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

2. 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

3. 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

4. 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

5. 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

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

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

8. HEALTH BUILDINGS

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

10. HEALTH BUILDINGS ACAD Centre, Central Middlesex Hospital
Avanti Architects

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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. An Integrated Services Model
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.

20. 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

21. Level 4 - Acute Hospitals
180 km

22. Level 3 - Local Hospitals
BANGOR
NEWTOWNARDS
180 km

23. Level 2 – Community Treatment and Care Centres
180 km

24. 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

25. 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

26. IMPACT OF DESIGN ON LIFE-COSTS
Cost in Use to Client :
Cost of Maintenance : 5
Cost of Building : 1
PFI
Cost of Design : 0.1

27. 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

28. 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

29. 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

30. 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

31. 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.

32. 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

33. 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. 

34. 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.

35. 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.

36. 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

37. 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

38. 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

67. 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

68. 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

69. Better Health Buildings Heal Better

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