A new replacement for a 70s hospital which removed valuable parts of central Liverpool, a major new health facility for the city bridges healthcare and academia, restores urban quality, and has more ensuite single rooms than any other UK hospital. James Parker reports
The new Royal Liverpool University Hospital finally opened in October 2022, after a saga which included the demise of this PFI project’s original contractor Carillion, and a consequent financial shortfall (£300m) to make up. However, the result now achieved represents a major milestone for the NHS; the biggest hospital yet constructed with all of its 640 bed rooms being single and ensuite, and restores urban fabric lost during the late 20th century.
Reflecting a move in recent decades towards single bedroom provision in modern healthcare facilities, driven principally by infection control requirements but also other factors, Liverpool’s new hospital is a standard bearer for the concept.
The client is Liverpool University Hospitals NHS Foundation Trust (LUHFT), which also runs Aintree University Hospital, Broadgreen Hospital and Liverpool University Dental Hospital, and was designed by NBBJ/HKS, a bespoke collaboration between the two architectural practices. The new hospital has 18 operating theatres for both inpatient and day-case surgery, and 40 critical care beds for patients in the intensive care and high dependency units. In addition, there’s a substantial colocated clinical research facility, which, says architect HKS, “will place LUHFT as a national and international leader in clinical trials and studies.”
Site & response
Creating a new general hospital in a city centre location means thinking about the wider urban planning ramifications and potential benefits of such a major addition, and with the same level of rigour as the many clinical drivers involved. Liverpool, as David Lewis, partner at NBBJ, confirms, has been transformed since being the European City of Culture in 2008, making the architects’ task of knitting into this new urban fabric even more critical.
The existing low-rise 1970s hospital in the centre of the old urban block, which the new unit replaces, was not an architectural response that did justice to the area, as it destroyed the historic urban density and connection to the wider city. David Lewis explains that the design strategy was to “reconnect the site back into the urban fabric,” including creating a central public square which echoes Abercromby Square, a key part of the university estate located a few hundred yards to the south.
There was a further incentive to emphasise the potential landmark nature of the building, due to the fact it sits on a prime position anchoring the rest of the development of the area. This is a prestigious location, north of the city centre, and close to many of the university’s prominent buildings, such as those designed by Alfred Waterhouse in the late 19th century. The site, says David, is an important “entry point into the main part of the city.”
The site, which slopes from west to east, was originally at the heart of a rich mix of residential properties, squares, and major civic buildings such as churches, university faculties, museums and the Royal Infirmary. However, a large part of this area was removed when the new hospital was constructed in the 1970s. “They actually completely destroyed the urban fabric,” Lewis asserts. NBBJ and HKS were determined to use the opportunity to stitch back some of this urban connection with their new building, adding good quality public realm in the process. The architects designed a new urban block in effect, harnessing the potential to concentrate acute and day case healthcare alongside research and facilities management, on one site.
The low-rise 10,000 m2 clinical science building provides a crucial function, removing lab and office functions from the expensive acute hospital space into a separate building. It also “reinforces the edge of the site,” asserts Lewis. It was able to be opened earlier than the main hospital, enabling the trust to use it to support functions as it awaited the new accommodation.
Procurement & pitfalls
The architects have been through the ringer on this long and convoluted project, which has intrinsic challenges being a PFI scheme – which meant they were more distant from the client, sitting within a PFI consortium with the contractor. However during the competition phase they were able to engage with the hospital management and clinical users “quite extensively,” says David Lewis. They created a range of repeatable ‘standard’ bedrooms which had to be “spot on” in order to be selected as preferred bidder he says, while other more utilitarian rooms such as clean and dirty rooms didn’t need to be designed to such a detailed degree at that stage.
As is common in major healthcare projects, design consultation was facilitated with the clinical groups at certain stages according to the level of detail they required to input into the design, as well as the larger scale 1:500 drawings showing how departments relate to each other.
There was an understandable hiatus between Carillion going into liquidation in 2018 and Laing O’Rourke being appointed to take over the project, when an assessment was carried out to discover “how far they had got and what there was left to do,” says Lewis. He adds that because the architects had a “very good relationship with the trust,” they were retained, and moved to working with the trust as client rather than Carillion.
There was another positive in this eventuality, namely that the trust was able to take a step back and revisit the brief, which had led to a 2011 design so naturally there were potential changes to make to reflect changing healthcare needs. This revisited output specification was then put out to tender, with Laing O’Rourke victorious. Jess Karsten gives some examples of the changes incorporated in the interim “Some were from changes to healthcare certification, for example our radiopharmacy department was upgraded in order to comply.” The endoscopy areas were also refurbished, to further assist functionality for the client, and post-Grenfell there was an even greater focus on fire compliance.
Covid also had an impact – “some thinking changed around how you isolate and separate,” says Lewis. However the ward design was already well suited to any segregation needs, assisted by the double ‘cranks’ which enable the wards to easily be split into three sections if needed.
Design levels
In terms of the overall design approach, says Lewis, the architects’ overall thinking about the new hospital was “to look at the whole site, not just a new building.” This meant that they were able to explore a range of volumes albeit within a fairly constrained curtilage, and create a strong landmark at the south, city centre-facing and higher extremity of the site. This would be a 12-level tower, which, thanks to the site’s gradient, has level access both at the Emergency department level (first floor) and at the ground floor level (where outpatients and radiology/nuclear medicine are located).
The building is shaped somewhat like two asymmetrical horseshoes on plan, and bisected by a glazed street, both sections surrounding publicly accessible courtyards. Generally, the programme is distributed with the hi-tech departments at lower levels (‘hot’ floors), and the ward areas on upper levels. There is a lower ground level, which also has direct external access from the south side on West Derby Street, housing ophthalmology, renal and breast units, but also spiritual care facilities and two landscaped courtyards.
As well as the Emergency department, the first floor has the facilities management distribution entrance, where all of the crucial hospital supplies arrive, located within the clinical sciences building at the north-east flank. The architects worked hard to separate the circulation flows of patients, staff and supplies into distinct pathways on this relatively tight, relatively deep-planned site. The general strategy is that patients, visitors and staff come up in lifts through the centre of the building, and there are separate pairs of lifts for facilities management at the extremities, fed from the Level 3 (non-public) floor, which bring supplies in and take waste out.
Creating external as well as internal circulation connections is critical to ensuring that healthcare planning serves patients’ as well as clinicians’ interests, and gives them the most efficient routes around what can be complex sites to navigate. There’s a double link bridge at level three, connecting the tower with the clinical sciences building to the north end of the site. This allows the FM distribution to ‘come in at the back’ of the tower, and not impede patient circulation. This is one example of how the architects have successfully managed to separate the flow of patients and the efficient distribution of supplies. The central street is enhanced by trees, and it functions somewhat as a new public space.
As Jess Karsten, of co-architect HKS, tells ADF, “direct links” have also been created to the new Clatterbridge Cancer Centre to the west of the site. “We have bridges at multiple levels connecting to the centre, making it very efficient for staff and patients to move between.” This was also a part of the overall focus on ensuring that ‘patient pathways’ were made as helpful and effective as possible for patients, she says: “They were key to the overall design organisation in terms of circulation, space and ease of wayfinding, for example we located departments like ophthalmology and outpatients on the lower ground floor, to make it very easy for ambulatory patients to get in and out.”
The organisation and location of theatres was also carefully considered in terms of the different “patient streams” that would be using them, for example Emergency, inpatients or day surgery, “to maximise patient flow and make that flow efficient and easy, to help them find their way around.” The critical care level is located next to theatres and directly above Emergency, which were optimal adjacencies. Where patients are fully ambulatory such as when arriving at day surgery, “a very specific route has been planned, versus a patient who may be arriving in a wheelchair or in a bed,” she adds.
The two glazed stair cores to north and south extremities are accessible for patients, and they have been finished to a high specification to maximise the quality of the experience. The staff stair to the south corner is lit at night to try and present a welcoming face to the city.
Form
Formally, the architects “wanted the building to step up” visually, says Lewis, with the eye-catching cranked medium-rise ward block still the tallest point, sitting at the bottom of the gently sloping site. “Traditionally, hospitals have a flat top, but we wanted to emphasise that corner.” The resulting form is a dynamic rectilinear statement that takes full advantage of the ‘prow’ of the site. It’s topped off by the restaurant for both staff and visitors on the 10th floor, giving diners great views of the city.
The building appears massive from the exterior, but on plan it’s revealed as fairly shallow-planned, thanks to the two large courtyards, bringing copious light into internal areas. However, cross ventilation was not possible due to the density requirements and site constraints.
As it’s a city centre site, car parking provision is relatively minimal, but there are 300 visitor spaces located under a terrace, to reduce the visual impact of parking and to prioritise pedestrian amenity. It’s located on the ‘lower entrance’ level, with the ground level entrance one floor down. This avoided any need for excavation, instead the requirement was to build a flat terrace, leading from Prescott Street to the entrance where patients can be dropped off before parking.
A single interstitial floor
The third floor is taken up by an interstitial services level, which is a tweak on the established approach of including low interstitial floors to obviate suspended ceilings for maintenance in hospital departments. However, the architects decided to dedicate one entire level to accommodating plant such as air conditioning and medical gases, freeing up the entirety of the rest of the building.
The interstitial floor also serves to divide the ‘hot’ heavily serviced floors beneath from the wards above, and enables a different structural grid to be used above, to allow the optimum layout for both sections. This arrangement also brings maximum efficiency, for example, on level 2, which is “mainly theatres,” says Lewis, and the servicing comes from above. Without the use of the interstitial floor, stacking the wards above it and placing services in the roof would have meant bringing them down several storeys. Here they just need to descend one level. The other option of excavating a basement for services, on the rocky geology of this site, would have been cost prohibitive – this solution also offset the extra cost of creating an extra floor at level 3.
Facades
Despite the building housing a wide range of different departments, in a tower and podium, the architects wanted to “wrap” the base so that there wasn’t too much visual distinction between the volumes. Part of creating this unity was informed by the Portland stone of many of the surrounding significant university buildings.
The podium facade as well as east elevations are in a Portland-like pale grey tile at lower levels, arranged in a varied pattern, using an algorithm to give a feeling of stone cladding. By contrast the glazed ward block is curtain walling with vertical bands of aluminium in a greyer hue, and solar control glass plus integral blinds. This produces a strong verticality to add further presence to the articulated cranked volume, but also resolves the issues of potential misaligned windows from the internal arrangement dictated by clinical need.
David Lewis explains that the architects worked from the public realm materials “framework” which was developed when Liverpool was European city of culture, in choosing the facade materials for the new hospital. He explains that this “integrates it into the city much more than us choosing all our own materials, as it’s a palette that had been set out by the city itself.”
Wards
The architects “did a lot of work” with LUHFT to identify what bedroom design they really wanted. David Lewis says it involved questions like “do we have an inboard ensuite, do we have an outboard ensuite, is everything mirrored? He says that they “very quickly settled on what we call a nested ensuite.” This entails a square room template offering easy views in and good views out, with two ensuites ‘nested’ efficiently next to each other between each pair of rooms. “It is an optimum bedroom shape, because you don’t have an ensuite poking into it,” says Lewis, admitting that the only issue is it creates long elevations containing ‘strips’ of bedrooms.
The shape of the wards was partly driven by the solution to this potentially overly-linear arrangement, with a design of two ‘wings’ of eight bedrooms flanking a ‘core’ of 12, surrounding a staff base. There are four of these wards on each level and due to the site’s shape they have slightly different dimensions on plan. One of the crucial benefits of the cranked shape is that the floor to ceiling glazing where each ward articulates provides excellent natural light into its staff base, as well as views out, and long corridors have been avoided. The repeated layouts of the ward floors allow the client to insert different functionality into some of them,” says Karsten, such as on level eight where one ward is allocated for infectious diseases; a radionuclear department occupies one quadrant on another level.
As well as all bedrooms having copious glazing, staff have visual connection to the city and its landmarks, including the nearby Metropolitan Cathedral. Small meeting spaces have been placed at the edges of the staff bases next to the floor-to-ceiling windows to take full advantage of this.
There has been a growing movement towards 100% single rooms in the NHS, principally driven by infection control requirements, post outbreaks of infections such as MRSA. David Lewis says that following major schemes such as Dumfries and Galloway Hospital going 100%, “it’s the way everyone is going to go.” With all-single rooms clearly being more expensive than wards in terms of capital cost, LUHFT did a clinical study which discovered that the shorter time spans that patients on average spent if they were in a single room meant an overall cost saving to the facility and better health outcomes for patients.
Conclusion
Although reportedly 90% complete when Carillion collapsed in 2018, new contractor Laing O’Rourke had to remediate a “series of major defects” which were discovered after Laing’s predecessor left the stage. The decision was taken in December 2019 to push the opening date back to 2022, five years later than the original planned opening. It was also revealed that an additional £300m was needed to complete the project.
The delivery team handed the hospital to the client on 28 September 2002, which allowed a controlled, phased move to take place over 24 days. On the final day, 20 October, the Emergency department was successfully relocated into the new building, marking successful completion of the move.
As David Lewis of NBBJ asserts, using this new building as a chance to “reconnect” this part of the city has meant this project has achieved a wide range of goals beyond merely healthcare. It represents “a sort of anchor tenant for the rest of the site development,” in this prime position, he says, bringing a strong punctuation to a block that has a prominent cancer centre, but integrated with both it and the university. In so doing it will be a major platform for attracting investment and talent, and thereby helping to catalyse more regeneration in the centre of Liverpool.