AfH Glasgow Event 2013 – full version

Health Procurement in Scotland

Mike Baxter, Deputy Director of the Scottish Futures Trust
Opening the debate on a sunny Glasgow afternoon to a 70 strong audience at the Lighthouse Gallery, Mike Baxter, an accountant by training, immediately made the audience at ease by relinquishing his tie in an effort to blend in with “a room full of architects”.

Mike outlined the context for the procurement of health buildings in Scotland, drawing interesting comparisons with the English system, and explained the key organizational difference in Scotland ie that Government policy is delivered through 14 health boards, who are responsible for all services from primary, community through to acute healthcare services. He pointed out that there are no equivalent PCT’s or Commissioning bodies and this is with the expressed aim of being to provide an integrated healthcare service across the full range of services.

It was refreshing to hear the emphasis being placed on both quality and skills at the heart of the Trust’s 20/20 Vision. This document sets out the vision for healthcare services in Scotland over the next 20 years, with the inclusion of strap lines such as “streamlining delivery, maximizing value”, and “improving practice, reducing waste, getting it right first time”. Defining qualitative ambitions as “person (specifically not patient) centred”, safe (where have we heard that before?) and effective with the focus on prevention, Mike explained this would be targeted through the shift from acute care to care in the home or community.

The Trust’s 20/20 Vision was explained, formalized by a new Bill introduced to target the integration of health and social care, reflecting the shift from acute to community care with the aim of the population living longer, healthier lives either at home or in a homely setting. The 2012 Annual State of NHS Scotland identified that 26% of the estate was more than 50 years old, 75% in good condition and 65% described as “functionally suitable”.

Whilst £1.5bn had been identified for the period 2012-2015, moving forward there is continuing downward pressure on capital budgets and a definitive shift towards addressing £948m of backlog maintenance.

Three routes for procurement are prescribed: firstly, Framework Scotland, the national construction framework for large new build or refurbishment acute projects; secondly, Non Profit Distributing (NPD) for high value new build projects; and thirdly the NHS Initiative for community based projects, financed by public capital and revenue.

Reflecting on the last four years, it was felt there had been some cultural changes within the industry, perhaps fuelled by new forms of contract (eg NEC3) with more meaningful dialogue with PSCP’s allowing better benchmarking and a more structured approach to learning and development.

In summing up and looking to the future, Mike expected there to be continued collaboration between the industry and Trusts, seeking better communication, higher expectations of quality, with projects likely to be arranged around the integration of acute and community care.

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Southern General Hospital

Neil Murphy, IBI Nightingale & Paul Serkis, Brookfield Multiplex Construction Europe
The sheer scale of this project was underlined by an astonishing set of statistics – an £850m new build district general and children’s hospital occupying a site area of some 80,000m2, creating a new hospital of some 170,000m2, comprising 1100 odd in-patient beds (100% single bed) and 32 operating theatres. The project is currently under construction and due for completion in January 2015.

Neil Murphy, the Project Director, talked through the background to the scheme – a competitive PFI response to an Exemplar Design which had a number of fixed site attributes. These included an island site and a number of recent new build schemes on the hospital land including a new laboratory complex.

In response to the brief’s requirements for discrete expression between the component parts of the hospital, the architects drew visual reference from the area’s historic shipbuilding heritage, using this to try and come to terms with the scale of stacking wards some 14 storeys high, using the analogies of “beacon, dock and vessel” to articulate the wards, diagnostics and theatres and the Children’s Hospital respectively.

Constraints and opportunities around the site were explained with great effort expended in grappling with the optimum site layout to make for ease of orientation, wayfinding, navigation and drop off at the “front door”. This included the repositioning of previously fixed multi deck car parks. There was an overriding aspiration to introduce as much green space into the site as possible, whether this be at ground level or at the various intermediate deck levels.

The wards are arranged into 28-bed clusters, with four tapered fingers spreading out from a square “doughnut” in plan. Cores and FM accommodation project into the central atrium enclosed at roof level by an EFTE roof.

Informed by the recently completed laboratory building, the ward façade successfully abstracts a bar code effect into a two storey high slick, treble glazed curtain wall system. This is interplayed with coloured spandrels set above a monumental in-situ concrete base. In contrast, the smaller Children’s Hospital will be finished with white render and coloured panelling.

Once again, one was struck by the sheer scale of the building as demonstrated by the interior views of the atrium (one holding 747 aircraft!) and ideas of internal terraces and pods articulating this vast space. Interior views of the Children’s Hospital promised more playful and intimate surroundings, with design work in collaboration with the Glasgow Science Centre seeking to incorporate a range of interactive art and touch technology devices.

Paul Serkis launched into a description of the timeline and staged bid process, with the key milestones being the issue of the PQQ in March 2009, clearance to go ahead with the scheme following approval to the Full Business Case in February 2010 allowing a site start in March 2011; with a target completion date of all aspects of the project in 2015.

Statistics were coming thick and fast at this point-notably an incredible 1600 workers on site and 7m hours of work completed to date! Adopting a hybrid structure of precast columns and in-situ flat slab construction, the frame was relatively quickly erected. Much emphasis is placed heavily on off-site fabrication (particularly mechanical services), modularization and partnering to assist with the logistical challenges of this large scale build.

Our appetite was definitely wetted for the site visit the following morning……

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Lessons from Large to small: NHS Dumfries and Galloway

Dennis O’Keeffe NHS Dumfries & Galloway
with Graeme Armet, Richard Murphy Architects and Colin Carrie, Keppie Design

With barely time to draw breath, Dennis O’Keefe from NHS Dumfries introduced two projects within his “patch” as vehicles to illustrate the design, delivery and qualitative evaluation processes currently being used.

Firstly, starting with the larger of the two projects, Colin Carrie of Keppie Design talked through their proposal for the, as yet, unbuilt scheme for the new 50,000m2 Dumfries and Galloway Acute Hospital. The scheme is currently being procured via the NPD (Net Profit Distributing) Process, where a “reference design” was tested to prove affordability towards achieving RIBA Stage C plus. During this process clinical briefing meetings were held over a six week period informing an iterative design process.

Examples of good quality healthcare schemes were cited by A&DS in the Design Statement and further recent examples were visited by the design team in Scandinavia, although it was unclear what lessons emerged from these.

Adopting a fully 100% single bed ward provision, analysis duly followed of a typical single en-suite bedroom, exploring the advantages and disadvantages of the en-suite location and stating that in the UK “observation is the key”. Further analysis of the impact on ward design and travel distances, which on some of the recent v-shaped wards can be extensive, the architects moved towards a “hollow finger” solution to introduce daylight into the centre of the plan through the introduction of an internal courtyard and to minimise travel distances by grouping bedrooms around core services.

Once again, the architects went to great length to describe their site strategy, seeking a “campus” approach in locating wards where they could enjoy the natural views of the site with car parking etc against the less attractive industrial site on one side.

We now have to wait to see how this materializes as the project moves towards Preferred Bidder stage.

The smaller project was introduced by Graeme Armet from Richard Murphy Architects and related to a single storey 18-bed mental health unit for Stratheden Mental Health Trust, which had been operational for two years.

Graeme set out the background to the design, illustrating the existing unit the new facility was to replace – a dimly lit double loaded corridor with a mix of multi bedded bays and single bedrooms either side. Following the same train of thought as the previous speaker, a single bedded option in the wrong hands could simply result in even longer and dismal corridors, and so the practice has sought to address the “tyranny of the corridor” by aspiring to minimize corridors and use the circulation spaces intelligently as subtle activity/quiet spaces to support bedroom clusters, articulated by the introduction of natural light.

Multiple investigations into the plan form were subject to clinical input at each iteration, with each option seeking to balance operational requirements a with a clear architectural diagram, culminating in the built form comprising a courtyard scheme with circulation effectively lining the inner face of the landscaped courtyard, with clusters of bedrooms arranged on the outer edge. Careful positioning of the staff base on one side of the courtyard at the main entrance allowed for visual observation without being necessarily obvious for patients.

The resultant scheme was beautifully detailed and executed with quite clearly as much effort put into the building section and elevational composition as the generation of the plan form.

Dennis O’Keefe regained the podium to sum up and gave an interesting view of the importance of the social dimension of the briefing process in the evaluation of design quality, stressing that the collaborative nature of the briefing process was the start of an evaluation approach which should continue through the design, construction and into the buildings use – coining the phrase “ontological primacy” to reflect the practice of being, doing and learning together. Rather than using Design Quality Indicators such as AEDET and ASPECT, the participants in the project should drive the evaluation method to reflect the process itself and focus on qualitative value.

At this point, questions from the floor probed the question of change management and the impact on design, noting that in Scandinavia change management occurs prior to the briefing process, but in the UK it was felt there is often tension in how a project brief was derived –perhaps more of a “push and pull” scenario, where the possible future may be prejudiced by the efforts to distill the brief.

This prompted debate from the floor about best intentions when it comes to Post Occupancy Evaluation. It rarely happens although there are glimmers of hope that shared knowledge was beginning to flow under P21+. Heather Chapple from A&DS inadvertently introduced her own talk by referring the audience to the Architecture & Design Scotland’s website “Pulse” where case studies and lessons leant are available.

View this presentation at Architects for Health Presentations

Primary Care Reference Design Project

Heather Chapple Architecture & Design Scotland
Heather introduced a new publication entitled “Quality and Efficiency”, which sets out the lessons from a Reference Design project, commissioned by the Scottish Futures Trust and Hub, in which two design teams were asked to test and explore design responses to the new service context through engagement with stakeholders for a real project. Design teams had access to 30 clinicians/stakeholders with fortnightly meetings held over a 12-week period and were tasked with both providing a high quality environment and realising savings through the “intelligent use of a scarce resource”. Ready, set, bake!

Key design lessons in the resulting document included the “new front door”; ease of wayfinding and legibility; efficient patient circulation; adoption of changing working methods; flexibility and space efficiency (a less departmental approach); room for reduction (e.g. move to electronic records) and multiple use of public spaces. Through such measures it was estimated that the designs realised savings in construction terms of 22 times the design fee to stage C! Surely something to be communicated to the widest possible audience?

SFT have also compiled useful database information giving various area measurement standards for primary care centres, area efficiency measurements and funding metrics, and this is included in the publication.

The second part of the presentation dealt with the Design Context in Scotland, effectively looking at how design quality is becoming embedded in government policy, manifesting itself as a requirement for all Boards to prepare a Design Statement for projects of a certain scale. This is then monitored by HFS and A&DS throughout the project approval process, similar to the former CABE reviews in England.

The Design Statement should address specific issues linking business objectives to the built environment; it is developed by walking through a day in the life of the facility capturing key experiences/attributes for patients, staff and visitors; what “success” might look like and a clear approach to how the process will be assessed, monitored and evaluated.

In conclusion, the Vision of Health for NHSScotland, captured in a statement by Dr Harry Burns CMO, was to develop “an estate designed with a level of care and thought that conveys respect; buildings that grow from the local history and landscape, that are developed in partnership with the local community – a work of joint learning and joint responsibility that is particular to that community and that place; ‘Not off the shelf shoe boxes’…”

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Design Policy in Practice: A Client’s Perspective

Steve Shon NHS Lothian
Picking up directly on the theme of the Design Statement, Steve Shon talked about how a specific Design Statement was being developed for a new Mental Health facility at the Royal Edinburgh Infirmary, where it was being used as both a design control document and as a promotional tool for the project.

Here the Design Statement was developed through a series of stakeholder workshops, with patients, staff and technical advisors. It established key patient objectives as welcoming and therapeutic, a facility integrated with the community and well served by public transport for accessibility; easy to understand and navigate from a clear main entrance; with wards that were “friendly and encourage interaction”. Flexibility was seen as important as were a sense of control over the patient’s own environment and an appreciation of the importance of external spaces for green therapy.

The design process on this project is ongoing and so it was difficult to judge how these laudable principles are being captured in the design, however it appeared that the client felt the Design Statement for this project has become a very useful tool in enshrining key principles which have now set the tone for wider site development and integration within a site masterplan.

We look forward to a revisit of the finished article in due course…..

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Design for Primary and Community Care: Eastwood Health & Care Centre

Clare Kemsley, Gareth Hoskins Architects
Clare explained that GHA were on of two practices that carried out the Primary Care Reference Design Project to RIBA Stage C and were now selected as the preferred team to see the project to conclusion, although the precise form of procurement has yet to be finalized although design work has now progressed to Stage E/F.

The design of GHA’s own Sandy Road Clinic informed the initial ideas of a strong organizational device – in that case the atrium – to provide transparency and visual connectivity throughout the building, together with strategic decision on how spaces could be used in a flexible manner. Primary Care precedents were examined in Northern Ireland and Glasgow, specifically revealing how public and private areas were separated but yet retained visual connections. This was a current theme being pursued in GHA’s Ballymena Health Centre which is currently underway.

The new Health & Care Centre was to provide 4 GPs, physio, podiatry, childrens, mental health, addictions and staff offices and is one of four NHS primary care projects being delivered by Hubwest.

Moving swiftly into an intensive design and consultation phase of workshops with multiple users, the aim was to look at new ways of working, the flexible use of space and activities and deliver a new facility for £1400/m2.

Clare talked through the design iterations, grouping shared, flexible and public spaces around a three-storey atrium, thereby allowing these to be used for different activities and generating activity around the atrium space. Either side of the atrium courtyards were enclosed by various elements of clinical accommodation, with 15m2 consulting rooms that are standardised as far as possible. Smaller sub wait areas are introduced at key points, with views of the courtyards adding relief to the internal corridors. GP surgeries are arranged around paired reception areas allowing a level of flex in the service.

Staff areas are similarly grouped around the atrium and adopt much more open patterns of working than is the norm, providing a mixture of meeting rooms and touch down and hot desk areas. The placement of the staff room at the centre of the plan deliberately sets out to avoid this becoming an underused room at the end of a corridor.

Once again, it will be interesting to see how the project develops as built and in-use and no doubt this will be a project to revisit in the future. From the designs and images presented, it came across as a sensitive and well thought out centre in planning terms with high levels of architectural interpretation.

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Discussion
Debate centred on the cultivation of “new blood” in the industry and particularly in the design professions. It was felt that events like this helped to raise awareness of the importance of healthcare design. AfH’s annual Student Design Charette, held in conjunction with Guys & St Thomas’s Hospital and London South Bank University, is specifically set up to foster new talent. Leslie Welch welcomed approaches from local practices who are interested in taking this discussion forward on a local basis.
To view the speakers’ CVs…

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