If anything, Prasad underestimates the scale and rate of development in the health sector. In its drive to upgrade the NHS to a level of that enjoyed in Continental Europe, the government committed itself in its NHS Plan of June 2000 to several targets. They include: developing 20 diagnostic and treatment centres for day surgery by 2004; 3000 GP surgeries by 2004; 750 one-stop primary care centres by 2006; 100 acute hospitals by 2010; and tackling £3.1bn of backlog maintenance.
In England, the capital budget of the NHS, set out in the Treasury's Comprehensive Spending Review in July, will rise from £2195m this year to £6129m in 2007/8 – and that does not include another £8.6bn of private funding planned through PFI.
The problem is that hospitals, clinics and even small GP surgery refurbishments are all such complicated and changeable building types that they cannot be simply rolled out on a production line like standard housetypes. Intelligent brief writing and design are crucial to make these buildings work; in fact, they present an even greater challenge than that of physically constructing them.
First, there are problems within the design community. A record of underinvestment stretching back decades means that expertise in healthcare planning and building design has atrophied in the UK. Yet healthcare buildings such as acute hospitals are not only highly complex building types, but highly lethal ones, too. Lapses in design or performance can kill patients.
Second, there are problems with the procurement methods favoured by the government, such as PFI. Critics say they squeeze costs and design time and hence, innovation. Forward-thinking design is crucial because, third, we are on the verge of a healthcare revolution triggered by rapid developments in information and medical technology. Medical techniques are being progressively miniaturised, throwing open the question of where treatment will be delivered in the future – in a hospital, in local clinics, or even at home.
The good news is that the government is well aware of the design challenges presented by the health sector and it is lining up a battery of big guns to hit the targets. In the wake of Tony Blair's personal commitment to better public buildings in 2000, a many-sided initiative called Better Health Buildings was launched last November by health secretary Alan Milburn. It involves the Prince's Foundation, architectural watchdog CABE and the newly constituted Centre for Health Design at NHS Estates, the agency responsible for overseeing the development of healthcare buildings.
CABE addressed the main issues of healthcare building design in a report entitled 2020 Vision: Our Future Healthcare Environments, published in June with the Medical Architecture Research Unit of South Bank University. Its summary states: "The 2020 Vision research project suggests that the current generation of healthcare buildings will have only limited relevance in the future."
For its part, NHS Estates has forged ahead of the design evaluation game. It pioneered its Achieving Excellence Design Evaluation Toolkit, or AEDET, in April, several months before the closely related, general-purpose Design Quality Indicator was unveiled by the Construction Industry Council. It has also set up a network of 250 design champions among chief executives and finance directors of NHS trusts, charged with responsibility for the design quality of the new buildings.
The question remains, however, as to whether these enlightened initiatives will be enough to prevent our 21st-century health buildings from becoming rapidly unworkable or obsolete. The following pages set out the main hurdles to be overcome.
Complex building types
Hospitals that deal with acute cases not only make up the most complex building type, but are the ones with the most severely conflicting requirements. They combine high-tech equipment and services with complex layouts that accommodate a multiplicity of departments and user groups, each with its specific requirements.
Yet only recently has it dawned on health officials that such high-tech, deep-plan buildings can seem oppressive and inhuman to patients. In the words of Prince Charles, who is championing patient-focused design: "They are places where we are likely to go when at our most vulnerable, and so need to be as reassuring and comforting as possible to the spirits of the individual patient, their families and loved ones."
He goes on to point out that: "Many health facilities are also civil buildings, which means they should take their places as elegant expressions of 'civility' in the public domain … It is a sad truth that very many of the NHS' buildings fail to live up to these standards."
The 2020 Vision research project suggests that the current generation of healthcare building will have only limited relevance in the future
In nearly every British city or large town, great Victorian hospitals are being replaced by modern acute units. They are often the largest buildings in the town – certainly the largest public buildings – and inherit city-centre sites from their predecessors, all of which puts a premium on their civic presence. In such central locations, planners demand minimal car parking, which does not go down well with hospital staff working unconventional hours. One solution is Anshen Dyer's design for the new giant complex of Manchester Joint Hospitals (see case study), where the original Victorian hospital buildings have been retained for administration and academic
use, behind which a large public park has been created, and clinical buildings erected behind them.
More than any other building type, hospitals are prone to obsolescence, and all the signs are that the rate of change in healthcare is accelerating.
Sylvia Wyatt, who runs the Future Hospital Network of NHS trusts, outlines a triangle of driving forces for change: medical and information technology, human resources and consumerism.
Over the coming decades, rapid advances in medical and information technology promise a continuing revolution in diagnosis and treatment. In Japan and France, robots linked to magnetic resonance imaging scanners are conducting surgical operations with more precision than any human surgeon. Meanwhile, staff procedures are becoming more automated and versatile in response to the increasing scarcity of specialist skills. Nursing in particular is suffering from chronic staff shortages: London hospitals this month reported an annual turnover in personnel as high as 38% a year. Finally, the NHS is at last beginning to recognise patients as customers with demands and wishes, rather than passive recipients of treatment. Patients are asking for more comfort, more privacy and pleasanter surroundings – meaning smaller wards for between one and four patients with en-suite toilets.
The simple response to these changes is to design loose-fit buildings that can be easily adapted. Even so, the impact of change is likely to be far more radical than reconfiguring a few interiors. The 2020 Vision report states: "Advances in medicine, biomedical engineering and information handling will create the option of cascading care out of hospitals into settings nearer where people live." This process of moving healthcare closer to the patient begs the question of what size facility should be developed, or whether one is needed at all.
Kate Silvester of the NHS Modernisation Agency applies production-line thinking borrowed from the manufacturing industry to healthcare processes.
"It should take just three hours to diagnose lung cancer, and this could be done on the same day a case is referred by the GP," claims Silvester. "But because the system has been fractured between different departments, diagnosis involves multiple appointments that can take up to 60 days. The more we divide up the process, the worse we make the queues." And, of course, the lower the chances the patient will survive the cancer.
For Silvester, the ideal diagnostic system has been developed in Australia. "They use diagnostic pods, which they can install in just three weeks, one at a time. They get patient flows much earlier. And they start generating revenue while they are putting them up, rather than waiting seven years."
This fast-track approach aims to re-engineer the process and then design a shell to house it. The NHS is looking at its own version of such a system. Inventures, a public-private joint venture spun off from NHS Estates, intends to roll out efficient diagnostic and treatment centres across the UK at half the cost of the award-winning Ambulatory Care and Diagnostic Centre of Central Middlesex Hospital, completed three years ago. The private partners for the project include US healthcare corporation Johnson & Johnson and Danish-owned civil engineer Carl Bro. Inspired by American and Scandinavian practice, the idea is to develop, equip and run up to 500 such centres in quickly erected modular buildings, or even within existing industrial sheds or shopping centres. "I think there is enormous need for more innovative and quicker ways of delivering such a service," says the project's director Tom Mann.
Minimum building costs
Despite the immense capital investment in health buildings sanctioned by the Treasury, many architects complain that construction budgets for individual buildings are low. Sinclair Webster, designer of the mould-breaking Chelsea & Westminster Hospital, completed in 1993, and now head of healthcare design at HOK International, says: "Clients look at what can satisfy the minimum brief at the lowest cost."
He argues that the minimum standards laid down in NHS Estates guidance are interpreted as maximum standards by NHS trusts, drawing the analogy with minimum standards for public housing published in the Parker Morris report of 1963, which were converted to maximum housing cost yardsticks by the Department of Environment in the 1970s.
It should take just three hours to diagnose lung cancer but because the system has been fractured between different departments it can take up to 60 days
CABE commissioner Prasad points out that invitations for PFI bids give more weight to "affordability" than value for money. Referring to the latest round of PFI projects, he says: "The problem is that public sector E E comparators are based on historic construction data, whereas general construction costs have increased by 11%. Smart corporations invest more in buildings because they know they can get the best out of the people who use them."
Dearth of expertise
Decades of depressed healthcare development has left the UK seriously short of architects with expertise in hospital design and of the health planners who draw up their design briefs. Hence the sudden influx of large, experienced American architects such as RTKL, HOK and Anshen Dyer.
The problem is that even with the upsurge in workload, design expertise is still concentrated in the hands of a few large practices, and these are not known for the architecturally distinguished buildings sought by the Better Health Buildings initiative. None of the UK's signature architects have tackled hospital buildings, with the exception of Michael Hopkins & Partners, which won a design competition for a children's hospital at St Thomas's on London's South Bank.
It seems most architects are reluctant to engage with such difficult and unglamorous projects as hospitals. Susan Francis of the Medical Architecture Research Unit (MARU) says: "Health is not a sector that has a track record in winning awards, and some architects say they won't touch it. There are also very few healthcare projects set by schools of architecture, and architects don't yet think of them as a good idea for their portfolios." Francis does, however, note that mainstream architectural practices are starting to take an interest in designing smaller community health centres.
Jonathan Wilson, partner of David Morley Architects, who drew up the design exemplar for a PFI hospital in Walsall, detects signs of brain activity in NHS Estates. "The old guard just recommends the same half-dozen firms with experience," he says, "but now there's new blood in the Centre for Healthcare Design that is genuinely forward thinking."
For HOK's Sinclair Webster, the real bottleneck is caused by the health planners who draw up the design briefs. "Building designs depend on the quality of the brief. But health planners come from financial and nursing backgrounds and tend to use NHS Estates data rather than thinking things through from first principles," he says.
PFI procurement stifles design
In terms of architectural design quality, it is still the PFI procurement process that draws most criticism. The basic problem is that the PFI bidding process pushes architects down the pecking order behind contractors, accountants and lawyers.
The one area where PFI does score well is that it encourages PFI consortiums to invest in durable, high-quality materials that work out as more economical over the facilities management contract period of 25 or 30 years. That is why Keppie Design was able to specify Luxulon aluminium cladding for the new Edinburgh Royal Infirmary at twice the cost of an NHS standard brick cavity wall.
The PFI is also criticised for inhibiting innovation and creative design, in practice if not in theory. CABE commissioner Prasad argues: "I think the PFI is an intelligent way to build these hospitals. It enables joined-up thinking by giving one organisation responsibility for a complete facility. But this has not been fully taken on, because responsibilities are split between a private-sector organisation for the building and a public-sector organisation for the healthcare process. That means that the PFI consortiums are given the output of a working hospital to achieve, rather than the final outcome of improved patient health. In theory, the only brief should be customer satisfaction. But in practice, briefs for hospitals are becoming more prescriptive, with precise measurements set for bed centres."
For HOK's Webster, the big banks are to blame for this. "The whole concept of the PFI is to burden the construction industry with huge speculative costs. Contractors must get backing from banks, and banks like to do due diligence, which means taking no risks. Innovation is driven out by the bidding process, and you end up with a checklist approach."
Yet another criticism of the PFI is that the competitive bidding process limits dialogue between the architect, the client and planning authorities. Anshen Dyer's Ken Schwarz argues: "There are set rules for evaluating and comparing bidders' designs. That means that you are not given the time or opportunity to challenge the brief, which stays close to NHS guidance to protect the NHS trust."
Only at the margins of the NHS is the PFI process challenged. John Cole, head of NHS Estates in Northern Ireland, is so concerned about the lack of dialogue between architects and clients that he is pioneering new procurement methods. In projects whereby he retains the PFI, he has separately commissioned fully designed exemplar schemes, and in the case of three community care centres designed by Penoyre & Prasad, he has abandoned the PFI in favour of a system of performance-related partnering.
NHS organisations influencing designNHS Estates
This repository of NHS expertise in the design and delivery of healing environments, including PFI projects, employs 106 staff in Leeds. It publishes and updates design guides and advises NHS trusts, which are the actual client bodies. Recent initiatives to promote better health buildings have included the Centre for Healthcare Design, run by architect Vijay Taheem. The NHS’s own design quality indicator is called the Achieving Excellence Design Evaluation Toolkit, or AEDET, and several pilot projects have been carried out with CABE and the Prince’s Trust. Sadly, for an organisation charged with drawing up and disseminating good practice, the quango works hard at putting off enquirers and potential collaborators.
Inventures was spun off from NHS Estates in July 2001, when chief executive Kate Priestley walked out with 270 staff. The agency’s remit is to set up innovative partnerships with the private sector to provide and run smaller healthcare facilities costing under £40m, such as walk-in diagnostic and treatment centres and cancer care centres, for which PFIs are unsuitable.
www.inventures.co.uk NHS Modernisation Agency
The Modernisation Agency was set up in the wake of the NHS plan of 2000 “to help local staff across the service make radical and sustainable changes”. It includes a redesign team that looks ahead at how rapidly advancing information and medical technology and staff multiskilling could dramatically speed up healthcare services. Its remit to modernise healthcare services cuts across the concern of NHS Estates to create permanent buildings.
www.modern.nhs.uk Future Hospitals Network
The Future Hospitals Network “addresses the large gap between the current state of knowledge about the shape of acute hospitals and what will be required for 2010 and beyond”. The network is part of the NHS Confederation and advises NHS trusts on major hospital developments. It focuses “primarily on what facilities to build, rather than on how to build facilities”, and takes into consideration the changing nature of models of care, technology, the workforce and building design.
Inner-city health park: Manchester Joint HospitalsThe £300m scheme to redevelop a cluster of five out-of-date teaching hospitals in inner Manchester clocks in as the UK’s largest PFI healthcare project unveiled to date. It is also the first of the next generation of PFI hospitals. It is designed by the Anglo-American architect Anshen Dyer for Bovis Lend Lease’s PFI arm, Catalyst Healthcare Management, which was announced preferred bidder in June. The 170,000 m2 complex is to provide a total of 1660 hospital beds and spreads over an area equivalent to four city blocks around the existing Manchester Royal Infirmary on Oxford Road. This makes the aim of the project as much urban regeneration as specialist healthcare provision. The result will be a large campus with a wide swath of public parkland cutting through its heart. The new park is described by Ken Schwarz, director of Anshen Dyer, as a “green lung” and the second largest open space in inner Manchester after Piccadilly Gardens. Its main function will be as a main access spine or boulevard running through the campus. Replacing a congested warren of old ward blocks and ad-hoc additions, the boulevard will also divide the campus into two main strips of accommodation. Lining the Oxford Road are the listed front buildings of the Edwardian hospitals in a self-confident arts-and-craftsy style, and these will be retained as administrative and academic buildings for the teaching hospital. All the clinical accommodation for the four acute hospitals will be housed in a wide continuous strip to the rear of the park. The exceptions are one 1970s hospital building, which will be retained, and a mental health hospital, which will be built as a free-standing block at one end. In this strip, all the intensive medical functions of four hospitals, comprising in-patient wards, outpatient departments, high-tech diagnostic and treatment facilities and research laboratories, will be concentrated into one giant seven-storey megastructure of 110,000 m2. In theory, this concentrated arrangement should provide an efficient critical mass of medical services, but it brings with it the severe risk that the multiplicity of hospital departments could seize up in a musclebound tangle of high-tech spaces and services. Accordingly, Anshen Dyer has separated out critical elements within the megastructure (see diagram). The megastructure can be read as a strip of four individual hospitals spliced together side by side. Each will have its own clearly articulated front entrance leading to a reception desk in an atrium overlooked by the wards, much like in Anshen Dyer’s award-winning Norfolk & Norwich Hospital, completed last year. The four atriums are linked together at the rear by a four-storey circulation spine. Beyond the circulation spine lie all the diagnostic and treatment spaces, including operating theatres, on three floors. This is the high-tech core of the complex, and it is serviced downwards from a fourth floor totally dedicated to plant rooms and service corridors. At the top of the megastructure rise four three-storey wings containing high-tech research laboratories, which can plug into the plants and hospital spaces directly below. Concentrating diagnostic and treatment spaces for the four hospitals into a single continuous strip offers flexibility – a vital consideration given the rapid rate of change in intensive healthcare – as it enables them to overlap and flex over time. Flexibility is also provided by high-level servicing, as the clinical strip is fully sprinklered and air-conditioned throughout, allowing functions to be changed without big modifications to the building. At one end of the campus, one of the existing listed buildings will be converted and extended to provide some 600 affordable homes for key workers, and a job centre. This element was not part of the NHS trust’s brief but an addition devised by Catalyst in one more acknowledgment that the project combines urban regeneration with specialist medical services.
Touchdown: Americans corner the UK’s healthcare design marketSpecialist design expertise in acute hospitals is concentrated in the hands of fewer than 10 architectural practices, and most of these are either wholly or partly American-owned. The attraction of the UK hospital building programme to American architects is explained by David Beard, who runs the London office of the American giant RTKL: “I see Britain as the most dynamic healthcare facility environment in the world, because of the commitment of the British government.” This government commitment is only three years old. For decades before that, the UK allowed its health service and its hospital development programme to languish, while the United States pioneered new forms of healthcare and invested heavily in them. Not only do American practices such as RTKL and HOK International have experience of the most up-to-date concepts in hospital design, but their large office networks are prized by PFI consortiums for their ability to push through hospital blockbusters at high speed. According to Ken Schwarz, American director of Anshen Dyer in London, “The NHS has been inward-looking for so long that it has put the blinkers on British architectural forms. Americans are more open to change in the healthcare system, which is becoming more international.” There are likewise only a handful of major contractors bidding for PFI healthcare projects, though these are nearly all British-owned. “The general wisdom is for each contractor to select one out of a small group of architectural practices, usually three, to work with on each project,” says Schwarz. “I believe that’s healthy, as there’s a certain amount of cross-fertilisation.” Given that there are now many more projects than contractors and consultants bidding for them, this arrangement often results in partners on one project competing with each other on the next project.
PFI preferred bidder Catalyst Healthcare Management Main contractor Bovis Lend Lease Facilities manager Sodexho Architect Anshen Dyer Structural engineer Mott McDonald Services engineer DSSR Quantity surveyor Cyril Sweett Landscape architect Gillespie