Dr Grant Mills from the Bartlett School of Construction & Project Management at UCL has been working with Dr Chris Goodier from Loughborough University and Dr Jennifer Kingston from Cranfield University to improve the procurement of construction methods and processes currently being used to design and build clinical spaces. This academic partnership brings together respective expertise in health infrastructure, Modern Methods of Construction, and astronautics and space engineering.

The NHS has been one of the biggest adopters of offsite construction in the UK. However, past and existing delivery models still call for traditional design and manufacture platforms. While an encouraging step forward, this only allows for high-volume repeatability and doesn't support the level of modularisation required for more specialist settings, such as hospital theatres. Procurement and construction systems need to better support the complex and varied clinical needs that hospital buildings have and are calling out for more innovative solutions that draw on learnings from other industries. And with £21bn worth of major projects planned for 2020 and beyond, the NHS has a real opportunity to change the way hospitals are designed and delivered.

This project showed the clear need for a wider industry platform approach to Design for Manufacture and Assembly (p-DfMA). Policy guidelines issued to NHS Estate Directors outline a 40% increased efficiency for manufactured schemes, versus 20% for volumetric schemes, and 10% for component-led. These new procurement practices, inspired by the procurement approach to space engineering, create a huge opportunity to increase the productivity and quality of construction across the entire healthcare portfolio. Not only that, but using p-DfMA in hospital builds can improve clinical outcomes, and patient safety and experience, showing direct benefits to the end users of these buildings.

The teams at UCL and Loughborough approached Cranfield University to explore ways to apply Modern Methods of Construction to the healthcare industry and improve the delivery of its vast estate portfolio. They quickly saw how the parallels with the highly complex environment of spacecraft could help them both challenge and reimagine the procurement of surgical operating theatres. Both are driven by high levels of technologies; both need to be sterile environments that are air-tight; and both require a significant level of oxygen distribution. This insight led them to apply for investment via the Transforming Construction Challenge fund to support a new collaborative research programme.

The new collaborative between UCL, Loughborough and Cranfield Universities kicked off their research programme with five interviews, three steering group meetings and two workshops to explore the existing approach to theatre design and manufacture, and understand if functional compliance was stifling innovation. Armed with these insights into current practices, the research team went on to explore new scenarios for procuring improved operating theatres - comparing the modular platform approaches and delivery methods with the expertise used in the space sector.

There has traditionally been a fragmented approach to project delivery in hospital construction. While this might be more attractive to short-term budgets, lowest cost doesn't always deliver the most value over the long-term or the greatest benefits to the end users of hospital spaces. As a result, significant opportunities exist to increase innovation, integration and value from the early involvement of the specialist supply chain. A longer-term alliance, or enterprise-based delivery model, has the potential to improve cost and speed of delivery, as well as clinical outcomes for surgical teams and patients.

The research team has made recommendations around how innovative planning and a platform approach to Design for Manufacture and Assembly (p-DfMA) in hospitals could be applied to deliver Modern Methods of Construction (MMC) and increase the whole-life value of surgical buildings. The project recommended an evidence-based planning and design model which would provide a standardised modular approach across the project, supply chain and industry and put market scale, reliability, continuity and quality as key success criteria. And the learnings from the space sector showed the need for specialist and long-term client skills development, a long-term design perspective, integrator and manufacturer frameworks, aligned commercial relationships; and ongoing incentives to support innovation and integration. Specifically the recommendations supported the use of common modular process and project management standards; rigorous concurrent engineering; and a whole system view of digital integration. It will involve expert systems integrators and advanced client quality teams carrying out factory inspections and championing zero error to minimise operational failures. And it will call on research and development in every organisation and at every stage of delivery. Further work by the research team will focus on exploring the three categories of MMC to deliver the health infrastructure plan (HIP): volumetric, component-led, and manufacturing-led.

The recommendations made by the project team included improvements in digital systems integration using a modular approach. Parallel work by the UCL team has shown that a digital systems integration approach could reduce errors (such as late changes), it could increase quality, and optimise interface design and management. Just increasing the adoption and standardising the use of digital approaches could reduce rework and defects (believed to be 5% of project value). Digital design for construction compliance, such as electronic site inspection and visualisation derived from BIM, and the optimisation of design, planning and installation solutions would deliver additional benefits. Digital procurement would also better support collaborative planning and supply chain management, and the subsequent transfer of data through to digital manufacturers would minimise errors in offsite manufactured components and benefit design production checks and smart construction site approaches. 

NHS England and the Department of Health & Social Care have stated that manufacturing-led construction offers the greatest opportunity to improve efficiency and productivity in health construction. Martin Rooney, Estates Delivery lead at NHS England and NHS Improvement, wrote to NHS Trust Estates directors making clear that Trusts developing new capital schemes should use Modern Methods of Construction wherever feasible. He explained the longer term value of this approach includes reduction in time focused on planning; greater ability to match capacity and demand; and bigger control over the supply chain of manufacturing. This is a huge step forward in the purchasing of hospital buildings to ensure they have the highest levels of quality and customisation, as well as the greatest overall cost saving.

This research project brought together a large number of stakeholders to support the research. Those organisations who inputted into core presentations and research included: Adept Management (AML); blacc; Health Facilities Scotland; UCLH Infection Control; Greener Anaesthesia & Sustainability Project (GASP); and Kier (ProCure 22).  There were also specialist construction companies involved in the recommendations around advanced design and Modern Methods of Construction (MMC). They included: Bryden Wood; Hassell Studio; Manufacturing Technology Centre (MTC); and SRM.  Partners from advanced engineering, asset management and manufacturer organisations included: Hulley and Kirkwood; Elliott; Balfour Beatty Kilpatrick; Sir Robert McAlpine and McGuire PBM. And lastly, a number of healthcare policy and hospital service users contributed towards the research, including: NHS Improvement; Guyʼs & St Thomasʼ NHS Foundation Trust; GE Healthcare Partners; UCLH; and Royal Free London.

• Adept Management Ltd
• Balfour Beatty Kilpatrick
• Bryden Wood
• Elliott Group
• GE Healthcare Partners
• Greener Anaesthesia & Sustainability Project (GASP)
• Guy’s & St Thomas’ NHS Foundation Trust
• Hassell Studio
• Health Facilities Scotland
• Hulley and Kirkwood
• Kier
• MTC
• McGuire PBM
• NHS Improvement
• Royal Free London
• SRM
• Sir Robert MacAlpine
• UCLH
• UCLH Infection Control
• blacc

The Transforming Construction Network Plus funded £98,400 towards this nine month project. It supported the research team in the dissemination of its work, giving the team several opportunities to present their research and engage with key stakeholders. Network Plus also actively liaised with external organisations to ensure a professional delivery of the industry report. 

Over £21bn of hospital programmes are planned and need to be delivered in a way that is more productive, sustainable and supportive of clinical outcomes. The programme set out to double the service life of a theatre and increase the speed of refurbishment through a flexible and modular design, while reducing disruption. The results have shown that time and research is needed to embed Modern Methods of Construction into NHS procurement practices to increase the productivity and quality of construction across the entire healthcare portfolio, and avoid any negative impacts of its rapid introduction. In addition, p-DfMA could improve clinical outcomes, and patient safety and experience, showing direct benefits to the end users of these clinical buildings - but further research is needed to evidence-base design, manufacture and assembly.

By analysing the effectiveness of spacecraft design it gave the team massive inspiration to learn from a best in class scenario. Something as technical as rocket science could be deployed in another specialist, complex setting - operating theatres. This brought together a huge collaboration of neurologically diverse individuals, teams and organisations to begin solving this construction challenge. The resulting recommendations not only support a more efficient and collaborative supply chain but point to a better environment and experience for clinicians and improved patient outcomes.

The research programme investigated a range of processes, drawing on the design and development of spacecraft for its inspiration. Specifically, it explored delivery model governance, planning and design, capability development and digital systems integration approaches and recommended they are aligned across projects, supply chains and a wider hospital infrastructure delivery platforms. This new platform-based thinking is embedded into each stage, from design for manufacture, factory optimisation, quality systems, supply chain integration, logistic flows, skills development and measurement and optimisation.

£21bn worth of major health construction projects are planned for 2020 and beyond, so the NHS has a real opportunity to change the way hospitals are designed and delivered. The new policy guidelines issued to NHS Estate Directors outline a 40% increased efficiency for manufactured schemes, versus 20% for volumetric schemes, and 10% for component-led. Adopting this new way of designing and building hospital theatres could result in 33% lower costs to the industry; 50% faster delivery due to a reduction in parts, fabrication, logistics and assembly; 50% reduction in emissions; and 50% increase in whole-life value. If the number of planned theatres manufactured offsite increased from 33 to 250, it could increase the productivity of projects by 15%.

Collaboration
The research team have triggered supply chain innovation by using the space sector as a comparison and drawing on wider inter-disciplinary experience and capability. The recent example of the NHS Nightingale Hospitals has shown this in action. They saw many contractors and suppliers working in a more agile and aligned way, and using expedient procurement processes, allowing these hospitals to be delivered in three to four months. Bringing together specialist healthcare contractors with advanced design, engineering, asset management and manufacturing has also encouraged new interactions and created innovative delivery, sustainability, inflection and rapid deployment targets that were unconstrained by typical lowest cost tendering.

Emissions
The team investigated the delivery of a more sustainable operating theatre, with a goal to lower emissions by 50%. To do this, they recommend decarbonising through innovations in local bulk gas capture, extraction and purification. It's critical to establish specialist supply chain alliances that are incentivised to, for example, mitigate the impacts of anaesthesia gas scavenging systems, because some gases are 2,540 times more warming than CO2.

Health
The programme looked at how theatre infection control could be transformed through a standardised platform. The research explored the standardisation of requirements, design and assurance to reduce the risk of poor design, execution and operational errors. And although not empirically tested, the research suggested that a platform approach to Design for Manufacture and Assembly (p-DfMA) could address the significant cost of surgical site infection, the costs to the patient and the societal costs, such as antimicrobial resistance.

Productivity
The research programme showed that only 5% of theatres procured currently use offsite manufacture. Yet if the number of planned theatres manufactured offsite increased from 33 to 250, it pointed to opportunities to increase the productivity of projects by 15%. From the team's analysis of 60 processes involved in the theatre delivery (conducted in collaboration with AML), they created guidance that will minimise design, procurement and onsite delays and potentially limit errors as a result.

Time
The team is aiming for a 50% faster delivery time due to a reduction in parts fabrication, logistics and assembly. This would support offsite manufactured theatres being delivered in five months. However the researchers are working with the SEISMIC II team and Moorfields Hospital to investigate whether this could be cut to as little as four months with greater productisation of the processes.

Uptake
As a result of this research, NHS England and the Department of Health & Social Care have stated that manufacturing-led construction offers the greatest opportunity to improve efficiency and productivity in health construction. Martin Rooney, Estates Delivery lead at NHS England and NHS Improvement, confirmed that Modern Methods of Construction should be a critical part of the NHS Health Infrastructure Plan (HIP). And with £21bn worth of major projects planned for 2020 and beyond, this is a huge step forward in the purchasing of hospital buildings to ensure they have the highest levels of quality and customisation, as well as the greatest overall cost saving.

UCL case study
How spacecraft engineers are improving operating theatre construction