Architecture and ideologies of care

Health and social care settings are material expressions of welfare ideologies (Sloane and Sloane Reference Sloane and Sloane2003). Architectural practice reproduces prevailing ideals and, through the design of buildings, contributes to the fabrication of those who populate them, such as ‘the patient’, ‘the child’, ‘the nurse’ and ‘the user’ (Prior Reference Prior1988). Allen (Reference Allen2006) suggests that architecture holds an ‘ambient power’, with buildings exerting a degree of agency in orchestrating the movements and affective responses of those inhabiting them (see also Rose, Degen and Basdas Reference Rose, Degen and Basdas2010). More than simply acting as repositories of symbolic power or ideological meaning (Jones Reference Jones2011), buildings help to enact ideologies – of care, health and wellbeing – through the social practices they enable and encourage.

When designing residential care homes, architects can be said to give shape to the settings where care will take place, and thereby have the potential to reformulate philosophies of care. Andersson (Reference Andersson2015) explored how socio-political visions of care for later life were articulated in design competitions throughout the 20th century in Sweden, where architectural plans became influential within evolving welfare regimes. He identified an aspiration to develop humane and personalised care, and this forms a key trope throughout the 20th century, even if eventual buildings reveal national variations. Bromley's (Reference Bromley2012) exploration of architects’ operationalisation of person centredness in contemporary hospital design, for instance, reveals how architects imported hospitality-sector designs which sought to disguise the hospital as a site of clinical care. This chimes with Heathcote's observation that health-care settings must ‘attract patients’, with ‘the hybrid of hotel and mall … emerging as one of the key contemporary models from the USA to Japan’ (Reference Heathcote, Jencks and Heathcote2010: 89). These design models seek to adjust the feeling of the hospital to counter the logic of biomedicine and scientific rationality and are part of a more profound shift towards a neo-liberal subjectivity, in which the patient is reconstituted as a consumer and where the practices of health care are played out in hybridised sites of consumption (Martin et al. Reference Martin, Nettleton, Buse, Prior and Twigg2015). It seems likely, therefore, that architects may similarly configure residential homes as hybrid sites through competing narratives and contested meanings.

Gubrium and Holstein's (Reference Gubrium and Holstein1999) ethnomethodological exploration of ‘the nursing home’ finds that the term itself is generative of meanings. As a ‘membership categorisation device’, it ‘guides and ramifies body talk relevant to disease, care giving and dying’ (1999: 519). They argue that the ‘nursing home’:

More widely, in media images the care home remains imbued with negative representations of ‘feared old age’ (Gilleard and Higgs Reference Gilleard and Higgs2011), continuing to anchor the ageing body in discourses of decline. Nonetheless, representations of spaces for old age are changing, reflecting wider shifts in relation to the representation of ageing (Laws Reference Laws, Jamieson, Harper and Victor1997). Discursive constructions like the ‘third age’ and the ‘baby boomers’ have become widely familiar (Gilleard and Higgs Reference Gilleard and Higgs2010; Twigg and Majima Reference Twigg and Majima2014; Ylänne Reference Ylänne2012), with older people presented as active and independent consumers of care. These multiple discourses, as we shall see, impact on the ways architects imagine older people. Although as Gubrium and Holstein argued, the ‘residential care home’ discursively anchors the body, it now does so in more varied and flexible ways.

Imagined bodies and body workers in health and social care

Ideologies of care intertwine with competing ontologies of bodies. Modern ‘Western’ medicine, long dominated by a ‘mechanical’, ‘functional’ body and an objectified view of the patient (Leder Reference Leder1992), now engages with the ‘lived body’ (Prentice Reference Prentice2013), and is located within philosophies that privilege ‘person-centred’ and ‘relationship-centred’ approaches (Shapiro Reference Shapiro2008). It has, however, long contained orientations that emphasise objectifying practices of medicine – ‘slicing’, ‘probing’, ‘talking about’, ‘measuring’ and ‘counting’ bodies (Mol Reference Mol2002: vii). As a result, practitioners routinely move between different conceptions of the body, such as the ‘lived’ body talked about by patients and the ‘mechanical’ body or ‘measured body’ of diagnostic practices (Prentice Reference Prentice2013).

Previous literature has tended to focus on how notions of the body emerge from ‘hands on’ work on bodies, and those professionals who carry out such ‘body work’ (Twigg et al. Reference Twigg, Wolkowitz, Cohen and Nettleton2011). More recently, a growing exploration of ‘imagined bodies’ has led to a call for an extension to the concept of ‘body work’ to include ‘multiple bodies in care work, including virtual bodies rendered visible by technical devices’ (Kerr Reference Kerr2013: 467; Lupton Reference Lupton2014), as well as the examination of a wider range of professional roles. For example, Kerr's (Reference Kerr2013) analysis of practitioners’ accounts of their decisions, in the context of the provision of assisted conception, finds that those involved in the allocation and delivery of the service are touched by the emotional consequences of their decisions, even where they do not meet the service users in person. They are, she argues, sensitive to the ‘imagined bodies’ in receipt (or not) of services and showed ‘displays of empathy and shared frustrations’ (Kerr Reference Kerr2013: 476) associated with their decisions. In the context of pharmacy practice, Jamie (Reference Jamie2014) similarly explores how pharmacists work with ‘symbolic’ as well as physical bodies, and with the multiplicity of bodies they encounter in their roles as retailers, dispensers and public health practitioners.

Moving to architects as designers of care, ‘body work’ can give analytic purchase to explore how they imagine the bodies of those who they anticipate will populate their buildings. Research to date suggests that attention to bodies in architecture, and the range of bodies attended to, is limited. Imrie, for example, set out to explore the ‘bodies in mind’ as ‘conveyed by architects’ self-testimonies’ (2003: 52) and found these to be relatively ‘partial and reductive conceptions of the human body’ (2003: 63). The feminist philosopher Elizabeth Grosz (Reference Grosz2001) has written extensively on the need for architectural practice to engage with the mess of corporeality and difference, and most particularly the need for architecture to be explicit about embodiment and the relations between sexualised and racialised bodies. She argues for a continuing political engagement, whereby architects relentlessly question their ideas as to how best to configure spaces, bodies and their interconnections. She writes:

For Grosz, architecture, like any discipline, must engage with a somatic politics.

Imrie's study of architects working in the United Kingdom comes to a similar conclusion. He found that in architectural practice and training the body, in all its diversity, was largely absent; and ‘if the body did figure at all’, it was a Cartesian, geometric and essentialised body, ‘little more than an object with fixed measurable parts’ which was ‘neutered and neutral, that is without sex, gender, race or physical difference’ (Imrie Reference Imrie2003: 47). On those occasions where architects anticipated the use of buildings, they did so by drawing on their own personal experiences with ‘their own bodies as the dominant point of reference’ (2003: 57), a finding replicated in our data as we discuss below. Imrie also found that the body was ‘rarely conceived as an organic fleshy, entity’, and ‘more often than not, the human body is defined as “people” who populate designs, or as collective categories of users predetermined by the function of the building being designed’ (2003: 57). Imrie argues for a more reflexive form of architectural design that ‘recognises, and responds to, the diversity of bodily needs in the built environment’ and, like Grosz, an architecture which is ‘open minded’ and ‘sensitised to the corporealities of the body’ (Imrie Reference Imrie2003: 64).

Our discussions with architects undertaken over a decade after Imrie's study indicate that they do appear, at least, to appreciate a diversity of bodily needs in ways that Imrie's study participants did not. This could well be because our work addressed design projects for the care for men and women in later life, with the spatial form of the residential care home anchoring a culturally problematic body (Gubrium and Holstein Reference Gubrium and Holstein1999) rather than a generic body – indeed, in recent guidance to architectural professionals, the residential setting is identified as a potential barrier to thinking about designing in age-friendly ways (Handler Reference Handler2014: 17). It may also reflect ideological shifts towards person-centred and non-institutional forms of care outlined above, in concert with a politicisation of bodies in all their diversity. Moreover, in building design since the end of the 20th century, embodied issues have been foregrounded in legislation relating to, for instance, issues of access and inclusive design (Imrie and Luck Reference Imrie and Luck2014; Soldatic, Morgan and Roulstone Reference Soldatic, Morgan and Roulstone2014). Nevertheless, the prominence of the architects’ rehearsal of multiple imagined bodies throughout the interviews was striking, as we explore in the following sections.

Study and methods

To begin to unravel architects’ work in the care home sector we undertook 20 semi-structured interviews with 26 architectural professionals in 2014–15, with some single interviews involving two or three architects. Maximum variation sampling led to the inclusion of architects from large and small firms, and those whose portfolios included a variety of projects in different sectors of care, ranging from firms working for large private-sector care providers to those working with local authorities, and firms working with smaller charitable organisations. All participants worked on projects in other areas, but all had a portfolio of care projects they could discuss. Of the 26 architects and designers interviewed, seven were female, as might be expected in a profession still dominated by traditional gender norms (Sang, Dainty and Ison Reference Sang, Dainty and Ison2014). Participants were asked to talk us through the various processes of the planning, construction and completion of buildings. Questions included: How are the architectural briefs for care homes negotiated? What issues arise in site-specific contexts? How do they as architects communicate with clients, builders, planners and other stakeholders? What types of knowledge about the care needs of eventual users are sourced and how are these translated into design?

As we familiarised ourselves with the data, we were struck by the amount of body-related talk. Following initial coding, we revisited the data using ‘body work’, ‘imagined bodies’ and the ‘body multiple’ as sensitising concepts. It became apparent that architects were anticipating bodies within care settings, especially as they spoke about strategies by which they might attend to the needs of users. We identify several such strategies described as they reflected on designing for later life. Our analysis also reveals how they work with particular constructions of ‘ageing bodies’ and how they reproduce and yet also try to challenge discourses of ageing. The architects’ strategies for imaging bodies and their constructions of ageing also rub up against, or at least have to engage with, the imagined bodies conceived by other stakeholders involved during the design process, as we explore in more detail below.

Strategies for imagining bodies

Strategies for imagining bodies took various forms of empathetic engagement with users including: envisaging oneself as a potential user, referencing one's own experience of physical environments, drawing on the presumed needs and experiences of older relatives, role play within projected design settings, and consulting with users. Through these processes various bodies were conceived of in the reflections of our participants, and through this the architects engaged in forms of body work, understood as the rendering of bodies as visible within particular material contexts.

Interviews opened with questions on approaches to designing residential homes and it was striking how some participants foregrounded a living body. One female architect immediately focused on the body at the start of the interview when asked how she would approach designing a care home.

She goes on to explain how anticipating the bodily experience of service users, and most especially those with dementia, is a ‘challenge’ requiring the architect to ‘step into the shoes’ of someone who is differentially embodied. As another architect said, ‘I think the most important part is the empathic process’, before posing the question of ‘how do we create that empathic process?’ (Interview 7). This apparent sensitivity to the lived bodily experience of older people with dementia was seen as necessary for meeting acceptable standards of design in this field, with this particular architect even describing it as an ‘obligation’. We can situate these reflections within a growing demand for empathic and emotion work in medical (Kelly Reference Kelly2014; Shapiro Reference Shapiro2008) and design professions (Suri Reference Suri2001), and as a form of contemporary affective labour (Pedwell Reference Pedwell2014). In this, our data may be tapping into wider ideological changes as compared with the late 20th century, when Imrie's research was undertaken, as well as increased research within architectural circles on the topic of designing in age-sensitive ways (Handler Reference Handler2014).

Nevertheless, consistent with Imrie's (Reference Imrie2003) research, we found that architects were self-referential, drawing on their own experiences to imagine the lived bodily experiences of later life. In particular, they drew on aspirations for anticipated care needs – for themselves or their relatives: ‘You always keep thinking, would I want my mum to do that, or would I want my mum to live there, and I always try and put myself in someone's shoes’ (Interview 8). A few employed strategies that were more concrete, using their bodies to experience settings empathetically and pragmatically as they developed:

This suggests a process of imagining as ‘perceiving in the hypothetical mode’, as understood by Murphy in his discourse analysis of how architects work in configuring the eventual user experience of their buildings (Reference Murphy2004: 277). Other architects created ‘mock-ups’ of care home spaces, physically putting themselves in the place of the user: ‘I'm lying in bed here, can I see the toilet?’ (Interview 8). These techniques can create a ‘powerful feel for bodies’ (Prentice Reference Prentice2013), cultivating strategies of ‘empathic design’ (Kouprie and Sleeswijk-Visser Reference Kouprie and Sleeswijk-Visser2009).

While this body work sought to provide empathetic insight into user perspectives, there is however the potential to reinforce relations of difference between ‘the emphasiser’ and the ‘other’ (Pedwell Reference Pedwell2014). This ‘othering’ was evident in the language used by some, such as the ubiquitous use of ‘little’ as in ‘little old ladies’, ‘designing a little kitchen area’ with a ‘little table’ and also references to ‘poor old lady’ and descriptions of people with dementia as ‘very sick’ and ‘very frail’. This reflects how care homes continue to anchor particular (gendered) repertories and images of ageing, including infantilising discourses (Hockey and James Reference Hockey and James1993). However, in other cases self-referential work had the potential to engender ‘shared vulnerabilities’ (Shildrick Reference Shildrick2001), and unlock the emotional challenges associated with negotiating unfamiliar space. As one architect comments:

To some extent, this ability to invoke ‘shared vulnerabilities’ depends on the architects’ social location. Interviewee 5 went on to draw on her own experiences of growing older in imagining these embodied challenges: ‘when you're young you can't imagine what it's like to be old, and as you get older this awful awareness sinks in!’ In contrast, a younger male architect distinguished his own preferences from that of older residents, dichotomising the design needs of young and old (Woodward Reference Woodward1991): ‘the ground floor is popular which kind of goes against what we would want as younger people’ (Interview 2).

The participants did, however, go beyond personal experience, and a further strategy was the recourse to training resources and written guidance such as those issued by the University of Stirling's Dementia Centre to guide their design and to grasp the visual, cognitive, auditory, sensory needs of people with dementia. The Stirling Standards seek to encourage empathic engagement; ‘written in first person to ensure that dementia friendly design is understood from the perspective of the person with dementia’ (Dementia Services Development Centre 2012: 1). They highlight the diverse sensory aspects of the space: reducing noise, ‘plenty of light’, the visibility of staff and relatives and ‘good colour/tonal contrast’ in the toilets. Training workshops encouraged architects to use their bodies to imagine the experiences of people with dementia, such as ‘putting on gloves’ whilst attempting everyday tasks. This guidance was often felt to provide a ‘way in’ to the experience of ageing, which would not otherwise be accessible, as one architect said: ‘other than having a personal experience with a grandma that was in a care home, we would not be able to perceive that side’ (Interview 7).

Nonetheless, some architects found these prescriptions to be normative and restrictive. Self-referentiality at times trumped evidence-based guidance which details the importance of bright and primary colours in care home settings, with some architects eschewing this on the basis that it is not what people would want in their own homes, and thus revealing a propensity for the imposition of the designer's own values and aesthetic. Others argued that ‘reliance upon published information’ is no substitute for spending ‘time actually in a care home with people with dementia’ (Interview 1) and appreciating their personalised and individualised needs. One described how ‘we don't have much contact with people with dementia or older people in care’ and so ‘I've tried to make an effort to get to know people with dementia’, even joining the board of a local care home (Interview 11). Another, who refurbished existing properties, emphasised the importance of regular ‘face-to-face’ consultation with users throughout the process (Interview 3). In general, however, consultation with users was limited, taking place only ‘post-occupancy’. Furthermore, architects varied in the extent to which they felt user engagement should be incorporated into the design process, particularly with frail older people with dementia who were sometimes described as too ‘difficult’ to consult with, due to their ‘confused state’.

Consultation with service users and staff was more common among those working for small charities, local authority or National Health Service facilities, or involved in the refurbishment of existing care homes or sheltered housing. The extent to which such consultation took place depended on who the client was and whether it was written into the brief, reflecting the collaborative and contingent nature of the project work – a point we return to below. Discussions with users often exposed the limits of imaginative perspective taking (Imrie and Luck Reference Imrie and Luck2014), as care home residents raised issues ‘that probably you and I wouldn't even dream about’ but ‘were massively important’ (Interview 3) to them. Architects spoke about getting ‘little gems from service users’ regarding how their designs could be improved to accommodate bodily needs and preferences; for instance, altering the width of bathroom doors following feedback from a service user that ‘when you go from a corridor area, to a bathroom area, the hoist can wobble just a little bit and slip’, causing him to ‘bang his elbow on the doorframe’ (Interview 2).

These examples focus on bodily impairment, reflecting how, as Gubrium and Holstein (Reference Gubrium and Holstein1999) argue, the care home discursively orientates body talk towards disease, care-giving and dying, rather than other aspects of embodiment. However, consultation with users and personal experiences with relatives could facilitate a more balanced understanding of the lived body. One architect reflected that when he ‘entered the field of elderly care design’ he had a rather stereotypical, ‘idealised view of what older people are like’. However, through spending time in care homes and ‘working with people directly’ this ‘opens you up to that spectrum’ in terms of the diversity among older people (Interview 16). Another architect described how consultation with users highlighted various everyday concerns: how important ‘having some identifiable personal space outside’ is, ‘where and whether a settee would fit in’ or ‘what would the tiles be like in the bathroom?’ (Interview 3). His personal account of his parents’ physical and emotional challenges associated with their changing needs also illuminates the complex entanglements of bodies, places and things in negotiating meanings of ‘home’:

This quotation figures care as an art of dwelling that ‘enacts being-at-home by reassembling bodies, emotions, technologies, and places in highly specific, complex ways and often fragile and precarious ways’ (Schillmeier and Domènech Reference Schillmeier and Domènech2009: 288). We might discern processes of othering (Pedwell Reference Pedwell2014) and a characterisation of older people as potentially irrational through the use of absurd humour here, but we also hear the voice of a practitioner who seeks to attend to the detail of care work in practice – as he articulates a sensitivity to the salience of personal effects and material objects.

It was rare for architects to know the personal histories of those who would reside in their buildings. Thus, architects tended to ‘flesh out’ service user's lives through the use of imaginative strategies whereby they reconstructed idealised ‘embodied biographies’ (Williams Reference Williams2000), drawing on familiar generational motifs, as indicated here: ‘A lot of their working adult life would have been outdoors all year so they'll be used to being outdoors so having what we call “the wind on the face”’ (Interview 2). They also constructed ‘narrative vignettes’ (Blythe and Wright Reference Blythe and Wright2006) that ascribed histories, personalities and interests to virtual users, as in the comments about ‘an old man who wants to sit and talk about his days in the army for an hour before they talk about whether he would prefer a small garden outside his apartment’ (Interview 3). Naming is also a significant part of personification (Prentice Reference Prentice2013), illustrated by the use of names such as ‘Mavis’ and ‘Elsie’, as in the comment ‘we'll have an oven so that … Elsie can make cakes when she wants to’ (Interview 3), which in the UK context have generational associations. Yet these characters remain ‘quasi-subjects’ (Prentice Reference Prentice2013), potentially ‘unconvincing because they are composites’ (Blythe and Wright Reference Blythe and Wright2006: 1141). These imaginings therefore reproduce cultural tropes connoting pre-war generations, as well as gendered images of old age and elder care. It is to these wider images and constructions of ageing bodies that we now turn.

Constructions of the ageing body

While architects made efforts to engage creatively with the fleshy, lived body of residents, their discussions were nonetheless anchored in dominant cultural repertories around ageing, at times reproducing stereotypical depictions of old age. In seeking to reconstruct the daily experience of the service user, architects’ narratives could reduce older people to bodily needs and (dys)functions. There was a focus on the ‘body zones’ of the bedroom and bathroom in their accounts (Imrie Reference Imrie2004: 748). Indeed, when asked about approaches to designing residential homes, a number of the architects emphasised how they ‘start with the bedroom’ when designing for care and in this space imagine the daily life of the user. Discussion of these ‘body zones’ summoned images of dependent, leaky bodies:

Such discussions construct the ageing body in terms of disability and dysfunction. Therefore, in contrast to architectural design more generally, where there is a presumption of able bodies (Imrie Reference Imrie2003), the care home is embedded within images of frailty, decline and dependency (Gullette Reference Gullette1997), dominated by routines of bed and body work (Gubrium Reference Gubrium1997). Such images of ‘leaky’ bodies were also gendered (Lawton Reference Lawton1998), generally focusing on women. These assumptions about decline were embedded in discussions of ‘flexible’ spaces that are able to adapt to deteriorating mental and physical abilities.

Yet architects’ constructions also drew on newer, more positive images of ageing, describing older people as ‘embracing life’, having ‘so much opportunity’, ‘being part of a vibrant community’ and having a ‘nice lifestyle’ within the care home. These changing concepts of the lifecourse reflect a ‘new generation’ of spaces for old age (Barnes Reference Barnes2002; Ylänne Reference Ylänne2012) that increasingly take their architectural cues from the hotel and leisure sectors. Just as hotels offer grades of accommodation – standard en suite, premium, and so on – so too do some care homes. One architect illustrated how in some care homes he designed ‘the bedroom at three different standards, bronze, silver and gold’ (Interview 7), and another had designed ‘premium’ bedrooms for one care home (Interview 20). Others describe their designs as resembling ‘luxury’ hotel-like spaces, with residents ‘receiving a service’ and an ‘experience’:

Cinemas, shops, hair salons, cafes and bars are incorporated into the design of care homes, suggesting places of consumption and active leisure. With their emphasis on ‘luxury’ and ‘elegance’, they present a vision of life that is implicitly classed and remote from institutional models associated with welfare and need.

Not all architects were comfortable with the incorporation of ‘hotel-like’ facilities and services into care settings, preferring what was construed as an alternative ‘domestic’ model. This too, of course, could draw on normative models of classed lifestyles. Nonetheless, there was consensus in terms of the need to move away from institutional models of care. Reflecting Bromley's (Reference Bromley2012) findings, architects sought to disguise the fact that their building was ‘an institution’ for the delivery of care. One architect spoke of ‘trying to remove the medical connotations completely from people's minds when they are living there’ (Interview 2). Interviews are replete with references to ‘human scale’, ‘lack of corridors’, ‘personalised bedrooms’ and shared spaces that encourage active rather than passive encounters and social practices.

Such discussions emphasise personalised, person-centred and consumer-orientated services rather than medical care, and yet semantic slippage reveals tensions between new models of care and the fact that the residential care home is based on the spatial segregation of older people, and predicated on bodily dysfunction. The same architect who described a shift away from ‘medical connotations’ and hotel-like ‘services’ then went on to state:

This quotation returns to medical models of ageing, and images of older bodies as diseased, declining and ‘vulnerable’, contrasting with depictions of positive ageing earlier in the interview.

This duality in architects’ narratives of ageing is embedded within broader cultural images, which dichotomise ‘third agers’ as active and healthy consumers, with the fourth age as time of dependency and decline (Rees Jones and Higgs Reference Rees Jones and Higgs2010). Popular tropes such as the ‘baby boomers’ surfaced in architects’ imaginings of older people. For instance, one contrasted the ‘generation of 85 who lived through the war, hard times’ to the ‘baby-boom generation’ who have ‘got a bit of money … had a very good quality of life, moments cruising around the world maybe’ (Interview 2). Though the rhetoric of the baby boomer has been challenged as representing a sectional, often classed account in which the significance of cohort is exaggerated (Jönson Reference Jönson2012; Twigg and Majima Reference Twigg and Majima2014), it is widely pervasive in the popular culture. It has obvious commercial appeal within the design industry, ‘presenting a vision of later life that is up-beat, optimistic and forward facing’ (Twigg Reference Twigg2012: 1049). As one architect comments, this is a vision which actively sells the care home:

This consumerist model of care is something that the architects felt that ‘a lot of care providers want’ because it appeals to those purchasing care – which was presumed to be the relatives of potential residents rather than older people themselves. Certainly, research suggests that relatives choosing a care home often interpret the physical environment, including ‘good decor and comfortable furnishings’, as an indicator of care quality, in the absence of any detailed guidance (Davies and Nolan Reference Davies and Nolan2003: 441). Thus, the hotel model removes institutional connotations associated with feared old age, reassuring relatives that ‘mum will be well looked after here’. These discussions also reflect the commodification of care, and an increased emphasis on ‘branding’ and selling care within the competitive market of the contemporary care sector (Holden Reference Holden2002).

These discursive divisions between ‘consuming and active bodies’ and ‘diseased and declining bodies’ were also enacted spatially, in the spatial ordering of bodies through design. The architects reported that clients preferred people with dementia to be located on the top floor, excluded from downstairs spaces which constitute the ‘public front’ of the care home (Lee-Treweek Reference Lee-Treweek1997):

Therefore the design of new, ‘vibrant’ spaces of ageing is dependent on concealing the ‘abject bodies’ of people with advanced dementia (Gilleard and Higgs Reference Gilleard and Higgs2011), as well as concealing design features that might speak to institutional or medicalised settings. Various design guides stress the importance of access and proximity to outdoor spaces for older residents’ quality of life (e.g. Delhanty Reference Delhanty2013; Dementia Services Development Centre 2012; Homes and Communities Agency 2009), and it has been argued that locating residents with dementia on upper floors can act as a barrier to access (Chalfont Reference Chalfont, Froggatt, Davies and Meyer2008; Chalfont and Rodiek Reference Chalfont and Rodiek2005; Torrington Reference Torrington2006). While balconies may overcome access issues on upper floors (Delhanty Reference Delhanty2013), these were often opposed by clients due to concerns with risk. Therefore possibilities for new images and spaces of ageing are constrained by competing notions of ‘risky’ and ‘calculated’ bodies, to which we now turn.

Juggling multiple bodies

Attempts to imagine bodies of users were invariably tempered by the bodies ‘imagined’ by other participants and stakeholders in the design process. Consequently, we find that architects are engaged in a process of ‘juggling’ differing ontologies of bodies. These variably enacted bodies may collide; contradicting and constraining each other and yet still ‘hang together’ (Mol Reference Mol2002) as the end users who are anticipated as living in the finished building. Architects’ design work takes place in the busy series of negotiated compromises, within the clamour of local politics and material constraints (Gutman Reference Gutman, Cuff and Wriedt2010). Latour and Yaneva (Reference Latour, Yaneva and Geiser2008) liken the architect to a ‘juggler’, relentlessly having to respond to a multiplicity of material and political demands. The evolution of design is a fluid process wherein the architect must ‘absorb a new difficulty and add it to the accumulation of elements necessary to entertain the possibility of building anything’ (Latour and Yaneva Reference Latour, Yaneva and Geiser2008: 84). Such juggling implies a form of complex affective and empathetic labour, where craft and co-operative practice are combined (Sennett Reference Sennett2009, Reference Sennett2012). What is evident from our analysis is the extent to which designing for care involves collaborating with other body workers such as occupational therapists, physiotherapists and care workers. The following account of a project meeting captures how stakeholders’ different conceptions of the body come into conflict in the design process: ‘calculated bodies’ driven by budget interests; ‘declining bodies’ as the object of care; and material bodies that need to be mobilised.

Thus, the body work of architects involves negotiation and struggle over the prioritisation of the differentially imaged bodies of the other body workers involved in the delivery of health and social care. Stakeholders bring with them differing conceptions of the body to their discussions with architects. Discussions with planners were reported as frustrating when people with dementia were purely and merely seen as ‘risky’ bodies (Phillipson and Powell Reference Phillipson, Powell and Tulle2004). An example of this was when one architect's plans to introduce a ‘pedestrian bridge’ to ‘help the local community come into the building’ were overruled by the planner as they were perceived to be too risky: ‘the planner is like: “Oh bridges? People with dementia? Oh no, you can't have that” (Interview 11).

Despite an aspirational focus on the lived body in discussions of architectural design for care, the abstraction of bodies into measurable and quantifiable units (Imrie Reference Imrie2003) dominated interactions with clients and architectural briefs. Initial consultations with clients start with the number of bedrooms, and the amount of space needed per resident in order make the home profitable:

These discussions again reflect the commercialisation of care, alongside increased government regulation and standardisation of the spatial allowance per resident, which mean that care homes must be large enough to achieve ‘economies of scale’ (Holden Reference Holden2002: 80).

Architects’ experiences of negotiating client briefs varied, however, according to a range of factors including: the procurement process, the type of client, size of the organisation, their relationship to the architect, the type of development (e.g. care home or sheltered housing) and their care philosophy. These factors intersected in complex ways, although initial interviews with architects suggest that larger, for-profit organisations have a stronger focus on commercial issues, as one architect said:

In contrast, some architects described small charitable organisations and in some cases local authorities as more user-focused, with housing associations in particular often having a ‘flexible’ brief which is developed in consultation with the client and service users. However, several architects suggested that in the context of funding cuts, these organisations are growing ‘more financially conscious’, and increasingly ‘have to be self-supporting, and this becomes the sort of driver’ (Interview 17). This reflects wider arguments that the marketisation of care can undermine the interests of service users, contrary to the rhetoric of consumer choice and empowerment (Brennan et al. Reference Brennan, Cass, Himmelweit and Szebehely2012; Oldman and Quilgars Reference Oldman and Quilgars1999).

Cost efficiency is in tension with the wish to reform care regimes according to standards for dementia-friendly design, with the result that architects become embroiled in juggling competing logics of care (Mol Reference Mol2008). Some of these logics take on social, aetheticised and normative qualities.

Resonating with long-standing debates about the nature of residential care, this comment captures particular tensions around the nature of the space, and whether it is public or private, communal or domestic. Bland's (Reference Bland1999: 558) detailed study of the residential care sector, for example, found amongst care providers ‘uncertainty as to whether residential care homes are supposed to be run like hospitals, hotels or domestic residences’. Our interviews show how these tensions can also be found upstream, in the conflicting imperatives and perspectives that architects articulate and negotiate in their designs and routine professional practice.