After years of planning, design, and construction, a comprehensive approach to commissioning a new hospital is an essential part of the development process. Good commissioning helps to ensure the new hospital is able to deliver the quantity and quality of healthcare that justified the original investment decision. This includes not only the Facilities Management (FM) elements of learning how to operate the building, but also the process of the healthcare provider planning and implementing their delivery of services from the new premises. A comprehensive approach to commissioning includes an organisational change and development process begun well in advance of occupation, referencing back directly to the clinical model, operational policies, and design brief that drove the hospital design. However, all too often the organisational change required to harmonise activity with the building is neglected, left too late, or not undertaken at all. The outcome is a building that doesn’t function in the way it was designed to, producing sub-optimal delivery of care and value for money outcomes.
The problem with commissioning
In the UK it has been widely recognised, both anecdotally and through more formal research such as post-occupation evaluations, that commissioning is often a neglected and ineffective part of the hospital development process. In response, in recent years much work has been put into ensuring that delivery partners, including design teams, project managers, and construction contractors, collaborate with NHS Trusts in planning and training how to use and manage their new building during the handover process. This is encapsulated in programmes such as Government Soft Landings (GSL), which has been to varying degrees incorporated into most public hospital delivery approaches.
Despite these efforts, many small and large NHS hospital projects still suffer from an inadequate commissioning process. Its importance is often overlooked, resulting in inadequate amounts of resource and planning allocated by the Trust and delivery partners. In addition, compressed programmes at the project completion stage, project budgetary constraints, organisational inertia and the associated difficulties of undergoing an organisational change process compound the problem, as does the shear length of time between determining how a building will be used during the briefing and design process and actual occupation.
The outcome is Trusts effectively shoe-horning themselves into the new hospital, bringing existing working practices from their previous building into the new one rather than delivering care in-line with the care model and operational policies they developed during the briefing process. The Trust ends up working at odds with the building; the resulting friction causing a significant reduction in efficiency, capacity, and quality of care delivered. The success of the new hospital, both in terms of value for money and in terms of quality of care delivered, is compromised. This is not as a result of its design or construction, but as a result of a commissioning process that failed to harmonise the activities undertaken in the building with the actual form itself.
Having worked as a Commissioning Manager, working with Trusts to manage this transition process on major projects, I have seen the scaling back of capital planning teams result in hospital commissioning becoming something of a lost art in the UK. Often there is a small and under-resourced team, usually just one person, who ‘learns’ the skills and processes for one project and then goes back to a day job, and the experience and knowledge is lost for the next project. The commissioning function is reduced to basic FM aspects of building operation, and orientation and equipment training for staff, rather than a fully integrated organisational change process that prepares staff with the changes to their environment and ways of working.
What is good commissioning?
A good commissioning process starts years in advance of opening day, and involves a dedicate team responsible for planning and coordinating all aspects of the process. It is allocated a sufficient budget and resource, is identified on the programme critical path, and has buy-in and representation from the most senior Trust and delivery partner personnel. It covers both the physical occupation and FM operation of the building, and an organisational change and training process that prepares the Trust’s clinicians, managers, and support personnel for delivering care in the new setting. In terms of adding value and realising the potential of the new hospital, it is the organisational change element that is most important –the best approach to which is a direct link to the clinical design brief.
The clinical briefing process for a new healthcare facility does two key things; it determines how a Trust will deliver a given quantity of care, and it specifies the design and space requirements for the building to support that delivery of care. Whilst the latter aspect goes on to inform the investment appraisal of the business case and the actual design of the building, the former aspect is often ignored and, if not discarded, then certainly left on a metaphorical shelf to get dusty. The value lost in not using the brief as a guiding totem for not just the design, but also the commissioning process itself, is huge. The clinical design brief, and specifically the care model and operational policies, effectively form the instruction manual for how the healthcare provider should use and deliver care in the new hospital. As such it should drive the organisational development and training element of the commissioning process to ensure the way the healthcare provider delivers care fits seamlessly with the building designed and built to support that delivery approach. This takes a significant amount of time and resource, and in order to get this right it should be undertaken well in advanced of building occupation.
The outcome of linking the commissioning process directly to the clinical design brief is a healthcare organisation which has been structured and trained to deliver care specifically in line with the model of care and resulting operational policies that their new facility has been designed around. As a result, an organisation and its building tessellate, maximising the efficiency and effectiveness of both and delivering the volume of care required at the right level of quality.
Commissioning from project start
Planning and implementing commissioning should begin much earlier than it currently does in most NHS hospital development projects. Using the above approach, it starts along-side the briefing process, with the development of an outline organisational development and training plan that identifies the gap between where the Trust currently is, where it needs to be in order to deliver the model of care, and an outline of the process of how it will get there. The approach of many healthcare providers in the United States, where ‘activation’ often plays a much more prominent role in the hospital development process, is to have an extensive planning team and process in place from the briefing and design stage, gradually expanding their activities throughout the construction stage.
This has been the case under certain procurement models in the UK. The first project I worked on was a small community hospital procured via the Private Finance Initiative (PFI) method. As the PFI payment started at practical completion of the construction works, the Trust chose to transfer services into the new building over just a two-week period to minimise having to pay for two premises or delay achieving disposal returns for the old premises. During this period all of the new and transferred furniture and equipment was delivered and services transferred over a phased period. Planning for this two-week period started two years before practical completion of the new hospital, with the outline commissioning plan being included within the project contract documents.
Local Improvement Finance Trust (LIFT) projects shared a similar funding structure to PFI and often had a similar timescale for commissioning in order to minimise the time that a new building is not fully operational and generating income. Whilst the planning period was often two years, the operational commissioning period when the building was complete was often two weeks. Years of planning went into this process and required close working relationships with the construction contractor to ensure that the building and staff were ready to move in and treat patients. All available research confirms that the commissioning process should be started at least 18-24 months before the first patient is due to be seen.
I recently visited the redeveloped Chase Farm Hospital, and it was refreshing to hear that the Trust had implemented all changes to working practices well before staff moved into the new building. This enabled staff concentrate on familiarising themselves in their new environment, rather than also coping with adopting new ways of working. This is a common cause of project failure because staff have to cope with a new building as well as embedding new ways of working. Often this results in the new ways of working being rejected and the building declared to be poorly designed.
The demise of capital planning departments in many NHS Trusts, along with procurement models that incentivise a comprehensive commissioning process falling out of favour, means commissioning increasingly risks being poorly planned and executed. Understanding the importance of the commissioning process, and specifically the organisational change and development element of this, is key in ensuring the full value of a new hospital is realised. This requires buy-in in terms of the importance of commissioning from the senior personnel in the Trust and delivery partners. It also requires the process to be well resourced, well planned, and begun years before opening day. Most importantly, the care model and clinical design brief should be used as the key reference points for determining the organisational change that needs to take place.
Senior Consultant – MJ Medical