Join the club

The NHS is the biggest client for healthcare buildings in the UK, but projects can be complicated to manage. How can architects add value?

‘Please be brave. We need you to make a difference’ – Mike Pringle.
‘Please be brave. We need you to make a difference’ – Mike Pringle.

Despite burgeoning demographic, epidemiological, and economic pressures that might fuel a construction frenzy, the current NHS mantra is in the opposite direction. Investment either addresses an historic maintenance backlog or goes into upgrading or refurbishing existing infrastructure. The King’s Fund has criticised this work for being rapidly redundant, out of date, over-specified, inflexible, expensive to operate or reconfigure, and difficult to finance. 

What’s more, the NHS estate has surplus land (over 640ha in 2014), according to the ‘Five Year Forward Plan’ – the Conservative government’s transformation strategy. It offers a glimmer of hope that with more entrepreneurial development skills, these assets can be sold or rethought. 

A recent RIBA round table with clients asked how architects can add value. Contributors agreed the estate should be squeezed for optimum value and that architects had a significant role in imagining how to do that and delivering solutions fit for the future. As John Cole, former chief executive of Health Estates Investment Group in Northern Ireland, said, ‘The architectural profession’s core skills of visioning, strategic planning, devising solutions and making places will be essential.’

Architects could help in several ways. Making the estate work harder by, for example, sharing premises with other public services or commercial sectors, is one idea. Others include conceiving new kinds of buildings such as, for example, modular hospitals that respond flexibly to local need. 

Swimming against the tide

It is a huge task. The way the NHS constructs business cases, its inconsistent, often convoluted and restrictive procurement processes, its organisational structures and focus on the short-term inhibit the kind of radical solutions that might help. 

Indeed, the architect tends to be distanced from the head client, lost in the contractor-led supply chain and strangled by red tape and the need to comply with Health Technical Memoranda (HTMs) and Health Building Notes (HBNs). ‘The appointment of an architect is just another step in the bureaucratic public procurement process,’ said Cole. ‘Often it is the contractor who selects the design team, further reducing the connection between client and designer.’

However, John Hicks, global lead for healthcare at Aecom, pondered the potential for architects to ‘shift the conversation away from HTMs into healthier lifestyles and mergers around healthcare.’ Christopher Shaw, senior director at Medical Architecture, identified a vacuum preventing such conversations. ‘No-one knows how you might change planning systems, adapt the way that we use budgets, or what the relationship is between capital and operational expenditure.’

Andrew Simpson, of Dominic Lawson Bespoke Planning, thought that manoeuvring into these conversations is difficult under traditional procurement routes. He advocated RIBA Competitions as a viable alternative, where the architect can be appointed as the lead professional ‘to develop the brief as well as to be the designer.’

'Architects should not underestimate the threat from people outside the profession' – Mike Major.
'Architects should not underestimate the threat from people outside the profession' – Mike Major.

Regardless of how, clients want architects to dive in. Mike Pringle, president of the Royal College of GPs, pleaded for leadership: ‘Please be brave. We need you to make a difference.’ According to Alan Kondys, health sector director at Vinci Construction UK, architects should embrace a co-ordinating role. ‘Somebody has to do it, and I think the architect is in the best position.’ However, Skanska director Mike Major warned that the door will not stay open indefinitely. ‘Architects should not underestimate the threat from people outside the profession.’ 

No conversation is credible though without a good working knowledge of health service provision. Shaw again: ‘We need to really understand what clients’ business and clinical strategies are.’ In Kondys’ experience, architects must challenge the client on several levels. How well is the building aligned to their estate strategy? How well does that strategy underpin their clinical strategy? And how robust is the clinical strategy? ‘The clinical strategy will improve health outcomes; the building merely enables that.’ 

Hone your soft skills

People skills, personality and communication matter. Paul Mercer of Tangram Architects believes clients want to be inspired, while Major needs to be confident that he can get on with the individuals in his architect team. Independent consultant Dr Barry Trindall said that since some healthcare clients are comparatively inexperienced, ‘a good architect also needs to educate’. For example, in primary care, Pringle emphasized the need for creative guidance through good communication. ‘GPs need examples of how forward planning produces buildings that remain fit for purpose 10 years down the line’.

‘A good architect also needs to educate’ – Dr Barry Trindall.
‘A good architect also needs to educate’ – Dr Barry Trindall.

In such a complex sector, consulting all the stakeholders is critical. Cole regarded facilitating in-depth iterative dialogue between an informed client, key user representatives, especially patients and staff, and the architect as ‘the most important determinant of success’. Since staff costs are so high, and because staff are critical to getting better health outcomes, Phil Nedin, healthcare facilities consultant at Arup, thinks their needs must be centre-stage. ‘Better environments improve staff morale, which in turn allows them to give a better service’

However, no solution is immune to the rapid pace of change in service delivery, so building in truly sustainable flexibility is equally important. Major again: ‘Smart clients avoid filling their site with ramshackle stuff which they then have to demolish and rebuild over time. Flexibility costs more money up front but not in the long term.’ 

Should architects have experience in the sector? Trindall regarded it as critical: ‘I do not want to pay for their learning curve.’ David Kershaw, programme director at Balfour Beatty, on the other hand argued that ‘the best solutions don’t arise simply because the architect has done it previously’. Shaw’s advice to practices wanting to break into the sector was collaboration, and targeting smaller projects for primary healthcare to begin with.

'HBNs shut down any opportunity for innovation. The architectural process transcends that – that's where the value lies' – Keith Millay.
'HBNs shut down any opportunity for innovation. The architectural process transcends that – that's where the value lies' – Keith Millay.

As the de facto standards in healthcare design, HBNs and HTMs were generally considered not fit for use. Keith Millay, UK managing director at Steffian Bradley Architects, warned against designs that are too rooted in them: ‘They shut down any opportunity for innovation. The architectural process transcends that – that’s where the value lies.’ But clients fall back on them in the absence of better alternatives. As Major puts it, ‘No one’s going to be sacked for complying with HBNs’. 

This is a hot topic. Kershaw has been involved with various academic bodies and is struck by the ‘quite remarkable’ lack of evidence. As well as leveraging design research, architects should make a point of following up on how their designs perform in use. Michael Phiri, author of ‘Evidence-based Healthcare Design’, calls for architects to collect ‘the softer evidence’. Without it, architects are less able to persuade clients of the benefits of investing in good design. 

The market’s priority is to remodel existing stock to serve changing healthcare work flow, rather than to design new buildings, and architects aligned to respond to these demands will benefit. More importantly, clients and users are more likely to get buildings fit for the challenges ahead in a fast-changing healthcare economy. 


1.    Understand the wider health provision context to identify the real value adds.
2.    Influence strategic conversations by proposing innovative ways to squeeze more value from the existing estate.
3.    Engage the client through education and by reaching for higher standards.
4.    Keep users – especially staff – and flexibility in focus during the design.
5.    Collect evidence of what works to persuade clients of the benefits of good design and for the benefit of the health service in general.

The RIBA’s Client Liaison Group is running a series of round table discussions to listen to and understand external perceptions of the profession and the value architects bring to the project team, and ultimately to identify the tools needed to promote architectural services in these sectors successfully. Feedback from interviews with workplace clients is included here; and 60 second clips of one-to-one interviews are available on