Achieving the Client’s Objectives in PFI Projects John Cole Chief Executive , Health Estates

EVIDENCE-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 QUALITY Most fundamental requirement an informed client, who at the highest level is committed to design quality and understands its contribution to service delivery and better patient outcomes A comprehensive client brief that clearly articulates specific design quality objectives as key targets in the project delivery Best practice design quality control tools / mechanisms The ability to set design standards and evaluate design solutions prior to and after construction

ACHIEVING DESIGN QUALITY FUNCTIONALITY IMPACT · Uses · Character and · Access Innovation Added · Spaces · Citizen Satisfaction value · Internal Environment · Urban & Social Excellence Integration Added Added value value BUILD STANDARD · Performance · Engineering AEDET · Construction

DESIGN EVALUATION PROFILE BUILD STANDARD FUNCTIONALITY USES 6 Excellent CONSTRUCTION 5 ACCESS 4 3 ENGINEERING SPACES 2 1 Poor PERFORMANCE CHARACTER AND INNOVATION URBAN & SOCIAL INTEGRATION CITIZEN SATISFACTION INTERNAL ENVIRONMENT (PATIENTS & STAFF) IMPACT

HEALTH BUILDINGS Would you prefer to go to a ward in a corridor like this? Hospital ‘A’ Ward corridor

HEALTH BUILDINGS Or this? Ward Corridor, Intermediate Care Centre, London

HEALTH BUILDINGS

HEALTH BUILDINGS North Croydon Medical Centre AHMM Architects Norfolk and Norwich University Hospital Anshen Dyer Architects

HEALTH BUILDINGS ACAD Centre, Central Middlesex Hospital Avanti Architects

EDUCATION BUILDINGS Into a lobby like this….. School A - school street

EDUCATION BUILDINGS Or this…..? School D - entrance hall and school street

DESIGN 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 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 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 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 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 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 Model 150-300 Thousand Acute Hospital Local Hosp. 4 1.7 Million Regional Hospital Acute 100 Thousand+ CTCC. Local Hosp. 3 Non-health agencies HC CTCC 2 20 – 70 Thousand Individual homes HC 1 2-10 Thousand Other Community Facilities.

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 from acute 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

Level 4 - Acute Hospitals 180 km

Level 3 - Local Hospitals BANGOR NEWTOWNARDS 180 km

Level 2 – Community Treatment and Care Centres 180 km

BENEFITS 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 PPP/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-COSTS Cost in Use to Client : 50 - 200 Cost of Maintenance : 5 Cost of Building : 1 PFI Cost of Design : 0.1

MANAGING 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 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 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 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

THE EXEMPLAR MODEL Client produces Strategic Context and Outline Business Case 1 to gain approval-in-principle to project and funding approval for exemplar design process User Client places advertisement for ‘Exemplar’ design team  Client shortlists and issues preliminary brief to short-listed design team Competitive Design Interviews held to select ‘Exemplar’ design team and formal appointment on pre-determined fee. Period of research, dialogue with user clients and testing of project brief in parallel with site(s) analysis and planning investigations. Iterative refinement of brief.

THE EXEMPLAR MODEL 6. Preparation by the ‘Exemplar’ design team working in close collaboration with the client of the following: Statement of client’s key quality objectives for the building  Flow diagrams demonstrating key inter and intra department relationships, and main internal and external circulation routes Full performance specification including landscaping and art  Schedules of accommodation M&E services requirements / Energy targets etc  Specialist planning or equipment-related requirements  Exemplar plans and sections to illustrate a high quality design solution which would meet user requirements and planning constraints  Exemplar elevations demonstrating massing, modelling and external treatments indicative of the design quality expected by the client and which reflects discussions with planners  Examples of buildings which may be used as bench-marks for the design quality threshold to be adopted  Up-dating of the costs within Outline Business Case 1 to provide the Public Sector Comparator for inclusion in Outline Business Case 2

THE EXEMPLAR MODEL 7. Issue of all the above information as part of the Information Document / Invitation to Participate in Dialogue explaining the use by the client of the exemplar as representing the design quality threshold. The consortia should be encouraged to seek to improve upon the exemplar by the introduction of innovative planning solutions that either build on the basis of the exemplar design or represent completely new design solutions. Range of formal and informal discussions with short-listed consortia on exemplar and related information, allowing the information to be interrogated fully and emphasising the non-prescriptive nature of the exemplar drawings. Submissions and presentations by consortia of design proposals through the competitive dialogue stages. Assessment of compliance with functional, spatial, planning, technical and quality requirements. 

THE EXEMPLAR MODEL Assessment of aesthetic and environmental design quality by separately appointed independent and experienced expert assessors. 12. Preparation of Design Report on each submission, confirming whether or not it has met the required design thresholds. Those that have not should be excluded. (Possible request for further design work) Incorporation of design scores for those submissions which meet the design quality threshold into overall scoring leading to selection of preferred bidder. Compilation of an agreed formal Contractor’s Proposals document in sufficient detail to clearly define the extent and quality of all aspects of the proposed building to be incorporated into the PFI contract documentation. This should include a comprehensive product specification for all building, engineering and landscaping elements.

THE EXEMPLAR MODEL 15. Preparation of full business case and approval to proceed 16. Monitoring role by the ‘Exemplar’ design team during detail design development to ensure that agreed layouts, space allocations and quality of finishes, fittings and equipment are incorporated prior to formal contract signing. As detailed a definition of contract content as possible. 17. Monitoring role by ‘Exemplar’ team during construction to ensure compliance with agreed standards. 18. Post-project evaluation and formal report on degree of achievement of project objectives and any proposals for improvement in process.  

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

THE 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 Hospital Omagh Hospital Ulster Hospital Royal 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 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 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 Better

Achieving the Client’s Objectives in PFI Projects John Cole Chief Executive, Health Estates