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

169 



CHAPTER SIX 

THE SUCCESS OF THE KING'S FUND BED 

Design turns ideas about the world and social relations into the form of 

physical objects.^ 

Introduction 

Once considered radical, the above assertion is now almost prosaic. In 
much historical and cultural analysis of design and technology there is 
general agreement that artefacts embody ideas about the world. The task 
is demonstrating how. In this concluding chapter I will pursue the question 
of how the design specification for, and early built forms of, the King's Fund 
Bed embodied ideas about the changing worlds of hospital medicine and 
professional design in the 1960's. In both spheres, long- standing social 
relations, and practice, were altering rapidly. I shall argue that the success 
of the King's Fund Bed, in terms of its widespread appearance in British 
hospitals by 1975, was very closely related to how successfully it embodied 
some of these ideas. The bed was indeed a success for Archer's method, 
but possibly for reasons beyond systematic design's own criteria of 
satisfying the conflicting user needs identified in the method; that is unless 
the notion of need is problematised. 



Expertise 



A. Forty, Objects of Desire, Thames and Hudson, 1979, p.245, (1986 edn. 



170 



In the design world of the 1960's, science provided a powerful rhetoric. It 
was useful internally, in challenging traditional hierarchies such as that still 
prevailing in Britain in 1959 of 'fine artists first, craftspeople second, 
communications designers third and industrial designers a poor fourth'. 2 
And those who were able to use the new rhetoric had a powerful new 
mandate for the design profession as a whole. When directed externally, 
an alliance with science brought advantages, as so many professional 
groups discovered in the post war years; theoretical justification, certainly, 
but also contracts. 3 Bonsieppe's solid, serviceable sort of person who 
rationalised decision making and optimised design solutions, 'just what an 
industrial system needs', again comes to mind. Bonsieppe, an astute 
internal critic at Ulm, commented in 1967 that 'the word "science" . . . still 
performs an essentially suasive function in the process of consolidating the 
social status of the designer'. 4 Nearer home, hearing Janet Daley's fierce 
criticisms of Design Methods in the late 1960's, Broadbent wrote that 
'perhaps she underestimates ... the desperate need that many 
environmental designers have to be recognized as "respectable" by 
science' (this was at the Conference on Design Methods in Architecture). 5 

2 

Frayling, The Royal College of Art, p. 147, quoting Misha Black. 

3 

As methodological pluralism grew in sociology, for example, in the 1970's, practitioners were 
aware of the commercial disadvantages that a retreat from scientistic methods would 
bring. 'Anarchy is difficult to sell, and ... a lot of sociology is being bought and sold in the 
market place ... A loss of confidence in positivism (would) almost certainly make 
consultancies harder to obtain, make sociology less demonstrably useful.' C. Bell and H. 
Newby, 'The rise of methodological pluralism', in C. Bell and H. Newby (eds), Doing 
Sociological Research, London, George Allen and Unwin, 1977, pp.1 7-30. 

Quoted in Lindinger (ed), Ulm Design, p.1 1 1 . 

5 

G. Broadbent, 'Design method in architecture', in Broadbent and Ward (eds), Design Methods 
in Architecture, pp.1 5-21 :1 8. 



171 



If science provided a powerful rhetoric, abstraction provided a 
powerful tool. The abstraction of design problems to numbers, to diagrams, 
to generalised schedules and checklists promised a superordinate and 
universally applicable method which, by incorporating 'expert opinion', in 
suitably codified fashion, potentially did away with the need for it in any 
particular instance. Kenneth Agnew's description of a hospital equipment 
designer as a 'sort of boiled down and concentrated hospital staff is 
apposite here. 6 Furthermore, the process would be self-generating. It was 
pointed out by Archer and others that the use of operational research type 
methods in planning new hospitals in itself meant that there would be a 
need for expert opinion on equipment and other design issues long before 
any medical or nursing staff were appointed. 7 Other advantages were not 
lost on the MOH. Operational research-derived techniques such as 

network analysis 

could be used to sort out some of the complications of the planning 
process and also, incidentally, to demonstrate to medical 
consultants and local committees when they made suggestions for 
changes in the plans, what the cost of changing the project at that 
stage might be. 8 

The movement of power away from long-standing traditional locations 
within the professions, where it had resided at least since the beginning of 
the twentieth century, has come to be identified as a fundamental part of 
the growth of managerialism. For some designers, this trend pointed the 



AAD/1 989/9, Job 30, Kenneth Agnew, lecture to Castors conference, 9.5.68. 
7 AAD/1 989/9, Job 1, Working Document 8, 13.10.61. 

p 

E.L. Wallace of the MOH, addressing Work Study Officers on 'the thoughts that the Ministry 
had had on the matter'. Anon., 'Network Analysis in the Hospital Service', British Health 
and Social Service Journal, November 20th 1 964, pp.1 674-1 675:1 674. 



172 



way to a vastly expanded role. Others were not so sure. Misha Black, 

Archer's professor at the RCA during the bed project, was at pains to point 

out frequently during the 1960's and early 1970's that design and 

management were different activities; designers were indispensable to 

managers of course, but different. The designer was the: 

. . . irritant in the oyster ... he might well be the odd man out in tidy 

industrial hierarchy. Professional competence alone was insufficient 
. . . visionary capacity subsumed his practical everyday competency 
... the essential quality of design is creativity 9 

Design, as a profession, was a more precarious, and recent, activity than 
medicine. Leading exponents such as Black saw the need to defend an 
intrinsic expertise, often described as residing in the 'creative' aspects of a 
designer's work, against the threat posed by managerialism; something 
'anyone' could do. 

Notwithstanding Black's concerns, the designer/manager was a 
useful individual to other managers, similarly engaged in replacing expert 
opinion with a superordinate expertise and its operational consequences of 
centralisation, clear organizational structure, and standardisation. In few 
places in British institutional life were these power struggles more clearly 
played out than in the NHS, and in particular in the large organisational 
units of the Service, the hospitals. Slowly but surely, the King's Fund Bed 
made its way through the various factions, its protagonists sometimes 
anticipating opposition from the traditionally powerful which did not 
materialise, sometimes, as outsiders, getting the power relations wrong. 
The Bed's protagonists overestimated some (such as nurses) and 



g 

Misha Black, 'The Designer and the Manager', Tiffany Lecture Series on Corporate Design 
and Management, 24.10.73, audiotape, AAD/1 980/3. 



173 



underestimated others (such as the King's Fund) but for much of the time 
they were guided by those greater managers, the civil servants, with whose 
interests the project largely coincided. 10 1 shall now proceed to put some 
flesh on the bones of this argument, revisiting many of the episodes 
described in the previous chapters. 

The privileged status of science, and scientific method as a way of 
acquiring knowledge about the world, was an overriding presupposition in 
Archer's method. 11 His scientism was pervasive. As noted in Chapter Two, 
it underlay not only the methods he advocated for the design process, but 
also his preferred accounting for what others might regard as social or 
cultural phenomena. Creativity, for example, was discussed in terms of 
randomness and chaos theory. 12 In psychology, he was interested in the 
'personal construct theory' of George Kelly and considered employing it in 
eliciting user needs. 13 This is at first sight surprising, given that Kelly is 
credited with abandoning an objective, behaviourist approach to 



For a study of these issues in the English Civil Service during the inter-war period see Gail 
Savage, The Social Construction of Expertise: The English Civil Service and Its Influence, 
1919-1939, Pittsburgh, University of Pittsburgh Press, 1996. 

What constitutes scientific method is of course open to interpretation. Archer cited, among 
others, Russell Ackoff, whose book on scientific method was prompted by the operational 
researcher's problem of how to apply it in unfamiliar spheres. Ackoff adhered to an 
orthodox, positivist account, but was careful to point out that 'science itself was a 
phenomenon that may be looked at in many different ways'. Russell Ackoff, Scientific 
Method: optimising applied research decisions, New York, John Wiley and Sons, 1962, 
p.vii. 

12 

Other authors in the 1960's and 70's found in elements of the 'new physics' a potential 
explanation for human qualities such as creativity. See, for example, Michael Talbot, 
Mysticism and the New Physics, London, Routledge and Kegan Paul, 1981 . (Apparently 
written circa 1970.) 

1 3 

G. Kelly, The psychology of personal construct, New York, Norton, 1955. Kelly was one of a 
number of psychologists, including Leon Festinger, Fritz Heider and H.H. Kelley, who 
established the study of interpersonal relationships on a cognitive rather than a 
behaviourist footing. Smith, History of the Human Sciences, p. 777. 



174 



interpersonal relationships and substituting a concern with cognition, 
attributing behaviour to thought and expectation rather than motive and 
need. Since Archer did not hesitate to use the latter concepts in much of 
his published work it was perhaps more likely that the attraction of personal 
construct theory lay in its key model of everyday human interaction, which 
Kelly regarded as being 'identical to the process of science'. Like much 
cognitive psychology, it was equally insistent in its striving for objectivity. It 
is not difficult to see the attraction of this for Archer, nor why, in later 
writing, he cited Karl Popper as the spiritual father of Design Research, 
(operational research was its mother). 14 He considered that the impact of 
Popper's Conjectures and Refutations, published in 1963, 'was immense. 
Conjecture, exploration and refutation (or, more popularly, proposition, 
development and test) is exactly what designers do! Design activity was 
scientifically respectable!' 15 

But in the 1960's it was a rejection of scientism which underlay 
much of the criticism of systematic methods such as Archer's which came 
from the design professions themselves. Some practitioners, like Black, 
feared the reduction of 'creativity' to science. Archer recalled that greatest 
opposition within the RCA came from the departments of fashion and 
graphics; both fields where individual creativity had a high premium. 16 And 
for many designers in commercial practice, everyday realities meant such 
methods appeared irrelevant, or beyond their resources 'when they had a 

14 

Bruce Archer, 'Design, innovation, agility', Design Studies, 20, 1999, pp. 565-571 :567. The 
term 'Design Research', was preferred to 'Design Methods' from around 1980. Much of the 
content was similar. 

15 

Ibid, p.567. Many participants in the Design Methods debates had recourse to the philosophy 
of science. Popper, Kuhn, and (much less frequently) Polanyi, were the most cited authors. 

Bruce Archer, Interview, 10.5.99. 



175 



deadline for tomorrow'. But in academic circles, theoretical criticisms were 
made explicit. The proceedings of the British conferences on Design 
Methods held during the 1960's chart a change from advocates of new and 
apparently helpful techniques addressing generally receptive audiences 
with similar outlooks, to intense debates where proponents of scientistic 
approaches might be subjected to 'onslaughts' and 'the severest of 
philosophical criticisms of their work'. 17 (The general rejection of Design 
Methods that came in the 1970's, its partial 'saving' by the creation of 
'second' and 'third generation' methods, the contribution of the movement 
to computer aided design techniques, and its rebirth in the form of 'Design 
Research', where it is apparently 'alive and well', need not be pursued here 
to any extent. 18 It might be noted that in an almost exactly analogous 
process, second, third and even fourth generation methods have been 
devised in evaluation, another area where the role of scientistic methods 
has been hotly debated. 19 ) 

During the 1960's conferences and ensuing debates, Archer's 
assertions about design came under scrutiny. Some commentators were 
impressed. His model of the design process 'as an assemblage of OR 



Proceedings of the first conference are in Jones and Thornley (eds), Conference on Design 
Methods, 1962. (Archer was on the organizing Committee) and of the third in Broadbent 
and Ward (eds), Design Methods in Architecture, London, Lund Humphries, 1969. See 
Broadbent, 'Design method in architecture' in this volume p. 1 7-21 , for an account of 
Daley's 'devastating attack' on behaviourist views. 

1 8 

For a summary of these changes see Cross, Developments in Design Methodology, pp. SOS- 
SOS. 

19 

Egon Guba and Yvonna Lincoln, Fourth Generation Evaluation, Newbury Park, Sage 
Publications, 1989. See Ghislaine Lawrence, 'Rats, Street Gangs and Culture: Evaluation 
in Museums' in G. Kavanagh (ed), Museum Languages: Objects and Texts, Leicester, 
Leicester University Press, 1991, pp. 9-32, for an exploration of these debates in the 
museum context. 



176 

techniques . . . was enormously sophisticated'. 20 Others suggested there 
might be alternatives to his view of a house as 'built to keep in a consistent 
climate and to keep out predators', rather than, say, as a sacred space, 
or said of his assertion that 'We grow, gather and eat food to keep our 
metabolism on an even keel', 'even primitive man does much more than 
that'. 21 Gradually a coherent critique emerged of 'first generation' design 
methods such as Archer's and Alexander's, which focused on several 
issues but in particular their behaviourist assumptions. It was this issue 
which formed the basis of one of the earliest and most cogent attacks. The 
philosopher Janet Daley delivered a paper at the 1967 Design Methods 
conference which in her view demolished many of the arguments of 
speakers who came from engineering or science backgrounds and were 
less well versed in philosophy. 22 

Some of these speakers' assertions could indeed have come from a 
neo-behaviourist tract of the 1940's. 'The chief difficulty in building for 
human needs', said one 'is that the needs themselves cannot be observed. 
We can see people's behaviour'. Behaviour was 'a system of operationally 
defined needs . . . within a given environment'. 23 That behaviour was the 
empirical counterpart of need was a fundamental tenet of behaviourists. 24 

20 

G. Broadbent, 'Design Method in Architecture', in Broadbent and Ward (eds), Design 
Methods in Architecture, pp.1 5-21 :1 5. 

21 

Amos Rapoport, 'Facts and Models' in Broadbent and Ward (eds), Design Methods in 
Architecture, pp.1 36-1 46:1 43. 

22 

Janet Daley, 'A philosophical critique of behaviourism in architectural design', in Broadbent 
and Ward (eds), Design Methods in Architecture, pp.71 -75. Daley expanded this critique in 
1982 in 'Design Creativity and the Understanding of Objects', reprinted in Cross (eds), 
Developments in Design Methodology, 1984, pp.291 -302. 

23 

G. Broadbent, 'Design Method in Architecture', in Broadbent and Ward, Design Methods in 
Architecture, pp. 15-21:18, paraphrasing another contributor, Studer. 

24 

For what has been constant and what has not in 'behaviourism' as variously defined, see 



177 



Critics however considered that design methods which overemphasised 
what was 'measurable in the physical sense, computable and otherwise 
supported by "objective" evidence' neglected what was variously described 
as 'the humanness of human affairs', 'values', and 'emotion or 
judgement'. 25 

This criticism of behaviourist operationalism was to recur in widely 
disparate fields in the 1960's. For whereas behaviourism had been, for 
much of the twentieth century, a school of thought in psychology, by the 
1960's it provided a theoretical underpinning for rather more extensive 
enterprises, principally 'biological psychology' or 'sociobiology', 
neuroscience and cognitive science. Like behaviourism, all three were 
associated with claims to have established objective science in their field, 
and also with claims to a unified science; science that joined the physical 
and human sciences and, within the human sciences, united psychology 
and sociology into 'a single field'. 26 Biological psychology was the recipient 
of massive funding by United States foundations in the 1950's and the 
basis of the Behavioural Sciences Programme funded by the Ford 
Foundation from 1952, which took as its goal 'an ideal unification of 
psychology and the social sciences', thereby creating a science applicable 
to public affairs. This, and related programmes, have been well 
documented by historians, highlighting as they do the central relevance of 



Peter Senn, 'What is "behavioural science?"(sic)- notes toward a history', Journal of the 
History of Behavioral Sciences, 2, 1966, pp.1 05-1 22 paper. For a more recent perspective 
see chapters 2 and 3 of Bernard Baars, The Cognitive Revolution in Psychology, New 
York, The Guilford Press, 1986. 

25 

G. Broadbent, 'Design Method in Architecture' in Broadbent and Ward (eds), Design Methods 
in ArchitecturewAb^ :1 8. 

Smith, History of the Human Sciences, p. 801 . 



178 



the war-time and post-war contexts, and of military and corporate 
sponsorship, to the trajectory of the behavioural sciences. Steve Heims 
account of the Cybernetics Group, subtitled 'Constructing a Social Science 
for Postwar America', is based around the ten conferences sponsored by 
the Macy Foundation from 1946-53, and these conferences also have a 
central place in Donna Haraway's account of the creation of the 
sociobiological synthesis of the 1970's. 27 Other historians have focused on 
the RAND Corporation's sponsorship of social science, supported by the 
U.S. Air Force and entailing much work on game theory, simulation and 
other techniques derived from operational research. 28 

Archer's published work drew heavily on concepts and analogies 
current in these fields. His early thinking was also, by his own account, 
'dominated by systems analysis'. 29 General systems theory, the attempt to 
construct an objective science of everything, was of considerable interest 
to those who looked for unified sciences. 30 Although systems theory 
became very closely associated with science and, especially, engineering, 
it had originally attracted practitioners from very disparate disciplines. In 
Britain, the Institute for the Comparative Study of History, Philosophy and 
the Sciences was founded in 1 946. 31 It began publishing its journal, 

27 

Heims, The Cybernetics Group, 1991, Haraway, 'The High Cost of Information Technology', 
1981-2. 

See Mirowski, 'Cyborg Agonistes', 1999, for example. 

29 

Archer, 'Design, innovation, agility', p.567. 

30 

Pickering divides the cyborg sciences into those dealing with complex systems, and those 
dealing with the mind. The systems sciences were 'ontologically promiscuous. Rather than 
respecting the traditional boundary between the human and the nonhuman, one could do 
the systems science of humans, of nonhumans or of assemblages of humans and 
nonhumans.' Pickering, Units of Analysis, p. 3. 

31 

Editorial, 'The Aims of the Journal', Systematics, 1, no 1, 1963, p.1. 



179 



Systematics, in 1963, following 'the discovery that systems have 
characteristics so completely universal as to make possible a synthesis of 
our appreciation of the three great fields of human enquiry: Man, the 
Universe and God.' 32 Volume One contained papers on, among other 
subjects, religion in the ancient Americas, the phenomenology of 
perception, theoretical physics, chess playing machines, the relation of 
geophysics to 'Plato's Atlantis and the Exodus', psychical research and the 
control of industrial engineering plant. 

In the United States, the Society for the Advancement of General 
System Theory was organised under a section of the American Society for 
the Advancement of Science in 1954. Its prime instigator was the biologist 
polymath, Ludwig von Bertalanffy. Bertalanffy published 'An Outline of 
General System Theory' in the British Journal for the Philosophy of 
Science in 1950. 33 Although these British and American groups 'started 
from widely differing premises', by 1963 they had, according to the first 
editorial in Systematics 'converged to a point where interchange (could) be 
fruitful'. Early forms of systems theory had attracted holists such as 
Gregory Bateson and Margaret Mead, both of whom also attended Macy 
conferences. 34 But in later forms, such as that propounded by the now 
Toronto-based scholar, Anatol Rapoport, the field was dominated by more 
utilitarian concerns. Rapoport was an influential exponent of both a logical 
and mathematical basis for systems theory and its practical application. 
Systems theory became increasingly attractive to engineers and 

Ibid. 

33 

L. von Bertalanffy, 'An Outline of General System Theory', British Journal for the Philosophy 
of Science, 1 , August 1 950, pp.1 65-1 71 . 

34 

Heims, The Cybernetics Group, p. 24. 



180 



management theorists as its original holistic and organismic character 
dwindled in favour of operationalised knowledge based on objective 
science, as expounded by Rapoport. In one important respect this holistic 
character was retained. This was in the functionalism which informed all 
the cyborg sciences of systems and their efforts to produce science which 
would usefully contribute to human policy making, or perhaps even control 
it. 35 

Another prominent facet of systems theory as developed by 
Rapoport was its operationalism. Operationalism had gone hand in hand 
with behaviourism for much of the latter's existence, given the 
behaviourists problem of what it was they were actually measuring 36 
Rapoport's operationalism was concerned, not with the elucidation of 'new' 
knowledge under the classical controlled conditions of scientific 
experiment, where the number of variables was reduced to a minimum, but 
with the determining of mathematical algorithms that could be applied to 
the uncontrolled social world where the number of variables was, in 
principle, infinite. In what he referred to as 'practical science', Rapoport 
sought ways of matching up the two worlds 'nearly enough', as a means of 
operationalising the abstract and generalised knowledge he sought to 
apply. A central strategy involved invoking the classical theory of heuristics. 
(Heuristics subsequently became of enough interest to management 
scientists to warrant its own journal of the same name). Archer made use 

35 

Stafford Beer is a British proponent of the cyborg sciences who 'has applied cybernetic 
reasoning to industrial processes and socioeconomic systems and tested them when he 
assisted Salvador Allende's government in Chile in managing the social and economic 
organisation of the country' according to Heims, The Cybernetics Group, p.283. 

See 'Operationism in Psychology: A discussion of contextual antecedents and an historical 
Interpretation of its Longevity', Journal of the History of the Behavioural Sciences, 25, April 
1989, pp.1 39-1 53. 



181 



of the concept, citing not Rapoport but a book entitled How to Solve It, first 

published by the Stanford-based mathematician G. Polya in 1946. 37 

Subtitled 'a new aspect of mathematical method' the book was an attempt 

to revive the 'ancient study of heuristics ' in a modern and modest form'. 

'Heuristic reasoning', asserted the author, 'is reasoning not regarded as 

final and strict but as provisional and plausible only, whose purpose is to 

discover the solution of the present problem'. It was often based on 

induction, and on analogy. 38 

Although Archer did not cite Rapoport it seems likely that his 

systems theory informed key elements of his design method. During 

Archer's year at Ulm, Rapoport's ideas had been much discussed. Archer 

did however cite Herbert Simon, the 'theorist of groups and organizations' 

who went on to become involved in computer simulations of the human 

brain. In Models of Man, mathematical essays on rational human behaviour 

in a social setting, which Simon published in 1957, he developed an 

alternative to the concept of rational man, used in classical economic 

theory and in earlier forms of decision theory, who was required to have: 
. . . powers of prescience and capacities for computation resembling those 
we usually attribute to God. When we take seriously the limits of 
human capacity for calculation, we are led ... to a significantly 
different view of rationality; and we begin to see how the rational 
and the non-rational are compounded in administrative man'. 39 



37 

G. Polya, How to Solve It, Princeton, Princeton University Press, 1945, (2nd edn. 1957). 

Ibid, pp.1 1 2-1 1 3. Polya acknowledged, among others, the gestalt psychologist Wolfgang 
Kohler and the originator of pragmatism, William James, as influential to his thinking. 

39 

Herbert Simon, Models of Man: mathematical essays on rational human behaviour in a social 
setting, New York, John Wiley and Sons, 1957, p. 72. 



182 



This concept of 'bounded rationality', which he was careful to distinguish 

from 'irrationality', led Simon to focus on ways of simplifying the choice 

problem in decision theory to bring it within the powers of human 

computation. The key to this process was the replacement of: 
... the goal of maximising with the goal of satisficing, of finding a course of 
action that is "good enough" (his italics) ... it will be seen that an 
organism that satisfices has no need of estimates of joint probability 
distributions, or of complete and consistent preference orderings of 
all possible alternatives of action. 40 

Archer made explicit use of Simon's concepts and terminology in his 
systematic design method, and was later to remark that it was only after 
1960, and the publication of works by 'people such as Herbert Simon', that 
'it was generally accepted that systems analysis was not so much an 
explanatory theory as a useful methodology'. 41 

This is a pertinent comment. I have alluded to the likely theoretical 
antecedents of Archer's ideas on design in the 1960's at some length 
precisely because the progressive operationalisation of knowledge which 
many of them entailed served to distance theory from method. This 
resulted in his, and many other's methods being presented as useful 
techniques devoid of theoretical origins or assumptions. This was 
compounded by a tendency to cite secondary sources and textbooks, 



40 

Ibid, p.204. In the essay entitled 'Application of servomechanism theory to production control', 
Simon draws 'obvious analogies' between powerful techniques developed for the analysis 
of electrical and mechanical control systems and servomechanisms and human production 
control systems used to plan and schedule production in business concerns. ' ... the 
notion of a servomechanism incorporating human links is by no means novel . . . many gun 
sighting servos involve such a link ... all such systems would be included in Wiener's 
general program for cybernetics.' Simon, Models of Man, pp.21 9-24. 

41 

Archer, 'Design, innovation, agility', p.567. 



183 



perhaps as more accessible to his intended audience, the notoriously 
unintellectual British designer. 42 Citations can be found in Archer's work to 
Bertalanffy, and to Wiener, but are more often to writers such as Russell 
Ackoff, Stafford Beer, and C. West Churchman, who made plain the 
potential of an applied, objective and unified social science for 
management and control. 43 A similar pattern of citation is to be found in the 
work of others who wrote in favour of Design Methods, with British and 
North American authors in particular favouring the secondary material and 
a more atheoretical stance. 

But such operationalised knowledge did of course bring theoretical 
assumptions which betrayed its close links to behaviourism, and which 
were of considerable import for the King's Fund Bed. As outlined in 
Chapter Two, the first article in Archer's series Systematic Method for 
Designers described a key 'man-tool-work-environment system', in which 
each element might react on each of the others, which served to make a 
tool-using individual situated among environmental variables the subject of 
enquiry. He represented this by means of a diagram consisting of a circle 
with three equidistant points on its perimeter labelled tool, work and 
environment. At the centre is a line drawing of a woman operating a 
vacuum cleaner, labelled (wo)man. The three points and the central figure 
are linked by arrows to each other in both directions. The diagram is said to 
'imply' nine activities: man acts on tool, tool acts on man, man acts on work 

42 

As Piatt points out in her survey of sociological research methods, one cannot assume that 
the citation of a particular author means that their methods were actually employed, but 
makes the relevant point that patterns of citation are closely linked to questions of intended 
audience. Piatt, A History of Sociological Research Methods in America, p.1 39. 

43 

Ackoff, Scientific Method, 1962, Stafford Beer, Decision and Control, New York, John Wiley, 
1966, C. West Churchman, Prediction and Optimal Decision, New York, Prentice-Hall, 
1961. 



184 



. . . and so forth. Earlier exponents of systems theory including the English 
author J.G. Bennet had elaborated complex theories of the properties of 
systems composed of monads (single entities), dyads (two related entities 
), triads (three related entities) and so on. In Bennet's terminology, similar 
to Archers, each was said to 'imply' certain properties, and the triad is 
represented diagrammatically by the same device, the punctuated circle of 
arrows, which Archer used to represent the design process. There is, after 
all, no reason perse why a circle of arrows should represent the design 
process, but the diagram did useful work in abstracting the design process 
to a generalised system. Diagrams have not been greatly studied in the 
history of science or representational practice generally, but the studies 
that do exist suggest they are a fruitful area to explore. It is perhaps not 
entirely coincidental that one of the rather few analyses of the work done 
by diagrammatic representation concerns the publications of E.O. 
Wilson. 44 The architect of sociobiology, Wilson, like most proponents of 
design methods, was also preoccupied with the relevance of natural 
science to the social world. 

Formulating the design problem in this way led rather directly to the 
individual nurse and the work which she did with the bed becoming the 
primary focus to which disciplines employing the methods and concepts of 
the behavioural sciences could be applied. Those to which Archer had 
greatest recourse were ergonomics, together with the anthropometrics on 
which it was based, and, to a lesser extent, applied psychology in the later, 
evaluative stages of the project. Most of the history of ergonomics to date 



44 

G.Myers, 'Every picture tells a story: Illustrations in E.O. Wilson's Sociobiology, in M. Lynch 
and S. Woolgar, Representation in Scientific Practice, Cambridge, Mass., The MIT Press, 
1990, pp231 -266. 



185 



has been written by practitioners, especially those who fostered the subject 
in the immediate post-war years having been involved with military 
operational research. 45 But it was not only its war-time origins that 
ergonomics shared with other cyborg sciences. Participants describe 
seemingly obvious improvements waiting to be made to the design of 
equipment and the workplace once somebody (i.e. a scientist) studied it 
objectively. Donna Haraway provides an alternative perspective in her 
account of the sociobiological synthesis of the 1970's, describing 

ergonomics as being: 

. . . about optimising the energy-information relations of all known 

components in the organisation of labor ... the second systems 
theoretic tool for reconceptualising organisms and societies ... a 
cybernetics of the hierarchical division of labour. 

which provided the data for the optimisation techniques of operational 
research. 46 The central recourse to ergonomics in the bed project had 
rather direct consequences. It prioritised consideration of firstly, work over 
'not work', and therefore nurses (workers) over patients, and secondly, the 
individual over the social, nurses over nurses as a group. 47 1 shall pursue 
first the question of the 'not-workers', that is the patients. 

It is striking how often published accounts of the King's Fund Bed 
specification gave improved patient comfort as the primary reason for the 
new design. Journalists seem to have assumed this to be the case. 48 The 



45 

See for example Murrell, How Ergonomics Became Part of Design', pp72-72. 

46 

Haraway, 'The High Cost of Information', p. 250. 

47 

It was noted by the RCA team during a subsequent project to design a commode that the 
commode was a 'patient aid', not a 'nursing aid' like the bed. AAD/1 989/9, Job 124. 

48 

For example, 'A bed to succour the sick', New Scientist, 9 March 1967, p.463. 



186 



King's Fund Working Party, in the document summarising their findings 
before the RCA team joined forces with them, listed the patient's needs 
first. From time to time after this, Working Party members raised concerns 
to do with patient needs. During preparation of the questionnaire to the 
Chase Farm patients, for example, they directed that 'a question should be 
included in the attitude survey to determine what advantage would be 
gained if the backrest was operable by the patient', though no such 
question appeared in the final questionnaire. 49 In practice, the fact that the 
trials were being carried out with formal procedures overseen by the RCA 
team meant the latter's concerns largely prevailed. Archer had made it 
clear from the outset that subjective issues, such as comfort, were 
'notoriously hard to measure'. Where issues concerning patients' use of the 
bed were susceptible to objective measurement, either directly, or by 
means of indicators, they were certainly addressed. They were to be 
discovered largely by referring to anthropometric and physiological data. 
(Not surprisingly, rather little ergonomic data concerning patients existed.) 
It was anthropometric data for males up to the ninetieth percentile lying 
down that determined the bed length initially stipulated in the first draft 
specification, a significant increase on the usual length for hospital beds. 
Quantifiable behavioural indicators were also employed. Statistics 
concerning falls from or around hospital beds mattered to hospitals, were 
widely available, and could be invoked in support of a low height facility 
which would assist patients getting in and out of bed or reduce the severity 
of falls from the bed. 

But other factors in the methods adopted, which were geared to 



49 A/KE/PJ/17/19, KFWPHB Minutes, 5.5.65. 



187 



studying one sort of behaviour, that is work, tended to diminish the 
prominence of behaviour concerned with 'not work'. So although the list of 
bed usages contained those of being 'an identifiable home to the patient, 
or of providing privacy, these were not often correlated with specific, 
distinguishable and therefore countable behaviours. The techniques 
involving numerical ranking that were used in the early stages to 'direct the 
designers attention to what was important' were derived from the list of bed 
usages. 'Critical factors (those properties necessary to support a 
usage/activity) were attached to each usage, and a ranked list of factors 
produced by means of placing those which were relevant to more 
usages/activities above those relevant to less. And although the overall 
number of bed usages relating to patients was greater than that relating to 
nurses, the usages relating to nurses were defined according to different 
kinds of work practices which made them susceptible to sub division into 
large numbers of activities. Therefore nurses' 'use of the bed as a 
treatment table' comprised five activities, demanding twelve critical factors, 
and each time a critical factor was ascribed to an activity, it rose higher on 
the ranked list. Use of the bed as an examination table, and as a 
workbench, were listed separately, further adding to the number of relevant 
activities demanding critical factors. At the other extreme, patients' 'use of 
the bed as a social centre', required no critical factors, only general 
appearance being relevant. 50 

Such techniques contributed in large measure to the bed being 
height adjustable. This elegant solution to the conflicting needs of patients 

50 

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, May-August 1964. 



188 



and attendants potentially solved the objectively measured problems (such 
as height, falls, lifting) of both groups, but had implications for the 
'notoriously subjective' issue of comfort. With the mattress at the specified 
lowest height, there was very little space below the mattress platform to 
accommodate both the mechanism and room for attendants to get their 
feet, or cleaning equipment, underneath. To maximise this and still achieve 
the low overall height, the mattress itself had to be as thin as possible. 
(The design of the mattress was not within the specification, but a thin 
mattress was an almost inevitable requirement if the full range of height 
adjustment specified was to be achieved.) This resulted in criticism from 
some quarters and in the team specifically searching for evidence that 
patients could be comfortable on four inches of foam. (Sprung mattresses, 
still often used in hospitals at the time, could not be made as thin as this.) 
Although the low height was partly for the benefit of patients getting in and 
out of bed (this also reduced nurses lifting problems), the underbed 
clearance problem arose because of the mechanism to raise the bed to the 
optimal height for nurses and medical attendants. 51 

The solution was not of course a necessary one. Even when there 
was agreement on the problem, different solutions were available. U.S. 
bed studies, also considered a contribution to rational design making in the 
hospital field and based largely on anthropometric and ergonomic data, 
also found that high height was best for nurses, and low height best for 
patients, but some had concluded 'that nurses did not spend enough time 



51 

A focus on the ergonomics of lifting also inclined the team to make the bed as narrow as 
possible. Physiotherapists to whom they suggested running a trial of this told them it was 
common knowledge that lifting patients was easier in a narrow bed, and thought what 
ought to be investigated was whether patients were comfortable in narrower beds. 
Interview, Gillian Patterson, 29.1.98. 



189 



by the bed to warrant adjusting it to their needs'. 52 American nursing 
practice differed from British, but presuppositions about how important 
nurses needs were clearly affected the outcome here, as they did in the 
RCA study, but with different result. In theory, the RCA study could have 
come to the same conclusion; how much time by the bed was 'enough' to 
warrant adjusting the bed to the nurses' needs? If the issue was to be 
decided by who spent more time in proximity with the bed, then the patient 
would always win out. But in the RCA study different presuppositions about 
the bed 'problem' prevailed; presuppositions about work, workers, labour 
shortage and expenditure in the NHS. The breakdown of bed usages, 
apparently so obvious as not to require the substantial evidential 
justification that accompanied each point in the resultant specification, in 
fact relied heavily on an ergonomic view of the bed. 'Not work' was largely 
invisible to the method, unless it could be dealt with anthropometrically, or, 
sometimes, but not always, physiologically. Laboratory research on sleep 
was taken into account, for example, but some pressing patient concerns 
do not appear to have been constituted as design problems by the team, 
even though they had a physiological component. 

Perhaps the most prominent of these was the question of bedpans. 
Most available sources of information on hospital inpatients' views 
suggested that the use of bedpans was one of the most disliked aspects of 
life in the ward. 53 The 'bed pan round' was still a feature of ward routine in 
many hospitals in the 1960's, with bed space curtains relatively new and 
not universally installed . (Movable screens around beds were used prior to 



52 

Ganong/Smalley 



53 

See the sources in notes 57, 58 and 59. 



190 



this, though not, apparently, in some military hospitals). Early on in the 
project, Doreen Norton told the RCA team 'our hospitals are not well 
provided with toilets: we will therefore use bedpans for some time. 54 

Although the purposes of a bed listed by the RCA study included 
those of providing 'an identifiable home' to the patient, and privacy, the 
team dealt with the bedpan question under the bed usage described as 'a 
place for excretion.' Consideration here was largely from the point of view 
of the nurse: the critical factors said to be involved were 'height adjustment, 
stability, drainage, cleaning, parking for vessel, and tucking in surfaces'; a 
statement of the attendant's requirements rather than the patient's, 
assessed from a mechanical, rather than an attitudinal point of view 
(nurses didn't like bed pans either). 55 

Again, the solution was not, per se, a necessary one. A bed 
available on the US market incorporated 'a personal toilet and shower'. 
Whilst the team's preconceptions as to what would be acceptable 
financially would have undoubtedly (and correctly) precluded such a 
solution, it does seem that the problem of bedpans had not figured large. 
And although subjective issues of patient's embarrassment were at stake, 
so were physiological ones of constipation. But not surprisingly, ergonomic 
data on defaecation was unavailable, despite the fact that it, too, was 
reducible to dimensions, muscular forces and motivation. Less emphasis 
on height adjustment and its mechanism would perhaps have allowed for 
the exploration of innovative solutions which might have alleviated to some 



54 

AAD/1 989/9, Job 7, note of conversation with Doreen Norton, 29.11.63. 

55 

Royal College of Art, Studies in the function and design of non-surgical hospital equipment, 
Report No17 General Purpose Hospital Bedstead: summary of analyses leading to user 
specification, May-August 1964. 



191 



extent problems of privacy and posture for the patient, and of lifting for the 
nurse. These, however, might well have required use of the under-bed 
space that was largely unavailable because of the demands of adjustable 
height and its mechanism. 

Apart form anthropometric and some physiological data, nursing 
opinion was the other principal source of information on patients. Although 
the occupants of beds in the Chase Farm trials were asked for their 
opinions by means of a structured questionnaire, patients' views do not 
appear to have been solicited in the decisive early stages of the project 
prior to the publication of the draft specification. None were included with 
the groups of hospital staff answering the Panorama' questionnaire, though 
plenty of former hospital patients must have been among those watching 
prime- time television. Nor do any of the 'focus groups held in the early 
stages of the project seem to have involved them. This was a rather direct 
result of the methodological concerns, but was also perhaps not surprising 
given the status of most hospital patients in Britain throughout the 20th 
century, as either objects of charity or beneficiaries of the State. The 
studies of everyday life in NHS hospitals which began to appear from the 
late 1950's onwards had a number of consistent themes. Patients, it 
seemed, were often not treated as responsible adults and found it hard to 
obtain information about their condition. Hospital life was characterised by 
petty rules, inflexible regimes and loss of dignity and privacy. On the whole, 
however, nobody complained very much. 

In 1958, the Central Health Services Council had commissioned The 
Pattern of the In-Patient's Day, published in 1961 . 56 The much-cited The 



56 Central Health Services Council, The Pattern of the In-Patient's Day, HMSO, 1961. 



192 



Patient's Attitude to Nursing Care, by Anne McGhee, was also published 

that year. 57 This work was certainly known to the RCA team. Articles in the 

hospital press included "The Patient's View of the Hospital' by S.C. 

Haywood et al. 58 The tone of these studies was moderate and criticism 

was implicit rather than overt, but the patient was at least now visible to 

other than the medical gaze. And an alternative source of patients' opinion 

provided distinctly alternative views. The years immediately following 1948 

had seen little adverse comment from users of the NHS, but by the mid 

1950's a small but growing number of complaints began to appear in the 

national press. These largely concerned the 'high-handed' way in which 

patients were treated and their lack of various rights. A well-known 

journalist gave his distinctly negative views on being a patient to the 

national and hospital press; he had experienced: 
. . . inexcusable examples of rudeness and thoughtlessness . . .routine 

automatically took precedence over the patient's comfort and his 

basic right as a human being to know what was being done to him . . 

. When I asked the nurse what injection she was giving me, she 

snapped that it was nothing to do with me. 59 

Another journalist's account, What's wrong with the hospitals?, by Gerda 
Cohen, was outspoken about 'a world of hierarchies, humiliations, rules 
and condescension'. 60 The Patient's Association began 'ten years hard 



57 

Anne McGhee, The Patient's Attitude to Nursing Care, Edinburgh, E & S Livingstone Ltd, 
1961. 

S.C. Haywood et al., 'The Patients View of the Hospital' The Hospital, October 1961, pp. 644- 
650. 

59 

Stanley Hill, 'SGH talks to Mr Derek Hart', Hospital Management, March 1967, pp.128-129. 



Gerda L. Cohen, What's wrong with hospitals?, Harmondsworth, Penguin Books, 1964, 
cover. 



193 



campaigning' in the mid-1 960's which eventually obtained for patients the 
right to refuse to be used as 'teaching material' for medical students and 
junior staff. 61 In the 1960's patients could not opt out of this, nor, 
depending on the whim of ward sisters, might they be able to have 
personal belongings on view on bedside lockers or choose whether their 
bedclothes were crumpled or straight. Given these prevailing attitudes, and 
the fact that most information about patients' views which the team 
solicited, apart from the Chase Farm questionnaire, seems to have been 
through nurses, it is perhaps not surprising that certain choices regarding 
bed design were apparently eliminated from consideration at an early 
stage. 

This point is related to a second criticism of early design methods, 
made increasingly frequently as the 1960's wore on. This was the premise 
that they began from a 'clean slate', that is, without assumptions about 
solutions. Most proponents, including Archer, designated the initial stage in 
the design process as information gathering. Many seem to have regarded 
this as a purely inductive process. Janet Daley had had little difficulty 
demolishing this model with a brisk account of the history of empiricism 
from Hume to Kant, and critics of many persuasions took issue with the 
notion that innovation could arise 'de novo', or that the designer could put 
himself in such a 'preconceptionless' state; inevitably designers brought 
assumptions to problems which actually prestructured them, and thereby 
prefigured solutions. 62 The notion of the designer as purely objective 
information gatherer and abstract problem solver was untenable. 'External' 

Helen Hodgson, 'Hobson's Choice in the NHS', Health and Social Service Journal, 
September 6, 1975, p.19. 

Daley, 'A philosophical critique of behaviourism in architectural design', p. 73. 



194 



factors prestructured the problem, whether these were overt, as in express 
client demands, or less overt, as in prevailing societal norms to do with 
appearance, or economics, or standards. In addition, 'internal' factors 
ensured that 'what is to be called data is already determined by some prior 
theoretical exercise.' 63 In his later rejection of design methods, Jones 

asserted that: 

The interdependency of (problem and solution) is evident throughout. The 
initial expression of objectives, or needs, however abstract and 
absolute, is, I think, full of hidden assumptions about how the 
person satisfying it thinks it can be satisfied, eg the statement "solve 
the unemployment problem" could imply that we are to become 
engaged in a search for jobs of some kind, but an imaginative 
response may well suggest ways of workless living in which 
unemployment is no longer the problem. 



Other critics made the related point that it was impossible to 'know' 
everything about the problem, in advance or perhaps ever. Alexander, 
writing about architectural design, asserted that 'the difference between a 
really good lobby and a really bad lobby will hinge on much subtler 
questions which most of us don't know.' He cited the example of a new 
courthouse intended to diminish the backlog of cases waiting to be heard. 
Doing away with the long corridors and passageways of the older building 
had had the reverse effect, since many out of court settlements had 
apparently been reached while traversing them in relative privacy. 
The story may be apocryphal, but it served to emphasise the reliance 
placed on prior 'information gathering' stages. Like most of the early design 
methods, Archer's divided the process into stages. These varied between 
methods but usually involved at least analysis, synthesis and 'feed back'. 



B. Hillier et al. 'Knowledge and Design', in Cross (ed), Developments in Design Methodology: 
258. 



195 



Analysis culminated in 'an initial statement of the problem, all that is 
known'. Certainly this was to be qualified by 'feedback', which might affect 
the statement of the problem, or, for any proposed solution (prototype or 
'hypothesis'), the details of design. But the King's Fund Bed project is 
indicative of just how influential the 'initial statement of the problem' could 
be for subsequent stages and the eventual outcome. If the first draft 
specification for the bed is taken to be the 'initial statement of the problem', 
two points are of note. Firstly, the final specification, published nearly three 
years later, differed from it only in aspects of detail, and secondly, the 
extent to which this initial statement was compiled from abstract 
information gathering, either written sources or the formalised 'expert 
opinion' which had to be drawn on in the absence of those sources. After 
this stage, the team considered there to be only twelve questions about 
bed design to which they required answers and where there was no 
general agreement among their sources. This was the basis for proceeding 
to the television survey. A very short time (less than three months) after the 
results of the survey were received, the first version of the draft 
specification was completed. 64 After this, being less interested in designing 
than in design methodology, Archer gave the job of designing the prototype 
to Agnew, and did not actively direct his work. 65 

The determining nature of the earliest stages of the project seem 
inescapable, and Archer's comments about the organization of his year's 

64 

The draft specification was presented to the Working Party on 6.5.64 and a design 
specification their next meeting on 1 8.6.64 where it was approved with one or two 
amendments. It was then agreed that, although the draft specification would be sent for 
comment to participants in the enquiry, fresh amendments would only be made 'in the light 
of new evidence which could be regarded as conclusive'. A/KE/PJ/17 KFWPHB Minutes, 
18.6.64. 

Interview, Bruce Archer, 9.5.00. 



196 



work with Butter, 'as soon as you have put something away in a filing 
cabinet you have embarked on a particular method of working', together 
with the fact that he preferred not to see other bed designs early on in the 
project not wanting them to influence the specification, resonate strongly 
with the idea of beginning with a clean slate, in as near an approximation 
to objective scientific method as possible. But some crucial prior 
assumptions affecting design decisions were not made overt; assumptions 
about cost, for example. It was decided that a unit cost should not be 
specified, because the prime concern was to determine the 'best' solution, 
on the other hand, the aim of the specification was to include 'only what 
was essential'. 66 What was deemed essential, however, was clearly the 
result of preconceptions which the RCA team had acquired from well 
beyond the confines of the method. Design decisions were often made 
based on the assumption (certainly correct) that the Health Service would 
not contemplate a 'very' expensive bed, and that unit cost would have to be 
kept down. This was understandable, given that the team's initial 
introduction to the 'problem' of hospital bed design had been in the context 
of concern over labour and economics in the NHS. But this was a rather 
different problem from the one which the King's Fund Working Party had 
originally been formed to address, of how individual hospitals should 
choose the best beds for their patients. This latter problem might have 
been solved, for example, by comparative testing and a 'best buy' list, such 
as was employed by the new consumer organisations. Shared 



When the RCA prototype was being tried out in the experimental ward set up at Greenwich 
by the Architect's branch of the MOH for example, Agnew was encouraged to include a 
'monkey pole' (a bar on a chain above the head end of the bed that could be used by 
patients to pull themselves up). He refused on the basis of increasing unit cost. 
AAD/1 989/9, Job 15, Howard to Agnew, 31.5.66. 



197 



assumptions about the problem, and its solution (variety reduction), 
enrolled political support. 



Politics 

It seems highly unlikely that the King's Fund Bed would have appeared in 
British hospitals at all without this support. There were many contingent 
circumstances at various levels in the MOH (and later the DHSS), and in 
the hospital service, which served to further the project and the resultant 
specification and beds built to it over the period from the early 1960's to the 
mid 1970's. In the early 1960's, for example, Enoch Powell was embroiled 
in the conflict over nurses' pay. His rigid imposition of the government's 
2.5% pay freeze on a group widely perceived as under-remunerated and 
unfairly treated, brought approbium even from his own party. The issue of 
the nursing shortage was powerful ammunition for those who supported a 
more generous increase in nurses' wages; so powerful indeed that, in 1961 
under Powell the MOH declared 'public war on the myth of "shortage" of 
nurses'. 67 In the light of this It is not difficult to see why 'mechanization of 
the nurses task', and the consequent saving of nurses' time, had been of 
considerable interest to him. MOH staff were deputed to follow up reports 
of 'robot nurses' in the press 68 . The initial focus on the hospital bed as the 
first item of equipment for scrutiny to this end was a very direct result of 

Webster, The Health Services since the War, II, p. 173. 

68 Not, it turned out, cyborgs, but the electronic monitoring devices that were to become 

commonplace in the new intensive care units as early warning devices, but which were first 
marketed, astutely perhaps, as aids to saving nurses time. Davies to Hollens, 13.7.62. 
MH136/12. 



198 



Ministerial strategy in the imposition of government policy on public sector 
pay in support of their wider economic policy. 

As the nurses' pay issue receded, at least temporarily, this concern 
dwindled. The interests of the next Minister of Health, and of senior MOH 
civil servants, centred more directly on equipment expenditure, both 
because of criticism from the Public Accounts Committee, and because of 
the implications of the Ten Year Hospital Plan. These issues enabled the 
Ministry to revisit the issue of joint and central contracting, and its 
necessary prerequisite in the field of equipment supply, standardisation. 
Too wary to promote official policy encouraging standardisation since the 
Messer Committee's findings in 1958, the MOH position was strengthened 
on this by the Public Accounts Committee's pronouncements of 1962 and 
1963. As a newly appointed Minister of Health, Anthony Barber's concern 
to refute accusations of wasteful spending were understandable, and 
manifest in his speech of January 1964 announcing the setting up of 
specification working parties. The MOH undertook to provide specifications 
for 22 types of equipment by the end of 1964, but these could hardly be 
expected to report before the end of the financial year 1964/5. The King's 
Fund Bed project offered hope of an earlier, high profile, result. (In the 
event the delays outlined in Chapter Three prevented this.) Hunt, as 
Controller of Supplies, and the individual who had to go before the Public 
Accounts Committee in February 1965, had every reason to promote 
evidence that the issue was being vigorously addressed for one key piece 
of hospital equipment. It is clear that once this purpose was served, 
however, the Ministry were not contemplating a repeat of such an 
extensive, and expensive, procedure. Aware in 1965 that Archer and 
Harrison 'intended to recommend that a permanent team to evaluate 



199 



equipment should be set up in the Health Service', Supplies Division 
considered this was just 'not on'. 69 

The context of the Ten Year Plan was highly relevant. Although 
widely applauded as evidence of Powell's far-sightedness in 1962, there 
had been concerns from the outset that the project would be unsustainable 
on the planned levels of expenditure. These proved to be correct. A radical 
revision of the Plan was announced by the Minister of Health (now 
Kenneth Robinson) in 1966 which modified or postponed several 
schemes. 70 From the outset in 1962, advocates of the Plan had had to 
protect it both rhetorically and practically. The unusual seniority of the 
MOH's first representative on the King's Fund Working Party is 
understandable in this light, particularly in view of the fact that the 
Undersecretary in question, Raymond Gedling, was apparently the civil 
servant who had originally drafted the Plan. 71 

The Ten Year Plan magnified everything it touched, including 
expenditure and potential savings through standardisation. During the bed 
project the MOH veered between alarm at the former and attraction to the 
latter. In the mid 1960's, anxious to produce at least one specification for a 
piece of equipment, and make at least one version commercially available 
to hospitals, the MOH agreed to fund Archer's field trials when the King's 
Fund drew the line at further expenditure. The Ministry subsequently 
provided the initial large order for Nesbit-Evans without which the latter had 



69 

A/KE/PJ/17/28, Irfon Roberts' note of a phone conversation with Howes, Supplies Division, 
7.10.65. 

The Hospital Building Programme. A Revision of the Hospital Plan for England and Wales, 
HMSO, 1966. 

71 Interview, Lawrence Brandes, 2.10.00. 



200 



been unwilling to proceed. But for these two interventions, it is unlikely that 
King's Fund Beds would ever have come into existence as commercial 
products. The brief for the King's Fund Working Party was only to produce 
a specification. Confronted with an apparently unrealistic one, and what 
was to them a rather extraordinary prototype, the rest of the bed-making 
industry would probably have ignored the whole affair. 

By the time the bed specification was published in 1967, and the 
real negotiations on pricing, contracting and supply began, the Ministry's 
concern with expenditure surfaced again, detectable in their cautious 
official statements and two year hesitation before allowing purchase on 
central contract. This had the ironic result that, whereas initially advocates 
of the specification had stressed the large proportion of patients for whom 
the bed was suitable, in order to emphasise the potential benefits of 
standardisation such as joint contracting and price reduction, they now 
pointed out that there were sizeable groups of patients for whom it was not 
necessary. 72 This, it seems, was in order to convince the MOH to make it 
available on central contract at all. Between 1967 and 1969, the Ministry 
conducted a sort of damage limitation exercise based on identifying just 
what proportion of patients actually 'needed' the bed. For them, the project 
had been almost too successful. This was at least in part because the 
long-expected opposition to standardisation, which might have served to 
limit demand for this expensive bed, had largely failed to materialise. Why 
was this? 

In large part the answer seems to lie in the radical changes in 

72 

Early Reports and specifications had described a bed 'suitable for the majority (say, 60%) of 
patients being nursed in the ordinary wards of hospitals'. The final published specification 
for the King's Fund Bed described 'a bedstead suitable for general purposes'. King's Fund, 
Design of Hospital Bedsteads, p.5. 



201 



hospital management that took place during the 1960's. The seemingly 
inexorable trend away from lay committee management towards 
management by senior officers, increasingly with specialist 'management 
training', was both promoted by, and served to promote, a rhetoric of 
rational management that reverberated stridently through public and 
private sectors alike. In the hospital service, 'new building' was linked very 
closely to 'new management' The inherited "patchwork quilt" with an infinite 
range of variation of procedures, methods, organisation, staffing and 
buildings, will gradually be replaced, through the operation of the Hospital 
Plan, by a more logical system of hospital services and buildings and this 
in its turn will inevitably entail changes in the control and management of 
the resources at the disposal of the hospital service ... the rationalisation 
of hospital services and buildings must be paralleled by the rationalisation 
of hospital management 73 

The hierarchy of 'line management' supplanted the older 'Bradbeer 
style' administration and the 'trichotomy' of matron, consultants and 
hospital secretary. In general this was welcomed by the MOH and 
promoted by the DHSS. It was the system which prevailed in the Civil 
Service itself and one which offered potential relief from the intransigencies 
of both lay HMCs and the consultants. The shifting alliances brought about 
by these changes are detectable at many instances in the project. As 
noted above, when the King's Fund declined to fund the field trials, Archer 
went directly to Hunt to enlist Ministry support. It was at this meeting that 
the comment about the King's Fund Working Party being 'liable to go off in 
all directions at a moment's notice, and most atypical of the hospital 

73 

Anon., 'Hospital Work Study makes progress', British Hospital and Social Service Journal, 
12 April 1963, p.417-417. 



202 



service as a whole' was made. An editorial in the British Hospital and 
Social Service Review in 1 966 was in no doubt that it had become 'more 
and more obvious that active management was a matter for professional 
officers and not for amateur committees'. 74 The King's Fund Working Party 
was of course an advisory body brought together by a charitable 
foundation, not a management committee, but the relevance of lay 
committees to the hospital service was under scrutiny at this time. 

Within the changing management ethos of the NHS, the role of the 
supplies officer also altered. Around 1960, supplies officers were a diverse 
and nervous occupational group who considered themselves 'a threatened 
species'. 75 In the eyes of some hospital administrators at this time, the best 
sort of supplies officer was still 'the quartermaster who got the ammo up 
the line.' A few hospitals had begun to experiment with dispensing with the 
post altogether, leaving ordering entirely in the hands of the finance officer 
or a Secretary/Supplies Officer 76 The relatively low status of supplies 
officers at this period, and their exclusion from policy making is clear. The 
function of the MOH's Standing Advisory Committee of Supplies Officers, 
in existence since 1 951 , was still, in 1 960, 'to discuss day to day supplies 
problems informally; questions of policy were not proper to these meetings 
and would not be discussed.' 77 In the early sixties, standardisation 
appeared to threaten the supplies officer's role even further, restricting his 
purchasing choice and reducing him to an order clerk. But by the end of 

74 

Committees and Management, British Hospital Journal and Social Service Review, 
August 5, 1966, pp1 442-3:3. 

75 

Minutes of a meeting to discuss joint contracting, 1 7.1 0.61 , MH1 36/1 7. 
'The Supplies Function', British Hospital and Social Service Journal, June 7 1963, p. 1053. 
77 Davies to Hughes, 28.4.60, MH 90/81 



203 



the decade, involvement in new hospital building and increased 

expenditure had given supplies officers a key place in the new, rational 

management with its emphasis on information and control. The supplies 

officer dealt with eminently quantifiable assets and outcomes. Perhaps 

even more importantly, he could himself be controlled within a chain of 

command, having no troublesome specialised knowledge beyond that of 

his counterpart in commerce or the military. 

These changes were reflected in a new salary scale for supplies 

officers and in changed attitudes. More secure in their positions, they now 

endorsed 'rationalisation' of supplies, including standardisation, thus 

gaining visibility and credence with management, whose objectives they 

came increasingly to embrace as their own. In particular, standardising the 

supply function itself, by separating it from the hospital group structure, and 

therefore direct control by HMCs, appeared now to offer potential 

advantage. 

The recommendations of the Hunt Committee for the organization of 

supplies on an area basis were opposed by some long-serving supplies 

officers who warned that they would be returned to conditions resembling 

the pre-NHS era when, in London County Council Hospitals, for example, 

they had been 'unable to condemn so much as a scrubbing brush' without 

a visit from a condemning officer from the supplies department who came 

every fortnight for the purpose. 78 Less nervous colleagues however, 

considered that 'the future for the supplies officer lies with the Hunt report.' 

The variation in size of hospital groups meant that 
Some supplies officers were responsible for a group of 1 .500 beds, but in 
smaller groups a clerk filling in forms was referred to as supplies 

'Hospital Supplies and the Hunt Report', British Hospital and Social Service Review, 9 
December 1966, pp.2361 -2367:2365. 



204 



officer. ..there should be no heartburnings if Hunt casts the clerk out 
into clerical work . . . Supplies officers should . . . regard themselves 
as part of the main stream administration, and aim for the highest 
posts . . . supplies officers had been recognised to be educated men 
and specialists' (though 'still not sufficiently. In the USA ... the 
purchasing agents are master men'). 79 



The real power shift implied in the Hunt Committee's recommendations 
was again towards the centre, to 'areas', not regions, but certainly away 
from the HMCs. 

But what of medical opposition to standardisation of equipment? 
This was, after all, what had been identified as the cause of all those 
different available bed designs in the first place. In the event, this failed to 
materialise, except among geriatricians. In 1970, the year after the DHSS 
made the King's Fund Bed available on central contract, a consultant 
geriatrician, James. Andrews, published an article in the British Journal of 
Hospital Medicine entitled 'Geriatric Ward Equipment'. In it he cited the 
patient area furniture report produced by the DHSS in 1969 which had 
stated that certain items 'were more in the nature of medical equipment 
than furniture and should be purchased locally in accordance with the view 
of the geriatrician'. 80 He took the DHSS to task, therefore, for subsequently 
stating in the same report that where contracts were made centrally for 
specific items their use by hospital authorities 'should be made mandatory'. 
In Andrews' view, 'the days of ordering 30 identical beds for a 30-bed ward 
should have gone'. Given that he was writing in 1970, only six years after 
the Minister of Health had expressed dismay that over 300 designs of bed 



Ibid. 

fin 
J. Andrews, 'Geriatric Ward Equipment', British Journal of Hospital Medicine, Equipment 

supplement, April 1970, pp21 -25:21. 



205 



were available to hospitals - the situation that had in part given rise to the 
King's Fund project - the days of ordering 30 identical beds for a 30 bed 
ward must have been very short indeed. Andrews devoted much of the 
content of the paper to beds, and references to the King's Fund Bed were 
largely critical, or damned with faint praise. 

But he was one of only a handful of doctors who had anything to say 
about the issue. Given the zeal and relatively high profile which the King's 
Fund gave the project in hospital circles, and the assiduousness with which 
Archer and his team were known to be soliciting information, medical 
interest in the subject overall was rather slight. Specific enquiries placed by 
the RCA team in the British Medical Journal and the Lancet in 1964 as to 
degrees of tilt actually used or required in practice resulted in only two 
replies from doctors over the subsequent six months. Andrews himself 
opened one of his articles with the words 'All consultants talk about 
hospital beds but few are interested in them'. 81 He was probably right. For 
the general physicians and surgeons it is likely that beds had become of 
less concern. The power of their intervention was increasingly wielded 
through other categories of diagnostic and therapeutic artefacts: scanners 
and endoscopes, gamma rays and heart lung machines. These were 
specific, interventive (and very expensive) tools and techniques at the 
'cutting edge', not non-specific issues of bed rest, diet and locomotion 
which were central to geriatrics. Apart from geriatricians, and perhaps the 
allied groups of long-stay institution doctors, only the orthopaedic surgeons 
still evinced much interest in hospital beds. But orthopaedic beds were 
contraptions central to their treatments of traction, extension and so on, 



J. Andrews, 'Hospital Beds', The Lancet, February 27, 1971, pp.442-443. 



206 



and as such securely in the category of 'surgical equipment'; that category 
which the RCA team had agreed was 'out of bounds.' It was the 
geriatricians in particular who still felt their interests threatened by variety 
reduction in 'general purpose' beds. Several published requests for 
specialist geriatric beds. Andrews considered it 'unfortunate' that the Chase 
Farm trials had been on a women's surgical ward, and that this reduced 
their relevance to use by geriatric patients. However, as Harrison, the work 
study officer in charge of the trials, pointed out, many of those women 
surgical patients were also geriatric 'as Andrews well knew'. 82 Their 
positions were predictable. Andrews, questioning the suitability of the bed 
for geriatric patients, chose to point out that the trials had been held on a 
surgical ward. Harrison, responsible for the trials being properly carried out 
and therefore meaningful, chose to stress that many of the surgical 
patients were 'old', and ipso facto, geriatric. The geriatrician, however, had 
a point. As noted above, the definition of the geriatric patient was 
problematic in the late 1960's. The work study officer saw it purely as a 
physical (and quantitative) matter of chronological age, and if old people 
defined in these terms had been included among the trial patients, then the 
bed had been 'tested' for them, too. But this was not all there was to it. 
Archer had expressly chosen a female surgical ward for the trials for 
particular reasons. Female surgical patients could be seen as being, 
transiently at least, the group of general hospital patients who were most 
dependant on hospital staff and subject to the widest range of 
'interventions' from them. Furthermore, the temporal pattern of many 
surgical patient's condition, passing from total incapacitation to, it was to be 



op 

AAD/1 989/9, Job 15. Correspondence, April 1970 'Response to Andrews'. 



207 



hoped, total recovery, provided the widest range of situations in which to 
test the bed. Hospital life for geriatric patients did not follow this pattern. 
Their condition generally changed slowly, or remained static. They were 
not usually having surgical treatment, or other interventionist procedures. 
Their beds were not foci for 'early ambulation', but places where they might 
sleep for 12 hours or more. Some of the new geriatric units were 
experimenting with more flexible routines akin to domestic, rather than 
institutional life. 

Defining the geriatric patient as different was essential to defining 
the relatively new and still insecure specialty of geriatrics. One of the 
founders of hospital geriatrics, the eminent physician Cyril Cohen, felt it 
necessary to reply to comments from the Group Secretary who had had 
difficulty in defining a geriatric patient (see Chapter Four, note 10) with a 
two page article. Geriatric medicine was 'a distinct branch of general 
medicine', there were 'fundamental differences between the medicine of 
the elderly and that of younger people.' It required 'special study and a 
great deal of research'. 83 

But for most doctors in the late 1960's, it seems standardisation of 
beds posed little threat and was of rather little interest. Had matters gone 
further, however, things might have been different. In the United 
States, the hospital administrator Gordon Friesen had pushed 
standardisation and rationalisation of hospital supply to its limits, designing 
the entire hospital around the supply function. 84 Friesen 'sought to exploit 
Taylorist possibilities to the full' in a brief for ten United Mineworkers of 

Cyril Cohen, 'Planning and reality: Geriatrics', Hospital Management, August/September 
1967, pp.423-424:424. 

84 

Hughes, 'The Design of Hospitals in the Early NHS', pp. 39-40. 



208 



America Welfare and Retirement Fund hospitals in Virginia and Kentucky. 

A major part of the brief involved the removal of the maximum number of 

functions to central departments away from the ward, where they could be 

'surveyed, controlled and rendered more efficient through the application of 

work-flow studies, job specialization and mechanization'. To a very limited 

extent, this system was adopted in British hospitals for departments such 

as central sterile supplies. The 'matchbox on a muffin' style of hospital 

architecture lent itself to the arrangement, with centralised departments 

located in the vertical central core. But there were 'knock on' effects of 

centralising services away from the wards which proved profoundly 

unsettling to some British observers, who commented on Friesen's 

'objective, almost ruthless attention to every detail of the supply system 

from . . . service areas to every item in the patient's room.' In particular, 

was 'it necessary to box in the patient with supply cupboards and 

lavatories, so that he cannot be seen from the nurse's station or 

corridor?' 85 Such a system challenged a tenet of British hospital ward 

organisation so entrenched that most administrators, it seems, regarded it 

as sacrosanct. This was the view that patients must be continuously 

visible. The concern dominated to a large extent the many debates on 

improved ward design held during the 1960's, promoted by the Nuffield 

study and embodied in the experimental wards at Greenwich, Larksfield 

and Muswell Park. 86 The matron at Greenwich, speaking at a conference in 

1965: 

was sceptical about the six-bed wards being planned in many new 

'Ward Planning', British Hospital and Social Service Journal, June 28, 1963, p. 754. 

Experimental ward blocks were built at Larksfield Hospital, Greenock, 1951-6, and Musgrave 
Park, Belfast, 1956-9, as part of the Nuffield Hospitals Programme. The MOH's Architect's 
Branch redeveloped Greenwich as an experimental hospital layout. 



209 



hospitals ... it was absolutely essential that the nurse should be 
able to see and hear the patient, especially at night. If patients were 
going to be shut up in single rooms and small wards it would be 
necessary to consider how they should be monitored, perhaps even 
by means of closed circuit television. 87 



Another speaker agreed. 'The Nightingale ward gave what no other unit 
gave, and that was constant detailed observation.' Falls, and patients' 
peace of mind, were often cited as reasons why there had to be a clear 
sight line between nurse and patient. Speaker after speaker alluded to this 
issue, until one group secretary had the temerity to suggest that direct 
observation of the patient by the nurse might not be as important as it was 
made out to be. How much could the nurse in fact observe unless she was 
standing by the patient's head? And did patients, other than those who 
were acutely ill, really need to be under constant observation?' Perhaps 
emboldened, two other speakers agreed. The principal matron of United 
Birmingham Hospitals said that 'a nurse could stand at the bottom of a 
patient's bed and not realise he was dead'. A bacteriologist from 
Cambridge said 'he had never understood why it was so important that a 
patient should be seen to fall out of bed.' The majority of speakers, 
however, nursing and medical, remained wedded to the concept of 
constant observation. 

Had the King's Fund Bed challenged entrenched views of this kind 
(for example by including a personal lavatory as did the US bed mentioned 
in Chapter Three, or cupboards), medical opinion might have been 
mobilised against it. 88 But the RCA's methods, rooted as they were in 

'The Ward of the Future', British Hospital Journal and Social Service Review, December 31 , 
1965, pp2465-2467:2466. 

QQ 

There are issues here to do with the relationship between medical and nursing practice which 
I have not explored. Clearly nursing practice cannot be reduced to medical dictat. 



210 



ergonomics and anthropometry, had produced an artefact particularly well 
suited to British ward practice in the mid-twentieth century, where patients 
were relatively powerless, passive, to be observed at all times, and 
positioned correctly; a problem certainly analogous in physical terms to that 
of Enoch Powell's '150 lb work load passing through a series of industrial 
processes'. 89 That the work materials should be in correct physical and 
visual alignment with the operator was a fundamental principle of 
ergonomics. What the King's Fund Bed most resembled was an adjustable 
work bench. This is perhaps the best explanation for the insistence on 
height adjustment, despite its expense, engineering problems and knock on 
effects on the rest of the bed's functions. Gillian Patterson recalled that, at 
a very early stage in the project, 'height adjustment drove the literature 
search'. 90 As the charge nurse of the ward where Nesbit-Evans bed was 
trialled remarked, 'For too long we have thought of the bed as a shelf on 
which we would rest our patients and carry on regardless.' 91 Moving 
patients the short distance from a shelf to a workbench was uncontentious 
in British hospital medicine of the period. As Alexander had commented in 
his rejection of design methods, the success of an artefact will depend on 

89 

The subject of positioning patients warrants further study. Nursing textbooks prior to around 
1970 list large numbers of positions, often eponymously named, into which patients might 
have to be placed, with instructions on how the nurse should do this. Bed manufacturers 
attempted to cater for these. In many circumstances, such positions were mandatory; 
delivery, for example was to take place with the patient in either the left lateral or the dorsal 
position. Positioning becomes less prominent in nursing textbooks in the 1980's and 90's. 
Some positions, such as those for postural drainage, had gradually fallen into disuse 
because of new therapies, including antibiotics. But a more general cause would seem to 
be the adoption of a less interventive, and less ritualistic, approach to patient care: less 
washing and blanket bathing, fewer enemas and irrigations, less extensive 'prepping' for 
operations. And during the 1970s, procedures were increasingly carried out in a dedicated 
treatment room, rather than in the ward bed. 

90 

Interview, Gillian Patterson, 14.9.98. 

91 

Southwood, 'Nesbit-Evans King's Fund bedsteads in use', p. 541 



211 



much subtler questions than those expressly addressed, 'most of which we 
do not know'. These subtler questions, about power and hospital 
practice,were not amenable to the objective and quantitative techniques of 
Design Methods, which largely served to obfuscate them, and also to 
perpetuate them. The Movement was, with its functionalist stress on 
reconciling conflicting 'needs', profoundly supportive of the status quo. 
Conflict was to be solved by changes in the artefact, not society. The issue 
of nurses backs is a case in point here. The RCA team saw minimising 
back injuries as a user need to be fulfilled by proper design. The Royal 
College of Nursing maintained that staff shortages were to blame. The 
Lancet, while agreeing that the King's Fund Bed would help, thought better 
training of nurses was the overall answer. 92 From the mid-1970s legislation 
was gradually introduced to limit the loads that nurses would be expected 
to lift in hospitals. 93 

Further evidence that the success of the King's Fund Bed may have 
had to do with 'subtler questions', rather than the factors explicitly 
quantified and optimised in the method, is perhaps indicated by 
subsequent changes in some of those factors. It was a third criticism of 
Design Methods that they were 'inflexible', precisely because of the 
intended closeness of fit between design and user needs. User needs, it 
was pointed out, could and probably would change in a shorter time than 
the intended life of the design. It was unrealistic to painstakingly match 
design factors to a 'snapshot' of users and their needs taken at one 



92 

The Nurse's Load', Lancet \\, August 28, 1965, pp.422-423:423. 

93 

Hospitals were brought under the health and Safety at Work legislation in 1974, but could 



still claim crown immunity. 



212 



94 

particular moment. 



The RCA team attempted to minimise this problem by anticipating 

future trends and their implications for the specification. They depended 

here on the opinions of other specialists, some of which proved incorrect. It 

was realised, for example, that the anthropometric data which was the 

basis for substantial parts of the specification was based on compilations 

from the existing literature 'for Anglo Saxons'. Aware, as they could not fail 

to be in Britain in the mid 1960's, that the proportion of immigrant nurses 

might increase, the team consulted A. H. Brodrick, an anthropologist at 

University College, London, 'to determine whether any time should be 

spent in considering other than "A-S" (AngloSaxon) populations' since 

'Europeans, Negroes, S. Asians and Latins live and work here in 

considerable numbers.' Brodrick's views were recorded as follows: 
Although there is a well established stream of immigration, in particular of 

West Indians, it would be unsafe to predict that it 
might continue for very long ... the reasons for this immigration are neither 
fixed nor enduring. Comparatively small changes in the economic, 
social and legislative balance between the UK and the rest of the 
world could stop or re-direct this movement overnight. He pointed 
out that considerable numbers of negroes stayed here only a short 
time either because of the very trying climate or because they had 
come for specific purposes, i.e. training or to earn a little capital. 
These factors would operate more or less for all the exotic races 95 

On the basis of Broderick's advice, no additional anthropometric data was 
sought. But in fact, by 1975, at the end of the period under consideration, 
over twenty percent of all student and pupil nurses in NHS hospitals came 



94 

Mitchell, Redefining Designing, p. 

95 

AAD/1 989/9, Job 7 'Anthropometrics, Doct 1532'. 



213 



from overseas, and of the 4,332 foreign nurses granted British work 
permits that year, the great majority came from the Caribbean, Mauritius 
and Malaysia. 96 

Future trends in 'nursing practice' which appeared to require catering for in 
the specification were listed among the 'critical factors' to be taken into 
account. Considerations under this heading largely came to focus largely 
on two potential trends in 1960's hospitals: the use of 'mobile bed systems', 
and the giving of anaesthetics in ward beds. In neither case, however, did 
the trend materialise to any extent, though the specification was designed 
to accommodate these potentially changed user needs. 

Standard ward beds prior to the 1 960's were often fitted with castors 
which were raised from the floor to immobilise the bed when not in use. 
These small diameter castors allowed for limited mobility in the ward, but 
such beds were inadequate for travel to other parts of the hospital with the 
patient in situ. Although a degree of mobility was clearly desirable, nothing 
like the full mobile bed system was ever adopted in Britain. 
One implication of moving patients around the hospital in their beds would 
have been that they would still be in them when they were anaesthetized 
prior to being moved to the operating table. The question of whether 
anaesthetics would be administered in hospital beds concerned the team; 
anaesthetic gases in the presence of static electricity were an explosive 
hazard. As noted in Chapter One, there had already been several 
accidents in operating theatres. The MOH would demand equally stringent 



96 

Lesley Doyal, The Political Economy of Health, London, Pluto Press, 1979, p. 206. By the mid 
1960's, agency nurses, of whom an even larger proportion were from overseas, constituted 
the 'entire night staff in some hospitals. In 1965, Hospital Secretaries agreed that agency 
nurses 'ought to be banned' but this might close 'one third to one half of all beds'. 
MH90/86, Sec BG 6/65. 



214 



precautions over the design of all ward equipment should anaesthetics be 
given in beds with any frequency. Although this trend, like the fully mobile 
bed system to which it was related, did not materialise, explosive gases did 
appear on the wards, by a different route. The central supply of oxygen, 
piped to outlets by patients' beds, became increasingly frequent during the 
1960's. In this case, the specification was correct, but perhaps fortuitously. 

The opposite situation, where possible attributes were deemed 
unnecessary because of future trends, also occurred. The RCA team were 
told that the problem of bedsores would largely disappear with the 
introduction of new antibiotics, so the incorporation of measures either to 
mitigate their formation, or assist with the frequent turning needed for 
immobile patients, was not pursued. (Turning was onerous for nurses and 
distressing for patients. Some nurse juries had suggested a facility for 
lateral tilt of the mattress platform would be beneficial.) In fact, bedsores 
remained a widespread and intransigent problem in hospital patients. 

The 'user need' for some design factors incorporated in the bed 
diminished during subsequent years : foot high tilt, for example. The issue 
of tilt had occupied the team considerably. The decision to provide tilt at all 
levels of height adjustment, increased the engineering problems and the 
cost. 97 The solution of combining height and tilt mechanisms went some 
way towards reducing the cost but certainly not to below that of a height 
adjustable bed without the tilt function. And it was the range of tilt at high 
height that caused the most severe problems of stability for the bed, and 
necessitated its fairly 'massive' construction. But the team's conviction that 
tilt was necessary had existed since the early days of the project. It had 

97 

The very wide range of tilt stipulated in the first draft specification was later reduced 
somewhat. 



215 



been one of the most obvious user needs to identify (though not to 
quantify). Their nursing contacts had frequently told them how it was 
standard practice to raise the foot of a collapsed patient's bed as an 
emergency procedure. This was done by nurses heaving the bed end onto 
metal supports (known as bed elevators) or wooden blocks, or, failing all 
else, the seat of a chair. Clearly impressed by the physically inefficient and 
potentially injurious nature of this procedure, the team spent a great deal of 
time and effort on the matter. 

From around 1970, however, emergency resuscitation procedures 
for the collapsed patient changed. Lesser degrees of head down tilt 
remained standard for patients with low blood pressure, post-operatively 
for example, but heroic levels of foot high tilt were abandoned. Intravenous 
fluids played a greater role in the treatment of circulatory collapse, and in 
cardiac arrest, external cardiac massage became standard practice. 
Resuscitation was the province of rapid response teams of junior doctors, 
rather than nurses. The primary requirement of the bed for this purpose 
was that it should provide a hard, flat surface beneath the patient, who 
otherwise had to be got onto the floor (or, if the event was anticipated, 
nursed with wooden boards under the mattress). Unlike older, sprung 
beds, King's Fund Beds did provide a hard flat surface, by virtue of the rigid 
and continuous mattress support. But the solid base had been an almost 
inevitable result of the restrictions imposed by the height adjustment 
mechanism, which necessitated the thinnest possible structure. Doreen 
Norton made the team aware of the new technique of cardiac massage but 
it was not one of their first-line justifications for the rigid base. 

My point in citing the fallibility of expert predictions is this. Carefully 
documented user characteristics changed, practices which the bed was 



216 



specifically designed to facilitate fell into disuse, anticipated user needs 
failed to materialise, and yet still hospitals bought King's Fund Beds. In the 
light of these discrepancies the closeness of design fit to user needs (as 
defined in the project) seems a less than satisfactory explanation for 
continuing rising sales. I do not want to overstate the case here, but such 
discrepancies raise again the question of how much getting the 'right' 
answers to the questions posed in the method used to design King's Fund 
Beds contributed to their initial success, and how much this was 
attributable to contingent factors, related interests and shared assumptions 
about solutions, and also to what might be termed the Bed's 'image'. 

Because if the success of a designed artefact could be affected by 
subtler issues which were not amenable to calculation and optimisation, 
some of these issues concerned how successfully or otherwise its 
protagonists negotiated the social world. An obvious example here is 
advertising. But the negotiation process can begin much earlier. From the 
time of Archer's involvement with the project, the issue of hospital beds 
took on a higher profile. He had perhaps learnt from the experience of the 
Nuffield year where much time was spent working on documentation 
largely in isolation from the sponsors. The working arrangements with the 
King's Fund were in any case much closer and friendlier, involving many 
informal meetings. At the Nuffield, the sponsors were largely the medical 
elite, and remote. At the King's Fund there was regular informal contact 
with Irfon Roberts, the Committee Secretary, who was soon enrolled firmly 
behind the project and convinced by Archer's methods. (He subsequently 
promoted them in articles on equipment in the hospital press.) Roberts was 
instrumental in persuading the Fund to continue beyond the original end- 
point of the project, which had been the production of the specification. 



217 



The Committee itself was largely of laypeople without a strong medical 
presence. Russell Grant, its only medical member, was a physical 
medicine consultant concerned with developing his own design of hospital 
bed. This was with the express purpose of allowing patients (especially in 
long-stay institutions) to adjust it for themselves, a very different artefact 
from that described in the RCA specification. It is clear that as momentum 
gathered with the RCA's work, the influence of the Working Party on the 
content diminished. But Roberts and the Fund's publicity resources 
ensured plentiful coverage, and throughout the project, Archer had been 
mindful of its presentation. 98 Formal reports were produced on every 
aspect of the research, and no opportunity lost to stress the amount carried 
out (always in terms of units). Research was a powerful commodity, as the 
newly formed Consumer's Association pointed out in a slightly different 

context. In the face of: 

... the power of capital, the knowledge of research and the influence of 
advertising ... the consumer was isolated, weak and ignorant. By 
fortifying him with the research . . . (the Association) would help to 
bring the whole shebang into a better state of equilibrium'. 99 

Research strengthened knowledge claims. Both Archer and Agnew later 

stated that this had been one reason for doing both the amount and type of 

research carried out. 'We needed to be able to face potentially hostile 

politicians or pathologists with firm evidence', said Archer, and Agnew 

wrote that: 

The . . . bed project I think involved a number of experiments with ranking 
and scoring simply because we had to demonstrate the conclusions 

98 

Journalists at the time of the publication of the specification were offered 'background stories 
for the bed of how nurses break their backs at old-fashioned fixed height beds, and 
patients break their legs. Archer to Wainwright, 2.3.67, AAD/1 989/9, Job 1 3. 

99 

Jonathan Woodham, 'The Post War Consumer' in N. Hamilton (ed), From Spitfire to 
Microchip, pp. 6-1 1:7 



were not subjective. It was the primary reason for employing us. 



218 

100 



And, as Archer later recalled, reflecting on the success of the project, 'we 
talked to a lot of people'. These people had included the Ministry and the 
industry, the real determinants of supply and demand. The help proffered 
by individuals in these groups had included advice on negotiating the social 
world. 'You must make it more embarrassing for the MOH to stand up and 
say there is no money for these (King's Fund) beds than to make extra 
provision for them', Hunt told the team; useful advice indeed from the 
Controller of Supplies. 101 'Networking' (a term most appropriately derived 
from the cyborg sciences) was important. 

A passing comparison could be made here with another medical 
artefact for which a standard specification was produced in the 1960's. 
This was the Medresco hearing aid, designed by the Medical Research 
Council, with a sole contract for its production awarded to The Post Office. 
The device was widely regarded as a failure. It had a very low uptake, and 
the sole contract with the Post Office was considered 'to have destroyed 
the British hearing aid industry'. 102 Though there are clearly many factors to 
be considered here, the level of advocacy for the new device by its 
designers and manufacturers, respectively MRC scientists and Post Office 
officials, may not have been high. 

Another comparison is possible, and that is with how the King's 
Fund Bed fared in circumstances where the benefits of 'networking' were 
largely absent or greatly reduced. This was in the overseas context. The 



Personal communication. 
101 Interview, Gillian Patterson, 29.1.98. 

102 

Office of Health Economics, Hospital Purchasing, London, 1972, p.26. 



219 



bed did not, on the whole, sell well abroad. Hopes that it would prove an 
exception to Britain's poor export performance did not materialise. In 1966, 
British imports of medical equipment totalled some £60 million, whereas 
exports were only around £8.5million. 103 At a major international trade fair 
for such equipment in the Netherlands in 1967, 'barely half a dozen' out of 
170 exhibitors were 'of British origin or direct association'. 104 Despite 
Britain's repeated applications to join the EEL) during the 1960's, medical 
equipment firms still looked, if they looked abroad at all, to dwindling 
traditional markets in former dominions and colonies. 105 The pattern could 
be detected within Nesbit-Evans, with older, family member Directors 
pursuing markets in Nigeria, South Africa and Jamaica. 106 In some cases 
this had a direct effect on companies' methods of construction, since some 
techniques were considered too sophisticated for manufacture under 
licence in such countries. 107 Largely through the efforts of others, such as 
Weston, and the RCA, who were careful to pass on any foreign interest in 



1 03 

A. Rowe et al., 'The Bath Institute of Medical Engineering', British Journal of Hospital 
Medicine, Equipment supplement, April 1970, pp. 29-31 :29. 

104 

'Medica '67, Utrecht', Hospital Management, November 1967, pp526-528. 

105 

The Crown Agents, the government purchasing authority originally set up for the colonies, 
had traditionally ordered large numbers of very basic British Standard beds, unlike British 
hospitals, where 'nobody ever bought them'. Interview, Kenneth Crisp, 20.7.00. 

Dermot Nesbit-Evans had a working scale model of the King's Fund Bed made in which the 
foot pedal could be operated with a finger tip to demonstrate to potential buyers abroad. 
Interview, Toby Weston, x. 11.98. In 19.. he was pressing for urgent attention to the 
hydraulics of the beds so they would function in tropical climates. 'The Medical Officer of 
Health for Jamaica may go "off the boil" if we do not make his bed work satisfactorily very 
quickly. Dermot Nesbit-Evans to Kenneth Agnew, 1.11.67, AAD/1 989/9 Job 15. 

Dermot Nesbit-Evans resisted closure of their foundries and a change to all-welded 
construction since he considered 'sales in underdeveloped countries should be based on 
cast corner beds.' Toby Weston to Kenneth Agnew, 30.4.70, AAD/1 989/9 Job 
15. 



220 



the bed to him, newer markets were pursued and manufacturing rights sold 
in some countries, including Holland and Yugoslavia. 108 An Australian 
company bought rights, but never made the bed, so did an Italian 
manufacturer, who had little success, the bed being 'too sophisticated' for 
that country's market. 109 The 'closeness of fit' of some of the explicitly 
considered factors in the method to the British hospital situation was partly 
responsible. It was standard practice in some European countries, for 
example, to autoclave the entire bed each time a patient was discharged. 
Stainless steel was the only finish which would stand up to this treatment; 
the powder coated steel specified for King's Fund Beds would not. 110 But 
clearly, expectations, norms and assumptions played a central role. 
Sometimes these were related to the economics of health care, and 
sometimes not. A US bed manufacturer was initially interested in the beds. 
'This interest came about, of course', he told the RCA, because of our new 
Medicare program in this country'. 111 Medicare patients could not expect 
the electrically powered beds enjoyed by private North American patients, 
and the King's Fund Bed might have been a good compromise. But the 
situation in other countries bore no direct relation to the economics of their 
health care. In Denmark, beds were almost universally of fixed height, and 
built to a national standard. 'Nobody seemed to have the slightest difficulty 
with this'. 112 In Switzerland in 1964, a lifting back rest (that is the rising 
108 Reportof a meeting at Nesbit-Evans Factory, 12.10.73, AAD/1 989/9, Job 15. 

109 

'Roger', Milan, to Kenneth Agnew, 13.5.70, AAD/1 989/9 Job 15. 
Interview, Kenneth Crisp, 20.7.00. 
111 AAD/1 989/9, Job 13. Weke to Archer, 8.11.66. 

1 12 

'AAD/1 989/9, Job 7, 'Tour of Scandinavian hospitals'. Denmark spent slightly more on 
hospital care per person than England and Wales in the mid-1 950's (as a proportion of 
average income per head). Office of Health Economics, Hospital Costs in Perspective, 



221 



base in the RCA prototype as an alternative to the pull out back rest, 
abandoned in Nesbit-Evans first versions) was 'thought most essential and 
all hospitals . . . had hydraulically operated backrests which could be used 
by nurse or patient.' 1 13 National standards themselves varied widely. In 
France the national standard specified the height for a fixed height bed as 
16" (40cm), compared to the British 24" (61cm). 114 A study as long as this 
one would probably be required to elucidate the factors beyond those 
explicitly considered in the RCA's method which determined hospital bed 
types in each of these countries. 115 But certainly protagonists for the King's 
Fund Bed did not have abroad the links with powerful interests that had 
been constructed at home. 

A minor episode occurred in the year after the specification was 
published and King's Fund Beds went on the market which adds a small 
postscript to the question of the success of the King's Fund Bed. In late 
1968 the RCA' s prototype Bed was considered for a prestigious Council of 
Industrial Design award the following year. 116 It was the first time that the 
scope of this annual competition had been widened to include capital 
goods, a probable result of leadership changes within the Council. The 
Secretary since 1946, 'an ex-Wrens officer of great charm' retired at the 

London, 1963. 
113 AAD/1 989/9 Job 7 Tour of Swiss Hospitals', Evered and Co. March, 1964. 

1 14 

John Gainsborough, 'Current Trends in Hospital Design in London and Paris', British 
Hospital and Social Service Journal, June 7, 1963, pp. 664-667. 

1 15 

There are instances of very direct technology transfers into medicine from prominent 
national industries. Swedish hospitals, for example, adopted the 'boil in the bag' vacuum 
packed meal system originally developed for miners in the north of the country. 

116 Report of a meeting at the COID, 20.12.68, AAD/1 989/9, Job 15. 



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beginning of the 1960's 117 She was replaced by Michael Fair, a long- 
standing associate of Archer's and a professional designer with a high 
profile in industry. It was probably this connection which furthered 
consideration of the bed for an award (and also the sympathetic interest of 
the COID throughout the project). A bed was duly delivered to the Design 
Centre and examined by the judges who, although they 'were leaning over 
backwards to try to justify giving it an award', couldn't bring themselves to 
do so, largely on aesthetic grounds. 1 18 Despite, presumably, Farr's goodwill, 
and the powerful rhetoric of satisfied user needs, the bed did not fit with 
the notion of 'good design' at the COID; a concept that had proved almost 
indefinable, though much discussed, in the essentially conservative circles 
there. 

Conclusion 

The above episode illustrates the fact that it was not only in the esoteric 
world of medicine that success depended on other than the computable. 
It also serves to underline just how accommodating has been the concept 
of user or consumer need, and how fine the line is between serving needs 
and serving interests, if indeed the line exists at all, except in semantics. 
Needs are supposedly 'basic', essential, justified and, especially if they can 
be defined biologically, relatively unassailable. Interests are partisan, and 
contestable. Needs belong in the natural world, interests in the social. In 
fact needs are no less contestable than interests. Who shall be allowed 



Plummer, 'Fitness for Purpose', pp. 8-9. 
1 1 8 John Blake to Toby Weston, 1 1 .2.69, AAD/1 989/9 Job 1 5. 



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needs, how needs will be defined, and what constitutes proper satisfaction 

of need, is all contestable. 

The identification of user needs in the King's Fund Bed Project, and 

perhaps more generally, may be seen in large part as a legitimation of 

interests, an obfuscation whereby the interests of powerful factions were 

translated into the 'needs' (largely biologically defined therefore particularly 

unassailable) of less powerful (but useful) users. (This is not to suggest by 

any means that protagonists for the bed consciously intended this to be 

so.) 

Many of those involved with the Hochschule fur Gestaltung at Ulm in the 

1960's were alive to the political dimensions of design, and preoccupied 

with the role of design in a consumer society and they continued to debate 

these issues in a way that was, until relatively recently, largely absent from 

the studiedly apolitical North American and British tradition of writing about 

design. Horst Rittel, for example, discussing user needs, suggested that 

one approach for the designer was to 'confess that he was a politician and 

that this in itself was not disgusting'. In 1964 he had characterised Archer's 

method as one which concerned itself with the organisation of the decision 

space. It used 'simple methods of organisation . . . very primitive methods 

but these are useful for better organization of data, for a disciplined and 

effective approach . . , 119 But Rittel later came to reject such methods 
The first generation model works like this: you work with your client to 
understand the problem, then you withdraw and work out the 
solution; then you come back to your client and offer it to him ... at 
every step in developing such a solution you have made deontic or 
ought-to -be judgements that he may or may not share but that he 
cannot read from the finished product offered in your solution. 120 

119 

Rittel, The Universe of Design, p. 86. 

120 

Quoted in Cross, Developments in Design Methodology, p. 322. 



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The clients for the King's Fund Bed couldn't read them either, but it didn't 
matter. The design solution was perfectly attuned to shared assumptions 
about patients, nurses, and management in the NHS. It was not until these 
assumptions changed that some of the 'deontic or ought-to-be' judgements 
became visible. In the 1990's the talk was of consumers, not patients, and 
this term is now commonly used in official and research publications on the 
Health Service. Economic relations have not changed, British health care is 
still paid for through taxation and free at the point of use, so presumably 
the changed language is intended to convey an alteration in attitude. 

In line with this trend, King's Fund publications also talk of 
consumers, not users, or patients. This terminology was employed in 1998, 
when the Fund revisited the specification for the King's Fund Bed. A 
steering group re-examined this 'one off study that had remained influential 
for years'. 121 

Talk was now of occupants, informal carers and staff, in that order, 
and of 'stakeholders' generally. The key areas were occupant 
independence, pressure sores and back injury, again in that order. It was 
recommended that a 'forum for continuing partnership' should be set up. 
The study encompassed beds for nursing homes and occupant's own 
homes, as well as hospitals; the 'district general' has been replaced by 
'care in the community' as a central focus in health care delivery. The 
conclusions of this subsequent study of hospital beds highlight the way in 
which successful design solutions depend on the successful embodiment 
of prevailing assumptions and the powerful interests which maintain them. 



121 Mitchell et al., Better Beds for Health Care, p.1998. 



225 



I will conclude with two quotes. Jean Baudrillard, in line with a now 

orthodox post-modern view, opined that 

'The empirical object ... the object is nothing. It is nothing but the different 
types of relations and significations that converge, contradict 
themselves, and twist around it, as such - the hidden logic that not 
only arranges this bundle of relations, but directs the manifest 
discourse that overlays and occludes it.' 122 



It is largely this view, that the object is the manifestation of a 'hidden logic', 
that has been propounded in this thesis. The German Romanticist, Novalis, 
two centuries earlier, wrote that 'everywhere we seek the unconditional, 
and all we ever find is things.' 123 While well aware of the anachronism of 
plucking sound bites out of the past and using them out of their original 
context, it might perhaps be permissable to assert that it is in the 
contingent nature of 'things' that their value to the historian lies. 



122 

Jean Baudrillard, For a Critique of the Political Economy of the Sign, St Louis: Telos Press, 
1981, p.63. 

123 

Novalis, quoted in Erlhoff, 'Ulm as a Model of Modernity', p. 54. Novalis was the pseudonym 
of Friedrich von Hardenberg, German Romanticist poet and polymath, 1772-1801.