Jonathan Baillie, discovered from two of those involved in the project during a visit to Derriford, its rapid provision was made possible only through the innovative FLEX managed services project package developed by MTX, and ‘extraordinary collaboration’ between the contractor and University Hospitals Plymouth NHS Trust.
The new offsite-manufactured three-storey REI building brings together outpatient and surgical eye treatments previously provided within the main Derriford Hospital in Plymouth, and is designed to enable operations on an additional 520 patients each month, plus an additional 2,300 outpatients appointments annually. Formed from 112 volumetric modules, it incorporates three operating theatres, an increased number of treatment rooms, and an expanded area for young patients. Its ‘off site’ location on William Prance Road also improves access for patients, with a drop-off zone and parking immediately outside.
The ground floor incorporates three operating theatres, recovery areas, and treatment rooms, with one of the three dedicated to sub-specialisms such as oculoplastic, orbital, and corneal surgeries. The first floor houses consulting/examination and testing rooms, while the second features offices and plant areas for the medical IT and uninterruptible power supplies and air-handling systems. As part of the project, MTX has also built an adjoining Energy Centre, housing HV and LV switchrooms, medical gases, and a water tank.
Critical success factors
MTX and University Hospitals Plymouth NHS Trust (UHP) say that among the ‘critical success factors’ on the project were adapting the new REI building’s design to the sloping site location, dealing with a sub-basement void uncovered during site preparation, achieving the required building specification and compliance, and managing the tight timescale and a limited budget.
MTX’s FLEX five-year managed services solution was, it says, a key element in progressing the project — ‘providing the flexible financial arrangements that enabled it to proceed’.
MTX explains: “An early project start guaranteed access to Government funding for the University Hospitals Plymouth NHS Trust, and avoided increased inflation-related costs that would have been inevitable had the project been delayed.” MTX describes FLEX as ‘a true no-capital and cash-neutral solution which covers all the project costs — from groundworks through to hard and soft FM requirements’ — and which can operate either as a hire or managed services solution. It said: “FLEX enables fast expansion of clinical capacity via a simple ‘pay-as-you-grow’ fixed-term monthly fee, with us delivering fully compliant facilities using Modern Methods of Construction for rapid deployment.” The MTX team can handle all pre-construction, construction, project management, service, and maintenance, to deliver a full managed service. Working closely alongside existing FM teams, the ‘package’ includes ‘tailored’ hard and soft FM.
Progressing quickly to retain funding
The timescales precluded a full tender, and the Trust’s Procurement team identified that the project would be challenging to deliver within the budget and time constraints, particularly as the preferred structure of the deal was an operating lease, requiring the supplier to share some of the associated risks. Following discussions with various suppliers, it became apparent that MTX was the only one prepared to share an element of risk and offer the full turnkey package of design, build, finance, and operation. MTX also offered the option of wrapping the services into a managed healthcare facility agreement to achieve a VAT-efficient model.
The Trust had worked successfully with MTX on numerous projects previously, and identified that a combination of using MMC principles, and more quickly securing the necessary finance via FLEX, could save up to six months in the project schedule. MTX said: “A collaborative approach was essential to ensure project delivery within the required timescale and limited budget. This began at Outline Business Case stage, with us fully engaging through the RIBA 0-1 stage while our Pre-construction team assisted with the structure’s design. The underpinning collaboration and co-operation between the Trust as the client, and us as the contractor, were essential in successfully completing the build programme.”
To find out more, I visited the building, meeting MTX Project director, Paul Williams, and Gill Nicholson, the Trust’s Service Line manager for Ophthalmology. By way of historical context, the latter explained that Plymouth’s first ophthalmology hospital was established by Doctor John Butter, a local surgeon, in the early 1820s. Despite seemingly encountering local opposition, with the support of Doctor Edward Moore, the Plymouth Eye Dispensary was opened on 25 December 1821 in a house in the city’s Cornwall Street. In 1823 it changed its name to the Plymouth Eye Infirmary, and on 30 October 1901 — the original 22 January opening having been postponed due to the death of Queen Victoria that day — Plymouth’s Royal Eye Infirmary opened on a site in Mutley Plain.
Royal patronage
King Edward VII consented to continue the Royal Patronage, further cementing a royal patronage begun by HRH the Duke of Clarence, later King William IV, in 1828. In early 2013, the Plymouth Hospitals NHS Trust decided the 19th Century building in Mutley Plain, which had served local people for over a century, was no longer suitable for the ‘ever-expanding and developing service’, and it was decided that ophthalmology treatment offered there would transfer to Derriford Hospital. Gill Nicholson explained that since moving to Derriford in 2013, the bulk of inpatient and outpatient ophthalmology services had been provided on level 3 of the main hospital, about 15 minutes’ walk from the new REI building.
She said: “Following the move to Derriford, eye surgery was originally performed within the main Derriford Building.”
The new REI building gives us an additional ophthalmology theatre, increases our outpatient activity by over 20%, and thus improves our waiting list position. It also provides a Macular Treatment Centre, with two purpose-built injection facilities for our patients.”
She continued: “Since opening we have increased our cataract theatre provision and reduced our waiting list for HVLC (high volume, low complexity) procedures to three weeks on average. The new building has improved patient access, reduced waiting times, and delivered a better service, treating patients from across Plymouth and some of Cornwall. The building has predominantly been built for ophthalmology, but we will potentially use it for other theatre specialisms in the future. The ophthalmology surgery is predominantly undertaken using local anaesthetic here, but the new building is also set up to take general anaesthetic cases. It is great to have all of our 200 staff and services back under one roof, and to have new, purpose-built theatres.”
Time was of the essence in getting the new building constructed and operational — one of the main reasons the Trust opted for a contractor renowned for its Modern Methods of Construction expertise. In fact, MTX not only provided the finance, but also designed the new REI from a Trust brief, and alongside building it undertook all the structural and M&E-related works ‘in house’.
Paul Williams said: “MTX has undertaken a number of schemes at Derriford Hospital over the years. This project was not won via a traditional tender; rather it began with a pre-construction information pack, and us developing the scheme with UHP — looking at the outset at where the new building would best fit. The land for the new REI has in fact been leased from Plymouth City Council.”
He continued: “FLEX gives hospitals the ability to look at a finance agreement as a way of getting projects off the ground without necessarily securing the full funding from the government — in this case from the Elective Recovery Fund — at the outset.” As part of the package, MTX provides a full 10-year managed FM service agreement.
Gill Nicholson explained: “The designs were developed with the staff, and — post-COVID — clinical pathways have certainly changed. Now, a lot of Ophthalmology pathways are moving towards ‘virtual pathways’; these require additional imaging equipment, but are better for patients. We’re now seeing best practice, improving our capacity, and getting a diagnosis quicker. This building is fantastic — both for our local community, and patients in Cornwall. With three purpose-designed theatres, cataract patients have their own inpatient area, and can be seen, have surgery, and be discharged, within about 45 minutes. Previously, in the main hospital, we could complete six cataract operations in the morning and six in the afternoon, but the new facility can increase that to 10 per morning / afternoon session. Two of the three new theatres are ophthalmology-specific but have multi-use capacity. Everything has been designed with the patient pathway in mind.”
Comprehensively equipped theatres
The three operating theatres are equipped with Merivaara Q-Flow LED surgical lights and CP9 touchscreen control panels from Bender UK, which has also supplied resilient medical IT power for the theatres and uninterruptible power supply (UPS) battery back-up Group 2 power systems. Bender’s ‘unique’ glass CP9 touchscreen theatre control panels deliver control and monitoring of the operating room equipment through a central location. They also provide the alarm status of ventilation, surgical, and room lighting, and monitor medical IT power provision and uninterruptible power installations for the facilities.
Gill Nicholson added: “Our emergency Ophthalmology pathway remains on the Derriford site. Most Ophthalmology procedures are day case, which is why the new REI is set up as it is. One theatre here is dedicated solely to cataract procedures.” Operations performed in the other two include vitreo retinal surgery, ocular plastic surgery, and glaucoma surgery. Gill Nicholson explained: “Having three theatres set up with anaesthetic rooms gives us considerable additional flexibility, while the first floor houses the new Macular Treatment Centre.” She added: “Many of our Ophthalmology patients are long-standing, and at the official opening in October, our longest standing patient, Robert Johns, cut the ribbon.” She explained that in addition to the three new theatres and associated anaesthetic rooms and recovery areas, the ground floor houses a new ‘walk-in’ Urgent Care Centre, open 8.00 am — 6.00pm weekdays, with additional weekend cover.
Outpatient facilities
On the first floor are the new Outpatient facilities, including a Paediatric-specific area, the main adult outpatient unit, and the Macular Treatment Centre. Commonly patients with macular conditions visit every two weeks for an injection, and in the new REI they can have an imaging assessment simultaneously, making the new MTC a ‘one-stop-shop’ for them. The first floor incorporates eight imaging rooms. Gill Nicholson explained: “Ophthalmic care and treatment requires a lot of specialist diagnostic equipment; we predominantly use Zeiss equipment. Our Imaging team runs Saturday imaging-specific lists upstairs for both our glaucoma virtual risk stratification pathway and macular treatment risk stratification pathways; both imaging-led. They are GIRFT (Getting It Right First Time)-recommended, and thus classified as best practice.”
Within the Macular Treatment Centre there is an imaging area, orthoptist rooms, and optometry-led services and consultant facilities. As Service Line manager, Gill Nicholson supports all services within ophthalmology, including governance structures, working with a team to devise and implement best practice pathways, liaising with the clinicians to ensure that their pathways are up and running, helping write business cases, and during construction she also project-managed the new REI. She said: “We have 200 staff in Ophthalmology, and everyone has been delighted to come back together in a new, state-of the art building. The space vacated on level 3 of the main hospital now houses a new ward and a Frailty Unit.”
To simplify patient access, the REI building has a sizeable ‘patient only’ car park around its perimeter, the Trust having secured staff parking nearby. The second and top floors, Gill Nicholson explained, incorporate a ‘very beautiful office area’. She said: “All the offices — used by consultants, administrative staff, Fellows, and ACP practitioners — are light and airy. We also have a dedicated teaching room.” The second floor incorporates the main plantroom. “There are many thoughtful touches incorporated into the design to simplify and speed patient flow, and improve efficiency and flexibility,” Gill Nicholson explained. “For instance, the consulting rooms running down the centre of the first floor have doors either side — one opening to the Paediatric Outpatient area, and the other to the Adult Outpatient area, allowing us to easily switch the rooms’ use.”
Paul Willliams explained that the Trust and MTX identified the brownfield plot just off William Prance Road as optimal, particularly given that there was no suitable space available on the Derriford Hospital site. The site formerly housed a Royal Marines barracks, believed to have been demolished in the late 1990s. Paul Williams explained: “We didn’t have floorplans, so we didn’t initially know where the new building would sit. On digging trial holes we discovered some old basements and stair cores. With the location leased from Plymouth City Council, and not on a hospital site, we liaised closely with Council planners throughout; they had considerable input.”
Initial groundworks
MTX began its initial groundworks in February 2022 with a reduced level dig to get to the foundations, a couple of metres lower than the existing ground. Paul Williams said: “Within that phase we hit some remnants of previous buildings which we had to get rid of. We came across three or four rock seams quite low down, which caused delays, because the rocks were extremely strong, and we had to bring in large machines to break them down. The planners wanted us to build lower, and the deeper we went, the more rock we hit.”
He added: “We found what we think were the bases of MOT inspection bays. Some of the areas were contaminated, so we had to address that, including via sampling. In the end the groundworks took until August 2022 to complete — including 4-5 weeks of delay due to the ground conditions.” For the foundations of the new building, MTX used a cast slab across the whole base.
Paul Williams explained: “The volumetric units we put in were floorless. We also installed a large 200 metre retaining wall on the sloping site. At the far end, where we cut down two metres, we installed 2-metre-wide concrete rings to provide additional support and backfilled in between. We based our foundations on the specific ground conditions and slope.”
In all 112 volumetric units were used to create the new building. The MTX site team was able to make use of an adjoining empty site, rented from the Council, to store the modules, while groundworks continued. Over a 21-day period in September 2022, the volumetric modules were lifted into position. Paul Williams added: “Without the wet weather delays, we’d have got the building watertight in peak summer, but dealing with the rock seams pushed everything back, and the primary build time became winter, rather than summer. It was challenging, because we then had biblical amounts of rain to contend with right through from September into November.”
“After 21 days,” he continued, “we were watertight, and had the shell. The internal floors come with a hollow Lewis steel rib deck, onto which we applied a liquid screed. This project used volumetric empty units fitted together with traditional concrete floors and then fitted out on site.”
Gill Nicholson said: “There are specific ophthalmology microscopes in the new theatres, bolted into a steel frame, rather than attached to the building. There were specific vibration requirements; the vibration factor here is 1. While there will be some vibrations, they won’t impact theatre activity because of the structure and design.” Paul Williams added that due to the use of the Lewis deck, the vibration factor on the upper floors would be the same as in the ground floor theatres.
The ‘complex’ building services work undertaken by MTX included installing three roof-mounted air source heat pumps, which at the time of design, Paul Williams believes, were the biggest Mitsubishi had ever provided in the UK. He said: “We specified air source heat pumps as a design team, looking at their heating capabilities and what’s required, the Building Regulations, and working with Plymouth City Council on future-proofing the building for its potential use as part of a district heating system. The air source heat pumps, housed in a louvred enclosure, are energy-saving, and their use means there is no gas going into the building. They are supplemented by back-up heat exchangers and calorifiers.”
The second floor plantroom houses six air-handling units — one per theatre, and the others serving the building’s common areas. The new Energy Centre houses an HV transformer, and LV electrical plant, plus a medical gas enclosure, a water tank room, and a refuse room. Paul Williams explained: “We have trenches running underneath for the gases and cables, which come up the back of the lift shaft, over the roof, and into the plantroom.” Each theatre receives 20 air changes / hour, with the rest of the building receiving 6-8. In line with the Trust’s Net Zero aspirations, there are photovoltaic solar panels on the roof.
Theatre equipment
Gill Nicholson said: “The theatre equipment is state-of-the-art; our existing Zeiss microscopes are fitted to the roof of two theatres. We also have a standing microscope for the third. Because ophthalmology is such a specialist field, a lot of other equipment came across.”
I asked what she felt had been the key challenges for her in managing the project. She said: “COVID has changed our pathways dramatically. With risk stratification pathways, we are now moving towards a diagnostic service, with a lot of Ophthalmology now ‘one-stop’. I think that’s changed healthcare across the board over the last three years. We’ve had to look at the original designs for the new building created pre-COVID, and then re-look at them and the new pathways post-pandemic.
“Equally,” she said, “I’m not a builder, so for me it’s been about understanding that there’s different languages, and between ourselves and MTX we’ve had to take that working relationship forward smoothly. Working with the site team, my team and I learned a lot, and we navigated any obstacles to come out the other side with a fantastic building.”
Paul Williams explained that the project was at one point around six weeks behind schedule, but got back on track and completed with handover in time for the October opening. He explained: “For us — apart from not knowing what we’d find in the ground — the biggest challenge was material and staff shortages, a consequence of COVID, and not things you can really plan for.”
Gill Nicolson said: “To mitigate the delay, our team worked closely with MTX to bring in some of our specialist equipment while the construction team was still active on site. Then, when the handover occurred, we had a target of a week to move from old to new facility. All the microscopes and imaging equipment were moved by a specialist team from Zeiss. The CQC application process for the new facility was a priority, and we worked closely with the Commission to ensure that all the necessary recommissioning of each piece of equipment and CQC sign-off happened promptly. MTX assigned us an area within Urgent Care so we could take receipt of and start the commissioning process while the building was still being completed. We were very much working as a team.”
Planning conditions
In addition to addressing the challenges of the sloping site, subterranean void, and old foundations, the MTX team also had strict planning conditions to adhere to. Paul Williams said: “For example, there were badger sets on parts of the site, so we couldn’t start working at the beginning in those areas. We had to get in a Conservation Officer, there were Notice Periods, and people had to come and check, which caused a delay of about 12 weeks. There were also deer running up and down between the trees behind the site. Once we had sign-off from the relevant specialists — including Simon Geary Ecology Services, who put cameras into the badger setts to ensure the badgers had vacated them, the Council gave us permission to begin working in those areas.”
He continued: “The pine trees behind are all under Tree Preservation Orders, necessitating extensive dialogue with the Council and the tree conservationist, because the roots extend so far. There were thus only certain ways we could dig in Tree Protection Zones, which extend three metres around the base of each tree, and there were further restrictions based on trees’ age. All this had to be factored into the design of the car park, which is on that side, to ensure we weren’t encroaching on protected locations.”
I asked Gill Nicholson what she considered were the biggest clinical benefits of the new building. She said: “The 20% increase in the current space is number one. (The new building is just over 4,250 m2 in area). Obviously, the new REI brings improved access for patients, we have theatres and Outpatients back in one environment, and it’s ophthalmic-specific built. These are the biggest wins for us. Clearly,” she continued, “the amount of diagnostic imaging equipment to be accommodated has required careful thought in terms of the structure’s design.” Paul Williams said: “That’s one of the main reasons why the base floor on the ground floor is 300 mm thick concrete.”
Gill Nicholson said: “While we have concrete floors, our consultants still had concerns, having experienced vibrations in the previous building. That is why the structure for the microscopes here is — as Paul Williams described it to me — ‘an independent steel goalpost’.” He elaborated: “So, the uprights, hidden in the walls, are bolted into the concrete, and then the horizontal is in the ceiling void, which is where the microscopes are bolted into.”
Paul Williams said Gill Nicholson had ‘done really well’ in sharing the project plans and information. He said: “Often our end-user clients struggle to understand our drawings. As a contractor, we are used to looking at them daily, but put 2D plans in front of most people and they struggle to visualise what’s going on. It’s been good on this project to get that understanding early on.” Gill Nicholson admitted: “It took a lot of learning, but it was also about not being afraid to ask questions. Every time I did so, people sat down and explained the answer to me. It was challenging at times, but we built a really good relationship to navigate those differences and the different languages we all have and bring that back together. In fact, I only joined the project 20 months before completion, just as the first modules arrived, so it was a steep learning curve.”
Inside the building, all the clinical areas, as well as toilets and shower rooms, feature an Altro Whiterock laminate non-porous wall cladding, favoured by the Trust’s Infection Control Team for its hygienic, wipe-clean properties and smooth seamless finish. To differentiate the various clinical and non-clinical spaces, specific areas have their own colour schemes — ranging from light blue to peach for instance. Theatres feature a dark blue finish, and Reception yellow.
“All the signage inside is in line with the RNIB recommendations, which is bright yellow, with black writing,” Gill Nicholson explained. As one approaches the new building, the striking external cladding — finished in a combination of black/ dark and light grey — catches the eye, complemented by tinted brickwork chosen by Plymouth City Council, giving the completed building a handsome modern feel. There is no doubt that the new REI has a distinctly different external appearance. Paul Williams explained that the metallic standing seam cladding was developed by MTX jointly with the planners at Plymouth City Council. He said: “You’d certainly not see some of these features were the building on a hospital site. It has definitely benefited from its location, because the planners have been much more engaged.” Externally, complementing the striking facade, the building was planned with a landscaped paved area through which visitors walk to the main entrance. A one-way entry system for vehicular traffic applies, with a drop-off point at the side of the building, and ambulance access to the Urgent Treatment Centre.
MMC’s benefits
Paul Williams told me he is a big advocate of an MMC approach on projects like this. He said: “The major contributor to cost on construction projects is the time spent on site. Take a traditional build and consider that no on-site construction could have started here until the groundworks were completed in August. Here, volumetric unit production was taking place simultaneously, so the units could be installed, and the building quickly made watertight once the site was prepared. We could never have completed such a complex clinical building via traditional build within the same time.”
Gill Nicholson explained: “We have all been on a considerable journey, but all the effort that has gone into the scheme ensures that we have an ophthalmology facility that will provide excellent services to our local population for years to come, as well as being a great working location for our staff.”