Select Committee on Health Appendices to the Minutes of Evidence


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 appearance.


  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 environment—in terms of functionality, overall appearance and comfort—that is clearly desired by the Government. This is a view shared by the Office of Health Economics[3], the Institute of Public Policy Research[4] and the King's Fund.[5]

  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, Carlisle);

    —  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 Hospital London).

  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 tender stage.

  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 InputsNumber of doctors and nurses
Social OutputsNumber of patients treated
Social OutcomesLevel 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 promoted.

  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 PFI process.

  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 process.

  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 this.


October 2001

3   The Economics of the Private Finance Initiative in the NHS 2001. Back

4   Building Better Partnerships 2001. Back

5   Private Finance and Service Development 2000. Back

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