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