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Fitness for purpose
The compact six-storey hospital functions efficiently, with a central street and atrium providing good, legible circulation for patients, staff and visitors and a single entrance for security. The straightforward office-block construction system has proved to be highly adaptable to frequent changes in hospital needs.

Comfort ***
Daylight fills the central atrium and the rooms opening off it. But these rooms are insufficiently ventilated through the atrium and can be stuffy. The reception desk suffers from draughts and glare.

Delight ****
The glorious extended atrium is the scene of one of Britain's most celebrated collections of healing arts, including sculptures, paintings and concerts. In a recent survey, most patients, staff and visitors said that these greatly reduced their stress levels. The building is well mannered in its traditional high-street setting, but is let down by a gloomy entrance canopy.

Maintainability ***
The early example of an ETFE membrane roof is holding up, despite minor problems. The linoleum floor is bleaching in the atrium, much of the services plant is packing up prematurely and the exterior is weathering poorly.

At a glance

Completed in 1993, the Chelsea & Westminster broke the mould for an NHS facility and was a precursor to the current drive towards patient-friendly design. The huge 665-bed teaching hospital replaced four obsolete west London hospitals stretching from Westminster to Fulham, and was paid for by the disposal of three of these sites. Born out of commercial property deals, the building shares its architectural format and construction techniques with contemporary office buildings. Some 111,500 m2 of accommodation was packed into a six-storey block that was itself shoehorned into the unsold site. Fast-track construction techniques included a steel structure, composite metal-deck floors and stud partition walls. Development costs of £202m, or £310,000 a bed, were 156% higher than the NHS norm.

The hospital was designed by Sheppard Robson and built under a management contract by Laing Management, with CS Project Consultants as project manager, Waterman Partnership and Buro Happold as structural engineers, Donald Smith Seymour & Rooley as services engineer and Gleeds as quantity surveyor.

Fitness for purpose

Efficient high-density layout
The 111,500 m2 of hospital accommodation is efficiently laid out on six floors around an elongated atrium. Outpatient departments are located on the ground and first floors, with ancillary accommodation in the lower-ground floor and L-shaped wards and operating theatres arranged around the perimeter of the upper floors. Primary circulation is provided by spinal "streets" on three floors that run the length of the building and are punctuated by four banks of lifts.

According to Jeremy Booth, in charge of the accident and emergency unit: "The hospital works very well – far better than an NHS standard nucleus hospital. It's very ergonomic, and patients seem to flow through very easily."

Central street provides orientation and security
The internal street, which runs in a straight line and at the same level from the main front entrance off Fulham Road to the rear of the block, gives visitors a clear sense of orientation in the huge multistorey labyrinth of rooms. From the internal street, the 10 main wings of the building, each wrapped around a distinct part of the atrium, or "sub-atrium", are legible and accessible by banks of lifts.

The single public entrance supervised by the reception desk also makes for good security at a time when hospitals are beset by attacks on staff and robberies.

The main entrance directly on the Fulham Road certainly gives the building a prominent public face and accessibility. On the other hand, congestion is created directly in front of the entrance, where the pavement has been reduced in width to accommodate a vehicle drop-off point and is further constricted by bulky columns supporting an overhead canopy.

Office-block structure for adaptability
"The hospital is evolving all the time to meet new demands and keep up with advances in medical specialisations," says John Curtis, the NHS trust's development manager. "This building fulfils that evolution because it is very adaptable."

In the eight years since opening, the functions within the building have changed radically. Some 125 beds have been removed as part of a general switch to less invasive "keyhole" surgery and day treatment. A highly serviced endoscopy unit including a six-bay ward, a burns unit, two more paediatric operating theatres and extensions to two more departments have been added. Offices have been created to house the trust's finance, human resources and chief executive departments, which have been relocated from other buildings. All the new accommodation, with the exception of the accident and emergency extension, has been provided within the original building envelope.

The straightforward commercial office-block structure with its wide-span steel frame allows the metal-stud and plasterboard partitioning to be easily demolished and new partitions erected elsewhere. The 100 mm thick composite metal-deck floors can be cut through to make way for services risers, in some cases by adding steel trimmer joists as reinforcement.

"The building is very easy to dismantle and put back again," says Curtis. "That means you can get a project up and running very quickly." Estates technical services manager Peter Rooney adds: "Eight fire lifts have been located around the perimeter. These are useful to builders, who can carry out work without getting in the way of patients and medical staff."

The adaptations have not just been a matter of converting one type of accommodation into another. "The building was designed in such a way that you can gain extra square footage without anyone noticing," says Curtis. In some cases, such as the endoscopy unit, spacious plant rooms on the second floor have been requisitioned by the simple expedient of shifting air-supply ducts up into a new ceiling void within the original 4.1 m clear storey height. The same unit has also been extended sideways by one bay to occupy an unused terrace overlooking a sub-atrium.

Externally, the accident and emergency extension is tucked alongside one of the escape stair towers. Projecting beyond the lower-ground floor, the single-storey extension reduces daylight on two floors and interferes with the air intake on the lower ground floor.

Comfort

Draughts and glare at reception desk
The problem with the large single entrance and wide internal street is that the reception desk is placed directly in front of three revolving doors, with its back to the atrium. As a result, receptionists complain of draughts, and visitors suffer from glare from the atrium when talking to them. Estates manager Rooney's suggestion of erecting screens was rejected on security grounds.

The area directly behind the reception, which had been designated a patient pick-up point, also suffered from draughts from the main entrance and from the naturally ventilated atrium. "Temperatures could drop as low as 5ºC," explains Rooney. "This was quite unacceptable for patients waiting in wheelchairs after treatment. They are now picked up at the medical day unit."

Poor ventilation in spaces overlooking atrium
Whereas operating theatres are fully air-conditioned and patient wards around the building perimeter benefit from mechanical ventilation and comfort cooling, the offices, single-bed wards and other accommodation overlooking the atrium are ventilated only by the updraft from the naturally ventilated atrium.

Although they had been specified to tilt and turn, the windows that were supplied overlooking the atrium can only tilt to give a slight opening of 100 mm at the top. As a result, occupants complain of inadequate ventilation and cooling.

Ample daylight in atrium
The large central atrium with its roof of translucent ETFE membrane is awash with daylight, enough to serve the spaces overlooking it.

To maintain high lighting levels at night, the atrium is fitted with spotlights and lamp standards at close intervals. Partly to save energy costs and partly at the request of occupants, lights are switched off in two of every three lamp standards and in several spotlights.

Delight

High-quality art and architecture reduce stress
Chelsea & Westminster Hospital is rightly famous for the prominence of high-quality art within the building, which is organised by a private trust with no NHS funding. Art in the building starts with a giant curvilinear sculpture in the atrium design by Allen Jones, and a cascade of hanging colourful leaves by Sian Tucker on the opposite side. Beyond these, smaller pictures permeate nearly all the public areas.

Performing arts also feature prominently, with two or three performances of opera, instrumental music, choirs, jazz or dance staged each week on a platform located in the centre of the atrium and overlooked by many of the wards.

The art collection, performances and overall hospital environment, including the architecture, light and colour, were recently subjected to the first systematic appraisal in Britain of the impact of hospital arts on patients, staff and visitors. After analysing 1001 questionnaires, the research team reported: "75% of each population [patients, staff and visitors] replied that the visual and performing arts greatly diminished their stress levels, changed their mood for the better and helped to take their minds off immediate worries or medical problems." Significantly, the performing arts scored higher than visual arts in terms of taking the mind off immediate worries or medical problems.

Well-mannered exterior marred by tatty entrance
In urban design terms, the huge hospital building fits with relatively little disruption into the surrounding townscape of Victorian four-storey brick terraces. The bulky six-storey block is placed perpendicular to Fulham Road, and steps down by one storey to present a plain, orderly flat facade of wide window bays set in brick surrounds to the main road. Shops and cafes line the pavement on either side of the main entrance, continuing the row of shops on the high street.

Unfortunately, the well-mannered scene is marred by a large fabric canopy at the front that makes the pavement below gloomy, and this dowdy image is exacerbated by tatty steel columns containing rainwater pipes.

Maintainability

ETFE membrane glazing performing well
The atrium roof incorporates one of the first major uses of ETFE membrane in Britain. Each glazing panel consists of three leaves of membrane with air cavities between, which are inflated to create insulating pillows.

General repair and maintenance is carried out twice a year by Vector, the original supply contractor. The lower sections of the ETFE pillows are beginning to discolour as dirt builds up inside the cavities.

Linoleum bleaching and cracking
Linoleum flooring in a vivid ultramarine contributes to the uplifting ambience of the hospital. But below the roof of the atrium, it has faded dismally in the strong sunlight.

To make the flooring softer on the feet, the linoleum was laid on a 3 mm cork underlay, and in the corridors high wear and tear has resulted in fraying at the joins between sheets.

Services plant out of action
After eight years, much of the services plant is prematurely failing. According to development manager John Curtis: "Three out of four of the absorption chillers are on their last legs." Likewise, gas turbines have failed in the combined heat and power plant, and a temporary stand-by generator has been hired for emergencies.

Interior kept clean
Cleaning of the internal structure within the atrium can only be safely carried out by abseilers, and dust and dead flies tend to build on the horizontal louvres. On the other hand, the white acoustic board linings to the atrium still look pristine.

Exterior weathering poorly
The outside of the building is showing premature signs of weathering. The stove-enamelled panels to the plant rooms at the head of the escape stair towers are discolouring. Poorly detailed cornices without flashings allow rainwater to leak between precast concrete units and stain the brickwork below.