Radiotherapy Linear Accelerator Replacement Programme. Debbie Kadum - Chief Operating Officer

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1 Reporting to: Title Sponsoring Director Author(s) Trust Board Radiotherapy Linear Accelerator Replacement Programme Debbie Kadum - Chief Operating Officer Caroline Mansell - Radiotherpy Department Manger Paul Evans - Head of Medical Physics Dr S Khanduri - Consultant Oncologist, Clinical Lead Paper 4 Previously considered by Executive Directors Executive Summary The purpose of the business case is to describe a service model that will enable the Trust to deliver cancer services in the future that are fit for purpose and meet the needs of our local population. To support the delivery of cancer services requires both technological upgrades and an increase in capacity; this case presents the future options and details the costs, risks and benefits associated with each of these options. The case identifies 3 options and the impact and consequences associated with each option. It focuses on the purchase, utilisation and staffing of a 3rd Linear Accelerator to increase capacity The business case seeks approval for the development of radiotherapy services, with the purchase and staffing of a 3rd Linear Accelerator by 2014/2015. The case also describes a joint funding option with Lingen Davies for purchase of the linear accelerator. Strategic Priorities Quality and Safety Healthcare Standards People and Innovation Community and Partnership Financial Strength Operational Objectives Meet forecast activity and demand post 2015 Maintain national targets for waiting times for radiotherapy as set out in the NHS Cancer Plan Deliver the Cancer Reform Strategy Meet National Radiotherapy Advisory Group (NRAG) guidance Retain Cancer Centre status Provide local services within the county Provide modern, effective and accessible radiotherapy facilities that ensure the quality and outcomes of cancer care Support and recognise the commitment within our in-house workforce training programme

2 Board Assurance Framework (BAF) Risks Care Quality Commission (CQC) Domains If we do not deliver safe care then patients may suffer avoidable harm and poor clinical outcomes and experience If we do not implement our falls prevention strategy then patients may suffer serious injury If we do not achieve safe and efficient patient flow and improve our processes and capacity and demand planning then we will fail the national quality and performance standards If we do not have a clear clinical service vision then we may not deliver the best services to patients If we do not get good levels of staff engagement to get a culture of continuous improvement then staff morale and patient outcomes may not improve If we are unable to resolve our (historic) shortfall in liquidity and the structural imbalance in the Trust's Income & Expenditure position then we will not be able to fulfil our financial duties and address the modernisation of our ageing estate and equipment Safe Effective Caring Responsive Well led Receive Note Review Approve Recommendation Members of the Trust Board are asked to APPROVE this business case.

3 The Shrewsbury and Telford Hospital Confidential Business Case Radiotherapy Linear Accelerator Purpose: To outline the need to increase Radiotherapy treatment capacity in line with the forecast growth in cancer services. This involves securing additional Linear Accelerator machines, facilities and staff to match demand over the next 10 years. Centre: Surgery, Oncology and Haematology Authors: Caroline Mansell Paul Evans Dr S Khanduri Date: 13 th January rd LinAc Business Case 13 th January 2014

4 The Shrewsbury and Telford Hospital Confidential Contents Section Page 1 Executive Summary Current Service Profile Case for Change Stakeholder Analysis 10 5 Option Appraisal Risk Analysis Workforce 14 8 Financial Analysis 14 9 Investment Appraisal Summary of Recommendations Expected Benefits Timescales 16 Appendices 1 Network Radiotherapy Group: National Radiotherapy Advisory Group Recommendations 1a Population projections & 21 based on ONS projections 2 Detailed Financial Analysis 2 3 rd LinAc Business Case 13 th January 2014

5 The Shrewsbury and Telford Hospital Confidential 1. Executive Summary 1.1 Introduction The purpose of the business case is to describe a service model that will enable the Trust to deliver cancer services in the future that are fit for purpose and meet the needs of our local population. To support the delivery of cancer services requires both technological upgrades and an increase in capacity; this case presents the future options and details the costs, risks and benefits associated with each of these options. The case identifies 3 options and the impact and consequences associated with each option. It focuses on the purchase, utilisation and staffing of a 3rd Linear Accelerator to increase capacity The business case seeks approval for the development of radiotherapy services, with the purchase and staffing of a 3rd Linear Accelerator by 2014/ Background Demand for cancer services is predicted to increase significantly over the next 5 years as a result of population growth, ageing demographic and national screening programmes (Ref: Living with and beyond cancer taking action to improve outcomes: DOH, Macmillan Cancer Support & NHS Improvement see also Appendix 1 & 1a) All patients should have access to radiotherapy treatment within 45 minutes of where they live The Radiotherapy Department requires two Linear Accelerators in order to meet current demand and three Linear Accelerators to meet the predicted forecast growth expected by 2015/16 The two current Linear Accelerators are operating at 97% of existing capacity (NRAG advises maximum 87% capacity) The development of Cancer Services has been identified as a Key Service Development within the Trust s Annual Plan and Integrated Business Plan. The Trust has developed and supported a training programme to develop specialist skills that are required to deliver future cancer services 1.3 Case for Change Increased Demand Annual Increase graph Shows demand exceeding current capacity by 2014/15 Delivered and Projected Radiotherapy Fractions (RSH)per per Financial Year Year 25,000 20,000 Maximum capacity for 2 Capacity Linacs for 2 Linacs 15,000 Number of of Fractions 10,000 5, / / / / / / 2017 Financial Year 3 3 rd LinAc Business Case 13 th January 2014

6 The Shrewsbury and Telford Hospital Confidential With our current demand delivered from 2 Linear Accelerators we are already working at 97% capacity and vulnerable to a loss of capacity when a machine requires maintenance or planned safety checks. With continued working 97% capacity we will remain vulnerable to breaching Cancer targets due to the inability to respond to fluctuating demand. Recommended Number of Linear Accelerators at RSH (NRAG 2008) vs Financial Year Extended working day started Trigger point for third Linac Number of Linacs / / / / / / 2017 Financial Year The 3rd Linear Accelerator will enable the Trust to: Meet forecast activity and demand post 2015 Maintain national targets for waiting times for radiotherapy as set out in the NHS Cancer Plan Deliver the Cancer Reform Strategy Meet National Radiotherapy Advisory Group (NRAG) guidance Retain Cancer Centre status Provide local services within the county Provide modern, effective and accessible radiotherapy facilities that ensure the quality and outcomes of cancer care Support and recognise the commitment within our in-house workforce training programme 2. Current Service Profile 2.1 Equipment The Radiotherapy Department currently has two Linear Accelerators and three bunkers in use, as shown below. Bunker Machine Installation / Commissioning Year LA2 Varian CLinAc 2100CD replaced in LA3 Varian CLinAc 2100iX linear 2006 LA1 Varian Truebeam rd LinAc Business Case 13 th January 2014

7 The Shrewsbury and Telford Hospital Confidential 2.2 Utilisation of existing Linear Accelerators The Radiotherapy Department require two Linear Accelerators to meet the existing demand. NRAG advises that departments should plan to operate at 87% capacity in order to allow for peaks and troughs of patient demand. The department is working at 97% capacity, with an extended day. This current practice enables the delivery of the existing levels of activity however it is not sustainable long term and does not support routine planned time for repairs and corrective maintenance. The National Cancer Action Team Cancer Toolkit Report, depicting average machine attendances per Linear Accelerator over the last 12 months, demonstrates that we are delivering one of the highest levels of fractions per Linear Accelerator. This is achieved in spite of not having a service continuity machine, which many larger departments have. A service continuity machine is not normally staffed but can be used in the event of the breakdown of another machine, or to treat patients during routine maintenance and quality assurance of machines. This allows for a higher throughput per Linear Accelerator due to less time lost. X Shrewsbury Source: National Cancer Action Team. National Cancer Commissioning Toolkit 2.3 Service Delivery and Access Currently with only 2 Linear Accelerators SaTH has implemented an extended working day (9.5 hours), from 2010/11 as recommended by NRAG to provided sufficient capacity. It must be stressed that this solution is only valid up to 2015/16 when a third Linear Accelerator will be required. Given the department s current activity, it is now anticipated that current capacity on the two Linear Accelerators may be reached and exceeded by 2013/14, one year ahead of the NRAG guidance. Once demand exceeds capacity, the waiting times for radiotherapy will fall outside the Government targets stated in the Cancer Reform Strategy, National Cancer Measures and also the recommended guidelines from the Royal College of Radiologists. 3. Case for Change 3.1 Demand for Services Local Demographics Demographic changes have a significant impact on the demand for services. Overall population growth, disease prevalence and the ageing profile will all increase the demands on all cancer services including radiotherapy. 5 3 rd LinAc Business Case 13 th January 2014

8 The Shrewsbury and Telford Hospital Confidential Our local population is estimated to grow by between 5% and 10% from 2011 to 2021 (2023 for Powys). The disease prevalence in both Shropshire and Powys is higher than the national average. The population in Shropshire and Powys is considerably older than the national average with 20% and 23% of the population over 65 respectively in Within our local catchment the population aged over 65 is estimated to grow significantly and by % of Shropshire will be aged over 65 and 31% of the Powys population. The ageing population is driving an increased prevalence in cancer. The following table shows the demographic projections within the county and across the border in Powys Shropshire Telford and Powys County Wrekin Forecast overall population growth 4.9% 10.4% 6.9% Disease Prevalence 2.2% * 1.6% 2.3% ** Forecast growth in population aged >65ys) 29.1% 25.2% 43% Age Profile 2011 (% of population > 65ys) 20.8% 14.8% 22.9% Age Profile 2011 (% of population > 65ys) 25.6% 16.8% 30.7% *Disease Prevalence for England = 1.8% ** Disease Prevalence for Wales = 1.9% See appendix 1 & appendix 1a 3.2 Demand for Services Clinical Developments and NICE Guidance In addition to capacity requirements it is predicted that over the next few years IMRT(Intensity modulated Radiotherapy) will be offered to up to 50% of total radical radiotherapy patients (2013 level 33%). IMRT technology maximises tumour control and reduces morbidity, together with IGRT (Image guided Radiotherapy) which improves treatment accuracy. The Varian Truebeam Linear Accelerator, which has now been purchased as the replacement for the 2 nd machine, will enable SaTH to deliver levels of IMRT and provide advanced technology from October 2013, an additional machine of the same specification will provide capacity to enable the anticipated increased demand for IMRT/IGRT. 3.3 Demand for Services National Cancer Waiting Times The department is required to deliver Radiotherapy treatment within waiting times specified in the National Cancer Strategy The targets that have a direct impact on the Radiotherapy department are: 62 day wait a target of 94% of patients to receive their first definitive treatment for cancer within 62 days from GP referral, Consultant referral or referral from a screening programme. 31 day wait a target of 94% of patients to receive subsequent treatment for cancer within 31 days where that treatment is Radiotherapy. Without sufficient capacity the department will become unable to meet consistently these Cancer Waiting times standards. 6 3 rd LinAc Business Case 13 th January 2014

9 The Shrewsbury and Telford Hospital Confidential 3.4 Demand and Capacity The forecast activity figures shown below demonstrates a need for more than two Linear Accelerators, rising to three by 2015/16 in the Radiotherapy Department at the Royal Shrewsbury Hospital. This is consistent with The National Radiotherapy Advisory Group (NRAG) guidance targets and endorsed by the Network Radiotherapy Group (NRG). (As detailed in Appendix 1) RSH Actual and Predicted Requirements for Radiotherapy 1700 Number of Radiotherapy Courses (Patients) Maximum capacity for 3 linacs based on NRAG recommendations Maximum capacity for 2 linacs based on NRAG recommendations Year Note: approximately 10% of SaTH s Radiotherapy activity comes from Mid Wales. Provision for Radiotherapy within Wales is provided by three centres, Boddelwyddan in North Wales, Swansea covering South East and Cardiff covering the South East of Wales. A report produced by the Welsh Government looking at Radiotherapy requirements acknowledging the need for greater Radiotherapy capacity recommended that this be achieved by increasing the capacity at the three established centres which would have little or no impact on patients attending SaTH from Mid- Wales. The number of machines required is calculated based on the total demand for Linear Accelerator time in fractions divided by the machine capacity in fractions and is shown below: Calculation of Future Linear Accelerator Requirements for a Population of 580,000 (i.e. Shropshire & Mid- Wales*) Year Fractions LinAcs Required Cancer Incidence % Uptake Total Patients Total Course Average per course Total NRAG target fraction rate Current fraction rate 2011/12 2,620 40% 1,048 1, , /16 2,830 40% 1,132 1, , rd LinAc Business Case 13 th January 2014

10 The Shrewsbury and Telford Hospital Confidential To provide further sensitivity testing the uptake rate was increased to 50% (as predicted by NRAG), this produced the following results: Future Linear Accelerator Requirements with 50% increased access rates Year Cancer % Total Total Fractions Incidence Uptake Patients Course Average Total per course LinAcs Required NRAG target fraction rate 2011/12 2,620 50% 1,310 1, , /16 2,830 50% 1,415 1, , Current exposure rate The table above indicates that if future access rates increase to 50% then the Linear Accelerator requirements increase to 3.5 assuming a target fraction rate (increase of 1 from previous), or 3.1 assuming current fraction rates. The tables above suggests that SaTH historically have delivered a low rate of fractions per course, but that this has increased following implementation of RCR fractionation guidelines, e.g. for prostate cancer (37 fractions). It must be recognised that for a small department such as SaTH, the trigger point to move from 2 to 3 Linear Accelerators is when 2.5 machines are required, or less. This is because two Linear Accelerators (unlike a department with 4 or more) cannot deliver the necessary increased fractions required by NRAG, even working an extended day and waiving some of the NRAG guidelines. To deliver the full recommended RCR 3 Linear Accelerators would be required. The addition of a third Linear Accelerator will ensure that: Mandatory targets laid out within the NHS Cancer Plan are met sustainably (31 and 62 day treatment targets) To ensure the future local provision of radiotherapy services in Shropshire and Mid Wales Modern, effective and accessible radiotherapy facilities to ensure the quality and outcomes of cancer care (IMRT/IGRT) Anticipated financial support for increased level and complexity of radiotherapy under the new national tariff funding system 3.5 Capital Funding The Trust will approach Lingen Davies to request a grant for this additional machine however if this is not possible the requirement will be added to the Trust s stretched 5 year Capital Programme. 4. Stakeholder Analysis Patients accessible provision of radiotherapy treatment services for Shropshire & Mid Wales cancer patients. ( Cancer Patient Group / Forum ) Oncology Consultants will require capacity and improved technology to implement prescribed treatments Oncology Radiotherapy Staff will need to expand team to operate 3 rd Linear Accelerator Medical Physics - will need to expand team to maintain 3 rd Linear Accelerator and plan treatments Lingen Davies have been briefed by Chief Executive (April 2013) on the trusts LINAC plans Trust Centre replacement plan being presented to Trust board to secure sustainable radiotherapy provision. Local Health Economy commissioning services from department who is able to deliver. 8 3 rd LinAc Business Case 13 th January 2014

11 The Shrewsbury and Telford Hospital Confidential 5. Options Appraisal The following options have been considered as part of the sustainability and viability assessment. Option 1 - Do nothing continue to work at 97% capacity with an extended working day Option 2-7 day working Option 3 - Install a third Linear Accelerator in existing decant bunker and remove Varian CLinAc 2100CD 5.1 Option 1 - Do Nothing The department currently treats patients from Monday to Friday working an extended day from 8:15am -6:15pm. If the department continues to operate at this level we are not able to meet fluctuating demands upon the service in the event of increased referrals during a given period, and or machine breakdown. Operating the Linacs at 97 % capacity as opposed to the recommended 87% capacity hampers the delivery of high quality responsive service that meets patients needs adequately. Current activity shows a 5% increase compared with figures for comparable period last year and is also qualified by predictive modelling tools of activity eg Malthus. As there is no likelihood of the demand for radiotherapy reducing in the foreseeable future additional capacity must be created in order for patients to be treated in a safe and timely manner. If the Trust wishes to continue to provide an effective and efficient radiotherapy service to the catchment population, the Do Nothing option should be discounted however for completeness this option has been assessed. 5.2 Option 2 - Extended working day to full 7 day working Fractionation schedules are for five continuous days out of a seven day week. Option 2 would increase capacity by extending the working week to provide a full 7 day service. Radiotherapy is not a standalone service delivered by radiographers but requires comprehensive additional support from nursing staff, Consultant Clinical Oncologists, Medical Physics, Planning and Pre-Treatment services, Chemotherapy Day Unit, Pharmacy, and administrative support to supply the same level of care for patients treated at the weekend as those treated during the normal working week. Seven day working cannot be operated on a basis of skeleton staff working with inadequate back up. The additional Radiographer and Medical Physics staff required would be 82% of that required to run a third Linac not including provision for enhanced rates of pay and any contingency for overtime payments in the event of essential repair work being required out of hours. If there is a need for increased Oncologist cover with an increase in staff numbers required this would also have to be quantified. Increased hours of operational use would be expected to reduce the lifespan of this equipment (Currently 10 years, based on 40 hour week). Although more long term monitoring is required there is already evidence to suggest that running the Linacs an additional 10 hours per week may reduce the lifespan of the machine by up to 15%. With full seven day working there is no leeway for spare capacity to cover maintenance and quality assurance without reducing patient throughput. Any breakdown would result in patients experiencing unscheduled interruptions with no opportunity to absorb the effects or rectify the underlying problems. External maintenance support provided by Varian (current Linac supplier) is currently 9am -5pm, five days a week. The Radiotherapy Department has explored further extending the day, however recent experiences has confirmed that patients do not wish to receive treatment late evening, therefore by implementing this, patient experience and satisfaction levels would decrease. 9 3 rd LinAc Business Case 13 th January 2014

12 The Shrewsbury and Telford Hospital Confidential The risk of service interruption with the reliance on two Linear Accelerators beyond 2015/16 is unacceptable due to inevitable service disruption and consequently delays in patient care. The current Radiotherapy Service demonstrates a need to: Ensure current radiotherapy capacity is sustained; Ensure that the existing radiotherapy treatment capacity exists to meet Government targets for waiting times as laid down in the NHS Cancer Plan, the current recommendations of Clinical Governance and best Clinical Practice; Ensure that the needs of the patient are taken into account in the design and building of the facility Ensure that alternative treatment facilities are available for the transfer of patients in the event of failure of the Linear Accelerator; Ensure the most efficient use of available resources. This Option is discounted based on the justification for replacement in section Option 3 Install a third Linear Accelerator in existing decant bunker and remove Varian CLinAc 2100CD The Varian CLinAc 2100CD has reached the end of its clinical life and was replaced by the Varian Truebeam Linear Accelerator in September The Trust will decommission this machine in 2014, although no plans have been approved to remove the machine (no costs have been calculated to undertake this but are believed to be in the region of 20k). The Varian Truebeam Linear Accelerator was evaluated as a preferred model by the Trust in This enables patients of the SaTH NHS Trust access to technology already available within our Cancer Network. This machine maximises tumour control and reduces morbidity, together with IGRT which improves treatment accuracy and IMRT. The empty bunker could be used to accommodate an additional Truebeam Linear Accelerator. This option will provide the additional capacity required to treat the increasing number of patients within the National Cancer waiting time targets. 6. Risk Analysis The following section identifies the risks within the service following the implementation of the above options. 6.1 Option 1 No additional capacity combined with increasing workloads which will lead to inability to guarantee that all patients will start treatment within National Cancer Waiting time targets. A requirement for Trust executive exit strategy for the safe transfer of patients requiring radiotherapy to other Trusts with risk of delay in patient pathway, reduction in quality of patient care. Loss of income due to removal of patient groups to neighbouring Trusts where capacity is sufficient to ensure national targets are met. Risk of poorer outcomes for patients as number of interruptions that can be compensated for increase due to breakdowns. At a time of national staffing shortages in Radiotherapy and without up to date levels of equipment, SaTH will be unable to compete with other Trusts in the UK to recruit and retain staff. With reduced access to curative radiotherapy within reasonable travelling times patients will suffer poorer outcomes for their disease. Inability to cope with demand will mean that some patients will be required to access radiotherapy services out of county. Patient experience and outcomes will be seriously compromised without additional capacity. Increased risk of total loss of Radiotherapy Service 10 3 rd LinAc Business Case 13 th January 2014

13 The Shrewsbury and Telford Hospital Confidential 6.2 Option 2 Increased rate of breakdown of the Varian Linear Accelerator due to longer operating hours and high workloads which will lead to inability to guarantee that all patients will start treatment within national target times. Risk of poorer outcomes for patients as number of interruptions that can be compensated for increase due to breakdowns. Increased hours of operational use would be expected to reduce the lifespan of this equipment (Currently 10 years, based on 40 hour week). No leeway for spare capacity to cover maintenance and quality assurance without reducing patient throughput. Any breakdown would result in patients experiencing unscheduled interruptions with no opportunity to absorb the effects or rectify the underlying problems. External maintenance support provided by Varian (current Linac supplier) is currently 9am -5pm, five days a week. Currently we are not aware of any Radiotherapy Department in England or Wales operating full seven day working, if seven day working was implemented at SaTH is likely to generate dissatisfaction and lead to difficulty in recruitment, although it is acknowledged that 7 day working is a national priority. The Radiotherapy Department has explored further extending the day, however recent experiences has confirmed that patients do not wish to receive treatment late evening, therefore by implementing this, patient experience and satisfaction levels would decrease. 6.3 Option 3 The installation of a third Linac within an existing bunker secures extra capacity but with any subsequent Linac replacements there would be no ability to install a replacement machine without a reduction in capacity during a minimum of 6 month installation and commissioning process. In practice this would mean running two machines seven days a week over an extended day to meet demand (with associated risks as detailed for option 2) or patients would have to be sent out of county to receive radiotherapy. Commits the Trust to operating and maintaining a three Linac service which will require additional capital expenditure. Recruitment of additional team members within Medical Physics and Radiotherapy with the correct skills could be considered a risk Risk Analysis Summary Risk Likelihood Impact Mitigated Risk Score Option 1 Quality Lack of capacity leading to a failure to meet Cancer waiting time targets Financial Potential loss of work to other radiotherapy departments Workforce Loss of staff and inability to recruit Option 2 Financial Potential loss of work to other radiotherapy departments Workforce Loss of staff and inability to recruit Quality No capacity to compensate for gaps in treatment due to breakdowns rd LinAc Business Case 13 th January 2014

14 The Shrewsbury and Telford Hospital Confidential Option 3 Financial If predicted increase in workload fails to happen Workforce Inability to recruit to additional posts Workforce To staff and maintain a third Linac will require Medical Physics & Radiography staff revenue funding and recruitment to deliver patient treatments. This team increase would be phased over 2 years to coincide with the initial instalment of the equipment and expected demand increase in activity. The table below identifies the staffing changes associated with each of the options considered; Grade of Staff Option 1 Option 2 Option 3 Linac engineer band Clinical Scientist band 8A Dosimetrist band Band 7 Specialist Imager Band 6 Radiographer Band 5 Radiographer Band 3 Care assistant Band 2 Receptionist Total Radiographic Staffing Guidelines per linear accelerator hour 1.33 WTE for core activities, this takes into account cover for annual leave, maternity leave, sickness CPD. We currently run at 85% of this level. Clinical hours on Linac are 8:30am -6:15pm ie 9.75 hours 9.75 x 1.33 = % of this is 11 staff required. Recommendations are that up to 10% can be non radiographers. 8. Financial Analysis Capital Option Option Option Linac 3 1,550 Enabling Costs 250 Total 0 0 1,800 The purchase price is based on information provided from NHS Supply Chain VAT has not been included as it is assumed this will be a donated asset Enabling costs have been included at 250k until further information is provided. Revenue Option Option Option Income Pay (672)* 702 (551) Non pay 0 (152) (152) Capital Charges 0 0 (17) Total 0 (122) (18) 12 3 rd LinAc Business Case 13 th January 2014

15 The Shrewsbury and Telford Hospital Confidential * Please note these are direct pay costs only and do not include indirect costs associated with seven day working. Capital charges assumes charges on the enabling work only 9. Investment Appraisal An options assessment considering the key factors that impact on a future decision was undertaken, this summary is shown in the table below; % weight Option 1 Option 2 Option 3 Capacity Cancer Targets Complex treatments (tariff) Unscheduled treatment break avoidance Meets time constraints Financial viability Total (max. 100%) Scores are from 1 to 5, based upon the arguments set out in the discussion. Weightings are based upon the relative importance of the respective factor in the overall decision. Total score is based upon a % of the theoretical perfect score of Summary of Recommendation After review of the options outlined above, the recommendation is option 3, which provides the most viable solution in order to realise the project benefits desired. Option 3, the provision of a new Truebeam machine in the existing bunker, is the preferred option for the following reasons; The installation of an additional machine supports continuity of service within acceptable timeframes. The increased staffing revenue costs will be offset by the increase tariff income based on increased levels and complexity of workload. 11. Expected Benefits It is envisioned the following Key Performance areas / metrics will be measured and sustainable improvement will be achieved. Local service delivery: Maintenance of access to curative Radiotherapy within reasonable travelling times resulting in better outcomes for patients. Ability to develop further advanced treatment techniques and Image Guided Radiotherapy which attracts a higher tariff and associated increase in income. Both these are also subject to a Specialised Commissioning Quality dashboard. Maintain 31/62 day Cancer Waiting time targets Sustainability of service 12. Timescales Linear Accelerators have a life expectancy of approximately 10 years To install and commission a new machine takes 6-9 months 13 3 rd LinAc Business Case 13 th January 2014

16 The Shrewsbury and Telford Hospital Confidential 13. Appendices Appendix 1 Network Radiotherapy Group: National Radiotherapy Advisory Group Recommendations Section 1.1, 4.1, 4.4 Appendix 1a Population projections & 21 based on ONS projections Section 1.1, 4.1 Appendix 2 Detailed Financial Analysis 14 3 rd LinAc Business Case 13 th January 2014

17 Greater Midlands Cancer Network Radiotherapy Network Group Preliminary Recommendations to Achieve NRAG Standards Appendix 1 Current total GMCN population is GMCN contains 8 PCTs : NHS Dudley NHS North Staffordshire Shropshire County PCT South Staffordshire PCT NHS Stoke on Trent NHS Telford and Wrekin Wolverhampton City PCT Worcestershire PCT GMCN contains 7 Acute Hospital Trusts: Dudley Group of Hospitals NHS Trust Kidderminster Hospital Mid Staffordshire Hospital NHS Trust Robert Jones and Agnes Hunt NHS Royal Wolverhampton Hospitals NHS Trust Shrewsbury and Telford NHS Trust University Hospital of North Staffordshire NHS Trust GMCN contains 3 Acute Hospital Trusts with Radiotherapy departments: Royal Wolverhampton Hospitals NHS Trust Shrewsbury and Telford NHS Trust University Hospital of North Staffordshire NHS Trust Most External Beam Radiotherapy is delivered on megavoltage Linear Accelerators (LinAcs) NRAG recommends: R/T fractions per million population by R/T fractions per million population by 2016 Maximum LinAc capacity by 2011 : 8000 Maximum LinAc capacity by 2016 : 8700 All new LinAcs should have Image Guided RadioTherapy (IGRT), Respiratory Gating and Intensity Modulated RadioTherapy (IMRT) Capacity Required by GMCN is therefore (see spreadsheet) fractions by fractions by 2016

18 Current Equipment in the three R/T Centres Appendix 1 Trust Catchment Current LinAcs Population (2007 Method A) Varian 2100CD Varian 2100CD Elekta Synergy Elekta Precise Varian 2100CD Varian 2100iX Varian 2100iX Varian 2100iX Varian 2100iX Varian 2100iX Date of Installation Date of Expected Replacement Maximum Capacity Royal Wolverhampton Hospitals NHS Trust Shrewsbury and Telford NHS Trust University Hospital of North Staffordshire NHS Trust TOTAL Current Activity in three R/T Centres Fractions delivered by GMCN Fractions RWH SaTH UHNS total predicted Year On current projections of the GMCN activity from the past five years the demand for radiotherapy treatments will exceed the current capacity of 80,000 fractions per year by 2015, but will still be within the 87,000 limit All three centres within the GMCN deliver IMRT to selected patient groups However current staffing only allows 7.5 hours of treatment time per day (AfC). To achieve the 8700 target per LinAc within the 239 treatment days per year each unit would be treating 9 hours per day, requiring a 20% increase in radiographer, scientific and technical and clinicians. Without this uplift only 1793 treatment hours per LinAc is available. With the implementation of Intensity Modulated RadioTherapy (IMRT), to improve efficacy and reduce morbity and Image Guided RadioTherapy (IGRT) to improve accuracy, an essential requirement for IMRT, it cannot be envisaged that more than four patients per hour could be treated. Therefore the combined availability and expected patient throughput without a 20% investment in staff would limit the annual total to less than 8000 per machine or 80,000 across the network. NRAG also recommends that each department has a service efficiency machine to compensate for breakdowns, quality assurance and servicing downtime. The three radiotherapy departments across the GMCN do not possess such units. NRAG predicts a capacity requirement of 107,000 fractions per year by 2016.

19 Appendix 1 Conclusions Working a nine hour day, 8:30-18:00, 5 days a week, four patients per hour would enable 8600 fractions per year per linac. This would require a 20% increase in staffing costs. To allow for the predicted increase in capacity by 2016 a further fractions must be made available requiring a further 2.4 LinAcs, with support costs. The attached map shows the geographic borders of the GMCN with the three radiotherapy centres and their individual catchment areas of 15miles. This demonstrates that the geographical distribution of these departments allows coverage of approximately 70% of the network within 15 miles and that the south western corner that falls outside these mileage zones is less populated compared to the eastern side. Because of the disproportionate set up costs in establishing a new department outside of the existing centres and the extra running costs because of economies of scale, there is no compelling reason to install new LinAcs other than at the existing departments It is recommended to schedule the building works for new facilities to complement replacement of existing units.

20 GMCN Catchment Area Appendix 1

21 Appendix 1 Greater Midlands Cancer Network Projected Populations Total Fractions pmp 2006 Total Fractions pmp 2011 Total Fractions pmp 2016 Total Fractions pmp 2021 Code PCT Min Base Max Min Base Max Min Base Max Min Base Max Case Case Case Case 5PE Dudley PCT 305, , , ,300 43,604 51,919 63,031 46,830 55,789 67,793 50,147 59,810 72,653 53,406 63,795 77,401 5PH North Staffordshire PCT 211, , , ,100 60,658 73,413 91,030 64,629 78,285 97,195 68,798 83, ,586 72,911 88, ,820 5M2 Shropshire County PCT 289, , , ,500 51,626 61,832 76,316 54,143 64,883 80,180 56,722 68,058 84,077 59,146 71,079 87,689 5PK South Staffordshire PCT 603, , , ,400 14,250 16,821 20,571 14,908 17,607 21,564 15,608 18,451 22,601 16,323 19,318 23,643 5PJ Stoke on Trent PCT 247, , , ,900 62,771 75,228 91,546 67,210 80,602 98,202 71,785 86, ,959 76,453 91, ,760 5MK Telford and Wrekin PCT 161, , , ,400 33,691 39,358 47,551 35,423 41,375 50,017 37,288 43,573 52,644 39,183 45,826 55,295 5MV Wolverhampton City PCT 236, , , ,100 32,709 38,566 47,199 35,223 41,533 50,887 37,778 44,571 54,589 40,332 47,625 58,250 5PL Worcestershire PCT 552, , , ,900 19,262 22,828 27,864 20,192 23,941 29,260 21,191 25,148 30,729 22,185 26,359 32,170 N35 Greater Midlands CN 1,885,445 1,934,525 1,989,366 2,046,070 27,585 49,814 40,228 29,095 52,477 42,491 30,646 55,274 44,787 32,173 58,081 47,020

22 Appendix 1 R/T NSSG NRAG Strategy LinAcs RWHT Build new and Replace 2 Replace Replace Elekta decant bunkers Varian LinAcs Elekta Synergy Precise Install 5 th LinAc UHNS RSH New bunker New LinAc (1) Decommission LinAc 2 Install 3 rd LinAc Build new and decant bunkers Replace LinAc 3 Install 5 th LinAc Commence Replacement of 4 LinAcs Comments UHNS Currently fractions per year Existing 4LinAcs due for replacement 2019 Predict fractions per year minimum by??2018, cannot reduce to 3 LinAcs RWHT Currently fractions per year Existing four LinAcs due for replacement Need historic data to predict fraction growth trend, but will not be able to reduce to 3 LinAcs SaTH Currently fractions per year Existing Linacs due for replacement 2012 and 2017 Need historic data to predict fraction growth trend, but will not be able to reduce to 1 LinAc

23 Risk Rating Matrix Step 1 Consider the Consequence 4/5 What are the consequences of this incident occurring? Consider what could reasonably have happened as well as what actually happened. Look at the descriptions and choose the most suitable consequence. Consequence Appendix 1 SECTION 1 Future CONSEQUENCE or level of IMPACT. RISK MATRIX Descriptor Insignificant Minor Moderate Major Catastrophic Objectives/ Projects Insignificant cost increase/schedule slippage. Minor reduction in score or quality. Reduction in scope or quality identifying additional work Significant overrun of project. Inability to meet primary objectives. Injury (physical/ psychological) No apparent injury or minor injury not requiring first aid. Minor injury or illness requiring first aid treatment. RIDDOR/NPSA reportable. Major injury or long term incapacity/disability (loss of limb). Death or major permanent incapacity. Patient Experience or Outcome Unsatisfactory patient experience not directly related to patient care. Unsatisfactory patient experience readily resolved. Mismanagement of patient care, short term effects (less than a week). Serious mismanagement of patient care, long term effects (more than a week). Totally unsatisfactory patient outcome or Hospital Acquired Infection Outbreak Severe impact on services Complaints/ Claims Locally resolved complaint. Justified complaint peripheral to clinical care. Below excess claim. Justified complaint involving lack of appropriate care. Claim above excess level. Justified multiple complaints. Multiple claims or single major claim. Service/Business Interruption Loss/interruption > 1 hour. Loss/interruption > 8 hours. Loss/interruption > 1 day. Loss/interruption > 1 week. Permanent loss of service/facility. Staffing and Competence Short term low staffing level. Ongoing low staffing level. Late delivery of key objective/service due to lack of staff. Uncertain delivery of key objectives/service due to lack of staff. Non delivery of key objective/service due to lack of staff. HR/ Organisational Development Temporarily reduced service quality (< 1 day). Reduces service quality. Minor error due to ineffective training. Ongoing unsafe staffing level. Serious error due to ineffective training. Loss of key staff. Critical error due to insufficient training. Financial Inspection/ Audit Insignificant loss. < 100k Minor recommendations. Minor non-compliance with standards. Minor > 100k Recommendations given. Non-compliance with standards. Moderate > 500k Reduced rating.. Noncompliance with Core Standards. Major Loss > 1m Enforcement. Action. Major non-compliance with Core Standards. Catastrophic > 3m Prosecution. Zero rating. Severely critical report. Adverse Publicity/ Reputation Rumours. Local Media short term. Minor effect on staff morale. Local Media long term. Significant effect on staff morale. National Media < 3 days. National Media > 3 days. MP concerns (questions in house).

24 Appendix 1 Step 2 what is the likelihood? What is the likelihood of the consequence identified in step 1 happening? Consider this without new or interim 4/5 controls in place. Look at the descriptions and choose the most suitable Likelihood. Likelihood: SECTION 2 LIKELIHOOD OF OCCURRENCE Risk Score 1. RARE The event may only occur in exceptional circumstances. 2. UNLIKELY Unlikely to occur. 3. POSSIBLE Reasonable chance of occurring. 4. LIKELY The event will occur in most circumstances. 5. ALMOST Most likely to occur than not. CERTAIN Probability Step 3 calculate the risk score rating SECTION 3 RISK SCORING MATRIX Likelih ood Consequence/Impact Score ained from the risk matrix are assigned grades as follow For gra din g risk, the sco res obt 1-3 Low risk 4-6 Moderate risk 8-12 High risk

25 Appendix Extreme risk Level of Risk: Extreme High Moderate Low Extreme Escalating Risk Having calculated the level of residual risk, the following table sets out the minimum response E Extreme Risk Completion of an action plan proforma. Executive Lead or Divisional General Manager informed of the gaps in control and/or assurance and the planned actions as soon as is practicably possible Executive Lead or Divisional General Manager to record formal approval of the action plan proforma at a minuted meeting of the Executive Board/Divisional Management Team Corporate report provided to the Executive Board on a six monthly basis or as requested H High risk Completion of an action plan Proforma. Divisional Risk register Executive Lead or Divisional General Manager informed of the gaps in control and/or assurance and the planned actions as soon as is practicably possible Executive Lead or Divisional General Manager to record formal approval of the action plan proforma at a minuted meeting of the /Divisional Management Team M Moderate risk Department/Ward/Team risks rate moderate and above must be discussed via line managers, with the Directorate Manager if risks can not be controlled for consideration of escalating to the Directorate/Divisional Risk Register. L Low risk Assign local responsibility and action. Maintain risk assessment evidence locally and manage by routine procedures

26 Appendix 1

27 Shropshire County Age group % change % change ,200 15,040 14,880 14,720 14,560 14, % 14, % ,300 15,520 15,740 15,960 16,180 16, % 15, % ,300 17,120 16,940 16,760 16,580 16, % 17, % ,000 17,760 17,520 17,280 17,040 16, % 16, % ,700 13,500 13,300 13,100 12,900 12, % 11, % ,300 13,600 13,900 14,200 14,500 14, % 13, % ,900 13,200 13,500 13,800 14,100 14, % 15, % ,700 16,220 15,740 15,260 14,780 14, % 16, % ,500 20,740 19,980 19,220 18,460 17, % 15, % ,800 22,680 22,560 22,440 22,320 22, % 18, % ,700 21,240 21,780 22,320 22,860 23, % 22, % ,900 20,220 20,540 20,860 21,180 21, % 24, % ,300 21,920 21,540 21,160 20,780 20, % 22, % ,400 19,940 20,480 21,020 21,560 22, % 20, % ,100 15,780 16,460 17,140 17,820 18, % 21, % ,100 12,460 12,820 13,180 13,540 13, % 17, % ,100 9,320 9,540 9,760 9,980 10, % 12, % ,700 5,880 6,060 6,240 6,420 6, % 7, % 90+ 3,000 3,220 3,440 3,660 3,880 4, % 5, % 294, , , , , , % 308, %

28 Telford and Wrekin Age % change % change group , ,000 12,400 12,800 12, % 13, % ,200 10,500 10,800 11,100 11,300 11, % 13, % ,800 10,500 10,300 10,200 10,300 10, % 12, % ,300 11,400 11,400 11,300 11,200 11, % 10, % ,000 12,000 12,000 12,000 12,000 11, % 11, % ,200 11,700 12,000 12,300 12,500 12, % 12, % ,000 10,200 10,600 10,900 11,200 11, % 13, % ,000 10,400 10,000 10,000 10,100 10, % 12, % ,100 13,100 12,700 12,400 11,800 11, % 10, % ,200 13,300 13,500 13,300 13,300 13, % 11, % ,100 11,500 11,900 12,400 12,800 13, % 13, % ,500 10,400 10,500 10,500 10,700 10, % 12, % ,500 10,300 10,100 10,100 10,100 10, % 10, % ,300 8,900 9,300 9,700 9,800 10, % 9, % ,500 6,600 6,800 7,000 7,300 7, % 9, % ,500 4,700 4,900 5,100 5,200 5, % 6, % ,200 3,200 3,200 3,200 3,300 3, % 3, % ,900 1,800 1,800 1,800 1,800 1, % 2, % 90+ 1,000 1,000 1,000 1,000 1,000 1, % 1, % 171, , , , , , % 189, %

29 Both PCTs combined Age % change % change % change % change % change % change group ,200 15, % 14, % 14, % 14, % 14, % 14, % ,300 15, % 15, % 15, % 16, % 16, % 15, % ,300 17, % 16, % 16, % 16, % 16, % 17, % ,000 17, % 17, % 17, % 17, % 16, % 16, % ,700 13, % 13, % 13, % 12, % 12, % 11, % ,300 13, % 13, % 14, % 14, % 14, % 13, % ,900 13, % 13, % 13, % 14, % 14, % 15, % ,700 16, % 15, % 15, % 14, % 14, % 16, % ,500 20, % 19, % 19, % 18, % 17, % 15, % ,800 22, % 22, % 22, % 22, % 22, % 18, % ,700 21, % 21, % 22, % 22, % 23, % 22, % ,900 20, % 20, % 20, % 21, % 21, % 24, % ,300 21, % 21, % 21, % 20, % 20, % 22, % ,400 19, % 20, % 21, % 21, % 22, % 20, % ,100 15, % 16, % 17, % 17, % 18, % 21, % ,100 12, % 12, % 13, % 13, % 13, % 17, % ,100 9, % 9, % 9, % 9, % 10, % 12, % ,700 5, % 6, % 6, % 6, % 6, % 7, % 90+ 3,000 3, % 3, % 3, % 3, % 4, % 5, % 294, , % 296, % 298, % 299, % 300, % 308, %

30 The Shrewsbury and Telford Hospital NHS Trust APPENDIX 2 Scheduled Care Group Surgery, Oncology and Haematology Centre 3rd Linac Business case Income 2013/ / / / /18 Total Forecasted Activity 1,000 1,000 1,100 1,190 4,290 Planning 37,479 37,479 41,227 44, ,787 Based on SC51Z Delivery 126, , , , ,548 Based on SC23Z Total Income 0 163, , , , ,335 Planning activity assumptions based on an average of 15.8 fractions per patient Pay Costs (Full Year Effect) Option / / / / /18 Total 2013/ / / / /18 Total WTE WTE WTE WTE WTE WTE Radiotherapy Staffing Band , , Band ,967 85, , Band ,301 70, , Band , , Band , , Sub Total , , , Medical Physics Staffing Band 8A 0 62,841 62, , Band 5 35,100 35,100 35, , Sub Total 35,100 97,941 97, , Total 35,100 97, , , , Option / / / / /18 Total 2013/ / / / /18 Total WTE WTE WTE WTE WTE WTE Radiotherapy Staffing Band , , Band ,302 72, , Band ,563 59, , Band , , Sub Total , , , Medical Physics Staffing Band 8A 0 52,852 52, , Band 5 29,521 29,521 29, , Sub Total 29,521 82,373 82, , Total 29,521 82, , , ,