Case for Change (published July 2021)

Section 6: Our hospitals

Our hospitals are some of our region’s most significant assets. They are anchor institutions providing healthcare and employment to 40,000 people.

We have now reached a critical situation with the condition of some of the estate: the depth and extent of problems at Royal Lancaster Infirmary (University Hospitals of Morecambe Bay NHS Foundation Trust) and Royal Preston Hospital (Lancashire Teaching Hospitals NHS Foundation Trust) are unparalleled. They make up some of the worst hospital estate in the North West, if not the country.

Furness General Hospital (University Hospitals of Morecambe Bay NHS Foundation Trust), located in Barrow- in-Furness, is in a geographically isolated area with significant population health needs, and is a major local employer. This area also houses some of the UK’s major strategic national assets. The sustainability of this site is a vital consideration for the New Hospitals Programme.

Investment in our infrastructure is essential. Without it, services could fail, impacting on our population’s health, economic prosperity and the sustainability of other providers which cannot absorb the additional demand. Figure 5 below shows all hospital sites across our region.

"The estate is falling down and we must tell the truth about that. We cannot deliver 20th century, let alone 21st century care in these conditions.”

Figure 5: Map of NHS hospitals across Lancashire and South Cumbria

1. Royal Preston Hospital
2. Chorley and South Ribble Hospital
3. Royal Lancaster Infirmary 
4. Furness General Hospital
5. Westmorland General Hospital
6. Royal Blackburn Teaching Hospital
7. Burnley General Teaching Hospital
8. Blackpool Victoria Hospital

Our estate

In this section, we outline the condition of our estate and the impact this has on our ability to deliver the highest standards of care and experience for our patients and staff.

Our estate restricts our capacity to provide high-quality safe, efficient and cost-effective services for our patients and impacts our ability to attract and retain staff.

Royal Preston Hospital has suffered from decades of under-investment. 70% of clinical facilities date from 1970s to 1990s and, as a result, experience serious dilapidation.

• Backlog maintenance costs total £157m
• Demand exceeds capacity across all clinical areas, and aged buildings lack flexible capacity leading to congestion and overcrowding
• Non-compliance with Health Building Notes – space and single room provision (19%)
• Poor clinical adjacencies and lengthy circulation spaces
• Some tertiary services have developed and expanded without fully being able to meet all the estate requirements
• Independent appraisal has confirmed 80% of the site requires redevelopment or demolition over the medium to long term
• Limited potential to redevelop the current site in a way that is practically achievable and compliant with the Government’s New Hospital Programme.

Royal Lancaster Infirmary has suffered parallel underinvestment, with 65% of facilities constructed before 1985.

• Backlog maintenance costs total £88m – this is predominantly relating to the condition of the estate
• Running costs double that of a new build at £442/m2 due to the age of the site; running costs involve replacement i.e. lifecycle costs over maintenance
• Site is configured over a challenging topography – access is particularly challenging for those with a disability and transport to some parts of the hospital (separate ward blocks) is only possible by ambulance at £500,000 per year cost to the Trust
• The estate fails to meet many HBN standards – single room provision is only 50% of the recommended standard and less than a third of our ambition for 70% single rooms
• Car parking is desperately insufficient across both sites.

Furness General Hospital requires investment over the longer term due to its strategic importance as a provider of healthcare services to a geographically isolated population.

• Backlog maintenance costs total £63m
• Investment is needed restore the condition of the estate together with isolated investments to satisfy the health needs of the population over the longer term
• Significant challenge to meet modern carbon emission standards on this estate
• Car parking is desperately insufficient across both sites.

The need for new hospitals is unequivocal. The age, condition and poor functional content of the current hospital estate means that we must address this critical need if we are to serve both the current and future needs of our local population, and meet the NHS’s net zero carbon ambitions. Loss of these services would have a deep impact on the health and wellbeing of the communities we serve.

Estate overview

Lancashire Teaching Hospitals NHS Foundation Trust

Lancashire Teaching Hospitals NHS Foundation Trust (LTHTr) serves a local population of 400,000 in Central Lancashire and 1.5m people accessing specialised services. The Trust employs 7,000 staff. LTHTr operates from two main sites:

1. Royal Preston Hospital was built in stages between 1975 and 1983 and includes services that transferred from Preston Royal Infirmary (which closed in 1990) and Sharoe Green Hospital (which closed in 1992). Royal Preston Hospital is a major trauma centre and the main provider of specialised services for our region.
2. Chorley and South Ribble Hospital began as a cottage hospital in 1893 and has had a range of developments over its history, the most notable being a Nucleus Hospital block opening in 1997.

LTHTr’s two sites offer good accessibility via motorway links from the M6, M61, M65 and M55. The journey distance between the hospitals is 13.6 miles, with a 20-30 minute journey time by car.

University Hospitals of Morecambe Bay NHS Foundation Trust

University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT) serves a population of approximately 360,000 across the Morecambe Bay ICP area and employs 7,500 staff.

UHMBT operates from three sites:

1. Royal Lancaster Infirmary (RLI) hospital services moved to the current site in 1896, on a steeply sloping ground that had several previous uses. The hospital was extended in 1929. One of the administration office buildings, still in use today on the upper part of the site, was previously the railway terminus for the city before it moved in 1849. The original building has Grade II Listed status under Planning (Listed Buildings and Conservation Areas) Act 1990, as amended, for its special architectural or historic interest. The main hospital building (Centenary) is a Nucleus Hospital block, which opened in 1996, but several wards are in older and separate buildings.
2. Furness General Hospital (FGH) opened in 1984, replacing four local hospitals.
3. Westmorland General Hospital (WGH) opened in 1992, replacing cottage hospital buildings nearby in Kendal.

Motorway access to the sites is limited due to the rural geography, with road networks of A-roads at best. According to Google maps, car travel times between the sites are 31 minutes (WGH to RLI), 51 minutes (WGH to FGH) and 1 hour 15 minutes (FGH to RLI).

 

 

Overall concerns about our estate’s condition

Because of concerns around the extent of dilapidation and functional obsolescence of the principal sites being considered for change (Royal Preston Hospital and Royal Lancaster Infirmary), the Trusts have commissioned property condition surveys to inform their immediate priorities and medium to long estates strategies. Figure 8 sets out the site-specific running costs and area of the estate.

We have set out the results of these surveys on a site- by-site basis around some common key themes.

"We know the current situation with the estate is unsatisfactory with reports of poor patient experience, low staff morale and increasing demand. The current model is unsustainable. It is time to reflect and make radical changes. We have a once-in-a-lifetime opportunity to completely redesign our hospitals.”

Common key themes

(i) The age of our estate: Over 65% of clinical facilities date from 1970s to 1990s and as a result experience serious dilapidation. The age profile of the sites is shown in Figures 6 and 7.

Figure 6: The age profile of Royal Preston Hospital site

• 8% dates from before 1955
• 69% dates from between 1975 and 1984
• 2% dates from 1985 to 1994
• 21% dates from 1995 to 2004

Figure 7: The age profile of Royal Lancaster Infirmary site

• 19% dates from before 1955
• 3% dates from between 1965 and 1974
• 15% dates from between 1975 and 1984
• 18% dates from 1985 to 1994
• 3% dates from 1995 to 2004
• 36% dates from 2005 to 2014
• 6% dates from 2015 to 2024

(ii) There are high backlog maintenance costs across all sites, with £157m for Royal Preston Hospital and £88m for Royal Lancaster Infirmary. A full condition survey has been carried out on each of the sites: these figures are shown in Figure 8 below and indicate the investment that would be required to return the site to operationally sound.

Figure 8: Backlog maintenance and investment required

• Royal Preston Hospital (LTHTr): 20 hectare site, gross internal floor area of 123,294 square metres, £157million backlog maintenance, £30million per year estate running costs, £234 per square metre estate running costs and a bed stock of 708.
• Chorley and South Ribble Hospital (LTHTr): £5million backlog maintenance
• Royal Lancaster Infirmary (UHMBT): 8 hectare site, gross internal floor area of 55,882 square metres, £88million backlog maintenance, £25million per year estate running costs, £447 per square metre estate running costs and a bed stock of 426.
• Westmorland General Hospital (UHMBT): 8 hectare site, gross internal floor area of 23,824 square metres, £25million backlog maintenance, £6million per year estate running costs, £251 per square metre estate running costs and a bed stock of 65.
• Furness General Hospital (UHMBT): 15 hectare site, gross internal floor area of 45,376 square metres, £63million backlog maintenance, £17million per year estate running costs, £375 per square metre estate running costs and a bed stock of 351.

(iii)  Due to the age of the buildings, spaces lack flexibility and capacity. Entrances, waiting areas and circulation spaces built 40 years ago were not designed for the current volumes of patients so become congested and over-crowded. Capacity in clinical areas is constrained: this impacts on distancing and infection control, adding clinical risk.

(iv)  Corridors are also elongated, at times creating a travel distance of 1km for our patients and staff. Corridors remain too narrow, making it a challenge to safely move patients around the hospitals and navigate day-to-day hospital traffic.

 

(v)  Poor clinical adjacencies add to the running costs – from more portering to the downtime experienced by clinicians as they wait for patients to arrive from distant areas.

(vi)  Car parking is consistently highlighted as a concern in our feedback from staff and patients. There are approximately 2,000 car parking spaces at Royal Preston Hospital. This is not sufficient for our workforce, so around 1,000 staff members are required to park off-site and use Park and Ride services. At Royal Lancaster Infirmary, there are 460 spaces for the 2,809 staff based there, with limited Park and Ride facilities. There are no electricity charge points at either site.

(vii)  The sites do not comply with Health Building Notes standards for space and single room provision. Space compliance issues are specific to each of our sites; however there are specific shortcomings in single room and en-suite facility provision. These remain well below the national average of 30% and 21%, respectively. Our ambition for our patients is 70% single room occupancy (HBN requirements are 50%). Single room capacity is important as it:

• Creates flexible capacity which can be used to segregate / isolate and adapt for other uses such as increased acuity of care
• Ensures privacy and dignity
• Improves infection control
• Can accommodate new technology and equipment.

“We want a future hospital that has an ample car park with easy access to the department to be attended, with signposting that is easy to follow.”

(viii)  The current estate does not enable separation of elective and non- elective flows.

(ix)  Lack of decanting space: a modern hospital is designed with sufficient space to allow clinical units to be decanted during refurbishment or improvement. Neither Royal Preston Hospital nor Royal Lancaster Infirmary has useable space to allow this. Every time a ward is upgraded or reconfigured, a very slow programme takes beds out of the hospital capacity for months. Upgrading technical clinical areas (such as operating theatres and endoscopy units) may require modular replacements unit at very considerable cost causing further parking and accessibility issues.

“I was at Guys recently and saw their fantastic new build - loads of single rooms with all the privacy and advantage this gives to patients and visitors and they had overcome the issue of being able to see the patient from the central nurses’ bay. They have several stations that are less noisy and in line of sight for all patient rooms and loads of diagnostics all monitored from the stations – brilliant.”

Further detail: Royal Preston Hospital site

 

Services provided

Royal Preston Hospital (RPH) provides a full range of district general hospital services including: Emergency Department (ED); critical care; general medicine including elderly care; general surgery; oral and maxillo-facial surgery; ear nose and throat surgery; anaesthetics; children’s services; and women’s health and maternity. It also provides several specialist regional services including: cancer; neurosurgery and neurology; renal; vascular; plastics and burns; rehabilitation; and is the major trauma centre for Lancashire and South Cumbria.

Site layout

RPH has developed in a largely opportunistic manner, with the majority of the estate planned to 1950-60s specifications and built in the 1970s and early 80s. The site is landlocked with little space to extend.

Condition

Backlog maintenance totals £157m and is the highest of all sites. This is the investment required to return the estate to an operationally sound condition. Over a third of these costs are related to the site’s basic functional suitability due to changes or expansions in service provision within buildings designed for another purpose. The six-facet survey highlighted that a significant proportion of the buildings is characterised as poor in three categories: physical condition, functional suitability and quality.

“In Royal Preston Hospital we have episodes of flooding into clinical areas due to the age and condition of some parts of our hospital. This has resulted in operations being cancelled and damage to clinical equipment. Episodes of flooding are unpredictable, and result in some occasions of clinical care being delayed.”

Figure 9: Results of the six-facet survey for Royal Preston Hospital illustrates the physical condition, functional suitability and quality of the estate – a significant proportion is characterised as poor in all three of these categories

Compliance

Health Building Notes (HBN) standards

The Royal Preston Hospital site does not comply with modern building standards for space:

Almost all operating theatres and all day case theatres at RPH are well below the HBN recommended size of 55sqm. The rationale behind these space requirements is to enhance flexibility in accommodating new technology. Supporting scrub, anaesthetic and sterile preparation rooms are up to 75% lower than HBN capacity requirements. Figures 10 and 11 detail this.

Compared to the HBN standard, a typical 28-bed ward at RPH would need to increase capacity by 220% to comply with current space standards, as illustrated in Figure 10.

Specific matters of concern

• Day case capacity
• Single room accommodation
• Tertiary (highly specialised) service capacity.

Figure 10: Comparison of current day case theatre capacity and supporting functions with HBN 26 requirements.

• Operating theatre: currently 35.6 to 43 square metres (HBN recommends 55 square metres)
• Anaesthetic room: currently 16 square metres (HBN recommends 19 square metres)
• Scrub up and gowning – three person room: currently 8 square metres (HBN recommends 7 square metres)
• Preparation room: currently 7.6 square metres (HBN recommends 12 square metres).

Figure 11: Comparison of current theatre capacity compared to HBN 10-02

• Operating theatre: Theatre A is currently 30 square metres, Theatre B is currently 18 square metres, Theatre C is currently 30.62 square metres and Theatre D is currently 31.17 square metres (HBN recommends 55 square metres)
• Scrub room: Theatre A is currently 8.37 square metres, Theatre B is currently 0 square metres, Theatre C is currently 9 square metres and Theatre D is currently 7.77 square metres (HBN recommends 11 square metres)
• Anaesthetic room: Theatre A is currently 15.46 square metres, Theatre B is currently 0 square metres, Theatre C is currently 15.31 square metres and Theatre D is currently 20 square metres (HBN recommends 19 square metres)
• Sterile preparation: Theatre A is currently 8.24 square metres, Theatre B is currently 0 square metres, Theatre C is currently 14.27 square metres and Theatre D is currently 6.94 square metres (HBN recommends 12 square metres)
• Dirty utility (serving one theatre): Theatre A is currently 8.37 square metres, Theatre B is currently 0 square metres, Theatre C is currently 8.13 square metres and Theatre D is currently 7.17 square metres (HBN recommends 12 square metres).

Figure 12: Example of increased ward space required to meet HBN space requirements within the existing ward block at Royal Preston Hospital

• Current 28 bed ward: 600 square metres
• Ward area to increase by 220% to comply with HBN-04 guidance
• Theoretical comparable footprint size for 28 bed ward to HBN-04 guidance would be 1,320 square metres, with 50% single beds.

Single room accommodation

• 19% of beds are single rooms
• 11% of beds have en-suite facilities

Capacity for tertiary services

Tertiary services have developed and expanded at LTHTr without being fully able to meet all the estate requirements of these highly specialised services.

Future of the Royal Preston Hospital site

The Royal Preston Hospital site has been independently assessed as 80% requiring demolition or redevelopment, significantly limiting opportunity for refurbishment.

The site is congested, with limited development space available and gaining planning consent could be challenging. Figure 13 shows the redevelopment profile. The need for investment is unequivocal to support the viability of services provided from this site and to provide the quality of care and experience our patients deserve.

The need for investment is unequivocal to support the viability of services provided from this site and to provide the quality of care and experience our patients deserve.

“The Neurology ward is in a unit not physically connected to the main hospital site. This results in patients requiring an ambulance transfer within the grounds of the Royal Preston Hospital to move from the Neurology ward to the main hospital building. This provides a poor patient experience, and the reduced amount of ward space available has resulted in this location for the regional Neurology ward.”

Figure 13: Development Control Plan for Royal Preston Hospital: long term

Further detail: Royal Lancaster Infirmary site

 

Services provided

Royal Lancaster Infirmary (RLI) is UHMBT’s principal hospital, providing a range of general acute hospital services with an Emergency Department, critical coronary care units and various consultant led services. RLI also provides a range of planned care including: outpatients; diagnostics; therapies; maternity and day case and inpatient surgery.

Site layout

The Royal Lancaster Infirmary (RLI) comprises around 20 separate buildings of varying sizes and ages. Most but not all the buildings are linked by long passages, with some buildings separated from the main complex by public highways. Consequently, staff and patients must make longer journeys than is desirable, leading to poor experiences of care and significant operational inefficiencies. Several services are provided in temporary buildings offering poor quality accommodation and others are past their useful life. Most of the site is on a slope, which in some areas is too steep for patients to be safely moved except by ambulances. The hospital lacks an obvious main entrance, which can be confusing for patients and visitors.

Condition

The overall backlog maintenance is around £88m. The six-facet survey (illustrated in Figure 14) shows that the majority of this relates to the physical condition of the estate. Some of the estate has limited functional suitability, which is challenging to address in old estate. Space utilisation is a specific issue, with some overcrowding.

The topography of the RLI site provides some challenges around suitability and movement / accessibility between buildings and departments, particularly for patients of reduced mobility, but this was excluded from the six-facet survey.

“Royal Lancaster Infirmary is bursting at the seams, there is no room to expand, parking is insufficient and emergency vehicles have to travel through a congested city centre.”

Compliance

Health Building Notes (HBN) standards

The RLI site does not comply with modern building standards for space.

Operating suite floor areas are non-compliant for all areas: Theatres at RLI are well below the HBN recommended size of 55sqm and space requirements for an anaesthetic room, preparation room, scrub up and gown or dirty utility are not met. Figure 14 shows this.

Figure 14: Comparison between RLI operating theatre space and HBN space requirements

• Operating theatre: currently 38.4 square metres (HBN recommends 55 square metres)
• Anaesthetic room: currently 15 square metres (HBN recommends 19 square metres)
• Scrub up and gowning – three person room: currently 9.9 square metres (HBN recommends 11 square metres)
• Preparation room: currently 7.6 square metres (HBN recommends 12 square metres)

• Multi-bedded bays predominate which exceed the current Health Building Notes (HBN) standard of four beds as a maximum. At RLI there are many seven to ten bedded bays in the Centenary Building, with six bedded bays in Medical Unit 2.
• The resus bay within the Emergency Department is non-compliant and not fit for purpose. 20 square metres would be the minimum standard for a resus bay in addition to having a larger cubicle for bariatric patients. The resus bay highlighted in Figure 15 is 11 square metres.

Figure 15: The resus bay is 11 square metres. Given today’s standards, the cubicle would be deemed non- compliant and not fit for purpose.

• Ward areas are non-compliant with HBN requirements. Figure 16 illustrates the space required to meet these within an existing ward block at RLI.

Figure 16: An existing ward at RLI compared with an HBN compliant ward

• Existing 25 bed ward: 518 square metres
• HBN compliant ward: 1,075 square metres

• Sluice provision is limited and does not meet HTM standards of one sluice per 14 beds. This often results in sewage leaks due to inadequate plumbing capacity.
• The air handling units in many of the theatres are beyond their appropriate life span and external inspections have highlighted this issue. Units are often on the roadside and are exposed to wildlife including birds when recommendations state that they should be protected and away from roads / transit routes.
• Electricity supply does not currently meet national standards.

Figure 17: Results of the six-facet survey for Royal Lancaster Infirmary – the physical condition of a high proportion of the estates is rated poor

Specific matters of concern

• Running costs

• Single room accommodation

• Flexibility and capacity

• Clinical adjacency

• Fabric of the building.

Running costs

RLI has estate running costs of £442 per square metre: these are double equivalent benchmark (new) sites. This is a result of limited investment over the years, but moreover due to requirements for replacement over maintenance costs because of the age of the buildings.

Single room accommodation

28% of beds are single rooms – with 11% en-suites, compared to an HBN requirement of 50%. Many of the patient toilet facilities are inadequate partition-style facilities, with two or three toilets in one room. These create a significant risk of infection, in addition to providing a poor patient experience and lack of privacy.

Many are not wheelchair accessible and the toilets are too low, requiring an additional seat raiser, which is a risk similar to the use of a commode. If integral shower and toilet facilities were available for each multi-bed bay or single room, then partial closures would be possible, increasing our bed capacity and ability to cope with outbreaks.

Flexibility and capacity

Our ability to manage demand has been constrained by the inflexibility of the estate. This was highly apparent during Covid-19, when oxygen and electricity supply could not be increased to meet surges in demand. Oxygen supply is identified as a critical area of investment across the estate.

For example, the Emergency Departments were not designed for the level of demand they are currently experiencing: the RLI ED has a capacity of 40,000 per year, with actual attendances at around 60,000. FGH ED capacity is 25,000, but actual attendances are around 36,000.

“The ward is not connected to the main hospital and requires the patient to be transferred within an NHS or private ambulance. Over a three-month period, we had 130 ambulance transfers out of hours, 28 of these patients either had diagnosed dementia, undiagnosed dementia, delirium or cognitive impairment and 11 of the total had a definite diagnosis of dementia.”

Clinical adjacency

The radiology department, medical assessment unit and surgical assessment unit are not co-located with the Emergency Department. Endoscopy and maternity theatres are also further from the Critical Care Unit than HBN standards would ordinarily mandate.

In-patients can only travel between some of the buildings by ambulance due to the incline – this costs UHMBT £500,000 per annum.

Fabric of the building

Many of the wards and departments are very worn, with surfaces that are not intact and, as such, are unable to be adequately decontaminated.

Future of the Royal Lancaster Infirmary site

Figure 18 shows the medium to longer term development control plans for the RLI site.

Over 50% of the estate is requiring demolition and the majority of the remaining site will require refurbishment if it is retained in use. There is a powerful case for investment in new estate.

Figure 18: Development Control Plans for the RLI site

The Furness General Hospital site

Services provided

Furness General Hospital (FGH) provides a range of general acute hospital services, with an accident and emergency (A&E) department, critical / coronary care units and various consultant-led services. FGH also provides a range of planned care including: outpatients; diagnostics; therapies; maternity and day-case and inpatient surgery.

Site layout

The FGH site has a reasonable amount of strategic expansion space available. Some of the land is currently used inefficiently. There is an opportunity to reduce the percentage of the site currently set aside for non-patient facing activities to increase and improve the estate for patients.

Condition

Facilities at Furness General Hospital are generally more modern than at Royal Lancaster Infirmary and the site has good functional compliance. This is illustrated in Figure 19, which shows the results of the six-facet survey.

Key challenges and specific investment needed to meet the future heath needs of the local population that can be addressed in line with the strategic priorities of the national New Hospital Programme include:

• Significant backlog maintenance, which requires attention. This includes an element of physical condition and lifecycle works, which are required to return the estate to condition B as per the six-facet survey. Furness General Hospital has estate running costs of £375/m2.
• The estate fails to meet some HBN standards and capacity requirements. In particular, the Critical Care Unit / High Dependency Unit. Our ambition is to improve the environment for patients and staff, including increasing the single room provision.
• The geographic location of FGH is remote, meaning it is essential we accommodate the latest digital technologies and robotics to create an agile network of care across the region.

Figure 19: Results of the six-facet survey for Furness General Hospital illustrates the physical condition, functional suitability and quality of the estate is categorised as good

Future of the Furness General Hospital site

Figure 20 shows the medium to long term development profile for the FGH site. The overall quality of the estate is good – there is no medium to long term need for redevelopment or replacement of the site that is as pressing in absolute terms as at RPH and RLI.

However, there is a strong case for investment to support its future sustainability in the context of its strategic importance in the provision of services to the population of Barrow-in-Furness and its proximity to major strategic national assets.

Figure 20: Development Control Plans for the FGH site