Scottish Hospitals Inquiry

Health boards must ensure that in the event of any adverse situation that could affect the wellbeing of patients and their families, there is a communication strategy in place to liaise with this crucially important group. The Scottish Government should ensure that this liaison is supported in any overarching communication strategy it may wish to introduce.

Accordingly, in situations where the funding model or procurement route changes mid project, a risk assessment should be conducted to assess whether work done on the project up to that point is suitable for the revised project. The rationale for decisions taken in this regard should be formally recorded.

The party carrying out the risk assessment should be the party on whom the potential risk falls and which is in a position to mitigate the risk, unless there are sound reasons why this should not be the case. In the case of the RHCYP and DCN project that party was NHS Lothian, notwithstanding that it was Scottish Government that made the decision to change the funding route, and consequentially, the contractual model.

It is critical that a health board formulates and then presents its requirements for the key building systems in a proposed healthcare facility (its "brief") in terms which are full, clear, and unambiguous, and that that brief is finalised before a contract is signed and Financial Close is achieved.

While development of the design can be carried over to a later phase, clarification of the health board's brief should not be. The health board, in consultation with relevant stakeholders and its clinical and technical advisers, is best placed to identify which output parameters of key building systems are required for the particular clinical uses it intends for the facility and its constituent parts (and how these uses may change and develop). These should be specified by the board as part of its brief and not left to the judgment of the project company and its subcontractors during the design phase. Identification of environmental output parameters should not be regarded as a matter of design; design should address how previously determined environmental parameters are to be achieved, not whether they should be achieved. In determining what the specified environmental parameters should be, the board should follow the recommendations in Scottish Health Technical Memoranda, including SHTM 03-01, in their most recent versions (which can and should be regarded as statements of current good practice), subject to any derogations agreed in writing by, in respect of ventilation, the board's Ventilation Safety Group (VSG). In the event of a derogation being proposed, the relevant recommendation should be specifically identified, and the derogation should only be agreed where there is convincing evidence that the proposal will provide a degree of safety no less than if the recommendation had been followed. If a proposed derogation is agreed, the reasons for it and any limitations on its application should be recorded, all as is currently required by SHTM 03-01 Part A Interim Version (February 2022) paragraph 4.10.

While a health board should follow the recommendations of the relevant current Scottish Health Technical Memoranda (subject to duly agreed derogations) in formulating its brief, and it may, separately, choose to include a general obligation on the contractor to comply with Scottish Health Technical Memoranda, it should never rely on reference to such a general obligation as a substitute for presentation of the brief in the manner set out below.

The purpose of the brief is to ensure that the facility and its building systems meet the clinical requirements of the board. Accordingly, the brief should include, as a minimum, a clinical output based specification for departments or other areas having a clinical function, setting out the patient cohorts and activities which these areas are intended to accommodate, together with a schedule of accommodation identifying how areas are to be laid out and their adjacency to other areas. In addition, the brief should include documentation identifying the environmental parameters of all spaces within such areas, including the ventilation parameters. There should be precisely specified references to air change rates, pressure differentials, levels of air filtration and temperature, the specifications being set out either in room data sheets or in an environmental matrix which comprehensively and exactly identifies every space within the proposed building.

While, as a matter of contract, design responsibility may lie with the Project Company, ensuring that the health board's requirements are met should be regarded as a joint objective of parties to be arrived at collaboratively. Accordingly, the procurement process should accommodate a gateway meeting prior to Financial Close at which a common understanding of the health board's brief is agreed and recorded.

The evidence before the Inquiry from the public sector (including NHSL), and industry, indicated that a standard form of derogation for use throughout the NHS in Scotland would be beneficial. This would ensure that derogations are captured and recorded in a uniform way. This would result in consistent and uniform practices. It would also bring clarity to how and why a derogation is agreed and ensure that the approval of all parties is recorded in an appropriate and familiar way.

I would accordingly recommend that NHS Scotland Assure, in exercise of its guidance function, prepare and issue a suitable standard form for a derogation to be used by healthcare organisations throughout Scotland.

The precise structure of such a standard form would be for NHS Scotland Assure to determine, following consultation with stakeholders but, having regard to the evidence available in the report dated 10 June 2024 by the Inquiry's expert, Andrew Poplett, my expectation would be that it would be of the nature of a template for a readily accessible document held in a database or other digital file which records: the facility or operation which is the subject of the derogation and its current application; the provision being derogated from; the precise extent of the derogation; the reasons for the derogation; the predictable consequences of the derogation; and the mitigation put in place to ensure a degree of safety no less than if the relevant guidance had been followed. The standard form might incorporate or otherwise include a decision-making algorithm such as the questionsets prescribed for the HAI-SCRIBE process under SHFN 30.

A range of procedures now exists to help ensure health board projects meet appropriate standards. One is the NHS Scotland Design Assessment Process ("NDAP"). There is also a Sustainable Design and Construction Procedure ("SDAC"). In addition, there is the NHS Scotland Assure Key Stage Assurance Review (KSAR) procedure. These can be time-consuming and demanding to complete. There is a risk that they become unduly bureaucratic and focused on process rather than substance. It is important that they be streamlined, and potentially merged, to ensure they are thorough and robust whilst avoiding duplication and unnecessary delay and cost. They must be genuinely helpful to boards and cognisant of the commercial and other pressures likely to affect projects.

Consideration should also be given to how complimentary procedures - such as aspects of the HAI-SCRIBE process set out in SHFN 30 - can potentially be streamlined to avoid duplication with other processes.

It is important that common project errors are not repeated. One helpful step is to ensure health boards undertaking projects have information about such common errors, and that this information is clearly communicated to them. This would ensure that health boards are aware of such errors and thereby better equipped to avoid them. The information should be updated as new, significant errors are identified. It should be drafted to be genuinely useful, so should focus on material errors which, if repeated, would have a material impact, and for which there are identified solutions which are capable of being readily implemented.

I would recommend that Assure should consider, in consultation with relevant stakeholders, whether and how to provide health boards with more detailed information about common errors and issues experienced with projects than is currently provided. For example, while I acknowledge that the 2022 paper is currently being updated and that it may be intended for a quick and preliminary reference online, I would observe that the examples of lessons learned listed there are referred to in very brief terms indeed. While I understand that brevity is desirable, a list of problems identified by short bullet points provides little by way of learning as to why it was that the problems came about, how they could have been avoided and whether and how they were resolved. NHS Scotland Assure could develop its documentation on learning from common errors in these directions.

It is clearly desirable that a health board has the assurance prior to the handover of a new or refurbished healthcare facility that the facility's specialised ventilation systems have been independently validated by an Authorising Engineer as fit for purpose and capable of achieving the operating performance originally specified.

I accordingly recommend that, whatever the method adopted for funding, contracts for the construction of new hospitals should permit independent validation by an Authorising Engineer, appropriately witnessed and with safeguards for all parties. The independent validation should be undertaken on behalf of the health board in accordance with the guidance contained in SHTM 03-01 (2022) with a view to a report or reports being sent to the health board's lead project manager.

In making this recommendation I acknowledge that simply to permit a healthcare provider to carry out independent validation, does not necessarily bring with it any contractual consequences in the event of failure to meet requisite standards; it is merely a way of providing the client with information. As a further step, I see merit in consideration being given as to whether the standard form of contract for revenue-funded projects requires more radical revision. Such revision would be with a view to strengthening the healthcare provider's power to ensure that the completed facility is fit for purpose and constructed in accordance with the healthcare provider's requirements, before the provider accepts handover.

I accordingly recommend that priority be given to protecting scarce IPC resources. With that objective in view, what is expected of consideration and advice from individual disciplines at various stages of a project should be made clear. Job and role specifications for various disciplines, particularly IPC should be similarly identified. I acknowledge that work which may achieve these objectives is already underway. NHS NSS is currently in the early stages of producing a replacement for Frameworks Scotland 3, the primary procurement vehicle for major capital projects, and expects to further consider roles and responsibilities as part of this work, in collaboration with stakeholders. The Inquiry heard evidence that NHS National Education Scotland is working on a knowledge and skills framework for the built environment. The Chief Nursing Officer advised that it is proposed to produce a role specification for IPC teams. I recognise too that at a project level, it is the responsibility of the senior responsible owner, project director and project board, committee or steering group to define the specific roles, responsibilities and project governance. This should be done when setting up procedures such as the Project Initiation Document and Project Execution Plan.

More generally, consideration should also be given to whether there are sufficient IPC professionals to resource the current system. It is less than satisfactory to impose further duties on a service which is already over-stretched. Several witnesses raised concern about there being insufficient IPC staff to implement the procedures introduced by Assure. As is obvious, if there are insufficient personnel to resource the system, it will not work effectively.

I accordingly recommend that a similar procedure should be considered when technical advisers (particularly engineers) are providing specific technical advice in relation to a project such as the RHCYP and DCN. There should be a clear record of the advice requested, and the advice tendered. This should ensure that there is clarity around what expert input advisers are providing in circumstances where such input is required. This is particularly important where, as on the RHCYP and DCN project, the technical advisers work closely day-to-day with the health board's project team and are engaged in commenting on design or construction proposals. Such arrangements can lead to informality and a lack of clarity about the scope and role of the advice, and the reliance which can be placed upon it. In contrast, the approach I recommend should be such as to generate a sufficient body of evidence to support and document relevant decisions. This should contribute to more robust governance and oversight of decision making.

This issue was highlighted in the Grant Thornton report where similar recommendations are made to what is set out above. NHSL has taken steps to address the issue. However, it is not clear from the available evidence that any such changes have taken place more widely within the NHS. I accordingly recommend that a uniform policy or procedure should be adopted for health boards undertaking new build hospital projects in relation to obtaining, and recording, technical advice on key issues.

I would recommend that IPC professionals should receive some basic training on the recommendations made by the NHS's own guidance for engineering systems, insofar as they are made in the interests of patient safety and care, before they are recruited to work on large scale hospital projects.

Similarly, engineers would benefit from basic training on infection control principles and clinical requirements before embarking on new build hospital projects.

Clinicians involved in projects would also benefit from basic training in the recommended output parameters of building engineering systems which have a direct bearing on the safety and care of patients in their departments.