Sustainability in Re-use

Sustainability in Re-use The impact and opportunities of re-using healthcare facilities

(above) Kings Cross Health Centre corridor - Before (below) Kings Cross Health Centre corridor - After

Sustainability in Re-use The impact and opportunities of re-using healthcare facilities

In the on-going drive to deliver high quality healthcare environments, the reuse and renovation of existing buildings is a key opportunity for increased sustainability in the NHS estate through energy and material savings. Existing buildings can be seen as ill-suited for adaptation to modern standards. However, this is not necessarily the case, as demonstrated by the four case studies presented in the following pages where new or improved service configurations have been realised through the re-use of existing facilities. The existing estate held by the NHS is extensive and it is now frequently no longer appropriate, sustainable or affordable to demolish, sell land and rebuild. There can be substantial benefits in the continued use of existing buildings. Scottish Government policy places a high value on sustainability and waste reduction, and client teams must consider the reduced impact of refurbished buildings on the environment as well as the best use of resources already invested in the buildings. The location of existing health buildings within settlements also links with wider policy, context and benefits, supporting transport plans, healthcare access and sustainable local communities. This study aims to support the work of estates teams in the NHS tasked with making decisions on the re-use and replacement of buildings, helping them to more fully appraise the value and performance of the existing estate when the time comes to make inevitable changes.

1. Emerging Issues The first section introduces five new issues around building material performance, highlighting emerging changes in the assessment and relative merits of refurbishing/re-working existing buildings versus demolition and starting anew.

2. Case Studies of Re-use In the second section four case studies in NHSScotland of re-modelled and re-used facilities are described in more detail, considering: re-use of surplus buildings for new functions, internal remodelling and combining remodelling with extensions. These are described in terms of the functional benefits, the realised environment and the process of delivery.

3. When to Re-use? The final section discusses some of the common functionality issues and opportunities facing those considering re-configuration vs new build facilities, supported by some of the solutions which have been employed in the case studies and suggests indicators for re-use.

4. Appendices

(cover) The wall of the remaining part of the original building at Chalmerâ&#x20AC;&#x2122;s Sexual Health Centre, now part of the new atrium.

An assessment of the embodied and operational energy balance of each case study building is included in Appendix A, and compares the energy impact of the buildings as built, with the impact of a similar building as a new-build. Calculation notes are provided in Appendix B.

www.healthierplaces.org

1. Emerging Issues Five issues that should change the way we look at existing buildings.

Resource Use and Waste may be More Important Than Energy Use Although climate change, energy and carbon accounting tend to dominate the sustainability agenda in the UK and Scotland, a 20041 study found that materials and waste comprise the most serious and pressing environmental concern in Scotland accounting for 38% of Scotland’s ecological footprint2, with food (29%) and energy (18%) following well behind. Scotland produces about 17 million tonnes of waste every year. By far the largest portion (44%) is made up of construction and demolition (C&D) waste3. Quite apart from issues to do with landfill pressure, this waste costs Scotland’s construction industry substantially in transportation costs and landfill taxes, and increases emissions associated with climate change due to the associated handling and transportation, as well as emissions released when the material is landfilled.

Controlled waste produced in Scotland13

As stated in Scotland’s Zero Waste plan 20104, the Scottish Government target is to recycle and prepare for re-use 70% of construction and demolition waste by 2020. Recycling, however, only partially addresses the construction waste problem, because it can use up considerable resources in reprocessing and transportation. Only a fraction of construction elements are actually reclaimed and reused for their original purpose. For this reason the Scottish Government’s Zero Waste Strategy proposes ‘waste prevention’ and ‘re-use’ as critical principles and tactics for addressing waste. Whilst this is not an exact science, this would suggest that the current prominence given to carbon emissions, particularly within the construction industry, needs to be reviewed. It also suggests that we should be giving considerably more attention to material flow and waste than we currently do. In the context of refurbishment, it would suggest that a greater emphasis be placed within sustainability assessments on the value of the retained resource (building) and less on the energy efficiency of both the existing and the alternative new-build. Currently the issue of building re-use is not prominently addressed in sustainable building strategies, nor valued in the BREEAM assessment for sustainability in construction. This disguises the benefits of re-use over recycling in terms of waste, as well as the energy, cost and pollution associated with recycling/reclamation. The material flow and waste in Scotland, and the general principles of waste prevention and re-use, point to a presumption against demolition and a new emphasis on re-using existing buildings. Following from this, it seems prudent to look at ways in which the tangible benefits of building re-use can be integrated into the assessment methodologies currently used.

Total C02 emissions arising from the life cycle of a dwelling5

Embodied Energy is More Important Than Previously Thought There are two distinct sorts of energy use associated with buildings. One is the energy required to maintain the building once occupied, to heat/cool spaces and water, run electrical appliances, and so on. This is known as the operational energy of the building, shown in purple on the diagram above and this has conventionally been the main area for investigation of “energy efficiency”. The second type of energy, shown in blue, is that associated with the extraction of raw materials and manufacture of all the materials and services required to build the building, transport of all components to site, and that associated with demolition and reclamation etc. This is known as the embodied energy and had traditionally been considered a much smaller part of the overall energy equation, receiving, as a consequence, relatively little attention. Two particular developments have changed the territory. Firstly, the operational efficiency of buildings has improved substantially; so much so that the operational energy overall is now proportionally much less than it was previously. This pattern is likely to continue given the nature of the proposed changes to regulation in Scotland and the UK. Secondly, investigation of carbon accounting and life cycle analysis has increased enormously and that the full impact of embodied energy on the whole-life carbon impact of a building is now being revealed5. Conventional wisdom until quite recently held that embodied energy comprised perhaps 5 to 10% of the total energy footprint of a building during its lifespan. A draft paper by the Royal Institute of Chartered Surveyors (RICS)6 however, suggests that this figure may actually be between 20% and 30%, depending on building type (more in some cases). Further research by the National House Building Council (NHBC)7 foundation suggests a figure around 35% for timber frame housing and more for masonry housing. The proportion varies depending on anticipated lifespan, building type, actual operational use and materials used. But even with such variances, this research illustrates the importance of the issue and the impact that specification choices can make in the long run. The same document suggests that reductions of around 10%-15% in the embodied energy can be readily achieved without significant impact on the operational energy performance. The issue of embodied energy has an impact on the consideration of newbuild versus re-use of buildings since there is a good deal of embodied energy “locked away” in existing buildings. A study8 by the Empty Homes Agency showed that a new build house contained around 50 tonnes of embodied CO2, whilst a refurbished home contained around 15 tonnes. This meant that it took around 50 years, sometimes more, for a new-build house 5

to ‘catch up’ with the savings that could have been made by refurbishing an existing house. While new homes were said to be upto four times more efficient than older homes, the study also showed that refurbished homes can be just as efficient as new homes. Less research has been conducted specifically into embodied energy in healthcare buildings9, but the lessons learnt elsewhere clearly have relevance when considering the existing built stock in the NHSScotland Estate. A brief analysis has been undertaken in Appendix A which compares the four case studies - supporting the findings mentioned above - and features a substantial refurbishment compared to notional new-build alternatives.

U-Values of Solid Walls Are Better Than Previously Thought It is commonly thought that older buildings are harder to bring up to modern standards of energy efficiency. There is growing evidence however, that points to the fact that existing buildings probably perform better than previously modelled. Overall lifetime C02 emissions of different building types 19

U-values describe how much heat passes through a material, i.e. how much heat is lost to the outside. Historic Scotland have carried out a number of in-situ U-value tests of traditional masonry buildings and compared these to the assumptions given in conventional guidance documentation and popular software products used to assess energy use in buildings10. They note, however, that the guidance and software tends to be reasonably accurate for modern forms of construction, it is considerably less accurate for older buildings, which tend to behave quite differently both thermally and in relation to moisture. They conclude that conventional guidance tends to overestimate the U-values for solid masonry walls of older buildings, proposing they allow more heat to escape than actually does. For example, for a 600mm thick sandstone wall finished internally with lath and plaster, the Energy Saving Trust11 suggests a representative U-value of 1.7 W/m2K, while the CIBSE guide12 suggests 1.38 W/m2K. However, in situ tests provided consistent evidence of U-values in reality of around 1.1 +/- 0.2 W/m2K. Whilst this may not sound dramatic, it does mean that assumptions and predictions used to assess the existing stock are not likely to be accurate. The impact across the NHSScotland estate is difficult to quantify, although, as 36% of the estate is over 50 years old, it is likely that a large proportion of these buildings will be solid construction13. Further, 23% of Scotland’s housing stock has solid walls of sandstone or granite. Therefore, a similar range (23-36%) of solid construction could be assumed for NHSScotland’s estate, suggesting that the efficiency of a significant portion of the estate may be being underestimated.

The Performance Gap of New Buildings There is a small but rapidly growing area of investigation around what is termed the “performance gap”. This is the gap between the predicted energy efficiency (commonly evaluated through a Standard Assessment Procedure (SAP) or Simplified Building Energy Model (SBEM) calculation) and the results of in-situ tests which accurately measure the real life performance of the buildings once completed (but not inhabited, i.e. free of occupant behaviour variables such as poor heating management). The focus of study in this area so far has tended to be new-build housing and has been set against the context of recent UK government aspiration for “zero carbon” housing by 2016. It is becoming clear that one of the most significant threats to achieving ‘zero carbon’ housing is this performance gap. The graph, right, illustrates the scale of the problem. The green columns indicate the predicted heat loss of the buildings (using SAP) while the adjacent blue columns show the actual heat loss, as measured on the completed building. The pattern is immediately clear: the actual heat loss is consistently higher than predicted, and in one case, the discrepancy was 120% more than the predicted amount. Worryingly, the buildings on which the study was done were almost all projects with a particular focus on improved energy performance, where particular attention was being paid to ensuring the buildings behaved as intended. Results from buildings without this emphasis would almost certainly be even worse. The graph is from a report14 which notes some of the problems regularly encountered across the whole industry. These range from design issues at every stage: installation and maintenance, procurement and supply chain issues, lack of tangible feedback, building fabric issues (e.g. airtightness), and services/controls issues, such as poorly understood renewables installations.

Measured v predicted whole-house heat loss for 16 dwellings23

A similar result was found with a non-domestic project which won the Green Building of the Year Award15. In this case the actual energy use was well over twice the estimate. It is hard to avoid the conclusion that the accuracy of our current prediction software is open to question. The relevance of the findings affects the whole building construction industry and the implication is that new build healthcare projects are unlikely to be performing as well as predicted. Decisions on whether or not to build new are often currently based on predictions regarding superior energy performance of new buildings. Given the evidence noted above, these predictions are likely to be optimistic. If the discrepancy between new and old is not so great, this driver towards demolition and new-build will require review.

Scotland’s Footprint: A resource flow and ecological footprint analysis of Scotland’, 2004, Best Foot Forward Ltd. Free to download at http://www.scotlands-footprint.com/ 2 “Construction and demolition waste produced and managed in Scotland 2009”, SEPA Factsheet July 2011 3 Source: SEPA, downloadable from http://www.sepa.org.uk/waste/waste_data/waste_data_ reports/construction__demolition.aspx 4 ‘Scotland’s Zero Waste Plan’, The Scottish Government, Edinburgh June 2010. Downloadable at http://www.scotland.gov.uk/Topics/Environment/waste-and-pollution/Waste-1/wastestrategy 5 “Operational and embodied carbon in new build housing: a reappraisal” NHBC Foundation 2011 6 RICS Draft Information paper – “Methodology for the calculation of embodied carbon as part of the life cycle carbon emissions for a building”. https://consultations.rics.org/consult.ti/embodied_ carbon/consultationHome 7 “Operational and embodied carbon in new build housing: a reappraisal” NHBC Foundation 2011 8 ‘New Tricks with Old Bricks’: How reusing old buildings an cut carbon emissions, Empty Homes Agency, March 2008 9 We have used a figure for Primary Care Buildings sourced from Atkins Masterplanning Tool 2010, as quoted in RICS Draft Information paper – “Methodology for the calculation of embodied carbon as part of the life cycle carbon emissions for a building” (see 6) 10 Baker, P, 2008. In situ U‐value measurements in traditional buildings: preliminary results. (Historic Scotland Technical Paper 2) Edinburgh: Historic Scotland. Available at http://www. historic‐scotland.gov.uk/technicalpapers. Also, Baker, P., 2011. U‐values and traditional buildings In situ measurements and their comparisons to calculated values (Historic Scotland Technical Paper 10’) Edinburgh: Historic Scotland. Available at http://www.historic‐scotland.gov.uk/ technicalpapers 11 Energy Saving Trust, 2004. Scotland: assessing U‐values of existing housing. (Energy Efficiency Best Practice in Housing: CE84) London: Energy Saving Trust. Available at http://www. energysavingtrust.org.uk/business/content/download/180012/ 441763/version/4/file/ce84.pdf 12 Anderson, B., 2006b. Thermal properties of building structures. In: The Chartered Institution of Building Services Engineers, 2006. CIBSE guide A: environmental design. 7th ed. London: CIBSE. Ch.3. 13 State of the NHSScotland Estate 2011, Scottish Government, February 2012, accessible from http://www.scotland.gov.uk/Resource/0038/00387509.pdf 14 Carbon Compliance for Tomorrow’s New Homes: A review of the modelling tool and assumptions. Topic 4: Closing the Gap between designed and built performance, Zero Carbon Hub / NHBC Foundation, August 2010 15 see discussion in S Curwell et al “Green Building Challenge in the UK” Building Research and Information 27(4/5) 286 as presented by Bill Bordas of the Useable Buildings Trust in August 2010 in a talk entitled “A new professionalism: An Introduction to Soft Landings” 1

(right) Staff room at Kings Cross Hospital

2. Case Studies Four studies into the re-use of buildings to provide new or improved services.

2.1 Kelso Health Centre, Scottish Borders 2.2 Kings Cross Hospital, Dundee 2.3 Galashiels Health Centre, Scottish Borders 2.4 Chalmers Sexual Health Centre, Edinburgh

(left) The atrium at Chalmers Sexual Health Centre, Edinburgh

Client: NHS Borders Architects: Campbell and Arnott Completed: 2006 Value: £2.088m (inc. equipment) Area: 2,000 m2 £/m2: £1,044 (inc. equip)

2.1 Kelso Health Centre, Scottish Borders Introduction The Kelso Health Centre is a GP and dental facility in the Scottish Borders. It is a renovation and extension of the Health Centre which has been on the site since the 1960’s, in an unconventional building by distinguished architect Peter Womersley. The original buildings were initially quite separate curved ‘pavilions’ in a landscaped area with access between them in the open air. Subsequent alterations provided sheltered walkways between the pavilions but little additional space, and ultimately the growing population in the area forced NHS Borders to consider major expansion. (above) The Kelso Health Centre

(below) The Kelso Health Centre, main entrance

The extension and renovation was carried out to accommodate an increase in population using the facility, overcome adjacency issues in the building, and resolve impractical room shapes. Separate new-build options were considered as an alternative to extending the facilities. Two possible sites sufficiently close to the town centre were considered but neither was ideal: one would have required a lengthy change of planning zoning and one was prone to flooding. On the existing site there was sufficient space around the original buildings to expand, it was close to the bus route and it had flat access for pedestrians. The decision was taken to refurbish and extend.

This decision was also supported by the disadvantages of selling the site; the accounting and valuation processes within NHS Borders would mean that doing so would have been punitive cost-wise, and any other use of the site would have required a change of zoning. The idiosyncratic original buildings, whilst not listed, were of architectural and historical interest with unusual curvaceous forms, restricting alternative uses for the building and all in all, making it far from ideal for prospective purchasers. However, as local landmarks they provided identity to the facility. The project involved the construction of a two rectilinear storey extension of consulting rooms and office space adjacent to the existing building, forming a courtyard with a predominantly single-sided corridor running around it on the ground floor. Most of the curved spaces, although far from ideal in their original function as clinical spaces, were re-envisioned as open plan waiting areas with the main functional clinical rooms re-located to new, rectilinear spaces in the ground floor of the extension. The extension allowed the organisation to address issues of adjacency which had been major problems with the original building, with Practice Nurses now located adjacent to GPs, and other adjustments which simplify and ease the day-to-day workings of the facility. Existing rooms were insulated and refurbished where needed, though several areas of previously external walls are now internal and extensive work was not therefore needed for these. The building size was also future-proofed; based on population studies, the main anticipated squeeze on resources will be the community services/outreach work and ample space has been provided to allow for expansion of this service in the future by the creation of spacious facilities on the upper floor for these teams. The population studies conducted suggest that the facility should be able to cope for many years ahead, but that should pressure points develop, physical expansion might not be required, Further expansion could be accommodated by increasing the timetabled use and availability of the facilities.

(above) The original health centre

(below) Ground and new extended first floor plan of the reconfigured centre.

KEY Patient treatment Staff admin Primary circulation Building services

(below) Ground floor plan of the first renovation of the centre, to include more circulation.

BEFORE

AFTER

(above and below) Original curved consulting areas re-configured as waiting areas.

The newly expanded building provides a good deal more space. Previously, consultants and nurses had struggled to provide services efficiently in cramped, unsuitable rooms, which were not ideally located in relation to supporting service delivery points in the building. The renovations allowed key clinical spaces to be completed with good adjacencies and appropriate technical resources. This has reduced strain on the staff and streamlined the experience of the patients. The administrative staff also gained from a far larger area for storage and greater privacy for users at the reception desk. The building work was carried out in two phases to allow the centre to continue to serve the community; first building the two storey extension, and then moving the services into that area to allow the original building to be reconfigured. The centre was officially opened in its entirety in 2006.

Experience As you approach along the road the buildingâ&#x20AC;&#x2122;s distinctive curved walls and irregular roof are highly visible, giving the building presence and character. New built elements are generally shielded from view behind the original building, hiding the bulk and rectilinear form of the consulting block. The architects Campbell and Arnott used a sympathetic but distinct set of materials for the extension areas. Externally the connecting areas are white render to match the original then turn to brick further round for the main extension. Although the new areas are rectangular, curved elements, such as the stairwell, reference and join the two parts.

You enter through the original entrance where circulation and reception areas view onto the charming landscaped courtyard. The dental wing to the right has a small but airy waiting room inhabiting the glazed connection area built

in the first renovation. The main waiting area was also created within the original building area, and has been used as an opportunity to enjoy and utilise the small curved spaces and upper level lighting through the partial removal of walls. This has created a series of free-flowing spaces with inviting enclosures, peaceful views and are flooded with natural light from rooflights and the courtyard. This successfully provides visual interest for waiting spaces and overcomes the prior problems of fitting contemporary clinical or administrative furniture into curved corners. Internally, simple and consistent materials blend the “new” and “old” elements, such that there is no sense of an extended or altered building, despite the different building elements and shapes. The main circulation circles the courtyard, providing good user orientation as well as clear and enjoyable movement around the building. The consulting rooms are spacious, pleasant and welcoming, placed near to additional treatment areas that might be needed. Though the consulting wing is placed close to the boundary of the site, the careful use of planting and hedges create a feeling of natural shelter outside, without seeming confined. The upper floor is light and well proportioned, with offices and staff areas looking over the unique roofscape and nearby trees.

(above) A transition between original and new parts of the building

Reaction The building has been very well received. Initially there were misgivings from the users about extending and renovating the building, but as the project developed these worries were overcome.

“When I came along to the GPs and others and said “well, look what we’re going to have to do almost certainly is stay here, but there’s an awful lot we can do about making staying here better”. There was scepticism until the architect started to produce some plans which showed what we could do.” Warwick Shaw, NHS Borders

The clinical and admin staff are delighted with the increased space, and the streamlined working practices that are facilitated due to the improved adjacencies and room usage. The patients have also been happy to continue to use the building though the renovations, and are now pleased with the end result. No problems were reported in relation to the site process itself which was clearly handled effectively with good communication to users, and effective phasing of works and de-canting ensuring an acceptable level of disruption for those involved. The client team are very pleased with the result and the process. There have been very few complaints and the team credit this to extensive involvement by stakeholders throughout the process, and the ability of the architectural team to pull these views together into a logical, coherent building that seems to please everyone. An element that is particularly popular is the courtyard, which was felt to be key to the success of the building.

(above) The spacious new first floor community nursing base

(below) The central courtyard and new two storey wing, seen from the main corridor

Parking at the Centre is fairly restricted and whilst no problems were reported, this is clearly a slight pressure point. An unanticipated problem has been that parents dropping off children to the adjacent school tend to use the driveway as an informal dropping off point, causing problems of access for staff and users at certain times of day.

Client: NHS Tayside Architects: NHS Tayside Completed: 2008 Value: ÂŁ3.9 million (excl. equipment) Area: 2,450 m2 ÂŁ/m2: 1,592 (excl. equipment)

2.2 Kings Cross Health Centre, Dundee Introduction The Kings Cross Health Centre sits at the southern end of a large urban block containing a number of other healthcare facilities including Kings Cross Hospital. Until the mid-nineties, the building had served as a unit for the treatment of infectious diseases but had lain empty for around seven years and was in an extremely bad state of repair when it was selected for re-use in 2006 as a centre for specialist consultancies, primarily physiotherapy, audiology and dentistry. The initial choice for the new relocated services had been an adjacent two storey building also on the site. However, during the brief development process, the schedule of accommodation increased beyond the capacity of that initial choice but neatly matched that of its derelict neighbour.

(above) Before and after, the gym area, seen from the car park. (below) The building plan as re-configured (the original plan was highly similar, but without the curved corridor walls)

The functions now contained within the Health Centre were previously located across disparate sites around Dundee, all of which re-located once the building was completed, so there were none of the disruption or temporary de-canting issues associated with some refurbishment projects. The refurbishment was procured in a traditional manner, and the NHS Tayside in-house architect was involved in a lengthy consultation period with a wide range of stakeholders, before the design was set.

KEY Patient treatment Staff admin

Primary circulation Building services

The service areas have been carefully scaled to ensure the footprint allows for a ten year demand expansion with some excess allocation of space and potential for ‘hot desking’ and ‘hot rooming’, while other rooms have been sized and serviced in order to allow for a variety of potential uses. Adjacencies have been carefully considered. Physiotherapy is now located next to reception due to the difficulties some patients have in walking long distances, while the Audiology department is now located furthest away from the noise of Reception. Audiology benefits from views over the gardens to the rear, and allows for informal consultations to be undertaken on the walk to the Consulting or Treatment rooms. The whole building was comprehensively refurbished and the new footprint broadly follows that of the original. Despite initial appearances (see before photo-right), the Design Team were confident a low energy, naturally-lit and pleasant building could be created from a single-storey, multi-cellular configuration, with open courtyards allowing almost every room a window.

“this building, because of its figure of eight/two square doughnuts bolted together shape, lent itself very well to a low running cost model. We’ve had very little M&E plant, and we had windows to open for fresh air supply and because of the cross section between the building it would allow quite a lot of natural light into the building, so less running costs from artificial lighting etc.” Jonathan Milne, Architect, Capital Projects Department, NHS Tayside

(above) High level windows for ventilation in the consulting rooms (below) Before and after - the main corridor

There were other plus points leading to the choice of refurbishment of this building;

“It was in the community, it was in the spirit of the Care Commission, it was central, it had X-Ray facilities, it was in do-uppable condition and so it ticked all the boxes, it was likely to be cheaper than a new build, and likely to be more convenient for everybody”. Arnot Tippet, Project Manager for NHS Tayside

The site is broadly central within Dundee and well served by public transport as well as being easily accessible by car. The adjacency to the existing neighbouring services such as X-ray counted in favour of development of any sort on this site. Cost played a part when it became clear that the building could be fully refurbished for less than a comparable new-build. Speed was also important since a very tight timeframe had been issued; with much of the basic structure and services already present, reusing a building gave the team a head start on a new-build option. Interestingly, those interviewed commented in addition that having an existing building to work with was easier than when given a ‘blank slate’ with which to work, contrary to the perception that it is easier to start afresh with no restrictions.

(above) The corridor in the children’s audiology department

As noted above, one reason the building was chosen was because its multicellular, courtyard layout meant that almost all rooms could be naturally lit and ventilated. An explicit aim of the Design Team was to keep the services extremely simple, eschewing complex (and expensive) air handling in preference to openable windows, and keeping heating controls at a domestic level of simplicity – just TRVs (thermostatic radiator valves) in each room – meaning each occupant could control the temperature in each room. This low energy strategy also had the effect of keeping costs down and by adopting this approach, for both energy efficiency and cost reasons, the whole process of refurbishment was made considerably simpler. The existing suspended concrete floor was levelled and finished without insulation, the existing bitumen felt roof finish was removed and replaced with a high performance single layer membrane, while 100mm of rigid insulation was installed between the existing roof joists. Existing areas of cavity brickwork were retained and insulated within the 50mm cavity, but all glazed and framed elements were removed and replaced with either well insulated timber frames or high performance double glazing units. Internally, the wall plaster was retained where possible, stabilised and made good. New linings were applied to ceilings and the rest of the fit-out and services installed were new.

(above) Staff area in one of the landscaped courtyards

Experience The building itself is single storey and not visible from the road as it sits low behind a high wall and trees. However, the wider hospital site is well known and the Health Centre is accessed from Hospital Road which gives a clue to the history of the site and the local familiarity.

(above) Open plan office for community nursing staff. (below) Main entrance

Once you enter the building the entrance hall is spacious, comfortable and well-lit with natural light from above. An “hotel-style” reception welcomes you from a stylish desk and the waiting area is supplemented by an adjacent café space and meeting room. The entrance itself and approach have been designed for safety and shelter but seems a missed opportunity visually, feeling somewhat in contrast to the welcoming nature of the rest of the building. From the entrance space, the majority of the building functions can be accessed to the left, while the dental facilities are accessed to the right, and have their own “hole-in-the-wall” reception. Moving left into the main building, you enter the corner of a ‘figure-of-eight’ corridor with two landscaped courtyards between, providing natural light to all circulation areas. The courtyards themselves are used to help with the recovery of patients and are landscaped to provide different surfaces and textures, levels etc. for those relearning to walk after treatment. The two courtyards also serve as an attractive focal point around which it is easy to orientate oneself, making the building easy to understand. The curving walls to the consulting rooms enliven the routes and provide a momentary breathing space when entering and leaving. This provides a genuinely attractive circulation space which successfully dispels any hint of institutionalisation.

Most of the Consulting or Treatment Rooms are located on the perimeter, and benefit from windows in the outside walls and glazed partitions into the corridor and also from high level clerestory glazing (a retained feature of the original building). This makes each room very well naturally lit and responsive to the changing nature and direction of light during the day.

Reaction The building has been very well received. Principal Physiotherapist Freddie Warden was among those Clinical Staff who were heavily involved in the design development and can find little or no fault with the finished product,

“if you were giving it a number out of ten, then from my point of view as a Physio and from what I’ve heard [from others involved], I really would be thinking is it nine, is it nine and a half or is it ten?” In terms of what would be done differently, beyond technical improvements in terms of insulation etc., the two most prominent suggestions would be to enlarge both the Gym and the Café, both of which have proved to be extremely popular (despite initial scepticism in the case of the café). Staff report a good reception from users, part of which could be associated with the improvement over the previous, disparate locations. However, the logic of bringing the services together and the attractive fit-out and courtyards has been particularly appreciated. The success of the building was recognised at Government level too. The Physiotherapy Department won an award for the innovative way in which it re-worked its processes, becoming gatekeepers for Consultants and radically improving efficiencies.

(above) Dental surgery, with clean/ dirty equipment cupboards which are managed from a corridor behind for infection control

(below) The staff room

Client: NHS Borders Architects: Camerons Completed: 2007 Value: £2.4m (inc. equip+some staff) Area: 1,850 m2 £/m2: £1,297 (inc. equip+staff)

2.3 Galashiels Health Centre, Scottish Borders Introduction The original building of the Galashiels Health Care centre was built in the 1960’s for three GP practices previously scattered across the town. The refurbishment and extension accommodates four GP practices and other health facilities including sexual health, speech and language therapy, dental, and dieticians. The original building is largely single storey with one block of two storey accommodation, and the extensions follow this with additional single storey areas and a large block of two storey administrative accommodation. New-build options were considered for the facilities but there was a lack of suitable town centre sites which could offer a similar level of accessibility. The site is uniquely accessible to all manner of transport options; the bus and train hubs are within 150m and the facility also shares over 700 parking spaces with adjacent supermarkets, which is key as the majority of users come by car due to the large dispersed catchment for the centre.

(above) Office and consulting room areas

(below) Main waiting area and practice receptions

The original building suffered from a lack of space and an unhelpful arrangement of facilities. A large proportion was duplicated admin and reception facilities, the waiting spaces were all small and separate, and the circulation unnecessarily circuitous and confusing. The increase in services and practices in the building meant expanding the building on three sides, which could have exacerbated the already complex circulation and very tight site. The organisation was made more difficult by the many practices and users, and the need to keep the centre open throughout the build. The changes were made very strategically to simplify the layout and increase opportunities for flexibility whilst retaining the different practices’ identities. The consulting rooms were pulled from the outer wall and standardised so that

KEY Patient treatment

BEFORE

AFTER

Staff admin Primary circulation Building services

they can be used by any user, with some deliberately designed with additional servicing so that they can be used by multiple high tech specialities. The main success of the reconsidered layout of the building is the reconfiguration of the centre of the building into a large joint waiting room and distinct admin and reception areas. Another smaller pooled waiting area is shared by a fourth practice and the other services in the centre, placed by the entrance so that it can be securely used out of standard opening hours. Combining the waiting areas was at first resisted by the GPs but it has been very successful, giving the centre two spaces large enough to act as an anchor point for orientation in an otherwise potentially rather complicated arrangement, meaning that the spaces internally work far better than before.

(above left) Ground floor plan of original health centre (above right) Ground floor plan of the re-configured and extended health centre

Experience The drive to ensure that all consulting rooms have an external view means that these rooms are well liked, bright and airy. The waiting areas are spacious and allow a far more relaxed and comfortable experience than smaller individual practice waiting areas would have, though additional reduction of admin spaces might have been possible with co-ordinated reception facilities, perhaps leaving space to improve privacy at reception. The waiting areas do not, however, have windows and while there are daylight tubes, the spaces feel very internalised. Larger roof glazing or windows would have really improved the environment. Though clearly the revised layout provides many improvements in the function of the facility, an opportunity has been missed in the extension and external works to improve the initial impression and provide a more welcoming and attractive entrance.

(below) Main entrance and reception

Reaction The extended building has been well received by its users and staff. Initial concerns about pooling the waiting areas evaporated and all involved now agree that this has been successful. The circulation problems of the older building have been successfully resolved and the staff appreciate the additional space and the better arrangements and adjacencies which allow for smoother operation of the centre. The sensible layout decisions have substantially improved the functioning of the centre. But equal concentration on daylighting, detailing of the built elements and the external environment could have further improved the human experience. The refurbishment process involved a carefully planned sequence of build phases and de-cant phases with a comprehensive communication strategy with all users and other stakeholders which clearly achieved a level of acceptance among those disrupted, none of whom mentioned the process of refurbishment as a problem.

Client: NHS Lothian Architects: Campbell and Arnott and jmarchitects Completed: 2011 Value: £6.6 million Area: 3,500 m2 £/m2: £1,886

2.4 Chalmers Sexual Health Centre, Edinburgh Introduction The Chalmers Sexual Health Centre caters for a wide range of sexual health, gynecological and fertility issues in the NHS Lothian region. The centre occupies the 19th Century Chalmers Hospital which has stood on the site for around 150 years. It stopped functioning as a hospital in the 1990’s and was used for a variety of clinical and administrative roles until it was wholly refurbished and extended in 2009/2010. It was opened by Michael Matheson, Minister for Public Health in 2011.

(above) Original main entrance, now staff entrance

(below) New main entrance

An important part of the decision to locate on this site was the fact that it is central within the city and easily accessible by public transport. Another factor when considering location of a sexual health clinic was that there may be (perceived or otherwise) stigma associated with attending the Centre, so its integrated city centre site was important.

(left top) Entrance level plan of previous layout (left bottom) Entrance level plan of new reconfigured and extended centre

BEFORE

AFTER

KEY Patient treatment Staff admin Circulation and waiting Building services

(below) The old and new building facades

The front and main part of the building is B-Listed so demolition and replacement was unlikely. The plan initially was to refurbish the building as it stood (including a large rear extension) and use the entirety of the refurbished building to house the Family Planning Facility. At an early stage however, GUM (genito-urinary medicine) facilities were introduced into the project and there was no longer sufficient space within the existing footprint. The architects, Campbell & Arnott, re-worked the building layout and produced early versions of the final plan, which included the removal of the rear extension and its replacement with the atrium and much larger parallel extension.

Being a listed building, there were a number of restrictions on what could be altered in the original building. The original main entrance was stepped and whilst a temporary ramp was installed, it was decided early on to move the main entrance to a side street to facilitate level access throughout and a better flow through the building. The ceilings and ceiling cornices etc. had to be retained and this, coupled with the scale of rooms (which had been large, open plan “Nightingale” wards) made it difficult to incorporate modern clinical spaces with proper infection control in this area. The decision therefore was taken to use the original building, in the main, for administrative purposes, while all of the clinical and treatment spaces were housed in new purposebuilt rooms in the extension. In between the old building and new extension, a large atrium was located, bringing natural light into all adjacent areas. This also ensured that the existing wall of the original building was retained and protected, and enabled the different levels to be accommodated. In the retained sections, the roof was completely overhauled, repaired where necessary and insulated and there was a complete fit out internally, with new electrics and decoration, floor finishes and secondary glazing to all windows. There were some areas where the modern requirements for air handling caused problems for the scale of air handling ductwork, but these have all been successfully resolved through careful detailing. Future use was considered and a degree of both flexibility and ‘extra’ space built in to the scheme, both of which have been of benefit already as roles, functions and usage patterns adjusted slightly once the building was in operation. All involved in the project are clear that the project was cheaper than trying to provide the same facilities as a complete new-build.

(above) the colour-coded waiting areas in the atrium (left) The central atrium

(below) Section through the new and old building areas, showing the central atrium that joins them

Experience The building is well known locally and occupies a prominent site on Lauriston Place, a busy city centre thoroughfare, and directly opposite the College of Art. Despite being set back somewhat from the road, the building maintains a significant presence on the street. The previous entrance has a large and imposing set of stone steps, accessed across a walled parking area, so the main entrance of the new facilities has been moved to the side of the building, entering directly off Chalmers Street. You now enter at a mid level with full accessible routes throughout. Due to the shielding of the previous entrance by the staff car park wall, the new route is more straightforward and quite clear from the road. It is well articulated and signed and once inside, the arrangement makes perfect sense.

(above) Consulting room in the basement of the original building, top lit with large rooflights to the car park area.

The waiting room is the first port of call upon entry and there are slightly formal reception kiosks for registration and onward direction. From there, most journeys involve passing into the atrium. This is an impressive, attractive and organisationally successful space, creating a degree of separation between the old and new, whilst ensuring that natural light floods down through three storeys, illuminating most of the otherwise deep plan. The atrium forms the main circulation space so that most clinical rooms are accessed off secondary waiting areas which are colour-coded and appear along the lower concourse. Additional seating in this area could assist in dealing with peak use. The architects have carefully and successfully married the old and new elements, respecting the existing ashlar stonework and traditional sash and case window patterning of the old, whilst introducing contemporary elements and openings to ensure not only the smooth operation of the new facilities, but an attractive and interesting composition of its own. The scale of the atrium not only makes sense organisationally, but allows the new elements to hold their own when set against the imposing three storeys of original building.

(below) Main staff corridor in the original building

Whilst the new part of the building contains mostly small scale clinical and treatment spaces, along with the associated waiting areas and atrium, the original building has been opened up to provide a number of large open plan administrative spaces which work well, where original features such as the original windows and ceilings have been retained and integrated into the overall design.

Reaction As David Brown, project manager for NHS Lothian states, â&#x20AC;&#x153;Everybody is delighted with the building.â&#x20AC;? Staff in all sections came from a number of smaller properties which were significantly overcrowded and poorly arranged for the functions, so not surprisingly value the extra space and layout of the new building. There are the inevitable niggles, but staff were quick to point out that they were just that, only niggles. Certainly the fact that part of the building was a refurbishment has not affected the general level of satisfaction, with administrative staff, using largely the old building, equally as effusive as those using the new build clinical spaces.

In addition, staff involvement in the design meant that a number of crucial adjacencies have been achieved, such as locating recovery rooms centrally within a group of treatment rooms – something that wasn’t possible previously. These practical solutions are appreciated by those who work in the building as well as patients and other users for whom the new layout appears to work well. But this appreciation goes beyond the merely practical. Fiona Cowan, Project Co-ordinator NHS Lothian notes,

“I like the entrance into the atrium. I think it’s got the wow factor when you come out of the reception area and just see the spacing of it, I think that’s pretty stunning. For patients too it is one of the highlights. It makes the building work actually, the levels between old and new don’t match up so [the architects] needed to put in the right distance between old and new to get the gradients. Also, you can’t just build up to a Grade B listed building, you’ve got to get some separation.”

(above) Staff room in original part of the building with new internal “pod” containing toilets and changing facilities

The user’s involvement in the design process has deepened and extended their appreciation of the built solution, and this emphasises the central importance of engagement of users in the design process, not just for the practical purposes of ensuring that the building ‘works’, but to create this level of buy-in and ownership which will surely lead to a well-loved, well-run and well-maintained building long into the future. (below) First waiting area and reception

3. When to Re-use? There are a number of key considerations for those contemplating a building re-use vs new build. Depending on the circumstances, these considerations can be both a challenge and an opportunity. This concluding section considers common preconceptions and offers insights on how these challenges have been overcome in the case studies described earlier in the report and suggests indicators for re-use.

“the building is obsolete, it can’t be changed to work as well as a new build” Older buildings were built for older service models, and consequently, the service can change so that the current configuration and range of facilities is no longer suitable. Facilities may be reconsidered due to large scale changes in service delivery; increased requirements for integrated community services, links with other services such as social work and requirements for more specialised care within the community. Continuing improvement in building guidance also requires more exacting standards for infection control, new processes, and new equipment. The Galashiels Health Centre houses four separate GP practices which previously had separate waiting areas. A key part of the works was persuading the individual practices to ‘give up’ their own waiting areas and allow the space to be pooled, along with space saved by removing corridors. This freed-up space previously wasted on excessive corridors and walls, and allowed the main waiting area to be much more spacious and attractive, considerably improving the experience for all users.

Indicator for re-use: - Buildings with lots of basic rooms of a good size, and where consolidation of other areas can free up space for other functions.

It is easy to think that older buildings, particularly ones in poor repair, will not be capable of accommodating these changes; that they cannot be made “fit for purpose”. In this study however, we examine four buildings that were reconfigured and re-used for new or enhanced functions and which are now manifestly well-suited to their new functions and service demands. In many cases, older buildings may be very well suited to accommodating new functions, depending on their basic form. Older buildings often have a cellular form, with many good sized rooms, which are very adaptable to a wide variety of space needs, both administrative and clinical. Space standards in older buildings can be generous and suitable for many functions, particularly once cramped or bottle neck areas have been altered. Reconsideration of circulation routes and jumbled corridors, combining routes and removing walls, can lead to spaces being simplified and opened up, (as in Galashiels Health Centre (left)), and wayfinding streamlined. Concerns over the ability to accommodate high tech areas, or focus on infection control can be overcome through use of extensions, as in Chalmers Sexual Health Centre, or through stripping back the existing building to its essential structure and rebuilding with suitable surfaces, as done at Kings Cross in Dundee.

“if we have a new building we can make it easy for everyone to access and use” The Scottish Government aims to achieve ‘almost complete decarbonisation of road transport by 2050’15 and NHSScotland has a responsibility to support this target. The Good Corporate Citizenship Assessment Model (GCCAM) sets out six key areas of action, the first of which is travel. It is acknowledged that 24% of the NHSScotland carbon footprint in 2004 was associated with patient and staff transport, so encouraging both walking/cycling and the use of public transport to and from NHSScotland premises forms a key consideration in the location of any facility, existing or new. Existing buildings tend to be local to the community they service and have become established within the local network of public transport, creating an ‘embedded’ advantage over new sites where such linkages must be created and may not be possible, while the local familiarity with established transportation routes and connections can all weigh heavily in favour of retaining facilities where they are. However, existing sites can be tight. At Galashiels, the facility was positioned by all major public transport routes. The client team negotiated parking arrangements with the adjacent supermarket, to reduce the need for extra parking in the area, and allowing space for expansion. While the location of existing premises tends to work in their favour, accessibility within individual premises can often be seen to work against them. Older buildings, created long before recent accessibility imperatives, can often be extremely inaccessible. While the abundance of steps and stairs can usually be addressed, the issue goes beyond obvious impediments to access to include issues of ease of use for ambulant disabled and those with visual or hearing impairments to matters of orientation in layouts which may have over time become labyrinthine. In some cases this issue alone may trigger either a move or rebuilding of premises, but in most cases, a degree of careful analysis and design should ensure compliance with minimal cost and disruption, such as at Chalmers Sexual Health Centre (right).

Access was a major driver at the Chalmers Sexual Health Centre, Edinburgh. The existing entrance was not readily upgraded and so, as part of a major upgrade and extend project, a new main entrance was created. This entrance sat ‘behind’ the main building but in line with a new atrium which connected the older building to a new wing and, along with an entirely reconfigured movement strategy, internally ensured easy, compliant, and attractive movement to all parts of the facility.

Indicator for re-use: - Buildings located in the community they serve, on major transport routes and near other amenities.

“won’t a new building will be much easier to maintain?” When faced with costly maintenance bills for older buildings, it is perhaps tempting to imagine that a new-build facility will be cheaper to maintain. Where buildings have been poorly maintained over a long period of time, the costs of bringing them to a decent standard can be high, but in general, the condition of a building and the need for urgent or expensive maintenance is not linked to age. This is supported in the ‘State of the NHSScotland Estate’16 which describes both the age profile of the estate, and its physical condition by NHS Board area. There is no correlation between those areas with a higher proportion of older buildings and those with higher percentages of buildings in a poor condition17. What is not often appreciated is that in many cases older buildings used higher quality materials, frequently with longer lifespans, and used them in such a way that they were easily repairable. Stone walls in lime mortar and

The age profile of buildings in NHS Scotland’s estate (includes all 22 boards, from “State of the NHSScotland Estate” 18)

Indicator for re-use: - Buildings where the structure contains high quality materials with lifespans equal or longer than would be used in new buildings.

single nailed older Scottish slate, for example, lend themselves to simple repair and maintenance while cement mortared concrete facing block and double nailed Spanish slate do not. Using materials and components of high quality (worth reusing or repairing) in a manner which allows for repair or reuse is a key aspect of ‘designing for deconstruction’19, itself an important principle for reducing waste at source.

“buildings have to meet energy efficiency targets, surely this would be easier in a new build?” It is commonly believed that older buildings are harder to bring up to modern standards of energy efficiency. For reasons explained in section 1, the relative inefficiency of older buildings, compared to new buildings, is often overstated. Although, the case remains that buildings in general are not energy efficient, and that the costs of bringing older buildings up to current standards can be significant.

The narrow plan and courtyard-based layout of the existing building at Kings Cross in Dundee allowed for naturally ventilated, cellular clinical and office spaces. By spotting this potential, it was possible to dispense with complex, unattractive, disruptive and costly air handling equipment by ensuring each room had ample natural ventilation opportunities using both low and high level opening windows, using the building’s pitched roof system

Indicator for re-use: - Buildings where the narrow plan lends itself to natural ventilation and lighting strategies and the service to be provided is of a lower tech nature such as primary care.

Building energy use, including heating and lighting, accounts for 23% of the overall NHSScotland carbon footprint at an annual cost of around £70 million20. In the past 20 years, NHSScotland hospitals have reduced energy consumption by around 40%, which is an impressive achievement. It serves to reinforce the fact that there is significant potential to reduce energy use and costs, but it is telling that during the same period, annual energy costs have doubled21. Since energy costs are only likely to continue to rise, the imperative to find efficiencies can only increase. Meanwhile, increasing environmental legal requirements, including legally binding government CO2 reduction targets will ratchet up pressure on new-build and refurbishment projects alike, and a number of initiatives are in place to inform and ensure compliance with ever tougher requirements. In parallel to the increasing energy efficiency requirements, servicing requirements for modern healthcare buildings have increased significantly in the recent past. This can create problems where highly serviced functions needs must be housed in older buildings. The biggest problem tends to be that of air handling, since the ductwork needed is usually bulky and disruptive, but there will be circumstances where other servicing needs will force the issue to the fore in existing buildings. It is, however, important to consider that older buildings often made good use of natural ventilation, since there was no option at the time they were designed and built, and with a greater understanding of the principles and advantages of natural ventilation, contemporary designers can now take advantage of these ‘inbuilt’ advantages, and avoid the need for complex installations, and the costs of installing and running them.

“and then there’s familiarity and community identity..” On the whole, people do not like to see older buildings demolished in the cities, towns and villages where they have spent most of their lives. Michael Benedikt wrote that “We count upon our buildings to form the stable matrix of our lives”22 and there is little doubt that the rapid increase in the rate of change in the fabric of our places is upsetting and usually perceived negatively. Demolition and replacement are processes which have taken place in every society in every age. Nonetheless, most people would accept that unnecessary change is not desirable; the difficulty is allocating any tangible value to the existing built form, though anyone who’s tried to relocate an older hospital will know the emotional attachment communities have to their public buildings. Though not specifically raised in the four case studies, it is possible however that had the notion of moving out been seriously put forward, the issue might have made more of an impact, particularly in the cases of Kelso and Chalmers as it leaves once significant public buildings with an uncertain future, potentially becoming private places23 or being demolished altogether. The Sustainable Development Strategy for NHSScotland notes that ‘listening to the views of the local community on their needs from healthcare buildings’ will be a part of the overall drive to a more inclusive and sustainable NHSScotland. So whilst it is a difficult issue to quantify, there is no doubt that this is an area of importance.

Old photographs of the original Kelso Health Centre hang in the public areas of the refurbished building.

At the Chalmers Sexual Health Centre, the main entrance had to be moved and most spaces in the original parts of the building restricted to administrative, rather than clinical use, due to restrictions imposed by the listing. This however resulted in a building layout that was straightforward and pleasant to use.

Indicator for re-use: - Buildings that are culturally or visually significant, which are an attractive part of the community fabric, irrespective of listing status.

“it’s not possible to keep delivering the service whilst we alter the building” A challenge for all projects in occupied buildings is how to maintain service continuity during the inevitable disruption caused by construction or fitout works. The scale of the challenge depends on the exact nature of the building, and the type and extent of proposed works.

At Kelso Health Centre, a new suite of consulting rooms and outreach areas were built in an extension, whilst the existing centre continued. After its completion, the service moved temporarily fully into the extension, whilst the original centre was refurbished to form the main admin and waiting areas.

Perhaps surprisingly, the issue was deemed of very little significance in the two case studies where service was being provided in the building during alterations. In those affected, service continuity had been provided without any great disruption by a combination of careful and sensible phasing of the works and a good communication strategy for all stakeholders (ensuring everyone involved, including users, was kept abreast of progress and informed about the reasons for the works.) As a result, disruption was both minimised and accepted by both staff and users.

Indicator for re-use: - Buildings and designs where changes can be made to distinct areas whilst others remain in use, or where phasing can move people around without too much confusion.

Scottish Government Climate Change Delivery Plan – Meeting Scotland’s Statutory Climate Change targets, June 2009 16 State of the NHSScotland Estate 2011, Scottish Government, February 2012, accessible from http://www.scotland.gov.uk/Resource/0038/00387509.pdf 17 Each NHS Board has a Property & Asset Management Strategy (PAMS) which categorises property into four levels related to condition, where Category A is good, and level D is ‘unsatisfactory’ 18 State of the NHSScotland Estate 2011, Scottish Government, February 2012, accessible from http://www.scotland.gov.uk/Resource/0038/00387509.pdf 19 See for example, http://seda.uk.net/design_and_detailing_for_deconstruction.html, or Design for deconstruction, principles of design to facilitate reuse and recycling. Construction Industry Research and Information Association (CIRIA), London, 2004, or SBSA, Design for disassembly and re-use: Case study assessment of the potential for keeping materials in the building industry loop, 2006 20 In 2007-2008, according to A Sustainable Development Strategy for NHSScotland Consultation Draft, Health Facilities Scotland June 2011 21 ibid 22 Benedikt, ‘For an Architecture of Reality’, p.14 23 “Building up our health” Historic Scotland http://www.historic-scotland.gov.uk/ scotlandshospitals.pdf 15

(right) Kelso Health Centre

Appendices Appendix A - Embodied and Operational energy calculations for each of the case studies Appendix B - Technical calculation details and notes for the calculations in Appendix A

Appendix A - Embodied and Operational Energy It is generally thought that the energy / carbon benefits of energy efficient new-build facilities quickly make up for the losses incurred in the loss of existing buildings and the construction of the new facilities. New research suggests that this is not necessarily the case. Using the latest information on both embodied and operational energy, this notion has been tested using the four case studies. This section considers the various parts of the buildings that have been kept, refurbished or extended and compares the embodied energy (energy held in the materials used in the construction) and operational energy costs of the buildings as refurbished, with the equivalent figures for demolishing and completely rebuilding a similar facility. The refurbished buildings have lower embodied energy costs, but higher operational energy costs (partially as they are refurbished to older standards) and these figures are then used to show how long it takes for the annual savings in operational energy in a new build to pay for the additional embodied energy costs required for that option. At this level of brief analysis, such a comparison can only be indicative due to the myriad of variables involved. The key attitudes taken to these variables in the calculations here are described in more detail in the notes in Appendix B. A simple payback figure has been provided indicating the period by which the new-build option would ‘catch up’ with the refurbished option. From that point on, it would represent a more efficient option. However, this overlooks the fact that over the years, even new buildings are upgraded and re-refurbished. This increases the embodied energy in that option and often, since many operations are to improve energy efficiency, also reduces operational energy use. This is likely to occur to an extent with both refurbished and new-build options, but other studies suggest that the payback period lengthens when these aspects are taken into account. In other words, a more accurate account would probably lead to slightly longer payback periods in reality. What this brief study shows is that new-build options tend to pay for themselves (in terms of carbon) in the 25 to 50 year timescale, compared to a partial refurbishment option. The critical issue then, becomes the anticipated lifespan of the new-build options. Where the anticipated lifespan of a new facility is perhaps 25 to 30 years, it is clear that the newbuild option makes less sense. Where such a new-build option is being considered, it would be prudent for clients to insist both on a greater minimum lifespan (say 60 or 100 years), combined with measurable (not just predicted) low energy performance. It is important to stress that these are necessarily rough estimates; the intention here is to provide a sufficiently accurate analysis to be able to ‘get a feel’ for the relative importance of embodied energy and carbon.

Kelso Health Centre Equivalent carbon dioxide (CO2e) Assessment of energy use of the building as developed embodied energy related to new construction (tonnes CO2e) proportion of building left, refurbished or rebuilt.

operational energy over building lifetime (tonnes CO2e)

per m2

total as a one off at time of construction

per m2 per year

total per year

retained + left

200 m2

0.073

14.69

retained +refurbished

650 m2

0.150

97.50

0.059

38.19

demolished

100 m2

new build

1150 m2

0.615

707.25

0.046

52.79

804.75

105.66

Assessment of the energy use in an alternative complete New Build embodied energy related to new construction (tonnes CO2e) proportion of building left, refurbished or rebuilt.

operational energy over building lifetime (tonnes CO2e)

per m2

total as a one off at time of construction

per m2 per year

total per year

demolished

2000 m2

new build

2000 m

0.615

1230.00

0.046

91.80

1230.00

91.80

Comparison of the energy use of the refurbished building and the alternative new build (Tonnes CO2e) Extra embodied 425.25 carbon needed to construct the new build

Extra carbon needed per year to operate the refurbished building

13.86

Payback time (years taken for the savings in operational energy in the new build option to offset the additional embodied energy costs of rebuilding and hence become more energy efficient than the refurbished option) 31 Years

Kings Cross Equivalent carbon dioxide (CO2e) Assessment of energy use of the building as developed embodied energy related to new construction (tonnes CO2e) proportion of building left, refurbished or rebuilt.

operational energy over building lifetime (tonnes CO2e)

per m2

total as a one off at time of construction

per m2 per year

total per year

retained + left

0 m2

0.073

retained +refurbished

2450 m2

0.400

980.00

0.050

122.35

demolished

0 m2

new build

0 m2

0.615

0.046

980.00

122.35

Assessment of the energy use in an alternative complete New Build embodied energy related to new construction (tonnes CO2e) proportion of building left, refurbished or rebuilt.

operational energy over building lifetime (tonnes CO2e)

per m2

total as a one off at time of construction

per m2 per year

total per year

demolished

2450 m2

new build

2450 m2

0.615

1506.75

0.046

112.46

1230.00

112.46

Comparison of the energy use of the refurbished building and the alternative new build (Tonnes CO2e) 526.75 Extra embodied carbon needed to construct the new build

Extra carbon needed per year to operate the refurbished building

9.90

Galashiels Health Centre Equivalent carbon dioxide (CO2e) Assessment of energy use of the building as developed embodied energy related to new construction (tonnes CO2e) proportion of building left, refurbished or rebuilt.

operational energy over building lifetime (tonnes CO2e)

per m2

total as a one off at time of construction

per m2 per year

total per year

retained + left

300 m2

0.073

22.03

retained +refurbished

700 m2

0.200

140.00

0.059

41.13

demolished

0 m2

new build

850 m2

0.615

522.75

0.046

39.02

662.75

102.17

Assessment of the energy use in an alternative complete New Build embodied energy related to new construction (tonnes CO2e) proportion of building left, refurbished or rebuilt.

operational energy over building lifetime (tonnes CO2e)

per m2

total as a one off at time of construction

per m2 per year

total per year

demolished

1000 m2

new build

1850 m

0.615

1137.75

0.046

84.92

1230.00

84.92

Comparison of the energy use of the refurbished building and the alternative new build (Tonnes CO2e) Extra embodied 475 carbon needed to construct the new build

Extra carbon needed per year to operate the refurbished building

17.26

Chalmers Sexual Health Centre Equivalent carbon dioxide (CO2e) Assessment of energy use of the building as developed embodied energy related to new construction (tonnes CO2e) proportion of building left, refurbished or rebuilt.

operational energy over building lifetime (tonnes CO2e)

per m2

total as a one off at time of construction

per m2 per year

total per year

retained + left

200 m2

0.073

14.688

retained +refurbished

1150 m2

0.150

172.50

0.059

67.56

demolished

1200 m2

new build

2150 m2

0.615

1322.25

0.046

98.69

980.00

180.94

Assessment of the energy use in an alternative complete New Build embodied energy related to new construction (tonnes CO2e) proportion of building left, refurbished or rebuilt.

operational energy over building lifetime (tonnes CO2e)

per m2

total as a one off at time of construction

per m2 per year

total per year

demolished

2550 m2

new build

3500 m

0.615

2152.50

0.046

160.65

2152.50

160.65

Comparison of the energy use of the refurbished building and the alternative new build (Tonnes CO2e) Extra embodied 657.75 carbon needed to construct the new build

Extra carbon needed per year to operate the refurbished building

20.29

Appendix B - Calculation Notes Embodied Energy We are not aware of any studies which look specifically at embodied energy in healthcare buildings. We have used a generic figure given in a paper24 from the RICS which notes the typical embodied energy of a new-build Health Centre or Surgery at 615 kgC02e/m2, or 0.615 tonnes CO2e/m2. In the paper it is noted that the figures are gleaned from the Atkins Masterplanning tool (Atkins 2010) and indicate a spread of results mostly higher than the single point figure used. In the calculations below we have had to make a judgement on the figure to be given for refurbishment, as opposed to complete new build. This has been based on discussions with the Project Team and our understanding of the extent of new work in each case but acknowledge that this can only be indicative at this level of analysis. At Kings Cross Health Centre in Dundee, for example, the building was comprehensively stripped back to the main structure and masonry walls, so the figure input here is closer to that of a full new-build, whereas in the other three examples, the refurbishment involved largely superficial elements and services so we have used a lower figure.

Operational Energy Operational energy in buildings is used in a number of ways, to heat space, heat water and provide electricity for fixed items such as lighting and a variety of other services. For the purposes of this report, we are principally interested in space heating since that is the factor most affected by the efficiency, or inefficiency, of older or new buildings. Other energy demands are largely independent of the building age and condition. However, accurate analysis is made difficult by the variables involved. The energy efficiency of a building also affects the electrical consumption via air conditioning, ventilation and in some case direct electric heating. Another important variable is the occupancy of a building. While hospitals, for example tend to be occupied 24/7, smaller health centres tend to be open only 9-5 and so the heat demand and resulting energy figures are not readily comparable.

(below) Benchmarks for energy use

Type of Hospital

Heating (kWh/m2 per year) Typical

Good Practice

Teaching

249

215

Acute

308

296

Cottage

345

322

Long stay

332

252

Whilst there is a good deal of published information pertaining to larger hospital energy consumption, it is surprisingly difficult to elicit figures for the smaller buildings such as Primary Care Health Centres, which are the focus of this study. The table25, left gives benchmarks for annual heating demand use in hospital buildings across the UK. Using the figures given for smaller cottage hospitals we can propose that a sensible figure for new build primary healthcare buildings, assuming that they achieve a good practice level, should be around 300 kWh/m2/yr. We can further surmise that the difference between good practice and typical practice is not significant, around 20%. A typical figure for an (inefficient, older) primary healthcare building might be around 350 kWh/m2/yr. A report26 for Scottish Building Standards described the installation of cavity fill insulation into an existing 1980s-built Health Centre in Boâ&#x20AC;&#x2122;ness. The annual heating energy demand before cavity fill was 217 kWh/m2, which reduced to 187 kWh/m2 once the works were completed. At around 1,000 m2 the building is representative of the case studies in this report. A further report27 by the same authors described a Health Centre built in 2007 which was predicted to achieve an annual space heating load of

83 kWh/m2. Yet another report, as yet unpublished indicates heating demand for new build hospitals at around 100 kWh/m2. These two latter sets of figures are based on predictions, rather than real energy use figures, so may be optimistic28. A 2002 report29 specifically on Primary Care facilities by the UK Government’s Best Practice programme indicated more divergence between poor, average and good practice, see right. However, there is no breakdown between space heating and other forms of energy use so we cannot derive comparable figures from this, although they are likely to be in the region of 250 kWh/m2 for poorer performing buildings and around 100 kWh/m2 for good practice examples. In private correspondence with the Author, Consultants experienced with Health Centres indicated a typical space heating demand of around 150 kWh/m2. The information above on energy use, however, is not consistent and because of this the Author spoke directly to the Engineering and Environment Department of Health Facilities Scotland to establish some representative figures for Health Centres in use. Information gathering on Health Centres and other Primary Care facilities is in the early stages of development, so the following figures are based only on a total of nine examples. However, these provide a reasonably consistent set of figures which can be reported with some confidence. Target annual heating performance across the nine examples is around 260 kWh/m2 while actual annual heating demand varies between 237 kWh/m2 and 976 kWh/m2, with an average for the 5no Clinics of 347 kWh/m2 and for the 4no Health Centres of 471 kWh/m2.

(above) Typical energy consumption for primary health buildings30

These figures relate to Health Centres of a comparable scale and are based on real performance, not predictions. For this reason, it is proposed that we use these figures as the basis for our calculations. Picking a single representative figure for typical (existing) and good practice new-build is difficult, but we shall use 250 kWh/m2 for a good practice new-build, and 400 kWh/m2 for existing buildings. Translating the above figures into annual CO2 emissions (kg of CO2 per square metre) is done using a conversion factor of 0.1836 kgCO2/kWh assuming natural gas is used in all cases30. This gives us figures of 45.9 kgCO2/m2/yr and 73.4 kgCO2/m2/ yr respectively for good new-build and typical (existing) buildings. Combining these figures with the embodied energy figures allows us to directly compare the overall energy / carbon footprint of the decisions taken regarding demolition / refurbishment/ new build over any given period.

RICS Draft Information paper – Methodology for the calculation of embodied carbon as part of the life cycle carbon emissions for a building. Provided by Craig Jones of Sustain 25 Source: Energy Efficiency Best Practice programme: Energy Consumption Guide 72, Energy Consumption in Hospitals, 1996 26 Refer: http://www.scotland.gov.uk/Resource/Doc/217736/0091331.pdf 27 Refer: http://www.scotland.gov.uk/Resource/Doc/217736/0092656.pdf 28 Refer also section on the ‘Performance Gap’. That SBEM tends to underestimate energy use is the experience of the Author, though this opinion is supported by comments (p51) in a report “Making Existing Healthcare Buildings Sustainable” by SHINE: the Learning Network for Sustainable Healthcare Buildings, June 2010 29 Energy Efficiency Best Practice Programme, GIL 62 Reducing Energy Consumption in Primary Care Buildings – Guidance for Estate Managers, 2002 30 from Carbon Trust Fact Sheet:’Conversion Factors 2011 Update’ and is based on data published by DEFRA / DECC 2011 24

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