Cardigan Integrated Care Centre Full Business Case. March 2016

Transcription

1 Cardigan Integrated Care Centre Full Business Case March 2016

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3 Contents 1 Executive Summary Purpose Overview of Proposed Scheme Economic Case Commercial Case Financial Case Management Case Recommendation Strategic Case Introduction Part A: The Strategic Context Organisational Overview Hywel Dda University Health Board Demography Population in Ceredigion Deprivation Life Expectancy Ethnic Background National Business Strategies Setting the Direction: Primary and Community Strategic Delivery Programme Programme for Government Together for Health (November 2011) Delivering Local Health Care Accelerating the Pace of Change (2013) A Framework for Delivering Integrated Health and Social Care for Older People with Complex Needs (2014) Social Services & Wellbeing (Wales) Act Agreeing Individual Care with People who have Long Term Conditions (2014) NHS Wales Planning Framework / NHS Outcomes and Delivery Framework 2015/ Well-being of Future Generations (Wales) Act Our Plan for Primary Care in Wales up to March P a g e 1

4 Prudent Healthcare Local Strategies Your Health Your Future (2012) The Framework for Delivering Integrated Health and Social Care for Older People with Complex Needs Statement of Intent Integrated Medium Term Plan Part B: The Case for Change Service Changes since SOC and OBC Submission Strategic Outline Case Outline Business Case Current Services Current Activity Justification and Business Needs Demography and Demand Current Accommodation Services: Cardigan Health Centre Services: Cardigan Memorial Hospital Investment Objectives Estimating the Benefits Constraints Financial Constraints: Non-Financial Constraints: Dependencies Economic Case Introduction Critical Success Factors The Long Listed Options Summary of Review of Long List of Options Non-Financial Option Appraisal Benefits Criteria Benefit Criteria Weightings Shortlisted Options P a g e 2

5 3.7 Scoring of Options Raw Scores Weighted Scores Sensitivity Analysis Conclusion to the Non-Financial Evaluation Financial Option Appraisal Capital Costs Lifecycle Costs Revenue Costs Savings Optimism Bias Key Results of Economic Appraisal Financial Option Ranking Sensitivity Analysis Combining the Financial and Non-Financial Appraisal Option Appraisal Conclusions Update of Option Appraisal for Full Business Case Risk Appraisal Commercial Case Introduction Scope Procurement Strategy Proposed Contractual Arrangements Consultant Advisors Charging Mechanisms Compensation Events Resolution Process Risk Allocation Project Delivery Programme Personnel Implications (including TUPE) Accountancy Treatment Disposal of Assets Estates Annex P a g e 3

6 5 Financial Case Funding and Affordability Capital and Funding Requirements Impairment and Balance Sheet Treatment Revenue Affordability Overall Affordability Management Case Introduction Project Management Arrangements Project Roles and Responsibilities The Investment Decision Maker/Senior Responsible Owner (SRO) Project Director Capital and Estates Lead Project Manager Service Planning & Commissioning Project Accountant Project Reporting Structure Project Board Stakeholder Board Operational Project Management Team Service Model Workstream Design Development and Estates Workstream Design Team Communications and Engagement Workstream Finance Workstream Informatics Workstream Procurement Workstream Other Groups Engagement of Key Stakeholders Use of Special Advisors Project Plan and Milestones Change Management Arrangements Outline Arrangements for Contract Management P a g e 4

7 6.7.3 Project Closedown Report Post Project Evaluation Post Implementation Review (PIR) Project Evaluation Reviews (PERs) Benefit Realisation Expected Outcomes Outline Arrangements for Risk Management NHS Wales Gateway Review Arrangements Contingency Plans Figures: Figure 1 Proportion of Population by Age & Sex 2010 Figure 2 Population Projections for Hywel Dda Figure 3 Local Fifths of Deprivation: Hywel Dda Figure 4 Life Expectancy in Hywel Dda Figure 5 Outpatient & Therapies Activity 2013/14 Figure 6 Distribution of Patients by GP Practice Locality Figure 7 Outpatient Attendances by Specialty April 2012 March 2015 Figure 8 Physiotherapy Activity: Cardigan Hospital / Community Figure 9 Attendances in the Minor Injuries Unit Figure 10 Outcome of M.I.U. Attendances Figure 11 Cardigan Hospital X-Ray Activity Figure 12 Cardigan Health Centre Community Dental Activity 2013/ /15 Figure 13 Reasons for Referral to CRN Team 2015/16 Figure 14 Number of Hospital Bed Nights Avoided by CRN Team 2015/16 Figure 15 Number of CRN Active Patient Cases per Day 2015 Figure 16 CRN Discharge Location 2015/16 Figure 17 Total Outpatient Attendances Cardigan Hospital Figure 18 Project Management and Governance Structure Figure 19 Project Reporting Structure P a g e 5

8 Tables: Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 Table 11 Table 12 Table 13 Table 14 Table 15 Table 16 Table 17 Table 18 Table 19 Table 20 MSK Outpatient Service Activity Total X-Ray Procedures Undertaken in Cardigan Hospital NHS Infrastructure Objectives and FBC Investment Objectives Benefit Criteria & Investment Objectives Critical Success Factors Summary of Review of Long List of Options Shortlisted Options Benefit Criteria Weightings Shortlisted Options Benefit Scoring Criteria Weighted Scores Economic Appraisal Assumptions Key Results of Economic Appraisal Summary of Results of Option Ranking Combined Option Appraisal Risk Transfer Matrix Project Delivery Programme Capital Cost Summary Preferred Option Capital Cash Flow Requirements Revenue Impact of Scheme Appendices (Document 2) Appendix 1 Estates Annex Addendum November 2014 Appendix 2 Correspondence with Welsh Government during the OBC Approvals Process Appendix 3 Equality Impact Assessment Appendix 4 Letters of Support Ceredigion County Council and GP Practice Appendix 5 Non-Financial Evaluation of Options Appendix 6 Generic Economic Model Appendix 7 Cost Forms (FBC) Appendix 8a District Valuer Estimate of Completed Scheme Valuation Appendix 8b Impairment to Market Value P a g e 6

9 Appendix 8c Appendix 8d Appendix 9 Appendix 10 Appendix 11 Appendix 12 District Valuer Estimate Market Value of Cardigan Health Centre District Valuer Estimate Market Value of Cardigan Hospital Revenue Costs and Capital Charges Communication and Engagement Strategy Benefits Register Risk Register P a g e 7

10 Section1: Executive Summary P a g e 8

11 1 Executive Summary Cardigan Integrated Care Centre FBC 1.1 Purpose The purpose of this Full Business case (FBC) is to set out the investment required to support the development of an Integrated Care Centre in Cardigan. Since OBC approval the scheme (outlined in section 1.2 below) has been further developed and Full Planning Permission was granted on 9 th December Overview of Proposed Scheme The Health Board has developed and implemented a new model of care to support the local population to remain as healthy and as independent for as long as possible, by promoting wellness and reducing illness. Care will be provided as close to or within the patient s own home, reducing demand for acute hospital care and travelling and disruption, whilst increasing the efficiency and effectiveness of care. In order to deliver this model of care, modern integrated health and social care services are required in a high quality, appropriate, fit for purpose environment. This FBC identifies the development required within Cardigan to provide the model of care to the local population. The development will replace the current Cardigan Memorial Hospital and Cardigan Health Centre, and provide an Integrated Care Centre which will be owned and managed by Hywel Dda University Health Board. The new Integrated Care Centre will provide: General Medical Services (Cardigan Health Centre GP Practice); Community Dental Service; Community Pharmacy; Minor Injury Service GP/Nurse led, walk-in service with telemedicine links to the Emergency Department; Radiology and diagnostics digital x-ray with remote reporting; Phlebotomy service; Outpatient suite with consulting rooms and clinical treatment facilities for preassessment and outpatient consultations by visiting consultants, specialist nurses/therapists and social workers and opportunities for multi-disciplinary one stop clinics; Disease specific services e.g. heart failure, motor neurone disease clinics and COPD services; Enhanced telemedicine equipment in clinical areas providing remote access to specialists from across the professions; Rehabilitation services providing opportunities for intensive and slow stream rehabilitation to restore function and improve independence, supported by therapists, nurses and social care staff within the Community Resource Team; Mental health and learning disabilities services; Base for Community Resource Team in the South Ceredigion Locality; Third sector services. P a g e 9

12 1.3 Economic Case Cardigan Integrated Care Centre FBC Non-Financial Appraisal of Options The investment objectives for the scheme were identified and developed as SMART objectives: Investment Objective 1: Facilitate the delivery of the new model of care To provide accommodation that will enable the multi-agency integration, single point of assessment, rehabilitation and optimal use of health and social care resources. Investment Objective 2: Improve local access to services To provide access to a wider range of local services for all those living within the designated catchment area of Cardigan. Investment Objective 3: Provide appropriate service capacity To provide accommodation that will at least meet the needs under the new model of care of the projected 2031 defined Cardigan catchment population. Investment Objective 4: Provide a high quality physical environment By January 2018 all facilities will be at least compliant with statutory HBN and CSSIW standards for health and social care facilities, including requirements for privacy and dignity and the Disability Discrimination Act. The non-financial appraisal was undertaken in May The longlist of 10 options had been reviewed and a shortlist of 4 options agreed: Option 1 Option 2 Option 3 Options 4/5/6 Do Nothing retain existing facilities and undertake backlog maintenance New build Integrated Care Centre with no inpatient beds and no additional investment in community support / services New build Integrated Care Centre with no inpatient beds but with additional staff working in the community; plus access to a mixed economy of beds within the Cardigan area New build Integrated Care Centre with inpatient beds and no additional investment in community support / services. These options were appraised against the weighted benefit criteria and Option 3: New build Integrated Care Centre with no inpatient beds but with additional staff working in the community; plus access to a mixed economy of beds within the Cardigan area was identified as the non-financial preferred option. This outcome was subjected to a sensitivity analysis and there was no scenario where Option 3 was not the preferred option. An additional option was requested by Welsh Government during the OBC approvals process. This option was Option 7: Do Minimum undertake improvement works to the existing accommodation. This option had been originally discounted during the development of the Strategic Outline Case (SOC) in The Health Board considered this and reached the conclusion that, as Option 7 would not be able to provide the required accommodation and would therefore not have scored highly it was not necessary to rerun the non-financial appraisal. Option 7 was, however, evaluated financially. P a g e 10

13 1.3.2 Financial Option Appraisal A discounted cash flow for each option was undertaken in line with the requirements of HM Treasury Guide to Option Appraisal. Capital cost estimates were developed for each option along with lifecycle costs, revenue costs and optimism bias. The financial option ranking is shown below: Option Net Present Costs (NPC) 000 Equivalent Annual Cost (EAC) 000 Variance over Option 1 Ranking Switch Value 1 34,813 1, ,405 1, (40) 3 58,470 2, (422) 4 76,562 2,903 1,108 5 (1,108) 5 90,729 3,440 1,645 6 (1,645) 6 92,497 3,507 1,712 7 (1,712) 7 53,713 2, (241) Combining the Financial and Non-Financial Evaluation The preferred option was identified by combining the financial and non-financial appraisals as below: Weighted non-financial score Option 1 Option 2 Option 3 Option 4 Option 5 Option Non-Financial Ranking Option 7 EAC impact of options Economic Ranking Benefit Points per m EAC Combined ranking Difference -71% -46% 0% -43% -52% -53% - The overall preferred option was Option 3, to develop a new build Integrated Care Centre with no inpatient beds but with additional staff working in the community, plus access to a mixed economy of beds within the Cardigan area. It was agreed that the inclusion of Option 7 at the request of Welsh Government after the non-financial evaluation workshop would not have affected this outcome. This option appraisal was reviewed by the Project Board at its meeting on 14 th October It was agreed that the critical success factors, benefit criteria and scoring of the options remained relevant and the option appraisal continued to reflect a realistic outcome. P a g e 11

14 The economic appraisal undertaken as part of the OBC has been reviewed and updated as part of the FBC work to reflect: The tendered capital costs The reviewed revenue costs The current optimism bias on the scheme. The Generic Economic Model is given at Appendix Risk Appraisal Adjacent Site Following extensive ground investigation of the site during the Outline Business Case stage of the project, the Supply Chain Partner (SCP) developed a robust ground engineering design solution for the scheme as part of the detailed design process. However, at a site visit in late 2015, ground surface tension cracks were observed on the adjacent site, beyond our common site boundary. Further inspection of the retaining structures on the adjacent site revealed an ongoing failure to the adjoining retaining structure along the top of the adjacent site. This has raised concerns of a risk that potentially the similar adjoining retaining structure along our common boundary could be compromised. Due to concerns about the adjoining site, additional ground investigations are planned for a six month period commencing March 2016, with an interim assessment of risk after several months. This interim assessment will show any changes and inform the development of costings for remedial action if this is required. The Health Board is awaiting a formal response from the adjoining developer to ensure that their intentions match those of the Health Board s engineers requirements. The Health Board will consider the need for a separate case to cover any remedial action resulting from these investigations. 1.4 Commercial Case The Estates Annex provides more detail of the contractual arrangements in place to support this development. The procurement strategy for this development is Designed for Life / Building for Wales DFL3 and the procurement route is the All Wales Capital route utilising the Welsh Government for Life Building for Wales DFL3 NHS Framework. The use of DFL frameworks for the procurement of capital schemes is mandatory for all schemes over 4m works costs. DFL3 is the appropriate route for schemes with an estimated works cost of 10m and over. The Health Board has appointed from the framework following a selection process: Health Board Project Manager Gardiner and Theobald Management Services; Health Board Cost Advisor Gardiner and Theobald; Supply Chain Partner Interserve Construction Ltd. P a g e 12

15 1.4.1 Charging Mechanism Cardigan Integrated Care Centre FBC HDUHB intends to make payments as below: Charging will be completed under the Designed for Life Building for Wales Construction Procurement Framework pre-agreed fee arrangements. The contract will be managed by Hywel Dda UHB under the NEC3 Option C Target Cost Contract. All payments will be approved by the Cost Advisor and Project Director before being passed to HDUHB for payment Risk Allocation The Designed for Life: Building for Wales framework dictates that the NEC3 contract is used. It is a collaborative contract that requires a project to include a Costed Risk Register with risk allocated to the party best able to deal with it. The early involvement of Supply Chain Partners means that they are fully briefed about risks in the project and can accept ownership of more risk than would normally be the case under a more traditional form of contract Project Programme The detailed master delivery programme for the project is included within the Estates Annex. The key dates are: Disposal of Assets Project Delivery Programme: FBC Submission to WAG April 2016 WAG approval of FBC May 2016 Construction mobilisation June 2016 Construction phase (17 months) June 2016 to November 2017 Commissioning November 2017 to January 2018 Target go live date January 2018 Post Project Evaluation Target January 2019 The Health Board envisages that in delivering the Cardigan Integrated Care Centre the existing Cardigan Hospital and Health Centre sites will be surplus to operational requirements and therefore available for disposal. The Health Board will develop a disposal strategy for each of the sites taking into account the project programme above and therefore the possible vacation dates. The site disposal values within this FBC are based upon current market value. P a g e 13

16 1.5 Financial Case Cardigan Integrated Care Centre FBC Capital and Funding Requirements The Health Board is looking for capital funding of 21,197,970 to support the development, as shown below: Total 000 Works Cost Total 11,443 Fees 2,305 Non-works Costs 887 Equipment Costs 1,142 Risk Contingency 1,213 Land 979 VAT 3,229 Total for Approval Purposes 21,198 The above costs are based on a start on site date of June 2016, and are based on BIS PUBSEC (MIPS FP) 221. These capital costs exclude the costs of additional works in connection of the adjacent site issues, and are based on returned tenders of packages of works as per the requirements of the DFL3 framework. Capital Cash Flow Requirements Pre 2015/ / / /18 Total Total 1,763 1,246 7,207 10,982 21, Revenue Affordability There are cash releasing savings associated with the scheme of 83,507 per annum as shown below: Original Cost Base 2017/ / Site based costs incl. staffing 1,387 1, Community Nursing Services GMS * GP ** 2 10 Revenue Costs 1,607 1,571 1,523 Additional Depreciation 351 Total Charge to Revenue 1,607 1,571 1,874 P a g e 14

17 * GMS General Medical Services. These costs are reimbursed to Primary Care by the Health Board; ** GP General Practice. These costs are borne by the Practice and are not reimbursed by the Health Board. There are also revenue consequences of the capital expenditure (depreciation). These additional costs represent an estimated increase in the Health Board s baseline depreciation non-cash funding requirement of 351,440. The estimated capital receipt from the disposal of the two exiting sites is currently estimated to be in the region of 850,000. The proceeds of the sale of these two sites will flow back to the Welsh Government upon site disposal. The anticipated sale proceeds are not factored into the capital costs, but are included in the economic appraisal based on information provided by the District Valuer Overall Affordability The gross capital cost of the proposed project is 21,970. The recurring annual cash releasing savings in revenue is 83,507. There will be additional depreciation costs associated with the scheme of 351,440. This scheme is therefore concluded as being affordable to the Health Board, subject to agreement to the strategic funding of the capital charges by Welsh Government. 1.6 Management Case Project Management Arrangements The Health Board has adopted the general principles of PRINCE 2 in managing the activities and outputs of the project. Specialist professional and technical advisors have been appointed for activities where the necessary skills and experience are not otherwise available to the project structure. The project management and governance structure is shown below: Hywel Dda University Health Board Business Planning and Performance Assurance Committee Capital Estates and IM&T Committee Cardigan Integrated Care Project Project Board Stakeholder Group Operational Project Management Service Model Workstream Design Development and Estates Workstream Communications and Engagement Workstream Finance Workstream Informatics Workstream Procurement Workstream Capital Revenue P a g e 15

18 1.6.2 Post Project Evaluation The Health Board is committed to the full evaluation of all major schemes and projects through the formal evaluation methodology in accordance with guidance from the NHS Wales Assurance Hub. Outline arrangements for both post project review and post project evaluation reviews have been established in line with best practice Benefit Realisation As part of the business case process the benefits to patients, staff, the Health Board and the wider health economy have been assessed. Specific indicators have been assigned for each of the anticipated benefits and the baseline and target performance for each is recorded in the Benefits Register, which is given at Appendix 11. The Benefits Plan will be monitored at the Project Board on a quarterly basis Risk Management The key risks of the development have been assessed and strategies for managing them outlined. The Risk Register is given at Appendix NHS Wales Gateway Review Arrangements A Gateway 3 Review is scheduled for late April Contingency Plans Due to the extremely poor existing facilities and their inability to be functionally and spatially improved, Hywel Dda University Health Board has no contingency plans in place in the event this project is not successful. 1.7 Recommendation Hywel Dda University Health Board recommends that the Welsh Government give approval for the capital funding and funding of the additional capital charges associated with the development of Cardigan Integrated Care Centre to enable the Health Board to provide significantly enhanced facilities and integrated services for the catchment population of Cardigan. Signed Date: Senior Responsible Owner Project P a g e 16

19 Section 2: Strategic Case P a g e 17

20 2 Strategic Case Cardigan Integrated Care Centre FBC 2.1 Introduction An Outline Business Case (OBC) for the development of an Integrated Care Centre in Cardigan was submitted in December 2014, and following some amendments to the design and financial outcomes was approved by the Welsh Government in June The OBC challenged the assumptions made in the previous SOC in light of: Changes to the University Health Board strategy and Model of Care Shifts in national and local policy, towards care being delivered closer to home Further integration of health, social care and the third sector and new systems, pathways and relationships that will be in place to integrate care delivery across organisational, professional and administrative boundaries The lengthy time period between SOC and OBC completion and the growing pressures on health and social care, both clinically and financially. In the intervening period the plans for the Integrated Care Centre have been developed in detail. The strategic context has been reviewed, challenged where necessary and updated. Part A: The Strategic Context 2.2 Organisational Overview Hywel Dda University Health Board On 1 st October 2009, a new Health Board was established for mid and west Wales, replacing the three Local Health Boards in Carmarthenshire, Ceredigion and Pembrokeshire, and Hywel Dda NHS Trust, and it attained University Health Board status in December The Hywel Dda University Health Board is the main provider of primary, community and acute healthcare, mental health and learning disability services in the area, covering a large and predominantly rural area of mid and west Wales and serves a population of around 372,000. Each of the three Counties covered by the Hywel Dda University Health Board is designated as a rural authority in Health in Rural Wales (December 2008). Hywel Dda University Health Board (HDUHB) covers a quarter of the landmass of Wales and is one of the most sparsely populated health board areas. It contains the local authority areas of Pembrokeshire, Carmarthenshire and Ceredigion and has four District General Hospitals: Bronglais Hospital Glangwili Hospital Prince Philip Hospital Withybush Hospital P a g e 18

21 Estimated population (thousands) x Demography Cardigan Integrated Care Centre FBC Hywel Dda is one of the most rural Health Boards in Wales. Overall, health is generally similar to or better than the Wales average. Ceredigion consistently fares better than Pembrokeshire and Carmarthenshire, where there are pockets of poor health in urban areas. With 13 per cent of Wales population within the Health Board s boundary, the area s age profile is similar to that of Wales as a whole. There are, however, notable differences with fewer people aged and more people aged 55-79, as shown in Figure 1 below: Figure 1: Proportion of Population by Age & Sex 2010 Proportion of population by age and sex Hywel Dda Health Board and Wales, 2010 Produced by Public Health Wales Observatory, using 2010 mid year population estimates, ONS Hywel Dda females Hywel Dda males Wales females Wales males Proportion (%) of population Current population projections suggest that the total population of Hywel Dda will rise to over 425,400 by 2033, with an increase in those aged over 65 years from 88,200 in 2013 to 127,700 by 2031 and a rise in the older population (75 years and over) from 35,000 (10% of the total population) in 2006 to 70,000 (16% of the total population) in These estimates are based on assumptions about births, deaths and migration and are highlighted in Figure 2 below. The increase in the number of older people is likely to lead to a rise in chronic conditions such as circulatory and respiratory diseases and cancers. Meeting the needs of these individuals will be a key challenge for the Health Board and its local authority partners based population projections for Hywel Dda LHB, persons: Figure 2006 to 2: 2031 Population Projections for Hywel Dda Data source: Statistical Directorate, Welsh Assembly Government / ONS P a g e 19

22 2.2.3 Population in Ceredigion Using the latest 2011-based WG projections the population of Ceredigion is set to increase from 75,600 in 2013 to 77,540 in 2023, an increase of 2.6% which is a little lower than the projection for Wales as a whole. The latest Mid-Year Estimate of population for Ceredigion is 75,400 (2014), with 19.6% of the population aged (as opposed to 17.3% of the total Welsh population of 3,092,000). This age group is forecast to increase by 14% both in Ceredigion and in Wales. What is most remarkable is that the number of people in their sixties in the county (unlike in Wales as a whole) is projected to decrease, whilst numbers in their seventies and eighties increase. This must be taken into account when planning services for the increasing number of older people who may be living with a range of health and mobility challenges. It is possible to estimate the health challenges that an aging Ceredigion population is likely to face: The number of people aged over 65 with dementia is likely to rise by 59% by 2030 An increase of 12% in the number of older people with diabetes 46% increase in number of older people with mobility problems 55% increase in hospital admissions because of falls (Source: Daffodil Cymru available at Deprivation Deprivation is a wide concept that refers to the problems caused by a lack of resources and opportunities. The Welsh Index of Multiple Deprivation (WIMD) is the official measure of deprivation in small areas in Wales and measures the relative concentrations of deprivation at the small area level. In Figure 3 over, the Lower Super Output Areas (LSOAs) in Hywel Dda have been ranked and divided into fifths depending on their WIMD score. LSOAs in the most deprived fifth are coloured dark blue through to the least deprived fifth in light blue. An area itself is not deprived: it is the circumstances and lifestyles of the people living there that affect its deprivation rank. It is important to remember that not everyone living in a deprived area is deprived and that not all deprived people live in deprived areas. There are areas of deprivation within the Health Board boundary, including parts of Llanelli, Pembroke Dock and Cardigan. P a g e 20

23 Local fifths of deprivation: Hywel Dda Figure 3: Local Fifths of Deprivation: Hywel Dda Measuring inequalities Most health outcomes are worse for lower socio-economic groups, indicating inequities in health outcomes. Inequities can also be apparent in access and use of health services. There is some evidence in the UK that lower socio-economic groups use preventative health services less and may have less access to secondary care except for emergency care Life Expectancy Life expectancy in Hywel Dda, as in Wales in general, is increasing. In the average life expectancy in males was 77.4 years and 82.0 in females. However, this increase is not experienced equally across all areas. The Slope Index of Inequality (SII) measures the absolute gap in years of life expected between the most and least deprived, taking into account the pattern across all fifths of deprivation within the UHB area. This highlights that there are substantial gaps in life expectancy between people living in the most and least deprived areas of the UHB area. There are even more stark differences in healthy life expectancy and disability-free life expectancy. For example in men, the gap in life expectancy between the most and least deprived fifths is more than 11 years, while the gap in healthy life Disability-free life expectancy is expectancy over 22 years Moreover, these differences are increasing despite the overall improvement. Life expectancies in Hywel Dda Females Comparison of life expectancy, healthy life expectancy and disability-free life 75.9 expectancy Life at birth, Hywel Figure Dda 80.6 HB 4: Life and Expectancies in Hywel Dda 8.8 fe expectancy e expectancy e expectancy fe expectancy 77.3 Produced expectancy by Public Health Wales Observatory, 81.7 using ADDE/MYE (ONS), WIMD/WHS (WG) Life expectancy with 95% 64.7 Inequality gap Healthylife confidence interval (SII in years) 60.8 Males expectancy Life expectancy Disability-free life expectancy Healthy life expectancy e expectancy 66.1 Disability-free life 58.8 expectancy 62.0 e expectancy Females Life expectancy Healthy life expectancy Disability-free life expectancy Produced by the Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD/WHS (WG) Measuring inequalities P a g e 21

24 2.2.6 Ethnic Background The Health Board population is predominantly white British with 1.0 per cent of the population coming from a minority ethnic background. 2.3 National Business Strategies Following the approval of the SOC in 2010 a series of documents were published with the common theme of providing integrated care closer to home. These formed the basis of the revised Model of Care and resulting plans for the Cardigan Integrated Care Centre, and are summarised below: Setting the Direction: Primary and Community Strategic Delivery Programme This document, published in 2010, identified a preventative, primary and community led NHS as the fundamental approach to drive improvements in health and social care across Wales. It provided a framework to enable the shift towards locally-designed community focused care Programme for Government The Welsh Government s Programme for Government and its 5 year NHS Plan, Together for Health, set out an ambitious programme for health and healthcare in Wales, including: 21 st Century Healthcare Improving health outcomes by ensuring the quality and safety of services is enhanced including improvements in chronic disease management, integration with social care to support safe and sustainable services and control of health acquired infections Improving access and service user experience including 7 day services and mobile outreach Preventing poor health and reducing health inequalities Rural Communities Improving public services for rural communities including ensuring that health services are provided as close to people s homes as possible; improving access to care in rural areas through mobile outreach Supporting People Providing users and carers with a stronger voice and greater control over the services they receive including support and encouragement from the Third Sector Ensuring people receive the help they need to live fulfilled lives including provision for multi-agency, early stage, preventative team around the family support Together for Health (November 2011). The Welsh Government s five year NHS Plan, puts primary and community services at the centre of delivery, and is supported by a suite of delivery plans. P a g e 22

25 2.3.4 Delivering Local Health Care Accelerating the Pace of Change (2013) Building on the above documents, this is a three year plan to strengthen local health care services for the people of Wales. Its purpose is to increase the pace and scale of change in the way services, care and support are planned, organised and delivered, to better meet the needs of people in local communities across Wales. It provides a framework for action for Health Boards, Local Government and Third Sector partners to work together to provide high quality, safe and sustainable services. The key themes are: Improving health and wellbeing Improving access to local care Supporting people with long term conditions Improving care for older people Create equitable resilient services across all areas in Hywel Dda Encourage greater integration between health and social care and create a single system of care planning and delivery for services for older people Reduce the health inequalities gap through targeted investment of resources A Framework for Delivering Integrated Health and Social Care for Older People with Complex Needs (2014) This document launched a new Framework for the integration of health and social services for older people. The Welsh Government s policy aim is to improve existing services and develop a wide range of preventative services that can help people of all ages manage their own lives at home and avoid as far as possible having to go into hospital or residential care. The core concern of the new framework is to bring an end to fragmented care that confuses and frustrates providers and recipients alike. It acknowledged that fragmentation wastes resources, effort and opportunities Social Services & Wellbeing (Wales) Act 2014 Section 14 of the Act places a duty on health boards and local authorities to jointly undertake an assessment of the local population s care and support needs, including the support needs of carers. This assessment must also identify: The extent to which those needs are not being met; The range and level of services required to meet those needs; The range and level of services required to deliver the preventative services required in the Act; and How these services will be delivered through the medium of Welsh. The population assessment will ensure health boards and local authorities jointly produce a clear and specific evidence base to inform various planning and operational decisions, including IMTPs. The link between the population assessment and the IMTP process is set out in the statutory code of duty. P a g e 23

26 In Ceredigion, the elements of care that are key components within the community are related to prevention, early intervention and integrated health and social care for adults at risk of developing complex needs. This includes the creation of a prevention and early intervention strategy, including integrated health and social care service provision for those with complex needs or who require longer term care; and expanding rehabilitation / intermediate care services to assist in avoidance of hospital and nursing home admission through the development and extension of reablement service or shorter term targeted interventions Agreeing Individual Care with People who have Long Term Conditions (2014) This document states that promoting independence, not dependence and prudent healthcare are key and integral principles of agreeing individual care with people who have mental health, cancer and other long term conditions. The principles of this document will be at the heart of multi-disciplinary team working for the north and south Community Resource Teams in Ceredigion NHS Wales Planning Framework /16 The 2015/16 NHS Planning Framework was issued to the service on 31 st October It reaffirms the importance of effective planning across the NHS in Wales and has been strengthened in the following ways: National planning requirements have been clarified, with a focus on defining success and setting out expectations of the Integrated Medium Term Plans (IMTPs); Clear policy imperatives for strengthening primary and community care, embedding prudent healthcare and reducing health inequalities have been added; Decision making and approval responsibilities have been made clear; and The steps that will be taken to strengthen the planning profession across NHS Wales have been identified NHS Outcomes and Delivery Framework 2015/16 The 2015/16 NHS Wales Outcomes and Delivery Framework was developed to signal a new approach to performance management and monitoring. The aim was to ensure a greater focus on the improvement of population outcomes, and not just simply process. The framework was based around seven domains that have been identified through extensive public and stakeholder engagement Well-being of Future Generations (Wales) Act 2015 The Act places a statutory responsibility on Public Services Boards and certain public bodies, including NHS, local authorities and other partners, to plan services jointly. Working towards the well-being goals set out in the Act, with health needs assessments and community engagement central to this process, will help improve the health of the population and the delivery of prudent public services. P a g e 24

27 Our Plan for Primary Care in Wales up to March 2018 The plan gives details about the future development of the services provided and proposes action on the following five areas: Planning care locally Improving access and quality Equitable access A skilled local workforce Strong leadership The plan also provides details about the further development of the primary care workforce in Wales and the actions that need to be taken by a range of delivery partners to secure, manage and support a sustainable workforce shaped by local population needs and by prudent healthcare principles. The document sets out four main areas where action is needed: Putting in place the foundations for a more robust approach to workforce planning Supporting the continuing development of primary care clusters and the sharing of best practice Investing in the development of the wider primary care workforce Stabilising key sections of the current workforce Prudent Healthcare The new service model is based on the principles of prudent healthcare utilising coproduction and shared decision making: Achieve health and wellbeing with the public, patients and professionals as equal partners through co-production; Care for those with the greatest health need first, making the most effective use of all skills and resources; Do only what is needed, no more, no less; and do no harm. Reduce inappropriate variation using evidence based practices consistently and transparently. P a g e 25

28 2.4 Local Strategies Cardigan Integrated Care Centre FBC Your Health Your Future (2012) In response to these national policies, Hywel Dda UHB developed and consulted the public on a sustainable integrated strategy for health services across the Health Board. One of the supporting technical documents provided information about the Community Hospitals within Hywel Dda in terms of their location; services provided levels of efficiency and productivity and put forward proposals for their future use as part of the clinical services strategy. A Bed Utilisation Review was commissioned in 2011/12 to undertake a detailed analysis of the use of all acute and community hospital beds in Hywel Dda hospitals which found that high numbers of service users were ready for discharge and no longer needed to be in a hospital. There was little evidence of admission avoidance services, little sense of urgency regarding discharge planning and very long waits for specialist home equipment and adaptations prior to discharge. It highlighted that many service users occupying beds in acute and particularly in community hospitals could have their needs met in a different care setting. Reasons included the following: Service users were ready for discharge Service users were awaiting alternative provision Service users would have been appropriate for care at home if community health services had been available. At the time of the report Cardigan Hospital was providing 12 inpatient beds. The report found that 69% of these service users were suitable for an alternative level of care. The report cited observations as below: Admission avoidance: An Acute Care Consultant documented patient can go home or to Cardigan Hospital ; Discharge Planning: little pro-active discharge planning; no discharge planning lead; Culture re: admission avoidance / care coordination /discharge planning: risk adverse culture, lack of urgency to admission avoidance or discharge planning. Other Lack of carers in the community to provide care to service users after discharge Patients wait funding for continuing health care Need for staff training to maintain / improve skill level The report concluded that Hywel Dda should be a community led provider delivered by Primary, Community and Social Care teams operating from modern, enhanced community resource centres with full access to diagnostic services and a range of ambulatory care services. To deliver the Health Board s vision, Your Health: Your Future included specific proposals for: Seven localities within Hywel Dda providing care for the frail elderly in their own home or in their own locality. Care to be delivered in the service user s own home or in their local community by a multi-disciplinary team, so maintaining independence for longer. Developing health and social services care services based on a new integrated community service model. P a g e 26

29 A range of Mental Health improvements including the Welsh Government funded Mental Health (Wales) Measure 2010, extending therapeutic day services and a range of community services across the 3 counties The Framework for Delivering Integrated Health and Social Care for Older People with Complex Needs Statement of Intent 2014 This statement was produced by the partner organisations with statutory responsibility for health and social care services in mid and West Wales, namely: Carmarthenshire County Council Ceredigion County Council Hywel Dda University Health Board Pembrokeshire County Council The Statement reflected a long standing strategic commitment between the organisations to develop and deliver Health and Social Care Services, including those for older people, in an integrated way. This includes services for older people with dementia and other mental health conditions. The case for integrated care is reinforced by the need to develop whole-system working to address the demands arising from an ageing population and increases in the number of people with multiple long-term conditions. Consequently a key element of the local health plan is to develop a system of care that deals with a growing problem of frailty through continuing to build integrated systems of care. This model of care aligns with the policy direction within Delivering Local Health Care Accelerating the Pace of Change and the Framework for Delivering Integrated Health and Social for Older People with Complex Needs Integrated Medium Term Plan All Health Boards and Trusts were required to submit a draft Integrated Medium Term Plan (IMTP) to Welsh Government, covering the period 2015/16 to 2017/18 by 30 th January 2015 with a final version submitted by 31 st March This Full Business Case for the Cardigan Integrated Care Centre is entirely consistent with the approach of the Hywel Dda University Health Board for a fundamental shift towards providing care closer to home. It is also included in the capital development plans within the IMTP and is aligned with the Strategic Objective To deliver, as a minimum requirement, Outcome and Delivery Framework Targets and specifically eradicate undue travel and unnecessary waiting times as well as return the organisation to a sound financial footing over the lifetime of this plan. P a g e 27

30 Part B: The Case for Change 2.5 Service Changes since SOC and OBC Submission Strategic Outline Case In March 2010 Hywel Dda Health Board submitted a Strategic Outline Case for the introduction of a new model of care and development of new health and social care facilities in Cardigan, which would result in the closure of the existing Cardigan Hospital and Cardigan Health Centre and the relocation of Social Services Care staff. At that time the preferred option was to provide an integrated care facility with a total of 21 inpatient beds, at a total capital cost of 28,992,000 and additional revenue costs of between 93,000 and 282,000 per annum. Following SOC approval in 2010, there was a significant shift in both national and local policy towards providing integrated care closer to home. The Welsh Government s policy aim is to provide existing services and develop a wide range of preventative services to help people of all ages manage their own lives at home and avoid as far as possible having to go into hospital or residential care. Collectively the Welsh Government and NHS Wales identified a need to raise the ambition and effectiveness of planning in NHS Wales, which is facing some of the biggest challenges and opportunities since its creation, including: A rising elderly population Inequalities in health Enduring austerity Increasing numbers of service users with chronic conditions Some specialist services being spread too thinly In response to these challenges, Hywel Dda University Health Board (UHB) developed and consulted the public on a sustainable integrated strategy for services across the UHB. The resulting document Your Health Your Future (2012) proposed to develop health, social services and third sector care based on a new integrated community service model. As a result there have been significant changes in the way that services are delivered since the SOC was approved, with the emphasis now firmly on care closer to or within the patient s own home. The requirements for inpatient services in a community hospital setting has been replaced by the discharge of patients from acute hospital settings directly to their own home or to an alternative short stay setting for reablement and rehabilitation. Service user flows have changed and there is a greater requirement for primary care and community based services to support early discharge and prevent hospital admissions. This has resulted in a much clearer definition of the underpinning model of care. Inpatient Beds in Cardigan Evidence gathered from a bed utilisation audit in 2011 suggested that at least 50% of inpatients within Cardigan Hospital could be cared for in other environments or were ready for discharge if alternative care could be provided. Combined with concerns regarding the poor environment, privacy and dignity issues and extreme difficulty in providing sufficient registered nurses overnight, these findings resulted in the decommissioning of 9 inpatient beds during 2011, leaving a total of 12 beds open. P a g e 28

31 During 2013 a combination of factors affected the safe and sustainable operation of the remaining in-patient facilities within Cardigan Hospital. As a result of these issues, the UHB decided to decommission the remaining 12 inpatient beds in February At this time the new model of care was piloted. The new model of care involved the transfer of ward based staff into the community setting to strengthen the integrated health and social care team and the commissioning of a range of Interim beds in the Cardigan area. These included commissioning of placements within Residential Care, Nursing Care, Sheltered and Extra Care Housing to provide a much more flexible infrastructure that can support the longer term vision and model. Since February 2014 the use of the Interim Beds in nursing homes has been closely monitored and to date there has been no change in patient flow to more remote community hospitals or any increase in delayed transfers of care. During 2014/15, 76% of patients were associated with timely discharge and 24% with admission avoidance and this pattern has continued into 2015/16. This will continue to be monitored as part of the evaluation process Outline Business Case The Outline Business Case was submitted to Welsh Government as a draft at the end of July 2014 for initial scrutiny. The OBC proposed a new build Integrated Care Centre at a gross capital cost of 19,922,944 with recurring annual cash releasing revenue savings of 87,136. Revenue Consequences of the Project At the time of submission of the draft OBC in July 2014, it was acknowledged by the Health Board that further work would be required in order to reduce the revenue impact of the project. The Health Board identified two ways of achieving this: By reviewing the workforce model for the project; By undertaking a further review of the functional content of the building. The Health Board carried out these detailed reviews and incorporated the outcome of each into an updated Outline Business Case which was submitted to WG in December The updated OBC was supported by a detailed Estates Annex Addendum document and the main changes are summarised below. Workforce Model The updated OBC (submitted in December 2014) contains details of the proposed workforce model for the new facility and the anticipated revenue cost impact of the project. Further Review of the Functional Content of the Building Based on scrutiny comments, the Health Board completed an in-depth review of the functional content of the preferred option, which resulted in a reduction in the proposed schedule of accommodation from 4,058m 2 to 3,550m 2 which represents a reduction of some 500m 2. P a g e 29

32 The floor plans for the preferred option were subsequently revised to reflect the reduction in floor area. A copy of the revised schedule of accommodation for the preferred option and the revised 1:200 floor plans for the preferred option are included as appendices to the Estates Annex Addendum document (November 2014). (Please refer to the Estates Annex Addendum Document given at Appendix 1). Further Development of the Do Minimum Option In addition to the above, one of the main comments in the scrutiny grid was that the Do Minimum option should be a realistic option capable of delivery. The Health Board therefore introduced a new option as part of the revised OBC submitted in December 2014, which was shown in the short-list as Option 7 the Do Minimum Option, with the previous Do Minimum option (Option 1) becoming the Do Nothing Option. In this new option (Option 7 Do Minimum), the current Cardigan Hospital would be completely refurbished and altered to accommodate the required schedule of accommodation. In developing this option it was immediately apparent that at circa 1,730m 2, the building would not be big enough to accommodate the required 3,550m 2 from the revised schedule of accommodation and so it was agreed that the GP s would have to remain in their existing building which would also be fully refurbished as part of this option. In developing the new Option 7 Do Minimum option, the following approach was taken by the Design Team in conjunction with the Health Board. The first approach was to take the existing floor plans for Cardigan Hospital and strip out the internal non-load bearing partition walls to show the load bearing elements of the building. The total floor area of the existing building is 1,730m 2 as noted above. The current building falls a long way short of compliance with the Building Regulations, inparticular Part L and the assumption is that the external fabric would need to be upgraded to meet the building regulations. At this stage, it was assumed that a 200mm zone in each room would be required to upgrade the fabric. This would have the effect of reducing the internal floor area to circa 1,515m 2. An exercise was then carried out to determine how much accommodation could be fitted into the building (excluding the GP accommodation) around a primary circulation route on each floor. The outcome of this was that only 53% of the revised schedule of accommodation could be fitted into the available space. The Do Minimum option therefore has the following limitations:- The desired level of accommodation cannot be delivered within the existing buildings to meet the Health Boards aspirations of its required model of care and will also not provide the integration of services as Health Board, GMS and Social Services staff would not be co-located. The original 2008 site option appraisal exercise concluded that whilst the Cardigan Hospital site has good access to town and the trunk road, the site is too small, is bordered by a listed building and has flood plain issues. Out of a total of 7 options, the Cardigan Hospital site was ranked as the 5th out of 7 in the site option appraisal. There are also a number of construction related issues with the current hospital building and site: The nature of the load bearing structure is such that the spatial arrangement limits flexibility and would be very difficult to adapt to modern space standards. P a g e 30

33 There are several level differences in the building meaning that a lot of work would be required in order to improve accessibility entering and moving horizontally and vertically through the building. The existing lifts in the building are not compliant and don t serve the top floor. The existing stairs in the building do not conform to the current Building Regulations. They are too steep and do not have the appropriate landings. It is probable that the position of the windows in the building could compromise the planning of spaces and impede the natural ventilation and daylight strategy. There is known asbestos in the building and hence a programme of removal would be required prior to commencement of any refurbishment works. This would also be likely to impact on current services at the site. It is understood that the existing façade of the hospital may have some historical significance which could restrict alterations to the fabric of the building and could have an effect on the internal layout. It would be difficult to achieve a BREEAM very good rating for the site. A number of existing fire escapes from the hospital involve external stairs or a stepped exit which are unlikely to conform to current standards. There would be added car park pressures, as parking is already underprovided on the site. The drainage, mechanical, electrical and plumbing infrastructure at the hospital is approaching the end of its functional life and would require wholesale replacement to meet the required capacity and to conform to current standards. In order to carry out the works to both the hospital and the Health Centre, it would be necessary to decant some/all services off site for the duration of the works. This is likely to be particularly problematic as it would require patients and visitors to attend a different site with the logistical issues that this would bring. This option was not considered viable and was discounted. Updated Cost Forms The OB cost forms for the preferred option were updated, based on the revised floor area of 3550m 2, resulting in a reduction in the forecast project out-turn cost from 21,917, to 19,922, The final updated version of the OBC was submitted at the end of December 2014 to WG for formal scrutiny. Further discussion during OBC Scrutiny Process As a result of further discussions with NWSSP-FS and WG during the OBC scrutiny process, the floor area was reviewed again and this resulted in the floor area being reduced from 4,058m 2 at OBC submission to circa 3,152m 2. Appendix 2 provides details of the correspondence with WG during this period. The OBC was finally approved by WG in June 2015 on this basis. N.B. It should be noted that during the FBC design process, the floor area of 3,152m 2 approved in the OBC has increased slightly to circa 3,170m 2 as a result of an extension to the building draft lobby arrangements. P a g e 31

34 Equality Impact Assessment An Equality Impact Assessment (EqIA) has been undertaken to evaluate the impact of the project proposals on groups or individuals with protected characteristics under the Equality Act 2010, and this is given at Appendix 3. The document was approved by the Project Board on 9 th December The process of EqIA enables the organisation to consider the effects of its decisions, policies or services on different communities, individuals or groups Current Services The following services are currently provided within or from the current Cardigan Hospital site: Outpatient Services Minor Injury Unit Radiology Dietetic Services Physiotherapy Occupational Therapy Speech & Language Therapy Podiatry and Orthotic Services Pulmonary Rehabilitation Paediatric Rheumatology Base for the Community Resource Nursing Team, Health Visitors & School Nurses Sexual Health Services Maternity Services Ophthalmology Services Continence Services Lymphoedema Tissue Viability Macmillan Nursing Clinical Musculoskeletal Assessment and Treatment Service Children s Continuing Care Team The following services are currently provided within Cardigan Health Centre: General Medical Services Community Dental Service Current Activity a. Outpatients and Therapies During the last financial year (2014/15) there were over 8,500 attendances at Outpatient Clinics and in the Therapy Departments in the current community hospital. Figure 5 shows the distribution of patients, which demonstrates that 92% of patients are from the Cardigan and district locality, with the vast majority from South Ceredigion. P a g e 32

35 Figure 5: Outpatient and Therapies activity 2013/14 South Ceredigion North Ceredigion North Pembrokeshire South Pembrokeshire Out of Area Taf / Teifi / Tywi Ammen / Gwendraeth Llanelli The distribution of patients by GP Practice locality is shown in the analysis below, with the majority of patients being registered with the original GP Bed Fund Practices: Cardigan Health Centre (3,127); Ashleigh Surgery (1,889); Meddygfa Emlyn Surgery (1,375) in South Ceredigion and Newport Surgery (533) in north Pembrokeshire: Figure 6: Distribution of patients by GP Practice Locality P a g e 33

36 b. Outpatient attendances Outpatient attendances between 1 st April 2012 and 31 st March 2015 have been reducing in number due to the inadequate facilities within the current Outpatient Department: Figure 7: Outpatient Attendances by Specialty April 2012 to March 2015 Conversely, Therapies activity over the last three years (1 st April 2012 to 31 st March 2015) shows a year on year increase, with a marked increase in physiotherapy activity: Figure 8: Physiotherapy Activity: Cardigan Hospital / Community It should be noted that the activity for 2015/16 has been extrapolated from actual activity undertaken April 2015 to March P a g e 34

37 c. Minor Injury Unit Activity in the Minor Injury Unit between April 2013 and September 2015 is shown in Figure 9 below. This shows that activity increases during summer months in line with the transient holiday population to the area. The activity is increasing year on year as the service becomes more known. Figure 9: Attendances in the Minor Injury Unit Figure 10 below identifies the outcomes of these referrals to the Minor Injuries Unit between September 2013 and September Of the 5,181 attendances during this period, 80% were treated within the Minor Injuries Unit, 10% were referred to a local General Practitioner and only 10% were unable to be treated on site and therefore referred on for further investigation or treatment within an acute hospital setting. Figure 10: Outcome of MIU Attendances P a g e 35

38 d. Radiology Services The existing Radiology Department at Cardigan Hospital provides a general plain x-ray service and the department is open Monday-Friday. The current X-Ray equipment was retro-fitted into existing space and its capacity is limited as it is a floor mounted X-Ray tube which is cumbersome to use. The equipment is already beyond its formal replacement date and cannot be transferred to the new building. Radiology activity over the last five years is shown in Figure 11 below. This shows that the number of patients examined continues to gradually increase year on year, and it is anticipated that this demand will continue to grow. Figure 11: Cardigan Hospital X-Ray Activity e. Community Dental Community Dental Services are currently provided at Cardigan Health Centre on three days per week and activity levels are increasing year on year, as shown in Figure 12: The increase in first contacts is due to the increasing complexity of cases being treated. Figure 12: Cardigan Health Centre Community Dental Activity 2012/ /15 P a g e 36

39 2.6 Justification and Business Needs Demography and Demand As already discussed in Section 2.2.2, South Ceredigion has a higher proportion of residents in the higher age groups (55+), and a correspondingly lower level of residents in the age groups than the Wales average. These statistics may be due to the older population retiring to the area, whilst those of working age seeking employment elsewhere. The result is that there are a larger proportion of older residents who, by their nature, will require health and social care support, with a smaller workforce to provide for them. In addition to this, over the next 20 years Ceredigion is predicting slightly higher than the national average population growth of 0.7% per annum. The effects of this demography have been assessed in relation to actual activity within Hywel Dda. This rapidly growing ageing population and associated increasing likelihood of multiple comorbidities is changing the demands made on health and social care. All areas of Hywel Dda have a higher proportion of residents over 65 years than any other areas of Wales. Due to this, combined with increasing life expectancy having the potential for increased years living with poor health and dependence, it is predicted that there will be an increase in the elderly who will experience increasingly complex needs which will need to be met in order to enable them to remain at home. A detailed workforce plan was developed and implemented as part of the Integrated Medium Term Plan (IMTP) planning process for 2015/16. The workforce plan factored in significant growth in community nursing and community therapy staff over three years to reflect the anticipated demographic changes and the changing balance from acute care to care closer to home Current Accommodation Services for the Cardigan locality are currently provided from Cardigan Health Centre and Cardigan Memorial Hospital. a. Cardigan Health Centre P a g e 37

40 The original building was built in As of October 2015 the backlog total was 400,400 and the occupancy costs were circa 25,600 per annum (including utilities, maintenance, rates, waste and cleaning services). A Portakabin in the car park is used for the administrative base for the Practice. This is now approximately 37 years old, and allows ingress of water. The following information is listed for Cardigan Health Centre: Space Utilisation within Estates Code = Category O/F (Overcrowded / Fully Used) Functionality within Estates Code = Category D (Poor) Energy Performance = Poor Further information on the estate is given in the Estates Annex. b. Cardigan Memorial Hospital The original building dates back to the early 19th Century, and was converted into the Memorial Hospital in As of October 2015 the backlog total was 2,278,804 and the occupancy costs were circa 159,443 per annum (including utilities, maintenance, rates, waste and cleaning). The following information is listed for Cardigan Memorial Hospital: Space Utilisation within Estates Code = Category O/F (Overcrowded / Fully Used) Functionality within Estates Code = Category D (Poor) Energy Performance = DEC Rated D Further information on the estate is given in the Estates Annex. P a g e 38

41 The general lack of space made available through the site, including both clinical and nonclinical facilities fall well below expected standards. This lack of space combined with the shortfall in facilities has an adverse impact on the overall functionality of the hospital. The physical condition of the site has deteriorated through age despite general maintenance and other building and engineering upgrades. Despite the efforts of staff who maintain a high level of service, it can be concluded that the current space and functional constraints do not support the standards expected of a modern health care facility. P a g e 39

42 2.6.3 Services: Cardigan Health Centre a. General Medical Services Current Position Cardigan Health Centre provides the full range of essential and additional services as defined under the new GMS contract along with a number of enhanced services. The Partners in the Surgery have a variety of special interests in asthma, diabetes, CHD, child health, hypertension and women s health. The Practice is also minor surgery accredited with activity figures capped at 80 excisions and 80 injections per annum. The Practice could undertake more minor surgery procedures if appropriate building facilities were in place. Their current Practice population list size is 7,800 patients with a noticeable higher proportion of these patients being elderly. The Practice size is slowly increasing with a marked increase in requests from patients wishing to transfer into the Practice from elsewhere. Although the net list size is increasing moderately, the attrition of patients is much greater than in the past. South Ceredigion has the greatest percentage of its practice population aged 65+ and 85+ of all the GP Clusters in Hywel Dda. The Practice has 26% of patients over 65 years old. Following the opening of the Maes Mwldan Extra Care Housing Scheme in Cardigan the Practice has seen an increase in the number of patients with complex health needs. As a result, the Practice experiences a higher prevalence of incidence in the majority of chronic diseases against the all Wales and national average (QOF Prevalence Report 2014/2015). In particular there has been a noticeable increase in the number of patients who have hypertension and diabetes which has doubled over the last five years. The Practice has engaged with HDUHB and signed up to offer the diabetic enhanced service and has utilised existing nursing staff to support the work of the diabetic lead nurse. The Practice also serves five nursing and residential care homes within the Practice boundary. The Practice population also swells during the holiday season with an increase of between temporary patients annually with the majority, patients, between April and August (based on 2014 figures). Due to the premises constraints, the Practice is currently not a training practice. At the current time, the Practice is experiencing such a shortage in space they feel they are unable to undertake the training course as there is no space to accommodate a locum to cover for the GP s training time. The Practice is currently unable to provide all the services that it would like due to the constraints of the current accommodation. It is anticipated that the new accommodation will further facilitate closer working relationships with the Health Board, Social Care and Third Sector to develop services further. The Cardigan Health Centre Practice operates from three premises in close proximity to each other: GMS services are provided from the main Health Centre premises (built in 1972) located in Cardigan town centre at the following address: Cardigan Health Centre, Feidrfair, Cardigan SA43 1EB. The Practice currently operates from 6 very small consulting rooms which do not meet current spatial standards, and is 3 rooms short of WHC guidance. The Practice is unable to take on additional staff as the current space is fully utilised and overcrowded. P a g e 40

43 Cardigan Health Centre GP Consulting Room P a g e 41

44 Treatment Room 2 Workstations The practice also has a portakabin located in the Health Centre car park (at the same address above). The portakabin houses administrative staff due to the lack of space at the Health Centre. Portakabin showing Data Cabling for the Health Centre Site P a g e 42

45 Administration and IT Server Area in Portakabin Medical records are housed and clinical meetings held in an end of terrace house adjacent to the health centre located at 30 Feidr Fawr, Cardigan SA43 1EB. The terraced house was built pre As well as housing medical records it is used for doctor s meetings with other agencies e.g. LHB, CMHT, Drug Workers, which leaves little scope for further use by staff. The facilities are too small to allow any group training sessions. Whilst the current Health Centre and portakabin are owned by the Health Board, the terraced house is owned by the GP practice. A decision has not been made as to its future however it will not be used for GMS purposes once a new facility is operational. Record storage in front entrance of Terraced House opening from Main Road Further details of Cardigan Health Centre are given in the Estates Annex. P a g e 43

46 Business Need In recent years the Health Centre has received some minor improvements to the building, such as an upgraded reception area, the addition of a disabled WC and the provision of a container outside the Health Centre for additional storage of health records as the Practice has outgrown the existing space available. However, it has not been possible to extend any services or increase staffing due to the limitations of the accommodation. The current accommodation from which the GP Practice is providing services is inadequate and not fit for providing modern primary health services. New, enhanced accommodation will be essential for the Practice to continue to provide existing services going forward and enable the development of enhanced provision such as: Meeting standards for accommodation within GMS facilities; Providing services for the predicted growth of population within Ceredigion, which has been estimated at an additional 1,000 new patients for the Practice; Providing dedicated phlebotomy accommodation Increased minor surgical procedures Becoming a training practice; contributing to the training of future GPs whilst providing up to date support and education for the entire practice The Practice is continuing to review all chronic disease clinics to ensure the best use of current nursing staff. This is fully supported by continuing to improve nursing skills, training and education through internal and external courses. The new Cardigan Integrated Care Centre will be invaluable in supporting this both in terms of the provision of suitable training accommodation and closer proximity to a multidisciplinary team. Improving integration between health, social care and third sector providers within the Cardigan locality. The new facility will also support the work of the South Ceredigion and Teifi Valley GP Cluster Network Plan 2015/16 which is aimed at complementing individual Practice Development Plans, tackling issues that cannot be managed at an individual Practice level or addressing challenges that can be more effectively delivered through collaborative action. Through the work of the Cluster Network the new facility will enable the Practice to host a number of new staff, namely two Pharmacists and a Community Frailty Nurse. Improved and additional clinical accommodation to support cluster planning work for example Doctor First triage system already launched by the Practice. This system allows for many more patient contacts in the day. Provision of dedicated accommodation for two newly appointed Emergency Nurse Practitioners. b. Dental Services Cardigan Health Centre Current Service Currently the Community Dental Services (CDS) are provided from Cardigan Health Centre, and provide dental care predominantly for service users requiring special care dentistry, vulnerable service users and those unable to access general dental services. This includes physically disabled and mental health patients. During 2014/15, 1,391 dental service user contacts were delivered to these service users, and this level of service is increasing year on year in spite of accommodation limitations. The facilities are limited and in poor condition and the closest alternative facilities are in Haverfordwest, Aberystwyth or Lampeter. P a g e 44

47 There is currently no provision of Orthodontic Services or Oral Surgery in Ceredigion and Pembrokeshire, with service users having to travel to Carmarthen or Swansea to receive treatment. Prevention services and programmes through the Community Dental Service and Designed to Smile, and Oral Cancer screening are not currently available due to lack of suitable facilities. The facilities do not allow for any Community Dental Services to be provided for bariatric service users or wheelchair users, who currently have to travel to Cardiff. Business Need New facilities are required in order to improve the range and quality of dental service currently available in the Cardigan area and provide the opportunity to repatriate additional dental activity to the Ceredigion area. A new, purpose designed facility would allow the development of a multi-functional dental suite able to be used by various dental disciplines: The current Community Dental Service (CDS) generates 1,391 service user contacts per annum. There are an additional 562 service users on the UHBs waiting list for a General Dental Practice in Ceredigion, with an average of 26 patients being added each month in the last twelve months (up to February 2016). The new surgery will be fully staffed for 6 sessions per week and there will be a further 2 sessions assigned to domiciliary visits, which will use the site as its clinical base. Orthodontic Assessment Service. The current waiting list for Primary Care Orthodontics Treatment in Carmarthen includes circa 600 service users from the Cardigan and surrounding areas with demand for the service continuing to grow. 90% of assessments lead to treatment, and therefore 500 courses of treatment could be provided within Cardigan rather than in Carmarthen. Monthly Orthodontic Assessment Clinics will be held in the new facility. Oral Surgery. Between January and December 2015, 589 referrals were made from the Cardigan area for oral surgery assessment to Carmarthen or Swansea, which represents a 23% increase in referrals in the last two years. It is anticipated that in excess of 200 of these service users per annum could be treated within Cardigan if the facilities permitted. Prevention services and programmes through the Community Dental Service and Designed to Smile programme. Bariatric service users and wheelchair users from the locality would be able to access dental assessment and treatment within Cardigan, thereby avoiding travel to Cardiff. A multi-disciplinary facility would support the UHBs Local Oral Health Plan, delivering services locally and enable the CDS to underpin the UHBs dental service by way of expanding the current range of services offered, enabling dental services to be provided on a more cost effective basis. The current CDS workforce would transfer to a new facility and continue to deliver the service. P a g e 45

48 2.6.4 Services: Cardigan Memorial Hospital a. Community Resource Nursing Service (CRN) Community service delivery has been aligned to seven geographical localities within Hywel Dda to provide a locality partnership network of health, social care and third sector services that deliver a bespoke service to meet the needs of the local population. As a result of the new model of care in Cardigan, the ward based staffing has received additional training and experience on an individual basis to enable them to fulfil roles within the community nursing services and specialities. The South Ceredigion Community Resource Nursing (CRN) Service was established in 2014 following the decommissioning of the remaining inpatient beds in Cardigan Hospital, in line with HDUHBs Community Service Model providing care closer to home. Referrals continue to increase as the work of the CRN Team becomes more widely known. During 2015/16 a total of 1104 referrals were received. The reason for referral of these cases is shown in Figure 13: Figure 13: Reason for Referral to CRN Team 2015/16 (activated cases only) Figure 14: Number of Hospital Bed Nights Avoided by CRN Team The hub for this new service model is Cardigan Hospital where all referrals are received via a single point of access. P a g e 46

49 Business Need: The CRN works as an integrated part of the Ceredigion Community Resource model to ensure that: Care is provided closer to home; Focused on quality, safety and improving patient outcomes; Flexibly utilising a skilled and motivated workforce; Investing in prevention; Eliminating waste, duplication and enabling value for money. During the first nine months of operation the CRN: Received 900 referrals; Supported the Community Nursing Services, Targeted Intervention Service, the Ceredigion and Carmarthen Continuing Health Teams and Marie Curie; Has supported the staff in Tregaron whilst an intense training programme is being delivered; Has managed its own case load of 182 patients; Has delivered over 4000 home visits and saved 921 in-patient bed nights or an average of 3.4 beds; Has flexed to meet changing demands from other services and evolved over the period. The service is continuing to evolve whilst being continually monitored and reviewed to ensure it continues to meet the needs of the community. A priority for has been to raise awareness of the service in Glangwili General Hospital and identify any gaps in provision which result in patients not being referred. Impact on Hospital Beds The figure below illustrates the number of active patients seen by the CRN team who were referred either to enable a timely discharge or to avoid admission into hospital; it is assumed that for the duration of their case with CRN they would otherwise have occupied a District Hospital Bed. Figure 15: Number of CRN Active Patient Cases per Day 2015 P a g e 47

50 Discharge Location Whilst recording a location for discharge has not been captured for all patients, the figure below represents what has been recorded. Figure 16: CRN Discharge Location 2015/16 Flexibility of the service Since it began, the service has flexed to meet changing needs. The team is now smaller due to some nursing staff being regularly based with other Community Nursing Teams to enable a more consistent approach to allocation of patient cases. This demonstrates a natural progression towards integration. Since March 2015 the new focus of the team has been to support Tregaron Community Hospital to enable existing nursing staff to undertake training in the community setting without impacting on the in-patient service. This will support the introduction of the care closer to home model in the North Ceredigion locality in line with the service now provided in South Ceredigion. b. Physiotherapy The Physiotherapy Department is located on the southern side of the main block and consists of a split level open plan area with 4 curtained cubicles, and two treatment areas. The restrictions on space are twofold. Not only is there insufficient space to accommodate all the current service requirements, but the configuration of the rooms themselves have determined the room usage to the detriment of the service. The physiotherapy area itself is quite cramped due in part to the need for physiotherapy equipment and the location of the main entrance to the department which leads directly from the waiting area and the physiotherapy room. The main Treatment Room is adequate in size but the room itself is compromised by the need to accommodate an office area due to the overall lack of space within the department. The secondary treatment room located to the back of the department is adequate in terms of space but does seem claustrophobic due to having no windows. P a g e 48

51 Storage space is an issue, especially due to the size and quantity of equipment required to support a physiotherapy department. The store room is too small, and this has resulted in walking aids being stored outside the department Due to the limited open rehabilitation space it is not possible to conduct comprehensive group rehabilitation programmes, and staff therefore have to offer 1:1 sessions. There are no sanitary facilities within the department and no disabled toilet on this floor, which again makes the area unsuitable for service users in need of therapy. c. Musculoskeletal (MSK) Outpatient Service Current Service Table 1 below shows the musculoskeletal (MSK) referrals received, new service user and follow-up provided at Cardigan Hospital on average per month for 2012/13 and 2013/14, and projected activity from 2015/16 onwards: New referrals received Table 1: MSK Outpatient Service Activity 2012 / / / 16 onwards New Patients Assessed New referrals received New Patients Assessed New referrals received New Patients Assessed Followups Followups Followups Business Need The existing facilities are unable to support this increase in activity. There is a demand for group MSK sessions which is currently unmet due to the lack of suitable accommodation. This is resulting in service users receiving individual-only intervention which affects the efficiency of the service. This is already a significant issue, and will worsen with the anticipated future demand for the service, in particular Clinical Musculoskeletal Assessment & Treatment Service (CMATS) and self-referral. Additionally self-referral walk-in clinics are not possible due to the lack of space. These clinics have been established in other areas within Hywel Dda in order to streamline rapid access to MSK physiotherapy for those people with acute need, and therefore residents within the Cardigan area are being disadvantaged due to lack of suitable facilities. P a g e 49

52 d. Clinical Musculoskeletal Assessment and Treatment Service (CMATS) Current Service CMATS commenced during 2013/14 as a newly funded service being developed across Hywel Dda. CMATS provides a community clinic based service for the assessment and treatment of musculoskeletal conditions through a streamlined, interdisciplinary approach to achieve optimum outcomes for service users. It provides specialist musculoskeletal support to primary care as an alternative to secondary care Consultant Outpatient opinion. The service includes orthopaedic clinics and service users with complex MSK pain being referred to pain services, and offers GPs the option of referring to CMATS rather than to current secondary care specialists such as Orthopaedics, Rheumatology or Pain Clinics. The CMATS team provides a comprehensive assessment and treatment service ensuring that service users who do not require surgery are managed appropriately without being routed to alternative services by an orthopaedic surgeon. Those people who do require surgery receive pre-surgical support close to home. This support includes advice, lifestyle management support (e.g. obesity pathway), access to core therapy services, appropriate imaging / blood investigations etc., ensuring that service users arrive at consultant clinics in the best condition for surgical intervention and with all of the appropriate imaging undertaken, so the consultant can make rapid, informed surgical decisions. CMATS is reducing inappropriate referrals to Orthopaedics/pain/ rheumatology services. It is anticipated that the current levels of orthopaedic clinics provided within Cardigan will be maintained in order to reduce the waiting times for appointments significantly for outpatient orthopaedics. Business Need The current facilities within Cardigan are not able to fully support the current CMATS activity. Activity rose from 93 referrals in 2013/14 to 271 in 2014/15, reducing the demand on secondary care services. It is anticipated that annual referrals will continue to increase by 40%, based on the experience in Pembrokeshire when CMATS was introduced in Therefore, referrals overall will increase to approximately 1,084 during 2015/16. The existing facilities will not be able to accommodate this level of service. Without new facilities Cardigan will not be able to provide CMATS in line with Hywel Dda strategy and the anticipated increase in service demand. In addition CMAT clinics are regularly cancelled in Cardigan due to competing demand for clinical space. As part of a comprehensive MSK / CMAT service the Health Board are currently recruiting to Advanced practitioner posts to support a new pain service. Clinics and group sessions will be required to be delivered in Cardigan and local residents will be disadvantaged if facilities are not provided for this specialist service to be rolled out locally. The strategic direction for the development of primary care will involve the expansion of MSK and CMAT services. Musculoskeletal (MSK) conditions make up 30% of typical GP caseloads. This can rise to 50% of a GP s caseload for patients over 75 years of age. There is a strong and developing evidence base that demonstrates 85% of these patients can be appropriately managed by physiotherapists working in primary care. The development of advanced physiotherapy practitioner roles in primary care would allow for immediate and measurable reductions in MSK workloads on general practice, helping to lift some of the considerable pressures that these services are currently under. It is anticipated that over time service models in Cardigan will require an expansion of the core MSK and CMAT capacity. P a g e 50

53 e. Adult Community Physiotherapy Current Service The Adult Community Physiotherapy service is provided as part of the Targeted Intervention Service (TIS). The physiotherapists in the south of the county who deliver services in the Cardigan area currently receive an average of 210 referrals per annum. The service continues to develop to support chronic condition management, e.g. long term neurological service, falls, frailty and pulmonary rehabilitation. Business Need There are currently no facilities available to provide specialist intervention that cannot be delivered within the patient s own home. Patients who are managed by community services with neurological conditions such as multiple sclerosis often have significant physical disability requiring more specialised facilities such as larger plinths / hoist etc. They cannot be managed within the current facilities at Cardigan Hospital. To receive treatment in appropriate accommodation and with appropriate equipment, service users are therefore required to attend other hospitals. Travelling to these sites (for example Glangwili General Hospital, Carmarthen) can impact on a service user s functional performance and may negate the value of the intervention. Within the new development there will be a comprehensive therapies department, purpose designed and built to cater for these patients needs. Frailty Expansion of frailty services within the locality of Cardigan is anticipated with specific frailty clinics and MDT assessment and intervention as part of proposed CRT development. Physiotherapy will be a key component in the expansion of services to accommodate the aging population in Ceredigion. The Health Board will expect to maximize key physiotherapy skills in the early assessment and proactive management of people presenting with complex multifactorial health and social care needs focusing on frailty and complex neurological conditions. Key skills include autonomous medical and frailty assessment, clinical diagnosis, treatment, impact of disease and physical impairment on function, risk assessment regarding appropriate place of care, education, signposting to a range of professionals and agencies to support self-management strategies. Physiotherapy led MDT falls clinics and strength/ balance groups supported by specialist gait analysis sessions will be implemented if facilities are expanded. This has been supported through recent ICF bids. Current facilities are unsuitable for group led sessions. Chronic Disease Management A robust evidence base indicates that both cardiac (CR) and pulmonary rehabilitation (PR) have significant impact on quality of life, self-management of chronic disease and reduction in hospital admissions. A multidisciplinary team delivering CR and PR is provided within other Counties. However there is currently no PR service provision within Ceredigion and CR service is provided with nursing service only in local leisure facilities. A number of reports and National standards clearly articulate this compromises the service delivery and patient care. The provision of physiotherapy inequity of access, provision, funding and staffing of services is resulting in suboptimal uptake and benefits in patients with cardiac and respiratory chronic conditions. P a g e 51

54 These specialist services will need to interface with the generalist community resource teams, primary and secondary care services. CVD remains the number one cause of all deaths globally (30%) and the most common cause of death in the United Kingdom (UK), with a higher than average prevalence in Wales (4.3%). There are additional demands given the increased CVD morbidity within Mid & South West Wales and the rural nature of the Health Board. Ceredigion has an increasing resident population with projected increases in the proportion of over 65 s and 85years +. The elderly population are more concentrated in the rural areas of the County. Income levels are amongst the lowest in Wales. Access to services is poor due to the rural nature of the County. The reported prevalence of coronary heart disease in the county is the same as the Welsh average, with prevalence of hypertension, atrial fibrillation and heart failure being above average. Expansion of chronic condition management services within the new facilities will be priority. Hywel Dda has always been committed to improving the care for people who live with or at risk of a respiratory disease. A Respiratory Planning and Delivery Group was established in 2014 chaired by a Respiratory Consultant and supported buy all professionals working in respiratory care, patient representation, and BLF Wales representation. Pulmonary rehabilitation and integrated Breath Easy groups are to be delivered in a safe environment once facilities are made available. An integrated Breathe Easy group is a self-help support group run by and for people affected by lung disease which has a focus on helping members look after their health, and has strong links with local respiratory specialists. The local Breatheasy group supported by physiotherapy is currently delivered in public buildings and meeting rooms which are not conducive to supporting the exercise component in a purpose build facility. Paediatrics There is no identified children centre in Ceredigion or any of the other HB counties. There is no facility fit for purpose for assessment, intervention and follow up within a joined up approach in comparison to all other HB s. The paediatric physiotherapy service has historically spent time travelling to homes across large geographical areas within the counties, providing services within schools with no identified or protected therapy facility. Demands to the service in 2015/16 for children in Ceredigion and Pembrokeshire include: New Patients: Ceredigion = 74 Pembrokeshire = 156 Follow Up: Ceredigion = 445 Pembrokeshire = 546 The indirect travel time to meet assessment and intervention needs is disproportionate as a consequence of no identified fit for purpose facility available. The impact to children and their families and to staff is one of lack of recognition of value to date in terms of environment and facilities to meet need in line with other HB s. This is an opportunity to address some of the shortfalls. Neurological Services As part of the Neurological delivery plan it is recognised that there are inadequate facilities for assessing, treating and supporting rehabilitation for this specialist patient group. This spans across all neurological conditions and within the area of Learning disability. With the plan for an established Specialist team in neurological rehabilitation it is essential to ensure the P a g e 52

55 facilities and environment to assess and treat is fit for purpose with adequate space, equipment and solitude. Many of this patient group will be vulnerable; have potential behavioural and psychological issues in need of the appropriate environment to address. Lymphoedema In line with the All Wales Lymphoedema strategy it has been recognised that the clinical setting available to see patients is extremely limited and inadequate currently. The referrals to this specialist service in 2015/16 in Ceredigion include: New Patients: Ceredigion = 201 Pembrokeshire = 251 Follow Up: Ceredigion = 1,539 Pembrokeshire = 2,084 There is a trend of increasing demand to this service and the requirement to increasingly cross counties to deliver. There will be an expected increase in paediatric referrals already identified within the National Paediatric Lymphoedema programme. f. Occupational Therapy Services The scope of Occupational Therapy (OT) Services currently delivered to residents in the Cardigan catchment area is significantly restricted by the lack of facilities available, as described below. Current Service Community OT is provided in partnership with the Local Authority community service. During 2013/14, 371 referrals from the south of Ceredigion required OT and in 2014/15 a total of 399 referrals were received. Business Need Demand for Community Occupational Therapy is anticipated to increase significantly with the implementation of the new model of care, with service users being cared for as close to home as possible. However the service is currently limited due to the lack of in-reach facilities. Whilst the service is more appropriately provided in the clients home, critically the OT service for the south of Ceredigion has no access to facilities for assessment and intervention when the service user s home is not the optimum setting e.g. cognitive assessment, hand function, RA splinting. Within the new development there will be a comprehensive therapies department, purpose designed and built to cater for these patient s needs. This will importantly widen the scope of service available to meet local needs, including appropriate group and clinical provision with regards to Frailty; Chronic Conditions and Neurological Conditions Management. P a g e 53

56 g. Paediatric OT Current Service Cardigan Integrated Care Centre FBC Ceredigion was the last county in Wales to establish Paediatric OT, with the first NHS Paediatric OT being appointed in The Paediatric OT and OT Technician are both based at Cardigan Hospital. During 2014/15, 117 new referrals were received, and as the service is still newly established, referral numbers are increasing. Business Need Those requiring specialist assessment and intervention or use of technical equipment must travel to Carmarthen as there are no available facilities in Cardigan. This applies to both the child and the Occupational Therapist, causing significant inconvenience and disruption for the child and their family, and significant reduction in the efficiency of the OT service. Within the new development there will be a comprehensive therapies department, purpose designed and built to cater for these patient s needs. This will enable the Paediatric OT service to become more efficient and effective, and increase activity without an increase in revenue. h. Outpatient Department The current Outpatient and Minor Injuries Department was built during the late 1970s and early 1980s, and includes Dietetics, Speech & Language Therapy, Phlebotomy and Podiatry Services as well as Outpatient Clinics and Minor Injuries services. There is a lack of space throughout the department to accommodate adequate treatment rooms, equipment storage, office space and changing facilities, and this has a detrimental effect on the department. The outpatient section consists of two Consulting Rooms and three Examination Rooms, which have to double up as inadequately sized treatment rooms. P a g e 54

57 The overall functionality of the Department is reduced further by the lack of adequate sanitary facilities and poor provision of disabled facilities. Patients have to leave the Outpatient Department to access two single WC s which open directly onto the Main Reception corridor, providing very poor privacy and dignity. There are no breast feeding facilities available in the hospital and the baby changing facility is in the disabled toilet. Access to the disabled toilet is through a narrow corridor at the back of the reception and is difficult for patients in wheelchairs to get to. In addition, patients have to be escorted to the disabled toilet by a member of staff as it is situated within the staff area. Car parking facilities are also very poor, particularly during main outpatient clinic times, and this leads to patients arriving late for appointments. Current Outpatient Service Cardigan Hospital currently hosts a range of outpatient clinics. The facilities available are not designed for the provision of modern healthcare services. There are 5 rooms in total which are cramped and do not provide clinical hand washing facilities to modern standards. One of these rooms has no IT access or telephone, as it was the originally set up for Field Tests for Ophthalmology clinics. There are no dual access facilities available within these rooms, which severely limits the examinations and procedures that can be undertaken. Service users are weighed and measured in a public corridor, providing little privacy and dignity, and there are no separate waiting areas for adults and children. There are insufficient areas or appropriate facilities for staff to hold private discussions or counselling with service users and their carers. There is one small Phlebotomy Room which is inadequate for the throughput of patients, as up to 120 patients per session require phlebotomy. The Phlebotomy Room is also used for nail surgery as the podiatrists do not have access to a treatment room. The only treatment room within the OPD is used for the Minor Injury Service. There is no clinical accommodation specifically available for Occupational Therapy or the Dietetics Service. The overall condition of the facilities is very poor. They do not meet current standards and do not instil confidence in the service users or the visiting clinicians. Business Need There has been a noticeable decrease in Outpatient activity over the last four years, as shown in Figure 17 below. Due to the poor facilities, lack of treatment room facilities and up to date equipment, many specialties have withdrawn from Cardigan, particularly from new Outpatient appointments. In particular, Gynaecology which requires access to Ultrasound; and General Surgery and Urology services which require access to a Treatment Room for minor procedures. Figure 17: Total Outpatient Attendances Cardigan Hospital P a g e 55

58 To support the continuation of the existing level of service and increase both the volume and range of outpatient services, new, purpose designed and expanded facilities that meet current standards for hygiene, privacy and dignity and spatial standards are urgently required. Sexual Health Services outpatient sessions have been transferred from the Health Centre to Cardigan Hospital during the last year and are now based in the former Derwen Ward inpatient area. However, although 4 sessions are held per week, the environment is not ideal as toilet facilities are inadequate, the dirty utility room is used as an entrance / exit for community staff, confidentiality arrangements are poor and there is no reception facility. The following additional clinics have already been identified as able to be provided in Cardigan when the appropriate facilities are available: Acute Pain Service Teledermatology Additional Orthopaedic Clinics Nurse-led pre-assessment Orthopaedic Clinics. Ophthalmology : Wet AMD Pilot The Health Board is planning to pilot a community based wet AMD service to provide this service more locally. The service for Ceredigion patients is currently provided at Bronglais General Hospital, which is 40 miles from Cardigan (and an hour by road) and for Pembrokeshire and Carmarthenshire patients the service is provided in Ammanford, which makes access to the service difficult for patients in the Cardigan area. The reason for the pilot is to address the following patient safety issues in Ceredigion: Wet AMD follow-up in Ceredigion; The 14-Day referral to 1st injection pathway; The total ophthalmic population currently on the follow-up not booked list i.e. requiring follow-up but without appointments. The new service will have to be piloted in Crymych Health Centre, as there are no suitable facilities within the current Cardigan Hospital or at Cardigan Health Centre. It is planned that the service will transfer to the new Cardigan Integrated Care Centre when commissioned. The following clinics have already been established in the existing outpatient department, but are restricted by the current facilities and poor environment: Tissue viability General Surgery, Urology and Colo-Rectal Surgery Clinics Haematology Clinics Motor Neurone Disease Clinics The provision of service appropriate outpatient facilities in accordance with the guidelines for minor surgical procedure facilities will enable the transfer of services from acute hospital settings thereby reducing demand at other sites, and provide necessary care closer to home for residents of the Cardigan area. P a g e 56

59 i. Dietetic Services Current Service The catchment population includes service users from the following GP Practices: Ashleigh Surgery, Cardigan, Meddygfa Emlyn, Teifi Surgery and Llynyfran Surgery in Llandysul and New Quay Surgery. On average 23 new adult service users per month are currently seen in clinics held in either Cardigan Hospital or Cardigan Health Centre. However, there are an additional 45 new referrals per month received from local GP Practices which cannot be accommodated in Cardigan. Due to the limitations of the current facilities in Cardigan these service users (the majority of referrals) have to travel to other Health Board bases. The new: follow-up review ratio in adult services is 1:2 and there is regularly a backlog of reviews due to lack of accommodation in Cardigan. This does not include the MSK dietetic service demand which is managed separately; the demand for this specific service is increasing. The current average monthly paediatric new referral rate is 4 per month, with a new: follow up ratio of 1:3. A trial of increased paediatric dietetic service in Cardigan from other counties was held for 6 months in 2011; there was a doubling of demand for clinic capacity as a result, with families opting for Cardigan clinics from all three counties. This demonstrated that there is unmet need for paediatric dietetics in Cardigan. Business Need Demand for dietetic clinics outstrips available space at Cardigan Hospital currently; this is hindering the development of services locally. There is a need for the following services: Additional general adult Dietetic clinics Additional Paediatric Dietetic Clinics Paediatric Group Education, this is being developed to address the increasing demand for dietetic services, for example, food allergy management group interventions Adult Weight Management programmes, including Foodwise for Life and Dietician led level 2 weight management group programmes Musculoskeletal Pathway lifestyle services including weight management programmes as above Dietetics Community Resource Team Delivery of increased XPERT adult diabetes structured education programmes, an eight week programme delivered by dietetics and diabetes nurse specialist Delivery of Type 1 diabetes structured group education to align with the NSF (programme to be decided but not currently available) and group carbohydrate counting and insulin dose adjustment sessions. New paediatric diabetes multi-disciplinary team clinics (to accommodate families living in the Cardigan area from the 3 counties; this will also enable more effective use of the diabetes MDT resource) and linked to this group paediatric diabetes education Provision of a childhood obesity service including a structured family based weight management programme (group) which is currently not available and is an unmet need across the Health Board P a g e 57

60 The Clinical Nurse Specialist (CNS) Nutrition Service is hosted by dietetics. There is a need for joint pre-enteral tube feeding and review assessment clinics to be delivered in Cardigan to reduce the need for increasing domiciliary delivery, making better use of limited staffing resources and to reduce patient travel. This service requires access to a clinical consulting room. Two recently appointed MSK weight management dietetic staff members are based in Cardigan Hospital (Dietician and Assistant Practitioner). There was previously a prolonged service gap while post holders were recruited. MSK Dietetic activity levels in Ceredigion (Cardigan) are now increasing significantly. In order to run efficient and effective lifestyle and weight management service additional, appropriate accommodation for 1:1 consultations and group interventions is required. A Community Dietitian (South Ceredigion) was recently recruited to a service vacancy and a part time replacement paediatric dietician (Ceredigion) will have Cardigan Hospital as a partial base from April May Other dietetic staff members delivering specific clinics in Cardigan (for example Diabetes and MacMillan Dietician) use the Cardigan office as a hot desk facility. j. Speech and Language Therapy Current Service Speech and Language Therapy (SLT) for the whole of Ceredigion is based at Cardigan Hospital. The Therapists work intensively with adults and children with a huge variety of speech, language and communication difficulties; feeding and swallowing difficulties; and children with severe and complex special needs. Currently service users are referred to Cardigan from Aberaeron, Lampeter, Cardigan, Llandysul, Newcastle Emlyn, Newport, Fishguard and Ashleigh Practices. Over 450 adult and paediatric service users were seen in 2015/16. The number has increased and continues to increase year on year. This figure reflects the number of service users, and not activity, as it is typical for each individual service user to be seen a number of times, though this number differs from case to case. The provision of SLT within Cardigan is currently restricted due to the lack of suitable accommodation. There is one small clinic room, which is used full time on a sessional basis by Adult and Children s SLT. This leaves no room for expansion of services as the population needs grow and change and cross-boundary working increases for example demand for adult SLT is anticipated to increase with the development of the OT Community Reablement Teams. Particular pressure is noted during holiday times, as many children are seen at school during school holidays, which are ideal times for group therapy to be provided, and for parents to be more involved in their child s therapy. Service users with such conditions as Cleft Palate, Head and Neck Cancer, or neonatal feeding problems have to attend either Glangwili or Morriston Hospitals due to lack of facilities in Cardigan. Service users recovering from a stroke or have motor-neurone disease or Parkinson s disease can attend for SLT in Bronglais. However service users from the south of the County or North Pembrokeshire cannot access these services due to either the distance involved or limited facilities at Bronglais Hospital. The current facilities do not meet NICE guidelines for Autistic Spectrum Disorder assessments due to a lack of observation room, or for other observations and interventions. The existing room is unable to accommodate any form of group therapy or multi-disciplinary assessments and is also fully utilised, and therefore will not allow for any expansion of services as demand increases. Demand for Adult Speech and Language Therapy is P a g e 58

61 anticipated to increase with the development of Community services to support rehabilitation and patients with Head and Neck cancer. Business Need Additional and improved facilities are urgently required within Cardigan, to: Provide modern therapy for the evolving and increasing caseload of service users, both adult and children. Run effective group activities for children s SLT. These could be opened to provide a 3 county wide service inviting service users on the border from Pembrokeshire and Carmarthenshire, which will provide considerable cost and resource savings for service users and the SLT service. Deliver SLT to service users from the Lower Teifi Valley as well as North Pembrokeshire, removing county borders and improving access. Run adult stroke, motor neurone disease and Parkinson s groups, to both avoid local service users travelling to Bronglais and to offer access for the unmet need in the south of Ceredigion and North Pembrokeshire where access to Bronglais is not available. Introduce weekly Stroke Association communication workshops. Provide outreach clinics for Cleft Palate, neonatal feeding etc. from Glangwili and Morriston Hospitals. Introduce weekly Stroke Association communication workshops. Provide outreach clinics for Cleft Palate, Neonatal feeding, Head and Neck cancer, etc., from Glangwili and Morriston Hospitals. Within the new development there will be a dedicated, purpose designed Speech and Language Therapy Room with built-in one-way mirror into the adjoining room to enable observed testing and therapy to be delivered. This room is intended to be used by all therapy services. k. Podiatry and Surgical Appliance / Orthotics Service Current Service Routine podiatry clinics operate for 9-10 sessions per week at Cardigan Hospital, examining and treating up to service users per session (2,198 routine contacts between January and December 2015). Similar clinics in other counties aim to treat 8 9 service users per session due to the increasing complexity of interventions delivered, and therefore Cardigan is already providing podiatry services at much higher pressure than the norm due to the lack of clinical accommodation. Cardigan Hospital is the base for domiciliary services for South Ceredigion and North Pembrokeshire (692 domiciliary visits between January and December 2015). Nail surgery is currently provided in the Phlebotomy Room one day a fortnight treating an average of 6 service users per session with dressing appointments the following day in the Podiatry Clinic. The facilities are not clinically appropriate for delivering such interventional procedures, and demand is anticipated to increase further. One Ulcer Clinic is currently provided weekly, and corresponds fortnightly with the Diabetic Consultant Clinic (266 total contacts between Jan 2015 and Dec 2015). Demand exceeds this provision, and service users are also booked in as space allows within the OP Rooms P a g e 59

62 and routine Podiatry Clinic appointment slots. This demand is significantly higher during colder months when vascular problems are more prevalent. Open access, Podiatry Direct high risk / diabetic clinics are not available in Cardigan. Service users requiring this high risk service currently have to travel to Bronglais and Carmarthen. Provision of emergency appointment slots available daily when patients ring with infection, inflammation or broken area of skin. There is currently very limited Surgical Appliance Services available in Cardigan. Service users currently have to travel to Aberystwyth or Carmarthen to access some services. Orthotics manufacturing is no longer undertaken in Tregaron, which results in a disjointed service. Ceredigion has no laboratory facility to adjust and/or manufacture insoles. All other orthotic clinics in Pembrokeshire and Carmarthenshire have lab facilities. Ceredigion also lacks storage space for holding Surgical Appliances resulting in delay of issue to patients. (1000 contacts between Jan 2015 and Dec 2015 within Surgical Appliance clinics including Orthotist clinics and podiatry led insole/msk and orthopaedic footwear clinics). The Orthotist holds a full day clinic currently every 3 weeks. Podiatry Orthotic clinics are held weekly in the outpatients department as and when a suitable room is available. Private gait assessment areas are essential for surgical appliance clinics but not always available limiting full assessment of patients. Paediatric Podiatry Clinics are held 2 sessions a month at Cardigan Hospital in Derwen Ward (156 contacts between January and December 2015). Cardigan Hospital General Office also holds the podiatry booking office for the whole of the county with a dedicated phone line for podiatry and orthotic service users. All podiatry and South Ceredigion orthotic records are archived and managed at Cardigan Hospital. Business Need The increasing clinical need for podiatry services, combined with the increasing complexity of interventions required, results in a need for a podiatry clinic room dedicated to routine clinics with access to a second treatment room required to provide overspill clinic space for routine and specialist clinics. This will also provide joint use tissue viability sessions to include lower limb vascular assessments in conjunction with the leg ulcer specialized clinic now available at Cardigan Hospital. There is a business case for improved access to vascular assessment and diagnosis to cope with the increasing demand to vascular services - podiatrists are involved in consultant clinics and follow-ups in community (Vascular Pathway). In addition, Open access, Podiatry Direct high risk / diabetic clinics are to be developed in Cardigan in line with All Wales Diabetic foot standards, NICE Guidelines, and access to a suitable room will be essential to enable this development. The newly funded initiative CMATS Extended Scope Physiotherapy at Cardigan will also require access to a podiatry/orthotic room for up to 4 sessions per week initially but has shown to increase rapidly in other areas. CMATS podiatrists already operate in Pembrokeshire and Carmarthenshire counties routinely seeing Ceredigion patients (contact numbers 10 patients a day). An enhanced treatment room is required urgently to provide nail surgery procedures in a clinically appropriate setting, with access required to oxygen and adrenaline for the safe management of anaphylactic shock. It is planned that staff members will be relocated from Carmarthen to support the increase in podiatry services in Cardigan and a business plan is in place to increase staff numbers to cope with increasing demand on the service from diabetes, vascular insufficiency, obesity and chronic illnesses. P a g e 60

63 In addition to the invasive procedures undertaken, local podiatry services have incrementally developed their role in biomechanics, including the prescription and manufacture of lower limb orthoses. This has proven to lower the risk of diabetic foot ulceration which has a higher incidence of death than some cancers. New facilities in Cardigan will enable orthotics manufacture to enable closer working between all disciplines. An Orthotics Lab is to be provided in the new facility, and an orthotics treatment room with a private gait analysis area. l. Chronic Conditions Management A range of Expert Patient Programme Self-Management Programmes will be delivered from the new Integrated Care Centre, including programmes to improve self-care and selfmanagement. Rooms currently have to be hired in local community halls at high cost and often in inappropriate surroundings for these sessions to take place. The programmes include: Introduction to Self-Management (ISM) Chronic Disease Self-Management Programme (CDSMP) Looking After Me Programme (LAM) Chronic Obstructive Pulmonary Disease (COPDSM4L) Diabetes Self-Management Programme (DSMP) XPERT Diabetes Programme Chronic Obstructive Pulmonary Disease Plus exercise. These programmes reflect the principles of prudent health care, which are: Do no harm there is evidence of clinical benefits associated with self-management interventions; Equity higher than average prevalence is associated with areas of deprivation for COPD and courses are therefore targeted towards areas with the highest disease prevalence; Carry out the minimum appropriate intervention evidence shows that self-management courses are an efficient use of resources, as courses are delivered by one health professional and one volunteer tutor; Organise the workforce around the only do, what you can do principle the scheme enables health professionals to acquire additional skills that can be used during every patient contact, not just during course delivery; Consistently apply evidence-based medicine in practice the scheme interventions are evidenced as being clinically effective; Remodel the relationship between user and provider on the basis of co-production the scheme promotes the concept of equality of partnership between a person with a chronic condition and their healthcare professional. Patients are taught specific communication skills that facilitate a more equal relationship with their professionals. m. Pulmonary Rehabilitation Current Service The provision of pulmonary rehabilitation continues to be a challenge due to accommodation constraints within the existing hospital. P a g e 61

64 Business Need Cardigan Integrated Care Centre FBC Referral of COPD service users for rehabilitation is now included in QOF criteria following guidance issued from the National Institute for Clinical Excellence (NICE) but is not currently able to be provided due lack of facilities. The absence of a local service constrains practice development and resources for local people. The use of telemedicine to support the rehabilitation programme is envisaged. This service will be able to be provided in the adult therapy room in the new development. n. Rheumatology Current Service Rheumatology services are currently provided across the three counties in Hywel Dda; however, there has historically been a demonstrable inequity of service provision for Ceredigion. The former Consultant, provided just one clinic session a month, and retired in March The service became unsustainable and there were significant concerns around the clinical deterioration of service users, travel distances, predicted high levels of unmet need, etc. Business Need A Business Case was submitted in December 2013 to develop a fully networked Consultant model across the Hywel Dda area to provide modernised equitable care for service users. Cardigan is ideally situated as a base for the provision of holistic medical, nursing and therapies assessment and follow up, to provide integrated care close to home for service users for whom travelling presents challenges due to their disabilities. A full time Consultant has been jointly appointed to Carmarthen and Ceredigion and his job plan includes two sessions at Bronglais General Hospital. A Specialist Nurse has also been appointed, with leadership for this post provided by the current Clinical Nurse Specialists in Carmarthenshire. Input from therapies, prescribing and a contribution towards CELLMA (IT system) were also included in the Business Case submission but were not supported. This new model will ensure equitable service provision across the three counties, enabling service users to be treated in their local area and focusing on tackling the unmet need. Enhanced facilities within Cardigan will however be required to allow this. o. Lymphoedema Current Service Cardigan currently provides a Lymphoedema service from the Outpatient Department, and receives an average of 10 new referrals per month. Business Need The service was brought to Cardigan from surrounding DGHs several years ago, but dedicated accommodation has never been provided and it continues to be difficult to access appropriate clinic space. Due to the nature of the clinical condition (60% of the patients managed have cancer conditions, e.g. breast or genital oedema) they require very frequent treatment in private facilities which are able to accommodate bariatric service users. Clinical interventions require frequent multi-layer bandaging three times a week, and access is required to a dirty utility for disposal of body fluids and soiled bandages. P a g e 62

65 Plans for Complex Leg Clinics are underway. This service will run as a multidisciplinary clinic for service users with conditions including Lymphoedema, tissue viability and dermatology, and will require similar facilities as the Lymphoedema service. In order to support both these services going forward and provide a high quality service to patients with Lymphoedema, it is essential that there is access to discrete, clinically appropriate accommodation within a new Cardigan facility in one of the treatment rooms adjacent to clean & dirty utility rooms, which will enable the provision of a much improved service. This provision has been designed into the new facilities. p. Chronic Non-Malignant Pain Service Current Service There is currently very limited chronic non-malignant pain management available in Cardigan, due in part to lack of suitable facilities and supporting services. Service users suffering from non-malignant chronic pain are referred to DGHs, resulting in travelling challenges due to disability related to their chronic condition. Such chronic conditions can be categorised as: Musculoskeletal Medically unexplained pain syndromes CFS, chest, abdominal and pelvic pain Face and head migraine, trigeminal neuralgia, atypical face pain, dental pain Neuropathic diabetic, post herpetic, MS, post-stroke, chronic regional pain, traumatic injuries and phantom pain Vascular claudication, ischaemic rest pain, Raynaud s and angina Post-operative Business Need The Ceredigion Chronic Conditions Management Steering Group is developing a model of care for a community service based on the bio-psycho-social model and embedded in good medical care. Service users will only be referred to the secondary care specialist pain service when the complexity cannot be addressed in the community or there is a need for interventional treatment not available in the community e.g. spinal injection therapy. The existing health facilities within Cardigan are unable to provide suitable accommodation in which to support the introduction of this community-led model of chronic pain management. New facilities are urgently required to enable the pain service, working with the MSK and CMATS, to provide comprehensive services for the catchment population. There is potential for this service will be able to be provided from one of the Treatment Rooms in the new facility. q. Long Term Neurological Conditions Long term neurological conditions cover a range of conditions including: Long term effect of stroke Epilepsy Parkinson s P a g e 63

66 Multiple sclerosis Motor neurone disease Long term effects of head and spinal injury Ataxia conditions Cerebral palsies Motor neurone degenerative conditions Myalgic encephalitis Current Situation Currently Cardigan provides a weekly Parkinson s clinic and a monthly Multiple Sclerosis clinic. Across Wales a significant proportion of the secondary care support to people with Parkinson s disease is delivered via Geriatricians. Service users requiring more specialised support have to travel to Carmarthen or Morriston. A quarterly motor neurone disease clinic has been established. Business Need The proposed development in Cardigan would support the model of care recommended by the Royal College of Physicians and Association of British Neurologists, which recommends that most of the care of these service users should take place in the community managed by Specialist Nurses and General Practitioners with Specialist Interests (GPwSI) with identified link neurologists. Currently the facilities within Cardigan do not enable the development of this model of care. The proposed development will be well situated and designed to accommodate service users with conditions which are best managed close to home, to minimise the challenges that transport imposes on them. Regular Clinical Nurse Specialist clinics with telemedicine links to the specialist medical staff working at the hub i.e. Carmarthen or Morriston regional teams are proposed. Rehabilitation teams such as therapies and third sector disease specific groups who are active and supportive in the locality as part of the wider West Wales voluntary organisations, supporting people with neurological conditions, are committed to strengthening local services. Advice and support that is provided more effectively by people who also have the same conditions can be accessed via these organisations. The accommodation available at Cardigan is not currently suitable to provide this type of shared support. The following are also planned: Weight management Falls / Postural Stability Lifestyle Management Health Checks r. Minor Injuries Unit (MIU) Current Service The Minor Injuries Unit is an Emergency Nurse Practitioner led service working within the Health Board s Clinical Guidelines for Practice for Emergency Nurse Practitioners known as the scope of practice. They work autonomously to assess, diagnose, treat and discharge patients without reference to a doctor, but within pre-arranged guidelines. P a g e 64

67 Telemedicine links exist with Senior Clinicians based in the Acute Hospital sites to support practitioners in diagnosis and treatment decisions when necessary. The ENP s work closely with the X-Ray Department, Podiatry, local Pharmacies and Welsh the Ambulance Service to avoid unnecessary attendance at an A&E department. The Choose Well campaign supports this model of care. The current service is open 9-5, five days a week, excluding weekends and bank holidays. The MIU provides an invaluable service to the population of such a rural location as Cardigan, and demand is increasing year on year as shown in Section Business Need When the new facility is commissioned, it will provide two treatment rooms (as opposed to one currently) enabling two practitioners to work side by side, thereby reducing patient waiting times. There will be an opportunity to work more closely with GPs and Pharmacy as they will be co-located and to provide peer support which will reduce the risks of isolated practice. The staffing establishment has been increased to ensure a sustainable service and to provide the potential to extend the hours in the future. The Choose Well campaign will also help to move this model forward. s. Acute Response Team (ART) Current Service The Acute Response Team is currently based at Aberaeron Hospital, and the team attend to any calls within the Ceredigion locality. Although the team is County based, they work closely with both Carmarthenshire and Pembrokeshire ART to ensure effective and seamless cross boundary working. The ART provide enhanced acute nursing interventions to service users within their own homes, with the aim of preventing avoidable admissions to hospital and thereby reducing the number of medical admissions. The ART also facilitate earlier discharges from hospital allowing inpatients to leave hospital and continue their treatment regime within their own homes. The ART Evaluation Report for 2014/15 demonstrated that the ART service prevented 699 admissions and facilitated 111 earlier discharges. Business Need It is proposed to provide new ART services within Cardigan to enable service users who are currently attending Glangwili, Withybush or Bronglais Hospitals for treatments to access these locally. However, this important development is not possible currently due to lack of suitable facilities within the locality. Clinical treatment rooms in the new building will be utilised to provide complex procedures that need close monitoring and access to full resuscitation facilities. It is envisaged that the services being provided will expand and will draw on residents from a wide catchment area that historically would have had to travel to any one of the District General Hospitals. In the event of suitable treatment being available within Cardigan, the procedures that could be provided include: P a g e 65

68 Blood transfusions Iron infusions Platelet infusions Chemotherapy which would include all other routes of administration e.g. bladder Intravenous medication e.g. antibiotics, bisphosphonates, diuretics Venesection Peripherally Inserted Central Catheter insertion (PICC) Care and management of enteral feeding tubes Peritoneal dialysis Topical treatments Management of tracheostomy tubes Controlled environment for teaching t. Radiology Current Service The existing X-Ray Department within Cardigan Hospital has to date allowed provision of a general plain film X-ray service with some limitations due to the ageing estate and necessary upgrades to the IT infrastructure. Despite these limitations, demand for the service increases year on year as shown in Table 2. Table 2: Total X-Ray Procedures Undertaken in Cardigan Hospital Year Total X-Ray Procedures , , , , ,591 The existing X-Ray Room is housed in an adapted outbuilding. The ceiling is too low to allow for an overhead gantry. Staffing is provided from Bronglais General Hospital and latterly with cover from other Hywel Dda UHB sites when required. The department is open Monday Friday. There is currently no provision of ultrasound scanning or panoramic X-ray within the Cardigan catchment. Service users requiring these services are required to travel to Carmarthen or Bronglais. Business Need A purpose built X-Ray Department has been designed into the Cardigan Integrated Care Centre based on HBN 6 and is aligned with the service strategy for Radiology. The proposed x-ray room will be able to provide a full range of plain x-ray examinations appropriate to local and service needs, with the addition of a panoramic x-ray unit used for mandible trauma and orthodontic assessment (OPT machine). Workload is expected to increase due to the new department being purpose built, with DR equipment that will maximise efficiency and optimise P a g e 66

69 workflow. This facility will enable patients to be diagnosed and treated locally. In addition, the provision of bariatric and wheelchair accessible facilities will be the only such facility within the Health Board. The benefits of the new department and equipment are as follows: Faster imaging Increased patient throughput Better image quality Improved workflow management No need for imaging cassettes Long term cost savings possible following the initial investment Multiple storage options on-site or off-site Off-site reading and reporting possible as a backup on occasions of reduced capacity or for second opinion Added potential for a reduction in patient radiation dose The new equipment will be ceiling mounted, which will provide greater versatility and will be faster to use, improving efficiency, accuracy and quality. It will be ergonomically up to date and satisfy all current manual handling criteria. Potential for staff fatigue will be reduced as it will be more responsive than the current floor mounted tube and there will be no requirement for the physical handling of imaging cassettes. The department has been designed to HBN 6 standards and will satisfy all criteria to preserve privacy and dignity. It is positioned adjacent to the Minor Injury Unit and the Community Dental Department, which will result in: Improved workflow Improved patient experience Improved accessibility It will enhance services to the local community as all services and the majority of referrers will be co-located on one site. A new addition for the Integrated Care Centre will be the inclusion of an OPT machine which will benefit community dental patients. This is another enhancement to the Radiology service and it will be incorporated into the daily workload of the existing Radiology staff on site. Dedicated sessions for dental are a potential development and the impact of any additional activity will be monitored. u. Sexual and Reproductive Health (SRH) Current Service Currently a Genitourinary Medicine (GUM) Clinic is held for four sessions per week within Cardigan Hospital. The service delivers integrated sexual health care moving away from the traditional model of Genito-Urinary Medicine and family planning. A mixture of open access and appointed clinics are offered, including the delivery of specialist contraception. P a g e 67

70 Business Need Cardigan Integrated Care Centre FBC The service has been subject to a review conducted by the Public Health Department over the past two years with an extensive needs analysis followed by workshops attended by a wide range of professionals and stakeholders including service user groups. This has resulted in a new SRH strategy. The service will be consultant led and work on a hub and spoke model with extension of the specialist nurse role. It is proposed that the hub will be located in Carmarthen, and Cardigan has been identified as one of five spoke clinics where the service will work closely with general practice, providing specialist support and an educating role. The service will provide open access clinics for five sessions per week, including two evening sessions to increase accessibility for those who work office hours, when a specialist nurse and health care support worker will be in attendance, with medical input on at least one day per week. Access to ultrasound scanning will be necessary to enable the service to provide a more comprehensive and efficient one-stop service. The current facilities within Cardigan are not able to accommodate the new integrated service, due to lack of space, privacy and dignity and access to ultrasound scanning facilities. If the facilities are not improved it may not be possible to implement the required comprehensive service, resulting in the local population having to access care in Carmarthen, Haverfordwest or Aberystwyth. This would have a significantly detrimental effect on the ability to access sexual health care closer to home. v. Mental Health Services Current Situation In line with national and local mental health strategies, services are increasingly being delivered within community settings closer to the client s home, including newly developed teams providing assessment and treatment, increasingly aligned to primary care services. Therapeutic day services are currently provided from Aberaeron, Aberystwyth and Carmarthen for the population of Ceredigion. The provision of mental health services in Cardigan is currently limited due to the lack of suitable and appropriate facilities. An average of 800 appointments is currently available per annum; this number is limited due to lack of facilities. A room is used in Cardigan Fire Station to run group work, and sometimes the service has to pay to use facilities in local venues such as the Guildhall. Access to facilities to provide health promotion or self-help is very limited, and therefore service users, some of whom are severely disabled due to their condition, have to travel long distances to receive such help or do without. Business Need It is estimated that there are currently 45,000 people in Wales suffering with dementia. In 2011 it was estimated that in the Hywel Dda area, there was 5,712 people with dementia, and this number is predicted to rise to an estimated number of 10,161 by the year Mental health problems; of which dementia and depression are the most common, have a worse outcome in the 60% of older people who suffer from long-standing illnesses. Hywel Dda UHB has the second highest prevalence and percentage increase of people with a diagnosis of dementia within Wales, reinforcing the need to prioritise local developments for people with dementia within the community. Cardigan, being a largely rural area with an ageing population, needs mental health services that can be accessed by all in need locally, in line with the HDUHB Mental Health and Wellbeing Strategy New facilities are required to provide access to therapeutic day services, CPN-led sessions, individual and group therapies including evening P a g e 68

71 programmes, and increased consultations. Memory assessment follow-up clinics would also be provided to monitor progress and receive further support and treatment were facilities available. w. Third Sector Organisations: There is a wide range of third sector organisations in the Cardigan area that provide support services to the local community. These include: Age Cymru Ceredigion Alzheimer s Society British Red Cross Cardi-Cardiacs Cardigan Cancer Care Ceredigion Care and Repair Drugaid Crossroads Care Mid and West Wales CRUSE Bereavement Support Jig-So Macmillan Stroke Association Ceredigion Association of Voluntary Services Age Cymru Ceredigion Current Situation Age Cymru Ceredigion is developing Social Prescribing to support older people 50+ in the Cardigan catchment area, in order to help people to help themselves. There are currently no suitable facilities within Cardigan to enable them to deliver this service. The social prescribing project Age UK Integrated Care Project is reliant on funding and currently two applications are being pursued. Age Cymru Ceredigion also runs a volunteer nail cutting service at Cardigan Hospital which will continue to be provided in the new centre in more appropriate facilities. Business Need: New facilities are required for Age Cymru to provide the social prescribing project in Ceredigion. An outreach worker will be located within the new Integrated Care Centre to provide support with daily living skills; managing money and personal administration; emotional wellbeing and physical health. The outcomes of such a service will be either a referral to the GP with an appointment made, or conversely a reduction in GP attendances; one stop shop support for clients and integrated support across health and social care. It is anticipated that prudent investment in this field now could lever large health gain in the future. CRUSE Ceredigion CRUSE Ceredigion offers support to bereaved people throughout the county. This is normally through one to one meetings. Those who live in the Cardigan area used to be seen at the old Beacon of Hope building or in a room at Cardigan Health Centre, but neither of these venues is now available. The service has an alternative venue but the use of a room in the new Integrated Care Centre will make it easier for CRUSE to offer support in and around Cardigan. A significant number of referrals to CRUSE are from Cardigan GPs or local CPNs and the support provided by CRUSE can often ease the burden on the NHS. P a g e 69

72 x. Social Services Current Service Social Services staff serving South Ceredigion currently works from offices located in: Integrated Community Equipment Stores Felinfach Cardigan Hospital Morgan Street Offices, Cardigan Business Need A new way of working has recently been introduced in Ceredigion, creating integrated teams of health, social care and domiciliary care workers. The new model includes: A single point of access (SPA) Targeted Intervention Services (TIS) Planned Care and Support Team (PCST) A key aspect of moving to the new model of care is the integration of health and social care services. In order to fully integrate the staff in the south Ceredigion locality new facilities are required where these staff can be co-located to break down barriers and provide access to health, social services and GMS IT systems within the same office area. Ceredigion County Council Support Ceredigion County Council is enthusiastically involved in the development of the Integrated Care Centre. A letter of support is given at Appendix 4. y. Telemedicine Current Situation Within HDUHB there are a number of excellent examples of telemedicine initiatives, including: Use of videoconferencing for: Virtual multidisciplinary team meetings Management and clinical meetings Education and training sessions Clinical applications o Profession to profession o o o Profession to patient Medical and non-medical staff Transmission of data e.g. digital radiology images, histopathology images, live echocardiography ultrasound Use of electronic store and forward for diagnostic / triage of dermatology images P a g e 70

73 Over the last 15 years, Hywel Dda UHB has successfully demonstrated that the use of technology has the potential to improve the quality, delivery and efficiency of healthcare services. This includes the provision of healthcare to service users at a distance using telemedicine technology. This has involved consultations between patients and clinicians at different locations using videoconferencing, or clinicians diagnosing a patient s condition remotely using image transmitted electronically. Impact of Telemedicine Developments a. Quality Access to specialist services closer to home More efficient use of specialist staff consulting not commuting! Reduced waiting times for expert consultations Reduced patient journeys for expert consultations Faster implementation of treatment plans Ground breaking projects / services in rural Wales Remote supervision of generalist staff Staff meet CPD requirement regardless of working location Expert GPs meet governance compliance Multidisciplinary Team participation not limited by distance b. Costs Reduced travel costs for patients and clinicians Reduced CO 2 emissions for healthcare Reduced costs for CPD / study leave Potential for reduced service delivery costs Business Need The new Cardigan Integrated Care Centre offers an excellent opportunity to adopt current telemedicine service models, improving care closer to home, avoiding the need to travel, reducing travelling time and costs for both health service staff and patients. In order for telemedicine to be successful, it is essential that adequate facilities are available. The availability of videoconferencing equipment in appropriate clinical environments with patient access has been the biggest challenge in implementing telemedicine services in Hywel Dda. The existing facilities now severely limit the expansion of telemedicine within Cardigan. The requirement is to have Dedicated videoconferencing clinical suites for patient video consultations, e.g. two outpatient consultation rooms (one to include Speech Therapy) to be equipped with mobile videoconference clinical carts. The cart could be moved for shared use at any of the other outpatient consultation rooms, maximising use of telemedicine resources. All outpatient consultation rooms to have robust and adequate IT infrastructure to support PCs and hi-definition videoconference units. Investigate the use of wireless technology. P a g e 71

74 All meeting and training rooms to be equipped with videoconference equipment to maximise the use of videoconferencing for business and training needs. Staff to have desktop videoconference (web camera) for 1:1 meetings. The capital requirement to provide these improvements have been included in the F&E schedules. 2.7 Investment Objectives Investment Objective Review for OBC 2014 In preparation for the option appraisal the investment objectives originally identified at Strategic Outline Case stage were reviewed by all attending the Non-Financial Option Evaluation Pre-Workshop on 6th May It was agreed that the investment objectives remained relevant for the project, although they were updated as shown below to reflect the new model of care and the need for improving the efficacy, efficiency and cost effectiveness of the services provided. In agreeing these objectives the team has also identified measurable benefits which will be derived by service users, staff, the Health Board and wider health economy. The investment objectives were developed and described as SMART objectives as below. It should be noted that the project programme now indicates a completion date of January 2018 and not autumn 2016 as stated in the OBC and in the tables below. Therefore, the dates have been updated accordingly. Investment Objective 1: Facilitate the delivery of the new model of care To provide accommodation that will enable multi-agency integration, single point of assessment, rehabilitation and optimal use of health and social care resources Existing Arrangements The current system of health and social care in the Cardigan area remains fragmented and disjointed from both a service user and professional perspective. Inpatient facilities were closed on a pilot basis in February 2014 and the ward staff have been retrained to provide care within the service user s own homes, and care within the service user s own home is now increasing. Outpatient and rehabilitation services remain separated from primary care, community and social service teams. None of the existing facilities are capable of supporting collaborative working. Business Need Your Health Your Future Community Hospitals (2012), which is based on Welsh Government Strategies, requires a shift of emphasis from acute to primary care and community based treatment and prevention. It expects services to be planned around local need and delivered as close to or within the service user s own home through an integrated model of community services, with health, social care and third sector providers working in partnership. Appropriate facilities are required for this. Specific: Measurable: To provide accommodation for outpatient, rehabilitation, GMS & primary care, community and social care teams that will enable multi-agency working in Cardigan and surrounding areas. The accommodation will be completed and available for occupation as per the agreed schedule of accommodation, design brief and building specifications, and will be subject to post-project evaluation. P a g e 72

75 Achievable: Relevant: Time Bound: The preferred option will be able to be implemented and run within existing revenue budgets. The existing accommodation is unsuitable for the continued provision of services. The current system of health and social care in the Cardigan area remains fragmented and disjointed from both a service user and professional perspective. Inpatient facilities were closed on a pilot basis in February 2014, the ward staff have been retrained to provide care within the service users own home and this service is now increasing. However, the outpatient and rehabilitation services remain separated from primary care, community and social care teams. Whilst it is recognised that physical co-location is not the only issue in the integration of team working it is a very important aspect and the existing facilities and locations are hampering this development. Therefore the provision of appropriate suitable accommodation is relevant to the successful implementation of the new model of care. The accommodation to support the new model of care will be complete by January This date is dependent upon the timing of approval of this FBC. Investment Objective 2: Improve local access to services To provide access to a wider range of local services for all those living within the designated catchment area of Cardigan Existing Arrangements Multi-service integration and the development and expansion of services to be delivered in the service user s own home or close locality is fundamental to improving local access to services. The accommodation available to health, social care and third sector providers does not enable the integration of these services and the full development of care closer to home. In addition, the current facilities within Cardigan Hospital are so poor that existing outpatient services are not able to be expanded and indeed in some instances are being reduced. Business Need To meet this objective, improved, purpose designed accommodation will be required, to enable the safe and effective provision of a wider range of services. This accommodation will provide both facilities to provide a wider range of services, but also to enable the currently separate services to integrate their working practices and planning of services. Specific: Measurable: Achievable: To provide accommodation for outpatient, rehabilitation, GMS & primary care, community and social care teams that will enable both the development and provision of enhanced services multi-agency working in Cardigan and surrounding areas. The accommodation will be completed and available for occupation as per the agreed schedule of accommodation, design brief and building specifications, and will be subject to post-project evaluation. Activity information will be monitored, recorded and reviewed on a regular basis to identify both services provided and any incidents where patients have to travel to access services. The preferred option will be able to be implemented and run within existing revenue budgets. P a g e 73

76 Relevant: Time Bound: The current system of health and social care in the Cardigan area remains fragmented and disjointed from both a service user and professional perspective outpatient and rehabilitation services remain separated from primary care, community and social care teams. Whilst it is recognised that physical co-location is not the only issue in the integration of team working it is a very important aspect and the existing facilities and locations are hampering this development. Therefore the provision of appropriate suitable accommodation is highly relevant to the successful implementation of the new model of care. The accommodation to support the new model of care will be complete by January This date is dependent upon the timing of approval of this FBC. Investment Objective 3: Provide appropriate service capacity To provide accommodation that will at least meet the needs under the new model of care of the projected 2031 defined Cardigan catchment population Existing Arrangements Over the next 20+ years Ceredigion is predicting slightly higher national growth in population of 0.7% per annum. The growth in the population of Ceredigion is heavily biased towards the elderly population and the age group is predicted to grow 10 times more than the under 65 age group, and the 75+ age group 20 times more. Business Need To meet this demand, services need to be able to treat and care for more people in their own home (or as close to their home as possible), supported by a wider range of rehabilitation, specialist outpatient and diagnostic services, thereby reducing hospital admissions and providing more home and community based care Specific: Measurable: Achievable: Relevant: To provide accommodation for outpatient, rehabilitation, GMS and primary care, community and social care teams that will enable both the development and provision of enhanced services multi-agency working in Cardigan and surrounding areas. To enable clinical staff to work with their patients closer to home. The accommodation will be completed and available for occupation as per the agreed schedule of accommodation, design brief and building specifications, and will be subject to post-project evaluation. Activity information will be monitored, recorded and reviewed on a regular basis to identify services and activities provided and any incidents where patients have to travel to access services. The preferred option will be able to be implemented and run within existing revenue budgets. In line with the new model of care being implemented in Ceredigion, the preferred option will provide both the skilled workforce being enabled to work with patients closer to their home, and the provision of appropriate health and social care facilities to support this. P a g e 74

77 Time Bound: The accommodation to support the new model of care will be complete by January This date is dependent upon the timing of approval of this FBC. Investment Objective 4: Provide a high quality physical environment By January 2018 all facilities will be at least compliant with statutory HBN and CSSIW standards for health and social care facilities, including requirements for privacy and dignity and the Disability Discrimination Act Cardigan Hospital has numerous deficits in terms of its facilities; they fail to meet many HBN standards, significant areas are in Category C or D condition and they do not meet privacy and dignity or Disability Discrimination Act requirements. Cardigan Health Centre is likewise in a poor state of repair and its spatial restrictions are preventing service development. The Cardigan Adult Social Services team is based in a converted house which cannot provide community based services over the longer term and which does not provide any opportunity for joint working or assessment. The health and social services agencies need appropriate facilities for staff to provide the required services to the catchment population. Facilities will need to support integrated assessment and working, provide a single point of contact for service users, be conveniently located, meet future demand and comply with health and safety, infection control, privacy and dignity, Disability Discrimination Act and all other HBN, CSSIW and Welsh Assembly Government facilities expectations. Specific: Measurable: Achievable: Relevant: Time Bound: All facilities provided within Cardigan for the provision of health and social care will be at least compliant with statutory HBN and CSSIW standards for health and social care facilities, including requirements for privacy and dignity and the Disability Discrimination Act. The facilities will meet all of the above standards. The provision and maintenance of the facilities will be achieved within approved capital expenditure and available revenue budgets. In order to fully implement the new model of care, the Health Board needs to provide accommodation that is of acceptable spatial and quality standards for the staff to offer high quality services from. The accommodation to support the new model of care will be complete by January This date is dependent upon the timing of approval of this FBC Investment Objective Review for FBC 2016 The Welsh Government released NHS Wales Infrastructure Investment Guidance in This document provided revised NHS Infrastructure Investment Objectives. These investment objectives were compared against the existing objectives for this development at the Project Board meeting on Wednesday 14 th October 2014, as shown in Table 3 below: P a g e 75

78 Table 3: NHS Infrastructure Investment Objectives & FBC Investment Objectives NHS Infrastructure Investment Objective Support the delivery of safe, sustainable and accessible services, and facilitate high standards of patient care. Support changes to streamlining and transforming healthcare provision, with a focus on prevention and supported selfmanagement, the provision of care closer to home, and the integration and co-ordination of service delivery with partners. Promote the maximum efficient utilisation of assets and improve asset condition and performance. Promote the use of innovation to improve the quality of care, to reduce costs and to deliver the necessary service change. CICC FBC Investment Objectives 3. Provide appropriate service capacity: To provide accommodation that will at least meet the needs under the new model of care of the projected 2031 defined Cardigan catchment population 1. Facilitate the delivery of the new model of care: To provide accommodation that will enable multi-agency integration, single point of assessment, rehabilitation and optimal use of health and social care resources 2. Improve local access to services: To provide access to a wider range of local services for all those living within the designated catchment area of Cardigan 4. Provide a high quality physical environment: All facilities will be at least compliant with statutory HBN and CSSIW standards for health and social care facilities, including requirements for privacy and dignity and the Disability Discrimination Act 1. Facilitate the delivery of the new model of care: To provide accommodation that will enable multi-agency integration, single point of assessment, rehabilitation and optimal use of health and social care resources 2. Improve local access to services: To provide access to a wider range of local services for all those living within the designated catchment area of Cardigan 3. Provide appropriate service capacity: To provide accommodation that will at least meet the needs under the new model of care of the projected 2031 defined Cardigan catchment population The Project Board agreed that the FBC investment objectives remained appropriate for the development; supported the NHS Infrastructure Investment Objectives; and therefore did not need to be amended for the FBC. 2.8 Benefit Criteria The key benefits to be derived from the new service model and Integrated Care Centre are described in Table 4 below. These benefit criteria were drawn up, refined and agreed during the Non-Financial Evaluation Pre-Workshop on 6th May P a g e 76

79 Cardigan Integrated Care Centre FBC Table 4: Benefit Criteria and Investment Objectives Benefit Criteria 1. Access to Services FBC Investment Objective Increased and improved access to local services, with less dependence on centralised acute hospital services care closer to home 1,2,3 Provision of a wider range of services within the locality 1,2 Reduce hospital admissions and provide more home and community based care Easier journey through health and social care system with a single point of access 1,2 1 Equity of service provision irrespective of geographic location 2,3 2. Improve Clinical Quality of Services Enhance the quality of clinical services and training 1 Significantly improve clinical outcomes and experience for service users and staff 1,3 Right people, right skills, right place for all service users 1 Increase in care provided closer to or within the service users home 1,2,3 Greater promotion of independence, reablement and well-being 1 Maximise the benefits of service integration across health, social care and the third sector 3. Strategic Fit 1,2 Meeting the strategic needs of the locality for clinical services 1,2,3 Delivery of several national policy drivers for this locality (in particular the Primary and Community Services Strategic Delivery Programme and the Social Care and Wellbeing (Wales) Act ,2 Enabling the implementation of the new Model of Care 1 Facilitate modernisation, improvement and innovation in clinical practice and training 1,2,3 Service integration and greater efficiency in the use of resources 1,3 4. Flexibility for the Future Provide a flexible, local, sustainable range of care options for the community Support future expansion or contraction opportunities to cope with changes in demand and changes in the way services are delivered 5. Achievability 1,2,3,4 3,4 Practicality of delivery of physical proposals 4 Practicality of delivery of service proposals 1,3 Timescale for implementation / operational Autumn ,2,3,4 P a g e 77

80 6. Sustainability Making better use of human and estate resources in both the short and longer term 1,2,3 Meeting service needs within available resources 3 Encourage the development of partnerships between health, social care and the third sector services 7. Environmental Quality Provide an environment appropriate for clinical care and effective working 1,2,3 4 Improved functional suitability 1,2,4 Meeting consumerism standards of accommodation (e.g. space standards, privacy etc.) 4 Improving the quality of the estate Estimating the Benefits The benefits identified fell into the following main categories. Table 5: Main Benefits Type Direct to HDUHB Indirect to HDUHB Quantitative (or Increased access to UHB local services Increased activity to 3 rd quantifiable) Sector Services Reduce hospital admissions Improve the service users and staff experience Increase care delivered closer to service user s home Facilities with improved environmental quality, functional suitability and consumerism standards Cash Releasing Non-cash releasing Service integration enables staffing efficiency savings for reinvestment in the care closer to home model. Wider range of services delivered in the locality Delivery of scheme on time Service integration enables estate rationalisation and improved utilisation. Larger floor area but more efficient running costs per m 2. P a g e 78

81 Type Direct to HDUHB Indirect to HDUHB Qualitative (or nonquantifiable) Easier journey through health & social care Equitable patient access irrespective of geographic location Enhance the quality of services and training Focus on independence, reablement and wellbeing Enhance service integration / partnership working across health, social care & 3 rd sector Delivery of new model of care and policies Maximise flexibility of facilities 2.9 Constraints Constraints to the project have been updated to reflect the current position Financial Constraints: Capital This project has been identified as a priority for Hywel Dda University Health Board and has been included in previous corporate applications for central capital funding. As a result an indicative financial sum has been included within the All Wales Capital Programme. The overall capital programme for health at both national and local level is oversubscribed with many schemes competing for scarce funding. Therefore the availability of capital funding must be regarded as an absolute constraint and reflected in this FBC document. Revenue Equally there are pressures on revenue spending and it is recognised that the aim should be to make this a revenue saving scheme. There are also additional capital charges and other associated revenue consequences with a new build option. It is therefore expected that this project will be revenue saving to ensure affordability for the Health Board. There will be no increase in the workforce cost as a programme of workforce integration across health and social care in support of the new model of care is currently being piloted. In addition, all clinical and non-clinical space in the building will be fully utilised to justify the floor area and associated capital investment, with as much shared space as possible Non-Financial Constraints: Timescale The new facility must be available for use within a short timescale due to the poor condition of the existing premises. Even with further significant capital spend to maintain the current facilities; this would not result in improved functionality. P a g e 79

82 Site Constraints Cardigan Integrated Care Centre FBC A site appraisal workshop was held in 2008, which identified the Bath House site as being the preferred site for the new integrated development, and the site was purchased by the Health Board for the development. The site is quite steeply sloping causing some constraint on the design. However, innovative design has incorporated this without restraining the accommodation required. Due to concerns about the adjacent site, additional ground investigations are planned for a six month period commencing March 2016, with an interim assessment of risk after several months. This interim assessment will show any changes and inform the development of costings for remedial action if this is required. The Health Board is awaiting a formal response from the adjoining developer to ensure that their intentions match those of the Health Board s engineers requirements. The Health Board will consider the need for a separate case to cover any remedial action resulting from these investigations. Staff Recruitment Constraints Cardigan and surrounding areas are very rural, and historically have experienced some difficulties in recruiting suitably trained and experienced clinical staff. There is a particular issue with the recruitment of GPs both in the area and nationally. The provision of the new model of care combined with a new, purpose designed integrated care centre will only help in future recruitment activities Dependencies The project is subject to the following dependencies that will be carefully monitored and managed throughout the lifespan of the scheme. New Model of Integrated Care This project is part of a pilot to introduce a new model of integrated care in Cardigan and the surrounding area and the project is dependent of the success of this initiative. Evidence is available to demonstrate the initial success of the new model of care and monitoring will continue over an extended period in order to confirm its continued effectiveness. Availability of Capital It is acknowledged that there are pressures on the All Wales Capital Programme. development is dependent upon receiving capital funding. The P a g e 80

83 Section 3: Economic Case P a g e 81

84 3 Economic Case Cardigan Integrated Care Centre FBC 3.1 Introduction In accordance with the Capital Investment Manual and requirements of HM Treasury s Green Book (A Guide to Investment Appraisal in the Public Sector), this section of the FBC documents the wide range of options that have been considered in response to the scope identified within the strategic case and details the non-financial and economic evaluation of options and identifies the preferred option. 3.2 Critical Success Factors The critical success factors (CSFs) contained within the SOC were reviewed and updated at a pre-option appraisal workshop attended by Project Board members on 6 th May The updated CSFs were reviewed and agreed at the Non-Financial Evaluation Workshop (Section 3.7) which was attended by representatives from Cardigan League of Friends, CHC and Age Cymru. There is a full programme of engagement with stakeholders and a well-established Stakeholder Board in place. The agreed critical success factors were: Critical Success Factor Table 5: Critical Success Factors The extent to which the option: 1 Flexibility Can be adapted to meet the changing needs of the local population and the new service model 2 Strategic Fit Takes forward the national Policy and local strategic priorities 3 Achievability Can be achieved within the 2016 planning timescale for the project 4 Affordability revenue Can be delivered within the overall health and social care budget 3.3 The Long Listed Options The long-list of options was re-visited during the development of the OBC in line with the new model of care, and is given below: Option L1: Option L2: Option L3: Option L4: Option L5: Do Nothing retain existing facilities and undertake backlog maintenance New build integrated care facility with 25 inpatient beds New build integrated care facility with 21 inpatient beds New build integrated care facility with 12 inpatient beds New build integrated care facility with no inpatient beds and no additional staff working in the community P a g e 82

85 Option L6: Option L7: Option L8: New build integrated care facility with no inpatient beds but with additional staff working in the community New build integrated care facility with no beds plus additional staff working in the community; plus access to a mixed economy of beds within the Cardigan area New build integrated care facility without GMS facilities Option L9: Cease provision of non-gms services within the Cardigan area. (N.B. Community services in service user s own homes would continue, but there would be no Outpatient facilities or staff base in Cardigan). Option L10 Do Minimum. Undertake improvement works to the existing accommodation Each of these long-listed options was reviewed in detail to identify how well they met the investment objectives and the benefit criteria agreed for the scheme. Based on this review, the options were either agreed as warranting further investigation on the shortlist or discounted as being non-viable. The outcome of this review is summarised below. Option L1: Do Nothing (Do Minimum option in Draft OBC July 2014) retain existing facilities and undertake backlog maintenance In this option services would remain in their current locations. Backlog maintenance would be undertaken to the hospital and GP premises. Advantages: It was believed that this option could be delivered within the overall health and social care revenue budget. Disadvantages: This option would not facilitate the delivery of the new model of care. The existing buildings are not large enough to provide accommodation that would enable multiagency integration, single point of assessment, rehabilitation and optimal use of health and social care resources; The existing building layouts do not provide appropriate spatial standards for healthcare provision; Retaining the existing facilities would not provide any flexibility to adapt to meet the challenging needs of the local population and the new service model; The Cardigan hospital site is adjacent to the River Teifi and is situated in its flood plain. Flooding of the site was experienced earlier this year which prevented access from the lower main site entrance and to the rear of the building. Significant flood prevention works are required to safeguard the building in future as predictions are that river levels will continue to rise; The existing lifts would require replacement, and these do not provide any access to the top floor; There will be added car park pressures as parking is already underprovided on the site; P a g e 83

86 Due to the extent of backlog maintenance required to meet modern standards of accommodation in both the Hospital and GP Practice, and needing to undertake this work whilst retaining a safe working environment in both, it would not be possible to complete the works within the timeframe. Outcome: It was decided that this option did not meet the critical success factors or the investment objectives of the development. However, this option was carried forward to evaluation as the baseline comparator for other options. Option L2: Option L3: Option L4: New build integrated care facility with 25 inpatient beds New build integrated care facility with 21 inpatient beds New build integrated care facility with 12 inpatient beds It was agreed that, for the purposes of the non-financial evaluation the three options included the provision of beds would be reviewed as one overall bedded option, as it was decided that the issue to be evaluated was the inclusion of beds and not the number of such beds. In the event that a bedded option was identified as the preferred option further work would be undertaken at that stage to decide on an appropriate number of beds. It was acknowledged that the bedded options had been carried forward from the SOC In the intervening period the new model of care had been developed, which aims to provide as much care as possible closer to or in the patients own home, which had resulted in the inpatient beds within Cardigan Hospital being closed on a trial basis earlier in Advantages: It was considered that this option could improve local access to services; This option would provide a high quality physical environment. Disadvantages: This option does not support the new model of care, as resources would all be concentrated in the building and would not enable increased support closer to home. Resources would have to be drawn back into the building to support the inpatient beds, reducing the support in the community; This option would involve a larger scale and therefore longer build period, and would not meet the achievability target. Outcome: It was decided to carry the bedded options through for further evaluation, as one bedded option for the non-financial evaluation as it was the concept of inpatient beds being evaluated rather than the actual numbers. Each of the bedded options would be evaluated separately for the financial evaluation, as there would be different outcomes both in capital and revenue expenditure. P a g e 84

87 Option L5: New build integrated care facility with no inpatient beds and no additional staff working in the community In this option the staff previously employed on the inpatient ward would not be redeployed in the community setting. Advantages: This option would be achievable within the timescale; It was anticipated that this option could be provided within revenue affordability targets; This option would provide a high quality physical environment for the delivery of healthcare. Disadvantages: This option would not support the implementation of the new model of care, as there would be no additional support within the community; There is no provision for access to beds locally in the event of short term need; The decommissioning of the inpatient beds has not proved to be a popular decision with a proportion of the local community. Outcome: This option was carried forward for further evaluation. Option L6: New build integrated care facility with no inpatient beds but with additional staff working in the community In this option the staff previously employed on the inpatient ward would be redeployed in community or specialist care roles following additional training. Advantages: This option would support the implementation of the new model of care. Additional staff would be located in the community to support patients in their own homes; Increase in access to local services; This option should be achievable within the timescale; It was anticipated that this option could be provided within revenue affordability targets; This option would provide a high quality physical environment for the delivery of healthcare. Disadvantages: This option doesn t make provision for access to beds locally in the event of short term need; The decommissioning of the inpatient beds has not proved a popular decision with a proportion of the local population. P a g e 85

88 Outcome: This option was carried forward for further evaluation. Option L7: New build integrated care facility with no beds plus additional staff working in the community; plus access to a mixed economy of beds within the Cardigan area In this option the staff previously employed on the inpatient ward would be redeployed in community or specialist care roles following additional training. Access to an appropriate bed within the locality could be arranged for short term interim support on an individual basis. Advantages: This option would support the implementation of the new model of care. Additional staff would be located in the community to support patients in their own homes; This option enables appropriate access to beds within the local community on an individual patient need basis; Increase in access to local services; This option should be achievable within the timescale; It was anticipated that this option could be provided within revenue affordability targets; This option would provide a high quality physical environment for the delivery of healthcare. Disadvantages: The decommissioning of the inpatient beds was not a popular decision with a proportion of the local population. However, this option does provide access to alternative interim placement beds within the local community as an alternative to inpatient beds. Outcome: This option was carried forward for further evaluation. Option L8: New build integrated care facility without GMS facilities This option would provide a new build health facility for all services excluding the GMS services, which would remain in the existing Health Centre. Advantages: This option should be achievable within the timescale; It was anticipated that this option could be provided within revenue affordability targets; This option would provide a high quality physical environment for the services that would relocate to the new facility. However, the GMS services would continue to be delivered from the existing Health Centre, which is in a poor condition and is not conducive to the provision of modern healthcare. P a g e 86

89 Disadvantages: The GMS services would continue to be delivered from the existing Health Centre, which is in a poor condition and is not conducive to the provision of modern healthcare; There would be no integration between GMS and community health and social care services; This option would not support the implementation of the new model of care, as there would be no additional support within the community; There is no provision for access to beds locally in the event of short term need. Outcome: This option was discounted from further evaluation. Option L9: Cease provision of non-gms services within the Cardigan area. (N.B. Community services in service user s own homes would continue, but there would be no Outpatient facilities or staff base in Cardigan). Advantages: This option should be achievable within the timescale; It was anticipated that this option could be provided within revenue affordability targets. Disadvantages: The GMS services would continue to be delivered from the existing Health Centre, which is in a poor condition and is not conducive to the provision of modern healthcare; This option would significantly reduce local access to healthcare services in the Cardigan area; Patients would be required to travel to other towns in order to access services; There would be no integration between GMS and community health and social care services; This option would not support the implementation of the new model of care, as there would be no additional support within the community; There is no provision for access to beds locally in the event of short term need. Outcome: This option was discounted from further evaluation. P a g e 87

90 Option L10 Do Minimum. accommodation Undertake improvement works to the existing The Welsh Government, in its comments on the Draft OBC submitted in July 2014, requested that a more realistic Do Minimum option for usage of the existing Hospital and Health Centre facilities be developed and presented. Therefore, this option has been developed and is now presented as the Do Minimum option. This option had previously been considered in the original 2008 site option appraisal exercise, which concluded that whilst the Cardigan Hospital site has good access to town the trunk road it is too small, is bordered by a listed building and has flood plain issues. Out of a total of 7 options, the Cardigan Hospital site was ranked as the 5th out of 7 in In this option, the current Cardigan Hospital would be completely refurbished and altered to accommodate the require schedule of accommodation. In developing this option it was immediately apparent that at circa 1,730m 2, the building is not big enough to accommodate the required 3,550m 2 from the revised schedule of accommodation and so as a starting point in developing the new do minimum option, it was agreed that the GP s would remain in their existing building which would be fully refurbished as part of this. Advantages: It was anticipated that this option could be provided within revenue affordability targets. Disadvantages: The desired level of accommodation cannot be delivered within the existing buildings to meet the Health Boards aspirations of its required model of care and will also not provide the integration of services as Health Board, GMS and Social Services staff would not be co-located; There is known asbestos in the community hospital building and hence a programme of removal will be required prior to commencement of any refurbishment works. This is also likely to impact on current services at the site; The Cardigan Hospital site is adjacent to the River Teifi and is situated in its flood plain. Flooding of the site was experienced in 2014 which prevented access from the lower main site entrance and to the rear of the building. Significant flood prevention works are required to safeguard the building in future as predictions are that river levels will continue to rise; It would be necessary to decant from the existing buildings in order to undertake the works, causing disruption to services. No suitable alternative accommodation in which to decant has been identified to date; There would be no integration between GMS, community health and social care services; This option would not support the implementation of the new model of care, as there would be no additional support within the community; There is no provision for access to beds locally in the event of short term need; Due to the level of works required, it would not be possible to complete these works within the timeframe. P a g e 88

91 Outcome: At the request of the Welsh Government, this option was carried forward for further evaluation Summary of Review of Long List of Options The outcome of this review is summarised in the table below: Table 6: Summary of Review of Long List of Options Do Minimum Intermediate Maximum L1 L9 L10 L2 / L3 / L4 L5 L6 L8 L7 Long List Options Do Nothing - retain existing facilities and undertake backlog maintenance Cease GMS Services Do Minimum - Undertake New Build ICC with improvement works beds / no additional to existing community staff accommodation New Build ICC with no beds / no additional community staff New Build ICC. No beds. Additional community staff New Build Centre without GMS facilities New Build ICC with no beds. Additional Community staff + access to mixed economy of beds. Investment Objectives Critical Success Factors PP PP P?? PP PP PP PP PP PP PP PP PP P? PP PP PP PP PP PP PP Carry Forward Discounted Discounted Carry Forward Discounted Carry Forward Discounted Carry Forward Therefore, the options carried forward to the shortlist are summarised below: Table 7: Shortlisted Options Long Listed Options: Shortlisted Reference: L1 L6 L7 L2/3/4 L10 Do Nothing retain existing facilities and undertake backlog maintenance New Build Integrated Care Centre with no inpatient beds and no additional investment in community support / services New Build Integrated Care Centre with no inpatient beds but with additional staff working in the community; plus access to a mixed economy of beds in the cardigan area. New Build Integrated Care Centre with inpatient beds and no additional investment in community support / services Do Minimum undertake improvement works to the existing facilities Carried forward to the shortlist as Option 1 Carried forward to the shortlist as Option 2 Carried forward to the shortlist as Option 3 Carried forward to the shortlist as Options 4/5/6 Carried forward to the shortlist as Option 7 P a g e 89

92 3.4 Non-Financial Option Appraisal A non-financial evaluation of options workshop was held on Tuesday 3rd June The attendees were: Gill Davies Carys Davison Eirwyn Harries Jina Hawkes Sonia Hay Amanda Jones Gwyneth Jones Sue Lewis Dr Rowena Matthew Sandra Morgan Pamela Parsons Audrey Rogers Eldeg Rosser Claire Thomas Emma Whiteley Paul Williams Sue Collins Helen Jarvie County Director and Commissioner for Ceredigion; HDUHB Primary Care Development Manager; HDUHB Chair, Cardigan Hospital League of Friends Community and Primary Care General Manager; HDUHB Modernisation Manager; HDUHB Service Planning Manager; HDUHB Director, Age Cymru, Ceredigion County Director and Commissioner for Pembrokeshire; HDUHB (Project Director) Associate Medical Director Ceredigion; HDUHB Head of Therapies Ceredigion; HDUHB Hywel Dda Community Health Council Assistant Director Therapies and Health Science; HDUHB Head of Service Modernisation; HDUHB Primary Care Estates & Planning; HDUHB Locality Manager, South Ceredigion, representing Sue Darnbrook, Head of Adult Social Care Services, Ceredigion County Council Assistant Director of Planning; HDUHB Senior Healthcare Planner, SHP (Workshop Facilitator) Senior Healthcare Planner, SHP (Workshop Facilitator) The full report of the non-financial evaluation of options workshop is given at Appendix 5. The main outcomes are summarised below. 3.5 Benefits Criteria The benefit criteria for the scheme were ratified as: Benefit Criteria 1: Benefit Criteria 2: Benefit Criteria 3: Benefit Criteria 4: Benefit Criteria 5: Benefit Criteria 6: Benefit Criteria 7: Access to Services Improve Clinical Quality of Services Strategic Fit Flexibility for the future Achievability Sustainability Environmental Quality P a g e 90

93 3.5.1 Benefit Criteria Weightings The benefit criteria were then weighted to indicate the particular importance of each criterion relative to each other. The weightings given in Table 8 were agreed by all attendees: Table 8: Benefit Criteria Weightings Criteria Rank Weight Access to Services 1 26 Improve Clinical Quality of Services 2 23 Strategic Fit 3 15 Flexibility for the Future 4 14 Achievability 5 10 Sustainability 6 7 Environmental Quality 7 5 Total: Shortlisted Options The long list of options had been reviewed previously during the Non-Financial Evaluation Pre-Workshop on 6th May 2014, and a short list had been developed as shown in section 3.3. This was discussed during the Non-Financial Workshop, and the outcome of this review and it was agreed that the shortlisted options below were considered to be viable and therefore formed the short list of options to be subjected to both non-financial and financial evaluation as below. Option 7 has been added at the request of WG: No. Table 9: Shortlisted Options Option 1 Option 2 Option 3 Option 4/5/6 Option 7 Do Nothing retain existing facilities and undertake backlog maintenance New build Integrated Care Centre with no inpatient beds and no additional investment in community support / services New build Integrated Care Centre with no inpatient beds but with additional staff working in the community; plus access to a mixed economy of beds within the Cardigan area New build Integrated Care Centre with inpatient beds and no additional investment in community support / services. In the event that this option becomes the preferred option, additional works will be undertaken to identify the appropriate number of beds. Do Minimum undertake improvement works to the existing accommodation. P a g e 91

94 3.7 Scoring of Options Cardigan Integrated Care Centre FBC The non-financial evaluation was held on 3 rd June At that time Option 7 was not in the shortlist, as it had been previously discounted in Therefore, Option 7 was not included in the non-financial evaluation. The Health Board has considered this, and reached the conclusion that, as Option 7 would not be able to provide the required accommodation and would therefore not have scored highly, it was not necessary to rerun the non-financial evaluation. Option 7 was, however, evaluated financially, and the results are shown at Section 3.8. A detailed analysis of the Non-Financial Appraisal is given at Appendix 5. A summary is given below Raw Scores A 10 point scoring system was used and, following discussion, the attendees agreed to use consensus scoring rather than individual scoring. The overall scores from the non-financial evaluation were: Table 10: Benefit Criteria Scoring Raw Scores Benefit Criteria Consensus Score Option 1 Option 2 Option 3 Options 4, 5, 6 Access to Services Improve Quality of Services Strategic Fit Flexibility for the Future Achievability Sustainability Environmental Quality Total Score Rank Difference -85% -49% 0% -28% The only score where consensus was not achieved was the score for Options 4-6 (Integrated Care Centre with Inpatient Beds) and Benefit Criteria 1 Access to Services. The attendees from Age Cymru Ceredigion and the Cardigan Hospital League of Friends believed that this score should be 8, and it was therefore agreed that the score would be compiled twice, with their preferred score in the alternative total. This did not affect the ranking of the benefit criteria scoring. P a g e 92

95 3.7.2 Weighted Scores The weightings agreed earlier in the non-financial evaluation were then applied to the raw scores as below: Benefit Criteria Consensus Score Weighted Table 11: Weighted Scores - Consensus Scores Weighted Scores Weight Option 1 Option 2 Option 3 Options 4, 5, 6 Access to Services 26% Improve Quality of Services 23% Strategic Fit 15% Flexibility for the Future 14% Achievability 10% Sustainability 7% Environmental Quality 5% Total Score 100% Rank Difference -84% -58% 0% -34% The results of the consensus scoring non-financial evaluation show that the clear preferred option was for Option 3. The weightings were then applied to the raw scores of the scoring with the Age Cymru and League of Friends scores. It was confirmed that the ranking of the weighted scores remained unaltered Sensitivity Analysis Equal and Reverse Weights Both sets of scores were calculated on an equal weight basis and a reverse weight basis. Neither of these scenarios altered the rankings in both analyses Option 3 remained the clearly preferred option Conclusion to the Non-Financial Evaluation Through all analysis, and including the scores from Age Cymru and Cardigan Hospital League of Friends the preferred option was Option 3 - New Build Integrated Care Centre with no inpatient beds but with additional staff working in the community; plus access to a mixed economy of beds within the Cardigan area. There was no scenario where Option 3 was not the preferred option. P a g e 93

96 3.8 Financial Option Appraisal A discounted cash flow for each of the options has been undertaken using a discount rate of 3.5% for years 1-30 and 3% for years in line with the requirements of HM Treasury Guide to option appraisal (the Green Book ). Both the Net Present Cost PC) and Equivalent Annual Cost (EAC) have been calculated. EAC is used for comparison of options over different life spans as it converts the NPC to an annual figure. The key elements used in the analysis are summarised below: Initial capital outlay for each option exclusive of VAT Lifecycle costs Revenue costs for each option, excluding capital charges. In accordance with guidance, the cash flows exclude: Capital charges, as these are reflected through the life cycle costs, and VAT, as this represents a flow of money from one part of Government to another ( transfer payments ). Comment Table 12: Economic Appraisal Assumptions The start point for the economic appraisal is 2013/14 The cost base is 2013/14 Capital costs and life cycle costs for each of the short listed options have been provided by Gardiner & Theobald The capital costs for each option outlined in the OBC forms are based on the PUBSEC index of 194 for Q2 2015; however it is a fixed price for the duration of the contract A discount factor of 3.5% has been applied to cash flows for years 1 to 30. A 30 year appraisal period has been used for Option 1 as this is a refurbishment and a 60 year appraisal for all other options, 2013/14 being year Capital Costs Gardiner & Theobald have prepared the capital cost estimates for the options. OBC forms have been produced for each option and include the following assumptions: Construction costs are calculated at PUBSEC Q for approval purposes. VAT is at 20%, except for the professional fee element which is recoverable. Transition costs are included within the capital costs. The OBC forms were provided in full detail in the Estates Annex. P a g e 94

97 3.8.2 Lifecycle Costs Cardigan Integrated Care Centre FBC Gardiner & Theobald have estimated lifecycle costs for each of the options. These were summarised in the Estates Annex and Addendum and the Generic Economic Model provided by the Health Board Revenue Costs The detailed revenue costs used for all options were included as worksheets in the Generic Economic Model provided by the Health Board. They exclude transfer costs such as rates. The revenue costings included the following assumptions: Starting point was the 2013/14 outturn prices. Taking into account the above, 2013/14 base year was kept at 2013/14 outturn levels rather than e.g. being subject to inflation Savings There was a reduction in the running costs associated with the revised preferred option (Option 3) which was reflected in the Generic Economic Model Optimism Bias Optimism bias was calculated for each of the options and was included in the economic analysis Key Results of Economic Appraisal The results were summarised in Table 13 below: Table 13: Key Results of Economic Appraisal Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 Option 7 Undisc Disc Undisc Disc Undisc Disc Undisc Disc Undisc Disc Undisc Disc Undisc Disc Capital 5,708,453 4,287,644 27,036,514 18,595,357 25,873,016 18,028,928 34,520,463 24,053,775 37,176,703 25,885,176 38,134,589 26,532,893 11,447,521 8,621,126 Property & Opportunity Cost 0 547, , , , , , ,235 Recurrent 47,644,507 29,209,333 56,053,597 24,486,338 84,428,893 35,848, ,875,464 47,170, ,439,387 59,341, ,451,217 60,438,939 95,289,013 40,299,725 Total Costs 53,352,959 34,044,139 83,090,111 43,830, ,301,908 54,626, ,395,926 71,973, ,616,091 85,976, ,585,806 87,721, ,736,535 49,646,088 Actual Revenue 47,644,507 29,209,333 56,053,597 24,486,338 84,428,893 35,848, ,875,464 47,170, ,439,387 59,341, ,451,217 60,438,939 95,289,013 40,299,725 Cash Releasing Benefits Costs net Cash Releasing 53,352,959 34,044,139 83,090,111 43,830, ,301,908 54,626, ,395,926 71,973, ,616,091 85,976, ,585,806 87,721, ,736,535 49,646,088 Non-Cash Releasing Total 53,352,959 34,044,139 83,090,111 43,830, ,301,908 54,626, ,395,926 71,973, ,616,091 85,976, ,585,806 87,721, ,736,535 49,646,088 P a g e 95

98 3.9 Financial Option Ranking The results were summarised in the following table: Option Table 14: Summary of Results of Option Ranking Net Present Costs (NPC) 000 Equivalent Annual Cost (EAC) 000 Variance over Option 1 Ranking Switch Value 1 34,813 1, ,405 1, (40) 3 58,470 2, (422) 4 76,562 2,903 1,108 5 (1,108) 5 90,729 3,440 1,645 6 (1,645) 6 92,497 3,507 1,712 7 (1,712) 7 53,713 2, (241) From the analysis undertaken, it can be seen that in economic terms, Option 1 was: Clearly preferred over Options 4, 5 and 6 Less preferable over Options 2, 3 and Sensitivity Analysis The results of the economic appraisal were subjected to a specific sensitivity test to assess the level of cost driver (switch value) required to make any of the other options preferred economically over Option 1 as shown in Table 16 above. Thus, in order to switch preference in favour of Option 2: The EAC of Option 1 would have to rise by 40,000; or The EAC of Option 2 would have to fall by 40,000. Similarly, in order to switch preference in favour of Option 3: The EAC of Option 1 would have to rise by 422,000; or The EAC of Option 3 would have to fall by 422,000. In order to switch preference in favour of Option 4: The EAC of Option 1 would have to rise by 1,108,000; or The EAC of Option 4 would have to fall by 1,108,000. In order to switch preference in favour of Option 5: The EAC of Option 1 would have to rise by 1,645,000; or The EAC of Option 5 would have to fall by 1,645,000. In order to switch preference in favour of Option 6: P a g e 96

99 The EAC of Option 1 would have to rise by 1,712,000; or The EAC of Option 6 would have to fall by 1,712,000. In order to switch preference in favour of Option 7: The EAC of Option 1 would have to rise by 241,000; or The EAC of Option 7 would have to fall by 241, Combining the Financial and Non-Financial Appraisal From the above it can be seen that from a non-financial perspective there was a clear preference for Option 3. In economic terms there was a clear preference for Option 1. Consequently, the preferred option was identified by reference to the combined appraisal on the basis of the options that delivered the highest benefits per m EAC as follows: Weighted non-financial score Table 15: Combined Option Appraisal Option 1 Option 2 Option 3 Option 4 Option 5 Option Non-Financial Ranking Option 7 EAC impact of options Economic Ranking Benefit Points per m EAC Combined ranking Difference -71% -46% 0% -43% -52% -53% Option Appraisal Conclusions On the basis of the combined analysis, the overall preferred option was Option 3, to develop a new build Integrated Care Centre with no inpatient beds but with additional staff working in the community; plus access to a mixed economy of beds within the Cardigan area. It was agreed that the inclusion of Option 7 at the request of Welsh Government after the nonfinancial evaluation workshop would not have affected this outcome Update of Option Appraisal for Full Business Case This option appraisal was reviewed by the Project Board at its meeting on 14 th October It was agreed that the critical success factors, benefit criteria and scoring of the options remained relevant and the option appraisal continued to reflect a realistic outcome. The economic appraisal undertaken as part of the OBC has also been reviewed and updated as part of the FBC work to reflect: P a g e 97

100 The tendered capital costs The reviewed revenue costs The current optimism bias on the scheme The Generic Economic Model is provided in Appendix Risk Appraisal The Risk Register is reviewed by Project Board members at the monthly Project Board meetings. A Project Board Risk Workshop was held on 19 th June 2014 to formally review the risk register prior to submission of the OBC. During the course of the Full Business Case (FBC) stage of the project there have been a number of risk reviews culminating in the remaining risks being costed and assigned to the party best placed to manage them during the construction phase of the project. The more significant risks to the project are highlighted below. The full Risk Register is included within the Estates Annex. Adjacent Site Following extensive ground investigation of the site during the Outline Business Case stage of the project, the Supply Chain Partner (SCP) developed a robust ground engineering design solution for the scheme as part of the detailed design process. However, at a site visit in late 2015, ground surface tension cracks were observed on the adjacent site, beyond our common site boundary. Further inspection of the retaining structures on the adjacent site revealed an ongoing failure to the adjoining retaining structure along the top of the adjacent site. This has raised concerns of a risk that potentially the similar adjoining retaining structure along our common boundary could be compromised. Due to concerns about the adjoining site, additional ground investigations are planned for a six month period commencing March 2016, with an interim assessment of risk after several months. This interim assessment will show any changes and inform the development of costings for remedial action if this is required. The Health Board is awaiting a formal response from the adjoining developer to ensure that their intentions match those of the Health Board s engineers requirements. The Health Board will consider the need for a separate case to cover any remedial action resulting from these investigations. P a g e 98

101 Section 4: Commercial Case P a g e 99

102 4 Commercial Case Cardigan Integrated Care Centre FBC 4.1 Introduction This section of the Full Business Case outlines the proposed development in respect of the preferred option outlined in the Economic Case. For the purposes of the Commercial Case, cross reference is made to the Estates Annex and its sections and separate appendices. This commercial case section should be read in conjunction with these documents. 4.2 Scope The preferred option is to develop an Integrated Care Centre in Cardigan, which will replace the current Community Hospital and Health Centre, which are owned by Hywel Dda University Health Board (HDUHB). On completion of the project, the asset will be owned and managed by HDUHB. The scope of the scheme includes: General Medical Services (Cardigan Health Centre GP Practice); Community Dental Service; Community Pharmacy; Minor Injury Service GP/Nurse led, walk-in service with telemedicine links to the Emergency Department; Radiology and diagnostics digital x-ray with remote reporting; Phlebotomy service; Outpatient suite with consulting rooms and clinical treatment facilities for preassessment and outpatient consultations by visiting consultants, specialist nurses/therapists and social workers and opportunities for multi-disciplinary one stop clinics; Disease specific services e.g. heart failure, motor neurone disease clinics and COPD services; Enhanced telemedicine equipment in clinical areas providing remote access to specialists from across the professions; Rehabilitation services providing opportunities for intensive and slow stream rehabilitation to restore function and improve independence, supported by therapists, nurses and social care staff within the Community Resource Team; Mental health and learning disabilities services; Base for Community Resource Team in the South Ceredigion Locality; Third sector services. P a g e 100

103 4.3 Procurement Strategy Cardigan Integrated Care Centre FBC The procurement strategy is Designed for Life / Building for Wales DFL3 and the procurement route being followed for this scheme is the All Wales Capital route utilising the Welsh Government For Life Building for Wales DFL3 NHS Framework. The use of DFL frameworks for the procurement of capital schemes in Wales is mandatory for all schemes over 4m works costs with DFL2 being applicable for schemes with an estimated works cost of between 4m - 10m and DFL3 for schemes for an estimated works cost of 10m and over. The Cardigan Integrated Care Centre scheme is a DFL3 scheme and the development team is led by a Supply Chain Partner: Contract Strategy for all DFL frameworks is NEC Option 3 Target Cost. This procurement route offers the Health Boards the benefit of suitably experienced Supply Chain partner teams who are skilled in the delivery of complex health care buildings in accordance with relevant HBN / HTM guidelines and statutory legislation whilst taking account of cost, time and quality. The objectives of this framework are: Shared ownership of key project objectives and challenges; Environments designed to promote innovation and cross-project knowledge share; Open communication creating an environment to manage change; Greater certainty of quality cost and programme; and A mutually supportive team culture. The Health Board has appointed from the framework following a selection process undertaken at commencement of the OBC. Health Board Project Manager Gardiner and Theobald Management Services: to fulfil the contractual obligations imposed by the chosen contracts; Health Board Cost Advisor Gardiner and Theobald: providing independent cost advice to the Health Board and Project Manager; Supply Chain Partner Interserve Construction Ltd.: to provide contractor services as well as to lead the project s supply chain. The supply chain provide the design team services comprised of the following disciplines: - Constructor; - Mechanical and Electrical Engineering subcontractors/installer; - Architectural design (including interior design and landscaping); - Principal Designer role (CDM2015); - Civil and Structural Engineering Design; - Mechanical and Electrical Engineering Design; - Cost Managers. P a g e 101

104 4.4 Proposed Contractual Arrangements Contractual Arrangements have been entered into with all parties for the FBC stage using the NEC contract as prescribed under the Framework. For the Project Manager and Cost Advisor, the NEC 3 Professional Services Contract has been used, and for the SCP, the NEC Option C (Target Cost) contract has been used. The NEC 3 Option C with Target Cost is based on the following principles: Partnering ethos requiring mutual trust and co-operation; Clarity the contract is written in plain language; The risk-register as a key project and contract management tool; Foresight and early warnings; A Target Cost and cost not to be exceeded; Timely two-way communication; Compensation events. Payments to the externally appointed team will be as prescribed in the individual NEC contracts and in line with Designed for Life 3 practices and procedures. There are no key contractual clauses over and above the standard framework clauses Consultant Advisors It is the aim of HDUHB to develop new facilities that will enable the delivery of modern healthcare services to the local community. The Health Board is seeking full support from its appointed SCP, Interserve Construction Ltd and the following support consultants: Project Manager: Gardiner and Theobald Management Services (GTMS); Cost Advisors: Gardiner and Theobald (G&T); Supervisor: Not yet appointed; Healthcare Planner: Strategic Healthcare Planning LLP. 4.5 Charging Mechanisms HDUHB intends to make payments in respect of the proposed products and services as follows: Charging will be completed under the Designed for Life Building for Wales Construction Procurement Framework pre-agreed fee arrangements. The contract will be managed by HDUHB under the NEC3 Option C Target Cost Contract. All payments are to be approved by Cost Advisor and Project Director before being passed to HDUHB for payment. P a g e 102

105 4.6 Compensation Events Resolution Process A compensation event is an event which changes the contract resulting in an increase or decrease in cost. Reasons for compensation events are clearly defined within the NEC 3 Form of Contract. To manage this process and avoid conflict where possible, the Project Manager has worked with the SCP to agree a resolution. The main features of this process are: Early Warning Notice: The Project Manager or SCP may issue early warning notices. An early warning notice identifies a potential cost increase, but does not identify the cost sharing between the parties. An early warning notice may or may not be a compensation event. Early Warning or Risk Reduction meetings will be held as necessary to review the content of these notifications. Compensation Event: The Project Manager and the SCP may each notify the other of compensation events and will endeavour to agree validity in line with the contract. The definitions of some types of compensation events, particularly design responsibility compensation events, have given difficulties in interpretation. However, ultimately the Project Manager decides whether an item is a valid compensation event or not. Quotation: The SCP issues quotations for valid compensation events upon request from the Project Manager. Assessment: The Project Manager reviews the quotations and issues assessments of the compensation event values (in some cases the Project Manager will make their own assessment). Notification: Assessments are notified to Hywel Dda Health Board for their endorsement prior to payment. Objection: The SCP can object to an assessment and the Project Manager is obliged to review objections. Disputes: Should a dispute arise then it will be dealt with as per the dispute resolution procedure as set out in the Project Agreements. 4.7 Risk Allocation Risks will be apportioned between the client and its SCP. The adopted principle is that risks should be passed to the party best able to manage them, subject to value for money (VFM). The Designed for Life: Building for Wales framework dictates that the NEC3 contract is used. It is a collaborative contract that requires a project to include a Costed Risk Register with risk allocated to the party best able to deal with it. The early involvement of Supply Chain partners means that they are fully briefed about risks in the project and can accept ownership of more risks than would normally be the case under a more traditional form of contract. The Risk Transfer Matrix Table is shown in Table 16: P a g e 103

106 Risk Category Table 16: Risk Transfer Matrix Potential Allocation Hywel Dda UHB SCP 1. Design Risk 2. Construction & Development Risk 3. Transition & Implementation Risk 4. Availability and Performance Risk 5. Operating risk & Service Continuity 6. Variability of Revenue Risks 7. Termination Risks 8. Technology & Obsolescence Risks 9. Control Risks 10. Residual Value Risks 11. Financing Risks 12. Legislative Risks Shared During the course of the FBC stage of the project, there have been a number of risk reviews culminating in the remaining risks being costed and assigned to the party best placed to manage them during the construction phase of the project. 4.8 Project Delivery Programme The detailed master delivery programme for the project is included within the Estates Annex and indicates that the construction period of the project will be delivered over 73 weeks. Detailed planning of the construction programme has indicated the following key dates for the delivery of this project: Project Delivery Programme: Table 17: Project Delivery Programme FBC Submission to WAG April 2016 WAG approval of FBC May 2016 Construction mobilisation June 2016 Construction phase (17 months) June 2016 to November 2017 Commissioning November 2017 to January 2018 Target go live date January 2018 Post Project Evaluation Target January 2019 P a g e 104

107 4.9 Personnel Implications (including TUPE) It is anticipated that Transfer of Undertaking and Protection of Employment (TUPE) will not apply to this investment Accountancy Treatment The assets developed through this FBC will appear as a fixed asset on the balance sheet of the Health Board. This treatment is not expected to change as a consequence of the introduction of International Financial Reporting Standards (IFRS) Disposal of Assets The Health Board envisages that in delivering the preferred option, the community hospital and health centre sites will be surplus to operational requirements and therefore available for disposal. The Health Board will develop a disposal strategy for each of the sites taking into account the construction programme of the new facilities and the possible vacation dates. The key considerations which the Health Board will use to develop disposal strategies are as follows: Location; Possible planning approvals for future use; Timing of disposal; Impacts of retaining the premises for longer than desired. The site disposal values within the business case are based upon current market value Estates Annex The Estates Annex to this FBC provides more detailed information on the contractual arrangements in place to support this development. P a g e 105

108 Section 5: Financial Case P a g e 106

109 5 Financial Case Cardigan Integrated Care Centre FBC 5.1 Funding and Affordability Capital and Funding Requirements The figure below summarises the capital funding requirements of the scheme. The Health Board is looking for capital funding of 21,197,970 from the Welsh Government to support the development. FB Cost forms are given at Appendix 7 and in the Estates Annex. Figure 18 - Capital Cost Summary Preferred Option Total 000 Works Cost Total 11,443 Fees 2,305 Non-works Costs 887 Equipment Costs 1,142 Risk Contingency 1,213 Land 979 VAT 3,229 Total for Approval Purposes 21,198 It should be noted that the capital cost estimates are based on Option 3. The following assumptions have been made around the capital costs: VAT recovery will only be available on Health Board fees; Optimism bias is not included in the capital costs but has been included in the Economic Case. The above costs are based on a start on site in June The total capital costs are based on BIS PUBSEC (MIPS FP) 221. These capital costs exclude the costs of additional works in connection with the adjacent site issues. The capital costs are based on returned tenders of packages of works as per the requirements of DFL3 framework. The timing of the cash flows, by financial year, is shown in Table 19. This is based on a start on site in June Table 19: Capital Cash Flow Requirements Pre 2015/ / / /18 Total Total 1,763 1,246 7,207 10,982 21,198 P a g e 107

110 5.2 Impairment and Balance Sheet Treatment The preferred option will impact on the Balance Sheet of the Health Board by increasing the value of fixed assets by 9,825,534. This is in line with estimates provided by the District Valuer. The report is contained in Appendix 8a. This addition will however be offset by the NBV of the current Cardigan Hospital and Health Centre when they are disposed, the current net book value of both these properties are 2,236,780. The estimated impairment on this scheme on completion will equate to 10,001,764 based on District Valuer estimates. This calculation can be seen in Appendix 8b. It is estimated that there will also be an AME impairment of 1,386,780 to revalue the existing Cardigan Hospital and Health Centre to market value when they become vacant and available for sale. The detailed calculation and DV reports are given in Appendices 8c and 8d. Under current accounting guidance none of the expenditure may be netted off the Health Board's Revaluation Reserve. The Hywel Dda Health Board is assuming that both AME impairment on completion of the new build and on revaluing to market value will be funded as AME funding via Welsh Government. 5.3 Revenue Affordability The revenue costs included in the FBC have been reviewed and revised since the OBC submission. The costs for the new model of care are based on 2015/16 costs and the original base costs have been increased to take into account the National Finance Agreement since they were collated. There are cash releasing revenue savings associated with the scheme of 83,507 per annum, this being the change in revenue costs shown in Table 20 from the original cost base to the full year effect of the new service model in 2017/18. The movement in revenue costs are detailed in the table below. There are also revenue consequences of the capital expenditure (depreciation). These additional costs will represent an estimated increase in the Health Board s baseline depreciation non-cash funding requirement of 351,440. The figure below summarises the revenue impact of the scheme. Detailed schedules of costs can be seen in Appendix 9. P a g e 108

111 Table 20 - Revenue Impact of Scheme Original Cost Base 2017/ / Site based costs incl. staffing 1,387 1, Community Nursing Services GMS * GP ** 2 10 Revenue Costs 1,607 1,571 1,523 Additional Depreciation 351 Total Charge to Revenue 1,607 1,571 1,874 * GMS General Medical Services these costs are reimbursed to Primary Care by the Health Board; ** GP General Practice these costs are borne by the Practice and are not reimbursed by the Health Board The model of care enabled by this capital build allows the Health Board to shift the focus of the staff working within the model from a community hospital bedded model of care, to a care closer to home model which is available equitably to all the population of the area, not just those in hospital beds. The scheme enables a 620,000 re-investment in the community staffing model. The current staffing costs in the new service model allow for the Cardigan MIU to be open Monday to Friday. Moving to 7 day opening would have to be considered as a service development in the future. Both the Cardigan Hospital and Health Centre sites will become surplus to Health Board requirement when the new building is commissioned. It has been agreed that all the proceeds of disposal from the sale of these two sites will flow back to Welsh Government when they are sold. The estimated capital receipt from the disposal of the two sites is currently estimated to be in the region of 850,000. The proceeds of the sale will flow back to the Welsh Government upon site disposal. The anticipated sale proceeds are not factored into the capital costs, but are included in the economic appraisal based on information provided by the District Valuer. The District Valuer s assessment of this can be seen in Appendix 8. All the costs are based on the assumptions that Primary Care services provided in the current Health Centre move into the new build in the same timeline as the services provided on the current hospital site. 5.4 Overall Affordability The gross capital cost of the proposed project is 21,197,970. The recurring annual cash releasing savings in revenue associated with the development is 83,507 revenue. P a g e 109

112 There will be additional depreciation costs associated with the scheme of 351,440 depreciation. The scheme is therefore concluded as being affordable to the Health Board, subject to agreement to the strategic funding of the capital charges by Welsh Government. P a g e 110

113 Section 6: Management Case P a g e 111