Green development

With £5 billion on the table, the latest NHS construction programme has the potential to deliver substantial long-term benefits, not just to the wellbeing of its staff, visitors and patients but also to the environment. The issues, as I will explain later, are inextricably linked.
    
Spending approximately one billion a year, the NHS Estate is committed to providing the following by 2013:

• provision of 7,000 extra beds in hospitals and intermediate care
• modernising 3,000 GP premises
• spending about £2 billion via ProCure 21
• spending about £1.1 billion on 200 facilities via LIFT.

Generating waste
The NHS currently generates 3.4m tonnes in CO2 emissions, 350,000 tonnes of waste and consumes about 40bn litres of water per year. The nature of the latest procurement phase will have a crucial impact on the environmental performance of the NHS Estate.
    
Money wasted through inefficiencies (that could deliver enhanced environmental performance) is an obvious factor but environmental impacts also have measurable health impacts. Carbon emissions, for example, contribute to climate change, which will exacerbate public health problems in the UK. These might include rises in heat related deaths, increased UV exposure leading to increases in cancer and cataracts and increases in salmonella infections. It’s something of a cruel irony that buildings designed to make the public well can actually play a part in damaging their health.
    
The media has been full of negative stories surrounding the NHS in recent years. Issues such as MRSA and a lack of beds have contributed to a negative perception, which the Health Secretary and Prime Minister have been forced to react to on occasion. Media furore or not, my own recent experiences seem to confirm the link between the environmental performance of NHS buildings and the wellbeing of patients.

A personal experience
I accompanied my close friend Nick to two hospitals this year and the contrast between our experiences couldn’t have been any starker:
    
Having injured his knee playing Frisbee I took Nick to the A&E department of a local hospital. Arriving at the entrance, we didn’t know which door we were supposed to take or where the reception was. Locating the doctor was equally difficult. The lack of daylight in the waiting area didn’t help to improve our mood. The other patients didn’t look happy either – almost certainly not only due to the discomfort they were in.
    
Later, when Nick required some further specialised treatment, I made the journey with him to another hospital, also in London. This time our experience was very different: Clearly signposted from the moment we arrived, there was a light reception area and a café for patients and visitors, which we made use of as we waited. Sitting at one of the outdoor tables, I had a conversation with Alice, a five-year-old. She told me that she would have preferred to remain upstairs in the play area while waiting for her Mum - but Mum wanted a coffee. Still, I had the feeling that Alice wasn’t at all bothered about being in a hospital environment.
    
My experience demonstrates, albeit anecdotally, what impact the healthcare environment has on patients. But as well as the millions that the NHS treats, it is also the largest employer in the UK. And I imagine that the environmental impact is equally significant for the staff.

Improving wellbeing
There is consensus at all levels of government that both wellbeing and environmental issues need to be considered together. This can be demonstrated by the experience of Trusts, both at a national and local level. As well as a consideration of policy, local planning regulations, building controls, NHS policies and funding approval requirements all encourage Trusts to ensure that their healthcare buildings are sustainable. Some of these policies are simply good practice guidelines; others, such as the NHS energy performance target, can prevent or delay the approval and delivery of projects.
    
Understandably, when commissioning a new healthcare facility, the sheer number of issues NHS Trusts seek to address can seem daunting. But by engaging effectively with single issues, Trusts will often address secondary concerns.
    
Take my experience in the first hospital where there weren’t any windows in the waiting area. The other facility had a double-height reception area with a glass front. With the whole building oriented to the North, overheating wasn’t an issue and I’m pretty sure that little energy would have been needed to light the space. So this building not only provides a quality internal environment to support health and wellbeing for building users – the large windows also help to maximise resource efficiency.

Making economic sense
Sustainable building features are resource efficient. These features, however, also tend to be more expensive than conventional building features when a healthcare facility is built.
    
Many Trusts base their procurement decisions on these initial costs – the capital costs. This would be a useful approach if buildings were only used for five years or so. However, in reality new healthcare facilities have a lifespan of over 60 years. So it’s important to look at the longer term cost implications over the whole life of our healthcare buildings.
    
This approach makes good economic sense. In an era of rapidly increasing energy prices, installing solar cells will reduce the building’s operational costs. Ideally, the photovoltaic panelling will also reduce some capital costs if the modules replace building components such as roof tiles, structural glazing or even vertical walls.
    
This long-term view when costing the building or refurbishment of new healthcare facilities is called Whole Life Costing (WLC). Basically, this approach also considers operational costs of a healthcare building, rather than just looking at the initial construction or refurbishing costs. If you would like to find out more about WLC have a look at the new SHINE Learning Network for Sustainable Healthcare Buildings guidance module on Whole Life Costing.

Therapeutic effects
In addition to the economic benefits, whole life thinking can add value during healthcare service delivery. Take the therapeutic effects of a sustainable healthcare building: the physical and mental health of medical staff and clinicians are key to successful patient outcomes. The environment of care plays a role in staff health and may be leveraged as both a recruitment and retention tool. Reducing staff stress and fatigue through a healing and supportive environment may be achieved through application of evidence-based concepts such as including places of respite in health care design.
    
I’m sure that the Trust who owns the first (poorly designed) hospital that I visited recently did not decide that a depressing waiting area or artificial lighting at all times were better choices. I’m sure, however, that the Trust chose the most efficient (capital) cost solutions when building the facility, without understanding the wider (value) impacts and benefits on users, staff and patient wellbeing.
    
Whole life costing and whole life value are useful tools for Trusts when procuring new healthcare facilities. They can both help to build the business case for building a more sustainable facility and later on this year, SHINE will publish a whole guidance module on whole life value.
    
The staff sipping their cappuccinos outside in the sun at our second hospital visit certainly seem to prove that such a module could help Trusts to articulate the need for building features that increase user wellbeing. These users include, of course, the patients. Individuals are less likely to exhibit signs of depression, especially where access to natural light and opportunities for physical exercise are present.
    
For my friend Nick, exercise was the last thing on his mind during our visits. His knee is fine now and he has even started to play Frisbee again. But I know which hospital he would rather be in, if he’s unlucky again.

For more information
You can download all SHINE modules free of charge at www.shine-network.org.uk