HEALTHCARE INFRASTRUCTURE
another area where we are a big outlier compared with the rest of Europe; you’ll generally find that about 15-20 per cent of our hospital patients don’t need to be there, because they are waiting for some form of institutional or home care-based rehabilitation. We also all know how precarious the social care system is; you can’t empty your hospitals without these services, but people made bed forecasts reverse engineered to meet their financial projections.”
The result, he said, had been a number of hospitals having to put beds back in after they had been built, ‘at considerable expense’, The ‘second lesson’ was that while we still plan hospitals, they are ‘embedded in systems’, and without other investments (such as in primary care), they ‘don’t work’. Previous hospitals had also been ‘poor’ at thinking about how their activities would ‘connect’ with the wider economic development agenda, for example by creating opportunities for SMEs, and training and development opportunities, and linking into local transport and housing plans, although they were ‘getting better at that’. A third lesson had been ‘lots of idiosyncratic designs based on the preferences of the consortia building the hospitals, or the clinicians they spoke to’, with ‘not nearly enough standardisation, or testing and simulation’.
The cost of flexibility
While incorporating flexibility was key to ‘future-proofing’ healthcare, it ‘cost money’. Nigel Edwards warned, however, that ‘not having it when you need it becomes very expensive indeed’. “Unfortunately,” he said, “we have quite a lot of buildings where the flexibility was not incorporated.” One of the most inappropriately named processes in this area, he reckoned, was ‘Value Engineering’. He said: “The term tends to be applied where your scheme is too expensive, and people come in and strip out various components. Among the elements often value engineered out are those that create this flexibility – such as putting office space around your diagnostic departments, which then allows you to expand into the former.” Also often ‘value engineered out’ were art and aesthetic elements, which added to the patient experience. At one Glasgow hospital, ‘value engineering’ led to the installation of an air-conditioning system that afforded air changes rates ‘massively below the industry standard and safe practice’. “So,” he said, “it can get you into very serious trouble.”
‘Deep plan’ hospitals’ drawbacks In an attempt to save money, the NHS had also built many deep plan hospital buildings, large parts of which had to be mechanically ventilated, enjoyed no
34 Health Estate Journal January 2022
A ‘section image’ of Ab Rogers Design’s The ‘Living Systems’ hospital building. The 200-bed sites would be constructed using a prefabricated, modular 12-storey design, with an internal cross-laminated timber shell, so that wards can be easily partitioned into isolation rooms. The concept won the practice the £250,000 Wolfson Economics Prize 2021.
natural light, and posed high infection risks. They thus ‘weren’t great to work or be treated in’. Nigel Edwards said: “Meanwhile, primary care has not seen enough imagination to adapt to new models.” He said: “An additional problem here is that although capital is available – often provided by a vibrant market of private developers – there are few, if any, really good mechanisms to fund it.”
A lack of sufficient expertise When, in the last major UK hospital building programme, it came to designing and building the facilities, ‘due to us not building many hospitals’, the required expertise had been ‘in relatively short supply’. The speaker said: “We’ve had a history of poorly supervised buildings, with a whole series of problems. Those of you from Scotland will be familiar with walls falling down because they were not properly tied, including eight tonnes of bricks falling into a playground just after playtime. Due to the lack of oversight of contractors, and big problems with technology, we have seen important issues – such as a lack of proper fire damping, massive drain problems, and water leaks, including, again in Glasgow, a hospital water system which grows gram-negative bacteria at an alarming rate.” The construction sector had, he felt, lost a lot of the expertise and skills needed to construct really high-quality buildings.
The ‘digital revolution’
Nor had the last major hospital building programme taken sufficient account of ‘the opportunities often offered by ‘digital’ to reduce the need for space, but also to put digital tools at staff’s fingertips. Nigel Edwards added on another important note: “The NHS’s long-term workforce planning record is about as good as its record on capital investment, with the workforce implications of new schemes generally not sufficiently considered. We’re also much more aware today of the need for attention to sustainability aspects in design, although the last programme really neglected that.” While there was good evidence that daylight, and a pleasant environment, benefited patients and staff, the speaker said that ‘often we’ve cut it out, because it costs money, something we have also done with hospital art – even though it’s often charity-funded’. He said: “Remember that hospitals are prominent civic buildings; they make statements about the town or city they’re in, and people spend important parts of their life there. Equally, a large number of staff work there, and there’s no reason why they should be Stalinist or Brutalist in design.”
Insufficient attention to design In primary care, Nigel Edwards believed there had been ‘insufficient attention to what new design looks like’. He was also critical of the ‘massively cumbersome and
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