Queen Elizabeth University Hospital Independent Review - report recommendations: Scottish Government response

Response to Recommendations from Chapter 4 – Built Environment: Design

Recommendation 8

8. The implications of major funding changes need to be clear in relation to whole life costs and whole life risks, as the operational phase of a building's life is where such issues have the greatest impact.

Scottish Government's Response

The Scottish Capital Investment Manual (SCIM) already requires projects to set out the financial profile and funding consequences of the project. This includes operating costs, differentiating between the cost of clinical services and the cost of redesign and property running costs, and property lifecycle costs.

Recommendation 9

9. The expertise available to the project team must accurately reflect the requirements of the contractual and funding models.

Scottish Government's Response

The 'ownership' and responsibility for the investment planning process rests with the particular NHS Scotland body developing or leading the development of the programme/ project. The Scottish Government will write to NHS Chief Executives asking them to ensure that they make the appropriate expertise available to project teams. We will ask the National Centre to provide assurance that project teams have the correct expertise available to them.

Recommendation 10

10. The impact and benefits of single rooms should be reviewed so that future design and management of facilities take full account of this policy in the light of experience at the QEUH.

Scottish Government's Response

The Scottish Government will ask the National Centre to carry out a review. Timescales will be established in due course, but the management of the pandemic will be prioritised.

There are a number of advantages to single rooms, not least the fact that the presence of physical barriers separating patients makes it easier to isolate them from each other, reducing the risk of hospital acquired infections.

However, as the Review has identified, single rooms do also create other risks and these have to be managed effectively, including through the design process.

Recommendations 11, 12 and 13

11. NHS Boards should set up a specific working group for projects of long duration (more than three years) to advise changes or new guidance affecting IP&C and other key risks. This could be a function of the IP&C team or other dedicated resource, during major projects. (4.7.4)

12. When considering specialist built environment expertise, NHS Boards should make diligent enquiries regarding in-house and national NHS agencies, in addition to external consultants, and ensure they are involved throughout the project. Decisions around water and ventilation systems in particular, when accommodating patients vulnerable to infection, can greatly benefit from those who have experience in such matters, and who understand the impact of design and contractor variations on infection risks. (4.7.5)

13. When considering high-level options, design teams should consider fully the implications for built environment choices on IP&C, seeking specialist expertise early, and link satisfactory IP&C sign-off to release of funds (e.g. NHSScotland Design Assessment Process (NDAP). The new National Centre for Reducing Risk in the Healthcare Built Environment could provide or signpost to such expertise. (4.7.6)

Scottish Government's Response

The Scottish Government has taken steps since the design stage of the QEUH to improve Infection Prevention and Control measures in the design of healthcare facilities. Health Boards are required, as of July 2015, to use the Healthcare Associated Infection System for Controlling Risk in the Built Environment (HAI-SCRIBE). The aim of this system is:

"to ensure that IPC measures are not only designed-in but also maintained throughout the lifetime of the healthcare facility. It also aims to highlight potential IPC risks so that these can be designed-out. This is achieved through identifying the infection control risk associated throughout each of the following stages of lifecycle of the healthcare facility.

• Development Stage 1 - consideration of the initial brief and proposed site for development. This coincides with Business Case Stage: 1A;
• Development Stage 2 - Design and planning;
• Development Stage 3 - Construction and refurbishment;
• Development Stage 4 - Pre-handover check, ongoing maintenance and feedback."^[4]

The HAI-SCRIBE makes it clear that collaboration between different experts is fundamental:

"Successful use of HAI-SCRIBE is dependent on meaningful and ongoing dialogue and exchanges of information generated from representatives from Infection Prevention and Control and Estates & Facilities Managers, Project Managers and construction professionals who can contribute individual and relevant expertise in their own disciplines. Their active partnership and participation is essential."^[5]

At Stage 1, HAI-SCRIBE requires the following to be involved as a minimum: "representatives from the Project Manager, Infection Prevention and Control, Health & Safety, Estates, Clinical Environment, Domestic Services and Fire Safety".^[6]

In order to assist Health Boards in bringing together the necessary expertise, the National Centre will co-ordinate and deploy subject matter experts (SMEs) to support NHS Boards to deliver building projects and ongoing risk management through the built environment lifecycle based on identified needs.

The National Centre will also carry out Key Stage Authorisation Reviews to ensure that projects comply with guidance relating to the priority areas of water, ventilation, drainage, electrical distribution (including medical locations), fire safety, medical gases as they relate to the built environment, and infection prevention.

Recommendation 14

14. NHS building specialists and design teams preparing and reviewing guidance on BREEAM for certain specialist acute treatments should recognise the energy requirement that supports patient care and adjust goals for BREEAM accordingly.

Scottish Government's Response

We agree BREEAM should not influence a ventilation rate or water temperature requirement equally as it would not influence the quantity of operating theatres, patient bedrooms or the area briefed. While reducing any of these quantities may reduce total energy or carbon emissions, BREEAM does not change the design brief. Instead of 'totals' BREEAM measures, compares and scores the energy and carbon emissions 'efficiency' of the processes required to achieve the design brief.

Recommendation 15

15. The new National Centre for Reducing Risk in the Healthcare Built Environment should investigate and produce definitive guidance on the status and hierarchy of NHS Design guidance for IP&C and the built environment. Specifically, what is guidance and what should be mandatory. (4.7.8)

Scottish Government's Response

The National Centre will have an ongoing role in developing and maintaining guidance to inform the design, build and maintenance of healthcare built environments, including environmental laboratory guidance to ensure that they are free from avoidable risk. This includes the standards by which compliance within the healthcare built environment is measured and assurance can be provided.

Recommendation 16

16. Governance arrangements for change management, especially major changes during projects need to include input from those with knowledge and understanding of the built environment impact on IP&C.

Scottish Government's Response

The Scottish Government made the use by NHS Boards of HAI-SCRIBE mandatory to improve IP&C in designing healthcare facilities.

As above, in order to assist Health Boards in bringing together the necessary expertise, the National Centre will co-ordinate and deploy subject matter experts (SMEs) to support NHS Boards to deliver building projects and ongoing risk management through the built environment lifecycle based on identified needs.

Recommendation 17

17. NHS buildings guidance should make explicit reference to the need for secondary controls (beyond usual thermal control) for large and complex water distribution systems. (4.7.10)

Scottish Government's Response

The National Centre will develop and maintain guidance to inform the design, build and maintenance of healthcare built environments. This will include guidance on ensuring water systems are free from avoidable risk and we expect the Centre to consider this recommendation in preparing that guidance.

Recommendation 18

18. Advice and quality assurance on design issues that impact on infection risks - not just the water system but ventilation and others covered in Design Guidance SHFN 30 - should be stronger than it has been. The Design & Build form of contract should, in future, allow more robust design advice to clients. (4.7.11)

Scottish Government's Response

The National Centre will develop and maintain all relevant guidance on infection risks associated with the built environment.

Recommendation 19

19. NHS England and the new National Centre for Reducing Risk in the Healthcare Built Environment, with other UK national agencies with the remit, should produce the supplement for people with profound immuno-suppression, missing from Design Guidance SHPN 04. (4.7.12)

Scottish Government's Response

The National Centre will develop and maintain guidance to inform the design, build and maintenance of healthcare built environments. We will ask it to take forward this recommendation along with its UK counterparts.

Recommendation 20

20. NHS England and the new National Centre for Reducing Risk in the Healthcare Built Environment, with other UK national agencies with the remit, should agree and deliver a programme of guidance that reflects modern construction knowledge of good practice, and redress recent lack of investment in the HTM portfolio and associated publications. (4.7.13)

Scottish Government's Response

We will ask the National Centre to seek to agree a programme of guidance with its counterparts in other areas of the UK.