Andrew Rolf, Healthcare Technical Advisory lead at Mott MacDonald, Helen Sturdy, National head and Procurement Framework and Construction lead at ProCure23, and Colin Hamilton, Sector director – Health, ISG, discuss the Government’s growing preference for the use of Modern Methods of Construction (MMC) in both new-build and ‘refurb’ healthcare projects. Against this backdrop, they explain that a new NHS Modern Methods of Construction Toolkit, and accompanying User Guide, are intended ‘to provide a framework and key themes to create a coherent MMC strategy’.
ProCure 23 (P23) is a proactive framework, delivered by the NHS, for the NHS, which aims to meet the need for improved patient outcomes, to minimise disruption, and to add social value for local communities. Construction undertaken under ProCure23 will offer life-long value, quality, and adaptability, and a reduced environmental impact, as well as creating a desirable place to work. P23 recognises that NHS Trusts need support to understand the opportunities that Modern Methods of Construction (MMC) can bring, how they have evolved over time and continue to do so, and how they provide consistency of approach and the agility to innovate.
Why MMC?
MMC is an overarching term that considers construction innovations to help drive efficiencies, enabled by manufacturingled design approaches – Design for Manufacture & Assembly (DfMA) and Platform Design for Manufacture & Assembly (P-DfMA). Both on-site and offsite techniques can be considered as MMC, including:
Repeatable and standardised solutions.
Prefabrication and offsite solutions – with modular or prefabricated elements.
Industrialisation – the development of repeating processes.
Digitisation (the use of data and digital technologies to drive innovation).
The adoption of MMC is a key part of the UK Construction Playbook, and its key aims include delivering improved productivity, efficiency, and quality in the construction sector, as well as enhancing certainty and health and safety, while aiming to reduce carbon and waste. Although MMC has been around for many years, several industry-wide challenges and opportunities have seen an acceleration of key MMC approaches.
Key dates on the MMC journey
Some of the key dates on the MMC journey have included
Nucleus – 1976 to the end of the 1990s (standardisation).
Environmental Code of Practice for Buildings and their Services (March 1994; (circular economy).
Rio / Paris / Glasgow COP26 climate change agreements – 1992 onwards (carbon reduction).
Technology and skills in the Construction Industry (UK Commission for Employment & Skills report, September 2013).
Construction 2025: strategy. Department for Business, Innovation & Skills, 2013.
The Farmer Review of the UK construction labour model – Modernise or Die, Construction Leadership Council, 2016.
Reinventing construction through a productivity revolution. McKinsey Global Institute, 2017.
Methodology for quantifying the benefits of offsite construction. University of Cambridge, 2020.
The Construction Playbook. Cabinet Office. 8 December 2020.
DfMA Overlay to the RIBA Plan of Work, 2nd edition, RIBA, 2021.
ProCure22 MMC toolkit pilot. 2020. n Salix funding supporting heat decarbonisation. 2019.
ProCure 23 Toolkit evolved to meet all the NHS drivers. 2023.
NHS Net Zero Building Standard. NHS England, 23 February 2023.
To this end, the MMC agenda is being promoted in all its innovative forms – including design, construction, value capture, digital, production, and into use within healthcare
MMC toolkit
Within the NHS, MMC is now a core policy. This promotion of MMC to assist in the delivery of healthcare infrastructure results in the need to set targets. An aspirational national NHS target has been set as for any scheme to strive for 70% MMC for new-builds, and 50% for refurbishments. Where there are exceptions, where targets cannot be achieved, a full justification must be provided, with a full narrative of the options explored. Targets are reviewed at the stage of business case approval. Historically, these targets vary as much as the interpretation of MMC, with statements such as ‘ranging from 50-70%’ being quoted, but without an established method of measurement. Even existing MMC metrics, such as pre-manufactured value (PMV), have multiple interpretations and calculation methodologies, resulting in a lack of consistency of calculation and reporting.
A range of metrics used
This lack of consistency has, in some cases, strayed away from the original aims for promoting MMC, and led to unintended consequences, with a range of metrics issued as part of business case submissions. To ensure a consistent approach across the NHS ProCure 23 framework, the ProCure23 team has developed and piloted its MMC ‘toolkit’ over a number of projects. This Toolkit, titled NHS Modern Methods of Construction Toolkit, (and the accompanying User Guide, both of which will be viewable on the NHSE website in the near future), provide a framework and key themes to create a coherent ‘MMC’ strategy. The Toolkit can be employed by NHS Trusts, consultant teams, and contractors, at any stage of a project, although it is proven to be most effective with early contractor and supply chain engagement.
At the early stages of the project, the Toolkit can be used to set aspirations for the future development, procurement, and construction of the project, and help articulate the client vision and set the direction of travel for the development. This is when it is most effective, sitting alongside other supporting tools such as the Construction Innovation Hub Value Toolkit, the Net Zero Carbon Building Standard, and Social Value scorecards.
Definitions used
In 2019, the Ministry of Housing, Communities and Local Government (MHCLG) published a framework, categorising different forms of innovative construction techniques. It said at the time: “The intention is for this framework to regularise and refine the term ‘MMC’ by defining the broad spectrum of innovative construction techniques being applied in the residential market, both now and in the future.
While the framework was originally defined to encourage MMC in the residential sector, the same principles are easily applied to the healthcare sector, as MMC relates predominantly to supply chain capacity and capabilities, rather than sector-specific elements. The categories below (1-7) are used within the new Toolkit. The Construction Playbook (2021) goes further, and recommends that the use of MMC is driven by standardised componentry. Developed within the P22 and P23 framework, a further category of MMC ‘0’ is suggested as a precursor to the offsite and onsite MMC categories. This results in the following categories in the NHS Modern Methods of Construction Toolkit:
Category 0 – Briefing, scoping and design stage (standardisation): Use a standardised approach to the macro and micro building design; i.e. building grids, floor heights, rooms, and components etc. Category 0 is not part of the MHCLG framework, but is the enabler for successful MMC. Category 0 encompasses the development and adoption of construction ‘platforms’, with digital construction at its heart.
Category 1 – 3D primary structural systems: A systemised approach based on volumetric construction, involving the production of three-dimensional units in controlled factory conditions prior to final installation
Category 2 – 2D primary structural systems: A systemised approach using flat panel units used for basic floor, wall, and roof structures of varying materials that are produced in a factory environment and assembled at the final workface to produce a three-dimensional structure.
Category 3 – Non-systemised primary structural components: Use of pre-manufactured structures made of frame or mass-engineered timber, cold rolled or hot rolled, or pre-cast, concrete.
Category 4 – Additive manufacturing (structural and non-structural): The site-based or final workface printing of parts of buildings through various materials based on digital design and manufacturing techniques.
Category 5 – Assemblies and sub-assemblies: A design of different pre-manufacturing approaches that includes a unitised non-structural walling system, roof finish cassettes, or assemblies. Non-load-bearing mini-volumetric units (pods) used for highly serviced and more repeatable areas (e.g. bathrooms).
Category 6 – Material and product innovations: Includes traditional single building products manufactured in large formal pre-cut configurations, or with each jointing feature, to reduce the extent of site labour (e.g. prefabricated reinforcement elements).
Category 7 – Site process innovations: This category is intended to encompass approaches utilising innovative site-based construction techniques that harness site progress improvement falling outside the five main pre-manufacturing categories, 1-5, or materials in Category 6.
What is included in the Toolkit?
The new Toolkit contains several elements to help collate non-commercial data for healthcare projects. It enables teams to confirm the project typology, the extent of new or refurbishment areas, and the stage of development. The Toolkit also includes the following key elements
Benefits assessment
The first section captures client priorities for the project based around the principles of faster, better, sustainable legacy and economic value, these being aligned to the values described within the New Hospital Programme and other healthcare programmes. Each of the principles is underpinned be a series of metrics that can be assessed by the client team, with a measure of importance placed on each metric, as a score out of 10 (see Table 1). At high level, this client’s benefits assessment provides insight into their prioritisation for the future development, which will inform the forthcoming MMC strategy and typologies. This assessment can be developed through a collaborative workshop or guided individual assessment, with the intention of informing future design and procurement activities, aligning these decisions to the client priorities.
Though this assessment we can ask questions such as ‘Does the project need, or would it benefit from, faster delivery?
This process will help bridge the gap from client priorities to MMC typologies; if the answer is ‘yes’, faster delivery may indicate that consideration be given to greater use of standardised offsite products. This ‘Benefits assessment’ element may be further expanded over time to embed the Construction Innovation Hub Value Toolkit, and be reassessed at each project stage.
Constraints assessment
The type of healthcare building, site location, local or national policy, or local environmental conditions, may constrain or influence the MMC approaches for a given site. An outline Constraints Assessment form (see Table 2) is provided within the Toolkit, with a series of prompts, to allow the project team to assess project constraints. This list is not intended to be exhaustive, but is a ‘conversation starter’ to ensure that project teams have considered what impact the site may have on the MMC solution
Through this assessment we can ask questions such as ‘Does the project have specific site constraints limiting the size of components – i.e. is it a ‘constrained site?’ Again, this process bridges the gap between the designers, contractors, and suppliers; if the answer is ‘yes’, a constrained site may limit the forms of offsite components.
CAT 0 assessment
The Toolkit includes a qualitative assessment (see Table 3) of the Category 0 interventions proposed for a project. This includes a range of predetermined metrics seen as ‘good practice’ by the P23 Contractor group, cutting across project briefing, shell and core design, room fit-out design, stakeholder engagement, Building Information Management (BIM), and pre-construction activities. Further site-specific metrics may be added as required. The metrics embrace the role that digital design plays in facilitating the right design solution. The assessment provides increased scores under shell and core and room-fit-out design for greater levels of standardisation, acknowledging that this will underpin future deployment of MMC forms.
Under BIM, emphasis is placed on ensuring that the right documentation is in place, and that greater use of data is being employed. There is a focus on briefing, considering the ‘digital twin’ aspirations that may form part of future asset management. As standardisation is a key part of successful deployment of MMC, the expectation is that the trend will show greater deployment of MMC through higher Category 0 scores, as seen in other sectors (such as education).
CAT 7 assessment
Similar to Category 0, the Category 7 tool (see Table 4) logs potential interventions to improve onsite practices. This includes predetermined metrics such as the approach to construction delivery, temporary works, and asset and productivity tracking and commissioning. Again, site-specific innovations can be included to enhance the score
This assessment is best completed in collaboration with future suppliers. However, for the early stages of a project, the assessment will set the aspirations for the future construction activities. Completing this assessment during the SOC or OBC stages will inform contractor partners, if not already employed, of the aspirations of the client and consultant team, similar to well-known environmental assessment methods such as BREEAM, WELL, and LEAD.
Pre-Manufactured Value
A core part of the Toolkit is the calculation of the project Pre-Manufactured-Value (PMV), or Pre-Manufactured-Cost (PMC) (see Figure 3). This metric is central to developing the cost-based quantity of offsite construction within a project. It is the measure in proportion to the cost of offsite works within a given package, compared with the gross capital cost of that package.
Although seen as too simplistic by some, PMV is a widely used metric in the UK construction industry to measure the quantity of offsite elements within a project. It has thus been adopted with guidance around a standardised approach to quantification. A focus is on the consistency of the calculations completed for healthcare projects, to enable the collation and assessment of the data provided during business case submissions to NHSE.
The PMV part of the Toolkit has adopted the Building Cost Information Service (BCIS) categories widely used in the development of cost plans in England. However, this has been expanded to include further healthcare specific sub-sets to aid completion (if required). These have been divided into structural, architectural, and building services categories to enable successful data collection. The PMV calculation should be informed by the Category 0 and Category 7 assessments, with greater standardisation and on-site innovation aiming to drive better value
The Executive Summary
An Executive Summary at the start of the Toolkit (see Figure 4) provides details to the NHSE assurance team, offering a simple oversight on the development, the client prioritisation, MMC deployment, and a summary of the various assessments. The project scale and typology are also included to allow assessment across different typologies. A key part of this is the three project estimated percentages; the Cat 0, PMV, and Cat 7 values. The publication of these percentages enables NHSE teams to develop benchmarks and gain useful data insights into how the positive effects that standardisation, digitisation, and on-site innovations bring may aid the deployment of MMC. A key part of using these three metrics is to collate data that reinforces that MMC should help achieve cost-effective, predictable delivery of high-quality healthcare facilities, with the goal of improving outcomes for patients and staff.
Further ‘capture’ of innovations
As the data gathering progresses, the MMC Toolkit will enable the further capture and assessment of innovations, and it will become clear how this realises the client outcomes. Through consistent measurement throughout delivery, we can draw insights into optimism and accuracy inherent within the figures. The Executive Summary also provides an estimated MMC score – a weighted assessment that combines a factored Cat 0 and Cat 7 percentage alongside the PMV percentage. The overall MMC percentage is designed to give a single figure encapsulating everything that could be described as MMC, as it combines the on-site and off-site elements. This provides a clear and concise report for business case approval.
We have seen that PMV alone can result in unintended consequences – leading to a focus on driving offsite costs in lieu of value for the project. The Toolkit is intended to shift behaviours, currently weighted towards PMV, with the aim of moving toward a greater emphasis on Cat 0 and Cat 7 opportunities. This will ensure that we not only enable the right forms of off-site and on-site construction, but also deliver value for the client. The MMC Toolkit provides a holistic overview, unlike previous assessments, that may have focused only on PMV or non-quantitative approaches.
When can this be adopted?
The MMC Toolkit has been developed to be adopted at any business case or design stage. However, the intent of the Toolkit will vary with each stage. During the early stages of the project, RIBA stage 0-1 or Strategic Outline Case, it can be used to set project aspirations (utilising PMV benchmarks). This stage can help inform the briefing for future design stages – including the methodologies that may be best suited to the project.
During RIBA stage 2-3 or Outline Business Case, the Toolkit can capture how designs are evolving or performing, setting early stage PMV levels (based on estimated benchmark values or initial market engagement), and setting aspirations for construction innovation.
At RIBA stage 4 and into 5, Full Business Case and delivery, the Toolkit will be informed by supply chain involvement, and will be used to track project progress. Finally, at project completion, a post-completion review can be used to assess how the initial design approaches had impacted on final PMV and similar scores.
Trialling and feedback
The P23 MMC Toolkit is currently being trialled on a number of projects, and the initial feedback is being collated. It will be published on the NHS England website, allowing adoption across government. The Toolkit provides a consistent and well-supported approach for the greater good of the industry, driving cultural change and understanding of the opportunities.
Andrew Rolf
Andrew Rolf, Healthcare Technical advisory lead, is part of the Mott MacDonald health sector leadership team, supporting healthcare sector clients with all aspects of strategy development and project delivery. With over 20 years’ construction and engineering experience, he has design and delivery experience across a range of multidisciplinary, awardwinning, healthcare projects – including the delivery of off-site, industrialised construction forms. He supports the central NHS team across a range of subjects, including Modern Methods of Construction, delivery of Low-Carbon design, and specialist estates appraisal (including RAAC).
Helen Sturdy
Helen Sturdy CEng, MSc, BEng (Hons), FIHEEM, CIWFM, MCIBSE, MAPM, NEC4Reg, is National head of, and Procurement Framework and Construction lead, at ProCure23. She says: “As a highly experienced healthcare estates and facilities healthcare professional, I have been involved for many years in ensuring the delivery of safe, effective, and sustainable environments as part of a senior leadership team. I have a passion for driving excellence, and enjoy working on the NHSE ProCure23 framework (P23), which delivers NHS construction projects. P23 is as a real asset to the NHS, with driving innovation and collaboration at its heart. P23 is heavily supported by a collaborative team of experienced NHS professionals, contractors, and their supply chain. In this role I am able to use all my skills to make a difference on a national scale for the NHS and its patients.”
Colin Hamilton
Colin Hamilton, Sector director – Health at ISG, has 35 years’ construction experience, working in operational environments, investments, and account management. He has worked across several sectors, predominantly in healthcare, driving improvements for better patient outcomes, and has been involved in the NHS ProCure framework since its inception in 2002. Since 2019 he has supported central NHS teams to deliver emergency projects, and develop areas such as training, reducing climate change, social value, and Modern Methods of Construction. He is a chartered Civil Engineer, and sits on University College Birmingham’s Employer Board.
Construction specialist, ISG, employs over 2,900 staff in the UK and internationally. Its healthcare experience ranges from community facilities to technical hospital fit-outs, new-build cancer centres, and pioneering research institutions.