Primary Care Centres

Geoffrey Purves

• Publisher: Routledge
• Year: 2009
• ISBN:
  9781136436710
• Edition: 2
• Topic: Architecture
• Subtopic: Architecture General

Primary Care Centres explores the process of planning and designing buildings for frontline medical practice. Taking as a starting point the concept that good design contributes directly to healthy living, the book shows beneficial effects that a good design brief can bring to the staff, patients and visitors of health care facilities. It outlines principles for designs that are both practical and useful.

International case studies of healthcare facilities in the UK, US, Japan and South Africa provide technical detail and give best practice examples of well-designed healthy living centres, with an emphasis on building performance and catering for the latest government policy developments.

This new edition provides trusted guidance on investing in effective architecture for architects and project managers involved in the design of healthcare facilities.

Dr Geoffrey Purves is Chairman of Purves Ash LLP, a firm of Architects in Newcastle upon Tyne. He has held a range of professional appointments with the Royal Institute of British Architects and is an Honorary Research Associate at Durham University.

1

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.

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 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 well-designed 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 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 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 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.

2

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 ...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Case Studies
• Foreword
• Acknowledgements
• Executive summary
• Chapter 1 Introduction
• Chapter 2 An outline review of the main issues (including a summary of the approach to designing health buildings)
• Chapter 3 International comparisons
• Chapter 4 Political framework
• Chapter 5 Approach to briefing
• Chapter 6 Design development/measurement of design quality
• Chapter 7 Holistic care
• Chapter 8 Art in health
• Chapter 9 Case studies
• Chapter 10 The next steps
• Bibliography
• Further reading
• Acronyms
• Appendix A: Colour images
• Index