New age travel

Though it will be some years before the project can be fully assessed, it is evident that the architects of the Ambulatory Care and Diagnostic Centre in west London (first covered by HD in Jan '97) have produced a really fine building for this important new model of care. Peter Scher reports.

It would be preferable to forget the hype and just celebrate and enjoy the architectural excellence of the ACAD Centre but the former is too provocative to ignore. So before attempting to describe the unusually high quality of the building let us be provoked on a couple of issues.

ACAD, for those who still do not know, stands for Ambulatory Care and Diagnostic centre, and this new facility at the Central Middlesex Hospital in Park Royal, west London is the first of its kind for the NHS. Although it is on the site of the existing DGH it is designed to work quite independently of it. Nevertheless this facility "gives over 50% space savings compared with the traditional hospital departments" and is "a building capable of doing the work of a DGH two or three times larger" (Andy Black, Health Service Journal, 10 June 1999). Provocation number one; this comparison is meaningless without precise and independent evidence. In the same article the author states that "it will be many years before we have empirical evidence on ACCs." Instead of knocking down Aunt Sallys let's await the evidence instead of declaring this to be the "Holy Grail of health care" (Jeremy Melvin, Building Design, 28 June 1996).

This "trailblazing day hospital provides production line treatment for patients" and, according to the architect "the production line moves people quickly through the building" (Martin Spring, Building, 16 July 1999). The architect has also stated that "the physical design is merely a component of the re-engineering of the institution" (John Cooper, HD, Jan '97). Provocation number two; a hospital should be process focused, functioning as a flow system like a factory or a car repair shop, "a 'consumer' rather than 'Patient' model of service" (A Black, op cit). No: every patient is a unique human being and should be the focus of the best and most appropriate care available; we do not like to be treated as identical factory products for "pushing through" or even as cars with various mechanical and electrical defects to put right on a timed schedule.

According to David Ralphs of the British Association of Day Surgery: "It often gets overlooked that the internal repair and convalescence takes as long as it always has done." I feel quite sure that patients are given excellent and sensitive care at the ACAD Centre and the fine architecture quite simply contradicts the ugly image of a production line. It is unhelpful, at best, to discuss healthcare in mechanistic terms like this.

PROJECT STRATEGY

Nonetheless this is a building project for a truly innovative facility. Behind it is a shrewd strategy:

* a business case that cashes in on the most lucrative 'market', described by the health planners as "largely unthreatening procedures and a somewhat younger patient population";

* a no-cost-to-the-Exchequer project entirely financed by the sale of 'surplus' NHS land;

* a separate PFI deal for design, installation and maintenance of the high-tech medical equipment for use by the trust;

* revenue-earning "Business Suite" and a smart cafeteria as part of the project in a location hitherto without either.

Durrow Management Services was the health planning consultant for the project and the architect also acknowledges guidance from other specialists (Booz, Allen and Hamilton, CASPE). The building cost was L11.2m and, apart from areas in shell, areas subject to changed plans and the external works, was completed in about two years. The PFI contract with the giant italian company Impregilo was for L3.4m.

ACAD'S CONTENT

In broad terms the content of the ACAD Centre is as follows: outpatients and specialist clinics for consultation, diagnosis, medical intervention and dental surgery; x-ray and imaging departments for diagnostic work; an operating department of four theatres (with a fifth theatre in shell), two endoscopy rooms and an interventionary imaging room; recovery area with 18 trolley spaces, a 10 bed recovery ward for the not-so-ambulant patients who may need to stay overnight to recover, and a recovery area for children (a change, not yet completed, from the postanaesthetic recovery room originally planned).

This scale of provision is clearly what makes the ACAD Centre such an important innovation by comparison with the initial wave of day care centres. The speed of development in these services has been very rapid since the two volumes of HBN 52 were published (see HD, Sept '93). Adaptations of existing hospital buildings were followed by new purpose-built extensions or Nucleus templates, but all were departments of a large hospital. Now completely freestanding large day care centres, more independent but still at hospital sites, are appearing (eg HD, Sep '96 and Mar '99), perhaps given a filip by the tempting possibility of future privatisation (the previous government's preference, not yet revoked). Especially significant at the ACAD Centre is the inclusion of the most advanced imaging services and their integration with surgery and other interventions.

PLANNING

The site is a right-angled triangle in shape on the new boundary of the existing hospital's site formed by Central Way. At the end of the last century the original county hospital was set in rural Middlesex but was soon enveloped by the growth of the city. The countryside has long gone, replaced with the Park Royal industrial zone. Substantial factories and the busy roads that serve them surround the hospital now. In this debased environment with its high incidence of crime and vandalism, the only challenge to the architects was to create a building sufficiently distinguished from its neighbours to gain some respect. They have achieved fay more than that with a work of architecture that fully justifies a trip to Park Royal simply to see it.

The building's outline fits the shape of the site, a cental double-height mail dividing the accommodation into two different two-storey formations. They diverge from the entrance hall to occupy the spaces beside the two long sides of the triangle. This is completed on the short side in widening its form, achieved by inserting two internal garden courtyards, resulting in an approximate Y-shape.

The mall runs from south (entrance hall) to north. To the west of it following the boundary with Central Way is the high-tech accommodation - x-ray and imaging on the ground floor, theatres, endoscopy etc on the first floor. A third floor here houses the engineering plant. At the north end of this side is the service bay for deliveries and disposals, with staff changing and common rooms on both floors.

On the east side of the mall are the clinics and medical day care suite, ACAD's profile following the direction of a new site/access road between it and the existing hospital buildings. At first floor above are the reception, preparation, recovery and pre-discharge areas linked by bridges over the ground floor mall to the surgical departments.

FLOW PATTERNS

This is a clear and rational organisation of key elements, a sine qua non of good architecture. But it is also meant to reflect and facilitate the 'flow system' dealing (eventually) with 17 500 full consultant episodes a year.

On arrival a thin flat slab canopy on a block wall is seen projecting from the east side of the building to identify the entrance near the southern end. When the large name sign is in place this will be more easily recognised as at present the elegantly curved end of the building is clearly the cafeteria with the sign "Costa Coffee" over its entrance doorway and, on the paved terrace in front, tables and chairs.

Through the glazed doors of the entrance lobby one then enters the double-height space of the grand entrance hall. This is richly complex in form, resolving the meeting of curves and angles of several elements. Facing the entrance is the reception desk where patients check in. Behind it is the scheduling office, the nerve centre of ACAD where staff arrange and monitor the flow of patients through all the services using the software scheduling package that interconnects all its components. These staff advise patients where to go first, which will be to one of six destinations along the mall. Large (1.5 m high) bold numerals 1 to 6 make these places unmistakable down the wide mall which opens to the right of reception. Five of these are on the ground floor, x-ray and imaging to the left, consulting suites, clinics and dental surgery on the right. The sixth is on the floor above, its prominent numeral on the wall at the top of the open stairway.

For one-stop visits to the five ground floor sections, eg consultation, dental treatment or a diagnostic x-ray, the patients will leave by returning to the main entrance; otherwise, for further services they will be directed as appropriate, The important flow however is for all day patients undergoing surgery or other significant intervention. They are directed to the first floor up the main stair or via the adjacent lift to arrive in the middle one of three bars of the 'E'shaped layout to the east of the mall. This bar has the reception and pre-op areas where all patients are prepared for their procedures. When ready they are taken across a bridge corridor to the west side's high-tech departments which are off a broad corridor parallel to the mall below. After the procedure the patients, on trollies, will be taken back across one of two other separate bridges to recovery wards in either the top or bottom bar of the 'E' When recovered, patients from both units proceed along the upright of the 'E' to the middle where lift and stairs descend to an exit on the site road.

Clearly the plan enables a satisfactory flow system without inhibiting staff movement. They can have no difficulty moving around this two-storey building which has four lifts and eight stairways. There is always some controversy about the sight of the operating rooms and their equipment causing distress to conscious patients when they enter. Also the sight of other patients immediately after their surgery and not looking too great can be upsetting when their paths cross as they must in this flow system. Considerations of this kind however are rarely decisive and the compromise is deemed acceptable.

ARCHITECTURAL QUALITY

Although judgement has to be withheld on the operational performance and some technical aspects of the ACAD Centre there need be no hesitation in giving high praise to the quality of the environment that will be experienced by its users. As we have come to expect from Avanti Architects the style is modern in the very best sense, unblemished by any trace of post-modern grotesquerie. The 'public' spaces are especially fine - a combination of generous floor areas, double-height spaces and inventive geometry. The waiting areas on the ground floor are unobstructed expansions of the entrance and the mall and enjoy the prospects of the internal courtyards and a garden at the north end of the building through fullyglazed walls that, together with the continuous glazed roof above the mall, flood all these 'public' spaces with daylight and views.

At both floor levels the clinical areas on the east side of the mall and the staff rooms at the end are also beside the courts and garden. Other windows on the first floor overlook the double-height spaces giving intriguing views and providing orientation within this interior. Space, geometry and daylighting are not of course the whole story. The materials, textures and colours of the built forms play their part in creating the fresh and optimistic character which is totally modern. Walls, ceilings and glazed wall framing are white here, with some key wall areas picked out in colours such as ochre and terracotta; beech joinery is light and sunny to look at, too. Pale terrazo flooring in the mall meets dark carpetting in waiting spaces while working areas of the building have blue linoleum. Structural columns are in smooth pale grey concrete.

There is no art project as yet, save for a small temporary display of Avanti's design sketches in the mall and the imposition of muzak in some regions of the building. With this quality of architecture the need for visual enrichment is not overwhelming but the opportunities are there for work sensitively and professionally introduced. The high-tech interiors however are relatively joyless. This solid block of accommodation has one exterior wall to Central Way. Its design is understandably 'defensive' with only glass blocks or highlevel windows for daylight to rooms on this elevation. The majority of rooms in these areas are inboard and windowless. Doubtless the fierce demands of incorporating all that high- and low-tech gear have been met but I feel that the challenge of making these spaces into agreeable working environments for staff, not to say rather less than threatening places for conscious, ambulant patients, has not.

EXTERIOR

The 'defensive' elevation to Central Way is nevertheless well-designed. The lower floor is in buff blockwork with panels of glass blocks; freestanding terracotta-coloured concrete columns support the overhanging upper floors which are metal-panelled in white. Vertical service ducts, clad in cedar boarding are 'expressed' as projections from the the face of the upper floor (as they are, in white, in the mall).

This elevation's north end is at the apex of the triangular plan whence the adjacent side continues as a generous curve. Again the ground floor columns are exposed before the glass block wall of the cafeteria - but the overhanging upper floor here and throughout this flank of ACAD is in the buff reconstructed stone blockwork. Beyond the entrance and its canopy the form has a profile articulated by three of the building's stairways. Their design, all glazed, with black framing in horizontal pattern, is an hommage to the famous 1926 Bauhaus at Dessau by Walter Gropius and Adolf Meyer, a revered masterpiece of modern architecture. Completion of the landscaping around the building will also add beauty to this fine composition.

The innovative healthcare services at ACAD promises much for the NHS of tomorrow but the architecture is already delivering high quality positive experiences for the patients, staff and visitors today.

Client: North West London Hospitals NHS Trust

Floor area: 8000 m^sup 2^

Cost: L11.2m

Planning consent: Mar '96

Tender accepted: Jun '97

Completed: Mar '99

Open to patients: Jun '99

Architect: Avanti Architects

Services Structural Engineers: Ove Arup & Partners

Cost control: James Nisbet & Partners

Landscape architects: Elizabeth Banks Associates

Contractor: John Laing Construction

Copyright Wilmington Publishing Ltd. Oct 1999
Provided by ProQuest Information and Learning Company. All rights Reserved