MMC and the New Hospital Programme: unlocking the limitless potential of prefabrication

The UK government’s Construction Playbook and MMC may be must-haves on the New Hospital Programme in England, but the construction industry is arguably not yet ready to deliver MMC at scale or pace. For this reason, there’s a danger that expected cost and programme benefits will not be realised. Faced with this stark reality, it’s up to designers to think, act, embrace and implement MMC in a way that ensures the construction industry and ultimately the NHS, get value for money, argues healthcare engineer Adam Bradshaw.

With 48 new hospitals in the pipeline and an immediate investment to the tune of £3.9 billion, it’s no wonder that the NHS England team describes its New Hospital Programme (NHP) as the ‘biggest hospital building programme in a generation’.  With an ambitious delivery date of 2030 in place, the Infrastructure Projects Authority and the NHP team are looking to MMC to shift the build programme into top gear.

The use of offsite construction and prefabricated components on healthcare projects is not new. From fully modular pandemic response facilities to internal fitouts, the use of pre-fabrication has saved the sector time and money.  However, the NHP is unprecedented in size and scope – and this presents a potential problem, as the construction industry (and its supply chain) is not yet able to implement MMC at the scale and pace required. Progress is being made to invest and upskill, but designers recognise the utopian dream of a standardised approach that includes a library of components and widespread manufacturing facilities for prefabricated parts does not yet exist at the scale required.

Certainly, for those hospitals currently in the detailed design stage, there is a danger that MMC could be shoehorned into the design to increase pre-manufactured proportions without due regard to project specifics or the wider construction market, and the much sought-after social and programme benefits that we all seek from MMC will not be realised. It’s up to healthcare designers to bridge this gap between expectation and reality to make sure that the NHS gets value for money not only on the first wave of hospitals, but also across the future pipeline, so that it can take delivery of all 48 hospitals on time and on budget.

To navigate this challenge, AECOM is taking a strategic approach in our work on the first wave of NHP hospitals, which we hope will inform best practice on future phases. This article examines that approach in greater depth and explains why it is necessary in the current climate.  We also discuss steps the construction industry could be taking to get the most out of prefabrication on current and future NHP phases, which has relevance across the wider pipeline of government-commissioned work.

Current context

By placing  MMC at its heart, the NHP is following the best practice outlined in the UK government’s The Construction Playbook. The playbook was published in December 2020 and contains government guidance on sourcing and contracting public works projects and programmes across 14 key policies, of which MMC is one.  To ensure the best practice guidance is applied consistently, government departments and arm’s length bodies are required to adopt the policies on a ‘comply or explain’ basis.

Significant progress has been made in other sectors in adopting MMC principles and realising the benefits that this brings. However, a step change is needed to support the future 48 hospitals so they can comply with Construction Playbook best practice. The NHP has begun early engagement with the construction industry supply chain to create “new standards to help standardise the design of new hospitals and make use of modular construction methods to speed up the build”.

This will only succeed if the project management, cost management, and design teams educate clients, so they understand the benefits committing early bring to ensure the true value of MMC is unlocked.

However, the approach taken on the NHP hospitals currently in design does not propose a change in design process. The more measured approach requires engineers to evaluate how pre-fabrication is implemented into these projects to increase MMC adoption by recognising current constraints and utilising the existing supply chain to maximise benefits.

Maximising the benefits of MMC

How engineers and designers respond to the challenge on the first wave of hospitals has implications for the future pipeline, as it presents an important opportunity to influence thinking. To do this, our specialist healthcare teams have been drawing on experiences from schemes where MMC is at a similar or more advanced stage of adoption such as Clatterbridge Cancer Centre and The Grange University Hospital. Below, we list our recommendations.

1/Taking a system-agnostic approach

Through the application of MMC on the hospitals that have already been built, we have seen significant benefits from an increase in construction quality through factory-controlled processes and improved health and safety through to the reduction in material wastage and the potential for reduced carbon emissions.

However, designing for specific MMC types narrows markets, lessens competition, and increases risk in the event of failing contractors. By contrast, a system-agnostic approach that encompasses all MMC typologies drives competition, increases innovation, and embeds efficiencies and benefits regardless of construction techniques.

We must also consider the wider implications of increasing MMC to make sure the specific systems are used appropriately. It is a mistake to focus solely on maximising proportions as opportunities can be missed and inefficiencies can be introduced. For example, on a refurbishment project for an operational hospital, designing in modularised risers purely to increase MMC proportions would lead to increased embodied carbon for the module frames, and slow progress on site to thread the risers through a warren of existing services.

2/Embedding MMC principles right from the start

Early decisions made by the client and design team can either limit or increase the opportunities afforded by MMC.  Unravelling designs to accommodate MMC at a later stage is inefficient and often problematic. MMC principles must be baked in at the start of the project so that they guide the design.

Doing this successfully involves developing a full understanding of the project and constraints. Individual project characteristics vary significantly – from topography to location and from refurbishment to new build schemes – so a thorough understanding will inform how and where MMC can be incorporated effectively.

Furthermore, optimising the design for MMC should be done without stifling creativity or compromising functionality. Working with the NHP advisors and committing to collaboration across all NHP schemes through sharing expertise and combining knowledge is critical.

3/Engaging with the supply chain

The supply chain is evolving rapidly due to the government’s drive to embed MMC across its public sector programmes, but also in response to the pandemic, where off-site production is proving its worth over site-based activities.

Engagement with the supply chain brought tangible efficiencies to The Grange University Hospital in Wales. As the project’s building services engineer, we had taken a Design for Manufacture and Assembly (DfMA) approach right from the design stage, engaging with the contractor Laing O’Rourke and using its in-house component library. The resulting designs led to a 42-week (23%) programme saving and reduction in 237,099 working hours on site.  This was further improved to 52 weeks in response to the pandemic and a critical need for additional beds.  partial opening of the £350m hospital was achieved in April 2020, nearly a year ahead of schedule.

Ongoing engagement with the supply chain is therefore very important as understanding opportunities and constraints in this growing market can guide the designs. Given the imminent delivery of the pathfinder schemes. However, designers need to do this at an individual project level.

Further actions for the construction industry to take

Working with the Department of Health and Social Care, the NHS E/I and the NHP, here are three actions that the construction industry could take to improve MMC adoption of current and future phases.

Further engagement across NHP schemes. The gateways to allow projects to advance to the next stages and demonstrating a robust MMC strategy are now established. The NHS E/I have also begun to engage designers across the pathfinder schemes to find commonality or dissimilarity in their respective designs and gain benefit across the wider programme. Design teams must continue to collaborate and partner with the NHS E/I to drive wider MMC implementation across current and future schemes.  Without this learning process there is a danger future NHP scheme designs may have to be reviewed and reworked to increase proportions of MMC, which could delay delivery.

Collate data and a shared set of metrics.  Collating real-world data across sectors will be pivotal in informing future MMC strategies. Metrics on waste reduction, waiting times, transportation distances, skills uptake, quality and defects, health and safety records, cost, and programme can all be used to correlate the effectiveness in the increase of pre-manufactured value (PMV) and compare against MMC strategies. We must implement a common digital approach from design through to construction to facilitate this.

Review procurement routes. Future procurements and frameworks should support MMC with the development of a market and supply chain that can develop and deliver designs based on MMC principles, manufacture and supply components, and innovate to improve and develop over time.

Finding common ground

Ultimately, to get the most out of prefabrication, we would like to see the UK government adopt an open source approach that employs a library of components or ‘kit of parts’, a ready stream of contractors and prefabrication facilities to manufacture these components, as well as a reliable workforce. This would require government investment, incentives, plus a strategic approach across all government departments on major capital projects.

Until such time, designers, engineers, and contractors on the NHP must work together to find common ground to break down some of the barriers to rationalisation and repeatability that currently exist on the hospitals being built. If we take an open book approach to capture and share data, we can build on efficiencies from project to project for the greater benefit of the entire health service.