKinsey's, and then do a concept.

And then they handed it over to some Swiss architects who completely screwed it up, and it was given back to us to do all the clinical planning, handed to a second set of architects to do detailed drawings.

We did the detailed clinical stuff and we did the interior design, which was nice.

But what we had to do through all of this is to maintain their trust.

And what we did, again returning to health, green, was very simple.

We said to them, "Well, you're spending $100 million on this, which is an awful lot.

So I would imagine your patients, your staff, your funders, and everyone else would like to see a radical change."

So rather than entering through the top, we turned the building back to front, put in a parking lot.

Before I go further, they were developing what has become the biggest sports medicine center in Switzerland that is actually the center for their Olympic teams.

So they needed an external rehab yard space and it's very considerable.

So we thought what a nice idea that you have a bridge over it so that you're bridging over people recovering, so that you see active recovery.

Then you come onto a green base and then you walk into the building, and that because it was a sport, and this was their idea actually, that there was the bridge, and it's a very simple, Swiss elevation, that there was, along here was the gymnasium, huge gymnasium, which also had a climbing wall so that we poked the climbing wall up so that when you walked in, this was the glass from the foyer, you looked down to the climbing wall, and so that you were emphasizing throughout that if you were unhealthy, you were seeing people who were regaining health, which was an amazingly reassuring way to do it.

Now, I'm not sure, well, apparently your slang term is gig 'em, and I don't know for what minute what that means, so I think the message that I would leave you with is that there are universal qualities about healthcare architecture, and I hope I've made clear what I think mine are, and that those are applicable in whichever country that you work in, and that your reaction to and resolution of the issues of climate, context, pollution or not, as the case may be, those materials which are natural and to hand, the integration of nature, landscape, both internally and externally, the notion of adaptability, the notion of the building having a chassis which enables you to have wings that you can plug in and out of, and that you could demonstrate in a way could become offices or conference center or housing or whatever, that there are these issues which are very strong, especially at a time when climate change is increasingly central to the discussion and that these can shape a very strong notion of healthcare architecture that is in itself healthy, that supports the wellbeing of the staff and of the patients.

And the other thing is, be damned careful when you work abroad.

(chuckles) Assess the risk.

Know when to stop.

Be firm.

Try and, when programs overrun, I know we couldn't get anywhere on the project in Palestine, but be firm with the client.

I mean, in South Africa we would be invited to meetings in Johannesburg from London for which there was no agenda and we had to put a stop to that 'cause it was wasting their time, money, and everything else.

So don't hector.

Be subtle in your demonstration of your expertise and just enjoy the sheer excitement of different cultures, different clients, climates, food.

It's so exciting.

And if I were to work anywhere in the world at the moment, I would love to work in the developing world because that's where you can make the biggest change and you can do the most.

But anyway, thank you very much for listening.

I hope you haven't fallen asleep or forgone lunch for this, and if there are any questions, fire away.

- John, I want to first take a moment to thank you.

I know everybody in here enjoyed it.

(audience applauding) - Well, I hope they did.

- It was terrific hearing from you.

I loved the clarity in the organization and the lessons learned, and walking us through your experiences.

It was terrific.

John, we have consumed all of our time, and I must say- - Oh my gosh, have I overrun?

- No, no.

It was wonderful, John.

That wasn't meant as a reprimand.

It was meant as a thank you.

It continued past Q&A and we made no effort to stop it.

It was worth listening.

So thank you very, very much for joining us and sharing your experiences and insights with us.

And I will say thank you to everyone here who braved the weather and came to hear a really first-class presentation.

John, it's always fun, and I love the way, even subtly, maybe even unintentionally, the British humor sneaks into your remarks.

I find myself enjoying the content as much as the delivery, and that's a very special treat indeed.

Thanks so much, John, and to everyone here, we'll see you next week.

- [John] Thanks a lot, Ray.

Hope to see you (audience applauding) next year in London.