Linking together a new-build and a 1960s building has challenged Willmott Dixon and its project team to the limit at Sunderland Royal Hospital.
Project: Sunderland Royal Hospital A&E Department
Client: City Hospitals Sunderland NHS Trust
Contract value: £14.7m
Main contractor: Willmott Dixon
M&E subcontractor: H Malone and T Clarke
Architect: P+HS Architects
Start date: December 2014
Completion date: March 2017
Rising waiting times and A&E crises in the NHS hit the headlines this winter, with many hospitals becoming increasingly stretched as they try to deal with growing demand for services.
Some of these hospitals have had to manage facilities from the 1960s, which are unlikely to be designed with today’s levels of demand in mind, not to mention the modern technology and patient flows.
One such hospital is Sunderland Royal Hospital, which had an ageing A&E department in dire need of a complete overhaul.
It included a shared entrance for both paediatrics and adult patients, which pushed the facilities to breaking point, particularly on Friday and Saturday nights when demand was at its peak.
But now Willmott Dixon, alongside architect P+HS and M&E firms H Malone and T Clarke, is aiming to change all that with a highly complex refurbishment and new-build programme to bring the hospital’s A&E department into the 21st century.
The £14.7m scheme, which will see the partial demolition of the existing A&E building alongside remodelling of three internal wards, was originally conceived by the hospital’s own estates manager.
P+HS architect Adrian Evans explains the designs – which were presented to the team at an early stage – were inspired by visits to hospitals in Israel.
“In areas of conflict between Israel and Palestine, you either have little demand or huge demand on A&E services,” he says.
Mr Evans says the guiding principle for the building throughout its design and construction has been how a hospital can expand and contract based on differing levels of demand on its services.
This means that rooms can be utilised for different clinical uses depending on the demand on A&E services, and whether the patients are adults or children.
Willmott Dixon Sunderland Royal Hospital 1
There was also the need to keep adults and children separate, with a number of instances of drunken behaviour and alcohol-related A&E incidents making life difficult for the hospital.
“One of the main drivers for this redevelopment was to separate adults and paediatrics – and to stop children seeing what can happen to adults when they’re drunk,” Mr Evans adds.
The building has been designed so the A&E is split down the centre, with adults and children not crossing paths at all, aside from a shared resuscitation area, which can also expand and contract depending on the flow of patients.
There are also two separate entrances in the new design to replace the original shared entrance.
The project is designed in three distinct phases: for phase one, Willmott Dixon reconfigured two of the hospital’s existing wards, and demolished and altered parts of the existing structure while working around live wards.
For phase two, it demolished part of the existing building and replaced it with a new A&E and resuscitation building, which links to the original building.
The final stage, phase three, will see the contractor re-enter the wards that were remodelled in phase one to undertake final alteration works and link everything to the new-build part of the hospital.
Raising the roof
But before any of this could begin on site, the team drove an extensive value-engineering process to make the project viable, as Willmott Dixon construction manager Jeff French explains.
“We got a scheme that we thought worked, and the client thought worked, but the [medical] consultants asked for a number of additions, which made the cost go up substantially.”
These alterations pushed up the cost of the building to around £16m. As a result, the team came up with a solution to keep the building affordable while keeping the medical consultants happy, with a number of steps taken to shave more than £1m.
Willmott dixon sunderland hospital 7
One of these areas was the roof, where design changes saved more than £350,000, Mr French says. “Originally we were going to take the roof off [on phase one] and lift it by 300 m to get the M&E to sit in the ceiling space, which meant we would have to undertake a lot of demolition works.”
He adds that the team would have needed to install a temporary cover to the roof to keep the live wards below watertight, adding to the cost. “We decided instead to run some of the M&E on top of the roof, not take the roof off, and overlay it instead to get a longer lifespan out of it,” he says.
”The client assumed we could drive in an ambulance and it would be at the same level”
Adrian Evans, P+HS Architects
Other value-engineering measures included reducing the two-storey lobby area to one storey and reducing the specification of the glass canopy at the front of the building.
“There were slight specification changes on some materials, but little things like that have saved a bit of money,” Mr French says.
There were also a number of changes to the front of the building compared with the initial design, Mr Evans explains.
One notable area was the ambulance access ramp up to the entrance and ambulance bay, which was switched from a straight ramp to a curve – but Mr Evans says that while it looks impressive, this has not been done for any architectural reasons.
“The initial scheme we were given by the client didn’t have any appreciation of the fact the ambulance bay was 2 m above the ambulance entrance,” he says.
“They had assumed we could drive in an ambulance and it would be at the same level. [The curved access] is there because there was no other way of getting an ambulance from the entrance to the bay without [the ramp] being too steep.”
Once it had been extensively value-engineered, the team could begin phase one in earnest – but they found a whole host of challenges once work got under way.
A live environment
The main difficulties arose because hospital wards and operating theatres had to remain live while Willmott Dixon refurbished two wards on level C of the building.
The team worked in and around live operating theatres, at one point having to put steelwork through the theatres themselves.
“As you can imagine, we couldn’t just go in and shut theatres down because of the waiting lists we had to think about,” Mr French says.
The works were carefully phased as a result, with the team working theatre by theatre – often overnight and at weekends – to get the works done.
All of the hospital’s services had to remain live while works were going on, including everything from vents, power, extraction, water, refrigeration and medical gases.
Many of these services came from plant rooms at the back of the main hospital building, and as part of the refurbishment, new M&E services had to be linked in to the existing ones, while old, asbestos-riddled M&E was stripped out.
“The job is probably the most challenging that we’ve been involved with for many years”
Dave Gourley, H Malone
“We had to go down to level A – essentially a sub-basement – and work underneath the building, fetching all of that through, again dealing with asbestos alongside access issues and confined spaces,” Mr French explains.
Access into the wards themselves was also difficult, with materials for the works on the wards initially planned to enter the building via one of its main corridors.
Willmott dixon sunderland hospital 9
But at the time, the A&E at the front of the building was still live, and as a 24/7 hub of the hospital, Willmott Dixon could not find a suitable time slot to deliver what it needed.
Mr French says access to the phase one wards is blocked in three places by the existing structure, adding that the team had to plan carefully with the client to come up with a solution. “Ultimately any of the services that could go onto the roof ended up going on the roof.”
These complex M&E works also link into the new-build section of the building, which forms part of phase two.
For this phase, Willmott Dixon stripped the asbestos out of the existing building before demolishing it from front to back, where it joins the main hospital.
Mr French says this part of the job, where Willmott Dixon built a steel-frame two-storey building, was relatively straightforward – despite some initial setbacks before work began. (see box)
The new-build has a simple steel-framed structure supported by Holorib concrete floors, with brick cladding on the lower levels and curtain walling above.
But while this part may have been relatively simple, linking the services together with the existing building was far more challenging, as H Malone M&E director Dave Gourley explains. “To sum it up quite simply: we’re working in a 1960s hospital with service voids sized for M&E services of that time,” he says.
Work was originally scheduled to begin on phase two of the project in November 2015, but delays to a neighbouring scheme by a different contractor had the potential to derail Willmott Dixon’s project entirely.
Mr French explains that the job to refurbish an endoscopy suite was running late, which left the contractor without the necessary access to begin works.
Under the original programme, it would have led to a nine-week delay to phase two.
However, by overlapping parts of the programme, Willmott Dixon managed to reduce this significantly.
“The new building has two distinct external areas, and originally we were going to build them both separately,” Mr French says.
“We’ve now built part of the building on a different programme and handed it over to the hospital already – by doing that and changing the logistics of how they can access their buildings, we’re able to take possession of another part of the building earlier than planned.”
These steps meant the contractor could cut the potential delay from nine weeks to three-and-a-half weeks.
“The co-ordination of having to fit in everything we need – not just M&E-wise but also the steelwork that Willmott Dixon has had to put in, along with all the equipment to support that – has been extremely difficult,” Mr Gourley says.
The team took a decision early on to run a clash detection model of the ceiling spaces to help map out where new services would need to be and where they clashed with any existing pipework.
Mr Gourley adds that 95 per cent of the clash issues were ironed out by using the model. “It gave us that bit of comfort that we had a millimetre spare to fit things in, and that’s literally what it went down to,” he says.
“We couldn’t just go in and shut theatres down because of the waiting lists we had to think about”
Jeff French, Willmott Dixon
The team dealt with the same issues of working in a live environment, with a live ward above them as they tried to bring M&E services into the new building.
Mr Gourley explains that all the new ductwork had to fit around the existing services, as the hospital needed to stay live throughout the process, making it impossible to bring any of the risers up in a straight line.
He says the process of stripping out and remodelling existing M&E services took four months, before the M&E contractors could even begin linking it to the new building.
“The co-ordination of the job has probably been the most challenging that we’ve been involved with for many years,” Mr Gourley says.
Working in a live hospital environment was always going to be a challenge – and it seems that Willmott Dixon, P+HS and H Malone have had everything thrown at them, be it design changes, extensive value-engineering or highly complex M&E works.
But with phase three due to begin soon, signalling the end of this mammoth hospital refurb, it looks like the team is on track to deliver a modern A&E department to help Sunderland Royal Hospital stay ahead of the game.