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In the world of superhospitals, Birmingham is right near the top of the big numbers league. At 拢585m, it鈥檚 the biggest PFI hospital under construction outside London. When fully operational the 137,000m2 scheme will have 1,200 beds, 30 operating theatres, 300 teaching rooms and the largest critical care unit in Europe with 100 beds. The big numbers can mean fat profits for PFI providers, but on the flipside the sheer scale of these jobs means getting things wrong can take a massive chunk out of a contractor鈥檚 margin. For example, the northern division of Bovis took a 拢48m hit in 2007 largely because of problems delivering the 拢480m Manchester joint hospitals project.

This was very much on the mind of Roger Frost, the Balfour Beatty project director charged with delivering the Birmingham scheme for Consort Healthcare, the PFI arm of the contractor. 鈥淭he healthcare trust only starts paying the unitary charge when it gets the hospital,鈥� he says. 鈥淚t鈥檚 a big lump of money and if we don鈥檛 complete on time, the bank still wants its money, which we have to pay as liquidated damages.鈥�

Frost says the whole project was configured to ensure it was delivered on time. He also wanted a zero accident job and a high-quality end product, and decided that prefabricating as much of the building as possible was the solution. 鈥淧refabrication reduces time and the number of people on site, which in turn reduces the risk of injury. It also delivers a quality product,鈥� he says.

This sounds obvious, but Frost had quite a job on his hands. M&E is a big part of a new hospital so Balfour Beatty formed a joint venture with M&E arm, Haden Young (now Balfour Beatty Engineering Services). The trouble was Haden Young didn鈥檛 have a manufacturing plant capable of supplying a job of this size. On top of this, says Frost, at the time Balfour Beatty wasn鈥檛 big on off-site solutions, which meant people thought along conventional construction lines. 鈥淲e had a sense of purpose and what we wanted to achieve, but the biggest challenge was getting people to hit those objectives. It鈥檚 a mindset issue,鈥� he sighs.

A good example is the cladding. Originally this was going to be a mix of unitised cladding, which comes in ready-to-fit modules and is installed from inside the building without needing scaffolding, and a stick system, which is assembled on site. Frost wanted to go for an all unitised facade as this was quicker, safer and cheaper. But not everyone saw it like that. 鈥淥n paper it looks more expensive,鈥� Frost explains. 鈥淏ut once you factor in the saving on scaffolding, it works out cheaper.鈥� The cladding system was supplied by Permasteelisa, a company normally associated with high specification city centre offices where quality and speed of construction are the main drivers.

There was another reason why some people could be forgiven for resisting an all-unitised system. 鈥淚t was a big step to put 65,000m2 of cladding into one contractor鈥檚 hands,鈥� Frost says. 鈥淎t the time there was a problem with cladding contractors going bust.鈥� To mitigate the risk, Balfour Beatty did a 鈥渉uge amount鈥� of due diligence on cladding specialist Permasteelisa and structural steelwork specialist Severfield Reeve. 鈥淭hese are substantial organisations and we got backing from parent companies in case of problems.鈥�

Frost went for a steel frame because it fitted his prefabrication philosophy. Concrete is normally used in hospitals because it鈥檚 less prone to vibration, which could disturb patients and affect treatment, but instead Frost decided to use heavier steel sections and beefier connections.

With the frame and cladding sorted out, the team turned its attention to the fit-out. The high levels of servicing hospitals need meant this was a massively complex part of the job. To make it manageable, it was broken down into 96 zones ranging in size from 1,000m2 to 1,500m2, with the team working their way across the site from west to east. Each 1,000m2 zone takes 42 weeks to complete. 鈥淲e have resources moving from one zone to another in an organised manner, so we don鈥檛 have any peaks or troughs on the job,鈥� says Frost. The team have been completing zones at a rate of one every one or two weeks with the first completed nine months ago.

Prefabrication is a key part of the fit-out. Because Balfour Beatty Engineering Services didn鈥檛 have a big enough factory, Frost decided to build one locally in West Bromwich. The money came out of the hospital budget, but Balfour Beatty agreed to buy the factory 鈥� providing it was financially viable. 鈥淚f it hadn鈥檛 been a success we would have had a problem,鈥� laughs Frost.

This factory has been churning out 6m long service modules containing pipe and ductwork. They鈥檙e then taken to site where they are connected together. Initially a small contract was given to Babcock to supply a plant room, but Frost reckoned Balfour Beatty Engineering Services could make its own plant rooms in the new factory. The remaining plant rooms have been prefabricated either as complete units or, in the case of the larger plant rooms, in sections.

Modular, clip-together wiring has been used on the job to save time too. Originally this was subcontracted to a third party supplier, but Balfour Beatty bought them out and now uses the facility to supply its other jobs.

It adopted a similar strategy with the prefabricated bathroom pods. These were being made by a firm in Weston-Super-Mare but it got into financial difficulties so again Balfour Beatty bought the company out. The pods are made using glass-reinforced plastic, which serves as both the structural shell and the finished internal surface. This looks convincingly like white ceramic tiles complete with grout. The advantage is that the grout is actually part of the glass-reinforced plastic, which makes it easier to clean than the real thing.

Elsewhere, prefabricated units are used for servicing beds in the wards, the critical care unit and operating theatres. In the wards the services are recessed into the wall in prefabricated panels. Elsewhere, bedside services, including power and medical gases, are contained within ceiling-mounted pedestals, Balfour Beatty says a huge amount of work went into getting the ergonomics of these right.

Getting the pedestals right required close collaboration with University Hospitals Birmingham NHS Trust. There was intense debate between clinicians about the ergonomics of the pedestals, then the pedestals were trialled in the existing hospital before the go-ahead was given to fit these in the new building. Frost emphasises how close collaboration has contributed to the success of the job. For example the NHS trust agreed on a standardised bedroom layout that minimised the number of different bathroom pod and bed services modules needed.

The prefabrication strategy has paid off for Balfour Beatty. For a start there have been no disabling accidents after more than one million man hours of work, particularly appropriate for a hospital project. Frost will be able to sleep easy on those contract dates for completion 鈥� Balfour Beatty plans to hand over the first two phases of the project in December rather than on the contract dates of April and September 2010. It reckons the trust will get the third phase next September 鈥� 11 months earlier than the contract date, which is a thumping vindication of the benefits of careful planning and prefabrication.

What is the scheme like?

鈥淔rom the start it was apparent it was going to be an enormous hospital,鈥� says Andrew Smith, head of healthcare at architect BDP.

He adds that the main challenge was ensuring the building didn鈥檛 feel enormous and people could find their way around it. 鈥淲e concentrated on making it as easy and as intuitive to use as possible.鈥�

The whole design is intended to make people aware of where they are in the building and to give them a clear sense of where they need to go. The layout helps with this. For example, there is a hierarchy of three corridor sizes 鈥� large near the entrance and small near destination points such as wards. But the key element is ensuring people can always see outside which provides them with a reference point when navigating around the building.

The layout is simple and logical. All the outpatient and clinical investigation areas are on level 0 which is the ground floor. The A&E department is on level one but is accessible directly from outside as the ground slopes up to the A&E entrance. The operating theatres and critical care units are on level two. The plant rooms are just above this to simplify servicing the theatres, and the wards are above this.

The treatment areas are contained within one big podium structure, but above this the building becomes much more permeable. It is conceived as three big elliptical doughnut-type structures. Externally, this helps break up the bulk of the hospital, which is important as it is in a residential area. Plus, it makes it less intimidating to new arrivals. Internally, it offers several advantages.

The middle of each doughnut or tower is a outside courtyard wide enough so people can get a clear view of the sky and where the sun is, which helps with wayfinding. It also means every ward is filled with natural light. The wards are arranged around the doughnuts with a central corridor. The brief called for 50% of rooms to be single occupancy, so each ward contains 16 single rooms that are located around the outside of the doughnut and five four-bed wards which fit neatly on the inside.

鈥淲hether you are sitting up or lying down in bed you always get a view of the outside,鈥� says Smith. On the south side of the hospital the rooms feature windows that start 600mm from the floor rather than the more standard 900mm. On the north side where solar gain is less of an issue, floor-to-ceiling glazing is fitted, which means these rooms are flooded with light.

In this hospital patients and the general public will never see each other unless visiting a ward. 鈥淚n order to deliver patient privacy and dignity, plus help with an effective infection control regime, there is a high degree of separation,鈥� explains Smith. There are dedicated corridors and lifts that drop straight down into the treatment areas to keep patients separate from the corridors used by the general public.