Primary Care Centres, Second Edition: A Guide to Health Care Design

Primary Care Centres

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Primary Care Centres a guide to health care design Second Edition

Geoffrey Purves

OXFORD AMSTERDAM BOSTON LONDON NEW YORK PARIS SAN DIEGO SAN FRANCISCO SINGAPORE SYDNEY TOKYO

Architectural Press is an imprint of Elsevier

Architectural Press

Architectural Press is an imprint of Elsevier Linacre House, Jordan Hill, Oxford OX2 8DP, UK 30 Corporate Drive, Suite 400, Burlington, MA 01803, USA First edition 2002 Copyright © 2009, Elsevier Ltd. All rights reserved No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the publisher Permission may be sought directly from Elsevier’s Science & Technology Rights Department in Oxford, UK: phone (44) (0) 1865 843830; fax (44) (0) 1865 853333; email: [email protected]. Alternatively you can submit your request online by visiting the Elsevier website at http://elsevier.com/locate/permissions, and selecting Obtaining permission to use Elsevier material Notice No responsibility is assumed by the publisher for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use of operation of any methods, products, instructions or ideas contained in the material herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made British Library Cataloging in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalogue record for this book is available from the Library of Congress Library of Congress Control Number: 2009920711 ISBN-13: 978-0-7506-6696-1

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Contents Foreword

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Acknowledgements

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Executive summary

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Chapter 1

Introduction

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Chapter 2

An outline review of the main issues (including a summary of the approach to designing health buildings)

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Chapter 3

International comparisons

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Chapter 4

Political framework

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Chapter 5

Approach to briefing

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Chapter 6

Design development/measurement of design quality

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Chapter 7

Holistic care

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Chapter 8

Art in health

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Chapter 9

Case studies

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Chapter 10

The next steps

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Bibliography

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Further reading

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Acronyms

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Appendix A: Colour images

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Index

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Case studies A. LIFT 1. Community Health Centre Purves Ash LLP

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2. Conan Doyle Medical Centre Richard Murphy Architects

2. Vale Drive Primary Care Resource Centre Murphy Philipps Architects

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3. Community Centre for Health, Partick Gareth Hoskins D. Community care centres 1. Grassroots in Memorial Park Eger Architects

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3. Chelmsley Wood and Woodgate Valley Primary Care Centres One Creative Environments Ltd 4. The Vermuyden Centre PHS Architects B. Northern Ireland 1. The Bradbury Centre Penoyre & Prasad LLP with Todd Architects

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2. The Arches Centre Penoyre & Prasad LLP

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3. The Grove Well Being Centre Kennedy FitzGerald and Associates with Avanti Architects Limited

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4. Portadown CCTC Avanti Architects Limited with Kennedy Fitzgerald and Associates

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C. Scotland 1. Robin House Gareth Hoskins vi

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2. The Oak Tree Centre macmon chartered architects

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3. Washington Primary Care Centre PHS Architects

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4. Rothbury Community Hospital Mackellar Architecture Limited

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E. Special interest buildings 1. Clinical Education Centre Richard Murphy Architects

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2. The Richard Desmond Children’s Eye Centre One Creative Environments Ltd

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3. The Breast Care Centre, St Bartholomew’s Hospital Greenhill Jenner Architects

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4. Kaleidoscope Children and Young People’s Centre 161 van Heyningen and Haward Architects

Foreword It is remarkable how rapidly thinking and development can advance in any specialty in just a few years. When the first edition of this book appeared, I noted that health care buildings needed to change and adapt to the changes in the way services were being delivered. They needed to present patients and the public with a new vision of health, in the same way that practitioners were trying to think more of the needs of the person behind an illness. This volume shows just how much has been accomplished and how experience from different parts of the country and the world can inspire and how practical learning can occur. I also noted that at the heart of all health service architectural developments a focus on patients and the staff involved needed to be retained, and that the architect was part of a large team with the vision of improving patient care and well-being. Once again, this is a key part of this book. My own interests in the arts and health are represented, reflecting again on an important development in patient care. This area has developed substantially over the last ten years with the visual arts and architecture becoming more

prominent. This, together with the chapter on holistic care, puts patients where they matter, at the centre of the process. The major case studies provide a rich seam to mine for reflection and fresh thinking. In the first edition, I also noted that as a schoolboy I had always wanted to be an architect, perhaps because Charles Rennie MacIntosh had been a pupil at the same school before me. If things had been different and I had chosen architecture as a profession, I hope I might have written such a book as this, bringing together as it does many of my own professional medical interests in patient care, the arts, and my passion for space and buildings. A few words from CRM say it all: Reason informed by emotion, expressed in beauty, elevated by earnestness, lightened by humour; that is the ideal that should guide all artists. Professor Sir Kenneth Calman Chancellor, University of Glasgow

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Acknowledgements Since Healthy Living Centres was published in 2002, many changes have occurred in the government’s approach to the provision of primary health care services. I am therefore pleased to have this opportunity to re-examine some of the issues which have emerged concerning the design of doctors’ surgeries, and the increasing demands placed on these buildings. Patients are increasingly seeing the provision of health care services from the point of view of being a consumer and are expecting higher standards of environmental design. My practice, Purves Ash LLP – a result of the merger of the Geoffrey Purves Partnership with David Ash Partnership in 2003 – has continued to work in the primary health care sector and I would like to thank my colleagues for their support. I have been able to draw on their ideas which has allowed me to develop my research and follow the changes in academic thinking as we have designed buildings using new procurement routes such as LIFT. Much of the new material for this book is also included in my PhD thesis “The Design of Primary Health Care Buildings” (awarded by Newcastle University, March 2009) and I would like to thank my supervisors Prof Andrew Ballantyne and Dr Peter Kellett for their guidance and helpful comments.

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The production of this book would not have been possible without the encouragement, support and tolerance of the editorial staff at Architectural Press. I would also like to thank Sharon Brown who has helped coordinate and check all the illustrations and copyright issues as well as spending many hours dealing with my revisions to the text. Every effort has been made to contact the copyright holders for their permission to reproduce material in this book. However, I would be grateful to hear from any copyright holder who is not acknowledged so that any errors or omissions can be corrected in any future editions of this book. This publication was completed at an exciting time for architecture in the health sector and I am sure that many opportunities will unfold during the next few years as new government policies give direction to procurement routes and the development of professional employment contracts with the medical profession. The case studies illustrate the high standard of work that can be achieved and I would like to thank all of the architects who have provided detailed information about their projects which are illustrated in this book. Finally, I would like to thank my wife, Ann, for her support and encouragement to complete this project.

Executive summary

Introduction

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History can be written at any magnification. One can write the history of the universe on a single page, or the lifecycle of a mayfly in forty volumes. (Davies, 1997, p. 1) Norman Davies uses this description to justify his broad sweep of European history and offers an alternative approach to ‘the modern compulsion to know more and more about less and less’ (p. 1). This study of primary care health in the UK, its evolution and framework fills a slot at a particular time (2008) and seeks to explain the background, and highlight some influences during a number of key periods in history. It also identifies several factors and makes recommendations about how the design of primary health care buildings should be undertaken in the future, including how the medical profession should be engaged in that process. The specific contribution of this book lies in two areas of primary care architecture. 1. The importance of the brief in an architectural commission and the need to set out the ethos for design quality using tools such as design quality indicators and evidence-based design principles. 2. An examination of the procurement systems which need to become more flexible, with different structures of privately financed providers. This implies changes to the contractual employment conditions for doctors. The following summary of key factors includes issues identified by other research studies. The introductions and conclusions for each chapter more specifically set out my own findings.

Relationship between doctor and patient

From earliest times (before 3000 BC) the health and wellbeing of a person have been subject to a close relationship between two people – the patient and the doctor. This relationship can be traced through many civilisations and remains constant even as the development of knowledge about the body has increased. The Greeks paid close attention to the workings of the body as well as spiritual well-being. The Romans advanced aspects of care through the development of rest houses where the quality of life was seen as a vital component in recovery from ill health. These ideas continued to be refined in both the East and West with Islamic influences coming together with Renaissance intellectualism in Italy during the 15th and 16th centuries. Eighteenth-century Britain saw the development of wealth and civic responsibility evolve into charitable giving with the formation of the early hospitals in London and elsewhere in England. These well-meaning philanthropic ideals began to institutionalise health care, and although Florence Nightingale made huge strides by recognising some important issues in nursing standards the growth of Victorian Britain saw health care of variable quality. Technical standards in surgery gave rise to some barbaric practices. It was not until the early 20th century, when Lord Dawson attempted to focus attention again on primary care, and health services were provided within the community, that the significance of the patient as an individual was re-established. These far-reaching ideas were lost in the race to create the welfare state, a concept that was at the centre of political debate during the first half of the last century. The first 50 years of the NHS (the second half of the last century) saw the development of a bureaucratic system, dominated by the provision of health services for all, but implemented from the standpoint of the provider rather than the patient.

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Executive summary By the end of the 20th century the NHS was struggling to survive, unable to meet the escalating costs of medical care amidst a political climate of uncertainty about what to do next. The introduction of the NHS Plan 2000 was the beginning of a refocusing on patient-centred care and already (by 2008) the government is gaining confidence in promoting the ‘importance of patient power’ and showing increased confidence in being prepared to take on the entrenched attitudes of the medical profession. There is renewed interest in reestablishing a strong patient/doctor relationship as the core of medical care, but also a recognition that the quality of the environment and a sense of place are vital to provide a social framework in which individuals can thrive in terms of both mind and body. Conclusions 1.1 Everyone should have the freedom to choose their own doctor in the UK (or even in Europe and beyond). 1.2 Doctors should provide flexible services that are convenient for the patient (e.g. surgery hours should be appropriate to the locality). 1.3 Service standards should be comparable with other service industries (e.g. complaints procedures). 1.4 Patient care must be focused on giving priority to the patients’ needs (patient power). 1.5 The NHS should continue to develop electronic services for easy record-keeping and other communication systems and investigative procedures. 1.6 Primary care services should continue to be based in the community with specialist services based on locally accessible community hospitals.

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Cultural issues

As with the patient/doctor relationship, issues of spirituality have been interwoven with health care from the earliest recorded times. Overlapping with religious principles, the concept of healing the soul has always remained an important component in the overall well-being of mankind. The Renaissance saw many strands of mental health coming together with recognition that the quality of the environment, and therefore architecture, played a significant role in creating human settlements that were conducive to good health. These philosophical strands extended to other disciplines including music and art. Some of these issues are understood by the briefing documentation prepared for the design of hospices. The brief for a hospice starts out with the objective of creating a place that is most calming to someone who is physically ill. The conventional approach to the design of NHS buildings, including doctors’ surgeries, has rarely recognised the significance of these factors.

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Conclusions 2.1 The brief for a primary care health facility should adopt a holistic approach and should be cognisant of the benefits that art, music and good food can bring to a sense of well-being. 2.2 Mental well-being is about being content and a brief should be written that reflects this ethos. 2.3 A building should have a high-quality local environment. Not only should the internal spaces be designed for calmness and humanity but the external space and its relationship to the urban fabric of the neighbourhood should be accessible and welcoming. 2.4 A healthy place is somewhere people can enjoy living and can go about their daily lives free from stress; this leads to healthy lifestyles and healthy people. 2.5 Health care buildings should be integrated with the community. 2.6 Primary care buildings should contribute to a sense of place.

3 Therapeutic benefits Early civilisations understood in a largely non-scientific way that religious and spiritual issues were important to man’s well-being. This can be seen from the close relationship between a patient and their doctor, a pattern which can be traced over many centuries. As scientific knowledge increased, based on sound research, there was an increasing tendency to assume that health problems could be resolved by purely physical and technical interventions. From the Renaissance onwards, but particularly during the 19th century, medical practitioners became increasingly assertive on account of their technical expertise. This continued throughout the 20th century and until very recently the assumption was that medical advances would find solutions to all problems. Clearly, there are outstanding success stories which are continuing to unfold, such as the search for advanced techniques to treat all cancers, the latest DNA research and the possibility of genetic manipulation of the human body in a way which could not have been envisaged only a few years ago. The apparently exponential growth of scientific discovery is now balanced, however, by an understanding that we must look again at the provision of health care, how it is financed and the benefits that can be accrued from understanding some of the therapeutic benefits, physical and spiritual, known to the early civilisations. Therefore, architectural research into evidence-based design is giving substance and factual data to support the environmental benefits to which previous generations have responded intuitively.

Executive summary Conclusions

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3.1 The ethos of buildings should be welcoming and friendly. 3.2 Lessons should be learnt from the design of hospices, particularly the way in which architectural briefs are written. 3.3 Therapeutic benefits – the technical solutions need to be incorporated into design solutions for such issues as good lighting, sound insulation, views to the natural world, and a wide range of other design issues leading to accessible and friendly environments. 3.4 The quality of life should be central to the brief of any primary care facility.

Architects should be given the opportunity to create places within the health sector by responding to local needs and with greater flexibility in setting briefs. They should be designing buildings for various organisations who have become additional providers of GP facilities in the UK. Doctors need to be made more accountable to the marketplace. There should be a change from the contractual relationship between the government and GPs with the introduction of flexible employment packages via other providers, although these must be controlled by the government. Patients should have a choice of GP, not just based on where they live, and the government should continue to develop community services as part of an integrated primary care package including doctors, ambulance services, paramedic services, nursing and mental health services. All of these services could be under the umbrella of community-based structures. The existing PCTs should be encouraged to develop their procurement policies to generate a variety of building types.

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Architecture

The power of architecture to influence a person’s well-being has been recognised for centuries. The design of Egyptian temples was recognised as contributing to the spirituality of a place and the Greek and Roman civilisations clearly understood the beneficial effects of well-designed buildings as healthy places to live. More recently, the ability of architecture to contribute to a sense of well-being is known not only philosophically but also technically through the development of environmental standards for buildings. The brief is the starting-point for a well-designed building and for health care buildings the ethos must be set out if a successful building is to result. In the twentieth century, these ideas were recognised by Lord Dawson when he launched his ideas for health care buildings. Sadly, many of these concepts were lost after the NHS was set up, as bureaucratic systems and massive administrative structures were put into place to manage the nation’s health buildings estate.

Conclusions 4.1 Architects should have more training in health buildings. 4.2 The brief is crucially important and should set out the ethos for health buildings. 4.3 Architectural design should be driven by quality not function and cost. 4.4 The government should encourage and facilitate the procurement of buildings in the health sector from a range of other providers. 4.5 Private finance should be introduced to the provision of primary care buildings to a greater extent than exists at present. 4.6 Innovation should be encouraged so that different design ideas are explored depending on the scale of the building and its locality.

Professional services

Conclusions 5.1 Doctors should be exposed to the marketplace and understand that patients have the power to demand the service they require. This will give greater choice for patients, and lead to a wider range of types of service. A range of contractual arrangements covering the employment of doctors should be developed by the private sector. 5.2 These services should be available at times and in places convenient to patients, not just the doctors. 5.3 Individuals should be free to choose the type of GP service they require. For example, do they continue to use a traditional GP or would they prefer to use other providers such as supermarkets or other high street based providers? Alternatively, private GP services could also be available. 5.4 Architects should be encouraged to provide innovative design solutions for alternative providers. The government should ensure that procurement routes are simplified; for example, the current system of LIFT is causing substantial delays and delivering buildings very inefficiently. 5.5 The government should be more flexible in buying primary care health services. 5.6 Buildings should be designed to a high quality and this factor must come before functionality and cost.

Summary I would like to end this Executive Summary by identifying three key areas that should be considered when primary health care buildings are designed in the future.

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Executive summary 1 Political influences and the government’s role in shaping health policies in the future I have argued that the retention of the original NHS principles of free care available to all should remain the central tenet for government health policy in the UK. Elsewhere in the world (for example, in the USA) the escalating costs of an insurance-based national health structure are making it increasingly difficult to afford. The contractual arrangements between the government and GPs, however, do require further change. The government has introduced new contractual arrangements and is encouraging the creation of new primary care providers, but the power of the BMA should be reduced.

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Patient power

The government is using the phrase ‘patient power’ and this reflects the increasing trend of patients wishing to access medical services as consumers in the market economy. This also is the way in which individuals access most other personal services. We can anticipate the evolution of new patterns of health care in the UK as more GP service providers

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enter the marketplace. New contractual arrangements for doctors should be encouraged. Greater patient freedom will also bring the need for greater personal responsibility and the government is introducing schemes to encourage selfhelp with appropriate guidance. The continuing development of electronic records will help to speed up this process.

3 The design of primary health care buildings With a range of providers, greater expectations of patients about the quality of buildings, and better briefs being given to architects, the range of health care buildings in the future should be more responsive to local needs. They will be responding to an increasing volume of evidence-based design criteria, which will bring therapeutic benefits to the buildings’ users. Increasingly, designers should look beyond the immediate constraints of the individual building to examine how a primary health care building fits into the urban environment. Government policy will encourage the cross-fertilisation of ideas between urban planning and the generation of healthy places. There will also be an increasing awareness that welldesigned places bring a sense of well-being for both mind and body.

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Introduction Historically, there has been a long tradition of a strong relationship between patient and doctor. This evolved over an extended period from the care exercised in the mercy temples of early civilisations to the holistic treatments that were found in the monastic hospitals founded in the Middle Ages. The rapid advancement of knowledge, and its wide dissemination through the printed book invented during the Renaissance, saw the commencement of a scientific approach to medical treatment. By the mid 19th century there was a greater understanding of disease and Florence Nightingale introduced major changes in the way nursing was carried out. The Dawson Report (1920) advocated primary care policies based on local services by the GP. At the same time, political and social pressures led to the formation of the welfare state and the creation of the National Health Service (NHS) (1948). The Royal College of General Practitioners was not formed until 1952. General Practitioners (GPs) at that time (mid 20th century) did not have an influential position in the medical hierarchy. This developed into a pattern of control in the NHS which focused on ever more ambitious plans for large, technologically advanced hospitals during the second half of the 20th century. In turn, this culminated in the failure to deliver services on time and within budget giving rise to wide-ranging reviews on the structure of the NHS. In line with other major government spending (e.g. education) it became clear that tax revenues could not continue to rise indefinitely to service the ambitions of increasingly ambitious and technologically advanced hospitals. Due to financial pressures and social changes, giving more power to individuals as consumers, the NHS had to change to reflect these realities. Hence, private capital was introduced and health policies have been focused on providing patient focused care. Services are now examined in relation to convenience and the ability for medical care to be provided in the community. Community hospitals are being built reflecting considerable similarity to cottage hospitals, many of which were closed with great speed in the 1980s.

Ambulance services are also being redeployed on community needs and increasingly being linked to medical facilities (GP practices and community hospitals, particularly in rural areas) once again reflecting similarity to the recommendations of the Dawson Report of 1920. The advantages of a primary led health service are also reinforced by the successful policies found in developing countries. As young doctors have the means to work throughout the world often taking a ‘gap’ year before or after their medical training, they see the successful results of primary health care services operating in poor countries. The changing pattern of health care is beginning to re-establish the importance of the relationship between doctor and patient. Patient focused care returns power and influence to the individual who is able to exercise greater control over the medical interventions advocated for their body. Today, we are at an exciting point in the evolution of health care facilities with a wide diversity of options depending on a variety of political, social and economic pressures. However, each solution is striving to give appeal to the customer and with this comes the realisation that the medical facilities need to compete with each other in a market economy. The unexpected conclusion is that the NHS, although giving universal access to high quality medical services, did not provide a convenient or patient focused service. The government is grappling with the challenge of providing consistent and high quality technical competence, but in a manner which responds and reflects the needs and aspirations of the patient rather than the convenience of the medical and administrative staff of the NHS. The architectural design quality of new buildings is therefore of greater importance today than it has been for nearly a century. The therapeutic benefits of good design are now recognised in both the large hospitals under construction using the PFI (Private Finance Initiative) procurement route and the wider variety of small health buildings being procured using a variety of financial models.

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Primary Care Centres The starting point for good architecture is always rooted in the quality of the brief. It has been said many times before, and in many different ways, but the time spent by an architect understanding the aspirations of a client, and thoroughly digesting the spatial requirements that a building is expected to meet, is invariably time well spent. This functional analysis will develop into the architectural form of a building reflecting the ethos of the client. The design must also be capable of being executed within the permitted budget. These three tenets underpin the philosophical expression of firmness, commodity and delight, which have been restated more recently as built quality, functionality and impact and are the bases of the design quality indicator (DQI). This methodology is part of the evaluation tool developed by CABE (Commission for Architecture and the Built Environment) to assess the design quality of a building. This is never more important than with health buildings. However, health building present a particularly complex set of relationships between the medical staff and the patients who visit the building because many will be anxious, or indeed stressed. This provides an opportunity for the therapeutic benefits of a high quality building to contribute to the sense of well-being sought after for patients. The first edition of this book, Healthy Living Centres, published in 2002 concentrated on the relationship between the architect and the doctor. This second edition develops these themes and reflects the rapidly changing climate in the procurement methods and attitudes towards primary health care buildings that have evolved and are continuing to change. In particular, the approach to primary health care buildings is more readily identified with community-based initiatives. The NHS Plan 2000 underpinned the political will to focus attention on patient centred care. The NHS Plan 2000 had also set a new agenda to reinvigorate the NHS service, not just in patient care, but also the government’s move to privatise investment in capital projects, which has changed the basis for financing new buildings. New primary care buildings involve a wide range of skills and activities and the solutions being designed include community uses. Indeed, primary care centres can be seen as community resource buildings, reflecting the demands of a particular locality in areas such as social services, related medical services such as physiotherapy, dentistry, podiatry and pharmacy as well as preventive health initiatives such as leisure and fitness clubs, cafés with healthy food options, libraries and computer centres. These activities place an emphasis on encouraging a healthy mind and body as well as providing diagnostic services for those people who have become ill. The government has provided additional finance, which in the financial year 2004–2005 reached £78 billion and is continuing to climb. By 2008 the annual expenditure had exceeded £100 billion. Contraindications, which make the advances in health care more demanding, are linked to the nation’s sedentary lifestyle. This leads to a tendency for greater obesity and lack of fitness, and critics of current government policy point to such factors as the large number of school

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playgrounds that have closed in recent years, and the fact that few children now cycle to school as a result of parents citing health and safety problems. There has been a reduction in competitive sports in schools, which brings greater risks for developing diabetes, various cancers and cardiovascular problems (heart attacks and strokes). However, there is now a greater understanding that welldesigned buildings can have a positive effect on health outcomes. There has also been a growth in the area of evidence-based design and an increase in the number of research papers that point to the advantages that can be achieved.

Review of historical bureaucracy and procedures for building procurement The NHS is the last of the large nationalised industries to come under the spotlight of privatisation. Steel, coal, the railways, electricity and gas were all privatised many years ago but the NHS is continuing to go through a painful process of change. Although the government is committed to the retention of the NHS as a public service, the funding of services will include an increasing percentage of private finance. This will be particularly evident in the provision and financing of new buildings, including those in the primary care sector. There had been a philosophy of tight economic planning in the post-war period, which the public had accepted. The benefits of nationalisation and the ‘welfare state’ had significantly outweighed the shortcomings now coming under the spotlight. The new NHS Plan reflects some of these changing attitudes, in particular the influence of information technology and the importance of consumerism or putting the patient first. The NHS has not been customer focused. Historically, the perception (even if legally incorrect) was that the customer (i.e. the patient) had few rights and the attitude was often along the lines of ‘aren’t you lucky to have a ‘‘free service’’ ’. Although the government recognises the need for change, this will not happen overnight. Investment cannot take place instantly, and there will be a decade of changes as the new initiatives begin to be implemented. This does raise the question of striking a balance between political influence and power and the responsibility for the delivery of high quality medical services. Other countries have made greater strides in the introduction of joint venture agreements between public and private finance for their health programmes. Obviously, the American health sector has long been driven by a competitive market economy and is dominated by a two-tier service largely financed by insurance. There is a safety net for those without health insurance but it is regarded by most as a backstop position. The best doctors and the best equipment are found in the private sector. More meaningful comparisons can be found on the other side of the Channel, in France. Some in the medical profession regard the French system as superior to the British NHS Health Scheme. Certainly, there are many reports of excellent

Introduction health services being available in France, such as a patient visiting a GP in the morning, having a consultant undertake tests and further examination in the afternoon, and results being delivered the same evening. This may lead to some interesting unexpected developments. Medical politics in the UK has evolved as a process of the BMA (British Medical Association) acting like a trade union in its negotiations with its employer (the government). Perhaps inadvertently, doctors have not given sufficient attention to directing their discussions to the customer (their patients). Architects went through these same traumas 20 years ago when the Thatcher government turned the spotlight on the perceived restrictive practices of the architectural profession at the beginning of the 1980s. Mandatory fee scales for architects were abolished, and architects were thrown into the cauldron of the competitive open marketplace. Today, doctors find themselves at the centre of public interest, receiving wide publicity for those doctors who have strayed outside their professional boundaries with a series of damaging court cases and public exposés. The government is taking the initiative, and doctors are caught between the demands of a vociferous and articulate public and an employer adopting an uncompromising stance towards conditions of contract and expectations of the quality of service. Nevertheless, new contracts of employment for general practitioners appear to be more advantageous to doctors than was envisaged by their employers (the government). Medical services will also become increasingly international. Already, along the south coast of England, people are crossing the Channel to seek medical advice, and it is expected that this trend will increase in popularity. Obviously, many people also come to the UK for highly specialised treatment, but for initial consultations with a GP consumers are likely to become more demanding, more selective, and more likely to ask for second opinions. It can be argued that this may lead to a privatisation of GP services, similar to GP services before the introduction of the NHS. Already, there is evidence that in our more affluent suburbs, personal recommendation between patients is creating a network of preferred GPs who are perceived to have specialist knowledge in certain areas. Patients are saying ‘Let’s go and see Dr A – I’ve heard he is very good with knees.’ Patients are increasingly able and willing to pay for a second opinion. However, the privatisation of GP services, should this trend develop, will be heavily influenced by the pharmaceutical industry. It is difficult to predict how the pharmaceutical industry will react if, for example, the supply of drugs through the NHS was to begin to decline and an increasing percentage of medication was prescribed by doctors privately. At present, if doctors leave the contractual arrangements between themselves and the NHS, they are no longer able to give patients the benefit of subsidised medication. Further speculation invites consideration of whether the privatisation of GP services will be taken over by large commercial organisations, rather than left as a network of individual private practitioners as in the pre-NHS situation. Not that long ago every high street had a privately run optician’s

shop. Now, the market is dominated by a handful of large commercial organisations that employ large numbers of opticians within national networks of shops. There are those in the retail trade who have already spotted the opportunity for providing pharmacy services and the next step may be GP services, within their retailing empires. How convenient it would become, when doing the weekly shop, to see a GP at the local supermarket, particularly if this could be done at a time convenient to the patient. Already, many supermarkets are operating 24 hours a day. Time remains a crucial component of the cost effectiveness of GP services. The personal consultation period between a patient and their GP remains a vital interface for that initial consultation. There are examples of bad doctors (in medical terms) who are popular with patients because of their personal charisma. There are even examples of doctors hauled before the Disciplinary Committee of their professional organisations who bring their own patients as witnesses to support their defence. Time spent with a patient is crucial if a sympathetic, healing environment is to be engendered. For example, in the Mayo Clinic in the USA, consultants see on average four cases during a morning session, but in a typical NHS hospital a consultant’s caseload for a morning session is more likely to be 20 patients. For GPs, the national average consultation period in the UK is eight minutes – all too short if a meaningful rapport is to be developed between doctor and patient and those subtle tell-tale signs are to be identified from a patient’s unhurried description of their concerns. Intuitively, therefore, one is led to believe that buildings in the future for primary health care services need to be friendly, non-threatening, and full of old fashioned concepts of comfort, light, cleanliness, warmth and friendliness. They should be relaxing, accessible, community-based facilities, which patients are keen to make full use of – to pop in for a chat or to ask a nurse or a pharmacist or a social worker for advice.

Why has the NHS concentrated on time and cost parameters for health building procurement? Until recently, the government’s approach to financing health care facilities, in line with all government spending, has been based largely on negotiating lowest cost tenders within annual spending budgets. This tended to downgrade the consideration of whole-life costs, and it is only lately that the Treasury has begun to promote ‘best value’ as the basis for selecting successful bidders for government contracts. Inevitably, this led to an approach within the NHS bureaucracy to concentrate on setting targets for different sizes of GP surgeries and offering guidance on the space standards that would be acceptable. This approach created a cultural background to the provision of buildings encapsulated within the framework of the ‘Red Book’. Standards

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Primary Care Centres were set for accommodation, maximum allowances were set down for professional fees and cost limits were established. These principles were developed over many years resulting in a well-established set of procedures with which doctors needed to comply to improve or redevelop their premises. The environmental quality of these buildings was given scant attention. The philosophy regarding design was essentially that the administrators of NHS funds would establish a framework of requirements and set cost limits in the belief that this would leave designers free to interpret, in an imaginative way, the built form. Fortunately, because of the relatively short timescale between inception and completion for primary health care buildings, and the personal rapport between doctors and architects, many successful small surgeries have been completed over the last decade. However, there are many more of these buildings that could have been even better. There could have been more encouragement from NHS Estates to the doctors under their contract to build facilities that were more flexible, more responsive to their patients’ requirements and more likely to offer better value to the community. Functionality has been a key test of previous appraisal systems, a process devised by the administrators or service providers with negligible attempts to ask patients what they wanted. The new NHS Plan recognises the importance of putting patients first, and an exciting period lies ahead as new approaches to satisfying consumer demands begin to be developed and implemented. This is very good news indeed for patients, doctors and architects. The legacy of the previous approach to procuring health buildings does create some problems for the future. Those

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doctors who have invested in their premises, and may have substantial loans outstanding against their property, may find that there is little alternative use for their bricks and mortar should they be interested in moving on to more exciting flexible facilities under the umbrella of a coordinated housing, social services, and health programme. A question of equity values, the approach of district valuers and rental calculations, and alternative resale values will all need to be considered and it may be that the government will need to devise some systems to ensure that the problems of negative equity do not stifle development of health care services. These problems are likely to be greatest in those areas most in need. It is in those areas where property values are likely to be lowest, and the need for alternative combined resources may be greatest. At the time of writing (July 2008), the NHS is celebrating its 60th anniversary and the government has just published Lord Darzi’s review of health services. In future, the health service will be judged on quality and it will be interesting to see if the aspirations set out in the Darzi Report are fulfilled in the years ahead. Much has been spent on dubious pay settlements to health workers, particularly GPs, and now the recommendations include the expectation that patients will benefit from private sector competition in primary care contracts. The key founding principles for the NHS remain firmly intact but how the new expectations for the quality of patient care are paid for remains the critical challenge for government health policies over the next few years. The emphasis is now firmly on primary care services and architects have an exciting opportunity to shape the success of GP surgeries by the skills they bring to providing innovative and popular designs for buildings in the future.

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An outline review of the main issues (including a summary of the approach to designing health buildings)

Until the advent of scientific discovery led to the development of a technical base for medical practice, healing remedies relied on a holistic approach based on healthy living and the quality of life. Early civilisations in Egypt, from the third millennium BC, the ancient Greek communities from c. 1000 BC onwards and the Roman Empire spanning a few centuries before and after the birth of Christ all left evidence of their interest in medicine and the importance that it played in their philosophies and faiths. Early papyri from the Nile region of Egypt provide information about injuries and wounds. The most important papyri are the Edwin Smith Papyrus (1600 BC) and the Ebers papyrus (c. 1550 BC) found at Thebes. The literature is wide including Porter (1999, pp. 47, 48) and Walsh (2006). The Egyptians believed well-being was endangered by earthly and supernatural forces…was associated with correct living, being at peace with the gods, spirits and the dead; illness was a matter of imbalance which could be restored to equilibrium by supplication, spells and rituals. (Porter, 1999, p. 49) The Egyptians used a considerable number of remedies and physicians held clinics in the temples. Similar customs prevailed in Greece and the sick resorted to the temple of Asclepius where they spent the night (incubatio) in the hope of receiving directions from the god through dreams which the priests interpreted. They were run by priests and patients were encouraged to bathe, sleep and meditate.

The importance of the relationship between medicine and philosophy is implicit in a holistic approach to life advocated by the ancient Greeks. One examination of these concepts (Van der Eijk, 2005) draws out the significance of ‘spirit’ and the reluctance to adopt the materialist position that reduces mental phenomena completely to processes in matter. ‘Many of us, instinctively, seem to prefer to think of body and mind as distinct but interacting on each other.’1 Greek philosophers praised health as one of the greatest blessings of life and this approach was exemplified in the Hippocratic Oath. Writers such as Empedocles, Plato, Aristotle and the Stoics took a great interest in medical topics such as the nature of health and the causes of disease, phenomena such as respiration, old age, sleep and dreams, mental and psychosomatic illnesses such as epilepsy and melancholy, and questions of embryology, reproduction, fertility and sterility. Aristotle wrote, ‘how shall a doctor or a general who has had a vision of Very Form become thereby a better doctor or general? As a matter of fact it does not appear that the doctor makes a study even of health in the abstract. What he studies is the health of the human subject or rather of a particular patient. For it is on such a patient that he exercises his skill …’ (Thompson, 1953, p. 35). This is an early indication of the importance of the patient, which in 20th century medicine was obscured by the framework and systems of 1 Prof. P. van der Eijk, lecture notes, 20 April 2005, Newcastle University.

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Primary Care Centres health care only to re-emerge as a key factor in the present day philosophy of health care, now referred to as patient centred or patient focused care (NHS Plan, 2000). Plato also examined the holistic nature of health and the importance of mind and body in maintaining a sense of well-being. For with a view to health and disease and virtue and vice, there is no symmetry or want of symmetry greater than that of the soul to the body… – that we should not move the body without the soul or the soul without the body, and thus they will aid one another, and be healthy and well balanced. (Jowett, 1999, pp. 1213, 1214) More recently, Scruton (1994, pp. 210, 211) reminds us that ‘once again it is Descartes who set the agenda for modern philosophy, arguing for a ‘‘real distinction’’ between mind and body … in particular, thought does not belong to the essence of body. I therefore clearly and distinctly perceive that the mind is essentially distinct from the body and therefore in principle separable from it.’ We can see that for over 5000 years there has been interest in exploring the relationship between a renewed awareness that technical and scientific medical expertise continues to be influenced by the state of the human mind and our sense of well-being. New techniques to measure environmental conditions are being developed so that emotional and spiritual factors can be evaluated. These are broadly included in the term ‘evidence-based design’. The Hippocratic Oath has survived from its Greek origins when health care was viewed within a natural and totally holistic framework. I swear by Apollo the physician, and Aescuplapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgement, I will keep this Oath and this stipulation – to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring on the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my sons, and those of my teachers, but to none others. I will follow that system or regiment which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practise my Art. I will not cut persons labouring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption;

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and, further, from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not in connection with it, I see or hear in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot! This translation, quoted by Calman (1998, p. 218), is ascribed to Francis Adams. The Hippocratic Oath was updated by the Geneva Convention (adopted on 12 August 1949 and brought into force on 21 October 1950). The Declaration of Helsinki developed by the World Medical Association sets out the ethical principles for the medical community regarding human experimentation. It was originally adopted in June 1964 and distinguishes between therapeutic and non-therapeutic research. The Declaration made informed consent a central requirement for ethical research and is important in the history of research ethics as the first significant effort of the modern medical community to regulate itself. The development of regulations was stimulated by the exposure, by whistleblowers such as H.K. Beecher (1904–76) in the United States and M.H. Pappworth (1910–94) in Britain (Porter, 1999, p. 651), of unethical procedures being performed on vulnerable patients such as the mentally ill. There were other shocking examples including the Tuskegee (Alabama) experiment started by the US Public Heath Service in 1932 which deprived black men of proper treatment for syphilis. The Second World War focused attention on the German medical scientists who conducted programmes of human experimentation (including Dr Josef Mengele, camp doctor at Auschwitz). Other human experimentation took place in Japan where biological weapons were developed. The Hippocratic Oath is clouded by questions of academic authenticity; many versions exist and the library at Alexandra houses a collection of texts. However, Hippocratic medicine ‘was also to win a name for being patient-centred rather than disease-orientated’ (Porter, 1999, p. 56). Several parts of the Oath have been removed or reworded over the years as the social, religious and political importance of medicine has changed. Modern medical ethics have also addressed the historic difficulties of the Oath on issues such as abortion, confidentiality, surgery and the teaching of men but not women. A hospital was a place of hospitality (Latin: hospes, a guest; hence hospitalis, hospitable; hospitum, a guest house or guest room). With almost no technical knowledge as we know it today (but a long tradition of faith, wisdom and experience by practice and observation) health care was also associated with religion, music, poetry, the arts and good food. The lack of scientific knowledge as we understand it put reliance on the natural healing process which is today

An outline review of the main issues (including a summary of the approach to designing health buildings) receiving greater attention than ever before as an alternative approach to modern high technology medicine. The Romans incorporated both a scientific and mythological approach to medicine and health care. They adopted much of the Greeks’ scientific data concerning medicine. Primarily, the teachings of Hippocrates (460–384 BC) gave the Romans a holistic look at medicine and the treatment of illnesses and diseases. Instead of the Greek method of simply observing the symptoms and recording them in order to treat the patient, the Romans also included many prayers and offerings to the gods. Almost all the Roman gods had healing powers. This led to an eclectic medical system but despite this lack of focus the Romans enjoyed relatively good health for several reasons. The availability of fresh water prevented many diseases associated with standing water, and hygiene led to good health. The Roman baths became a part of life and kept germs and bacteria under control. Finally, the drainage system took old wastewater away from the population and prevented many illnesses and infections. The Romans also tried, whenever practical, to boil medical tools and prevent using them on more than one patient without cleaning. Health care was largely personal between the physician and the patient although in large households there were slave physicians caring for their sick fellows in valetudinaria (hospitals). The adoption of Christianity as the state religion of the Roman Empire gave an expansion of the provision of care, but not just for the sick. Galen (131–201 AD) was a prominent physician in the ancient world and worked diligently to expand medical knowledge. He pursued Hippocrates’ methods of observation and research by dissecting and studying human anatomy. Thanks to him, doctors for centuries afterward had at least a basic knowledge of practical medicine. In the Roman army, buildings were set aside for treating the sick and wounded. A standard military hospital plan evolved, with individual cells off a long corridor, a large top-lit hall, latrines and baths (Porter, 1999, p. 78). In England, the Venerable Bede (c. 672–735) was aware of the need to meld healing and holiness. Although Northumberland lay on the northern edge of the civilised world at that time, Bede and his monks possessed many medical writings. His influence is being carefully researched and recorded at Bede’s World in Jarrow (www.bedesworld.co.uk). The Islamic world was also developing medical practice and built up a high standard of care between the 8th and 12th centuries AD. There are records of hospitals in Sri Lanka, India, Baghdad, Damascus, Cairo and throughout Persia. The birth of the healing arts with Hippocrates was corrupted by the Medieval (Porter, 2000, p. 189). This is traced by the entry in Chambers Cyclopædia (1738). At length, however, they [Galen’s errors] were purged out and exploded by two different means: principally indeed by the restoration of the pure discipline of Hippocrates in France; and then also by the experiments and discoveries

Years 0–1800 – Care takes place at home or in the community 1800–2000 – Care takes place in medical institutions 2000 and beyond – Care takes place at home or in the community 0

1800

2000

(Valins and Salter, 1996, p. 4 )

Figure 2.1 Chronology for the place of care

of alchymists and anatomists; till at length this immortal Harvey overturning, by his demonstrations, the whole theory of the ancients, laid a new and certain basis of the science. Since his time, Medicine is become free from the tyranny of any sect, and is improved by sure discoveries in anatomy, chymistry, physics, botany, mechanics, etc.2 The Enlightenment brought scientific analysis to the forefront of academic study, although ‘by the middle of the eighteen century, however, strict mechanism was being judged incapable of accounting for the full complexities of living phenomena, especially properties like growth and reproduction’ (Porter, 2000, p. 139). Thus, the study of holistic forms of medicine is part of a process of reverting to care in the community, and is beginning to take precedence again over the institutionalised treatment of the ill, which has been prevalent during the last 200 years. Indeed, it is a fundamental aspect of current UK government health policy and part of the principle of patient focused care (NHS Plan, 2000). These ideas had also begun to influence policy in the USA some years earlier (in the 1990s). Based on a system of payment for medical services by insurance policies it was convenient to the patient and cost effective for the provider of health services to locate facilities within, or close to, residential areas. It is only comparatively recently that the focus has returned to care in the community. As medical invention and technology become further sophisticated so technology itself can begin to break away from hospital buildings and move into the community. Therefore the hospital no longer needs to be the focus of health care. This is also reflected in the world-wide economic crisis in the funding of large hospital programmes and the enormous expense of hospital technology which encourages providers towards the low tech form of treatment. Have we therefore come full circle? (Valins and Salter, 1996, p. 4) Although the rituals and belief systems of the ancient civilisations are not being revived, the philosophical issues between the mind and the body’s physical condition have parallels that remain as valid today as they were 2000 years ago. The same authors suggest a chronological split for the nature of caring in the Western world as shown in Figure 2.1. 2

Ephrain Chambers, Cyclopædia, 2nd edn (1738 [1728]), Vol. ii, unpaginated, ‘Medicine’.

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Primary Care Centres It could be argued that the first period (0–1800 AD) should be extended to 3500 BC–1800 AD. Although valid in wealthy, industrialised and technologically advanced societies this analysis would not be representative of countries where home and community care may be all that is available to the great majority of the population. Hospitals may be many miles away and very limited in medical skills and facilities. The World Health Organisation (WHO) – see below – has adopted policies which support locally based primary health services. Patient demand for convenience encourages this policy in Western countries together with the natural preference for people to be treated at, or close to, their home rather than in a large institutionalised building. These trends are likely to provide new opportunities for the design of specialist buildings, to provide sophisticated day-care treatment located within the localities they serve, thereby reducing the demand for highly expensive capitalintensive hospitals (although some will continue to be required for research and complex medical conditions). The historical pattern of health care has been reviewed by several authors. Verderber and Fine (2000) in Healthcare Architecture in an Era of Radical Transformation identify ‘six periods in the history of health architecture that capture key developments through the centuries’ (p. 10). The following quotations chart the six categories of health care identified by the authors. They trace the range of community facilities that were available, the links to ‘wellness’ and the development of a range of architectural solutions to accommodate the services provided. As medical knowledge increased so did the complexity of the built environment. Until about the 1850s, surgery could be performed in a variety of settings but steadily it became focused and interdependent with hospitals. This development of Victorian technical mastery led towards the concentration of medical expertise in hugely expensive and technologically sophisticated hospitals that continued throughout the 20th century. For many reasons, society (in the UK and other leading industrialised countries) has changed its approach to the provision of health care facilities. The emphasis has moved from large complex hospitals (although some of these will continue to be required as centres of technical excellence) to a pattern of smaller, community-based facilities. 1. The Ancient period follows the development of wellness care by the Greeks and the importance the Roman army put on military hospitals near the front lines throughout their Empire in both Europe and the Middle East. ‘Nature and the afterlife played a role in the healing process … although the earliest infirmaries were operated in conjunction with wellness and spiritual treatment centres. Wellness care was developed by the Greeks between 1000 BC and AD 100. The private room first appeared nearly three thousand years ago in the Greek Asclepion’ (p.10). (up to 500 AD or thereabouts: the Greek and Roman Empires)

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2. The Medieval describes the Catholic Church’s provision of monastic hospitals built on the edges of villages and cities. ‘These hospitals were the origins of the modern medical centre’ (p. 11). (500–1500: largely in Italy and Western Europe) 3. The Renaissance period saw the development of architecturally planned buildings with symmetrical, axial plans and formal facades. Many of these were constructed in response to the declining standards of hygiene that saw the spread of disease and plagues throughout parts of Europe including Britain (London’s Bethlehem Hospital, 1676, also known as Bedlam). (1500–1850) 4. The Nightingale phase saw functional ward designs emerge from dealing with casualties of the Crimean War during the 1850s. For the first time we see concerns for high levels of natural light to be introduced to wards for the benefit of patients. ‘She emphasized function above form some two decades before the phrase ‘‘form follows function’’ was coined by Chicago architect Louis Sullivan to epitomize the new epoch of modern architecture’ (p. 11). (British Empire – 1850s and later than that) 5. The ‘Minimalist Megahospital’ is a phrase used to describe the evolution of large ‘high-tech’ hospitals. These were developed in response to the complex scientific medical technologies that dominated health care in the 20th century. Particularly in the USA, where health care is insurance based (compared to the UK NHS system), this led to ‘huge, selfcontained ‘‘mothership’’ medical centres’ (p. 14). However, they ‘were to become anachronisms when they opened in an era of a restructured healthcare system soon to be refocused on community-based managed care. These hospitals therefore symbolized to critics everything wrong with the healthcare system in advanced industrialized nations’ (p. 14). They have become outdated as health care has reverted to a predominantly community-based structure reflecting the 21st century preoccupation with patient focused care. Developing from about 1990, ideas are fast changing: ‘the information age is profoundly influencing how we define health and how we care for ourselves’ (pp. 14, 15). (20th century – mainly USA) 6. The Virtual Healthscope anticipates a more flexible and open system for health care. New computer technologies are permitting health care solutions that offer greater choice, flexibility and accessibility for everybody. A concise history of medical buildings is Lorenzo Dall’Olio’s essay ‘Origin and development of health-care facilities’ (Materia, 38, August 2002, pp. 20–27). It emphasises the importance of the Hippocratic doctrine in attempting

An outline review of the main issues (including a summary of the approach to designing health buildings) ‘to go beyond the medicine of the priesthood in favour of clinical study of the patient’ (p. 20). He goes on to say, ‘the dual roots, secular and religious, of medical theory and practice conditioned for centuries the entire hospital and welfare system as well as the overall organization of health care’ (p. 20). More recently, Dall’Olio identifies Powell and Moya’s design in 1962 for Wexham Hospital at Slough as ‘perhaps the clearest attempt to design a hospital for patients, considering their needs, the psychological implications of everything that concerns the patients’ wellbeing, through a high quality environmental and architectural context’ (pp. 25, 26). The essay concludes with the following summation of policy: The ‘humanization’ of the hospital thus seems to be the primary objective of the research conducted in recent years, humanization that has to do with quality and even with the vivacity of interiors, finishes, materials and colors, that calls for the addition of new functions and spaces, for both patients and personnel, and for the visitors – shops, cafés, indoor gardens, meeting points, libraries and, lastly, breaking down the historic isolation of this type of structure, considers it fundamentally important to insert the hospital in the life processes of the city. (p. 27) The idea that health care buildings should be enjoyed and include works of art has historical antecedents. This approach is being developed by many architects who are designing health care buildings today after the austerity, financial restraint and practical approach to the design of health care buildings during the early years of the NHS. That the arts can be therapeutic is an idea that emerged in the 1980s and Sir Kenneth Calman, a former chief medical officer of the UK, used the phrase when writing in 2001 that embracing the arts and humanities with health and medicine was an ‘idea whose time had come’ (lecture, University of Durham, July 2001). Art in health buildings is usually thought of as a recent phenomenon and it is certainly true that there has been considerable interest, and awareness of the benefits, in recent years (Haldane and Loppert, 1999; Waller and Finn, 2004; NHS Estates, 2002). However, the Victorians decorated their public buildings, including hospitals, with paintings and sculpture celebrating great personal achievements. Proud of their financial and technical progress, benefactors were recorded for posterity by these self-indulgent acts of artistic patronage. A typical example is the entrance area of the Royal Victoria Infirmary, Newcastle upon Tyne. Known as the Peacock Hall, it is a richly decorated space with inlaid timber panelling. Plaques, portraits and busts commemorate people important to the institution including ● ●

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Portrait of Robert Stephenson (1805–1899) Portrait of Shute Barrington, Bishop of Hexham (1734–1826) Bust of Thomas Emerson Headlam (1777–1864), physician to the Newcastle Infirmary 1805–1840

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Plaque recording the official opening of the RVI on 11 July 1906 by King Edward VII commemorating the Diamond Jubilee of Queen Victoria’s reign. Also mentioned are the contractors, funding committee and the architects (Lister Newcombe and Percy Adams).

This tradition of recording significant people has been continued with a small brass plaque commemorating that Ludwig Wittgenstein, philosopher, worked at the hospital from April 1943 to February 1944. This legacy is still with us, often exercising the minds of today’s administrators as to the best way to incorporate these works in new hospital buildings. A historical anecdote illustrates how art was beginning to be associated with health. The story is that Nijinsky was taken ill during a visit to London in 1912 with Dyaghilev’s Ballets Russes and was taken to St Stephen’s Infirmary, a Victorian workhouse-turned-hospital on the site of the Chelsea and Westminster Hospital. On his recovery three days later he apparently performed L’Après-midi d’une faune and Dyaghilev had ‘distributed gold sovereigns to patients and staff ’ (Loppert, 1999). He obviously felt that this performance would help the other patients as well as being a ‘thank you’ for the improvement in his own condition. Susan Loppert, in charge of the arts programme at the Chelsea and Westminster Hospital, has developed a track record of integrating public awareness of cultural issues into a healing environment. Music, opera and the visual arts all have an important part to play in raising the environmental quality of the building for those who visit it. The hospital is now an important research centre (under the direction of Dr Rosalia Staricoff) for examining and quantifying therapeutic benefits and patient outcomes resulting from environmental factors. Art is seen not only as honouring the ‘great and the good’ but as enhancing public enjoyment; indeed it can be argued that art in health care environments should be conceived not just as an adornment to a building or a space but integral with the design of the environment as a whole. This approach and the potential importance of art and good design to hospital patients are summed up by Linda Moss in her study of Arts and Healthcare: The arts offer an important area in which the conflicts of the modern hospital provision can be partially resolved, or at least mediated. The arts are a human intervention, expressive of human emotion and response to experience. Their presence in the hospital can raise the profile of the human aspects of health care without infringing upon its clinical efficiency. (Moss, 1988) Others have promoted the importance of integrating art into the design of the building as a whole (including Leichak Staricoff et al., 2001; Francis, 2003; McDonald, 2002). I have argued (Purves, 2002) that quantifying the cost benefits of the intangible qualities of art presents today’s designers with considerable obstacles. These difficulties

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Primary Care Centres may be put into perspective if the concept of quality is not divided into tangible and intangible benefits. Our perception of intangible benefits is categorised thus only because the factors involved are more difficult to quantify. With more research, perhaps meaningful conclusions will be able to be drawn and the mysteries of concepts such as ‘welcoming’, ‘relaxing’ and ‘calm’ will be given quantifiable characteristics for the architect to manipulate. In this way, the control of environmental qualities will emerge as the future path to improving patient outcomes by offering therapeutic benefits. Today, we are seeking scientific evidence. There is growing awareness of the need for more research and over the next few years, our intuitive instincts will be tested and challenged by the results of the research being carried out by Ulrich and others known as ‘evidence-based design’. A study funded by NHS Estates (where I was a member of the research team) examined the role of art in a new hospital in the North East of England and suggests that there might be an additional cultural role for art in hospitals, and for hospital buildings (Macnaughton et al., 2005 – to be published in the International Journal of Cultural Policy). This work has been developed and Macnaughton considers the wider evidence for the changing role of art in hospitals, the history behind it and places the idea within an aesthetic framework. She says: that the art can be seen to have a wider role within hospitals than purely that of providing a ‘therapeutic environment’, has implications for arts and design planning and for the kinds of question asked in researching and evaluation current hospital arts and design programmes … For this synergy between hospitals and artists to work, artists do have to have some further potential professional benefit from displaying their works in these locations and information is essential to this process. From the research point of view theories about art and design in hospital spaces have not yet caught up with the idea that hospitals may be being used as a cultural resource in this way. The questions asked in the new evidence-based healthcare design movement (led by Ulrich) are entirely related to either clinical effectiveness or cost effectiveness. The evidence presented here suggests that the functions of hospitals are expanding to provide a social and cultural resource for their communities, although this is not necessarily uppermost in the minds of most day-to-day hospital users. Clearly the main focus for art and designs must be their impact upon patients and upon the NHS purse. However, it would be interesting in the future to extend research questions to look at the impact of arts programmes on the wider communities served by those NHS hospitals which are increasingly seeing them as part of their role. The perceptiveness of Florence Nightingale’s observations should be considered in the context of other views being expressed at the time. Goethe’s Theory of Colours was an example of holistic science and ‘parted radically with

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the dominant Newtonian light and optical theories of his time, but also with the entire Enlightenment methodology of reductive science’ (retrieved from http://en.wikipedia. org/wiki/Theory_of_Colours, accessed 29/1/06). Colour has an extraordinary power to move us emotionally and designers have long recognised its importance to the design process. Other ways of sensing colour via hearing, taste and smell have also been reported (http://midwest-facilitators. net/downloads/mfn 1999 1025 frank vodvarka.pdf, accessed 30/1/06). John Ruskin, writing in The Stones of Venice, which he started in 1849, said: We have seen that all great art is the work of the whole living creature, body and soul, and chiefly of the soul. (Ruskin, 2001, p. 319) Exhibited at the Academy in 1840, Turner’s painting Slavers Throwing Overboard the Dead and Dying – Typhoon Coming On reflects the great sunset blaze on a heaving sea. Romantic images are contrasted with the scientific work of Darwin and others during a period of great intellectual energy. Nightingale addressed the necessity of healing relationships with patients and family and with colleagues. Having travelled in Europe as a young woman with her family, she was exposed to a wide range of views and opinions and she thought that nurses were well positioned to create a new vision of healing that integrates relation-centred care into all aspects of the health care system. She saw that a person’s well-being was not just physical health but also psychological and spiritual health. By understanding that the environment was central to her concept of good nursing practice, she looked for ways in which the environment could be modified to improve conditions so that natural healing could occur. This had developed from her empirical observation that poor or difficult environments led to poor health and disease. In contrast to this holistic approach to health, Brunel had developed a modular hospital for casualties of the Crimean War. ‘In Brunel’s design he placed emphasis on the environment, particularly lighting, ventilation, drainage, colour and cleanliness, and the resulting hospital was found to provide a healthier environment, with better recovery rates than the other British hospitals…Florence Nightingale was aware of Brunel’s design concept and the improved infection rates, and this influenced her future thinking’ (Glanville, 2005, p. 1). Florence Nightingale had this intuitive foresight of therapeutic benefits in health care nearly 150 years ago. Writing in her Notes on Nursing: what it is and what it is not in 1859 she recorded: The effect in sickness of beautiful objects, of variety of objects, and especially of brilliancy of colour is hardly at all appreciated. Such cravings are usually called the ‘fancies’ of patients. And often doubtless patients have ‘fancies’, as e.g. when they desire two contradictions. But much more often, their (so called) ‘fancies’ are the

An outline review of the main issues (including a summary of the approach to designing health buildings) most valuable indications of what is necessary for their recovery. And it would be well if nurses would watch these (so called) ‘fancies’ closely … I shall never forget the rapture of fever patients over a bunch of brightcoloured flowers. I remember (in my own case) a nosegay of wild flowers being sent me, and from that moment recovery becoming more rapid. (p. 58) Going on she expanded on her views of the connection between mind and body in the healing process: This is no fancy. People say the effect is only on the mind. It is no such thing. The effect is on the body, too. Little as we know about the way in which we are affected by form, by colour, and light, we do know this, that they have an actual physical effect. Variety of form and brilliancy of colour in the objects presented to patients are actual means of recovery. But it must be slow variety e.g. if you show a patient ten or twelve engravings successively, ten-to-one he does not become cold and faint, or feverish, or even sick; but hang one up opposite him, one on each successive day, or week, or month, and he will revel in the variety. (p. 59) Perhaps even the more recent research examining the recovery time for patients which compared patients looking at a brick wall compared to looking at natural landscape (Ulrich, 1984) was anticipated by Florence Nightingale’s observations: The fact is, that these painful impressions are far better dismissed by a real laugh, if you can excite one by books or conversation, than by any direct reasoning; or if the patient is too weak to laugh, some impression from nature is what he wants. I have mentioned the cruelty of letting him stare at a dead wall. In many diseases, especially in convalescence from fever, that wall will appear to make all sorts of faces at him; now flowers never do this. Form, colour, will free your patient from his painful ideas better than any argument. (p. 60) He was a workman – had not in his composition a single grain of what is called ‘enthusiasm for nature’ – but he was desperate to ‘see once more out of a window’. Yet the consequence in none of their minds, so far as I know, was the conviction that the craving for variety in the starving eye, is just as desperate as that of food in the starving stomach, and tempts the famishing creature in either case to steal for its satisfaction. No other word will express it but ‘desperation’. And it sets the seal of ignorance and stupidity just as much on the governors and attendants of the sick if they do not provide the sickbed with a ‘view’ of some kind, as if they did not provide the hospital with a kitchen. (p. 61)

No one who has watched the sick can doubt the fact, that some feel stimulus from looking at scarlet flowers, exhaustion from looking at deep blue, etc. (p. 62)

International position World Health Organisation (WHO) The fact that health care is of great concern to all nations is reflected by the existence of the World Health Organisation. At the World Health Assembly in 1977 a commitment was made to ‘the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially useful and economically productive life’ (World Health Organisation, 1979). A joint World Health Organisation/UNICEF Conference at Alma-Ata in 1978 declared that primary health care was the most promising vehicle for ‘attaining the target of health for all by the year 2000 as part of overall development and in the spirit of social justice’ (World Health Organisation, 1978). This approach (since 1978) has had an impact on the planning, building and operation of health care facilities. It is therefore important, in order to avoid mistakes, to consider carefully what should be the place of these activities in a health system based on primary health care and what are the constraints to be overcome. This is further developed by Kleczkowski and Pibouleau, the editors of a World Health Organisation document published in 1983 (Kleczkowski and Pibouleau, 1983). They identify that the role of the hospital in the primary health care context will inevitably change, and argue that it is difficult to predict the full extent of that change until the primary health care programmes have become more firmly established. Many developing countries are staking large investments in vast national networks of health care facilities, and the success or failure of their planning, building and operation is an issue of high priority. They state that architects are frequently not involved in formulating the building brief ‘when decisions require relating to the size and scope of facilities and to their general standard of construction and equipment are being made’. At the design and production stage, an excess of project loads lead to a general lowering of professional standards and the easy adoption of ad-hoc designs as standard solutions. In achieving the ‘goal of health for all’ through the medium of health systems oriented towards primary health care, there needs to be a fundamental rearrangement of building and equipment priorities involving completely new building types, design approaches, methods of construction, uses of material and modes of implementation. USA – the early days for primary health care

And long before today’s view that blue is a colour inducing coolness and depression and that red suggests warmth and invigoration she had recorded:

In the USA, more literature is available on the evolution of the primary health care facility and its development over the last 50 years. During the 1950s, there was considerable

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Primary Care Centres development of the concept of a health centre. The Hill Burton Programme developed the provision of a range of medical services from the same building. Health centres ranged in size from 1000 to 20 000 sq. ft in area but the national median size was about 5000 sq. ft, although a greater number of about 3000 sq. ft were built, which were deemed capable of serving a rural population of up to 35 000. The general background of this programme is set out in Hospitals, Clinics and Health Centres (Hunt, 1960). The overall planning concepts were much the same then as they are today in the UK and the list of accommodation which was recommended would be familiar to an architect designing a doctor’s surgery under the requirements of the current ‘Red Book’ procedures3 (NHS, 1996). They include: 1. Waiting, including the main entrance. 2. Administration, including offices and record space. 3. Clinic, including subwaiting, examination, treatment and consultation rooms. 4. Service, including heating, storage and maintenance rooms. The importance of flexibility in the use of rooms was also recognised and ‘multi use of clinic space should be exploited in the interest of economy, not only of expensive space but of valuable personnel’. It was also recognised that benefits would accrue from incorporating additional medical services such as dental and x-ray facilities. The idea of collecting or putting interconnecting examination and consulting rooms in groups of two or more closely pre-dates the design of treatment suites in GP surgeries which were built during the last decade in the UK. The importance of using a doctor’s time as efficiently as possible has been recognised for 40 years or more. Today, there is increasing awareness of the value of patients’ time. Other facilities that were considered included nutritional advice and mental health clinics. It was estimated that one full-time mental health clinic per 50 000 population should be provided as a minimum need. However, it was acknowledged that the provision of mental health facilities was at an early stage of development and that the required standards were not fully understood (Hunt, 1960). Development work continued in the USA during the 1960s and 1970s and the design of primary health care facilities advanced. During this period, the emphasis also shifted from the treatment of disease to keeping people healthy. The trend is to prevent disease; to keep people out of the hospital through health education programmes and holistic ideology, making persons responsible for their own health. Raising the general public’s knowledge about the 3

Details of schedules of space and cost limits for GP premises (now superseded) were set out under the Cost Rent scheme in the Statement of Fees and Allowances (the ‘Red Book’). Various revisions and amendments were issued to this essential working document, which formed the core of negotiations for the designs of GP premises over many years.

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importance of proper nutrition, exercise and the risks associated with alcoholism, drug abuse, and smoking is perhaps the most effective weapon in the battle against disease. Health education centres as agents to hospitals and other health service agencies have sprung up recently in store fronts and shopping centres, making sound information accessible to the community. Future social, economic, and political considerations will change the character of health delivery systems considerably. Good medical care is now considered the right of all citizens, rather than the privilege of a few. In addition, we have increased longevity, so more elderly persons will be around to need medical care. These two factors demand a comprehensive health planning system co-ordinated on a nation-wide basis. From the stand point of economics, prevention of illness is more economical than disability and disease. (Malkin, 1982, p. viii)

Early NHS policy Functionality and cost The NHS Estates’ procurement policy was based until recently on the Capital Investment Manual, which required a business case approach to justify new investment. This led to a position where design quality was understood to be represented by functionality. Design quality was assessed by its functional suitability. That methodology was enshrined in their Estate Code document that set out a five-facet analysis process: ● ● ● ● ●

Space utilisation Functional suitability Energy efficiency Statutory standards (compliance) Physical condition.

These factors were used as a basis for design quality evaluation. This is done by subdividing each category into four sections from fully compliant (e.g. new building) to below an acceptable standard. With this background, an assessment of design quality does not include qualitative issues, or an assessment of the desired ethos of a building. The criteria set out in the analysis process do not include emotional responses such as ‘pleasantness’ or ‘calmness’ or indeed any suggestion of ‘therapeutic value’. However, the problem remains that even if appropriate categories of patient satisfaction were included there would be difficulties in measuring or placing values on these factors. Design quality had to be based on quantifiable data. The tests of functionality were set against cost targets established by the Treasury. Over the first 50 years of the NHS, management of the health budget for physical assets (buildings) was based on annual targets that provided little incentive to consider lifecycle costs or to allow for the development of value-for-money concepts.

An outline review of the main issues (including a summary of the approach to designing health buildings) Development of hospice design A comparison with NHS policies for GP surgeries can be made with the procurement of hospices. The concept of holistic healing had been lost in the development of technical medicine in the 20th century. As I have shown, a holistic approach to health care was much more central to the care of those who were ill in earlier civilisations. Examples of hospice briefing documents for both children and adults are discussed in Healthy Living Centres (Purves, 2002). The central difference of these briefing processes (for both children and adults) is that the care of the patient is central to the design objective. Costs and space standards are considered after the aspirations have been set to create an environment within the buildings that will be comforting to the patient. A conference (Breathing Space: Towards an Aesthetic for Cancer Care) held in Dundee (October 2003) examined the philosophy of the Maggie Centres, a network of buildings being created by Charles Jencks in memory of his wife who died of cancer. Jencks joked that ‘in the old days, people used to die in factories … called hospitals’. They are similar to hospices, in that the design ethos or therapeutic value of the spaces was central to the architectural brief. Funding, usually from charitable sources, was secondary to achieving a building that provided a calm and comforting environment for patients with life threatening cancers. The Glasgow Homoeopathic Hospital demonstrates that the qualitative factors of sensitive and therapeutic benefits can focus on environmental design issues, achieve high standards of architectural quality and yet still be constructed within NHS procurement cost limits. These differences between the briefing process for hospices and GP surgeries arise from the way they are funded. Most hospices are privately funded charities; they set their environmental standards or ethos for the building and then set about raising the finance. The Glasgow Homoeopathic Hospital was unusual because it was publicly funded on a site within a large general hospital complex. However, the brief, because of the determination of one person, reflected the aspirations for a caring holistic environment. The building was chosen by an architectural competition. It is a rare example that demonstrates that it is possible to design a caring environment which is architecturally sensitive within an NHS budget. The building provides a rare facility of ‘last resort’ where conventional technical medical services can offer no further treatment within normal NHS services so that patients can experience a caring ‘hospice’ environment on an NHS District Hospital site with palliative care in a pleasant environment. For further discussion of this project, see the case study in Healthy Living Centres (Purves, 2002, p. 133). Development of the NHS Until the last few years, the government’s approach to financing health care facilities, in line with all government spending, has been based largely on negotiating lowest cost

tenders within annual spending budgets. This tended to downgrade the consideration of ‘whole-life’ costs, and it is only recently that the Treasury has begun to promote ‘best value’ as the basis for selecting successful bidders for government contracts (Technical note 7, HM Treasury). Inevitably, this led to an approach within the NHS bureaucracy to concentrate on setting targets for different sizes of GP surgeries and offering guidance on the space standards that would be acceptable. This approach created a cultural background to the provision of buildings encapsulated within the framework of the ‘Red Book’.4 Standards were set for accommodation, maximum allowances were set down for professional fees and cost limits were established. These principles were developed over many years resulting in a well-established set of procedures with which doctors needed to comply to improve or redevelop their premises. The environmental quality of these buildings was given scant attention. The philosophy regarding design was essentially that the administrators of NHS funds would establish a framework of requirements and set cost limits in the belief that this would leave designers free to interpret the built form in an imaginative way. Because of the relatively short timescale between inception and completion for primary health care buildings, and the personal rapport between doctors and architects, many successful small surgeries have been completed over the last decade. There could have been more encouragement from NHS Estates to the doctors under their contract to build facilities that were more flexible, more responsive to their patients’ requirements and more likely to offer better value to the community. NHS Estates collected a great deal of data about the performance of primary care facilities but these statistics have not been used (or made available to others) for research or analytical purposes. The lack of direction in utilising these data seems to be lost in bureaucracy. Functionality has been a key test of previous appraisal systems, a process devised by the administrators or service providers with negligible attempts to ask patients what they wanted. Functionality was seen as a measure of how efficient the building was for staff and doctors to process the patient. The emotional well-being of a patient was secondary to issues such as special and ergonomic requirements. The new NHS Plan recognises the importance of putting patients first, and opportunities lie ahead as new approaches to satisfying consumer demands begin to be developed and implemented. Thus, the effects of supply 4

The ‘Red Book’, as it is known, is the General Medical Services Statement of Fees and Allowances (SFA). Bound in a bright red A5 sized file it was regularly updated and formed the basis for financial issues relating to GP practice. This included a section on premises where cost limits and allowable space standards were set out relating to different sized practices, particularly for practices between two and seven GPs. This document has now been superseded by the Statement of Financial Entitlement (SFE) with details available on the NHS website (www.dh.gov.uk/assetRoot/04/06/97/63/04069763.pdf).

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Primary Care Centres and demand and qualitative factors will emerge as patients begin to exercise their freedom to make choices (about the location of their treatment for health matters) in a market economy. The legacy of the previous approach to procuring health buildings does create some problems for the future. Those doctors who have invested in their premises, and may have substantial loans outstanding against their property, may find that there is little alternative use for their bricks and mortar should they be interested in moving on to more exciting flexible facilities under the umbrella of a coordinated housing, social services and health programme. A question of equity values, the approach of district valuers and rental calculations, and alternative resale values will all need to be considered and it may be that the government will need to devise some systems to ensure that the problems of negative equity do not stifle development of health care services. These problems are likely to be greatest in those areas most in need. It is in those areas where property values are likely to be lowest, and the need for alternative combined resources may be greatest. Peckham and Finsbury health centres Two health centres built in the UK in the 1930s represent a significant moment in the architectural response to designing health care centres at that time. The Finsbury Health Centre was designed by Berthold Lubetkin and was constructed between 1935 and 1938, and the Peckham Health Centre was built in 1935 to designs by Sir Owen Williams. The Peckham Experiment (notes extracted from www.open2.net/modernity/3): In 1935, two pioneering doctors opened the Pioneer Health Centre in Peckham, south London. Their aim was to conduct a huge experiment into the effect of environment on health. The Pioneer Health Centre (usually known as the Peckham Health Centre) was a bold departure in the medical field in the 1930s, concentrating on a preventative, rather than a curative approach to health. In order to facilitate their grand project, the two doctors housed their centre in a purpose built modern building, creating an early example of how new architectural techniques could help further bold new social experiments. George Scott Williamson and Innes Pearse were a husband and wife team who believed that an individual’s social and physical environment could decisively affect his or her long-term state of health. Nine hundred and fifty families signed up to be part of ‘the Peckham Experiment’. For one shilling a week, they relaxed in a clublike atmosphere: physical exercise, games, workshops, or even simple relaxation were all encouraged. All the time they were observed by Williamson & Pearse, and their team of doctors. There was no set programme of exercise at Peckham, and members were obliged to attend a thorough medical examination once a year.

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The Finsbury Health Centre (notes extracted from www.open2.net/modernity/3): Finsbury was one of London’s poorest boroughs. In the 1930s lice, rickets, and diphtheria were common and most residents suffered from poor housing and atrocious, vitamin-deficient diets. In Britain as a whole, 2,000 people per year died of whooping cough and tuberculosis killed 30,000 annually. The local council, one of the most leftwing in Britain, set about tackling the problems with the ambitious ‘Finsbury Plan’. The idea was to build a comprehensive health centre amid public baths, libraries and nurseries. In the end, only the health centre was built. The centre incorporated a TB clinic, a foot clinic, a dental surgery, and a solarium. The basement had facilities for cleaning and disinfecting bedclothes, and a lecture theatre and mortuary were also included. Lubetkin wanted people to feel welcome but never patronised. He also wanted the centre to be like a club, or a drop-in centre. It was important that people did not feel they were walking into just another bureaucratic staging post. To this end, the reception desk was left out of the original plans (but was added later), and furniture in the foyer was deliberately not arranged into traditional waiting room rows. People had to feel they could drop in at any time and see clinicians in a relaxed, unthreatening atmosphere. Lubetkin also wanted the centre to persuade people to live healthier lives, as well as treat their ailments. Murals on the walls encouraged patients to get some fresh air. The glass bricks of the front wall were a conscious attempt to ‘propagandise’ the physical benefits of a light, airy environment. The solarium allowed the children of Finsbury (who spent much of their early lives enveloped in a thick smog), a chance to feel the benefits of sunlight. Of this revolutionary new approach to public health, Lubetkin famously commented ‘Nothing is too good for ordinary people’. The interior of the Centre was bright-coloured in reds and azures which were designed to contrast with the gloom of the surrounding slums, and the expanse of glass walls on each of the wings would sparkle on sunny days – ‘as beautiful as the hair of a beautiful young girl in the summer sunshine’, according to Lubetkin. Finsbury shows that Modernist buildings do not have to be sombre. Lubetkin saw his Health Centre as a multicoloured beacon in the heart of the smoky city. The Centre was also designed to be a flexible building: in itself a progressive concept in a British building of the 1930s. Lubetkin foresaw that in years to come the changing technology of healthcare would require buildings which could be easily adapted to the new needs of clinicians. The building’s services – its plumbing, wiring, and piping – were all designed with adaptability in mind. The political significance of the Centre was not lost on Winston Churchill. In 1943 he suppressed an Army

An outline review of the main issues (including a summary of the approach to designing health buildings) Bureau poster designed by Abram Games which superimposed the shining centre onto a picture of starving children standing in a slum. Next to the Centre were the words: ‘Your Britain – Fight for it Now’. In 1945, Churchill would lose the General Election and the era of the welfare state, central planning, and the National Health Service, would begin. The marriage of modernist architecture and socialist reforming zeal, first seen at Finsbury, was about to take centre-stage. The most comprehensive analysis of Lubetkin’s work is by John Allan (1992). Allan first met Lubetkin in 1970 and traces a comprehensive review of his life through the 1930s when he founded Tecton (1931) and developed an architectural stance that set him apart from the architectural establishment of the time, and identified his artistic debt to Le Corbusier. The lack of organisation in health services prior to the creation of the NHS was typified in Finsbury as a microcosm of the uncoordinated muddle of facilities throughout the country … In this context of sluggish officialdom in the face of ever more compelling evidence, the Finsbury Health Centre, diminutive as it may now seem, was a conspicuous advance in social policy and administrative coordination, anticipating by a clear decade the reforms embodied in the 1948 Act and … on completion that it marked ‘the dawn of the new era in public health services’. (p. 333) It is interesting to compare the Peckham and Finsbury projects with American senior centres which have developed from the 1965 Older Americans Act. This identified senior centres as the preferred vehicle for coordinated delivery of a range of services in the USA. At the end of the 1980s some 15 per cent of older Americans were members of the 12 000 or so senior centres strung across the USA (Krout et al., 1990). It was predicted that Healthy Living Centres could become the UK equivalent of senior centres, but open to the whole age range (Iliffe, 1999).

Architectural context Design of GP surgeries During the 1980s and 1990s, the starting point for the brief of a doctor’s surgery had been based on the standards set down in the ‘Red Book’. Included in the document is a section on premises, which includes a series of schedules of space standards for different sized GP practices from two to seven doctors. The schedule of allowable areas is linked to a financial formula and establishes the area and financial limit for a new GP surgery. This document makes no reference to the quality of care to be provided within the buildings. Doctors could exceed the financial limits set down by these schedules but any additional finance had to be provided from the doctor’s own resources. In practice, this very rarely occurred.

There are guidance notes available to doctors, and their architects, giving additional information about the design of the spaces within a GP surgery, but there is almost no reference at all to the quality of the design. For example, Health Building Note 46, General Medical Premises, identifies under the sketch design stage at section 3.17 that ‘the architect will base the design of the sketch proposal upon the written brief – a statement of the operational policy and functional space requirements of the practice’. The brief is developed by the GP and the architect in discussion with the primary health care team and the FHSA. At section 4.1 it is noted that the building of new practice premises ‘provides the ideal opportunity to ensure that the building can accommodate all the functional and operational requirements of the primary health team’. As already noted (see section 3.1), the document makes no reference to consideration of the design ethos of the building, and does not invite doctors to consider the quality of the environment that they are wishing to create for their new building. The changing attitude of government policies is noted, including the new LIFT programme of contracts to expand and develop GP premises based on the aspirations of the NHS Plan. There has been a significant shift in government policy which now recognises the importance of good design in the development of new GP surgeries. ‘Red Book’ – the traditional approach The ‘Red Book’ set the standards for the modus operandi of GP practice in the UK for many years. It represented the outcome from a long period of development, periodic reviews and updating of data. It typifies the outcome of a bureaucratic approach of controlling a very large organisation. The rules, costs limits and schedules of permitted accommodation were very prescriptive, and it is interesting that much high quality architectural work has resulted from such a constricting briefing framework. Although the official briefing methodology offered little encouragement, a wide range of innovative GP surgeries has been built over the last decade. This framework of controls is now rapidly breaking down as new forms of procurement expand and develop in the joint public private partnerships that the government is encouraging. Controls on loose furniture, tight budgets, discounted fee scales for professional services and other prescriptive requirements for accommodation requirements and overall floor areas made life difficult for both doctors and architects. A different approach to building design is being advocated for the next wave of primary care buildings. They will be buildings that are flexible, can incorporate the demands of a knowledge-based economy and respond to the rapidly changing demands for information technology and different working methods that will develop from faster communications between doctor, patient and specialist testing facilities (e.g. x-rays, consultant reports). Government procurement methods are seeking to enable future buildings to be flexible shells within which highly serviced workstations can be developed

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Primary Care Centres and changed over short periods of time. For example, a doctor’s consulting room may have entirely different requirements in five years’ time than it does today – although it is likely to remain the fundamentally important space within which patient and doctor exchange information. Finance Lifecycle costs and ‘best value’ – the government’s approach Until recently, lifecycle costs were assessed in the government process of procuring buildings, including those for the NHS. The tradition has been to award contracts predominantly on a lowest cost basis. The Treasury has now changed its policy and the interest in design quality is also manifesting itself in a reassessment of whole-life costs. This approach is encapsulated under the umbrella of ‘best value’. All government departments and local authorities are taking a broader look at ‘best value’ issues and this is providing an opportunity to develop new thinking about a whole range of tangible and intangible aspects of a building during its overall lifespan. At the simplest level, building material manufacturers are able to demonstrate ‘best value’ for their products not only as the result of initial costs but also taking into account maintenance schedules and renewal timescales. With design issues the growing recognition of user reactions and user satisfaction levels is beginning to influence the decision-making process. GP surgeries are too small to justify the competitive precontract procedures that potential development partners face under PFI (Private Finance Initiative) procedures. The emerging policies from NHS Estates for their Procure 21 method of procurement are yet to be tested in the marketplace and the bundling together of groups of primary health care facilities seems to be a risky strategy. However, there is a growing group of specialist companies forming partnerships with GPs to finance new primary health care facilities. Their success rate in putting together viable procurement packages is being helped because of the changes in attitude by district valuers. District valuers are moving towards the creation of a special class of valuation for medical facilities,

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whereas previously they were seriously disadvantaged by being included with residential or local commercial values. These high valuations that are being rentalised as surgeries are enabling contracts to be written for a minimum of 25 year lease periods guaranteed by local health authorities under the terms of existing procedures. Cost limits and functionality – a restraint on innovation Hospital design in the UK over the last 50 years is considered by many to have been disappointing.5 With few exceptions, architectural quality has been bland, institutional and not responsive to patients’ needs. The procurement process has been extended, design quality has been largely ignored and functionality has been given high priority in a process largely controlled by the service providers and the administrators far removed from the interface between patient and doctor within the confines of a clinical ward. Similarly, primary health care buildings were constrained by a set of procedures contained within the ‘Red Book’ which is now outdated. There have been enlightened solutions in recent years by architects who have enjoyed a sustained period of work in this sector, but imaginative solutions have been the result of very good architects going beyond the brief which was set out only in terms of cost limits and functionality.

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For example, the Conservative Party has become interested again in good design. John Gummer is Chairman of the Tory Party’s new environmental group (appointed by the new Conservative leader, David Cameron) and he claims to have a very real passion for architecture and the built environment. He says, ‘Britain went through an enormous philistine period between the end of the Second World War and the early Nineties, when most decisionmakers seemed to almost make a virtue of vulgar Brutalism … this was the period when it seemed to be accepted that it was a morally good thing not to have any decoration or art … when I was secretary of state for the environment I like to believe I began to reverse this attitude, making art and architecture more important … it is too important for the quality of life of people to ignore these things’ (Dorrell, 2006).

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International comparisons

Introduction – overlapping interests

role of the patient. This emphasis on patient focused care is having two far-reaching results:

As long ago as 1961 Kerr White and his colleagues writing in ‘The ecology of medical care’ (an article that appeared in The New England Journal) observed that ‘the patient may be a more relevant primary unit of observation than the disease, the visit, or the admission’. This work was summarised in the ‘cube’ diagram of health ecology (see Figure 3.1). This research indicated to White and his team that health care delivery and the training of physicians did not bear any logical relationship to the actual experience of illness in a given population. They argued that greater attention should be devoted to primary, continuing medical care as opposed to more exceptional episodes of hospitalisation or consultation of specialists. Further support for these ideas has developed during the last decade. In Europe and the USA, the quality of design is being understood as a benefit to health care environments resulting in much more significance being placed on the

Total A population at risk: 1000

A

Persons receiving primary care: 720

B

B

Persons admitted to C general hospital: 100 Persons admitted to D university hospital: 10 Figure 3.1

Ecology of health problems, annual rates, USA

C D

1. The rich and highly developed countries understand that the primary health care policies of many developing countries are showing significant results. 2. The importance of the workplace environment is being increasingly recognised as a significant factor in achieving a healthy living lifestyle. Neither of these factors is dependent on high levels of income. A healthy diet and good quality working environment in conjunction with an efficient primary health care system can produce very beneficial results.

Health policy is shifting to preventive care in the primary sector Not only in the UK, but also in many other parts of the world, health policies are focusing on the importance of preventive care in the primary health sector. The World Health Organisation’s (WHO) declaration of Alma-Ata in 1978 remains as valid today as when it was adopted. The objectives were: 1. To promote the concept of Primary health care in all countries. 2. To exchange experience and information on the development of Primary health care within the framework of comprehensive national health systems and services. 3. To evaluate the present healthcare situation throughout the world as it relates to, and can be improved by, Primary health care. 4. To define the principles of Primary health care as well as the operational means of overcoming practical problems in the development of Primary health care.

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Primary Care Centres 5. To define the role of Government’s national and international organisations in technical co-operation and support for the development of Primary health care. 6. To formulate recommendations for the development of Primary health care. (World Health Organisation, 1978, p. 11) The declaration goes on (p. 34) to provide a definition: Primary health care is essential healthcare made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part both of the country’s health system of which it is the nucleus and the overall social and economic development of the community. Primary health care addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly. In order to make Primary health care universally accessible in the community as quickly as possible, maximum community and individual self-reliance for health development are essential. To attain such self-reliance requires full community participation in the planning, organisation and management of Primary health care. As long ago as 1995, an editorial in the BMJ (7 October, pp. 891–892) was highlighting that over the past 30 years a wide range of developing countries have successfully developed a model of primary care promoted by the World Health Organisation. This is based on the idea of ‘essential healthcare based on practical science particularly sound and socially acceptable methods of technology, made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain’. It went on to say that this ‘differs fundamentally from the primary care system in the United Kingdom, which relies more on technical and curative care than the community orientated approach. Many western countries, including the United Kingdom are now, however, shifting their policies to strengthen primary health care, and there could be lessons to be learnt from the achievements of developing countries. The WHO had recognised the importance of community health workers and put forward a global strategy goal of ‘health for all by year 2000’ and pointed out the task of achieving this based on primary health care during the Alma-Ata Conference in 1978. Community oriented primary care is a theme that has been picked up in the UK by the current Labour government as it has moved its policies set out in the NHS Plan 2000 towards its patient focused care objectives, and increasingly is advocating the development of community-based hospitals.

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In the 1950’s and 60’s many developing countries faced a daunting task. Economic recession meant that many could not even start to emulate the west’s medical model of health based on hospital medicine and high technology. A different model of care emerged, which recognised that the health of populations was determined by factors other than medical care and that these factors could be controlled by communities themselves, through collaboration with other sectors, such as agriculture, water sanitation and education in a spirit of self reliance and self determination. These words, from the same BMJ editorial in 1995, highlight the difference from Western health models and those supported and developed in countries with socialist administrations such as China, Cuba and Tanzania. The government of China has endorsed the WHO agreement and done much work towards implementing it. The new policies in the United Kingdom that are led by primary health care trusts have therefore resulted from international health policies based on the experiences of many developing countries over the past 30 years. A wealth of knowledge about primary health care exists in developing countries, which is now relevant to the NHS. It is time for us to recognise this and learn from it. China has drawn up a national plan for improving primary health care in rural areas, aiming to make services accessible to all rural residents who make up to about 80 per cent of its population. However, the gap between standards of health care between urban areas and rural areas is widening. Government officials have said that the goal of promoting primary health care in rural areas was to give basic medical services to every resident. This work was vital for the global fulfilment of health for all goals set by the WHO. In the coming years, departments of development planning, finance, public health, agriculture and environmental protection will work jointly to control infectious and endemic diseases, vermin and occupational illnesses, to help further improve village clinics and to ensure more people can have access to clean drinking water and standardised toilets. China achieved enviable improvement in the health status of its people between 1952 and 1982. Despite a limited number of well-trained professionals and hospital beds and an expenditure of US$5 per capita for health care, within 30 years the country increased the average life expectancy from 35 to 68 years (Hsiao, 1995). The developed and underdeveloped countries are, therefore, moving more closely towards a common philosophy for community-based primary health care services. South Africa is perhaps a good example where the excellent tertiary health care facilities have been modelled on Western standards. There is a high standard of academic medicine in the country and South Africa spends 6.4 per cent of its gross domestic product on health, which is more than the

International comparisons based on internal medicine. Confucius was opposed to cutting the human body so surgery was not developed. Chinese medicine was based on empirical knowledge – to observe the patient’s indications and to question the patient’s feeling as an individual. Chinese doctors investigated by observation a patient’s total sense of well-being or illness. In contrast, Western medicine has developed over the last two centuries, refining analytical skills and the development of specific technical research programmes. Today, China is struggling to understand the compromises between traditional Chinese medicine and Western technology. In Japan, before the introduction of Chinese culture and medicine in the 6th century, local Japanese medical skills were based on the ancient Shinto religion, which principally worships nature, so the Japanese had medical gods (Daikoku Ebisu), which could be compared to the Asclepious in Greece. After the introduction of Chinese medicine to Japan, most doctors were monks who had a strong influence on society including politics. There are great similarities between the Japanese monastic care services for poor people in temples and the Western monastic care during the same period. Gradually, Western culture invaded Japan but the Japanese government was concerned about the infiltration of Western high-tech culture and

goal – 5 per cent by the year 2000 – set by the WHO. But 46 per cent of this amount is spent on the private sector, which serves 19 per cent of the population. South African health policy for the primary sector aims to achieve a balance between promotion, prevention, rehabilitation and curative services. An example of a community resource (library and clinic) in the Blaawberg Municipality, City of Cape Town, is included as a case study.

Japanese primary health care systems The development of the Japanese health system, and its underlying philosophies, has been influenced by both Chinese and Western traditions (see Figures 3.2 and 3.3). Western traditions have been influenced by the Hippocratic period from early civilisations, the monastic care, which developed in the Middle Ages, and more recently the technical advancements, which began in the middle of the 19th century. Medical science rapidly developed and nursing care was transformed by the work of Florence Nightingale. In contrast, the development of Chinese medicine saw progress at a very early period (around 2000 years ago) but was

1776: The declaration of independence of the USA

Western and Eastern medical history timeline

Mid of 18C: Proposal for replacing hotel-dieu

Before Independence

USA

450–370 BC: Hippocrates

Western

China

1456: Ospedale maggiore

Philosophical medicine

500 Japan

Western monastery care 0

500

(Shinto Japanese religion)

Philosophical medicine

The basement of Chinese medicine completed

1000

400–200 BC: Chinese medicine got high level – herbal medicine, acupuncture, etc. Western Medicine

1500

2000

Chinese monastery care

Not much change in Chinese medicine

400–500 AD: Starting to introduce Chinese culture into Japan

Figure 3.2

Nightingale Kirkbride

Japan: Closure of ports Japan: Reopening of ports Western medicine into Japan Chinese Medicine

Diagrammatic history of medicine (timeline comparisons USA, Western, Japan and China)

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Primary Care Centres

Western medicine and Chinese medicine

Formative process

Western medicine Development period

Basement

Special field

Chinese medicine

From 16th century to17th century

From 4BC to AD2 (600 years)

Refined analysis and local specific research

Empirical knowledge Medical theory based on acupuncture and moxibustion, herbal medicine

Bacteriology, surgery

Internal medicine (Confucianism opposed cutting human body, so surgery has not been developed)

- Reveal the illness point and the cause based on objective scientific data from many examinations

- Observe the patient’s indications and question the patient’s feeling

- Value the type of diseases Exclude individual and categorise diseases

- Recognise comprehensive patient’s symptoms individually

Diagnosis

Treatment features

- Surgery - Drugs

- Acupuncture - Moxibustion - Herbal and mineral medicine

Figure 3.3 Comparison of Western and Chinese medicine

limited trade with overseas. Japan suffered a period of isolation and the Japanese culture flourished in this late middle age period. Thereafter, Japanese culture rapidly became Westernised. Today, as communications become global, Western and Chinese medicine are becoming increasingly inter-related. In contrast, the development of Western medicine has evolved through the research of special areas including bacteriology and surgery. Western philosophy is based on the diagnostic techniques to reveal illness and identify the cause based on objective scientific data. These ancient philosophical approaches can therefore be seen to have influenced modern political policies for health care in China, Japan and Western Europe including the UK. The priority given to the patient as an individual has changed in the West. As Western technology developed, the importance of the patient as an individual decreased, and it is only in the last 20 years or so that there has been a re-emergence of concern for the patient as an individual. In Japan, present day health statistics are very revealing when compared to those of the USA. Japan has universal health insurance and its total health expenditure as a percentage of the gross domestic product is almost 50 per cent less than that of the USA. In the USA about 15 per cent of the population under aged 65 are uninsured. However, the health of the Japanese population, as judged by neonatal, postnatal and total infant fatality, percentage of infants with birth weights below 2500 grams and life expectancy

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at birth and ages 20 and 65, is superior to the health of Americans. Primary care in Japan, as an academic discipline, and primary care training programmes are absent in Japan. However, considerable difficulties are emerging in Japan today with hospital outpatient departments seriously overstretched and record systems are at a surprisingly inefficient level. Compared to the UK, where everyone has a medical record held by his or her GP, Japan has no comparable system. This leads to great repetition of early diagnostic testing because no historical records are readily available. Hence, when someone visits a hospital outpatients department the diagnosis process starts very often from square one. This must lead to great inefficiencies and an overloading of health care services at the primary level. Figures 3.2 and 3.3 were prepared by Ruka Kosuge, PhD student, Tokyo University (unpublished lecture, November 2005). In recent years, there has been a series of initiatives and exchanges between UK and Japanese architects working in the health sector and there is a much better understanding of the differences between the systems for primary health care in the UK and Japan (Cooper, 2006). Although there has been no tradition to build primary care centres in Japan, a wide range of smaller health facilities have recently been constructed including community hospitals, private medical clinics and specialist health care projects such as sheltered premises for the elderly and small-scale private clinics for cancer patients. As in many other parts

International comparisons of the world, there is now a greater awareness of the quality of life and this has produced an emphasis on ‘healing and comfort’ (Cooper, 2006, p. 95).

Client: Blaawbert Municipality, City of Cape Town Blaawberg Sub-structure Architect: Ngonyama Okpanum and Associates (NOA) Introduction

Conclusion The lessons to be learnt, in general, from examining primary care systems in the developing world might be considered under three headings: 1. Health for all – a WHO objective sought through the primary care system. A community-oriented primary care system supported and encouraged by the developed countries but until recently not recognised as a model for their own environment. 2. Fear of socialism was a concern of developed countries, cautious that ideological concepts of primary care for all in developing countries would undermine the 20th century models of health care based on technical advancement and issues of professional status. 3. More recently (from the 1990s), the emergence of a caring society in developed countries, and the view that there are wider determinants of health by engaging with wider community issues and other sectors outside the health service. Although there are many initiatives under way throughout the world many of the ideas can be traced back to giving greater importance to patient focused care. In poor and underdeveloped countries, great strides are being taken to achieve better standards of primary health care. There is concern about the well-being of everyone as an individual, and how this is reflected in their working environment to provide a safe and healthy future for their economic development. In the rich countries of the world, these issues are being addressed by more imaginative architectural solutions, often for smaller-scale buildings. In Europe, a large number of smaller health buildings are being commissioned where the quality of design is given a high priority. Like the UK case studies, there are many examples around Europe of delightful environments being created for health facilities.

Albow Gardens Library and Clinic; Architect: Ngonyama Okpanum and Associates (NOA)

In 1999, Ngonyama Okpanum and Associates (NOA) were commissioned to design a public facility for the Blaawberg Municipality, City of Cape Town Blaawberg Sub-structure. The facility was to include a clinic and a library for the people of Albow Gardens, Brooklyn and Du-Noon. This previously predominantly disadvantaged community did not have any public facility and its inhabitants needed to travel great distances for these services. It is imperative to have a primary health care facility within a reasonable distance in all suburbs in Africa Urban Planning Context, in order to contain the scourge of all types of infectious diseases, such as malaria, TB, AIDS and others. The complex supports the government policy of accessible primary health care to all. This building encompasses two disparate services under one roof, and by so doing contributes to the community and its educational and recreational activities as well as to the quality of its built environment. Despite its size the new facility has become a focal point for the local community regardless of age, status and interests. Planning rationale

International examples of primary care and community buildings The following illustrations show a small number of buildings in Europe and Japan and, in addition, a more detailed description of a mixed use building (clinic and library) in South Africa.

South Africa Project: Albow Gardens Library and Clinic

The architectural planning articulating the complex reenforces the concept of combining public services into one facility. The building is compact in design and the arrival and movement of visitors is clear and unambiguous. The main entrance wing connects the clinic and the library wings, housing combined facilities such as a kitchen, ablutions and a community hall. These three building masses can be distinctly read from the parking area, which acts as a forecourt precinct to the building. On arrival, one is directed from the parking area to the amphitheatre and on to the main entrance to the secondary entrances of the clinic or the library.

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Primary Care Centres Simple H-plan concept While the conceptual bones of the design are kept to a simple H-plan, the concrete brick skin that wraps around the building modulates the perimeter walls. These external walls have various architectural elements designed to guide relief to the facade. It creates a play of varying shadows and light throughout the day. The corners of the library and clinic wings are cut away to accommodate a freestanding painted column. The rainwater down pipes are detailed and integrated into the brick structural nibs with a defined rhythm around the building. At the centre of each ‘wing’, the brickwork is recessed to create an inverted bay window. Albow Gardens Library and Clinic; Architect: Ngonyama Okpanum and Associates (NOA). See Appendix A for coloured figure

Building location on site This single-storey building sits in a prominent position in the centre of its site. Set back from the road, the building is easily visible from the street with its scenic backdrop of Table Mountain and Lion’s Head. The clerestory lighting protrudes from the building symmetrically to the entrance. This additional feature adds height and interest to the building frontage. The pedestrian access is defined by a bricked path which cuts through the parking areas and connects to a landscaped amphitheatre.

Additional elements Several climate control devices have been ‘clipped onto’ the external skin. Aerofoil sunscreens protect the western facade from harsh rays. They are located on the west facade neatly inserted within the space created by the modulated walls. The two entrances are defined by steel canopies that project, front and back, from the central ‘wing’. They relieve the formality of the rectilinear walls and are playful elements. Reception areas The reception areas on both sides of the main entrance are flooded with overhead light. Each reception area is defined by a steel frame suspended from the ring beam above. This beam delineates the central area of the room. From this point, the roof structure tilts up to allow natural south light to percolate into the spaces below. The timber trusses with steel ties are exposed which heightens the effect internally of the external architectural bulk. Microclimate control Mechanical fans are built into these windows to draw the warm air up and out of the spaces below. The structural elements of column, beam and truss are all painted blue, the steel ties red, creating colour contrast. Light shafts and dematerialisation of the corners

Albow Gardens Library and Clinic; Architect: Ngonyama Okpanum and Associates (NOA)

Once inside the complex there is an awareness of the large amount of natural light that floods into the rooms. The corners of the building dissolve into vertical light shafts. The windows are adapted to the functions within the rooms sitting squarely within the walls where necessary or below the ceiling to give privacy and light.

Urban square–amphitheatre feature The front entrance amphitheatre creates an urban square and an outdoor room as a precursor to the main entrance. The amphitheatre is landscaped and has curved steps, and two further landscaped courts are placed on either side of the main entrance. The dual purpose amphitheatre acts as a reading room for library school groups and as an overflow waiting area for the clinic.

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Conclusion It is necessary to highlight the importance of the presence of a primary health care facility that is predominantly located within the urban fabric and easily accessible for the public. The success of this facility as a valuable urban community complex has been enhanced by the fusion of its function and structure. Architecture is used as both a serious and attractive force to promote the needs of the people it serves.

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International comparisons

Albow Gardens Library and Clinic; Architect: Ngonyama Okpanum and Associates (NOA)

Primary Care Centres

24 Albow Gardens Library and Clinic; Architect: Ngonyama Okpanum and Associates (NOA)

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International comparisons

Albow Gardens Library and Clinic; Architect: Ngonyama Okpanum and Associates (NOA)

Primary Care Centres Japan

Germany

Designer: Hamada  Kawashima Architects

New Children’s Clinic, Darmstadt

New Children’s Clinic, Darmstadt; Architect: Angela Fritsch Spa Rehabilitation Clinic, Kawashima Architects

Amakusa;

Architect:

Hamada 

The Japanese have one of the longest life expectancies in the world, with over 20 000 centenarians.

New Children’s Clinic, Darmstadt; Architect: Angela Fritsch

New Children’s Clinic, Darmstadt; Architect: Angela Fritsch Machida Court, Tokyo; Architect: Masanobu Komuro, Sapporo, Japan

This building was built in a Tokyo suburb and accommodates a dental practice and two apartments.

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Designed by Angela Fritsch this building was inspired by Alvar Aalto. Having studied sculpture before architecture the building form is based on the rounded forms of a glass vase designed by Aalto.

International comparisons Radon Revival Spa in Menzenschwand, St Blasien

Radon Revival Spa in Menzenschwand, St Blasien; Architect: Sacker Architekten, Freiburg, Darmstadt

A new medicinal and wellness spa designed by Sacker Architekten built in a nature reserve in the Southern Black Forest. Vital Centre, Ostfildern

Vital Center, Ostfildern; Architect: HSP Hoppe Sommer Planungs GmbH, Stuttgart, Darmstadt

A health centre combining preventive care and rehabilitation with therapy for inpatients and outpatients. Facilities include treatment areas such as the exercise apparatus and physiotherapy area, the wellness area, sauna and steam bath.

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4

Political framework

The NHS Plan (2000) stresses the importance of patient centred care and envisaged the formation of Primary Care Trusts (PCTs). These Trusts are developing the control and procurement of primary health care facilities and are working with other agencies such as Social Services (a local authority function) and Mental Health Care to create community-based centres offering a wide range of services. They will respond to local services and the briefs will include specific needs, where appropriate, such as dentists, pharmacists, retail units and even cafés. Government policy regarding the design quality of health buildings has changed significantly since 2000. For example, NHS Estates identified design quality as one of four main themes in their Procure 21 programme and defined it as follows: Our programme aims to deliver design quality in NHS buildings. Good design creates the best atmosphere for the patients, staff and visitors, promoting more effective services and a speedier recovery. We propose to build on our existing programme, working with the NHS and other colleagues. This focuses on identifying and sharing best practice, anticipating development so that designs can reflect future clinical needs as well as design competitions, with NHS and Private Sector colleagues. (NHS Estates, 2000) At a national level, the UK government is also strongly promoting the importance of design quality in public buildings. However, results from the PFI (Private Finance Initiative) programme raise serious doubts about the effectiveness of good design intentions to survive the rigorous ‘value engineering’ processes.1 These concentrate on providing the best ‘value for money’ by focusing on quality control of the process rather than design quality of the product. Health Building Notes 36 and 46 published by NHS Estates set out their advice on the briefing and design implications of departmental policy. Health Building Note 46 ‘focuses on general medical practice premises and is

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intended to assist GPs and their architects in understanding the problems and principles involved in building new premises for general practice, or in converting or refurbishing existing premises. It seeks to help GPs and all those concerned in a project through the various processes of a building scheme from inception to completion.’ The document concentrates on functional and practical issues of design and typifies the historical approach to health buildings briefing which has concentrated on defining spatial requirements and setting cost limits, in the belief that the appointed architect would transform this data into a welldesigned building (NHS Estates, 1991). Health Building Note 36, Local Health Care Facilities, does include a statement that Primary Health Care Centres and Local Health Care Resource Centres should be planned and designed to provide patients and their escorts with high quality facilities which will be as easy as possible for staff to manage and operate. The layout of these Centres should be simple and straightforward: long corridors, awkward corners, and changes in level should be avoided. The design should help to assure patients that they are receiving a high quality service. To this end, particular attention 1

Value engineering (VE) is an American concept, developed at General Electric Corp. during World War II and is widely used in industry and government. VE is defined as ‘an analysis of the functions of a program, project, system, product, item of equipment, building, facility, service or supply of an executive agency, performed by qualified agency or contractor personnel, directed at improving performance, reliability, quality, safety, and life cycle costs’. VE is an effective technique for reducing costs, increasing productivity and improving quality. It is a technique directed toward analysing the functions of an item or process to determine ‘best value’. In this context, the application of VE in facilities construction can yield a better value when construction is approached in a manner that incorporates environmentally sound and energy-efficient practices and materials. (Office of Management and Budget: www.whitehouse.gov/omb/circulars, accessed 15/01/2006, circular no. A131.)

Political framework should be paid to the visual aspects of Centres as well as to functional and environmental needs. Patients and escorts may be anxious; the building design should help to alleviate patient’s stress. Particular care should be taken with the most public spaces, especially waiting areas. (NHS Estates, 1995, p. 21)2 However, there are no qualitative components to this design guide, and therefore the architect is given no guidance on the expected environmental qualities of these buildings. It is this lack of qualitative definitions that provides a major opportunity to improve the briefing process for future primary health care buildings. In the last few years there have been several initiatives that have produced a series of documents designed to enhance awareness of the importance of good design. These include ●

●

●

●

●

●

●

Advice – a document developed by the Design Brief Working Group (DBWG). Chaired by architect Richard Burton the group comprised a multidisciplinary team of practitioners in architecture, design, engineering and health care planning. Better Health Buildings – in October 2000 the Prime Minister published Better Public Buildings, which called for a step change in the quality of the nation’s public buildings. Better Health Buildings is the Department of Health’s response. Launched on 1 May 2002 it addressed many of the Department’s design initiatives such as Design Champions. Achieving Excellence Design Evaluation Toolkit (AEDET) – a toolkit for evaluating the design of health care buildings from initial proposals through to postproject evaluation. NHS Estates Design Review Panel – set up by the Secretary of State in November 2001 to provide advice, guidance and support to the NHS in the form of a design review. Initially looking at hospitals this peer review process is looking at primary care buildings and local community hospitals. The Architectural Health Care Environment and its Effect on Patient Health Outcomes – a report on the NHS Estates funded research project led by Professor Brian Lawson and Dr Michael Phiri of the University of Sheffield School of Architecture in collaboration with John Wells-Thorpe. CABE (Commission for Architecture and the Built Environment) is also looking closely at the design of health buildings with work led by Susan Francis. The RIBA (Royal Institute of British Architects) has also established CDAs (Client Design Advisers) to give independent advice to clients on procurement policy and briefing documentation.

The Prince’s Foundation also worked with NHS Estates on a joint initiative ‘Building a Better Patient Environment’ 2

Health Building Note 36 has been superseded by a website www.primarycarecontracting.nhs.uk/planning-and-design-guidance. php

assisting five NHS Trusts in delivering a design vision for their schemes. Following the winding-up of NHS Estates these design policy responsibilities are now administered by the Department of Health.

New policies funded with major capital investment Following the launch of the NHS Plan in 2000, procurement policies directed towards the health sector have been evolved based on the principle of introducing private finance to fund capital projects. The PFI model has been used for a number of large-scale hospital projects. Two other programmes have been developed specifically for the health sector known as Procure 21 and LIFT. Procure 21 is aimed at medium sized projects from £5 million to £25 million in capital value and includes a number of communitybased projects. The LIFT Programme (Local Improvement Finance Trust) is an initiative to stimulate the funding and operation of primary health care facilities. Many PCTs are developing programmes for the redevelopment of primary care facilities within their area using the LIFT Programme. The NHS Plan 2000 also tackles the issues that no health system is free. Generally, health expenditure in the UK as a percentage of GDP has been lower than in many other European countries and the USA. Since the launch of the NHS Plan 2000 the Treasury has steadily introduced measures through general taxation to fund a catch-up period with a target of health spending representing 9.4% of GDP by 2008 – easily matching European levels of health spending (Figure 4.1). The changes envisaged in the delivery of services, and the additional finance set aside to fund these developments, highlight how the 1948 model of the NHS is now inadequate for today’s needs. Figure 4.2 illustrates these comparisons (Department of Health – www.dh.gov.uk). Recent statements by the Department of Health set out present government policy, which is driven by more focus on patient responsibility. The major part of the structural changes in health care delivery is based on the development of the PCTs who will, over a period of years, become responsible for controlling budgets of over 75 per cent of NHS expenditure. The PCTs will be encouraged to promote diversity in supply and encourage new initiatives and incentives to develop patient choice. Patients will be given greater access to their medical information to enable a more informed choice about where that medical care should be provided. It may be at a location closer to a patient’s home or at a location where waiting lists are shorter. The following extract from Primary Care, General Practice and the NHS Plan (January 2001) sets out the framework envisaged by the government for primary health. 1. The NHS Plan is an ambitious but practical blueprint to restore and modernise the health service around its founding principles. The goal, through reform and investment, is

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Primary Care Centres 140.0 Expenditure (£ billions)

Education

120.0

Health

100.0 80.0 60.0 40.0 20.0 0.0 2003–04

2004–05

2005–06

2006–07

2007–08

2008–09

2009–10

2010–11

Figure 4.1 Pre-Budget Report 2008 summary (HM Treasury, 2008) – Health and Education spending

1948 model

New model

Values: free at point of need

Values: free at point of need

Spending: annual lottery

Spending: planned for 3/5 years

National standards: none

National standards: NICE, NSFs and single independent healthcare inspectorate/regulator

Providers: monopoly

Providers: plurality – state/private/voluntary

Staff: rigid professional demarcations

Staff: modernised flexible professions benefiting patients

Patients: handed down treatment

Patients: choice of where and when to get treatment

System: top down

System: led by frontline – devolved to primary care

Appointments: long waits

Appointments: short waits, booked appointments

Figure 4.2 Comparisons in the NHS (1948 model and current model)

to secure the modern, high-quality and convenient health service that both patients and primary care professionals want. 2. General practice has a vital role in achieving this goal. The future of the NHS rests on the strength of its primary care services. General practice has always been central to the NHS. Nine out of ten NHS patients are seen in primary care, while it remains the gateway to secondary care and has a key role in helping people stay at home and out of hospital. 3. The public trusts and values family doctors. But GPs and primary care staff also know that the expectations of patients are rising. People want more convenient and quicker access to advice and treatment. 4. GPs and other primary care staff share the desire to improve the NHS. Many practices are leading the way in meeting patient needs. The NHS Plan will build on their work by enhancing the role of primary care and putting in place the policies and investment to expand and improve services and raise standards further. The NHS Plan will mean: ● Primary care will provide a greater range of services with control over £25 billion of the NHS budget.

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●

●

●

●

Resources will be directed at improving professional working lives, increasing job satisfaction and supporting GPs and other primary care staff in improving patient care. Successful, flexible multidisciplinary working with respect for individual professionals will be developed further to delivery better services to patients. The practice will remain the basic unit of primary care within a system in which standards are improved and a wider range of more accessible services is offered. Practices will be offered greater freedoms and incentives as modernisation proceeds. ● 3000 GP premises to be substantially refurbished or replaced by 2004. ● 500 one stop primary care centres by 2004. ● All GPs have access to NHSnet by 2002. ● 50% of PCTs to have electronic personal medical records by 2004. ● Electronic prescribing of medicines by 2004. ● At least 2000 more GPs and 450 more than now in training by 2004. ● All PCGs to become PCTs by 2004.

Political framework ●

● ● ● ● ● ● ●

● ● ●

New Care Trusts to commission primary, community and social care. 1000 extra primary care mental health workers. 500 extra community mental health workers. A new national contract. A major expansion of PMS. New arrangements for single-handed practices. 48 hour appointment target by 2004. Practice staff to book hospital appointments within guaranteed timescales. NHS Direct to triage all out of hours calls by 2004. 1000 GP specialists. Nurses undertaking more roles.

Too many GP practices are housed in rundown and out-ofdate buildings that are depressing for staff and patients. The NHS Plan provides £1 billion investment to refurbish some 3000 GP premises and build 500 one-stop centres with doctors, dentists, pharmacists, opticians and other services on one site.

NHS LIFT The NHS Local Improvement Finance Trust (NHS LIFT) will work to provide capital for local investment strategies that have been formed from the bottom up, based on the assessment by PCGs (Primary Care Groups) and PCTs of the needs of their practices. There will be substantial investment in IT. Some 70 per cent of practices are already connected and access to NHSnet will become universal, funded fully by government. It will be developed to help GPs diagnose, inform, prescribe for and refer patients more easily. GPs and other staff will also use IT to access up-to-date and accurate information on patients’ medical histories and order tests more easily and quickly. GPs and practice staff should have straightforward systems to book hospital appointments on the spot in the surgery, offering their patients the choice of a convenient time within a guaranteed timescale. The government sets out its vision for primary care as follows: ● ● ● ● ●

universal, fast and convenient access by informed patients to an extended range of high quality services delivered in modern primary care settings by suitably trained and qualified primary care professionals.

These services require greater flexibility from the buildings developed by the NHS over more than 60 years since its formation in 1948. Primary care centres are one group of buildings in a wide range of facilities being developed from major acute hospitals with close links to world class research and teaching facilities to a wide range of smaller and more locally based buildings providing services for less urgent medical demands. This increase in flexibility is also reflected in the wider range of financial management of these assets.

NHS LIFT is one of the major government initiatives created to develop a wider range of primary care buildings. It is a vehicle for improving and developing front line primary and community care facilities, which will allow PCTs to invest in new premises in new locations. NHS LIFT is flexible in respect of the type of buildings it provides. The approach does not provide a building in which to put services. Rather it allows the building design to reflect the needs of the services. To date, LIFT is providing a range of building types including re-provision of GP premises, one-stop primary care centres, integrated health and local authority service centres and community hospitals. The one-stop shop principle is an important component of NHS LIFT – allowing the patient to be treated in his or her locality in so-called ‘One-Stop-Centres’ or primary care centres that are modern, convenient, easy to access and staffed by a wide range of health care professionals. The growth of the NHS over the first 50 years of its life has resulted in it becoming a victim of its own success. Following the publication of the NHS Plan (2000), the government has begun to develop its responses to a range of political pressures in both the acute and primary care sectors. Major expenditure has been channelled into the PFI system whereby private capital is introduced, thereby reducing the need for the government to raise additional tax revenue. This shift in financial policy is also reflected in the primary care sector by the introduction of LIFT as well as the encouragement of private developers to enter into private arrangements with GP practices. It has been noted (Nazarko, 2006) that the NHS employs 1.3 million people and is the third largest employer in the world after the Indian State Railways and Chinese Army. In the UK one person in 23 of the working population is employed by the NHS and since 1997 the NHS has taken on an extra 230 000 staff. The NHS now employs 386 000 nurses, 109 000 doctors and 122 100 scientists and therapists (Lister, 2004). Despite the increase in staffing and resources, the government is concerned that primary care is expensive and has not succeeded in moving the NHS forward. There are plans to reform primary care and to open up primary care provisions to foundation trusts and the independent sector. However, when the NHS was introduced politicians thought it would be more expensive in the early years and cheaper as the NHS improved the health of the nation. Increasingly, it is being recognised that there can be no limit to the amount of money being spent on ‘cures’ and that the balance of expenditure should move towards preventing people from becoming ill in the first place. This shift in government policy is now being reflected in the range of White Papers now emerging as the ten year programme of work envisaged in the NHS Plan of 2000 reaches its middle phases. Primary Care Trusts have been introduced (2001) and these were overseen by strategic health authorities. The Department of Health envisages that primary care would move from being purchasers and providers of care to simply being purchasers. Care would be purchased from a range of sources including arm’s length companies set up as community nursing, community hospitals and intermediate care teams. These ideas

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Primary Care Centres are developed in the White Paper ‘Our health, our care, our say’ (Department of Health, 2006), which explains that one of the aims of reorganisation is to open the market to more diverse providers with more freedom to innovate and improve services. PCTs will be expected to assess all the services they commission, including those they directly provide, to ensure that they provide equity, quality and value for money. This also raises the question as to whether the private sector can provide the same services more cost effectively. Also implicit in this approach is the idea that private sector employers can employ staff more efficiently and more effectively than the NHS where pension fund costs currently run at approximately 20 per cent of salary costs. Clearly, the cost of pension provision is an issue at the centre of government fiscal policy. Once again, the government is seeking to devise procedures to shift responsibilities for pension provision from the state to private individuals. Legislation is being introduced to oblige all employees to make contributions to pension provision. Fundamentally, the political debate will centre around the range of services provided by the NHS, and taken to an extreme view it raises the question as to whether the NHS will become a franchise rather than a provider of services. Secretary of State Patricia Hewitt, writing in the foreword of the White Paper ‘Our health, our care, our say’ (Department of Health, 2006), says that the document set out a new and ambitious vision for the future of our community services and that patients wanted ‘seamless health and social care to help them to stay healthy and to lead independent lives with more services provided locally’. She continues: ‘implementing the White Paper will involve a fundamental shift to provide care closer to home, where the overwhelming majority of people’s daily contacts with services take place, and where the services can fit around the lives people want to lead’. The aim is to help people to make healthy choices in environments that support their physical and mental health and well-being. The Department of Health is trailing individual budgets in social care and developing new approaches to prevention and shift in care out of hospitals. This is also giving rise to pilot projects to provide direct payments and individual budgets to provide new levels of choice and control for people who need support from social care services. The White Paper argues that practice-based commissioning gives primary health care teams the freedom and incentives to develop new models of support, to strengthen prevention and early intervention and avoid unnecessary admissions to hospitals. This development of the patient centred care philosophy recognises that new mechanisms and other tools and developments are required to provide the best services. This will include:

●

The government says that these principles are at the heart of everything they wish to undertake. However, the opposition, not surprisingly, is critical of these developments and the leader of the Conservative Party, David Cameron, said on 10 October 2006 that ‘he would give doctors more power, patients more choice and health providers more competition’. The opposition party have said that they would ensure that an NHS board would run the health service. The board would be responsible for allocating resources, commissioning services and increasing standards of care, the government would remain accountable to the electorate for spending and for decisions about the scope of what is offered by the NHS. A Conservative policy commission on health has also proposed introducing more competition in the NHS. This, it says, would allow patients to choose their health care provider and allow groups of specialist clinicians in private sector organisations to commission services. The White Paper ‘Our health, our care, our say: a new direction for community services’ was published at the end of January 2006. It advocates a new direction for social care and community health services with four main goals: ●

●

● ●

●

ensuring the changes put people at the centre of their care and developing the local partnerships that are needed to support them; getting upstream on prevention, early intervention and support for individuals for self-care and promoting wellbeing for the wider population;

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Better prevention and early intervention for improved health, independence and well-being. More choice and a stronger voice for individuals and communities. Tackling inequalities and improving access to services. More support for people with long-term needs.

The White Paper ‘Our health, our care, our say: making it happen’ developed the argument set out by the government and highlighted those areas where early substantial progress was being made. It identified a ‘road map’ towards implementation (Figure 4.3). With regard to primary care the targets set include the following points: ●

●

Exploring incentives for practices to expand – review of primary medical care contracts (2006/07). A nationally led, locally tailored procurement way of supporting equitable provision of primary care (2006/07).

Patients are identified as key partners in this process and the following targets have been identified: ●

●

planning how to shift care – not just shifting activity from one big building into another smaller one, but developing models of care that support people in communities and in their homes; reducing unnecessary admissions to hospitals and institutions; and getting in early to stop problems developing.

●

●

Framework for choice, incorporating information for choice (2007). Creation of expert patients’ programme community interest company with increased investment (2006). Development of information, prescription and piloting an integrated approach to provision, and searching, of information (2006/07).

Political framework

Users as partners • Services designed around people • Public engagement • Implementation of self-care strategy • Use of direct payments and individual budgets

Intelligent commissioning • Joint strategic needs assessment • Use of PBC, PbR/tariff • Use of LAAs • Plans for development of primary and community care, including shifting resources

Provision • Review of resource use • Integrated workforce planning and delivery • Exploration of co-location • Better partnership working with third and independent sectors

Starting point for local action

Leadership • Appointment of DASS and DPH • Joint leadership development of DASS, Director of Children’s Services, PCT Chief Executive • Strategic partnership/sign up to achieving WP goals

Quality • Use of informed best practice, e.g. NSFs, NICE, SCIE guidelines • Development and deployment of care pathways • Information for users • Implementation of choice • Survey of patient experience

Improved outcomes by... Better prevention with earlier intervention More choice with a stronger voice Tackling inequalities and improving access to community services More support for people with long-term needs Figure 4.3

‘Road map’ for implementing change (2006)

Evidence-based design and the evidence base of interventions are both seen as targets for defining and measuring preventive health budgets during the latest stages of the NHS Plan 2000. Politically, the government recognises the importance of greater patient participation in the management of each individual’s health care. It is moving towards better prevention and early intervention for improved health, independence and well-being. Research undertaken by the Department of Health indicates that people want to take more control of their own health and well-being but want more support to do this. This has led to the concept of NHS ‘life check’, which will be a two-part service – a self-assessment followed by personalised advice and support for those shown to be at risk – and is aimed at helping people to assess the risk of ill health created by their own lifestyles. Initially, NHS life checks are being developed for use at three key life stages – the first year of life, adolescence and mid-life (age 50–60). Piloting of these programmes is under way across the country. Research has also indicated that millions of people suffer from mild to moderate mental health problems, and treating them takes up about a third of GPs’ time. The White Paper also makes commitments to extend the availability of direct payments to groups of people currently excluded from receiving them, and to increase awareness and boost the uptake of direct payments. There is also a plan to pilot the use of individual budgets. The intention is that this will increase individual control over the services received.

Individual budgets will build on some of the features of direct payments by increasing people’s choice and control over the way they are supported. As well as social care funding, it will bring together different resource streams, but an individual might receive, for example, access to work and independent living funds, and allocate a single transparent sum to them. Following the White Paper ‘Our health, our care, our say’, published in January 2006, the government published the White Paper ‘Our health, our care, our say: investing in the future of community hospitals and services’ in July 2006. It announced that the Department of Health would invest £750 million of capital funding over the next five years in a new generation of community hospitals and services, and gave detailed guidance to PCTs wishing to bid for some of this capital. The design principles stated that the services should: ● ● ● ● ● ● ● ● ● ● ●

be locally led provide high quality services redesign patient pathways anticipate future needs as the population changes adopt new technologies plan across primary and secondary care be affordable for the whole health economy promote integrated service solutions engage and harness the potential of staff enable the transition of staff engage the public, the whole health and social care system and be innovative.

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Primary Care Centres Yet another White Paper, ‘Our health, our care, our say: a new direction for community services’, had been issued in January 2006 setting out new directions for the whole health and social care system. The government wants the people to have a real choice of the GP surgery they register with. The right of patients to choose one surgery over another will help to ensure that those surgeries are open at times that are suitable for them. The government argues that if patient choice and PBC (practice-based commissioning) expand then health services will develop that are safe, high quality and closer to home in the community. The aim is to meet people’s aspiration for independence and greater control over their lives and to make services flexible and responsive to individual needs. This will enable people to be more in control of their health care and place greater emphasis on the prevention of illness. Four main goals are identified: 1. Better prevention services with earlier intervention. The government response to this aspiration is the introduction of the new NHS life checks for people to assess their lifestyle risks and to take the right steps to make healthier choices. The aim is for this to be a personalised service in two parts. (a) The assessment tool will be available either online as part of health direct online or downloaded locally in hard copy. (b) Specific health and social care advice and support for those who need it will be available. 2. More choice and a louder voice. Patients will be given a guarantee of registration onto a GP practice list in their locality. To help them to make this choice it will be easier for people to get the information they need to choose a practice and understand what services are available in their area. 3. Do more on tackling inequalities and improving access to community services. There will be a clear focus on those with ongoing needs and the quality and quantity of primary care will be increased in underserved, deprived areas. People with particular needs will be targeted including young people, mothers, ethnic minorities, people with disabilities, people at the end of their lives, offenders and other special groups. 4. More support for people with long-term needs. The intention is to improve communications between health care and social care services. These changes are inextricably moving the original philosophical arguments set out for the NHS in 1948 towards a consumer driven service with an increasing element of private finance introduced to the provision of services. It would give GPs more responsibility for local health budgets, and it seeks to reorientate our health and social care services to focus together on prevention and health promotion. It is anticipated that more care will be undertaken outside hospitals and

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in the home. Work is also under way on commissioning social care services in conjunction with medical services. Health and well-being are essential planks of this shift in policy. General practitioners enjoy special status within the NHS, being the most public face of health care because they have most contact with the public. Just about everyone has at some time had reason to ‘see their doctor’. People are more likely to know the name of their doctor than that of any other public servant. Though GPs are paid out of the public purse, few of us think of them as public sector workers. They run their practices very much as private businesses – as independent contractors and for profit, and have done so since 1948. The argument runs (as described by Jenny Hjul in The Sunday Times of 17 December 2006) that if a private practice decided to move into the general practice market and take over a surgery, it is quite probable that patients would not notice the difference, rather like a favourite retail outlet being bought by a multinational, the defining characteristics that make the brand popular, the doctors in this case, would remain unchanged. Why, then, has there been concern over the proposed takeover by a private firm of a vacant GP practice in Hart Hill, North Lanarkshire, which would make it the first privately run practice in Scotland? What this amounts to, say critics, is a creep in privatisation of the NHS, the thin edge of the wedge. Shareholders’ dividends will take precedent over patients’ demands, services will be trimmed and the cherished doctor/patient relationship will be destroyed by a rapid turnover in locum staff. However, locums are often an essential part of most modern practices, and a telephone helpline is now the first port of call for out of hours emergencies. However, almost a third of the GP workforce is over 50 and nearing the end of their careers. Added to this, the feminisation of general practice – almost 60 per cent of GP registrars in Scotland are women – has brought a shift to more part-time work. The Royal College of General Practitioners (Scotland) conservatively estimates that by 2012 Scotland will be short of at least 750 GPs. If the government, in Scotland and in Westminster, wants to expand out of hospital community health services, it will have to invest more in GPs – in training, in offering incentives for doctors to return to work after childbirth and to remain in practice for longer. Funds will also have to be found to improve GPs’ premises. Three quarters of GPs surveyed by the BMA felt that their premises were not suitable for future needs. The BMA said a critical shortage of investment is to blame. It seems that Scotland’s reluctance to accept the private option in public health will be unsupportable. In England, private firms provide hospital services for the NHS and privately run diagnostic and treatment centres for NHS patients have cut waiting lists considerably. By 2008, private firms are expected to carry out one in every ten non-emergency operations. It seems a natural progression for this kind of investment to find its way into general practice and so help bring health care to the doorstep.

5

Approach to briefing

Any briefing process is complex and ultimately depends on the clarity and vision of the client to identify the ethos of the project. Of course, a successful building also requires a good architect who is able to interpret this mission statement, and balance the inevitably conflicting requirements to create an architectural solution that adds to its urban context and provides (in the case of primary health care buildings) a healing environment. Without the preset rules of a design school, architectural theory is either infinitely variable or confused depending on whether you take an optimistic or a pessimistic view of the opportunities that are presented by the lack of design guidelines. On the one hand, Jencks (1995) advocates the advantages emanating from chaos theory, resulting in a fractured and segmental architecture of great variety, or more negatively the philosopher Ludwig Wittgenstein is reported to have said ‘you think philosophy is difficult enough but I tell you it is nothing to the difficulty of being a good architect’ (Lawson, 1994, p. 2). Lawson (1994, p. 2) identifies four techniques we can employ to understand the designing process: 1. We can analyse the task and propose logical structures and processes that we imagine must or should take place. 2. We can observe designers at work. 3. We can conduct laboratory experiments on designers. 4. We can ask designers to tell us what they do. He concludes the review of these approaches by favouring dialogues with architects, and inviting them to describe their working methods. However, the subjective appraisal of his choice of architects interviewed relies on the arbitrary appraisal of what represents high quality. Can high quality be justified solely by those architects who are held in highest esteem by their peer group at any particular point in time?

An interview with Richard Burton (Lawson, 1994, p. 12) recorded the following points as being most important: ● ● ● ● ●

● ●

Interaction between members of a design team Relationship with client is critical Interactive nature of brief making Briefing is an absolutely crucial element The higher the level of client contact is in the client organisation, the better the process works Obtain feedback Importance of drawing as part of the design process.

Other architects identified their own crucial factors, for example: Hertzberger – human relationships are fundamental. Michael Wilford – sees himself as an editor waiting for copy to come forward from his staff. Eva Jiricna – design is a generic process, map out the range of alternatives. Richard McCormac – sees his role as making a series of interventions at different stages of the design process. Another explanation of the design process is made by using an analogy with the conductor of an orchestra. Working from a brief (the score), he or she coordinates and welds together a variety of contributions (individual musicians) each interpreting their line of the score – sometimes brilliantly, sometimes less so – to orchestrate a performance. The component parts may vary in skill and flair but sometimes are brought together for a memorable concert. There have been several recent attempts to develop systems to give scientific credence to artistic concepts, and it seems for the time being at least that progress in this field is dependent on providing an economic justification for all design processes.

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Primary Care Centres The key issue that emerges from an examination of these systems is that comparisons are being made between the expectations set out in the brief for a building and then compared with the results found in a post-evaluation study. However, the components of the brief are often very limited and it is therefore difficult to establish sufficiently worthwhile tests to measure the outputs from the finished building. This leads to the suggestion that the quality of the brief needs to be raised. A number of approaches attempting to quantify the qualitative aspects of a design use an arithmetical approach. Essentially, they are systems of point scoring against a series of scales judging performance. This leads to problems of assessment (Macnaughton, 1996) and the dangers and difficulties of assuming sliding scales of assessment which adopt a smooth or consistent gradient. There is undoubtedly very limited research, either completed or under way, in this broad field and more sophisticated briefing techniques will not appear overnight. We should be less apprehensive about linking the philosophical concepts of complementary medicine with mainstream professional methods. Exploration of the holistic approaches to alternative medicine should be looked at in parallel with scientifically founded evidence produced from control experiments of environmental factors. The Glasgow Homoeopathic Hospital is a good example of a recent building designed within the budgetary constraints of the NHS system and yet seeking out new ways to interpret a pleasing environment. Newspapers and magazines are full of articles about lifestyle: about how to remove stress from the workplace – about well-balanced diets – about ‘making over’ interior spaces. There is a newfound enthusiasm to control and influence our individual lives. The Prince of Wales, writing in The Times on Saturday 30 December 2000, says ‘we should be mindful that clinically controlled trials alone are not the only prerequisites to apply a health care intervention. Consumer based surveys can explore why people choose complementary and alternative medicine and tease out the therapeutic powers of belief and trust.’ With the medical profession under great pressure from society to become more responsive to consumer demands, another article in The Times (19 January 2001) starts from the premise that health is more fundamental to happiness, well-being and prosperity than anything else. Surely, this is the wrong way round: good health is likely to result from happiness, well-being and prosperity and it is our failure to understand the historic values of a holistic lifestyle that has led us into the trap which assumes that a technical solution lies behind every medical disorder. We should turn our attention to the quality of the environment; to the design of the places where we live and work and the therapeutic advantages that flow from the best examples. Doctors need to widen their horizons and understand the benefits that the humanities can add to our health. Science adds to our knowledge but philosophy and the arts make life worth living.

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Changes in NHS requirements An article published in Hospital Design in 1996 (Rogerson, 1996) set out the case that hard facts are needed to convince hospital administrators that good design brings therapeutic benefits. Since that time, the awakening of interest in this subject has spread widely, and as we have seen, the government has now accepted the arguments and is looking for the evidence to underpin its ambitious spending plans in the NHS. Under a previous administration, the Junior Health Minister in 1996, Tom Sackville, addressing a conference chaired by John Wells-Thorpe, said that ‘we have an enormous responsibility to get this right … buildings with architecture and design that lift the spirits of patients need be no more costly than the depressing, austere buildings so familiar to many who use and work in the NHS’. Already, there were anxieties about the influence of the PFI procurement procedure with the Minister going on to say: ‘I will not pretend PFI particularly helps (design quality) but it need not hinder it either.’ Therefore, we have seen the pendulum of opinion steadily shifting towards acceptance of the importance of good design in health buildings. In the mid 1990s, conference speakers still needed to remind their audiences that they were not doing the taxpayer a good turn by automatically opting for the cheapest option. What was needed was more serious research to form the basis on which therapeutic advantages could be measured. Another influential architect at that time was Richard Burton of Ahrends Burton and Koralek, who understood the need to create calming environments and to look at design from the point of view of the patient. He pointed out that ‘designs which are calming when one is healthy can be depressing when is in a subdued state … satisfaction measures are not enough – we need to measure behaviour and outcome’. This pioneering work has had an effect on policy within government circles and the then Prime Minister Tony Blair advocated high quality design for civic buildings. At the beginning of the 21st century, therefore, we are in a much more receptive culture to accept and understand the therapeutic benefits that can arise from well-designed primary care buildings. New design performance indicators are being developed to include a ‘delight factor’. Research at Sussex University under the direction of David Gann is investigating: ●

●

●

Functionality Does the building perform its purpose? What is a building’s productivity? Whole-life costing Sustainability In-use costs/adaptability Delightfulness Is it a focal point in the community? What do passers by think? Effect on the mind and the senses.

Approach to briefing These issues are not just about measuring the performance of buildings but about raising public awareness of the quality and delight that can be enjoyed from well-designed environments (Weaver, 2000). The complexity of these relationships leads back to the wide conceptions of life and the world which Bertrand Russell, in the introduction to his History of Western Philosophy, describes as philosophical and the product of two factors, ‘one, inherited, religious and ethical conceptions; the other, the sort of investigation which may be called scientific, using this word in its broader sense’. He contends that all definite knowledge belongs to science and all dogma belongs to theology. ‘But between theology and science there is no-mans land, exposed to attack from both sides; this no-mans land is philosophy.’ The design of health care environments occupies this space.

The design process – alternative approaches There have been many attempts to analyse the design process and to map out systematic patterns to guide the intellectual methods of design. Design education in universities has, until fairly recent times, followed a historical route, taking each time period as a subject of analysis. In the last quarter of the 20th century, more complex studies have been undertaken about the nature of design and studies have compared the design process between different fields of study, for instance comparing the differences between how fashion designers create their ideas and how civil engineers develop a structure (Lawson, 1997, p. 3). With architecture, the design process is influenced by two main characteristics, namely the design problem and the design approach. The following examination of various design systems considers how these two aspects are brought together by different people in the increasingly complex field of how an architect develops the brief and processes the information to produce a design product. Design is now taught as a skill as well as an art. Computer graphics involve manipulative skills that can be learned and developed by teaching students, and this will enhance their ability to convey their imaginative and innovative ideas into reality. A bee puts to shame many an architect in the construction of her hive but what distinguishes the worst of architects from the best of bees is this, that the architect raises his structure in imagination before he erects it in reality. At the end of every labour process we get a result that already existed in the imagination of the labourer at its beginning. (Karl Marx, Das Capital, cited in Lawson, 1997, p. 14) The design process has been formalised over the last 100 years by the development of professional organisations, not least by the Royal Institute of British Architects (RIBA), founded in 1834. The development of respect for the professions gave their members social status and for a while the division of labour between those who design and those who

make was a keystone of our technological society (Lawson, 1997, p. 22). The process of brief and design development has long fascinated architects. The model advocated by the profession for the architectural design process is set out in the Architect’s Job Book (6th edition 1995) published by the RIBA and this remains the basic approach adopted by most architectural practices when commissioned to design a new building. It is essentially a linear process and the foreword to the document states that ‘Architects are those who organise themselves to systematically translate their imagination and design flair into a building that meets their clients’ needs.’ It is a systematic approach to the design and construction process which has survived from the first edition published in 1969. The foreword boldly concludes by saying: ‘The Architect’s Job Book provides a framework for this systematic approach, which can be applied to any building or procurement method.’ The diagram of the process highlights the progressive linear path (see Figure 5.1). Although there are feedback loops which anticipate a dialogue developing between the written components of the brief and the evolving design

Client requirements

Initial brief Development of the brief

Constant interaction between brief and proposals

Feasibility studies A–B

Project brief Outline design

Development of the design process In smaller projects or those with a fast track programme the stages may be compressed

C Design brief Scheme design D Consolidated brief Detail design Production * information F–G

E

*The transition from detail design to production information is difficult to establish precisely and there is usually a measure of overlap. Figure 5.1 RIBA Plan of Work (source: RIBA Architect’s Job Book, 1995, p. 94)

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Primary Care Centres proposals, there is no reference to post-occupancy evaluations and feedback is only briefly mentioned at the end of the document. Debriefing is not referred to in the plan of work and most importantly not covered by the normal fee agreement entered into under the standard terms and conditions of appointment. Indeed, the Architect’s Job Book states that ‘both in-house appraisals and debriefing are exercises not normally listed in the services provided by the architect and are unlikely to be funded by the client … a full feedback study can be costly, and if the client wishes this to be undertaken, it will probably have to be the subject of a separate commission.’ The lack of provision for fees for post-occupancy work in an architect’s normal appointment is probably at the heart of poor appraisal and analysis of complete projects. Each architectural commission is often viewed as a unique opportunity to start with ‘a clean sheet of paper’ to create an individualistic solution to a client’s requirements. However, it goes further in almost discouraging the debriefing process. It states: ‘it is a sensitive area, and confrontation should be avoided at all costs. It will not therefore be a productive exercise in all cases and great care needs to be taken in deciding whether or not it will be worthwhile for a particular project.’ It seems remarkable in a document published in 1995 that there should still be such a negative attitude towards post-occupancy evaluation techniques and the benefits of cyclical learning, which is considered a prerequisite in other professional disciplines. Two obvious examples are the law and medicine. English law is developed on the principle of case law, or learning from previous experience, and likewise medicine is a developmental profession, which in the last 100 years has relied on the development of technical expertise. Elsewhere, I comment on the changing philosophy of health care from a medical point of view, which is moving towards a holistic approach not entirely based on scientific methodology. My interviews with, for example, Professor Sir Kenneth Calman have highlighted how leading members of the medical profession are beginning to advocate the introduction of artistic considerations to their work and have recognised the therapeutic benefits that can result from such combinations. The Seventh Edition of the Architect’s Job Book (RIBA, 2000), which remains the current edition in 2008, refers in the editor’s notes (p. 7) that ‘care has been taken to retain the straightforward and timeless advice which has made the Job Book a popular course of help for architects in the past’. However, this has resulted in little change from the Sixth Edition and continues the failure to recognise the importance of feedback and post-project evaluation. It states that ‘neither of these kinds of activities should be attempted if there is a risk of inviting acrimony and dispute’ (p. 280). There is such concern about feedback that it is not now listed in the Architects Plan of Work, nor is it referred to in current standard appointing documents and it advises that ‘the architect’s professional indemnity insurers should

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be informed before a full feedback study is undertaken for the client’ (p. 273). The attempt by the RIBA to distil the design process to a simplistic linear pattern would appear not to do justice to the complex inter-relationships, sometimes intangible, which build up the design process.

Traditional NHS procurement policy The NHS Estates procurement policy was based until recently on the Capital Investment Manual, which requires a business case approach to justify new investment. This has led to a position where design quality is understood to be represented by functionality. Design quality is assessed by its functional suitability. This methodology is enshrined in the NHS Estate code document which sets out a five facet analysis process: ● ● ● ● ●

Space utilisation Functional suitability Energy efficiency Statutory standards (compliance) Physical condition.

These factors are used as a basis for design quality evaluation. This is done by subdividing each category into four sections, from fully compliant (e.g. new building) to below an acceptable standard. With this background, an assessment of design quality can miss the point. Design quality had to be based on quantifiable data.

Hospice procurement policy An interesting comparison with NHS policies can be made with the procurement of hospices. The concept of holistic healing had been lost in the development of technical medicine in the 20th century, although historically it was much more central to the care of those who were ill. Examples of hospice briefing documents are discussed in Healthy Living Centres (Purves, 2002) for both children and adults. The central difference of these briefing processes is that the care of the patient is central to the design objective. Costs and space standards are considered after the aspirations have been set to create an environment within the buildings that will be comforting to the patient. A conference (Breathing Space: Towards an Aesthetic for Cancer Care) held in Dundee (October 2003) examined the philosophy of the Maggie Centres, a network of buildings being created by Charles Jencks in memory of his wife who died of cancer. Jencks joked that ‘in the old days, people used to die in factories … called hospitals’. The Glasgow Homoeopathic Hospital demonstrates that a hospice can focus on environmental design issues, achieve high standards of architectural quality and yet still be constructed within NHS procurement cost limits.

Approach to briefing Design quality indicators (DQIs)

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Pilot studies have been carried out by the Commission for Architecture and the Built Environment (CABE) to formulate design quality tools. An attempt was made by the DETR (Department of Environment Transport and Regions) in conjunction with the Housing Corporation to formulate a series of housing quality indicators (DETR, 1999). A key requirement of the system was for the Housing Corporation to be able to assess quality differences between schemes. It is based on a scoring system which examines a number of factors. A similar approach is being adopted by NHS Estates who are developing a quantitative methodology for evaluating design quality in the health sector and this work has been submitted to the Prime Minister’s Office as part of the background work in the government’s drive to raise design quality in public buildings. The development of a set of primary care quality indicators would similarly allow them to be used to audit the progress of a design and may be a more effective test of value for money than current PFI (Private Finance Initiative) procedures. They would also be appropriate for reviewing the design quality of small projects without having to resort to batching a large number of projects to achieve the critical financial mass to fit the PFI model. A diagram seeks to illustrate those areas of the design process where more work is required to develop a critical understanding of the healing environment. By acknowledging these issues, the briefing process will become more comprehensive and meaningful in helping to achieve high quality buildings. The introduction of design ethos concepts will enable the quality of the building (e.g. the product) to be raised as well as ensuring high quality of construction (e.g. the process). The Centre for Health Design have undertaken an extensive literature search and having looked at 78 761 articles have identified only 84 articles published within the last 30 years that contain relevant data concerning health care environment. They conclude that many of the ‘studies have significant methodological flaws that render their conclusions suspect or cast doubt on the generalizability of their findings. Future research into the effects of their health care environment on patient outcomes should be more carefully design and performed with greater methodological rigour’ (Rubin et al., 1998). Using the case study model, the Centre for Health Design has carried out a design evaluation of six primary care facilities for the purpose of ‘informing future design decisions’ (Kantrowitz and Associates, 1993). This report identifies a series of critical design issues arising from the data collected from the case studies. These are: ● ● ● ● ●

Design process Humanistic design Functional factors Technical factors Aesthetic factors

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Cost factors Materials and furnishings Primary care practice. The conclusions are hopeful: the research finds that although the definition of primary care varies among the six organisations, these groups have taken the initiative to custom fit the mix of primary care services to meet the needs of the population and communities they serve. These organisations are finding ways to lessen the sterile, clinical image of medical settings of yesterday and instead, are designing more comfortable, welcoming space in primary care facilities. There appears to be shift from large scale to smaller scale facilities and facility components that maintain a manageable yet effective size. Several of the six facilities attempted to decentralise a number of main functions in an effort to enhance the reality and the perception of personal attention in individual care.

How is policy related to theory The literature demonstrates that there is an emerging body of evidence to support the argument that high quality architectural design can bring therapeutic benefits to patients. There are also a small but growing number of research papers that demonstrate a positive connection between good design and patient satisfaction. The evidence suggests that there are two main strands to this evolving condition. 1. Medical results demonstrate a measurable improvement in patient recovery rates when treated in high quality environments. 2. Patient expectations in the health sector are rising in parallel with general higher standards and aspirations throughout all sectors of our lifestyle (education, safety, security, wealth, houses and other possessions). Hence, it is not surprising that government policy is reflecting these changes and is attempting to modify standards to incorporate these factors. The NHS Plan has set a broad policy target to put ‘patient centred care’ as the focus of its overall objective. A consequence of this policy is to create a significant demand for better primary care buildings. Through control of the briefing process, the beneficial results stated above are more likely to be achieved in primary health care buildings.

Work at the James Cook University Hospital Outline This section is based on the project undertaken for the NHS Research Group which examined the outcomes at the James Cook University Hospital.

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Primary Care Centres It sets out the methodological approach which considered both the design process as well as the outcomes of the architectural sequence of events. Background 1. As an architect in private practice I have been designing doctors’ surgeries for over 20 years. I became interested in the relationship between client and designer (usually doctor and architect) and the factors which govern the briefing process. 2. My book Healthy Living Centres (Purves, 2002) was the product of the background interest from my work as an architect, supplemented by a series of interviews which I conducted with a wide range of people in both the medical and architectural professions. 3. These professional interests led to my appointment as an honorary research assistant at the Centre for Arts and Humanities in Health and Medicine (CAHHM), a research group at Durham University. This group (2003/04) undertook a research evaluation of the design quality of the James Cook University Hospital. This has come about from the major reconstruction of the South Cleveland Hospital under a PFI contact of £120 m. The reconstruction will involve the disposal of Middlesbrough General Hospital and North Riding Infirmary, and the creation of a single site hospital on the South Cleveland Hospital site. The hospital has been renamed the James Cook University Hospital (JCUH) in honour of Captain James Cook, who came from the region. The Chief Executive of South Tees Hospitals NHS Trust and his planning team are committed to the delivery of high quality ‘patient centred care’ and believe that the solution lies in high quality architectural design and the integration of public art – commissioned and created regionally – into the health care environment. The development of the James Cook University Hospital has paid special attention to building design, therapeutic colour schemes, materials, lighting, space and acoustics. The design features and colour schemes are intended to individualise departments within the hospital to help create a sense of intimacy within the whole. (Extracts from 2nd interim report, CAHHM, June 2003)

Process issues 1.1 Introduction – government policy, a Health Resource Centre and a comparison with office buildings. 1.2 Reviewing the evolution of the decisions taken by the architect when designing a doctor’s surgery using the Geoffrey Purves Partnership data over a number of projects. 1.3 The documentation for the JCUH brief has also been examined and analysed to explore the objective of achieving a patient centred design. 1.4 Similarly, some of the data from the interviews I have conducted at JCUH have been used to examine the design process. The outcome of the design process has then been examined by: Outcome issues – outline 2.1 Discussing the results of the NHS questionnaire about GP surgery levels of satisfaction. In addition, the results of a survey undertaken by Geoffrey Purves Partnership on behalf of Brent and Harrow NHS Trust in 1996/97 are included in Appendix 5. This example of fieldwork demonstrates an early attempt by an NHS Trust to evaluate the environmental quality of its building stock. 2.2 This has been elaborated to a limited degree by two participant observation studies undertaken at GP surgeries designed by Geoffrey Purves Partnership (Gosforth Memorial Medical Centre and West Road Medical Centre). 2.3 Using data from interviews to assess satisfaction about a building’s success in achieving the design aspirations set out in the brief.

I have interviewed a number of senior staff, both administrative and clinical, together with members of the design team.

By using several sources of data, I have attempted to test some cross-fertilisation of ideas and concepts in a qualitative sense. There are strengths and weaknesses in this approach. By using several types of data and from a range of sources my conclusions have established trends and patterns and identified the qualitative components of a good design brief rather than generate statistically based quantitative results. However, the variety of data gives greater validity to those trends or patterns of opinion that emerge as common themes. A framework of the issues involved is shown in Figure 5.2. As previously mentioned, the financial implications have not been evaluated for this study.

Approach

Process issues

The research questions have been approached by considering both the design PROCESS as well as the OUTCOMES of the architectural sequence of events which led to the final building. Broadly, the design process has been explored by:

Introduction – government policy, a Health Resource Centre and a comparison with office buildings The briefing process in the health sector is changing rapidly and government policy has shifted markedly since the commencement of this research study (1997). Much of my early

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Approach to briefing

1 Physical

site restraints space standards

2 Emotional

design aspirations

healing environment

user satisfaction

3 Financial

budget/ estimates

cost limits/ procurement methods

value for money

Figure 5.2

functionality

Matrix of factors influencing the design process

experience (early 1980s onwards) as an architect in private practice was gained in the health sector by following the guidance contained in the ‘Red Book’. The ‘Red Book’ was the standard NHS document used by general practitioners as a framework for all aspects of their work, and it included details about how their surgery should operate. It set out room sizes and functional requirements for the main activities such as the consulting room, nurse treatment areas and waiting room. No quality issues are considered or required to be considered by this document although passing reference to quality issues is made in the NHS design guides available at that time. It is not oversimplistic to say that the design brief was set out in terms of space requirements and room areas. Against this schedule of accommodation, cost limits were set (and periodically revised). The process of approval by NHS managers did consider, although largely subjectively and dependent on the skill, experience and sensitivity of the appointed member of staff, the quality of the design proposed. With a good NHS manager and a good architect, many excellent small health projects were completed throughout the UK during this period. Equally, there were other projects which were more modest but there was no process available to identify low quality buildings. However, during the 1990s a number of initiatives began to emerge in government strategies to re-examine patient care and to focus the process on the patient rather than on the medical system. These issues were recognised in the new contract for health promoted by the government in 1998 (Our Healthier Nation, 1998). New alliances were explored between different sections of the NHS and, importantly, some people began to consider joining together NHS services with those of local authorities and other community-based agencies. Comparison with design criteria in the commercial sector for work environments Perhaps because of the commercial office market being led by financial and private sector interests, there has been more research carried out in this field than on health buildings. There is also, normally, a clear distinction between building owner and building occupier. Much of the office space in the UK is leased by the tenant from the building owner. Historically, this has not been the case with health buildings. All of the UK NHS Health Estate has been designed, built and owned by the government.

This is now changing rapidly with the huge increase in PFI projects and similar procurement policies such as Procure 21 and LIFT. They all introduce private capital into the provision of health facilities but the tenant (i.e. the NHS on behalf of the government) has only recently begun to attach importance to the design quality of the completed building. The concepts of change, working patterns and the way buildings need to change to accommodate these requirements have been developed more rapidly in the office sector of the property market. For over 20 years Frank Duffy has been leading his firm, DEGW, through an exhaustive series of experiments and research projects looking at the way office accommodation must change to cater for new working practices. This research work needs to be transferred to the health sector, and indeed ‘other workplaces’. … I should mention what I mean by ‘office’. I do not mean only prestige office buildings housing large corporations. I mean all places where professional, administrative, recording, accounting activities are carried out, whether they be factories, surgeries, shop windows or prestige blocks – any place in which people who used to be called white collar workers work. (Duffy, 1992) Duffy argues that applied research should be the basis for the development of this design work and should be based on an analysis of the way people use buildings. Buildings provide a framework for behaviour. They exist only to allow people to do what they want to do. (p. 38) These arguments are summarised in a neat list of variables (see Figure 5.3). His more recent work described in New Environments for Working (Laing et al., 1998) develops these issues and sets out a framework for describing working patterns and the differing types of environmental systems required to support these. Much of this research work needs to be urgently transferred to the health sector and transform the way in which primary health care facilities are conceived. It is essential to break the mould of the briefing document being based on static physical requirements so that future projects embody the human ethos and quality of life issues begin to take precedence over traditional space standard and cost factors. Notes on the design process for surgeries designed by Geoffrey Purves Partnership The Geoffrey Purves Partnership (now Purves Ash LLP) has been designing doctors’ surgeries since the early 1980s. During this period, the design culture has shifted from an approach revolving around the ‘Red Book’ procedures to the current environment where the procurement of GP surgeries is increasingly under the control of private sector financial arrangements. The ‘Red Book’ was the comprehensive

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Primary Care Centres

Organisation of work – the job

Whatever is directly to do with getting the work done, e.g. the task to be completed, the line of authority and responsibility, work communication channels, management style, equipment used, numbers of visitors, etc.

Behaviour at work – the worker

The social consequences of getting work done, e.g. display and prestige, work expectations, visitor communications, sex, age, income, education of the workers, secrecy required, etc.

Building form – the building

The physical consequences of job and worker, e.g. location, space and equipment standards, disposition of groups and workers in plan, arrangement of equipment, size of room, use of partitions, screens, room dividers, etc.

seems valid to look at the briefing process of this hospital to understand how qualitative issues were addressed. The research group looked at the management approach that was adopted during the design process and considered whether the design development process was effective. The JCUH was one of the early PFI hospital projects, and more recent contracts undoubtedly place greater emphasis on assessment protocols to examine the effectiveness of the design quality outputs. This focus on design quality by the government is discussed in several documents including ‘Improving Standards of Design in the Procurement of Public Buildings’ (OGC and CABE, October 2002 – for more details see www.ogc. gov.uk or www.cabe.org.uk). This is discussed in greater detail in Chapter 6. I have examined the PFI documentation including the ● ● ●

Figure 5.3

Variables on the way people use buildings

NHS handbook for GP methods and included a section on the requirements for surgery buildings. Review of the documentation for the James Cook University Hospital brief The James Cook University Hospital (JCUH) provides an interesting example of the briefing process for a major PFI hospital development at Teesside. As a member of the research team from CAHHM at Durham University, I have been involved in the work funded by the NHS Estates Research and Development Group to evaluate the design quality of the new hospital. The key questions that the group examined were: 1. How were patient centred care concerns articulated in the brief? How was the design process managed to ensure that these priorities were maintained? 2. How closely does the completed building reflect the patient centred aspirations of the brief? 3. How important are the briefing process and the design brief in influencing the outcomes of the building project for the users? There were two underlying assumptions to this study as follows: 1. Is it possible to define a patient centred care strategy in the brief? 2. If patient centred care is appropriately articulated in the brief it will be possible to identify the benefits of the completed building. Although the scale of this project at approximately £150 million is vastly greater than the value of a GP surgery, it

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single site pre-selection information memorandum outline business case overview evaluation report full business case (including the design report).

The study did not examine financial aspects of the contract in detail and it did not include value engineering appraisals, value for money assessments, or financial comparisons between PFI and traditional procurement routes. From an examination of the documentation and interviews with key members of the design team, two key factors in the briefing process became apparent. 1. The documents consistently stressed the design quality aspirations that had been established for the new hospital. These were based on a patient centred care strategy and the excellence of clinical care throughout the full range of acute services in both the new and existing buildings. 2. The success in not losing sight of these objectives has been greatly assisted by the inclusion of senior clinical members of staff in the core planning team established from the earliest meetings of the project. The involvement of the senior clinicians who had ‘hands-on’ medical responsibilities ensured that the design development process had the support of a wide range of staff all the way through the design process. Although this technique was very expensive in terms of time for senior staff, it did ensure ownership of the design. Even the early briefing documents such as the outline business case (spring 1995) included qualitative statements and aspirations such as: ● ●

●

‘Will deliver demonstrable benefits for patients’. ‘Providing scope for a new pattern of healthcare tailored to … patients’ requirements and aspirations’. ‘A draft development control plan has been produced … based upon an innovative patient centred model to ensure the proposed development is human in scale and highly efficient’.

Approach to briefing The design report section of the full business case (November 1998) included the following objectives: ●

●

●

●

‘Provision of facilities to maximise the development of patient centred services’. ‘The provision of facilities which encourage the physical, mental and spiritual well-being of all patients’. ‘The provision of a safe, attractive and reassuring environment for all diagnostic and treatment services’. ‘The location of wards, outpatient and diagnostic services in close proximity to each other, to limit transfers and minimise travel distances for patients around the site, to enhance the development of the patient centred care concept’.

This emphasis on patient centred care spreads throughout all aspects of the hospital development proposals including the site layout, departmental adjacencies, flexibility and patient environment such as minimising travel distances and making signage an important aspect of the design. The Design Report accompanying the Full Business Case (November 1998) analyses these issues from the qualitative stance. For example, the landscape setting is regarded as important in establishing a therapeutic environment and minimising the impact of the roads and car parks. How successful this has been is questionable as demand for parking increases relentlessly. The low rise buildings have been designed to allow high levels of natural light ‘to provide a link with life outside’ and a ‘degree of individual environmental control has been achieved’. The Full Business Case also says: ‘views have been deemed to be important – to external landscapes and internal courtyards or artworks, as they can appear to extend space and provide a secure connection to the outside world’. Throughout the design process, great emphasis was placed on maintaining the integrity of these core principles. The patient centred care strategy was paramount but the development of the institute concept within the hospital so that various departments were grouped together for the greater convenience of patients influenced the planning constraints established by the architect. Overlaying these basic physical parameters, other qualitative factors were introduced such as the James Cook theme. By naming the hospital the James Cook University Hospital, the local roots of the community were recognised and this provided a platform to use various themes throughout the hospital associated with James Cook. For example, the artistic activities, scientific discoveries and educational opportunities arising from James Cook’s voyages of discovery to the Southern Ocean could be exploited throughout the hospital. This helped to create patient focus, local involvement with the community, a sense of pride and a range of devices to improve, identify and find one’s way around the large-scale building. Importantly, the requirement for hospital buildings to provide facilities that encourage the physical, mental and spiritual well-being of all patients was given appropriate

prominence in the briefing process. The new hospital has both a multifaith chapel and a holistic care centre. The success of the qualitative issues inherent in the new James Cook University Hospital facilities is largely due to the successful leadership of the design development team. This was stimulated by the then chief executive, Bill Murray, and rigorously pursued by the hospital briefing team, which included, as already mentioned, both administrative and clinical staff with senior managerial responsibilities. Notes from interviews conducted at JCUH concerning the briefing process As part of the NHS Estates Evaluation Study being undertaken by CAHHM, I interviewed a range of senior members of the management team including the chairman, the chief executive, senior members of the planning team and several senior clinicians. They had all been involved in the design process at the JCUH from the initial stages of the PFI contract. Clearly, this is not similar to the scale of operations encountered with the design of a new GP surgery but it does reflect an involvement in all members of the team from an early stage. Their views confirmed that they believed this to be valuable and helped them to understand what the new building would look like and to have an influence on the interdepartmental relationships. Examples demonstrating this support include: Well, Ken and Bruce worked with the Trust’s project team, as we called it, and produced a public sector comparison in terms of the site development control plan which had required a number of discussions with individual parties and ultimately received 90–95% approval in that people were delighted with the plan, particularly in terms of the adjacencies. Another comment from a senior non-clinical administrator includes the comment: There were lots of meetings but, you know, the brief really was to make things as patient positive as possible, to have specialities working adjacently so that specialities and that sort of thing work as near to each other as they could. And you know we actually got it right for the patients. Another example: I suppose for me it was less on the cost issue, we were involved less on cost and more on design and making the, coming from a nursing background I was very keen personally to make sure that the nursing issues … make it easier for the nurses … better for patients. That was always in the back of my mind, but we were encouraged. And the public were consulted as well: Yes there was public consultation and the part I remember was terms of public consultation – new building – and

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Primary Care Centres all the consultation that was necessary in the scheme of things – we were very encouraged by patient involvement and really they kept us on the straight and narrow ensuring that the services were adequate and suitable … Continuing: Question: Was there any constraint on design expectations or ambitions as a result of cost? Yes, well I mean, there were restrictions, we had to limit the number of offices to the number of people we had at the time and the whole scheme has to be frozen at a point in time in order to secure the contracts for building maintenance, but I think other than that there was a lot of clinical freedom as to how and input as to how it best be developed for the patients. These short extracts illustrate typical responses indicating how the whole team took ownership of the concept of patient centred care, and worked together to develop a high quality brief. Undoubtedly, it was expensive in terms of staff time and resources but there was no serious criticism that, at the end of the day, this was not a worthwhile investment to secure a high quality design of the new hospital. Outcomes issues The NHS has no data on the results questionnaire issued to GPs. With the publication of Environments for Quality Care – Health Buildings in the Community (NHS Estates, 1994), doctors were invited to complete a self-appraisal questionnaire about their own premises. It provided a comprehensive review of topics to allow doctors to examine the day-to-day running of this practice and to gauge its performance against patient satisfaction. The questionnaire (see the appendix at the end of the chapter) sets out a series of questions covering the following topics: ● ● ● ● ● ● ●

First impressions Access Reception and waiting area Consulting, examination and treatment rooms Circulation spaces Staff areas Building efficiency.

The last question invited doctors to ask themselves ‘Does the building convey a message of well-being?’ Obviously, this questionnaire does not gather information about the views of other users of the building such as patients or members of staff, although some doctors may have canvassed views from other people before completing the forms. In addition, some of the questions only invite a selfassessment of policies which will have been established by the doctors themselves.

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In addition, the National Primary Care Research and Development Centre have carried out a survey of ten innovative projects where the processes of service development and premises development have been interactive (Bailey et al., 1997). This has led to the resultant buildings developing individual facilities particular to their locality. The NHS Estates questionnaire is the potential source of a great deal of valuable data, but there has been no process to collect or collate the results. An opportunity has been lost to invite doctors to return the forms so that an analysis of their views could be undertaken. What does the ‘Environments for Quality Care’ questionnaire demonstrate about existing facilities? The questionnaire was an imaginative initiative by NHS Estates and sought to look beyond the traditional assessment criteria of functionality and cost effectiveness for primary health care facilities. The questions reflect the philosophies that were common currency a decade ago. As a self-appraisal system designed to give doctors a quick review of how their surgery performed, in their eyes, it served a valuable purpose. However, it is disappointing that NHS Estates did not collate any of the information and therefore no statistical results have been published. The same questionnaire could have been made available to a randomly selected cross-section of patients and staff and the results compared with the judgements scored by the doctors. Therefore, the questionnaire is not an assessment of patient satisfaction and more probing questions might have been asked about patient needs and facilities not included in the designs. It would have been useful to go back to the briefing process to see if appropriate challenges had been set for the design team and the quality thresholds set out as a requirement for approving the design. Lessons might be learned from the commercial world of marketing and PR, where customer requirements are reviewed and analysed by focus groups and other surveys conducted from the point of view of the customer. Fortunately, these issues are now better understood and acknowledged by the NHS and the annual patients’ survey has begun to tackle these issues. More work remains to be done as priority shifts from meeting the requirements of the service provider to satisfying the services expected by patients. Analysis of questionnaire results from GPP (Geoffrey Purves Partnership) designs Of the primary care centres designed by the Geoffrey Purves Partnership 14 have completed the questionnaire. An analysis of the results highlights some interesting points. The overall response to section 1, First Impressions, shows a high level of satisfaction (88.9 per cent). The main criticism from this group of questions arises at 1.03, which indicates that there is dissatisfaction with the level of parking for patients and staff. All of the respondents said that their building appeared welcoming and that there was easy access for disabled people and parents with prams.

Approach to briefing However, section 2 on Access showed the lowest level of satisfaction of all the sections with less than half (46.4%) considering that all parts of the building were accessible to everyone, and that adequate provision had been made for people with mobility, hearing and sight difficulties. This immediately suggests either that the briefing requirements to the architect are inadequate, or that the architect has failed to respond adequately to the needs of patients and staff with disabilities. Although there was a high level of satisfaction with the questions regarding reception and waiting areas, the design and structure of the questionnaire itself is suspect in that doctors were scoring against their own requirements for the brief. For example, all surgeries were satisfied with their patient call system. This should not be surprising because the patient call system in every case is that which was requested by the doctors themselves. Following a more limited participant observation exercise involving two waiting areas, it was apparent that there were many deficiencies in the detailed functioning of the reception and waiting areas which would not necessarily be apparent to the doctors or staff of the surgery in question. However, there were significant shortcomings when seen from the patient’s perspective. The patient call system does, of course, touch upon the very essence of the patient/doctor relationship. Should a doctor greet a patient personally, which is time consuming, or should a patient be called to the consulting room by the use of indicator boards, tannoy systems, or simply by reception staff calling out names? In many cases, the patient feels disadvantaged, and immediately less equal than the doctor. An apprehensive patient, feeling unwell, waiting to be called by the doctor conjures up the mental image of a child being called into the headmaster’s study, or in an adult scenario, someone seeking a job being called in to present themselves to an interview panel. A visit to a private hospital, for example the Nuffield Hospital in Newcastle upon Tyne, illustrates the different approach taken where consultants come to the waiting area personally to greet their patient on neutral territory. How do you measure the cost of these alternative approaches? High levels of satisfaction were expressed for the consulting, examination and treatment rooms. These spaces are the subject of detailed briefs within the NHS procurement system and doctors have a significant control over the detailed layout of their working environment. However, there was a significant level of dissatisfaction (21 per cent) of the confidentiality ensured in terms of both sight and sound (question 4.04). Generally, circulation spaces were not criticised although 64 per cent of the respondents said that staff could not circulate without going through the waiting room. Although not stated, the implication of this question is that it was disadvantageous for staff to use the waiting room as a circulation route. This, of course, may not necessarily be so. Lighting in the staff areas was not considered to have been designed to meet flexible working needs by 29 per cent of respondents.

The highest levels of negative answers to the questionnaire were in the building efficiency section. Overall, only 61.3 per cent answered yes to the questions in this section and only 36 per cent thought that there was flexibility in relation to future needs. The question regarding telephone systems is flawed, in that it asks two questions (i.e. is the telephone system adequate and is a telephone provided for patient use?).

Current government policy for primary care buildings General practitioner surgeries If the special needs and cancer care buildings illustrate an outstanding concern for designing sensitive environments then the general practitioner buildings demonstrate the rapidly changing procurement routes that are revolving in primary health care. We have seen that the special needs and cancer care buildings have had more opportunity to explore the development of a design brief outside the constraints normally imposed by the NHS procedures. With general practitioner buildings the pressures for development have focused on the procurement route and a variety of models have begun to emerge. Primary sector finance is being introduced, both by the government through its LIFT initiatives and by developers offering comprehensive building services to health providers. PFI contracts have explored batching general practitioner premises together to form larger contract values. The projects that are illustrated include a variety of procurement routes, as well as several examples from the last generation of cost rent generated projects based on the principles laid out in the ‘Red Book’. The best of the new examples not only succeed in embracing new procurement and financing routes but also rise to the challenge of producing high quality architecture with stimulating environments and an understanding of the therapeutic benefits that good design can provide. Over the next few years the opportunity to explore these trends should be grasped. The design and theory of a patient focused architecture needs to be shared internationally. We can expect to see a new wave of buildings offering spatial flexibility, patient accessibility and a caring environment. Pushing at the boundaries of this work is a group of professionals who have recognised the need to mix disciplines, and design buildings that are humane and contribute to the built environment. During the last decade there have been very many excellent examples of primary care buildings. The RIBA Clients Advisory Service (CAS) lists over 600 practices with experience of designing primary health care buildings and their database provides a substantial track record of competent buildings. Many are excellent, and will continue to provide a good service to patients for many years. Some of these good examples can be found on the NHS CD-Rom ‘Design Quality’, and, of course, the NHS booklet Environments for Quality Care published as long ago as 1994 provides a selection of exemplar projects from around the UK.

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Primary Care Centres More recently, the results of innovative architects working with sympathetic medical practitioners have explored a number of approaches to improve environmental quality and these are discussed elsewhere in this book. Issues such as the introduction of artworks, stained glass and improved disability access (including mobility, audio and visual impairments) have all added to the knowledge base for buildings used for primary health care purposes.

A Contract for Health

46

Local players and communities can:

People can:

Provide national coordination and leadership.

Provide leadership for local health strategies by developing and implementing health improvement programmes.

Take responsibility for their own health and make healthier choices about their lifestyle.

Ensure that policy making across government takes full account of health and is well informed by research and the best expertise available.

Community facilities As we have seen, a variety of solutions have been designed to meet the multifarious requirements of local circumstances both in the UK and around the world. These buildings are invariably complex and lay down a challenge for the clarity of the design to be preserved during the procurement route. Hence, the buildings encapsulate the often conflicting objectives of ‘product v. process’ discussed more fully in earlier chapters. They are a test of the UK government’s policies to achieve high standards of design while seeking to introduce private funding including the use of PFI contracts. This has led to differences of opinion within the architectural profession. On the one hand, academics such as Susan Francis, at the Medical Architecture Research Unit, say: ‘Over the past 10 years some of the most successful designs have come through primary and community settings.’ However, she is concerned that NHS LIFT will mean the batching of smaller buildings within a given area to form larger contracts that will be procured through framework agreements. This, she believes, will lead to a lack of site-specific work and will attract consortia that might not otherwise be interested in jobs of this scale. Mike Nightingale of Nightingale Associates does not share such a pessimistic view. He says: ‘We do both building and interior design in the health sector so are well set up. It is a good time to be specialising because there is a wealth of work and a feeling that days of utilitarian hospital architecture are over: first the Egan Report suggested good design was good for patients and now CABE is working with the Government through the NHS Design Forum on the importance of good design. Starting small with clinics will give small firms a chance to get in, but they will have to show competence and an ability to cope with complex work. There is evidence that PCTs will be quite entrepreneurial about procuring buildings’ (Richardson, 2001). Of course, the other major factor in the shape of primary health care buildings of the future will be the working practices of GPs themselves. Doctors are under increasing pressure in the UK to modify their working practices, look again at job descriptions and the work that may be undertaken by nurses, and their involvement, if at all, in the financial structure of the ownership of medical buildings. Examples in the UK and in other countries illustrate the range of work and approaches adopted for primary health care community facilities in response to these changing needs of both the medical and architectural professions (see Figure 5.4).

Government and national players can:

Work with other countries for international cooperation to improve health.

Work in partnerships to improve the health of local people and tackle the root causes of ill health. Plan and provide high quality services to everyone who needs them.

Ensure their own actions do not harm the health of others. Take opportunities to better their lives and their families’ lives, through education, training and employment.

Assess risks and communicate those risks clearly to the public. Ensure that the public and others have the information they need to improve their health. Regulate and legislate where necessary. Tackle the root causes of ill health.

Figure 5.4 A contract for health – national and local responsibilities

The same document (p. 31) identifies two key aims: ●

●

To improve the health of the population as a whole by increasing the length of people’s lives and the number of years people spend free from illness. To improve the health of the worst off in society and to narrow the health gap.

These policies were further reinforced in the NHS Plan which lays down the criteria for a patient focused health service, and increases further the emphasis placed on primary care and the preventive nature of those services. A list of proposals includes more routine screening tests and guidance to patients on how to minimise or reduce risks to their health. In essence, it is a policy about encouraging communities to adopt healthier lifestyles. As 90 per cent of all health care is undertaken at the primary level there are obvious cost benefits to aim for in a service that costs the country over £40 billion each year. The introduction of NHS Direct, which allows people to make direct contact by telephone to health professionals, will encourage individuals to regard the NHS as a resource from which they can seek assistance to develop a healthier lifestyle, and look after themselves in their own homes.

Approach to briefing What are the design and policy consequences of preventive medical care? There has been a fundamental reorganisation of the way in which primary care is organised in the UK. The introduction of Primary Care Groups has changed the landscape of GP services and the effects of these changes will snowball as the Primary Care Groups assume the status of Trusts, with the attendant responsibilities of self-administration and control of substantial resources beginning to become effective. The integration of social services within these Primary Care Trusts will provide a comprehensive range of services covering primary care, mental health and social services, thereby creating a wide-ranging resource. In part, these changes are, perhaps, a result of the recognition that patients are consumers, and the medical profession has been slow to recognise the higher standards of service which a market economy has provided for the consumers of most other service providers. Therefore, there is a very rapid learning curve in process whereby the medical profession understands that the patient is a customer who will have all the usual questions of efficiency, cost effectiveness and quality of service uppermost in their minds when seeking health advice in the future. The medical professions should see this as an opportunity, particularly with regard to health care facilities where the physical assets can be designed with quality as a key factor in the briefing process. The brief will recognise that buildings of the future should be designed to provide a healing environment. The aim will be to achieve therapeutic benefits by the use of good design to provide flexibility, long life and visually satisfying environments. Even the Treasury is recognising that intangible benefits should be taken account of when looking at PFI projects. Not that PFI is an appropriate vehicle for the design of small primary care health facilities. Therefore, the history of primary care health facilities is set to embark on another phase of development. Following the first health centres designed in the 1930s, for example the Finsbury Health Centre designed in 1938 by Lubetkin, through the generation of health centres designed in the 1950s (not a success because they were unpopular with GPs) and moving away from the ‘Red Book’, generated GP surgeries of the 1980s and 1990s. This last group of buildings produced many very well-designed projects arising from the close working relationship between GPs and architects. It provided an example of health buildings that were procured relatively quickly, and avoided the bureaucratic and extended delivery period of the hospital building programme of the same period. Unfortunately, the financial constraints encapsulated in the ‘Red Book’ still frustrated the fluidity of much innovative design and both doctors and architects were constrained in their aspirations. For example, the cost allowances only allowed for fixed furniture. How does a doctor provide sofas in a consulting room? A doctor may not wish to tell a distressed patient that cancer has been diagnosed, or deal with a serious mental anxiety,

across the corner of a desk sitting on upright chairs more appropriate to an office. Few doctors have been prepared to supplement the ‘Red Book’ allowances to fund additional equipment and furniture to personalise their surgeries. Stereotyped room data requirements have stultified innovative solutions within consulting rooms. The next generation of health care buildings for the primary sector will be flexible long-life buildings, based on a comprehensive briefing document where design quality plays a major part in establishing the design philosophy.

GP policy aspirations Many doctors do not wish to be building owners. Many doctors also wish to be salaried employees, rather than selfemployed contractors to the NHS, providing a service where their remuneration is based on the quality of care they provide, rather than on accountancy rules using patient lists, and number of visits and consultations as the basis for pay. Professional demarcations have also become outdated, and we will see developments in the integration of social service personnel, mental health practitioners and greater specialisation for routine procedures to be part of the GP’s future contract of employment. Technology will develop and telemedicine will offer more rapid diagnostic services from the laboratory back to the consulting room. The aspirations for future doctors will be more rounded, less clinical and integrated with the community in an accessible building. The next generation of doctors will have a much broader-based education involving the humanities as well as the traditional clinical and technical basis for their studies. Already being introduced by Durham University at the Stockton campus, there will be a programme of humanity modules including literature, the arts and architecture to encourage a holistic approach to the complete healing environment. Similar courses are also being introduced in London and Wales (University of Wales, Swansea).1 Far better to have a community thriving with a high quality of life than doctors fighting a rearguard action to treat diseases which are often the result of poor environmental standards. Perhaps doctors may even prescribe environmental conditions. We already understand some of these issues, for example: ● ●

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Safer driving reduces accidents. No smoking in offices and restaurants reduces the risks of cancers. Fitness and diet are promoted as health policy.

The provision of new facilities will embrace a new partnership between public and private finance. 1

These issues are more fully discussed in Medical Humanities, A Practical Introduction (eds Deborah Kirklin and Ruth Richardson) published by the Royal College of Physicians, 2001. It includes schemes of modules for the MA (Wales) in Medical Humanities and the BSc in Medical Sciences and Humanities.

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Primary Care Centres Evolution of concepts Evidence-based design The changing pattern of the approach to health has evolved through phases of holistic care, followed by more technical solutions. More recently (over the last decade), there is emerging a greater awareness of the importance of welldesigned buildings and justification for this approach is being directed through ‘evidence-based design’ (EBD). The most widely cited and quoted researcher internationally in the area of evidence-based health care design is Roger Ulrich, Professor of Architecture at Texas A&M University. In 2005, he began working in the UK for the NHS. Although most of his work relates to hospital design, aspects of his research are relevant to primary care health buildings. He has reviewed more than 650 scientific studies linking aspects of the designed hospital environment to reduced patient stress, better medical outcomes, increased patient safety, improved staff morale and effectiveness and reduced operational costs. A helpful source for a review of literature on this subject is to be found in two university research papers. 1. ‘A Comparative Study of the Impact of Environmental Design upon Hospital Staff and Patients’ (Leather, 2000) looked at the design of a measure of environmental appraisal within a context of ‘therapeutic environment’. It defined ‘therapeutic’ as ‘an environment which is supportive of patient needs and which portrays a ‘‘nurturing’’ and ‘‘non-threatening’’ image which ‘‘helps to put people at ease’’’ (Carver, 1990). It concludes that ‘the physical design of a hospital environment is not simply a matter of functional purpose and specification. Rather it is a matter of symbolic meaning. Put simply, the image created by any particular design conveys an important set of messages about such things as the likely feelings to be experienced there, the value placed on patients and visitor comfort, and the hospital’s humanness and competence as an institution.’ The report goes on to make two further statements about the relationship between patient satisfaction and well-being. 1.1 The conclusion which follows is that positively appraised environments are beneficial to patient satisfaction and well-being. At the very least, they are conducive to the generation of positive moods. Beyond that, however, there is also evidence that they are associated with increased mental capacity, lower drug use and a shorter post-operative stay. 1.2 The major conclusion drawn, that hospital design is an important factor in promoting patient well-being, is certainly worthy of further systematic attention and research. The effects of design are clearly not arbitrary. It is important, however, that the full range and size of these effects is carefully and scientifically investigated, rather than being the subject of personal opinion, anecdote and unsupported conjecture.

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2. A more recent report commissioned by NHS Estates in 2002 was titled ‘Investigation and Assessment of Attitudes to and Perceptions of the Built Environments in NHS Trust Hospitals’ (University of Salford, 2002). It concluded from its literature review ‘that it was possible to use the built environment to support patients’ recovery. The research reviewed suggested that the built environment of hospitals influenced the healing process and that it had a direct impact on patients’ health outcomes through enhanced relaxation, enabling views of nature and creating a healing environment. In this way, the built environment of hospitals can facilitate and encourage optimistic perspectives, attitudes and responses from patients. Through its healing environment, it can help to reduce the stress that patients encounter during their hospitalisation period and thereby help them in their personal recovery and recuperation.’

Work in this area is being taken forward by another research project funded by NHS Estates (Leeds) being undertaken by CAHHM at the University of Durham. The research project evaluated the quality of environment at the James Cook University Hospital. ‘The object is to investigate whether the Trust and the architects’ vision of the new hospital development as one which promoted wellbeing is indeed achieved’ (2nd draft report). The project is a £140 m major reconstruction of the South Cleveland Hospital under a PFI contract. The brief sets out a commitment to the delivery of high quality ‘patient centred care’ and one of the research questions addressed was ‘what did the architects and the Trust aim to achieve with this new hospital and how did they go about it?’ From the pioneering research of Roger Ulrich (Ulrich, 1984) the USA has been at the forefront of environmental design quality work in health buildings. Much of it has been centred around a group of people working at the Texas A&M University, together with a further group of specialists who have created the Center for Health Design, based at Martinez in California (www.healthdesign.org). More recently, a series of research initiatives has developed in the UK, with considerable interaction between MARU (Medical Architecture Research Unit) (London), Manchester, Sheffield, Nottingham and Durham Universities, all of whom are developing research outputs. Several international conferences have been held and the output of properly researched papers examining various aspects of environmental design, and the therapeutic benefits that can be achieved, is steadily increasing. Wayne Ruga is an architect, and was responsible for founding the Center for Health Design, and organising its first international symposium in 1986. Now working in the UK at Manchester University, he is interested in the relationship between the environment and our culture. He asserts ‘that in order to improve an organisation’s environment you must first improve its culture, giving the patient the empowering Plaintree model in the US as a successful example in health

Approach to briefing care’ (Parker, 2001). The challenge to bring together robust evidence-based data and combine it with the philosophical theories of human nature continue to give difficulties to research groups around the world. The Center for Health Design has produced a number of reports, including the following four studies particularly of interest for the design of primary health care facilities:

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Design evaluation of six primary care facilities for the purpose of informing future design decisions. Gardens in health care facilities: uses, therapeutic benefits and design recommendations. Consumer perceptions of the health care environment: an investigation to determine what matters. An investigation to determine whether the building environment affects patients’ medical outcomes.

In the UK MARU has been a leader of research into the design of health care environments and has produced a wide range of documents and publications. The difficulty remains the requirement by government policy makers that research must be evidence based before priorities are changed in the procurement process for new facilities. The requirement to demonstrate economic advantage continues to be a difficulty: for example, work undertaken by the Department of Design and Architecture at the University of Luton, looking at the design implications of the Patient’s Charter, identifies the shortcomings in the questions asked of patients about their perceptions of the building environment. ‘The design variables highlight the conflicting views of some patients when comparing information or data. The results showed that questions relating to the patient’s perception of the built environment generated an average response on the aesthetics and functional aspects of the hospital. Whereas questions relating to their immediate wellbeing and personal relationship with medical and professional staff generated a higher response from patients’ (Amoah-Nyako and Henderson, 2001). A conference in Stockholm (June 2000) also brought together many influential speakers and participants in the field of environmental design quality research. The transactions of the symposium (Dilani, 2001) provide a valuable summary of the information available at that time. However, it is apparent that the empirical research data available is limited and more high quality evidence is required. This research continues to evolve and further conferences (Montreal 2003, Frankfurt 2005 and Glasgow 2007) arranged by the International Academy for Design and Health have built on the data available. The last conference in Glasgow has highlighted the move towards the need to create a healthy environment which is socially and economically sustainable. This underpins the sense of wellness and spiritual fulfilment which is necessary to enjoy a healthy lifestyle.

Future plans Community-based health/holistic approach (echoes of Finsbury and the Peckham Experiment) It is interesting to compare the latest government proposals for the provision of primary health care buildings with the Peckham Experiment and Finsbury Health Centre models of the 1930s. There is a return to providing primary health care facilities at a community level (80–90 per cent of all health care is provided by GPs outside of hospitals) through the programme of Health Living Centres and other initiatives which are developing new procurement policies such as the PFI programme, Procure 21 and LIFT. Better informed patients/consumerism Patients are better informed today than when the NHS was introduced over 60 years ago. Consumerism will influence the attitude of patients who are used to high levels of customer care in other sectors of the economy. As the NHS Plan makes clear, ‘too many patients feel talked at rather than listened to’ (NHS Estates, 2000). It will take time for patients to understand the new power within their grasp to influence the shape of future facilities. However, the influence of supply and demand in the market economy will inevitably challenge the providers of buildings to meet the new requirements. CABE The Commission for Architecture and the Built Environment (CABE) has replaced the Royal Fine Art Commission. It is developing a role to monitor and comment upon design standards for major new buildings including health buildings. The Office of Government Commerce (OGC) has published a report ‘Improving Standards of Design in the Procurement of Public Buildings’ (OGC, 2002). This document underlines the change in government policy towards design standards. The Rt Hon. Paul Boateng MP, then Chief Secretary to the Treasury, says in the foreword: ‘the report underlines the Government’s repeated message that sound, creative design is an essential ingredient to achieve best value for money. Through the working life of a building, design excellence can make service delivery more efficient and enhance the working environment for all those who use our public buildings.’ This is followed by Sir Stuart Lipton (Chairman of CABE at the time) noting that ‘two years ago the Prime Minister asked for a step change in the quality of new public building projects’. Importantly, HM Treasury is reported as recognising the value that design adds, not only in the construction process but also over the lifetime of the building. The document identifies that ‘setting clear benchmarks for the expected design quality on best practice’ is an important goal as part of the government’s commitment to the largest public building programme for a generation. A massive increase in public capital investment is occurring, doubling the level of investment in just four years to £38 billion per year by 2003/04. One of the main products of this commitment will be new and improved hospitals, schools

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Primary Care Centres and other public buildings and infrastructure. Issues identified as being important include

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● ● ● ● ● ● ● ●

fitness for purpose build quality sustainability adaptability safety efficiency appreciation of context and an aesthetic impact that contributes to civic life.

However, contradictions and problems are thrown up by this approach. The government recognises the importance of the breakdown of a building’s cost. Over the lifetime of a building, the construction costs are unlikely to be more than 2–3 per cent of total costs, but the costs of running a public service will often constitute 85 per cent of the total. On the same scale, the design costs are likely to be 0.3–0.5 per cent of the whole-life costs, and yet it is through the design process that the largest impact can be made on the 85 per cent figure. The report acknowledges that ‘to date, the evidence suggests that we have made considerable progress in achieving the improved efficiency but that we have not yet consistently achieved excellence in terms of design quality’. CABE summarises good design as being a mix of the following attributes: ● ●

functionality build quality

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efficiency and sustainability designing in context aesthetic quality.

These aspirations are further explored by examining the design process within PFI contracts and by the appointment of Design Champions by Clients. Although not directly related to primary health the experience of the research project undertaken by CAHHM at the new James Cook University Hospital in Teesside is a useful comparator. Some early results from PFI contracts for the procurement of new hospital projects have been criticised in the press as being poorly designed. Indeed, the design by HOK for the new London Hospital (St Barts) has been severely criticised as poor by CABE. Communications between client, clinicians, contractor and design team are blamed but the heavy weighting on value for money has driven design standards down, in the view of many outside commentators. It would seem that the aspirations for good design have now been recognised by the government and it is keen to include high quality environmental standards as a target within building briefs. However, the tests for evaluation are still poorly developed and there is evidence that the Treasury continues to use lowest cost as their key benchmark when awarding PFI contracts (Nisbet, 2004).

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Design development/measurement of design quality

Outline of chapter and introduction This chapter reviews the traditional approach to designing GP surgeries, considers the development of alternative procurement routes introducing private capital and looks at several evaluation toolkits that are in use to look at the performance of health buildings. Over the last 20 years the starting point for the brief of a doctor’s surgery has been based on the standards set down in the ‘Red Book’. The ‘Red Book’ is a comprehensive manual defining a wide range of operating standards to be used by doctors when running their GP practices. Included in the document is a section on premises which includes a series of schedules of space standards for different sized GP practices from two to seven doctors. The schedule of allowable areas is linked to a financial formula and establishes the area and financial limit for a new GP surgery. This document makes no reference to the quality of care to be provided within the buildings. Doctors could exceed the financial limits set down by these schedules but any additional finance had to be provided from the doctor’s own resources. In practice, this very rarely occurred. There are guidance notes available to doctors, and their architects, giving additional information about the design of the spaces within a GP surgery, but there is almost no reference at all to the quality of the design. For example, Health Building Note 46, General Medical Premises, identifies under the sketch design stage at section 3.17 that ‘the architect will base the design of the sketch proposal upon the written brief – a statement of the operational policy and functional space requirements of the practice’. The brief is developed by the GP and the architect in discussion with the primary health care team and the FHSA. At section 4.1 it is noted that the building of new practice premises ‘provides the ideal opportunity to ensure that the building can accommodate

all the functional and operational requirements of the primary health team’. The document makes no reference to consideration of the design ethos of the building, and does not invite doctors to consider the quality of the environment that they are wishing to create for their new building. The changing attitude of government policies is explored, including the new LIFT programme of contracts to expand and develop GP premises based on the aspirations of the NHS Plan. There has been a significant shift in government policy, which now recognises the importance of good design in the development of new GP surgeries. Finally, a range of challenges is identified which are likely to affect the future design of GP surgeries, and the issues which will need further exploration to build on the principles of evidence-based design.

Traditional approach – the ‘Red Book’ The ‘Red Book’ has represented the modus operandi of GP practice in the UK for many years. It represents the outcome from a long period of development, periodic reviews and updating of data. It typifies the outcome of a bureaucratic approach of controlling a very large organisation. The rules, costs limits and schedules of permitted accommodation are very prescriptive, and it is remarkable that so much high quality architectural work has resulted from such a stifling environment. A wide range of innovative GP surgeries built over the last decade have been achieved despite the procurement process being heavily weighted towards issues of functionality and cost rather than design quality. Fortunately, this framework of controls is now rapidly breaking down as new forms of procurement expand and develop in the joint public private partnerships that the government is encouraging, but there is a long way to go.

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Primary Care Centres Controls on loose furniture, tight budgets, discounted fee scales for professional services and other prescriptive requirements for accommodation requirements and overall floor areas made life difficult for both doctors and architects. A completely different approach to building design is required for the next wave of primary care buildings. They must be buildings that are flexible, can incorporate the demands of a knowledge-based economy and respond to the rapidly changing demands for information technology and different working methods which will develop from faster communications between doctor, patient and specialist testing facilities (e.g. x-rays, consultant reports). Government procurement methods must enable future buildings to be flexible shells within which highly serviced workstations can be developed and changed over short periods of time. For example, a doctor’s consulting room may have entirely different requirements in five years’ time than it does today – although it is likely to remain the fundamentally important space within which patient and doctor exchange information.

Lifecycle costs and ‘best value’ – the government’s approach Until recently, lifecycle costs have been relatively unimportant in the government process of procuring buildings, including those for the NHS. The tradition has been to award contracts predominantly on a lowest cost basis. The Treasury has now changed direction and the welcome interest in design quality is also manifesting itself in a reassessment of whole-life costs. This approach is encapsulated under the umbrella of ‘best value’. All government departments and local authorities are taking a broader look at ‘best value’ issues and this is providing an opportunity to develop new thinking about a whole range of tangible and intangible aspects of a building during its overall lifespan. At the simplest level, building material manufacturers are able to demonstrate ‘best value’ for their products not only as the result of initial costs but also taking into account maintenance schedules and renewal timescales. With design issues the growing recognition of user reactions and user satisfaction levels is beginning to influence the decision-making process. GP surgeries are too small to justify the competitive precontract procedures that potential development partners face under PFI (Private Finance Initiative) procedures. The government policies for their Procure 21 method of procurement seem to be stalling, with considerable delays and increasing resistance from the contractors who have subscribed to the framework agreement. However, there is a growing group of specialist companies forming partnerships with GPs to finance new primary health care facilities. Their success rate in putting together viable procurement packages is being helped because of the changes in attitude by district valuers. District valuers are moving towards the creation of a special class of valuation for medical facilities, whereas previously they were seriously disadvantaged by

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being included with residential or local commercial values. These high valuations that are being rentalised as surgeries are enabling contracts to be written for a minimum of 25 year lease periods guaranteed by local health authorities under the terms of existing procedures.

Cost limits and functionality – a restraint on innovation Hospital design in the UK over the last 50 years has been disappointing. With few exceptions, design quality has been disappointing, sometimes institutional, and not responsive to patients’ needs. The procurement process has been too extended, design quality has been largely ignored and functionality has remained too important in a process dominated by the service providers and the administrators far removed from the interface between patient and doctor within the confines of a clinical ward. Similarly, primary health care buildings have been constrained by a set of procedures contained within the ‘Red Book’, which is now outdated. There have been enlightened solutions in recent years, by architects who have enjoyed a sustained period of work in this sector but imaginative solutions have been inhibited by the cost limits and tests of functionality.

Changing procurement systems It was encouraging, therefore, that the government launched a new organisation, NHS LIFT (Local Improvement Finance Trust), first previewed in the NHS Plan (p. 45) and included in the government’s proposals for new legislation in the Queen’s speech given on 6 December 2000. The intention is to mirror the PFI programme for hospital developments with a scheme suitable for family doctors. The Department of Health envisage 3000 GP premises, mostly in inner cities and poor estates – more than a quarter of the total – being transformed by a £1 bn fund combining public and private money. NHS LIFT will be set up as a limited company, working jointly with the private sector. The government’s first allocation will be £175 m (Hawkes, 2000). The Secretary of State at the time (Alan Milburn) foresaw a complementary programme of public private partnership invested in primary care facilities to improve accessibility, particularly in the neediest areas. It is envisaged that the new facilities will also combine other services such as retail outlets, an optician’s shop, a pharmacy, or other related services. Similarly, the intention is to bring primary care and social services together to improve communications and coordination of needs, thereby achieving a one-stop service for health, social services and housing. The ‘Red Book’ policy continues to focus on room areas and cost parameters but new procurement systems will emerge. The NHS Plan is moving in the right direction. The

Design development/measurement of design quality new financial proposals through LIFT will introduce private finance and increase the flexibility of procuring new primary health care facilities. We can anticipate that there will be fewer partnerships, and that doctors will move towards being salaried employees of Primary Care Trusts. Younger doctors, in common with many other professions, are increasingly reluctant to take on the financial responsibilities of a partnership in an economy that has seen sustained and steady growth with security of employment prospects. Financial success and security can often be achieved without taking on commercial risks. The historical advantages of partnership are increasingly being overtaken by new structures for professional services. Therefore, we can see a major shift towards greater concern for design quality as more sophisticated measuring systems are introduced to evaluate ‘value for money’. Much more research is required to develop accurate appraisals of whole-life costs. From an environmental stance, all five senses of the human body should be considered. 1. Touch 2. Smell 3. Sight 4. Hearing 5. Taste. Some research work is under way paying particular attention to these issues (John Wells-Thorpe, who is chairing a research group based at Sheffield University under the direction of Professor Bryan Lawson).

The Health Minister, Alan Milburn, said when he announced the publication of a report on the progress necessary to improve the NHS Estate (February 2001): One third of our hospitals were built before the NHS was created, and one tenth dates back to Victorian times. You cannot deliver 21st century care in 19th century buildings. For too long investment in NHS infrastructure has been a low priority when it should have been a high priority. Capital investment in the NHS was lower at the end of the last Parliament than it was at the beginning. The consequences are plain for all to see. Buildings that are shoddy, equipment that is unreliable, hospitals that are out of date. Kate Priestly, Chief Executive of NHS Estate when speaking at the CABE conference in London on 6 February 2001, restated that the NHS has the largest property portfolio in Europe. However, 30 per cent of the estate was built before 1940. As part of NHS Estates’ plan to raise the importance of design quality to meet the aspirations set out in the NHS Plan 2000, the biggest ever hospital building programme in the history of the NHS has been launched with a £7 billion capital investment planned by 2010. By then, 40 per cent of the NHS Estate is planned to be less than 15 years old. Part of this plan is to achieve a £1 bn investment in primary care facilities. These issues are now being challenged with huge investment by the government and rapid change is gaining momentum.

Government policy

Construction targets

Procurement routes are changing. Primary health care facilities are becoming larger multifunctional ‘healthy living centres’ offering integrated health and care services. A variety of agencies and professional skills will work in buildings serving the local community. Private finance will be provided by specialist developers and local initiatives will ensure greater control of matching requirements with services. This will have the benefit of allowing the new community facilities to include a wider range of services such as pharmacies, dentists, physiotherapists and alternative or complementary medical practitioners to work all under one roof. As health and care services become more integrated, the new community buildings, or healthy living centres, will grow in size and become multifunctional with a target of 500 new healthy living centres. Opportunities for small and medium practices are set to expand. Building costs can be expected to range between £500 000 and £5 million.

Primary care buildings have faired better during the last 20 years, with some excellent projects having been constructed, showing innovation in design and procurement. Potentially better is to come following the announcements in the NHS Plan.

The condition of the existing estate An examination of the NHS buildings that followed the launch of the NHS Plan in 2000 recognised the size of the problem.

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Refurbish or replace 3000 GPs’ premises. Build 500 ‘one-stop’ primary care centres by 2004.

The formation of Primary Care Trusts is an important policy change creating separate legal entities that can own property and act as clients. Previously, GPs were the main client body, often raising their own commercial loans to finance surgery buildings. Problems of negative equity have arisen and this has discouraged younger doctors to take on the responsibilities of debt to finance their partnership aspirations. The attraction of salaried employment has encouraged specialist developers to offer long-term leases for new premises. How are these ambitious investment plans going to be achieved? The construction industry as a whole is witnessing an upheaval in its procedures, and procurement routes, which are more radical than at any time in the last 50 years. In the mid 1980s over 70 per cent of construction was procured

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Primary Care Centres using ‘traditional’ contractual arrangements but this had reduced to less than 40 per cent by 1998. The last 20 years has seen an unprecedented upsurge in new contractual arrangements between client and builders which has all had an impact on the way in which design teams have been employed and briefed. There has been a decline in the traditional role of quantity surveyors, project managers are beginning to emerge as a separate professional discipline and design and build contracts have offered maximum price building costs, but all too often there was disappointment about the finished building. The translation of design aspirations often led to disappointment in the realisation of the finished product. Buildings were often over budget, delivered late and had too many defects. The Latham Report, ‘Constructing the Team’ (1994), was the first major investigation set out to examine how buildings were commissioned and built in the UK. This was followed in 1998 by the Egan Report, ‘Rethinking Construction’, a document that concentrated on improving the construction industry by viewing it as a manufacturing process. It identified targets to reduce defects, reduce costs, encourage standardisation of components and offer continuity of work by encouraging the major clients to enter into framework agreements with selected contractors and design teams. Many architects were concerned about the implications of these reports upon their profession, believing that their influence would be diminished and that they would be marginalised by big guns in the major contractors and client bodies – and for a while these concerns were probably well founded. More recently, stimulated by a refocusing of effort in looking at the quality of the product, as well as the quality of the process, there has been a resurgence of concern for high standards of design. These arguments are covered elsewhere in this book. Society has become more aware of the importance of a sustainable, environmentally friendly environment and is developing an understanding for designs that embrace the quality of life factors – the joy and delight that architecture can add to the fabric of society. This highlights the need to fundamentally shift priorities in the current briefing process. The ethos of the organisation must be the springboard for the development of the brief. Procurement routes are therefore changing, and developing to reflect these requirements: ●

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Criticism of the PFI route – architects have felt their influence constrained by often being expected to work speculatively, or at peppercorn rates, during the competitive bidding stages of appointment often taking many months (if not years) to reach a conclusion. They also feel subservient to the main contractor after their novation in a winning team and sometimes lose authority over their own designs. Procure 21 – the NHS Estates’ proposals for meeting government expectations for repeat business to a selected list of approved large contractors but subject to much criticism by medium sized architects and contractors.

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The LIFT scheme promises to meet many of the difficulties inherent in the other procurement routes particularly for primary health care facilities.

The potential damage caused by the marginalisation of SMEs (small and medium sized enterprises) in the procurement route is considerable, with a loss of skills, resources and local knowledge. There should be a rejection of policies which polarise organisations as either small or very large. The damage done to medium sized contractors, architects and many others in the design process is likely to be enormous.

LIFT (Local Improvement Finance Trust) The launch of LIFT is a new initiative to stimulate the funding and operation of future primary health care facilities. This scheme has superseded the earlier concept of batching primary care facilities together to form the ‘critical mass’ necessary to carry out improvement work under PFI rules. Newcastle had been a pilot study area for the batching of 32 primary health care buildings to create such a single contract opportunity under PFI rules. The Outline Business Case (OBC) had been prepared, but for a variety of reasons the number of sites was reduced to 22. Extensive and helpful comments were received on the OBC from the regional office. However, the launch of the NHS Plan included proposals for LIFT which is designed to introduce private finance in a structure that devolves responsibility down to smaller building blocks at a regional and local level. This company would have a board of advisers and oversee the allocation of funds to regionally organised LIFT companies. These in turn will attract further finance from local authorities, housing associations and Primary Care Trusts and would operate with local boards. The regional LIFT companies would then seek to enter into joint venture agreements with local developers to provide new local primary care facilities. Hence, the initial government funding is designed to lever in a substantial proportion of private finance. A concern is whether the local companies would be of sufficient size (i.e. big enough) to provide competencies in the key areas of: ● ● ●

Strategy Construction Facilities management (FM) and health services.

It might be anticipated that all these skills may be difficult to find within one company, which would be of a size commensurate with the scale of project envisaged at a local level.

Local responsiveness and flexibility To provide high quality local primary care facilities requires flexibility, and a local responsiveness to the needs and

Design development/measurement of design quality requirements that are particular to a community. It can be argued that the provision of the physical building should be separated from the provision of health services and the attendant facilities management needs during the life of a lease. Other sectors of the building industry and property market make clearer distinctions between the provision of the buildings and the operation of the services within them. As discussed elsewhere the office market has clearer structures which govern the way buildings are commissioned and occupied. Although some building owners occupy their own building, a much more sophisticated briefing process has evolved in recent years to enable a greater understanding of flexibility, efficiency and satisfaction by the people who use the spaces. The development of similarly comprehensive briefing documents should be a prerequisite for all new primary health buildings. Within the structure of NHS Estates, regional responsibilities are also limited to an expenditure level of £25 m. This will also limit the size of packages that can be put together at a local level if responsibility and accountability are to be kept within the communities requiring the services. Site acquisition is likely to be a critical factor, and location is a crucial component in the success of a primary health care building. It seems essential, therefore, to ensure that this imaginative initiative is fully explored at a local level, to ensure that the mechanisms are in place to provide the flexibility and responsiveness that will be required for its success. Medium sized developers, consultants and construction firms will need to work together so that collectively the competencies required are provided. This fundamentally different approach to PFI will encourage a ‘bottom-up’ rather than a ‘top-down’ approach to new solutions. There are those who argue for repetition, and standardisation in the provision of primary health care facilities leading to ideas of the same building being reproduced on many sites. An analogy might be drawn to the standardisation of fast food outlets such as McDonald’s, or even the larger supermarket operators such as Tesco or Sainsbury’s where there is a standardisation of building design. However, the NHS is not dispensing commodities; people do not go to their GP to buy off-the-shelf products and the diversity of services suggests that primary care demands a more flexible solution, which will respond to local needs and the peculiarities of a particular community. Perhaps there will be components of a building which could be standardised but health care needs to accommodate the social values that can flow from flexible and humane spaces.

Green to submit designs for five sites at Walker, Brunton, Benwell, Shiremoor and Kenton. The first three were designed by the Geoffrey Purves Partnership and the last two were designed by B3 Burgess. An extensive round of negotiations was conducted before final bids were submitted to the Primary Care Trust. There was a prolonged and exhaustive appraisal process, including a presentation and interview session involving many of the agencies involved in the design process. The client body was complex, including both the local authority and individual GP surgeries. This involved subgroups of activities including dentistry, social services, housing benefit agency, podiatry, physiotherapy and other nursing services. Robertson Capital Projects were successful with their bid and the Geoffrey Purves Partnership was therefore invited to design primary health care facilities at Walker, Brunton and Benwell. These three areas are all suburban locations around Newcastle upon Tyne. The Brunton site is located in an affluent area of middle class housing whereas the Walker and Benwell sites are located in areas of high social deprivation. The concept of providing multifunctional services from the same building led to many conflicting requirements in the brief. For example, it was difficult to allocate responsibility for individual waiting areas, and therefore allocating the cost of cleaning and maintaining these spaces. However, the brief does set out aspirations for design quality and does make reference to the internal environment. The interview process and final selection showed interest in the architectural responses to these issues but the appraisal system for selection resulted in a small percentage of the score being allocated to architecture. Although precise details were treated as confidential, the design team was led to believe that only 30 per cent of the assessment score was allocated to design and construction matters. The balance was given over to other issues including legal matters, facility management services and the overall financial package for the 25 year life of the contract. Within the 30 per cent score allocated to construction and design there was also a significant percentage given over to functionality issues such as the robustness and suitability of materials, their lifespan and suitability for a medical environment. By deduction, therefore, the percentage of the scoring system allocated to design matters could have been as low as 10 per cent. Extracts from the briefing document for the Walker Satellite Facility and the Brunton Park Facility are included in Box 6.1.

Newcastle and North Tyneside LIFT Project

Government aspirations for good design

In September 2002, the Geoffrey Purves Partnership was selected by Robertson Capital Projects Ltd to join their multidisciplinary team to bid for the Newcastle and North Tyneside LIFT Project. They were joined by a second team of architects, the B3 Burgess practice, together with quantity surveyors Gardiner & Theobald and engineers White Young

With better design being seen as part of New Labour’s ‘Cool Britannia’, architects find themselves in the position of political encouragement from the highest level. How is this manifesting itself on the ground? The public sector programme being led by Sir Steve Robson at the Treasury may have some validity for the handful of big hospitals that

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Primary Care Centres

Box 6.1 Nature of the service and clinical specialities to be provided The Satellite Facility will bring together a number of community oriented services that can be summarised as follows: ● ● ● ● ● ● ● ●

Chiropody/Podiatry Welfare Food Health Visiting District Nursing Consulting Suite for Dietetics, HV, Sure Start, DN Community Dentist Mental Health Physiotherapy – initial assessment

Key functions of the primary care teams not only include the delivery of direct patient and client care but also health needs assessment, health promotion, treatment protocols, care management and the PCT will continue to develop a range of (specialist) services through enhanced collaboration with other professionals/agencies.

●

●

●

●

●

●

Design Quality The NHS is committed to achieving excellence in healthcare design, and LIFTCos’ designs will be assessed against the following principles: ●

●

●

●

Functionality. The design should deliver the occupants’ functional requirements detailed in section 3.0 with sufficient flexibility to ‘future proof ’ the design. Access. Good access to facilities both for everyday and emergency situations, using both private and public transport, should be available for all irrespective of physical ability. Way finding and signage will be clear and an integral part of the design solution. Proximity to areas of pedestrian activity with good lighting and being overlooked from public spaces help to minimise the risk of crime and provide a sense of comfort to all users. Access to the reception area is, for most people, the point where the first impression is made, however, the approach to the building and the ease of access will also play an important part in that process. Space Standards. Space standards shall be developed around ergonomically sound principles. Patient areas should be sized to enable an efficient yet comfortable and therapeutic environment. Character and Innovation. Facilities should be welcoming for patients and conducive for staff to give their best results.

NHS Estates has to deliver over the next few years. But how will it be able to implement this policy for the multitude of small community-based health projects that are going to form the backbone to the primary care health sector in the future and that will need to mesh with local conditions? Their success will depend on the ability to be flexible and responsive to complement existing patterns of housing, education, shopping and transport systems. The emphasis coming out of PPG3, which the private house building companies are being asked to follow, places

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Citizen Satisfaction. The design of public health facilities should stimulate civic pride, acting as a focal point for the community. Internal Environment. Designs shall ensure that patients are treated with privacy and dignity in safe and comfortable surroundings. The building must also provide staff with the optimum working conditions. Urban and Social Integration. The buildings shall be designed to integrate into the fabric of their surroundings, rather than be insular, detached or self contained. Integration of landscape and external works into the overall design will be critical from the outset. Performance. Standards of day lighting, artificial lighting, ventilation, acoustics and thermal comfort should be tailored to deliver the highest levels of patient comfort and staff efficiency in a safe and secure environment. Engineering. Designs should incorporate the latest and emerging technology. Construction. Construction should be of a high build quality with a strong regard for sustainability issues to minimise maintenance and life cycle costs. Standardisation and prefabrication of building elements could be considered if they are appropriate.

LIFTCo should be aware of the importance the NHS places on design by consulting the NHS Estates’ website, which can be found at www.nhsestates.gov.uk. Designs will be assessed using the ‘Achieving Excellence Design Evaluation Toolkit (AEDET)’ which can be found on NHS Estates’ website. The designs should also reflect the content of the CABE ‘2002 Vision: Our Future Healthcare Environments’ report published in June 2002. Account should be taken of the guidance on design quality included in the DCMS publication ‘Better Public Buildings’, the OGC guidance ‘How to Achieve Design Quality in PFI Projects’ and the 4Ps ‘Achieving Quality in Local Authority PFI Building Projects’. The designs should also aim to meet, as appropriate, the key objectives of the Egan Report.

General The buildings should provide: ●

●

●

a professional environment from which staff can deliver a wide range of high quality integrated services to patients an environment that will promote a sense of well being for both staff and patients an improved image of the service and the organisation

The design should incorporate principles which are sympathetic to the environment and create a sense of place which will make working in or visiting the building an uplifting experience.

the emphasis on good design very much at the level of the local planning authority. Although PPG3 recognises that there may be building technologies to be examined by the house builders, the emphasis is on ‘small is beautiful’. Therefore, is good design sitting in the middle of procurement methodologies that are diametrically opposed? The government is encouraging partnering, which is perhaps a response to dealing with decades of frustration in delivering big projects behind programme and above budget. The Egan philosophy of productivity benefits and

Design development/measurement of design quality economies of scale has yet to be proven in the construction industry where each project is a unique product. It is very different to the production line technologies of 20th century economic theory of supply and demand. A knowledge-based sustainable environment has more to do with recognising the uniqueness and individuality of each site. The challenge for NHS Estates is to find procurement methodologies that meet Treasury objectives, that do not stifle high quality design, and offer flexibility, not standardisation. The government has set out its aspirations for good design and is looking to the private house building industry to rise to this challenge. However, will it be able to achieve the same high standards of design for the big public sector projects via partnering? Perhaps the private sector might just have an opportunity to demonstrate its flexibility and responsiveness by producing better quality designs, that are also better value, be it for housing or privately funded community health projects.

Local competencies Partnering at small and medium levels of contract size also offers potential for productive working relationships. If the LIFT programme is to be successful, cooperation at a local level to allow specialist skills to flourish would seem to argue against all the necessary competencies being provided by one organisation. One possible split is: ● ● ●

Strategic Construction Facilities management/health services.

Allowing competencies to evolve at local level suggests the willingness to consider separately function and ownership of primary health care facilities. The provision of health services and their management and maintenance are quite different to the skills required to build a high quality flexible building that is sustainable, environmentally friendly and efficient to run. The LIFT programme, by encouraging the leverage into the system of private finance, provides every opportunity to develop the more sophisticated marketplace for the provision of primary health care buildings.

Challenges for the future and issues to be taken forward This chapter has explored the very different approach taken by the traditional (or ‘Red Book’) approach to brief writing when compared to the objectives set down for the design team in the brief prepared for buildings in the hospice sector, and more recently the emerging body of work being undertaken under the LIFT programme. The focus of attention in the traditional brief was on functionality and cost. The NHS did not set down guidelines or expectations for patient comfort beyond functional practicalities such as adequate toilet facilities and an appropriate number of seats in the waiting area.

Not being constrained by these requirements, the hospice movement started out from a very different position when the need for such a building had been identified. Funding for these buildings often came from charitable or fundraising sources and their procurement was led by a group of committed people who were seeking a caring environment for patients who would not be offered any further treatment within the NHS system. Consideration of the needs of the dying led to a more humane set of objectives for the environment of these buildings. The language of the brief was different, referring to homely and comfortable aspects of the accommodation above setting down space standards or placing a cost limit on the building. The challenge, of course, is how to measure personal interpretations of the physical environment and this is discussed in greater detail in this chapter. The government is supporting the move towards greater awareness of high quality design and is supporting research in this field such as the evaluation of the briefing process and outcome of the design at the James Cook University Hospital. Policy changes can be detected in this governmental shift towards good design in public buildings and evidence can be found in both the briefing documents and the selection process of the appointed construction teams. The government can be seen, therefore, to be responding to patient requirements and expectations in this consumer-led society, which typifies the first part of the 21st century.

Design quality in health care Outline and objectives There is a need to manage the design process to ensure that the expectations of the patient are achieved. There is also a need to ask ‘How closely do completed buildings reflect the vision and aspirations of the brief and achieve patients’ needs and expectations?’ Put another way, does quality make a difference? The development of research agendas has been limited, not least by very restricted budgets; for example, the NHS research budget amounts to a few hundred thousand pounds per year which is miniscule compared to the overall cost of the NHS which is in the order of £50 bn per year. The shape of the primary health care sector in the UK has been modified much more fundamentally by government policy, which has developed out of the NHS Plan published in 2000. Focused on the concept of patient centred care Primary Care Trusts have been established and the procurement of new and upgraded GP facilities is being channelled through the LIFT programme. The LIFT programme represents a dramatic change in approach reflecting a more fluid and flexible response to patients’ needs based in the community. The brief involves multi-agency activities and recognises the importance of community-led civic pride but at the same time is dependent upon private finance finding economic solutions to build the facilities. Because of commercial pressures there is awareness that evidence-based design should play an increasing role in

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Primary Care Centres how a building is procured. The objectives for PCTs include the following issues: ●

●

●

Medical approach – The services of locally based GPs will be supplemented with greater involvement of consultant services being offered in the community. Specialist clinics will be established, often tailored to suit local demand. Financial approach – The injection of private capital will be influenced by the availability and value of sites in any particular locality. Design – Consumerist factors will influence the weighting of the other factors so that the local LIFT company will be responding to demand from and convenience for the patient.

Part of this process is a recognition that a well-designed building will provide greater patient satisfaction. This is demonstrated by the work of CABE (Commission for Architecture and the Built Environment) and also NHS Estates through its publication ‘Advice’ which develops a concept of AEDET (Achieving Excellence Design Evaluation Toolkit). This builds on the work done by Prasad for the CIC (Construction Industry Council) and this chapter examines this work. The evaluation of design quality issues is further considered by post-occupancy evaluation techniques. NHS has historically used cost parameters as a benchmark for design evaluation It was said by Kate Priestley, a former Chief Executive of NHS Estates, that ‘the NHS is the most complex organisation in Europe. Employing 1 in 20 of the working population in the UK, the NHS has an annual expenditure of £42.5 bn.’1 The estate includes 11 000 GP surgeries. It is not surprising, therefore, that enormous challenges arise when fundamental changes are planned, such as modernising the procurement process for health buildings. NHS Estates was included in the government’s plans to change traditional forms of construction contracts (such as the Joint Contract Tribunal or JCT model forms) for building procurement in all but the most exceptional circumstances. From 1 June 2000, all central government clients were asked to limit their procurement strategies for the delivery of new projects to PFI, Design and Build and Prime Contracting. Refurbishment and maintenance contracts

will be included in these procurement routes from 1 June 2002. The Treasury has said: ‘this means that traditional, non-integrated strategies will only be used where it can be clearly shown that they offer the best value for money. This means in practice that they will seldom be used.’ As already mentioned, the guidance notes for GP surgeries is heavily biased towards achieving value for money. Projects are expected to ●

● ●

The process flowcharts do not include an interchange with the patients, the ultimate client, and for whom the facilities are being provided. The business case is established on the perceived aims and objectives of the health authority and the doctors. For example, the Guide to the Provision of Leasehold Premises for GP Occupation includes a 17 stage checklist of activities. At stage 4, Prepare Outline Proposal, a series of key issues that should be examined is listed: ● ● ●

●

● ●

●

●

●

●

● ● ●

1

This information was updated in The Times (20 March 2004). One in every 23 of the working population is employed by the NHS. Almost 1.3 million people – or the combined populations of Birmingham and Coventry – now work for the NHS, which is one of the world’s biggest employers. Since 1997, the number of NHS staff has risen by nearly 230 000 with a record 59 000 people – enough to fill Old Trafford football stadium – joining last year alone. A total of 1 282 900 people in England have jobs with the NHS: 4.3 per cent of the 30 million people of working age. Only the Chinese Army and the Indian State Railways are believed to employ more people – with 2.3 million and 1.5 million staff, respectively – but both workforces represent a far smaller proportion of the national population.

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improve the quality and range of services in proportion to the extra cost promote the right pattern of services provide practice accommodation reasonable for the needs of the patients in the area.

The problem(s) that the project is aiming to address. Analysis of key issues of service need. Objectives of the proposals – which should be specific, measurable and achievable. Key benefits of the project and how these are to be quantified. What other options could meet the objectives of the project? Costs and implications of doing nothing, or doing the minimum. Building and other costs are reasonable and provide VFM (value for money). Other costs will include additional staff, IT and business rates. A statement confirming the commitment of all parties associated with the project. An outline of the risks involved with the project (e.g. security of rental income, assumptions, financial risks to the practice/NHS Trust/HA and other users) and what management structure will be in place. Identification of opportunities for other primary care users, e.g. dentistry, pharmacy, community nurses and other professionals involved in primary care. Analysis of potential facilities management content. DV’s initial assessment of CMR. Environmental impact study.

In ‘A Guide to the Size, Design and Construction of GP Premises’ the introduction ‘explains the principles of the Schedule of GP premises which provides maxima both in terms of size of premises and building costs attached to them. Also provided are guidance notes for the development of the design brief and the assessment of individual schemes.’ Design quality factors in the briefing process NHS Estates considered that their involvement in primary health care was primarily to provide mechanisms for

Design development/measurement of design quality There follows a series of sections about lighting, heating, ventilation, hot and cold water, power, security, communications, patient call system, acoustics, fire safety and lifts. During the last few years many of these factors have been picked up by government departments, and other agencies such as CABE, as design quality issues have emerged as an important component in the procurement process for health buildings.

reimbursing the costs of providing premises for GPs, who, as independent contractors to the NHS, have the responsibility of providing premises for the delivery of services to their patients. They were not overly prescriptive in this, preferring to delegate responsibility for managing the process to the local health authorities who, in conjunction with local GPs, are considered best placed to make decisions which meet local needs and are within the resources available to them. This policy was reflected in General Medical Practice Premises – A Commentary (1998) which included a section entitled ‘Environment’. It says:

Advice on the main components of the design brief for health care buildings

the control of the internal environment should be considered at the brief stage when opportunities to minimise maintenance and running costs can be addressed successfully. The performance of the building services will be a major determinant of the comfort and perception of the premises by both patients and staff. Draughts, smells, poor ventilation and noise should be avoided.

The CIC and NHS Estates have worked closely together, in conjunction with CABE, in developing methodologies for evaluating design quality in the health sector. Figure 6.1 shows the relationship between ● ● ●

functionality impact and build quality.

Location

Type specific attributes

Siting orientation Composition

Efficiency

Fu

nc

tio

Adjacencies

Space allowance

Community/ privacy

Circulation efficiency

Wayfinding

Type specific attributes

Civic contribution Conviviality

Valuing the user

Artificial lighting Image

Natural light

Adaptability

Innovation

Vision

Character

Acoustics

Health and safety

Integration

Material quality

User control

Finishes

Ease of maintenance Construction detail

Durability

Spatial qualities External form

ct

Clarity

pa

Fitness

Landscape

Im

na

lity

Accessibility

Thermal comfort

Structural elegance

Finishes

Natural light

Acoustics

Structural elegance

Artificial lighting

Type specific attributes

Build quality

Figure 6.1

Relationships between functionality, impact and build quality

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Primary Care Centres This has been developed and used as the basis for the design guide briefing document ‘Advice’ published by NHS Estates. However, it is still difficult to see how this advice is adhered to other than by a determined and clear-sighted client. Benchmarking standards remains largely subjective and subject to pressure from the PFI contractor. At the James Cook University Hospital, the design aspirations were fixed by a determined client who invested a very large amount of staff time in controlling the vision for patient centred care.

These relate to the engineering performance of a building, which includes structural stability and the integration, safety and robustness of the systems, finishes and fittings. 3. Functionality: ● use ● access ● space. These are concerned with the arrangement, quality and interrelationship of spaces and how the building is designed to be useful to all.

Design quality indicator This work has led to the development of the Design Quality Indicator (see Figure 6.2). The more overlap there is between these three quality fields the higher the overall quality. Each topic under the three main indicator sections is separately rated against a group of about ten questions. 1. Impact: ● character and innovation ● form and materials ● internal environment ● urban and social integration.

2. Build quality: ● performance ● engineering systems ● construction.

Added value

Basic

y lit na ity tio od nc m Fu om c

Bu i fir ld q m u ne al ss ity

This system is a tool for evaluating the staff and patient environment in health care buildings. Although the method provides a logical scoring system for assessing the quality of a health care environment the user is still left with no direct financial connection between the result and the implication it may have on the design of the building.

User questionnaires

These refer to the building’s ability to create a sense of place and to have a positive effect on the local community and environment. They also cover the wider effect the design may have on the arts of building and architecture.

Excellence

AEDET (Achieving Excellence Design Evaluation Toolkit)

Impact delight

A national survey of NHS patients was conducted in the last quarter of 1998. The government is committed to carry out a similar survey annually to enable systematic comparisons to be made of the experience of patients. It will also allow comparisons to be made about the performance of primary care services in different parts of the country. The survey was administered as a self-completion questionnaire posted to 100 000 people and the results are based on over 60 000 completed questionnaires. The Department of Health said that the GP survey was designed to help assess the quality of general practice through the patients’ eyes and covered a wide range of issues including access and waiting times, communications with patients, patients’ views of GPs’ knowledge, out-of-hours care, courtesy, and the availability and helpfulness of other surgery staff and services including practice nurses and receptionists. However, it appears that an opportunity has been missed to ask patients to comment on the quality of the buildings. There has been no attempt to connect the information potentially available from the self-administered questionnaires sent to GPs (referred to in the last section) or to invite patients to address similar questions. It would be hugely beneficial if future annual surveys included a section about patients’ perceptions of the quality of the built environment. Valuable data could be built up over a period of years about a range of qualitative issues. For example: ● ●

Figure 6.2 delight

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Design Quality Indicator – firmness, commodity and

● ●

Did patients find the building convenient to use? Did the building have a calming or relaxing atmosphere? Was the building warm and comfortable? Did it feel welcoming?

Design development/measurement of design quality ● ●

● ●

shortage of this type of data to back up statements that health outcomes are improved from well-designed buildings.

Was it accessible? Did it function satisfactorily (e.g. toilets, soundproofing, privacy at the reception desk)? Was it clean? Were there views to the outside (to a garden or natural surroundings)?

Key performance indicators The use of key performance indicators (KPIs) has evolved out of the KPI Working Group which has been looking at these issues on behalf of the Department of the Environment, Transport and the Regions. They identified seven major groups:

Some of these points have been identified by the Picker Institute: The environment around us can set a mood, create a barrier, provide a distraction, give us pleasure or cause us harm. Yet, it is surprising to find that little systematic research has been done examining the impact of the health care environment on its consumers – patients, family members and clinicians. How these consumers are impacted by the physical or built environment is poorly understood. Hitherto, we have not had answers to questions such as: What do patients notice in the physical environment when they go to a doctor’s office, a hospital, or a nursing home? What stands out in their minds? What gets in the way? What matters most to them? What impact does the built environment have on them? Throughout health care, patients and family members are increasingly recognised as the ‘experts’ about the subject of quality of their experience – what matters, what makes them feel better, and what they need to help them recover, heal, and adapt to significant changes in their lives. Because they are truly the only individuals who can tell us this information, as we work to create ‘life enhancing’ environments in health care, we must understand how patients and their families experience those environments and what it is about them that matters to them most. (Picker Institute, 1998)

● ● ● ● ● ● ●

Time Cost Quality Client Satisfaction Client Changes Business Performance Health and Safety.

Interpretation of the key project stages (see Figure 6.3) For the most common systems of procurement, experience of the first year’s use of the construction industry KPIs suggests the following common interpretations of the five key stages (see Figure 6.4). However, given the diversity of modern procurement systems and the many variations in practice, it may be appropriate or necessary to adopt different interpretations. The key project stages In order to define the KPIs throughout the lifetime of a project, five key stages have been identified:

The important point of these data would be to make the connection between the quality of the environment and the quality of the medical services. If design is to be taken seriously then it is essential that hard statistical evidence is used to examine the quality of health care. There is an acute

A

Commit to invest – the point at which the client decides in principle to invest in a project, sets out the requirements in business terms and authorises the project team to proceed with the conceptual design.

Key project stages Commit to invest

Commit to construction Planning and design

A

Figure 6.3

Available for use

Defect liability period

Construction

B

End of defects liability period

C

End of lifetime of project

Lifetime of project

D

E

Key performance indicators – key project stages

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Primary Care Centres Procurement system

Typical milestone at key point/stage A

Figure 6.4

B

C

D

E

B

D

E

Traditional (designer led)

Appointment of lead designer

Appointment of lead (main) contractor

Handover of built facility for use; payment of all non-retention monies

End of defects liability period (often 12 months); payment of any retention monies

End of useful life

Design and build

Appointment (if any) of consultants prior to main contract

Appointment of lead D&B contractor

Ditto

Ditto

Ditto

Construction management

Appointment of lead designer

Ditto Appointment of construction manager

Ditto

Ditto

PFI

Appointment of ‘special purpose vehicle’

Handover of Appointment built facility of lead for use contractor (if different), or sanction to proceed with construction phase

End of defects liability period if relevant

End of concession useful life; ongoing payment to contractor

Procurement systems and five key stages

Commit to construct – the point at which the client authorises the project team to start the construction of the project. Available for use – the point at which the project is available for substantial occupancy or use. This may be in advance of the completion of the project. End of defect liability period – the point at which the period within the construction contract during which the contractor is obliged to rectify defects ends (often 12 months from point C). End of lifetime of project – the point at which the period over which the project is employed in its original or near original purpose ends. As this is usually many years after the project’s completion, this is a theoretical point over which concepts such as full life can be applied.

made on design solutions quickly and efficiently. It is easy to use and gives a valuable indication of the performance of a building design.

Post-occupancy evaluation The RIBA (Royal Institute of British Architects) Architect’s Job Book lays out a systematic app-roach to the design and construction process. It is presented as an aide-mémoire to assist architects with the design of all building types. The sequential and systematic framework advocated is with ‘feedback’ at the end of this process and identifies three possible areas for examination: ●

The KPIs The KPI groups, their associated indicators and guidance on their use are shown in Figure 6.5.

NHS Environmental Assessment Tool (NEAT) The BRE Environmental Assessment Method (BREEAM) provides another valuable evaluation tool. Largely based on a ‘tick-box’ approach the tool enables assessments to be

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C

● ●

An analysis of the project records An inspection of the fabric of the completed building Studies of the building in use.

It recognises that a full feedback study may be expensive and suggests that it may be necessary to negotiate a separate commission with the client should this work be deemed to be necessary. This highlights the failure of the profession to grasp the enormous value to be gained by constantly reviewing all available knowledge about the design problem in hand. As often as not, this feedback process suffers

Design development/measurement of design quality

Group

Indicators

Level

Time

1. 2. 3. 4. 5.

Time for Construction Time Predictability - Design Time Predictability - Construction Time Predictability - Design and Construction Time Predictability - Construction (Client Change Orders) 6. Time Predictability - Construction (Project Leader Change Orders) 7. Time to Rectify Defects

Headline Headline Headline Operational Diagnostic

1. 2. 3. 4. 5.

Headline Headline Headline Operational Diagnostic

Cost

Quality

Cost for Construction Cost Predictability - Design Cost Predictability - Construction Cost Predictability - Design & Construction Cost Predictability - Construction (Client Change Orders) 6. Cost Predictability - Construction (Project Leader Change Orders) 7. Cost of Rectifying Defects 8. Cost in Use

Diagnostic Operational

Diagnostic Operational Operational

Headline 1. Defects Operational 2. Quality Issues at Available for Use 3. Quality Issues at End of Defects Rectification Operational Period

Headline Client Satisfaction 1. Client Satisfaction Product - Standard Criteria 2. Client Satisfaction Service - Standard Criteria Headline 3. Client Satisfaction - Client Specified Criteria Operational Change Orders

1. Change Orders - Client 2. Change Orders - Project Manager

Diagnostic Diagnostic

Business Performance

1. Profitability (company) 2. Productivity (company) 3. Return of Capital Employed (company) 4. Return on Capital Employed (company) 5. Interest Cover (company) 6. Return on Investment (client) 7. Profit Predictability (project) 8. Ratio of Value Added (company) 9. Repeat Business (company) 10. Outstanding Money (project) 11. Time taken to reach Final Account (project)

Headline Headline Operational Operational Operational Operational Operational Diagnostic Diagnostic Diagnostic Diagnostic

Health and Safety 1. 2. 3. 4. Figure 6.5

Reportable Accidents (inc. fatalities) Reportable Accidents (non-fatal) Lost Time Accidents Fatalities

Headline Operational Operational Operational

Key performance indicators: main groups and associated criteria

from the day-to-day pressures of dealing with the next job in hand. It always seems to be more important to press on with the excitement of the next design challenge, and even if there was time available there never seems to be the right moment to ask a client to spend more money on a project which as often as not will be stretching financial limits to the brink of acceptability. How easy it is to gloss over a few rough edges, not question a few embarrassing oversights in meeting the brief or open up old discussions about compromises on the quality of finishes due to cost limitations.

All architects are familiar with this scenario and the most important issue on their minds may well be ensuring that their last fee instalment is paid on time. The culture of sharing knowledge and the benefits which might accrue if the same design team is commissioned to build a second or third building of the same type is a luxury rarely shared in the construction industry. Of course, the Egan and Latham Reports seek to address these issues but unfortunately they concentrate on improving the quality of the process rather than the quality of the product (see Chapter 3).

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Primary Care Centres In 1996, MARU (Medical Architecture Research Unit) published a review of primary health care buildings including a helpful section about evaluating buildings in use. It recognises the circular process of reassessing design decisions and suggests three types of evaluations:

●

●

●

1. Audit – measurement of certain criteria against an implied standard, in a defined location, to establish a range of values and indicate relative position. 2. Case study – investigation of selected examples to learn lessons. 3. Evaluation – assessment of the success in terms of specific criteria. However, a more thorough review of post-occupancy evaluation techniques is described by Mardelle McCuskey Shepley (Shepley, 1997). This broad review of methodologies includes a comprehensive list of references at the end of her chapter in Healthcare Design, edited by Sarah O’Marberry. A more specific publication is The Exeter Evaluation (Scher and Senior, 1999). This report sets out the detailed results of an intensive research project undertaken at the new Royal Devon and Exeter Hospital. The report ends with five conclusions concerning: 1. Awareness and communications (a programme to inform all staff about the benefits of art in the healing process). 2. Displaying visual arts (careful consideration of location in both public spaces and in close proximity to patients). 3. Staff participation (using staff skills in music, photography and writing, for example). 4. Resources (establish a budget heading). 5. The value of arts in health care (increase knowledge). Although not directly relevant to primary care facilities this work represents an example of the systematic evidencebased research work that will become increasingly necessary to justify design quality decisions. The intuitive and artistic responses of the architect will in future require justification and substantiation to ensure design approval.

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the process: the client is determined not to lose sight of the vision during the procurement process urban design: civic responsibility and community involvement must engage with patient and indeed all users of the building benchmarking: evaluation techniques should be used to monitor progress of the design during the construction stage, and after completion by post-occupancy evaluations patient centred: priority must be given to patients as consumers in the health sector.

The research has highlighted the contradictions that exist between the power of architecture to influence human emotions and the practical constraints imposed by the requirements of a functional brief. The research questions are reconsidered and recommendations are made about how to improve the design quality of primary health care buildings.

Contradiction between the influence of architecture and the demands of a functional brief This book has examined the quality of design in primary health buildings and how this is expressed in the brief, and compared it with the functional issues and standards of construction more usually set down as a client’s expectation. The conclusion remains elusive. Leaving aside the issues of therapeutic benefits and holistic care considered in earlier chapters, Frank Lloyd Wright’s philosophy displays as powerful an argument about the influence of architecture to create a healing environment as it is possible to state. ‘He pioneered the “organic” approach to architecture, which was a radical departure from the traditions of his day, dominated as it was by European styles that dated back hundreds of years’ (Knight, 2001). His clinic for Dr Kenneth Meyers in Dayton, Ohio, built in 1956 provides a timeless and compelling example of the power of place.

This chapter has identified a growing range of evaluation toolkits to assess design quality. There is recognition in government of the value of striving for high standards of design. However, the connection between the high standards of design and financial accountability remains elusive and inadequately defined. In essence, it remains in the gift of the client who is determined enough not to lose sight of design aspirations and to strive for excellence – essentially an intellectual target, but with growing evidence that it can be justified. The key issues seem to be

The patient arrives through an entry between two rectangles, which are set together not at a right angle but at a wider, right-angle-and-a-half: on the left is the waiting room, a harmonious and regular rectangular space. When called to see the doctor, however, the patient moves into a more mobile zone – also rectangular but with half an octagon joined to it to supply examination rooms. The laboratory is situated under the peak of the octagon, with the practice library tucked away on the far side. The opposite side of the rectangle contains further examination rooms and the x-ray space, with a darkroom attached. This means that the surgery area, unlike the waiting room, itself invites change and a sense of progression – architectural optimism appropriate for a centre of healing. (Knight, 2000)

the vision: a client has a clear view of the design quality envisaged

The vigorousness of this debate is further encapsulated by the strength of feelings expressed about the design of the

Summary

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Design development/measurement of design quality new Royal London Hospital. Widely reported in the architectural press (e.g. Building Design, 6 August 2004) the government’s PFI strategy is being challenged over the quality of the design solution. Criticism of the procurement system is made by both the interim chairman of CABE (Paul Finch) and the president elect of the RIBA (Jack Pringle). There are major lessons we have to learn from the way the Royal London has been procured … the fact that the result is, in our view, a failure in significant aspects is as much a criticism of the process of hospital procurement in this country as of the efforts of the trust or its preferred bidder. (Finch, 2004) CABE’s coruscating criticism of this project’s strategic design decisions made early in the procurement process and the quality of the resultant design puts another nail in the coffin of this crude type of PFI mechanism … Architects and their clients need to work with the real client, the hospital trust. (Jack Pringle, RIBA president elect, 2004) The current sensitivity of these divergent pressures on the design process continues to be very much under scrutiny in the architectural professional press as this book is being written (autumn 2008). Austin Williams, writing in the Architects’ Journal (26 August 2004) says: ‘the noble Vitruvian ideals of commodity, firmness and delight have been reduced to mundane tick box criteria such as “functionality”, “build quality” and “impact”.’ Compare this interpretation with the aspirations of the CIC’s work undertaken by Sunand Prasad (see Chapter 6). Williams denigrates that stance thus: ‘Value added’ is now a recommended assessment tool in architectural circles. Whereas we used to get on with the business in hand, knowing that the product of architecture had intrinsic value, these days we all seem to be angst-ridden about whether we are adding enough value and if it is the right quality value. After all, how do we measure how valuable the added value is; is the value that we are trying to add sufficiently valued by others? Could a concentration on certain core values devalue other fringe values? We just don’t know and so we continue to have conferences to pontificate about it with little chance of reaching a conclusion. This is the recipe for building by numbers, with architects playing a demoralising never-ending game of benchmarking. He goes further and says: … architects now have to justify their work in moral terms: does the design improve wellbeing? Does it add value to business efficiency? Will it improve the health of the occupant? Vitruvius did not judge the success of architecture by getting a range of responses from lay user and community groups. He did not use a questionnaire. He understood

that good architecture could lift the spirit but did not claim that architecture could heal the sick. He did, however, acknowledge that good architecture advances the health of society. Architects need to find their critical voice again and start challenging the craze for value added, that actually adds no value other than increased regulation, and for design quality masquerading as social engineering. These criticisms of the procurement process for health buildings highlight the weaknesses and shortcomings in many present day briefing processes. Most research has been conducted on large projects, and in particular PFI projects, but 90 per cent of health care in the UK is dealt with by GPs in primary health care buildings. This book has used the literature about large hospitals but aims to provide recommendations that are appropriate to small buildings which are usually very much part of the local community and the need to have a sense of place appropriate to their locality. The ethos of the building is a generator of its stature in the community and an important factor in a patient’s sense of being at ease in using the space. It contributes to the sense of well-being.

Quotations The following quotations highlight the holistic approach to designing primary health care buildings which many people believe brings advantages to all users of the facility. Architecture is also about the spiritual needs of people as well as their material needs. It has much to do with optimism, joy and reassurance; of order in a disordered world; of ‘privacy’ in the midst of many; of space in a crowded site; of light on a dull day. It is about quality. Increasingly, there has rightly been a focus on the commissioning of hospitals and other healthcare buildings of quality, durability and style. Of course it will continue to be important to control costs, but aesthetic and architectural considerations must also be given proper recognition. (Lord Foster, quoted by Mr Chris Smith, as Secretary of State for Culture, Media and Sport at the Opening Plenary Session of the Arts in Hospitals and Healthcare Conference, held in Strasbourg, France, 4–6 February 2001) Increasingly doctors and other healthcare professionals will need to work more closely with their patients to explore which treatment the patient feels best meets their need. I believe the potentially powerful role of complementary therapies will need to be increasingly recognised and incorporated into an individual’s healthcare. (HRH The Prince of Wales, 11 November 2000, at the Millennium Festival of Medicine Conference) You can have the most efficient procurement process in the world but if you don’t have a decent design you will still end up with a second-rate building.

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Primary Care Centres Quality and quantity must be evaluated together, with quality receiving a far higher weighting. The client’s design advisers should be just as important as the Quantity Surveyors. (Sir Stuart Lipton, Chairman of the Commission for Architecture and the Building Environment). In public health, we’ve got to address the rising expectations of consumerism. People demand better buildings. (Peter Wearmouth, NHS Estates acting chief executive).

Anticipating the future The information age has given us the ability to share knowledge globally. There has been a new awakening of moral attitudes and responsibilities arising out of the Human Rights Act which is giving a greater sense of respect for the individual person. This is reflected in health care which is once again becoming focused on the patient as an individual. We should be encouraged by the opportunities now being presented to capture the ethos coming out of thoughtful building briefs. Everyone involved in the provision of primary health care is increasingly aware that individuals must be the centre of their own health care or well-being. There seems to be a universal acceptance that this policy can apply in both rich and poor economies. Health for all really is a policy for primary medical care, which has no opponents and crosses political boundaries. The training of doctors is becoming more broadly based. Many university departments are now recognising that a scientific and technology-based approach for medical education does not give a sufficiently well-rounded training for the doctors of the next generation. Humanities are being introduced to the curriculum of medical schools which reflect the recognition that doctors need to treat patients in a more holistic manner. In the same way that architects have moved on from the principle of ‘a house is a machine for living in’, so doctors are recognising that well-being is more complex than scientific enquiry alone. The government is also moving its position on health care policy with a new understanding of the importance of patients’ needs. The requirements for health care are being assessed from the perspective of patients and there is recognition that the social agenda for health care needs to become more inclusive. Inevitably, this will lead to greater complexity in the organisation of services, and the crossing of boundaries between traditional concepts of health care, social services such as housing and the treatment of mental health issues. One is led down the path of recognising the importance of the built environment to provide a humane place in which to live a healthy life.

Trends The research brings together a range of solutions from which it is possible to distil a series of common strands in the design approach.

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1. Policies around the world are concentrating on improving health care services at a primary level. 2. There is universal attention to patient centred care irrespective of the size of the building, or wealth of the country, in which it is located. 3. Architecture and medicine are talking to each other. The quality of the humane healing environment is seen as a positive benefit. The technocrats are acknowledging the contribution to health care from urban design. The quality of the place we live in is important to our well-being. 4. Our well-being is reflected in the environmental quality of our new health buildings: smaller, community-based flexible spaces, easily accessible and welcoming. They are designed for the benefit of the patient rather than the provider of medical services. 5. There is a high incidence of curved shapes in the design of small health buildings. The building form envelopes the user, provides comfort and is reassuring. It is non-threatening and not confrontational. By a combination of form, light and colour, buildings around the world straddle cultural differences with an architectural language that individuals can recognise whatever their mother tongue.

Objectives of a brief Doctors and architects need to work more closely together. Through the development of briefing documents, we should be optimistic about the opportunities that will arise for primary health care buildings in the future. They will provide the physical framework within which the complex social interaction of the community can engage with the medical profession. There is agreement that many of the better examples of good design for health buildings have been built in the primary care sector. 1. The brief should be the central and fundamental cornerstone for the provision of future health care buildings. It should set down the ethos and culture for the health care environment. Many of these overarching objectives will be common to the design of a doctor’s surgery anywhere in the world. 2. There are both strategic and practical levels of planning. It is at the practical level where there may be more substantial differences in the briefing document between one country and another. 3. The brief should set down the design aspirations. It will set out the ‘wish list’ and establish the sense of wonder which excites the spirit when good architecture is encountered. 4. The brief must bring together current ideas and anticipate future trends. 5. It must also capture the sense of change which is sweeping through the primary health care design field not just in the UK and the USA, but in many parts of the world. 6. In another decade we are likely to find much broader acceptance of alternative therapies. In the West, we have only recently begun to understand and accept the contribution

Design development/measurement of design quality that alternative health remedies can bring. How much more there must be to learn about traditional Chinese medicine, for example, and environments such as the Glasgow Homoeopathic Hospital may well be the forerunner of many other buildings in the future seeking to combine traditional medicine, alternative therapies and a high quality of environmental design. 7. More sophisticated linkages are likely to emerge. Key words and phrases to consider when writing a brief are shown in Figure 6.6. An examination of these issues will assist in establishing the strategic framework for the design of a new primary health facility. It may be helpful to prepare checklists on these points as an aide-mémoire during discussions with key members of the client and design team. This will give focus and direction to the establishment of both the strategic and practical aspects of the brief.

Design quality Our modern understanding of a primary health centre was set out in the Dawson Report (1920) as ‘An institution equipped for services of curative and preventive medicine to be conducted by general practitioners of that district, in conjunction with an efficient nursing service and with the aid of visiting consultants and specialists.’ It remains a valid definition today, but during the intervening 80 or so years the earlier professional arrogance of architects and doctors has shifted markedly towards a more humane, understanding and listening attitude. This approach is explored in the editorial of Medical Humanities (volume 27, number 1). Medical Humanities as an aspiration looks both forward and backward, seeking in part the rediscovery of a certain attitude towards medicine, its natural objects/subjects (patients) and its place in the cultural, artistic and scientific order. That attitude is embodied in the idea of a Renaissance Man or Woman embracing an interdisciplinary (even omni-disciplinary) view of the world, a universal gaze which is, on the face of it, no longer available

Key words: networking concepts • Government policy

• Finance and funding

• Community facilities

• Flexibility

• Education (training)

• Communications

• Sustainability

• Location (accessibility)

• Knowledge (transfer of skills) • Transport policy • Value for money

• Patient needs

Figure 6.6 Brief writing – key words and phrases

to us in a world of runaway specialisation in knowledge. Consider how one might both celebrate ‘The beauty of the human form and the nobility of the human spirit’ and peruse ‘An insatiable curiosity for the materiality of the here and now, a Faustian itch to explore … ’ – a universal gaze which, fused within an individual mind, may seem paradoxical, rather than merely daunting. Be that as daunting – or as paradoxical – as it may, we suggest that one source of both moral and intellectual renaissance for the contemporary physician lies in recapturing a sense of wonder at the human body, its place in the natural realm and its miraculous functioning as the fount, and the medium, of embodied human experience. (Evans, 2001) This view is echoed by the government, by CABE and by many others in the architectural profession in recognising the importance of design quality and the need for a ‘wow’ factor. The excitement and vision that architecture can give to the human spirit can be more readily seen as the basis of a health policy built around personal well-being. In short, a holistic approach. Perhaps all this was foreseen by Anton Chekhov who said in a letter to a fellow writer: I thought then that the sensitivity of the artist may equal the knowledge of the scientist. Both have the same object, nature, and perhaps in time it will be possible for them to link together in a great and marvellous force which is at present hard to imagine. By closer cooperation the medical and architectural professions will be better equipped to answer in a more rounded and complete way our individual health needs. The large commercial architectural practices in America are beginning to question the philosophy of creating very large hospital complexes, partly as a result of pressure on cost fitting policies in the USA. The problems being experienced in the UK with the quality of the new wave of hospitals procured through the PFI process highlight the historical priorities given to functionality and cost standards in the UK building programme. The sheer size of some of the largest hospital projects invites comparisons with the environments of some large airport complexes, or even the new town developments of the 1960s. The government, fortunately, is now recognising the importance of good design and the limitations of a project management profession which has mushroomed in recent decades. Perhaps the ambitions of grandeur on a larger scale would be better served by a more humble approach to meeting the smaller scale of human requirements of social interchange at a person-to-person scale. It is at this scale that the all-important relationship between patient and doctor takes place. The gap between large practice, working on the big hospital projects, and those who are working on the smaller primary health care projects is a difficult one to bridge.

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Primary Care Centres The LIFT programme is promising but is still at an early stage in development. Government policies are not consistent. For example: 1. The government is advocating better design standards in civic buildings. 2. The NHS Plan has a very ambitious programme for investment in small-scale buildings (i.e. GP surgeries). 3. The government seems intent on pursuing building procurement through the PFI process (which is not suitable for small projects and is attracting a great deal of adverse criticism on the design standards achieved in recent health projects).

Right at the beginning of the document there should be a section that encourages the design team to set out the quality aspirations expected from the building. It needs to encourage future users of the building to think about what the ethos of the building should be; to set out what the building users want out of the building; and to consider the intangible values that the designers aim to achieve. For example, should the building be: ● ● ● ● ● ●

Recurring themes The following list sets out a number of key issues that have kept re-emerging throughout the preparation of this book. ●

● ●

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Emphasis on quality of architectural design – importance of high quality environmental factors. Emphasis on the patient as an individual. Patient focused care as a local level of primary care being the hub of patient treatment rather than the start of a linear process of passing through various levels of specialisation. Building flexibility – design for change, openness, accessibility. Buildings have not played a key role in health policy, but need to in future. There has been insufficient recognition of the importance of environmental quality, and the effect that this can have on health care. Architects need to take up the opportunity to build on the new interest by doctors to embrace health and humanities. It is people that regenerate places, not places that regenerate people. Over-reliance on economic, social and physical modelling techniques and statistical analysis at the expense of visual stimulus undervalues the importance of architecture. Visual stimulus is a key ingredient of the built environment. The delight of architecture should not be squeezed out of the built environment by analytical methodologies. Give status to the product as well as the process (think of design as well as construction). Put architecture back into health. The patient must come first.

A framework for the brief – the ethos The key words and phrases listed earlier in this chapter (Objectives of a brief, point 7) will shape the brief and establish the starting point for defining the ethos of the building that is being commissioned.

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● ●

Friendly? Efficient? Welcoming? Relaxing? Comfortable? Warm? Pleasant? Accessible?

There should be a fundamental skew to the way briefing documents are written compared to the priority given to the tests for functionality and finance which have been the benchmark for commissioning primary care health buildings until recently. The brief should seek to encourage the achievement of high design standards through the eyes of the patient – the tests of functionality and cost should be a secondary, albeit essential, requirement of the procurement process for any new primary health care building. Huge potential benefits are coming out of these changing philosophies in primary health care buildings, which will influence the quality and procurement methodology for our health buildings at the specialised end of health care. Opinions are being voiced about larger hospital sites being broken down into villages, with different architects being appointed for specialist departments, or even viewing a hospital in terms of adjacent development within the urban planning of adjacent blocks in our existing city centres. Medical schools are responding to these challenges by the introduction of humanity courses. Architectural departments in our universities should similarly respond by giving greater attention to the training of future generations of architects in the health sector. There is little attention being given to the design of health buildings at either an undergraduate level, or research programmes for post-graduate study. Jessica Corner articulates some of the shortcomings from the eyes of the nurse when she says the clinical setting adopts, through its architectural presence, both the interior design and building structure, a message of progress, cleanliness and efficiency. This takes precedence over comfort, reassurance, information or participation. The architecture supports the quite literal transportation of people into the world of treatment and its time dimensions … There is a process of separating people from normal life in the manner from which they are conducted from the hospital door towards all departments inside … Clinic, ward and consultation room structures reinforce the separation between

Design development/measurement of design quality patient and professional … These are the architectures of treatment and not of personal care.

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●

She goes on to argue that

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policy makers for healthcare need to determine the form of future buildings. Buildings, whether they are large hospitals or local surgeries, need to be different. They need to embody different meanings. In particular buildings need to convey recognition of people’s sense of self, of ‘me’, rather than promote, as they do now, the collective need for healthcare to get ‘the job done’ by controlling and processing patients. (Corner, 2001)

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● ● ● ●

Strategic components of a brief Having established a framework of ideas or ethos, and understanding the context and networking requirements for a particular building in a specific location, the strategic components of a brief can be more precisely laid down. These will include: ●

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●

●

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The vision – how will the experience of visitors, patients and staff be enhanced by the building? – how will the design quality add to the expectation of excellence? – how will a high quality environment be achieved? – will it be patient focused? The process – select an appropriate procurement method to ensure that design quality is not stifled. Urban design – will the building contribute to the sense of place? – will transport linkages work? Benchmarking – is the building going to add to the level of competencies prevailing in the vicinity? Value for money – will it represent ‘best value’? Patient centred – will the brief encourage good environmental design and achieve therapeutic benefits for patients and all other users of the building? – is it patient centred?

Practical components of a brief After the ethos of the project has been defined, and the strategic objectives have been agreed, the practical issues of functionality and cost can be explored. What this research has revealed is that what benefits would arise if a new databased handbook for primary health care facilities was available, but written through the eyes of the patient rather than from the perspective of the health service provider. Thus, new standards could be quantified and dimensioned for:

patient control of their environment in treatment rooms, waiting rooms and other spaces design of furnishings, fixtures and fittings flexibility in the layout of equipment within a space flexibility of use of a space environmental design standards and performance specifications compliance with access for the disabled transportation links (on foot, by cycle, car or public transport) functionality landscaping building materials cost limits.

A 19th century approach to well-being for town dwellers was the Victorian park, which was conceived as a green lung to improve the public health of the urban workforce. Allowed to fall into disrepair during the 20th century they are being restored, once again, and their original qualities are being rediscovered. Healthy living centres should be seen as a future resource (in the 21st century) for good advice – a patient centred facility in the community where help can be found about diet, fitness, health checks, social services and a range of other activities to encourage a sense of well-being in the place where we live. Although not exhaustive, these items are typical of the main thrust of a design brief, which needs to be analysed by looking at patient convenience, effectiveness and efficiency. The practical performance of a building is obviously important and it must work efficiently – i.e. there must be a basic level of design competence of technical matters but they must contribute to achieving the design quality issues set out in the ethos. The process should be completed by ensuring that postoccupancy evaluations are undertaken to measure the success (or otherwise) of meeting the aspirations for the building which were set out in the ethos statement.

Recommendations During the research period for this book, the approach to design quality in health buildings had significantly changed. Positive support for good design is now being given by the government and the effect of this change of policy is cascading down through a variety of commissioning bodies and agencies with responsibility for approving projects in the primary health care sector. This is excellent news for all architects, and doctors can expect higher quality buildings than sometimes was the case 10 or 20 years ago. Architects should exploit the opportunity to develop a brief that reflects design quality as the primary benchmark of any new commission. There is ample evidence to support approval for putting patient priorities

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Primary Care Centres Assembling a brief

A framework of issues for doctors and architects to discuss together when developing a brief for a healthy living centre – to compare, contrast and challenge each other about ideas when establishing the criteria for a new building. Issue

Architecture

Medicine

1

Functionality

space standards, initial cost effectiveness, data sheets

flexibility, meeting future working patterns

1

Multi-agency

planning flexibility, long life, loose fit

choice of agencies, services to be offered

1

Accessibility/ convenience

transport linkages, pedestrian routes, parking, disabled access

patient adjacency, alternative locations

environmental performance standards

good practice models, standard room plans

1/2 Exemplar design models

1/3 Site/location/ urban context, land acquisition planning constraints, value for money 2

Brief – the ethos architectural of the building language, style, patient comfort, therapeutic benefits

convenience, visibility of building, availability personal rapport with patients, relationships, working environment, sense of well-being

2

Community

quality of the place, welcoming, comfortable

friendliness, reassurance, accessible

3

Finance – procurement method, costs

contractual arrangements, PFI, LIFT, design criteria, project management, programming

PCGs/PCTs ability to influence funding, budgets, access to finance

3

Sustainability

energy consumption, lifecycle costs

recycle facilities, medical efficiency

3

Standardisation standard components routine procedures, within unique design, clinic requirements, compatibility with choice of materials other surgery operating systems

2. Consider the strategic objectives

3. Establish the requirements for patient satisfaction

4. Identify the practical requirements (functionality)

5. Check: (Post-occupancy evaluation – have points 1, 2, 3 and 4 been achieved?)

Figure 6.8 Writing a brief – flow chart of actions

Quality ●

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Key: 1. Physical 2. Emotional 3. Financial

Figure 6.7

1. Define the ethos

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Writing a brief – matrix of factors to consider

first. Seen from the perspective of the patient let us consider three key elements of an architectural brief: 1. Quality – to set the standard for well-being. 2. Functionality – to check the technical performance. 3. Cost – to ensure economic viability and value for money. Taking these in order, the following bullet points highlight a series of issues which should be discussed, and written into the brief before design work commences.

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‘Building a 2020 vision: future healthcare environments’ by the Nuffield Trust (Francis and Glanville, 2001) summarises the changing attitudes towards designing health care buildings, including primary care facilities. It offers an excellent overview of likely future trends and is the product of a series of focus groups consisting of some of the most informed health care professionals working in the UK in the period 2000–2001. Quality needs to be viewed from a wide perspective including the social and community values which new buildings should seek to meet. Aspirations and ambience are both words that invite a description of the cultural environment within which a building will sit, and which extends beyond any perception of its physical limitations. Patients and staff, as well as doctors, should be asked for their views. The World Health Organisation’s view that the single most important factor for health in a hospital is the atmosphere captures the sense of well-being that flows from a well-designed environment. The therapeutic benefits of this approach are accepted, as the increase in the literature of evidence-based research demonstrates.

Functionality ●

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The brief should list all technical standards that are required to be met. This will include both NHS space standards and statutory regulations. Performance specifications should be reviewed and discussed with all users so that expectations of colour, light,

Design development/measurement of design quality

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sound and other environmental factors are understood. This will include the Disability Act to ensure compliance with all legislation for accessibility. Several recent documents provide guidance and checklists to simplify this task for architects. Security and external accessibility, e.g. transportation links, pedestrian routes and other practical aspects of the building fitting into its urban context, need to be assessed. Flexibility of the building shell over its anticipated lifespan. Multipurpose community uses. Location. Sustainability – consider the choice of materials and the economic and environmental factors. An analysis of benefits arising from local services may show considerable improvement in lifestyle and well-being. Construction methods – the government is encouraging a variety of techniques for larger projects (including large health buildings) to show economies of scale such as repetition and standardisation. This is to encourage construction to be seen as a manufacturing process. With smaller projects, usually the norm for primary health care buildings, these perceived advantages are usually harder to achieve.

The brief will comprise two parts: ● ●

The initial brief should include the following. Introduction and overview: ● ● ● ●

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Procurement routes are changing. PFI is advocated by the government for large projects but has limitations for small projects. LIFT offers new challenges for primary health care facilities through the Primary Care Trusts and Primary Care Groups. Procurement methodology will evolve and new models will be tested over the next few years. Direct construction costs must be judged to give value for money. The cost to society brings to bear more complex economic analysis including lifecycle costs. Indirect costs, as well as the direct construction costs, need to be considered, such as pride in the locality and lifestyle satisfaction issues. What value is placed on a sense of well-being?

Ethos, aims and objectives of the project Key constraints Organisation Population.

Operational policy statements for: ● ●

Cost ●

Initial brief Full brief.

Clinical functions Support functions Administration Reception, admissions, appointments Materials handling Waste management Security Domestic services Portering Car parking Sanitary facilities Staff amenities Visitor amenities.

Design quality statement Schedule of accommodation: ●

Room by room schedule including: Unit area of each room type Number of rooms of each type Room occupancy. Functional relationships diagram:

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Network of adjacencies and links between scheduled spaces.

Typical layouts (1:50) of key accommodation types showing:

Example of typical specification for a brief The following notes are a typical specification for a brief for a health care building as proposed by Gordon Kirtley (from personal discussions and correspondence). A crucial component is the development of the ethos, aims and objectives of the project which should form part of the initial brief.

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The full brief should include for each room or space. ● ● ●

Typical specification for the brief of a health care building The brief for the project should comprise a comprehensive but concise statement of the requirements of the client and the user groups, normally following the scope and format described in the Capital Investment Manual.

Key modular dimensions Generic equipment and furniture layouts.

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Equipment list for Groups 1, 2 and 3 equipment Key dimensions, including room height Requirements for: Wall, floor and ceiling finishes Daylight/blackout Acoustic requirements Doors and access (size, security, vision panels, etc.) Other special requirements Room data sheets for engineering services requirements.

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Primary Care Centres Note: The client should appoint an equipment specialist who will liaise with the user group and collect detailed information on equipment items, including procurement proposals (e.g. existing equipment relocated, new equipment, etc.). The role of the briefing consultant will be to collate and coordinate this information.

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Fire safety (may be covered by H&S) Security Facilities management and estates issues, including deliveries, waste, domestic services, catering and maintenance.

Preparation of the brief

Summary

The initial brief and the full brief will be prepared in consultation with the client’s nominated representatives. A typical consultation process would include, for each user group, a series of three meetings:

The conclusion and recommendations of this chapter provide an opportunity to set out four key guides to providing better primary health care centres in the future.

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Initial briefing meeting Review of the first draft Review of the final draft.

The briefing consultant will prepare an agenda and chair the user consultation meetings. User groups In addition to core user groups for clinical services, there should be special working groups for the preparation of the initial brief, including: ● ● ● ●

Interior design Equipment coordination Phasing and decanting Health and safety

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1. Doctors and architects must work together and develop common briefs for the next generation of primary health care buildings. They must be written for the benefit of patients. 2. The buildings must be designed to create a framework for the social interaction of the community that they serve. They must be socially inclusive, flexible, caring and accessible. 3. Well-designed primary health care buildings will become the focal point for the next generation of health buildings and will influence the shape and operation of larger and specialist facilities. 4. Primary care buildings will become the catalyst to encourage greater harmony between health policies around the world. Sustainable construction methods will develop and at the same time provide shelter for holistic medical protocols to flourish.

7

Holistic care

In an earlier chapter we saw that holistic care was a central part of caring for the sick. The development of hospitals began out of a wish to offer hospitality to those in need. In those early times, up until the Renaissance, almost everything done for the sick in Western Europe was provided by the church. However, with the development of scientific medicine much of this pastoral care was gradually taken out of the church’s hands and during the past two centuries the medical profession has become secularised (House of Bishops, 2000). The development of the medical profession, in a technological sense, has developed with the creation of the Royal Colleges and the establishment of specialised qualifications. Unfortunately, this has led, until recently, to an attitude of mind that saw death as a failure of medical treatment. In a similar manner to taking your car to a garage where you expect the repair to be fixed, the medical profession pursued technical innovation which saw death as a failure. The World Health Organisation has reported that the single most important factor for health in a hospital is the atmosphere. If this is true then the spirit in which the medicine is practised is important. However, with government policy rapidly changing the focus of attention onto patient centred care based in the community we know that the vast majority (75 per cent or more) of the health budget of the NHS is spent in the primary care sector. This would suggest that there is an urgent need to address the provision of holistic care services within the primary care sector. A recent government report, NHS Chaplaincy (Department of Health, 2003), addresses the need for chaplaincy services in hospitals and includes the following key roles for chaplains: ●

● ● ●

provide appropriate spiritual and religious care to patients, staff and other users provide pastoral care provide regular opportunity for religious expression identify and assess the needs for chaplaincy/spiritual care within the organisation regularly

●

support multi-faith working which respects and supports faiths identified within the trust.

The main thrust of the document is based on the provision of hospital chaplaincies. It identifies that spiritual and religious care has been part of the NHS since 1948, and the Human Rights Act, introduced in October 2000, enshrines in English law the right of the individual to religious observance. Similarly, the Scottish Executive offers guidelines on chaplaincy and spiritual care on the NHS in Scotland (Scottish Executive, 2002) but this also focuses on the role of hospital spiritual caregivers. Therefore, we should re-examine the role of holistic care in the primary health sector. Many GPs already have links with alternative medical treatment offering guidance on complementary medicine and alternative therapies. Should community-based GP surgeries have more direct links with chaplains or representatives of other faith groups? Should GP surgeries be encouraged to develop formal links with faith groups in their locality? Perhaps primary care buildings should reflect these issues of well-being in their design, and provide spaces for contemplation or rest. This is part of the development of an environment for healing. There is an immense shift from assessing the value of what is being done by many medical and nursing staff as a sense of vocation to assessing it in terms of cost effectiveness. Do staff need to rediscover the sense of vocation where they have to help in healing and not just regard themselves as ‘service providers’? The use of language is important. A balance has to be struck between the book-keeping elements of running a GP surgery and offering compassion for suffering people. The hospice movement has developed rapidly over the last three or four decades. Modern hospices are historically routed in Christian belief, although in practice they are broadly theistic. Interestingly, a survey of findings from chaplaincies in hospices and hospitals in England and Wales (Wright, 2001) traces the development of the modern hospice movement

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Primary Care Centres led by Cicely Saunders who was following the tradition of the ancient Christian ‘hospes’ of welcoming the sick and performing the works of mercy contained in Matthew chapter 25 verses 35 and 36. The report goes on to argue that evidence is emerging of a continuing desire to recognise the importance of the spiritual domain, particularly within health care. In essence, spirituality has been described as a universal human attribute that goes beyond religious affiliation and may also be found within atheists and agnostics. Whether religious or non-religious in orientation, spirituality is considered to address the most profound question of all – the ontological significance of life – and is thought to come into sharper focus when human beings are confronted by serious illness and death … however, in view of the spiritually intrusive claims of the so-called holistic and palliative models of care, questions also arise relating to the features of spiritual care evident within both hospitals and hospice. (p. 230) In conclusion, this report finds ‘hospital patients require religious care more frequently than hospice patients’. Caring about those in need properly involved attention to their social and physical context as well as to their immediate cause for concern. An approach to health care based upon what is now termed in the system ‘pastoral care’ involves attention to the patient as a person rather than just to his or her particular disease. That is exactly what is denoted by the passionate emotions to victims of the synoptic healing stories (Gill, 2004). Spiritual care is not necessarily religious. Religious care, at its best, should always be spiritual. The spiritual approach to healing has been the subject of a comprehensive review by the Church of England (House of Bishops, 2000). This report brings up to date the work of an earlier commission set up in 1953 which was the first time members of the British Medical Association and the Church of England had met officially to tackle this subject together. The NHS has also recently revised its policies and approach to spiritual and religious care (NHS Chaplaincy, 2003b). This document states that ‘Spiritual and religious care has been part of the NHS since 1948. Since 1992 all NHS Trusts have provided spiritual support for patients, staff and relatives through Chaplains and Faith Community representatives.’ The CAHHM (Centre for Arts and Humanities in Health and Medicine) evaluation study at the James Cook University Hospital includes the hospital chapel within its study. It conducted its study by questionnaire surveys (user satisfaction) and semi-structured face-to-face interviews (Macnaughton et al., 2005). This shift towards greater recognition of the spiritual and religious needs of patients perhaps is another indicator of the growing recognition that a holistic approach to health care brings therapeutic benefits. Additionally, the Human Rights Act sets out the right of the individual to respect religious observance. It can be argued that a fundamental shift is required in the design objectives for primary health care buildings. Preconceived ideas of form and function should be dissolved in a more free-flowing solution of philosophical objectives.

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This includes the concept that design should respond to all five senses (smell, taste, touch, sight and hearing) (WellsThorpe, 2000). There should be a concentration on the human scale. A naturalistic, human centred design approach should permeate the briefing document. Lord Robert Winston is an advocate for the healing environment: I was on the island of Kos in Greece. At dawn the deserted Temple of Apollo, with a gentle breeze through the ancient olive trees and the smell of resin and honey, produced an astonishing feeling of complete tranquillity. Perhaps this is what it was like during the time of Hippocrates. He was born on Kos and during his life people came to him by the thousands. They were medical pilgrims seeking cures and what they found was this healing temple dedicated to the god Asclepius … … In those days there was little more a healer could do than give the body a chance to save itself. Hippocrates made little use of drugs, relying upon fomentations, bathing and diet. The diet was very simple and included vinegar and honey. Above all, he did not try to interfere with nature. He knew that most diseases had a natural tendency to cure themselves … … we doctors must take a more holistic approach. We need to be less authoritarian and more open-minded. This is not a plea for so-called ‘alternative medicine’. Rather our treatments must be based on sound science and the recognition of the power of genetics. We doctors also must have the humility to accept that our bodies may well know what is in their own best interests. (Winston, 2000) This suggests that architects must similarly embrace the natural world and embody in their designs, especially for the design of primary health care facilities, humility for the natural world; to create buildings that put people first and which contribute to their quality of life.

Development of hospice movement Special needs and cancer care buildings The provision of facilities for the care and treatment of cancer patients has seen the development of many sensitive and caring environments. Although some of them have been built within the constraints of financial limits that are either the same as or, at least, very similar to NHS standards the briefing process has formed the central pivot around which the client, patients and architect have developed, with the medical teams, buildings which put the healing environment at the top of the list of priorities. There is an overriding concern that the patients who will be using these buildings need to be able to enjoy their surroundings, often because there are no conventional medical remedies to their illness. Where conventional medical remedies have reached the end of the line, this seems to stimulate the desire to search for a more humane architecture. This lesson, quite simply, should be taken on board for all primary health buildings.

Holistic care Fortunately, this approach has rapidly gained wider acceptance and a series of general practitioner facilities are now being designed that reflect this philosophy. There is a wish to provide services at a community level, in buildings that are friendly and accessible. There is more humility in the design approach where technology is important but subservient to the needs of people. Background to the hospice movement The importance of the British hospice movement is largely due to the work of Dr Cicely Saunders who had received her nursing training in pain management at St Luke’s Hospital in London in the unit for terminal cancer patients. This had begun in 1967 when she founded the St Christopher Hospice in London (Verderber and Fine, 2000). Her work was followed in America with the first freestanding hospice being built at New Haven, Connecticut (1972–74). The emergence of the hospice movement evolved from a treatment philosophy centred on palliative, as opposed to restorative, care. This, fundamentally, changed the attitude of medical treatment. It was about the management of death to preserve dignity for the patient. Somehow, the attitude had developed in the large sophisticated hospitals that death represented a failure of technological excellence; as if it could be avoided. Obviously, as we all know, death is inevitable for all of us and the hospice movement opened up an approach to medical care which was also to influence the physical surroundings of hospice buildings. By a remarkable coincidence, the establishment of St Oswald’s Hospice in Newcastle is directly linked to the work of Dr Cicely Saunders at St Christopher’s Hospice in London. Access to the briefing files for St Oswald’s shows that the link was to come out of the work of a young woman, Jenny Jameson, who left Newcastle to become a sister at St Christopher’s. Her parents, Dorothy and Geoffrey Jameson, lived in Jesmond, and they formed a group including the Vicar of St George’s Church (Rev. Geoffrey Bateson), his wife and Geoffrey Mellor, a general practitioner. Cicely Saunders encouraged the group to explain the work of a hospice to people at large in the Newcastle area. She also encouraged two Newcastle women (Marion Angus and Mary Aiden) to leave substantial sums in their wills for a Newcastle hospice and hence St Oswald’s was established.

St Oswald’s Hospice, Newcastle upon Tyne Another example of a building designed where care and humanity were implicit in the brief is St Oswald’s Hospice in Newcastle. Pain relief clinics had developed during the 1960s and 1970s in a number of UK hospitals, growing out of the need to treat war casualties with chronic pain conditions. This was the springboard for many projects in the hospice movement to develop, including St Oswald’s Hospice. The Macmillan Nursing Service had come into being in Newcastle in 1980 and this service was run alongside the pain clinic at the Royal Victoria Infirmary. The need for a

dedicated hospice began to emerge and a committee was set up to develop a building concept. An architectural competition was organised and the winning architect, David and Jane Darbyshire, won first prize. Writing an article recording the progress of the hospice’s development Jane Darbyshire identified that the original brief that David Rock had provided was a fantastic document for anyone doing a competition, but to us the most important part was the bit that was written under ethos which I think is important: ‘The hospice’s job is not to cure but to relieve physical, social and emotional pain and to provide peace and security while the patient’s relatives gain confidence and support.’ She goes on to write that a hospice is not a hospital and must not have the railway station atmosphere and particular character popularly associated with hospitals: the noise, certain smells and appearance, signboards and impersonal hurry and tedium. The furnishings and fittings of the building itself and its surroundings must be domestic rather than institutional, the hospice being a house and not a hospital. Cyril Winskell, Chairman of the Appeals Committee, has given me access to his personal file and extracts from some of the early fundraising documentation emphasised that the humanity and serenity of the building were paramount factors in the design brief. Significantly, the description of the hospice’s function as a home with an atmosphere of calm and friendliness, comfort and support for those who were ill takes precedence over the financial parameters which are so often the starting point for traditional health buildings. The philosophy of the building was the driving force behind the energy that was committed to making the building a reality and only when that was settled did the business of fundraising become important. The significance of this work is underlined when it is remembered that these documents were being produced around 1981. The scale of the challenge is underlined by the appeal target which was set at £2 m. When compared to the traditional procurement route for health buildings at that time the audaciousness of this project becomes even more apparent especially when contrasted with the design quality of some hospital buildings being built at that time. The development of primary care projects was in its infancy and the success of the St Oswald’s Hospice project is clear for all to see. More recently, it has gone on to extend its buildings and provide a wider range of services, including the opening of a specialist children’s unit. This background of compassion, care and dignity for terminally ill patients was also to alter the approach to briefing the architect. The emphasis was on the quality of the place, to be comforting, friendly and beautiful. The vision for the building was established on those qualitative factors rather than any practical list of space requirements with a cost limit. Those problems were tackled after the aspirations had been set. Numerous examples now exist where the architect is giving greater emphasis to these qualitative issues. The ‘Light Garden’ for the Dana Farber Cancer Institute in Boston, designed by Linda Lichtman, is an interesting exercise in the use of stained glass lit from behind to create a ‘glowing

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Primary Care Centres window of light’ in a sub-basement devoid of natural light (Raguin, 2003). Other techniques to bring a vision of the natural environment into cancer radiation treatment rooms (necessarily surrounded by dense lead-lined concrete structures) include changing light patterns of a woodland scene on the ceiling and an internal courtyard garden. The Maggie Centres, in memory of Charles Jenks’ wife, are a programme of small specialist cancer centres under construction around the UK designed by a number of distinguished architects. Their briefing highlights the differences between the design of a hospice and a NHS health care building.

Holistic care The changing attitudes and policies, representing a shift from scientific theory, have been further reinforced by a plea from a former Archbishop of Canterbury, Dr George Carey, saying that religion is being replaced by therapy. ‘Western culture today is obsessed with three alternative saviours – therapy, education and wealth, among many others – none of which can provide lasting healing for our broken world.’ He went on to say: ‘Our society is fascinated with the healing of the body and mind. Its unspoken assumption is that if we can but keep in tune with the well being of our inner selves, all will be well’ (Gledhill, 2000a). His encouragement for the importance of faith to be reconsidered encourages a return to traditional values.

A healing environment What has emerged from a diversity of architectural theory is a rapidly growing awareness of the need to create healing environments in our health care buildings for the future. Medical schools are introducing courses on the arts and humanities so that the next generation of doctors has a more rounded and broader education. Architectural research is pursuing new avenues to provide the evidence demanded by politicians; this is necessary to justify the funding decisions consequential to policy changes which embrace quality. The promotion of a feeling of well-being is now central to the design of many new health facilities, including primary care community buildings. Many of these ideas are included in a diagram prepared by HLM, a firm of architects responsible for the design of several new hospitals being built under the new PFI (Private Finance Initiative) scheme. The art and science of creating environments that prevent illness, speed healing and promote well-being define the challenge which both the medical and architectural professions must address in seeking to advance the theory of health care. A central hypothesis of this book is that a holistic lifestyle brings with it therapeutic benefits. Historically, numerous quotations highlight this long-held view of the relationship between medicine and the environment. Health depends on a state of equilibrium among the various factors governing the operation of the body and

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the mind; this equilibrium in turn is reached only when man lives in harmony with his external environment. (Hypocrates) A more modern example of the same philosophy is set out in the briefing document for the Glasgow Homoeopathic Hospital which was held in 1999. We aim to help people self-heal – if possible from their disease, but always from their suffering. We wish to create a space, a place, an atmosphere, an approach and an experience that helps this healing happen. We strive to treat each patient as a unique, individual, and whole person, recognising that their inner and outer life can have a significant impact on the processes of disease and healing. We seek to discover what is of value within traditional and complementary care, and integrate this with the best of orthodox care, blending the arts and sciences of healing. We recognise that our work as carers requires us to address our own understanding, health and well being. We aim to share this knowledge and experience with our individual patients, and with the community. (Reilly, 1995) These ideas are gaining ground in medical education and Professor Sir Kenneth Calman has been instrumental in initiating lecture courses in the humanities in the medical schools of Glasgow and Durham. There is an old adage that medicine is both a science and an art. We try to give a detailed explanation of what that means, and to show how the evidence-based medicine movement can be integrated with the arts or humanities in medical education movement. This integration provides the basis for the sound clinical judgements which are evidence in practice. (Downie and Macnaughton, 2000, p. ix) However, there remains a problem of how to sustain a design methodology based on qualitative evaluations. Arts for Health is a movement that has been gaining support and offers a convenient and easy route for NHS Hospital Trusts to acknowledge the importance of works of art in medical environments. However, the more fundamental challenge, and one that is infinitely more complex and difficult, is to integrate the whole design process for the building fabric within a design framework striving for a high quality environment. Good design is about the quality of the spaces; about creating a place; about providing a caring environment that lifts the spirit. We have all experienced the joy of being inside this kind of space but we cannot measure it in scientific terms. Of course, these holistic concepts are not limited to the visual arts, but include music, dance and drama. In a civilised society, where the importance of culture is recognised, the value of such a policy would be selfevident. In the UK, where culture is all too often seen as separate from life itself, we badly need to get away from the surgeon/barber institutionalised vision of health care,

Holistic care and acknowledge the potential of the holistic approach. There is an urgent need to develop far-sighted cultural policies for health. Such a policy ties in with the growing interest in and use of complementary medicine, and the holistic approach which aims to cure the whole person, rather than simply deal with their physical symptoms. (Senior and Croall, 1993) A shortage of research is limiting the introduction of such philosophies into the NHS system. This must change. Unfortunately, in our current accountancy-led, marketdriven economy there is an expectation that a financial cost/ benefit analysis is necessary to justify any capital expenditure. As has been previously explained, a non-scientific system for an arts programme (with no evidence base) is an inadequate and defenceless criterion for a capital-spending programme. Many of these arguments were touched upon when HRH The Prince of Wales formed his Institute of Architecture and he wrote in 1995:

may claim is the case on the basis of evidence provided by what is purely visible and tangible. Health also has a spiritual base, a foundation in the individual’s sense of personal wholeness and in his relation to the other wholes in which we all live: our families, our communities, our nations, our world … Is it not time that we began to escape from a stereotyped and bureaucratic approach to hospital design? Prince Charles returned to this subject when he delivered the Reith Lectures in 2000. He attacked the dangers of unrestrained scientific research and the perils of tampering with what he calls ‘the grain of nature’. Written following a pilgrimage to a Greek monastery he went on to argue that in this technology-driven age, it is all too easy for us to forget that mankind is part of nature and not apart from it and that this is why we should seek to work with the grain of nature in everything we do.

Conclusion … there is a need for great recognition that mental and physical health are not simply about medical repairs. We are not just machines, whatever modern science

Perhaps a good way to summarise the importance of creating a sense of well-being when designing health care buildings

A sense of control Patient retaining independence

Promote well-being

Reduces stress

Integral to design

Access to social support carers and nursing staff nearby

Total healing environment in patient areas

External views bringing the outside (nature) inside Reduces stress Access to positive distractions

and patient well-being

Memorable surroundings humanise the ‘inhospitable’ hospital

Public areas Different atmosphere to healing environment

Positive distractions/stimulation neither too high or low — appropriate level of stimulation low level of stimulation — produces boredom/negative feelings positive distractions hold interest — can have positive psychological effect Acoustics acoustic environment improved by selection of interior surfaces/furnishings positive side of sound — music

Scent smell and emotions are closely intertwined plants can provide pleasant fragrances some plants can clean the indoor air plants provide a design interest plants bring nature inside

Light health benefits of lighting sunlight different light sources — windows/atria window views — provide the daily variation in light (as well as nature) windows — relevant to visual, thermal and psychological aspects of comfort

Figure 7.1

Colour varied hues/tones

Tactile bodily comfort furnishings surface treatments different environments — comforting

Orientation warm/cool colours to north/south facing areas

Space progressive care settings (sensitively designed — like hotel) pleasant environment humanise external/internal views private space

Procurement of furniture fittings to be coordinated between commissioning office and interior design

James Cook University Hospital Promotion of well-being: patient centred care

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Primary Care Centres is to refer to Christopher Day’s work at Prince Charles’ Foundation. He sets out his views as follows: Wholeness and health Architecture for the human being involves life energy, feelings and individuality as well as body issues. Every aspect of life is permeated by these four levels of influence – even the realm of economics. Wealth, in physical terms of money or resources is the same in both boom and recession. What differs is the rate at which it flows through society. And this depends on whether we ‘feel good’ or are fearful, depressed. And this, in turn, upon our confidence and positivity – the ‘spirit’ of the times.

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We live in a time of widespread concern to better human environment – but focus is primarily on the physical sphere. Human beings are more than just bodies. For wholeness – the basis of health – we need nourishment at every level. The complex and dynamic organisation of the physical body underpins our relationship to spatial qualities. Life-enhancing qualities around us support our life energies. Colour, harmony, and multisensory delight support our feeling of life, particular moods redressing personal and situational imbalances. Journey sequences, beauty and care-imprinted environment can nurture our spiritual development. Buildings built upon these principles are buildings to nurture the whole human being. (Day, 2002, pp. 186, 187)

8

Art in health

During the 1990s, there emerged a strand of research looking more closely at art in health. Initially, it was predominantly centred on a discussion about the inclusion of works of art, meaning the display of visual images. However, the pioneering work by Professor Peter Senior and others through the Arts in Health Programme has stimulated a wider discussion. It has acted as a catalyst for a new enthusiasm to take on board the concept of environmental quality assisting in patient recovery rates. This recurring theme has been identified by many including Ann Noble (1999). The Hospice Movement is the response to the failure of mainstream hospitals to meet the needs of terminally ill people and their families and there are many wider lessons that can be learnt from them. The fear, and for some, the likelihood, of dying are very real and ever present in all hospitals; yet requirements which are fundamental to the design of hospices – such as surroundings which are reassuring and inspiring, with views of sunshine – are either totally absent from modern hospitals or are regarded as no more than optional extras. However, she goes on to explain the difficulties: The value of and the need to provide a therapeutic environment in hospitals are surely axiomatic but the best way of achieving them is less clear. One reason for this is the complexity of interactions between patients, staff and the building. (Noble, 1999) The success of the Arts in Health Programme should not be underestimated. It has motivated the wider debate which is now rapidly accelerating to examine the therapeutic benefits from an improvement in the environmental and design qualities of the building fabric. Art, in the sense of pictures on a wall, has been the key to unlocking the bureaucratic attitudes in health administration. However, art is integral with good design and not an agent to dress up mediocrity.

In 1996 (Parker, 1996), it was still being debated whether or not NHS Estates should provide more central direction and encouragement for art, and foster research into its therapeutic benefits. There were certainly some who thought that it was best left to individual bodies, and there has been a reluctance by the NHS to become involved in design issues. Only recently have these views begun to change, and it will be some time before the culture of the service provider switches to the awareness required to satisfy consumer demands. The concept of art in health buildings is at the heart of ‘value for money’ evaluations. There is a case for saying that health care is itself an art with a scientific basis (Downie, 1994) and this is difficult to reconcile with the current NHS view that art in health needs to be justified by evidence to support funding. As Lord Robert Winston has noted, science only asks the questions; it is an enquiring process. Healing is a more all embracing concept; it involves our minds and our feelings and our spirits as well as our bodies. It is therefore perfectly natural to go along with Handel’s view and accept that music can heal our sadness. As Downie points out: ‘The most obvious common ground between healing and the arts is morality’ (Introduction: p. XV). As these more rounded views begin to become widely accepted a number of research groups are beginning to examine how to demonstrate ‘value for money’ for good design. At the University of Sheffield, under the chairmanship of John Wells-Thorpe, Professor Bryan Lawson is engaged on a research project, and at the University of Nottingham, Dr Phil Leather is developing research methodologies to examine those aspects of design that contribute towards the creation of a therapeutic environment. He states in his draft report, ‘A Comparative Study of the Impact of Environmental Design upon Hospital Staff and Patients’ (February 2000) that: Many traditional hospital designs, however, create a very different image, one which is strange and alien to many. Carver (1990: 86), for example, compares being admitted

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Primary Care Centres to a modern hospital to ‘entering an alien spacecraft’, where the atmosphere can be ‘intimidating and unfamiliar’. Veitch & Arkkelin (1995) suggest that the mere mention of the word ‘hospital’ is enough to conjure up ‘thoughts of long sterile hallways, stainless steel utensils, banks of life-monitoring equipment, people in white uniforms rushing to and fro, specialized rooms for specialized functions, wheelchairs lined up at elevators, and the smell of rubbing alcohol and disinfectant.’ Not surprisingly, then, the unfamiliarity and strangeness characteristic of the hospital environment has been found to generate strong negative emotions, including threat, vulnerability and fear, together with those associated with suffering and death (Brown, 1961). Ulrich (1991) argues that such emotions derive directly from a design ethos, which emphasises the functional delivery of health care at the expense of patient needs. The results, he concludes, are hospital designs which are ‘psychologically hard’ and ‘unsupportive’ and which work against the ‘wellbeing of patients’. Psychologically hard facilities have this negative impact upon patient wellbeing either because they are experienced as stressful in themselves, or because the effort needed to cope with them adds to the total burden of illness. Psychologically supportive designs, on the other hand, facilitate patient coping with the stress known to accompany illness and are thereby complementary to drugs and other forms of medical technology in fostering the process of recovery. An important goal for design, then, is the creation of hospital facilities that convey a positive image e.g. fostering an environment that patients find pleasant and relaxing and which are thereby conducive to reduced stress and improved wellbeing. (pp. 2 and 3) Creative arts can: ● ● ● ● ●

Alleviate stress Reduce boredom Provide reassurance Give comfort Increase motivation and mobility. (Steel, 1999, p. 118)

Art is to be enjoyed and it can take many forms: the visual arts, including sculpture, the dramatic arts, music, poetry and, of course, architecture. The influence of this trend was identified and has been described as ‘the best medicine’. Take, for example, extracts from an article published in 1998: A high-level group of doctors, academics and healthcare practitioners met in Windsor recently to launch an ‘arts on prescription’ campaign. Their aim is to encourage the use of art – from poetry to pottery – to promote longevity and healthier living. Dr Robin Phillip, a senior clinical lecturer at the University of Bristol, drew attention to one of the potential benefits of the scheme: ‘We spend £81 m a year in Britain on antidepressants, and the cost

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per patient can be as high as £300 a year. If we can wean just a few of these patients off such drugs through the use of arts in healthcare, then it will be worth it.’ If the idea of expecting sculpture to alleviate dermatitis, or Debussy to cure depression, sound airy-fairy nonsense cooked up by new age idealists, think again. The Hopi and Navajo tribes in North America have for centuries created sane pictures to heal their sick, and as early as the 4th century BC, Theophrastus – Aristotle’s favourite pupil – noted that ‘the sound of the flute will cure epilepsy and sciatic gout’. One of the most vivid manifestations of Nightingale’s ‘variety of form and brilliancy of colour’ is to be found at the Chelsea and Westminster Hospital in London, which must be the only hospital in the world to have a donations box cast in bronze by Sir Eduardo Paulozzi, let alone a magnificent Veronese resurrection in the chapel and a marble sculpture by Dame Barbara Hepworth in its dermatology unit. For all the entertainment value of much of the art she has installed, Loppert (Susan Loppert, Director of the Hospital Arts Project) is deadly serious about her work’s purpose. ‘We are not a frivolous optional extra here,’ she says. ‘And nothing we do is depriving you of a bed, or a hip replacement, or vital clinical research. We see the hospital arts project as an equally important part of the healthcare we offer. It’s long been known that if you’re in a colourful, healthful environment, you do get better more quickly’. Mens sana in corpore sano was how the Romans put it, and an awareness that health is a function of consciousness is taking hold in the West, despite the efforts of drug companies to persuade us that if we take more pills we shall be saved. As Freeman adds: ‘What we do is therapeutic, but it’s not therapy. In creating a stimulating engaging environment, we are shaking off the shackles of hospitals being places where you come to die.’ (Wright, 1998)

Development of art in health care buildings Buildings should be enjoyed and include works of art That the arts can be therapeutic is not of course a new idea. But it is an idea whose time has come. (Sir Richard Attenborough, 1989) The arts and humanities in health and medicine is an idea whose time has come. (Sir Kenneth Calman) Art in health buildings is usually thought of as a recent phenomenon and it is certainly true that there has been a surge of interest, and awareness of the benefits, in recent years. However, the Victorians decorated their public buildings, including hospitals, with paintings and sculptures celebrating great personal achievements. Proud of their financial and technical progress, benefactors were recorded for posterity by these self-indulgent acts of artistic patronage. This legacy is still with us, often exercising the minds

Art in health of today’s administrators as to the best way to incorporate these works in new hospital buildings. An interesting historical anecdote illustrates the introduction of the Arts in Health. As early as 1912, it is suggested that Nijinsky was taken ill during a visit to London with Dyaghilev’s Ballets Russes and was taken to St Stephen’s Infirmary, a Victorian workhouse-turned-hospital on the site of the Chelsea and Westminster Hospital. On his recovery, three days later, legend records that he performed L’Après-midi d’une faune and that Dyaghilev had ‘distributed gold sovereigns to patients and staff ’ (Loppert, 1999). Susan Loppert, in charge of the arts programme at the Chelsea and Westminster Hospital, has developed an impressive track record of integrating public awareness of cultural issues into a healing environment. Music, opera and the visual arts all have an important part to play in raising the environmental quality of the building for those who visit it. Under Dr Rosalia Staricoff the hospital is now an important research centre for examining and quantifying therapeutic benefits and patient outcomes resulting from environmental factors. Art is seen no longer as recording the ‘great and the good’ but as enhancing public enjoyment; indeed art should not be seen as an adornment to a building or a space but integral with the design of the environment as a whole. In my book (Purves, 2002) it is argued that quantifying the cost benefits of the intangible qualities of art presents today’s designers with insuperable obstacles. Perhaps these difficulties can be put into perspective if the concept of quality is not divided into tangible and intangible benefits. Our perception of intangible benefits is categorised thus only because the factors involved are more difficult to quantify. With more research perhaps meaningful conclusions will be able to be drawn and the mysteries of concepts such as welcoming, relaxing and calm will be given quantifiable characteristics

for the architect to manipulate. In this way the control of environmental qualities will emerge as the future path to improving patient outcomes by offering therapeutic benefits. Today, we are still groping for scientific evidence, using the defence of philosophical concepts, but this is changing. There is growing awareness of the need for more research and over the next few years our intuitive instincts will be tested and challenged by the results. James Cook University Hospital A research project completed by CAHHM (Centre for Arts and Humanities in Health and Medicine) (Durham University) at the James Cook University Hospital evaluated the design quality of the new buildings compared with the aspirations set out in the brief. The project is a £120 m major reconstruction of the South Cleveland Hospital under a PFI (Private Finance Initiative) contract. The brief sets out a commitment to the delivery of high quality ‘patient centred care’. Specifically, one of the research questions asks: ‘what is the user response to the art work placed or integrated within the new hospital building?’

Art and science in medicine The relationship between medicine and architecture requires greater study but there are many parallels that can be drawn between the theory and practice of the two professions. A doctor, as well as having technical knowledge based on scientific principles, must also make clinical judgements and these issues are discussed in a recent book (Downie and Macnaughton, 2000). They use a diagram to illustrate the main relationships (Figure 8.1). Doctors who are in the middle of their careers (i.e. the 40 and 50 year olds) were trained as clinical scientists and

Science

Scientific understanding Scientific method Evidence (scientific and technical)

Arts and humanities

Ethics Interpretation Insight

Technical judgement

Educatedness (adaptability personal development broad perspective)

Humane judgement

Clinical judgement Figure 8.1

Clinical judgement: a diagrammatic summary (Downie and Macnaughton, 2000, facing p. 1)

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Primary Care Centres this has led many leaders in the medical profession to begin to question training methods. With the government increasing expenditure to encourage greater numbers of medical students to commence their training, developments are taking place in the design of curricula to include non-medical subjects. Special Study Modules (SSMs) are being proposed that would deal with not only ‘ancillary medical subjects such as mathematics, physics, the social sciences, and philosophy’ but also non-medical subjects particularly in the arts and humanities (Downie and Macnaughton, 2000, p. 173). These traditional values have also pointed to the next generation of primary health care buildings being more akin to a cottage hospital than a ‘high-tech’ building. Such scientifically based buildings represented the intellectual high ground of both professions in the 1980s and 1990s and are now increasingly being questioned by those advocating a more rounded and broadly based philosophy of life. Cottage hospitals are to be created from GP surgeries as part of a drive to cut NHS waiting lists for operations. ‘… family doctors will be encouraged to earn extra fees by training to perform procedures such as cataract removal in their own mini operating theatres. There are thousands of people waiting for the 12 minute procedure to restore their sight. Moving this and similar non-complex operations into a new generation of the cottage hospitals that used to feature in small towns and villages will do much to meet an ambitious 6 month maximum waiting time target for all operations’ (Rogers and Prescott, 2000). It is this challenge that architects need to meet to satisfy the demand for new facilities that can accommodate the new services in a caring and humane environment. New policies are unfolding to encompass a comprehensive re-examination of primary care policies, management and required facilities.

Examples of good practice Some of the best examples of successful small-scale caring environments in the UK have been created outside the NHS procurement route. There are many examples of good

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design where clients have been looking for a more sensitive approach to provide facilities for special health needs.

Support for an arts programme The background to the current wave of enthusiasm for better design in health care environments includes the introduction of art in a wide range of buildings. There are many innovative examples of NHS projects that have been improved by the introduction of art works. Typical of this approach is the work done by Northern Arts (much of it under the guidance of Germaine Stanger and Mike White). This also resulted in the establishment of artists’ residences after the completion of original commissions in four local hospitals. They were instrumental in encouraging and helping to see through to completion a range of projects.

Conclusion The last 10 to 15 years of the 20th century saw a return to recognising the principles of health care that had been used in earlier civilisations. The importance and influence of art, music, food and architecture all began to re-emerge as significant factors in designing primary health care buildings as there was a greater recognition that a sense of well-being included healing the soul as well as mending the body. Broadly understood as holistic care, architects found they were able to persuade clients and doctors to incorporate aspects of these ideas into the design of new primary health care buildings. The briefing process for new buildings began to focus increasingly on the patient and to learn from some of the successes of good design seen a decade earlier in the provision of hospices. Politically, it was necessary to explore new ways of financing and designing health care buildings and this richness of factors began to speed up the rate of change and give more confidence to politicians to place patients at the centre of their agenda.

9

Case studies

Introduction The first edition of this book, Health Living Centres (2002), illustrated as case studies a number of GP surgeries, polyclinics, hospices as well as several other types of community health facilities. During the last five years there has been an increase in the number of small-scale health buildings, resulting in greater architectural variety and a range of procurement systems attracting higher levels of private finance. More flexibility is possible using alternative procurement routes and there have been changes in policy and attitude within the NHS. The development of PCT (Primary Care Trust) strategies has developed and funding structures are continually being looked at to generate a variety of solutions. In this book, the case studies have been assembled to reflect that increase in diversity of procurement pattern and financial structure. They are loosely assembled under five broad headings: 1. LIFT (Local Improvement Finance Trust) 2. Northern Ireland initiatives 3. Some flexible approaches to procurement in Scotland 4. Examples of community care centres embodying a range of mixed uses that meet local demand 5. Special interest buildings.

LIFT Five years ago the LIFT programme was in its infancy. Now the LIFT schemes under construction are setting examples of innovative primary care facilities that reflect the needs of local communities. The launch of LIFT was a new initiative to stimulate the funding and operation of future primary health care facilities. The procurement route was designed to introduce private finance in the structure which devolves responsibility down to smaller building blocks at a regional and local level. Partnering at small and medium levels of contract size also offers potential for productive working

relationships. If the LIFT programme is to be successful, cooperation at a local level to allow specialist skills to flourish would seem to argue against all the necessary competencies being provided by one organisation. One possible split is: ● ● ●

Strategic Construction Facilities management (FM)/health services.

By allowing competencies to evolve at a local level suggests the willingness to consider separately function and ownership of primary health care facilities. The provision of health services and their management and maintenance are quite different to the skills required to build a high quality flexible building that is sustainable, environmentally friendly and efficient to run. The LIFT programme, by encouraging the leverage into the system of private finance, provides every opportunity to develop the more sophisticated marketplace for the provision of primary health care buildings. The LIFT programme also reflects government aspirations to modernise GP facilities and to integrate them more closely in the community. The government has taken the shift towards the introduction of private capital in the procurement process to encourage the incorporation of various agencies in one building. This varies from location to location and is a positive attempt to provide appropriate facilities in the right place in the community. The socioeconomic profile of an area can be reflected in the facilities provided by the new community centres. These buildings have a prospect of becoming the hub of local activity and perhaps taking on the role of a rural village hall in an urban context. By providing a range of facilities in the same building, designed to a high standard, it is expected that the local community will respect the building and take ownership of it thereby inducing a sense of civic pride. If this happens, vandalism against the building can be expected to decline. The location of these new LIFT projects is being debated exhaustively by the PCTs which have been given the

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Primary Care Centres independence and financial authority enjoyed by other NHS Trusts responsible for the hospital programme. They are working in conjunction with the private sector companies to form new special purpose vehicles (SPVs) to fund and maintain the facilities for 25 or 30 years. By March 2007, there were 42 LIFTCos, 106 buildings in operation, 70 under construction and 70 more at the planning stage (Noble, 2007). Of some concern is the fact that ‘design’ is relegated to a minority percentage in the procurement assessment process with the financial, legal and facilities management aspects of such a long-term project having equal or greater influence in the outcome of the selection process.

Northern Ireland Over several years the Northern Ireland Health Estates have been developing a different approach (when compared to the rest of the UK) to the procurement of health buildings. Known as the Primary and Community Care Infrastructure (PCCI) it has commissioned a number of architects to carry out feasibility studies on 45 potential projects. Under the direction of John Cole, who is in charge of the building programme approaching £2bn, the approach is to give proper reward by fixing the fee and the construction budget and taking it out of the competitive process so that the evaluation process comes down to design and quality based on a thoroughly worked-out brief. Singled out by the President of the Royal Institute of British Architects (RIBA), George Ferguson, in his presidential lecture in 2004, Cole is overseeing a procurement process which is regularly producing architecturally acclaimed health buildings that are within budget. Cole is an excellent demonstration of an architect who is influencing the environment as a client rather than as a practitioner. He advocates four necessities for successful development. 1. The right culture – client 2. The right processes – performance-related partnership 3. The right resources – budget 4. The right people – team. The following section is from an article written by John Cole in February 2007. Strategic planning for healthcare facilities John Cole is an architect by profession with many years’ experience in the planning, design and construction of health facilities. He is currently Chief Executive of Health Estates, an agency of the Department of Health, Social Services and Public Safety in Northern Ireland. There is now almost universal recognition of the major contribution that high quality architectural design incorporating art and landscaping can make to improving patients’ experiences and outcomes. As a result the objective of achieving a high quality environment is increasingly seen as a fundamental requirement for all health facilities.

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However the delivery of high quality architecture, landscape and art cannot be seen in the world of health as an objective in itself. It must be achieved within a wider strategic planning context which clearly contributes to improving or facilitating the improvement of the health of the population. A health estate that does not do this has little purpose. It is essential in planning the health estate that the locations, forms, clinical profiles and capacities of individual facilities are based upon their combined contribution towards the achievement of a clearly articulated model of care designed to optimise health outcomes. In order to do so there needs to be recognition that the physical life and hence the use of the buildings we are currently producing will extend over many changes of health policy, practice, technological advances, demographic trends, epidemiology and public expectations. We cannot afford to be constantly replacing inherently long-life assets to reflect the rapid frequency with which these changes are occurring. Accordingly those responsible for the strategic planning of our estates must as far as possible understand and plan for specific requirements and policy developments in both the short and longer terms. To do this we need to articulate a vision for the future. Development without a vision is like driving without a destination We have essentially two planning horizons to satisfy: 1. Meeting clearly defined specific planning requirements for the short to mid term based on reasonable statistical analysis and 5–10 year projections of service changes and relatively well understood emerging models of care. Unfortunately even this shorter time horizon is frequently not properly addressed with a significant number of developments looking backwards rather than forwards for their models of care and tending to replicate current design solutions that are already outdated in terms of location, form, layout and capacity. 2. Meeting more generic planning requirements for the mid to longer term through flexible design solutions based on much less firm knowledge and greater hypothesis about the future patterns of health care provision. This is by definition much more difficult to achieve and is rarely done well. In order to produce this strategy we need to set out very clearly two interdependent visions. The first of these, the Service Vision, is the key building block in establishing the need and the models of care to meet that need. Without a clear articulation of the service vision any further development of strategic capital planning is impossible. The second requirement is a Design Vision which should demonstrate the principles of the design response to that need including the ability to cope with the uncertainty as to how that need will change over time.

Case studies The Service Vision should establish: ●

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An agreed service model reflecting projected changes in demography, epidemiology, demand, models of care, clinical practice, technology, service development, political thinking and consumer expectations A strategic capital development programme fully reflecting this model and aiming to provide an integrated range of facilities, providing the right combination and quantification of services in the right locations in order to best meet the health needs of the population served The Design Vision should establish:

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Generic and specific functional and quality objectives that recognise the major contribution measured in terms of impact on health and well-being outcomes that design can play by creating actual healing environments A strategy to facilitate in-built flexibility for change of demand and use for health-related purposes and where practical for conversion to non-health uses over time Design principles to ensure that health facilities as far as possible contribute to the quality of the wider built environment and enhance and enrich wider community engagement and development A focus on whole-life rather than simply capital costs whilst ensuring the delivery of the required quality of design and the contribution to wider environmental, social and economic sustainability

Northern Ireland is unique in the United Kingdom in that responsibility for the organisation and delivery of health services and social services is integrated under the auspices of a single organisation, the Department of Health, Social Services and Public Safety. The Proposed Model: The most recent review of the Health Service in Northern Ireland concluded that we needed to seriously reconsider the concept of the stand-alone acute hospital as the main provider of clinical and related services and that our strategic capital development programme should focus not so predominantly on the acute sector but seek to create an integrated continuum of facilities from the home through primary, community, sub-acute and acute facilities supported by structured networks. The following are a series of key extracts from the report.

Two key trends emerged as a current consensus in relation to the suggested future delivery of services. 1. The first of these, and the more significant, is the decentralisation of less specialised activities away from the larger acute centres towards community-based facilities. Additionally a focus on the importance of personal responsibility for health and well-being has emphasised the contribution of non-health-specific interventions. These should aim to improve physical fitness and diet, to provide education and information on the management of chronic diseases and other conditions including access to community-based support groups, and to support members of the community in managing stress-generating issues such as financial, housing and employment problems which can directly or indirectly lead to health problems. These analyses have identified the need for new models of care, highlighted the importance of fundamentally reviewing patient pathways through the total system and reinforced the need for new types of community health facilities aimed at bringing an improved integrating mechanism to the delivery of services. One of the principal objectives is to facilitate as seamless as possible cooperation between the primary, community and acute sectors through a system designed about the patient experience and enabling earlier access to diagnosis and any necessary interventions. As a system response to this it has been decided to reduce the number of Trusts from 17 to 5 and to make each of these 5 responsible for provision of the full continuum of health and social services within their geographical area rather than focussing on either secondary or primary and community care. These services exclude regional specialities which will still be largely provided by the Belfast Trust centres of excellence. 2. The second trend is the movement in the opposite direction i.e. from local general hospitals to acute centres or regional centres of excellence, of those services that due to their complexity require specialised skills and expertise that cannot be easily replicated in local hospitals. In developing the new strategy for delivering services it is important to recognise that the location, number and form of facilities was only one of four distinct strands of the process of redesigning the total system. The four strands were: ●

●

●

●

●

‘Patient care is best seen as a system in which the acute episode is an event in an unfolding and ideally seamless pattern of care’ ‘We were attracted by the concept of a virtual hospital, or a hospital without walls’ ‘Part of the objective is to keep people out of acute hospitals who should not or need not be there’ ‘The day of the stand-alone institution attempting to do everything from its own resources, acting in isolation from the wider system is already gone’

● ●

●

establishing new models of care re-engineering the workforce optimising the contribution of developments in information technology and redesigning the facilities

The proposed model for Northern Ireland on which our current Strategic Development Plan is based is shown in Figure 9.1 indicating five levels of facility. It is intended that all of the levels from 1 to 5 will be linked by clinical and information technology networks and

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Primary Care Centres An Integrated Services Model

3 100kⴙ

150–300k 4

Nonhealth 1.7 million 5 2

20–70k

Individual homes Other community health facilities

Level 1. Local health centre

1

2–10k

serving 2–10k

Level 2. Community health centre serving 20–70k Level 3. Local hospital

serving 100k

Level 4. Acute hospital

serving 150–300k

Level 5. Regional centre

serving 1700k

Figure 9.1

An Integrated Services Model for Northern Ireland

will have clearly established protocols for patients’ access to and pathways through the total system. There is not a rigidly fixed definition of which services are delivered at each level, rather the system will be designed with some flexibility around a set of agreed principles. In recognition of the differences between urban and rural areas, and criteria such as travel distances, accessibility and scarcity of some groups of key staff or specialist equipment, the local application of the model will vary to reflect local circumstances and needs. However individual examples of any one type of facility will generally include similar combinations of services in line with the model of care. The typical range of services provided at Levels 1 and 2 are: Level 1: Local Health Centres (construction cost range: £1 m to £5 m) GP practices Non-complex diagnostic testing Basic treatments and nurse-care Range of therapies Level 2: Community Health Centres (construction cost range: £5 m to £15m) Usually Level 1 Services plus Out-of-hours GP service Outpatient consulting suites Minor procedures suite Non-complex imaging and diagnostics Children’s services Physiotherapists Speech therapists Podiatrists

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Dental services Social services Mental health services Multidisciplinary outreach teams Voluntary sector Community facilities Pharmacy The fundamental objective behind this new model of care is to improve accessibility to and the quality and timeliness of the particular services the public need. The key role of the community health centre As can be seen it is proposed to construct approximately 48 Level 2 facilities, i.e. community health centres, across Northern Ireland. These projects are seen as key facilitators, firstly in enabling the transition of appropriate services from secondary to community care with a focus on health promotion, illness prevention and earlier diagnosis and intervention and secondly in bringing together and integrating in a single facility the majority of community services that are currently dispersed both physically and operationally. In so doing they act as a vertically integrating mechanism for the five levels within health. They also act as a horizontally integrating mechanism providing a natural interface for cooperative working between health and social services and other agencies providing public services which directly or indirectly impact on the health and well-being of the local community. The sites for these projects have been chosen to optimise public accessibility by locating them in the centre of communities close to natural transport and shopping hubs. Both the population served and the size of the facility vary to reflect local circumstances. One of the most interesting Level 2 projects, located in the Belfast area and currently under construction, is the Grove Project, a scheme that fully integrates in a single development a Community Health Centre with a new major leisure centre being funded by the City Council together with a public library being funded by the Department of Culture Arts and Leisure. This is an excellent example of joined-up government, working in an area of the city with high levels of deprivation, to bring a focus on improving the health and well-being of the local community whilst also making a major contribution to the regeneration of this locality. In addition to the primary functions of the key elements of the Grove development, a wide range of synergistic opportunities have been established including the use of the swimming pool for hydrotherapy, the fitness suites for physiotherapy, the games areas as amenities for groups of the elderly during periods of lower demand by the general public and the library functioning as a resource centre to assist in providing healthy living information to the public as well as providing access to information on support networks and employment, housing, financial and educational issues. The facility also incorporates facilities for use by voluntary community groups and a retail pharmacy.

Case studies Level 2 (Approx 48 across Northern Ireland)

Integration

Complementary therapies

Regional hospitals Acute hospitals Local hospitals

Horizontal

Community and voluntary sector

Integration

Private sector Community treatment and care centres

Vertical

Health care and social services Related public sector

Primary care: local health centres GPs, surgeries

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Figure 9.2 Vertical and horizontal integration of services (level 2) for Northern Ireland

All of these functions will make joint use of a central café, reception area and other ancillary accommodation. This facility in its combination of elements is a physical demonstration of the central roles to be played by exercise and access to information in the new strategy for improving the health of the people of Northern Ireland. Given this emphasis on health promotion it is proposed to call this project the Grove Health and Well-Being Centre. Designing for flexibility It is intended that the design approach to the total programme of development will facilitate changes in capacity, models of care, practice and technology and optimise the benefits of the initial capital investment over a longer lifetime. Conclusion The future Northern Ireland health model will focus on health promotion and illness prevention with improved accessibility to diagnostics and earlier interventions delivered in communities closer to where people live.

Scotland In A Partnership for a Better Scotland the Scottish Executive made a commitment to develop a strategy for sustaining small, rural and community hospitals where they are safe and effective. This strategy goes far beyond that original commitment. In the spring of 2007, the Scottish Minister for Health and Community Care (Andy Kerr) said that ‘our vision of the future provision of health services in Scotland as set out in Delivering for Health demands a new approach. The expansion of community based primary care led services provides a new challenge in both rural and urban areas. We believe this challenge can be met in part by a new model of community hospital. The strategy, therefore, provides a blue print

for NHS Boards and their community health partnerships to develop modern, locally sustainable hospital services that are responsive to local community needs in a wider range of settings than currently exist. It moves beyond the vision of community hospitals in rural areas to include urban settings.’ There are ideas to launch a ‘hub’ programme. Similar to LIFT it aims to provide flexibility in the procurement structures to give the mix of agencies an opportunity to ensure community-based services meet local requirements. Politically, the aim is to encourage joint working arrangements between public sector agencies and private venture developers. Scotland has also seen the development of more Maggie Centres, an outstandingly successful programme of cancer care support buildings. Scottish architecture, in parallel with the political changes which have led to devolution and the establishment of the Scottish Parliament, is searching for a new identity. It is seeking recognition that its buildings should be assessed independently. The architectural profession in Scotland is flexing its muscles to raise the status of its cultural heritage in demanding a separate national appraisal of its work. This nationalistic fervour is encouraging the development of links with other northern European countries (for example, Scandinavian countries, such as Denmark, Sweden and Norway) where there are similarities of climate, culture and population density. The Nordic and Celtic traditions are encouraging a robust architectural response to the climatic conditions in Scotland and the independence of its people. An affinity with nature, and the use of natural materials, perhaps is one reason why they are already embracing the more inclusive or holistic approach to the next generation of health buildings. These demonstrate the benefits that result from small-scale buildings using natural material that are in tune with the environment. People engage with these buildings in a way that is impressive to see. A well balanced design process including strong user focus is key to improving patient and family choice, access to fresh air, out-patient services, rehabilitation, complementary therapies, information and support. Marie Curie aspire to a facility which measures up to the hopes and expectations of patients and visitors and will allow staff and volunteers to continue and enhance their expert care in 21st century surroundings. Central to the building’s design is access to the view of the Campsie Fells to the North on this otherwise steeply sloping enclosed backland site within the grounds of Stobhill hospital. In liberating this view and ensuring that as many patients as possible had access to this from their rooms Jane Darbyshire and David Kendall Ltd designed an elongated single-storey wing of patient bedrooms and terrace running along the upper contours of the designated site looking out to the North, over the rooftop of the new hospice’s admin, education and day services facilities. The vast majority of rooms within the accommodation brief are below 25 m2 and require a window for natural light and ventilation, and so must be located on an external wall. So a series of wings and gardens rather than a block will be

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Primary Care Centres created. This enables the building to be broken down in scale and mass, and therefore being more responsive to the existing topography and ease of visitor experience, promoting positive impact on the surroundings and those using the building.

Community care centres The Department of Health has set out a useful explanation of its approach to community hospitals. There are two commonly used definitions of a community hospital, one focusing on primary care and the other on acute care. Modern community hospitals are likely to be a meeting point bridging acute and primary care. Acknowledging the bridge between primary and acute care, Professor Lewis Ritchie defines a community hospital in the following way A local hospital, unit or centre providing an appropriate range and format of accessible healthcare facilities and resources designed to meet the needs of local people. These will typically include inpatient beds, out-patient clinics, diagnostic facilities, day care, minor injuries service and other extended primary care and intermediate care services. Medical care is predominantly provided by GPs working with Consultant medical colleagues. Staff work in multi-disciplinary and multi-agency teams to provide services including rehabilitation, acute medical care, palliative and terminal care, step-down care and respite care. Professor Geoff Meads has focused on the primary care elements of community hospitals in his definition: The community hospital is a service which offers integrated health and social care and is supported by communitybased professionals. (Meads, 2004, ‘Participate’ University of Warwick) Description of a community hospital’s functions ●

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A modern community hospital service aims to provide an integrated health and social care resource for the local population to which it belongs. These local facilities develop as a result of agreements between local people and service providers, largely by GPs. The health and social care provided may include medical care, rehabilitation, palliative care, intermediate care, mental health, maternity, surgical care and emergency care. Community hospital care is characterised by care pathways that make the most of local sources of support. The community hospital provides a focus for local community networks.

The government is continuing to progress its interpretation of the proposals set out in the NHS Plan first published in 2000. Recent initiatives are based around the ‘Your

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Health, Your Care, Your Say Initiative (YHYCYS)’ and is one of the largest and most public engagement exercises ever mounted in the UK. This process was to reinforce the importance of placing patients at the centre of policy assessment. How successful this programme of public participation will be is yet to be evaluated but the government is driving ahead with its plan to place the patient at the centre of its NHS reforms, developing locally based initiatives, and encouraging the financing of these new facilities by the introduction of private finance.

Special interest buildings Over the last few years, a number of relatively small facilities have been built dealing with particular medical specialities. The case studies included cover podiatry, ophthalmic, breast oncology and children’s centres of excellence. Buildings of this scale, which are similar in size and complexity to some of the new community care centres, are likely to increase in number and may begin to evolve using private capital as the provision of facilities develops in the future. Able to respond to regional demands these buildings show a sophistication of briefing which is encouraging and moves significantly beyond the procurement methodologies used by the NHS during earlier phases of its existence. In addition to the case studies describing several special interest buildings a wide range of projects have been commissioned under the King’s Fund award winning Enhancing the Healing Environment (EHE) programme which was launched by HRH The Prince of Wales in 2000. The programme has received widespread recognition as a national exemplar both in terms of the individual projects and for acting as a catalyst for the NHS to consider the impact of the environment on recovery and the way care is delivered (www. kingsfund.org.uk). Nightingale Associates have been responsible for designing several projects under this initiative including, for example, their Mental Health Unit at Clatterbridge Hospital. The brief was to provide improvements to patient, staff and visitors’ areas and gardens. The project team which was assembled was nurse-led and included an art therapist, service user, Head of Estates, Head of Therapies and an architect. This small project (£70,000.00) for the Cheshire and Wirral Partnership Foundation NHS Trust demonstrates a response to local requirements, focused on patients’ needs.

The future Increasingly, the focus of good design in health buildings is moving towards well-designed neighbourhoods as a basis for healthy lifestyles. The aim is to create places that are socially, economically and environmentally sustainable. The sense of well-being, which is about being both physically and mentally at ease with oneself, brings confidence to the individual to make choices about their own health care.

Case studies

Case study A1 Project: Community Health Centre, Walker, Newcastle upon Tyne Client: Newcastle & North Tyneside LIFTCo Architect: Purves Ash LLP Budget/Cost: £3m

Briefing context and process One of the first projects to be commissioned under the LIFT programme, Purves Ash was appointed as architects in 2003. The bidding team (which was one of three competing teams) was successful for the design of three buildings commissioned by the Newcastle and North Tyneside LIFTCo. There was an extensive series of meetings with the client, the end users and the client’s technical representative (Howarth Litchfield). Working with Robertson Construction, the design team was appointed as preferred bidders and commenced development of the brief which had been provided by the client in the form of ‘technical requirements’. The design team prepared ‘landlord’s proposals’ and planning submission documentation. In theory, all design proposals are agreed and frozen at financial close stage but this did not happen. The design process continued to evolve which strained resources for the design team within the agreed budgets. The site of this building is adjacent to Walker Park in the east end of Newcastle, an area associated with shipbuilding. As the brief points out the area has suffered because of the decline of this industry and the immediate hinterland has suffered from high levels of vandalism and antisocial behaviour. The adjoining parade of shops is of mediocre quality and we were left in no doubt from the User Group meetings that safety and security should be given high priority in the design of the new facilities. Solutions have been developed that respond to the particular needs of this site. Also, we have interpreted the comments made from the User Group meetings have been applied to best practice FM principles and to the interpretation and inter-relation of spaces, surfaces and life cycle components.

wanted to include a rent and cashiers’ office to service their local housing need, and provide both offices for welfare services and access and enquiries for general customer services.

Design aspiration or ethos The building was to replace an existing GP surgery, located on the edge of Walker Park. The building was also close to the local parish church and could be considered a greenfield site, although within the city boundaries. There was also a need to protect a wildlife corridor through Walker Park; hence, the aspiration to have the building fronting onto both the park and the church walk leaving a corridor open for wildlife. A curved form with central entrance provided a focal point for all users of the building. The form was not to dominate the high rise housing behind and materials were planned to be sympathetic to the park with extensive timber boarding on the elevations. The pleasant shape and form (curves) were designed to help and relax patients and staff and be sympathetic to the natural environment in which the building was sited. The aim was also to provide top lighting to the double height spaces planned within the building.

Community uses/patient centred care The community centre had three main user groups: ● ● ●

A seven GP medical practice NHS/Primary Care Trust (mental health services) Newcastle Council (housing office).

The GP practice also had requirements for a baby clinic and minor operations. The PCT had requirements for podiatry, physiotherapy, community dentistry and training. There was also a requirement for x-ray facilities. The council

CSC A1-1 Title: Timber facade; Architect: Purves Ash LLP; Courtesy of: Purves Ash LLP

This building is located in one of the lower income areas of Newcastle city centre and the existing building had been subject to considerable vandalism. The GPs, in particular, were very anxious about the security of the new building and considerable discussion and debate took place about the level of

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Primary Care Centres protection which should be afforded to the external face of the building. For instance, the size and type of perimeter fencing was discussed at length, as well as the need or otherwise for shutters at windows. The building is designed to be nonthreatening and has been well received by staff and patients. The design solution curves like a spine across the site which has been defined by the Newcastle Planning Department as an area of landscape. The building is designed to be sympathetic to the natural form and shapes of the landscape and our low line building, with an asymmetric section, moves across the site in a gentle non-confrontational manner. We hope people will engage with the building in a positive manner, so that they come to respect and value its place in the community where help and assistance are easily found. The form of the building is in direct response to the brief which requires a non-intrusive response to this suburban location. The architectural language is restrained, and we have designed a building that will not challenge the antisocial elements in the surrounding population.

CSC A1-2 Title: External view; Architect: Purves Ash LLP; Courtesy of: Purves Ash LLP

The building will become a forum for the community. We believe that in the future the local community will seek greater usage of the building out of normal working hours, which is reflected in our design in terms of flexibility and appearance and in detail concerning robustness and specification. Change is in the air – procurement methods, funding arrangements, ownership and management systems are all under review. The challenge is for the architect to marshal these events, to put patients first in high quality buildings and to design healing environments. This project offers the

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opportunity not only to meet the specific spatial requirements of the brief, but to highlight the importance of good environmental design and the therapeutic benefits which can accrue in a health environment. A sense of well-being is important for good health and buildings have an important part to play in creating a comfortable environment. The ethos of the building is an important starting point to achieve an environmentally well-designed building that can offer therapeutic benefits to patients and other users of the building. The building needs to be flexible and efficient and to reach out to form linkages with the community and to acknowledge the need to be sustainable. The NHS Plan places patient centred care at the heart of its objectives and the interpretation of the brief provides an opportunity to present a building for the future from which this patient centred health strategy can be effectively delivered. The Walker facility is located in an area with a number of significant social problems. The present environment in the immediate vicinity of the site consists of a tower block and shopping area. There are high levels of vandalism with a low level of respect for buildings. The doctors in the existing clinic complain about serious vandalism to their cars, problems of drug abuse and other antisocial behaviour. Experience of working in other deprived areas of Newcastle City has made us aware of the challenge in changing attitudes to one of respect for the surroundings. The architectural opportunity is used to provide new facilities where the building is respected and recognised as a positive addition to the urban environment rather than designing a building which needs to be defended and protected from abuse. The design solution sets out a framework for this approach, and seeks to minimise the chance of the worst types of abuse occurring on or adjacent to the building. The aim is to build on the potential of the site, to use the positive aspects of the landscape setting adjacent to Walker Park and to encourage the community spirit to accept responsibility for ‘ownership’ of the new facility. The community spirit in Walker is strong, and there are deep-rooted traditions which we believe the new building will help to re-emerge.

Design flexibility The linear form allows expansion of the building at various points. The GP suites could be extended, as could the PCT facilities. For example, the dental facilities are expected to grow and this could be accommodated easily with additional spaces plugging onto the existing dental rooms. The Walker site also offers possibilities for retail functions to be added to the building. The entrance area would be ideal for a pharmacy and general small retail area which might include fresh fruit and vegetables for healthy eating, a fitness club, or perhaps a small coffee shop area. The local community needs to be encouraged to take ownership of their resource centre so that it becomes a place to meet and improve their lives.

GP STAFF ENTRANCE FIRE EXIT

CLIN’L WASTE ST

CONSULTING ROOM 4

STAFF BIKE STORE (under) CONSULTING ROOM 3

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LA STAFF ENTRANCE

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CONSULTING ROOM 1 / TRAINING

ADMIN AND RECORDS

CONSULTING ROOM 7

DIS

CONSULTING ROOM 8 / TRAINING

VID CONF

SERVER ROOM

PRESCRIPTION HATCH

STAFF WC

FIRE EXIT CONSULTING ROOM 14

GP RECEPTION

CONSULTING OR RECOVERY ROOM

GP INTERVIEW

L.A. WAITING G.P. WAITING AREA

ST.

CONSULTING ROOM 9

REGISTRAR

LIFT

W. FOOD DIS. WC ST.

PCT RECEPTION

STAIRS CLEANERS ST.

PUBLIC TOILETS (male) PUBLIC TOILETS (female) ST.

NURSE TREATMENT

UTILITY/ ST

PCT WAITING AREA UTILITY/ ST

db st TREATMENT ROOM /MINOR OP’S

PODIATRY 1

PCT CONSULT ROOM

MULTI FUNCTIONAL ROOM

PCT CONSULT ROOM

Title: Ground floor plan; Architect: Purves Ash LLP; Courtesy of: Purves Ash LLP

MF ST

CONSULTING ROOM 13

CONSULTING ROOM 12

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Case studies

FIRE EXIT

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CONSULTING ROOM 11

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Primary Care Centres

92 STAIR MEETING ROOM

OUT OF HOURS ACCESS AREA

DENTAL SURGERY 2

LA STAFF ROOM

LIFT

DENTAL SURGERY 3

HOUSING OFFICE (SIM)

HOUSING OFFICE (OHM) UNISEX STAFF WC (DIS) BRIDGE

HOUSING OPEN PLAN OFFICE

HOUSING ADMIN (SIM)

UNISEX STAFF WC UNISEX STAFF WC

DENTAL SURGERY 4

WR OPEN PLAN OFFICE

HOUSING ST.

X-RAY

Compressor

SECTION & STORE

VOID AUTOCLAVE LA SERVER ROOM

DENTAL SURGERY 1

NURUSES AND/OR COUNSELLING/ CONSULTING

VOID

IT OFFICE

DENTAL SUB-WAITING AREA

VOID

HEALTH VISITORS OFFICE

DISTRICT NURSES OFFICE

LIFT STAIR BRIDGE

M.H ST

VOID

VOID

DENTAL STORE

MENTAL HEALTH OFFICE

DENTAL OFFICE GP/PCT STAFF ROOM

CSC A1-4

Title: First floor plan; Architect: Purves Ash LLP; Courtesy of: Purves Ash LLP

UNISEX STAFF CLEANER’S WC STORE

UNISEX DUCT STAFF WC

DUCT

ASST P.M.

PUBLIC TOILET (DIS) UNISEX STAFF SHOWER UNISEX STAFF WC

PRACTICE MANAGERS OFFICE GP ADMIN GP MEETING/ GROUP ROOM 1

Case studies The internal street with top lighting will provide a curving spine to give identity and a sense of location within the building. With daylight flooding in at a high level, the natural environment will help to give a sense of direction and maintain contact with the external environment. The circulation routes have been organised to avoid unnecessary contact between staff and visitors to the building, many of the office spaces being located on the first floor. Security has been considered for the large cash sums from rental payments and a separate exit for the transfer of money has been provided. The circulation and way-finding within the building provides a relaxed internal environment and the colours, textures and other finishes are designed to establish an ethos for the building as if patients were visitors to a hotel foyer. There is a good supervision of the waiting areas from the reception desks with clear sight lines to ensure overall security in the building, and there is easy access to patient toilets.

a safer perimeter avoiding recesses and re-entry corners so that loitering and antisocial behaviour are discouraged. With external lighting, the building will provide an elegant addition to the landscape, curving through the trees.

Procurement route The bidding team was assembled to compete for the LIFT programme of work in Newcastle and North Tyneside. The aim is a rolling programme of work to upgrade or replace all the primary health care buildings within this PCT. The bid team consisted of a contractor (Robertson Construction), architect, health planner and engineers. The design frieze envisaged at preferred bidder stage was difficult to sustain and subsequent changes had to be incorporated. The landlord’s proposals included design requirements and legal requirements for 25 years. The high design standards achieved with the building are due to the technical requirements in the briefing documentation. However, there was pressure on maintaining these standards during the value engineering processes undertaken with the design team and client representatives. The architects were also appointed to work with the facilities management team for any alterations during the lease period.

Financial constraints/project costs Costs were rigidly controlled by the main contractor (Robertson Construction); however, the design was more ambitious due to the encouragement to be bold at the bidding stage. The approximate cost was £3m with an

CSC A1-5 Title: Reception atrium; Architect: Purves Ash LLP; Courtesy of: Purves Ash LLP

Landscaping As the site is adjacent to Walker Park the design continues the landscaping tradition of the area creating a low maintenance secure environment. The building form provides

CSC A1-6 Title: Aerial view; Architect: Purves Ash LLP; Courtesy of: Purves Ash LLP

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Primary Care Centres initial target cost of £1400 per sq. m, although this did rise to nearer £1600 per sq. m.

Case study A2

Schedule of accommodation

Project: Vale Drive Primary Care Resource Centre Client: Barnet, Enfield and Haringey LIFT (BEH LIFT) Architect: Murphy Philipps Architects Budget/Cost: £5.3m

Total site area: 1.5 acres (0.6 hectares)

Briefing context and process Building Local authority: Doctors’ practice: PCT: Shared area and plant: Total: Contract: Engineers: QS: Planning supervisor:

5710 sq. ft (530 sq. m) 7560 sq. ft (700 sq. m) 3770 sq. ft (350 sq. m) 3650 sq. ft (340 sq. m) 20690 sq. ft (1920 sq. m) Start on site June 2004 Completion on site August 2005 WYG Gardiner & Theobald (up to financial close) Gardiner & Theobald

The Vale Drive Primary Care Resource Centre (PCRC) forms part of Barnet, Enfield and Haringey LIFT (BEH LIFT) in North London. It was completed in August 2005 and went operational in November that year. The BEH LIFT area has diverse health needs and significant pockets of deprivation. Prior to LIFT, the standard of local primary care services varied and all three PCTs were keen to transform the quality and range of services provided in a primary care setting, to support modernisation of the secondary care sector in line with Department of Health strategic objectives.

FRONT / WEST ELEVATION

REAR / EAST ELEVATION

SIDE / SOUTH ELEVATION

SIDE / NORTH ELEVATION

CSC A1-7

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Title: Elevations; Architect: Purves Ash LLP; Courtesy of: Purves Ash LLP

Case studies The site itself posed a challenge, with an existing two-storey health building positioned on a narrow, steeply sloping site with one long elevation overlooking residential properties on the approach road, Vale Drive, and the other facing a steep gradient up to the busy A1000 on Barnet Hill. An analysis of the site indicated that an enlarged building arranged over two and three levels, located on top of the footprint of the existing building, would provide the best solution. This approach makes use of the natural gradient to provide level access on both the ground and lower ground floors and minimises excavation and site works. The main part of the building is a linear element, running parallel to Vale Drive with a second element introduced at an angle, apparently crashing through the main building that runs parallel to Barnet Hill.

Community uses/patient centred care The new Vale Drive Centre represents a £5.3m capital investment by Elevate, the LIFTCo, to increase primary health care in the Underhill ward, Chipping Barnet constituency. The clinic provides the following services: ●

● ● ●

General medical services from practice accommodation for four GPs Practice nurse services Family planning services Children and families team services

CSC A2-1 Vale Drive Primary Care Resource Centre; Title: Main entrance; Architect: Murphy Philipps Architects; Courtesy of: Murphy Philipps Architects

● ● ● ● ● ●

Adults and older peoples team Speech and language therapy Community chiropody Community ophthalmology Community dentistry Child and Adolescent Mental Health Services (CAMHS, a Barnet Enfield and Haringey Mental Health Trust Service).

Although no specific community uses were highlighted as a requirement at the ITN (invitation to negotiate) stage, it was felt that the building layout should be arranged to accommodate such a future provision, by allowing easy controlled access to generic facilities such as meeting rooms and exhibition space that could be used by local people. It was important to incorporate a strategy of phased shutdown so that various parts of the building could operate out of hours without compromising the security of the unoccupied areas of the building. The close integration of community and voluntary activities with clinical services reflects changes in the provision of care, both locally and nationally. A large degree of flexibility and adaptability has been included so that future changes can be accommodated with minimum disruption to the building fabric. This strategy includes the use of modular room sizes where possible and clustering of generic clinical rooms supported by appropriate utility and storage space. This flexibility was put to the test as there were initial delays in relocating the intended GP practice into the building.

CSC A2-2 Vale Drive Primary Care Resource Centre; Title: Internal view; Architect: Murphy Philipps Architects; Courtesy of: Murphy Philipps Architects. See Appendix A for coloured image

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Primary Care Centres During this time, the GP accommodation was utilised for community services without any structural alterations. The building has now generated a critical mass of activity and several other practices have expressed an interest in moving into the facility.

Design aspirations or ethos The key design driver for the building was to provide a welcoming, pleasant and therapeutic series of space for patients, with simple way-finding and arranged to enable patients to easily orientate themselves within the building. For staff, an efficient and comfortable working environment was required, with a layout that minimises travel distances around the building. Introducing a double-height entrance foyer with a balcony maximises the distribution of natural light into the public areas of the building. A small courtyard has also been used to bring light into the heart of the building, especially into the circulation routes, and to provide a visual reference space. The functional requirements and clinical adjacencies within the building are designed to provide an integrated, holistic, approach to care provision and to facilitate improved communications between the care providers. The PCRC operates as a single entity arranged around a main entrance and waiting foyer, and responds to the requirement for fast-throughput services to be accommodated on the ground floor. Due to the topography of the site, the main entrance is located centrally, with clinical accommodation on floors both above and below it. The ‘hub’ of the building is the large, double height space from which corridor routes radiate. This space is clearly visible from the outside and from the entrance door. It also provides access to shared public facilities such as toilets, baby feeding area, buggy park and pantry, as well as the lifts and stairs. The main reception desk overlooks this space as well as the entrance to the building. The ground floor contains GP accommodation to one side of the reception desk, including a treatment room with associated utility spaces. There is a direct link by stairs to office accommodation for community staff (district nurses, health visitors, etc.) on the first floor. The remainder of the ground floor accommodates treatment and consulting rooms for chiropody, minor procedures, sexual health, speech and language and family services (such as baby clinic). These spaces are arranged around a circular corridor, passing the small internal courtyard, to enable them to be flexed easily from service to service. Slower throughput services requiring specialist rooms, such as dental, ophthalmology and counselling, are located on the first floor where they are served by a dedicated waiting area, which overlooks the foyer. Other than for reception, administration spaces have been located away from the clinical areas, which is seen as a positive way to encourage interdisciplinary working, while maximising opportunities for future change and growth. Offices are located in a staff-only area, also at first floor level, where they have easy access to a shared staff room.

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CSC A2-3 Vale Drive Primary Care Resource Centre; Title: Ground floor plan; Architect: Murphy Philipps Architects; Courtesy of: Murphy Philipps Architects

The CAMHS accommodation has been located at lower ground floor level, where it is easily accessible by lift or stairs from reception, or directly from outside. This was thought to be particularly useful for this client group, as the service will be open for extended hours and as some sensitivities exist relating to attendance.

Vale Drive Primary Care Resource Centre; Title: North-east elevation; Architect: Murphy Philipps Architects; Courtesy of: Murphy Philipps Architects CSC A2-4

Enternit Glasal: Fibre cement cladding panel with mineral enamel surface

Aluminium windows

Expressed concrete lintel

Louvres to plantroom

Fire escape stairs

Key

Case studies The interior of the centre has been designed to provide a friendly, efficient, welcoming and pleasant environment, with natural light and generous reception and waiting spaces. The double height space in the centre of the building and the bold use of colour help to lift the spirits and reinforce the therapeutic nature of the environment. The location of the building also provides wonderful views across the valley from the main waiting area.

Procurement route The Vale Drive Primary Care Resource Centre is part of the Barnet, Enfield and Haringey LIFT in North London, one of the 24 third wave LIFT schemes announced in August 2002. It was one of the two sample schemes evaluated as part of the bidding process. The ITN was issued in April 2003 to three shortlisted bidders. gbconsortium was announced as preferred bidder in October 2003 with financial close in July 2004.

Financial constraints/project cost Design development took place predominantly during the preferred bidder stage within the cost parameters set down in the original bid submission. By closely monitoring detailed design during this stage it was possible to remain within the initial cost envelope.

Case study A3 Project: Chelmsley Wood and Woodgate Valley Primary Care Centres Client: Birmingham and Solihull Solutions, Prime UK Developments and Carillion Architect: One Creative Environments Ltd Budget/Cost: Chelmsley Wood – £4.8m/Woodgate Valley – £3m

Briefing context Procured under the NHS LIFT programme Chelmsley Wood and Woodgate Valley were the first two buildings completed by Birmingham and Solihull Solutions, the partnership between the public sector and their private sector partners Prime UK Developments. Both projects are a catalyst for planned regeneration in the communities they serve. The schemes were both sample projects during the bid process started in December 2002, concluding with the appointment of preferred bidder in July 2003. During this time, architect and design team leader One Creative Environments Ltd met extensively with building users, patient representatives, trust advisers and other parties such as local authority planners to develop schemes deliverable against the aspirations and constraints of the programme.

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Primary Care Centres

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Vale Drive Primary Care Resource Centre; Title: Section; Architect: Murphy Philipps Architects; Courtesy of: Murphy Philipps Architects

Case studies On such potentially complex projects, with a lengthy period of gestation, bringing and keeping together so many disparate services, users and aspirations meant engagement was vital. Key to ensuring a meaningful and lasting engagement was ongoing consultation throughout the process giving transparency and ownership of the design and development process.

Briefing process

Community engagement An extensive consultation period before design work involved the PCT discussing changes to service requirements and provision with the local community and patient groups affected by the proposals. Throughout the design process a number of public information events kept local residents and patients informed of progress, with representatives from the design team, PCT, private sector partners and service providers in attendance to answer questions and comments as they arose. To reach the widest possible audience, events were held in local schools, community centres and health centres.

Engagement with ‘users’ The major engagement for the design team on the project was through ‘user group’ meetings. These open forums were comprised of representatives from each of the building users, the design team and client technical advisers and were chaired by the lead from the PCT overseeing the development from the public sector. Initial meetings with the design team dealt with qualitative issues such as design aspirations, often starting by discussing the pros and cons of current facilities and buildings outside the health care arena. Working patterns and methods were discussed with the design team to gain an understanding of workplace reality, going beyond simple technical and legislative requirements. As proposals developed, starting with simple functional arrangement diagrams and block plans, the design team facilitated an interrogation of the brief and, principally, the schedule of accommodation, itself subject to wide consultation by the PCT prior to design team involvement. In some instances, this meant that traditional working practices were challenged, resulting in deviations from areas of the brief as the scheme took shape. Specialist consultees were involved throughout this process to agree design developments that could affect technical guidance, the requirements of the ITN and statutory requirements. Current practice on user groups often sees this split into two groups with a ‘working group’ comprising the PCT lead, technical adviser, private sector development manager and design team lead reporting decisions to and instigating discussions with the wider user group on specific ‘technical issues’ which may have previously tied up the group for long periods but offered little to influence the overall design of the building. It should still be noted, however, that the user group is kept appraised of and has a contribution to all decisions relating to the design of the building.

Specialist input Hard FM issues clearly form part of the ongoing design appraisal but an important aspect of the consultation in relation to those facilities being developed through LIFT is appropriate discussion and engagement with specialist parties affected by the design. Waste collection, cleaning services and security were all consulted during development of the design and their comments fed back into the user group forum.

Public arts programme While some ‘art’ has been procured for the completed buildings, subsequent projects have benefited from a more extensive public arts programme which has been developed in conjunction with One Creative Environments Ltd and which would involve a lead artist sitting within the design team from an early stage. It is envisaged that a key part of their role in this team will be to facilitate public consultation through an arts programme which may not culminate in a ‘piece’ of work in the completed building but which might instead use the process of consultation through the arts as a basis for the ongoing design brief for the development of the project.

Community uses and patient centred care Each of the new centres saw an increase in the services offered. At Woodgate Valley, the smaller of the two projects, this was the addition of further examination, consulting and treatment rooms, a retail pharmacy, a state of the art minor surgery suite with dedicated recovery suite, scrubs area and patient waiting. This exceptional facility vastly increases the potential range of procedures offered at a local level by the GPs and visiting specialists. Chelmsley Wood, by far the larger of the two schemes, brought together and enhanced not only those services provided on the existing site, GP, district nursing, health visitors and dentistry, but also pulled additional services from elsewhere within the PCT including physiotherapy, podiatry, audiology, and child and adolescent mental health services (CAMHS). As with Woodgate Valley the design also included an extensive minor surgery and recovery provision and this was amended during construction to include a significant endoscopy provision. Other non-clinical services in the building include offices for social services and the inclusion of a community café and retail pharmacy both accessed off the central reception and waiting area.

Design aspirations and commendations In each case, the proposals represented the most significant investment made in the local community in a generation. From the outset, the intent was to set a benchmark for the planned

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CSC A3-1 Woodgate Valley Primary Care Centre; Title: Roof detail; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

CSC A3-2 Chelmsley Wood Primary Care Centre; Title: External view; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd. See Appendix A for coloured image

future regeneration of the area and to create designs true to their position as community buildings. Public approaches are readily accessible and welcoming with internal spaces clearly linked to the wider public environments. Where possible, the building and soft landscaping formed the boundary to pavements and roads avoiding ‘bunker-like’ security fences and gates. Security glazing, building orientation, landscaping and latent supervision of vulnerable areas reduce the need for grilles and shutters to windows. The form of the building directs visitor flow to the well-supervised main entrance and designs out the ‘nooks and crannies’ so detrimental to combating antisocial behaviour. The designs have been exceptionally well received, with the Commission for Architecture and the Built Environment (CABE) commenting: New buildings are often built without full advantage being taken of their potential impact in regeneration terms. We are impressed that One Creative Environments Ltd has risen to the opportunity at Woodgate Valley and Chelmsley Wood primary care centres. Both give something of a quality to their respective areas, striving against the institutional and benefiting from a welcoming feel. The attention to detail also demonstrates the practice’s expertise in rigorous consultation and liaison with key figures and a good understanding of the opportunities and constraints within healthcare building design. (Lucia Hutton, Enabling Officer at CABE)

CSC A3-3 Chelmsley Wood Primary Care Centre; Title: External view; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

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Staff and patients have been equally impressed by the results with positive feedback proving very forthcoming on completed buildings for which they have a genuine feeling of ownership and involvement.

Case studies

CSC A3-4 Woodgate Valley Primary Care Centre; Title: Roof detail; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd. See Appendix A for coloured image

contractor’s project team to test each decision, requirement and aspiration against some very rigorous cost assumptions made during the bid and ultimately to ensure a fit across the wider benchmarked costs. With costs per square metre running at approximately £1800 for Chelmsley Wood and £2200 for Woodgate Valley, the projects were within the benchmark, giving overall construction costs for the projects of £7.8m. Woodgate Valley was completed in July 2005 and Chelmsley Wood in September 2005.

Case study A4 CSC A3-5 Chelmsley Wood Primary Care Centre; Title: Reception; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

It’s brilliant, (Chelmsley Wood PCC) patients like everything being under one roof and they really appreciate the surroundings. It’s not like a typical health centre – one patient described it to me as an elegant airport terminal. (Tracey Millward, Clinics Administration for Solihull PCT)

Financial constraints and project costs A key part of the LIFT initiative is the principle of ensuring, checking and proving ‘value for money’ on each project. Nationally benchmarked costs are applied on all schemes with a requirement that new schemes sit within that framework. Throughout the design process One Creative Environments Ltd worked closely with the

Project: The Vermuyden Centre Client: Doncaster Community Solutions Architect: PHS Architects Budget/Cost: £5.1m

Briefing context and process The new Integrated Care Centre at Thorne, recently renamed the Vermuyden Centre, represents the first of a series of community buildings for the Doncaster Primary Care Trust developed, delivered and managed through their NHS LIFT Public Private Partnership called Doncaster Community Solutions. The vision was to create a multiuse community building bringing together not only primary care services, but related housing, social services and local authority front-line services in one building; part of the scheme content included a new library. The brief comprised a summary of likely stakeholders, together with an indicative schedule of accommodation

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Woodgate Valley Primary Care Centre; Title: Site plan; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

Woodgate Valley Primary Care Centre; Title: Elevations; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

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Case studies

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Primary Care Centres

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Woodgate Valley Primary Care Centre; Title: Ground floor plan; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

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Chelmsley Wood Primary Care Centre; Title: Ground floor plan; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

Case studies

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for some, but not all, services. In particular, while the general practice services were carefully itemised, the PCT and local authority spaces were broad brush overall allowances without any particular detail about potential use, number of occupants or likely functional relationships; these details were to come out through a series of workshops with interested stakeholders. Each bidder was given access to the stakeholder teams, with the opportunity to revisit and

Scale 1:100

North Elevation

Ground + 79.750

First + 83.050

Second + 86.350

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Windows & Doors:Kawneer 600/1202 Series, colour RAL 7005

WINDOWS & DOORS

Eaves, Fascias, Soffits:Corus Pressed Profile, Ref. PR8, colour Albatross

Flat roof:Sarnafil G410-18ELF Single Ply Membrane System, colour Light Grey

Pitched roof:Kingspan KS1000 RW Composite Sheet System, colour Albatross

ROOF

Compositepanel:Kingspan KS1000 MR Insulated Composite Micro Rib Cladding Panel, colour Albatross

Alseco Render:Ecomin 200' EWI System self-coloured render, ref 1024

Alseco Render:Ecomin 200' EWI System self-coloured render, ref 1411

Facing Blockwork:NBK Terrart Large Format Terracotta Blocks

Facing Blue Brickwork:Ibstock Staffordshire Blue Brindle Smooth

Facing Buff Brickwork:Baggeridge K284 Classic Cream

WALLS

FINISHES KEY

B

Primary Care Centres

CSC A3-10 Chelmsley Wood Primary Care Centre; Title: Elevations; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

present ideas as the schemes evolved during the bidding process.

Community uses and patient centred care

As this was the first integrated community facility in the Doncaster LIFT area, the users were keen to incorporate

Case studies as many users as possible and the chosen site was large enough to allow development to include a range of services. The brownfield site, a former school previously demolished, was masterplanned during the bid process to include the new centre, together with public open space and an affordable housing development to the rear. Key stakeholders were the Thorne Community groups, who wanted to incorporate space for local groups and voluntary agencies, as well as the publicly funded community health services from the PCT and Doncaster MBC. Services include: ● ● ●

●

● ● ● ● ● ● ●

● ● ●

Two GP practices Minor surgery District nursing, health visitors, community midwives and school nurse Physiotherapy, occupational therapy, speech and language therapy and dietetics Counselling Podiatry and chiropody Health promotion National service framework clinics Sexual health Secondary care outpatient services Diagnostics suite, including ECG, ultrasound, haematology and retinal screening Oscopy services in a dedicated suite Voluntary sector meeting spaces Mental health services

CSC A4-1

● ● ● ● ●

Community dentistry Full library service and ICT suite Housing services Welfare services Community pharmacy.

Design aspirations or ethos Thorne is an area of some deprivation, following the demise of coal mining in the area and subsequent lack of investment. The high street has a number of vacant premises and the chosen site fronted onto the main road on the approach to the town centre. Although the site was mainly cleared, a redundant and derelict former Victorian training institute fronted the main road, hiding the site at the rear. Initially, the presumption of the brief was that this building would be retained and converted as the new library, with a potential link to new premises at the rear of the site. Unfortunately, although the majority of the site was level, there is a rise of around 2.0 m from the road to the main plateau area. Converting the Victorian building and linking to new premises on the plateau would have given rise to significant accessibility issues. Furthermore, although the general presumption was that the library could be housed in the old building, this was very different from the aspirations of the library service, who felt that for many years rural libraries had been housed in out-of-date accommodation.

The Vermuyden Centre; Title: External view; Architect: PHS Architects; Courtesy of: Iain Denby, Iain Denby Limited

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Primary Care Centres In developing the scheme, a number of key strategic decisions were taken, which resulted in the building providing the functionality needed by the users, and winning the bid: ● ●

●

The existing Victorian building shields the site; it was felt that the retention of this building, not listed but within the Thorne Conservation Area, prevented the creation of a new symbol of regeneration. This was tested out with a presentation to the Thorne Community groups and universally accepted. The library was located within the main new building, as a striking glazed frontage. We wanted to have the most transparent and welcoming approach to the building; the library is a facility chosen by users for pleasure and

CSC A4-2

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relaxation, rather than a service needed through illness. It also allowed a legitimate reason for visiting the building for those anxious about confidentiality or embarrassment. The services were accessed from a single point – a shared reception area staffed by PCT, local authority community information staff and library services staff – and the travel distances within the building to other services (GP practices and community services) were all short, with the services arranged around a central courtyard for ease of way-finding and orientation. Much discussion took place about access out of hours, but the library at the front provided the gateway to other services with potentially the longest opening hours. All clinical and public services are on the ground floor.

The Vermuyden Centre; Title: Ground floor plan; Architect: PHS Architects; Courtesy of: PHS Architects

Case studies Procurement route The Thorne scheme was one of the three sample schemes in the bidding round for Doncaster LIFT, a third-wave LIFT scheme. Doncaster LIFT is a public private partnership between Community Solutions for Primary Care, Doncaster PCT, Doncaster MBC and Partnerships for Health and is named Doncaster Community Solutions (DCS). This bidding process was held up for around six months while the PCT team clarified land ownership for the Thorne site and the bids from the shortlisted teams were submitted in

CSC A4-3

January 2004, selection of preferred bidder in April 2004 and financial close in the autumn of 2005. Work started on site in autumn 2005 and the project was handed over four weeks early in October 2006. The building is leased to the tenants – GPs, the PCTs and the local authority – under a 25 year Lease Plus arrangement with DCS which includes a wide range of management and maintenance services. In order to aid affordability of the scheme there is additional third party space in the form of an Alchem pharmacy which is let under a separate arrangement for a similar lease term with DCS.

The Vermuyden Centre; Title: First floor plan; Architect: PHS Architects; Courtesy of: PHS Architects

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Primary Care Centres

CSC A4-4

The Vermuyden Centre; Title: Site plan; Architect: PHS Architects; Courtesy of: PHS Architects

Financial constraints and project cost The overall project construction cost was set by the bidding team, the cost being a significant factor in the determination of the overall Lease Plus payment under the LIFT contract. Under LIFT, the preferred partnering team are also responsible for the lifecycle costs of the finished building so considerable thought went into minimising future maintenance rather than absolute reduction of first cost. Overall construction cost was £5.1m.

Case study B1 Project: The Bradbury Centre Client: South & East Belfast (Health & Social Services) Architect: Penoyre & Prasad LLP with Todd Architects Budget/Cost: £6m As part of the ongoing NHS modernisation programme, South & East Belfast (Health & Social Services) Trust is developing new ways of delivering health and social care to its resident population of 205 000. This vision includes the replacement of 70 separate buildings with three community treatment and care centres offering a one-stop approach to

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service delivery, providing a focal point for people’s care, treatment and information needs within local communitybased centres. The second of these, The Bradbury Centre, has replaced many dispersed small service buildings to become a landmark centre for health and social services serving a diverse population of 70 000 in South Belfast. Ranging from two to four storeys, the centre provides 3700 m2 of accommodation and cost £6m. This new centre represents significant innovation in the delivery of a range of services including social care, primary and community health care and acute care out of hospital. It incorporates the most up-to-date thinking in the design of health care facilities, and is intended to facilitate future changes in practice, technology and demand, and to take account of future work patterns. Patients and visitors enter into a lofty atrium space with a glazed roof, where they can enjoy a cup of coffee in the café, speak to a CAB (Citizens Advice Bureau) adviser or find out health information at a computer. This atrium also provides easy orientation to the three storeys of health and social services departments above. The ground floor contains a minor surgery suite and consulting rooms for use on a sessional basis. The first floor is dedicated to children’s services, comprising community paediatrics, community dentistry, speech

Case studies

CSC B1-1 The Bradbury Centre; Title: Three storey high atrium; Architect: Penoyre & Prasad LLP with Todd Architects; Courtesy of: Northern Ireland Health Estates

and language and a dedicated play area. Upstairs is podiatry, physiotherapy and mental health, while the top floor contains offices and staff areas. The Trust is committed to customer (patient) focus as the centrepiece of its mission, and this is the overarching philosophy informing the design. The morale and working conditions of the staff are also crucial to delivering high quality care, so they too have been well catered for with efficiently planned clinical areas, large open plan offices and a generous staff club with a roof terrace for dining and meeting. On this basis, every element of the design of the new centre has been thought through from the point of view of its impact on the well-being of all who use it. The value the Trust places on the power of good design to fulfil these aims has been evident from the start of the project with the selection of the design team through a shortlisted design competition. The city centre location was carefully chosen by the Trust to serve its resident population, for accessibility by public transport and to become a high profile beacon for health and social services. Previously occupied by semi-derelict terraced housing with decaying industrial buildings behind, the site is flanked by the mainline railway, and dwarfed by the tower of the City Hospital behind. The main planning concern was the traffic impact; the site posing more problems for the successful design of a long thin building than for planning consent.

CSC B1-2 The Bradbury Centre; Title: Atrium with undulating glazed wall; Architect: Penoyre & Prasad LLP with Todd Architects; Courtesy of: Paul Megahey Photography. See Appendix A for coloured image

Responding to this difficult restricted narrow site, the end result is a striking addition to the streetscape, with a curved glazed organic form nestled against a long thin brick and render building. The main entrance is in a slot between these forms signalled by a glass banner by artist Martin Donlin. The long elevation to the railway line is carefully composed of large window assemblies with coloured aluminium panels, opening windows and clerestories within rendered panels. The most striking internal feature is an undulating and leaning three storey glulam and glass wall to the top-lit atrium, containing reception areas on each level, conference rooms and staff club. Use of colours, materials and plenty of natural light helps make the centre an enjoyable place to visit, and careful consideration has been given both to orientate visitors and to address the needs of those with disabilities and sensory impairment. The building was procured though the innovative Performance Related Partnering process pioneered by Northern Ireland Health Estates. The Bradbury Centre is the second of three buildings to be built consecutively by the same team. The contractor for the first building was selected at an early stage on the basis of a competitive interview, offering both a commitment to work with the design team to deliver the building for a predetermined guaranteed maximum price, and suggestions as to how best value could be delivered

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CSC B1-3 The Bradbury Centre; Title: Elevation; Architect: Penoyre & Prasad LLP with Todd Architects; Courtesy of: Penoyre & Prasad LLP with Todd Architects

CSC B1-4 The Bradbury Centre; Title: Section; Architect: Penoyre & Prasad LLP with Todd Architects; Courtesy of: Penoyre & Prasad LLP with Todd Architects

through supply chain expertise and efficiencies. This gave cost certainty to the client while allowing for high design ideals to be maintained. This, the second building, and the third were offered to the same contractor subject to satisfactory performance on the first, allowing negotiation of favourable terms with subcontractors and supply chain. The end cost including external works and fittings was £1621/sq. m. All three buildings were designed through a process of close immersion in the culture of the Trust immediately after the competition win. The Bradbury Centre then went on hold while the first phase of the Arches Centre was built. This allowed both of these first two buildings to open at roughly the same time, on programme, suiting client funding and operational policy.

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Awards 2006 Building Better Healthcare Awards Winner ‘Best Use of Art in Hospital Award’ 2006 Building Better Healthcare Awards Commendation for ‘Best Primary or Community Care Design Award’

Summary of timetable Design competition win: Design development: Work stopped: Production information:

June 2001 July 2001– February 2002 February 2002–September 2003 September 2003–February 2004

Case studies

CSC B1-5 The Bradbury Centre; Title: Ground floor plan; Architect: Penoyre & Prasad LLP with Todd Architects; Courtesy of: Penoyre & Prasad LLP with Todd Architects

PRP selection of contractor: Construction: Client occupation and service delivery:

October 2003–March 2004 March 2004–October 2005 January 2006

Case study B2 Project: The Arches Centre Client: South & East Belfast (Health & Social Services) Architect: Penoyre & Prasad LLP Budget/Cost: £8.6m As part of its NHS modernisation programme, South & East Belfast (Health & Social Services) Trust is developing new ways of delivering health and social care to its resident population of 205 000. The vision includes the replacement of 70 separate buildings with three community treatment and care centres, each offering a one-stop approach to service delivery, providing a focal point for people’s care, treatment and information needs within local community-based centres. First to be completed, the Arches Centre was a formerly busy but lacklustre health centre that has now been doubled in size and rejuvenated by the construction of a new building in front of the old one with a generous linking atrium. The new centre represents significant innovation in the delivery of a range of services including social care, primary and community health care and acute care out of hospital, as well as seven separate GP practices. It incorporates the most up-to-date thinking in the design of health care

CSC B2-1 The Arches Centre; Title: External view; Architect: Penoyre & Prasad LLP; Courtesy of: Technal

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Primary Care Centres facilities, and is intended to facilitate future changes in practice, demand, technology and changing work patterns. The morale and working conditions of the staff proved as important for patient care as the facilities themselves. In this case, half of the 300 staff are outreach workers delivering care in people’s homes. It was important to make the facilities good enough to attract staff back to the building at lunchtime to meet their colleagues and share knowledge about their patients. To encourage this, we designed a staff club on the roof with panoramic views out across Belfast. The value the Trust places on the power of good design to fulfil these aims has been evident from the start of the project with the selection of the design team through a shortlisted design competition. Construction of the first phase was successfully carried out while the existing centre, including all the separate GP practices, remained fully operational. The second phase involved substantial refurbishment and remodelling of the existing block and was completed in September 2005. The combined new facility is a beacon for health and regeneration in the area, now providing total accommodation of 6300 m2 and costing £8.6m. As one of the largest buildings in the Holywood Arches area, the old centre had a considerable townscape impact but a poor appearance. The planners particularly welcomed the enhanced civic presence of the new facility which will promote further regeneration of the area and set an example in high quality building and urban design. The biggest constraint was the high voltage pylon and underground cable running very close to the new facility.

The design enabled continuous operation of the health care facilities during the construction process. A new fivestorey concrete framed building was first built joined to the existing building by a glazed atrium. The new building was clad in render with a striking composition of bright aluminium panelled windows, and curtain walling incorporating a three-storey artwork over the new entrance, designed by Martin Donlin. Once the new block was completed clinical services moved across and the rear block was stripped right down to its concrete frame and substantially remodelled inside and out. Only in September was the inner hoarding taken down and the full impact of the lofty atrium with its waiting balconies revealed. Procured though the innovative Performance Related Partnering (PRP) process being pioneered by Northern Ireland Health Estates, the Arches Centre is the first of three buildings to be built consecutively by the same team. Early contractor selection through competitive interview offers both a commitment to work with the design team to deliver the building for a predetermined guaranteed maximum price as well as suggestions as to how best value could be delivered through supply chain expertise and efficiencies. This gave cost certainty to the client while allowing for high design ideals to be maintained. The second and third buildings are then offered to the same contractor subject to satisfactory performance on the first, allowing negotiation of favourable terms with subcontractors and supply chain. The end construction cost including external works and fittings was very keen at £1365/sq. m.

Awards 2006 Building Better Healthcare Awards Winner ‘Best Use of Art in Hospital Award’ 2006 Building Better Healthcare Awards Commendation for ‘Best Primary or Community Care’ 2006 Building Better Healthcare Awards Winner ‘Best Primary or Community Care Design Award’ 2006 RIBA Award

Timetable Design competition win: PRP selection of contractor: Decant/Enabling: Construction phase 1: Construction phase 2: Client occupation (phase 1): Client occupation (phase 2):

June 2001 October 2002–April 2003 January–March 2003 April 2003–August 2004 August 2004–September 2005 August 2004 September 2005

Case study B3

CSC B2-2 The Arches Centre; Title: Central glazed atrium; Architect: Penoyre & Prasad LLP; Courtesy of: Technal. See Appendix A for coloured image

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Project: The Grove Well Being Centre Client: Belfast City Council, North and West Belfast Health and Social Services Trust, Belfast Education and Library Board

Case studies

CSC B2-3

The Arches Centre; Title: Ground floor plan; Architect: Penoyre & Prasad LLP; Courtesy of: Penoyre & Prasad LLP

SOUTH (FRONT) ELEVATION

NORTH (REAR) ELEVATION

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The Arches Centre; Title: Elevations; Architect: Penoyre & Prasad LLP; Courtesy of: Penoyre & Prasad LLP

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The Arches Centre; Title: Sections; Architect: Penoyre & Prasad LLP; Courtesy of: Penoyre & Prasad LLP

Architect: Kennedy FitzGerald and Associates with Avanti Architects Limited Budget/Cost: £16.3m

Briefing context and process In January 2002, Kennedy FitzGerald and Associates (KFA) were commissioned by Belfast City Council to design a new leisure centre to replace the existing Grove Baths in Belfast. Before briefing had really commenced KFA were contacted by Health Estates who were working on the primary health care strategy for North Belfast in conjunction with the North and West Belfast Trust (NWBT). Having identified the need for a new community treatment and care centre (CTCC) in the area of the proposed Grove Leisure Centre, which would combine both the Trust’s primary care services and a number of GP practices, it was recognised that there was an opportunity to combine these two new facilities to create an integrated health and well-being centre. Agreement to proceed with the development of a design for a building containing all of the proposed services was reached in early 2003 and KFA formed an association with Avanti Architects (AA), a London-based practice with extensive experience in primary health care architecture,

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to assist them with the development of the project. KFA assumed overall responsibility for the coordination and design of the project with AA leading on the planning of the health centre. The two firms worked closely together to ensure that the building as a whole was functionally and architecturally coherent and the project gained significantly from this collaboration. The Grove is the first centre in Northern Ireland to combine health, leisure and information services. The building brief was developed through a series of workshops and meetings during which the potential ‘synergies’ that could be realised between the various service providers were identified. The objective of the brief was the creation of a centre that will allow the local population access to a range of primary health care and GP services, leisure facilities including swimming pools, fitness suite, soft play area and ten-pin bowling and a library and information centre. Locating all three public agencies in one centre is an innovative concept which creates a synergy between the public agencies. It is intended that the mix of uses will lead to increased community participation in heritage-, culture- and arts-related activities, lifelong learning, fitness, sport and physical recreation. As well as providing better access to health care services, opportunities were identified for patients to utilise facilities and resources in the leisure centre and to benefit from leisure

Case studies services promotion of fitness. Patients will also benefit from the provision of information on health-associated issues and health promotion programmes by the library service. The briefing process also identified the potential for further gains in the development of unique ‘synergy services’, delivered by staff from all three organisations. These will be as disparate as wheelchair training (with an external set of gradients built into the landscaping of the new centre), day care for older people, reminiscence sessions and information on benefits from the library, and the provision of therapeutic and recreational sessions in the disabled accessible swimming pool. In developing this innovative brief for the project, the three client bodies, Health Estates which is providing project management services and the design team, have all been conscious of the opportunity for the Grove project to serve as a prototype for the development of other health and well-being centres in Northern Ireland and beyond.

Community uses/patient centred care

CSC B3-1 The Grove Well Being Centre; Title: External view; Architect: Kennedy Fitzgerald & Associates with Avanti Architects Ltd; Courtesy of: Kennedy Fitzgerald & Associates with Avanti Architects Ltd

A central entrance concourse divides the well-being centre into two halves. The three-storey concourse provides the main vertical circulation for the public as well as acting as a control device allowing access to each of the individual services, without perceived barriers. The large spaces of the leisure centre are located to the right-hand side of the entrance and the health services to the left-hand side of the concourse. The concourse can also be accessed at first floor level from the car park at the rear of the site giving direct access to the library which is also located at this level. The

CSC B3-2 The Grove Well Being Centre; Title: External view; Architect: Kennedy Fitzgerald & Associates with Avanti Architects Ltd; Courtesy of: Kennedy Fitzgerald & Associates with Avanti Architects Ltd. See Appendix A for coloured image

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Primary Care Centres concourse also contains a pharmacy, and an information and exhibition area located beside the public café.

Health facilities The health facilities are located in three fingers of accommodation each of which has three floors. The fingers are arranged in a row with courtyards between and are linked by a circulation spine. The plan form allows the provision of control of circulation, access to light and views from the waiting areas and draws the landscape into the public areas of the building by the use of courtyards that relate to the public areas.

GP practices The first floor provides accommodation for a total of seven GP practices. The practices have a shared reception and records area located next to the entrance concourse. A shared treatment area is located opposite the GP reception. Social services offices The second floor provides office accommodation for a number of social services department services. Library and information services

Primary Health Care Trust services

The library is located at the front of the building at first floor level. It provides the following services:

The ground floor contains the primary care services including: ● ● ● ● ●

Minor surgery suite Dental surgery Podiatry Physiotherapy and occupational therapy – delivered in a coordinated way to provide a rehabilitation service.

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Lending library Reference library Computer resource centre Schools visits to library Health promotion Special events to celebrate heritage, culture and arts.

CSC B3-3 The Grove Well Being Centre; Title: Plans, sections; Architect: Kennedy Fitzgerald & Associates with Avanti Architects Ltd; Courtesy of: Kennedy Fitzgerald & Associates with Avanti Architects Ltd

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Case studies The leisure centre

Financial constraints/project cost

The leisure centre is organised on three floors. It provides for the following activities:

The construction budget for the project was £17 500 000 with completion in April 2008.

● ● ● ● ●

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Swimming Fitness suite Sports hall Ten-pin bowling alley/soft play area Sports injury clinic for the assessment of injuries and health matters and rehabilitation Day care for the elderly. The rooms associated with this are within the leisure centre side of the building and are available to the community for other uses during the evening.

Design aspirations – urban and architectural design Leisure centres are often blank shed-like buildings that, because of their function and location, are not required to present an interesting or attractive urban facade to the street. Primary health care centres, in contrast, tend to be domestic in scale with small cellular rooms which require daylight and views and which must also be relatively private. They are often designed to look more similar to detached suburban houses than urban street architecture. What both leisure facilities and health centres have in common, however, is that they are often surrounded by a moat of tarmac and car parking. The clients’ aspiration for the Grove project has always been the creation of a single integrated facility. It therefore seemed appropriate that the design and composition of the building should reconcile the scale and character of the different kinds of accommodation contained within the building in a unified architectural form and to make this unified building work as street architecture in its urban design context. The shape and topography of the site provided the opportunity to create a long thin building with a long facade facing the street and to locate a substantial portion of the car parking required for the centre to the rear of the site. The building has been further unified by the use of an overarching roof form that connects the bulk of the leisure centre and the smaller health centre ‘fingers’ into a single shape that echoes the form of the hills that surround the city. The land behind the building rises sharply before levelling off to a plateau on which there is a public park. This means that the building, which has a three-storey presence on the street frontage, had a greatly reduced impact on the park. To reduce further the impact of the building of the park, the roof has a green sedum finish. It is intended that the presence of the building as a social facility and its positive quality in terms of urban street architecture will act as a catalyst in the regeneration of the area.

Procurement route The construction of the project was procured using a traditional form of building contract, JCT98 Local Authorities version, with the production of a full bill of quantities.

Case study B4 Project: Portadown CCTC Client: Southern Health and Social Care Trust Architect: Avanti Architects with Kennedy FitzGerald and Associates Budget/Cost: £11.9m Stage: Due to start on site January 2008

Briefing context and process In August 2006, Avanti Architects with Kennedy Fitzgerald Architects won a commission to design a new community treatment and care centre (CTCC) in Portadown for the Southern Health and Social Care Trust. The centre will replace the existing health centre which no longer meets the growing demands of the local community.

Client vision statement Portadown will have a recognised centre of excellence, providing modern and dependable primary care for adults and children. Internally, the building will be dynamic, able to respond to ever-changing patient need and functionally fit for purpose. In response to the outcome of public consultation and service user involvement, the interior design will be conducive to the provision of high quality health care. Externally, the building will reflect the very best in contemporary architectural design. The centre will be in keeping with the Portadown Development Plan. This development forms part of the DHSSPS Northern Ireland strategies’ ‘Primary Care and Community Infrastructure’ (PCCI) and ‘Caring for People Beyond Tomorrow’, which in summary are catalysts for the following changes: ●

●

Introduction of new models of care and pathways to recognise the need for integrated community care across the local economy. The need to discharge patients earlier from hospital, or indeed avoid hospital admission, creating greater throughput and more complex care provision in a primary setting.

The new CTCC is included in the Portadown Development Plan as a flagship development for regeneration of the town. The land for the site is being provided by Craigavon Borough Council on a land swap basis, has been equality impact assessed and is seen to be a neutral and accessible environment for both of the main religious communities in Portadown. The

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Primary Care Centres existing health and social services centre will be transferred to the council upon completion of the CTCC, and will be converted into ‘open space’ for the local community.

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Community uses/patient centred staff The centre will deliver the entire primary health care provision for all of the population of Portadown. In addition to the services, the centre will provide access to a range of voluntary and community groups who will be invited to ‘book’ space to hold meetings, information evenings or support groups. The accommodation in the new centre will not only replace the existing services provided in the existing centre but also include new services to meet future demands and service delivery. At present, the following services are delivered from the HSS centre: ● ● ● ● ● ● ● ● ● ● ●

Eight GP practices (23 GPs) Podiatry Occupational therapy Speech and language therapy Family planning District nursing Health visiting Treatment room nursing Social work for elderly and child and family Domiciliary care management Orthoptics. In addition to these services, the new CTCC will include:

● ●

● ● ●

Minor surgery Specialist GP and integrated teams, e.g. to reduce waiting times in orthopaedics, ENT and dermatology Audiology Pharmacy Visiting consultant services

CSC B4-1 Portadown CCTC; Title: View across the atrium for the main entrance; Architect: Avanti Architects with Kennedy FitzGerald and Associates; Courtesy of: Avanti Architects and Big Lolly. See Appendix A for coloured image

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● ● ●

Out of hours services Radiology Alternative therapies Psychiatry clinics ECG Specialist nursing Dentistry.

The new building will also contain a café, a staff restaurant, a drop-in crèche for patients to leave children safely during their consultations, a docking bay for mobile screening and MRI and a local Citizens Advice Bureau.

Design aspirations or ethos One of the principal aims of the new centre is to create a onestop primary care centre in which different services and agencies are located together. In addition to patient convenience, a further aim of colocating different services is to foster better integration and coordination between service providers. The compact building, in which there are shared reception, clinical and staff facilities, building management and security arrangements, provides the opportunity to maximise the use of resources and improve operational efficiency. The Portadown CCTC is planned as a compact triangular building with a triangular atrium space at the centre. The perimeter accommodation around the atrium is arranged on three floors each of which is 11 metres wide and has windows overlooking both the outside and the atrium. This accommodation houses all of the clinical departments in the building as well as a number of administrative areas. The atrium at the centre of the building is covered with a glazed roof to form a three-storey high enclosed space. At the ground floor entrance level the atrium contains a main reception and information desk, a number of secondary reception desks associated with specific clinical areas in the perimeter accommodation plus waiting areas, planting, a café and a freestanding lift and staircase core. The core

CSC B4-2 Portadown CCTC; Title: View across the atrium at first floor level; Architect: Avanti Architects with Kennedy FitzGerald and Associates; Courtesy of: Avanti Architects and Big Lolly

Case studies provides access to the perimeter accommodation at first and second floor levels by bridges. Locating all public circulation in a central atrium space makes it relatively easy for staff to monitor everything that is going on in the public spaces of the building, creates a non-institutional atmosphere and makes way-finding much easier for the patient. The building also has a lower ground floor which occupies the entire footprint of the building, including the area below the atrium, and is used for secure staff car parking, storage and plant space.

Flexibility and legibility One of the few certainties about health buildings is that their function will change over time. The number of GP surgeries may well reduce and their size may increase. It is difficult to predict exactly what other changes will take place, but one only has to look at the impact of changes in health policy, medical technology, the demographics of the population and patterns of disease over recent decades to conclude that dramatic changes will continue to occur in the future. The planning, structure and services systems of a large primary health care building must, therefore, provide for future change and adaptation and this has been a major consideration in the development of the building design. At the ground floor level, departments in the perimeter accommodation can be accessed from the atrium at any point. This provides maximum flexibility for the subdivision of the accommodation.

The perimeter accommodation on the first and second floor is accessed from the circulation core. At each floor level the lifts and stair arrive at a platform from which bridges cross to the middle of each side of the triangle of perimeter accommodation creating a layout in which there are potentially separate entrances to two departments on two sides of the triangle. On the third or north side of the accommodation a bridge leads to a circulation route which runs along the edge of the atrium at first and second floor level. This means that on this side of the building the perimeter accommodation can be accessed at any point. This arrangement provides easy public access to many separate departments, without the need to use corridors or to pass one department in order to reach another. The arrangement also allows for the relative size and number of departments to be changed in the future, both by replanning the perimeter accommodation and by relocating the bridges, two of which on each floor are movable. The detailed design and integration of the structure and the services in the building have also been developed so as to provide a high degree of flexibility and to create an energy efficient and sustainable facility.

Procurement route The design and construction of the project is being procured using a Project Related Partnering Framework Agreement.

CSC B4-3 Portadown CCTC; Title: Bird’s eye view of the building from the north east; Architect: Avanti Architects with Kennedy FitzGerald and Associates; Courtesy of: Avanti Architects and Big Lolly

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CSC B4-4 Portadown CCTC; Title: Plan, section, elevation; Architect: Avanti Architects with Kennedy FitzGerald and Associates; Courtesy of: Avanti Architects with Kennedy FitzGerald and Associates

Case study C1 Project: Robin House, Balloch Client: CHAS – The Children’s Hospice Association Scotland Architect: Gareth Hoskins Budget/Cost: £7.96m

Briefing context and process CHAS – the Children’s Hospice Association Scotland – is a charity founded in 1992 by a small group of parents and professionals, in response to the lack of respite facilities available to children with life limiting conditions in Scotland. Following their first Scottish children’s hospice, Rachel House located in Kinross, east Scotland, CHAS identified a need to disperse hospice services across the central belt of Scotland so that a wider community could have easier access to their services.

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CHAS looked at over 60 sites and settled on the 2.36 hectare site on the edge of Balloch, a small town located on the southern shores of Loch Lomond, within the Loch Lomond and the Trossachs National Park. The site was a greenfield within a working farm used for pasture, with a difference in level of 14 metres sloping from north to south, with no utility connections and a history of severe flooding. The site, however, fulfilled the client’s criteria for privacy, transport links, recreational facilities and ease of access to complementary health care facilities. The brief for Robin House was essentially another Rachel House adapted to suit the site, with facilities for the provision of respite care for eight families at any one time, also catering for teenagers and providing a hydrotherapy pool. The accommodation includes: medically equipped sleeping quarters; administration offices; a seminar space; a communal kitchen-living-dining space; staff accommodation; a teenagers’ ‘den’; therapy rooms including a ‘multi-sensory therapy’ room and a soft-play room, bereavement suite

Case studies

CSC C1-1

Robin House; Title: Viewed from the south east; Architect: Gareth Hoskins; Courtesy of: Andrew Lee

and quiet room. The brief explicitly called for a design that was non-institutional. The description used by CHAS was ‘a welcoming home away from home’, one which would be appealing to children and young people.

Community uses/patient centred care Together with Rachel House, Robin House provides specialist respite, emergency and terminal care for children or young people in Scotland with life limiting, life threatening and terminal conditions who are not expected to live into adulthood. Until Scotland’s first children’s hospice, Rachel House, was opened in 1996, families had to travel long distances to hospices in England to receive this specialist support. Robin House provides an opportunity for children and their families to spend recreational time together in a suitable environment, closer to home. In addition to (physical, mental and emotional) care for children, the professional team of staff and volunteers at Robin House provides friendship, information, advice and practical support for families, such as help in their own homes at times of special stress and bereavement counselling. The home-from-home atmosphere and staff team ensure that Robin House has a happy environment where children and their families can take regular short-term breaks in a place based on love, care, fun and support.

Design aspirations or ethos The building is positioned on the site to maximise the view over the south facing gardens, which are terraced to

provide level access for wheelchairs on all sides, allowing the building to nestle into the contours, minimising its visual impact. A hierarchy of spaces is organised into wings and two courtyards, one a welcoming entrance space. The other is glazed over to enclose a play space incorporating the ‘multi-sensory therapy’ and soft-play pods. The two children’s bedroom wings are orientated south to maximise daylight and views, with each culminating in a fully glazed space – the library and hydrotherapy pool. The ‘ribbon roof ’, which encloses and defines the foyer and day spaces, is a response to the plan geometry and the desire to maximise natural daylight, generating a distinct identity for the building. The predominant material chosen for the elevations is untreated larch, used for rainscreen cladding as well as doors and windows. This was chosen to reflect vernacular Scottish agricultural buildings, while maximising the use of a natural material which will weather well in its surroundings. The same material is used to line the soffit of the ribbon roof, while the north elevations are finished with a smooth render in a heather colour. Extensive use of glazing creates strong connections between the landscape and the interior. The two metre cantilevered roof overhangs are designed to provide shade to the glazing in summer, and shelter from the Scottish rain throughout the year. The structure of the hospice reflects the nature of the various internal spaces. The wings have been constructed using load-bearing concrete block walls with traditional timber roof construction while bespoke steel frames are used to achieve the more complex geometries of the play areas and ribbon roof at the heart of the building.

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Primary Care Centres

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Robin House; Title: Internal play area; Architect: Gareth Hoskins; Courtesy of: Andrew Lee. See Appendix A for coloured image

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Robin House; Title: Site plan; Architect: Gareth Hoskins; Courtesy of: Gareth Hoskins

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Case studies

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Robin House; Title: Plan at Level  1; Architect: Gareth Hoskins; Courtesy of: Gareth Hoskins

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Robin House; Title: Plan at Level 0; Architect: Gareth Hoskins; Courtesy of: Gareth Hoskins

Procurement route Robin House was procured through a traditional contract in order to achieve a high quality finish and to provide a degree of cost certainty for the CHAS, which is a charity. Initially, the project was tendered on a two-stage basis to accelerate the build process, allowing works to commence on site before the full package of drawn information was produced. This process had the added advantage of allowing

the design team to work in collaboration with the contractor and utilise their expertise to identify potential cost and time savings for the project. Unfortunately, the original contractor went into liquidation in early 2004 and the original contract was determined. By this time the project information was sufficiently detailed to allow the project to proceed on a single stage traditional contract and following successful negotiations with the second contractor works recommenced in May 2004.

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Primary Care Centres

CSC C2-1 Conan Doyle Medical Centre; Title: View of courtyard from Liberton Road; Architect: Richard Murphy Architects; Courtesy of: Richard Murphy Architects

Financial constraints/project cost Commission: Planning: Start on site: Completion: Cost of project: Internal area in square metres: Cost per square metre: Funded by:

July 2001 March 2003 April 2003 June 2005 £7.96m 2691 m² £2958/m² CHAS, the Scottish Executive and public donations.

eastern perimeter is a pedestrian route linking Cameron Toll Shopping Centre car park with the junction of Liberton Road and Gilmerton Road. The Liberton Bank House is a C listed cottage and has some notoriety as a place where Sir Arthur Conan Doyle spent some of his summer holidays as a boy. This cottage was converted simultaneously by Nicholas Groves-Raines Architects for the Cockburn Conservation Trust acting on behalf of Dunedin Special School and the entire site was master planned by Richard Murphy Architects. The site contains a number of mature and semi-mature trees and is part of a section of pleasant planted low lying ground.

Case study C2 Design Project: Conan Doyle Medical Centre at Nether Liberton Lane, Edinburgh Client: Kilmartin Properties Limited Architect: Richard Murphy Architects Budget/Cost: £2.1m Procurement: Design and build Completion: October 2007

Location and history of site The site covers an area of approximately 3065 square metres. It sits at a level of approximately 4.5 metres below the adjacent Liberton Road and is bounded by a stone retaining wall along its entire western perimeter. Along the

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The medical practice of eight consulting rooms, treatment rooms and other facilities is placed on the ground floor for ease of access to the public. The first floor is reserved for non-surgical activities and will be used by a variety of users, not just those working with patients in the buildings but health visitors, district nurses, midwives, etc., who will come and go during the course of the day. The principal design idea behind the group practice is that all patient waiting areas and circulation on the ground floor, and staff common areas and circulation on the first floors, should focus on a major private walled garden. The garden acts as an oasis on the site for those visiting the doctors, can be used by patients on sunny days and is seen directly through the entrance doors. It will therefore also have

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Conan Doyle Medical Centre; Title: Sections; Architect: Richard Murphy Architects; Courtesy of: Richard Murphy Architects

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Primary Care Centres

NORTH ELEVATION

EAST ELEVATION

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Conan Doyle Medical Centre; Title: Elevations; Architect: Richard Murphy Architects; Courtesy of: Richard Murphy Architects

the characteristics of a ‘secret garden’ and will produce a calming and appropriate atmosphere for those waiting to see a doctor and indeed the staff working at both levels. The other major design principle is that the impact on the site of the group practice should be as minimal as possible. The floor level has been determined by the 200 year flood level at this point. The path to the east will be built up and then ramped down to rejoin the existing path to Gilmerton Road. The idea for the impact of the medical practice to its surroundings is to make relatively blank brick walls pierced by occasional low level or slot windows adding an air of ambiguity as to whether the building is indeed a building or a garden wall. The roofs of the single-storey sections of the building are planted with a green sedum roof adding to the sense of ambiguity. Within this site the consulting rooms are placed around small paved walled gardens to allow a view but to also ensure privacy to patients and doctors. The doctors’ accommodation on the first floor extends onto a terrace with the elevation to the south and west being largely glazed.

Case study C3 Project: Community Centre for Health, Partick Client: Greater Glasgow NHS Primary Care Trust Architect: Gareth Hoskins Budget/Cost: £2.3m

Briefing context and process In 2002, Greater Glasgow NHS Primary Care Trust commissioned the design of a new Community Centre for Health in the Partick area of Glasgow, replacing a day nursery housed previously on the site off Dumbarton Road and combining it with an existing clinic on the adjacent site of

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CSC C2-4 Conan Doyle Medical Centre; Title: North east corner; Architect: Richard Murphy Architects; Courtesy of: Richard Murphy Architects

Sandy Road. This building was procured through a traditional contract to a rapid programme on a very restricted urban site. The emphasis of the brief was to provide open flexible spaces that promote an awareness of health care in the community but which would allow an evolution for the provision of any future service. The range of service requirements was wide and included doctors, nurses, dentistry, podiatry, physiotherapy, old people’s mental health and other community health clinics. It was also to be a base for health workers, such as district nurses and health visitors, who work throughout Greater Glasgow.

Case studies

CSC C2-5 Conan Doyle Medical Centre; Title: View of waiting area; Architect: Richard Murphy Architects; Courtesy of: Richard Murphy Architects. See Appendix A for coloured image

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Conan Doyle Medical Centre; Title: First floor plan; Architect: Richard Murphy Architects; Courtesy of: Richard Murphy

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Conan Doyle Medical Centre; Title: Ground floor plan; Architect: Richard Murphy Architects; Courtesy of: Richard Murphy Architects

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CSC C3-1 Community Centre for Health, Partick; Title: Main entrance; Architect: Gareth Hoskins; Courtesy of: John Cooper. See Appendix A for coloured image

Community uses/patient centred care The Community Centre for Health is located centrally in a dense residential area with the aim of providing primary care locally, avoiding lengthy trips to hospitals or larger health centres. This is of particular importance to parents of young children and the elderly who often require frequent treatment and for whom hospital visits are more daunting. The scale of the centre, the relaxed atmosphere and the community emphasis are in contrast to a hospital environment and more appropriate to the range of services available, with clear benefits to the patients. The centre is used by a number of groups such as baby clinics, slimming clubs and aerobics classes where the emphasis is on preventive medicine and health awareness.

Design aspirations or ethos The surrounding area is predominantly tenemental with ground level shops facing onto the main road. This grain breaks down somewhat in the immediate vicinity to the site and the new build helps to restore the urban pattern of the area. Owing to this incoherent nature of the area, the city planners initially were keen that the building try to restore the tenemental scale to the site with four to five storeys and a pitched roof. On further discussion with the architect, the massing, position and palette of materials were understood to be suitable for this non-residential building in a

residential area, by raising the roof line of the rearmost box and using horizontal standing seam zinc cladding to echo the precision and scale of the adjacent stone facades and a clear material delineation to the boundaries of the building. The concern that adjacent tenement windows might be overshadowed was alleviated by setting the building back from the existing building line. The building is set back from the line of the road to create a punctuation to the streetscape, emphasising this landmark building within the community, while at the same time echoing the public buildings along this arterial road into Glasgow and giving a clear street presence. The site has a dual aspect that is reflected in a distinct separation between the contrasting functions of the building, comprising of three storeys of clinical accommodation and a nursery at lower level. The street facade is formed by a zinc clad ‘box’ above a glazed ground floor while the rear facade is made up of untreated cedar clad box with cedar louvres over the floor to ceiling windows – volumes that reflect some of the organisation within. The principal spaces (consulting rooms, large offices and nursery spaces) are predominantly contained within the timber box to the rear of the building, which is expressed internally through a finished timber wall rising through the full height of the building, with the void expressed on the front facade facing Dumbarton Road. An open stair within a triple height void links the clinic, which is split over two levels, and forms the hub of the building. This void also links the final area, the administrative office space on the top floor, which is comprised of open offices to the rear and

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Community Centre for Health, Partick; Title: View from Dumbarton Road; Architect: Gareth Hoskins; Courtesy of: John Cooper

cellular offices on the street side. The lower storey is accessed through a ramp which proceeds along the facade down to the nursery which is entered from the rear of the site. The glazed facade creates an open aspect to the streetscape, which beckons to the passing public while at the same time internally avoids a sensation of containment. Careful consideration has been given to the clarity of circulation and orientation within the centre with most public areas positioned towards the street side of the building, partially screened for privacy, and the sensitive treatment and consulting rooms located towards the rear. This nursery accommodation is an autonomous part of the building. There is a requirement for a degree of privacy and containment, hence it is physically separated from both the road and the rest of the building in a half basement at ground level and faces south with the main spaces relating directly with the garden. It is built under a projecting canopy that creates sheltered play spaces. These spaces adjoin the garden and produce a secure oasis from the noise and pollution of the busy main street. The floors at the rear have three distinct levels, with the varying heights reflecting the development of the growing children and the different nursery classes – from entry age

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through to pre-school. These stages are also repeated in the garden area. The building succeeds not only in setting itself apart as a landmark building appropriate to its function within the community but also in providing a functional and enjoyable environment for staff and visitors alike.

Procurement route The centre in Partick is one of a series of clinics commissioned by Greater Glasgow NHS Trust over recent years which have in common a notably high standard of design. Instead of using design and build contracts, the buildings have been procured though traditional contracts with the architect doing a full set of details and supervising the work on site, and thus having the opportunity to ensure design quality is maintained through to completion. However, the reason for the consistent high quality of the buildings undoubtedly goes back a stage further, to the clients’ reliance on choosing architects through competition where design quality is given due dominance over fee bids or company turnover.

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Community Centre for Health, Partick; Title: Elevation; Architect: Gareth Hoskins; Courtesy of: Gareth Hoskins

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Community Centre for Health, Partick; Title: Section; Architect: Gareth Hoskins; Courtesy of: Gareth Hoskins

Financial constraints/project cost

Commission: Planning: Start on site: Completion: Cost of project: Internal area in square metres: Cost per square metre: Funded by:

March 2002 August 2002 March 2003 July 2004 £2.3m 1586 m² 1450/m² Greater Glasgow NHS Primary Care Trust

The timescale of the building was concise, the commission originating in March 2002, planning being submitted in August and Building Warrant in September 2002, both of which had to be granted before tender in November, to allow for a site start in the New Year. The preliminary works to the site were separate contracts to allow for a more rapid spend for the client, and included the temporary relocation of the existing nursery and the demolition of the old nursery building together with providing a disabled access to the old clinic. As it happened, the planning permission for the temporary accommodation together with the necessary preliminary work to the site meant that the site start was March 2003 with practical completion 16 months later.

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Community Centre for Health, Partick; Title: Plan; Architect: Gareth Hoskins; Courtesy of: Gareth Hoskins

Case study D1 Project: Grassroots in Memorial Park Client: West Ham & Plaistow New Deal for Communities (NDC) Architect: Eger Architects Budget/Cost: £2.8m The brief set by West Ham & Plaistow New Deal for Communities (NDC), a government funded regeneration programme, asked for a landmark building that would be socially, environmentally and financially sustainable, bringing together a range of services under one roof (café, community hall, nursery, crèche, play spaces, nurse led medical practice, health improvement team, police offices). The design process included extensive community consultation from project inception through to completion. The building is sited in Memorial Park, East London, and the brief asked for a centre to form a catalyst for regeneration of this run-down urban park and to assist to re-establish pedestrian and cycling routes between different areas of the West Ham and Plaistow NDC Area surrounding the park.

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The building’s undulating roof is covered in grass, giving the impression that there is a small hill nestled in the corner of Memorial Park. The building is designed to be an integral part of the park landscape, and to avoid the loss of green and amenity space. There is a great view of the park, Canary Wharf and docklands from the highest point. As part of the NDC strategy ‘Reclaiming a lost urban park’ several other projects are planned and are in the process of being built. Standing side on to Grassroots healthy living centre, you would not notice it was even there. But face on, Grassroots is the epitome of 21st century design. Glass-fronted, it comes equipped with solar panels to provide energy and concrete ceilings to cool the inside during the hot summer months. The building attempts to maintain the highest standards of environmental sustainability. The solar panels are photovoltaic and provide a significant amount of the energy used by the building, and the building features an integral combined heat and power unit. The entire external facade of the building is clad in galvanised steel mesh, which acts both as a security device (essential for a building located within a park context) and

Case studies

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Grassroots in Memorial Park; Title: View across park from south; Architect: Eger Architects; Courtesy of: Eger Architects

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Grassroots in Memorial Park; Title: South elevation; Architect: Eger Architects; Courtesy of: Eger Architects

to facilitate temperature control. This mesh allows the tilt and turn windows to be left open at night, allowing cool air to percolate through the building. The concrete shell structure is lowered into the landscape allowing easily ramped access both over the building and into it. Finishes to walls and ceilings within the building

are ‘fair face concrete’. As well as providing an aesthetic materiality, the concrete acts as a ‘heat sink’, absorbing cool air throughout the night and providing a passive cooling throughout the following day. Throughout the building linear acoustic baffles are suspended from the ceiling between the light fittings. They

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CSC D1-3 Grassroots in Memorial Park; Title: Internal nursery courtyard; Architect: Eger Architects; Courtesy of: Eger Architects. See Appendix A for coloured image

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Grassroots in Memorial Park; Title: South elevation & section; Architect: Eger Architects; Courtesy of: Eger Architects

absorb sound and prevent echoes bouncing from the smooth concrete finish. Rainwater runoff is collected in a large underground rainwater harvesting tank through the sluices in the south facing terrace and along the perimeter of the mounds and is reused throughout the building as ‘grey water’ – for toilet flushing and irrigation for the planted roof. A meter showing water reuse is located in the café area. Similarly, a gauge shows the amount of electricity generated by the solar photovoltaic panels. There are two courtyards located centrally in the building forming outdoor play spaces for use by the nursery and crèche. A ‘tornado’ mesh pattern across the courtyard

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prevents items from being thrown down from the accessible roof into the space. The play surface flooring is made from recycled car tyres. Such a stylish design inevitably means there are unintended consequences – in this case motorbike riders were said to be eyeing up the grass roof. Careful landscaping in the form of planted moats near the base of the mound prevents motorcyclists and cars misusing the mound. At a seminar held at Grassroots, John Sorrell, chairman of the Commission for Architecture and the Built Environment (CABE), said well-lit, sustainable, welcoming health centres such as this are key to the government’s

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Grassroots in Memorial Park; Title: East elevation & section; Architect: Eger Architects; Courtesy of: Eger Architects

vision of providing more NHS services in the community as set out in the recent White Paper. ‘Good design is essential in improving access to facilities’, he said. ‘It is all about getting people into centres and across the barriers that prevent the most needy from accessing health services. ‘By having something like Grassroots with a variety of services we can attract people in. And once they are in, the environment is calming.’ However, it is not just about the building itself. The people behind Grassroots wanted to twin the centre with the park. ‘The benefits to NDC residents are manifold – they deliver local mainstream services that are currently unavailable or are difficult to access. The building itself provides a pleasant location for people to receive these services and a focus for community activity.’ Construction procurement was managed using a traditional local authority contract by Durkan Pudelek who built the centre largely within time and the £2.8m cost to a high standard of finishes.

Care Trust. Sapley Square, prior to redevelopment, was a dilapidated 1960s shopping precinct which bridged Coneygear Road and was regarded as a ‘no-go’ area after dark by local residents. macmon were approached by the Acorn Surgery who wanted their new building to reflect the same design ethos as macmon’s award-winning Glasgow Homoeopathic Hospital. In addition to reproviding for the existing surgery and pharmacy, the new building enables, in accordance with best practice primary care strategies, for the provision of a ‘one-stop shop’ integrated facility, which accommodates: ●

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Primary care services operated by Huntingdonshire Primary Care Trust. These include community nursing, health visiting, physiotherapy, podiatry and dental services; Administrative support for Huntingdonshire PCT Services; Complementary therapies such as homoeopathy and aromatherapy; Community health education space; Multipurpose meeting and seminar space; and Community café.

Case study D2 Project: The Oak Tree Centre Client: Huntingdon Primary Care Trust Architect: macmon chartered architects Budget/Cost: £8m

Project background The Oak Tree Centre is a purpose built community health centre providing shared facilities for the Acorn Surgery, led by Dr Boyle and Partners, and the Huntingdon Primary

In this way, and while maintaining traditional health care services, the Acorn Surgery and Huntingdonshire PCT sought to engage the community and promote initiatives for preventive care and healthy living. The Oak Tree Centre was also an integral and leading part of the initiative to regenerate the heart of the Oxmoor estate in Huntingdon in order to create a vibrant, outward looking, public space and meeting area. Huntingdonshire District Council, Cambridgeshire County Council, Huntingdonshire Housing Partnership and macmon worked in unison with the Oxmoor community to provide new housing, community space and retail provisions.

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Grassroots in Memorial Park; Title: Ground floor plan; Architect: Eger Architects; Courtesy of: Eger Architects

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The Oak Tree Centre; Title: External view; Architect: macmon chartered architects; Courtesy of: Neville Chadwick Photography

CSC D2-2 The Oak Tree Centre; Title: Courtyard; Architect: macmon chartered architects; Courtesy of: Neville Chadwick Photography. See Appendix A for coloured image

Architectural design remit The architectural remit called for the creation of a high quality environment for patients and staff alike – one that is secure, functional, comfortable and stimulating, promoting sustainability and energy efficiency issues through both

well-considered constructional and engineering specifications and the harnessing of natural lighting and ventilation. The remit also called for the design to be integrated with the Oxmoor regeneration plan, in the widest sense including road/footpath/transport infrastructures, and to be a landmark building for the heart of Oxmoor.

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The Oak Tree Centre; Title: Internal view; Architect: macmon chartered architects; Courtesy of: Neville Chadwick Photography

Development description General arrangement of site The design recognised an ‘area wide’ master plan which promoted the demolition and redevelopment of Sapley Square (at the same general location but on the west side only), but with the retail frontages reversed to face outwards into a new public space. The Oak Tree Centre forms an eastern boundary to this public space with new housing (flats and dwellings, under the auspices of Huntingdonshire Housing Partnership) forming a northern boundary. Sallowbush Road/public footpath forms a southern boundary. The principal entrance to the Oak Tree Centre is taken from the new civic space and this frontage is further enlivened through a community café and pharmacy being presented on the same elevation. This arrangement intended to create an open, supervised space, made safe by design, each day all day, through the presence and movement of residents. The master plan design maintained pedestrian and cyclist crossover of Coneygear Road by means of a new bridge. The above master plan arrangement, with the new civic space, helps punctuate Oxmoor Lane and promote it as a green, car-free artery for the community. Scale and massing of development The building respects the scale of the surrounding, twostorey dwellings by restricting the development height to that of the frontages in closest proximity. The principal elevation of the development, which faces east towards Sapley Square and which is not in proximity

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to any existing dwellings, is arranged over three storeys. In addition to meeting an accommodation need, the increased height of this part helps define the public square. For the same reason, the notional flatted development (not part of Oak Tree development), suggested for the northern edge of the square, is also set at three storeys. The overall plan concept of the Oak Tree building is as a ‘courtyard’ form. The courtyard space provides a green, inner sanctum offering a natural outlook to accommodation at a deep plan location, and promoting natural light and ventilation to the same areas. The roof form is best described as a ‘split’ monopitch. This configuration allows natural lighting and ventilation to spaces that would otherwise be fully internal. Over and above interests of energy efficiency, the design recognises the proven benefits to health and general well-being arising from the natural environment. The principal, three-storey block is designed with a central atrium space which, again, allows natural light and ventilation to penetrate to all levels. Pedestrian and vehicular organisation Pedestrian movement, on a barrier-free path and ramp system, is available on all perimeters. The principal movement of pedestrians takes place from the car park areas set in the new civic space and in adjoining bays on Maple Drive. However, the site can also be accessed from all surrounding parts and from bus stops on Sallowbush Road. A new pedestrian crossover at Sallowbush Road enables safe movement to and from Oxmoor Lane. While movement from the crossover to the health centre entrance is

Case studies

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The Oak Tree Centre; Title: First floor plan; Architect: macmon chartered architects; Courtesy of: macmon chartered architects

most directly achieved by steps, an option exists for level access on a sloping pathway, which meets disability access standards (1:20 gradient). Cyclists are able to negotiate all parts and cycle racks are provided at a supervised location, close to the main entrance. The Oak Tree Centre generates a significant demand for car parking and this is met through a number of car parking areas in and around the site. A principal objective of the design brief has been to try to disperse parking to avoid the sterility of a single mass of car spaces. The Acorn Surgery ensures that the use of car parking spaces is managed in a way that prioritises parking for patients and that drop-off/pick-up zones are available. Building organisation The Oak Tree Centre is organised so that public access ways into the development are clearly defined and lead directly to a point of enquiry and information.

From that point, if interest relates to either the Acorn Surgery or an associated service provider, visitors move to a further reception area within the ground floor of the principal block. If related to Huntingdonshire PCT, visitors move to the upper levels of the same accommodation block. Generally, PCT accommodation is set at upper levels. The principal patient waiting area is within the ground floor of the atrium and interfaces with the café, community room and pharmacy. Separate waiting zones are offered for GP consultation, dental and complementary care. For reasons of patient safety, and security for all, waiting zones are supervised. For the same reasons, patient movement to and from consulting and treatment areas is controlled. Within clinical and treatment areas, incidental spaces are offered for staff relaxation and patient subwaiting.

Procurement route The project started as a traditional JCT contract but, at a later stage, was changed to a design and build contract.

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The Oak Tree Centre; Title: East/west elevations; Architect: macmon chartered architects; Courtesy of: macmon chartered architects

The Oak Tree Centre; Title: Ground floor plan; Architect: macmon chartered architects; Courtesy of: macmon chartered architects

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Primary Care Centres Project cost The total cost of the project came to £8m and was funded by Huntingdonshire District Council.

Case study D3 Project: Washington Primary Care Centre Client: Sunderland Teaching Primary Care Trust Architect: PHS Architects Budget/Cost: £8.96m The government’s new White Paper, ‘Our health, our care, our community’, provides for a whole new range of community hospital services delivered under a variety of procurement methods. One of the first four in this initial wave is the new Primary Care Centre in Washington, Tyne and Wear. As part of the major reform and modernisation of services for patients in Sunderland, there is a requirement for models of health care service that are innovative and creative. Sunderland Teaching Primary Care Trust has developed a strategy to provide four new health facilities referred to

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as ‘Primary Care Centres’ in Sunderland and the proposed scheme at Washington will be the third of these centres to be developed. The Washington proposal draws upon the success of the first Primary Care Centre at Grindon Lane, Sunderland, also designed by PHS Architects, and looks to improve further the quality of primary care settings, taking the opportunity to develop new models of service delivery. The PCT developed the second Primary Care Centre in conjunction with Sunderland City Council with a view to the facility becoming a ‘one-stop shop’ for health and community resources. The facility was completed in 2006 and now, in addition to the GP and community health care facilities, provides library, pharmacy, housing advice centre and gymnasium, the latter being used effectively for both general community use and ‘exercise on prescription’. Located on a greenfield site to the south of Washington town centre amenities, the arrangement of the building has been designed to maximise its location on the edge of existing parkland and the external appearance aims to provide a modern and exciting health care facility with a human scale which reflects the model of care. The site is located adjacent to Washington Leisure Centre, giving opportunities for shared resources such as provision of exercise on prescription.

Washington Primary Care Centre; Title: Aerial view; Architect: PHS Architects; Courtesy of: PHS Architects

Case studies Washington Primary Care Centre will provide approximately 2400 m2 of accommodation over two floors providing services for people with minor injuries and ailments; diagnostic tests, such as x-rays and ultrasound; planned care for people with chronic conditions, such as a community renal dialysis unit, and specialist clinics to which patients are referred by their GP or other medical professional. The scheme will also provide 125 new parking spaces, as well as improving pedestrian links to the existing town centre and will incorporate a new landscaping scheme which will include a new pedestrian ‘boulevard’ to link the centre to the neighbouring uses on and around the site. The selection of the sites for each of the Primary Care Centres within the city boundary is critical. Each must be located within an area easily accessible by as large a population as possible, therefore close proximity to good public transport links is essential and ideally located within large areas of existing population. A series of detailed public engagement events were completed by the PCT in order to determine the service content of this centre. A public consultation event also took place on the design of the centre highlighting specific issues that had to be addressed in the design development, e.g. family toilets, fully accessible adult changing facilities. The overriding design aspiration was for the new building to be fully accessible and non-clinical in terms of layout, materials and environment. This has been achieved by the careful selection of materials, colours, textures and abundant use of natural lighting and ventilation throughout the building. Glass artist Bridget Jones was appointed by the PCT with the assistance of the Arts Council to work with the design team to develop works and installations fully

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integrated into the building fabric. Bridget also worked on the Grindon Lane Primary Care Centre for the PCT. Seeking to reduce the carbon footprint of the new facility, various low energy systems have been incorporated into the design, including roof mounted ‘wind catchers’ to facilitate the natural ventilation of the building and roof mounted solar pre-heating panels linked to the domestic hot water system. The PCT considered various procurement methods for this facility but opted to appoint Laing O’Rourke as their principal supply chain partner (PSCP) operating within the NHS Procure 21 (P21) framework. Grindon Lane Primary Care Centre, completed in October 2005, was procured by the PCT via P21 using the same PSCP and associated supply chain partners. The project value was £8.96m with the building due for completion in summer 2008.

Case study D4 Project: Rothbury Community Hospital Client: HMC Group Architect: Mackellar Architecture Limited Budget/Cost: £2.5m Rothbury is an attractive rural village in the Coquet Valley of mid Northumberland. A replacement for its cottage hospital, which no longer satisfies current NHS spatial requirements and regulations, has been a priority for many years to serve this local community, but an appropriate site has been difficult to obtain.

Washington Primary Care Centre; Title: Elevations; Architect: PHS Architects; Courtesy of: PHS Architects

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Washington Primary Care Centre; Title: Ground floor plan; Architect: PHS Architects; Courtesy of: PHS Architects

The village expanded significantly early last century around an elongated central area and with extensions up river and south-east from the river bridge. The centre is predominantly built in stone with slate roofing, with burghage plots backing towards the river meadow playing field areas. The Northumbria Healthcare NHS Foundation Trust, in partnership with HMC Group Limited, was the facility provider. The NHS Trust was the primary briefing body for the new community hospital to provide inpatient beds, outpatient services and community facilities. Comments on functional requirements, including standards for infection control, were sought from the Trust management, carebased staff and external consultants. Schedules of accommodation were agreed through a process of regular user group meetings. Local community groups were consulted and kept informed during the briefing process. Schedules of accommodation and activity database sheets were developed through regular meetings during the design period. Agreed design data was finally signed off (but with decisions reserved on the final colour scheme). Following an exhaustive search for locations within the village settlement, a site south-west of the river bridge was identified. Although the site is relatively isolated, it offers the potential to group a cluster of related facilities including the new hospital with rehabilitation and cottage hospital functions. The site has a direct footbridge access to the village centre. Studies of the Pipers Field site were conducted to identify access, parking and servicing requirements and to

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formulate an overall plan for the disposition of functions and uses. This identified an optimum location for the hospital functions, and highlighted the opportunity to utilise the site characteristics in establishing access and floor levels. This new hospital provides 12 inpatient bed spaces and various outpatient facilities. Mainly providing rehabilitation facilities, the proposal integrates the hospital with community services under one roof, comprising two storeys. The character and the overall aspect of the new building are dedicated to less mobile patients. The brief is not limited to medical aspects in the strict sense, but extends to cover all of the assistance required by the patients’ guests, community groups and staff themselves. Spatial distribution and creation of the two main blocks, separated by a glazed link, clearly identify the various areas and their specialised functions. A compact user-friendly building with distinctive but interacting forms and elements has been developed by giving form to the independent specialised zones. The glazed link provides the users on both levels with a clear view through the entire building, while acting as the waiting area downstairs and a common area upstairs. The surrounding landscape can be enjoyed at all times while waiting for consultation or treatment. This link also acts as a psychological rehabilitation area. Inpatients are able to walk through this space towards the day activity area, which floods the two blocks with light and allows extensive external views. Functions are expressed in a layout distributed around a central glazed space and vertical circulation guaranteeing good visibility and security. Users and patients can orientate

Case studies

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Rothbury Community Hospital; Title: Aerial view; Architect: Mackellar Architecture Limited; Courtesy of: Mackellar Architecture

CSC D4-2 Rothbury Community Hospital; Title: Entrance; Architect: Mackellar Architecture Limited; Courtesy of: Mackellar Architecture Limited

themselves and locate the various services more easily to their advantage. This also provides efficiency for specialised permanent and visiting staff. Exterior and interior spaces achieve a balance between contained and open zones to ensure a psychological choice between privacy and public exposure with progressive

CSC D4-3 Rothbury Community Hospital; Title: Glass art in foyer; Architect: Mackellar Architecture Limited; Courtesy of: Mackellar Architecture Limited. See Appendix A for coloured image

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Rothbury Community Hospital; Title: Elevations; Architect: Mackellar Architecture Limited; Courtesy of: Mackellar Architecture Limited

Case studies transition from public to private spaces. The building enables patients, visitors and staff to manage the degree of privacy or interaction with other groups. The main materials used are stone, timber, glass and render. The first is linked to traditional materials in Rothbury. These materials provide the building with a contemporary aspect. Wood is used, both internally and externally, to create a ‘warm’ environment, while being honest and functional for the mainly linear elevations. It is increasingly favoured as a building material for both internal and external applications in health care environments and has the benefit of being sustainable. The continuous texture of the external cedar strips is interrupted by large fenestration, which projects the outside to the interior spaces. From most of the internal spaces, especially bedrooms, the green landscape of the surrounding countryside is framed and can be enjoyed by all users. Extensive glazing is used to create spaces flooded with light and achieves a characterful light airiness, promoting a positive patient experience. The hospital is visually integrated within the community especially at night when the roof glazing above the corridors demonstrates activity within the building. Stained glass artist Claudia Phipps was engaged by the NHS Foundation Trust to provide glass artworks for communal areas within the hospital – the designs for these were produced through a series of workshops with local primary school children, using the local environment as inspiration. The elevations of the bedrooms on the first floor are marked by a secure rhythm. The other constituents of the building form are fragmented to prevent a large mass dominating the site. One of the larger spaces in the building is the projecting gym, which is the only space within the building requiring a higher ceiling height. This space is the centre of rehabilitation and projects out toward the village and its community avoiding any sense of exclusion. The other larger space is the group room located near the entrance and community garden providing interaction with all user groups and encouraging progressive treatment. The key to the design and massing was to keep a low profile with straight rooflines to reduce their impact on the landscape and skyline. The flat roof is ballasted, providing a natural finish. The steep drop in levels on the north side provided the opportunity to create a balcony area for patients’ rehabilitation. An external landscaped area is provided to the south of the building where users can choose privacy or public interaction. It is intended that the design extends the building traditions of Rothbury and provides a sustainable state of the art facility.

Procurement CSC D4-5 Rothbury Community Hospital; Title: First floor plan; Architect: Mackellar Architecture Limited; Courtesy of: Mackellar Architecture Limited

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Originally part of the main Wansbeck Acute Hospital Phase 2 PFI and retained in this form despite different location, scale and programme. This allowed the asset

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Rothbury Community Hospital; Title: Site plan; Architect: Mackellar Architecture Limited; Courtesy of: Mackellar Architecture Limited

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to be ‘off balance sheet’, although the NHS Foundation Trust acquired the site to facilitate the project; The PFI route imposed disproportionate costs (legal, etc.) on the project, and the site was valued on a residential basis although it is outside the settlement boundary, and unlikely ever to be released for such use; Savings were generated through careful specification in non-clinical areas (avoiding HTM levels); The relatively remote location increased preliminary and overhead costs; Costs increased due to the extended development process, particularly in terms of site acquisition and granting of planning approval.

Case study E1 Project: Clinical Education Centre Client: University of East London, Stratford Campus Architect: Richard Murphy Architects Budget/Cost: £4.5m

Introduction Masterplan for the Stratford Campus of the University of East London – two-stage tender leading to a traditional contract The Clinical Education Centre is home to the former London Foot Hospital (which until recently operated from

Fitzroy Square in the West End) as well as accommodating the University of East London’s physiotherapy department. On a limited budget, the aim was to produce an exemplary treatment of podiatry for patients. Both podiatry and physiotherapy departments moved into the new premises in April 2006 with the intention of working in close concert. The two departments have a combined student population of 446 persons and academic and administration staff of 50 persons. It is anticipated that the podiatry department is likely to have a daily throughput of some 80 patients, the vast majority of whom, will be able to walk to the building, but on occasion access by ambulance will be required from a new public entrance off Ferns Road. Issues of patient privacy were examined and the solution adopted was a two-storey space with cubicles arranged in a gentle curve. Podiatry patients access the space from the waiting area via individual doors to their respective cubicles and every patient has a view out to the college green; in this way patients do not see other patients being treated but concurrently academic staff are easily able to supervise the six students in their charge. The top floor of the podiatry section steps back in plan to allow light to penetrate into the adjacent gardens and accommodates all semi-public facilities, such as biomechanics and gait analysis as well as housing orthotics manufacturing facilities. The building extends over the former road known as ‘The Green’ at first and second floor levels and connects with the physiotherapy department to the south. This comprises four physiotherapy laboratories, a laboratory of physiology

CSC E1-1 Clinical Education Centre; Title: View of podiatry cubicles; Architect: Richard Murphy Architects; Courtesy of: Richard Murphy Architects

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Clinical Education Centre; Title: West elevation; Architect: Richard Murphy Architects; Courtesy of: Richard Murphy Architects

CSC E1-3 Clinical Education Centre; Title: View of waiting area from stair; Architect: Richard Murphy Architects; Courtesy of: Richard Murphy Architects

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CSC E1-4 Clinical Education Centre; Title: Ground and first floor plans; Architect: Richard Murphy Architects; Courtesy of: Richard Murphy Architects

and a sports exercise laboratory which has additional external accommodation on a roof terrace. The new Clinical Education Centre not only attempts to perform its functions well, but also tries to repair an abandoned piece of city by connecting an isolated group of houses on Ferns Road with other university buildings further down the street, as well as forming one side of the new college green. This is the first of what will be a number of steps on the campus to repair not only the university estate but also the surrounding area.

rear of 33A The Green, the building has been set back both in plan and section to accommodate light angles to the rear garden of 33A and ground floor and first floor rooms. There is a garden for patients associated with the waiting area immediately adjacent to that of 33A, which incorporates the existing substation. The waiting area is a singlestorey space housed under a pitched roof to assist west light penetration to the garden of 33A and to minimise any sense of crowding to the rear of these houses. The entrance to The Green is passively supervised by a small café placed adjacent to the main entrance and is available for staff, students and patients alike.

General description The design of the building is highly conscious of the transition on this site between a broadly two-storey residential area and larger university buildings. On the Ferns Road elevation the building steps down from the ex-chemistry building first to a three-storey construction, then a setback bridging over ‘The Green’ and finally a two-storey block abutting the end terrace house, 33A The Green. The entrance for ambulance patients and those approaching from outside the campus is to the east in the middle of the new building, which re-inhabits this part of the street, although it is anticipated that the majority of patients will approach across the college green from the west. To the

Internal description Podiatry department patients, students and staff are immediately greeted by the reception area upon entry, with the waiting area apparent beyond. Patients are generally restricted to ground and first floors and, unusually, the podiatry booths are placed on two floors and accessed from the rear. The two-storey podiatry area incorporates a large window which gives all patients a view out to the college green. The 24 booths are observed by four groups of six students and the arrangement provides maximum privacy with good student supervision but also a pleasant view for the

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Clinical Education Centre; Title: Second floor plan and roof plan; Architect: Richard Murphy Architects

patients. In addition, on the ground and first floors there are some private consulting rooms at the north end of the building. The top floor is reserved largely for academic use although occasionally a patient will be invited to use the gait analysis room. At the south end of the building the physiotherapy section comprises four identical laboratories on the ground and first floors (which are capable of internal subdivision) while the second floor accommodates a sports exercise laboratory to the east, designed as an open glazed attic space with a small external terrace, and a physiology laboratory to the west.

Disabled access All parts of the building are accessible to the disabled via a lift placed centrally in plan. There is a secondary ground floor entrance to the physiotherapy department placed to allow covered external access from the podiatry department.

External materials The Ferns Road elevation comprises red brick to tie in with the existing brick terrace, fibre cement cladding panels, steel framed windows, timber soffit and a single ply polymer roof. The college green elevation makes use of the same materials apart from white render taking the place of red brick.

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Construction began in February 2005 and was completed in April 2006.

Case study E2 Project: The Richard Desmond Children’s Eye Centre Client: Moorfields Eye Hospital NHS Foundation Trust Architect: One Creative Environments Ltd Budget/Cost: £13.7m Moorfields Eye Hospital is a unique national and international resource for the treatment, research and teaching of ophthalmology. The range of services and volume of patients cannot be matched by any other institution in the world, with over a quarter of a million attendances each year. The Trust’s mission in creating the Richard Desmond Children’s Eye Centre was to provide the best functioning children’s eye hospital in the world without it looking like a hospital. The outline business case, approved 2001, stated the new ICEC was to provide the following paediatric accommodation; an A&E department; a primary care clinic for the local area; an outpatient service; a day surgery unit linked directly to the existing operating theatres; a dedicated research space linked to the institute of ophthalmology; and a 24-hour short stay hostel for patients/parents. The site of the new RDCEC is located within the Moorfields Conservation Area between the existing

Case studies

CSC E1-6

Clinical Education Centre; Title: Site plan; Architect: Richard Murphy Architects; Courtesy of: Richard Murphy Architects

CSC E2-1 The Richard Desmond Children’s Eye Centre; Title: Ground floor reception and café; Architect: One Creative Environments Ltd; Courtesy of: Cassius Taylor-Smith

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CSC E2-2 The Richard Desmond Children’s Eye Centre; Title: Aluminium louvres protect the south facing facade; Architect: One Creative Environments Ltd; Courtesy of: Morley von Sternberg. See Appendix A for coloured image

Moorfields Eye Hospital buildings on City Road and UCL Institute of Ophthalmology buildings on Bath Street. The local planning authority identified the key planning issues as the height and mass of the new building and the need for the scheme to be a piece of significant contemporary design. The constricted nature of the site, the internal layout of clinics and the necessary connections to the existing first floor operating theatres and the research floor of the Institute on the second floor all contributed to a clear vertical arrangement of spaces within the eight-storey building. Externally, the mass of the building is lifted clear above a largely glazed entrance platform containing a café, shops and, deeper into the building, the arrival and pre-op areas for the surgical patients and relatives. Bridges cross a slot of space running up the building separating the lifts and stairs, acting as a pause prior to entering the clinical areas and introducing a sense of space and scale. Waiting areas have translucent-coloured play pods, one of which bursts through the floor above, making a table there. The south facade, facing onto the open space across Peerless Street, is protected from solar gain through an arrangement of freely placed folded aluminium louvres, held within a large frame enfolding the facade, on a tensioned cable net suspended in front of glass curtain walling. A projecting bay breaks through the net signalling the most populated part of the building – the main outpatient waiting area on the third floor. The challenge of building adjacent to the existing hospital had the added complexity of functioning operating theatres in close proximity. As the new building could not take support from the existing building, a series of mini piles and

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CSC E2-3 The Richard Desmond Children’s Eye Centre; Title: Glazed facade with projecting bay; Architect: One Creative Environments Ltd; Courtesy of: Morley von Sternberg

The Richard Desmond Children’s Eye Centre; Title: Ground floor plan; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

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CSC E2-5 The Richard Desmond Children’s Eye Centre; Title: Typical upper floor; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

CSC E2-6 The Richard Desmond Children’s Eye Centre; Title: Elevation; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

cantilevered foundations were constructed. The remainder of the building is a reinforced concrete (RC) framed building using flat slab construction with exposed circular RC columns all supported on an RC raft foundation.

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The main facade is glazed curtain walling with folded aluminium louvres forming a filigree in front. The projecting bay on the third floor is clad in aluminium rain screen coloured bright orange. The east elevation has a ceramic

Case studies granite finish with circular glazed openings set within it. These ‘lenses’ give views at various levels internally for both children and adults as they move through the building. The remaining elevations have a calm and restrained appearance, with a palette of brick, render and aluminiumframed windows.

Award 2007 Building Better Healthcare Awards Winner ‘Best Hospital Design’

Summary of timetable, programme and budget constraints Competition/competitive interview Design team appointed Stage AB/C Planning submission Stage C/D P21 selection

November 2002 May 2003 June–September 2003 December 2003 October 2003–January 2004 February–March 2004

P21 partner (Balfour Beatty) appointed Stage E/F (including enabling works) GMP agreed Stage F Enabling works (inc. demolition) Construction (RDCEC) Completion

March 2004 April 2004–August 2004 September 2004 November 2004–May 2005 October 2004–August 2005 February 2005 December 2006

A design team led by One Creative Environments Ltd was appointed following an invitation through the OJEC and a competitive design/interview process. The project started on the presumption of a two-stage tender D&C procurement route. Post-stage D Balfour Beatty (BBCL) were selected on a cost/quality basis from the NHS ProCure 21 framework of contractors to take the project to completion. The design team were reappointed to the contractor to complete the design. Following approval of the GMP documents in September 2004, construction commenced in October 2004 and completion was reached in December 2006.

CSC E2-7 The Richard Desmond Children’s Eye Centre; Title: Section; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

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Case study E3 Project: The Breast Care Centre, St Bartholomew’s Hospital Client: Barts and The London NHS Trust Architect: Greenhill Jenner Architects Budget/Cost: £8 164 382

Barts and The London Breast Care Centre Barts Hospital, part of Barts and The London NHS Trust, has realised innovative plans to build an integrated screening and diagnostic centre for women with breast cancer. The hospital has a catchment of 80 000 women in the 50– 70 age screening bracket, and aims to incorporate several disparate breast care facilities into a single location: the West Wing, a Grade I listed Italianate four-storey building designed by James Gibbs between 1723 and 1758. The project, funded by charitable appeal, set a target of £13m, including construction work and the latest medical equipment. Architects Greenhill Jenner were appointed as lead consultants and architects in the autumn of 2000: they began a process of intensive consultation with the Trust, patients and staff. Representatives from the patient support group, hospital service staff, members of the hospital community and clinical staff formed a steering group that worked with the design team throughout the design phase. Working from information gathered through the consultation process, the design team set out to create a building that fused the best advantages of new technology with a patient-focused refurbishment programme that remained sensitive to the building’s heritage throughout. In this they sought to respond to the IT revolution in communication and organisation, the miniaturisation of archiving and ease of digital image transmission which have opened up possibilities for new and creative uses for old buildings previously deemed redundant for present-day medicine. The convergence of innovative modern architectural design, new technology and a culturally-significant building have made for a prime environment that is totally supportive to patients who arrive in varying states of distress and anxiety. (Nigel Greenhill, Director, Greenhill Jenner Architects) The Breast Care Centre includes several innovative patient-focused developments, including a boutique selling cosmetics and clothes for women living with the aftereffects of breast surgery, and a ‘patient resource centre’, run by volunteers, many of them ex-patients, with a library, kitchen and counselling room. The centre also incorporates staff-focused innovations, such as a teleconferencing unit and a fully AV-equipped conference centre, with large screen closed-circuit broadcasting capable of linking to operating theatres for teaching purposes.

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CSC E3-1 The Breast Care Centre, St Bartholomew’s Hospital; Title: Entrance to the west wing; Architect: Greenhill Jenner Architects; Courtesy of: Nigel Greener, Greenhill Jenner Architects

In setting out to re-purpose a heritage site, the design team set up a detail programme to survey the site in-depth. Paintwork, plaster and structure were analysed for age, revealing that much of the building’s internal framework had been repaired and renewed during its 200 year life; the absence of much of the original framework allowed the Trust to take an adventurous approach to the refurbishment, fusing contemporary with traditional styles. As a result, the internal treatment, consulting and diagnostic facilities are sited in self-contained enclosures in the centre of the building, with circulation space around the outside, adjacent to the external walls: the aim of this is to keep patients grounded, with permanent access to external views. The Breast Care Centre also benefited from an arts programme that was integrated into the design from its earliest days. Led by the Trust’s own arts project for healing and well-being, Vital Arts, the programme commissioned six site-specific works from internationally known artists including the striking 18  50 m Julian Opie image ‘I dreamt I was driving in my car (country road 2002)’ which hung in front of the West Wing during construction. The West Wing project was completed three weeks early and met its budget targets. The Breast Care Centre opened

Case studies its doors to patients in September 2004, with the first diagnostic tests taking place in mid-October.

Case study E4 Project: Kaleidoscope Children and Young People’s Centre, Lewisham Client: Lewisham Primary Care Trust Architect: van Heyningen and Haward Architects Budget/Cost: £8.45m

CSC E3-2 The Breast Care Centre, St Bartholomew’s Hospital; Title: Waiting spaces designed for informal contacts; Architect: Greenhill Jenner Architects; Courtesy of: Marcus Lyons, Greenhill Jenner Architects. See Appendix A for coloured image

Kaleidoscope is a new primary and social care centre that combines a variety of health, social and educational services for children and young people into a one-stop care provision, as a pioneering holistic solution. Designed by van Heyningen and Haward, the five-storey building in Lewisham, south London, enables diverse health and social care departments to work together, within a shared environment. This approach allows children, young people and their carers easily to access a range of services under one roof, which were previously in various locations across the entire borough. Brian Lymbery, chair of Lewisham Primary Care Trust, said: ‘we are absolutely delighted that our long held dream, to build a high quality integrated centre for children and young people, has become a reality. This is an amazing building, impressively and imaginatively designed, which will make an enormous difference to our staff, those in our partner agencies and the families using it. It marks a standard that all newly commissioned buildings should aspire to. After a decade of planning, Kaleidoscope has taken

CSC E3-3 The Breast Care Centre, St Bartholomew’s Hospital; Title: Main waiting room in former 18C ward space; Architect: Greenhill Jenner Architects; Courtesy of: Richard Glover, Greenhill Jenner Architects

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Consulting sub-wait Main stair Nurse station Nurses' office Consulting room Patient lift Staff lift Nurse prep Consultant base Document lift Patient wc Disposal hold Changing room Counselling lounge Plant room

ST BARTHOLEMEW'S HOSPITAL WEST WING BREAST CARE CENTRE

FIRST FLOOR PLAN Consultation Suites

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The Breast Care Centre, St Bartholomew’s Hospital; Title: First floor plan; Architect: Greenhill Jenner Architects; Courtesy of: Greenhill Jenner Architects

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Case studies ST BARTHOLEMEW'S HOSPITAL WEST WING BREAST CARE CENTRE

LONG SECTION

SHORT SECTION

CSC E3-5 The Breast Care Centre, St Bartholomew’s Hospital; Title: Sections; Architect: Greenhill Jenner Architects; Courtesy of: Greenhill Jenner Architects

18 months to build and after years of working in cramped accommodation, our staff can now deliver high quality services in a fit for purpose, modern and spacious centre.’ The architects won the commission in a high profile competition organised by CABE in April 2003. Support from CABE and a willing client, Lewisham Primary Care Trust, enabled Kaleidoscope to be realised almost exactly as it was originally designed. While changes were made during the construction process, hardly any elements of the projects were diluted or omitted and, as a result, the building features high quality design throughout. While Kaleidoscope is radically different, it has been built at a comparable cost to traditional health care buildings – highlighting the fact that the best architectural design can be achieved while remaining cost effective. The

total construction cost of the building was £8.45m, which is £1965 per sq.m. Mairi Johnson, Head of Buildings at CABE, said ‘there is growing evidence that well designed health buildings – those that are easy to find your way round, that bring daylight into the building and offer views out – can create calming, welcoming environments where users of the service do better, and staff retention is higher. Kaleidoscope is a great example of such a health facility, and it acts as an attractive and functional local focus for a range of health and social welfare activities. CABE worked closely with the client and the architect to ensure that good design was integral to this project, and we are delighted by the end result.’ Set on a site bordering the tree-lined Rushey Green in Catford, the building is C-shaped in plan, with

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CSC E4-1 Kaleidoscope Children and Young People’s Centre; Title: Internal reception area with view to courtyard garden; Architect: van Heyningen and Haward Architects; Courtesy of: Nicholas Kane. See Appendix A for coloured image

accommodation arranged around a central courtyard garden. The building includes two storeys of specialised consultation and treatment facilities at ground and first floor levels and three upper floors of administration accommodation. The ground floor has a larger footprint than those above, which step back to overlook its roof and the garden area. The outdoor space is pivotal to the design in that it is a contemplative time-out space and because all internal circulation space is located looking out on to it, easing orientation and way-finding. This also removed all enclosed corridors from the design, a specific request that came out of consultation within user groups. All rooms are located directly off this day-lit circulation space. Colour is used extensively and purposefully on the project, presenting an inviting building, and furnishing it with the name Kaleidoscope, chosen from a public competition. The ground floor facade refers to the varied shop fronts of neighbouring buildings with a multicoloured translucent glazed skin. Internally, the reception area features orange elements, while large circular roof lights in the vibrant blue ceiling flood the space with natural light. Each floor of the building also has a different colour scheme, which is highly visible from street level. Set off against a white backdrop and polished concrete columns, it helps with orientation and provides an environment entirely different from conventional health and social care premises.

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CSC E4-2 Kaleidoscope Children and Young People’s Centre; Title: External view along Rushey Green; Architect: van Heyningen and Haward Architects; Courtesy of: Tim Crocker

The building is entirely naturally ventilated and energysaving measures, including motion-sensitive lighting and Battiso cooled ceiling panels, are used throughout. The external facades of the upper floors of the building are rendered in off-white to the outer elevations, with, on the street facade, windows punching through at seemingly random intervals. Overlooking the garden and projecting ground floor roof, the facade is fully glazed, with sun shading to the southerly aspect. Views out are dominated by the mature trees on Rushey Green, which provide an unusually leafy vista for an otherwise thoroughly urban environment. Practice principal Joanna van Heyningen says: ‘we are excited by the potential of this building and the message it sends. It has been well received by everyone who will be using it and its completion provides that you can design high quality health buildings, which incorporate truly sustainable measures, for a cost comparable with that of traditional health care buildings.’

Case studies

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East Elevation from Rushey Green

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CSC E4-3 Kaleidoscope Children and Young People’s Centre; Title: East elevation from Rushey View; Architect: van Heyningen and Haward Architects; Courtesy of: van Heyningen and Haward Architects

CSC E4-4 Kaleidoscope Children and Young People’s Centre; Title: Section; Architect: van Heyningen and Haward Architects; Courtesy of: van Heyningen and Haward Architects

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CSC E4-5 Kaleidoscope Children and Young People’s Centre; Title: First Floor Plan; Architect: van Heyningen and Haward Architects; Courtesy of: van Heyningen and Haward Architects

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CSC E4-6 Kaleidoscope Children and Young People’s Centre; Title: Ground Floor Plan; Architect: van Heyningen and Haward Architects; Courtesy of: van Heyningen and Haward Architects

10

The next steps

I have outlined the historical development of health care facilities from the early Egyptian civilisation (3500 BC) to the beginning of the 21st century. There are a number of issues that are important to ensure that the next generation of health buildings provides the expected level of care and satisfaction for patients and staff. These points need to be set out clearly in the brief. Contradictions exist between the power of architecture to include human emotions and the practical constraints imposed by the requirements of a functional brief. Fundamentally, there is going to be greater flexibility in the way in which buildings are commissioned and private finance will increasingly become an important ingredient in enabling the process to proceed. Perhaps not surprisingly there are many components in current health policies which appear to have elements of ‘reinventing the wheel’ in them. For example, a variety of titles are being given to community hospitals and there have been cynical comments that these represent a reinstatement of cottage hospitals, many of which were closed in the 1980s and 1990s. The management of new multifunctional clinics is also subject to a wide variety of approaches. Large commercial organisations are seeking to control and manage GP polyclinics in much the same way as is found in the USA. Access to GP surgeries is likely to be widened over the next decade so that opening times are more responsive to the requirements of the local population. This is likely to include weekend and evening opening times to suit the working pattern of the local population. There is also a move towards consideration of the overall architecture of a community, and the sense of well-being that can be derived from an urban area that is environmentally friendly. Social geographers are researching this more intensively than the architectural professionals who are looking more closely at the physical design of individual health buildings. Following the demise of NHS Estates, the continuation of research projects looking at health buildings is being

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taken up by a number of leading architectural practices. This is indeed very commendable but, of course, runs considerable risks of being vulnerable to commercial pressures and potential conflicts of interest. The NHS does not seem to have responded to this research need and the initiative is falling into the private sector. However, an interesting strand of work is being investigated by the geography of health and cultural issues. For example, one area of research is looking at the ways in which different environments affect physical, mental, spiritual, social and emotional components of healing. It draws on research on therapeutic landscapes or places that have achieved a lasting reputation for healing (Epidauros in Greece, Bath in England and Lourdes in France) (Gesler, 2003). A conference (Healthy Planning and Design – London, 23 November 2005) explored the design of hospitals and other treatment and therapeutic spaces alongside a wide range of indicators such as access to green space, decent housing, employment and transport. A core theme of the WHO healthy cities programme is healthy urban planning. Growing interest in the connections between planning and public health shows that healthy urban planning is set to become a key feature of urban design and urban development. The promotion of ‘healthy’ cities builds on earlier Agenda 21 initiatives aimed at promoting cross-sectoral linkages across health and environment. The WHO qualities of a healthy city are: ●

● ●

●

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A clean, safe physical environment of a high quality (including housing quality). An ecosystem that is stable now and in the long term. A high degree of participation in and controlled by the citizens over the decisions affecting their lives, health and well-being. The meeting of basic needs (food, water, shelter, income, safety and work) for all. Access to a wide variety of experiences and resources.

The next steps ●

An optimum level of appropriate public health and sickness care.

The academic and professional groups should come together and learn from each other’s skills. CABE (Commission for Architecture and the Built Environment) is recognising the importance of some of these issues and looking at the components of sustainable design which encompasses social, economic and environment values. This places importance on the value of whole-life costs. It is important to understand the effect of master planning, quality of place and sustainability (Frances, 2007).

Conclusions and recommendations The conclusions and recommendations of this study provide an opportunity to set out four key guides to providing better primary health care centres in the future. 1. Doctors and architects must work together and develop common briefs for the next generation of primary health care buildings. They must be written for the benefit of patients. 2. The buildings must be designed to create a framework for the social interaction of the community that they serve. They must be socially inclusive, flexible, caring and accessible. 3. Well-designed primary health care buildings will become the focal point for the next generation of health buildings and will influence the shape and operation of larger and specialist facilities. 4. Primary care buildings will become the catalyst to encourage greater harmony between health policies around the world. Sustainable construction methods will develop and at the same time provide shelter for holistic medical protocols to flourish.

An independent NHS: a review of the options In 2007, ‘The Nuffield Trust commissioned an examination of the options for independent management of the NHS and a contribution to the current debate about the future of the NHS’ (Edwards, 2007, p. 7). This report looked at a series of alternative structures of the NHS and compared them with recent restructuring programmes that had gone on in other industries such as the Post Office, the BBC, the railway industry and British Telecom. It set out a series of alternative models including the following: 1. Modernised NHS Executive within the Department of Health – designed to separate policy from delivery. Not very radical but it might be a stepping-stone to more sweeping changes later on. 2. NHS Commissioning Authority – modelled on the Higher Education Funding Council for England and operating as a non-departmental public body at arm’s length from

ministers. Its job would be to develop commissioning skills, and it would fit easily into the current NHS pattern, with primary care trusts acting as its local delivery arms. 3. NHS Corporation – a fully managed national service on the BBC model comprising all publicly owned assets, including foundation trusts. This is what most people imagine an independent NHS would be like, reminiscent in some respects of an old-style nationalised industry. 4. NHS Corporation limited to planning, commissioning and inspecting NHS services – provided with its own charter, it would be more powerful than a commissioning authority but there are questions about how much can be achieved by better commissioning and how long it would take. 5. Regionalised NHS – the NHS would be run by independent regions that could be non-departmental public bodies or public corporations. Might work best if England ever moved to regional government. 6. NHS commissioned by local government – local authorities have responsibility for commissioning care. This model could be trialled in a big city and the results independently evaluated. 7. NHS as a public insurance company – the NHS would be defined as an insurance company funded by taxation and would license other organisations to commission health services. This could introduce competition as the licensed organisations – Primary Care Trusts, general practitioners, insurance companies, large employers or trade unions – could compete to provide best access to health care through providers with whom they strike deals. A radical change, though not outside the founding principles of the NHS. The report also includes a diagram of the NHS illustrating the relationship between Primary Care Trusts (PCTs) and general practice (Figure 10.1). I would argue that this diagram reflects much of the thinking of the NHS that has gone into the development of management strategies since its formation. What appears to be a relatively small component of the NHS – the link between PCTs and general practice – represents over 70 per cent of the financial value of the service. There remains a great weight of bureaucracy overseeing the PCTs as decisions cascade down through the system from Parliament, through the Department of Health and Strategic Health Authorities before arriving at Primary Care Trusts. None of the alternatives set out adequately or emphasise the role of general practitioners and the market forces which should be opened up to enable competition to develop freely. Of the seven options listed in this report, options 1 and 7 perhaps would permit the development of a free marketplace. The development of and connection between quality and price are identified by Edwards (2007) and he states that ‘the economic notion that with standard price competition can be about access and quality has yet to be thoroughly tested in the real world’ (p. 63). The weight of evidence shows that the BMA (British Medical Association) has consistently resisted change and continues to operate as an old-style trade union. Edwards touches on this issue when he discusses economic levers and notes that ‘the powers of

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Parliament

Department of Health

Secretary of State for Health (as sponsor)

Strategic Health Authorities

Independent regulators Healthcare Commission; monitor

Special health authorities

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• Foundation trusts (members) • Independent providers (shareholders) • Third sector (charities and NFP)

Residual NHS trusts

Community services

General practice Figure 10.1

The NHS: England 2007 (Edwards, 2007, p. 29)

any NHS Authority to shift the economic levers, including whether to have a tariff or not, would need to be clearly established. Could they, for example, significantly change the GP commissioning policies by expanding or limiting their role? Could they experiment with patient held budgets? Could they introduce new penalties and incentives for providers?’ (p. 63).

The next generation There is a number of interconnecting key strands that can be followed through the development of the health sector in the UK and which will have an important part to play in the future development of primary health care services. These include: 1. The patient/doctor relationship. 2. The WHO (World Health Organization) and the influence on UK doctors of overseas policies for primary health care. 3. The NHS – and the continuing acceptance of the principles set out in the Beveridge Report when the National Health Service was introduced in 1948.

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Contract Accountability

4. Government policy – and increased political confidence in handing responsibility for health care to the individual. 5. Commercial issues and how consumerism and the increase in the range of primary health care providers will influence the provision of primary health care facilities. 6. Privatisation of services – introduction of private capital to fund fixed assets (surgeries, clinics, hospitals, and virtual services such as electronic computer systems, etc.) as well as greater choice and individual freedom to mix NHS services with private supplementary services (better hotel type services in hospital, purchase of advanced technology for areas such as dental, aural or orthopaedic procedures). The testing ground for primary health care buildings of the future, or to use a generic term, healthy living centres, is most likely to be in the community sector. Rich opportunities for innovative design, imaginative briefing, and new methods of funding and procurement will shape the next generation of small health buildings. There are, therefore, many exciting challenges ahead for both doctors and architects to work out new arrangements of cooperating professionally so that these two honourable professions can forge

The next steps

Box 10.1 The following was provided by Jian-Guo Wu, a Chinese doctor who trained in traditional Chinese medicine (TCM) at the University of Traditional Medicine, Guangzhou, a city in South China. He is researching project management techniques in the UK to see how they can be applied to the development of health clinics in China. He summarises the approach of TCM – one of the four quintessences of Chinese culture – in this description: 1) What is Chinese medicine? To many Western readers, Chinese medicine may seem strange and unreliable. It is hard for them to understand why the needle and herb can cure the disease. It is the case, even in China, that some Chinese look on TCM as a mysterious thing. But it is a truth: as you know. China is a country that has a long long history and magnificent national culture. And TCM emerged at least 3000 years ago (in Chinese history, that is Shang Dynasty – 1000 BC), and has serviced the Chinese people for about 3000 years. Generally, TCM is a unique system of diagnosis and health care approaches. It is based on a profound philosophy and the concept of the universe outlined in the spiritual insights of Daoism (one of the Chinese religions), and it has produced a highly sophisticated set of practices to cure illness and to maintain health and well-being. These practices include acupuncture, herbal remedies, massage, diet, meditation and both static and moving exercises. Although they appear very different in approaches, they all share the same underlying sets of assumptions about the nature of the human body and its place in the universe. 2) The basic theory of TCM TCM can be traced to 1000 BC, but the first and most important classic of TCM had been completed during the Qin Dynasty (200 BC). The classic Huang-di Nel-jing (Inner Classic of the Yellow Emperor) – first built up TCM theory completely. Many basic concepts of TCM were expatiated in this work such as the fundamental substances in TCM, the meridian theory and the basic approach to diagnosis and treatment and so on. The basic

a closer relationship and a common objective of building a healthier lifestyle for everybody who will use these buildings. No doubt, different solutions will emerge as private finance influences the public funding of the NHS. The briefs for community buildings will have to balance the need for flexibility with multipurpose rooms and the need to offer more specialised facilities closer to a patient’s home. In the USA, a range of specialised facilities has tended to emerge where there has been sufficient wealth to support the demand for those services. Therefore, there are many medium sized buildings in the USA providing specialised community services in, for example, cancer care, ambulatory clinics, care of the elderly, cardiac centres, clinics for children and other medically discrete treatment centres. Other parts of the world continue to focus on patient centred therapies. The Western civilisations, predominantly English speaking, should look more closely at alternative health philosophies. Chinese traditional medicine, including herbal, acupuncture and mental therapies, will become better understood in future years and more research should

substances include: Qi, Jing, Xue, Jin-Ye and Shen. Qi means ‘energy’, ‘vital energy’. Jing can be translated as ‘essence’, governing growth, reproduction and development. Xue means ‘blood’, but not merely the physical substance that is recognised as blood in Western Medicine. It nourishes the body and Shen. Jin-Ye, which means ‘body fluids’, is considered to be the other organic liquids that moisten and lubricate the body. Shen can be translated as the mind or the spirit of the individual. The Meridian system consists of 12 main channels, each links together one by one in to a cycle of circulation. And the basic substances (Qi, blood, etc.) flow in the channels. Each channel has many specific, recognised acupuncture points. Actually, it is hard to understand and it is impossible to explain the above concepts fully in one English word or phrase. 3) Medicine East and West Perhaps someone still argues whether TCM is science or not. But TCM has been developed in China for several thousand years before Western Medicine was introduced into China in the Quing Dynasty (about 100 years ago). In fact, Medicine East and West are two quite different ways of seeing and thinking about the body and disease. Western Medicine is concerned mainly with seeing and thinking about the body and disease. Western Medicine is concerned mainly with isolatable disease categories or agents of disease and tries to change, control or destroy them. The Chinese Medicine, in contrast, directs the attention to the complete physiological and psychological individual. Illness is a pattern of disharmony of the whole body (entity). Treatment aims to restore harmony and to rebalance the interconnection between all aspects of the organism. Anyway, TCM is an old science but with good prospects. I am sure that the Chinese Medicine will be widely accepted throughout the world in the next 50 years. No side-effects No laboratory reports No stethoscope No Aspirin No antibiotics/Penicillin

be undertaken to look at the whole body approach to wellbeing which has been adopted by the Chinese (see Box 10.1). The dilemma of affluent societies is highlighted by these two different approaches. Where wealth alone does not solve lifestyle health problems there is a greater willingness to look more closely at human attitudes towards health. There was, perhaps, a closer correlation between the philosophy of health, and therefore the facilities which society provided for the ill, in the Chinese and Roman civilisations of 2000 years ago than there is today in our Western civilizations. These arguments return us to the importance of the brief to reflect the ethos of the client. Architecture and medicine need to work together to build healthy living centres for the future.

Polyclinics The government is seeking to introduce more diversity and choice in the primary care health sector as it encourages

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Primary Care Centres private providers to begin to create a commercial marketplace. Lord Darzi, Health Minister, who has been tasked by Gordon Brown to reform the NHS, would like to reorganise the English GP system. He favours larger polyclinics, which would replace current single GP practices. The polyclinics would offer specialist services and would be run by several doctors and health care professionals. According to the British Medical Association, the polyclinic route would undermine the continuity of patient care – it could waste hundreds of millions of pounds and damage the GP system. In a BBC Breakfast programme interview, Lord Darzi stressed that the sole GP practice is a thing of the past. Even though most people like their GP, he warns that an overhaul is coming. Patients’ needs would be better served by polyclinics, Darzi added, which would have GPs plus other medical services generally only available in hospitals. Darzi said to the BBC ‘I have no doubt in the future we are going to see a critical mass of general practitioners working together, rather than what we used to see in the past which were practices with a single-handed clinician.’ If the plan goes ahead, it could start with a 150 polyclinic project throughout the country. (Nordqvist, 2008) The response from the BMA was discouraging and alleged that the proposals were ‘going to waste hundreds of millions of pounds of scarce NHS resources creating very large health centres that many areas of the country simply don’t need or want’. The main thrust of the BMA’s opposition to this initiative is one of the protectionism for the working conditions of GPs, and of the generalist role to any patient who presents themselves at a clinic. It avoids the point that GPs have undermined their function of providing continuous care following the curtailment of ‘out-of-hours’ services. A major concern, as alternative providers compete to offer GP services, is the availability and accuracy of medical records. The experience in Japan, where primary care services are poorly coordinated, results in many diagnostic tests being repeated because there is no reliable transfer of data from previous consultations. In effect, every time a patient moves to a different location, the first visit to a new GP may result in the need to re-create a patient’s medical history – something that is both inefficient (and potentially inaccurate) and costly. The RCGP (Royal College of General Practitioners) reacted by saying that ‘it wants to use the scheme to highlight the importance of the doctor–patient relationship and continuity of care’ (www.rcgp.org.uk, 18 February 2008). Polyclinics are not a new idea and were discussed in 1920 by Lord Dawson (see Chapter 2). This terminology reinforces the return to a policy structure which seeks to place patients at the centre, and in a controlling position, of individual and personal health care strategies. The BMA in 2008 continues to raise objections that appear to be based more on self-interest and professional protectionism rather than accept the move towards greater competition. This would

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require the medical profession to acknowledge that the patient was the customer and, therefore, commercially had the controlling interest.

The Darzi Report The Darzi Report (Department of Health, 2007b) is a review of the progress made in the NHS since the publication of the NHS Plan (2000). The assessment by Lord Darzi is that the NHS is ‘perhaps two thirds of the way through its reform programme set out in 2000 and 2002. In my visits across the NHS I have detected little enthusiasm for doing something completely different; instead the majority of opinion is that the current set of reforms should be seen through to its conclusion. I agree.’ This is further evidence, confirming the findings of the Nuffield Trust reviewed earlier in this chapter, and that the fundamental principles of the NHS continue to demonstrate that the policy framework continues to provide opportunities for world class health care. However, the medical profession is concerned about the implications for privatisation which are implicit in the recommendations of the Darzi Report interim findings. A difficult negotiation with the BMA has resulted in the government succeeding in reaching agreement for doctors to increase accessibility to doctors’ surgeries by having weekend opening and late evening surgery sessions. The medical profession is resisting the competitive marketplace which will threaten the traditional direct relationship between GPs and the government. The Darzi Report (p. 24) restates that more than 80 per cent of NHS patient contact takes place in primary care. He identifies a series of key objectives including: 1. PCTs will work with all new and existing GP practices in their areas to develop greater flexibility in opening hours – our aim is that at least half of all GP practices will open on Saturday mornings or one or more evenings each week. 2. Over 100 new GP practices, including up to 900 GPs, nurses and health care assistants in the 25 per cent of PCTs with the poorest provision. These new practices will increase capacity and offer an innovative range of services, including extended opening hours. They will improve health outcomes in these areas with more targeted and preventive interventions that identify and tackle illness at an earlier stage. 3. New resources to enable PCTs to set up 150 GP run health centres open seven days a week, 8.00 am to 8.00 pm, situated in easily accessible locations and offering a range of services to ensure more patients have access to GP treatment and advice at a time that is convenient to them including pre-bookable appointments and walk-in and other services. 4. To help people choose their GP and switch if they are unhappy, key information about all GP practices – including the results of the patient survey, practice opening times and performance against key quality indicators – will be made available on a single website, NHS Choices.

The next steps 5. To help develop future strategy on primary care a new advisory board will be appointed that includes GPs, community nurses and other health and care professionals. This report into the future of the NHS restates the government’s commitment to the privatisation of the NHS. It also reveals Gordon Brown’s plans to push privatisation into more areas of the NHS than ever before. Lord Darzi claims that independent health providers – private companies – ‘have helped to extend a choice, add capacity and spur innovation’. Therefore, new general practices should be set up by independent contractors or new ‘private providers’. His vision is of a health care system run by private companies. The recommendations set out in this report support my research to provide more private providers of health care services in the primary care sector, and this will require more flexible approaches and a re-examination of the contractual terms of appointment for GPs.

The balance of power and money in the NHS Sunand Prasad, currently (2008) President of the RIBA (Royal Institute of British Architects), argued that In the UK the balance of power and money in the Health Service is undergoing its most radical transformation in 50 years. The post-war health service had the hospitals as its apex – now 75% of National Health Service money will be channelled through the primary care sector, the so-called ‘shift from the acute to the primary care then NHS’. Among other things this change is a simple acknowledgement of the fact that less than 10% of the ‘health events’ passing through the NHS are handled by the acute sector. This leads to a more integrated view of the Health Service as (a) whole. (Prasad, 2008, p. 11) This recent book, Changing Hospital Architecture (Prasad, 2008), briefly summarises many of the historic trends in health care design and identifies that the road maps, or methodologies, for higher standards of design quality have been significantly advanced during the last 20 years or so. However, this publication concentrates on hospital architecture, arguing that the book is intending to be a tool and ‘its aim is to help improve the quality of design by pointing to potential exemplars, presenting key issues and occasionally signalling caution.’ (p. 11). Although there are similarities in the design concepts, this research identifies that there is a need to integrate design quality concepts into the procurement routes for private providers in the primary care sector who are responsible for the largest percentage of ‘health care events’.

A glimpse into the future It seems likely that the next few years will see significant change in the NHS. In 2008, the government is experimenting

with a variety of changes to the structure and provision of primary care services. Private sector providers are being encouraged to start up new services and the development of a marketplace seems likely to speed up. The BMA has consistently resisted initiatives for change that the government has sought to introduce since the formation of the NHS in 1948. We can expect consumerism and patient power to become much more influential in determining the selection of primary health care services and we might see the following ideas emerging: 1. GPs issuing well notes instead of sick notes. This recent initiative (objected to by the BMA) was designed to encourage doctors to examine a patient for their ability to return to work, even if restricted to undertake certain tasks only. There has been criticism of sick notes being abused by patients and that GPs were sometimes too ready to be complicit in signing off a patient. 2. Personal health budgets might be established with analogies to the way taxation operates in the UK. There could be tax credits or thresholds of service availability from GPs with optional extra services that could be secured by additional payment. This could be a more sophisticated framework to the already privatised network of services which operates for dental treatment and opticians and some selection which operates with prescriptions and the purchase of medication generally. 3. With advancements in technology records, systems could be held on plastic cards (similar to credit cards). Google have already announced plans to create personal health care databases. The plans would put Google’s database of health records at the heart of a broader health information system that draws in health insurers, doctors and others, potentially giving the internet company a central role as the health industry moves towards greater use of information technology. (Waters, 2008) This technology could open up a wide range of new services, probably not yet envisaged, which will allow patients to take control of their own records and enable the data to be transferable between GP providers. New entries could be put on to the record card by GPs, which could be recorded centrally as well as providing an up-to-date personally held card. 4. The range of providers is likely to widen considerably, with a variety of contractual arrangements between the providers and the GPs providing medical services. Various levels of service could be offered to patients. Comparisons with the taxation system are again useful with basic health services being guaranteed, similar in concept to a PAYE system. The cost of these services could be monitored through an employer or an equivalent of self-employed status which would bring greater independence, and responsibility, to individual patients to maintain their health record card. 5. With a health care service still maintaining the original NHS principles of free access to basic health being available to

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Primary Care Centres all citizens, government policy would begin to focus on the relationship between public health standards and the quality of design. Increasingly, the relationship between healthy places and healthy people would become more important in establishing planning policies. Well-designed urban environments, which were stress free, friendly, accessible and safe, would provide important linkages between the nation’s health and the quality of the built environment. 6. With greater personal responsibility you would anticipate an extension of the life check initiatives so that each citizen would become more responsible for monitoring their lifestyle decisions. By access to internet programmes, selfcheck appraisals could monitor and record health trends and identify early warning signals about diet, weight, exercise, blood pressure and other routine checks. Built into the programmes could be periodic tests for eyesight, hearing and age-related degenerative and cognitive diseases (e.g. types of dementia). The advantage for this framework for health in the future is the opening up of design opportunities for innovative architecture that produces calm and humane solutions for everyday living.

Trends in UK health policy These statements remain a central and crucial element of the health policy of most countries and provide the underlying objective that health care should seek, first of all, to be preventive. So far as the UK is concerned there has been a reawakening of the importance of primary health care and that the real gains are to be made in economic terms by reducing illness rather than treating disease. The 21st century perhaps may see an increasing interest in building healthy environments – the places in which we live and work. People need to take responsibility for their communities and primary care centres will be part of that society in which wellness is fostered through lifestyle choices. Three broad areas of change can be identified: (a) Professional conditions of engagement GPs are seeing significant changes to the terms of reference for their employment as the government attempts to open up a competitive marketplace in the provision of primary health care services. New forms of contract have been introduced and new private sector providers for GP services are being encouraged to compete for the provision of additional services, particularly for the provision of 150 polyclinics. There have been delays in the delivery of projects being procured through the LIFT (Local Improvement Finance Trust) process and there are allegations of delay and procrastination by

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PCTs where there are many examples of bureaucratic inefficiency delaying the timely flow of decisions. On a positive note, the introduction of more competition between service providers is creating a healthy climate of innovation in the architectural profession, which is responding to the need to design a wide range of primary care buildings. Briefs for these buildings are becoming more comprehensive and the aspirations of the doctors and patients are being articulated more clearly than has been the case previously.The recognition that environmental quality is important is being reflected in the terms and conditions set out in architectural briefs. There is a better understanding that the ethos of a building should be clearly expressed in the brief. (b) Political will Over the last decade, and longer, there has been an increasing level of understanding that environmental design standards are important in health care buildings. Evidence-based design has provided many good research papers indicating best practice in architectural design solutions. The therapeutic benefits that can be derived from good design are now readily acknowledged as being desirable. These principles are moving beyond GP surgeries into the design of community hospitals and the external spaces around health buildings. Research work has demonstrated the positive benefits of extending these ideas to the creation of healthy environmental standards across the community as a whole. We are therefore seeing government policy beginning to interact between social aspirations for a community and the quality of health care that is achieved as a result of integrated policies for health, planning and transport. (c) Cultural well-being Social change, and in particular the approach towards solving social deprivation, is increasingly acknowledging the importance of a healthy mind or a sense of spiritual wellbeing. This concept demonstrates the direct linkages to civilisations 5000 years ago (see Chapter 2). The nature of mankind has not changed and the core values of human beings are as important today as they ever have been. Historically, technical knowledge within the medical profession was very limited and over the centuries scientific knowledge and technical competence have dramatically increased. It is only in the last 20 or 30 years, however, that government policy has begun to appreciate the full importance of the factors influencing a sense of well-being. In our lifestyle choices, each of us remains vulnerable to making inappropriate decisions that may threaten our ‘wellness’. The government is seeking to give each of us responsibility to make decisions about the quality of our lives, which is a great responsibility but fundamentally important if we are to understand that our quality of life depends on factors that have remained largely unchanged for 5000 years.

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Further reading

Allan, P., et al. (2005). The art of medicine in ancient Egypt. New York: Metropolitan Museum of Art. Anon. (2000a, July 30). Only half way to health. The Sunday Times. Anon. (2000b, June 21). Better health. The Financial Times. Anon. (2000c, May 15). Unhealthy ambitions. The Times. Anon. (2000d, June 25). Radical medicine. The Sunday Times. Anon. (2007e, May 13). Brown gives taster of leadership manifesto. The Sunday Times, 2. Arab, S. M. (2008). Medicine in ancient Egypt. http://www. arabworldbooks.com/articles8c.htm Accessed October 30, 2008. Barrick, A. (2000, April 20). Building (p. 9). Barton, A. (2008 March 6). GP ‘forced into deal’ to save cash. The Journal (Newcastle). BBC News. (1942). Beveridge lays welfare foundations.  http://news.bbc.co.uk/onthisday/hi/dates/stories/ december/1/newsid_4696000/4696207.stm Accessed October 31, 2008. BBC News. (2005 June 16). UK health ranked ninth in Europe. London: BBC News, 14.05 GMT. BBC News. (2006). People to be offered ‘health MOT’. London: BBC News, Wednesday, November 7, 2007, 01:45 GMT. BBC News. (2007 November 7). Traffic light rating for patients. London: BBC News, 01:45 GMT. Beveridge, W. (1942). Social insurance and allied services (Nov 1942): A report. London: HMSO. Beveridge, W. (1944). Full employment in a free society. Woking: Unwin Brothers Limited. The Bible. (1961). The new English Bible: New testament. Cambridge: Oxford and Cambridge University Press. Black, S. (2003). Environmental makeover. In: Design and health: III – Health promotion through environmental design. Stockholm: International Academy for Design and Health.

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Blyth, A., & Worthington, J. (2001). Managing the brief for better design. London: Spon Press. Bowra, C.M. (1957). The Greek experience. London: Weidenfeld and Nicholson. Boyce-Tillman, J. (2000 August). The rhythm of life. Classic FM, 66, 48–51. Bristow, G., et al. (2000 February). Calling on mobiles. Hospital Development, 11. British Academy. (2001). The quality of life in the European Union: A social research agenda. www.britac.ac.uk British Medical Association. An outline history of the British Medical Association. http://www.bma.org.uk Accessed February 16, 2008. British Medical Association. NHS – BMA’s support. http:// www.bma.org.uk Accessed February 16, 2008. Brown, G. (2007a). Courage – Eight portraits. London: Bloomsbury Publishing Plc. Brown, A. (2007b). I’ll take the politician’s fingers out of the NHS pie, says Cameron. http://www.timesonline.co.uk Accessed January 7, 2007. Burchell, A., & Gilbert, B.K. (1982). Appraisal of development options in the National Health Service. London: Department of Health and Social Security. Burk, K. (2003). Short Oxford history of the British Isles – The British Isles since 1945. Oxford: Oxford University Press. Bush-Brown, A. (1996). The healing environment. In M.S. Valins & D. Slater (Eds.), Futurecare: New directions in planning health and care environments. Oxford: Blackwell Science Ltd. CABE. (2003). Creating excellent buildings – A guide for clients. London: Commission for Architecture and the Built Environment. CABE. (2006a). Designed with care: Design and neighbourhood healthcare buildings. London: Commission for Architecture and the Built Environment. CABE. (2006b). The value handbook: Getting the most from your buildings and spaces. London: Commission for Architecture and the Built Environment.

Further reading Callaham, J. (1987). Time and change. London: Williams Collins & Co. Ltd. Calman, K.C. (1998). The potential for health: How to improve the nation’s health. Oxford: Oxford University Press. Calman, K.C. (2007). Medical education. London: Elsevier. Cammock, R. (1981). Primary health care buildings: Health centres, neighbourhood clinics and group practice surgeries: A briefing and design guide for architects and their clients. London: The Architectural Press. Castle, B. (1980). The castle diaries 1974–76. London: Book Club Associates by arrangement with Weidenfeld and Nicholson. Chisholm, J. (1992). Making sense of the cost rent scheme: The business side of general practice. Oxford: Radcliffe Medical Press. Coates, S. (2007 May 14). Health service policy: One of four Blair era ‘mistakes’. The Times, 4. Cole, J. (1995 May). Finance over function. Hospital Development, 26(5), 9. Cole, J. (2000). Capturing design quality. Unpublished paper presented at Architects for Health Seminar on 17 February 2000. London: Reform Club. Collins, P., et al. (2007). NHS hospital ‘Chaplaincies’ in a multi-faith society – The spatial dimension of religion and spirituality in hospital. NHS estates P(05) 04, final report. Department of Anthropology & Centre for Arts in Humanities, Health and Medicine. Durham University. Concode Advisory Group. (1984 May). Concode – A brief description. London: DHSS Health Service Estate 53, 31–32. Construction Industry Council. Can we measure the quality of design in buildings? Coonan, R. (1996). Time for design: Good practice in building, landscape, and urban design. London: English Partnerships. Cox, S., & Hamilton, A. (1995). Architect’s job book (6th ed.). London: RIBA Publications. Crisp, N. (2005). Commissioning a patient-led NHS. London: Department of Health http://www.dh.gov.uk Accessed October 30, 2008. Critchlow, K., & Allen, J. (1995). The whole question of health. London: The Prince of Wales’ Institute of Architecture. Dall’Olio, L. (2002). Origin and development of healthcare facilities. Milano: Federico Motta Editore Spa. Materia, 38. Darzi, Lord (2008). High quality care for all: NHS next stage review final report. London: Department of Health. Daunton, C. (2000). Society and economic life. In: The nineteenth century; Short Oxford History of the British Isles. London: Oxford University Press. DCMS, Department for Culture, Media and Sport. (2000). Better public buildings – A proud legacy for the future. London: Department for Culture, Media and Sport. Department of Health. (1989). Working for patients. London: Department of Health Publications.

Department of Health. (1992). The Health of the nation. London: Department of Health Publications. Department of Health. (1994). Capital investment manual. London: The Stationery Office. Department of Health. (1996). Choice and opportunity: Primary care: The future. London: The Stationery Office. Department of Health. (1998a). General medical services: Statement of fees and allowances. London: Department of Health. Department of Health. (1998b). Our healthier nation: A contract for health. London: The Stationery Office. Department of Health. (1998/9). Saving lives: Our healthier nation. London: Department of Health Publications. Department of Health. (1999). Healthy living centres. London: Department of Health Publications. Department of Health. (2000a). The NHS plan. London: Department of Health Publications. Department of Health. (2000b). New initiatives to modernise GP premises. London: Department of Health Publications. Department of Health. (2001). Primary care, general practice and the NHS plan. London: Department of Health Publications. Department of Health. (2002). Saving lives: Our healthier nation and reducing health inequalities: An action report. London: Department of Health Publications. Department of Health. (2004a). Making partnerships work for patients. London: Department of Health Publications. Department of Health. (2004b). New investment in doctors premises. London: Department of Health Publications. Department of Health. (2004c). Choosing health: Making healthy choices easier. London: Department of Health Publications. Department of Health. (2005). General medical services: Statement of financial entitlements. London: Department of Health. Department of Health. (2007a). Community hospitals. London: Department of Health Publications. Department of Health. (2007c). Rebuilding the NHS: A new generation of health care facilities. http://www.dh.gov. uk/en/Publicationsandstatistics/Publications/Publications PolicyAndGuidance/DH_075176 Accessed October 31, 2008. Department of Health. (2008). Helping people to look after their own health and well being. http://www.dh.gov.uk/ publications Accessed March 6, 2008. DETR, Department of Environment, Transport and the Regions. (2000a). By design – Urban design in the planning system: Towards better practice. London: Thomas Telford Publishing. DETR, Department of Environment, Transport and the Regions. (2000b). KPI report for the minister for construction. London: HMSO. Duffy, F., et al. (1993). The responsible workplace. London: Butterworth-Heinemann Ltd. Duffy, F. (1997). The new office. London: Contran Octopus Ltd.

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Primary Care Centres Edelstein, L. (1943). The hippocratic oath. Text, translation and interpretation. Baltimore: Johns Hopkins Press. The Egan Report. (1998). Rethinking construction. London: Department of Trade and Industry. English Partnerships. (1998). Time for design; good practice in building, landscape and urban design. London: English Partnerships. Faith in the City. (1985). The report of the Archbishop of Canterbury’s commission on urban priority areas. London: Church House Publishing. Finsbury Health Centre. The Open University/BBC. http:// www.open2.net/modernity/3 Accessed October 30, 2008. Foque, R. (1999). Healing environments: New typologies for health care architecture. The Architects for Health open lecture for 1999 (27 May 1999) held at the Royal Institute of British Architects. London. Francis, S., et al. (1999). 50 years of ideas in health care buildings. London: The Nuffield Trust. Francis, S. (2000). Capturing design quality. Unpublished paper presented at Architects for Health Seminar on 17 February 2000. London: Reform Club. Francis, S. (2006). Healthcare design development in UK. In: Design and health IV – Future trends in healthcare design. Stockholm: International Academy for Design and Health (pp. 69–79). Francis, S. (2007). Valuing the healthcare design environment. In: UK healthcare design review conference book. International Academy for Design and Health (pp. 83–87). Fuller, S. (1977). Science. Buckingham: Open University Press. Galbraith, J.K. (1958). The affluent society. London: Penguin Books. Gallup, J.W. (1999). Wellness centres. New York: John Wiley & Sons, Inc. Gibson, B. (Ed.). (1999). Human rights and the courts. Winchester: Waterside Press. Giddings, B., & Horne, M. (2002). Artists’ impressions in architectural design. London: Spon Press. Gledhill, R. (2000b, October 19). Carey attacks ‘arrogance’ of surgeons. The Times, 9. Gombrich, E.H. (1964). The story of art. London: Phaidon Press Ltd. Goodman, M. (2008 February 10). £300 m dentists group snapped up by Merrill. The Sunday Times. Grafton, A. (2002). Leon Battista Alberti: Master builder of the Italian renaissance. London: Penguin Group. Hall-Dendy, A. (1997 February). Banking on design quality in PFI. Hospital Development, 28(2), 8. Hardman, R. (2000 May 17). We’re doomed if we ignore nature says prince. Daily Telegraph. Harris, J. (1977). William Beveridge: A biography. Oxford: Clarendon Press. Harrison, J. (1984). Engineering evaluation programme – An interim report. London: DHSS Health Service Estate, 54, 50–53. Harvey, D. (1997, November). The nature of enquiry and explanation in the social sciences: A neoclassical view.

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Unpublished lecture notes. University of Newcastle upon Tyne. Hattersley, R. (1997). Fifty years on: A prejudiced history of Britain since the war. London: Little Brown and Company (UK). Hawkes, N. (2007 August 20). GPs given ultimatum to open at night and weekends. The Times, 1. Hawkes, N. (2008 March 7). Grudging GPs give in and agree to open evenings and weekends. The Times. Healey, P. (2001). Researching people, place and urban governance: A city planning perspective. Talk for RAND Corporation Workshop ‘Population, health and the environment’ theme, 11–13 January. Santa Monica, CA. Health Buildings Evaluation Manual. (1986). London: Department of Health and Social Security. Heath, E. (1998). The course of my life. London: Hodder and Stoughton. Henderson, J. (2006). The renaissance hospital: Healing the body and healing the soul. New Haven and London: Yale University Press. HM Treasury. (2002). Securing our future health: Taking a long-term view (The Wanless Report). London: HM Treasury. Horam, J. (1997 March). Horam gets tough on designers and builders at PFI conference. Hospital Development, 28(3), 10. Hosking, S., & Haggard, L. (1999). Healing the hospital environment. London: E&FN Spon. HRH The Prince of Wales. (1989). A vision of Britain. London: Doubleday. HRH The Prince of Wales. (1996). Sacred in the modern world. Invest. Corp. Dinner, London, 10 July 1996. http://www.princeofwales.gov.uk/speechesandarticles/ index.html Accessed October 30, 2008. HRH The Prince of Wales. (2000a, May 18). We must go with the grain of nature. The Times. HRH The Prince of Wales. (2000b, December 30). Complementary and alternative medicine needs – and deserves – more research 2000. The Times. Hsiao, W. (1995). The Chinese health care system: Lessons for other nations. Social Science & Medicine, 41(8), 1047. Human Rights Act 1998. (c. 42). London: The Stationery Office. Jacobs, J. (1961). The death and life of great American cities. London: Penguin Books Ltd. Jamieson, P. (2007). Interview with G. Purves, 26 February. Jencks, C. (1995). The architecture of the jumping universe. London: Academy Group Ltd. Jencks, C. (2003). Breathing space: Towards an aesthetic for cancer care. Conference lecture, September 26, 2003, DCA. Jian-Guo Wu. (2000). Unpublished correspondence with G. Purves. Jones, A. (2000). Capturing design quality. Unpublished paper presented at ‘Architects for Health’ Seminar on 17 February 2000. Reform Club, London. Jones, R.V.H., Bolden, K.J., Pereira Gray, D.J., & Hall, M.S. (1978). Running a practice. London: Croom Helm Ltd.

Further reading Kamara, J.M., et al. (2002). Capturing client requirements in construction projects. London: Thomas Telford Publishing. King, H. (2001). Greek and Roman medicine. London: Gerald Duckworth & Co. Ltd (Bristol Classical Press). The King’s Fund. (2003). Evaluation of the King’s Fund’s enhancing the healing environment programme. London: HMSO. Kirklin, D., & Richardson, R. (Eds.). (2003). The healing environment: Without and within. London: Royal College of Physicians of London. Kirtley, G. (2000). Briefing healthcare facilities – A résumé. Unpublished notes from correspondence: 29 May. Kuffner, D.J. (1996). Patient-focused design. In M.S. Valins & D. Slater (Eds.), Futurecare: New directions in planning health and care environments. Oxford: Blackwell Science Ltd. Lacey, R., & Danziger, D. (1999). The year 1000. London: Little Brown and Company. Lasagna, L. (1943). The Hippocratic oath. Boston: School of Medicine, Tufts University. Latham Report. (1996). Constructing the team. London: Department of the Environment. Lawson, B., & Phiri, M. (2003). The architectural healthcare environment and its effects on patient health outcomes. London: HMSO. Leather, P. (2001). A comparative study of the impact of environmental design upon hospital staff and patients (Draft report). University of Nottingham (Institute of Work Health and Organisations). Lloyd, G. (1983). Hippocratic writings. London: Penguin Books Ltd. Long, K., & Lewis, J. (2000 September 22). Doubts over PFI hospitals. Building Design. Lord Lawson, N. (1992). The view from No. 11 – Memoirs of a Tory radical. London: Bantam Press. McLellan, D. (Ed.). (1995). Karl Marx: Capital, a new abridgement. Oxford: Oxford University Press. MacManaway, B. (2004). Healing. http://www.isleofavalon. co.uk /GlasonburyArchive/ … /m_01.htm  Accessed February 05, 2004. MacRae, S. (2000). Patient centred healthcare: An interview with Susan MacRae. www.Best4Health.org Accessed October 30, 2008. Malkin, J. (1992). Hospital interior architecture. New York: John Wiley & Sons, Inc. Marr, A. (2007). A history of modern Britain. London: Macmillan. Martin, M. (2000). What is architecture? Unpublished lecture notes, University of Newcastle upon Tyne, September. MARU (Medical Architectural Research Unit). (1996). Designing primary healthcare premises: A resource. North West Regional Health Authority. Maxwell, G. (1997 March). In search of design values. Hospital Development, 28(3), 13. Menin, S. C. (1997). Relating the past: Sibelius, Aalto and the profound logos. Unpublished PhD thesis, Faculty of

Law, Environment and Social Sciences, Newcastle upon Tyne. Morgan, J. (2000 September 3). Charles wants minorities to aid architects. The Sunday Times. Morris, N. (1997). Niche opportunity. Health Service Journal, 27 February, 9–10. National Health Service (Primary Care) Bill. (February 27, 1997). London: The Stationery Office. National Primary Care Research and Development Centre. (1995). Prospectus 1995–1997. University of Manchester. Newcastle City Health NHS Trust. (1999). Newcastle General Hospital: Development options for the Southern frontage of the site. Newcastle upon Tyne: Newcastle City Health NHS Trust. NHS (National Health Service). (1996). Statement of fees and allowances. London: HMSO. NHS Estates. (1999). Improving the quality of design of healthcare buildings. Unpublished report, 15 December. NHS Estates. (no date). Advice to trusts on the main components of the design brief for healthcare buildings. London: NHS Estates. Nightingale, F. (1860). Notes on nursing: What it is and what it is not (Unabridged reproduction of the first American edition, as published by D. Appleton and Company – Dover Edition 1969). Mineola, NY: Dover Publications Inc. Nilsson, U. (2003). Music and health: How to use music in surgical care. In: Design and health: III – health promotion through environmental design. Stockholm: International Academy for Design and Health (pp. 103–104). Norfolk Health Overview and Scrutiny Committee. (2006). Community hospitals, specialist support services and intermediate services. http://www.norfolk.gov.uk/consumption/ groups/publi… Accessed November 27, 2008. North West Regional Health Authority. (1996). Designing primary healthcare premises: A resource prepared for North West Regional Health Authority/NHS Executive North West by MARU, Health Buildings Research and Policy Centre. Liverpool: North West Regional Health Authority. Norwich, J.J. (2006). The middle sea: A history of the Mediterranean. London: Chatto & Windus. Nugent, R. (1995 July/August). Shaping the future: New horizons. Hospital Development, 26(7), 11–12. O’Gorman, F. (1997). The long eighteenth century: British political and social history 1688–1832. London: Hodder Arnold. O’Marberry, S. (Ed.). (1997). Health design. New York: John Wiley & Sons, Inc. O’Neill, D. (2000). Whom do we serve? www.healthdesign. org Accessed October 30, 2008. Orr, R., & O’Marberry, S. (Eds.). (1991). Innovations in healthcare design. New York: Van Nostrand Reinhold. 1995 Palumbo, L. (1995). Design quality in higher education buildings; Keynote address (pp. 7/8). London: Thomas Telford Publishing. Parker, J. (1997 March). Urban landscapes. Hospital Development, 28(3), 21–24.

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Primary Care Centres Parker Morris Committee. (1961). Homes for today and tomorrow. London: HMSO. Pena, W., Parshall, S., & Kelly, K. (1987). Problem seeking – An architectural programming primer. Washington: AIA Press. Persaud, R. (2000 August). Ultra sounds. Classic FM, 66, 56–59. Pevsner, N. (1960). Pioneers of modern design. London: Penguin Books Ltd. Pollock, A. M. et al. (2007). The market in primary care. http://www.bmj.com/cgi/content/extract/335(7618)475 Accessed November 27, 2008. Primary care, General Practice and the NHS Plan. http:// www.dh.gov.uk/ Accessed February 24, 2008. Purves, A.G. (2006a). Churches of Newcastle and Northumberland. Stroud: Tempus Publishing. Purves, A.G. (2006b). Evaluation of PFI-built James Cook University Hospital. In: Design and health IV – Future trends in healthcare design. Stockholm: International Academy for Design and Health (pp. 81–88). Rasmussen, S.E. (1959). Experiencing architecture. London: Chapman and Hall. Read, H. (1949). The meaning of art. London: Penguin Books Ltd. RIBA. (1995a). Architect’s job book (6th ed.). London: RIBA Publications (RIBA Companies Ltd.). RIBA. (1995b). Strategic study of the profession; phases 3 & 4: The way forward. London: RIBA Publications. RIBA. (1997). Future premises for primary health care: Report on a symposium (2 April 1996) and a workshop (3 December 1996) organised by the RIBA health buildings design quality forum. London: RIBA/NHS Estates. Robertson, P. (1996). Music in mind. London: Channel 4 Television. Robertson, P. (2000a, August). In sound health. Classic FM, 66, 55–59. Robertson, P. (2000b). The 2nd international conference on health and design, integrating design and care in hospital planning for the new millennium, 18–22 June 2000, Stockholm. Rouse, J. (2000). Why surveyors haven’t got a clue. Building, 24 November. Royal Fine Art Commission. (1996). Design quality in higher education buildings. London: Thomas Telford Publishing. Russell, B. (2002). History of Western philosophy. London: Routledge. St. Oswald’s Hospice. (1991). A report outlining the story of the hospice presented on 12 March 1991, Newcastle upon Tyne. Sayili, A. (2006). The emergence of the prototype of the modern hospital in mediaeval Islam. International Congress of the history and philosophy of science, Islamabad, Pakistan, 8–13 December 1979. Scher, P. (1995 May). First fruit: The orchards health and family centre. Hospital Development, 26(5), 21–25. Scher, P. (1996). Patient-focused architecture for health care. Manchester: Faculty of Art and Design, Manchester Metropolitan University.

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Scher, P. (1997 October). Letter from Norway: ‘Human centred’ design. Hospital Development, 28(9), 5. Scottish Executive. (1999). The development of a policy on architecture for Scotland. Edinburgh: Scottish Executive.  http://www.scotland.gov.uk/library2/doc04/dpas-00. htm Accessed October 31, 2008. Scottish Executive. (2007). Developing community hospitals: A strategy for Scotland. http://www.scotland.gov. uk/publications/2006/12/18142322/1 Accessed October 30, 2008. Scruton, R. (1996). An intelligent person’s guide to philosophy. London: Gerald Duckworth & Co. Ltd. Seldon, A. (1997). Major: A political life. London: Weidenfeld and Nicholson. Senior, P. (Ed.). (1999). The culture, health and the arts world symposium. April 1999. The Manchester Metropolitan University. Shwarz, K. (2006). Delivering healthy environments via Private Finance Initiative (PFI). In: Design and health IV – Future trends in healthcare design. International Academy for Design and Health (pp. 57–67). Singleton, F. (1938). Health centres – Two styles. Spectator, 28 October 1928. In J. Allan (Ed.), Berthold Lubetkin: Architecture and the tradition of progress. London: RIBA Publications. Skidelsky, R. (2003). John Maynard Keynes (1883–1946): Economist, philosopher, statesman. London: Macmillan. Social Insurance and Allied Services. (November 1942). Report by Sir William Beveridge. London: HMSO. Stanger, G. (1998). Royal Victoria Infirmary, Newcastle upon Tyne, Ophthalmology Department, Arts Lottery Project. Stark, D. (2006). Healthcare procurement methods. In: Design and health IV – Future trends in healthcare design. Stockholm: International Academy for Design and Health (pp. 93–98). Stigsdotter, U. (2003). A garden at your workplace may reduce stress. In: Design and health: III – health promotion through environmental design. International Academy for Design and Health (p. 147). Thatcher, M. (1993). The Downing Street years. London: Harper Collins Publishers. Theory of Colours. (2008). http://www.wikipedia.org/wiki/ TheoryofColours Accessed September 20, 2008. Thomson, W.A.R. (1964). The doctor’s surgery: A practical guide to the planning of general practice. London: The Practitioners. The Times. (2001). Doctor in court: Medical evidence must be treated as robustly as any other. Letter, 19 January, 23. Timmons, N. (2008 January). Promise of a greater patient choice. The Financial Times, 2. Toye, R. (2007). Lloyd George and Churchill, rivals for greatness. London: Macmillan. Toynbee, R. (1972). A study of history: Revised and abridged edition. London: Oxford University Press and Thames and Hudson Ltd. Treasury Taskforce Technical Note 7. (2007). How to achieve design quality in PFI projects. London: HM Treasury.

Further reading Turner, J. (2003). Governors, governance, and governed: British politics since 1945. In K. Burk (Ed.), Short Oxford history of the British Isles: The British Isles since 1945. Oxford: Oxford University Press. Valins, M. (1993). Primary health care centres. Harlow: Longman Group UK Ltd. Venter, J.C. (2007 December 4). A DNA-driven world. The Richard Dimbleby Lecture. BBC. Vesey, G., & Foulkes, P. (1990). Dictionary of philosophy. Glasgow: Collins. Vodvarka, F. (2008). http://www.midwest-facilitators.net/ downloads/mfn19991025frankvodvarka.pdf Accessed November 20, 2008. Walsh, J.J. (2006). Hospitals. http://www.catholcity.com/ encyclopedia/h/hospitals:html Accessed January 17, 2006. Warner, L. (2006). NHS primary care trusts and ambulance trusts. House of Lords Debates, Tuesday, 16 May 2006.  http://www.theyworkforyou.com/lords/ Accessed October 30, 2008. Weston, R. (1995). Alvar Aalto. London: Phaidon Press Ltd. Wheen, F. (1999). Karl Marx. London: Fourth Estate. White, M. (2001). Leonardo the first scientist. London: Abacus.

Wilkin, D., Butler, T., & Coulter, A. (1997). New models of primary care: Developing the future, a development and research programme Primary Care Discussion Paper 2. National Primary Care Research and Development Centre, University of Manchester. Wilson, A.N. (2002). The Victorians. London: The Random House Group. Wilson, C.St.J. (1992). Architectural reflections: Studies in the philosophy and practice of architecture. Oxford: Butterworth-Heinemann Ltd. Wilson, H. (1971). The labour government 1964–1970, a personal record. London: Weidenfeld and Nicholson. Winslow, W. (2008). 5 things you should know about your local surgery. The United Benefice of Kirkwhelpington with Kirkharle, Kirkheaton and Cambo Church Chimes, February/March. Wittkower, R. (1962). Architectural principles in the age of humanism. London: Alec Tiranti Ltd. Woodham-Smith, C. (1950). Florence Nightingale: 1820– 1910. London: Constable. Wylde, M., & Valins, M.S. (1996). The impact of technology. In M.S. Valins & D. Slater (Eds.), Futurecare: New directions in planning health and care environments. Oxford: Blackwell Science Ltd.

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Acronyms AEDET BMA CAB CABE CAHHM CAMHS CCRC CHAS CHC CIC CTCC DHA DHSS DHSSP DQI EBD FBC FM GP GPP HSS HSSC ITN

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Achieving Excellence Design Evaluation Toolkit British Medical Association Citizens Advice Bureau Commission for Architecture and the Built Environment Centre for Arts and Humanities in Health and Medicine Child and Adolescent Mental Health Services Continuing Care Retirement Communities Children’s Hospice Association Scotland Community Health Council Construction Industry Council Community Treatment and Care Centre District Health Authority Department of Health and Social Services Department of Health, Social Services and Public Safety Design Quality Indicator Evidence-Based Design Full Business Case Facilities Management General Practitioner Geoffrey Purves Partnership Health and Social Services Health and Social Services Centre Invitation to Negotiate

ITU JCUH KPI LIFT MARU NDC NEAT NHS NHSA NICE NPV OBC OGC PCCI PCG PCRC PCT PFI PSC RCGP RIBA SHA SLC SPV UK

Intensive Treatment Unit James Cook University Hospital Key Performance Indicator Local Improvement Finance Trust Medical Architecture Research Unit New Deal for Communities NHS Environmental Assessment Tool National Health Service National Health Strategic Authority National Institute for Health and Clinical Excellence Net Present Value Outline Business Case Office of Government Commerce Primary and Community Care Infrastructure Primary Care Group Primary Care Resource Centre Primary Care Trust Private Finance Initiative Public Sector Comparator Royal College of General Practitioners Royal Institute of British Architects Strategic Health Authority Senior Living Communities Special Purpose Vehicle United Kingdom

Appendix A: Colour images

Image 1 Albow Gardens Library and Clinic; Architect: Ngonyama Okpanum and Associates; Courtesy of: Ngonyama Okpanum and Associates

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Image 2

Wideopen Medical Centre, Newcastle upon Tyne; Architect: Purves Ash LLP; Courtesy of: Purves Ash LLP

Image 3

Brunton Park Satellite Facility (LIFT), Newcastle upon Tyne; Architect: Purves Ash LLP; Courtesy of: Purves Ash LLP

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Appendix A: Colour images

Image 4

West Road Medical Centre, Newcastle upon Tyne; Architect: Purves Ash LLP; Courtesy of: Purves Ash LLP

Image 6 Chelmsley Wood Primary Care Centre; Title: External view; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

Image 5 Vale Drive Primary Care Resource Centre; Title: Internal view; Architect: Murphy Philipps Architects; Courtesy of: Murphy Philipps Architects

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Image 7 Woodgate Valley Primary Care Centre; Title: Roof detail; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

Image 9 The Arches Centre Title: Central glazed atrium; Architect: Penoyre & Prasad LLP; Courtesy of: Technal Image 8 The Bradbury Centre; Title: Atrium with undulating glazed wall; Architect: Penoyre & Prasad LLP with Todd Architects; Courtesy of: Paul Megahey Photography

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Appendix A: Colour images

Image 10 The Grove Well Being Centre Title: External view; Architect: Kennedy Fitzgerald & Associates with Avanti Architects Ltd; Courtesy of: Kennedy Fitzgerald & Associates with Avanti Architects Ltd

Image 11 Portadown CCTC; Title: View across the atrium for the main entrance; Architect: Avanti Architects with Kennedy FitzGerald and Associates; Courtesy of: Avanti Architects and Big Lolly

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Image 12

Robin House Title: Internal play area; Architect: Gareth Hoskins; Courtesy of: Andrew Lee

Image 13 Conan Doyle Medical Centre Title: View of waiting area; Architect: Richard Murphy Architects; Courtesy of: Richard Murphy Architects

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Appendix A: Colour images

Image 14

Community Centre for Health, Partick; Title: Main entrance; Architect: Gareth Hoskins; Courtesy of: John Cooper

Image 15

Grassroots in Memorial Park Title: Internal nursery courtyard; Architect: Eger Architects; Courtesy of: Eger Architects

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Image 16

The Oak Tree Centre Title: Courtyard; Architect: macmon chartered architects; Courtesy of: Neville Chadwick Photography

Image 17 Rothbury Community Hospital; Title: Glass art in Foyer; Architect: Mackellar Architecture Limited; Courtesy of: Mackellar Architecture Limited

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Appendix A: Colour images

Image 18 The Richard Desmond Children’s Eye Centre; Title: Aluminium louvres protect the south facing facade; Architect: One Creative Environments Ltd; Courtesy of: One Creative Environments Ltd

Image 20 Kaleidoscope Children and Young People’s Centre; Title: Internal reception area with view to courtyard garden; Architect: van Heyningen and Haward Architects; Courtesy of: Nicholas Kane

Image 19 The Breast Care Centre, St Bartholomew’s Hospital; Title: Waiting spaces designed for informal contacts; Architect: Greenhill Jenner Architects; Courtesy of: Marcus Lyons, Greenhill Jenner Architects

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Index B indicates material in boxes

A AEDET (Achieving Excellence Design Evaluation Toolkit) 29, 60 Albow Gardens Library and Clinic, South Africa 21–6 Ambulance services 1 The Arches Centre, Belfast 113–14 innovation in delivery of a range of services 113 procurement 114 second phase, refurbishment and remodelling 114 Architects 29 giving emphasis to qualitative issues 75–6 provision of innovative design solutions xi Architect’s Job Book, RIBA fails to recognise importance of feedback and post-project evaluation 38, 62–3 model Plan of Work 37–8 Architectural influence and demands of functional briefs 64–5 new Royal London Hospital, strength of feelings about the design 64–5 philosophy of Frank Lloyd Wright 64 Architecture xi, 1, 174 reflects ethos of client 2 Art in health care buildings 9–10 problem of quantifying cost benefits 81 public arts programme 99 support for an arts programme 82 Arts for Health 76–7 Arts in Health programme 79–82 development of art in health buildings 80–1 early anecdote 81 ‘Arts on prescription’ campaign 80

B Best value, Government approach 52 BMA agreed to weekend and evening surgery opening 172 discouraging response to polyclinic idea 172 The Bradbury Centre, Belfast 110–13 city centre location 111 procurement 111–12 represents innovation in service delivery 110–11 BRE Environmental Assessment Method (BREEAM) 62 Breast Care Centre, St Bartholomew’s Hospital, London 160–1 Briefing, approach to 35–50 changes in NHS requirements 36–7 Community Health Centre, Newcastle upon Tyne 89 key issues 36 Briefing process and context 94–5, 97, 99, 101, 106, 116–17, 119, 122–3, 128 James Cook University Hospital 42–3 notes from interviews 43–4 Briefs xi, 11, 55, 134 a framework for 68–9 functional demands of 64–5 and emotive architecture 168 for GP surgeries based on Red Book 51 for hospices 13 importance in architectural commissions ix, 2 key elements 70–1 objectives 66–7 key words and phrases to consider 67 openness to alternative therapies 66–7 should set down design aspirations 66 practical components 69 preparation of 72

for Primary Care facilities 47 strategic components 69 typical specification 71–2 for Walker Satellite and Brunton Park Facilities 56B writing of 70 Building procurement cost limits and functionality – restraint on innovation 16 historical bureaucracy and procedures reviewed 2–3 lifecycle costs and best value 16 see also procurement policyprocurement routes Buildings, variables in usage 41, 42

C CABE 2, 29, 46, 49–50, 100, 163, 169 importance of design quality and ‘wow’ factor 67 Care, chronology for 7–8, 7 Care in the community 7 Centre for Health Design report identifies some critical design issues 39 studies on design of primary health care facilities 49 Changing Hospital Architecture, Prasad 173 Charles, Prince of Wales and holistic care 77 Prince’s Foundation 29 Chelmsley Wood and Woodgate Valley Primary Care Centres 97–101 briefing process 99 design aspirations and commendations 99–101 financial constraints and project costs 101 Chelsea and Westminster Hospital, London 81 arts project important in healthcare offered 80 Chinese traditional medicine 171

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Index Clinical Education Centre, University of East London 151–4 descriptions, general and internal 153–4 disabled access 154 Community care centres 88, 134–51 Community Centre for Health, Partick 128–33 design aspirations or ethos 131–2 financial constraints/project costs 133 Community Health Centre, Walker, Newcastle upon Tyne 89–94 design aspiration/ethos 89–90 design flexibility 90–3 financial constraints/project costs 93–4 main user groups 89 Community health centres, Northern Ireland 86–7 Community hospitals 1, 33–4, 168 modern, functions described 88 Community services, a new direction for (White Paper) 32–3, 34 concept of NHS ‘life check’ 33 patients as key partners 32 plan to pilot individual budgets 33 road map for implementing change 32, 33 ‘Comparative Study of the Impact of Environmental Design ....’, quoted 79–80 Conan Doyle Medical Centre, Nether Liberton Lane, Edinburgh 126–8 location and site history 126 Corner, Jessica, hospital shortcomings from eyes of a nurse 68–9 Cost limits and functionality, restraint on innovation 52 Cottage hospitals 82, 168 Creative arts, effects of 80 Cultural issues x

D Darzi, Lord, and polyclinics 172 Darzi Report 4, 172 Dawson, Lord ix discussed polyclinics in 1922 172 Dawson Report (1920) 1, 67 Debriefing, not covered by normal fee agreement 38 Department of Health, news ideas on social care 32 Design approach, common strands in 66 Design brief, advice on main components for health care buildings 59–60 Design evaluation, in the NHS, cost parameters as a benchmark 58 Design, evidence-based 48–9 Design flexibility 87, 90–3 Design, good 1 adds value to buildings 49–50 documents enhancing awareness of 29 government aspirations for 55–7 and diametrically opposed procurement methods 56–7

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importance of in health buildings 36 summarised by CABE 50 Design process 35, 39 alternative approaches 37–8 influential factors 41 James Cook University Hospital 40–5 Design quality 56B, 67–8, 69 of health buildings, changed since 2000 28 in healthcare 57–64 factors in the briefing process 58–9 key issues 64 move towards greater concern for 53 Design quality indicators 2, 39, 60 Design standards, concern for quality of 54 Disability Act, ensuring compliance with 71 Doctor—patient relationship ix–x, 1 Doctors 3 future, more rounded aspirations 47 move towards being salaried employees of PCTs 53 need to be accountable to the marketplace xi training becoming broader 66, 76, 82

E Egan Report ‘Rethinking Construction’ 54

F Finsbury Health Centre (London) 14–15, 47, 49 shows lack of organisation in health services pre NHS 15 tackling health of the poor 14 use of glass and colour 14 Functionality, a key test of appraisal systems 13

G General Medical Practice Premises — A Commentary 59 Glasgow Homeopathic Hospital 36, 38, 137 unusual because publicly funded 13 ‘we aim to help people to self-heal’ 76 GP polyclinics 168 GP services, privatisation of 3 GP surgeries 14, 15, 47, 52, 73 current government policy 45–6 PFI being introduced 45 flexibility of room use 12 funds needed for improvement of 34 guidance notes and value for money 58 and the Red Book 15–16, 51 target setting for 3–4, 13 GPs 34, 35, 83 changes in terms of employment possible 174 forming partnerships to establish new primary health care facilities 52 many have links with alternative therapies 73 policy aspirations 47 pressure to modify working practices 46

Grassroots in Memorial Park, London 134–7 Greeks, early Hippocratic Oath 6 holistic approach to life 5–6 Grove (Health and) Well-being Centre, Belfast 87, 114–19 combines health, leisure and information services 116, 119–20 design aspirations 119 financial constraints/project costs 119

H Healing environments, necessary in health care buildings 76–7 Health Building Note No.36, Local Care Facilities 28–9 Health Building Note No.46, general medical practice premises 28 Health care 8 importance of recognising the spiritual domain 74 Health care buildings advice on main components of the design brief 59–60, 61 art in 9–10, 79, 80–1 importance of environmental design standards 174 typical specification for the brief 71–2 Healthcare policy, government moving position on 66 Healthy living centres a future resource for good advice 69 see also primary care buildings Healthy Planning and Design (Conference – London) 168 Hippocratic Oath 6 updated by Geneva Convention 6 Holistic care 7, 73–8 Holistic life style brings therapeutic benefits 76 Hospice movement, development of 74–5 background to the hospice movement 75 special needs and cancer care buildings 74–5 Hospices design briefs for x design development 13 modern, development of 73–4 not constrained by NHS requirements 57 procurement policy 38 response to failure of mainstream hospitals to meet needs of the terminally ill 79 see also St Oswalds Hospice, Newcastle upon Tyne Hospitals 6–7, 11, 73 Brunel’s design for Crimean War casualties 10 design quality disappointing 52 early times 73 humanization’ of 8–9

Index new, problems with those procured with PFI funds 67 Human Rights Act 73, 74

I ‘Improving Standards of Design in the Procurement of Public Buildings’ (OGC) 49 Individuals, responsible for own healthcare and well-being 66 Injuries and wounds, information from early Egyptian papyri 5 James Cook University Hospital, Teesside 39–45, 48, 50, 81 CAHHM evaluation study, includes hospital chapel 74 outcome issues 40, 44–5 process issues 40–4 Design Report 43 notes from briefing process 43–4 review of documentation for brief 42–3

K Kaleidoscope Children and Young People’ Centre, Lewisham 161–7 naturally ventilated, with energy-saving measures 164 new primary and social care centre 161 radically different, but costs comparable to traditional buildings 163 Key issues, recurring themes 68 Key performance indicators 61, 62, 63 Key project stages, interpretation of 61–2, 63

L Latham Report ‘Constructing the Team’ 54 Lifecycle costs and ‘best value’ 52 LIFT Programme 15, 29, 31–4, 52, 71, 83–4, 89–99 concerns over use of 46, 54 dramatic change in approach by the NHS 57–8 government vision for primary care 31 and local competencies 57 Newcastle a pilot study area 54 promising but still at an early stage 68

M Machida Court, Machida, Tokyo, Japan 26 Macmillan Nursing Service 75 Maggie Centres 38, 76, 88 philosophy of 13 MARU 48 leader in research into healthcare environment design 49 published review of primary care buildings (1996) 64 Medical care, ecology of 17 Medical humanities, as an aspiration 67 Medical profession, development of 68, 73 Medicine, art and science in 81–2 Special Study Modules (SSMs) 82

N NEAT (NHS Environmental Assessment Tool) 62 Negative emotions, triggered by hospital environments 80 New children’s clinic, Darmstadt, Germany 26–7 Newcastle and N. Tyneside LIFT Project 55 many conflicting requirements in the brief 55 NHS ix, x, 1, 3–4 balance of money and power in 173 being moved towards a consumer driven service 34 changes in requirements 36–7 comparison between 1948 and present model 30 early policy 12–15 development of hospice design 13 functionality and cost 12 independent management, review of options 169–70 introduction of holistic concepts limited 77 numbers employed in 31 revised policies and approach to spiritual care 74 traditional procurement policy 38 use of privately run facilities 34 NHS Chaplaincy 73 NHS Direct 46 NHS Estates 12, 39, 48, 55–6, 57, 58 condition of existing buildings 53 effects of demise 168 Procurement 21, 16 procurement policy 38 role of art in new NE England hospital 10 NHS Estates Design Review Panel 29 NHS LIFT see LIFT Programme NHS Plan 2000 x, 2, 4, 7, 30, 46, 88 and formation of Primary Care Trusts (PCTs) 28 importance of putting patients first 13–14 included proposals for LIFT 54 refurbish or build primary care centres 53 tackles issues no health system free from 29–30 Nightingale, Florence 10–11 views on connection of mind and body in the healing process 11 Northern Ireland 84–7 case studies 110–21 community health centres, key role of 86–7 Design Vision 84, 85 proposed model 85 Service Vision 84–5 strategic planning for healthcare facilities 84

O The Oak Tree Centre, Huntingdon 137–44

architectural design remit 139 development description 140–1 project background 137

P Pain relief clinics 75 Pastoral care 74 Patient centred care and community uses 89, 95–6, 99, 106–7, 117–18, 123, 131 development of a philosophy 32, 73 Patient focused care, emphasis on 17 Patient power x, xii Patients and art 9, 79–80 attention to as people 74 better informed 49 should have choice of GP xi well being affected by environments 80 Peckham, Pioneer Health Centre (London) 14, 49 Planning and design, of Local Health Care Facilities 28–9 Polyclinics 168, 170–2 Portadown CCTC 119–22 client vision statement 119–20 community uses/patient centred staff 120 design aspirations or ethos 120–1 flexibility  legibility 121 Post-occupancy evaluation 62–4 broad review in Healthcare Design (Shepley 1997) 64 MARU 64 report, The Exeter Evaluation 64 Preventive medical care, design and policy consequences 47 Primary care, plans for reform 31 Primary Care Centres 31 Primary care and community buildings Germany 26–7 Japan 26 South Africa 21–6 see also primary health care buildings Primary care facilities embarking on another phase of development 47 flexibility and local responsiveness needed 54–5 in the LIFT programme 83 and public private partnerships 52 repetition and standardisation or flexibility 55 see also primary health care buildings Primary care services, new ideas emerging 173 personal health budgets 173 well notes 173 widening range of providers 173 Primary Care Trusts (PCT) 29, 53 integration of social services within 47 objectives for 58 relationship with general practice 170

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Index Primary and Community Care Infrastructure (PCCI) 84 Primary health care 18 in China 18, 19 Japanese systems 19–21 comparisons with USA and UK 20 learning from systems in the developing world 21 in South Africa 18–19 Primary health care buildings x, 53 community facilities 46 as community resource buildings 2 constrained by ‘Red Book’ procedures 16, 52 current government policy for 45–6 design xi fundamental shift required in objectives 74 future, key areas for consideration xi–xii quotations highlighting holistic approach 65–6 huge potential benefits from changing philosophies 68 key guides for provision of better centres 72 new buildings must be flexible 52 the next generation 170 Primary health centre, in Dawson Report 67 Primary health, framework envisaged by government 29–31 Private Finance Initiative (PFI) 29, 41, 47, 71 briefing process for James Cook University Hospital 42–3 criticism of 54 and NHS LIFT 31 in primary care buildings 45–6 and ‘value engineering processes’ 28 Private sector, and provision of care 32 Procedures, unethical 6 Procure 21 programme 29, 52, 54 and design quality 28 Procurement policy must now enable flexible buildings 52 of NHS Estates 12 traditional NHS policy 38 Procurement routes 82, 93, 97, 109, 119, 121, 125, 132, 141, 149, 151 changing 53 and developing 54, 71 in LIFT programme 83 Procurement systems ix, 62 changes needed 52–3 Professional services xi

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R Red Book 12, 41, 47 ignored environmental quality of buildings 13 the traditional approach 15–16, 51–2 RIBA Architect’s Job Book 37–8, 62–3 established Client Design Advisers (CDA) 29 Richard Desmond Children’s Eye Hospital 154–9 challenge of building adjacent to the existing hospital 156, 158–9 created by Moorfields Eye Hospital 154 site 154, 155 Robin House, Balloch 122–6 design aspirations or ethos 123 financial constraints/project costs 126 Romans mens sana in corpore sano 80 scientific/mythological approach to medicine 7 Rothbury Community Hospital, Northumberland 145–51 dedicated to less mobile patients 146 main materials used 149 procurement 149, 151

S St Oswald’s Hospice, Newcastle upon Tyne 75–6 emphasis on the quality of the place 75 functions as a home 75 need for 75 Saunders, Dr Cicely, and the hospice movement 75 Scotland 87–8 case studies 122–33 effect of Nordic and Celtic traditions 87 Sedentary lifestyle, problems of 2 Special interest buildings 88, 141–67

T Therapeutic benefits x of art in health care 10–11 of good design 1 of religion and spirituality x

U UK development of series of research initiatives 48–9 trends in health policy 174

USA 48 early evolution of primary health care 11–12 Hill Burton Programme 12 health policy in 7 Plaintree model 48–9 provision of specialised community services 170 senior centres 15 User questionnaires 60–1 an opportunity missed 60–1

V Vale Drive Primary Care Resource Centre 94–7 community uses/patient centred care 95–6 design aspiration or ethos 96–7 financial constraints/project costs 97 Value added, criticised by Austin Williams 65 Value engineering 28 Value for money 71 and art in health buildings 79 has driven design standards down 50 The Vermuyden Centre, Thorne 101–10 brief 101, 106 design aspirations or ethos 107–8 financial constraints and project costs 110 Vitruvius, and successful architecture 65

W Walker, Brunton and Benwell, design of primary health care facilities 55 briefs for Walker and Brunton Park facilities 56B Washington Primary Care Centre, Sunderland 144–5 design aspiration 145 greenfield location 144 Wexham Hospital, Slough 9 WHO 8, 11, 18, 70, 73 declaration of Alma-Ata (1978), objectives 17–18 joint conference with UNICEF at AlmaAta 11 model of primary care 18 qualities of a healthy city 168–9 Wholeness and health, Christopher Day 77–8 Winston, Lord Robert 79 advocate for the healing environment 74