How decanting can address current NHS challenges

HEJ’s readers will be acutely aware of the growing NHS building maintenance backlog, and with an ageing healthcare estate on the one hand, and ever higher expectations for care on the other, many – and especially, older, healthcare buildings – have reached a condition where refurbishment or reconfiguration to bring them up to modern standards is an absolute imperative. In recent months, the daily pressures felt by Estates teams to undertake maintenance and refurbishment on their highest risk buildings with minimal delay has been supplemented by another – mounting concerns over the structural integrity of the RAAC planking used in a number of healthcare and educational buildings from the 1950s to the 1980s. Indeed recent Government mandates and associated funding to address the issue, in the process ensuring the safety of such buildings’ users, have seen many NHS Trusts embark on the required remedial works as quickly as the available manpower and financial resources have allowed.

Of course any such major works – whether routine maintenance, significant reconfiguration, or addressing RAAC planking, normally requires patients in the affected buildings to be re-located for the duration of the programme. On older, more constrained NHS hospital estates, however, finding a suitable location to ‘decant’ them to can be a considerable challenge in itself. Such ‘decanting’ is, of course, now a well-established and well-rehearsed practice, and in the simplest terms requires an effective, well-thought-out, and well-managed plan to relocate patients, staff, and equipment, from one part of a healthcare estate to another. It is entirely reliant, though, on sufficient availability of suitable temporary accommodation. 

All those involved in providing services to the healthcare sector are well aware that the decanting process can often be challenging. For example, how many times do we hear consultants and contractors claiming they are frequently asked to deliver projects where, in many cases, the budget and programme for decants do not exist, as the very nature of the ‘decant’ is an emergency requirement or a short-term provision that would have never been planned for? Is there, however, a way in which this process could be improved? 

Roundtable discussion at sector’s biggest UK event

McAvoy, which has more than 50 years’ experience within offsite manufacturing, decided to tackle the issue by inviting a panel of UK industry experts – all from the health sector – to explore the topic, ‘How can decanting assist with the current challenges NHS Trusts are facing with the provision of new facilities?’, at a special roundtable event held during last October’s Healthcare Estates conference and exhibition in Manchester. The participants were:

• Martin Harvey, head of Design and Technical Services – McAvoy.
• Mel Jacobsen Cox, head of Healthcare – HLM Architects.
• Melissa King, Senior Category lead – NHS Shared Business Services.
• Warren Percival, director – RSK.
• Chris Argent, Preconstruction director – Dowds Group (MEP).
• Alyson Prince, Built Environment Infection Control Consultant Nurse.
• Keith Hodgson, assistant director of Estates, Planning – Strategy – Capital.

Prioritising consultant and contractor involvement

The roundtable began with discussion on whether – in some cases – consultants and contractors are often being introduced too late 

Mel Jacobsen Cox (MJC) began: “This is an area of building and design that doesn’t  reach the expectations that are required. The greatest challenge is agreeing on a strategy upfront, and developing a toolkit to help Trusts assess their need for decant, and then propose the correct solution. That would avoid clients having to change plans midway due to changing requirements as the project is developed, as is quite often the case.”

Alyson Prince (AP): “It’s absolutely critical that everyone understands what the construction project scopes are at the very beginning when it comes to decant. From a clinical point of view, the perspective is vastly different. If you don’t have a proper understanding of who you’re putting in the space – both in the short-, and possibly the longer term, then you have to specify it to the very highest standard, because you could be using that space in a whole variety of ways.”

Martin Harvey (MH): “We have discussed this very issue with our clients, Alyson; however, quite often this results in overdesigning, and consequently much higher project costs which then can put the project at risk. As solution providers, we want to deliver the best healthcare facilities possible – but that can often become complicated when requirements are not clear – for example whether the space is simply a short-term fix, or it could be repurposed and used in another capacity further down the line.” 

MJC: “RIBA Stages start at 0, and go all the way through to 7. Quite often, as a healthcare architect, we don’t get involved until Stage 2. However, we do have a role in Stages 0 and 1, and many times don’t have the opportunity to take part in them. Ideally, the project architects, engineers, consultants, and contractors, should be at the table from the very beginning. Frequently, we inherit something at Stage 2 that we must try and make work.”  

AP: “From an infection control standpoint, we are only ever brought in at Stage 2, and only find ourselves involved in the later stages of design. Many times, the design has been frozen, and budget has already been allocated to other priorities.

Chris Argent (CA): “From an MEP perspective, we get brought in at best at RIBA Stage 3. We’re rarely engaged in RIBA 0, 1, 2, or 3, by which time designs are generally quite well developed from a contractor’s perspective. If we were engaged earlier, the resulting cost-benefit ratio could be more positive to deliver a more robust, fit-for-purpose solution that delivers long-lasting results.” 

Need for a balance

Melissa King (MK): “There is a balance there, because if you were called in at Stage 0, there may be more costs on the front end of that process that weren’t accounted for. However, if you were involved at this earlier stage (Stage 0), costs would probably be a lot lower from RIBA Stage 4 onwards, because you’ll know and understand the design, as you’ll have been brought on that journey. I think having that visibility and going on that journey of a project end to end would be really helpful.” 

MJC: “I have discussed this same issue with a number of our clients, specifically on Net Zero carbon, and how this standard applies to the architect in Stages 0 and 1. But how is this going to happen if we’re not employed at 0 or 1? Who’s going to do that work? Making the best decisions at the beginning is ultimately going to give you the best success later on.” 

MH: “It’s up to us to push for this conversation right at the beginning of the project – even if it does cost us some time and effort at that early stage, to achieve a better solution. We need earlier discussion to understand our clients’ needs better, challenging the brief to ensure we are working towards the optimum solution, and bringing everyone on the journey. Also, having the team fully informed, so that designs meet all parties’ requirements, and ensuring that budgets are allocated in the best way possible.” 

Keith Hodgson (KH): “We should all spend more time pushing for that early engagement collectively, especially in terms of design, process, and specifications. It’s our responsibility. We have the knowledge and experience in this group to highlight risks attached to late engagement, and the benefits – in terms of time, money, and quality – of wider involvement at the earliest stage possible.

Prevention always better than cure  

AP: “The cost of getting it wrong far outweighs the cost of taking that little bit of extra time at the front end, because when it goes wrong the costs can be eye-watering. For example, there’s a project that has been publicised recently which was specified at more than £200 m, and they’re now £93 m over that budget because they got the ventilation specifications wrong, and they’re having to go back and fix it.”

MJC: “In my experience, a mistake corrected on paper is so much better than one corrected on site.” 

Warren Percival (WP): “One area that’s often missed is electrical demand and energy. Are we talking to the client early enough about these decant temporary facilities that are probably not going to be temporary? Have we considered the additional electrical load, and thought early enough that perhaps if you’re trying to hit a Net Zero target, you’re going to have to speak to your DNO sufficiently early, knowing it could be up to two years before you can get additional power into the site to accommodate a higher electrical load?”

MH: “I think we are all agreed that earlier involvement in the project would be beneficial not only to the project team, but also to provide a better solution for our clients. It’s clear from the conversation that during this early involvement, we can understand the client’s requirements better; both their short-term requirements for one type of use, and their longterm requirements for future uses. This can cover all the points we have just discussed.” 

The barriers to early engagement

MK: “As I see it, there are too many barriers to that type of collaboration. What often occurs is that people are working in isolation. Clinical experts, the Procurement team, and the Estates team, should plan and work together to avoid building something that wasn’t really needed, or that is perceived as an afterthought. When that doesn’t happen, everything is urgent; we have insufficient space in a car park, and we thus need extra space right away. This lack of planning also compromises staff wellbeing, as no one has discussed what the staff needs are upfront. We then end up in a vicious cycle, as the people using the facilities, and the ones who paid for them, are not satisfied, because it’s not what they wanted or needed. We must have these discussions internally and externally right at the beginning.”

MH: “Our solution to that is standardisation, using standard room layouts that are multi-functional, and it doesn’t mean they have to be more expensive if they are designed with everyone’s involvement early on.”

CA: “How can we use the existing systems to drive better engagement across the specialisms to enable Trusts / NHS to be informed of risk, compliance, and supporting business case, to deliver a long-term, adaptable, solution?”

Early engagement’s benefits

AP: “Often the issue is that the NHS is so constrained by budget. Organisations need a fit-for-purpose space, which may need to be used for a variety of specialisms over the life of the building. The space is then designed in good faith for the initial use, but later repurposed for something it wasn’t built for. It’s vital that we talk to the clinical teams about the purpose of the space, and the technical requirements it entails.”

MK: “A major issue is the poor perception of what the temporary facilities may look like, and how they will function. There is a lack of understanding of how such facilities can function. There are many good examples of offsite manufacturing providing high-quality permanent and temporary solutions. While many of these spaces may be used for 1-5 years, there is an opportunity to repurpose the buildings and get a lot more value from them, if properly planned from the outset.”

MJC: “You need to have a clear direction for the project, and know exactly what you’re trying to provide. Not being this clear from the outset can cause the design stages to fail. That’s why it’s so important to consult with the client and everyone involved in the project from the beginning. We need to understand their needs and issues, and then consider the potential situation 5-10 years down the line. However, it’s really difficult for a Trust to look this far forward and plan for requirements that are not yet known.

“For example, in terms of meeting the Net Zero carbon standard, you can’t achieve Net Zero carbon if you haven’t designed the building with this in mind from the outset. Furthermore, depending on how you categorise it as a facility, you can’t upgrade the spaces; you can only downgrade them technologically. So, if you really want to future-proof, the building should be designed and built as a top-end high-tech acute facility, but naturally there are costs involved. So, some of the big questions for NHS Trusts are: ‘What does the decant mean to you?’, and ‘Do you see it as a really viable part of your estate, or just a temporary fix?’ It might be a temporary fix in your head, costing not very much, but to us, it’s a project that we are delivering with reasonable care and duty and to meet compliance standards.” 

Focusing on clinical needs

WP: “Clearly there’s a need to focus on clinical needs, because the clinical functionality should inform the design process, but we should also not lose sight of the fact that not every decant facility directly provides a clinical setting. For example, it could be a back-office type of department that’s fundamentally important to the success of a clinical environment, so it’s important that the needs of those individuals are considered. I know of many instances in which, over the last 10 years or so, temporary or decant facilities have basically turned into permanent facilities for staff, and that has resulted in spaces being used for something they were never intended for. That’s not the kind of environment that staff – whether back office or clinicians – should be accepting as part of their day-to-day work, given the importance of their wellbeing.” 

MJC: “Another issue, more from an architect’s and engineering point of view, is that we’re synonymous with a product. At Stage 0 and Stage 1, the product we are providing is advice and mapping. It’s everything that we put into our drawings, specs, and our product information later on – but that thinking time upfront is so key.” 

Presenting a range of options to the client

MH: “Bringing all the different consultants on board, and front-loading activity, will enable us to present a range of options to the client. For example, one option can be compliant with the Employers’ requirements (ER), but delivered quicker with little consultation from Stage (0-2). An alternative option may be to offer a fully compliant solution, but with dedicated engagement from the outset, at Stage 0. This may take a few weeks longer, with some more professional fees, but the added time taken to understand our clients’ current and future needs better would ultimately result in a more tailored solution for staff and patients.

“If we worked as a team, and had all the different consultants on board, we can bring a solution to a Trust: this is our programme; this is our design phase; and this is what we’re going to do for you that’s compliant to the ERs. However, here’s another solution. It’s going to take you another couple of months longer and be slightly more expensive in design fees. We will need, for example, another three or four weeks on the programme, and we explain the benefits of early engagement and front-loading activity to achieve long-term savings.” 

WP: “We’re not talking necessarily about just off-the-shelf products, or plugand-play systems that come together in some of the projects. A lot of this revolves around an intensive creative process, whether it’s architecture-led or a multidisciplinary consultancy-led project. Ultimately, you’re talking about identifying the need, how you make the building work, organise the programme, develop the cost plan, and risk-assess all those parameters.”

AP: “The problem I’ve seen in recent projects, especially through the pandemic, is that you’ve got a modular build, and people come in and utilise the space as if it were a permanent structure which, for all intents and purposes, it is. However at the same time, they don’t realise the space may have been built to a different specification due to budget, and the clinical team is not informed or does not receive clear information on this. Or, sometimes they are completely overruled by people who have budgetary, finance, project management, and programme management responsibilities

“This can result in a number of issues – for example, some healthcare buildings have not been occupied due to scoping and specification issues; the installation hasn’t considered the infection control requirements until it is too late. It is generally only when something as serious as this goes wrong that lessons are learned, but these are often very expensive. We need to find a space to share this learning collectively.”

MH: “Learning lessons is key for everyone to help us deliver better facilities. McAvoy recently asked for feedback from some SEN (Special Educational Needs) Trusts on the buildings that had been designed and delivered specifically for them. One Trust, responsible for multiple SEN schools, gave us a presentation on real-life building management issues they experienced. This was such an eye-opener for our designers and delivery teams. A lot of the issues were simply resolved, but because they had never been communicated or fully understood, they manifested in significant issues for the building users. This proves that client feedback is invaluable.”

Semi-permanent or permanent?

KH: “I think all roads lead back to understanding better what the differences are between temporary decant accommodation and permanent facilities in terms of briefing and product definition. Should there be any differences in reality? Late engagement of the design team on either option is not ideal. It’s less likely to happen on a £10 m or £20 m new hospital building, but very likely to happen with a decant or quick turnaround accommodation. The responsibility lies with groups like ours today to try to drive early engagement of the design and build team, and the importance of establishing accurate requirements. I think it’s with design teams, contractors, and other service-providers, to fight that corner to some extent, alongside NHS clients.

What do adaptability and flexibility really mean?

MJC: “I think it’s really important to get a handle on how the Trust defines adaptability and flexibility. We’re always told to write about it in our bids, but what does it actually mean? Does it mean partitions that you can move around? For us, adaptability is about standard rooms, so that you have a suite of exam / consult rooms that are repeated, that are exactly the same for everybody. So, any consultant, GP, clinician, or other staff member can use those rooms, and they can go into any room because they’re going to find exactly the same kit – and you can go to any facility across that Trust and know that everything will be in the same place. That’s flexibility and adaptability, because it’s giving them the option to do what they want wherever they want. In my view, it’s not about moving partitions around.”

MH: “McAvoy has done this. We can be a solutions provider where perhaps adaptability and flexibility weren’t considered in the existing building. In 2013, for instance, we provided two new theatres at a third-storey level connecting to the original circulation corridor of the existing theatre suite at Daisy Hill Hospital in Newry. This avoided the need to separate the theatre provision on the hospital site. It could be accessed using the same lifts, waiting areas, and staff spaces. In this instance, offsite manufacturing provided a flexible and adaptable solution that hadn’t been considered as a possibility to start with. However inside the space, I really like your idea of that standard room that can be adapted, rather than actually changing the room sizes, areas, or equipment.”

MJC: “We forget that we’ve got a huge wealth of standardised information available to us. If we go back to buildings that we designed 15 years ago, they might have changed a couple of things, but the consulting room still functions in a similar way. The equipment is getting smaller all the time. So, I think we can be quite resolute that what we’re providing is flexible enough to have a variety of uses. We have to remember that, and use it as a rationale that goes through these buildings – because if we go back to the cost aspect of it and, for example, for an 80% standardised approach and 20% bespoke, then you can manage the cost a lot more easily, because you’ve got repetitive elements that you know the cost of, and they stack up.”

Key conclusions to emerge

Following this in-depth discussion, among the key messages to emerge were:

MH: “Collaboration needs to start earlier than stage zero, and as a team, we need to position ourselves to make that happen. We also need to drive standardisation, particularly for key rooms that provide multi-functional spaces for our clients. McAvoy has pre-tested offsite solutions that can facilitate this standardisation.”

MJC: “For me, it’s about asking the right questions, right at the beginning.”

MK: “From a procurement perspective, it’s how we can encourage the conversations that are required to deliver the best outcome and remove any barriers to success.”

KH: “Ensuring that we have a clear understanding of what we’re classifying as temporary decant accommodation versus a more traditional type of permanent building is key. Also, we might consider investing more money at the front end (briefing/high-level design stages) for the benefit of latter stages, ensuring robust coordination, and that we achieve future- proofed design and specifications.”

WP: “Being bold enough to challenge the scope at the beginning, but at the same time, we need to find the right mechanism to facilitate that process and engage with the client without fears of collusion.”

CA: “From our perspective, we always want to be involved in the process earlier. From an MEP perspective, engaging with NHS Trusts and architects earlier in the journey is key to supporting the future-proofing of decant facilities.”

AP: “For me, it’s understanding the use of the space and its needs, to provide some insights and education to all involved in the project, and through early engagement.”

This closed an interesting and forthright discussion.