When people think of NHS architecture, they imagine grey monoliths with endless corridors and stark fluorescent lighting. but all that is changing in a drive to increase design impact – with a little help from ancient Rome …

Public sector buildings have come in for a hammering in recent years, especially over their design. The idea that "the Victorians designed water pumping stations to look like cathedrals; today cathedrals are designed to look like water pumping stations" suggests there is a widely held view that modern civic architecture is often mediocre.

The issue reached a head in 2001 when the Prime Minister launched an initiative to improve design throughout the local and central government. NHS Estates responded by launching its own initiative "Achieving Excellence in Healthcare Design".

This NHS Estates programme focuses on improving the healthcare design through better guidance, design evaluation, and creating partnerships with organisations such as the RIBA, the Prince's Foundation, King’s Fund, the Major Contractors Group and CABE, along with private practitioners.

It aims to promote good design in healthcare buildings and participate in the design review process. As well as liaising with organisations supporting the NHS Estates initiative, the Centre for Healthcare Architecture and Design is working with more than 350 design champions within NHS trusts.

Raising standards applies to all healthcare projects, no matter which procurement route is selected. With ProCure21, however, the bar has been raised even higher, with all 12 PSCPs nominating their own design champion to raise awareness and contribute to NHS Estates work.

As with all healthcare projects, ProCure21 schemes are subject to two assessments to gauge the quality of their design and their environment impact.

NHS Estates’ AEDET ("Achieving Excellence" design evaluation toolkit) was launched in November 2001 and the quality of design is measured on a score sheet. Such a method of evaluation is not as new-fangled as one might think. Its roots lie in ancient Rome, where Vitruvius wrote down thoughts on architecture and engineering based on three principles – firmness, commodity and delight.

"AEDET follows the same principles, but we use modern-day language to describe them – build standard, functionality and impact," says Brian Coapes, NHS Estates' senior architect.

He continues: "Traditionally, within the NHS, we have had a good handle on functionality and build standard. They have been done well, but often to the exclusion of impact. It has been the delight, or wow-factor, that has often been missed out, making the buildings soulless places."

AEDET assessments are generally carried out at workshops attended by a small group of stakeholders in the project such as the trust's management team, clinicians and NHS Estates staff, and often with patients' representatives. The idea is that assessments are carried out at appropriate stages during the design process, such as near the beginning to check the three principles are being observed and also before the full business case for the project is finalised. Two further assessments are required – the first within a month of completion of the project and the second after the building has been operational for a year.

traditionally, buildings were built well but
to the exclusion of impact

Brian Coapes, NHS Estates senior architect

Using a spreadsheet program, stakeholders have to answer a series of questions based on the three criteria to find out if the design is up to standard and meets their needs. Build standard is covered by three sets of questions covering performance, engineering and construction. Functionality also has three sets of questions on use, access, and space. Impact is covered by four sets of questions on character and innovation, citizen satisfaction, internal environment, and urban and social integration. Answers are marked from 1 (poor) to 6 (excellent). "Low scores flag up the need to reconsider the design," says Coapes. Even when the design has scored well, average scores in any of the categories highlight where improvements can be made on future projects.

All schemes of more than £25m are also considered twice by the design review panel run by NHS Estates. The first is early in the design process, about the time the outline business case is finalised. The second review is held when the project approaches completion. Coapes says the review panels advise if a design is straying outside NHS standards, which could result in a costly redesign or even costlier outcome.

In addition to AEDET, the NHS can subject designs to an environmental assessment. Again, the methodology centres on a weighted scoring system based on the NHS environmental assessment toolkit (NEAT). It was launched in April 2002 and covers issues such as conserving resources, preventing or reducing waste and pollution, energy, water, construction and transport – all crucial issues to the NHS.

NEAT applies to both new-build and refurbishment projects. New schemes should achieve a minimum score of 70% to pass, and the minimum for a refurbishment is 55%. There is also a requirement on energy consumption of 35-55 gigajoules per 100 m3 a year for all new-builds as well as major redevelopment and refurbishments.

Lorraine Brayford, who was a member of the governmental Construction Client Panel's sustainable construction group, says: "Initially we looked at using BREEAM (research group BRE's environmental assessment method), but it was not entirely appropriate for healthcare buildings. So we received funding from the Department of Trade and Industry to develop NEAT, which is in line with BREEAM's approach, and is therefore regarded as a creditable tool."

Although it is intended initially as a tool to evaluate the early stages of design, Brayford remarks: "We have seen many instances where trusts ask contractors for a NEAT score during the selection process." It is also used again at project completion to examine the delivery of sustainability through the build process.

She continues: "Design is so crucial in producing an energy efficient footprint. In the past, not enough thought was given to natural light and ventilation or things like growing trees as windbreaks."

In NEAT's two-and-a-half years of existence, Brayford has noticed a significant shift in attitudes towards the environment. "In April 2002, my phone was red hot with people saying: 'You are expecting too much, this is one step too far'. Now, I get calls from people asking: 'How we can go one step further?'"

Good design = Happier staff + Patient recovery

It's widely held that a well-designed building lifts the spirits of staff as well as patients and visitors. Yet until recently, there was not enough concrete evidence for this belief to make any difference, as far as NHS buildings were concerned. But NHS Estates’ Environment for Care programme is changing all that. This makes available research and best practice showing the connection between good design and patient satisfaction, clinical outcomes, recruitment and cost effectiveness. Jane Riley, NHS Estates’ director of policy and development, says: “The NHS and industry are recognising and using the evidence base.

It is now indisputable that patients and staff benefit from the right environment.”

In addition, NHS Estates is working with Professor Roger Ulrich of Texas University – a leading authority on the relationships between design, patient recovery times and the risk of hospital-borne infections. NHS Estates' senior architect Brian Coapes says the evidence will be incorporated in a toolkit, AEDET Evolution, to be launched in a few months' time. This will provide guidance on how to use the findings to further improve design.

Research published by CABE in July revealed that design played an important part in the recruitment, retention, performance and morale of nursing staff in NHS hospitals.

Nearly 500 nursing directors responded to the survey with 84% reporting recruitment difficulties of which 78% said the design and layout of their hospitals was a major factor.

CABE's interim chairman Paul Finch comments: "This research proves what we have long suspected: that design of hospitals has a major impact on the performance of staff, their treatment of patients and their decision whether or not to work in a particular hospital." So CABE is now upping the ante with its healthier hospitals' initiative, which highlights examples of good design and invites comments from clinicians on how design affects their working lives.