The Cumberland Infirmary was the prototype PFI hospital, and therefore a test-bed for how well the private and public sectors work together. Building visited it three years after it opened and makes a disturbing diagnosis
Britain's first completed PFI hospital, the £87m Cumberland Infirmary in Carlisle, opened in April 2000 in a blaze of publicity. And despite being officially opened by Tony Blair two months later, that publicity was largely hostile. Hospital Development journal reported that, the day before the prime minister's visit, more than 80 staff protested that working conditions were so cramped that they posed a health and safety risk. A few weeks later, The Observer published a catalogue of catastrophes, including flooded wards caused by burst water pipes, two windows that blew in – one showered a consultant and a nurse with glass – and the internal mall that turned into an oven on sunny days.

Three years on, the bad publicity shows little sign of abating. Last February, the Commission for Health Improvement, an NHS inspection body, criticised the cramped conditions and "considerable clutter" in the wards. It castigated the NHS trust for lack of leadership, a charge that provoked the resignation of chief executive Nick Wood. The staff union, Unison, rubbed salt in the wounds by publishing its own withering 10-page dossier entitled Angry Voices Reveal Truth About New Cumberland Infirmary. These "angry voices" belonged to hospital staff, and they complain about faulty plumbing, leaking roofs, lack of storage and the PFI company's exorbitant charges for building alterations.

The hospital management dismisses much of the criticism as muck-raking by a union committed to overthrowing the whole PFI system, and the building defects are, it says, teething problems that were resolved years ago. Alan Davidson, the NHS trust's project director, claims the hospital has now "settled in", and Martin Bennett, projects director for the PFI joint venture of Amec and Interserve, says facilities management has now reached "a steady-state environment".

However, walking round the hospital, a visitor quickly senses the palpable malaise at its heart. But it is not the large new building itself, which is attractive enough with its red-brick cladding and light and airy internal mall, that strikes one as defective. It is the morale of the staff within it. And those building problems that do still exist have been exacerbated by a festering stand-off between staff and management.

According to Linda Weightman, a convenor for Unison, "Staff are seriously demoralised and undervalued. It has a very negative effect, and turnover is quite high. More than 490 nurses have left since the hospital opened, and there are a huge number of job vacancies." As a result, she says, union membership has risen from 300 to 1600 members out of a total of some 2250 staff working in the hospital for the trust and the PFI company.

Weightman blames poor management in both the NHS trust and the PFI consortium. "The trust was formed in 2001 out of two hospitals 50 miles apart, and nobody was taking decisions. It had a seriously detrimental effect on staff and strategic direction.

"And as for Interserve [the facilities management arm of the PFI joint venture], they are appalling employers. Their unofficial slogan is: 'If you don't like it here, get out.' People are sick and tired of complaining about the way they are treated. But there's nothing we can do, so we have to put up with it."

Bennett accepts that an "us and them" attitude prevails among staff. He adds: "Our main challenge is to develop a true partnership spirit with the trust and to challenge negative perceptions."

As well by abysmal human resources management, staff are alienated by the cramped, dingy working conditions in the building. Many administrative offices and consulting rooms are airless, windowless internal spaces. As a result of chronic lack of storage space, medical records have accumulated into tottering piles of paperwork on desks. The restaurant has been relegated to the lower-ground floor, with only a bare lightwell to look out to. And in the kitchen, the creative activity of cooking has been deskilled into the drudgery of putting ready-made meals into walk-in fridges and reheating them on trolleys.

Pamela Boyd, manager of the shockingly congested medical records office, reveals the consequences of excluded the end-user from the design process. "During the design stage, we were told: 'You are not a priority, so don't tell us your problems.' When we eventually got in and I saw the lack of bookshelves, I was stunned. We were never consulted about this building, so we will not take responsibility for it."

As for the facilities management contract, awarded to Interserve, this is governed by a self-monitoring system of quite amazing comprehensiveness. It is also an astonishing confidence trick played on the hospital. Performance in 10 categories, including catering, cleaning and estates management, is continually monitored 24 hours a day, seven days a week, with each category producing a box full of data each month. The results are printed on a "performance scorecard matrix". However, as Bennett admits, the scorecard appraises response rather than output – that is, whether staff turned up to inspect a fault within a given time, rather than whether they put it right. As a result, Interserve regularly walks away with performance scores of 100%.

Carol Johnston, who keeps an eye on Interserve's self-monitoring system on behalf of the NHS trust, says: "I see maintenance jobs that have not been finished, but they don't show up on the system. For instance, I reported a hole in a partition caused by a trolley a while ago, and it hasn't been fixed."

In 2001, the endoscopy unit's two administrators, Anne Nixon and Denise Whitehead, were moved into a poky, stuffy, windowless office that had been converted from a consulting room. "We phoned the helpdesk two or three times," says Nixon. "Someone comes and nothing is done. Interserve did turn heating off, but now there's no ventilation. They put a fan in, but papers fly everywhere. Now we just leave the door open, or it would get too stuffy."

Bennett counters this criticism with the assertion that there are "very few" complaints about the building. "We take very seriously every complaint," he says. "I don't think the PFI has compromised healthcare in the hospital. I think it has improved it. Since the hospital opened in April 2000, all medical facilities have been 100% available."

Alterations to the building carried out by Interserve do not come cheap, and the NHS trust is already in the red to the tune of £3m. There are no current building rates or menu of agreed prices in the PFI contract, but Weightman estimates that it costs £10 to put in a single screw. When it comes to more ambitious alteration proposals, the NHS trust's project director Alan Davidson explains another problem. "If you want a variation that would cost £25,000, you would need a change order from the PFI company. They would then need to inform their funders, and their advisers would have to ensure due diligence. So you could end up paying an extra £8000-10,000 in fees alone."

Despite these problems, the NHS trust's Davidson is proud of the new building, which "was designed with the future in mind", he says. "It's a flexible building, with dry-lined walls, wide-span structure, modular wiring and generous floor-to-floor heights." He adds, rather less convincingly, that the "teething problems" could have occurred under a conventionally procured building and should not be blamed on the PFI system. But he does admit that, with all its bureaucratic processes, the PFI contract is inflexible. This, combined with the chronic antagonism between management and staff, militates against the building being used to its full potential.

Five-star rating

Functionality **
The new acute 444-bed hospital is too small. It was built three years ago with 10 beds fewer than the hospital it replaced, yet admissions have increased by some 2.2% a year. To compensate, a temporary 16-bed ward was built last year, and hospital consultants are now calling for a permanent extension. Beds in five-bed bays are so close together that patients complain of lack of privacy and consultants fear it could spread diseases. More positively, consultants find the compact layout of medical facilities works efficiently. Impact ***
Set behind a new public park, the orderly, four-storey building fits fairly happily into the cityscape of Carlisle. Internally, the central mall brings daylight, fresh air, space and external views into the heart of the building, but the public restaurant is depressing and many staff work in windowless rooms. Build quality *
Three years after handover, the building still suffers from technical problems. Two wards and several other rooms are stuffy, the mall overheats in summer and gets cold in winter, and flat roofs leak.


Building too small
“As a whole, the building is too small with not enough acute beds,” says Donald Clark, who as chairman of the medical staff committee represents the 85 medical consultants working in the hospital. The new hospital was originally designed with 474 beds to replace the old infirmary with 454 beds, but in the event it was built with just 444 beds. Insufficient bed space has been partly – and blatantly – rectified by installing a prefabricated module containing a 16-bed ward next to the hospital’s main entrance. The module has planning permission for just 18 months, which the trust reckons will be long enough to reduce the hospital waiting list to a manageable level for good. However, Clark is not so sure. “The unit has been heavily used since last October, but I don’t see the waiting lists dropping. So I don’t think it will be shut down in another few months.” Clark blames the undersizing of the hospital on future projections of admissions that he says were “fundamentally flawed”. He says: “The primary care trust looked at figures over three years. If they had looked at figures over 10 or 12 years, they would have come up with more realistic projections.” Other reasons why too few beds were developed are given by medical consultant William Reid, who advised the trust on the design brief in 1997. “The government initiative at the time was to reduce bed spaces and rely more on day surgery. There’s also a problem with bed-blocking, when people are left in acute beds for several weeks because they have nowhere to move on to for recovery. This relies on the integration of the health service with local authority social services and is very difficult to achieve.” The medical staff committee is now campaigning for a permanent extension to be built at the rear of the hospital. Beds too close together
Five-bed bays in the wards have been criticised as being too cramped, with beds spaced at 2.2 m intervals. The PFI joint venture at Carlisle insists that, although NHS space standards have increased twice since the hospital was designed in 1997, the design complied with standards current at the time. However, Hospital Building Note 4 revised by NHS Estates in March 1997 states: “Each bedspace should not be less than 2.9 × 2.9 m.” A report by inspector the Commission for Health Improvement noted that “a number of patients [complained] about the lack of space and privacy, particularly in the five-bedded bay areas.” Hygiene may also be compromised if gaps between beds are too narrow. “The closer patients are, the easier it is for bugs to spread,” says Clark. On the day of Building’s visit, one of the wards was closed down to clear an outbreak of diarrhoea. The CHI report noted the “frequent closure of wards as a result of viral gastrointestinal infection, which affected both staff and patients”. Efficient clinical layout
“Most clinicians find the building functions extremely well in terms of adjacencies of departments,” says consultant William Reid, a view seconded by Clark. The radiology department, which brings together all the hospital’s scanning facilities, has been suitably located alongside the accident and emergency department on the ground floor and directly below the operating theatres and anaesthetic department on the first floor. Lack of storage
Lack of storage space in the hospital is a recurrent complaint. The CHI report noted that “facilities originally designated as patient areas [were] being used as storage areas. For example, shower rooms had been converted to storage spaces.” It also criticised “considerable clutter in ward areas, which compromises fire exits”. However, ward sister Jean Strong, prefers to keep some of the more frequently used equipment, such as patient hoists, in the corridors next to the bed bays. “We can’t wait until we get them out of the store,” she says. The medical records office, where patients’ files are piled high on the desks, is probably the worst affected. The storage needs for medical records were downplayed at building design stage in 1997, as it was assumed that hard copy would be superseded by electronic patient records. Yet six years on, no steps have been taken in that direction. The agreed solution is to decant the medical records to a warehouse building lying a couple of hundred metres from the hospital. But this solution brings new problems, according to department manager Ann Gadstone. “If an emergency case is brought in after hours, it will be a real worry to access their case notes,” she says. The lightweight metal-stud partitioning system, which was specified in the name of flexibility, has had the effect of reducing the storage capacity of the building. “Because the walls are plasterboard, we can’t put any weight on them, so everything is free-standing,” says Unison convenor Linda Weightman. “This means that whereas in the old hospital we could keep everything off the floor, avoiding safety risks, everything now has to go on the floor, but there is nowhere to stand anything.” Fire doors impede circulation
Circulation around the hospital is impeded by a primitive fire prevention strategy that relies on multiple sets of heavy spring-loaded fire doors. The Unison reports quotes an outpatient staff nurse as saying: “We have patients in wheelchairs having to go through five sets of double doors that won’t stay open.” Orderlies pushing beds and trolleys have similar problems.


Pleasant building
Unlike PFI hospitals at Edinburgh, Worcester and Norwich, the Cumberland Infirmary was built on the site of the former facility, and is just a mile from the city centre. As one of the largest structures in Carlisle, the 40,000 m2 building fits into the townscape without too much disruption. Its three-storey bulk is set behind a classical stone building retained from the old hospital and new, richly landscaped gardens. Red brick walls and regular window bays contribute to an orderly, but not over-clinical appearance. Airy internal mall
The hospital’s circulation spine is a wide glass-roofed atrium that brings daylight, fresh air, space and external views deep inside the building. It also acts as the hospital’s social hub, with ample seats, a shop and a cafe. “You have to go through the atrium to get from one department to another, and psychologically, it’s like being outside,” says consultant Donald Clark approvingly. “It’s like walking down a high street, where you bump into people you know.” Depressing restaurant
The restaurant does not benefit from the space, light and views of mall. Just the opposite: it has been pushed down to the floor below, where it has only a prison-like light-well to look out on to. The dreary restaurant and its unappetising food are a public relations disaster for the hospital, as local residents contrast it with its predecessor, a well patronised civic attraction prominently located next to the former hospital entrance. Union convenor Linda Weightman recalls: “Between nine and 10 every morning, you couldn’t find a policeman in Carlisle. They were all having their breakfast in the hospital restaurant.” Windowless workspaces
Many staff work in windowless internal offices in the hospital. Anne Nixon, administrator in the endoscopy department, says: “There’s only one window in the whole unit, and that’s in the operating theatre. We’ve got no idea what’s going on outside. By the end of the week, we’re totally sapped of energy.”

Build quality

Overheating in mall
Beneath its glass roof, the mall turns into an oven in summer and a fridge in winter. Last year, automatic roof blinds were installed in an attempt to counteract overheating, but staff still complain. Low winter temperatures are counteracted by issuing padded jerkins to the receptionists. Power shut-down
“Of all the things that have happened to the building, a power failure gave me the greatest concern,” says the NHS trust’s project director, Alan Davidson. “There was a failure in the mains power supply, and the hospital’s stand-by generators didn’t take the load. It happened during the defects maintenance period.” All life-supporting equipment shut down without warning for 13 minutes. Nurses were forced to ventilate patients under general anaesthetic by hand. One patient was trapped with her head in a scanner and had to remain in that position in total darkness until power resumed. Stuffy rooms
The PFI joint venture has accepted responsibility to rectify stuffiness in two wards. “They are not chilled as much as they should be,” admits Martin Bennett, the joint venture’s project director. “But the problem will be solved.” But for those staff who occupy windowless offices, there is no commitment to eradicate stuffiness. “The issue of stuffy rooms will always be there,” says Carol Johnston, liaison officer between the NHS trust and Interserve. “People in endoscopy have moaned about the problem for three years. In the old building, all the offices had windows. So people will never be happy with windowless offices.” Leaking roofs
“We have had a number of leaking roofs, in the stairwells, in the link corridor and in the main atrium,” says Davidson. “They frustrate me. They could be a failure of inverted roofs or rainwater goods. All of them have been put back to Interserve as defects to be resolved.”