health & science

Dunedin: new hospital puts many balls in air

In the second of two pieces about the renewal of Dunedin, David Williams examines a single construction project that will force change across a city.

Dunedin’s hospital, north of the Octagon towards the university, has been substandard for years – parts of it for decades.

A hodgepodge of old buildings crammed onto a limited site throws up predictable problems of poor design and bad layout. But those issues are compounded by leaks, asbestos scares and a spiral of health board cost-cutting, including maintenance spending, brought on by years of rising deficits.

Hospital staff – there are about 3000 – have been frustrated and demoralised by the neglect. Trainee doctors have been warned by unions to stay away. The hospital lost accreditation for intensive care training and radiology services, the latter of which remains operational but means it can’t access ACC revenue.

All this increases risks to patients. The emergency department has missed waiting times targets, and the wait for some scans has extended for months. The board had to apologise to a Mataura man who lost sight in his right eye while waiting for follow-up appointments.

In opposition, Labour MP David Clark – now the Health Minister – described Dunedin Hospital to the Otago Daily Times as being in a “Third-World state”. The much-talked-about and much-needed hospital rebuild, like building maintenance, seemed to be on the back-burner.

As the projected deficit soared to $42 million, the axe fell. Board chairman Joe Butterfield was replaced in 2015 and, later that year, the board was sacked and commissioners installed.

In late 2016, an assessment of the hospital for ministers was a turning point. It found four Dunedin Hospital buildings were uneconomic to repair. The “crumbling” facilities placed the board in a “position of considerable clinical, financial and organisational risk”. That made a $300 million placeholder figure wholly inadequate and the chance of the hospital remaining on its existing site seemed slim.

In August last year, with a general election looming, the Bill English-led Government announced a $1.2-to-$1.4 billion rebuild for the hospital – “the largest hospital build in New Zealand” – to be completed in February 2027. Days later, Labour leader Jacinda Ardern raised the stakes by promising a new hospital would be built in the centre of Dunedin in a Labour Government’s first term – without private money. Building would start in its first term, she promised.

Ardern formed a Government and, in May of this year, it was announced most of the new hospital would be built across two central city blocks, including the old Cadbury factory site (for which the Government reportedly paid $11.6 million) and a block containing a Wilson Parking carpark.

Four Dunedin Hospital buildings are so run-down they’re uneconomic to repair. Photo: Southern DHB

Late last year, Health Minister David Clark, whose office didn’t respond to Newsroom’s interview request, sacked the Southern Partnership Group chair, Andrew Blair, and replaced him with former Labour Health Minister Pete Hodgson. Clark and Hodgson then set up a local advisory group to get the councils, NZ Transport Agency and Ngāi Tahu (represented by Potiki) informed and involved. It’s been well-received.

Hodgson says when he was appointed the project was dysfunctional. The committee overseeing the project was mainly meeting in Wellington and Dunedin people were skeptical it would happen. These days, he says, “I’m pushing against an open door”.

Excerpts from Clark’s briefings on the hospital rebuild, released to Newsroom under the Official Information Act, show the new Government’s criteria for the new hospital site factored in Ardern’s promise. The criteria were proximity to the existing hospital and university, speed of acquisition, and that construction could start by September 2020.

Dunedin-based National Party list MP Michael Woodhouse accuses Clark of wanting a self-serving photo opportunity. Woodhouse, a former boss of Dunedin’s Mercy Hospital, also says the new Government has been “black box” by not releasing minutes of Southern Partnership Group meetings since May. (Newsroom raised this with Hodgson, twice, but no more minutes have been made public.)

Woodhouse: “Ultimately the taxpayer is being asked to fork out an eye-watering amount of money for this, and therefore the taxpayer needs to know that they’re getting the right product or service and they need progress reports, right from now.”

Hodgson retorts: “There are plenty of people who have asked me for briefings and I haven’t declined anyone. Michael hasn’t bothered to ring me.” (That’s something Woodhouse said he’d do in the parliamentary recess.)

Dunedin Hospital’s entrance on Great King St. Photo: David Williams

From a ubiquitous meeting room in Dunedin Hospital, accessed via a zig-zag of corridors and up a grand old staircase, Southern District Health Board chief executive Chris Fleming surveys his crumbling empire.

Various buildings, including the clinical services building, children’s pavilion, psychiatric services and the Fraser Building, are visible from the window. You have to crane your neck to see the top of the 10-storey ward block. To rub salt in the hospital’s land-locked wound, across Cumberland St are two Otago University halls of residence, Cumberland and Hayward Colleges, in buildings formerly owned by the health board.

The original Dunedin Hospital upgrade plan was to rebuild the clinical services building – which houses the emergency department, radiology and surgical theatres – somewhere else on the site. “If you can’t demolish it, because there’s people in it now, where would you put it? There’s not much room,” Fleming says.

Upgrades at such an old hospital require creative solutions. Stage one of the intensive care unit (ICU) redevelopment, on the fifth floor of the ward block, was officially “opened” last week – although patients won’t be treated there until early December. Fleming says thousands of holes needed to be drilled into the concrete slab above, because the gap between floors isn’t as big as a modern building’s would be. The drilling sent vibrations into the sixth floor, where psychogeriatric patients were. “If you’re aged and confused, and everything starts vibrating and being very noisy, it’s just not right,” Fleming says.

The $14.8 million ICU project, with bigger bed spaces, clear sightlines and central monitoring systems, is a taste of what’s to come in the new hospital. Once finished, the high-dependency unit will be next-door, instead of on the floor below. (In another inefficient quirk, the medical assessment unit is on the seventh floor of the ward block, while the emergency department is on the ground floor. They should be adjacent.)

Fleming: “I’m really delighted after listening to the implications of disruption just for the ICU development that we’re not trying to rebuild and re-purpose on the existing site. Because it would be chaotic and the clinical risk would be significantly increased if we tried to continue to provide clinical services on that site, whilst at the same time doing major redevelopment.”

(University of Otago chief operating officer Stephen Willis says the rebuild is incredibly important for recruiting high-calibre staff. “Some are employed by the university and the hospital because they want to retain and develop their skills in both spheres.”)

The oncology department – in the hospital’s newest building, opened in 1993 – will stay at the existing site until new radiation machines, called linear accelerators, are needed. With about 15 patients a week going from the ward block to the oncology building, that makes the position of the new acute block on the new site important, considering some very sick people needing radiotherapy need to get there.

There are also questions about the future location for mental health services, the majority of which are some four kilometres away at Wakari Hospital, in Halfway Bush. The board’s yet to complete a mental health business case, to decide which services, if any, might be added to the new hospital site later.

“In terms of maintaining a hospital of this size, there’s tens of millions of dollars that will need to be spent on Dunedin Hospital to keep it running.” – Chris Fleming

Fleming says the Southern Partnership Group – the Government-appointed body overseeing the hospital project which Hodgson now chairs – is listening. He’s happy with the progress on the new hospital to date. His biggest headache, however, is how to keep the existing buildings operating until the new hospital’s ready.

“It is a tough thing. For every dollar you put into these buildings now you know you’ve got a very limited time life for the utilisation of that.”

How much are we talking? Fleming: “In terms of maintaining a hospital of this size, there’s tens of millions of dollars that will need to be spent on Dunedin Hospital to keep it running.” (Right now, the board’s working on a business case for $20 million of additional funding for what Fleming calls “behind the scenes critical infrastructure”.)

And sometimes redevelopments don’t work. Consider the $2 million Southern DHB spent on a new air-handling system beneath the asbestos-contaminated ceiling in the radiology department.

A hospital source tells Newsroom: “They’ve put in a huge number of heat pumps, 50-something heat pumps, which has obviously cost a fortune, but for some reason they can’t regulate the temperature.” It’s either too hot or too cold, they say.

Leaks have been an ongoing problem. For a while, patients had to walk around a bucket in the radiology reception area. An internal spouting system has been installed in one part of the department, to catch the dripping water. Our source says: “It’s really, really bad working conditions at the moment.”

Are there still leaks? Fleming says the critical leaks have been addressed, but it would be wrong of him to say there’ll never be leaks in the hospital’s out-of-date buildings. “In any building of this age, there will always be challenges.”

He adds: “I’ve got a lot of admiration for staff that are working at Dunedin Hospital.”

Deborah Powell, national secretary for the Resident Doctors’ Association, says the old hospital is a “nightmare” to work in. It is just too old to be fit for purpose, she says, which leads to health and safety risks. She also says oncology management and staff aren’t happy with being left as a stand-alone department on a separate site.

Pete Hodgson is Health Minister David Clark's eyes and ears

for the Dunedin Hospital rebuild. Photo: David Williams

Basically, former health minister Hodgson’s role, heading the Southern Partnership Group, is to act as a go-between for the Ministry of Health, which is building the new hospital, and the Southern DHB, which will run it. He also tells people involved in the hospital to get a wriggle on, agitating for progress, and then gives ministers – of health and finance – a frank assessment of how it’s going.

“It feels okay,” Hodgson says of the spades in the ground by 2020 goal. “There are a lot of balls in the air and you don’t touch one without it sort of ricocheting on others. It is quite a complex thing but it feels okay. It feels as if we’ve got momentum building satisfactorily.”

He adds: “Whenever I’m talking to David Clark, he asks the same question and he’s getting that answer.”

Some of those balls in the air include the number of buildings – “four or five”, Hodgson says. At the moment, that’s a large inpatients’ building, a “medium” outpatients block, an energy centre, an administration block and an inter-professional learning centre, shared with the university and polytechnic, which might become a floor of the admin block. (The hospital is likely to be lifted a metre or so above street level, “due to hydrology and projecting forward on climate change scenarios”, Hodgson says. That makes it likely “a lot” of carparking will be built under the inpatients’ building.)

Another outstanding question is whether the largest building will be on the northern Wilson block or the southern Cadbury block. It was initially thought north but “the preponderance of viewpoint has shifted”, Hodgson says. Questions have recently emerged about the underlying geology of the Wilson site, which has caused delays in site planning and, ultimately, could prove costly. And now there’s consideration about whether to stage the development – “we are actively exploring whether it’s sensible”.

All the while, the “functional brief” – how all the hospital departments will fit into the new buildings – is expanding and contracting. There’s a continual effort at what Hodgson calls value management – “which is a euphemism for shrinking the thing a bit”.

“The whole shebang is in the order of 100,000 square metres,” Hodgson says. “It’s probably gone up to 106,000sqm. If it has, we’ll need to bring it back a little.” (The existing hospital is about 89,000sqm.)

Hodgson’s still sticking to a March deadline to provide the Government with what he calls an “investment-ready business case” for the new hospital and an opening date – which seems exceedingly ambitious – of July 22, 2026.

Where did that date come from? Hodgson explains he found it in “one of the many umpteen friggin’ Gantt charts that I’ve seen” about 18 months ago. The problem is “we’ve not made 18 months’ progress in the last 18 months”. He has since interviewed the chart’s writer who said he included the date “under duress” – that he was told to include the date but wasn’t comfortable with it. “He’s starting to walk away from his own July 2026 programme, but I’m not. I’m happy to go on the record as saying I want to keep it there.”

As sure as night follows day, big, technical construction projects take longer than expected. The hospital’s detailed business case was delayed. Master site planning – figuring out where everything’s going to go – is behind schedule. The Health Ministry is holding back on formal requests from architecture firms until that work’s done. The Public Works Act hasn’t yet been invoked for the Wilson site, which has eight owners. That’s not to mention the possible delays if the development is staged.

“Why do you bring an elderly person into the middle of town when they could have a geriatric clinic in the community health hub in South Dunedin, or in Balclutha?” – Chris Fleming

Staging the new hospital could actually be a god-send for the Southern DHB.

Right now, some day surgery doesn’t happen in day surgical theatres because they’re substandard. Instead of building temporary facilities – a worst-case scenario – Fleming would prefer to run day surgery from the newly built outpatients building, what he calls the ambulatory building, the smaller of the two main buildings in the new hospital. (Hodgson confirms it’s possible that building will have theatres.)

“If things can move out of Dunedin Hospital sooner rather than at the end of the completion of the new build, that frees up space,” Fleming says. “If we can have that ambulatory building, or even part of the ambulatory building, as long as it includes day surgery, then that takes some blocks out of existing Dunedin Hospital. But in saying that, we would then need to spend some money to re-purpose the spaces that are vacated. That’s the most logical and, from what I can see, the most sensible pathway.”

The project’s not just about bricks and mortar. Dunedin Hospital is changing to a more generalist model of care. That means setting up what the DHB is calling community health hubs for primary and some specialist services – in an attempt to reduce demand and waiting times. In other words, only the very sick should go to hospital.

“Currently we suck people into the hospital to do things that could actually be done out in community health hubs,” Fleming says. “Why do you bring an elderly person into the middle of town when they could have a geriatric clinic in the community health hub in South Dunedin, or in Balclutha?”

The DHB will shortly ask for expressions of interest in health hubs – looking for both investors and health professionals. “We’re thinking there’ll be two or three in Dunedin. There’ll be one or two in Invercargill. And the rural hospitals are likely to form the basis of the community health hubs in those rural settings – Waitaki, Balclutha, Gore, Dunstan, Lakes.”

Patients will get appropriate service at the appropriate time in the appropriate location, Fleming says.

An example of poor hospital decisions made recently was the case of a terminally ill patient who spent nine of the last 10 days of her life in hospital waiting for decisions to be made and waiting for tests.

Fleming: “The prognosis was this lady was going to die anyway. And why did we subject them to 10 days of waiting when, actually, if we had had the right conversations at the beginning then instead of the lady spending 10 days in hospital she might have spent 10 days at home, with the appropriate support, and passed away in an environment that she might have wanted to?”

Dunedin is perceived as a 24-hour, seven-day-a-week hospital. But Fleming says the DHB has underfunded so-called allied health – people like physiotherapists, occupational therapists and social workers. Too many of those services, for his liking, are done Monday to Friday. So people languish in the hospital in the weekends, waiting to be assessed,

Somebody told Fleming last week a person can wait five days for a needs assessment. “If that is indeed happening it’s just nuts. We need to get our resources to meet the needs when it’s needed so that people can get care and also go home in a more timely manner.”

(Another problem is the city has only one after-hours medical centre and it closes at 10pm.)

Dunedin's closed Cadbury factory, one of two central city blocks

where the new hospital will be built. Photo: David Williams

The Health Ministry hasn’t started its formal “market informing” roadshow to court project managers. But the informal approaches have started. “People are turning up in Dunedin, and every time they turn up and want to see somebody they ring me, and every time they ring I say yes,” Hodgson says. “Folk are coming from other parts of New Zealand and Australia and there’s a steady stream of them. When we do have our master site plan and we’ve got some graphics to show them, the ministry will be going to other jurisdictions, starting with Australia.”

And while consultants, architects and engineers pick over plans, tweak designs and dig holes to check the ground under the new hospital site, Hodgson is there, looking over shoulders and being “a bit pushy”. “Because if you are not pushy, no one will do things ahead of when they need to do them, and you can often do things ahead of when you need to do them.”

There seem to be more questions than answers right now about the new Dunedin Hospital, like who will build it, how long it will take, and the total cost. Hodgson is happy to talk about dates for digging holes in the ground but refuses to be drawn on cost, saying his job is just to ensure the tendering process is reasonably competitive. “You cannot get me to predict what the market will be, I decline.” (The consensus from those Newsroom spoke to is the cost will sail over the $1.4 billion top-end of the budget.)

What he will say on price, however, is that there are good economic and healthcare reasons for a new hospital to have multiple buildings. “That becomes a factor that should maintain good competitiveness – and also keep some money, keep nearly all the money, I hope, in New Zealand.”