While in the past the NHS designed its own buildings, most NHS projects are now done on a design and build basis. Many of these projects use standard form project agreements, often with ongoing operating obligations. These agreements include private finance initiatives, local improvement finance trust schemes or ProCure21 agreements.
Trusts need to understand how design responsibility is allocated between themselves and their project company. If they do not, there could be fitness for purpose defects with resulting buildings or disputes between trusts and project companies.
With most healthcare buildings, the contractor takes primary responsibility for the design of the building, but the trust may have some responsibility for its clinical functionality.
Private finance initiatives
Large projects are procured using the health sector standard project agreement, SF3, which is used for projects exceeding£25m.
Signing off the project agreement means that the trust accepts (subject to written comments) that the proposals satisfy its requirements in respect of clinical functionality. After the project agreement is signed, the trust reviews and signs off drawings and other details. Signing these items off signifies that they satisfy clinical functionality. This includes:
appropriateness of access;
placement of departments and rooms;
the quantities, descriptions and areas of those rooms and spaces;
the placement of equipment, furniture and fittings.
Local improvement finance trust schemes
LIFT schemes are generally for healthcare facilities up to£20m. A LIFT company, which is jointly owned by the private sector and the NHS, is awarded exclusive rights in a particular area to procure healthcare facilities. The trust is tenant and the LIFT company is the landlord, normally for 27 years plus the construction period.
As with SF3, there is a standard form LIFT lease agreement, which provides for development obligations, collateral warranties and the appointment of the independent tester.
For facilities that do not involve complex procedures, such as day surgery, the design of the facility is the responsibility of the LIFT company. Such projects do not need clinical functional expertise from the trust and are treated as normal construction projects, with single point responsibility (apart from responsibility for the client's requirements) placed on the LIFT company.
Where there are complex facilities, then, like a PFI project agreement, the trust must confirm that the proposals satisfy the requirements of clinical functionality.
These projects involve direct procurement by trusts at the design stage and then the construction stage. These contracts are awarded to framework construction partners and are often procured on the NEC option C, target cost standard conditions.
The design is worked up by the contractor in consultation with the trust, but there are no special provisions for sign off by the trust for design regarding clinical functionality within the standard form documentation. The default position is that the contractor has single point responsibility with no pass back to the trust.
There are three types of designer in a healthcare project. The trust needs designers to prepare its requirements and to undertake the review functions described above. The PFI contractor, LIFT company or framework partner will engage the normal design team, such as an architect, structural engineer and services engineer. The trust or the contractor may need input from a healthcare planner.
Healthcare projects are particularly reliant on good clients, because the expertise in their effective design and use lies with the purchaser. A client often needs the services of a good client design adviser. The design process needs to take into account operational policies for buildings in the future, where the operational horizon may be limited to 10 years ahead.