Site for sore eyes

Cumberland Infirmary PFI

Carlisle's major PFI scheme was celebrated for its innovative bond issue funding mechanism, yet what of the building itself? James Parker reports on the progress made thus far.

The contract for the second major NHS PFI scheme, the L75.8m, 474-bed Cumberland Infirmary at Carlisle, was signed on 3 November last year. The long-awaited development was brought to its financial close rapidly, partly due to an innovative funding mechanism, but also largely thanks to the commitment from all sides involved to progress the scheme. This can not be unrelated to the fact that the completion date for the building is 14 May 2000 - an unprecedentedly short timescale for a hospital of this size.

The project is intended to rationalise services at three local hospitals; the City General, the City Maternity Hospital, and the existing Cumberland Infirmary, which is adjacent to the new scheme. A small part of the hospital services, serving radiotherapy, medical physics, dietetics, a Diabetes Centre and social workers, will be provided from refurbished accommodation in the existing Cumberland Infirmary (11000 m6sup 2^), directly accessible to the new building via a new link.

Inefficiencies present in the existing accommodation were one of the primary reasons for the scheme, which originally dates back as far as the 1960s - when in excess of a 1000-bedded hospital was planned in three phases. According to the trust's project director Miles Timperley, (who is also director of support services), "the City General was inefficient and quite wasteful in terms of energy, due to the nature of the building". Duplication of services was another problem identified, eg with two xray departments being provided, and clinical risks with the splitsite working of doctors and nurses that was necessitated. There was poor functional suitability, with building stock "of all ages," according to Timperley, "which is typical of the NHS". Commonly also, backlog maintenance was a huge problem which the new DGH is intended to at least ameliorate. Finally, mixed sex wards are a continuing headache for the trust, given the new Patient's Charter requirement, and its current Nightingale wards will be replaced by single rooms and five bed bays for flexibility in the new building.

The scheme which is currently under construction by Amec, and designed by Llewelyn-Davies, is believed by the trust to have a superior design to the public sector scheme, with more new buildings being provided, and the option of demolishing the tower block, which will not be required for NHS use. The design is intended to improve functional relationships between clinical departments in a high-quality environment, that exploits external spaces for physiotherapy and rehabilitation activities. There are two listed buildings on the site - the Doctor's Residence and the original Cumberland Infirmary, with its grand pillared entrance, and it remains to be seen how comfortably the massive new development will sit with these examples of grand architecture.

PROCUREMENT

The announcement of the scheme was placed in the

Official Journal of the European Community in January 1995, and 15 expressions of interest from PFI consortia were received by the trust. These were eventually reduced to three shortlisted bids - Swan Hill, Laing and Health Management Group, led by contractor Amec. The latter became the winning bid as the other two withdrew to concentrate on other PFI deals, with Laings for one having found it undesirable to take on too many tenders. The deal was negotiated during last year, and brought to a close rapidly, following the change of government and the introduction of legislation to clarify trusts' ability to enter PFI schemes, and the government's willingness to underwrite them. During the tight schedule that this scheme has been tied down to, 35 legal agreements have been produced.

Unlike the normal 60-year contract being used as the model for health PFI schemes, the Cumberland Infirmary lease is only 45 years, with a break for the trust at year 30. At this time, the building will either return to the NHS at a 'peppercorn' rent, continue to year 45, or be vacated by the trust. The latter is seen as unlikely.

The entire floor area of 44 000 m^sup 2^ includes 33 000 m^sup 2^ of new build. According to the trust and the consortium, Health Management Carlisle (HMC), the scheme "replicates the public sector comparator," in that it provides the same number of beds. This is due to "changing technology, plus the clinical drive for day surgery," says Miles Timperley. However the project does require an extra L390 000 per year from the North Cumbria Health Authority in order to plug its original affordability gap. However it is still believed to be better value over the standard 60 year period than either the "well developed" public sector funded scheme or the "do only the minimum" option. It will also provide expanded services in some areas, for example more theatres and renal facilities.

INTERNAL AREAS

The building consists of four pavilions, each with a courtyard, which are arranged either side of a large street-cum-atrium that runs the entire length of the scheme. The arrangement of the pavilions, looking from the air, resembles a half-open concertina with the departments and circulation spaces between the pavilions in a wedge form due to the fact that the pavilions are not parallel to each other. The atrium itself has a pleasantly uneven form also, being far wider at the main entrance, where the huge glazed wall at its end forms the orientation point for visitors, than at the other extremity.

Even viewing the building with only its steel frame and roof in place, it is easy to imagine the street being a bustling focus of activity, feeling like an open air thoroughfare with the space rising to four storeys. Three of the blocks are arranged over four storeys, and the remaining one over three, due to the sloping site. The ground floor is accessed by the main entrance, and there is substantial accommodation beneath on the lower ground floor, including pharmacy, CSSD, laboratories, mortuary, kitchen and dining areas, and physio, hydro and occupational therapies. HMC is looking at providing CSSD facilities for other trusts, to produce extra revenue for the Carlisle Hospitals Trust and the consortium. This lower level is served by a special access road to enable delivery vehicles to reach the rear of the building without disturbing the main patient and visitor routes to the entrance.

The relationships between departments, while standard - the eight operating theatres located above the A&E for example have been decided with the full participation of the clinical staff. They were required to sign off the 1:500, 1:200 and 1:50 drawings, in a process that took only nine months. Geoffery Plews, general manager of the project for the HMC's facilities management arm, Building & Property, says that the 1:500 designs were established "very early," and the 1:200 "was visited along the way". Designs for generic rooms, for example some areas in outpatients, and main theatres, were duplicated, once one was signed off.

The ground floor is predominantly "ambulatory" accommodation - medical investigation, fracture clinic, obstetrics and gynaecology, rheumatology, ENT/audio, radiology, A&E, endoscopy, and, adjacent to the latter, day surgery. The first floor accommodates "hot" care departments, eg surgery, anaesthetics, and maternity, and the wards are placed on the second floor, with related specialties located near each other. In terms of engineering services, giant plantrooms cover the entire top (third) floors of the pavilions, with access only provided to Building and Property's FM staff.

CONSTRUCTION

The design and build contract has been formulated with its "edges taken off," says assistant project manager for Amec, Keith Breeze, though the process is by necessity contractor-driven. He adds "there has been a lot of consultation with the users - more than usual". One key to the speed with which the construction has gone up is the fact that the local authority has worked "as part of the team. There was no `them and us'," Breeze adds.

Life-cycle costing has been one of the chief values present in the design, and achieving the corresponding inevitable balance between cheapness and low maintenance long-term resulted in choosing "proven products". One of the more interesting details in the scheme is an inflated roof, similar to that used at the Chelsea and Westminster. Made of a Teflon-based material, it will cover the atrium but allow natural light to penetrate.

A salient endorsement of the positive atmosphere of cooperation that the project demonstrates, regardless of whether the finished project is an outstanding building, comes from Matthew Hall services engineer and deputy project manager Chris Vint. He says: "It's been very refreshing that everyone's working together - it's not just getting the cheapest services". One reassuring note of tradition is that the specifiers used Department of Health HTM and HBN guidance to formulate designs.

FAST- TRACK FLEXIBILITY

Apparently as a result of the contract being design and build, the detailed 1:50 design has not been finalised, but "it is not far away," says Timperley. The design will also be flexible post-completion, eg for changes in bed numbers. "If we want to increase outwith the present curtilage, that's covered [in the deal]," Timperley says. "We do have outline bed numbers for each specialty but that can flex," he adds. "The whole philosophy behind the design is flexibility because healthcare treatments will change over the next five years". A change in bed numbers "may be a cost to the trust," Timperley says however, "depending on the variation. We don't see a change during the construction phase, because it's so quick".

The scheme should be completed in 2000, and indeed the roof is already complete, but achieving the frenetic level activity necessary to finish on time, and thus safeguard HMC's lease payments, could be problematic. However Geoffery Plews says "what we hope is that there will be a parallelling of activity because of the fasttrack process". The detail for each department is being set "one at a time" however, due to "limited resources". Things that were likely to have an impact on the programme were done early, which is understandable. It will be "beneficial to the trust to have a short build programme," says Miles Timperley. In comparison to the PSC (public sector comparator), "there will be less decanting with the private sector case, due to the increased amount of new build".

The trust's main criteria within the payment mechanism for the scheme, which will be performance monitored by the trust, are as follows:

availability of building - the lease payment will be reduced if rooms are not available;

services - cost of items (variable)/service provision;

usage - the trust carries the risk of more patients being admitted than the agreed norm in which case its payments would increase.

The trust has agreed the full service output to be provided, as well as the matrix for monitoring performance. "Time will tell whether we've got what we want," says Timperley realistically.

FACILITIES MANAGEMENT

"The true test of PFI is the partnership," says Miles Timperley, and the interface between the trust and the Building & Property, will be where the scheme succeeds or fails on a day-to-day operational basis. Of the trust staff currently working in support services, 350 will transfer to Building & Property, and thus Health Management Group.

The trust says in its brochure on the scheme that "less [hotel services and estates] staff will be required for these functions as the new facilities will be smaller in size than the sum total of the current three hospitals". This is also the case with the PSC. However the trust adds that "it is hopeful that, with the natural flow of leavers and retirements, compulsory redundancies should be avoided". Support services staff are not the only ones to face a period of upheaval - clinical teams will be required to review their working practices to fit the new building.

Geoffery Plews of Building & Property says that his firm and the trust "need to work together for mutual benefit - this is a close liaison because it's not a normal short-term contract". The staff transfer is being done in phases, with phase one - the transfer of all estates staff bar one having already being completed. The sole estates advisor is being retained by the trust to provide an important part in the "informed client" role. Plews adds: "The term 'partnership' sounds glib, but what's not always recognised is that the consortia needs the trust as much as vice versa. A genuine symbiosis is the only way it can work".

The transfer over to what is effectively a new culture has been designed to be as smooth as possible. Says Plews: "My job is to ensure end users don't really notice the change". However, if need be, "there will be a mechanism for change" further down the line. He admits that "the usual client liaison route is removed, but we do of course talk to Miles". One requirement that the trust stipulated was for comparable pensions for transferred staff, which comes outside the remit of TUPE, and this has thankfully been achieved.

The consortium is putting its faith not only in the building contract to deliver, but also in the health purchasing structure of the area of Cumbria that the Carlisle Hospitals Trust covers. "The area has a very stable purchaser structure," says Timperley.

The expansion of primary care groups into a more powerful commissioning role however will create a new dynamic that the new hospital needs to be able to cope with, eg perhaps in terms of electronic patient records and discharge procedures. Plews says that "developments that the Government is trying to deliver are already happening here". Let's hope that the finished scheme will not only be ready in time but also able in its design to cope with what may be a very different NHS in the next century.

Copyright Wilmington Publishing Ltd. Aug 1998
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