A healthy discount
To deliver a string of new mid-sized private hospitals at lower cost and consistent quality, offsite prefabrication is just what the doctored ordered for the Circle Partnership. Jan-Carlos Kucharek reports.
Having cut its teeth on the £22m Circle Bath hospital, designed by Foster + Partners, the private healthcare provider Circle Partnership conducted a post-completion internal review of strategies to see how it could reduce costs, maintain quality and reduce risk on its future hospital building regime. The result is Circle Reading, a £25m, 10,100m2 state-of-the-art facility completed last month, which serves as a prototype for Circle’s prefabricated procurement aspirations. Circle Partnership not only managed to build the new facility with 25% per m2 savings relative to Circle Bath, but delivered it in little over 18 months.
As much of the hospital as possible was procured using offsite manufacturing techniques, resulting in a hybrid steel/ concrete structure, internally fitted-out with room and bathroom pods — all brought to site on the back of a lorry.
At this level of technical specification, the project was a real challenge for contractor Vinci.
Defined by its eye-catching faceted black glass facade, the 30-bed Circle Reading hospital, with a dedicated day case area for out-patient treatment, comprises six operating theatres and clinical support facilities, including MRI and CT scanners, consultancy and treatment rooms. Each of the upper level in-patient rooms faces across to a landscaped roof garden area, and these floors are connected to the ground level consultation and treatment spaces and first floor operating theatres via a tall, narrow central atrium.
For Circle Partnership head of format and design Dries Hagen, who oversaw the shift from a bespoke one-off facility to this prototypical, prefabricated approach, the change was as much about how the organisation modified its own procurement techniques as it was about challenging the industry.
“Bath was a great hospital in terms of look, feel and service offering, but where we felt improvements could have been made was in the integration of the design disciplines,” recalls Hagen. “Our view was that the clinical functionality of the building in the end was secondary to the architecture. With Reading, we wanted to see how that aspect could be improved upon.”
Hagen signed up with Circle’s senior management to delivering 25% cost savings on Reading and set about reviewing Circle’s Design Guide, the spatial template used to deliver the programme. After discussions with clinical staff, this took the form of “a bubble diagram that became a form of generic plan of this and future hospitals — the common spatial, dimensioned description of the project for all the consultants”. In tandem with this, Hagen decided that the way to bring surety to hospital building was to “freeze” the design at an early stage, ideally pre-contract — which made prefabrication not only viable, but preferable.
Architect BDP had already designed Circle Reading to Stage C, but Hagen wanted to ensure that the project had a greater level of design/clinical integration. The missing link proved to be design firm Bryden Wood, whose proven expertise in prefabricated construction made up for a lack of clinical experience. Bryden Wood had previously worked with BAA on its airport delivery programme, and had an integrated team of architects, structural and M&E engineers.
The west elevation shows the largest elevation of back sprayed black glass and lower level treatment and consultation spaces
Staircases and concrete slabs were brought to the site from Cheshire
The main atrium space is designed around a regular 3.9m x 5.7m grid
Looking to the future
Bryden Wood also understood the priorities of a client looking 10-20 hospitals into the future, says Hagen. “The key was programme, quality and repeatability — we were looking to the future with this and knew we wouldn’t get the economies of scale we needed from just one hospital,” he adds.
The new team then went back to Hagen’s spatial bubble diagrams, where the notional room areas were rapidly turning into an actual building plan. Bryden Wood founding partner Martin Wood says the diagram’s clinically-led approach also governs everything about the prefabricated design. “It was clear for us from the outset that the grid would be related to the clinical brief and not about engineering or architectural concerns, so not about the depth of a steel beam or the size of a concrete raft,” explains Wood.
Circle’s clinical research brought it to an optimised planning dimension of 3,900mm x 5,700mm, a grid that fits both bedroom sizes and treatment/ consultation rooms and this repeats all over the plan and allows for future flexibility. “It’s planned so that the first floor admin offices, for instance, could be moved off site, and the area converted into more treatment spaces or bedrooms,” explains Hagen.
The grid also dictated the materials used by the team. “The industry is driven along material lines, and it might have been easier for a contractor to do it all in steel or concrete, but that wouldn’t necessarily work in the client’s interests,” says Wood. “With the fact that we needed a repeatable methodology, we decided on a hybrid structure of prefabricated concrete floors and steel structural columns.”
There was a clear logic to this decision. “Steel columns worked for us. Had they been concrete, they would have been 400mm x 400mm. Steel ones came in at 200mm x 200mm, which were far less intrusive, freeing up floor plate for treatment space,” says Wood. “Precast concrete slabs were suitable too — vibrations and sound transfer was minimised between floors. As far as the client was concerned, they were only interested in the material being used to solve their specific clinical issues.”
Offsite manufacture achieved crisp detailing and minimal tolerances
With structural steels clad in fireproof plasterboard, the atrium’s height and light helps patients/visitors to orientate themselves
But dedicated clinical areas such as operating theatres are designed around a different, larger grid, and have their mechanical servicing placed directly above them within a deep, cross-braced steel transfer structure.
The placing of plant directly above the areas it services was a deliberate move: for high-volume lamina flow [forced air] systems employed in operating theatres to prevent cross-contamination, duct runs are reduced significantly and there was less necessity for pump equipment — which contributes to lower operational costs over the facility’s working life. Sustainability benefits from this approach were marked enough to allow Bryden Wood to argue for not installing on-site renewables when discharging the facility’s planning conditions.
Through Vinci and the NEC3 contract it worked under, a supply chain was pulled together based on firms’ ability to carry out the works, both now and in the future, as well as best price. South Wales steel fabricator Rowecord was contracted to construct the steel structure for columns and the above-theatre transfer structure, while Cheshire specialist concrete fabricator Buchan set about creating the concrete slabs that would form the floors of the hybrid superstructure. “We chose the firms we did because no one in the south could match these firms on quality and deliverability at that price,” says Hagen. And it appears the choice was a good one — the prefabricated structural components and their interfaces are visually very slick.
These slabs, some weighing up to 23 tonnes, were then transferred on lorries down the M6. Given the distances that columns, floor slabs, bedroom equipment and toilet pods had to travel, and the logistical and carbon footprint issues around this, Vinci pushed for in-situ and on-site construction to be adopted instead, but Hagen says that this option was firmly resisted. “Reading was a prototype for a building method, and that would have been a cul-de-sac. We needed to move away from that ‘one project thinking’. Of course, it costs us more to adopt this method once, but not over a wider roll-out. For us, the more the site resembles an assembly line, the better.”
Hagen certainly confirms that the site did have that feel when the building was going up. “There seemed to be very little activity on site at one point,” he recalls.
“No wet trades, no jack-hammering — eerily quiet. I had to remind myself that people were actually working on it, just elsewhere — in factories, fabricating things.”
As Hagen emphasises, the value of the prefabricated approach can only be realised over the course of a multi-facility roll-out and once the supply chains have been fully established.
Relative to Circle Bath, costs per m2 were reduced significantly here from £3,333m2 to £2,475m2, without, he claims, any impact on final specification. And both Hagen and Wood believe there’s scope for further savings. Wood because, even though it wasn’t employed here, he can bring BIM into the equation, lowering project design costs; and Hagen through pressurising the supply chain to deliver economies through scale of production.
In this regard, he doesn’t seem afraid to push the envelope. “On the face of it, suppliers may feel that they are signing up to eye-wateringly hard contractual deals, but once on board they know everything’s fixed and that they reap the benefits in the long term.”
Nevertheless, negotiations can be a fraught process. “We push them and they push back,” he admits. “It’s a tension-laden process because it’s about changing the way things are done.” But Hagen plans to persist in squeezing their margins in pursuit of his “Holy Grail” of bringing delivery cost down to £2,400m2.
Wood agrees that this figure is possible, but will only be reached over time. ‘We made it clear that the primary benefit would be with the design, followed by the construction process, then a rationalised supply chain — the first can be done quickly, but the others require time and effort. With Reading, I’d say we achieved 75% of the first, 50% of the second and 25% of the third.”
Hagen too acknowledges this point, calling the quest for cost-savings “a journey rather than an event”, but adds that further improvements will have to be industry rather than client driven. But here the signs are good. With Reading under its belt, Vinci is now more comfortable with the procurement and supply chain regime. Despite the risk they took on to deliver the project using offsite techniques, they ended up shaving 20 weeks off the programme target, and gained valuable procurement intelligence to take forwards to future projects.
Foster + Partners’ Circle Bath
Bryen Wood’s Circle Reading
The contractor’s view
Vinci’s Alan Kondys on the difference between working on Reading and Bath hospitals
Vinci Construction UK was also contracted to build Circle Bath, but says delivering Reading was a completely different kettle of fish.
Alan Kondys, healthcare sector and framework director, admits that the new working relationship has not been “without its tensions”, but he views this as a healthy challenge in a longer-term procurement strategy. To that end, the contractor is engaged with Circle in discussions over the next two projects to look into cost savings and continuous improvement of offsite and modular construction — what Kondys terms “meaningful, medium-term” project goals.
Kondys agrees that there was a lot more standardisation evident at Reading in comparison to Bath, making a precast frame solution tenable. But he sees Vinci’s understanding of supply chain costing as key in helping to bring the cost of the offsite elements down in the next generation of Circle hospitals.
“Supply chains are always interested in driving down costs — for us it’s about facilitating the environment in which they can do that,” says Kondys, who highlights the part that logistics has to play. “We’re actively pushing our supply chain to invest in the tooling to produce the standardised components of the design that Circle has now ‘frozen’, in an effort to reduce costs further,” he says.
It’s been a steep learning curve for Vinci, but it is building up intelligence it is looking to use elsewhere. Kondys already sees potential in transferring knowledge to other client frameworks, including Vinci’s ongoing Integrated Health Project with Sir Robert McAlpine for the NHS’s ProCure 21+ initiative, although he admits this is more a reactive than proactive procurement methodology. Nevertheless, he feels the NHS “has a lot to learn from Circle’s benchmark prefabricated approaches and re-use of otherwise ad hoc expertise”.
However, with public procurement, issues such as embodied carbon and demands to ensure that public sector operational carbon goals are met creates targets that prefabricated components have to meet as materials in their own right rather then just as an alternative to traditional construction methodology.
The eye-catching out-patient recovery bays
In-patient bedrooms are located on the upper levels and face a landscaped roof garden area
One of the six operating theatres with the prefabricated “theatre hood” air-handling units installed