Simon Corben looks at the health estate…
We live in interesting times, as the saying goes, and the challenges we need to meet in healthcare design are exactly the same as those for most capital projects these days - more for less. More sustainable, more innovative, more future-proofed solutions, delivered in double-quick time with a minimum spend.
For all sectors, when the focus is on minimum spatial requirements to meet current best practice standards, there’s a clear pressure on commissioners to deliver what is needed today, and worry about tomorrow when it comes. In the long term, though, this may lead to the polar opposite of the ideal solution: adequate space capable of flexing to the needs of users throughout the lifetime of the facility. As we all know, in relative terms, initial capital outlay is far outstripped by lifetime costs, and estate strategies should be developed that produce the maximum income for each square metre.
For healthcare, any cost efficiencies made can be ploughed back into frontline care. Every £30,000 saved can fund an extra nurse. As the cost to occupy buildings in the NHS is typically between £250 and £400 per sq m, a correctly sized estate can make a significant contribution to meeting required efficiencies.
NHS QIPP is a large-scale transformational programme for the NHS to improve the quality of care the NHS delivers whilst making up to £20billion of efficiency savings by 2014-15, which will be reinvested in frontline care. (The NHS estate comprises 25million m2 of occupied floor area and has a value of £36billion for buildings and equipment. The Government aims for all new non-domestic public sector buildings to be zero carbon by 2018.) The QIPP ambition is for an NHS that delivers high quality and financially sustainable services, to make savings while maintaining quality and productivity and above all ensuring a safe and secure environment for patients, staff and visitors alike. A key enabler in delivering ‘better for less’ is the scope, use and application of the healthcare estate.
The NHS Operating Framework emphasises ‘As well as truly clinically led commissioning and a robust and diverse provider sector, service change requires the right environment at local level’. Responding to the current economic climate and a national focus on asset management, healthcare providers can simultaneously deliver better outcomes, secure significant cash-releasing savings and define the irreducible level of fixed assets required to meet healthcare needs both now and in the future.
Layout and size have been subject to many changes over the centuries as concepts for healthcare facilities evolve. In the early 20th century acute hospitals tended to be places for the very sick and to be designed largely on a task-oriented basis. Victorian premises, for instance – some still in use – were not built to provide facilities we now take for granted such as single-sex, single bed room inpatient accommodation with ensuites and access to peaceful space.
Modern hospitals call for designs that promote wellness and wellbeing rather than merely the treatment of diseases and for patient-centric design. Medical and technological advances (such as endoscopic surgery and surgical robots), digital communications, telehealth, the shift to care closer to home (“healthcare without walls” is the phrase coined by Capita Symonds) all play into the mix of factors influencing the design of healthcare facilities. The design of healthcare facilities is centred on complex functional and user requirements, needing to meet minimum standards for infection control and sterility, easy access (including emergency routes), clinical observation, patient, staff and visitor privacy, dignity and security among others. Patients are vulnerable and staff under pressure so, without compromising these requirements, there is a need to provide aesthetically pleasing, health-promoting environments. Important considerations include, for example, access to external views (the need for which can be affected by restriction of movement often experienced by patients and staff). Studies show that the efficiency of staff when dealing with tasks of a repetitive, technical or intensive nature can be improved simply through provision of an external view.
In summary, healthcare facilities designed with specific reference to the needs of users should provide positive outcomes, reducing stress levels and aiding patient recovery. Supportive environments will have good internal layouts, circulation and accessibility. A successful healing environment will be inviting, attractive and hygienic, have natural light and views and be warm and secure. It will significantly improve clinical productivity. In the era of increasing patient choice, healthcare providers are very aware of the importance of ensuring not only that spaces are an appropriate size for the activities being undertaken, but also that they are an intrinsic element of high-quality, comfortable and attractive environments. That means, of course, being neither cramped nor over-generous: while too-small spaces can be dangerous and unpleasant, rooms with m2 to spare can become dumping grounds for equipment and informal storage solutions. Getting it right over time can be tricky. While predicting likely future needs over the lifetime of facilities is not straightforward, the use of zones to plan can optimise choices and trade-offs. Patient, staff and visitor expectations are continuously changing and at an accelerating pace. New planning concepts and ideas evolve through the design response to these expectations. The ideal healing healthcare environment is a moving target.
Care closer to home
It is recognised that any discussion about developing new models of integrated care must focus on shifting care closer to home. In many health communities moving care closer to home starts by looking at issues such as urgent care or individual long-term conditions and then quickly migrates to the development of new and imaginative approaches to dealing with frailty and the more effective management of population health. For example, the development of multi-disciplinary teams (including social care, mental health and other services) wrapped around groups of practices using a shared record and care plan and getting significant input from specialists that would previously have been confined to hospital. Many of these approaches are experimental, leading to evolutionary change that will be significant over time and could eventually be radically different. The first step should be rethinking the operation of community care.
Moving care to the home setting can produce significant savings and improve patient care. It also reduces the need for capital investment and improves the backlog maintenance position, with further opportunities to protect clinical and clinical support space to deliver modern healthcare environments. And it significantly changes the demands made of healthcare facilities of all shapes and sizes.
Ergonomic evidence base
Recent research (1) shows that ‘space layout planning at the starting point of hospital design needs to consider the benefits from the users’ perspective in addition to geometrical and topological requirements’ and recommends ‘investigation of the perception of either care providers or patients to identify how space layout design can be influenced ... applications are needed in various sustainability scenarios and in development of automated space layout planning methods’.
The use of specialist space planning applications provides ready-made data, such as exemplar room layouts and data sheets listing common activities for those rooms that can be used as a starter for ten. Exemplar schedules of accommodation provide numbers of functional units and sub-units, quantities of rooms and allowances for circulation, engineering, communications and so on. These applications make a contribution to understanding flexibility at unit level, allowing planners to manage operational changes effectively. Research also shows (2) that there is a set of seven attributes which ensure flexibility of operations from short to long term: multiple division/zoning options; peer lines of sight; patient visibility; centrality of support; resilience to move/relocate/interchange units; multiple administrative control and unit spread options and ease of movement between units and departments.
The Department of Health (DH) produces guidance and tools to assist with briefing, design and procurement of healthcare facilities. Guidance is policy-driven, making a clear link between standards and policy. Today’s guidance is generally regarded as providing baseline recommendations or standards to which the design of healthcare facilities should conform.
The DH space planning tool, Activity DataBase (ADB), links to its Health Building Notes, Schedules of Accommodation and Health Technical Memoranda to provide a comprehensive suite of best practice guidance that drills down to finer details and in essence provides users with a rationale for a set of minimum and recommended space standards for primary and community, acute and tertiary and mental health care facilities. The focus of the guidance is on clinical and clinical support spaces. The DH ADB data can be manipulated by users to create bespoke projects, which can be exported to CAD programs, Building Information Modelling systems and so on.
The use of these tools and documents provides those planning healthcare facilities with a vast amount of off-the-shelf data, and access to a risk-managed, common set of genericised space and environmental standards optimised for infection control, privacy and dignity and other considerations – reduction of falls, improvement of acoustics and so on. Since the early 1960s, a huge investment in evidence-based research by leading experts – architects, ergonomists, healthcare planners, healthcare engineers and estates managers, supported by input from clinicians, Royal Colleges and other user representatives – has built this catalogue into a resource of world-class significance. On occasions the guidance provides a range of ergonomic values from ‘minimum’ to ‘recommended’ (as do Australasian Health Facility Guidelines). The use of a range of values tends to reflect an emphasis on the need for local planning based on such factors as traffic type and volume, passing widths of specific equipment used and functional adjacencies. Another consideration is the increasing prevalence of non-standard equipment required for special circumstances such as care of bariatric patients.
Minimum space standards
The benefits of minimum space standards include risk management through shared use of evidence-based design standards and principles across primary, community, acute and tertiary sectors. They also mitigate the risk of over-sizing healthcare facilities – and thus capital and revenue costs. Healthcare planners, architects and designers are expert at using these standards as the baseline for their machinations, ‘right-sizing’ bespoke solutions where functional units, adjacencies and other planning relationships and calculations are based on service need and proven best practice. However, where pressures to reduce space standards to the bare minimum are over-riding, complex trade-offs may not only reduce user satisfaction, but also the inherent flexibility and efficacy of a facility. The application of minimum space standards can be very limiting. A further consideration is that while creating the ultimate multi-purpose space is a fine aim, it too has its limitations.
Zoning and built-in flexibility
Building on the approach taken by the DH Healthcare Premises Cost Guides (HPCGs), which link to ADB, Health Building Notes and Health Technical Memoranda, clever use of zoning could improve hospital design, increase inherent flexibility and reduce lifetime costs. DH cost guides for each specialty are produced as an overall cost/m² and are based on a new zoning approach of public, staff and clinical zones. Designing facilities with in-built flexibility within zones allows for efficient, straightforward adaptation over time.
Good healthcare facility design integrates functional requirements with the human needs of its users. Hospitals inherently comprise different functional zones and departments that take into account the workflow of inpatients, outpatients, visitors, staff and equipment. Traffic is segregated according to patient type, sterility degree, urgency and other criteria.
Healthcare facility zoning can also be used to control the movement of users and equipment in order to segregate clean and dirty traffic (and therefore create restricted zones accessed by staff only). Zoning assists in keeping inpatient and outpatient movements separate, and in providing functional proximities and departmental relationships and adjacencies that optimise staff and patient movement. Zoning for infection control factors can define activity spaces as low/medium/medium-high/high risk (from offices ‘low’ to intensive care units ‘high’), allowing planners to identify appropriate flows and adjacencies and eliminate unnecessary risk of contamination.
DH HPCGs provide a cost per sq m for building and engineering services costs, calculated by costing exemplar briefing schedules in detail. Spaces are differentiated such that public, clinical and staff spaces are recommended to be grouped together to create separate zones within facilities. A vital issue in enhancing unit flexibility is the ensuring the continuing ability to provide functionally appropriate facilities as operational changes demand, say, more clinical support space. Grouping similar types of space in separate zones enhances long-term flexibility. The zoning approach very much encourages in-built flexibility at room level too.
DH guidance states that consideration should be given to forms of construction, storey heights, structural grid, floor loadings, fire stair and riser locations etc which, in conjunction with a modular approach to room sizing, can result in buildings that have increased residual value, should needs change in the future. A loose-fit, non-bespoke approach to space planning will lead to flexible buildings that are suitable for conversion to alternative uses. This is particularly useful in schemes where building costs may not be fully recouped during the lease period or where significant reductions in service provision are anticipated.
It follows that Health Building Notes recommend adoption of a limited number of room sizes that will lead to building layouts that use economic structural spans, stack efficiently and allow for natural cross-ventilation. As well as encouraging simple layouts of rooms around a central corridor with standardised building spans and grids, the modular approach can be extended to provide additional benefits (including off-site fabrication for elements (such as standard plumbing modules) – which Capita Symonds used for Whiston Hospital and St Helens DTC projects). Other ‘flexible and adaptable forms of construction’ recommended by DH include: acoustically-treated folding partition walls; changeable signage; mobile rather than fixed equipment and furniture; wireless technologies; use of framed construction to allow partition walls to be altered; installation of surface fixed trunking; provision of adequate spare plant and service access space to have sufficient capacity to accommodate future M&E expansion and equipment replacement; developing a modular approach to planning and construction.
We are currently exploring innovative, proactive ways to take the HPCG and Health Building Note zoning approach forward. We believe it will enable better strategic planning for long-term sustainability and flexibility and should provide schedules of accommodation in terms of types of spaces suitable for a wide range of activities, enabling adaptations over time to make best use of existing adjacencies, engineering, communications and access provision. Most importantly, it will improve the experience of patients, visitors and staff, not just in the here and now, but over the lifetime of healthcare facilities.
Simon Corben is Business Development Director in Capita’s Health Property team
This article first appeared in Health Estates Journal.
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