A new 28-bedded ‘concept ward’ combining single-bedded en-suite rooms with four-bed bays, built by Health Spaces at Great Yarmouth’s James Paget University Hospital, and officially opened on 27 May this year, will be used both to house patients while RAAC panel remediation is undertaken on parts of the hospital estate, and to enable the James Paget University Hospitals NHS Foundation Trust to evaluate the ‘pros and cons’ of single-bedded rooms versus multi-bed patient accommodation as it plans for a new hospital on the site. HEJ editor, Jonathan Baillie, reports.
The construction of the new modular-built ward at the James Paget University Hospital began last October – with preliminary groundworks on the chosen location to the rear of the existing hospital. This included site surveys and a check for unexploded bombs, since Great Yarmouth and the surrounding area were heavily bombed during World War II. Thanks to the use of offsite Modern Methods of Construction, with the modules assembled in a controlled factory environment in East Yorkshire, and delivered to site with the building fabric 80% complete (with some first-fix M&E works also competed), the new single-storey ward block’s creation progressed extremely fast
The new facility, which has received a BREEAM ‘Excellent’ rating at Design Stage (with the same rating anticipated for Construction), was handed over on schedule to the James Paget University Hospitals NHS Foundation Trust by Health Spaces – who also designed it, in conjunction with the Trust – in late May this year, with the first patients admitted on 8 June. Officially opened by NHS Chief Nursing Officer for England, Dame Ruth May, on 27 May, the ward is needed to provide decant space while some of the hospital’s existing wards undergo remedial work. In particular, the roof of a number of wards incorporates RAAC – or reinforced autoclaved aerated – planks – a form of lightweight concrete panels widely used in the mid-1960s and mid-1970s, which have suffered failures. As a result, Government guidance has set out a series of measures for organisations including operators of NHS hospitals and schools whose buildings may incorporate the panels to ensure that, where they are present, they are identified, evaluated for structural integrity, and – where necessary – failsafe supports are installed
Forty-year anniversary in 2022
The James Paget University Hospital, at Gorleston-on-Sea, serves the Great Yarmouth and Waveney area. It was formally opened in July 1982, but had been receiving patients since 21 December 1981, when the first emergency cases were accepted, and outpatient clinics started. The hospital was named after Great Yarmouth-born surgeon to Queen Victoria, Sir James Paget. As well as, in his lifetime, serving as President of the Royal College of Surgeons in England, a Fellow of the Royal Society, and Vice-Chancellor of London University, he is widely regarded as the father of British pathology. He was also the first to describe a number of medical conditions, including Paget’s disease of bone (named after him), and compression of the median nerve, known today as ‘carpal tunnel syndrome’.
Parts of the hospital are now showing signs of age, and in 2020 it was announced that the Trust would receive national funding through the Department of Health and Social Care to explore all options for the construction of a new hospital on the site, as part of the Government’s Health Infrastructure Plan. In consultation with the Trust, the New Hospital Design Team at Penoyre & Prasad developed a masterplan based around the creation of a healthcare ‘campus’ for the Strategic Outline Case (SOC).
In the meantime, updating of parts of the main hospital building is underway due to plans for its continued use until 2030 – with a particular focus on achieving the RAAC failsafe works. Reinforced autoclaved aerated concrete planks feature in the roof of most of the buildings, including the wards. This work necessitates a phased decanting of the wards so the RAAC failsafe work can take place without disrupting care. The new 28-bedded ‘concept ward’ building will be used to accommodate patients from each ward in turn during this refurbishment, but, as I discovered when I spoke recently with the hospital’s Chief Nurse, Paul Morris – who has led the project for the Trust on the clinical side – the new ward block will also serve a second, very important purpose.
A flexible decant space
He explained: “The major project driver was to provide us with a facility to accommodate a variety of patients in while we empty wards so that the remedial work to the roof can proceed. One of our key criteria was that the internal layout be sufficiently flexible to enable us to house medical wards, surgical wards, children’s wards, and then clinical sub-specialities in turn, as required. So at one point it may be an elective surgery ward, and then – as work progresses – a cardiac ward.” This is where the new building’s second key function comes in. Paul Morris explained: “Rather than simply re-creating a mirror image of what we have in our existing hospital, and recognising that the New Hospital Programme is working towards 100% single rooms, we wanted to examine how we can best achieve this in our new hospital, especially now that we have had the go-ahead to build it.
“Patients in the existing hospital are nearly all accommodated in bays of four or more beds,” he continued. “We recognised that with the NHP presumption that all new hospitals should be single-bedded, incorporating a high proportion of singlebedded rooms would enable us both to evaluate the potential patient benefits, and the advantages and challenges for our nursing and clinical staff. In fact we will be undertaking detailed research on all these aspects once the ward is fully in use, comparing nursing and patient experience in the four-bedded bays with that in the single rooms, and hope to learn some useful lessons in the process.”
‘Listening events’ held
Prior to drawing up detailed plans for the new building – which is located to the north-west of the existing hospital – and connects to it via a 40-metre link corridor, Paul Morris explained that as Project lead from the clinical side, and working with Health Spaces’ lead architect on the scheme, Jaime Bishop, he arranged a number of ‘listening events’ in the local community. Here, former patients, patient representative groups, and the public, could hear about the plans, and give their views. He elaborated: “While we followed the national guidance for the New Hospital Programme, we also wanted the views of those who have already been patients with us, or who could be in the future, on our proposals. Equally, early in the project we sought our clinical and nursing staff’s views, and – particularly as the scheme and the designs evolved – have had considerable input from the Trust’s Estates & Facilities team, and staff from a number of other disciplines. Throughout – right from the initial site visit – the Health Spaces team has been receptive and responsive to our ideas.”
Paul Morris explained that, having considered the overall clinical priorities, and what the clinical and nursing teams wanted to achieve – in terms of the new block providing an opportunity to discover more about what looking after patients in such accommodation would entail for staff, and how patients might benefit – the Trust opted for a new building containing 20 single-bedded en-suite rooms – including two isolation rooms, and two four-bedded bays.”
As well as being used as a decant facility, and to evaluate the pros and cons of single-bedded rooms, the new ward will provide an environment in which to evaluate new technologies designed both to improve the patient experience, and clinical efficiencies. Paul Morris said: “Mark Flynn, our Strategic Projects director, the head of Estates and Planning, Steve Balls, and the Estates team, have been heavily involved – including working in conjunction with clinical teams to select technology to enable us to deliver the optimal care. This ranges from an advanced nurse call system which allows two-way communication, facilitates the creation of a silent ward, and gives patients some control over their room lighting, to specifying items such as patient and clinical washbasins, interior finishes, lighting, and furniture.”
Speed of delivery
Paul Morris explained that the main reason the Trust decided on a modular offsite-built solution was the speed at which it could be assembled, delivered, installed, fitted out, and ready to admit patients. He said: “Also key were the fact that offsite construction means considerably less disruption on site, and the ability to create a really flexible healthcare building – in terms of how we use the spaces, and adapt their use over time. Modular-built facilities can employ a repeatable design, meaning we can not only tailor different room uses for patients of differing acuity, age, and condition, but also try out different approaches. For example, patients in the new ward will benefit from a semi-covered outdoor garden, and it also features a ‘traditional’ day room. We worked on this with Jaime Bishop, who based the concept on Japanese research on such spaces’ benefits in healthcare facilities.” He continued: “The design will also ensure that clinical areas benefit from ample light, and – importantly – that there are excellent sightlines for staff – partly a result of the curvature and indentation of the corridor walls. This means that from their touchdown bases, staff can see more than one patient simultaneously; in fact by rotating their chair by 360 degrees they will be able to see two patients in rooms in front of them, and two behind.”
“All aspects of the new ward’s internal design have indeed taken a great deal of thought,” Paul Morris added. “For instance, there are bariatric hoists, while two of the single-bedded rooms are designed as isolation rooms, with the ability to change between positive and negative air pressure, and tailored air flows / air change rates. With natural light and external views known to aid recovery, all the rooms feature large windows with internal bench seating. About half will look out over grassy area at the rear, and the other half into a new semi-covered, multi-surfaced garden, with piped oxygen available to patients needing this. This space will offer even quite seriously ill patients, and, of course, staff and visitors, an opportunity to go outdoors, but under cover, either in the sun, or – if they prefer – in a shaded area.”
A ‘silent ward’
Inside, Paul Morris reiterated that the ability for staff to keep a close eye on patients from staff bases was considered a priority. He added: “For the optimal healing environment, we will be aiming for this to be a silent ward. We are thus aiming to have active listening so patients can interact with staff, but also active listening for alarms, so that while nurses are promptly alerted, the patient doesn’t hear alarms inside their room. We’re currently exploring, with the nurse call supplier, Ascom, both the facility for patients to talk directly to staff from their bedside, and to then get an idea – perhaps via a voice or screen message – of how long it will be before the nurse or doctor is with them.
“We will also be linking the nurse call system to the room lighting so that patients can adjust the colour and intensity of the ‘mood lighting’. When a doctor or other clinician walks in – for instance to examine the patient – they can then switch from the patient setting to a clinical lighting setting.”
I asked about ventilation. Paul Morris explained: “We have active ventilation in all the rooms, with high air exchange rates. As you would expect, we have placed considerable emphasis on an environment that minimises infection risk – with hygienic wall cladding, and both clinical and patient washbasins, in patient rooms.” The room layout is designed for easy entry and egress, with the sinks positioned so that when a porter pushes in a bed they don’t hit the sink. The patient bathrooms incorporate their own washbasins and a wetroom design. In the four-bedded bays, the beds are staggered, with solid partitions between patients that have windows with blinds which rise up from the floor towards the ceiling. Staff can thus see across the bay, but patients can also have privacy
In all the new building comprises nearly 50 modules, and I wondered how easy it had been to get them onto site. Paul Morris said he had been impressed with how well Health Spaces managed the process. “It was much like air traffic control in terms of them arriving when they were needed ‘just in time’,” he explained. Health Spaces’ senior Principal for Delivery, Nigel Thompson, added: “Our transport teams planned out the route to get the modules smoothly from the production facility in Yorkshire to the site, as they were pretty wide loads. The modules measure up to 4.2 m wide, and the heaviest weighs 22.5 tonnes. They key was to ensure that the crane was in position ready to receive the units as soon as they arrived.”
Evaluating the nursing and patient experience
Once the new ward is occupied, Paul Morris and his team will be evaluating a number of aspects of the nursing and patient experience – looking in particular at patient experience, length of stay, infection control, and how nursing practice differs when looking after patients in single-bedded rooms and four-bedded bays. The team will also be monitoring several elements of the new building’s performance. He said: “While we will primarily be harnessing the research to help us plan for our new hospital, we will also look to make the information more widely available.” The Chief Nurse explained that he and his team had already worked with ward staff in preparation for them moving over and needing to adapt to different working methodologies, and new technology.”
I finished by asking what aspect of the new ward building most excited him. He said: “I think the scheme has been an amazing opportunity to bring together modern-day healthcare architecture, and patient and staff views, and to work in partnership to design a usable space that supports physical and patient wellbeing, with added benefits such as enhancements to infection control, rest, mobility, the ability for patients to shower in their own en-suite facilities, and improvements in privacy and dignity. I’ve already referred to the setting, and the indoor and outdoor space, but we also anticipate improvements to technologies within medicines management, education, and training. We also expect the new ward to enable us to address some of the everyday frustrations in healthcare, such as inadequate equipment space for storage, medicines management, and for updating electronic records. We’ve attempted to design out these issues. On the maintenance front, Health Spaces has worked with us to ensure that the space can be easily cleaned and decontaminated.
“What we have aimed to do in designing our Concept Ward is to take all the frustrations our staff and our patients feel when we are working and caring for people in our current hospital environment, national and international research, and best practice, and amalgamate all this into one setting.
The construction elements
A couple of days after discussing the clinical and site-related drivers for the scheme with Paul Morris, I talked through some of the key construction elements with Health Spaces’ Nigel Thompson. He said: “My team’s first real involvement on site was in June 2022, with our initial site survey. This entailed taking window samples to understand the make-up of the ground to calculate structurally what foundations we would need. We didn’t need to dig too deep before we found clay, and there was no contamination evident. We also involved a specialist to conduct a UXO assessment to ensure there were no unexploded bombs, given that the Norfolk coast was targeted by German bombers during World War II. Fortunately nothing was found, but the UXO survey was required as part of planning consent. We did, however, brief all who would be working on the site of there being some risk of finding unexplored ordnance.”
The new ward building is located close to Paediatrics and a cancer ward. Nigel Thompson explained: “Site access was, in fact, quite straightforward, although bringing the modules in proved a little challenging, because some are 14 metres long. After completing the site and UXO surveys, we began our groundworks early last October, which included diverting a mains water supply and HV cable. The priority was to get the site ready for the building, and with many of the patient rooms incorporating en-suites, we had to install a number of pop-ups for drainage. The most involved element was probably diverting the HV cable, but we did this over a Saturday night, and the following morning, to minimise disruption.
“A big advantage of offsite build is that the modules could be assembled while we were preparing the ground. The modular build company began its work in late September, with the schedule stipulating that the modules should be in situ by around 20 December last year.” In all, Nigel Thompson explained, there were 42 modules to install (31 ward bays, four for linkways, six plant deck bays, and one internal staircase), and 11 separate plant decks, for fitting to the roof, all of which had to be carefully craned into position.
Link corridor
He explained: “Four of the modules form a link corridor that connects the Reception in the new ward at one end with an entrance to the existing hospital at the other. Our task installing and fitting out the modules was considerably simplified by the fact that much of the first-fix electrical work had been completed in the factory, leaving mainly mechanical and electrical services work to complete on site. Once the modules were in place, we applied a temporary seal to make them watertight while the permanent Firestone roof sealing works were completed – a rubber membrane with a 25-year warranty.
I asked Nigel Thompson how Health Spaces had ensured the flexibility and adaptability the Trust required for the spaces inside the building. He explained: “Health Spaces’ design team, led by Jaime Bishop, developed initial ideas for the Concept Ward early in 2022 after meeting the client team at the Trust. As discussions progressed, we looked more at how the building’s use might evolve, and how the hospitals of the future might look, which informed how the plans developed.
“While we believe strongly in the benefits of standardisation, we also look to tailor the modular-built facilities we create to the client brief. We usually begin with an outline plan, before creating 1 to 200 scale drawings that provide more detail. Here – as we did on this project – we will involve clinicians, nurses, Estates personnel, and many other Trust staff to get their feedback. Next, we proceed to a 1 to 50 scale plan, which includes considerable detail – to the extent that you feel you could almost walk into the clinical space, and touch and feel parts of the room. Our approach is a bespoke one to standardisation. We also use BIM on all projects.
“Take the two isolation rooms in this new ward, for example,” he added. “Instead of entering these straight from the corridor – as with the other patient rooms – we have built in access lobbies with the option of positive or negative pressure. While standard air change rates in the majority of the single rooms are 6 per hour, here we have tailored the ventilation to provide 15 air changes per hour. Working closely with the architects, the sub-contractors, and the various Trust stakeholders from the start – whether consultants, other clinicians, nurses, Infection Control personnel, or the Estates team – with regular progress meetings to address any issues – has underlined the benefits of collaborative working.”
Managing the delivery and installation
Nigel Thompson added: “The biggest challenge on what has proven a generally straightforward and well-worked project was the speed of delivery required, and managing the modules’ installation due to their size – all competed to a tight schedule over seven days. We had some nice plaudits on how smoothly we managed this.”
Nigel Thompson explained that Health Spaces is a strong advocate of offsite build – the speed with which this new building has been created underlining why. He said: “The tight programme made offsite volumetric construction the obvious solution. While we were undertaking the groundworks, the modular supplier was building the modules, bringing a massive time saving. There is also evidence that offsite building significantly reduces embodied carbon emissions, and there is considerably less waste, because you are building off site in a controlled environment, which also cuts labour costs, and addresses health and safety concerns.”
HTM-compliant
He continued: “At the James Paget we have focused on building a really highquality, fully HTM-compliant, ward with excellent materials and finishes, and with the patient and staff experience, privacy and dignity, modern communication and other technology, infection control, and durability, all high on the agenda. We are still looking at finishing touches such as incorporating further artwork to enhance the interior. The linkway corridor features photographs showing how the hospital has evolved over the past 40 years. It’s been exciting to see the new ward block come to fruition, and I hope it will mark a positive new chapter in the hospital’s history.”
Mark Flynn, director of Strategic Projects at James Paget University Hospital, added: “Constructing this new ward is an exciting and important project for the Trust – and brings two benefits. Firstly, it will give us additional capacity so we can continue a programme of precautionary remedial works to our hospital roof in ward areas. In addition, by incorporating the latest specifications, it will provide us with valuable information to assist with ward design within our new hospital, for the benefit of both patients and staff.”
He added: “We felt it was essential to create a new decant ward so we could decant existing wards and other clinical areas to allow us to progress with our RAAC panel remediation in parts of the hospital. RAAC is a lightweight concrete construction known to be defective, with which there have been issues at some hospitals and schools. Here we are in the process of mitigating the effects via a remediation programme being undertaken in stages, with the support of structural engineers.
“In creating the new ward, we wanted to ensure it could be part of our new and permanent buildings as part of our masterplan for our new estate. We also wanted to challenge ourselves on research to support national thinking on the future of hospital design as part of the New Hospital Programme. We have sought patients’ views on designing the new ward, and have had considerable input from the Trust’s Estates and Capital Planning teams, the architects at Health Spaces, our New Hospital Team, and our clinicians. We also had feedback from our engagement during 2022 on our planned new hospital, with over 200 comments from staff, patients, and other stakeholders, and from our own New Hospital Programme team
Tying in with the Trust masterplan
“One of our main priorities was to ensure that whatever we built would accord with our current strategy, but also our masterplan. We also wanted to ensure we could retain the new decant facility as the new estate came together, that it would tie in with our plans for a new diagnostic centre and an elective surgical facility, and connect seamlessly to the current building. Simultaneously, we wanted to upgrade some of our infrastructure – including our power supplies and medical gases. We also knew that the national direction in England is towards 100% single rooms, which gives us real benefits on one hand, but challenges on the other.
Diane Goodwin, the Operations director within the Trust’s New Hospital Programme team, said the preferred option for the new ward was for its to be ‘hybrid,’ but with a high percentage of single rooms. She elaborated: “To enable us to test out new ways of working, we’ve retained some four-bedded bays, which will help with our research in comparing the pros and cons of single rooms versus four-bedded bays. We have some four-bedded bays in the existing hospital, but those in the new ward will be designed to new size standards, and are much enhanced. We have also built into the new ward the potential to upgrade it, and indeed the two four-bedded bays will be easily convertible to two single en-suite rooms. We’ve also taken staff wellbeing strongly into account, it having become very evident this was an area lacking in our existing hospital during the pandemic. There are places for staff to change and shower, and relaxation facilities so they can switch off during breaks.”
She continued: “There will be no large central nurses’ station; instead the nurses will be dispersed throughout the ward using touchdown bases. There will be ample support facilities and equipment storage – to enable staff to locate the items they need fast, a dedicated pharmacy, and sluice rooms at both ends. The two, slightly bigger, isolation rooms incorporate ante-rooms for infection control, and will receive 15 air changes / hour, meaning they can accommodate a low-level ICU critical care-type patient. The therapy garden will be accessible to both staff and patients, with a major focus on enabling people to get outside and have some fresh air
“There will be modern ventilation throughout, with both positive and negative pressure available. We would like to have upgraded the ventilation in the existing hospital to this standard – which would have been particularly beneficial during the pandemic. While some improvements were made, it was challenging to achieve in the existing estate.
We’ve also looked at embedding digital solutions wherever possible. We wanted this to be a ‘silent’ ward, so, for example, we have fitted a new nurse call system where if the patient triggers the alarm, staff are alerted silently, and can then respond to the patient directly. We’ve also installed additional M&E infrastructure to enable us to incorporate further digital technology with minimal disruption in the future.”
‘Mood lighting’
Diane Goodwin went on to explain that the new concept ward will also incorporate patient-controllable ‘mood lighting’. She added: “We know we will be caring for both children and adults with neurodiverse conditions in it, and the ability to change the lighting’s colour and intensity can be very therapeutic.”
Built using Modern Methods of Construction, the new ward has an anticipated 50-year lifespan. Diane Goodwin said of the single rooms’ layout: “We’ve put considerable effort into designing them, with the patient bed on the same side as the en-suite. This orientation ensures that patients have a pleasant view out of the window, there is visitor seating, and all rooms will have a sink”
She continued: “The four-bedded bays will also be larger than our existing ones, with views to the garden, and will each be served by an en-suite bathroom and toilet. The corridors are much wider than hospital’s current ones, and will have staff touchdown bases equipped with a computer and desk. Nurses and clinicians will have visibility of two patients in single rooms ahead, and – if they turn around – two behind. We are hoping most patients will be able to walk to, or be assisted to, the garden when they wish to visit it. It will feature a covered area with an oxygen supply for those patients needing this
“All in all,” she concluded, “we are all very excited about what should be a fantastic new ward environment, and were delighted to see the building completed on schedule – to a very high standard – and handed over to us in late May.