HEJ editor, Jonathan Baillie, recently met up with Associate Director for Estates & Facilities at East Cheshire NHS Trust, Rob Few CEng, FIHEEM, to discuss an ambitious and far-reaching portfolio of refurbishment, new-build, and carbon and energy reduction measures currently in progress at Macclesfield District General Hospital and two smaller hospitals operated by the Trust. The investment required to put all of the work in hand is the largest the organisation has seen for a decade.
I met up with Rob Few, the East Cheshire NHS Trust’s Associate Director for Estates & Facilities, at the Estates office at Macclesfield District General Hospital in late March. There he enthusiastically talked me through the wide range of ongoing improvements to the Trust’s built estate, and a concerted carbon and energy reduction drive, both of which have been made possible by the Trust securing significant funding over the past year and half. A Chartered Engineer and Fellow of IHEEM with specialist ventilation expertise, Rob Few joined the Trust 10 years ago as Head of Estate Operations, progressing to become Associate Director of Estates & Facilities
Macclesfield District General Hospital, where he and his team are based, is the Trust’s largest hospital – a 48,000 m2 , 350-bedded acute healthcare facility that opened in 1983. The Trust also has two smaller hospitals – Congleton War Memorial Hospital – which provides specialist care for patients on Pathway 2 needing short-term rehabilitation or transition to their own home, and Knutsford and District Community Hospital – which offers a variety of outpatient services.
Developments taking place in a momentous year
Rob Few explained that it was timely that the developments we would go on to discuss at all three hospitals were taking place in the NHS’s 75th anniversary year, with the multi-million pound schemes set to bring to life the Trust’s priorities of strengthening and expanding services through partnership working, and making the best use of its resources to deliver outstanding care. The ‘vision to create future-proof hospitals’ was – he said – actively in development, while the benefits would not only ripple out across all the communities that East Cheshire NHS Trust serves, but also among staff and volunteers. He said: “It’s widely acknowledged that it’s been a tough few years within the NHS due to COVID, as well as other system pressures. Our staff and volunteers have been amazing – always putting the patient and their loved ones first, and continuously going the extra mile. Looking after our workforce is a priority, and we have a strong focus on health and wellbeing, with many support measures and services in place that provide help not only for our workforce, but to their families too
“The very fact that there is significant investment being channelled into the working environment is giving staff a real boost; they feel as valued as our patients do, which is really important. Nearly 70% of our staff live in the area, and there is a real sense of pride and tangible excitement across the Trust among our people, who are witnessing first-hand the developments in progress. It’s a brilliant time to be working at East Cheshire, and to be part of the story, as the journey to creating our future-proof hospital environments takes place.”
The Trust has a fully in-house hard FM team, while soft FM activities – including cleaning, catering, security, and portering – are undertaken by ISS. Rob Few said: “We are a small Estates & Facilities team managing the estate – with a three-man Capital Team, and a six-man Operational Team. If we get particularly busy, however, we can ‘flex up’ by using external consultants, contract administrators, and project managers, and ‘flex down’ again when we no longer need this external support and expertise. We also have a five-man EBME team, seven mechanical and electrical technicians, and four handymen.”
Difficult time funding-wise
Moving to discuss some of the work currently ongoing or already completed at the three hospitals – with the main emphasis on Macclesfield District General Hospital – Rob Few explained that ‘like many other NHS Trusts’, the Trust had seen a number of years of low investment. He said: “One of the consequences was that the Estates & Facilities team then didn’t feel able to make the environment better for patients, staff, and visitors; the funds were simply not there to do so. COVID-19 however, changed all that, because we had to look at the estate in a totally different way. Not only did we have to re-focus on patient and staff well-being, but with the associated impact on ventilation systems and space, we also had to change our whole approach to operating, managing, and maintaining our hospitals.”
He went on to explain that one of the pandemic’s impacts on the Trust’s current Estate Strategy had been that some of the work in it had been brought forward via the funds the Trust has recently secured – largely thanks to the ‘very proactive approach’ of its CEO, Ged Murphy, and Director of Finance, Kara Mason. He explained: “There are a number of elements to the exciting and far-reaching work I have brought you up to Macclesfield to discuss. There is the decarbonisation of the estate, for which we have obtained a £7 m grant from Salix, and which is absolutely key for us given the NHS’s Net Zero ambitions, and a number of other significant refurbishment and new-build elements, which perhaps we can discuss first?”
Delayed by the pandemic
He continued: “Our last full Estates Strategy ran out in 2019, and the pandemic delayed us formulating a new one – because we knew significant changes were emerging. The Board has built up a strategy called ‘Working Together’, and we are aiming to dovetail into it with our updated Estates Strategy, which began running last year. Historically,” he added, “our Estates Strategies have run for a fiveyear period. Having experienced delays in a number of areas of planned work with the outbreak of COVID-19, much of the funding we have received in the past 18 months has been around improving our facilities for elective surgery, and elective recovery, and upgrading our Emergency Department here in Macclesfield.
New MRI suite being built
“We are also having a new MRI suite created here – currently being built – and a new ultrasound department, and enhancing our Endoscopy Department so that it can achieve JAG accreditation.” Another of the key focuses in the current Estates Strategy is to remove non-clinical services from clinical areas, and provide better staff and patient facilities within the footprint. Rob Few elaborated: “So, what we’ve done is to take office staff out in some areas, and put in wellbeing and changing rooms and breakout spaces for staff on each of the hospital’s 12 wards. Our ERIC returns indicate that our estate is 99.6% full, so it’s largely been about reviewing how we are using our buildings to provide an improved, more modern, patient and staff environment
“A good example of how a relatively small-scale investment can make a big difference,” he explained, “has been our recent work with ISS to upgrade the hospital’s (first floor) popular Treetops Restaurant, which is used by staff, patients, and visitors. We have put in a ‘breakout’ area so people can charge their phones – with a bit more of a ‘Costa’ feel to it, provided new desks and tables, and a new servery, re-decorated the space, and installed a plant divider, to give a feel of nature. The restaurant has a pleasant view, – as its name suggests – over treetops at the front of the hospital. We also have in our Estates Strategy plans to replace the windows, paint the rendering, and generally make the restaurant a more inviting place to come into.”
Backlog maintenance and energy reduction
Rob Few explained that the Trust’s Estates and Facilities team has typically received ‘circa £2 m’ annually to offset backlog maintenance. He said: “This year, however, we obtained around £7 m from Salix for energy projects, to which the Trust has added about £1.5 m, meaning that, overall, we are spending around £8.5 m on energy and carbon reduction activity. We also have a funding allocation for a new Elective Treatment Centre (Phase 1), which will be at the front of the hospital, and is being created via the refurbishment of an existing ground floor area. Being built by City Build, this will house four new general surgery rooms, and will give our day case activity a real boost.”
The new elective treatment facility will also house a new Women’s Unit, while the broader goal is to make it as ‘multi-purpose’ as possible, with both male and female facilities. The Centre will be linked to the hospital’s Outpatients’ Department, and will principally be used for day case procedures. The Trust has also recently received a further £200,000 to expand its Mammography services in the New Alderley House building close to the Estates office on the Macclesfield District General Hospital site, again via refurbishment – the hospital is the lead provider for such services in Cheshire.
Coming together simultaneously
“A lot of this new-build and refurbishment work is coming together simultaneously, so it’s an extremely busy and exciting time,” Rob Few explained. “We are investing £6 m jointly in the hospital’s Endoscopy Treatment Unit and the new MRI suite, which will have a new MRI scanner. To extend our Endoscopy unit on the hospital’s first floor, directly above Radiography, we’ve had to build the ground floor elements to support it, which left a void space, into which we are moving the new Ultrasound Department. The new MRI suite will then be where ‘Ultrasound’ formerly was.” The new MRI is due to be delivered in June, and will be located close to ‘ED’ within the existing Radiology Department.” The hospital already has two CT scanners and an MRI, as well as a mobile MRI in a car park, which will no longer be needed once the new, permanent, second machine is in situ
Moving to another recent development, Rob Few said: “We will also have a new Education Centre in New Alderley House above the Mammography Suite, a £1.6 m investment being created very much in line with the Trust’s aspirations for Macclesfield District General Hospital to become a teaching hospital.”
New cancer centre
Meanwhile, in December 2021 a new cancer centre had been completed on the Macclesfield site in partnership with The Christie NHS Foundation Trust. This has not only improved local cancer care, but also freed up some of the space required within the hospital for the new Elective Treatment Centre. The two-storey, £30 m cancer therapy facility, called The Christie in Macclesfield, includes Outpatients’, Chemotherapy, Radiography, two linear accelerators, a CT scanner, and support services. A facility Rob Few described as a ‘fantastic new cancer treatment centre’ was predominantly funded by The Christie charity, and built by VINCI Construction
‘ED’ refurbishment project
He added: “Another important project here at Macclesfield District General Hospital, which is starting as we speak, is a full refurbishment of our Emergency Department – Phase 2 of the Elective Treatment Centre project – which will take 12 months to deliver. This will aim to improve both the patient pathway and the patient experience, and fully support the elective treatment centre pathway, with a separate children’s area, new ‘resus’ facilities, and additional capacity – with three extra consulting rooms, making 14 in total.” He added: “Our ‘ED’ is already incredibly busy, and in fact there are eight separate phases to undertake to complete the refurbishment.” The refurbished and enhanced ED will be fully ventilated, with new medical gases, medical IT and UPS, complete re-wiring, and new lighting.” The existing Emergency Department was – Rob Few explained – not only struggling capacity-wise, but couldn’t achieve the Infection Prevention and Control team’s criteria in some key respects – for example around ventilation. He elaborated: “The existing ventilation only provides minimal fresh air requirements, without the correct air exchange rates or appropriately filtered air. While the existing Emergency Department’s windows provide some natural ventilation, the central core rooms receive only minimum fresh air requirements. The ‘new’ ED will have HTM 03-compliant air exchange rates, i.e. six air changes / hour in general areas, and 10-15 air changes / hour in the ‘resus rooms’ and ‘Majors’ clinical rooms.”
Opportunity to bring in new technology
Rob Few said the ED project would also be ‘a great opportunity to introduce new technology’, such as a new patient monitoring system that will afford consultants and other clinicians improved patient oversight, as well as enabling patients to talk to nurses direct. He said: “On all these schemes, we are aligning the M&E equipment with current HTM stipulations. To get to that point from where we were in the estate will be fantastic. Much of the existing estate was built in the 1980s, and the buildings were thus designed to previous HTM standards.”
The associate director for Estates & Facilities explained that his team is also overseeing a refurbishment of the first floor Maternity Unit at Macclesfield District General Hospital. He explained: “We are fitting new medical gases, LED lighting, ceilings, and flooring, and upgrading the unit to IPC requirements, with new washhandbasins, as well as new furniture.” Also fitted will be a new baby tagging system, while the electrical infrastructure on the ward will be upgraded.
Decarbonisation work
Having by this point discussed quite a number of different built estate upgrading and improvement projects at Macclesfield District General Hospital, we next focused on the decarbonisation work either ongoing or planned. Rob Few explained: “The key element of this is a new air source heat pump here in Macclesfield, which will offset the gas used by our boilers, generating heat by using electricity. The scheme as whole will offset our 2032 NHS England carbon reduction target, and obtaining the investment for our decarbonisation plans has been a huge positive.
Rob Few explained that the new £2 m heat pump is being installed in a new Salix-funded Energy Centre, with its own transformer and electrical HV supply. He said: “The Energy Centre, which is currently being built, will be single-storey, but with a mezzanine above to house new chillers. The heat pump has already been craned in
Energy Conservation Measures
“As part of Energy Conservation Measures – which are part of our Trust Green Plan,” Rob Few continued, “we will also be upgrading our (Open Building Services) Building Management System, and decarbonising our HSDU (Sterile Services Department) in the Service Centre on the first floor of the hospital here in Macclesfield. This will involve de-steaming the site, and installing electrical steam generators in the HSDU, which handles surgical instruments for all three hospitals, and is a significant carbon emitter.”
He added that the two main gas boilers at Macclesfield District General Hospital will be fitted with new burners, but with the heat pump in situ, will operate less frequently, as a ‘top-up’: “The air source heat pump will generate around 300 kW, and the site’s overall peak demand is around 1600 kW,” he explained. “We already have a CHP in place, with a 600 kW output, and Centrica has modified this as part of our decarbonisation work, fitting a new engine to make it run more efficiently.”
EPC updated
Rob Few explained that – via the Carbon & Energy Fund (CEF) – the Trust has an Energy Performance Contract (EPC) with Centrica. He said: “We have recently updated our EPC by way of a re-statement and amendment to the Trust’s existing EPC. In 2029, the existing contract will end, and a new one will then run until 2039. That is fantastic news, because it means that over the next few years we can work with Centrica and the CEF on new, innovative technology to make sure we hit the 2040 NHS Net Zero carbon target.”
He continued: “The EPC commenced in 2014, and Centrica is responsible for the full maintenance of the CHP. On a normal day here at Macclesfield District General Hospital, with the 300 kW from the new heat pump, and the 600 kW generated from the CHP, our boilers shouldn’t need to be on, apart from at peak demand times. One upshot however, is that we are increasing the electrical demand coming onto the site.
“The Trust thus needs to ensure that it has the right provision in place to make these changes.” Accordingly, Rob Few explained, the Estates & Facilities team has been working with the DNO, Electricity North West. He said: “To decarbonise and move to electricity your cables need to be bigger. If we do need to upgrade our cabling, it could cost around £1.5 m, which means being very careful about managing and monitoring our electrical capacity on site, via our upgraded BACnet-based BMS. As part of the BMS upgrade, we will be enhancing our remote monitoring capabilities, and linking in some of our other systems, such as generators and associated critical alarms.”
New sub-station
I wondered about any particular infrastructure challenges of installing the air source heat pump. Rob Few said: “It has its own HV supply, which has meant installing a new sub-station for the Energy Centre, and there are also additional monitoring and controls aspects. The pipework involved should not be underestimated either; it will run for about 200 metres from the Energy Centre to the existing boilers, and isn’t a straight run – it goes on top of roofs, and through different plantrooms, and will need to be appropriately lagged and insulated.”
The pipework from the heat pump will connect to the existing boiler header. Rob Few explained: “The electricity produced will generate the heat through the heat exchangers, over which the water will pass and go to the boilers. This means the boilers don’t have to work nearly as hard, and you’re not using gas, apart from during peak demand. We will be working continuously with the CEF and Centrica over the next 17 years to ensure that our carbon and energy consumption continues on a downward trajectory.”
Guaranteed savings
Rob Few emphasised that the CHP EPC guarantees savings, requiring Centrica to ensure that the recently upgraded CHP runs as efficiently as possible, with any savings shared between the Trust and the company. He said: “All of what we have discussed falls under our new Estate Strategy, which started in 2022. In all the total investment at our three hospital sites in the 12 months from late 2022 to late 2023 will be around £25 m.”
My interviewee explained that out of the £8.6 m total made up of £7.1 m in Public Sector Decarbonisation via Salix, and the Trust’s £1.5 m contribution, the Estates & Facilities team intends allocating around £1.5 m for re-roofing four of the wards at Macclesfield District General Hospital. He said: “We will be creating warm roofs by leaving in the existing low-level insulation, but adding additional insulation between the trusses, which will increase the roof height. The enhanced thermal efficiency should help reduce our boiler use, and thus cut our gas consumption.”
Electricity vs gas
Rob Few explained that the various decarbonisation initiatives should bring the Trust around £100,000 annually in guaranteed savings. He added: “However, to use the heat pump, and implement the changeover to electricity in the HSDU, we will increase our utility costs, since electricity costs more to buy than gas. The Trust Board was made aware of this early on – that to be sustainable, some of your running costs will rise.” The Trust already purchases 100% of its energy from renewable sources, he added. In all, it expects to reduce its carbon emissions by around 712 tonnes CO2e annually, and by 15,000 tCO2e overall by 2040.”
He said: “As you can see, we have a large number of projects – both construction and/ building fabric-related, and decarbonisation-focused – ongoing here after a somewhat fallow period. As the person heading up the Estates & Facilities team, there are so many different elements to think about – from appropriate ventilation air change rates to sustainability, optimal use of clinical and non-clinical space, and patient and staff wellbeing. With our latest Estate Strategy and decarbonisation work we are bringing all of this together, and are implementing our plans, because we’ve got this additional funding – which is fantastic.”
Rob Few explained that the £6 m cost of the new Elective Treatment Centre and Emergency Department upgrade is being funded via the Government’s Targeted Investment Fund (or ‘TIF’) – announced in the 2021 Autumn Spending Review. He added: “The funding for the new MRI and Endoscopy Department project is from the local ICS, while the £1.6 m investment in our new Education Centre is charity-funded.” He said of the various projects: “This is certainly the largest overall investment we have seen in our estate for a decade. With a relatively small Estates & Facilities team, however, the team is determined to deliver on all capital projects. It is very much-needed, and every staff member has fully bought into the overall ambition of making the environment better for patients and staff. It’s been a fantastic journey.”
Backlog maintenance
From the Trust’s backlog maintenance surveys, it had become clear that parts of the hospital were in need of investment. Rob Few said: “We are gradually tackling our current £20 m in backlog, and probably offsetting that figure by about £4 m through the funding and all the work we are doing, which is fabulous.”
Rob Few explained that there are two acute NHS Trusts in East Cheshire – East Cheshire NHS Trust, and Mid Cheshire NHS Foundation Trust. The catchment area for East Cheshire is around 200,000 people. He added: “About 50% of the demographic are over 55, so our 28-bedded community ward at Congleton War Memorial Hospital is really important. As part of our Estate Strategy, we have improved the Outpatients’ facilities and the main entrance at the hospital, re-surfaced the car parks, improved signage, and installed new windows.”
Next plans
Acknowledging that – despite all that had already been achieved – there was ‘still a long way to go’, Rob Few said: “Our next step will perhaps be to build a new discharge facility, and thus improve stepdown capacity, at the Congleton site, as well as looking at all the infrastructure at our sites to make ensure that we have as sustainable an estate as possible.”
Rob Few was keen to emphasise how important collaboration had been to what had already been achieved. He said: “The close working relationships that have developed between the Trust Board, the clinical teams, the IPC team, and Estates & Facilities, as well as with external contractors and project managers, have been of utmost importance – because while we’ve managed the various projects well, without this collaboration, planning and implementing such a wide range of schemes could have been a nightmare. Luckily, everyone has really bought in.”
To date, no patients have had to be moved, but, for instance, when the reroofing of the four wards at Macclesfield District General Hospital gets under way, the Estates & Facilities team will need to shut six-bed bays at a time, reducing capacity, since the Trust currently has no de-cant capacity. Wards are currently 28-bedded, and a mix of six-bed bays and single bed rooms. Rob Few explained: said: “Each ward template is about 500 m2 . If you built these new today the template would be about 850 m2 , which immediately presents us with a problem, since we currently only have four single rooms per ward, as opposed to the 50% ratio (or 100% in some cases) we should have.” He continued: “Addressing this will form part of our future Estate Strategy.”
External expertise
Rob Few explained that the Estates & Facilities team uses an external contract administrator, ESE Project Management, and works with architects, Gilling Dod, on all the current schemes, including the PSDS work. He said: “Gilling Dod has always been extremely responsive – for instance over our desire to have natural colours throughout our new and refurbished buildings. The colours will come from the furniture, feature walls, and artwork.” He added: “Our Infection Prevention and Control team is absolutely delighted with what we are doing; they cannot support us enough. The IPC team’s engagement on aspects such as washandbasins, ventilation, and wipeable surfaces, has been fabulous. When you are doing as much as we are doing on a small footprint, I would reemphasise that this sort of engagement, having the Board fully engaged, and working with robust plans, are all key.”
Clinical team’s buy-in
Most of the work we had discussed, apart from the ED re-modelling and extension, is scheduled for completion by early next year, Rob Few explained. He said: “The ward re-roofing will start this summer, and could continue into next year, depending on what sort of winter we have.” He added: “Since we will be taking six beds out of service at a time, the input of our Clinical team will be key. We won’t be working directly above patients, but when re-roofing over the nurses’ desks – which we can’t take out of service – we will be installing crash decks.”
He continued: “Considerable thought has gone into how we will undertake this project. We will also be replacing manually openable Velux rooflights on all the wards – there are about 25 on each – with electrically operable ones. With natural ventilation on the wards, some of these rooflights have seized up, so in summer the wards tend to overheat. The long-term plan is to have mechanical ventilation throughout. Our aim is to use every bit of cash to enhance the patient and staff experience. Currently,” he added, “we have close circuit cooling, and install temporary IPC-approved chillers on the wards, which costs us about £20,000 per year. As we can’t put DX chillers in every room, we will install two on our most critical wards, such as ‘Respiratory’, creating ‘cool rooms’ for the most in-need patients, catering for up to 12.”
Day case load more efficiently addressed
Macclesfield District General Hospital currently has seven operating theatres, five of which have UCV canopies. Rob Few said: “Currently, some of our elective day case surgery is being undertaken in a theatre, but the Elective Treatment Centre will take on many of these procedures. This will free up theatre space for other surgery, and simultaneously increase our capacity for elective procedures.
“All in all,” he concluded, “it’s fantastic for my team and I to have this funding, after years of very little money being available to improve our estate, and to see so much work ongoing or already completed. In combination, the various schemes should transform our buildings, and enable us to offer even higher quality, patientcentered care, as well as a much improved experience, for all who use our hospital sites”