Achieving the Client’s ObjectivesAchieving the Client’s Objectivesin PFI Projectsin PFI Projects

John Cole John Cole Chief Executive , Health EstatesChief Executive , Health Estates

EVIDENCE-BASED DESIGNEVIDENCE-BASED DESIGN

No longer simply intuitive – now research backed

The Health Sector

Up to 20% reduction in post operative recovery / length of stay Up to 15% reduced use of analgesics Reduced hospital acquired infections, medical errors and

patient accidents leading to claims Reduced aggression towards staff by up to 40% Easier recruitment and retention of staff – up to 56% increase

in levels of staff morale Lower pulse rates and blood pressure readings leading to

better outcomes Improved staff efficiencies – up to 20% more effective use of

nursing resources

ACHIEVING DESIGN QUALITYACHIEVING DESIGN QUALITY

Most fundamental requirement an informed client, who at the Most fundamental requirement an informed client, who at the highest level is committed to design quality and understands its highest level is committed to design quality and understands its contribution to service delivery and better patient outcomescontribution to service delivery and better patient outcomes

A comprehensive client brief that clearly articulates specific A comprehensive client brief that clearly articulates specific design quality objectives as key targets in the project deliverydesign quality objectives as key targets in the project delivery

Best practice design quality control tools / mechanismsBest practice design quality control tools / mechanisms

The ability to set design standards and evaluate design The ability to set design standards and evaluate design solutions prior to and after construction solutions prior to and after construction

ACHIEVING DESIGN QUALITYACHIEVING DESIGN QUALITY

AEDETAEDET

FUNCTIONALITYFUNCTIONALITY

UsesUses AccessAccess SpacesSpaces

BUILDBUILDSTANDARDSTANDARD

PerformancePerformance EngineeringEngineering ConstructionConstruction

IMPACTIMPACT

Character andCharacter andInnovationInnovation

Citizen SatisfactionCitizen Satisfaction InternalInternal

EnvironmentEnvironment Urban & SocialUrban & Social

IntegrationIntegrationAddedAddedvaluevalue

ExcellenceExcellenceAddedAddedvaluevalue

AddedAddedvaluevalue

DESIGN EVALUATION PROFILEDESIGN EVALUATION PROFILE

FUNCTIONALITYFUNCTIONALITY

URBAN &URBAN &SOCIALSOCIAL

INTEGRATIONINTEGRATION

11

22

33

44

55

USESUSES

CITIZENCITIZENSATISFACTIONSATISFACTION

CHARACTERCHARACTERANDAND

INNOVATIONINNOVATION

INTERNAL INTERNAL ENVIRONMENTENVIRONMENT(PATIENTS & STAFF(PATIENTS & STAFF))

ACCESSACCESS

SPACESSPACESENGINEERING ENGINEERING

PERFORMANCEPERFORMANCE

CONSTRUCTIONCONSTRUCTION

PoorPoor

66 ExcellenExcellentt

IMPACTIMPACT

BUILD BUILD STANDARDSTANDARD

HEALTH BUILDINGSHEALTH BUILDINGS

Hospital ‘A’ Ward corridorHospital ‘A’ Ward corridor

Would you prefer to go to a ward in a corridor like Would you prefer to go to a ward in a corridor like this?this?

HEALTH BUILDINGSHEALTH BUILDINGS

Ward Corridor, Intermediate Care Centre, London Ward Corridor, Intermediate Care Centre, London

Or this?Or this?

HEALTH BUILDINGSHEALTH BUILDINGS

HEALTH BUILDINGSHEALTH BUILDINGS

North Croydon Medical CentreNorth Croydon Medical Centre

AHMM ArchitectsAHMM ArchitectsNorfolk and Norwich University HospitalNorfolk and Norwich University Hospital

Anshen Dyer ArchitectsAnshen Dyer Architects

HEALTH BUILDINGSHEALTH BUILDINGS

ACAD Centre, Central Middlesex ACAD Centre, Central Middlesex HospitalHospital

Avanti ArchitectsAvanti Architects

EDUCATION EDUCATION BUILDINGSBUILDINGS

Into a lobby like this…..Into a lobby like this…..

School A - school streetSchool A - school street

EDUCATION BUILDINGSEDUCATION BUILDINGS

Or this…..?Or this…..?

School D - entrance hall and school streetSchool D - entrance hall and school street

DESIGN QUALITYDESIGN QUALITY

Has to meet the needs of 6 constituencies:

Patients Staff Hospital Management Facilities management The wider health system The general public

All successful buildings must satisfy these various needs

Designing for PeopleDesigning for People

A Patient Focus

human scale and a non-intimidating friendly environment that gives confidence accessibility, easily understood, good way-finding personal respect and privacy cleanliness proper space standards/ uncluttered/ uncrowded enabling visitors control over their personal environment choice telephone / television / sound insulation outlook / landscaping / natural light / art / colour / texture well–chosen furniture and artificial lighting an environment that promotes healing

Designing for PeopleDesigning for People

A Staff Focus:

patient flows through building correct adjacencies supervision / observation / support / security storage space capacity proper space standards / functionality / / flexibility appropriate technology facilities for administration / training / relaxation / changing / eating / overnight

accommodation / exercise outlook / landscaping / natural light ambience / quality of building/ pride and ownership in their organisation

Designing for PeopleDesigning for People

The Public Experience:

accessibility / car-parking and way-finding friendly / inviting / non-institutional clearly identifiable entrances / reception points long waits / range of seating / waiting areas/ space for private interviews facilitating families with children diversion / amenity / shopping / visitors / overnight stays art / landscaping / outlook public realm / buildings for people community pride / enhancing the local environment contributing to social / economic / environmental sustainability

Designing for PeopleDesigning for People

The Management Experience:

facilitating the required service model development control plan site circulation / car-parking complaints good way finding / short travel distances efficiency of layout flexibility / adaptability / extendibility over life Future - proofed for technology design for maintenance / long life / low energy/ whole life costs security / supervision / management of entrances attracting and retaining staff public perception / first impressions / cleanliness cost reductions / income generation opportunities

The Service Delivery Client’s RoleThe Service Delivery Client’s Role Strategic Vision for the Service in Total Integrated Trust Service Vision across primary / community / acute

sectors Quantification of service need / Location of facilities Site identification, planning permission and acquisition Whole building and departmental operational policies Functional content of buildings / Schedules of accommodation Equipment requirements Space standards / key functional relationships/ room data sheets Environmental and engineering services requirements Design quality objectives Flexibility / extendability Sustainability standards Articulation of concept design solution and ratification or refinement of

brief Appropriate budget

An Integrated Services ModelAn Integrated Services Model

1.7 Million RegionalHospital

Acute Hospital

Acute Hospital

Other CommunityFacilities.

Non-healthagencies

Individualhomes

HC

1

2-10 Thousand

150-300 Thousand

Acute Hospital

LocalHosp.

LocalHosp.

4

HCCTCC

2

20 – 70 Thousand

100 Thousand+

CTCC.

LocalHosp.

CTCC.3

Key Trends in Location of Services Key Trends in Location of Services

1 - Local Health Centres

2 - Community Health Centres

3 - Local Hospitals

4 - Acute Hospitals

5 - Regional Centres

Movement of out-patients diagnostics and treatments fromacute towards community Key issue is the movement of chronic disease management to the community preventing unnecessary hospitalisation

Movement of complex specialties or specialties benefiting from higher critical mass to Centres of Excellence

ALTN AG ELVIN

C AUSEWAY

AN TRIM

ENN ISKILLEN

C RA IG AVO N

M USG RAVE

BC H

D A ISY H ILL

ULSTER

Level 4 - Acute Hospitals

180 km

OMAGH

M IDULSTER WHITEABBEY

MATER

SOUTH TYRONE

LURGAN

LAGANVALLEY

DOWN

Level 3 - Local Hospitals

180 km

BANGOR

NEWTOWNARDS

BELLEEK

ENNISKILLEN

IRVINESTOWN

FINTONA

OMAGH

CASTLEDERG

CARRICKMORE

STRABANE

COOKSTOWN

MAGHERAFELT

LIMAVADY

CITY CENTRE

SHANTALLOW

WATERSIDE

COLERAINE

ROBINSON

DALRIADA

BRAID

ANTRIM

NEWRY

S ARMAGH

ARMAGH BANBRIDGE

HILLSBOUROUGHPORTADOWN

DUNGANNONBROWNLOW

KILKEEL

NEWCASTLE

BALLYNAHINCH

LISBURN

DUNMURRAY

LARNE

WHITEABBEYCARRICKFERGUS

DOWNPATRICK

PORTAFERRY

COMBER

HOLYWOODDONAGHADEEBANGOR

ARDS

Level 2 – Community Treatment and Care Centres

180 km

BENEFITS OF PPP/PFIBENEFITS OF PPP/PFI

Potentially earlier availability of funding

Potential for innovation

Potential benefits from related commercial development

opportunities

Consortium input to buildability / life-cycle management

Guaranteed maintenance over contract period

Replacement of equipment (if included)

Payment related to availability of facility

PERCEIVED PROCESS PROBLEMS WITH PERCEIVED PROCESS PROBLEMS WITH PPP/PFIPPP/PFI

Poor Public Sector Comparators produced Lack of clarity/understanding of strategic and specific needs of

client Bidding costs to client and contractor Wasted resources Length of time taken to closure Affordability gap due to lack of adequate work by client prior to

bidding process Inadequate definition of quality issues prior to formalisation of

contract Potentially opposing objectives Occasionally the quality of the final product

IMPACT OF DESIGN ON LIFE-COSTSIMPACT OF DESIGN ON LIFE-COSTS

Cost of Maintenance : 5

Cost of Building : 1

Cost of Design : 0.1

Cost in Use to Client : 50 - 200

PFI

MANAGING DESIGN DEVELOPMENTMANAGING DESIGN DEVELOPMENT

A 10% increased efficiency in capital and life-cycle maintenance equates to only 0.6 of the original capital cost

A 10% increased efficiency in costs-in use equates to up to 20 times the original capital cost

The current payment mechanisms do not incentivise PFI consortia to focus on the user-client’s costs-in-use

The user-client must ensure the design facilitates its core needs and activities

All procurement models must enable the user client to properly establish the brief and control design quality of the final building

OWNERSHIP OF THE CONCEPTUAL DESIGNOWNERSHIP OF THE CONCEPTUAL DESIGN

Only providers of complex services such as health services can

fully understand implications of key issues for their populations

such as:

strategic development needs

developing models of care

technological advancement / research requirements

changing medical and nursing practice

patients’ expectations

In-depth dialogue between the user-client and the design team

is essential for successful high-quality design

This is most important during the conceptual design stages

RELATIONSHIP ISSUESRELATIONSHIP ISSUES

Consortium’s Design team are not able to properly research specific

needs of client

Limited opportunity for in- depth dialogue / brief development with

user-client during key design conceptualisation stage until after

competitive stage of design process is completed

Inadequate time for initial design development and often inadequate

allocation of fees to properly resource this stage of the project

Potential for mis-interpretation of ‘output’ specification

Design quality aspirations sometimes not shared

Incomplete definition of product

Compromises during construction

THE EXEMPLAR MODELTHE EXEMPLAR MODEL

Fundamentally using this model the real client is much more specific about:

The strategic and detailed needs of the client The quality aspirations of the client The type of design that would satisfy these needs and

aspiration The cost of such a facility

Through appointing a creative design team on quality-based criteria to test the brief fully and produce an exemplar design fully reflective of the client’s requirements and which the client would be happy to accept as such

OBJECTIVES OF EXEMPLAR MODEL User Client has properly agreed and signed off strategic medium to

longer-term vision and current operational need Proper research/visits carried out with exemplar design team Full consultation and sign-off with key user-groups during brief

development in iterative design process Clear identification of required quality objectives and performance

specification Consultation with town-planners on specific site requirements Testing of site infrastructure requirements Establishment of a design solution fully acceptable to users and

signed off as such Pricing of site specific design solution and signed-off

affordability test prior to market engagement Reduced cost and time for bidding process, fewer barriers to entry

Managing Uncertainty through Exemplar Managing Uncertainty through Exemplar ProcessProcess

Clarity for bidders on service model, capacity requirements, space requirements, functional relationships, quality requirements, affordability user buy-in site and planning issues

THE EXEMPLAR MODELTHE EXEMPLAR MODEL Used successfully on the Belfast Cancer Centre and Altnagelvin Laboratory and

Pharmacy Last week PAC report on the failed Paddington Hospital PFI asked why they

hadn’t adopted the Northern Ireland Exemplar Model Currently being employed on:

Enniskillen HospitalOmagh Hospital

Ulster HospitalRoyal Mothers’ and Children’s Hospital

Being used for Primary Care and Community Infrastructure for a potential PPP model for a significant element of £600M+ programme

Dept of Health in England has recently introduced requirement to follow this approach in its PFI Design Protocol and Treasury currently reviewing its guidance

THE BENEFITS OF THE EXEMPLAR MODELTHE BENEFITS OF THE EXEMPLAR MODEL

Client gets much better understanding of issues through involvement in design development process and is much better placed to assess bidders’ proposals

The Public Sector Comparator is much more realistic in terms of actual costs and affordability as it is based on a well developed design reflecting the required quality, space standards, layouts and specific site–related issues

Bidders get much better understanding of client’s strategic and specific needs and quality aspirations

Bidders’ costs are reduced Client retains control of conceptual design, content and design

quality Design proposals are much more informed and customer

focussed Reduces wasteful processes Speeds up process from OBC to on-site

PPP – The FuturePPP – The Future

Greater use of private finance subject to affordability Strategic Partnership arrangements for smaller projects Focus on real partnerships and less adversarial contractual

relationships Major emphasis on creating true ’Healing Environments’ using

EBD Design Excellence and Sustainability Objectives driven by

exemplar process Seeking to further reduce time and costs of bidding process so

as to allow greater entry to market thus improving competition Best practice standardised without reducing innovation

Better Health Buildings Heal BetterBetter Health Buildings Heal Better

Achieving the Client’s ObjectivesAchieving the Client’s Objectivesin PFI Projectsin PFI Projects

John Cole John Cole Chief Executive, Health EstatesChief Executive, Health Estates