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22 May 2019

Alms race: the search for housing fit for the end of life

There was a time when many of us died before we got old. But now ageing populations are forcing governments to rethink public health priorities. 

By Ken Worpole

On New Year’s Day 1900, in a spirit of high optimism, the Swedish designer and social reformer, Ellen Key, published her design manifesto, Barnets Århundrade (The Century of the Child). The Italian  philosopher and educationalist, Maria Montessori, whose ideas on pedagogy were shortly to circle the globe, claimed that Key had defined the great social project of their age. As the design historian Juliet Kinchin wrote, this was  “that the well-being of children was the defining mission of the century to come”.

In 2012 the Museum of Modern Art (Moma) in New York celebrated Key’s manifesto in a retrospective exhibition called Century of the Child: Growing by Design 1900–2000, charting the child-centred ambitions of architecture and design in the 20th century. The exhibition revisited Key’s ideas, while provocatively suggesting that it was designing for children that enabled the critical breakthrough into modernism. The young were perceived as having a natural affinity with colour and pattern – as well as appreciating the tactile and sensual attributes of design – all of which became distinguishing characteristics of the modernist credo.

Women designers and educationalists such as Key herself, Montessori, Jane Addams, Grete Lihotsky, Friedl Dicker and, here in Britain, the McMillan sisters and Dora Russell all played a major part in this stylistic and social upheaval. According to Kinchin it was the kindergarten movement that created “the building blocks of modern design”. Architects such as Frank Lloyd Wright, Jan Duiker, Kaj Gottlob, Richard Neutra, Eliel Saarinen, Aldo van Eyck and Grete Lihotsky were inspired by the new pedagogy, and their designs for nurseries, open-air schools and children’s clinics created the pattern book for a modernist civic architecture. While not everybody was happy with this fundamental refashioning of childhood, it became a settled state of affairs, and remains an unprecedented achievement.

If the 20th century was the century of the child, then the 21st century may well become the century of the elderly. Ageing populations are causing governments to re-think public health priorities and resources. Where spending money on the health of children and young people possessed a simple moral clarity – who could possibly disagree with “investing in the future”? – prioritising the needs of the elderly in an age of austerity is new political territory, as living to old age is a recent phenomenon.

The two are connected. The unprecedented increase in life expectancy in the first half of the 20th century was a direct result of the reduction in levels of infant and child mortality brought about by the campaigns of Key and others. What they sowed, we now reap. To adapt the song by the Who, most people died before they got old. Old age was once venerated because it was rare; now the elderly are sometimes regarded as surplus to requirements.

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Over 65s now make up 18 per cent of the UK population, but by 2046 this figure will be 25 per cent. Many will be in relatively good health, but the demands older people make on health services increase exponentially with each additional year of life. The Nuffield Trust estimates that 40 per cent of NHS spending is taken up by the over 65s, and international studies suggest that around 10 per cent of all health spending is devoted to those in their last year of life (in Finland this figure is 14 per cent). Such statistics set alarm bells ringing in a world in which cost-benefit analysis is now embedded in neoliberal economics.

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Balancing the differing care needs of the elderly, the infirm and those approaching the end of life, has become an ethical and financial minefield. The borders between the care of the elderly and “end of life” care remain strictly demarcated – attracting differential status and funding – even though both are part of the same “continuum of need”, to use a phrase from the late philosopher Mary Warnock. This makes no sense at all given that, as American physician and writer Atul Gawande suggests in Being Mortal (2014), “most of us will spend significant periods of our lives too reduced and debilitated to live independently”.

Two trends are clear. There is growing disillusionment with institutionalised care homes (“God’s waiting rooms”), and this is now producing a political movement towards “ageing in place” programmes, where people are cared for at home as long as possible; both trends can be seen across Europe according to an international symposium recently held at Leiden University. The rationale for home-based care is as much financial as ethical, given the cost to the public purse of residential care. In the UK local authorities pay on average £600 per week for a care home place, £800 per week for a nursing home place, and the cost to the NHS for an elderly patient to occupy a bed in a general hospital (where many old people spend their last months) is in the region of £2,000 per week. 

What Ellen Key’s book did for childhood, Philippe Ariès’s eschatological history, The Hour of Our Death (1980), has done for the ethics of end-of-life care. Ahead of his time, Ariès predicted “the triumph of medicalisation” as societies succumbed to the idea that death could be postponed – if not finally resisted – by advances in medication and prosthetic technology (as Silicon Valley transhumanists now hope). Governed by a prerogative to preserve life, medical professionals understandably supported such advances, not anticipating that other ethical dilemmas would arise once death was perceived as a system failure rather than as an existential inevitability.

“Modern society tries to deconstruct death by turning it into a series of medical battles,” was philosopher Zygmunt Bauman’s opinion. Ending one’s days in hospital may offer reassurance and clinical expertise, but the conditions are frequently demeaning and occasionally brutal. 

For increasing numbers of elderly patients suffering with dementia – and perhaps even more for their families – it is the ultimate nightmare. This is the contemporary horror Nicci Gerrard describes in her recent book What Dementia Teaches Us About Love. Soon there will be one million people in the UK suffering from dementia – which Gerrard says is now known as “the disease of the century”.

The failure of hospitals as places for the dying led to two major UK success stories in palliative care: the modern hospice movement and Maggie’s Cancer Care Centres. Since Cicely Saunders established St Christopher’s Hospice in Sydenham in 1967, more than 200 hospices have been established in Britain. Largely funded by charitable donations, they have become much-loved local institutions.

So too with the Maggie’s Centres. Founded by the artist and cancer patient Maggie Keswick Jencks and her husband Charles Jencks, who is an architectural historian, the scheme was instigated in reaction to long waits in grim buildings during the last months of Maggie’s life. Using their impressive address book, the couple commissioned some of the world’s top architects to design places that would, in the words of the splendidly terse architectural brief, “rise to the occasion”. Since Maggie Jencks died in 1995, 21 have been built in the UK, prototypes of a new era of social architecture.

The hospice movement continues to develop and adapt. Once quiet enclaves for the terminally ill, they have become therapeutic communities open to those needing palliative care, whether as inpatients, outpatients or at home. When it opened, St Christopher’s was solely an in-patient facility with 38 beds. Today it provides care, support and therapy to more than a thousand further patients. Like other hospices it has adopted the mantle of a “living village” or “open house”. As with the new almshouse movement, these are community spaces busy with life and activity – an interesting journey from their monastic origins.

According to Gawande, patients who receive palliative care may well live longer than those who fight death with technology and medication. Furthermore hospice or almshouse care costs less than being kept alive in a hospital ward wired up to monitors and dependent on feeding tubes, with emergency trips to the CPR suite for cardiopulmonary resuscitation. Sooner or later, the distinction between “managed dying” (which is what hospices do), and “assisted dying” (which is against the law) will have to be reconsidered. In March, the Royal College of Physicians dropped its long-standing opposition to assisted dying in favour of a neutral position.


Witherford Watson Mann’s design for a new development in Bermondsey, south London

Five years ago I was invited by architects Stephen Witherford and William Mann to collaborate on a commission from United St Saviour’s Charity in Southwark to design an  “An Almshouse For The 21st Century”. Visiting other care homes in London and listening to the experiences of staff and residents, one incident stayed in our memory. Alighting from a taxi outside a new building in leafy west London, we spoke to a resident who had manoeuvred his wheelchair into the entrance car park.  Behind him stood a top-of-the-range care home, with well-furnished common rooms and lounges, a conservatory and extensive landscaped gardens – but this man preferred sitting in the car park. Why, we asked?  The answer was that he loved seeing people go by, some of whom would wave or stop for a chat. 

The elderly fear being immured, cut off from everyday life. With dementia patients this sequestration from the outside world is sometimes built into the design. This is a controversial issue in the Netherlands, after it became known that in some dementia homes exit doors had been disguised, and bus stops and street cafés built into internal corridor systems, to create the impression that the world the residents now inhabit is the only world that exists – an end-of-life version of The Truman Show.

At the Leiden symposium this was a hot topic, with some participants arguing for the safety and peace of mind this gave residents, while others saw the shutters coming down on human autonomy and free will. A different approach is taken by hospices where, as Professor Rob George, medical director at St Christopher’s, told me: “We are not trying to disentangle people from their past lives and relationships when they come here. The more they remain entangled in life, the more resilient they will be, even at the end.”

While public sector care homes struggle to fund growing demand, new ideas are emerging from the philanthropic and fee-paying sectors. Commercial developers are building retirement villages for those with money released from the sale of family homes or generous pensions, often taking their cue from Hartrigg Oaks in York, a pioneering development by the Joseph Rowntree Housing Trust (JRHT), opened in 1998. This consists of 152 one- and two-bedroom bungalows plus a 42-bed care home, with common services such as a spa, swimming pool, library, café/restaurant and IT suite.

In Hartlepool the JRHT has developed a mixed tenure development where some properties are owned and others rented, with shared amenities. Older Women’s Co-Housing is a development by 26 women aged from 50 up into their 80s, formerly living on their own, who have built their own community in north London, with the help of architects Pollard Thomas Edwards. Co-housing is another way of “ageing in place”, designed to facilitate forms of mutual support and reciprocal care. There will be more, as new architectural practices enter the field with imaginative ways of designing for the elderly.

The site for Witherford Watson Mann Architects’ almshouse is in Bermondsey, south London, located along what was once a meandering medieval lane and later a Victorian high street with a post office, shops, pubs, doctors’ surgeries and the popular “Blue Market”. The design comprises 57 one- and two-bedroom self-contained apartments organised around a garden court, all at affordable rents. The configuration of spaces echoes the dimensions and focus of the traditional coaching inn courts along the not-too-distant Borough High Street.

Each apartment will open on to a generous glazed gallery that overlooks the garden court – a key feature of the scheme, and a more communal alternative to rows of tiny private balconies. The galleries will be wide enough to enable residents to sit outside their kitchen with others, or place potted plants to extend their homes. In warm weather the galleries will be open to the elements, becoming closed winter gardens when necessary.

The almshouse will be integrated into the life of the high street, providing a shared “lounge/cafe” accessible for residents and – at certain times – the public. Planning permission was awarded in 2016; construction is planned to commence in early 2020.

My design hero, Aldo van Eyck, was one of the principal architects of the new world order for children. A prolific designer of playgrounds, children’s homes and communal housing, he wrote that, “If a childhood is a journey, let us see to it the child does not travel by night.”

In designing his famous Amsterdam orphanage of 1960 as a children’s casbah of interlocking, non-hierarchical rooms and dormitories, all with their own small courtyards, he spoke of “the medicine of reciprocity”.

We need something similar in architecture today: places that enable the elderly to remain involved in life until the end, an end that may be more of their own choosing than it is today.

Ken Worpole’s books include (with Mike Seaborne) “The Isle of Dogs: Before the Big Money” (Hoxton Mini Press)