Here we go again

John Cooper’s thoughts on the upcoming national hospital building programmes

The new decade is going to start with a major hospital building programme, the second this century. This is very good news despite the awkward fact that we should be leading with a Health Infrastructure Plan and not an Acute Hospital Plan. But let us avoid negativity. What has changed and what can we learn from the last investment cycle?

In 1998 I was coming back from a meeting in a taxi with the CEO of a progressive NHS Trust – the Blair hospital building programme was in the air- – ‘Ah well’ he said ‘they will soon be flaring off capital.’

Two years later a book was published by the Nuffield Trust: Building a 2020 Vision: Future Healthcare Environments. It set out the component parts of a modern healthcare estate – patient centred care, integrated care systems, the migration from acute to community services, the need for adaptability, excellent design, off site manufacture and sustainable development. Virtually everything in this book applies today – I cannot think of another policy document that has retained this level of relevance.

Well capital was flared off but over 100 hospitals and hospital buildings were designed and built between 1998 and 2015 in a national programme of healthcare redevelopment of real scale. A few of these projects were excellent, many were good and many were quite disappointing. Taken as a whole they did achieve a step change in hospital architecture but failed to become component parts in an evolutionary restructuring of our healthcare systems.

Retrospective criticism has centred on their PFI procurement - quite rightly so. But my principal disappointment is this. The Blair hospital building years never became a coordinated programme, they established an investment pipeline for a set of locally generated projects. These were a series of one-offs, commissioned by often inexperienced trusts relying on process rich and conservative advice. Many of the briefs were out of date before construction started, some were based on antiquated operational policies, many space standards had been superseded before the buildings were even completed.

Harsh - maybe. In their defence a degree of inertia is inevitable and this programme came into being after a decade or more of relative inactivity. It had to generate the expertise it needed and many of us were learning on the job.

But what is inexcusable is that in the decade that followed there was no systematic review of the completed projects, no international comparisons and no production of an evidence base that could inform the next wave, as Building Schools for the Future did before it got junked.

I am getting the feeling that exactly the same thing is happening again with HIP1 and 2 as the scramble for the band wagon gathers pace. Consider:

1. This is a new generation of acute hospitals and, if promises are honoured, these will be

delivered in a 10-15 year investment pipeline. We must clearly define - and then explain -

what these hospitals should be. What are the component parts of a 2020 hospital now

that they are operating as parts of integrated care networks?

2. There have been two paradigm shifts in the last twenty years – the accelerating climate

crisis and our ability to truly harness the digital revolution.

3. We must produce carbon zero/carbon minimal buildings and design integrated

networks that achieve substantial carbon reduction. We must develop buildings and

systems that can become genuine component parts in a circular economy. This will have

a fundamental influence on the briefing, planning, design and construction of these new

buildings - a far more creative process than gaining a tick box BREEAM Excellent

essential though this may be.

4. Believe in planning - this programme must shape the sum of its parts.

5. Review the last wave of buildings – what worked /what didn’t / over and under

provision/build quality/adaptability etc. etc.

6. Set up a small dynamic HIP team with strong powers. My recent experience suggests that

the NHS operates in pyramidal committee structures that make it very difficult to move

quickly and decisively.

This needs a small expert team to guide this programme, inform, collate best practice,

review and promote commonalities across all projects, delegate, optimise knowledge

share from the best available evidence bases and raise quality without cost premium. A

fifteen year long programme offers real opportunities for continuous improvement.

Reset your default setting. Ensure that the team that you assemble are leading experts in

their various fields, with more than half of the team selected from outside the NHS.

Appoint people not companies.

7. Standardise key parts of the development process. Clearly identify what can be

standardised – not in a 20thcentury clumsy ‘jellymould’ one size fits all way – but in seeing

what parts of the planning, briefing and design processes can be standardised to enable

investment decision-making to be streamlined and the business case process to be

simplified as an excellent “deemed to satisfy” product. Don’t get me wrong – this is

standardising process not design.

8. Take this further: hospitals are far less complicated than people think. Only 22% of their

floor area is what can be described as high spec / high tech space. 78% is either hotel or

office space with wash hand basins and much higher MEP servicing (slight exaggeration

maybe). See how far we can run with this as clients and designers.

Twenty generic room types make up more than 65% of their clinical space. Radically

improve and extend the current library of repeatable rooms. In the UK we often design

good hospitals and then fill them with third rate ill-assorted furniture and fittings. Look at

what should go into these rooms, many of which are over-specified and think again. The

NHS has immense buying power - direct it better. See what the commonalities are across

the projects.

9. The construction industry must be represented in this core team - it has much to bring to

the table in strategic terms. It should take a lead from the commercial sector (and P21+)

and collaborate in shaping the briefs, provide design guidance to maximise MMC

standards and then advise on buildability. The procurement process is probably best

served by clients developing schemes to a schematic + design stage and then procuring

their buildings through short CD tender and single phase Design and Build contract.

Constructors’ very fragile finances need to be de-risked.

10. Put the National back into the National Health Service and make sure that what we plan,

design and build in the next 20 years is delivered by individual trusts but is guided,

informed and led by a national programme.