arup in healthcare 2013

7/28/2019 Arup in Healthcare 2013

1/76

Collaborating globally

Arup in Healthcare


2/76

Arup is the creative force at the heart of many of the worlds most prominent projects in the builtenvironment and across industry. We offer a broad range of professional services that combine tomake a real difference to our clients and the communities in which we work.

:HDUHWUXO\JOREDO)URPRYHURIFHVLQFRXQWULHVRXUSODQQHUVGHVLJQHUVengineers and consultants deliver innovative projects across the world with creativity and passion.

)RXQGHGLQZLWKDQHQGXULQJVHWRIYDOXHVRXUXQLTXHWUXVWRZQHUVKLSIRVWHUVDGLVWLQFWLYHFXOWXUHDQGDQLQWHOOHFWXDOLQGHSHQGHQFHWKDWHQFRXUDJHVFROODERUDWLYHZRUNLQJ7KLVLVUHHFWHGLQHYHU\WKLQJZHGRDOORZLQJXVWRGHYHORSPHDQLQJIXOLGHDVKHOSVKDSHDJHQGDVDQGGHOLYHUUHVXOWVWKDWIUHTXHQWO\VXUSDVVWKHH[SHFWDWLRQVRIRXUFOLHQWV

7KHSHRSOHDW$UXSDUHGULYHQWRQGDEHWWHUZD\DQGWRGHOLYHUEHWWHUVROXWLRQVIRURXUFOLHQWV

We shape a better world

+RVSLWDOGHO1RUWH0DGULG6SDLQ_ John Fass


3/76

Arup in Healthcare Collaborating globally 4-5

Planning todays estate to meet tomorrows needs 7-12Phil Nedin Global Business Leader, Healthcare

Revitalising ageing healthcare buildings 13-15Mike Durtnall UKMEA

Healthy sustainable cities: a roadmap to panacea 17-20Andrew Bradley Australasia

The co-existence of clinical activities and construction 21-24Alex Ramos, Mark Aitken Australasia

Designing a dementia sensitive environment 26-29Pam Turpin UKMEA

Maintaining operational continuity during change 30-33Darren Briggs UKMEA

ICU helps in building healing environment 35-40Dr Gerard Healy Australasia

Assessing the full carbon impacts of healthcare 42-45Paul Brockway UKMEA

Creating premises for indigenous Australians 46-49Doug Kingham and Rob Isaacs Australasia

Do single patient rooms reduce infection risks? 50-52Katherine Roberts UKMEA

Faade led upgrades revitalise older buildings 53-56Philip King UKMEA

Towards merging Chinese and Western medicine 58-61

Alice Chown and Elise Chan East Asia

No walls here a remarkable vision realised 62-65Georgina James Australasia

Pioneering in the new Poland 66-70Andrew Kozlowski - Europe

Sustainable health design needs a different approach 71-4Tyler Krehlik, Alisdair McGregor and Afaan Naqvi Americas

Contents

Arup would like to thank all clients, design partners and collaborators for their

support in developing the papers included in this publication.

These articles have been previously published in the Digest of the International

Federation of Hospital Engineering (2010, 2011, 2012 and 2013 editions).


4/76

Arup is not a healthcare provider, but Arups expertise supports the

delivery of high quality healthcare around the world. Through our broad

understanding of the healthcare environment, we have the expertise to help

meet the needs of patients, clinicians and administrators to benefit from

well designed facilities. We have experience of the approaches necessaryfor the delivery of both existing and new build projects. We expect our

multidisciplinary solutions to minimise infection, satisfy low energy

requirements, and create spatial flexibility to ultimately provide appropriate,

cost-effective and efficient facilities.

Arup has built up an enviable track record in the healthcare sector, adding

value to over 3,000 healthcare projects worldwide. Just a few of those value

stories are told here. These articles represent a fraction of the knowledge that

is embedded in the firm. They illustrate our information sharing ethos andreflect the experience we bring as part of the delivery team, collaborating

with partners and experts internationally. Yet the really impressive part of

Arup is our people and their determination to stay alert to the new ideas

and new technologies through multi-disciplinary collaboration that will

allow us to go further and do ever more for our partners and, ultimately, for

the patients. As an employee-owned firm, Arup is in a unique position to

match the ambition and expertise of our people with the highest standards of

independent advice and strategic delivery.

I hope you enjoy reading about our work around the world in the field of

healthcare design, project management and business consulting. I hope you

also gain some insight into the values, the ideas and the technologies that

inspire us to shape a better world for healthcare professionals and patients

wherever they may be.

Phil Nedin Director, Global Business Leader, Healthcare | Arup

Collaborating globally

Arup in Healthcare


5/76

JohnFass

CharlotteWoodPhotography

DavidWakelyPhotography/A

nshen+Allen



6/76

D

reamstime

The estate can be a burden or an enabler to improvingQDQFLDOSHUIRUPDQFHDQGSDWLHQWRXWFRPHV7RGD\WKHUH

DUHPDQ\RSSRUWXQLWLHVWRLPSURYHH[LVWLQJDVVHWVWRSURYLGHPRGHUQDQGVXVWDLQDEOHIDFLOLWLHVWKDWPHHWQHZVHUYLFHUHTXLUHPHQWVZKLOVWRSWLPLVLQJVSDFHHQHUJ\DQGFRVWV

Arup supports trusts to reassess their healthcareIDFLOLWLHVDQGKRVSLWDOHVWDWHVWRXQGHUVWDQGWKHRSWLRQVDYDLODEOHWRLPSURYHFOLQLFDOSDWKZD\VPHHWVWUDWHJLFDVSLUDWLRQVDQGVDWLVI\EXVLQHVVREMHFWLYHVWKDWDUHH[LEOHIRUWRGD\VDQGWRPRUURZVGHPDQGV

&RQVXOW'HVLJQ'HOLYHU

ZZZDUXSFRPKHDOWKFDUH

,V\RXUHVWDWHZRUNLQJVPDUWO\IRU\RX"


7/76

Phil Nedin Global Healthcare Leader, Arup

RESTRUCTURING

www.arup.com 7

time, identifying healthcare costs and

potential solutions is becoming morecomplicated.

Much of the low hanging fruit hasalready been picked so we need to considerthe opportunities for savings as a series of co-benefits that is underpinned by a whole-lifecost based financial model. The potential fora single solution with a zero cost implicationto significantly affect the bottom line of ahealthcare system is a mirage. Applying multi-faceted, innovative solutions are the order ofthe day. Yet to transfer this early adopterapproach to a profession steeped inevidence-based outcomes can creatediscomfort, resistance and delay.

In global terms, the result is that costs canvary widely even in countries of similareconomic standard. Table 1 includes the costof some healthcare systems in different partsof the world.

Table 1 reflects the cost of healthcare perperson as well as the % Gross DomesticProduct (GDP) for some selected countries.GDP may be an acceptable metric foreconomists and politicians, but it does noteasily allow the consumers of healthcare tounderstand the cost implications of theutilisation of the system. This is importantbecause we are now experiencing a changingglobal disease burden where, for the first

time, more people (60%) are dying fromnon-communicable disease (NCD) thancommunicable disease. One result of thisshift is that it will be more important thanever for the public to take responsibility fortheir own health and manage their lifestylesto reduce their reliance on the healthcaresystem.

Healthcare requirements are changing

rapidly and these changes will have amajor financial and operational impacton the existing healthcare estate. Notonly are costs increasing, but there arepressures on estates to reduce costs,reduce size, become more specialised,integrate more with the community andreduce energy and carbon emissions.

In addition, the estate also has to deal withthe ongoing drivers of medical and scientificchange (Fig. 1). So, the challenge faced bydesigners and construction professionalstoday is how to plan the adaptation of the

healthcare estate to deal with the manychanges to come and communicate thesecomplex solutions to the clinical teams.

The only part of this equation that is fixedis the quantity and quality of the existingestate. Figure 2 illustrates the age profile ofthe National Health Service (NHS) estate inEngland. There can be as many as eightgenerations of building types in existence,with each generation having their ownspatial, environmental and constructionstandards, potential for flexibility andmaintenance liabilities. Many otherhealthcare estates in the world mirror thissituation. Firstly, we must consider some of

the changes that the healthcare estate will beforced to accept.

Healthcare under financial pressureThe financial burden of an unhealthypopulation was recently estimated by theUKs Department of Health in a report whichstated that the annual economic costs ofworking-age ill health could be over 100 bn.In short, a healthy population drivessuccessful business and has a substantialoverall benefit to the economy.

However, there is an enormous financialburden on countries that maintain asophisticated healthcare system. Given thecomplex evolving nature of healthcare,neither the costs of illness nor the benefits ofhealth remain static.

To maximise the benefits and minimisecosts, innovative solutions are required acrosseach of the drivers of change. At the same

There must, therefore, be a greater

understanding of the financial cost tothe system of doing i.e. smoking,alcohol abuse, poor diet and lack ofexercise and treating i.e. diagnosticscan, diabetes treatment, emergencyadmission and a bed day in an acutehospital etc. The changing diseaseburden will involve a radical shift in theapproach to population screening,treatment, medication and monitoringwith the inevitable changes to thehealthcare estate of scale, acuity anddistribution. These being underpinnedby information technology systemsconnecting between acute centres,

acute centre to community andcommunity to home. This willundoubtedly require significant shortterm investment to ensure long termbenefit which, at a time of globalfinancial constraint, will be a challenge.However, the alternative is aninefficient healthcare delivery system.

Phil Nedin

Phil Nedin is a Chartered Engineer and a Director of Arup, responsible for its global healthcare

business. This role has taken him to many regions in the world to investigate best practice

solutions in healthcare engineering.

Phil has been with Arup for more than 23 years, currently based in the London office.

Previously, he worked for the National Health Service in a regional health authority designgroup in London.

Phil is a past President of the Institute of Healthcare Engineering and Estate Management

(IHEEM) and is currently on their international committee. In November 2011 he was awarded

the IHEEM Lifetime Achievement Award. He is also a Fellow of the Institute of Mechanical

Engineers and a member of the UK Department of Health design review panel.

We need to consider

the opportunities for

savings as a series

of co-benefits that is

underpinned by a

whole-life cost based

financial model.

Planning todays estate tomeet tomorrows needs


8/76

RESTRUCTURING

8 www.arup.com

It is expected to reach 75 in 2050 as deathsbecome more concentrated in older age.At the same time, deaths from heart attackand stroke have been declining for more than50 years and the screening practices for anumber life threatening diseases have alsoimproved.

The result is that in 2012 we have 800million people over the age of 60 or around11% of the worlds population. By 2030 thatnumber is forecast to be 1.4 billion, or 17%,

and 2.0 billion by 2050 or 22%. Indeed,based on current trends, for the first time inhistory a higher proportion of people in theworld will be aged 60 and over (21.0%) by2047 than are aged under 15 (20.8%).

The increase in life expectancy anddeclining fertility has some profoundimplications for society. For example, theincrease in older people will drive a sharpdecline in the support ratio i.e. the ratio ofpeople of working age (15-64) versus thoseaged 65 or over.

At the same time, those living longer arevery unlikely to live free of illness. So, theincidence of chronic illness will be more

prevalent in the elderly. Also people with achronic condition usually have more thanone (multi-morbidity). For example, 50% ofover 65s have two or more chronic conditionsand 50% of over 75s have three or morechronic conditions, such is the complexity ofmulti-morbidity. This means that thechallenges ahead become even more complexand more expensive.

As we live longer our chances of sufferingfrom dementia increases. Indeed, with varying

The changing nature of diseaseWe have touched on the changingdisease burden as a major globaldriver of change for the healthcare

estate. At a United Nations meetingin September 2011 it was noted thatthe rise in NCD threatens thesustainability of healthcare systemsin high-income countries, as well asthe expansion of healthcare systemsin low and middle income countries.NCDs such as cardiovascular disease(CVD), diabetes, chronic obstructivepulmonary disease (COPD) andcommon cancers can often belifestyle diseases attributed totobacco, poor diet, physicalinactivity and the harmful use ofalcohol.

This, of course, begs anotherquestion why do we as a society dothings to our bodies that createssignificant long-term harm? Are wejust weak in the face of temptation? Are wegiven sufficient information about the risksinvolved? Are we the victims of peer pressure?Does the DNA of some have an inherentsusceptibility? Are we drawn in by slickmodern marketing? Government interventionwas successfully implemented with thesmoking ban in many countries and perhapsnow we need the same approach with theprice and availability of alcohol and clearerguidance on diets, particularly relating to the

balance of macro nutrients (fats, proteins andcarbohyrdrates).

What we do know is that the rise of NCDis going to move the goalposts in terms of thefacilities we need to deliver healthcare in theyears and decades to come. A study by theHarvard School of Public Health calculatedthat the costs of NCD plus mental healthproblems will total some $47 trillion over thenext 25 years about 75% of current globalGDP!

Given the sheer scale of the challenge,there is widespread agreement that ourcurrent healthcare systems are not going toadapt easily to changing needs. We currently

have systems that are by nature episodic,disjointed and acute hospital based. Thatmeans we have to think closely about thehealthcare estates we will need as the mannerof treatment shifts as shown in Table 2.

The ageing populationExacerbating the rise of so-called lifestylediseases is the impact of demographics.Global life expectancy at birth rose from47 to more than 67 between 1950 and 2012.

levels of acuity it may even become inevitablefor most people as they grow older.Worldwide, 35.6 million people live withdementia today and the numbers are set todouble every 20 years. The projections are65.7 million in 2030 and 115.4 million in2050. Alzheimers disease will also have asignificant impact on the UK economy in thenext 40 years. The projected increase in thosesuffering from Alzheimers is forecast to risefrom the current 700,000 to 1.7 million,

while the care period for Alzheimers sufferersruns from between 7 and 20 years.

In short, we must recognise that there is agreat deal to be done as we map out the long-term relationship between increasing lengthand the associated quality of life.

Patients of the futureThe good news is that we are at least makinga start. Patient-centric or patient-centredhealthcare are the new buzz phrases. Thisapproach allows clinical planners anddesigners of new models of care to focus onwhat is important. This is an essential firststep, but we must be aware that patients

come in many forms, both physically andemotionally. For example, healthcare systemswill soon be welcoming the first digitalgeneration as a bulk patient group. They willhave grown up on a diet of privacy and digitalcommunications. They will be adept atsearching the digital world for a diagnosis fortheir healthcare problems and engage withdigital self help communities. They willpossibly be as informed of the diagnostic andtreatment options as the doctors they visit.After all, the patient may have had two weeksto research their particular problem whereasa doctor in a primary care setting willtypically have 10 minutes or less to make adiagnosis and set a course of treatment.

That poses some interesting questions forpatient/doctor relationships. However, ingeneral, greater access to digital medicalintelligence has to be welcomed. Ifindividuals are going to be expected to take

The changing disease burden will involve a radical shift in

the approach to population screening, treatment,

medication and monitoring with the inevitable changes to

the healthcare estate of scale, acuity and distribution.

Figure 1: Healthcare drivers of change.


9/76

RESTRUCTURING

www.arup.com 9

infection, flexibility for more bedside

treatments, family and friends support, thefull use of digital systems and multi-culturalacceptability are all co-benefits of thischange.

There is a cost to this single bed roomprovision, with a new build floor areareducing the number of beds by 30% whenmoving from a multi bed ward to single bedrooms. This is reduced to possibly 50% whenthe transition takes place in a refurbishment

responsibility for their own health, then it is

good that they have the information to do so as long as that information is correct.

As well as being more tech savvy, thisfuture demographic is likely to be far moredemanding about their need for privacywithin the acute hospital environment. Thistrend is already happening, with single bedunits increasingly viewed as an essentialrequirement in hospitals and not just forreasons of privacy. Reduced spread of

project. This can, however, be offset by the

possible reduction of in-patientaccommodation in many countries, whichmay balance the equation.

We can therefore conclude that thesetrends point to some radical changes in howand where we deliver healthcare in the future.Whats more, the healthcare facilities we aredesigning and building today, given a typical60-year life will be in service to experiencethese new patient groups and the changesthey will bring to bear on the system.

Science and technologySo far the changes we have touched on havebeen financial, societal, public health and

demographic. There is, of course, a relentlessmarch of science to add into the mix.

Take the relatively new science ofmolecular biology, which has given us a deeplevel of understanding of the human bodythrough the sequencing of the humangenome. Understanding how we areconstructed at base level means that we notonly have the chance to gauge ourvulnerability to disease but also to predicthow the immune system might respond todifferent diseases and more crucially, totailored therapies. This may lead to morepreventative strategies and reducedattendance as in-patients.

A further scientific area of activity isnanotechnology. In terms of medicalresearch, there are opportunities here foradvanced therapies and drug delivery,innovative diagnostic imaging and structuralrepair. In the near future, the process of

Figure 2: Age profile of the NHS estate2007-2008.

Figure 3: Components of a modern acute hospital and the requirements for flexibility.

Table 1: The cost of healthcare.

Country GDP/Head Health GDP Healthcare cost/head

(US$) % US$

USA 47,150 17.9 8,439.85 6,680.69 5,297.02

Norway 85,390 9.5 8,112.05 6,420.17 5,090.46

Denmark 56,240 11.4 6,411.36 5,076.68 4,023.25

Netherlands 46,900 11.9 5,581.10 4,418.77 3,502.56

France 39,450 11.9 4,694.55 3,719.21 2,946.84

Sweden 48,900 9.6 4,694.40 3,716.74 2,946.09

Germany 40,120 11.6 4,653.92 3,687.12 2,907.87

Belgium 43,080 10.7 4,609.56 3,649.88 2,893.05

Australia 50,750 8.7 4,415.25 3,495.23 2,771.29

Ireland 46,170 9.2 4,237.64 3,355.10 2,659.44

Finland 44,380 9.0 3,994.20 3,162.20 2,506.84

UK 36,340 9.6 3,488.64 2,763.84 2,189.87

New Zealand 32,370 10.1 3,269.37 2,587.71 2,052.07

Italy 34,080 9.5 3,237.60 2,473.42 1,992.88

Spain 30,550 9.5 2,902.25 2,299.34 1,821.49

Greece 26,610 10.2 2,714.22 2,149.98 1,703.77

Portugal 21,490 11.0 2,363.90 1,872.49 1,483.86

Poland 12,290 7.5 921.75 730.13 578.59

SouthAfrica 7,280 8.9 647.92 512.87 406.66

China 4,430 5.1 253.93 200.98 159.37

India I,410 4.1 57.81 45.76 36.28

(Data source World in Figures 2013 Conversion $ to to Sep 2012).

HIGH

Hot floor(clinical diagnosis)

24%

Ward(hotel)27%

Office36%

Industry

13%

LOWClinical Operational Cultural Building standards

Decay rate over lifecycle

Probability

ofchange

SEGMENT YEARS %

1 2005Present 10.00

2 19952004 19.00

3 19851994 21.00

4 19751984 15.00

5 19651974 14.00

6 19551964 3.00

7 19481954 1.00

8 Pre 1948 17.00

1

2

34

5

8

76


10/76

the hot areas (diagnostic and treatment);the hotel accommodation (wards); theadministration (offices); and the industrialelements (laboratories, pharmacy, laundry,catering, etc). The need for change of each ofthese accommodation types was the subjectof work carried out in the Bouwecollege inUtrecht, Netherlands in 2005 (Fig. 3). Thismodel is very helpful in aligning functionalbuilding types with their need for flexibility,complexity of services and, ultimately, costdifferences.

However, since this model was developedthings have moved on and we must now

consider what proportion of each of the

radiation and chemotherapy as cancertherapies could even be replaced throughmore targeted nano-therapies. At the sametime, we may also see a new world indiagnostic imaging, using in vitro nano-cameras rather than large magnet-baseddevices.

The enabler for this technological changewill be the advances in computer sciencewhich continues to shape the medicalenvironment. Given that a typical mobilephone boasts computing power far in excessof the systems that carried Apollo 11 to themoon in 1969, we can easily predict that

much more is to come.What is clear is that the potential for

change within the healthcare environment isenormous. The manner in which diseases arediagnosed and treated could berevolutionised within 10 years and wouldhave a significant impact on the builtenvironment that supports the delivery ofhealthcare services.

The challenge then is that the buildingsthat we create today have to be up to the taskof meeting all these changes for the next60 years. We even need to ask ourselves theultimate flexibility question if this were nota hospital then what could it be?

Clearly, the health planners, architects andengineers charged with designing healthcarefacilities of the future need to understand thefull scale of the potential developments onthe horizon and plan sufficient flexibility intotheir designs to allow those changes to occur.

This long-term level of understanding willnot simply be gained through discussionswith local clinicians or patient user groupsalone, but by interacting and collaboratingwith scientists and clinical researchers.

The impact of changeon the acute healthcare estateSo, what does all this mean for the day-to-daybusiness of shaping healthcare environmentsthat will be fit for the future? Well, first of all,we can examine the basic model of how weapproach the problem now.

Modern acute hospital accommodationcan be divided in four main building types

functions will be carried out in thecommunity or at home and what could beoutsourced to local or remote third-partyproviders. This can only be ascertained by an

analysis of the future clinical and ancillaryservices to be provided, the models of careassociated with those services and theattitude towards public/private partnershipsetc. Only then can the accommodationnecessary to support the effective delivery ofthe service be fully considered.

In short, every healthcare estate will needa clinically led development control plan forthe short, medium and long term. It will alsobe essential that this plan includes all thesatellite facilities in the vicinity i.e. in-patient,outpatient, general practice and communitycare. This is critical to facilitate the futureadoption of a less centralised, more dispersed

service delivery model. This holistic approachwill be the basis of a vertically integratedsystem incorporating prevention, interventionand care, enabled by a powerful digitalintelligence platform.

Once we have fully considered the manycomplex changes that could occur over timeon the estate, we can turn our attention to thecondition of the building stock within thehealth estate at large. Given the complexnature of the problem, it is important that wehave planning models to help frame our multi-discipline approach to the building stock.One such model is the AssetMap (Fig. 4).This model was originally developed to guide

clients through the process of interrogating

Table 2: How health systems need to change to be better ableto prevent and manage NCD.

Current view Evolving model of careGeared towards acute conditions Geared towards long-term conditions

Hospital-centred Embedded in communities

Doctor-dependent Team-based

Episodic care Continuous care

Disjointed care Integrated care

Reactive care Preventative care

Patient as passive recipient Patient as partner

Self-care infrequent Self-care encouraged and facilitated

Carers undervalued Carers supported as partners

Low-tech High-tech

(Source Report on communicable diseases Imperial College London and Qatar Foundation 2012).

Priority AssetsWhich of your assets

offers the bestimprovement

potential?

AssetsOpportunitiesWhat retrofit

strategy offers thebest outcome?

Retrofit StrategyDevelop detailed strategy

including architecture,engineering, finance

and delivery

AssetMAP

Integrated Designand Delivery

Deliver the retrofitstrategy cost effectivelyand with minimum risk

PerformanceMonitoring

Use performance data to

drive continuousimprovement and to

inform portfoilio strategy

Understand MainDrivers

How can yourportfoilio best support

your business?

Figure 4: AssetMap an evaluation model to enable realisation of the potential of the existing estate.

RESTRUCTURING

10 www.arup.com


11/76

RESTRUCTURING

www.arup.com 11

the existing estate to maximise its potential.This makes the model ideal for re-calculating floor area requirements andbuilding adjacencies for a newly formed

estate that fits with the new clinicalrequirements and reflects the inevitableshrinking of the healthcare estate.

The opportunities are significant. Asthe estate shrinks, so the maintenance andenergy costs reduce. At the same time,land becomes available that can be usedfor other healthcare buildingdevelopments or used to provide greenspaces, healing gardens, or sold off to freeup capital for investment.

The model also tells us a lot about thepotential for maximising legacy and newhealthcare estates. If we take the NHS inthe UK, for example, we know that the

healthcare estate has developed over manyyears into a number of distinctive types.

Figure 5 illustrates typical buildingarrangements and relationships that havebeen used over the years to developcampus sites. These forms are expressed inmore detail in Changing HospitalArchitecture, (a Royal Institute of BritishArchitects publication). The structuralframe, floor slab details, wall construction,faade composition and building servicesrequirements are different for each form.Some of these forms and specific buildingtypes lend themselves to a reasonable levelof flexibility for the adoption of new

clinical functions while others do not.A further component of the constructionform is the effectiveness of the floor plateto accommodate a radical change of use.

Specific building types need to beanalysed to ensure that cost-effectiveupgrading can be carried out. The extentof the refurbishment can be as simple as aredecoration or as complex as multiplefloor extensions utilising new structuralframe, faade and building servicessystems: integrating multi-bed wards intosingle bed accommodation or creatingoutpatient clinics from existing in-patientfacilities. Whatever the project, it isessential that any upgrading review isconsidered with the potential to introducetherapeutic or healing environments.

Any revamped facility or healthcareenvironment should be developed toenhance the patient experience and allow

The prize will be

to future-proof our

healthcare systems

to enable effective

economic delivery

for future generations

of patients.

Figure 5: Different configurations of the acute healthcare estate.

1. Linked pavilion or finger planThe oldest typology and still in common use. The pavilions wouldoften have clinical spaces on lower levels with wards above.ExamplesWoolwich Hospital and St Thomass Hospital, London;Hotel Dieu, Paris; many others worldwide.

2. Low-rise multi-courtyard or checkerboardThis typology can offer a human scale in contrast to theinstitutional character that tends to overwhelm most hospitaldesign. However it will tend to apply to the larger, non-urbansites or smaller hospitals.ExamplesWexham Park Hospital, Slough; Venice Hospital (unrealiseddesign by Le Corbusier); Homerton Hospital, London.

3. MonoblockThe classic compact and circulation efficient type. The smallatria/lightwells can take many forms and the lower floors may havefewer, with deep planning for non-patient areas or operatingtheatres. There is a need for artificial ventilation and theopportunity to incorporate interstitial service floors.ExamplesGreenwich Hospital, London (demolished); Boston City Hospital;McMaster University Hospital, Ontario.

4a. Podium and slab/tower (also Bundles or Stacked in US)The wards are generally in the tower with the clinical and technicalarea in the slab. This typology can be effective on urban siteswith small footprinting but the upper floors can be problematicin terms of travelling distance.ExamplesBridgeport Hospital, Connecticut; Prince of Wales Hospital,Sydney; Royal Free Hospital, London; UCL Hospital (PFI), London.

4b. Podium with two or more towers/blocks over

This typology avoids some of the potential travel distance andscale problems of no 4a above but will require a larger site.ExamplesBirmingham Hospitals (PFI)

5. StreetThe attraction of this type has lain in its flexibility and extendibilityas well as the legibility that the street itself offers to patients.ExamplesWythenshawe Hospital, Manchester; Northwick Park Hospital,London; Westmead Hospital, Sydney; Rikshospitalet, Oslo.

6. Atrium/galleriaAtria have become extremely common in open plan office buildingswhere daylight can penetrate working floors from both sides.The cellular character of hospital buildings make atria a less obvious

solution but there are a number of successful uses of this typology.ExamplesNew Childrens Hospital, Sydney; Chelsea and WestminsterHospital, London; Hospital for Sick Children, Toronto; University ofMaryland Homer Gudelsky Building.

7. UnbundledUnbundled is a pattern of segregation of the diagnostic andtreatment functions on the one hard, and on the other the nursingfunctions along a shared circulation/support spine.Unbundled is a North American term and the typology isdominant in current design there; but it is also used worldwide.ExamplesNorfolk and Norwich Hospital; many US examples.

8. Campus

Individual buildings disposed around the site with or withoutenclosed circulation network.ExamplesHospital sites that have been built up over the years withsuccessive additions.


12/76

RESTRUCTURING

12 www.arup.com

future clinical and estate reconfiguration, aswell as with the multi-faceted changes that arebeing imposed by everything from newtechnology to novel gene therapies. Across allof this, we need to overlay the more practicalrequirements of site master planning, buildingby building analysis and project delivery.

The jump from strategic thinking topractical planning and delivery is never easy.However, with the changing healthcareenvironment we must think holistically toprovide the necessary cost-effective clinical

facilities that future generations can rely on.It is a multi-disciplinary approach where

technological and clinical scientists,engineers, medical practitioners, healthcareplanners, architects, cost consultants and

for future flexibility but just as importantly,it has to increase the performance efficiencyand effectiveness of the clinical staff. A wellexecuted new design or refurbishment hasthe added benefit of enhancing therecruitment and retention of the best staff bycreating improved external and internalenvironments. This is an important subjectgiven that there is already a shortage ofqualified clinical staff with aggressivecompetition for this rare commodity.

ConclusionThere is no doubt that the planning anddelivery of the future healthcare estate is anextremely complex subject. Necessarily, it hasto deal with the strategic blue sky approach to

constructors will be the agents of radicalchange.

It is a significant challenge, but the prizewill be to future-proof our healthcare systems

to enable effective economic delivery forfuture generations of patients. To dootherwise is unacceptable!

Acknowledgements Innovation Health and Wealth UK

Department of Health Improvement andEfficiency Directorate, December 2011.

Countering Non-Communicable DiseaseThrough Innovation Global HealthPolicy Summit 2012.

The United Nations High-level Meetingon the Prevention and Control of NCDs(New York, 19-20) September 2011.

Primary Care The Central Functions and

Main Focus Global Health PolicySummit 2012.

Changing Hospital Architecture RoyalInstitute of British Architecture (RIBAPublishing 2008).

It is important that we have planning models to help frame

our multi-discipline approach to the building stock.



13/76

Mike Durtnall Senior Consultant, Arup

RENOVATION

www.arup.com 13

for innovative ways to inject new life intoexisting buildings.

A good example of an organisation thatfaced these challenges is Guys and StThomas NHS Foundation Trust (hereafterreferred to as the Trust), a large teachinghospital serving south east London and

beyond and a founding partner of KingsHealth Partners, one of the UKs firstAcademic Health Science Centres.

Today the Guys campus is home to boththe NHS Trust and one of Londons leadingresearch universities, Kings College London(KCL).

At 143 m high and reputedto be the tallest healthcarebuilding in the world, GuysTower was designed byarchitects Watkins Gray andopened in 1974. The buildingactually comprises two towers,the User Tower, containing mostof the occupied space and theCommunications Tower,housing the lift shafts, risersetc. They are joined at eachfloor by a modest link bridge.The tower is occupied by a

How many of us have heard people

complain that their local hospital iscrumbling, dirty or unsafe. The reality isusually that the quality of care provided isexcellent. However, peoples perceptionsare often influenced by the condition andappearance of the buildings from whichcare is delivered.

Occupiers are faced by many challenges intodays healthcare market, not least theproblem of what to do about their ageingbuilding stock. Although some of the oldestbuildings with the most urgent needs havebeen replaced, large numbers of buildings

still in the use in the UK date back to the1960s or earlier. Many of these replacedearlier, Victorian hospital buildingsthemselves and at the time were welcomed asmodern, bright and spacious. After 35 yearsor more of service they are suffering however,both from deterioration of the building fabricand from the poor impression they give topatients, visitors and staff.

The economic downturn means thatcapital for investment in new buildings toreplace those seen as old and tired is in shortsupply, with financial markets taking a muchmore risk-averse approach when decidingwhether to invest and with public capital also

less accessible. In addition, lack of space todecant into, the need to maintain business asusual and avoiding disruption oftenconstrains the ability of healthcare providersto undertake a major new build. Theseproviders are therefore increasingly looking

Revitalising ageinghealthcare buildings

mixture of hospital departments, a dentalinstitute and teaching space and researchlaboratories run by KCL.

By 2008 the building facade wasexhibiting significant signs of deteriorationand the Trust realised that it needed to makea once-in-a-generation level of investment to

secure its future. At the same time, the Trustwanted to take advantage of theopportunities that this level of investmentoffered. It selected Arup, as a one-stop, fullmultidisciplinary team appointment, togetherwith sub-consultants Penoyre & Prasadarchitects, to help deliver its vision.

The economic

downturn means that

capital for investment in

new buildings to replace

those seen as old and

tired is in short supply.

An aerial view of Guys Tower.

Mike Durtall

Mike Durtnall, BSc, MAPM, joined the health

consulting team at Arup after spending nearly

10 years in senior posts at NHS Trusts in the

UK. In addition to leading capital planning,

development and property, he was Project

Manager on a PFI development.Mike is an experienced Senior Programme and

Project Manager and has worked on a number

of healthcareassignments both in the UK and

overseas. He was Project Manager for Guys

Tower from feasibility stage through to planning.


14/76

RENOVATION

14 www.arup.com

impossible to predict where they will occurnext. The deterioration is progressive,however, and if left unaddressed the risks tosafety and to operational and businesscontinuity would have become unacceptable.

In addition the windows, althoughdouble-glazed units, were at the end of theirworking life, with the frames in particularbeing badly corroded. Even though theoriginal thermal performance of the facadewould have fallen short of todays standards,

the condition of the windows and frames onlyserved to exacerbate the poor energyefficiency of the building, particularly underwinter heating loads.

On the pull side, in dealing with thedeterioration of the concrete and failingwindows, the Trust recognised that there wasa big opportunity to reduce cold bridging inthe User tower balconies and to makesignificant improvements in the performanceof the facade.

Improving energy efficiency, reducingconsumption and reducing carbon are on theagenda for all organisations and for the Trustin particular, which has a strong commitment

to sustainability and was already seen as aleader in the field of carbon management inthe NHS. The Trust therefore wanted to usethe Guys Tower project to make furtheradvances in this area.

Although the Trust was committed toinvesting a significant sum of money in theproject, this was conditional on achievingvalue for money. If sufficient paybacks on

The business caseThe value drivers that incentiviseorganisations like the Trust to consider thistype of project fall broadly into twocategories, what we might call pushes those factors compelling the organisation toact because failure to do so would result inunacceptable levels of risk to their business and pulls the opportunities that exist toimprove performance.

In the case of Guys Tower, the main push

was the condition of the concrete facade andwindows, but different approaches wereadopted for the User and Communicationstower facades. The User tower has ahorizontal profile with balconies wrappedaround all but the lowest levels faced withpre-cast concrete panels. These were inrelatively good condition for their age, buthad become badly stained through thedeposit of carbon and other particles in watertrickling down the external surfaces. TheCommunications tower is encased in an in-situ concrete profiled cladding forming adramatic vertical effect. However, theconcrete here was suffering badly from

spalling. The Trust had taken appropriatemeasures to manage this by undertakingregular, roped access inspections to checkthe spalls, break off loose material safely andseal. However, it was clear that this wouldonly be a short-term solution and thatsomething more radical was needed. Thechemical changes in the concrete that causespalling cannot be detected, so that it is

energy and carbon could not bedemonstrated in a business case, the TrustBoard of Directors would not allow theproject to continue. The Arup team were ableto achieve this through a process of thermalmodelling and analysis.

Energy consumption

The project was confined solely to theexternal facade and did not encompass thetowers building services and on this basis,the Arup building services team estimatedthat the project could only influence 18.5%of total energy consumption. 3D thermalmodels of the tower were built to assess thelikely impact of the faade design options.Individual room models were also built foreach facade to show the effects of the faaderefurbishment from a cooling plantperspective. Two separate models were built, abase model to provide a common comparisonpoint, and a refurbishment faade option,proposed by Penoyre & Prasad, which would

meet the latest thermal standards. Thethermal analysis indicated that re-claddingthe tower to provide this compliance wouldresult in a 7.6% reduction in annual energyconsumption, compared with current levels.

No project of this nature could be attempted without the

assistance and cooperation of the building users and the

clients asset management and operations staff.

Guys Tower is a good example

of what can be achieved with

the refurbishment of an old

building that would once have

been considered beyond

salvaging, or at the least not

worthy of the investment..An exploded view of Guys Tower showing the different sections of the buildings.

This image shows the concrete balcony panels

being cleaned. The impact this will have can be

clearly seen.


15/76

RENOVATION

www.arup.com 15

in the direction of a flexible design solutionbeing required. The design team also wanted

to provide a solution that would allow furtherimprovements to be made in the future, suchas the introduction of natural ventilationthrough mixed mode cooling.

For the Communications tower, the onlyrealistic solution was to repair the damagedconcrete and seal the facade in a new skinthat would prevent further deterioration andcontain any subsequent loose material. Adistinctive and bespoke profiled, anodizedaluminium rain screen cladding design wasselected. At the same time, Arups accessspecialists designed a new monorail cleaningsystem to replace the inoperative existing one.

For the User tower, having first stabilised

the concrete surface, a new thermal layer wasdesigned by Penoyre and Prasad. This highperformance layer will be placed in a line justin front of the existing columns to provide anew thermal line, up the building, tominimise thermal bridging.

Solar selective glass will be used to controlthe balance between solar gain insummertime (which adds to cooling loads)and natural light admittance, and willrespond to the orientation of each facade.

This innovative solution was designed to

Carbon reductionThe environmental impacts of the facaderefurbishment were assessed by Arupsfacades and materials specialists based on a

life cycle assessment (LCA) process to showpositive impacts from day one and how theseimpacts would be reduced in the future.Impacts against six environmental categorieswere assessed for six facade types and thenmultiplied by the planned area of each type.A carbon payback analysis was thenundertaken, calculating the initial carbonspend and the annual carbon savings,plotted on a graph. The results werecompelling over 18,000 tonnes of CO2would be avoided compared to a new build,over 8,000 tonnes saved over 30 years and acarbon payback point of around 12 years.

The challengesThere were a number of significantchallenges for the Arup team to overcome.Although all of the inpatient beds hadalready been moved out, there was no spaceinto which to decant occupiers and thebuilding had to remain operationalthroughout design and construction.Managing disruption would therefore be akey priority.

There were also considerable logisticalproblems to be overcome. Over time since1974, podium buildings and atria had beenadded and today the tower only touches theground externally on the western face of the

User Tower, so getting access to work on thefacades required significant temporary works.Planning contractors compounds would alsobe difficult in a congested, live hospital site.

ApproachAlthough the benefits had been established, apractical approach to design and delivery stillneeded to be developed. In the User tower inparticular, the need to minimise disruption,avoid intrusion into clean environments suchas the pharmacy manufacturing unit pointed

be fitted in front of the existing windowswhich allows them to be removed where

possible, or left in place until a futurerefurbishment, where removal is not practical.

The successful development of the designresulted from a partnership approachbetween the Trust projects and estates teams,the Arup team, the building users andspecialist supply chain members.

Successful deliveryNo project of this nature could be attemptedwithout the assistance and cooperation of thebuilding users and the clients assetmanagement and operations staff. The Arupteam began an extensive process ofstakeholder engagement at an early stage,

keeping them informed on progress at regularintervals, and this paid dividends in thelonger term. In order to plan the works at afloor and department level, questionnaireswere designed to gather as much informationon working arrangements, risks and hazardsas possible.

The project is currently on site with theappointed contractor. Due to the fact that thebuilding users will remain in occupationthroughout, for delivery of the constructionworks the overriding principle was to workfrom the outside wherever possible. The Usertower balconies facilitate this in part, butthere remain parts of the facade that require

working safely at considerable height andabove glass atria. Access is also difficult, butwith early design by Arups constructionplanners and final design of the substantialtemporary works by the contactor, a system ofgantries, crash decks, roof-mounted hoistsand wall climbers that will support delivery ofthe project has been developed.

ConclusionGuys Tower is a good example of what can beachieved with the refurbishment of an oldbuilding that would once have beenconsidered beyond salvaging, or at the leastnot worthy of the investment. By taking adifferent approach, not only will the Trusthave delivered an exemplar majorrefurbishment on an occupied building, itwill also have continued its remarkable recordin terms of reducing energy consumption andimproving carbon performance.

New faades for the Communications and User tower window bays.

The environmental impact of the facade refurbishment was assessed, based on a life-cycle assessment

process.

8,000

6,000

4,000

2,000

0

-2,000

-4,000

-6,000

-8,000

-10,000

Number of years

Carbonspent/saved(tonnesCO2e)

20212223242526 27 28 29 3010 11 12 13 14 15 16 17 18 190 1 2 3 4 5 6 7 8 9

Initial carbon spend

Paybackpoint

Total carbon saved


16/76

M

orleyVonSte

rnberg

0RRUHOGV(\H+RVSLWDO/RQGRQ8.


17/76

Andrew Bradley Arup

RESTRUCTURING

www.arup.com 17

issue and most of the developed nations ofthe world are facing a similar obesitychallenge. This indicator of modern lifestyleis changing the face of healthcare, resultingin rapid increases in chronic illnesses such asdiabetes and cardiac problems.

There is a clear link between obesity andchronic illnesses. In addition there is a directcorrelation with obesity, diet and exercise.

Unfortunately, the focus to date has beenon treatment rather than prevention. Atpresent, we are seeing unprecedented growthin healthcare spending in the developednations. Most of this expenditure is dedicated

Healthy, sustainable cities:a roadmap to panacea

to pharmaceuticals and maintaining orupgrading existing healthcare facilities.

The Organization for Economic Co-operative Development (OECD) countriescurrently spend a median of 9% of theirGross Domestic Product (GDP) on the

provision of healthcare. While this is a hugesum of money for countries to continue tofund, we should consider this against thecurrent spending of the USA which currentlysits at 16% of GDP.

If we look at an example in real dollars,Australia spends $103 bn ($4,120 perperson) annually on healthcare. The USA

The Organization for

Economic Co-operative

Development (OECD)

countries currently

spend a median of 9%

of their Gross DomesticProduct (GDP) on the

provision of healthcare.

Andrew Bradley

Andrew Bradley is a Chartered Professional Engineer with nearly 20

years in the construction industry. Throughout his career, he has

been responsible for the delivery a number of high profile projects,

both within Australia and internationally.

Currently he leads Arups Building Energy Services team inQueensland, which integrates all of the key engineers and specialists

required to design, manage and optimise buildings which are both

energy efficient and resilient.

In addition he also leads ArupsBuildings Healthcare team in

Australasia and has experience of best practice in healthcare design.

Figure 1: Schematic showing the city of the future with an integrated wellness model adopted.

Andrew Bradley offers a vision of some of

the options that could be adopted on acity-wide basis if wellness was to be trulyintegrated into the fabric of our cities inthe future to help reverse many of thecurrent global healthcare challenges suchas obesity and diabetes.

Globally, we are facing challenges on a scalenot seen before. For example, the globalpopulation is expected to grow by 50% by2050; we are experiencing a transition fromrural to urban communities; we are depletingour natural resources; there is an increaseddemand for resources from developing

nations; additional stresses are being placedon health services due to increasing chronicillnesses/lifestyle illnesses; there is additionaleconomic stress due to our ageing societiesand an increase in mental health issuesacross the age spectrum.

Our cities have developed and arecontinuing to develop in a reactionarymanner to accommodate these challenges.The same can also be said for the wayhealthcare is developing. Healthcareprovision has to react to the changing needsof the community it serves. For example,Australia, which is famed for the sportyoutdoor lifestyle, now has the fastest obesity

growth rate in the world, following fast on theheels of the United States in its obesity rates.

Australia is by no means alone with this


18/76

recommended daily fruit and vegetableintake. It is imperative that this is reversedand that children and young adults areeducated in the benefits to their futurehealth by eating fruit and vegetables. Recentresearch suggests that there can be up to45% reduction in risk from some cancers dueto eating a good daily quota of five-a-day.Further research indicates that encouragingyoung children to get involved with growing

their own vegetables can have a largeinfluence on them actually eating them.

Developing a culture where each personhas ownership of their wellness is alsocritical. People need to be informed on theimplications of poor behaviour patterns.We need to move towards a future wherepeople are aware of their wellness andillnesses and have easy access to the data fortheir own use and quick transfer tohealthcare professionals. The technology isnow available all thats missing is thewillpower!

Healthcare facilities are generally thoughtof as places you go to when you are ill, not

places to help you stay healthy and this is aperception that needs to change. Hospitalestates could be rebranded as WellnessCenters which include public gyms,swimming pools, healthy food stores,community gardening schemes and wellbeingawareness centers. If these facilities are to bea success they also have to be freely availableto all.

spend of $2,500 bn ($7,140 per person). It isclear to see which direction spend is drivenby Western societal consumption.

If the increase in ageing population is

combined with the increase in GDP, it isestimated that Australias spend onhealthcare will exceed 20% of its GDP or$500 bn by 2050.

This level of spending for treating illnessesis unsustainable and will impose a hugefinancial strain on the economy of a country.The potential scale of the problem is so largethat it is necessary to think outside of the boxif we are to find a solution. For example, whatif 1% of that spend annually was pushedtowards wellness rather than illness?

Healthier cities: by designA group consisting of Australias leading

healthcare practitioners, providers anddesigners were gathered together within adesign charrette to discuss what could bepossible if 1% of the annual nationalhealthcare spend was transferred to theprovision of wellness rather than thetreatment of illness. The focus was to developa sustainable solution, working towards theyear 2050.

The current estimated total spend onhealthcare between now and 2050 is $12.3trillion. 1% of this would be $123 bn. Anysolutions proposed had to be flexible enoughto cater for a range of scenarios from anexisting city with historic hospital

infrastructure to a new build acute hospitalon a green-field site, to a remote town in farnorth Queensland where there is a highproportion of indigenous communities.

For each scenario, the group workedthrough what could be achieved, within theavailable budget of 1% of annual healthspend. Four key challenges were addressed: Culture Masterplanning Healthcare facility design Low carbon solutions

Cultural changeLifestyle and cultural changes in Western

society is adding to the problem. Again, wecan turn to Australia as our indicator.Australians pride themselves on theirsporting prowess. This is well deserved as theyhave consistently punched above their weightin most sports. Historically, the image of atypical Aussie is a healthy sun-kissed being.In fact, in 2007, Australia had the thirdhighest life expectancy in the world. However,the average Australian is now overweight andit is estimated that 5% of the population willbe diabetic by 2020.

New arrivals to Australian shores are oftenastonished by the high cost of fresh foodscompared to other areas such as Europe andAmerica. These high costs prohibit somelower income families from providing theirchildren with a healthy balanced diet andthis is an issue that needs to be addressed.

The average Australian child (between2-16 years) eats a paltry 15% of their

Investment in the provision of suchfacilities would pay dividends with the long-term health of the nation and as such willreduce the cost of healthcare overall.

How the community is engaged with theWellness facility is a key issue. The publicneed to see the hospital as a good place tovisit and spend time. This would mean aradical rethink in how these buildings aredesigned and what other facilities are

included within them. There would have to bea dramatic improvement in the design of thebuildings to make them more welcomingplaces to spend time. This may includebringing in retail and recreational outlets.

Faith, which is often overlooked in thehealthcare industry, also has a role to play.Research carried out by Blue Zones(www.bluezones.com) suggests that faith-based communities tend to have a longer lifeexpectancy.

This is thought to be due to having asense of purpose and of belonging. Again,this would be another aspect which we couldbring to our Wellness Centers. It sounds like a

clich, however the centers could bebeneficial for the body as well as the soul.

MasterplanningHistorically, cities have evolved withhealthcare facilities in and around the centre.In addition, the cities have evolved somewhatseparately to suit the needs of business,largely ignoring the impact of the citysdesign on the wellbeing of its occupants.

In most cities, people movement occursvia car or public transport. The roads aregenerally so congested that people would notfeel safe cycling. In addition, most places ofwork do not have end of trip cycling facilities.Surveys indicate that the vast majority ofpeople would prefer to live and work in a citywhich has an exclusion zone for vehicles, onlypermiting people on foot or by bicycle. If wecould get people to build in naturalmovement and exercise into their daily

It is envisaged that

hospitals of the future

will be co-located with

universities and research

institutes.

Figure 2: We are experiencing a transition from rural to urban communities.

PeterHe

ad,

EnteringtheEcologicalAge

2008.

1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

7,000

6,000

5,000

4,000

3,000

2,000

1,000

0

Population(Millions)

Urban population

Rural population

RESTRUCTURING

18 www.arup.com


19/76

RESTRUCTURING

www.arup.com 19

workers that would wish to take a shower aftertheir short cycle/walk.

Healthcare facility designAs already discussed, there are major changesin the way we live our lives which will impacton the way that healthcare will need to bedelivered. The increase in chronic, cardiacand mental health illnesses over the next30-40 years will mean that a lot of the healthfacilities we currently have, or are building,will not be suitable.

As diagnostics, treatments and recoveryrates improve there will be less requirement

for in-patient accommodation. It is morelikely that, where traditional inpatientaccommodation is required, it will beprovided in distributed health centers andcommunity hospitals based out in thecommunities.

This then leads us to rethink the centralhospital model. It is likely that the city centrehospital will retain A&E, diagnostics andspecialist clinical services. In addition, therewill be stronger links with universities andincreased research.

Furthermore, with the semi-privatisationresulting from the move towards PPP delivery,there will be more collaboration with the

private sector particularly pharmaceuticalcompanies.

It is envisaged that hospitals of the futurewill be co-located with universities andresearch institutes. Given that hospitals tendto have large parcels of city centre land, thereis every likelihood that the Universities andprivate sector companies will relocate to whatwas originally the hospital estate.

routine such as cycling or walking the last2 or 3 km to their offices this would have amajor impact on the wellness of thepopulous.

Major hospitals are typically located in thehearts of towns and cities. As healthcarepractice changes and fewer beds are requiredwithin hospitals, there will be spare landcapacity on each site. These existinghealthcare facilities could become the heartof the new Wellness campuses. The hospitalwould, effectively, become a high-techdiagnostic, specialist treatment and researchfacility with a medi-hotel co-located on site.

This Wellness campus would contain end-of-trip cycling facilities, free gymnasiums andswimming pools. There would be an exclusionzone around the central hub, which wouldtypically be 5 km radius. At the 5 km

boundary, there would be multistorey parkingwhere people would commute partly to workby car and finish the rest of the journey bybicycle.

Figure1 demonstrates the model whereat the heart of the community, there is aspecialist acute/diagnostic/treatment/research facility. This facility would haveminimal patient beds as in-patient care wouldgenerally be provided in the distributedcommunity facilities.

The red zone indicates the outerperimeter of the city where general commutertransport is permitted. At this outer zonethere will be park & ride facilities where

vehicles can be parked and exchanged for abicycle or it is possible to walk into the centreof town. There would also be limited electricvehicular transport for people withdisabilities.

Also, at this outer perimeter, there wouldbe newly built sports centers incorporating arange of free facilities such as swimmingpools, tennis courts and gymnasiums.

The green zone indicates the no car zonein which there are only roads for emergencyand service vehicles. These areas are generallyclear and safe for commuters to enjoy theirstroll and cycle to their offices.

This would mean that people would

drive/commute to the outer perimeter eachmorning, park their cars in the park and ride,potentially take part in some form of sport orexercise and then complete their journey towork by bicycle or by foot. It is acknowledgedthat very few work places have end of tripfacilities, therefore a number of shower podswould be strategically located around the cityto provide adequate coverage for those

We estimate that the on-site inpatientaccommodation will be less than 10% ofwhat is normal today. However, there will bea much higher demand for hotel and short

stay facilities for visiting families, researchwork and clinical staff. Co-sharing of hotelrooms with minor surgery recovery suiteswill become commonplace, ensuringcapacity can fluctuate without impacting onthe patient experience.

The key to all of this will be completeflexibility in what we are designing today fortomorrow.

Other key issues, such as single patientrooms will also be addressed. The hugebenefits in terms of patient dignity, securityand infection control outweigh theperceived social benefits of multi-bed bays,which are preferred by the minority. This is

a debate we should put behind us, find thecapital expenditure to resolve it and moveon to the next challenge.

Recent studies carried out by FionaStanley Hospital (Perth, Australia) foundthat the extra capital expenditure requiredto provide an increase of 53% (23% to 80%)single beds was recouped in 3.6 years dueto the other savings gained in the overalltreatment process.

Further consideration has also beengiven to infection control and the impactthat hospital design has on this. A recentstudy into a number of hospitals inQueensland, Australia, established that over

90% of hospital facilities are served viaHVAC systems which recirculate largeproportions of air within the building in aneffort to save energy. Further analysis of oneof these facilities discovered that the actualamount of fresh air being delivered was wellbelow that which was required or that thesystem had been designed for.

In some cases, air was being recoveredfrom areas that are considered dirty andrecirculated to areas that are required to beclinically clean.

At present, typical healthcare designbriefs do not specify targets for IndoorEnvironmental Quality (IEQ). This is

something that needs to change. HVACsystems have the potential to greatly hinderor improve the cross infection rates within ahospital. It is essential that designers havethe adequate experience and knowledge toprovide solutions that ensure thecontinuous flow of fresh air from clean todirty zones.

Energy consumption is often cited as the

A hospital is one of the largest single energy consumers in a city. It has a unique load profile

with high daytime demands for cooling and evening demands for hot water. When this is

combined with the load profiles of offices, schools, restaurants, cinemas, etc, there are very real

opportunities to provide district energy schemes where the base heating/hot water load can be

generated as a by-product of the electricity generation.

Hospital estates could be rebranded as

Wellness Centres and integrate with more

community-based facilities and activities.


20/76

RESTRUCTURING

20 www.arup.com

load profiles of a hospital with those of othercity centre buildings.

A hospital is one of the largest singleenergy consumers in a city. It has a unique

load profile with high daytime demands forcooling and evening demands for hot water.When this is combined with the load profilesof offices, schools, restaurants, cinemas, etc,there are very real opportunities to providedistrict energy schemes where the baseheating/hot water load can be generated asa by-product of the electricity generation(Co-Gen). There are also opportunities toutilise district wide cooling schemes withchilled water storage.

If we go back to our proposed masterplan,the distributed Wellness Centers on theboundary of the no car zone could be nodeson a district wide energy solution. Depending

on the unique location of each Wellness

main reason for adopting recirculating HVACsystems, particularly in tropical and sub-tropical climates. However, new technologies,such as solar cooling and high efficiency heat

recovery systems, negate this issue.In a critical environment such as a

hospital, patient and staff safety are ofparamount importance. Therefore, we shouldbe moving towards systems with 100%outdoor fresh air.

Low carbon solutionsHealthy communities are inter-linked withlow carbon communities. The proposedmasterplan would remove a significantamount of air pollution from the city thusimproving the air quality and reducing thecarbon footprint at the same time.

However, there are additional benefits to

be gained if we could combine the energy

Center, there would be varying opportunitiesfor renewable technologies to be applicable for example wind power, solar cooling, largesolar arrays and heat pump technologies. If

we had distributed generation then we wouldalso achieve distributed resilience, which isessential for healthcare and modern cities.

Consideration could be given to peak loadmanagement with the incorporation ofelectric vehicles, plugging into the solarpowered car park during the day when theowners are at work. The vehicles wouldcollectively act as a large capacitor to take upsome of the over production and overdemand periods.

In conclusion, all of the above istechnically possible today. All we need issome out of the box thinking in terms offunding streams, a lot of vision and some

willpower.



21/76

MAJOR FACILITY DEVELOPMENT

www.arup.com 21

requirement throughout the constructionphase. The following performance objectiveswere set by the client: Increase capacity of the ED and design

the new floor layout to meet the ClinicalServices Plan which identified a need tomeet increased demand, particularly withoutpatient discharge stream (category 4and 5 presentations) and emergencymental health care services.

Implement improved model of care bybringing forward increased clinicaldecision making to the triage desk andintroducing a discharge and admissionsdual-stream triage system. The successfulimplementation of this new model was tobe enabled and supported through theeffective design of the floor plan to allow

The co-existence of clinicalactivities and construction

efficient operation of the two clinicalstreams, but also to allow adaptable andflexible use of the facility in the long term.

Control and minimise disruption bystaging the works. The project team wastasked with extending and refurbishingthe existing ED while maintaining full24-hour operations with zero reduction intreatment space numbers. The Cairns BaseHospital site constraints negated any

opportunity to decant the ED to anotherarea of the campus or to utilise temporaryoff-site facilities during constructionworks. The target for the project team waszero impact on health service care topatients with all efforts directed towardsachieving no harm to staff or patientsduring delivery.3

Alex Ramos MEng

CEng MICE MAIPM

Alex Ramos is a Senior Project

Manager based in Cairns,

Queensland. He joined Arup

in 2001 and has worked on

the design and construction

phases of a wide variety of

projects in Spain, Belgium

and Australia.

Mark Aitken

BEngTech CPPM

Mark Aitken is a Senior Project Manager

based in Brisbane, Queensland. He joined

Arup in 2006and commenced work on

the Cairns Base Hospital Emergency

Department before relocating to

Brisbane in 2010. His work has included

delivery of remote indigenous health

clinics and health facilities throughout

Queensland over the past five years.

Cairns Base Hospital, Emergency Department.

Alex Ramos and Mark Aitken Project Managers at Arup in Queensland, Australia

According to Australian Health Facility

guidelines Building, renovation andmaintenance activities within ahealthcare facility imposes risks uponthe incumbent population unlike anyother building site.1 Increasing healthservice needs continue to place pressureon existing healthcare facilities. This isoften exacerbated by constrained citycentre locations and an ageinginfrastructure. As a result, a highproportion of healthcare capital worksprojects are refurbishments and/orexpansions.

In such projects, the traditional constructionindustry expectation of a project beingmainly to design, build and hand over to acustomer/user can be challenged at manylevels.

The Cairns Base Emergency Departmentredevelopment project demonstrates bestpractice in both user engagement andclinical services integration throughout allphases of the project lifecycle. Itdemonstrates how positive clinical staffinvolvement during planning, design,procurement and construction phases canresult in decreased stress and increasedsafety for patients and staff as well as

improved efficiency in clinical servicedelivery.

The initiatives undertaken by the projectteam helped overcome the challengesinherent in this type of complex work anddemonstrate how the implementation of anew model of care can be translated into afunctional facility design.

The redevelopment project was initiatedin February 2008 with constructioncommencing on site early in 2009 andfinishing early in 2011. It involved arefurbishment of the existing EmergencyDepartment (ED) with an expansion of theoriginal facility from 30 treatment spaces to52 spaces, including an integrated threespace mental health pod area. The clientrequested that the ED be increased in bedcapacity to 36 beds by February 2009 andthat these 36 beds were to be maintained asa minimum baseline operational


22/76


22 www.arup.com

Integrated project teamThe project team recognised the need forclinical staff involvement in deciding how theproject was to be built, to minimise the

impact on clinical services duringconstruction. To achieve this, an integratedproject team was developed with sharedobjectives and a common goal.

Conventional delivery of capital worksprojects involves a design team developingthe facility design with some level ofconsultation with user groups comprising theoperational clinical staff. This can create alevel of tension between the two teams as thedesign is progressed with each team havingcompeting and differing priorities. ArupsCairns ED project management teamrecognised that the two groups should beintegrated into a high performing project

team. The vehicle to achieve this was therequirement for the works to be staged withno impact on healthcare service delivery. Inorder to galvanise this shared goal in theteam, a series of staging workshops wereundertaken to increase involvement of boththe clinical user groups and the design teamin designing the construction staging.

Designing the stagingDuring the design, staging sequences weredeveloped to meet the project objectives.Each stage was tested against the minimumtreatment space compliance, clinicalworkflows, operational requirements and

logistics, in addition to contractor access forlabour, material delivery, and constructionworkflows and activities.

The vehicle for this was a series of specificstaging workshops. These were heldseparately, and in addition to the traditionaldesign team and user group coordinationmeetings. The primary aim of theseworkshops was the shared objective ofdesigning the staging to allow full operationof clinical services. The benefits of thisapproach included: The design team gained an understanding

of the clinical needs of the user groupsand were able to adapt the design to

accommodate the staging plans. The clinical user group also gained an

understanding of the complexities of thedesign and construction activities and

The project liaison

officer fills a knowledge

management role that is

critical to the success of

any health project. They

are a repository of

invaluable unstated

information.

These plans provide an overview of the four main stages of work: blue indicates temporary

accommodation; red indicates construction areas; and, yellow indicates clinical flows.

Stage 4A Plan

Stage 4A Plan

Stage 4A Plan

Stage 4A Plan

FloorplansproducedbySutersArchitects.


23/76


www.arup.com 23

delays and complexity for the project team inthe early design phases, it does not mitigatethe need for staging of the works to beaddressed later. In doing this, there is a riskthat construction needs of the contractordrive the staging process rather than theclinical operating needs of the ED. In terms ofclinical safety, the service provider will alwaysretain ultimate risk and responsibility;therefore, it was recognised that in order toretain control over this process, theprocurement would be a fully documentedtraditional lump-sum model, supported withrobust staging plans embedded in thecontract documentation.

Project liaison officer the unsung heroThe project liaison officer fills a knowledgemanagement role that is critical to thesuccess of any health project. They are arepository of invaluable unstated informationwhich is pivotal to the successfulmanagement of stakeholder risk and projectscope creep. The project liaison officer is alsothe gatekeeper of daily clinical risk, havingfinal say and responsibility to approve orreject all permit to work requests issued bythe contractor.

Change managementChange management during the design wasimplemented through progressive sign-off ofdocumentation at specified milestones, wherescope and cost were locked in at increasinglevels of detail. Within these stages, design

constraints which helped their acceptanceof construction impacts during laterstages of delivery.

These workshops developed a sharedunderstanding of the project and developed ahigh-performing integrated project team,with a positive team culture. This allowed theteam to work collaboratively and openlyduring the difficult stages of construction aswell as providing a robust staging plan to thecontractor for delivery.

Specific provisions made in the design toenable the implementation of the stagedconstruction process were: A temporary demountable was added to

the scope during construction to providea buffer of additional treatment spaces,thereby enabling the requirement of 36

treatment spaces to be met. An additional pneumatic tube station was

introduced to limit long walking distancesduring the staging works whichadditionally provided future flexibility.

Several treatment spaces were internallyclad with panels and converted intoprovisional consumables stores.

Additional joinery and essential powerwere provided to non-acute areas for useduring construction as temporaryresuscitation bays.

The integrated project team looked at theopportunity of implementing the new dual-

stream model of care during the constructionworks to facilitate uptake of change by staff.This needed to be balanced against the riskof increased waiting times leading to acompromise of patient care and adversecommunity perceptions.

To alleviate this risk, the implementationof the dual-stream model was broughtforward to the commencement of the worksin February 2009. This was done by fittingout a store room with three fast-track bedsand a procedure room, staffed by a small teamconsisting of one registrar, two registerednurses and a nurse practitioner to make thenew fast-track team operational on a small

scale. The outcome was positive.In 2007, the Cairns Base Hospital

Emergency Department was one of the worstperforming departments in Queensland withregards to patient waiting times.3 Withcommencement of construction, it wouldhave been expected that the waiting times forcategory 4 and 5 patients would escalate.However, with the early introduction of thedual-stream fast-track team, reductions inpatient wait times were evidenced whencompared to 2007-2008 patient wait timefigures.

Procurement and riskThe procurement model for works deservesspecial mention. In many complex projects,the client and project team will seek to passrisk to the contractor through either a designand construct, or a managing contractor typecontract model. While this strategy reduces

took place as a normal iterative process.During the construction phase, changes

to the project scope can come from sourcessuch as latent site conditions,constructability issues and errors indocumentation. To distinguish the sourcesand provide necessary controls for eachvariation, during the construction phasevariations were classified in two types: Type 1 variations: These were necessary

to deliver the original scope of works asrequired by the client. These types ofchanges did not generally require clientapproval and were issued by the principalconsultant for the purposes of statutory

compliance. The project manager wasinformed of the variation and of thedrawdown in contingency funds.Type 2 variations: These were a change to

the original scope of works required by theclient. As such they were generally instigatedby the client, the user group stakeholders oras a request by the contractor for analternative material, finish, or product. AllType 2 variations required project managerand client approval prior to proceeding.

DecantingThis is usually a time of discovery and stressfor the user of any new health facility. Clinicalstaff members have their normal jobs to dobut have an added expectation of improvedperformance as a result of the new facilities,all the while adjusting to a new environmentand workflow.

There is a consequent risk of disconnect

At completion of the ED works there were zero incidents

involving construction work impacting on patients or health

staff, and at no time was there a reduction of bed capacity

or essential services.

Cairns Base Hospital.

www.andrewwatson.com.au


24/76


24 www.arup.com

meaning. The tendency by end-users is toapply it to anything they do not like, whetherit be a genuine builders defect, an omissionin the original design or a difference of userexpectation as to what the scope constituted.

In a staged approach to construction,once a typical stage is handed over, it isreasonable to expect that the majority ofdefects identified by the users in the first fewweeks will be builders defects. However, anemergency department, by its very nature,suffers a significant amount of heavy use, and

wear and tear, so damage to the facilities isnot uncommon.

In order to manage this effectively, in thestage immediately preceding that underconstruction at the time, defects identifiedby the users were processed by the projectteam, whatever their implied source. Theproject liaison officer and the projectmanager would bring the defect to thesuperintendants attention who would then

between construction and user group teamsimmediately after occupancy, as one groupwill be focussing on the construction of thenext stage and the other on working

effectively in the new space. If not managedproperly, this can lead to high levels of staffstress and low morale in both teams.

One of the measures introduced in theCairns Base Hospital ED after each phase ofdecanting was a walkthrough by key staffmembers directly after practical completion ofthe stage was reached, but before the start ofclinical operations. This served to familiarisedstaff with the new area ahead of the pressuresof operating clinically within the new space.It helped clinical staff to locate storage areas,nurse call communicators, lighting controlsand duress alarms.

During the decanting period, a suggestion

book was also introduced to the staff canteento enable staff to translate stress intoconstructive feedback. Importantly, the logsin the suggestion book were periodicallyreviewed and some converted into defectnotifications or variations to the contractor,thereby closing the feedback loop intosomething practical and effective.

Clinical safetyAlthough a physical barrier by way ofhoarding was in place, other aspects ofconstruction were impossible to physicallydemarcate from clinical services. For example: Requirement to isolate electrically

different areas, including shutdowns todistribution boards and switches betweenessential and non-essential power.

Requirements to tie into existing medicalgas networks, involving partial or totalshutdowns.

Access requirements in shared entrancesand exits.

Isolation and de-isolation of fire detectionand alarm systems.

Logistics of construction deliveriesconflicting with ambulance access.

These issues were managed through the useof a disruptive works notice system. The

contractor would raise a disruptive worksnotice justifying the need to undertakedisruptive works and describing their nature,duration and proposed timing. It would alsostate if there was a requirement for hospitalfire and security staff to be on standby.Following receipt of the notice, the projectliaison officer would contact the relevantinternal hospital stakeholders and discuss theimplications before approving the works.

DefectsThe constant rotation of construction areasin the project with individual practicalcompletion of each stage called for amethodical approach to the proactivemanagement of defects to prevent theclinical-construction relationship fromdeteriorating.

To most clinical professionals, the impliedterm defect is different from its contractual

advise the contractor and request action.For the stages completed prior to that,

however, the defects were issued directly tothe clients Buildings Engineering andMaintenance (BEMS) under the assumptionthat by then, the most likely cause of thedefect was wear and tear and notworkmanship. If, however, the BEMS teambelieved the defect did result from quality ofworkmanship or material then the issue waspassed on to the project manager andprocessed normally.

This process allowed the contractor tofocus on the construction of the currentstage instead of investigating defects in theprior stages, which could have beencompleted up to a year previously.

ConclusionsAt completion of the ED works there werezero incidents involving construction workimpacting on patients or health staff, and atno time was there a reduction of bed capacityor essential services.

The process of refurbishing existinghealthcare facilities is challenging but neednot be a stressful endeavour. Some lateral

thinking can often unlock opportunities atthe planning phase which pay dividends forthe project later on. Staging exercises beforeand during the design phase should, ideally,be led by a competent project manager.However, to do this effectively and get themost out of the combined knowledge of theproject team, high-quality user engagement isimportant and having a project liaison officerwith the right attitude and time to devote tothe project can help to achieve this.

References1 Part D Infection Prevention and Control.

Australasian Health Facility Guidelines V4; 2010

2 Fawcett W. and Palmer J. Good Practice Guide to

Refurbishing Occupied Buildings; CIRIA, South

Wales; 2004

3 Queensland Health, Queensland Government.

Quarterly Public Hospitals Performance Report;

September 2007.

Cairns Base Hospital.

www.andrewwatson.com.au


25/76

Ysbyty Aneurin Bevan6RXWK:DOHVLVWKHUVW

1+6JHQHUDOKRVSLWDOEXLOWLQWKH8.LQFRUSRUDWLQJ

VLQJOHEHGURRPDFFRPPRGDWLRQ,PSURYLQJ

WKHSULYDF\DQGGLJQLW\RISDWLHQWVDQGUHGXFLQJWKH

ULVNRIVSUHDGLQJLQIHFWLRQ

CharlotteWoodPhotography


26/76

espoused by Lawton,1 focused on theinteraction between a persons ability toundertake activities and the demands of theirenvironment. Such considerations are

particularly pertinent to those with dementia,whose ability to undertake daily living tasksdiminishes with the progression of thedisease.

Approaches to dementia careUntil the 1970s, the needs of olderpeople, particularly those withmental health conditions, weregenerally disregarded. Care was

We are all affected by our surroundings.

The quality of the environment is afundamental factor in determining thewellbeing and health outcomes of olderpeople and can be adapted to reduce theday-to-day difficulties faced by olderindividuals, such as sensory and cognitiveimpairments and increasing frailty.

Dementia has been recognised as a keyhealth and social care priority in the UKwhere currently 750,000 people are livingwith the condition. This number is predictedto double in the next 30 years.

Although dementia can affect younger

people, it is primarily a condition of olderage, when the symptoms can interact withother chronic conditions such as heartdisease, arthritis, hearing and sight loss.

As the condition deteriorates, a personwith dementia can find their environmentconfusing and difficult to comprehend,leading to feelings of inadequacy and highlevels of stress. It is, therefore, important toconsider what environmental features andassistive technologies (AT) could beintroduced that would help ameliorate suchdifficulties and improve quality of life.

arup in healthcare 2013

Documents