Planning for an uncertain future

Forming a clear picture of what’s changing the landscape of healthcare facilities, and discovering the best ways to plan for an uncertain future was the theme of a roundtable discussion between some of the health design industry’s key players. Alex Holderness reports.
ADAPTABILITY
Demographics
It’s no secret demands placed on health facilities are constantly changing, which means the services provided need to be flexible. So, can you really plan and forecast the needs of the Australian population?
There are a few strands that emerged during the discussion. Stuart Moore (Epworth Healthcare) referred to the analytical information Epworth used during the development stages of projects and how this can help with mapping provisions: “We look at data in terms of trends in clinical areas of all sides, public and private, across Australia. “We use this data to try to map out growth areas across Victoria (the market in which we operate). “That information directly impacts the development projects for our existing sites. “We also look at Greenfield opportunity sites in Geelong. “That information is used alongside the figures we get from Government forecasting, such as funding models etc.”
Anna Morgan (Southern Health) uses information from the Government, based on areas of growth, to gain a better understanding of the timing for expected growth in particular areas when mapping out services. “The growth catchment predictions impact decisions made in our area quite heavily,” Anna said. “We have a lot of older established areas that we currently serve, but in the outer regions there are identified nominated growth areas. “We have to understand what the time frames are for that growth so we can incorporate them into our plans.”
The fluctuating population growth rates and behaviour predictions of those people have been a challenge for health facilities in the past. Leonie Hobbs (Carramar Consulting) has first-hand experience in Queensland,a long-term design predicament: “We closed many beds because we had huge facilities at the time. “Then, something happened that we weren’t expecting: we had a huge population influx. “We hadn’t designed to manage that. “That’s the dilemma we are still stuck with now. “The population modelling was done correctly, it was the provision of services themselves that we got wrong – we were hearing people would use more ambulatory services and therefore need less bed days, but we still needed the beds.”
So how can we really predict population? Ultimately, modelling can never be exact, but the message is to use the data sources available to make the most informed decisions.
The Workforce Challenge
Of course, the adaptability challenge extends beyond the building of facilities to occupy surrounding communities; the service itself needs to be just as flexible. Two themes tie into the debate: the provision of services themselves and the location.
Perhaps one of the most interesting pieces of research happening currently is in Queensland around contestability. Leonie explained: “With the potential of outsourcing public work, there’s becoming a trend in Qld, NSW and WA where we are seeing more of a ‘fee for service’ model provided by the private sector. “This may be something on the landscape for the future.”
Projections produced by Health Workforce Australia in the ’Health Workforce 2025’ report make it pretty clear that without major reform in the pattern of health service delivery, Australia faces huge shortfalls in the nursing and related workforce, and in the supply of general practice and many specialities outside inner metropolitan areas.
Taking part in the round table were:
Leonie Hobbs, Senior Consultant, Carramar Consulting; Stuart Moore, Project Director, Epworth Healthcare Anna Morgan, Capital Planning Manager at Monash Health; Glen Scott, Country Segment Manager Healthcare, Australia New Zealand, Schneider Electric Buildings Australia; Arch Fotheringham, National Manager Health, Brookfield Multiplex; Owen Judge, Manager Capital Works and Asset Management, St Vincent’s and Mater Health Sydney; Chris Buntine, Senior Sustainability Development Engineer, Aurecon; Mark Mitchel, Director, Billard Leece.
There are considerations that should be made during the design and development to start to tackle this challenge. The first is around staff and the experience they have. If we make our facilities a better place to be, we’re more likely to retain staff. The second consideration is around how we’re providing the service.
Location-based Health
Arch Fotheringham (Brookfield Multiplex) suggests it’s important not to reduce options when providing services in expanding areas: “It’s easy to say there’s a growth area but you need to look at how you get people out to where that facility is. “A good example is if you look at the Western Melbourne area, where a large percentage travels to Central Melbourne for treatment because it’s not available in that area. It extends beyond buildings…”
We couldn’t look at location services without discussing the rural health challenge. We have an ageing population; a large number of people are retiring and moving to areas where there aren’t as many accessible sub-acute services. They currently have to gravitate back into the capitals.
Australia can’t continue to be so metro-centric. Leonie confirmed, “The models of care are changing rapidly. “We design to a model of care and it quickly changes. “Take cancer care. “We used to bring patients in for treatment and get great outcomes and survival rates. “We’re now seeing the day ambulatory oncology unit gets just as good outcomes.
Solutions need to be found and they’re expected to be driven through design innovations, extended workforce training and technology.
FUNDING
Value Management
The panel addressed statistics being released in several publications stating by the year 2020 nearly all of each individual States’ budgets would need to be spent on health to manage demand. It’s not sustainable, so how is it going to change? The Government and the private sector have to look at different deliveries for health treatments.
The phrase ‘value management’ emerged. As recently as August 2013, the Royal Hobart Hospital’s $580 million redevelopment was re-drawn to prevent a budget blow out. The hospital – which is now scheduled for completion in June 2017 – will have less floor space, five fewer operating theatres and will take a year longer to build.
Energy consumption also came into the value management debate, as Chris Buntine (Aurecon) says: “We’re starting to look at buildings that can reduce energy consumption by 50 per cent and in some cases look at zero carbon – it’s huge jumps in energy efficiencies, there’s potential for us to make drastic increases there.”
Funding Models
There’s a continued shift to alternative funding models. The ‘fee for service’ model is just one that’s growing in WA and NSW and Australia should be watching closely to see what the outcome of contestability is.
Anna explained there’s a need for a new form of thinking in Victoria: “ We are having to get a bit smarter with our funding and make it stretch a lot further, as we’re not getting the same sort of funding. “It’s time to think outside the box if we want to keep resourcing our facilities, not just looking to government for funding. “Look inside your organisation, at sponsorship and other support methods. “It’s a key way to get funding to renew services and facilities.
Technology
There is little doubt that technology will play a central role in healthcare reform to contain costs, improve accessibility, security, patient experience and, most importantly, save lives. The technology already exists; the challenge lies in collaborating, managing change and investing in the right technology upfront for long term cost efficiencies.
Mark Mitchell (Billard Leece) elaborated: “We need to create buildings around people using technology rather than technology people have to work around. “It should be at the centre as an enabler. “Adaptability and future proofing come at a cost – you need to find the balance.”
Project Director, Tony Michele is very familiar with the considerations that come with implementing new technology: “In Victoria we’re seeing a growing recognition that technology sits on a single backbone, something that’s not previously been pursued in public hospital buildings in Victoria.”
Public-Private Partnership (PPP)
According to a new Clayton Utz report, despite their critics, PPPs still have a role to play in helping to deliver Australia’s future infrastructure needs.
Arch has worked on five and insists there’s better design and better transfer of risk. “Long term, the facility is there for 25 years and still holds the same value at the end of the 25 years. “Other shorter term facilities quickly get in a position where money needs to be spent earlier to bring the building back up to scratch.” With PPPs, all the operator of the facility has to think about is providing the services it was designed for. “That’s a big benefit.”
Anna can see similar benefits: “One of our hospitals is a PPP and even at seven years old looks brand new. “It’s because of that continual replacement, it has to be maintained. “You walk into some other facilities and they certainly look their age, if not older. “In that sense, it certainly is value for money to make sure that infrastructure is sustained over a period of time.” However there’s scope for the industry to learn from PPPs without adopting the model: “We should be looking at what the public sector can learn from PPPs without necessarily going down that line. “There is better quality maintenance and more investment from the client upfront – more smarts up front, essentially ensuring that every dollar is spent in a better way,” explained Mark.
“We need to create buildings around people using technology rather than technology people have to work around.”
SUSTAINABILITY
For maximum efficiency, sustainability considerations are made during the planning stage, but what are the real benefits of sustainability incorporated into design and development? Mark explained: “It’s the science of sustainability alongside your evidence based design that come together through the experience, it makes people feel good and when people feel good, there’s a correlation with positive health outcomes.”Chris highlighted the need to keep focused on what you’re trying to achieve: “We often see too much points chasing, it’s a matter of finding out the priorities for the hospital and seeing how they line up. “The private sector is getting heavily involved in sustainability, we call it liveability – it’s a good story in terms of it marketability and it creates richer and more vibrant communities. “We’re finding it’s a shared initiative between public and private.”
Communities of the Future
This liveability factor extends beyond design of the facility, encompassing the potential influence a facility could have on the design of the wider community. Could Australia use hospitals as a driving force, creating a community approach to energy efficiency? Chris emphasised the potential in extending planning considerations: “When we’re talking about planning, that’s our opportunity to talk about the surrounding community and how that’s planned to promote greater levels of liveability with healthier, more integrated communities where you’ve got active lifestyles and healthy food options.”
Technology Infrastructure
Another key factor in sustainability comes with future proofing. Stuart explained his approach for managing this phase of development: “We’re talking four or five years on average and there are a number of packages within a construction contract which we (as a client) prefer to co-ordinate with service engineers. “We’ll then actually hold on to them ourselves until much later in the construction program before letting them as separate construction packages.”
Glen Scott (Schneider Electric) confirmed it’s the hardest part designing for something way down the line by the time it gets installed. With ICT there is a whole range of cabling for a whole range of different scenarios, whether it’s in the ceiling, or the walls – there’s a need to make provisions but not necessarily decisions until much closer to commission.
So how do we try to plan for the unpredictable? There was a consensus in the group that it ultimately comes down to not cutting off any options, but maintaining a balance.
CUSTOMER CENTRICITY
It’s essential to understand how to plan, design, construct, redevelop, manage and co-ordinate with stakeholders, as ensuring customer centricity is key to meeting objectives. We’re seeing huge leaps in design methods that take into account the environment for the patient and visitors throughout the course of their stay.
Patient Flows – Innovation in Design
One project capitalising on new innovation opportunities is The Royal Victorian Eye and Ear Hospital (RVEEH). Jenni Gratton-Vaughan, Executive Director Strategy, Planning and Redevelopment at RVEEH and Neil Appleton, Design Director at Lyons Architects recently shared the unique work they’re doing to create a change in the patient experience, ranging from flow throughout the facility to using high visual contrast to delineate between floor surfaces and wall surfaces.
It’s becoming paramount to identify where the stress points are for a patient and incorporate these into design. Other examples mentioned during the roundtable discussion included the new Queensland Children’s hospital, being naturally ventilated on the first three floors as a result of the design, responding to the feedback about children being around the air-conditioning.
Chris talked about incorporating Biophilic design: “It’s a big focus; we can give people more control of their environment and reconnect people to their natural environment, to provide a calming influence.”
The patient flow doesn’t start and stop at the front doors of the hospital, it’s important to ensure innovations in patient flow don’t also become a hindrance: “Technology can help mitigate stress in areas such as car parking and check in – but it’s a balance, and you need to know your customers, you don’t want to make it more hard work for patients. It needs to be appropriate and enable, not disable,” Leonie explained.
It’s predicted more elderly people will be visiting medical centres so the industry needs to test innovations to see if they’re the right answer before any significant roll outs.
Communication
Consultation and communication with user groups and stakeholders is a huge part of the development of any project; although it can often take the most time, it’s making substantial differences to the design and outcomes of Australian facilities. Mark’s had vast experience in the field and noted that perhaps it’s time for a change in the way users are communicated with: “We could educate users right at the beginning of the whole process; their role shouldn’t be to just go in and pick holes in the design. “They should be talking about how design could be better in terms of operating to that specific facility. “These people often know the building in and out, and know small tweaks that could be made to make big differences. That brief isn’t always given to them.
“Customer engagement is really changing the face of design; the design of healthcare over the last ten years has been so much more than the ten years prior to that. There is much more involvement from the public and different sectors, the collaborative process has really improved and I’, optimistic it will keep improving at that rate’
Australian Healthcare Week 2014
The roundtable certainly raised some interesting challenges that need to be tackled to meet future demand. The conversation is set to continue during Australian Healthcare Week 2014, to be held in Sydney on 25-27 March 2014. The event will bring together health professionals, contractors, architects and technology specialists to network and develop actionable strategies to:

1. Build and develop health facilities that are more efficient and suited to meet the health demands of the coming century;


2. Embed new technology that will improve health productivity whilst continuing to improve medical outcomes

For more information on these events, go to www.aushealthweek.com.au