The RIBA (Royal Institute of British Architects) in London.

Five visits where arranged: Rehabilitation Clinic, Basle; University Hospital, Basle; Nursing Home, Kannenfeld; INO University Hospital, Berne; and Women’s Hospital, Berne.
The visit was arranged through the co-operation of Karin Imoberdorf of Itten + Brechbuhl AG and was led for AfH by Claudia Bloom.
11 to 13 July 2007

Architects for Health where invited to exhibit at the Design and Health Congress in Glasgow.
27 to 30 June 2007

Operating Theatres of the Future was the title of an Architects for Health Event that took place at The RIBA, 66 Portland Place, London, on Thursday 31 May 2007

Chairman: Mike Sury, FRCA – Consultant Paediatric Anaesthetist, Great Ormond Street Hospital London, Honorary Senior Lecturer Portex Unit Institute of Child Health. Email: surym@gosh.nhs.uk

Speakers

“The Future of Surgery” – Professor Erik Fosse, professor and director of the Interventional Centre of Rehabilitation of the University Hospital of Oslo, Norway. Erik Fosse is specialised in general surgery and cardiothoracic surgery. He is professor and director of the Interventional Centre which is a research and development department at Rikshospitalet University hospital in Oslo. The department develops new treatment strategies based on advanced imaging technology and work closely with industry to develop and validate new technological solutions for surgical intervention and patient monitoring. http://www.ivs.no

“Surgical Work Places” – Andrew Walters of Maquet – Surgical Workplaces. Andrew is the Product Manager of Modular Theatre Systems of Maquet and will be talking on the Modular OR-System VARIOP, and the benefits that the company’s approach offers to surgical workplaces. http://www.maquet.com

” A recent case Study: The Barn Theatre at the Royal Liverpool and Broadgreen University Hospitals” – John Knape, Northern Regional Director of Nightingale Associates. John has throughout his career specialised in the design of healthcare facilities. He led Nightingale Associates’ team responsible for the design of the recently completed £70m Broadgreen Hospital Development, delivered through ‘ProCure 21′, which includes an innovative ‘Barn’ Operating Theatre. John will be talking about the reasons why he adopted the ‘Barn’ theatre solution and the perceived advantages from a surgical perspective (prior to occupation) before talking about the construction. http://www.nightingaleassociates.com

Contribution

Donal O’Donoghue, Divisional Director for Medical Surgery at The Royal Liverpool and Broadgreen University Hospitals, NHS Trust
John Davidson, John Davidson is a consultant Orthopaedic surgeon and Clinical Director of the Royal Liverpool and Broadgreen University Hospitals NHS Trust. John specialises in Joint replacement, specifically in knees and hips. He sits on International Advisory Boards for developing new technologies in surgery and is a frequent faculty member at international meetings on surgical technique and practice.
Donal and John will talk about how the ‘Barn’ theatre concept was considered and taken up by their team and the ‘Barn’ theatre in use – how it operates (i.e. the patient journey), whether it has met the surgeon’s expectations, infection rates, effects on staff morale, good/bad features and what they would want to have done differently if doing the scheme again. http://www.rlbuht.nhs.uk

Sponsor MAQUET

It was a stroke of brilliance by Architects for Health to hold this meeting only two weeks after the absorbing and uplifting meeting on Hospices. This one was quite as absorbing but hardly uplifting.

Professor Erik Fosse, Director of the Interventional Research Centre at Oslo’s Rijkshospitalet, presented a thorough and penetrating review of recent innovations in medical technology. This will furnish our professional discourse with an impressively advanced vocabulary – mulitmodal image guidance, telemanipulators, focused ultrasound, ‘Pathfinder’ robots and so on.

The purposes of the Interventional Research Centre are to develop new procedures and treatment strategies, to compare them with existing ones and to study the social and economic consequences. Non-invasive procedures and ‘Keyhole’ techniques are increasingly replacing conventional surgery. Day surgery and early discharge require patient follow-up to move to primary care.

Professor Fosse described the transformations already evident in surgery in terms of a change from a handicraft to an industrial culture. “You become what you do,” he said: cardiologists become cardiac surgeons, radiologists perform more complex procedures, surgeons become computerised and engineers, mathematicians and physicists enter the theatre now. Under seven headings Professor Fosse tabulated the differences between the handicraft and industrial cultures -
“ownership” – from individual to corporate
“product development” – from integrated to separated
“knowledge transfer – from personal to explicit
“collaboration” – from interdisciplinary to cross-disciplinary
“review” – from individual to evidence-based
“value” – from procedure to product-based
“treatment” – from tailor-made to standardised.

In considering surgery (or intervention as we must now call it) in isolation from health care, and for those who see “healthcare” as an “industry” delivering a “product” this analogy has some relevance. In answer to a question from Ann Noble, Chair of Architects for Health, Professor Fosse said that the handicraft tradition in which ownership, knowledge transfer, review, value and treatment were controlled by the expert consultant clinician and his/her team has become too expensive. “Hospitals are being run as corporations” and “it is only a matter of time before corporations take over medical education”.

The meeting was expertly chaired by Michael Sury, Consultant Paediatric Anaesthetist at Great Ormond Street. He asked about the barriers to change and Professor Fosse said they were “resources, which are very expensive” and the “challenge to existing human power structures”.

“Toys for the boys” are indeed very, very expensive but individual human care for sick, anxious and fearful patients is priceless. It never came up at this meeting while it had been the central theme of Hospices.

The well-attended meeting was generously sponsored by Maquet and Andrew Walters their Product Manager gave a clear and informative presentation of the Modular Operating Room System, VARIOP. John Knape of Nightingale Associates and John Davidson and Donal O’Donoghue, Clinicians of the Royal Liverpool and Broadgreen University NHS Trust, completed the session describing the well-known ‘Barn’ theatre there.

Peter Scher
June 2007

Hospices was the title of an Architects for Health Event that took place at The King’s Fund, Cavendish Square, London, on Thursday 17 May 2007.

Hospices are special buildings, not only because they are for special groups of people but also because the approach to design and the means of procurement frequently falls outside the public sector and thereby creates opportunities for new and different designs. Undoubtedly the wider health sector can learn from them.

Chair: Mr Simon Henderson from Macmillan Cancer Support.

Introduction to the Modern Hospice Movement;
Dr Nigel Sykes, Medical Director of St Christopher’s Hospice

Robin House Children’s Hospice, Balloch, GIA Design Award 2006, Winner
Sarah Murphy of Gareth Hoskins Architects

Evidence based design and impact; St Gemma’s Hospice, Leeds; Marie Curie Hospice, Glasgow; St Patrick’s Hospital and Mary Mount Hospice, Cork.
Ian Clarke of Jane Darbyshire & David Kendall Ltd

Enhancing the Healing Environment Programme for End of Life Care
Mura Mullan of Jane Darbyshire & David Kendall Ltd

Hospices are not very numerous or conspicuous and, as far as I can recall, they have not been the topic of any previous Architects for Health event. This gap was filled at a completely absorbing meeting chaired by Simon Henderson of Macmillan Cancer Support. The first excellent and authoritative presentation was given by Dr Nigel Sykes, Medical Director of St Christopher’s Hospice, with a succinct account of the development and of the present position of the hospice concept. His most striking message was that “hospice” is not a building type it is a concept of care. Palliative care as it has come to be called – formally defined, in fact, by the WHO – can be delivered at home, in a hospital or in a hospice. Some 80% of hospice beds are in the voluntary sector and all care is free, but with the NHS providing only 28% of funding.

Sarah Murphy of Gareth Hopkins Architects then presented the design of Robin House, the second children’s hospice to be opened in Scotland. It was completed in 2005 at a beautiful site to the west of Glasgow near the southern end of Loch Lomond. Showing design sketches alongside photographs of the completed building vividly demonstrated the designers’ care in understanding the users’ needs and in collaborating to realise them.

The firm of Jane Darbyshire & David Kendall Ltd has long been involved in hospice designs. St Oswald’s, Gosforth, received an RIBA Award in 1980. Ian Clarke’s presentation on Evidence based design and impact was a very thoughtful and illuminating analysis of the interaction of hospice users and the designed environment. His understanding applies, indeed, to the design of all health care facilities and derives from the clear patient-focused approach of Roger Ulrich and others. He regards “intangibles”, “soft issues” and suchlike vague excuses for arbitrary design as misnomers. Our work should be to eliminate the stress, anxiety, depression or boredom that can be brought on by the designed environment. It can be done.

Ian demonstrated this approach in the practice’s excellent designs for St Gemma’s Hospice, Leeds, the Marie Curie Hospice, Glasgow and, in collaboration with Scott Tallon Walker, the Mary Mount Hospice in Cork. The latter design is a very sensitive solution to an unusually difficult brief – 130 hospice beds on a steeply sloped, north-facing site.

The final presentation, by Mura Mullan, also of Jane Darbyshire & David Kendall Ltd, was both moving and inspiring. It was for a single room at the existing Marie Curie Hospice in Glasgow. This was one of the projects of the King’s Fund “Enhancing the Healing Environment Programme”. It was a classic “before and after” demonstration of how a small amount of money and an incalculably large amount of enthusiasm and commitment by users and designers can transform the culture as well as the environment for care.

An interesting discussion followed these presentations held at the King’s Fund and some very valuable insights were gained by the appreciative members.

Peter Scher
May 2007

Joint event with Architects for Health and London South Bank University

14 May 2007

The Architects for Health Study Visit to Belfast took place on 3 and 4 May 2007. This visit was hosted by John Cole – Chief Executive of Health Estates in Northern Ireland.

Visits to health care buildings where arranged, including a visit to the Arches Community Care and Treatment Centre (RIBA Award 2006).

Report on the AfH Study Visit to Belfast by Virginia de Vere: download here (PDF)

Report on the Architects for Health Reform Club Debate by Roy Carroll

The evening of 22 February 2007 saw members Architects for Health conduct their 13th annual debate, as is the custom, in the revered surroundings of Sir Charles Barry’s Reform Club in Pall Mall.

The event was sponsored by hbg construction and the motion was:

“This House believes that contract requirements to comply with Department of Health Guidance Notes stifles innovation and inhibits good practice.”

Supporting the motion was Professor Duane Passman, Head of Capital Investment – NHS London, Visiting Professor, School of the Built Environment, University of Salford; and Mike Hobbs, Director of Business Development for Carillion.

Opposing the motion was Chris Sherwood, Senior Projects Director, Nightingale Associates; and Dermot O’Reilly Sector Director Schal, RIBA Client Design Advisor, Chairman CIC Procurement Panel.

Interestingly, Mike and Dermot were on opposite sides although both are from the same organisation, albeit different sectors.

Chair for the debate Richard Griffin, Partner and Head of Healthcare at Sheppard Robson Architects, who did a splendid job of introducing the speakers, maintaining order, discipline and proper timekeeping throughout the proceedings.

The AfH ‘Godfather’, Professor Ray Moss, kicked off proceedings by reminding us how appropriate the setting was for the debate, since the purpose of the Reform Club, founded in 1836 by Edward Ellice, was to provide a forum for the radical thought and ideas represented by the Reform Act of 1832. The building itself, completed in 1841, was, despite the constraints of its classical form, full of Victorian innovation, such as steam powered spits and plate warmers. The topic, he said, “lies at the heart of the design work we do today.”

Duane spoke first for the motion, outlining that he was not concerned here with statutory or mandatory guidance such as British standards, or Building regulations which we follow to obey the law or comply with policy. His issue was with guidance notes requiring interpretation, and the imposition that project submissions must comply with all such guidance. For example, a mental health scheme may not need to utilise guidance concerning operating theatres or other specialties, yet we have to go through the exercise of itemising derogations from such documents.

Despite the lack of explanation for some of the recommendations they contain it is very difficult to deviate. Chelsea and Westminster Hospital would have ended up with concrete walkways and no (atrium) windows if it was to satisfy Firecode, and the interior design budget of Leeds General Infirmary would have been diminished if the HBN for Intensive Care Units had been followed to the letter.

According to Duane, using guidance was rather like a spacecraft using the ‘The Infinite Improbability Drive’ in Douglas Adam’s book ‘The Hitch Hiker’s Guide to the Galaxy’. Basically the spacecraft would have to touch all parts of the Universe before delivering you instantly to your destination – like guidance. If creation is introducing a new idea and innovation is implementing that idea, guidance denies creativity and innovation because we have to tick all the boxes and cover all areas.

First in line to oppose the motion was Chris, who, after correcting his charming Australian “G’day” to a more formal “Good evening”, proceeded to explain why there was no basis for the motion, or as he saw it, two motions. He was brave enough to say that “As I actually read some of this guidance….the pendulum swung”. The amusement aroused in the audience by his admission of this relatively recent scrutiny of the literature was probably a reflection on those of us who were in a similar position but not willing to admit it.

He went on to say that the motion does not state that there are people in the NHS who stifle innovation. Guidance is there to safeguard patients, and although democracy may be a lousy system, the alternatives are worse. Voluntary codes of conduct don’t work when they are overpowered by commercial considerations. Furthermore, while technical development outpaces guidance can we really say that we know more than the documents given the level of research that has been carried out? If we cut across guidance is it a bad thing to assess the risk?

Rather than go with an example from a popular cult sci-fi comedy, Chris chose to liken attitudes to guidance with a scene from a current cult police TV drama. When the character who is marooned 30 years in the past voices his concern about the rough treatment doled out by his police colleagues at the station, his guv’nor criticises him for talking about it as though it was a Bad Thing. Guidance does acknowledge that there may be other means of arriving at solutions. The ACAD at North Middlesex hospital, generally considered to be innovative in its execution, was completed within an NHS framework. Time constricts innovation and complying with guidance will save time rather than applying for derogations.

Mike Hobbs, second up for the motion, said that there should be an environment for innovation, not innovation occurring despite constraints, such as in the Reform Club. More clarity about outputs is required; guidance is a ‘fog of competing priorities’. We are ‘competing to comply’ to safeguard ourselves from a legal point of view. Executive summaries sound more like a ‘must do’ rather than a level of minimum requirements, and we innovate in footnotes, derogations and caveats, recreating history rather than looking forward.

Guidance should be ‘De Minimus’. How can the mountain of information be extant at any one point? We need standards but they should be minimum standards against which we need to exceed.

Dermot O’Reilly, for the opposition, accepted that these are terms of reference about what information should be used. He argued that the body of work available for reference is good practice, and even if it was not written into a contract our duty of care would prompt us to look at guidance elsewhere.

To demonstrate what happens when guidance is not followed, he cited the Building Schools for the Future initiative, where projects touted to be good examples are unable to fully support all the activities for which they were designed. If we went about healthcare design in the same manner would we end up in a position, for instance, where we had to say we could only do that operation when the Sun was shining?

Dermot quoted Thomas Edison for support: “I have n’t failed but found x examples that don’t work”. Throwing away guidance would be like throwing away all the examples that don’t work. Under John Cole in Northern Ireland clients work guidance into exemplar design, following through to ‘smart’ PFI. Who owns the concept risk? No one has been sued because of a flawed concept. Dermot maintained that if there is a will to innovate then it will happen, that guidance is not prescriptive but a platform to work from. It was a question of interpretation – if it’s good practice and innovation is required then a legal agreement is not the place to start.

When the discussion was opened up, comments from the audience ranged from feeling that the debate was ‘flat’ and somewhat unworthy of the Reform Club to the opinion that we should ‘just get on with it.’ Some attendees admitted they had come with preconceptions which they had changed or come close to changing after hearing the arguments, a testament to the quality of the debate despite some negative criticism. Naturally PFI, scapegoat for contractual ills, lack of innovation and all the worlds’ problems generally came in for a spot of bashing, and there was the usual tendency for the discussion to drift away from the precise wording of the topic and the odd grumble about whether we were discussing the right motion. Richard Griffin kept us on track, however and his stewardship gave everybody who wanted to contribute the opportunity to do so.

The turn out for the event was one of the lowest, but despite this the result was the closest ever, 16 for and 15 against – MOTION CARRIED

Roy Carroll
March 2007

AfH visit to John Radcliffe Hospital Oxford December 7th 2006, an invitation from Carrilion Health.

Hosted by Carillion Health and the Oxford Radcliffe Trust on Thursday 7th December, at 6.00pm

The event took the form of a project overview (joint Trust / Carillion) in the project offices, followed by a site tour.

Key points of interest included:

• Specialist Head and Neck Centre
• Specialist Children’s Hospital
• University Research Accommodation
• Consolidation of services from a city centre site onto the John Radcliffe site
• The first scheme designed to the SF3 form of contract

Numbers were limited to 30 visitors, members of AfH.

Report by Carole Crane:

It was a dark and stormy night yet several intrepid AfH members braved the elements to travel to Oxford for an open evening and tour of the new Oxford Radcliffe Children’s Hospital and Head and Neck Centre.

The invitation to have a look at the building had been extended by Dale Sager of Carillion and a willing team was assembled to first ensure we were dried out, fed and watered and then to escort us around the facilities following two short presentations on the design and construction of the project.

We had learned in the warmth and comfort of the project office all the facts and figures relating to the scheme.

Children’s Hospital

• Inpatient
• Daycare
• Adolescent services
• Out Patients department
• Childrens HEPAC Clinic
• Relatives and carers accommodation

Head and Neck Centre

• Neuroscience
• Head and Neck
• Plastic Surgery
• Adult services
• General Surgery
• Out Patients department

General Information

• 285 beds
• 55,00 sq m
• Nine floors with one level for car parking
• £135 k construction costs @ 2003 prices

Vickie Holcroft, the Trust project director.

• The hospital is a teaching hospital with links to the Universities of Oxford
• There were four hospital sites: – the infirmary dating from 1770 in the centre of Oxford and now closing with services to transfer; the Churchill, Horton and John Radcliffe, which forms the hub of clinical services from the Trust.
• The trust offers specialist and national services
  • Clinical safety
  • Neurosciences
  • Paediatrics, using shared services
• A combination of population growth, demographic changes, changes in clinical practice, old unsuitable buildings and new technologies had made it necessary to move the services forward.
• A new service strategy had evolved which clarified the management of emergencies and electives.
• Problems with recruitment and retention had been acknowledged and will be addressed.
• The new building promised significant environmental improvement.
• Immense effort and input from key members of the trust team had developed the SBC for issue in 1999, the OBC in 2001, FBC in 2003.
• The difficulties had been to fund the initial set up costs and to find resources to maintain the project and to take the team through the approval processes.
• Now the problems were to deal with the changes in revenue funding as PbR poses new risks for business cases.
• Transitional funding will be lost
• The Trust has no firm idea of how future funding will be obtained with the current financial climate or how resources will be managed, but in this respect they join forces with all NHS Trusts who share the same uncertainties and financial burdens.

Keith Hutton, Carillion Project Director.

• Explained how the SPV had been formed with RBS as financiers, the Hospital Company and Carillion as the D & B contractor.
• Other partners as before to create a framework familiar and common to many similar projects.
• The success factors were
  • An integrated team
  • An open collaborative relationship
  • Comprehensive “in-house” skills
  • Best whole life solution / value for money
  • M & E commissioning had provided a seamless transition to hard FM
  • Considerable planning / programming skills
  • Continuous improvement through “lessons learned”
• Sustainability
  • OGC recognised best practice
  • Biodiversity and sustainable plans were implemented
  • There was community engagement
  • Construction waste was diverted from landfill
  • There was a green transport plan
  • Lino floors
  • Ceiling tiles made from 30% industrial waste
  • Paint was supplied in tin cans
  • Biocide paints used
  • Sponsorship of local wildlife group
• Capital Works
  • £135 m over 3 years
  • 9 storeys
  • University accommodation
  • Re-located helipad
  • Car parks
• Key design Features
  • Clinical functionality
  • Separate clean and dirty routes
  • Two entrances – adults and children
  • Three level link to original John Radcliffe Hospital
  • Allowance for future flexibility and expansion
  • Crèche, retail, restaurants all provided
  • Sustainability designed in.
  • Conversion of 4-bed bays to single rooms designed in (drainage built in)
  • Soft space designed for future use as MRI / CT accommodation
  • Stronger colours and different approach to design in the children’s hospital.
  • Way finding designed around the ideas form local schoolchildren who had been involved throughout the design process.

Carillion were justly proud of their soon to be opened hospital in which, even at the late hour of night, the finishing touches were still being applied.

The tour of the building then took place. Plans and photographs not published at present until after the official opening and publicity.

After crossing the windswept road from the project office we entered the building via the security entrance located by the lower ground floor 2 car park close to the adult’s west block main reception. This took us into an imposing concourse from whence rose escalators to the lower ground floor 1 Out Patients’ clinics. Such is the topography of the site that the lower ground floor 1 at this point actually appears to be the first floor; the ground slopes up steeply towards the existing hospital where existing floor levels dictate the designation of new.

The site constraints forced deep plan floor plates with four centralised courtyards, perhaps a solution that would not be so acceptable today (only five short years later) but that was required at the time of the PSC and was maintained throughout the project. Through the concourse to the full height atrium which dominates the children’s entrance within which the children’s radiology department juts out into the atrium from lower ground floor 1. A view of activity in the atrium and of proposed artworks on the opposite wall can be obtained from within this “pod”. The works in the atrium are as yet unfinished; the intention is to place an artwork on the end wall which should make a dramatic impact on the view down the length of this large space. Signposting throughout seems to be very clear and straightforward though time will tell if this is in fact the case. How soon will paper notices appear on doors, walls and columns?

Up a single flight of stairs to the OPD level which has a large number of internal treatment and consulting rooms within the deep floor plan. Inevitably our party became lost in a maze of rooms but big bear footprints on the floor should have helped in our confused state. Rooms in the children’s area are brightly painted in strong colours and are well fitted out with robust built in furniture and fittings; though filled with furniture awaiting unpacking they appeared to be of generous size. On this dark and gloomy night it was difficult to judge how much daylight would filter through to internal spaces but a large courtyard play area shared between the OPD and the HEPAC clinic with a central dividing screen should enable a good supply of sunshine to some clinic areas.

From children’s OPD to the ophthalmology department in Head and Neck where a strangely high reception counter dominated the waiting room and this visitor, being short of stature, found the space somewhat intimidating. (Will the users regret their insistence on their lofty viewpoint?) Coloured lines on the floor assisted way finding in this department. From here in the lift to the upper floors to look at inpatient accommodation where we found a mix of single and four bed rooms in both adult and children’s hospitals; again the result of decisions made five or more years ago but see “key design features” above. The single rooms were of good size, comfortable, with fitted furniture and all with a view of surrounding countryside or of internal courtyards. Once more the colour schemes in the children’s hospital were strong and bright, those in the adult zones being muted but in the same range of hues. Theatres and specialist areas on these floors were out of bounds, having been cleaned ready for handover.

Down the impressive main staircase, a bright white steel structure which when lit creates a dominant focal point on the north elevation, across the upper level of the concourse where the smart idea of placing a café next to OPD pharmacy provides a pleasant sitting area to watch others below, and then back to the security desk to complete our all too brief visit.

This new hospital promises to be a significant addition to the healthcare estate and we look forward to an in depth appraisal.

Thank you, Carillion, for offering AfH a sneak preview.

Carole Crane
February 2007

The seminar Education: Opening the Debate was presented by Architects for Health following the AGM on 30 November 2006 at the new Libeskind Lecture Space at the London Metropolitan University.

With rare exception, healthcare facility planning and design is not taught in schools of architecture in the UK. This absence on the curricula has a direct effect on the perception that students, staff and the profession have of the skill base and competences which flow into practice.

Keynote Speakers

• Professor George J Mann – AIA, is the Skaggs-Sprague Endowed Professor of Health Facilities Design at Texas A&M University, USA. He has published numerous articles, and research reports giving presentations of his findings on both national and international levels. Biography
  http://archone.tamu.edu/faculty/gmann

• Professor Bas Molenaar – professor of architectural design & healthcare at Eindhoven Technology University, Netherlands. Biography
  http://www.bwk.tue.nl/ade/index.php

• Professor Ake Wiklund – professor of architectural design & healthcare at the School of Architecture at Chalmers University of Technology, in Gothenburg, Sweden. Biography
  http://www.chalmers.se/arch/EN/

Contribution

• Leo Care – Design tutor at the University of Sheffield. Biography
  http://www.shef.ac.uk/architecture

Chairman

• Robin Nicholson – Senior member of Edward Cullinan Architects. Biography
  http://www.edwardcullinanarchitects.com

Welcoming from London Metropolitan University

• Professor Graeme Evans – director of the Cities Institute, a multidisciplinary research institute working across sustainable urban environments and design, transport, housing and regeneration. Biography
  http://www.citiesinstitute.org

Sponsored by Drager Medical