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James Chapman: PFI and Design Quality

The following is a reprint of a paper given by Mr James Chapman F.R.I B.A., R. James Chapman and Partners, Architects, Manchester. At the Design Quality Forum on Primary and Intermediate Care, R.I.B.A. London, 1998.

PFI and Design Quality: Architects for Health Occasional Paper No 98/102

The Minister, in his introduction, stressed the need for partnership within the Health Service and that the Government were reviewing the efficacy of PFI within the healthcare sector, for smaller schemes batching and sharing were being considered as alternatives to the mechanisms for the larger projects, as these were taking time to develop and evaluate.

Before the last election in 1997 the President of the RIBA said:

"Politicians and Architects share one vanity - the belief that their actions can make this a better country in which to live."

The Institute called on the next Government to:

• establish procurement procedures using a quality based selection procedure
• reform this procedure - the Private Finance Initiative to make quality of design a key criterion
• create a post of Government Architect to work With the Treasury to set standards of Government procurement
• train the civil servants responsible for building procurement
• procure major public buildings through competition,

  but no reference was made to understanding the meaning of quality and added value.

What is PFI, the Private Finance Initiative?

Simply it is a way for Government to buy vital services for public use.

A way to transfer ownership of assets and direct provider of services, to become a purchaser of those services from the private sector.

An apolitical concept, to achieve an improved service at a 'better` price.

What does quality mean?

In the White Paper December 1997, The New NHS Modern Dependable

The Prime Minister in his introduction states, "For the first time the need to ensure that high quality care is spread throughout the service will be taken seriously. National standards of care will be guaranteed. There will be easier and swifter access to the NHS when you need it. Our approach combines efficiency and quality with a belief in fairness and partnership."

Six key principles underlie these changes:

Principle 5 states - 'to shift the focus of quality of care so that excellence is guaranteed to all patients, and quality becomes the driving force for decision-making at every level of service'. I cover the process later in this paper.

In the section on 'driving change in the NHS', the Paper states that quality and efficiency must go hand in hand throughout the service Everyone who works within the NHS should take responsibility for working to improve quality. This must be quality in its broadest sense, doing the right thing at the right time and this must apply to the procurement and briefing process as well as the operation of the units. The objective being to provide a quality experience for patient, staff and visitor!

The report continues to focus on quality stating that, 'quality standards will be central to the new local service agreements...

What will be the funding mechanisms?

The intent is that NHS money will flow around the system to support both quality and efficiency, thus

• Allowing clinicians to influence the use of resources by aligning clinical and financial responsibilities. An intimate relationship between user and designer, a chance to build on innovation.
• Funding of major capital programmes through PFI, expansion of public/ private partnerships. A need to understand and make the most of the process.

Is the PFI system working for the larger projects?

There are 4 major projects on site:

Norfolk and Norwich
Carlisle
Dartford
South Bucks

All these projects have taken a long period in the gestation phases and there has been considerable criticism in the professional and technical press of the procurement process. The need for the facility management skills is untried and many schemes have undergone significant changes in personnel and companies, as a consequence of understanding the provision of the wide range of services required by the NHS.

If we are to consider batching for the delivery of intermediate care, as described earlier by the Minister, then we need to study what has happened in the education sector and learn from those successes.

The accompanying tables indicate some of the changes in responsibility and additional risks if PFI is to be implemented. The loss of professional design skills from the Health Service has emphasised these differences and the need to have defined project sponsors with commitment and knowledge cannot be undervalued. (The presentations earlier today have demonstrated the benefit of this approach resulting in quality solutions, particularly those with dedicated individuals who understand the service and process and have clear quality goals).

Procurement route to manage the process OJEC notices 4 stages

• Pre Information notice, purpose to advise of your intention to do something (1 year)
• Restricted Procedures notice, define services and need (37 days)
• Shortlist and tender (40 days)
• Contract award notice

Independent professional advice

PFI requires changes to the normal method for appointing consultants.

There will be a need for financial, technical and legal advice to support the in house team.

Project Management

PFI projects are complex, you will require the right person with the necessary experience at the beginning of the project.

If this person is in-house, look for continuity for the duration.

Look for flexibility in approach as well as design. The solution PFI negotiations are complicated.

In the attached diagram 1 I have compared the traditional design stages with the equivalent PFI stages

How do you achieve and monitor design quality in PFI projects?

A significant challenge for the in-house team, as you are not only seeking an immediate design service to understand the need of your clinical team and establish the brief together but to provide an ongoing service to run the completed facility.

Within the client team there ought to be an experienced Estates Director supported by a consultancy team of quality and experience who are responsible for preparing the brief.

The PFI contracting team and their Consultants will be required to respond to this brief and make a competitive bid, which will be evaluated by the client team. This evaluation process is a complex activity and relies on a close understanding of the need and the service required.

See diagram number 2

At Norwich, quality of design and form was an objective established with the planning authority and taken further by the Royal Fine Art Commission, both the form and use of materials were established before the bids were made. This helped to. reduce uncertainty of quality at the bidding stage.

Determine quality issues for users, at Norfolk and Norwich this involved the creation of departments and room loaded sheets as part of the detail design, and a powerful in-house facilities management team. If you keep quality with the user at this stage the trust minimises risk.

As one of several initiatives to understand quality standards, NHS Estates and the Prince of Wales School of Architecture have begun a three year research programme on design quality.

Building Magazine has been running a series of articles on the 'success' of PFI and its approach to quality. Concern has been expressed in the delayed publication of guidance aimed at improving design quality. This work was considering not only the aesthetics of design but also the design could become an integral part of the process. See the attached diagrams.

My PFI experience both inside and outside the Healthcare sector confirms that the sooner design advice is gained and quality standards established, the, more likely the project will achieve the objectives. It is not easy, as With other advice it costs money and you need high calibre input.

Design competitions are an ideal starting point for many projects. The competitors should receive a fee, the winning bidder could pay this fee. (it happens elsewhere in Europe).

Well run competitions enable innovation to be brought back into the Health Service and should invigorate both the building and quality of care.

In summary the public sector client must see design as critical, and we designers and our teams must demonstrate the added value.

RJCA 13-04-98

References

1. The New NHS Modem Dependable
2. Opportunities in Intermediate Care NHS Anglia and Oxford
3. Can the NHS afford the Private Finance Initiative BMA December 1997
4. Future Premises for Primary Care RIBA/NHS Estate December 1996
5. Building for the Future RIBA April 1997
6. Building 20-02-98

There is a central quality which is the root criterion of life and spirit in a man, a building, or a wilderness. This quality is objective and precise, but it cannot be named.
Christopher Alexander - 'The Timeless Way of Building'

Quality is never an accident, it is always the result of intelligent effort. There must be a Will to produce a superior thing
John Ruskin

All excellence is equally difficult
Thornton Wilder

Quality, above all, is about care, people, passion, consistency, eyeball contact and gut reaction. Quality is not a technique no matter how good.
Tom Peters - 'A Passion for Excellence'

To fight against the shoddy design of those goods by which our fellow men are surrounded becomes a moral duty.
Nikolaus Pevsner

Mammoth hospitals, built like dreary office blocks on a devastatingly function basis, depress the spirits, however good the healthcare.
HRH The Prince of Wales - in a 'Vision of Britain'

DIAGRAM 1

GOOD HOSPITAL DESIGN SHOULD:

1. CREATE A USER FRIENDLY, HEALING ENVIRONMENT
2. REFLECT APPROPRIATE HEALTH BUILDING STANDARDS
3. BE EFFICIENT
4. BE FLEXIBLE
5. BE ECONOMIC
6. FIT INTO ITS SURROUNDINGS
7. SPECIFY APPROPRIATE CONSTRUCTIONAL STANDARDS
8. PROVIDE A SAFE AND SECURE ENVIRONMENT
9. PROVIDE EASY ACCESS

DIAGRAM 2

DESIGN QUALITY IN PFI PROJECTS: PFI STAGES

CRITICAL FACTORS FOR SUCCESSFUL PROJECTS

• SPONSOR

• PROJECT STRATEGY
  NEEDS AND OBJECTIVES
  TIME AND COST
  MANAGEMENT STRUCTURE

• SELECT PROCUREMENT ROUTE

• INDEPENDENT PROFESSIONAL ADVICE

• MANAGE PROJECT