A main tower block at Nelson Hospital and the special care baby unit at Waitākere Hospital are in the worst condition of any hospital buildings in New Zealand, a nationwide hospital stocktake shows.
These are among 24 such buildings in especially poor condition detailed in the first stocktake of its kind.
A hospital lab at Ashburton, the mental health unit Tamaki Oranga in Ōtara, and 5000sqm Ōtara spinal unit round out the top five worst condition clinical services buildings.
Engineers checked 166 buildings at 31 hospitals to gauge earthquake risk, asbestos and fire separation problems.
Acute clinical care units were assessed separately, with many falling far short of size and quality standards in modern hospital design.
The recommendation arising from that is to find ways to improve three emergency departments, five operating theatre suites, five intensive care units, seven mental health units and eight wards.
"Options could include a combination of changes to models-of-care, strengthening other services in the workflow, unit refurbishment and renewals," the stocktake said.
On the building front, the worst score for seismic integrity was at Taranaki Hospital's clinical services block.
That is closely followed by the largest of the 24 buildings in poor condition - Christchurch Hospital's Riverside, a 17,000sqm block that has several hundred patients in it.
Getting those Riverside patients into better, safer beds has been complicated by the government's funding gatekeeper, the Capital Investment Committee, last month forcing the Canterbury DHB to dump its $450m plans and settle for a $150m tower it knows will be over capacity when it opens.
Just more than 50 of the highest priority hospital buildings (called Importance Level 3 and 4 - IL3 and IL4 - buildings) are earthquake-prone.
Some - in Dunedin and Greymouth for instance - are being redeveloped.
IL4 buildings are meant to be able to be up and running straight after a major disaster, for the likes of doing surgery. This has not been assessed yet, with a tool to do it still being developed.
Of all the IL4 buildings, 30 are quake-prone (under 34 percent of NBS - New Building Standard) and 32 are a quake risk (under 67 percent of NBS). For IL3s, the respective figures are 22 and 77 buildings.
Wellington Regional Hospital's Grace Neill block is nearly as large as the Riverside one in Christchurch, and let down not by seismic weakness, but poor electrical and other infrastructure services.
The hospital has the worst sitewide electrical infrastructure of all 30 hospitals looked at, and among the worst mechanical services - though the main block was built only 12 years ago.
"Most of the high-voltage cables [at Wellington Regional]... appear to be beyond end-of-life and should be replaced. The site generators are in poor condition. The site main switchboard is at end-of-life ... Replacement is being investigated. The general mechanical infrastructure is in poor to average condition. The steam pipes and hot water storage are in poor to very poor condition. The hot and cold water pipe reticulation and the heating plant are in poor condition. The storm water drains, medical gases, heating pipes, fire water and cooling pipes are in average to poor condition.
"In the total energy centre, the hot water plant and heating distribution are in very poor condition. The boiler house and hot water distribution are in poor condition. The local HVAC, building management system, windows and doors are in average to poor condition. The centre's domestic heating, hot water valves, pumps and storage tanks are in poor condition and require constant attention."
The 86-page stocktake and a 33-page appendix, detailing poor buildings DHB-by-DHB, offers some reassurance:
"In general, DHBs have maintained their sitewide infrastructure to supply medical gases, water, sewer pipes and electricity," it states, but goes on to add how old so many boilers, pipes and valves are, and warns upgrade plans can "overlook" them.
"Buildings are mostly in average to good condition, with those in average condition having various poor components."
But some, such as mental health units, are okay on the outside, but poor on the inside, with bad design hampering medical care.
Many district health boards were managing "significant levels" of asbestos, the stocktake said.
"The most significant issues relate to the friable asbestos lagging of pipes.
"There are special procedures in place to protect building occupants."
In all, 117 buildings have a high asbestos risk, 230 medium risk and 465 low risk - another 372 have not been assessed.
Critical-care units, patient wards and the like are meant to be built with fire spearation, measures that prevent fire spreading quickly through holes in walls and ceilings.
"In many cases, passive fire separation has been compromised by poor practices around the installation of new technologies, such as cabling," the stocktake stated.
The new Acute Services hospital project in Christchurch has been delayed from opening by 8000 such fire protection faults, among many other things.
Recent builds in Hamilton have had similar problems.
"DHBs have advised the Ministry of Health that controls are now in place to ensure that fire cells are not compromised by new IT installations.
"In many cases, DHBs have remediation programmes that are expensive and time consuming already in progress."
In all, 126 buildings rate as high risk for fire separation, 182 medium risk, 616 low risk - and another 249 have not been assessed.
Fixing the problems
A national rebuild plan based on the stocktake will not be ready until 2022.
The stocktake faults health boards' asset management extends back years, but the entire system has not functioned well.
"Overall, there is limited consistency and transparency of information at either the local, regional or national levels."
DHB business cases were "often developed in isolation" from other boards.
The government said it had been and would keep on spending to tackle this, saying the stocktake was valuable for helping set priorities ahead of a national asset management plan due in 2022, and beyond.
However, work had not started even on some projects the government had already approved.
Palmerston North Hospital had a stopgap $26 million fix announced by the government in January to help alleviate acute care squeezes such as in operating theatres that are so cramped the lights sometimes bump surgeons' heads.
"We have done the business cases, the business cases are sitting in Wellington," the acting chief medical officer, Dr Jeff Brown, said.
"We haven't actually been able to start the reconstruction yet.
"Covid has disrupted a lot of what we are doing, but it hasn't taken away the urgency and the criticality of this work."
The Christchurch Hospital tower has only got to the verge of approval by bowing to Wellington's demands.
Minister of Health David Clark told RNZ today that when it came to deciding whether to sign off on the smaller tower, he would take advice from the Capital Investment Committee, which had looked at priorities.
However, the Canterbury DHB has said it was this committee that told the board to accept a $150m tower, or get no funding.
Similarly, officials rejected Northland DHB's billion-dollar-plus rebuild plan that was years in the making, so it has come up with a plan worth perhaps half that which must go through the hoops again.
Two years ago, the Treasury put a $14 billion bill on upgrading hospitals over the next decade.
"I think the $14 billion is a big number," Dr Jeff Brown said.
"It's a question of how quickly it is spent, and the money that can be given to projects that are ready to go needs to be hurried up.
"We understand that we need to have the right eyes cast over it at central [government]; at ministry; at Treasury; Cabinet; and investment committee levels. We would like answers as soon as possible."
The Association of Salaried Medical Specialists (ASMS), which represents senior DHB doctors, said it would take 15 to 20 years at current rates of government spending just to address the minimum upgrades the stocktake showed were needed - and it was going to get worse.
"It's not going to stay static," ASMS executive director Sarah Dalton said.
"That's a bit like when you start painting a bridge, and when you get to the end, you go back and start painting again. By the time they go back, part of the bridge may have fallen down."
What and where
A researcher into Māori public health at Otago University, Francis Kewene, said it was not just about what was now prioritised to build, but where.
"Originally hospitals were always located predominantly around European settlement, knowing that actually Māori are our priority," Kewene said.
"Are hospitals actually meeting the community's needs? And if they are not, they need to be moved."
The stocktake said a new model might have more "ambulatory care centres" - for outpatient checkups - "located to facilitate access for vulnerable populations or co-located with primary care teams rather than within a hospital".
Any such moves or upgrades must consult Māori a lot better than planners did now, Kewene said.
"Who's at the decision-making table? ... the DHBs' strategic direction and leadership needs to reflect its obligations under the Treaty and currently we have only one Māori CEO."
Iwi governance board input to DHBs was "really variable", Kewene said, depending on who it was going to and whether it was heeded.
Wider community consultation was key, but had been sorely lacking throughout the Covid-19 pandemic, she said.
"The Crown haven't recognised the expertise outside their own organisations."
At a small DHB with a high Māori population, Tairāwhiti, the stocktake rates the emergency department, operating theatres, and ICU as "poor".
Its chief executive Jim Green noted some benefits the stocktake had already helped deliver - $20m for a mental health unit that is being built, $3m for infrastructure services, and putting wheels under a long-planned much bigger upgrade of Gisborne Hospital.
"This report has given us some impetus around that and enabled us to identify some of the areas that we should really be concentrating on," Green said.
The stocktake was the most comprehensive his DHB had ever had access to, accurate, and had lots of input from clinicians.
"It will give us a smaller DHB, smaller community, some good profile around the status of the facilities here, and keep us up-front and visible."
Hospitals never had just one capital project to consider, but many that jostled each other, and the stocktake would help in fitting the pieces of that puzzle together at Tairāwhiti, Green said.
The stocktake warned against rushing any upgrades, or building like-for-like, considering there was constant change in healthcare and technology.
It found not even all the near-new acute-care facilities were "good" - for instance, Hamilton Hospital's Emergency Department rated just average.
Being new did not equate to being a great design, North Shore hospital emergency physician Andrew Ewens said.
"Each design we have, the next one should be improved upon. We should be learning every time there's a clinical build," Ewens said.
"I don't think there's a lot of resource put into that.
"I think we're just always 'on to the next thing'."
North Shore listened to clinicians when it built its emergency department, he said; the architect was told they did not want any corridors where patients might be parked and forgotten.
"It's absolutely vital that clinical staff using facilities are involved in the design and ... both the clinical staff and the architects [know] that they're designing the building for. So the function of the building has to match the form of the building.
"We need really good health architects."