Memorandum by the Commission for Architecture
and the Built Environment (PS37)
1. The Commission for Architecture and the
Built Environment is an Executive Non-Departmental Public Body,
established by the Government in 1999 to promote high standards
in the design of new buildings and the spaces between them. Its
remit covers England.
2. CABE is a non-statutory consultee in
the land use planning system. It is funded by grant-in-aid from
the Department for Culture Media and Sport, with additional resources
from the Department for Transport, Local Government and the Regions.
3. Commissioners are appointed by the Secretary
of State for Culture Media and Sport. They are drawn from a range
of areas of expertise and include architects, planners, an engineer,
a quantity surveyor and specialists in the field of housing design
and built environment education.
4. Some of the CABE's day-to-day work is
undertaken by committees, including a design review committee
and an enabling panel. The design review committee offers advice
to planning committees and others on the design of strategic development
projects. The enabling panel offers advice to clients in the public
and private sectors who aspire to quality but would welcome technical
assistance on matters such as brief development, selection of
architects and choice of procurement route.
5. This memorandum of evidence relates to
the impact on design quality of private sector involvement in
the design and construction of health facilities, including hospitals,
primary healthcare centres and GP surgeries. By design quality
what is meant is the functional performance of a building and
its relationship to its surroundings, as well as its external
6. CABE's design review committee and enabling
panel have advised clients on the design of proposed new hospitals
procured under the Private Finance Initiative (PFI). Both the
committee and the panel include members with professional expertise
in the design and planning of health facilities.
7. CABE has been actively involved in co-ordinating
the delivery of the Prime Minister's Better Public Buildings Initiative,
the explicit aim of which is to bring about a step change in the
quality of the design of new public buildings.
8. In association with the Office of Government
Commerce, the Treasury's procurement arm, CABE is undertaking
a review of PFI and its relationship to design quality.
9. CABE is working directly with NHS Estates
to produce guidance on defining and achieving design quality within
the health sector.
10. Since May 1997, the NHS has procured,
under PFI, 67 hospitals with a total capital value of over £6.2
billion. Over the same period, seven hospitals with a total value
of £0.2 billion have been procured conventionally with public
funds. In addition, there are proposals under the LIFT programme
to refurbish or rebuild 800 GP surgeries over the next five years
by means of public/private partnership.
11. CABE believes that the increasing involvement
of the private sector in the design and construction of new hospitals
has resulted in some benefits, most notably a marked reduction
in cost and time overruns.
12. However, private sector involvement
has not, in CABE's view, led to the degree of design innovation
in PFI hospitals that might have been expected. To date, many
PFI hospitals have failed to deliver the step change in the quality
of the built environmentin terms of functionality, overall
appearance and comfortthat is clearly desired by the Government.
This is a view shared by the Office of Health Economics,
the Institute of Public Policy Research
and the King's Fund.
13. This does not mean that PFI is a failure
or is in some way inherently inferior to traditional forms of
procurement, which CABE notes have also led to poorly designed
health buildings. It does mean that the PFI process needs improving
to ensure that it delivers high standards for patients and staff.
14. There are isolated cases of design innovation
in PFI health projects. For example, Swindon & Marlborough
Hospital has been innovative in promoting sustainability, South
Tees Hospital has instigated a strong arts programme and Edinburgh
Infirmary has brought in new ways of handling services.
15. But these are exceptions that expose
the generally low level of design quality of PFI health facilities.
CABE's recent investigations and casework have revealed the following
specific flaws which impact on the functional performance of the
buildings in question:
leaking plumbing; rooms so small
that doors hit beds; atrium too hot to work in (Cumberland Hospital,
dated design that hinders the application
of new technology (Calderdale Hospital, Halifax);
probability of poor functionality
and failure to relate to surroundings (proposed University College
16. CABE is also aware on a confidential
basis of one hospital where the design was substantially compromised
following financial closure and another where, following CABE
criticisms, plans are being reworked to improve the urban design
aspects of the proposal.
17. Although, as has been said, CABE believes
that PFI can deliver buildings of quality, there are nonetheless
significant problems that militate against this.
18. The first is the lack of skilled clients,
PFI is complex and yet there is an expectation that all NHS Trust
are able to manage projects successfully and make design judgements.
Powerful contractual consortia, with decades of experience and
clear commercial objectives, can often dominate inexperienced
Trusts. And the Trusts themselves, while willing to pay substantial
fees for legal and financial experience to aid them through the
PFI process, may fail to invest in the design skills needed to
successfully develop briefs, evaluate bids and "police"
the construction process.
19. The second problem is one of unrealistic
budgets. Clients may set budgets which are too low, in order to
get approval for PFI credits, and which then subsequently fail
to reflect the wider benefits of design quality over the lifetime
of the building.
20. Third, there is concern that Trusts
are still evaluating bids primarily on the cost, not the quality,
of proposals. In consequence, the private sector is unwilling
to innovate as they fear they will be undercut on price.
21. Fourth, although a client and consortium
may agree a design, the lack of a legal agreement, covering design
issues means that a consortium may easily "dumb down"
design quality once it is appointed.
22. Fifth, local planning authorities, aware
of the strong political imperative for the quick delivery of new
public facilities (particularly those related to health) are often
willing, in the interests of speed, to accept lower design standards
for hospitals than for private sector buildings.
23. Sixth, and related to the point above,
there is often too little time between the selection of contractor
and the start of construction for any meaningful design development
to take place. The private consortium will generally want to have
the building operational as soon as possible in order to start
the revenue stream. Designers are therefore designing on the run,
without the benefit of fully worked up drawings.
24. Finally, there is often a lack of investment
in design. While it is usual to expect designers to undertake
a certain amount of PFI work at risk, there are examples of architects
being paid very low sums by the contractor to take designs to
25. Beyond this, there is a broader problem
in PFI arising from a fundamental mismatch between the interests
of the private sector and wider public interests. PFI schemes
are generally a hybrid of public and private sector risk management;
the private sector provides the building and typically maintains
it while the public sector provides the health care services,
doctors, nurses, medicines etc. Many of the problems in design
terms arise precisely because the private sector has little or
no financial interest in the effects of design quality on social
outcomes (see table below). For example, the private sector currently
has no direct financial interest if a more efficient new ward
layout necessitates fewer nurses for the same number of patients,
or if patient turnover is increased because more pleasant surroundings
improve recovery rates.
SOCIAL INPUTS, OUTPUTS AND OUTCOMES IN HEALTH
|Social Inputs||Number of doctors and nurses
|Social Outputs||Number of patients treated
|Social Outcomes||Level of care/recovery rate
26. This mismatch would not matter so much if it were
not clear that design quality can have a direct and profound impact
on the overall patient experience, patient recovery times and
staff retention and recruitment. Evidence of the effect of the
hospital environment on health outcomes is given in the form of
an annex to this memorandum.
27. The relationship between a building's design quality
and the experience of those who use it has direct and important
resource implications for the NHS. For example, evidence from
Chelsea and Westminster Hospital shows enhanced staff satisfaction
ratings (and hence lower staff turnover) directly related to the
quality of the working environment. It is also evident that better
recovery rates for patients (which are linked to the quality of
the hospital environment) will reduce pressure on resources and
ease waiting lists.
28. In CABE's view, the Select Committee might usefully
consider why innovation is achieved in some major health projects
but not in others. A further area worth investigating is the relative
lack of clear, transparent evidence on the design standards of
new hospitals and how the aquisition of such evidence might be
29. More specifically, CABE suggests that both the Department
of Health and individual NHS Trusts should take action to improve
the chances of good design and maximum value emerging from the
30. Each NHS Trust should in CABE's view:
appoint a design champion in the form of a senior
board member with the clout to ensure that quality design is delivered;
develop budgets that factor in the added value
of design quality;
set clear and unambiguous standards for design
quality within the brief, the OJEC notice and in other material
sent to bidders;
ensure that the evaluation process gives proper
weighting to design quality and does not concentrate exclusively
on lowest cost;
ensure there is enough time for the development
of high quality design and that designers are not expected to
do too much design work at "risk" during the bidding
31. The Department of Health should in CABE's view:
increase the level of expertise available to NHS
Trusts to help them deliver quality. It is clear from CABE's experience
that the demand for help from Trusts far outstrips what is currently
available. Trusts need to be able to call on expert, impartial
experience at the very earliest stages of a PFI project;
increase capital budgets for quality design. NHS
Estates have stated their intention to increase the average budget
for building projects by 12 per cent. This needs to be ring-fenced
to ensure better patient and staff environments;
ensure strong and unambiguous statements from
the Secretary of State for Health and other Ministers on the importance
of delivering quality environments;
commission more research into what is a quality
patient environment and how to deliver it;
give NHS Estates stronger powers to demand that
individual Trusts set high standards from the PFI consortium and
that the private sector delivers these standards.
32. In conclusion PFI can deliver well design buildings,
but a much greater effort is required across the NHS to ensure
The Economics of the Private Finance Initiative in the NHS 2001. Back
Building Better Partnerships 2001. Back
Private Finance and Service Development 2000. Back