Develop a robust equipment strategy from the outset

The Hospitals of the Future Project is a new landmark hospital development that sits at the forefront of the Government’s New Hospital Programme (NHP). My role is one of many that form part of the Trust’s Building the Leeds Way Programme (BtLW) Team, led by experienced Programme director, Mike Bacon.

A new ‘state-of-the-art hospital’

Leeds Teaching Hospitals NHS Trust is one of England’s largest acute Trusts, and it is currently planning one of the most exciting and important developments for a generation. Its plan to build a new hospital will create a new home for Leeds Children’s Hospital, a new adults’ hospital, and one of the UK’s largest single site maternity centres, as well as being a catalyst for regeneration for Leeds city centre.

A central part of the national New Hospital Programme, our scheme had a major boost in May 2023 when the Trust received confirmation from the Secretary of State for Health & Social Care that our plans were fully funded and could proceed. This was excellent news for our patients, staff, and the wider Leeds economy, and, aligned with the Secretary of State’s announcement, we’re expecting the new facilities to be constructed by 2030.

The site for the new hospitals provides a fantastic opportunity for the very best designers and construction contractors to play their part in shaping the city’s landscape. It’s a unique site which is compact, sloping, and triangular, located in the heart of Leeds City Centre. The Trust’s experienced BtLW Programme Team, which is responsible for the delivery of the new hospital at the Trust, has worked with designers, contractors, stakeholders, and partners, to develop a robust, detailed set of design and buildability plans to ensure that the scheme can accelerate forwards into the next stage.

We plan to deliver a building designed to provide our patients with modern, individualised healthcare based on the most advanced treatments, technologies, innovation, and research, in state-of-the art facilities. It is an ambitious, long-term development that will change the way we think about hospital care, and will also bring improvements in healthcare for patients across the West Yorkshire region.

The story so far

The Trust has established a highly experienced delivery team that brings together design and build experience, hospital operational management experience, and the very best specialists from the private sector. The BtLW Programme Team, supported through strong partnerships and significant internal staff and external stakeholder engagement, has helped to shape and develop a strong vision and robust set of plans. This work has enabled the Trust to secure Outline Planning Consent (June 2020), secure approval to the outcome of public consultation (July 2020), and develop a robust set of design proposals that were highly commended in the Best Future Healthcare Category in the 2023 European Healthcare Design Awards. Further informing this work, we’ve also collaborated with the national New Hospital Programme Team since its establishment to ensure that our plans align with the vision for Hospital 2.0. The Trust has already delivered an award-winning (Highly Commended in the Health, Safety & Wellbeing Category at the 2022 Yorkshire Constructing Excellence Awards) set of complex enabling works, has a cleared construction site, and is ready to accelerate into the next stage of the national New Hospital Programme process.

However, our plans don’t just include the design of the building itself. We have already been developing our Change Management, Operationalisation, Digital Workforce, and Net Zero Strategies alongside a robust Equipment Strategy that is itself aligned to our vision to create a digitally-enabled and Net Zero hospital.

Equipment is an integral part of the healthcare delivery process, and both influences, and is influenced by, design, build, and operational maintenance strategies. However, it is often a secondary or late consideration in the process once a design is well established and progressed, and is then often forgotten until developments approach the operationalisation stages mid-way through construction. The failure to consider and continuously develop a robust Equipment Strategy as an integral part of the design, build, and construction process with key principles established early within the design process linked — for example — to the establishment of 1:50 designs, can have significant impact on the ability and process to operationalise and manage a new hospital, and even lead to delays in operationalisation and additional costs.

Regular updating

It would be easy to overlook key items of equipment if the Equipment Strategy and its plans are not sufficiently considered early in the process, and the plans and equipment schedules are not continuously updated as the design is developed. Something as basic as oxygen flowmeters can result in the need for expensive temporary solutions or delays to opening. For large, complex healthcare schemes the impact will be significant, as the timescales for medical equipment procurement, supply, installation, and commissioning, are typically in excess of six weeks, and if the equipment choice is subject to clinical evaluation, this may take much longer. The financial impact of such delays to opening new healthcare facilities can also be much wider and more significant.

The absence of a well-defined Equipment Strategy and robust set of plans that are continuously developed through the design and build process, when scaled up for a large complex project, could have serious consequences for its success.

Similarly, not having the correct infrastructure — such as a specialist mains outlet in an operating theatre for laser equipment, or appropriate stud work in the walls for equipment mounting arms — can result in additional costs, delays, and service interruptions. It is equally important that the design of new healthcare facilities not only considers the equipment itself, but also its functional requirements — in terms of infrastructure design, power, medical gas supply, drainage, data, and environmental control etc. An early process of supplier engagement and horizon scanning will also support the development of a clear understanding as to the likely evolutionary changes to equipment. Furthermore, considering the future management, maintenance, and replacement of complex equipment is also an important component of developing the design, equipping, operational, and maintenance strategies in parallel from the outset.

What has Leeds Teaching Hospitals done differently?

At Leeds Teaching Hospitals NHS Trust we’ve placed an equal importance on the progressive development of our Equipment Strategy and Equipment Plans to ensure that our proposals are integrated and comprehensive. Our approach has been to develop a strategy which not only considers what equipment we may need for our new facilities, but also the digital and Net Zero impacts of our equipment choices and future ambitions. So, what approaches have we taken?

Combining the knowledge and experience of the Trust’s internal BtLW Programme Delivery Team, with its clinical knowledge/visioning and internal specialist resources such as Infection Protection Control (IPC), alongside the specialist knowledge of external equipment consultants, has many benefits. External consultants are familiar with, and will be able to draw upon, a variety of equipping solutions developed and implemented across many projects — providing valuable experience to be combined within internal specialist clinical, operational, and equipment experience to develop equipping design strategies and solutions. The Trust’s internal BtLW Programme Delivery Team brings to the table the specialist knowledge of equipment models, preferred procurement strategies, clinical requirements, IPC and maintenance strategies, and financial solutions, while the external equipment consultants are fully conversant with different equipping solutions, and have the expertise to develop equipping lists based around equipment dimensions and weights. Together, this combined expertise and knowledge results in a successful solution. Finally, while local knowledge is important, the combined input and experience ensures effective and informed decision making and successful project delivery.

The BtLW Programme Team at Leeds has ensured that it embeds this resourcing approach — bringing together internal and external specialist expertise from an early stage in the project delivery — to support successful delivery, the goal being to minimise future delivery risk.

Use of equipment consultants

The Trust has been working with established specialist equipment consultant, MJ Medical, which has supported it in the preparation of its Equipment Strategy, Bill of Quantities (BofQ), Equipment Responsibility Matrices, and generic equipment specifications, and in the development of early design and operational strategies from an equipment perspective. Together, this information has proven valuable in informing the early design and business case processes.

The initial Bill of Quantities was produced using the NHS Activity DataBase (ADB) to identify the typical equipment needs of each planned space in the hospital. This is a useful baseline for developing the final equipment schedule in collaboration with clinical stakeholders as the design progresses. The BofQ in our project includes electrical outlets, gas fixtures, luminaires, chairs, tables, desks, storage, medical equipment, and mounting hardware etc.

Figure 1 highlights the key considerations for equipment selection, namely:

Considerations should start with a focus on the patient, taking account of their experience, along with how particular technology can improve service efficiency and productivity.
There needs to be alignment between the BofQ and the schedule of accommodation on a room-by-room basis to develop accurate equipment costs for the project.
The selection of equipment should consider the NHS Digital Strategy, innovation, and environmental impact, and other local matters — including maintenance, replacement, and IPC policies. Having this detail facilitates early 1:50 development, and supports standardisation and NHP design principles.
Collaborative input from clinical users, internal and external specialists, equipment suppliers, and contractors, is also important in identifying the equipment that will best support the planned activity, is clinically acceptable, and within budget.
Consideration of the range of funding sources available to be considered, such as capital, charitable funding, Managed Equipment Service, or rental. The optimum funding solution will depend on a variety of local factors and national influences, including the type of equipment, the level of investment, any requirement for ongoing maintenance, quantity sources, or the likelihood of advances in technology.

Equipment Strategy

The Project Equipment Strategy has been developed in collaboration with MJ Medical detailing the procedures, policies, processes and plans. The Equipment Strategy considers the process of identifying what equipment is suitable for transfer, how new equipment will be specified, selected, procured, and funded, and how / where it will be delivered/stored (on site or off-site), commissioned, configured, and made ready for user training and patient care.

The Equipment Strategy also describes who is responsible for selecting equipment, who will procure it, who will install it, and who will be responsible for ongoing maintenance and replacement in the future.

The days of considering equipment in isolation as a standalone item have now almost gone — with design, procurement, and commissioning decisions being replaced with the requirement for digital and building interfaces and an era of connected technology, plus an ambition for data collection, transmission, and storage. Modern medical devices are increasingly being designed and developed to integrate with the Electronic Patient Record (EPR), or use middleware to generate alerts to be sent to smartphones and digital display media etc., to provide results, share information, or to escalate a response to a patient in deteriorating condition. The interdependence of medical equipment and our digital ambition has led to strong collaboration between the equipment and digital workstreams, sharing the digital and data needs of medical equipment, and ensuring that they are specified and included in the digital infrastructure design.

Benefits of transferring medical equipment

It may be counter-intuitive to consider transferring existing medical equipment rather than purchasing all new, but I believe there are advantages, including:

Reduced impact on the project budget, and thus capital charges for new equipment.
Reduced capital charge write-off for disposed assets that are not fully depreciated.
Less financial impact on future capital replacement plans — no big spike in demand for capital funds in 7 to 10 years’ time.
Reduced commissioning resource for electrical safety testing, set-up / configuration time.
Less packaging materials to dispose of.
Less time lost for clinical user training, as users already trained.
Fewer deliveries to the new build — environmental benefits, traffic management etc, and less storage space needed.
Equipment maintenance already in place — ‘in-house’ team or contract maintenance cover in place.
Associated consumables already managed and stocked. Replacement will be part of the existing Trust capital replacement plan.

Competing demands

Leeds Teaching Hospitals NHS Trust, like many other Trusts, has many competing demands for limited capital funding each year. Purchasing new equipment with a high total capital value in a single year will place considerable pressure on the capital equipment replacement plan as the equipment reaches the end of its working life, or is declared ‘end of life’ by the original manufacturer. Although the working life of equipment is not standard for all medical equipment, a general rule of thumb may be 10-12 years at best. However, given the pace of technology evolution, the actual asset life could be much shorter, leading to a future multi-million-pound spike in demand for capital equipment replacement funding in a single year.

By only purchasing new equipment to meet increases in the bed base or to support service expansion, growth in the asset register, and thus the equipment age profile, can be better managed. However, all investment decisions surrounding replacement and transfer must be considered on a service and equipment-by-equipment basis, taking into account factors such as the age of the equipment, ability and ease to remove and transfer, costs of transfer, and potential service downtime.

It is important to align any new hospital equipment procurement plans with the existing Trust equipment replacement / procurement plan, ensuring that an agreement is reached on standard models for best strategic fit. Similarly, there is an opportunity to ensure that any new equipment selection made by the Trust during the design and build period of new hospital developments fits with the digital, connectivity, sustainability, and operational strategy of the new hospital build.

There are many lessons learned from the recent pandemic. Many Estates teams will be only too aware of the challenges of oxygen distribution, flow rates, and storage capacity that were experienced. Leeds is planning its new hospitals to provide sufficient bedhead services to permit the space to be used flexibly to meet future challenges and evolutionary changes in the delivery of healthcare. Standardisation of rooms in the new healthcare facilities will help to make patient rooms more versatile and adaptable in the future, and thus more cost-efficient, with an increasing focus on truly 60-year life hospitals.

Equipment stakeholders

When thinking about equipping clinical areas there are several stakeholders who should be consulted, and who will want to have input into equipment solutions. The most obvious of these stakeholder groups will be those staff who use the equipment and work in the area where the equipment is to be located. However, there are many staff who, with specialist skills and knowledge, must contribute to informing effective decision-making and, as already stated, a much broader range of personnel who may give input, including digital teams.

Examples of key personnel and disciplines who may effectively input into equipment decision-making and solutions include:

Clinical users — nursing staff, consultants, Operating Department Practitioners, and support workers.
Medical Physics personnel — with specific regard to specialist measures and policies, including radiation protection, and MRI safety.
Clinical engineering / Electrical and biomedical engineering teams — specifically to provide advice on internal maintenance / maintenance contracts, and routine calibration, as well as on Trust equipment makes and models, and clinical user training.
Estates teams — with specific regard to power supply, ventilation, water supply / filtration, drainage, specialist plant, and maintenance issues.
Infection Protection and Control, for advice on the suitability of materials such as worktops for drug preparation etc.
Back care specialists — for advice on moving and handling equipment and variable height workstations, for example.
Supplies and Materials Management teams — to support procurement strategies and processes, and with reference to future stock storage and consumables, and any impact for storage space requirements.
Pharmacy — with specific reference to drug storage, preparation areas etc.
Facilities — with specific regard to food preparation equipment, but also the general cleaning of equipment and support storage space requirements.
Informatics Teams — to ensure compatibility with Electronic Patient Record (EPR) systems, data storage, data protection, system connectivity, cybersecurity, and server capacity etc.

Transfer / move considerations

When transferring wards or departments, as part of wider hospital moves, and in line with the requirements of the Government’s New Hospital Programme, we should ask what we need in place on a new ward for the safe transfer of patients? It is usually necessary to have temporary equipment on the new ward during patient transfer periods. The type of equipment needed will vary depending on the clinical specialty of the ward and the condition of the patients being transferred. I would suggest that a crash cart with defibrillator and resuscitation equipment are in place, along with oxygen flowmeters, suction controllers, and some key consumables and drugs, as appropriate. For higher acuity areas, patient monitoring will likely also need to be considered through clinical assessment and the nature of the move itself. This equipment may need to be borrowed or hired for the duration of the move, and the associated costs factored into the equipment planning budget.

If the plan includes the transfer of imaging equipment, it is important to consider how the service will be provided during the decommissioning, move, installation, and re-commissioning phases. Is it possible or practical to hire a mobile unit for the duration? These costs need to be considered and factored into the project and equipment budgets.

Storage

Careful thought needs to be given to the storage of new equipment, and the timing of equipment deliveries, aligned to the equipment commissioning activity in preparation for the first patient. Whether storage is on or off site, security and storage environmental management are important. By transferring responsibility for the procurement of items such as desks and chairs to the main contractor, there is an opportunity to transfer risk and responsibility, reasonably enabling Trust teams to focus purely on the clinical equipment.

Having taken delivery and developed a commissioning plan it is important to consider waste disposal. Some suppliers use recyclable packaging, and can arrange to collect it from site, while others use disposable packaging that will quickly build up, particularly for major hospital building programmes. Waste materials are likely to be a mix of cardboard, wooden pallets, and plastic / polystyrene, and therefore arrangements should be considered with the principal contractor early during the design and construction planning phases, and appropriate requirements included in equipment tender specifications.

Having an Equipment Project manager from an early design stage is important from a clinical, structural, digital, and utility provision perspective. An early understanding of the equipment requirements of a new build, alongside the early development of delivery strategies for these requirements, will help to avoid expensive delays, changes, and other costs either during and/or after the build. Having a clear understanding of how the new build will be equipped informs the provision of service outlets, along with structural considerations such as floor loading, minimum ceiling height requirements, and stud positions in walls for mounting hardware etc. There is an interdependency of medical equipment on the digital design which should be understood and included in the digital architecture. Stakeholder engagement is invaluable for developing the equipment bill of quantities to ensure clinical suitability, and to inform a detailed equipment strategy that is ultimately needed for each stage of the project to support successful delivery.