A pioneering cancer treatment centre in Manchester saw international architects HKS harnessing high-tech methods for attacking tumours using proton beams, while providing a human-centred facility. James Parker reports
Proton beam therapy is an advanced and highly precise form of radiotherapy that fires protons at tumours, rather than the more established method of using x-rays. Like more traditional methods however, proton beams contain high amounts of radiation, but are precisely targeted at tumours and dissipate on contact. This means they are less likely to harm healthy tissue nearby, making the therapy particularly helpful in treating complex cancer cases such as in the brain and spinal cord, and in children for whom damaging growing tissue can cause side-effects in later life. This technology has been developed over recent decades for use in cancer facilities, with a few small privately run centres having been opened in the UK.
However it is only recently that the first large ‘high energy’ NHS proton beam therapy centre has been completed, at The Christie NHS Foundation Trust, Manchester, a specialist NHS cancer treatment centre.
The NHS decided around a decade ago to fund two proton beam centres, at a cost of £125m each, and The Christie teamed up with Central Manchester University Hospitals NHS Foundation Trust and Salford Royal NHS Foundation Trust to bring one to Manchester. Compared with the UK’s other facility, buried deep underground on a site at University College London Hospitals NHS Foundation Trust (UCLH), The Christie – relatively speaking – offers a straightforward built result. However behind the scenes, the building by architects HKS provides a carefully-wrought mix of high-tech and an intense focus on alleviating the rigours of undergoing cancer treatment for users, by providing a high quality environment. The architects’ relationship with the NHS’ proton beam programme extends back to 2010, and a feasibility study undertaken for Birmingham University Hospital, before the strategic decision was taken to fund two centres in the capital and Manchester instead.
The Christie Hospital wanted a facility that would be as supportive and empowering as possible for its adult, teenage and paediatric patients, who have to undergo a daunting and lengthy process. Proton beam therapy uses a large ‘cyclotron’ particle accelerator to generate the protons, which needs to be shielded in concrete – at 6 metres thick at its widest point in this facility, with 2 metre walls common. There are three ‘gantries’ positioned to the rear of the unit in a concrete bunker. These can rotate through 360 degrees to target the beam precisely at a predefined spot before the patient arrives (to lie immobilised on a static ‘robot arm’), the gantries’ structure extending a full three stories.
Procurement & briefing
As a result of this being a necessarily technology-led facility, the genesis of this project was equipment vendors expressing interest via an OJEU (Official Journal of the European Union) advert in autumn 2013. “There weren’t many vendors back then who had actually delivered these facilities,” says project architect Franko Covington. The winning firm was Varian, who have worked with The Christie in traditional radiotherapy rooms – and with the architects at the satellite radiotherapy unit the practice designed for Salford Royal Infirmary NHS Foundation Trust. HKS came on board with Design & Build contractor Interserve as part of the NHS Procure 21+ procurement framework used for the project, which offers the benefit of cost savings from using preferred suppliers. Interserve also had an ongoing relationship with The Christie, having built a brachytherapy and teenage and young adult unit on the site, a key driver for the architects to sign up with them. Covington adds: “they chose us because we were the only UK practice that had done proton beam internationally.” The practice visited units in the States as part of its research, however the set up here was going to be somewhat different. Unlike privately-run units, which are designed to throughput patients as quickly as possible while maintaining efficacy of treatment, this unit was designed to prioritise the needs of patients before, after and during treatment, with less pressure placed on maximising revenue. Covington explains the differences: “Private units have lots of patient prep spaces outside each treatment room, so that one patient can be prepped while another is being treated.” Here, as a result of the patients being prepared in the treatment room, space is freed up outside, and at The Christie the architects were able to provide more space for paediatric recovery. It also meant that on a site with a fairly constrained footprint, scanning functions could be on the same level as the treatment rooms, maximising convenience for patients and staff – who verify exactly where a tumour is, or how it’s reacting to treatment. This was particularly relevant given that proton beam therapy often requires patients to attend sessions for five days a week, over a six to eight week period.
Design theme
The outline business case for the project included a design developed by Scott Tallon Walker who also designed the UCLH proton beam therapy facility under construction in London. The contrasting concept developed by HKS, inspired by vegetation to the south-west facing front of the site, divided the building into three themes horizontally. These were ‘nature’ for the front, more public portion, ‘human care’ for what Covington describes as the “semi-private” ancillary and consulting spaces to the centre, and ‘science’ for the rear of the building, where the treatment gantries (and a proton beam research room) are located. Supported by the clinicians, this concept would extend through to finishes and artwork. Covington explains: “We pushed waiting space to the front – that allows us to have all our public functions on one side, and gets more and more private as you get closer to the treatment bunker.” The overarching benefit of this strategy was the creation of generous, daylit waiting spaces on the front facade, including a large double-height volume on the first and second floors.
Outpatients
The client also wanted to maximise use of the site beyond proton beam therapy however, as the addition is “quite a chunk,” says Covington, “and planning stipulated we could only go up to five stories.” He adds: “The proton beam element would only take up two or three stories, so we had to think about how else to use the site.” He says that from the outset it was clear The Christie wished to bring their outpatients function into the new building, and that was “a big challenge, because outpatients receives significantly greater volume than proton beam.” (Outpatients sees around 40,000 patients per year, versus around 650 patients for proton beam therapy). As a result, the entire ground floor is given over to outpatients, except for a separate front door and reception for proton beam patients – leading to an information area and glazed meeting room – as well as the main stair and lift up to the first floor waiting area. For outpatients, there is a link to the main hospital to the rear of the unit, which “maximises that connection,” says the architect, “a well-lit, really wide link corridor that ties back to the hospital street and dining room, which is used by outpatients and staff.” Outpatients provision is dramatically improved, with rooms now all HBN compliant when some had previously been very cramped. The architects also redesigned existing outpatients space to provide a more suitable area for the service, with the overall provision essentially doubling in size. As one side of the building sits along the concrete bunker, access to natural daylight is limited, therefore all consultant and waiting spaces are grouped around the external glazed walls opposite. More private outpatient exam rooms are located to the centre of the building.
Proton beam levels
The layout is efficient for staff but also straightforward for proton beam patients. After ascending from the separate entrance, they come into the main reception on the first floor (the main treatment level), and turn left for the adult and teenage waiting space, or right for paediatrics – which takes up roughly two-thirds of the support spaces on this level. “The clinical flows are all very discreet, from anaesthetic to recovery,” says Covington, and the concise plan makes them as short as possible. The layout was informed by the need for safeguarding children through separate clinical flows from adult patients (in addition to their distinct clinical needs such as for anaesthetics and recovery). Adults have a fully-glazed, double-height space, which “took cues from Maggie’s Centres,” in terms of not only its spatial quality, but the amenities on offer to provide a few home comforts. “They’ll be here every day for weeks, so we provided a little kitchen area to give a bit of a domestic feel. Also we wanted it to be social so they can share their experiences with other patients, because they’ll see the same faces.” There is an artificial tree in a planter – as a result of infection control requirements for immune-compromised patients – attractive ‘natural’ bent timber seating, and a large geometric artwork by Acrylicize suspended from the ceiling, promoting the nature theme by resembling a tree canopy, as well as providing acoustic benefits. Perforated external aluminium vertical fins help to add to the tree canopy effect, dappling light into the space, while ameliorating solar gain.
Teenagers have their own waiting area here, designed with advice from the Teenager Cancer Trust, with a teen-friendly sofa plus TV and gaming consoles. “They have space to hang out and be teenagers, it’s nice they have the ability to retreat somewhere,” says Covington. Also on this level are control rooms for the proton beam equipment, including a full time base for Varian staff to monitor the gantries and particle accelerator, as well as a control room for treatment spaces that’s run by clinical staff. Level 2 is ‘pretreatment’ – including rooms where patients are interviewed and examined a few days before treatment, or where bloods may be taken – here is also a mezzanine overlooking the main waiting space. There’s a similar layout to level 1 in terms of adult/paediatric waiting, and off the latter is a landscaped external play courtyard, featuring light-reflecting porcelain tiles, and timber seating. Covington says that the courtyard had to start at level 2 rather than the level below “because so much support space was needed there,” however it has the benefit of shorter walls as a result. With levels 2 and 3 mainly containing office/admin, it brings valuable natural daylight into middle of the floor plan to benefit staff wellness. The main treatment planning space, comprising around 20 workstations, is located here – where staff can ‘model’ tumours and decide how to treat them, plus physics and oncologists’ offices. “Clinical staff really like it because there’s natural daylight into all office spaces,” says Covington. There’s also a small terrace where adult patients can get some air, its access separate from the paediatric area. Where not given over to air handling rooms and power rooms sitting above the proton beam gantries, space on Level 3 houses a range of office accommodation. There are also multi-disciplinary meeting rooms which function as lecture halls, set up for visiting oncologists and radiation specialists, who can link audio/visually to universities and help further knowledge of proton beam and its future uses in healthcare. Level 4 is currently shell space, but has been specified for future inpatient use when the client requires. In terms of artwork, the architects designed nature-themed elements such as kitchen splashbacks and tree-themed vinyl backprinted glass in lift lobbies – which change from trunk to branches as users ascend the levels. The glass interview rooms are fritted with geometric patterns which play off the sculpture in the main waiting area. For paediatrics, the client commissioned lively jungle-themed murals, including a ‘Proton Panda’ character who clinicians encourage children to spot.
Exterior & structural
The project was specified to a tight budget, partly due to the Procure21+ strictures, and local suppliers and “standard yet robust” components were used wherever possible. The exterior is relatively sober, with a champagne-coloured anodised aluminium rainscreen, breaking up the darker cladding of adjacent buildings. However the high-tech nature of the building is signalled by a continuation of The Christie’s language of LED strips at high level, and to the rear the concrete slab at ground level is glazed and enhanced with the geometric graphics, and backlit. A key structural challenge was presented to Arup to ensure that radiation does not leak out as the proton beam is pushed down a vacuum pipe from the linear accelerator, and guided using electromagnets to each gantry. This pipe extends to a fourth room with a fixed beam which will be used for research into future use of the technology.
This meant that the individual pours making up the immense volumes of concrete in this building needed to be carefully sequenced, so they interlocked seamlessly in order to protect spaces outside. Covington explains: “Each pour needed to key in to the next so that you didn’t have joints in a straight line offering a path. The radiation can find the smallest cracks.” The whole project was modelled in 3D, “down to the light switches.” BIM (using Revit) was also essential to coordination, “especially when we had three vendors,” says Covington. “We had four structural models – one for each of the gantries then another one for the rest of the building, plus six M&E models and four architectural models.”
Conclusion
Funding for the research room had to come from donations, but luckily the client is “very successful” in this area, says Covington, however the efforts made to deliver this speak of the collaborative and engaged approach that characterises this project. For example, the project team climbed Kilimanjaro in 2017 (including Franko and HKS colleagues, plus members of The Christie Hospital’s project team, and several staff from Arup), raising an impressive £50K.
This is just one example of the unprecedented contribution this project makes to UK healthcare, in terms of the high-tech treatment benefits, but also the way it treats patients as people first and foremost. The project’s final testimony is the patients’ reaction – a 10 year old boy who attended with his mum and liked it so much that he wanted to bring his dad back with him the next time.
PROJECT FACTFILE
- Client: The Christie NHS Foundation Trust
- Architect: HKS
- Structural engineer: Arup
- Proton beam vendor: Varian
- Floor area: 133,000 ft2
- Start on site: 2015
- Opened: April 2018