A new hospital project proves that, when it comes to Procure21, design by committee works. Stephen Kennett discovers how collaborative working produced effective new solutions

Just a few miles from the centre of Liverpool, the first phase of a flagship pilot project for Procure21 is coming to completion on site.

The 30,000 m2 development, a joint project between the Royal Liverpool and Broadgreen University Hospitals and the Cardiothoracic Centre NHS Trust, is among the trailblazers of the national roll-out of the NHS’ new procurement method for healthcare buildings back in May 2002.

This is an extensive project. It includes a new diagnostic and treatment centre incorporating departments of urology, general surgery, orthopaedics, pre-op assessments and therapies, plus day wards and nine operating theatres. In addition to this, the Cardiothoracic Centre has acute wards, surgical intensive care and high dependancy units, coronary care and research laboratories. It also houses consultant’s offices, health records and patient services and the medical engineering department.

Among the factors making this development stand out from other Procure21 projects is its cost – at around £60m, it is three times the maximum value orginally allocated for schemes constructed under the programme.

Out of this total, the services installation represents £20m, with design and installation undertaken by Emcor Drake and Scull, as part of the Principal Supply Chain Partnership led by Norwest Holst Construction.

For most of those involved, it was their first experience of working with Procure21 and while they had to get used to a new way of working, it also provided an opportunity to try out new approaches. Because all parties are involved from concept stage, it’s a more collaborative way of working – which, in this case, shaved up to a year off the construction programme.

Although Emcor Drake and Scull would normally be involved at the interview stage on Procure21 projects, it first got involved in the Royal Liverpool and Broadgreen project after Horwest Holst had secured the contract. The M&E design was still at the concept stage and EDS took over design responsibility at this point, taking on the original consultant’s staff.

Although this meant more risk for EDS, there were benefits, says Terry Hewitt, director of EDS Health. “If we introduce some innovation or value engineering we can take responsibility for it,” he explains.

Hewitt believes the Procure21 process created benefits before construction got under way. One area it pays off in particular is in getting end-users involved. “We’re meeting with the end-user and developing the design, so you stand a much better chance of handing over what they want.”

Phil Bowman, Emcor’s project team leader warns that this strength of P21 can also be its weakness. “We get the chance to talk to all sorts of NHS people. The disadvantage is that everyone is around the table deciding what they want while the construction programme is moving forward and the timescale can get a bit out of control.” Hewitt also adds that clients need to make sure that clinicians and medical staff are briefed about what is affordable and what they can realistically have.

The EDS design team has been dealing directly with the trust’s infection control specialists on this project. “Compared to more traditional procurement route, using Procure 21 has enabled us to bring in new measures much sooner,” adds Bowman. “One thing we are very keen to do is challenge the Health Technical Memoranda and Health Building Notes – through our experience and by using our supply chain we might have a better alternative.”

The other advantage of these discussions, says Bowman, is that you can make sure that something doesn’t completely cut across the m&e design. “With traditional routes, this could totally disrupt the job, delay it and cost more.”

The Procure21 process also means that the trusts are rethinking where their priorities are in terms of capital spend. Do they air-condition an office or spend more money on infection control measures in the wards? “Some of the changes we’ve introduced are designed to increase the amount of services designed to reduce infection spreading,” adds Hewitt.

With the schemes built on a gross maximum price, there are incentives to stay under budget. EDS have been involved in cost control and value engineering throughout. However, says Bowman, “What it needs is someone to assess priorities – the best way to spend the money.”

EDS has won places with five PSCPs (see ‘A brief history’). The Procure21 programme’s value was originally estimated at £1.2–1.4bn per year. “It’s turning out to be more like two thirds of that. Initially we had about three enquiries a week, but this has dropped off recently.”

At best, Hewitt estimates that around 50% of trusts have bought into the idea of Procure21. “They say it costs them 20% more to go Procure21. You can probably knock a year off the time, if not more, so it’s difficult to see where they think it is more expensive.”

A brief history...

ProCure21 is the NHS’ standardised approach to the procurement of healthcare facilities. Developed to meet the massive healthcare building programme announced by the government in 2000, it was an initiative born out of Sir John Egan’s report Rethinking Construction and is based on long-term relationships with carefully selected supply chains. It was launched in May 2002 with five companies – the Principal Supply Chain Partners (PSCPs) – participating in pilot programmes throughout the North West and Midlands (the Royal Liverpool and Broadgreen project described here was one of those programmes).

The original five PSCPs were joined by another seven in September 2003 when the scheme was rolled out nationally, although following Medicor’s decision to drop out after failing to win a single contract after the pilot projects were launched, there are now only 11 projects.

Procure21 has been run by NHS Estates since its inception but, following a Department of Health review earlier this year, NHS Estates was abolished. For the time being, the programme has fallen under the DoH’s Commercial Directorate umbrella. The national framework agreement spans five years and is due to end in September 2008. A review of Procure21 commissioned by the DoH should be completed later this year and until then, no official decision will be made on its future.

New ways of working: solutions developed at the Liverpool and Broadgreen University Hospital

Goal: Reduce maintenance/improve installation time and lphw and cw systems

Solution: The Emcor team has made greater use of non-ferrous pipework on this project – copper has been used extensively. The preference was for lightweight plastic pipework, but the potential risk of overshooting the design temperature, which could destabilise the plastics, precluded this.

“When I looked into it on this job the margin of error was too tight: the energy centre supplying the hot water was out of our control and we couldn’t risk it,” explains Phil Bowman, project team leader with Emcor.

Crimp fittings have been used on all the copper pipework up to four-inch diameter. As well as helping to speed up and de-skill the installation, it also supports Emcor’s zero accident policy by reducing the need for hot works.

Goal: Return cost savings to the trusts through the gain share mechanism by working with them to adopt proven innovations

Solution: This is the first project where Emcor has used Flexishield cabling for all lighting and small power. FlexiShield is designed to do away with containment. “It saves time and reduces risk on overspend,” explains Bowman. “Because it has its own containment, it moves what was a second fix to a first fix activity.”

Bowman estimates a 40% reduction in installation times compared with traditional cabling systems. Although the initial material cost is higher, the main cost saving derives from the cable being installed within its own containment, therefore no additional secondary containment is required.

The cabling is also lightweight, weighing up to 60% less and requiring 20% less space than traditional small armoured cables. “This makes it easier to handle and install and allows lighter cable tray to be used for multiple layers of cables,” adds Bowman.

Integrated off-site assembled bedhead trunking, incorporating power, up- and downlighting and medical gases, is also used throughout to save costs – and provides the bonus of a neat solution.

Goal: Reduce the need for skilled operatives by using offsite manufacture

Solution: Prewired three-phase distribution boards have been installed throughout the project. The aim of these is to speed up the electrical installation – the board is pre-wired to the designed distribution schedule and fixed to the wall in advance of any wiring on site.

Each terminal is connected to DIN rail connectors housed in a box above the board as the circuit is wired. This should save the usual time spent looming and connecting wires to the board at the end of the process.

In practice, these have been met with mixed success. As a concept, it is right says Terry Hewitt, director of EDS Health. The main problem was in the way the job developed. “The way the design went, we were wiring in advance of the final distribution boards being approved and made, so by the time they were made, delivered to site and fitted there were already 50 cables hanging down. In future, if we have a project that is pre-designed and we know what the distribution board schedules are going to be, we can put the board in ready for the circuits going in.

Goal: Reduce maintenance/improve system component life by minimising potential for contamination in lphw and cw systems

Solution: Emcor and the trust’s infection control team worked with washroom controls specialist Rada to come up with a combined thermostatic mixing valve and basin tap. These feature a self-draining outlet with elbow operated lever – so users do not have to touch the tap with their hands. The all-in-one design eliminates the need for a separate under basin or behind the panel mixing valve.

While these offer improved thermostatic temperature control, they also enable reduced servicing costs as all the serviceable components are located in the tap body and accessed from above the basin. The design also eliminates the traditional dead-leg between the tap and the thermostatic mixing valve – a known source for breeding water-borne infections such as legionella. An anti-microbial finish has also been applied to basins and taps.
In a further bid to improve legionella protection, thermostatic valves are used on the hot water returns to replace traditional double regulating valves. These are used to balance the system and, because they are ‘plug and play’, reduce commissioning time. The valves are preset to 55°C and so adapt to changing conditions in and to the system.

Goal: Reduce cross/re-infection by preventing contamination before handover

Solution: The way a building is put together also helps with infection control once it is handed over. Rather than using ordinary water for the hydraulic tests on the hot and cold water pipework, the trust asked EDC to put a biocide in. “What they say is the minute you put the ordinary water in, you put the bugs in – and there they stay until you get rid of them,” says Bowman. “This is the first time we have done this, and it has really come from sitting around the table with the microbiologists and the infection control people. That is a real strength of Procure21.”

The same philosophy of keeping systems clean as they were installed extended to other areas such as ductwork.

Goal: Earliest possible and multi-phase handover by using offsite manufacture

Solution: Emcor’s strategy on the project was a simple one: to limit the amount of time needed on site to install the services and get the site labour down to a minimum.

Pre-assembled multi-service modules have been used for the corridor services. The 3 m- long modules were supplied complete with pipework and cable tray; ductwork can also be suspended from them. These were simply jacked up into place and connected together.

Constant pressure differential valves are fitted to main subcircuits (for each hospital department, such as a ward, theatre suite) in conjunction with two port valves and inverter controlled pumps. This means that when a new circuit is added to the system (as happens with a multi-phased project), previously balanced circuits are not disturbed – there is no need to rebalance the whole project again. The other way considered was to install multiple separately pumped circuits, which was more costly, used more space and took more time.

This technique enabled perimeter heating radiant panels and heater batteries to be fed from one constant temperature circuit and to combine 12 and 24hour departments. Although the technology has been around for some time, it is little used in this country, say Emcor.

Barn theatres: the concept behind multi-use operating theatres

Part of the Royal Liverpool and Broadgreen University Hospital development includes a new surgical unit with eight operating theatres. Four of these theatres are installed side by side in a single space, in what is often referred to as a ‘barn theatre’ – one of only three such facilities in the UK.

From a surgical point of view, it means there are more experts on hand should any difficulties be encountered during an operation, and as well as being a good teaching environment, it increases overall clinical efficiency. There is also a significant cost saving by sharing facilities such as scrub-up and cleaning areas.

According to Ken Lewis, design manager at Emcor Drake & Scull, the main potential difficulty is with cross-contamination/infection between the adjacent tables. This is tackled by the installation of ultra-clean ventilation canopies above each table.

Measuring 3.2 m x 3.2 m, the ventilation canopies deliver a laminar flow of clean air that produces a positive pressure around the table relative to the rest of the room.

This blanket of clean air is delivered via four 500 mm x 250 mm ducts from air handling units mounted above the theatre into a plenum which removes turbulence and creates an even pressure. HEPA filters contained inside the canopies remove particles (down to 0.3 microns diameter) that could potentially carry infections and the laminar airflow is then defined by 600 mm deep acrylic screens. Return air grilles with prefilters to remove particles such as lint and dust are incorporated around the canopy’s perimeter.

The theatre itself is always held at a slightly higher pressure than the rooms surrounding it, so that clean air is always moving away from the operating zones with pressure stabilisers installed above each door.

The theatre suite has been built using stainless steel partitioning panels with an innovative access system that allows services maintenance to take place outside the theatre itself. The walls and services are also watertight, allowing for easy decontamination.

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