"Hidden risks" in legacy buildings
This article was first published in Health Estate, September 2016
Facilities management is typically an integral part of a PFI agreement, with a new hospital’s Trust typically using the PFI partner’s facilities management company for all the buildings and grounds maintenance. The Trust is also usually bound to use the PFI non-clinical services company for services such as cleaning, catering, laundry and linen, car parking, security, switchboard services and portering.
The lowest bidder will almost inevitably have won the PFI contract, and for the PFI to make it work that means that FM services must be planned and delivered efficiently and cost effectively. You do not need to dig too deeply in the news to find examples of failures in hotel and cleaning services. Shortfalls in delivering essential air and water services are thankfully rare; but again delivering safe facilities to budget in these areas is certainly helped by having brand new infrastructure and, presumably, access to accurate records of every fixture and fitting – the reliable schematic asset register that is so often missing in older buildings.
In contrast, older buildings still being used for outpatient services or by partnership trusts are likely to have a legacy of historical black holes in the records, and the PFI’s facilities management arms often decline to bid contracts to deliver services in them. It is not just a simple case of cherry picking: their processes and infrastructure are not geared to these jobs. Authorising engineers and designated persons within Trust’s estates and facilities management team may find little understanding at board level of the complexity, workload and, yes, costs involved in keeping older premises safe.
Take Legionella, which is for most people’s a very high priority and fear. While newer buildings may have the advantage of zoned water systems and built-in flushing valves, systems in older buildings are often mysteries even to the people who manage them. There will be a history of refurbishments and minor works such that no-one really knows the system, or could locate every pipe, outlet and potential risk area. More worryingly, equipment may be found to be unfit for purpose or obsolete so that repairs and maintenance are difficult. Authorising Engineers will already have this on their agenda, but Trusts may not be prepared for the financial implications.
A typical example similar to real life situations we have experienced would be some 1000 TMVs in an older building that’s almost next door to the brand new general hospital with its enviable facilities, but a world apart. It has the legacy that typically comes from decades of organic change in use of different parts of the building.
In such an example a large proportion of the TMVs (thermostatic mixing valves) may be either so old no one knew their make or part number or, if they are identified, then the service kits are costing three times that of a modern value. In the medium to long term, it can be cheaper to replace them even if they are still working. Servicing intervals and procedures for TMVs are well documented and ultimately carry the regulatory requirements of ACOP L8 and HTM04 -01. A rolling programme of replacement will eventually deliver savings, but replacements are heavily loaded with upfront costs to cover the capital cost and the essential regime of pre and post-commission testing. It is often a hard sell to stakeholders.
Adding to the FM team’s workload is debate about where responsibility for these older properties lies: a Metal Health Partnership Trust using the building? The Hospital Trust leasing it to them?
For me the answer is simple: the buck stops with the people delivering the care and just ticking over and doing the minimum towards compliance will not suffice and will not manage the risk. For the Trust E&FM team, a few outbuildings can prove more time consuming than the PFI hospital that is the jewel in the crown.
If there are infrastructure issues that cannot be addressed by inspection and cleaning, they need to be identified and a remediation strategy put in place, and a budget negotiated. The work involved in specifying and replacing the best part of 1000 TMVs, for instance, is almost certainly not in a client’s original plans when they began delivering outpatients health services from the building – they’d originally expected tenders for operational servicing, not advice for capital replacements.
This is hopefully an extreme example, and the buildings usually have a long enough foreseeable working life to justify the costs. There may be older buildings that are effectively in run-off as Trusts optimise the way services are delivered. They may be converted to flats long before the useful life of any new equipment that was to be installed would have delivered a return on investment or passed its useful lifespan. So there is a clear incentive to avoid capital expenditure, and managing such facilities need special care, planning and realistic costing. These requirements often come as a shock.
Health Technical Memoranda cut no slack! The way to avoid emergency remedial work through good management comes down to the usual mantra: a schematic asset register is the foundation of good risk management and auditing. It is, after all, a legal requirement to have it and it means that investigative trace-and-access work is done and documented ahead of any emergency or positive test result. That would enable water treatment professionals to confirm the cause of any infection and where it might have spread to more quickly and cost effectively.
Positive danger
It has been our experience that older buildings do return a higher proportion of Legionella positive results, a trend that can quickly be reversed when the infrastructure and prevention regime is reviewed. While the buildings may be used for outpatients’ clinics, the outcome will still mean both major disruption and significant expenditure. Another common Achilles heel is hidden – literally – in the ventilation systems. There are rarely enough inspection hatches, just about every different type of fire damper will have been installed at some stage over the years, and it is extremely doubtful that there will be a central record.
Indeed, while Legionella grabs the headlines ventilation systems are also a key concern in older buildings. While there may not be a need to meet the extreme conditions required in treatment areas and operating theatres, old ventilation equipment could be a major challenge. You do not even need to do anything wrong, just failing to keep the right inspection and maintenance records can set alarm bells ringing and trigger emergency measures and costly closures.
Shutting down operational areas a building is a major logistical exercise and expensive in itself, before you even factor in the cost of remedial work. The recent doctors’ strikes have been a sobering reminder of how treatment paths fall down like a row of dominoes if appointments are missed, and the IT systems simply aren’t able to reshuffle them and get every patient back on track. Heads might roll in the estates department if an outpatients clinic in an old block is closed!
Even though a Legionella positive result, for instance, does not always mean that immediate shut down is essential, there is never going to be much time for delay; and institutional checks and balances make it difficult to authorise significant expenditure quickly enough, especially if these buildings have not been kept front of mind. There may simply be no time for competitive tendering or normal due process. It is the finance director’s nightmare – especially if there are still questions about where the responsibility lies – ‘landlord’ or ’tenant’. Better financial and legal minds than mine are unravelling that, but I still have no doubt that it the organisation delivering the healthcare services that has the immediate responsibility to act. Who pays further down the line is another matter.
A good head start on remediation is having the schematic and asset register in place and I would urge any organisation operating in older premises to challenge their estates manager on the accuracy of theirs. Even where risk assessments are thought to be in place, their inadequacy can be quite surprising, and that in turn can usually be traced to lack of understanding of the assets and infrastructure. Yet it is a key requirement of the guidance, which has de facto legal status that risk assessments should be carried out by competent persons, so it is even more surprising that good risk assessments are nowhere near ubiquitous.
The requirement for detailed schematics , and other requirements for risk assessment are laid out quite clearly in the UK’s Health and Safety Executives (HSE) Approved Code of Practice and Guidance (ACOP) "Legionnaires' disease: Control of legionella bacteria in water systems" (L8) .
For healthcare estates, there is an additional requirement to adhere to the relevant Health Technical Memorandum (HTM). HTM 04-01 or to give it its full title “Health Technical Memorandum 04-01: The control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems”. It goes beyond the requirements of ACOP L8 in a number of areas. One example is the treatment of water outlets that are not in regular use, which are likely to be more prevalent in older buildings that have seen many changes in use over the years.
British Standard BS 8580:2010 Water quality – Risk assessments for Legionella control – Code of practice clearly lays out the best practice for risk assessments, but takes the form of guidance and recommendations rather than being a definitive specification. It is down to the healthcare provider and their chosen advisers to get it right.
There cannot be comprehensive assessment of the risks if there is not a comprehensive asset register to identify potential problems. This is especially important with so many trusts now preferring to manage routine work internally. It is a logical approach that offers significant cost savings but these will quickly be wiped out if the regime fails to address the risks and there is an outbreak.
Yes, it may uncover the need for unexpected works; more often than not grasping the nettle and commissioning a survey avoids them. Above all it avoids the biggest expense of all- that of dealing with emergency remediation.
The lowest bidder will almost inevitably have won the PFI contract, and for the PFI to make it work that means that FM services must be planned and delivered efficiently and cost effectively. You do not need to dig too deeply in the news to find examples of failures in hotel and cleaning services. Shortfalls in delivering essential air and water services are thankfully rare; but again delivering safe facilities to budget in these areas is certainly helped by having brand new infrastructure and, presumably, access to accurate records of every fixture and fitting – the reliable schematic asset register that is so often missing in older buildings.
In contrast, older buildings still being used for outpatient services or by partnership trusts are likely to have a legacy of historical black holes in the records, and the PFI’s facilities management arms often decline to bid contracts to deliver services in them. It is not just a simple case of cherry picking: their processes and infrastructure are not geared to these jobs. Authorising engineers and designated persons within Trust’s estates and facilities management team may find little understanding at board level of the complexity, workload and, yes, costs involved in keeping older premises safe.
Take Legionella, which is for most people’s a very high priority and fear. While newer buildings may have the advantage of zoned water systems and built-in flushing valves, systems in older buildings are often mysteries even to the people who manage them. There will be a history of refurbishments and minor works such that no-one really knows the system, or could locate every pipe, outlet and potential risk area. More worryingly, equipment may be found to be unfit for purpose or obsolete so that repairs and maintenance are difficult. Authorising Engineers will already have this on their agenda, but Trusts may not be prepared for the financial implications.
A typical example similar to real life situations we have experienced would be some 1000 TMVs in an older building that’s almost next door to the brand new general hospital with its enviable facilities, but a world apart. It has the legacy that typically comes from decades of organic change in use of different parts of the building.
In such an example a large proportion of the TMVs (thermostatic mixing valves) may be either so old no one knew their make or part number or, if they are identified, then the service kits are costing three times that of a modern value. In the medium to long term, it can be cheaper to replace them even if they are still working. Servicing intervals and procedures for TMVs are well documented and ultimately carry the regulatory requirements of ACOP L8 and HTM04 -01. A rolling programme of replacement will eventually deliver savings, but replacements are heavily loaded with upfront costs to cover the capital cost and the essential regime of pre and post-commission testing. It is often a hard sell to stakeholders.
Adding to the FM team’s workload is debate about where responsibility for these older properties lies: a Metal Health Partnership Trust using the building? The Hospital Trust leasing it to them?
For me the answer is simple: the buck stops with the people delivering the care and just ticking over and doing the minimum towards compliance will not suffice and will not manage the risk. For the Trust E&FM team, a few outbuildings can prove more time consuming than the PFI hospital that is the jewel in the crown.
If there are infrastructure issues that cannot be addressed by inspection and cleaning, they need to be identified and a remediation strategy put in place, and a budget negotiated. The work involved in specifying and replacing the best part of 1000 TMVs, for instance, is almost certainly not in a client’s original plans when they began delivering outpatients health services from the building – they’d originally expected tenders for operational servicing, not advice for capital replacements.
This is hopefully an extreme example, and the buildings usually have a long enough foreseeable working life to justify the costs. There may be older buildings that are effectively in run-off as Trusts optimise the way services are delivered. They may be converted to flats long before the useful life of any new equipment that was to be installed would have delivered a return on investment or passed its useful lifespan. So there is a clear incentive to avoid capital expenditure, and managing such facilities need special care, planning and realistic costing. These requirements often come as a shock.
Health Technical Memoranda cut no slack! The way to avoid emergency remedial work through good management comes down to the usual mantra: a schematic asset register is the foundation of good risk management and auditing. It is, after all, a legal requirement to have it and it means that investigative trace-and-access work is done and documented ahead of any emergency or positive test result. That would enable water treatment professionals to confirm the cause of any infection and where it might have spread to more quickly and cost effectively.
Positive danger
It has been our experience that older buildings do return a higher proportion of Legionella positive results, a trend that can quickly be reversed when the infrastructure and prevention regime is reviewed. While the buildings may be used for outpatients’ clinics, the outcome will still mean both major disruption and significant expenditure. Another common Achilles heel is hidden – literally – in the ventilation systems. There are rarely enough inspection hatches, just about every different type of fire damper will have been installed at some stage over the years, and it is extremely doubtful that there will be a central record.
Indeed, while Legionella grabs the headlines ventilation systems are also a key concern in older buildings. While there may not be a need to meet the extreme conditions required in treatment areas and operating theatres, old ventilation equipment could be a major challenge. You do not even need to do anything wrong, just failing to keep the right inspection and maintenance records can set alarm bells ringing and trigger emergency measures and costly closures.
Shutting down operational areas a building is a major logistical exercise and expensive in itself, before you even factor in the cost of remedial work. The recent doctors’ strikes have been a sobering reminder of how treatment paths fall down like a row of dominoes if appointments are missed, and the IT systems simply aren’t able to reshuffle them and get every patient back on track. Heads might roll in the estates department if an outpatients clinic in an old block is closed!
Even though a Legionella positive result, for instance, does not always mean that immediate shut down is essential, there is never going to be much time for delay; and institutional checks and balances make it difficult to authorise significant expenditure quickly enough, especially if these buildings have not been kept front of mind. There may simply be no time for competitive tendering or normal due process. It is the finance director’s nightmare – especially if there are still questions about where the responsibility lies – ‘landlord’ or ’tenant’. Better financial and legal minds than mine are unravelling that, but I still have no doubt that it the organisation delivering the healthcare services that has the immediate responsibility to act. Who pays further down the line is another matter.
A good head start on remediation is having the schematic and asset register in place and I would urge any organisation operating in older premises to challenge their estates manager on the accuracy of theirs. Even where risk assessments are thought to be in place, their inadequacy can be quite surprising, and that in turn can usually be traced to lack of understanding of the assets and infrastructure. Yet it is a key requirement of the guidance, which has de facto legal status that risk assessments should be carried out by competent persons, so it is even more surprising that good risk assessments are nowhere near ubiquitous.
The requirement for detailed schematics , and other requirements for risk assessment are laid out quite clearly in the UK’s Health and Safety Executives (HSE) Approved Code of Practice and Guidance (ACOP) "Legionnaires' disease: Control of legionella bacteria in water systems" (L8) .
For healthcare estates, there is an additional requirement to adhere to the relevant Health Technical Memorandum (HTM). HTM 04-01 or to give it its full title “Health Technical Memorandum 04-01: The control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems”. It goes beyond the requirements of ACOP L8 in a number of areas. One example is the treatment of water outlets that are not in regular use, which are likely to be more prevalent in older buildings that have seen many changes in use over the years.
British Standard BS 8580:2010 Water quality – Risk assessments for Legionella control – Code of practice clearly lays out the best practice for risk assessments, but takes the form of guidance and recommendations rather than being a definitive specification. It is down to the healthcare provider and their chosen advisers to get it right.
There cannot be comprehensive assessment of the risks if there is not a comprehensive asset register to identify potential problems. This is especially important with so many trusts now preferring to manage routine work internally. It is a logical approach that offers significant cost savings but these will quickly be wiped out if the regime fails to address the risks and there is an outbreak.
Yes, it may uncover the need for unexpected works; more often than not grasping the nettle and commissioning a survey avoids them. Above all it avoids the biggest expense of all- that of dealing with emergency remediation.