Strategic Assessment: Investment in infrastructure to support ongoing provision of hospital services in Dunedin

Transcription

1 Report prepared for Capital Investment Committee Strategic Assessment: Investment in infrastructure to support ongoing provision of hospital services in Dunedin Sapere Research Group commissioned by the Southern Partnership Group 19 July 2016

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3 Document Control Document History Version Issue Date Changes June 2016 Initial draft June 2016 Incorporating initial feedback from Ministry of Health and Steering Group July 2016 Incorporating feedback from the ILM workshop and subsequent discussions with the Steering Group July 2016 Final report submitted July 2016 Final report resubmitted with requested changes For information on this report please contact: Name: David Moore Telephone: Mobile: dmoore@srgexpert.com Page i

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5 Contents Executive summary... v Strategic context... 1 Organisational overview... 2 Southern DHB catchment and population profile... 2 Southern DHB role Key environmental features Alignment to existing strategies Meeting the challenge General medicine central to meeting patient medical needs Signs of being under continuous financial pressure Clear under-investment in physical capital Many buildings on the Dunedin campus are at end of serviceable life The ward block needs systematic re-lifing Facilities create material risks Clarifying what needs to be undertaken at Wakari Key stakeholders and next steps Appendices Appendix 1 Investment Logic Map Tables Table 1: Southern DHB financial performance 2010/ /15 14 Table 2: Southern DHB operated facilities 15 Table 3: Net present value of services 22 Table 4: Overview of buildings in Dunedin Hospital Campus 32 Table 5: Life remaining of elements in Clinical Service Block 38 Figures Figure 1 Cascading set of strategic plans and strategies 2 Figure 2 Map of Southern DHB 3 Figure 3 Comparison of age distribution - Southern DHB and national 4 Figure 4 Comparison of DHB population composition by ethnicity 5 Figure 5 Comparison of DHB population composition by deprivation quintile 5 Figure 6 Comparison of DHB total population and proportion living in rural areas 6 Page iii

6 Figure 7 Comparison of travel time to nearest base hospital and population or largest town in provincial TAs 7 Figure 8 Resident and estimated tourist population, by TA and month 8 Figure 9 Projected DHB populations /16 to 2036/37 9 Figure 10 Southern DHB staffing by role type (February 2016) 12 Figure 11 Staffing by group 12 Figure 12 Distribution of overall DHB occupation by age, with national employee data 13 Figure 13 Health cost weights, by age group 20 Figure 14 Projected growth in SDHB population by age group, 2015/16 to 2036/37 20 Figure 15 NPV by decreasing order of service 23 Figure 16 Alignment of Southern DHB strategic planning documents and activities 24 Figure 17 Grid spacing in middle of clinical area, CSB 28 Figure 18 Grid spacing in middle of corridor, CSB 28 Figure 19 Top floor area where asbestos cleaning is occurring, CSB 29 Figure 20 Lifts closed due to asbestos cleaning, CSB 29 Figure 21 Clinical and office supplies stored in corridor, CSB 30 Figure 22 Narrow corridor, CSB 30 Figure 23 Patient beds stored in entrance of ED, between two sets of doors 30 Figure 24 Limited space around x-ray machine, CSB 30 Figure 25 Dunedin Hospital site layout 32 Figure 26 East side of Clinical Services Block 33 Figure 27 CSB building (west side) showing cladding panels at lower levels, ED entrance, and main hospital entrance via Ward Block (south side) 35 Figure 28 Emergency Department entrance area, CSB 35 Figure 29 Grid spacing in lab, CSB 37 Figure 30 Grid spacing in middle of corridor, CSB 37 Figure 31: Stakeholder interest and influence assessment 42 Page iv

7 Executive summary This Strategic Assessment was commissioned by the Southern Partnership Group (SPG) and is prepared by Sapere Research Group. Sapere acknowledges the considerable contribution of the District Health Board (DHB) in the drafting of this document and two other supporting documents, being the Strategic Services Plan for the district and the Detailed Services Plan for the Dunedin campus. The purpose of this Strategic Assessment is to outline the need to invest in infrastructure at Dunedin Hospital as one of a number of enablers required to respond to existing constraints on the efficiency and effectiveness of current health service delivery. This document outlines the strategic context for the investment proposal and the specific challenges for Dunedin Hospital, as well as the DHB more broadly. As per the Better Business Case process, two Investment Logic Mapping workshops were held. The outputs of these workshops are included as an appendix and will be further developed through subsequent stages of business case development. The Southern DHB is responsible for population health and the provision of health services to eligible people living in or visiting the Southern DHB catchment area. Southern DHB was created in 2010, as the result of a merger of Otago and Southland DHBs. While there have been efficiency gains in some areas as a result of the merger, health services in Dunedin suffer from a series of constraints upon their efficiency and effectiveness. The consequences of this are seen in (for example): ED attendance rates; High readmission rates; Cancelled operations; Historical lack of financial control; Fragmented nursing rosters; Unclear admissions criteria; Poor patient flow, and Some opaque and idiosyncratically organised clinical roles. In addition, Southern DHB faces a number of challenges in part due to its size, location and demographics: Dunedin Hospital is a relatively small tertiary hospital which inherently makes it more difficult to run an efficient model compared to larger tertiary hospitals; Southern DHB has two base hospitals while this may be necessary due to geographic distance, it does create challenges in terms of efficiency and standardising the model of care, and The DHB population is relatively small, but dispersed over a large area ensuring that the population living outside the main centres has appropriate access to care is both costly and logistically challenging. Page v

8 Further, the DHB has been running a deficit now for many years which has negatively impacted on its ability to invest, not only in the hospital infrastructure, but in many of the enablers required to shift demand for hospital services (outlined below). Southern DHB is embarking on a significant change process In order to address these constraints and challenges, the Strategic Services Plan identifies a number of strategic directions. These directions are in line with other strategic imperatives outlined in the DHB s various change initiatives, including the Southern Strategic Health Plan Piki te Ora, the Commissioners work programme Owning our Future and the culture change project Southern Future it is up to us. The Strategic Services Plan includes the following strategic directions unanimously agreed by key stakeholders: The need to invest in primary and community care services to keep people out of hospital, and where possible, reduce the length of patient stays and avoid readmissions where appropriate; The need to determine what the system needs from the six rural hospitals, as well as how to integrate rural hospital services with both the two main centres and primary care across the district; Integrate acute management, paramedics and rural hospital capacity; Improve access to imaging; Re-orient the Dunedin Hospital wards on a generalist basis, with specialists able to act within those general wards with standardised flows both within Dunedin Hospital and across the district; Focus on theatre productivity; Provide a different pathway for day surgery and outpatients; Consciously build telehealth and information technology infrastructure, investing in systems that support integration between primary and secondary/tertiary care and support clinical decision making, and Work with the University of Otago to ensure a high level transparent relationship, closely managing the introduction of any new medical technologies. Any future hospital facility needs to be seen as an enabler of the changed way of working together as set out in those strategic directions. A fit for purpose hospital campus is one of many enablers in the change process The current state of the Dunedin Hospital campus is impeding the rollout of more modern models of care required to improve efficiencies and effectiveness of hospital services. The SPG is clear that without changing the way in which services are organised within the hospital and how they integrate with primary care and allied health, the DHB will not be able to realise the benefits of the change process, namely improved quality of patient care, improved patient and staff safety, increased efficiency of service delivery, and reduced costs. This Strategic Assessment presents a case for redeveloping Dunedin Hospital within the context of this health system change. The DHB acknowledges that realising the benefits of a hospital rebuild is dependent on also achieving the wider change as described in the strategic directions listed above. Page vi

9 This report outlines the state of the hospital facilities. In brief, these can be described as: A deteriorating physical environment is eroding quality of care, creating safety risks, and causing distress to patients and staff: Several buildings on the Dunedin Hospital campus have been assessed as uneconomic to re-life: the Clinical Services Building (CSB), the Children s Pavilion, the Fraser Building, and the Psychiatric Service Building/Administration. The CSB is the most critical of these buildings, as it is the second largest on the campus. The CSB houses a large number of clinical services and support services including operating theatres, outpatient clinics, laboratories, central sterile services department, radiology, day surgery, fracture clinic, physiotherapy, emergency department, and the mortuary. Inflexible and inappropriate care facilities restrict service capacity, cause delays, and increase outsourcing costs, and Care facilities cannot absorb innovations, preventing efficiency gains and care improvements. This strategic assessment seeks approval to develop an indicative business case for investment in the Dunedin Hospital campus.. Page vii

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11 Strategic context 1. Southern DHB has a significant programme of work underway to merge and align the clinical, management and support functions of the two previous DHBs into one DHB, and to refresh and modernise models of care and models of hospital organisation. The DHB has significantly streamlined the executive and management teams, and efforts are underway to integrate services across the two sites. There is considerable effort in implementing the Southern Strategic Health Plan Piki te Ora aimed at providing for a single Southern health planning framework that sets the direction for realigning all of the DHB s work programmes. 2. There are other significant work-streams underway across the DHB. The Commissioners have their work programme Owning our Future in place, and significant effort is being put into making the culture of the organisation more patient-oriented with a culture change project Southern Future it is up to us, the first phase of which involved patient workshops called In Your Shoes listening series. The DHB has adopted Health Pathways and Xcerlr8 a managed innovation project tool. On top of this, there is an increasing level of collaboration with Alliance South and various Service Level Alliance Teams (SLATs, recently renamed Networks ) beginning work programmes. In addition, other significant service development projects are underway, such as a major radiology project and an interim capital spend to support urgent capital works including an Intensive Care Unit (ICU) renovation. 3. There is strong regional co-operation at a number of levels, including the South Island Alliance, which is responsible for supporting a number of initiatives including developing a joint clinical information infrastructure and a number of key services such as palliative care and older persons health. There is also collaboration across clinical services and this collaboration will need to continue, as well as be strengthened, to support vulnerable services in Dunedin and Invercargill. 4. Beyond the above-described activities, Southern DHB s strategic goals can be viewed within a cascading suite of planning documents, as shown in Figure 1 below. 1 1 Southern DHB. (2015). Southern Strategic Health Plan. Retrieved from: Page 1

12 Figure 1 Cascading set of strategic plans and strategies Source: Southern DHB 2 Organisational overview Southern DHB catchment and population profile 5. Southern DHB is responsible for providing or organising provision of health services to people living in the catchment area. The Southern DHB catchment area extends across the lower region of the South Island, from the Waitaki River south, as shown in Figure 2 below. 2 Ibid. Page 2

13 Figure 2 Map of Southern DHB Source: Ministry of Health 3 3 Ministry of Health. (2014). Location boundaries (map). Retrieved from Page 3

14 Population 6. The estimated resident population of the DHB in 2015/16 is 315, In addition, the DHB provides acute (urgent) care to a number of visitors to the region. 7. Compared to the total population of New Zealand, the DHB s population is: (a) Older Southern DHB has a lower proportion of people aged under 50 years and a higher proportion of people aged over 50 years (36% in Southern, compared to 33.6% nationally); 5 Figure 3 Comparison of age distribution - Southern DHB and national Source: Statistics New Zealand 6 (b) Less ethnically diverse compared to other DHBs, Southern has a relatively low proportion of people who are Māori, Pacific or Asian, and a relatively high proportion of people of Other ethnicity, as shown in Figure 4. 4 Statistics New Zealand. (2015). DHB population projections (prepared according to specifications provided by the Ministry of Health). 5 Ibid. 6 Ibid. Page 4

15 Figure 4 Comparison of DHB population composition by ethnicity Source: Statistics New Zealand 7 (c) Less deprived Southern DHB has a lower proportion of the population in the two lowest deprivation quintiles (fifth lowest proportion of population in quintiles 4 or 5), as shown in Figure 5. Figure 5 Comparison of DHB population composition by deprivation quintile Source: Statistics New Zealand 8 (d) The smallest and most rural of the tertiary DHBs Figure 6 below compares the percentage of the population that is rural (x-axis), and the total population for each DHB (y-axis). Southern DHB is shown in red, other tertiary DHBs are shown in orange, and all other DHBs are shown in blue. 7 Ibid. 8 Ibid. Page 5

16 Figure 6 Comparison of DHB total population and proportion living in rural areas Source: University of Otago 9 (e) Travel time to the nearest base hospital is longer for people living in some areas Figure 7 below compares the population of each provincial territorial authority (TA), with the travel time from the largest town in that TA to the closest base hospital. The populations in Queenstown (the largest town in Queenstown-Lakes TA), and Alexandra (the largest town in Central Otago TA) have noticeably longer to travel to the nearest base hospital compared to most other provincial towns. 9 University of Otago. (2014). NZDep2013 Area Concordance file. Retrieved from Page 6

17 Figure 7 Comparison of travel time to nearest base hospital and population or largest town in provincial TAs Source: New Zealand Automobile Association (AA) 10, and Statistics New Zealand Tourists constitute a significant proportion of the population in the Queenstown-Lakes district the tourist population in this area is seasonal, but bimodal with peaks in both summer and winter. The tourist population adds an estimated equivalent nightly population of approximately 5,000 in the low season and 12,000 in the high season It should be noted that these estimates will understate both the peaks and troughs of the tourist population, as it is an average across the month. However, the data provides a general estimate of the relative sizes of the tourist and local populations across the DHB and across the calendar year. 10. Figure 8 shows the estimated resident population (grey bars) and equivalent tourist population (red bars). 10 AA Travel. (2016) New Zealand Driving Time and Distance Calculator. Retrieved from 11 Statistics New Zealand. (2015). DHB population projections (prepared according to specifications provided by the Ministry of Health). 12 This estimate has been developed by using data obtained from the Commercial Accommodation Monitor (CAM), collected by the Ministry of Business, Innovation & Employment. Monthly tourist night data for each TA was converted to a nightly equivalent tourist population by dividing the number of tourist nights in a month by the number of days in that month. Page 7

18 Figure 8 Resident and estimated tourist population, by TA and month Source: Ministry of Business, Innovation & Employment Ministry of Business Innovation and Employment. (2016). CAM regional pivot tables. Retrieved from Page 8

19 Projected population 11. Figure 9 shows the projected populations of each DHB from 2015/16 to 2037/38. It reveals that most of the projected national population growth is concentrated in the large metropolitan DHBs. Most provincial DHBs are projected to have low population growth over this period. Figure 9 Projected DHB populations /16 to 2036/37 Source: Statistics New Zealand While the total population of the DHB is not projected to have significant population growth, sub-regions within it are projected to have quite different population patterns both in terms of growth or decline, and in terms of population composition. (a) The populations of Clutha and Gore districts are projected to decline over the next 30 years; (b) The populations of Southland, Invercargill city, Waitaki, and Dunedin city are projected to have very low growth; (c) The population of Central Otago is projected to have moderate growth (but less than the national average), and (d) The population of Queenstown-Lakes district (which covers Queenstown and Wanaka) is projected to have significant population growth. 13. The proportion of the population that is aged 65+ is projected to increase in all areas within Southern DHB, and largely to be at higher levels than elsewhere in New Zealand. 14 Statistics New Zealand. (2015). DHB population projections (prepared according to specifications provided by the Ministry of Health). Page 9

20 14. Similarly, the Māori, Pacific, and Asian populations are projected to increase in Southern DHB. Southern DHB role Aims 15. The Southern Way describes the principles by which the DHB manages itself and provides services to the community: The community and patients are at the centre of everything we do We are a single unified DHB which values and supports its staff We are a high performing organisation with a focus on quality We provide clinically and financially sustainable services to the community we serve We work closely with the entire primary care sector to provide the right care in the right place at the right time and to improve the health of the community 15 Core activities 16. Southern DHB was established on 1 st May 2010, as a result of the merger of Southland and Otago DHBs. 16 As with other DHBs, it is responsible for improving, promoting, and protecting the health of the population living in the catchment area. This includes planning, funding, and providing or contracting services to meet the health needs of the population. DHBs are required to seek the optimum arrangement for the most effective and efficient delivery of health services in order to meet local, regional, and national needs The core functions of all DHBs are described in section 23(1) of the New Zealand Public Health and Disability Act 2000 (emphasis added): For the purpose of pursuing its objectives, each DHB has the following functions: (a) to ensure the provision of services for its resident population and for other people as specified in its Crown funding agreement: (b) to actively investigate, facilitate, sponsor, and develop co-operative and collaborative arrangements with persons in the health and disability sector or in any other sector to improve, promote, and protect the health of people, and to promote the inclusion and participation in society and independence of people with disabilities: 15 Southern DHB. (2013). Southern Way. Retrieved from 16 Southern District Health Board. (2016). Health Strategy and Planning. Retrieved from 17 New Zealand Public Health and Disability Act S22(1)(ba). Retrieved from Page 10

21 (ba) to collaborate with relevant organisations to plan and co-ordinate at local, regional, and national levels for the most effective and efficient delivery of health services: (c) to issue relevant information to the resident population, persons in the health and disability sector, and persons in any other sector working to improve, promote, and protect the health of people for the purposes of paragraphs (a) and (b): (d) to establish and maintain processes to enable Māori to participate in, and contribute to, strategies for Māori health improvement: (e) to continue to foster the development of Māori capacity for participating in the health and disability sector and for providing for the needs of Māori: (f) to provide relevant information to Māori for the purposes of paragraphs (d) and (e): (g) to regularly investigate, assess, and monitor the health status of its resident population, any factors that the DHB believes may adversely affect the health status of that population, and the needs of that population for services: (h) to promote the reduction of adverse social and environmental effects on the health of people and communities: (i) to monitor the delivery and performance of services by it and by persons engaged by it to provide or arrange for the provision of services: (j) to participate, where appropriate, in the training of health practitioners and other workers in the health and disability sector: (k) to provide information to the Minister for the purposes of policy development, planning, and monitoring in relation to the performance of the DHB and to the health and disability support needs of New Zealanders: (l) to provide, or arrange for the provision of, services on behalf of the Crown or any Crown entity within the meaning of the Crown Entities Act 2004: (m) to collaborate with pre-schools and schools within its geographical area on the fostering of health promotion and on disease prevention programmes: (n) to perform any other functions it is for the time being given by or under any enactment, or authorised to perform by the Minister by written notice to the board of the DHB after consultation with it. Page 11

22 The workforce 18. Southern DHB has a total staff of approximately 3,600 FTEs. Figure 10 and Figure 11 provide a breakdown of staffing by role type and organisational group respectively. Figure 10 Southern DHB staffing by role type (February 2016) Source: Southern DHB 18 Figure 11 Staffing by group Source: Southern DHB 19. Southern DHB, as with other DHBs, has an ageing workforce, with the majority aged over 40 years. 18 Southern DHB. (2016). Staffing YTD February Spreadsheet provided by Southern DHB. Page 12

23 Figure 12 Distribution of overall DHB occupation by age, with national employee data 19 Source: Central TAS Funding 20. In 2016/17, the DHB will receive $822,938,000 in core government funding. 20 This compares to $789,623,000 in the previous financial year (2015/16). 21 Approximately half of this amount is used to purchase traditional hospital and mental health services and the remaining half to purchase community-based health services, including primary care As the DHB s population is not projected to grow as much as other DHBs, the share of funding under the Population Based Funding Formula is likely to reduce. While this is unlikely to lead to a decline in funding (due to the use of a minimum uplift or floor increase for all DHBs), the DHB will need to actively manage costs and improve productivity as much as possible. 22. The DHB has been running a deficit for many years. Table 1 below shows financial performance over the past five financial years. 19 Central TAS. (2015). DHB Employed Workforce Quarterly Report Dec Retrieved from 20 The Treasury. (2016) Vote Health. Retrieved from 21 The Treasury. (2015). Vote Health. Retrieved from 22 Southern District Health Board. (2016). Health Strategy and Planning. Retrieved from Page 13

24 Table 1: Southern DHB financial performance 2010/ /15 23 Total income ($000) Total expenses ($000) Surplus/(Deficit) ($000) Year Actual Budget Actual Budget Actual Budget 2010/11 814, , , , (14,901) 2011/12 836, , , ,910 (13,188) (10,491) 2012/13 849, , , ,186 (11,634) (10,978) 2013/14 873, , , ,170 (17,822) (9,039) 2014/15 883, , , ,324 (27,180) (14,799) 23. The DHB is undertaking a range of cost saving initiatives to address the fiscal deficit, but also faces a number of head winds as it does so: (a) Revenue is flat due to low population growth; (b) Demand for services is increasing as the population ages; (c) A large proportion of the costs relate to personnel. These costs are heavily influenced by national MECA agreements which establish national remuneration levels and increases; (d) The geographic area of the DHB has resulted in two base hospitals plus a number of smaller regional and community trust hospitals. This results in fewer scale efficiencies, and (e) Aging buildings at Dunedin Hospital are expensive to maintain and are expected to become more so as they continue to age. 24. The DHB is focussing on process efficiencies and cost controls to both increase quality of service and reduce waste, in order to manage the deficit down to a breakeven position. It is anticipated that this will be achieved in the 2019/20 financial year, although the steps to break even are not completely clear currently. Facilities 25. The DHB operates healthcare facilities at a number of locations throughout the Southern District. The table below provides an overview of all healthcare facilities used to provide services to the population. While the majority of events occur in Southern DHB facilities, there are also a number of facilities run by community trusts and private companies. 23 Southern DHB. (2016). Our Planning and Accountability Documents. Retrieved from Page 14

25 Medical Surgical Children s Geriatric Psycho-geriatric Mental health Intellectual Maternity X-ray Ultrasound CT MRI Table 2: Southern DHB operated facilities Certified beds 24 Certified services 25 Radiology 26 Dunedin Hospital 400 Southland Hospital 176 Wakari Hospital 120 Lakes District Hospital Ministry of Health. (2015). Certified providers. Retrieved from 25 Ibid. 26 Southern DHB. (n.d). Radiology Systems Project: Evaluation of current radiology provision for the Southern Health District. Page 15

26 Key environmental features 26. As required by the Better Business Case format, this section outlines the externally driven factors that are contributing towards the need for investment. This section is structured using a PESTD 27 approach to identify macro-environmental features or challenges that the DHB will need to navigate in the next 10 to 15 years. 27. However, it is clear that the primary driver of the need to invest is an internal one: the CSB in particular is at end of service life and is unable to be economically re-lifed, the Ward Block needs a substantial renovation, and three other buildings on the Dunedin campus have been assessed as being uneconomical to re-life. 28. The external challenges outlined below when taken as a whole highlight that it will be critical for the DHB to fully understand its costs, improve its processes across the spectrum, reduce spending that results in low health gain, and invest strategically in areas that will improve health gain over the next five to ten years. While there are many influences on its service and financial position that are outside its control (for example, low projected population growth leading to low projected funding increases), the skills and actions described above are fully within its control to continue to implement. 29. Every decision to continue using a workaround instead of improving a process, or a decision not to tackle an outdated clinical practice simply to avoid upsetting staff, is a decision that reduces the level and quality of care available for its population. Each individual decision may not appear to have much impact, but when taken as a whole it is the difference between a DHB that is able to navigate its way through some challenging waters and one that is not. Political 30. The New Zealand DHB model has been in place since 2000, and there have been no signs that politicians are considering changing to another structural form. 31. After an initial phase of individualism, over the past ten years there has been increasing pressure for DHBs to collaborate more effectively. This collaboration has come to the fore in particular service areas such as paediatric services and in managing the configuration of expensive and hard to sustain tertiary services. While the original legislation required DHBs to organise services at the most appropriate level be that local, regional, or national amendments to the New Zealand Public Health and Disability Act significantly strengthened this requirement by amending the core functions of DHBs. 32. The Southern DHB is now governed by Commissioners appointed by Ministers rather than by an elected board, because of the continued failure to deliver on 27 Political, economic, socio-cultural, technological, demographic. Page 16

27 financial budgets, and thus the need for ongoing fiscal support to cover ongoing deficits. 33. The Ministry of Health has maintained a presence in facilitating decisions around capital planning. Capital planning has a strong service provision base and the Ministry makes sure investment programmes are rational, both for the DHB and for the health system as a whole. 34. Such a large-scale capital decision inevitably attracts a great deal of community interest, particularly in Dunedin. 35. With respect to any development on the Dunedin campus, the Southern Partnership Group appointed jointly by Ministers of Health and Finance, includes one of the DHB s Deputy Commissioners and will provide advice and ensure central and local co-ordination. 36. As with all other employers, DHB obligations to its employees have been extended, due to recent changes to health and safety legislation. 37. In summary, while the structure of the DHB system appears to be stable, Southern DHB more than others has seen increasing scrutiny from both the community and from central government agencies as it struggles to find a way of providing sustainable clinical services. Economic 38. As a result of low projected population growth, the DHB s future funding path under the PBFF is likely to continue to involve lower year-on-year funding increases than the average for DHBs across New Zealand. However, the DHB is managing a complex system and this work provides an opportunity to both improve health and reduce elements of cost. This work also offers the opportunity to improve both clinical and financial sustainability. 39. There is also a complex interplay with commissioning decisions from the centre for national programmes, such as the upcoming bowel-screening programme, or funding of pharmaceuticals for treatment of melanomas. While funding for certain new programmes is typically provided to DHBs for the first few years, this funding is often then shifted into baseline funding and the pattern of spending may not follow that of the rest of the country. This means the DHB needs to continue to provide the service, but through PBFF funding. This creates more challenges for DHBs with low population growth, since expectations that they continue to provide these sorts of services limit their ability to invest in other services that they may consider higher value, based on the needs of their population. While in some cases new services or programmes will meet both needs, this is not always the case. 40. As a result, the DHB recognises it needs to strengthen its systems and processes to ensure that health gain is optimised using the available funding. Specifically, this will require it to have the capacity and capability to: (a) Understand costs and cost drivers; (b) Develop actions to reduce costs, and/or improve productivity, and/or improve quality, and/or improve patient and staff experience; Page 17

28 (c) Implement those actions, and (d) Monitor the impact of the change, and modify as needed. 41. Sustained financial pressure on Southern DHB, over a number of years, has led it to reduce capacity to undertake each of the four items described above. This is of significant concern, since while this is an understandable move for a DHB under significant financial pressure, it represents a false economy the costs involved of developing this capacity and capability are almost certainly likely to be less than the value (both financial and non-financial) of improving processes and reducing inefficiencies. 42. Within costs, the most significant factor affecting DHBs is labour costs, which account for more than half of DHB costs. The use of Multi Employer Collective Agreements (MECAs) has been successful in ensuring that staff costs are equitable across the country and that cost growth is appropriate and equitable. While DHBs can only influence MECAs, they do clearly have a choice around the number and composition of staff employed. 43. For Southern DHB, with a large number of high-end specialists, uptake of expensive new technologies is likely higher than in other areas. 44. In other tertiary hospitals, the cost of providing high complexity specialised services is paid in part by patients visiting from out-of-region (inter-district flows). While there is a significant transient and tourist population that seeks urgent care in Southern DHB, only a small trickle of patients from South Canterbury DHB come to Dunedin routinely for tertiary care. Otherwise, the patients it serves are its own and patients flow to other tertiary DHBs for other specialist input. 45. In summary, while the Strategic Assessment outlines an appropriate approach to improving the model of care, it is equally important to recognise the need to build on and further develop capability and capacity, and to be able to navigate through a sustained period of low funding increases as outlined above. Socio-cultural 46. There are growing expectations that health service providers will find ways to meaningfully engage with service users. This ranges from greater involvement in the content of consumer leaflets through to service design, more informed decisionmaking by patients of the treatment options available to them, and decisions around funding allocation. 47. There are also increasing moves for consumers to play a greater role in their own self-care. The benefits of this relate not just to increased understanding and sense of control of their own destiny, but also to reduced costs for both the consumer and the health provider. 48. Inherent in this trend is an understanding that consumers will have varying levels of health literacy leading to a range of interest and ability to take a greater role in selfcare. Rather than seeing health literacy as the responsibility of the consumer, it is now seen as squarely the responsibility of health service providers to develop services that lead to greater consumer engagement to ensure that services are Page 18

29 easy to navigate and to communicate with consumers in a way that they can understand. 49. In parallel, there has been a move to shift services from hospital to community settings, where appropriate. This shift has a dual purpose: both to make it easier for consumers to access services (due to less travel), and to improve efficiency by only using capital-intensive facilities (such as hospitals) for services that have high capital needs. 50. Southern DHB has been acknowledging this shift with the development of alliances with providers, including community providers and a focus on primary care and community care rather than hospital care. The DHB is also undertaking a major transformation programme based on listening to patients and staff stories of their experiences of the Southern DHB health system. Technological 51. New treatments and models of care are constantly being developed in the health sector. A subset of these developments is cost effective and beneficial to patients, and a smaller subset is cost saving. Given the level of clinical and analytical assessment required to evaluate new developments, the way in which DHBs decide to take on new developments (or not) is dependent on having streamlined yet robust systems to review proposals. 52. Relatedly, the close linkages with the University of Otago have led to proposals for participation in research and clinical trials. The University and the DHB have processes for assessing and identifying the level of funding required, if DHB resources (staff time, clinical supplies, support services, etc.) are to be used. It will be important that these processes are regularly updated, both to ensure that ethical requirements are met and that DHB resources are not used to subsidise activity for other organisations and purposes. 53. For Southern DHB a small tertiary DHB with a number of joint clinical appointments with the university it will be critical that fit-for-purpose processes are in place to deal with the two issues described above. Given the likely future funding path and increasing population health need, it is even more critical that DHB resources are used (and optimised) for DHB purposes or patients will miss out on getting the care they need. 54. Telehealth is a major technological development relevant to Southern DHB because of its large geographical span. The benefits can be a more productive health system, and relief for patients and staff from unnecessary and costly travel. Telehealth relies on a strong backbone of safe, secure, and up-to-date electronic record sharing. Southern DHB needs to establish the latter to make the former possible. Demographic 55. The most significant demographic factor that Southern DHB will need to respond to is providing services to a population where an increasing proportion is aged 65 years or older. Age is the single variable that best predicts health service need, and consequently health system cost, as shown below. Southern DHB recognises it needs Page 19

30 to re-organise to cover the needs of the fragile elderly it will care for over the next few decades. Figure 13 Health cost weights, by age group Source: Ministry of Health With an increasing proportion of the Southern DHB population aged over 65 years, it will be important to ensure that the model of care meets their needs in an effective and efficient way. Figure 14 Projected growth in SDHB population by age group, 2015/16 to 2036/37 Source: Statistics New Zealand The Treasury. (2010). Challenges and Choices: Modelling New Zealand s Long-term Fiscal Position. Retrieved from Page 20

31 57. Literature suggests that integrated care will be needed to meet the increasingly complex needs of frail elderly population. 30 This approach requires that the patient perspective is the organising principle of service delivery. This may appear simple, but in order to achieve it, services in the health and social sectors need to be significantly more coordinated than is currently the case in most parts of New Zealand: (a) The various arms of the health system (community care, primary care, and acute and elective hospital care) function as a well-coordinated system, and (b) The health system works in concert with other social service systems (such as long-term care, education, and housing) Evidence from health systems overseas that have implemented integrated care for elderly people strongly suggests that integrated care can achieve improved patient outcomes and experience of care such as improved functional status, greater coordination and continuity of care at the same time as improving efficiency by delaying rest home admissions and reduced hospitalisations The King s Fund outlined ten components in successful integrated care models for elderly people: Successful Integrated Care Models: The Main Ingredients Person-centred focus on frail older people with relatively high care needs, including careful targeting. 2. Responsibility for identified population and/or geographic area, including single entry point into system. 3. Case managed, inter-professional, evidence-based team care. 4. GP involvement, preferably an active role. 5. Direct control over broad package of services. 6. Heavy emphasis on care co-ordination. 7. Organised network of providers. 8. Innovative use of population health management tools and integrated information systems. 9. Common organisational umbrella or home and shared culture. 10. Alignment of financial incentives, including funding flexibilities (e.g., funds pooling, single funding envelope or capitation). 29 Statistics New Zealand. (2015). DHB population projections (prepared according to specifications provided by the Ministry of Health). 30 The King s Fund. (2012). Integrated care Models That Work for Frail Older People. Retrieved from 31 Adapted from: The Nuffield Trust. (2011). What is integrated care? Retrieved from june11_0.pdf 32 The King s Fund. (2012). Integrated care Models That Work for Frail Older People. Retrieved from 33 Ibid. Page 21

32 60. Where inpatient services have a caseweight attached to them, a net present value (NPV) of the inpatient care over a period can be calculated on the basis of the standard forecasts. This essentially provides the value in today s dollar terms of all care, in this case over the period 2015 to 2033, with a discount rate of 3.5% per annum applied to the future cost. The table below sets out the NPV of inpatient caseweights by service category, in millions of dollars. The total discounted value of Dunedin Hospital inpatient services to 2033 is $3,012 million. Table 3: Net present value of services Service Net Present Value ($M) Adult mental health % Cardiology % Cardiothoracic Surgery % Child/adolescent mental health % Emergency medicine % ENT % Gastroenterology % General medicine % General Surgery % Gynaecology % Haematology % Maternity-baby % Maternity-mother % Maxillo-Facial Surgery % Medical oncology % Neurology % Neurosurgery % NICU % Older persons health incl. psychogeriatric % Ophthalmology % Orthopaedic Surgery % Other % Paediatric Medicine % Paediatric surgery % Plastic Surgery % Radiation Oncology % Renal Medicine % Respiratory Medicine % Rheumatology % Urology % Vascular Surgery % Total % Page 22

33 61. Figure 15 shows NPV by service in decreasing order of size. Figure 15 NPV by decreasing order of service 62. The single largest service in these terms is orthopaedic surgery, reflecting the high volume and caseweight of inpatient services in that specialty. General medicine and older person s health combined constitute $435,533 of future services. Overall, surgical departments account for $1,474 million of the total, medical departments $1,133 million, and women s and children s services $310 million. Alignment to existing strategies 63. The Commissioner s Plan is the overarching document that demonstrates how the strategic plans and activities identified below interlink to ensure alignment of planning activities. Each of the strategic directions identified, with significant stakeholder input and unanimously agreed by stakeholders, are in line with its plans and initiatives, including the work of the Alliance networks. The SPG will work with the Commissioners and the DHB executive to continue to ensure operational alignment of the various interlinked plans. Page 23

34 Figure 16 Alignment of Southern DHB strategic planning documents and activities Source: Southern DHB Page 24

35 Meeting the challenge General medicine central to meeting patient medical needs 64. The hospital is operating in a model that is increasingly unable to meet today s patient needs, let alone tomorrow s needs. Already, there is a pressured ED and pressured medical wards. 65. The patient of the future, which is the patient already being managed in Internal Medicine, is likely to have multiple disorders and is likely to need support wrapped around them in the community as well as in the hospital. 66. The DHB recognises the need to develop a rapid discharge function, we all as more closely integrate services for older people at the point of admission. The DHB also recognises the need to transition the workforce to one that is able to deal with the acute needs of all patients, whilst also providing the specialism expected of a tertiary hospital. 67. While the baseline forecast for outpatient services shows significant growth, many services anticipate that there will be some degree, and in some cases a great deal, of shift of service setting from inpatient wards and theatres to outpatient settings. Notwithstanding that to some extent there is room to challenge some of the existing models of outpatient provision and that some level of outpatient services may in turn be provided in a community setting in the future, outpatient services are likely to be an increasingly major part of the service offering and new facilities and models of care will have to reflect this. To meet those needs, the hospital will need to re-orient its space to manage patients faster in outpatient and day patient areas, and to work quickly to identify and manage patient needs on the spot. 68. In achieving all of this, the DHB needs to work closely with both primary care services and allied health services. The DHB recognises it needs to work to keep people safe in their homes and to develop services in the community to support the elderly in the community. Where they need to come to a hospital, health services need to support them in the hospital, but also ensure they return home and live with independence as soon as possible. The DHB also needs to work closely with all health professionals in different ways, including making best use of technology and telehealth to reduce the cost on patients of travel. To do what is expected of it, the current hospital facility will need to change to meet that challenge. 69. The DHB will need to be innovative in the way it finds capital to make things happen. The DHB will need to provide for remote imaging and a modern regional laboratory service. Both provide opportunities for revision of the current public and private arrangements, including modernisation of technologies and bringing as much service as possible close to patients, while providing an appropriate workforce and new technology platforms. Page 25

36 70. The current hospital facility is ill-suited to meeting this challenge. There is no space for a rapid assessment function; the wards are constrained space wise and are not fit for contemporary care; there are too few bathrooms, inadequate power points around beds, inadequate space for medical equipment, and insufficient points for medical gases, etc. Nurse productivity suffers from these constraints and patient experience is less than ideal. Without setting out all of the issues, we observe poor co-location between radiology and the emergency department, poor ward sight lines, infection control risks, and a lack of privacy and dignity for patients. 71. Even more so, day patient and outpatient zones are severely deficient, imaging is dislocated from the clinical areas it needs to be close to, and patients flow into the wrong points of the hospital. For instance, inpatients and outpatients might be seen in wards. The DHB needs to be organised for 21 st century patient flow and safety (particularly infection control), but is locked in 1980 s or earlier buildings. The DHB will need to become more productive in surgery 72. A further material issue is meeting the demands of surgery indicated in the growth forecasts. At the moment, the DHB is having trouble keeping pace with acute and elective surgery needs. The importance of efficient surgery is best seen in the Net Present Value for orthopaedic surgery, totalling more than any other service over the forecast period. 73. There is a lack of options for the DHB to provide elective surgery. Elective surgery is held up through lack of theatre capacity. Some of this theatre capacity is used for scopes and other interventions that could be better achieved in treatment rooms, but those rooms are not available. Flows into the theatre are compromised by lack of space for anaesthetics and patient work-up. Equipment spaces are inadequate now and will come under more pressure as more equipment is brought into the theatre. 74. The DHB is undertaking a number of initiatives in the interim build project to provide more ICU capacity and to unlock this choke point for complex surgery. However, the overall facility redevelopment has a horizon of seven to ten years, meaning that the ICU will need to be reconfigured for the future. 75. Likewise with medical services, wards are often small and fragmented and not fit for contemporary purposes. 76. While surgical services have made strides in productivity improvement in recent years, the physical state of the facilities is a key constraint, and there is much scope to achieve improvements through improved theatre configurations and improved facilities for day surgery. ICU capacity has been a serious constraint on surgical services and even with the additional capacity planned for short-term implementation, there may not be enough for the longer term forecast increases in demand. If the DHB gets this right, it can increase both capacity and efficiency as well as improve patient experience and quality of care. Page 26

37 Signs of being under continuous financial pressure 77. After many years of financial pressure, Southern DHB has had limited expenditure on non-core functions, and this leanness has led to underinvestment in support people and infrastructure. Such underinvestment can result in systemic false economies that is, by not spending on a particular support function, either additional cost is created elsewhere in the system, or health status, patient outcomes, and/or experience are affected. 78. In services, the DHB sees a lack of resource in allied health services that is a constraint for many services across the hospital. Investment in a stable allied health workforce in both the hospital and the community has the potential to improve discharge processes and make them timelier, as well as to make more efficient use of hospital resources more generally by improving the effectiveness of rehabilitation. With a sharply ageing population, this will be a core issue for future service planning. 79. Primary care services are also less well developed. The DHB is working with allied health and primary care to develop patient oriented services through the continuum of health care. 80. Health services in Dunedin play an important role in supporting services which are provided geographically right across the Southern District, and this is likely to intensify as the population grows and ages in Central Otago. The role of Dunedin Hospital in supporting services in the rural hospitals and in primary care services across the district will range from telehealth support to physically delivering services in local settings (as currently happens with many outpatient clinics). The future of transport and retrieval will be core to service and facility design in Dunedin. Many services see at least some role for telehealth in supporting rural services across the district and in reducing the need for patients to travel. This has the potential to have an impact across services from maternity care to pre-operative assessment. 81. Ambulances and air retrieval are very important in this district more so than other areas, due to weather, distance and visitor numbers. Rural areas need a strong PRIME response. 82. Regional services development is as good as anywhere in the country and will get further impetus to supporting services in and around Dunedin. A recently established Clinical Group will look actively at service issues and opportunities for integration with other tertiary service centres to relieve pressure on Dunedin. 83. A further legacy of this lack of investment over the years also means clinical information systems are poor and fragmented: Clinical information systems are fragmented with legacy systems from two previous DHBs. This currently presents a real burden upon services and in some cases may present clinical risk. Clinicians and managers across the DHB see substantial benefits from improved information systems within the hospital, as well as a shared electronic record with primary care. Page 27

38 Clear under-investment in physical capital 84. Hospital facilities in Dunedin are not just in poor shape, but in some instances are crumbling. The major issue is around poor layout, flow, and condition of the current facilities, thereby making it difficult for the DHB to run efficiently or deliver contemporary care to patients. The inflexible and inappropriate nature of the current facilities directly leads to increased costs, reduced service capacity, reduced productivity, and poorer patient outcomes. 85. Examples of these costs whether direct or indirect are as follows: (a) In some cases, the need to employ additional staff as a direct result of facility layout. For example, since radiology is not co-located with ED, orderlies have to be employed to ferry patients from ED to radiology. (b) In other cases, staff costs are higher than they would be in a facility with more modern layout. For example, nursing costs are higher as a result of a structure based on relatively small wards. (c) Inflexibility creates a situation where certain processes or treatments occur in multiple locations across the facility whereas it would be more efficient if they could be provided in one location. (d) Inflexible design can also create hazards, such as those created by the column spacing in the CSB. Figure 17 Grid spacing in middle of clinical area, CSB Figure 18 Grid spacing in middle of corridor, CSB Source: Sapere Research Group Source: Sapere Research Group 86. Older buildings in poor condition require significantly higher costs for repairs and maintenance than in a newer facility: (a) Repair and maintenance costs are higher and likelihood of needing further repairs increases as patches are made on top of patches ; (b) In the context of Dunedin Hospital, while it has been known for several years that the Clinical Services Block is unable to be re-lifed, the costs of urgent works such as asbestos decontamination has been unavoidable; Page 28

39 Figure 19 Top floor area where asbestos cleaning is occurring, CSB Figure 20 Lifts closed due to asbestos cleaning, CSB Source: Sapere Research Group Source: Sapere Research Group 87. Lack of right size, right location facilities means that hospital capacity is unnecessarily constrained thereby increasing costs, as well as reducing productivity. (a) Lack of appropriate community-based facilities mean services that could be delivered in the community (with lower capital requirements) are being delivered in hospital (taking up capacity that could otherwise be used for patients who require hospital-level care). (b) Similarly, lack of ability to provide care in the appropriate location within the hospital increases costs for example, when day surgery patients are treated in main operating theatres, as opposed to in the day surgery unit. 88. The current building layout limits productivity, for example: (a) The lack of an appropriate space for acute assessment for patients presenting to ED with mental health conditions means that additional staff time is required to transport the person to the psych services/administration building. This building is located some distance from the ED and is somewhat isolated outside of working hours. (b) Lack of adequate storage areas creates clutter and increases risk that patients or staff could be harmed. Page 29

40 Figure 21 Clinical and office supplies stored in corridor, CSB Figure 22 Narrow corridor, CSB Source: Sapere Research Group Source: Sapere Research Group Figure 23 Patient beds stored in entrance of ED, between two sets of doors Source: Sapere Research Group 89. The condition and layout of infrastructure does not support features of safe care, leading to an increased likelihood of adverse events for both staff and patients. A combination of building layout, patient flow, and building condition mean that adverse events relating to delirium, infections, and falls are more likely. Challenges maintaining infection control a number of services have higher rates of infection compared to comparator facilities. High levels of noise and poor layout increase the likelihood of communication errors. Falls due to facility design such as in shower areas or where nursing staff are not able to easily maintain line of sight on patients. Figure 24 Limited space around x-ray machine, CSB Source: Sapere Research Group 90. A combination of the current infrastructure and model of care does not support provision of effective care in a number of ways: (a) By not focusing on recovery and mobility, the model inadvertently leads to a focus on illness and dependency; Page 30

41 (b) Dunedin Hospital is designed as a standalone facility, as opposed to being part of a network. This model is a reflection of the period of time in which the majority of the buildings were constructed. The impact is that the hospital is seen as a destination as opposed to being part of an integrated journey. 91. The campus design and patient flow leads to poor experience for patients and staff: (a) Patient access to the Dunedin Hospital campus is difficult there are multiple entrances, parking is difficult, and patient flow around the campus is not streamlined. In addition, State Highway One runs through the middle of the campus; (b) Undersized consult rooms and an insufficient number of amenities such as toilets affect the experience for patients and staff alike; (c) Similarly, lack of adequate space in special purpose areas such as resuscitation rooms and occupation therapy areas, and (d) Cramped office space creates a poor working environment for staff. 92. The combination of financial pressure and facilities that are inappropriate and/or the deteriorating condition of buildings have led to a number of decisions that while unavoidable appear to be false economies in that while they may be cost saving, they lead to higher costs in other areas and/or poorer patient experience and/or outcomes. This has led to a situation where inefficient processes or practices have become embedded and workarounds endemic. Many buildings on the Dunedin campus are at end of serviceable life 93. These buildings are critical to patient care and are uneconomic to re-life including one building that provides a large number of core clinical services. The buildings are crumbling and throwing up constant issues. 94. The Dunedin Hospital campus includes six buildings with construction dates ranging from 1935 to The figure below shows the layout of the Dunedin Hospital site. Page 31

42 Figure 25 Dunedin Hospital site layout Source: Southern DHB The table below outlines the construction dates of these buildings, and remaining estimated service life. Many of the buildings on the Dunedin Hospital campus are rapidly approaching the limit of their remaining service life. Table 4: Overview of buildings in Dunedin Hospital Campus 35 Building Year constructed RLB report 2012 WASL Psych Services Building Fraser Building Children s Pavilion Clinical Services Block (CSB) Ward Block Oncology 1993 Not included in the report 34 Southern DHB. (n.d.) NCC Background Document 100 Dunedin Hospital Site Plan. 35 Southern DHB. (2014). Brief for Capital Investment Committee Dunedin Hospital Campus. Page 32

43 The Clinical Service Block is at the end of its serviceable life, and is not able to be re-lifed 96. Reports completed in the past five years by both Rider Levett Bucknall (RLB) 36 and Beca 37 have identified a number of significant issues with ongoing use of the building for clinical services. The Clinical Service Block is effectively at the end of its serviceable life and is not able to be economically re-lifed. 97. The Clinical Service Block is the second most significant building on the Dunedin Campus, housing main operating theatres, the ED, outpatients, diagnostics, and many clinical support areas. 98. The Clinical Service Block was designed and built in the 1960s. The building has nine storeys, and has concrete floors and frames, precast concrete cladding, and aluminium framed windows. It is located on Cumberland Street, just south of the junction with Frederick Street. 99. The building currently houses a number of services: 7 th floor (roof): Water tanks and lift machine room. 6 th floor: Plant. 5 th floor: Operating theatres. 4 th floor: Outpatient clinics and theatre staff facilities. 3 rd floor: Laboratories. 2 nd floor: Central Sterile Services Department (CSSD) and ophthalmology. 1 st floor: Radiology. Ground: Day surgery, Fracture clinic, Physiotherapy, Emergency Department (ED). Lower Ground: Mortuary, Stores and plant. Figure 26 East side of Clinical Services Block Source: Sapere Research Group 36 Rider Levett Bucknall. (2012, December 19). Letter to Southern DHB. 37 Beca. (2014). Peer review of the 2012 Dunedin Hospital Re-lifing Analysis with Commentary on the Future Viability of the Clinical Services Block. Page 33

44 Problems with the condition of the building 100. The reports identify a number of shortcomings/defects that require expenditure, for example: 38 (a) (b) (c) (d) (e) (f) (g) (h) (i) Spalling concrete to external panels with underlying steel reinforcement corrosion requiring investigation and repairs. Water ingress through the roof requiring remedial works to gutters, parapets and penetrations. Water ingress to concrete walls causing cracking and loosening of copings. The windows are in very poor condition and require replacement. Replacement of large areas of internal suspended ceilings and mineral fibre tiles. Linoleum floor tiles beyond their serviceable life requiring replacement. The majority of the building internal areas are deemed to be in need of refurbishment/redecoration. Investigation is required to 5th floor egress routes and use of the corridors for clinical equipment storage due to lack of storage space. Numerous area and building components have been identified as containing asbestos In October 2015, routine testing confirmed a number of areas within the CSB with positive surface swab results. 39 Positive surface area swabs were found in the following areas of the CSB: (a) Lower Ground mortuary; (b) Level 1 radiology; (c) Level 3 laboratory lobby area and a number of rooms in molecular pathology; (d) Level 4 clinic rooms, theatre change rooms and corridor change rooms; (e) (f) Level 5 two internal corridors, and The main stairwell. 38 Ibid. 39 Southern DHB. (2015, October 22). Asbestos found during routine testing at Dunedin Hospital. Retrieved from 40 Southern DHB. (2015, October 23). Asbestos update 2 22 October Retrieved from 41 Southern DH. (2015, October 23). Asbestos update 3. Retrieved from Page 34

45 102. All air testing results for the CSB were below national exposure guidelines. 42 The finding of asbestos has further reduced the DHB s ability to monitor and maintain areas of the building. These findings compound the case that the CSB is not appropriate for re-lifing In addition, there are concerns that the CSB which houses the Emergency Department would not withstand a significant earthquake. A report by Hanlon & Partners found that the concrete cladding panels achieved 55% of the Ultimate Limit State (ULS) required for a building classified as Importance Level 4 (IL4) (buildings that must be operational immediately after an earthquake or other hazard event). The report found that the cladding panels in the lower levels of the building would likely fail under a ULS earthquake. Figure 27 CSB building (west side) showing cladding panels at lower levels, ED entrance, and main hospital entrance via Ward Block (south side) Figure 28 Emergency Department entrance area, CSB Source: Sapere Research Group Source: Sapere Research Group Not suitable for re-lifing 104. The Beca report identified seven issues that would be involved with extending the life of the CSB: (i) (ii) Building storey height and column grid spacings not flexible space when compared to current standards. Asbestos risk will incur higher costs for refurbishment. (iii) IL4 risk with regard to cladding panels, internal wall/frame connections and building services. (iv) Maintaining services/isolation of key services. (v) Phased refurbishment will require careful planning and control. (vi) Enabling works to provide access for refurbishment. (vii) Decanting of functions to other areas/buildings. 42 Ibid. Page 35

46 105. The Beca report concluded that as the CSB is used intensively, any upgrade or refurbishment for continued clinical use would be difficult (possibly impractical) and inefficient to undertake with enabling, decanting, temporary accommodation requirements likely to add significant expense for the following reasons: (a) The costs RLB estimated for removal of existing elements (estimated by RLB 10% of new built cost) would not effectively address the costs of strip out and removal of many elements. ( ) The costs of vacating areas, decanting, temporary accommodation, screening, and other enabling works to allow for items such as wall, floor and ceiling finishes are likely to be high as a proportion of the repairs/renewals. (b) Cladding panels achieved approximately 55% of the ultimate state limit (ULS) and would likely fail at the lower levels under a ULS earthquake. Furthermore, the report found that it was unlikely that internal fit out and building service systems would meet IL4 compliance requirements. (c) While refurbishing and reconfiguring the building for alternative use such as admin or education would need to be carefully considered and may not be economically viable. Asbestos: There is significant asbestos throughout all floors in the Clinical Services Block. It is known to be in unoccupied areas (the ceiling spaces, the ducts, and rises) and has been contained, but cannot be removed. The majority of necessary deferred maintenance programmes cannot be undertaken within the Clinical Services Block because ceiling spaces (apart from the first floor commented on below) have limited and restricted access. Any maintenance incurs significant cost and disruption due to steps required to minimise the risk of asbestos exposure to staff and patients. For example, the batch washers in the TSSU (theatre sterile services unit 5 th floor CSB) need replacing, and the need to access the ceiling spaces to do this will severely disrupt outpatients for two weeks. Access within the first floor ceiling space within the Clinical Services Block is even more difficult than other floors, as the ceiling space acts as an air plenum; no access is permitted into this ceiling space at all. Any incident requiring access to the first floor ceiling space means clinical activity directly below and adjacent to the issue may have to be relocated or closed. Further, the DHB needs to review other buildings used for clinical services to establish if asbestos containing material is present. Page 36

47 106. There are three key structural differences that differentiate the Clinical Service Block from other similar facilities in New Zealand: 43 (a) The building is narrower than other similar facilities. The Clinical Service Block has a width that ranges between 20.5m and 26m, compared to widths between 44m and 58m at other similar facilities. This is problematic for certain clinical functions that require spatial relationships in their internal planning. (b) The structural grid is more confined than other similar facilities. The grid spacings range between 6.7m and 7.01m, compared to grid spacings between 7.2m and 9.6m at other facilities. The Australasian Health Facility Guidelines (AHFG) recommend modular health facility planning, with a base dimension of either 300mm or 600mm. 44 The Klein report notes that recent guidance from Australia suggest that an 8.7m x 8.7m grid is most suitable for clinical uses. As the current grid is smaller, and not a product of 300mm, it would be difficult to adopt the modular approach advocated in the AFHG. Figure 29 Grid spacing in lab, CSB Figure 30 Grid spacing in middle of corridor, CSB Source: Sapere Research Group Source: Sapere Research Group (c) The floor-to-floor height is lower than similar facilities. The Clinical Service Block has a concrete slab to concrete slab height of 3.962m, compared to preferred heights ranging from 4.2m to 4.57m. Clinical spaces generally require floor to ceiling heights of 2.7m to 3.0m or more exclusive use of space required for mounted ceiling equipment such as air ducting, electrical and gas supply, etc., in operating theatres, procedure rooms, birthing rooms, CT & MRI procedure rooms, x-ray rooms, and ICU day beds. These spaces are also highly serviced, which means that they require a significant amount of space in the ceiling void for services. The theatres on the 5 th floor are currently serviced directly through the slab from the plant rooms on the floor above. The restricted height means that the theatres would not be able to be relocated to another floor within Clinical Service Block, due to the need to ensure services distribution. 43 Klein. (2014). Dunedin Hospital Clinical Services Block Health Planning and Architectural Review. 44 Australasian Health Infrastructure Alliance. (2016). Australasian Health Facility Guidelines, Part C: Design for Access, Mobility, OHS and Security (revision 5.0). Retrieved from Page 37