Millstone to milestone
There has been a hospital on the St Bartholomew's site in central London since 1123. Between 1723 and 1758 the medieval buildings were demolished and the James Gibbs-designed Italianate Piazza was built, including the West Wing building, completed in 1752. This continued in ward use until the early 1990s, but then was only partially occupied by medical departments. The question of its future was brought into greater focus by the general transformation of the hospital being planned under a £billion-plus PFI scheme. Reusing the West Wing became one of four advance projects to resolve problematic issues. This project is modest by PFI standards, at an £8.2 million construction cost, and separately funded by public appeal.
Barts has used this project to pursue a more general agenda of developing a holistic approach to patient care, and in particular to create a Cancer Centre that brings together groups from around the hospital under one roof. The focus is not only on cancer patients' medical care but also on their psychological, social and emotional wellbeing. The centre provides a boost both for staff and in-patients' experience, including support for people close to them. Some of this we have seen exemplified too in the Maggie's Centres, and Maggie's in Edinburgh was one of the places visited early in the project, along with other UK and US facilities. But while Maggies's Centres are essentially non-clinical, Barts' centre focuses on consultation and diagnosis.
While the Piazza is the architectural setpiece of Barts, and Gibbs' building is listed Grade I, it is not quite the historic gem this might suggest. The Bath stone facade was replaced with Portland stone in the mid 1800s, and analysis indicates that the internal plaster dates from this period too. Floors were replaced earlier that century. A lift was also added in the 19th century. There had originally been 12 huge fireplaces to heat the wards - four quadrant wards on each of three floors - but only three plus some fragments of the fire surrounds remain.
Over the years there has been much alteration, mainly partitioning. There is hardly anything visible inside or out that dates from 1752. So the City of London planners and English Heritage (EH) were ready to accept some internal change. Greenhill Jenner had already developed an understanding with them during its exterior refurbishment of the West Wing in 1995-96.
One of the agreed responses to this chequered building history has been to restore the ground floor, particularly the two principal front rooms, to something like their original condition. One room is the principal waiting area and cafÚ for patients and their supporters; the other is a conference suite for case conferences, lectures and use by the rest of the hospital. Both are treated like salons and contain complete fireplaces as well as repaired plaster and floors.
Doing this allowed a trade-off for more radical change on the floors above.
The fact that the building can be reused at all is in part thanks to design ingenuity, but also to developments in IT. The ready communication of patient data, including electronic versions of x-ray images, provides a lot of freedom to locate people and functions. The brief from staff had started as a list of accommodation and equipment, largely reflecting existing practice. Gradually this brief was developed into a more rounded view of the future service to be offered. This was helped by RKW Health Planners, brought in by the architect, which focused on the patients' experience and their journeys as they move from point to point in the building during a visit. This exercise also confirmed that the cancer care offered here should not extend beyond breast cancer.
Another key challenge to existing ways of doing things was the approach the architect took to layout of the first and second floors.
Most staff were used to spine-corridor buildings but this was not practical in the Gibbs building for two main reasons. One was Gibbs' original spine wall, around a metre thick (which included the fireplaces). The other was that building rooms along the perimeter would mean their width would be dictated by Gibbs' fenestration. The neat solution the architect has adopted is to group the rooms centrally, designed as modern pod-like structures (with their own HVAC on top). There have had to be some penetrations of Gibbs' spine walls, both for general circulation and for discreet movement between rooms on the diagnostic (second) floor. The compensation for these changes to the original structure is that, with the external walls freed up, a significant sense of the proportions of the original spaces is evident, and the views out can be enjoyed by all. Seating has been put under windows for people to stop and take a breath - much more expansive in feel than would be a cellular room.
Not surprisingly, there was some uncertainty about whether the new rooms, with their obscured glass windows, would work.
The hospital funded a mock up (as it did of floor fire-stopping) which proved convincing to designers, planners, EH and the patient support group (made up of ex-patients), as well as a help to the fundraisers.
Barts already has an arts initiative called Vital Arts and was ready to consider artwork here. A curator, Theresa Bergne, was appointed to manage the commissioning of artists and has been involved with the architect in reviewing interior design and furnishing. The main impact has been to bring some of the calmness of galleries to this workplace, making the interior design more background in line and materials palette so that the artworks have room to breathe. The one most integrated with the architecture is David Batchelor's neon work on the main staircase. Overall, some £250,00 has been spent, about 3 per cent of contract value.
Gibbs' staircase itself, a step too far in terms of the technology of the time that has always needed support, has been taken down and rebuilt, now supported by steel cantilever brackets set within the walls. Other refurbishment works include some floor strengthening and paint analysis. Plant is mainly located in the basement, with existing flues used as ducts.
Other facilities include offices in the mansard and a Maggie-like information and support space in a small replacement extension to the rear of the building. It may appear relatively small but then only about one in 10 of the 2,500 referrals per year reveals cancer. There is also The Boutique, selling wigs, treatments and clothes such as swimsuits.
Functionally, there is great improvement in communication and feedback for staff, in facilities and equipment (also part of the appeal), a faster service and generally much improved patient experience. This project was procured under a traditional contract with full drawings and bills of quantities. But architect Nigel Greenhill reckons that if you take out of the cost equation the heritage, restoration and art components, then the costs are comparable with a good quality PFI scheme. For Barts, the project sets a design quality standard for the forthcoming PFI project.