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Full text of "Hospital beds by design: a socio-historical account of the 'King's Fund Bed',1960-1975."

91 



CHAPTER THREE 

SPECIFICATIONS AND SIMULATIONS 



Introduction 

This chapter outlines the main events of the project as it was implemented 
at the RCA and the King's Fund from June 1 963 until February 1 967, when 
the final specification was published by the Fund. A number of investigative 
techniques were employed and I shall give a largely descriptive account of 
these, leaving more detailed consideration of their implications to Chapter 
Six. Contingent factors, such as the availability of resources, modified the 
methods. Time, in particular, was in short supply. Throughout the project 
there was, it seems, some discrepancy between the King's Fund's 
expectations of when the working party would report and the timescale the 
RCA team would have liked to complete their intensive investigations. 

The period may be considered in two phases. First came an initial, 
'information gathering' phase which resulted in just under a year in the draft 
user specification of April 1964. 1 Although relatively brief, this period was 
decisive for the final form which the specification took. A number of choices 
were made which excluded certain options and enshrined others. Despite 
many assertions that rigorous scientific methods were followed throughout, 
it was largely to the problem after it was constituted in this first phase that 
formal and abstract techniques were applied. 

Royal College of Art, Studies in the function and design of non-surgical hospital equipment, 
Report No 12, General purpose hospital bedstead: user specification, April 1964. 



92 



The second phase comprised nearly three years of model and 
prototype building, field trials, and revisions to the user specification. It 
involved the construction of 'simulated beds'; both small scale model beds 
as aids to the designers and advocates to the Working Party, and 
prototype beds or 'hypotheses' which were 'inserted' into the real world, as 
a form of controlled experiment. This was a simulation of everyday use in 
the real world; a world that both was, and yet was not, identical to it. 
Simulation was a key technique in operational research that was adopted 
and adapted in widely disparate fields, with different degrees of selection 
and abstraction. Flight simulators for training pilots, game theory consoles 
and 'role play' techniques used in management courses all shared similar 
theoretical assumptions, and origins in the cyborg sciences of the 1950's 
and 60's. 

Increasingly, however, this phase of the project became about 
negotiating the social world well beyond the confines of what went on 
within any controlled experiments. Getting the details of the specification 
right was important to the RCA team, but so was anticipating and 
circumventing potentially damaging opposition, whether from their 
sponsors or further afield. Pre-empting opposition, (much of which was 
expected to be part of opposition to standardisation per se), and promoting 
the specification, and by implication or otherwise the policy of 
standardisation itself, were rather different enterprises from fine-tuning the 
content of the specification. After a certain point in the project, it seems 
likely that investment by interested stakeholders was such that widespread 
acceptance of the specification became more important than its precise 
content. (This had probably been true from the outset for certain groups.) 
Rhetorical claims about a scientific and rigorous design method served this 



93 



purpose very well among certain key audiences, and were increasingly 
brought into play. 



Specifications 

'Information gathering' was an essential initial stage in Archer's method. 
Three types of formal exercise were carried out: a literature search, the 
holding of 'juries' or focus groups and a television survey. The results of the 
first and last were written up as separate reports by the RCA team. 2 
Despite the fact that the literature search was described as recording 'one 
thousand five hundred items of information', the team were disappointed at 
the lack of material they considered relevant to hospital bed design 
published within the previous decade; 'very little . . . was firmly based on 
experimental data'. 3 The data amassed included anthropometric and 
ergonomic findings, bed standards and specifications from various 
countries, and the few comparative studies of hospital beds which had 
been carried out elsewhere during the period. 4 For many issues relating to 

2 

Royal College of Art, Studies in the function and design of non-surgical hospital equipment, 
Report No 16, General purpose hospital bedstead: a list of sources of information, July 
1 964 and Report No 1 0, Result of a television enquiry on certain features of the hospital 
bedstead, June, 1964. 

3 

Ken Baynes, Industrial Design in the Community, London, Lund Humphries, 1967, p.47. 

4 

Principal among these were two studies carried out in the US: Warren L. Ganong, 

Comparative evaluation of hospital beds, Pittsburgh, Pittsburgh University Engineering 
Research Division, 1960, and Harold E. Smalley, A comparative evaluation of eight bed 
types, Atlanta, Georgia Institute of Technology, 1962. Smalley's work was a continuation of 
Ganong's investigations when the University of Pittsburgh programme moved to Georgia 
Institute of Technology. Both investigations were done under the auspices of 'methods 
improvement', a part of 'industrial engineering' (the American term for work study). See 
Harold Smalley and J.R. Freeman, (eds) Hospital Industrial Engineering: A guide to the 
implementation of hospital management systems, New York, Reinhold, 1966, pp. 59-80 for 
an account of the origins of and early programmes in this field. 



94 



hospital bed design there was apparently no published information, and the 
team looked to a second technique. 

A number of meetings were set up between the RCA team and 
groups of professionals considered to have pertinent views on hospital bed 
design. At the time they were referred to as 'juries', or, since nurses greatly 
predominated, 'nurse juries'. These were to 'brainstorm' the topic. A typical 
'nurse jury' held in September 1963 consisted of two matrons, a ward sister 
and a nursing research officer from the Ministry of Health. 5 In line with 
Archer's predilection for prior definitions, the meeting began by seeking 
agreement as to the purpose of a hospital, the aims of the NHS and the 
function of nursing care. Perhaps fortunately, members of the jury showed 
no inclination to disagree with definitions of these taken from various 
official sources. Because Archer considered that potential users should be 
asked to express their views about an artefact in terms of desired 
attributes, subsequent discussion was organized around individual 
properties which a hospital bedstead could or should possess. These 
included, for example: mobility, a backrest, adjustable height, cross (ie side 
to side) tilt and a divided mattress (one with an upper section that could be 
raised.). Notes for each were kept on individual cards. From cards 
completed during this particular jury it appears that, on the subject of 
height adjustment for example, they considered just a high and a low 
height necessary, 'adjustable height was important but more for the chronic 
sick'. They were also keen on cross tilt, considering that 10 degrees lateral 
tilt of the mattress platform in each direction would do much to ease the 

5 AAD/1 989/9, BoxA, Document 985, Notes of a meeting on 3.9.63. Another, on 20 August 
1963, had comprised two matrons, one ward sister and a nursing research officer. In 
general, London teaching hospital staff were strongly represented, although those from 
non-teaching hospitals were also involved. 



95 



nurses' dilemma of whether to cause patients disturbance and sometimes 
pain by turning them, or risk the production or worsening of bedsores. The 
number of these juries held was small. They were not intended to be large 
statistical samples but to identify attributes which the bed might possess 
and pointers for further research in the literature. 6 

As such, the process might be regarded as the first of a number of 
stages of elimination, of certain interests and certain design possibilities. 
Hospital beds which could be adjusted by the patient, and beds with 
profiling mattresses (divided into three or more sections each of which 
could be moved independently) were available, if expensive. At the more 
futuristic end of the market, hospital beds with integral ladders, lavatories 
or air-conditioning had all been produced. 7 

Very rapidly, however, the team had narrowed down their enquiry to 
twelve questions which they considered essential but which they were 
unable to answer on the basis of the literature search or the nurse juries. 
Given their concern with amassing large amounts of empirical data it was 
perhaps unsurprising that they turned to survey research, in the form of a 
structured questionnaire, to provide the 'definitive' answer to these 
questions. 8 The 1960's were the heyday of the social survey. Its position as 



Interview, Bruce Archer, 9.5.99. 

An air-conditioned hospital bed was shown at the Britain Can Make It exhibition at the Victoria 
and Albert Museum in 1946. See the illustration in Carlo Pirovano (ed) A History of 
Industrial Design, Vol 3, 1919-1990, Milan, Electa, 1992, p.187. For a history of hospital 
bed designs and a survey of those available in 1962, see Anthony Wylson, 'Ward 
Furniture: 1, Beds', Architectural Review, 132, 1962, pp. 64-74. 

Q 

The questions concerned height adjustment, pedal operation of this facility, design of backrest 
and footpiece, tilt, stowable safety sides, integral bed stripper (a shelf for bedclothes), the 
movement of beds, giving of anaesthetics in bed, cross infection issues and 'whether 
hospitals could use a bed of this basic specification'. BBC Archives, File script, Panorama, 
3.2.64. 



96 



the research tool par excellence of empirical sociologists, and its 
association with scientific method, had been established by the work of 
Paul Lazarsfeld, Samuel Stouffer and other U.S. sociologists involved in 
survey projects such as that known as The American Soldier. Reviewers 

responded to the latter as: 

. . . 'the new social science ... the rigorous testing of explicit hypotheses 
on largely quantified data accumulated by structured observation in 
empirical situations approximating ... the model of controlled 
experiments'. 9 

Applications such as market research and opinion polling used 'the survey 
technique', albeit in a simplified form. In Britain, the planning needs of the 
welfare state increased funding and opportunity. 10 A growing critique of 
survey methods from some sociologists in the 1960's did little to diminish 
their use. 11 Away from such academic debates, surveys produced useful, 
quantified, results. 'How to do it' handbooks were available, including 
several intended for practitioners in disciplines outside sociology and 
psychology who wished to avail themselves of the technique. 12 None of 
these, however, covered the precise procedure that Archer intended to 
use: this he dubbed a 'televisual' survey. 

It was Archer's view that 'a combination of a questionnaire and 



g 

Piatt, A history of sociological research methods in America, p. 60. 

The most comprehensive historical account of the survey is Jean M. Converse, Survey 
Research in the United States: Roots and Emergence 1890-1960, Berkeley, University of 
California Press, 1987. 

M. Benney and E. Hughes, 'Of sociology and the interview' in N.Derzin (ed), Sociological 
Methods, New York, McGraw-Hill, 1978, pp.19-33. 

12 

Stanley L Payne, 'The Art of Asking Questions', Princeton University Press, 1951 was a much 
cited handbook. For the medical field, see A.E. Bennet and K. Ritchie, Questionnaires in 
Medicine, Oxford University Press for the Nuffield Provincial Hospitals Trust, 1975. 



97 



television' would represent 'the most effective means for recording opinion 
and inducing general laws for a consensus of opinion on certain matters'. 13 
Other benefits were not overlooked. 'A well presented programme would 
make hospitals, especially those in the provinces, feel they had been 
adequately consulted in the drawing up of a specification'. 14 The idea was 
certainly novel. Since the advent of regular television broadcasting in 
Britain in 1953, no such attempt appears to have been made, possibly 
because researchers doubted their effective autonomy in such an 
undertaking. Perhaps naively, Archer assumed that 'as this enquiry is to be 
transmitted as part of a topical magazine programme (it) may be presented 
straightforwardly with the minimum of "build up" and staging'. He 
considered that 'A sober presentation, fully under our control is an absolute 
necessity if the TV programme is to be mounted'. The topical magazine 
programme in question was Panorama which, somewhat surprisingly, the 
BBC had suggested when approached by Archer. Panorama (it is still 
running) was a 'flagship' news and current affairs programme. As such, it 
was highly prestigious, but also subject to the vagaries of the day's events. 

Preparation for the programme by the RCA team was meticulous. 
Cardboard cut outs of the bed parts to be demonstrated were made, 
painted grey overall, but with the parts to which attention was being drawn 
during any particular question picked out in brighter colours. The format of 
the broadcast was to consist of the questionnaire being read out by Archer, 
while the relevant part or operation of the bed was demonstrated with the 
cardboard models. The script was timed to the last second. It ran, as 



13 AAD/1 989/9, Jobs 7 and 13, The TV Presentation', Bruce Archer, 21.11.63. 
14 AAD/1 989/9, Jobs 7 and 13, Box A, Trial by Television'. 



98 



agreed with the producer, for precisely twelve minutes. The 1 ,000 hospitals 
of more than sixty beds asked to participate in this 'bold venture in the use 
of modern communication aids' had been sent the questionnaires in 
advance. Some were requested to organize mixed groups of hospital staff 
to complete them while they watched the programme, others to distribute 
questionnaires to individual staff members. Some 20,000 hospital staff 
were involved. 

The programme was publicised in advance in the hospital press, and a fair 
amount of interest engendered, including a suggestion (not taken up) from 
the Canadian Nursing Association that they be allowed to participate via 
Telstar. 15 

The RCA team's hopes were high on the evening of 3rd February 
1964 as, throughout the country, nursing, medical and administrative staff 
gathered around hospital television sets. At the last moment, however, 
disaster struck in the form of the Soviet Foreign Minister, visiting Britain to 
celebrate the 40th anniversary of British recognition of the Soviet Union. 
Panorama secured an interview with the Minister which took half of the 
time allocated to the bed feature. Instead of twelve minutes of carefully 
timed questions, interspersed with explanatory diagrams and film, cuts 
made half an hour before transmission resulted in loss of almost all the 
explanatory material. After sitting through most of the programme, viewers 
were merely shown a close up of the questionnaire and given some 
'fatherly advice on how to fill it in'. To add insult to injury, nearly a full 
minute at the beginning of the item was taken up with 'an initial sequence 
of a scantily clad model rolling about on a bed.' The background music for 

15 

A/KE/PJ/17/1, memo 24.10.63. Telstar was the first active real-time communications 
satellite, used from 1962 to transmit television pictures across the Atlantic. 



99 



this was a humorous song about insomnia. 16 The broadcast was a great 
disappointment to the team and potentially highly damaging to the project, 
particularly since it was only recently that the RCA team had become 
formally associated with the King's Fund Working Party. Letters of 
complaint quickly appeared from hospital staff. A typical example, from the 
German Hospital in London, protested at 'the time-wasting fatuity' of the 
programme, which was considered 'an insult to our intelligence.' 17 Only 
prompt action on the part of the King's Fund and the RCA prevented a 
major public relations disaster. After an emergency meeting of the 
Secretary of the Fund with Bruce Archer and Irfon Roberts a letter was 
hastily sent by Archer to all participating hospitals as well as to the medical 
and nursing press. It expressed grave distress at the 'circumstances 
beyond our control' which had resulted in cuts to the script. 18 Lord 
McCorquodale, Chairman of the Fund, and Misha Black complained to the 
BBC. 19 Hospitals were persuaded to return the questionnaires, albeit 
incomplete. Five hundred groups of staff and nearly seven hundred 
individuals did so. 20 The team considered that the answers to nine of the 



BBC Archives, Broadcast script, Panorama, 3.2.64. The song began: 'When you're lying 
awake with a dismal headache, And repose is tabu-ed by anxiety, I conceive you may use 
any language you choose, To indulge in without impropriety . . . and continued in the same 
vein. 

See, for example, Letter, 'Hospital Beds on "Panorama" ', British Medical Journal, i, 1964, 
p.559. 

1 8 

Letter, ' "Panorama" Programme on Hospital Bedsteads', British Hospital and Social Service 
Journal, March 13,1964, p.334. 

19 A/KE/PJ/17, KFWPHB Minutes 17.3.64, Items 25 and 26a. 

20 

Royal College of Art, Studies in the function and design of non-surgical hospital equipment, 
Report No 10, Result of a television enquiry, p.2. 



100 



twelve survey questions were 'valid' without the televisual explanation. 21 In 
possession of these answers, they proceeded to compile the draft user 
specification. 

These then were the three formal methods of information gathering, 
the results of which were subsequently much quoted in support of the 
specification. But the kind of information gathered, and indeed the 
definition of what constituted relevant information, depended on how the 
design problem was formulated, and on preconceptions as to how it would 
be solved. Inevitably, these came from the assumptions, prior experience, 
tacit knowledge, disciplinary perspectives and personal and institutional 
interests of key participants, none of which were the subject of overt 
consideration in the method of arriving at the user specification. As Horst 
Rittel put it in 1 972, 'First generation methods', of which Archer's was one, 
'seem to start once all the truly difficult questions have been dealt with 
already'. 22 

Less than two months after receiving the replies to the television 
enquiry, the RCA team produced the first version of the draft user 
specification, in April 1964. In it, the general purpose hospital bedstead 
was still defined as 'one suitable for the majority (say 60%) of patients 
being nursed in the ordinary wards of general hospitals. The specification 
listed thirteen 'roles performed by the bed (not in order of importance)'. 
They were: 

1 Examination table 

2 Focus of nursing 



21 A/KE/PJ/17, Bruce Archer's Report to KFWPHB, 17.3.64. 

22 

Horst Rittel, 'Second-generation Design Methods', in Cross, Developments in Design 
Methodology, pp.31 7-327:322. 



101 



3 Treatment table (without apparatus) 

4 Workbench (with apparatus) 

5 Trolley for long travel 

6 Social centre 

7 Daybed or chair for rest (including occupational therapy) 

8 Place for sleep 

9 Obstruction (to other activities, including cleaning) 

1 Thing to be cleaned or maintained 

1 1 Place for assimilation (nourishment) 

12 Place for excretion 

13 Place for daily toilet 



There followed a list of ten 'Bed elements': 

1 mattress or pad element 

2 mattress support element 

3 frame element 

4 headpiece element 

5 footpiece element 

6 backrest element 

7 safety sides 

8 bed stripper 

9 other fixed features 
10 attachments 

Then came, for each bed element, specifications for its function, structure 
and dimensions. Appendices listed the team's evidence in support of the 
specifications. Broadly, this was of two kinds. Where possible, 
anthropometric and ergonomic data were cited, the latter often 
extrapolated from findings in other contexts. 23 Otherwise, reference was 
usually to Archer's 'consensus of informed opinion' (or, as it was more 
usually termed, 'nursing opinion') or to the television survey. 

Several documents, prepared over the following four months to back 



23 

Royal College of Art, Studies in the function and design of non-surgical hospital equipment 
Report No1 7, General Purpose Hospital Bedstead: summary of analyses leading to user 
specification. Much of the data amassed had been collected in the military context. A small 
amount came from work done in the furniture industry, on seat heights, for example. 
AA/1 989/9, Job 7, Document 986, 'USA anthropometrics general' and Document 1307, 'UK 
anthropometrics general'. 



102 



up the specification, provide insight into the team's methods. They were 
amalgamated into a report summarising the 'analyses leading to user 
specification, May-August 1964'. 24 In line with the stages in Archer's 
'Systematic Method for Designers', 'crucial issues' in bedstead design had 
first been identified. These comprised: future trends in patient care, 
manoeuvrability, operability, stability, ease of cleaning and of maintenance, 
and appearance. The source was 'nursing opinion'. Four 'constraints on 
development were noted: 'national and statutory, economic, materials 
limitations and environmental'. Six 'purposes of a bed' were listed. They 

were: 

'To provide means for the patient to adopt a comfortable posture, 
necessities of warmth, protection, etc, to render the patient 
accessible for effective nursing, provide privacy, a familiar 
environment and an identifiable personal home'. 



There then followed the now familiar lists of bed usages, or 'roles which a 
bed may perform', (increased from fourteen to seventeen) of bed elements 
and of the attributes required to describe them (such as size, structural 
performance, etc.) There were also two new lists. The first was a 
refinement of a working document first produced in June 1964, headed 
'Bed usage and critical factors in design'. The list of roles performed by the 
bed or 'usages' was expanded by addition of the activities each involved. 
Against each of these 'usages' and their constituent activities was placed a 
list of 'critical factors in layout'. Against 'bed as a focus of nursing', for 
example, six critical factors were listed: 'high height, leg and foot 
clearances, width, tucking in perimeter, obvious mode of operation and 

24 

Royal College of Art, Studies in the function and design of non-surgical hospital equipment, 
Report No 1 7, General Purpose Hospital Bedstead: analyses leading to user specification, 
May-August 1964. 



103 



obvious state of adjustment'. Against 'bed as an examination table' was 
'height adjustment, high height, length, obvious mode of operation, all 
round access, stability, sitting support, backrest support and neutrality (of 
colour). For the usage, 'bed as a social centre', there were 'no critical 
factors, main factor is general appearance'. 

The critical factors had been ascribed by the designers as 'the 

features which a mechanical object 
would have to have to support the role'. 25 
The ordering of the list of 
activities/usages was no longer random, 
but determined by placing those with a 
higher number of relevant critical factors 
above those with less. In the final list, 
headed 'Design factors extracted and 
ranked' the critical factors themselves 
were ranked, according to how many bed 
usages they were relevant to. Thus 
'stability' was first on this list because it 
was relevant to eleven of the bed's 
seventeen usages. Second came 
adjustable height, relevant to nine 
usages: as a focus of nursing, 
examination table, treatment table, 
workbench, focus of emergency, place 
for excretion, place for daily toilet, focus 



25 



Interview, Kenneth Agnew, 22.6.00. 



104 



Stability 

Height adjustment 

Obvious mode of operation 

Retention of mattress 

Sitting support 

Length 

High height 

Stable immobilisation 
Leg and foot clearance 
All round access 
Width 

Obvious state of adjustment 
Drainage 
Backrest support 
Access to immobilising device 
Tilt 



of ambulation and as an (un)loading 
surface. The first sixteen critical factors 
on the list were: 



all relevant to between twelve and six usages. Twenty five further factors 
were listed, the final five being relevant to only one bed usage each. The 
precise significance of this ordering is unclear. Its final form was produced 
for the purposes of the Report four months after the early version which 
formed the basis of the draft user specification. At least one other 
intermediate version exists in the archives. In retrospect, Archer 
considered it had been 'just an indication of what the designer should pay 
most attention to'. He also, once again, stressed the importance of being 
able to 'back up our conclusions'. 26 It was used to determine the wording of 
the final specification, which used the word 'shall', for example, for 
statements concerning factors high on the list, and 'should' for those lower 
down. Successive versions of the list show 'adjustable height' gradually 
rising to occupy a position second only to 'stability'. Some factors, notably 



26 



Interview, Bruce Archer, 9.5.00. 



105 



'adjustment by the patient', subsequently failed to materialize at all in the 
specification. 

The draft specification was widely circulated by the King's Fund. In 
essence it described a hospital bed of certain dimensions which was height 
adjustable, probably by means of a foot pedal, the foot end of which could 
be tilted over a large range at any height. The mattress base was to be 
rigid and continuous. A backrest element capable of supporting the 
patient's upper half at any angle to the horizontal was to be included. It was 
to have stowable safety sides and a bed stripper, castors suitable for 
travelling over continuous surfaces and be of antistatic construction. 



Simulations 

As noted above, the second phase of the project may be considered in 
terms of simulations of varying degrees of verisimilitude: both simulated 
beds and simulations of the real world. In the literature of operational 
research, and the management science derived from it, models and 
simulation were key concepts. 27 They were what the researcher working 
with 'real-life' problems employed in place of the controlled experiment in 
the laboratory. More than just hardware was modelled. Simulation involved 
modelling whole 'systems', such as military weapons or industrial plants. 
Occasionally, physical analogue models were used. 28 But ideally the 

27 

See for example, Irwin Brass, Design for Decision, Toronto, Collier-Macmillan Canada Ltd., 
1953, pp.161-182 and Rivett, Concepts of Operational Research, pp.14-33 and 140-157. 

One of the most well known was the 'cut out' map used to solve logistics problems in 
industry. The optimal location of a distribution depot was found by threading strings 
carrying weights proportional to the size of required deliveries through holes cut in the map 
at the delivery destinations. The strings were tied to a ring free to move across the surface 



106 



models were mathematical, an abstract expression of relationships, in 
which selected variables could be altered by the experimenter with ease in 
order to observe the effects. It was for problems which could not be wholly 
stated in mathematical terms that simulation was employed. 

Simulating 'real life' underlay two important stages of the research 
for the King's Fund Bed project. The first grew out of dissatisfaction with 
observation in the wards as a means of analysing nurses needs with 
respect to hospital beds. It was considered that the hospital situation, in 
which junior nurses deferred to the views and instructions of seniors, 
obscured proper examination of their work with beds. Ideally, the RCA 
team would have liked to run a full-scale work study investigation, following 
recommended procedures in ergonomics. 29 These were complex, however, 
involving the wearing of masks for measurement of oxygen consumption, 
special clothing to allow for the recording of body positions and 
movements, and the time consuming repetition of procedures. Time was a 
resource in short supply, so a modified form of investigation was 
employed. Nurses from near-by hospitals were asked to come into the 
RCA and demonstrate bed making on adjustable wooden trestles. This 
was specifically to eliminate the effects of the social structure in which they 
worked. These sessions, largely recorded by photography, provided data 
for Kenneth Agnew, who was given the job of designing a prototype to the 
specification. Copies of this prototype were to allow for a second, much 
larger, controlled experiment involving simulation: a major field trial of the 
beds. 

of the map. The resultant position of the ring, a product of the physical forces involved, 
indicated the optimal site for the depot. The method is described in Rivett, Concepts of 
Operational Research, p.21 . 

29 

Interview, Kenneth Agnew, 9.8.00. 



107 



First, however, a prototype had to be designed and built. It had not, 

in fact, been part of the RCA's remit to build a bed, merely to produce a 

specification. But it seems likely that Archer had this in mind from an early 

stage of the project. 30 The full implementation of his design method 

required the building and testing of a prototype design. He was careful to 

justify this expensive step in other terms as well, for example to prove that 

the specification could be met within a reasonable budget. (A reasonable 

budget was never specified). Subsequently, in a paper given in Vienna in 

1965, he stated that the four reasons for building a prototype were: 
that it was an excellent discipline on research if one knew that one must 
produce a design in conformity with it at the end. Secondly it is an 
excellent discipline upon the existing manufacturers who would be 
less inclined to say the specification could not be met . . . thirdly, it 
was necessary to have at least one bed design exactly meeting the 
specification in order to carry out field tests in hospitals . . . (and 
fourthly) there would be no justification for such research to be 
carried out in a design school if no design was going to result. 31 

In a major article for the design press describing the RCA prototype, 
however, written by the Council of Industrial Design's purchasing officer, it 
was stated simply that 'it had always been the intention that the RCA team 
would design and build its own prototype', and that 'the cost of the bed had 
not been a predominant consideration at this stage since it was felt that the 
first priority was to arrive at a design which was an optimum interpretation 
of the user requirements set out in the specification'. 32 This description was 



30 

At the first meeting of the Working Party attended by the RCA team, Archer outlined his plans 
for the research which culminated in 'a full-size prototype, in time for tests under hospital 
conditions to be well in hand by the end of 1964' A/KE/PJ/17/19 KFWPHB Minutes,1 7.3.64, 
Item 25. 

31 

Quoted in Baynes, Industrial Design and the Community, p. 48. 

32 

Cousins, 'A general purpose bedstead for hospitals', p. 54. 



108 



in line with Archer's view of the field trials as a controlled experiment. The 
prototype beds ('research tools') were to be placed in the real world, in a 
simulation of normal use. 

At this point however, a more traditional form of model making took 
place, at first as an aid to the team's own discussions of how best to meet 
the specification, but later with an important role in advocacy. Four small- 
scale physical models were made. Each addressed the main engineering 
problem posed by the specification: how to achieve the range of height and 
tilt adjustment specified. One model represented a bed raised or lowered 
by compressed air. In retrospect this was regarded as having been a light- 
hearted suggestion. 33 Other models used rotary drive, that is the turning by 
hand of a worm screw, the rotary motion of which is converted into linear 
motion of the bed. This mechanism was already in use for raising beds and 
is similar to that used in car steering or for opening high casement 
windows. It was a time-consuming and relatively onerous way of altering 
bed height however, and there was evidence to suggest that nurses did not 
bother to adjust the height of beds already available which used this 
mechanism. A third, very simple, model represented the solution finally 
advocated by the RCA. This was the use of hydraulic power from a slightly 
modified lorry jack to raise the bed. The mattress platform was supported 
by 'scissor arms'. A self-locking telescopic linkage between these provided 
the tilt function. 

Given that for Archer the design process was one of reconciling 



33 

Inflatable structures were in fact of considerable interest in the 1960's, some of it in the 
Industrial Design (Engineering) Research Unit itself. A project there to devise inflatable 
play equipment for disabled children led subsequently to the commercial development of 
'bouncy castles'. Interview, Gillian Patterson, 14.9.98. Other inflatables served more 
serious purposes; inflatable tanks were widely used in army manoeuvres. 



109 



conflicting demands, it is clear why the model stage was essential. The 
designer was to satisfy the maximum number of client/interest groups. 
Design models are without exception, highly selective in what they choose 
to represent. By and large, they tend only to represent what is at issue, 
what may prove contentious. What is deemed to be at issue will of course 
vary in different cases, according to how many assumptions are shared by 
the groups for whom they are made. For an architectural model, for 
example, the issues are to do with how a building will look, not whether it 
will protect people from the elements. This model represented only the 
height and tilt mechanism, contentious because it was by far the most 
expensive aspect of the specification, important to the RCA team because 
it was by far the most innovative one. This model, which reduced a highly 
complex and not yet worked out piece of engineering to a simple piece of 
moving geometry, was a literal reification of the issues, an advocate for the 
RCA's preferred solution, an assertion of 'doability'. The Working Party 
were persuaded, with the aid of this model, to accept further development 
of Agnew's prototype, but they 'took some convincing'. 34 It was not only the 
eventual cost of beds meeting the specification that was at issue. The cost 
of the project itself was coming under scrutiny. 

The technical details of the prototype designed by Agnew (see page 

7) were described as follows: 

The bed is constructed of welded steel. The lower chassis is of square 
section tube, sewn and arc welded. The moving arms, deck and 
superstructure are of thin sheet steel . . . This is power guillotined to 
shape and formed on a brake press into angles, trays and channels. 
These components are assembled into light, rigid box units by spot 
welding. Plywood jigs were used in making all the welded 
assemblies. There is a small number of machined components. 
Most of the bearings are plain with large assembly tolerance and 

34 

Interview, Kenneth Agnew, 22.6.00. 



110 



little need for lubrication, the bearings for the pedal drive are 
PTFE/lead used without lubrication. The finish is an acrylic enamel 
made by ICI. It is sprayed on and then stoved. 35 



The most obvious differences from conventional hospital beds were the 
scissor mechanism for height and tilt which supported the mattress 
platform, the boxed in mechanism beneath the platform which enclosed 
the jack, and the large, solid backrest with pillow straps. 

Archer had first introduced the King's Fund working party to the 
ideas of hospital trials in March 1964, just before the first draft specification 
was produced. At that time he had mentioned tests of 'a full-scale 
prototype' under hospital conditions. 36 In August, as Agnew's prototype 
neared completion, he reported that 'some thought had been given to the 
question of how new patterns of bedstead should best be tested under 
hospital conditions.' 37 At the same meeting, S. E. Harrison, Work Study 
Officer for the North East Thames Metropolitan Hospital Board was invited 
to report on two trials of hospital beds with which he had been involved. 38 
At the next meeting, in October, Archer reported that Reginald Talbot, of 
the College of Aeronautics at Cranfield 'would continue to plan field trials of 
the prototype'. And at a meeting of the Working Party a month later, a Plan 
for the Remainder of the Enquiry was presented: 39 
AAD/1 989/9, Job 1 , Agnew to Halls, 1 7.1 2.75. 

36 A/KE/PJ/17/19 KFWPHB, Minutes, 17.3.64, Item 25. 

37 A/KE/PJ/17/19 KFWPHB, Minutes, 20.8.64, Item 55. 

From 1960, the MOH allowed each RHB one work study officer charged to Exchequer funds. 
Some employed additional officers from their own resources. Considered innovative 
around 1960, as the decade wore on Work Study was more often involved with bonus 
calculation and contracting out of services. Anon., 'Hospital Work Study makes progress', 
British Hospital and Social Service Journal, April 1 2, 1 963, p. 41 7. 

A/KE/PJ/17/19, KFWPHB Minutes, 4.11.64, Item 70. 



111 



The Working Party was reminded that in issuing its design specification it 
had achieved the main object which had been agreed at its first 
meeting but that the ultimate purpose of the study would only be 
accomplished when a few approved patterns of bedstead were 
available for supply to hospitals at a price acceptable to the Ministry 
of Health. 

The next step should therefore be the confidential scrutiny of each 
design prepared to the Working Party's specification, preferably 
embodied in prototype form, so that those likely to result in 
satisfactory bedsteads could be chosen for trials under ward 
conditions. For this purpose an adequate sample quantity of 
bedsteads made to each design would have to be tested, and the 
results should be used in the revision of the specification and in the 
final selection of designs qualifying for the approval of the Ministry. 40 

At the same meeting, it was noted that although: 

... no grant would be available from the Fund to meet the cost of this 
development programme ... Mr Hunt considered it likely that the 
necessary commitments could be met from the Ministry's resources 
and assured the Working Party of his co-operation for this purpose. 



The Minutes of this stage of the project mask considerable reservations on 
the part of senior officials of the Fund, and several months of behind-the- 
scenes activity. Archer, aware that the Fund was increasingly concerned 
about expenditure of time and money, had approached the Ministry of 
Health directly late in 1964. Feelings were running high on both sides. After 
a meeting with Hunt, together with Davies and Howes from Supplies 

Division, Archer reported to Misha Black that 

... all three regard the Working Party as a gathering of eccentrics who are 
not only most unrepresentative of the hospital service but also liable 
to gallop off in all directions at a moment's notice. Mr Davies said 
that they would have produced nothing without our intervention. 
Proprieties demanded, however, that the development of an agreed 
bedstead specification (and a very small number of standardised 
designs) be done through the Working Party if it is humanly 
possible. Mr Hunt says that he must not be seen too clearly as 
leading, even from behind. He . . . would particularly welcome a 
programme for implementation of the design and field trials as set 

Ibid. 



112 



out in my memorandum. The Ministry would order and pay for up to 
200 trial beds and organise the manning of the team of observers . . 
. I pointed out that the King's Fund were threatening to withdraw or 
reduce their support. Mr Hunt and Mr Davies looked at one another 
and said they were sure they could get over that problem . . . there 
were precedents even for direct support. Since the Working Party 
has neither staff nor funds to carry out the field work itself, there 
should be no difficulty in persuading them to appoint agents to do 
the work and then meet in (say) six months time to endorse the 
results ... It occurs to me now, in retrospect, that it is quite 
extraordinary for the King's Fund to think of cutting down on our 
activities just when they are about to yield spectacular dividends. 



The practical results of this meeting were that the MOH agreed to fund the 
manufacture of twenty copies of the RCA prototype, and underwrite 
hospital trials to the tune of £20,000. Senior officials at the Fund were not 
pleased. Hall, the Director of Hospital Services, attended a meeting of the 
Working Party a few weeks later to make his views known: 

The Fund had paid the RCA a total of £13,200 . . . later it was suggested 
field trials were necessary . . . now MOH O&M people were talking 
of £20,000 (for these). Where was it going to end? He rejected the 
view that it was the Ministry's own business if they wanted to spend 
£1 0,000 or £20,000 on field trials, or that it was something to be 
grateful about. The Fund would under no circumstances give the 
RCA more than a further £2,500 to complete the studies . . .' 41 

The disagreements at this stage of the project are closely related to the 
interests of the various parties. The King's Fund's greatest asset was 
perhaps its reputation. Its judgement, and its financial management, were 
held in high esteem by the London medical world. It was not accustomed 
to pouring large sums of money into seemingly bottomless pits. Archer, 
understandably, was intent on pursuing his method to its conclusion; 
opportunities to carry out an experimental design project of this scale and 

41 AAD/1 989/9, Job 13, Main Box. Report on Working Party Meeting of 3.3.65, dated 5.3.65. 



113 



expense were likely to be few and far between. He and Hunt found 
common ground in their impatience with the Working Party, who may have 
been 'unrepresentative of the hospital service', but who were probably, for 
Hunt at least, all too representative of Hospital Management Committees 
throughout the country. Each of the members was, had been, or might 
easily have been invited to become, a member of an HMC. But Hunt had 
more pressing reasons to support Archer's field trials. His next appearance 
before the Public Accounts Committee was imminent, scheduled for 
February 1965, and he wanted to be able to report at least some progress 
towards the drawing up of equipment standards. 42 From this point, MOH 
officials became closely involved 'on the ground'. 

Twenty copies of the prototype were required for the trial and 
tenders were received from half a dozen companies. Only two were 
established in the medical field (Barnet Medical Developments and 
Hospital Metalcraft). Two were aircraft manufacturers, and the larger of 
these, Scottish Aviation, was awarded the contract in March 1965 on the 
basis of a unit price of £200 for twenty beds or £75 for a thousand. 43 Based 
at Prestwick, Scottish Aviation were seeking to diversify in the face of 
reduced demand for military aircraft. The twenty beds were built in space 
freed by the cancellation of the TSR2 project. 44 Their facilities impressed 
the inspector sent from the Ministry of Health's Technical Services Branch. 
Their engineering range was 'very wide . . . from close tolerance machine 



42 AAD/1 989/9, Job 7, memo, 29.10.64. 

43 

AAD/1 989/9, Job 13, List of Companies submitting tenders. 

44 

The TSR2 was designed to carry airborne nuclear weapons. The project was scrapped in 
Denis Healey's £56 million defence cuts announced in January 1965. Morgan, The 
Peoples Peace, 1990, p.249. 



114 



work on Rolls Royce engine castings to body building and fitting for ice 
cream vans.' 'As an aircraft firm looking to diversify', he added, 'Scottish 
Aviation are keen to please.' 45 Kenneth Agnew and Ministry of Health 
engineers made several visits to the factory during production and the 
twenty beds were completed relatively unproblematically. 

It had been agreed that Scottish Aviation could change 'materials, 
sections and detailed construction, provided general geometry remained 
the same and function was unaffected'. It was anticipated that their 
engineers might suggest alternative means of construction, such as the 
use of Bowden cables or other technologies common in the aircraft 
industry. In the event they suggested only 'variations in detail', and what 
amounted to twenty copies of Agnew's prototype were produced. 'What we 
ended up with', he was later to observe, 'was a set of theories dressed up 
as a finished product'. 46 In line with his view of the trials as a controlled 
experiment, Archer preferred to describe these beds as 'not an attempt at 
a design solution, but a research tool'. They were to be placed in a 
simulation of the real world, very similar to it in physical and behavioural 
terms, but less so in cognitive and social aspects. In addition, an attitude 
survey of patients and nurses was planned, together with morale and 
efficiency testing of nurses at Manchester University and energy 
expenditure of nurses at Edinburgh University. In the event, only the first of 
these was completed. 

Prior to the trials, what Archer referred to as prime facie 



45 

AAD/1 989/9, Job 13, Dean, Technical Services Branch, notes of a visit to Scottish Aviation, 
22.6.65. 

46 

Kenneth Agnew, 'Inventors and Inventiveness', lecture notes for Hatfield College of 
Technology, 22.4.68. 



115 



assessment of a single bed was carried out at the Westminster Hospital 
School of Nursing. Here 'Preliminary Validation Studies' were organised by 
the Work Study Department. There were resulting modifications to the 
backrest. The lock was removed, and rubber feet and a handle added to 
the base. 47 

The second phase of evaluation, comprising the field trials, took 
place at Chase Farm Hospital in Enfield. The North West Regional Board 
had an active Work Study team under the leadership of S.E.Harrison, who 
had already spoken to the King's Fund working party about evaluating 
hospital beds. The matron, Mary Larret, had recently arrived from the 
relative sophistication of a London teaching hospital. If these practical 
matters influenced the choice of hospital, more theoretical ones dictated 
the type of ward selected. A women's surgical ward was chosen as 
providing the most wideranging test of the prototype. I shall return to this 
issue in Chapter Six. 

The trials began on 20 September 1965. The procedure, worked out 
with the assistance of Harrison and Talbot involved a team of 'trained 
observers', most of whom were retired nurses, recording all activities 
involving ward beds from 6am until 1 0pm for a period of 5 months. For the 
first month the original ward beds were used. After this the new beds were 
substituted for 3 months, then the old ones returned for a further month. 
Observations were of two kinds: continuous, recording every incidence 
where attention was given to patients, and 'random', whereby the position 
of the movable elements of the bed were recorded at particular intervals. 
Both categories of observation were recorded as numbers, the continuous 



47 

AAD/1 989/9, Jobs 7 and 13, Trial Reports, Report on preliminary validation studies. 



116 



resulting in a 23 digit number, and the random a 37 digit number, which 
could be transferred to punched cards or tape. The trials were completed 
in January 1966, but there was substantial delay in the computer analysis 
that followed. 

The use of a computer to analyse the trial data was clearly of 
considerable importance to Archer in terms of the portrayal of the project, 
as well as the potential it gave for comparing large numbers of variables. In 
their published material, and in communications to the working party, the 
team took every opportunity to stress that the most powerful computer in 
the country was being used to handle the huge quantities of information 
generated by the investigation - invariably given as numbers of individual 
'pieces' or 'items'. 48 The computer in question was the University of 
Manchester Institute of Science and Technology (UMIST) Atlas. A. J. 
Wilmott, of the Department of Computation, was engaged to write the 
necessary programme. His analysis of the trial results dragged on into the 
summer. There were practical problems over getting the punched cards, 
prepared by a data processing company, to Manchester in the pristine 
condition required by the computer. Early batches had to be redone, and 
special containers purchased. Wilmott disagreed with Archer over the form 
in which the computer should produce results, complaining in July 1966 

that: 

The analysis so far has involved producing as much printed material as 
Dickens wrote into his novels. If a human being needs to look at, 
say, 500 tables, then a computer could do equally as well, provided 
the programmer was given adequate warning. 49 

48 

'No fewer than one and three quarter million separate pieces of information' were said to 
have been produced by the trials and validation studies. King's Fund, Design of Hospital 
Bedsteads, p. 10. 

49 

A/KE/PJ/1 7/1, Wilmott to Roberts, 5.7.66. 



117 



The King's Fund, mindful of the time and money expended, grew 
increasingly restive. The Chairman of the Working Party was heard to 
enquire, albeit while drinking sherry, 'Why a computer was essential, and 
what it could do that could not be done by someone with an adding 
machine?' At the same function another member opined that, as far as he 
could see, 'you feed a lot of garbage in and you get a lot of garbage out'. 50 
Eventually, however, the analysis was completed. Archer had requested 
that the computer be asked to compare 'every variable with every other 
variable'. For example, it would show how' often a patient got out of bed' 
varied in relation to the height of the bed. Each table was subjected to a 
significance test and it was anticipated that 'attitude studies and prime 
facie assessments (would) help direct attention to the most interesting 
relationships'. The team received the results in the form of columns of 
numbers which, for want of any other means, they resorted to pinning up 
all over the walls of a small room to see whether they could visually detect 
significant correlations. This was to answer three vital questions about the 
bed design: 1 .Does it fulfil the specification? 2. Does the specification 
correctly describe the user's needs? and 3. Is the ward-patient-nurse 
system created by the use of the new specification markedly better or 
worse than existing systems? 51 

It is questionable whether the computer analysis produced the 
results for which Archer hoped. Certainly it was answers to the third 
question that might prove most useful in promoting the specification. But, 

50 

AAD/1 989/9, Job 13, Gillian Patterson, Report on a meeting of the Working Party at the 
Hospital Centre, 1.8.66. 

51 

Quoted in Baynes, Industrial Design and the Community, p. 50. 



118 



on the question of reducing in-patient stays, for example, Harrison wrote to 
Gillian Patterson that 'the variations in length of stay month by month are 
startlingly large and clearly mask any effect which the new bed might have 
had'. The primary value in using a computer was probably rhetorical, 
especially among audiences alive to the growing role of computers in 
science and their potential role in management, including hospital 
management. Each of the professionals involved was anxious to bring 
credence to their particular disciplines. The sociologist who carried out the 

attitude survey wrote that: 

As a consumer survey this is probably one of the first of its kind since the 
introduction of a nationalised health service. Using the tools and 
concepts of sociology it has drawn to attention some features of 
hospital life which have been hitherto ignored or neglected . . . 
Above all it has helped to show how research methods in the social 
sciences can be used to help in solving hospital problems. 

But the small numbers of individuals questioned made the results of 
questionable value in what was then normal practice in survey technique. 
The nurses interviews were difficult, 'only thirteen had worked regularly 
with the new beds and one refused to answer any questions at all'. 
Interviewing the patients was difficult, too, 'Privacy was not always possible 
— frequently other patients would shout out their own opinions'. 

The report noted that 'Nurses liked the idea of the height adjuster 
but some day and all night nurses complained that they did not have time 
to use it.' The Report's summing up nurses attitudes was that 'the bed had 
some good features but they were put together wrongly'. Both Wilmott and 
Harrison published accounts of the trials, from the perspective of 
computing and work study, and both expressed the view that such 
techniques would become widely used, but there is no evidence that this 



119 



was the case. 52 For some contemporaries, they were a 'sledgehammer to 
crack a nut'. 

The Chase Farm trials had, however, a different kind of outcome in 
terms of modifications to the design of the bed. These were classed as 
'mechanical failures' which needed attention. The jacks fell too fast, the 
pull-out backrest was too awkward and the rising base was vulnerable to 
damage in its upper quarter. The observations which led to identification of 
these 'mechanical failures' were clearly regarded as different from the 
observation of interactions in the 'nurse-patient-bed' system. In part this 
was because what was being looked for in this 'system' were measurable 
effects of the 'bed as a whole' on wider issues. Did the new beds reduce 
length of patient stay? Did they encourage early ambulation? Did they 
reduce sick leave among nurses? It was the former type of question, 
however, that was of immediate interest to any potential manufacturer. 



52 

J.M. Haile and S.E.Harrison, 'Two views of the King's Fund Bed, I - Trials and Results', 
British Hospital and Social Service Review, May 5, 1 967, pp.81 4-81 6, S.E. Harrison, 
'Bedsteads on Trial', Hospital Management, Planning and Equipment, 30, May 1967, 
pp.245-7. A. J. Wilmott, 'Use of a computer in hospital bed design', Hospital Management. 
Planning and Equipment, 30, May 1967, pp.247-250.