Building a Better Patient Environment

Alan Milburn MP, Secretary of State for Health, discusses the programme of investment and reform taking place in the National Health Service.

It is a pleasure to be able to attend this Conference today. May I begin by thanking the Prince's Foundation and in particular your Royal Highness for hosting and supporting today's conference.

Your personal contribution to improving the quality of NHS hospitals and thereby, the quality of NHS care will be valued throughout the health service. Your role as a champion for good design will make a major contribution I believe to raising the quality of NHS hospital building programme across the country.

There is now a huge programme of investment and reform taking place in the National Health Service. This programme is intended to redesign care around the patient by changing those structures, processes and attitudes within the NHS which for too long have stood in the way of more patients getting quicker, higher quality care. It is about ensuring that the patient?s interest always comes first.

The quality of the buildings is vital to the quality of the care patients receive in them. One million patients a week use NHS hospitals. One third of those hospitals were built before the NHS was created. One-tenth date back to Victorian times. Many rightly feel that the neglect of the NHS buildings, over many decades, is a little short of a national disgrace.

The consequences are plain for those to see: shoddy buildings, unreliable equipment and out-of-date hospitals. In too many places, the environment in which the patients receive care is simple unacceptable.

And at the same time we expect NHS staff to deliver 21st century care in 19th century buildings. That, despite their very best efforts, sometimes is simply impossible.

In recent years a good start has been made in putting that right. On top of increased capital funding from the public sector we are now making extensive use of private sector funding. The Private Finance Initiative is playing a key role in delivering what amounts to the biggest new hospital building

programme in the history of the NHS. 68 major capital schemes, worth over £7.6 billion, have been given the go-ahead. 10 are already open. A further 17 are in the process of being built of which 6 more are due to open next year. All the completed hospitals have opened on or ahead of time. Norfolk and Norwich completed 20 weeks early.

I know that in some quarters the Private Finance Initiative is controversial but it is effective. In the past the building of new NHS hospitals was wholly funded by public capital, distributed to Government Departments by the Treasury as part of the annual public spending round. Under these arrangements NHS construction schemes were at the mercy of how much public capital the Government could afford to spend each year. Inevitably, there was a cautious approach because there was uncertainty about what could be afforded in the future years. The NHS found it difficult to make the private sector construction companies, working on one off contracts, take long term responsibility for what they built.

Investment was stop-start. Cost and time over runs were common. Schemes were phased in, scaled down and sometimes cut back. Some redevelopments were begun and never finished. As a result some NHS hospitals today have Victorian buildings, next to wartime nissen huts, next to 1950s prefabs. And to cap it all, patchy investment also resulted in the steady build up of maintenance backlogs.

Old- style public funding often led to bad design as well. Let me give you an example from near my own constituency. In Durham City people waited 30 years for a new hospital. Because of the capital constraints of the traditional funding route, the public funded proposals was for a 2 phase development which would have taken 7 years to build. Because it was on a sloping site it would have had 7 floors. Inpatient and outpatient departments would have been over 50 metres apart.

By contrast, the PFI option was developed in one phase, in 3 1/2 years and on a different part of the site with 3 main floors. The whole hospital inpatient and outpatient departments are fully integrated - which benefits both staff and patients. Happily, Durham now has a new hospital. On time and at cost.

There are of course lessons to be learned from some of the teething problems in the new PFI hospitals. The point I am making, however, is that the PFI, because it is more flexible and the more certain than the traditional funding routes, provides and opportunity to design hospital buildings- whole hospitals rather than piecemeal developments- from scratch in a way which makes them more functional for both staff and patients. In time greater standardisation and longer term partnership arrangements with the private sector will bring bigger benefits still.

It is the sheer scale of the hospital building programme that provides such a golden opportunity not just to have new buildings but to give our country the very best hospital buildings. First, it gives us the opportunity to design in from the start the space, the flexibility, the infrastructure in which staff can deliver the best quality care. Second, to design- in from the outset an appreciation of the importance of the patient environment to recovery and rehabilitation. And, third to design each of these new hospitals as symbols of local community pride in the public service that we in Britain most admire.

These are the opportunities which will flow from today's conference and the new partnership between NHS Estates and the Princes Foundation.

First then, designing-in flexibility and modernity. The hospital building programme gives us the opportunity to build in design that optimises new ways of treating and caring for patients.

More innovative ward designs are already enabling nurses to observe patients more effectively. They are improving the way wards work and enhance patient security. For example, nurses, physiotherapists and other clinicians from the Durham undertook a study tour of the USA to view the benefits of wards and bedrooms built on a triangular layout. They developed a proposal based upon this concept for Dryburn Hospital and the idea was fine tuned and included in the final hospital design. The triangular ward allows all of the bedrooms to be located around the periphery of the triangle with support accommodation located centrally. Nurse's stations are located at the apex of the triangle allowing very short travel distances to bedrooms. There are similar triangular wards at the new Norfolk and Norwich Hospitals.

I believe that involving staff in this way from the outset in designing the new hospital is central to designing in improved quality of care. The involvement of staff in designing new hospital buildings has already delivered some important improvements for patients. Rehabilitation services have been redesigned so that gymnasia are now provided on individual wards to prevent patients with mobility difficulties having to travel from one part of the hospital to another. Maternity services have been redesigned so that births and post natal care are delivered from one room with one team of staff rather than mums having to move from antenatal ward to delivery suite to recover ward with three different staff teams. The room changes to suit the stage of the delivery: clinical when required for the actual delivery, homely before and after the birth. These rooms also provide enough space to allow fathers and family to be part of the experience in privacy and comfort.

The design of our new NHS hospitals also has to be flexible enough to cope with changing patient expectations, new treatments and medical advances. The old 'Nightingale' wards were acceptable when they were being designed at the turn of the 19th century. They are unacceptable today. By 2004 Nightingale wards for the elderly will be gone from the NHS. All but a minority of mixed sex wards will be gone before then. In their place we will need more single rooms, more en-suite facilities, more homely environments which emphasise dignity, privacy, and well being.

Crucially we must learn from the mistakes of the past. From the outset, designing in flexibility in each of our new hospitals will help cope with changing public attitudes in the decades ahead.

It will help cope with potential medical advances too. Over time, more and more patients will be treated with drugs or as day cases rather than as inpatients. Hospitals will become almost paper-free environments. Already in some of our new hospitals X-rays and other imaging results such as ultrasound are quickly transmitted to computer screens around the hospital to wards, consultants and even to other hospitals. This dispenses with the traditional X-ray film, carried from department to department by the patient and frequently lost, speeding up test results and diagnosis, leading to faster more convenient care for patients. The important thing is to design with change and innovation in mind so that spaces do not in future become redundant or require wholesale reorganisation. Instead our hospitals must be designed today with the future in mind.

Second, hospital design has to pay attention to the impact the patient environment has on the individual patient: their prospects of recovery, their sense of well being.

Research shows that well designed hospital environments can have a real impact on patient recovery and welfare. The size and scale of the hospital building - its layout, lighting and landscape - all impact on the condition of the patient. A research study in progress with the Leeds Teaching Hospitals and Nottingham University is suggesting that the improved patient environment in the Hospitals Jubilee Wing has directly enhanced recovery times and patients' perceptions of their experience in hospital.

The NHS already knows the importance of tailoring design to patient needs. That's why specially-designed children's A and E departments are in place across the country. The important thing for us is to recognise that consideration of the impact on patients of the design of buildings does not end when the child becomes an adult. So, we do not have to ensure that as we design these hospitals of the future we are paying proper attention to the impact the design has on the most important people in the hospital: that is, the patient. That is why I am delighted to be able to launch today the Achieving excellence in healthcare design work programme which sets out how architecture and art can improve the well being of patients and not just the state of the physical environment.

Third, the new hospitals can be powerful symbols of a renewed commitment to public service, emphasising the importance we place on them for the work which goes on within them. Doctors, nurses and other NHS staff do a brilliant job, often in very difficult circumstances. Sometimes the work they do can seem like modern day miracles. It is surely right then, that the design of hospitals celebrates these daily achievements; that these new hospital buildings share the majesty of some of their Victorian forebears rather than the awfulness of some of the public building eyesores of more recent decades.

One hundred years ago public buildings were often the pride of Britain?s towns and cities. Whether as libraries, town halls or hospitals they embodied a sense of community and civic pride. We need to rediscover in this generation a renewed sense of community and civic pride. I believe that we in Britain can find focus for it in the values of fairness and decency that are at the heart of the National Health Service. Today our country's hospital building programme gives us the opportunity to find a new way of giving lasting expression of our pride in those values.

Design then must now be an important and vital feature of these new hospitals - to enhance quality, to embrace patient recovery and to deliver a powerful message about the importance of health and health services to our country.

To ensure that good design is embedded within the NHS hospital building programme I can say today that design proposals in future will be reviewed by a panel, led by NHS Estates with the Princes Foundation, CABE (the Commission for Architecture and the Built Environment) and others, at the earliest stages of the procurement process before a preferred bidder is chosen.

Each hospital embarking on a new development will nominate a local design champion from the Trust board to ensure that the new building provides a high quality patient-focussed environment with good working conditions for staff and buildings that make a positive contribution to the local neighbourhood.

In future, just as I have made approval for a new hospital projects contingent on the provision of extra beds for patients and new workplace nurseries for staff, future new projects will need to provide evidence of the involvement of staff, patients and the public in planning their design.

Finally I believe that this new partnership between NHS and the Princes Foundation will make a telling contribution to improved design.

Your Royal Highness, your involvement and that of your Foundation, is most welcome. Our whole country will enjoy the benefits of this hospital building programme. It is important that those benefits are enhanced by effective, attractive, and imaginative design. The building programme and the way future hospitals are designed can reinforce a sense of optimism and renewal in our vital public services. With your help these new buildings can provide a better environment for patients and be lasting symbols of a renewed and reformed NHS in which all our country can rightly take pride.