Health treatment

To translate the Plan into practice the government is relying heavily on the PFI route of procurement and as a result there will be £7 billion of new capital investment through an extended role for PFI by 2010. While the debate about whether PFI represents value for money is set to run and run, consulting engineers involved in such schemes have been getting to grips with the practicalities of procuring under the initiative. For Alan Wood, senior partner with consulting engineers Hoare Lea the reality of PFI is greater risk. "PFI procurement is a very lengthy process that can take one to two years to complete, and the deliverables required even in the early stages are increasingly demanding. Sometimes as much as 70-80% of the design is required." Although the biggest investment falls to the main contractor putting the bid together, time and money spent by consultants is only fully realised if and when the consortium wins the contract.

In a bid to streamline the process the government's Private Finance Unit introduced a number of measures in March of this year, including restructuring the PFI procurement model for healthcare schemes. For projects above £60 million, fewer bidders are being admitted to each phase of the process with four at the preliminary invitation to negotiate (pitn) stage and two at final invitation to negotiate (fitn), before selection of the preferred bidder. This omits the best and final offer (bafo) stage altogether and healthcare trusts will be expected to base their selection of a preferred bidder on a fully priced fitn. For schemes under £60 million, trusts will have the option of the four-two-one or three-one models, depending on the likely market interest. Wood sees this as a step in the right direction: "It slightly reduces the risk and takes less time, but the level of deliverables is still the same," he says.

New documentation to help trusts manage procurement has also been introduced. A standard pre qualification questionnaire and preliminary invitation to negotiate information request were published in June 2002. These, it is hoped, will enable the private sector to better anticipate trust's information requests and together with the changes to the procurement model will shave months off the timetable and reduce costs for both sides.

Delivering good design
As well as the lengthy procurement process, PFI schemes have come under attack for their poor design. At the Unison conference in September Sir Stuart Lipton, chairman of the Commission for Architecture and the Built Environment (CABE) said: "At the moment the majority of PFI buildings are poorly designed and will fail to meet the changing demands of this and future generations". He added that: "PFI contractors often seek to maximise financial return rather than quality of public service."

Although whole life cycle cost is the major issue for the facilities management arm of a PFI consortium, the construction group is still often only interested in first cost. "There needs to be much more integration between the two," says Wood. "We need earlier involvement of the facilities management side, and the industry has learned that."

Lipton also criticised PFI schemes for their lack of innovation. Steve Clifford of Hoare Lea says the two main drivers for innovation at the moment are programme and skills base, but clients also need to be better informed. "One of the things that needs to be reviewed by NHS Estates and the likes is the standards of HTM (Health Technical Memoranda) and HBNs (Health Building Notes). Some of them go back 10 years, they don't necessarily cover the modern materials and modern construction techniques that are used in the industry today," he says.

Trusts it seems are also often reluctant to opt for modern techniques such as modular wiring and plastic pipework for hot and cold water services, which have been used for decades on the continent. "One of the ones we can't understand is Victaulic joints which are standard in lots of building these days for all sorts of services, but there are still people who think they are not the right sort of joint for hospitals."

As well as the trusts, facilities managers also need convincing of new techniques. "There are miles of spiral wound ductwork that goes into these hospitals. Again you have a standard which says you should have an access door every 3 m, but you've got modern cleaning techniques that allow you to get a cleaner 30 m along a duct, it's making people aware of those systems," says Clifford.

The 2020 Vision report carried out by the Medical Architecture Research Unit at South Bank University suggested that many of the 70 new conventional hospitals being delivered on the basis of 30-year PFI contracts could be largely obsolete before the end of this period. One of the key contributing factors indicated in the study was the rapidly changing needs of the healthcare sector and development in areas such as bio-medical technology. "With healthcare schemes flexibility is a key issue in design," says Wood. "And because it is a 30 year period it is in their interest to be adaptable."

Clifford who worked on the £229 million Norfolk and Norwich University hospital which opened in November 2001 says: "As a practice we have got more involved in medical planning." Under PFI bids this has meant greater involvement in drawing up design briefs. "Whereas the old room data sheets were produced by the regional health authority and issued out to the design team to work to, the concept is landed squarely with the bidders. We get involved in that and when you're talking 4500 rooms it is a lengthy process."

One of the biggest areas of change that Clifford has seen is the development of day case procedures, doing away with the need for patients to stay in hospital for long periods of recovery. "Modern techniques in surgery are moving away from main theatres. They can do more day case procedure work now than they were doing 10 years ago. At Norwich the plans started with two day case theatres, with two to be developed, but we ended up with six."

Clifford points to the inclusion of 'soft' areas, which can be converted for different use in the future. Separating low tech, low serviced areas such as ward spaces from higher tech areas with operating theatres and x-ray rooms makes it easier to adapt spaces. But how does this tie in with the concept of PFI? "The trust will steer you on how much flexibility they want, should they want 100% flexibility then that would be reflected in the annual charge," says Clifford. "One of the things we are tied to for example is providing 25% spare capacity at distribution boards for future expansion and flexibility".

At Norfolk and Norwich rooms within the hospital were designed around a small number of basic room types, with room sizes and services standardised as much as possible to enable their use to change with future requirements. Two areas were set aside for future conversion into operating theatres and these are both currently being fitted out. Similarly, two magnetic resonance imaging facilities were also designated, the second one is now going in. A further change at Norfolk and Norwich since it opened is the conversion of office space in one ward tower into additional accommodation. "Although it requires medical gases, these are already there because of the way the gas distribution works on site," says Clifford.

With the second phase of PFI projects now under way it would seem that progress is being made, so will it succeed? "It's certainly the way it's going to be for a number of years," says Clifford. "Everyone is wanting to improve the quality of the health estate, I can't see how they can do it any other way".