WALSALL HEALTHCARE NHS TRUST

Transcription

1 WALSALL HEALTHCARE NHS TRUST Full Business Case for the Development of an Integrated Critical Care Unit at Walsall Manor Hospital DRAFT 1.5 January 2014 FBC ICCU

2 Version Control Table Version Issue Issued to Number Date /08/13 J Tunstall Initial Review Purpose /08/13 Project Steering Group Preparation for document review meeting 28/08/ /10/13 BCRG For Initial Review /11/13 ICCU Steering Group Review and sign off /01/14 BCRG Review and progression to PFIC and Trust Board /01/14 PFIC Review and progression to Trust Board FBC ICCU

3 Table of Contents 1 Executive Summary INTRODUCTION LOCAL AND NATIONAL CONTEXT Trust Integrated Business Plan DRIVERS FOR CHANGE, PROJECT OBJECTIVES AND BENEFITS Vision for Critical Care Drivers for Change Project Objectives ACTIVITY & CAPACITY Summary of Planning Assumptions ICCU Activity and Capacity Requirements THE PROPOSED SCHEME The Integrated Critical Care Unit Enabling Schemes Equipment Strategy Key Milestones and Construction Programme Benefits of the Proposal WORKFORCE PLAN TO SUPPORT THE DEVELOPMENT Key Skills Assumptions Nursing Workforce profiles April February Medical Staffing Model FINANCIAL ASPECTS OF THE PROPOSAL AND AFFORDABILITY Capital Costs Revenue Impact Affordability KEY RISKS AND APPROACH TO RISK MANAGEMENT Risk Register PROJECT MANAGEMENT AND BENEFITS REALISATION REQUEST FOR APPROVAL Introduction BACKGROUND Clinical Services Trust Vision and Strategic Objectives PROJECT OBJECTIVES SCOPE OF THE FULL BUSINESS CASE TIMETABLE FOR THE DEVELOPMENT Development of the Project and Procurement and Approvals Timetable Expression of Interest, Outline Business Case and Full Business Case Project Construction Programme LINKAGES WITH OTHER SCHEMES STAKEHOLDER INVOLVEMENT AND SUPPORT STRUCTURE OF THE FULL BUSINESS CASE SUBMISSION Strategic Context PLANNING HEALTHCARE IN WALSALL AND THE SURROUNDING AREAS NHS Walsall Commissioning Intentions Impact of Proposals For the Future of Mid Staffordshire NHS Foundation Trust Fit with National Priorities Summary of the Trust s Delivery Against National Policy/Quality Requirements FBC ICCU

4 3.2 TRUST PERFORMANCE Activity Levels Income and Expenditure Profile THE CRITICAL CARE DIRECTORATE Current Service Provision Workforce Profile Activity Levels Income and Expenditure Profile CAPACITY MODELLING ACROSS THE TRUST SUPPORTING STRATEGIES IM&T Critical Care Outreach THE TRUST S ESTATES STRATEGY CONSULTATION WITH THE LOCAL AUTHORITY HEALTH OVERVIEW AND SCRUTINY COMMITTEE Vision for the Future, Key Planning Assumptions and Project Scope VISION FOR CRITICAL CARE DRIVERS FOR CHANGE Compliance with National Standards Quality of the existing environment Management of patients in an appropriate care environment Flexibility of resources and capacity Change in the service model KEY PLANNING ASSUMPTIONS PROJECTED ACTIVITY AND CAPACITY REQUIREMENTS Trust Activity and Income Projections Critical Care Activity Critical Care Capacity Modelling The Impact of Mid Staffordshire NHS Foundation NHS Trust Review of the Outline Business Case INTRODUCTION IMPACT OF MID STAFFORDSHIRE HOSPITAL NHS FOUNDATION TRUST Proposed Solution Cost Implications OPTION APPRAISAL Review of Options Scores Financial, Economic and Cost Benefit Appraisal Revenue Budgets Capital Costs Economic Analysis Option Risks Conclusion of the Financial and Economic Analysis Combined Financial and Non-Financial Appraisal IMPACT ON OPTIONS OF MID STAFFORDSHIRE NHS FOUNDATION TRUST... ERROR! BOOKMARK NOT DEFINED. 5.5 SCHEME IMPLEMENTATION AND PROJECT PLAN Workforce Planning TRUST HUMAN RESOURCES STRATEGY ICCU REDEVELOPMENT PROJECT WORKFORCE PLAN Key Workforce Planning Objectives and Assumptions Key Skills Assumptions Adjustments since Outline Business Case Workforce profiles April February FBC ICCU

5 6.3 WORKFORCE PROJECT MIGRATION PLAN Effective change management Implementation Plan CONSULTATION AND ENGAGEMENT The Proposed ICCU Solution THE FUNCTIONAL CONTENT DESIGN SUMMARY Design Context Design Layout External Design Layout Internal Design Development OBC FBC Planning Statement BREEAM and AEDET Assessments Effective change management ENABLING SCHEMES SCHEME IMPACT CONSTRUCTION PROGRAMME OPERATIONAL POLICIES AND SERVICE IMPROVEMENTS Operational Policies Implementation & Embedding EQUIPMENT Vision Equipment Planning Equipment Project Timetable Installation of Commissioning of Equipment PROCUREMENT PROCESS CAPITAL COSTS FUTURE FLEXIBILITY KEY MILESTONES OF THE PROPOSED SOLUTION MATCH TO KEY BENEFITS AND PROJECTS OBJECTIVES Risk RISK METHODOLOGY KEY RISK AREAS RISK ASSESSMENT AND QUANTIFICATION RISK MANAGEMENT Financial Appraisal and Affordability INTRODUCTION CHANGES IN REVENUE POSITION CAPITAL AFFORDABILITY OVERALL CONCLUSION Project Management INTRODUCTION PROJECT ORGANISATION, STRUCTURE AND OBJECTIVES Project Manager Project Documentation CHANGE MANAGEMENT PROCESS PROJECT CLOSEDOWN Benefits Realisation and Post Project Evaluation BENEFITS REALISATION PLAN FRAMEWORK FOR THE POST PROJECT EVALUATION FBC ICCU

6 Evaluation of the Project - During Construction Evaluation of the Project in Use Shortly after Opening Evaluation of the Project - Once the Facility is Well Established Management of the Evaluation Process and Resources to deliver Conclusion and Request for Approval FBC ICCU

7 List of Tables Table 1-1: Activity Trends... 9 Table 1-2: Critical Care Activity Trends Table 1-3: Fit of the Business Case Proposals with National and Local Priorities Table 1-4: Projected Critical Care Bed Days Table 1-5: Projected Activity and Capacity including Mid Staffordshire Impact Table 1-6: Additional Departmental Moves Table 1-7: Equipment Project Timetable Table 1-8: Project Milestones Table 1-9: Construction Programme Milestones Table 1-10: Match of Proposed Solution to Key Benefits and Objectives Table 1-11: Nursing Workforce- Staffing Model Table 1-12: Capital Cost Summary Table 1-13: Comparison of revenue costs from OBC to FBC Table 1-14: Breakdown of Capital Charges Table 1-15: Summary Capital Programme Table 1-16: Capital Funding Cashflow Summary Table 2-1: Clinical Services Structure at Walsall Healthcare NHS Trust Table 2-2: Key Milestones for Approval Table 2-3: Construction Programme Table 3-1: Fit of the Business Case Proposals with National NHSE Priorities Table 3-2: Performance Against Key National Priorities Table 3-3: Trust Activity Trends Table 3-4: Planned Activity for 2013/ Table 3-5: Activity by Commissioner in 2013/14 (Plan) Table 3-6: Contract Value by Commissioner 2013/ Table 3-7: Historic Expenditure Profile & Financial Performance for the Trust Services Table 3-8: Current Nurse Staffing Profile- Combined ITU/HDU Table 3-9: Current Medical Staff Cover Table 3-10: Critical care Bed days by Specialty and Care Level Table 3-11: Expenditure Profile 2012/13 and 2013/14 Plan Table 3-12: Income Profile Table 4-1: Acuity Levels on HDU Table 4-2: Activity growth/casemix by point of delivery Table 4-3: Impact on Income Table 4-4: Projected Critical Care Bed Days Table 4-5: Projected Activity and Capacity including Mid Staffordshire Impact Table 5-1: Benefits Criteria and Definitions Table 5-2: Weighted Scores Table 5-3: Revenue Implications Table 5-4: Capital costs for short-listed options Table 5-5: Equivalent capital costs for the GEM Table 5-6: Option Risks Table 5-7: Evaluation of the Financial and Economic Analysis Table 5-8: Summary of Financial and Non-Financial Appraisals Table 5-9: Enabling works to support ICCU reconfiguration Table 5-10: Project Timetable - Key Milestones at OBC Table 6-1: Nursing Workforce Adjustments Table 6-2: Projected Workforce Profile for ICCU Table 7-1: Additional departmental moves Table 7-2: Equipment Project Timetable Table 7-3: Key Milestones from the Construction Programme Table 7-4: Match of Proposed Solution to Key Benefits and Objectives Table 9-1: Comparison of revenue costs from OBC to FBC FBC ICCU

8 Table 9-2: Breakdown of Capital Charges Table 9-3: Phasing of increased revenue costs Table 9-4: Forecast Capital Charges Table 9-5: 5 Year Income and Expenditure Forecast Table 9-6: Capital Cost Summary Table 9-7: Summary Capital Programme Table 9-8: Capital Funding Cashflow Summary List of Figures Figure 1-1: Image of Single Room Figure 1-2: View into the Unit Figure 1-3: Project Management Structure Figure 2-1: Trust Strategic Objectives Figure 2-2: Year of Integration Model Figure 3-1: Development Control Plan Figure 7-1: Proposed Developed Location- West Wing Figure 7-2: Proposed Location on Main Hospital Site Figure 7-3: Single Bed Bay View Figure 7-4: View into the Unit Figure 8-1: Risk Assessment Methodology Figure 10-1: Project Management Structure FBC ICCU

9 1 Executive Summary 1.1 Introduction On 1 st April 2011, Walsall Community Health and Walsall Hospitals Trust became an integrated organisation called Walsall Healthcare NHS Trust, which concluded the outcome of local Transforming Community Services organisational discussions. The Trust is the provider of local general hospital and community services. This has facilitated an increasing number of integrated care pathways targeted to support the key needs of acute illness, the full range of long term conditions and increasing elderly population. The activity profile and plan for the Trust for the period 2009/10 to 2013/14 is summarised in the table below. Table 1-1: Activity Trends Activity Type 2009/ / / / /14 Plan Elective Spells 28,796 28,939 29,597 27,605 27,389 Non Elective Spells Outpatient Attendances A&E Attendances Critical Care Bed Days Community Face to Face Contacts Community Clinic Contacts Lifestyle Services Contacts 27,184 28,181 28,634 31,970 30, , , , , ,823 73,059 74,689 74,025 74,552 77,634 8,968 9,513 8,868 10, , , , , ,698 99, ,190 99,703 99,341 95,130-42,344 49,760 57,392 48,760 44,550 The Trust operates Critical Care services in line with the standards issued by the Intensive Care Society and clearly differentiates between the different levels of care as defined by the society. Level 3- Intensive Care Level 2- High Dependency Care The service currently operates from two physically separate units operating on a funded basis of: Level 3-5 beds Level 2-8 beds FBC ICCU

10 Since submission of the Outline Business Case occupancy on the units has continued to operate at a very high level with ITU experiencing 58% of shifts with 6 or more patients. These beds have continued to operate although not fully funded. The total overspending at Month 7 standing at 94k. The combined occupancy across the two units currently averages 100.7%. Table 1-2: Critical Care Activity Trends 2010/ / /13 Specialty Level 3 Level 2 Level 3 Level 2 Level 3 Level 2 Total bed days Combined total Funded Bed days Local and National Context The proposals detailed in this case and specifically the preferred solution described in Section 7 will support the Trust in progressing the delivery of a number of national priorities and specific examples are provided in Table 1-3 below. Table 1-3: Fit of the Business Case Proposals with National and Local Priorities Policy The Outcome Framework 2013/14 and NHS Mandate How the case addresses the priorities Ensuring patients are managed in an appropriate environment to improve patient safety and outcomes. Minimise the transfer/ movement of patients by caring for critically ill patients in a single location. Improve staffing ratios and effective use of staff through single location. Mortality Review WMQRS Compliance- the review team highlighted that the rotation of staff was inappropriate. The operation of the single unit and single nursing workforce will avoid the requirement for rotation and therefore achieve compliance with this standard. Staffing- the ability to flex nursing staff to reflect actual acuity will ensure that nurse staffing resources are used effectively. Under the current staffing arrangements the beds are supported to their designation not their acuity of occupancy. Shift Co-ordinator- this supernumerary senior nurse will support all areas of the unit, providing support for the management of admissions. Under the current arrangement the shift co-ordinator also manages patient care and therefore in the event of support required the care of their patient is affected. Medical Cover- there will be increased access to senior medical staff advice and provision in a single location will allow quicker response times. 1 Please note this reflects the leap year in 2012 FBC ICCU

11 Policy Treating Patients and Service Users with Respect, Dignity and compassion How the case addresses the priorities Reduced delays for transfers from A&E patients are currently stabilised in A&E but encounter delays in transfer during peak occupancy- this will be reduced with the increased capacity and therefore transfer can be affected at the point when it is clinically safe to do so. Reduced delayed transfers from Wards when early warning signifies requirement. Ability to separate male and female patients and therefore address risks of Delivering Single Sex Accommodation (DSSA) compliance. Ensure patients treated in the most appropriate environment including single rooms if clinically or culturally required. Improves staff working environment; frees time to care appropriately. Improves carer facilities; ensures improved holistic support. Foundation Trust Trust Estates Strategy Critical Care is a vital clinical function which contributes to the high quality treatment outcomes of patients across a wide range of specialties. In terms of the priority to ensure every Trust is or is part of a Foundation organisation this development underpins the position of the Trust in the delivery of robust, viable clinical services in a manner which is fit for the future. The Trust has undergone significant redevelopment in the recent past with the construction of new PFI funded facilities to accommodate much of the Women and Children s Services and elective day and inpatient care. It has always been the vision of the Trust to undertake a second phase of development to embrace improvements necessary in acute/emergency care the development of an integrated Critical Care Function is a key component of that vision and the proposed solution outlined in this case will allow the Trust to pursue required improvements with the A&E Department by integrating the space occupied by HDU with the A&E Department thus release of clinical space adjacent to the majors section of A&E Trust Integrated Business Plan In its Integrated Business Plan (IBP) the Trust has articulated a number of strategic goals to support delivery of the Trust vision and values. The establishment of an Integrated Critical Care Unit will ensure that in terms of the key service these goals are achieved and will also contribute significantly to the ability of the other clinical services to individually and collectively deliver improvements in patient care and overall performance. 1.3 Drivers for Change, Project Objectives and Benefits Vision for Critical Care The establishment of a single Integrated Critical Care facility has been one of the key visions for the future of this service for many years. The provision of a single integrated facility would support more efficient utilisation of resources and step up/down thus supporting increased throughout as patients would move between Level 2 and Level 3 care as their condition required within a single clinical area. The FBC ICCU

12 unit will be designed to ensure that all of the beds were capable of accommodating a Level 3 patient but the staffing levels and equipment provision would reflect the anticipated ratios of Level 2 and Level 3 patients and peaks and troughs of activity. The facilities would also provide at least 50% of single rooms. The requirement for full isolation facilities has also been considered Drivers for Change The Critical Care Service has sought to pursue this radical change in its structure and service pattern as a consequence of a number of physical, safety and organisational drivers for change: Compliance with National Standards; Quality of the existing environment within both ITU and HDU; Management of patients in an appropriate care setting; Flexibility of resources and Capacity; and, Change/improvement in the service model Project Objectives The key priorities for the delivery of a modern service, which meets the changing needs of the patients and the clinical users of the Service. Optimise Critical Care Unit bed utilisation- a key benefit of an integrated unit is the ability to flex bed utilisation between Level 2 and Level 3, and allow the team to step up or step down immediately a patient s condition changes rather than waiting for an appropriate bed to be available in the correct unit; Improved patient safety- it is essential that there are sufficient critical care facilities accessible for Level 3 and Level 2 patients within a clinically safe and appropriately staffed environment; Improved patient outcomes through improved access, reduced requirement for transfers and consistent treatment protocols; Reduction in the number of cancelled admissions and operations due to a lack of Critical Care Beds; Avoid the need for patient transfer to an alternative hospital for non clinical reasons; Improved resource utilisation- to allow more effective utilisation of the medical team and will avoid duplication of key nursing and support roles; Improved patient/carer experience- the treatment areas need to be in line with national guidance and be supported by the appropriate support and infrastructure. The appropriate relatives support facilities should also be available for all patients; Improved access to Critical Care- to allow the unit to operate at a lower occupancy level (currently operating at 110%-125% within ITU across Level 2 and Level 3) which will avoid delays in access to beds, avoid cancellation of elective cases and support repatriation of inter hospital transfers; Improved access to appropriate facilities for management of immunocompromised or infected patients- within the existing units there is only 1 single room available to care for patients who require isolation or barrier nursing and this creates a significant risk to patients; FBC ICCU

13 Achieve compliance with key environmental standards- this reflects space, staffing and general care protocols; Improved working environment/arrangements for staff and therefore improved staff recruitment and retention; Improved and more efficient use of clinical supplies; will not need changing when patient steps up or down ; Provision of sufficient capacity to support any further increase in patient activity as a consequence of local service reconfiguration following on from the Francis Report: and, Improved throughput and access for the wider Trust clinical services- including time from referral to ICCU for patients on inpatient wards. It should be highlighted that a key objective has been added since submission of the Outline Business Case which recognises the potential impact on the Trust and its services of the proposed dissolution of Mid Staffordshire Hospital NHS Foundation Trust as recommended by the Special Administrator. 1.4 Activity & Capacity In developing the proposals for an integrated unit, the team have been mindful of the need to ensure that the facility is capable of accommodating safely the number of patients requiring Level 3 and Level 2 care including potential growth of activity should changes at Stafford Hospital be realised Summary of Planning Assumptions In terms of patient flows the significant clinical adjacencies are to the operating theatres, specialist imaging and A&E, and ideally the Unit would be on the same level in the hospital as these service areas. The key planning assumptions which have been agreed with the project team and which have been used to develop the options for appraisal are: Only Level 3 and Level 2 patients to be cared for within the Unit; An occupancy rate of 80%; Patients requiring NIV or CPAP to be managed within Respiratory Care unless clinically requiring the support of the ICCU; Adjacency to major clinical referring units; Beds to be managed flexibly based on the balance of Level 3 & Level 2 care; 50% of beds to be provided in single rooms with appropriate ventilation and a minimum of 2 isolation rooms with full gowning facilities; Maximum observation of all beds by clinical staff; and, No significant growth in overall activity with the exception of potential impact of any changes at Stafford. FBC ICCU

14 1.4.2 ICCU Activity and Capacity Requirements Having modelled the above changes on the Critical Care activity, and applied the planning assumptions for capacity calculation as summarised in Section 4.2 Table 1-4: Projected Critical Care Bed Days Specialty 2011/ /15 Level 3 Level 2 Level 3 Level 2 ENT General Medicine General Surgery Gynaecology Haematology 3 9 Included in Other Obstetrics Orthopaedics & Trauma Urology Other Total bed days Mid Staffs Impact N/A N/A 592 Combined total Table 1-5: Projected Activity and Capacity including Mid Staffordshire Impact Level of Care Projected Bed Days Occupancy Rate Number of beds required Level % 8.2 Level 2 (excl NIV) % 7.8 Mid Staffs Impact % 2.0 Total The Proposed Scheme The Integrated Critical Care Unit The proposed solution sees the establishment of an Integrated Critical Care Unit in the former West Wing Main Entrance. The current service delivery for HDU is an 8 bedded facility located within the West Wing adjacent to the A&E Department. Whilst the intention of having two 4 bedded areas is to support single sex areas, from time to time within a 4 bedded area will be mixed sex. This Full Business Case is written on the basis that the built solution will be for 18 beds however the unit will be equipped initially for 16 beds from point of opening. Expansion to 18 beds will only occur following Board Approval to be increasing workforce/staffing should the demand require it but it was felt important when planning this unit to future proof its functionality. 2 Staffing and operation of additional beds will be subject to a separate case and will only occur should the additional activity materialise FBC ICCU

15 The ICCU solution provides an 18 bedded solution with an overall footprint of 1360m 2. This area is in part a refurbishment of the former Main Entrance, but is also a significant new build extension which necessitates the demolition of the West Wing entrance canopy and uses part of the former ambulance slip road. Within the functional layout there are 9 single bed bays 2 of which will be provided as isolation single en-suite rooms. In addition there are 9 open plan bays, all approximately 20m 2. The unit will be accessed from the Hospital Street Corridor at Level 2, with a discreet access for patients and staff which will have access control. There is a further access/egress on Hospital Street Corridor intended for fire purposes only. In addition to bedded areas the accommodation includes 4 clean and dirty utility rooms, equipment and storage facilities, doctors/matron offices as well as patient and relative facilities; including interview rooms, sitting rooms and assisted toilets. A new link corridor is formed to support access and egress to/from the switchboard and the Hospital Street Corridor Since the submission of the Outline Business Case, the design of the ICCU has changed to reflect the need for two additional beds as the projected impact of any changes at Stafford Hospital. Inevitably this has meant a growth in the building footprint and therefore there is a cost increase in capital terms due to this factor. The key driver has been to support flexibility in the environmental solution providing appropriate space, medical equipment and medical gases etc to support patients throughout their stay in the unit. The design principles that underlie the arrangement of the accommodation of the ICCU is that there is a fully flexible working environment across the department to support the clinical stay of patients. Figure 1-1: Image of Single Room Figure 1-2: View into the Unit FBC ICCU

16 1.5.2 Enabling Schemes In order to support the above development, the former main entrance area needs to be completely vacated which necessitates a series of enabling moves. The key areas to note include are: Trauma and Orthopaedics Consultants and Secretaries to move to Area Route 109 in the Outpatient and Day Case Centre; Rheumatology Consultants and Secretaries to move to the same location; League of Friends Shop to move to an area adjacent to the Inpatient Entrance on Level 1; Post Room to move opposite to General Office; and, To enable the above to vacate the area, other departments across the main hospital site have had to relocate. These are tabled below: Table 1-6: Additional Departmental Moves Department Relocating Area From New location Dieticians Office Room Town Wharf Trust Management Admin Team Office Route 109 Office Room Tissue Viability Office West Wing Level 01 Town Wharf Equipment Strategy In view of the importance of this issue, the Project Steering Group put in place a structure to proactively manage this at an early stage via a Work Stream Project Group. This includes Clinical Leads for the unit as well as representatives of Estates and Facilities Division and the Design Team. The approach to the provision of the equipment (technical/ clinical and furniture) for the new development has sought to utilise appropriate funding streams including: Use of the Trusts equipment Replacement Programme; and, Equipment allocation within the Capital Costs. FBC ICCU

17 Through planning and reviewing, the Equipment Work Stream has been able to establish a project timetable for the purchase, installation and commissioning of equipment. This is detailed in Table 1-7. Table 1-7: Equipment Project Timetable Activity Milestones and Key Dates Invitation to Tender issued September 2013 Evaluation of Tenders and site visits October January 2014 Selection of preferred partner February 2014 Contract Award March 2014 Equipment design / lead time March- May 2014 Installation To accord with Construction programme Commissioning To accord with Construction programme Procurement Process During the preparation of the Outline Business Case the Trust sought legal advice in terms o the position of the PFI Agreement and its impact on developments within the retained estate for which the Trust retained the lifecycle risk. The advice received and included within the OBC confirmed that the contractual agreement did require the procurement of such schemes to be through Walsall Hospital Company. The Trust has therefore worked closely with WHC to undertake the final design of the Unit and the co-ordination of the market testing of the key work packages which underpin the construction programme. On completion of the market test an initial cost was provided and following extensive discussion and review by the Trust Cost Advisor, Walsall Hospital Company were asked to submit a Best and Final Offer (BAFO). This was received in October The final submission has been tested again by the cost advisor and has been subject to a joint value engineering review. The Cost Advisor has provided a detailed report of the cost review and has confirmed that the level of market testing is sufficiently robust to provide assurance that the costs are valid and that in overall terms the offer made by WHC demonstrates a Value for Money solution Key Milestones and Construction Programme A key objective for the project team has been to ensure that any critical path issues are identified and managed whilst also looking to deliver the new integrated service as soon as practical. Table 1-8: Project Milestones Milestone Outline Business Case Submitted December 2012 Outline Business Case Approved by NTDA [TBC] Market Testing for Construction works through Walsall Hospital Company September 2013 Date FBC ICCU

18 Milestone Planning Application Approved October 2013 Full Business Case Approved by Trust Board January 2014 Full Business Case Submitted to NTDA February 2014 Full Business Case Approved by NTDA April 2014 Start on Site May 2014 Construction Completion July 2015 Service Transfer and commencement August 2015 A detailed construction programme has been prepared showing all the key activities. Key milestones from this program have been extracted and detailed below in Table 1-9. Table 1-9: Construction Programme Milestones Key Milestone Start Finish Instruction To Proceed 01/01/ /01/2014 League of Friends Decanted 10/03/ /03/2014 Completion of Relocations from construction area 10/03/2014 Vacant Possession to the contractor 28/03/ /03/2015 Upgrade electrical supply 03/11/ /11/2014 Upgrade generator available 03/11/ /11/2014 Medical Gas connecting 06/10/ /10/2014 Commence electrical integrated system 13/04/ /04/2015 Fit out Main Area 16/06/ /04/2015 Works within existing Plant Rooms 16/04/ /10/2014 Testing & Commissioning 19/03/ /07/2015 Client witness, IC and Training 09/05/ /07/2015 Handover 15/07/ /07/2015 Occupation 01/08/ /08/2015 Date Benefits of the Proposal There are a number of key objectives which drive the development of the ICCU and defined benefits which it is anticipated will be delivered. The match of the proposed solution to these is summarised in the following table. Table 1-10: Match of Proposed Solution to Key Benefits and Objectives Objective Integration of the ITU and HDU facilities within a single area Key benefits Economies of scale Increased capacity for the future Improved layout and work flows Demonstration of improved efficiencies Improved accreditation compliance WMQRS Reduce wastage Value added tasks maximised Introduce new service models and operational procedures Ability to future proof the Fit achieved by the proposed solution Single location and design solution provides combined integrated critical care unit Co-location will allow maximum benefit from skill mix adjustments and overall utilisation Use of combined practices will maximise process redesign benefits Space within the new facility area provides capacity for the future expansion if additional capacity is needed FBC ICCU

19 Objective Re-profiling of workforce to reflect skills required for the future Establishment of service/ facilities which can respond flexibility to internal and external changes Maximise contribution/benefit of the service to the patient experience Key benefits directorate with additional space for bed capacity Improved Quality Overall improved quality of the patient experience Value added tasks maximised Introduce new service models to operation procedure Ability to future proof the department Introduce new service models Ability to future proof the department Improved flow through the system Enhanced patient care Improved patient flows Reduce length of stay Greater productivity of staff Greater productivity of equipment due to reduced downtime Staff turnover/recruitment improvement Ensure value added tasks maximised Provision of a safe/secure working environment Fit achieved by the proposed solution Co-location of support accommodation and overnight stay facilities to support improved patient care Process redesign and colocation of services will support improved care Co-location will support appropriate skill mix to ensure appropriate supervision whilst ensuring staff of the correct grade are allocated to appropriate tasks throughout 24/7 The workforce reprofiling will be supported by staff redevelopment programmes including succession planning. New service models within single integrated unit will reduce duplication and eliminate non value added tasks Space within the new facility area provides capacity for the future expansion if additional capacity is needed Co-location of support accommodation and overnight stay facilities to support improved patient care Provision of Pneumatic Tube with dedicated link to Pathology Process redesign and colocation Improved operating environment for staff Process redesign and colocation of service/staff will reduce duplication and eliminate non-value added tasks Co-location will support appropriate skill mix to ensure appropriate supervision whilst ensuring staff of the correct grade are allocated to appropriate tasks throughout 24/7 The facilities provided will be within a purpose designed building to current standards thus providing a much improved physical environment accounting for security, training and development and general welfare. Development of energy efficient Contribution to reduction in Achievement of 55GJ/100m 3 FBC ICCU

20 buildings Objective Key benefits overall carbon footprint Contribution to achievement of the DH Estates energy targets Site Rationalisation Elimination of building in poor state of repair Achievement of site Master plan Flexibility for phased site redevelopment Fit achieved by the proposed solution energy rating Adoption of sustainable design and construction methodologies Achievement of BREEAM Very Good Removal of buildings below condition B and require major investment to achieve condition B Reduction in Backlog Maintenance Improved energy efficiency/carbon reduction Improved functional stability HDU space when available to support the A&E Redevelopment 1.6 Workforce Plan to support the development In developing the integrated service proposals the key assumptions made by the team included: There will be a combined unit with appropriate adjacencies; The unit will comprise of 16 beds; Nurse to patient ratios of 1:2 Level 2 patients, 1:1 Level 3 patients in line with the general principles of Critical Care Nurses, Department of Health, Intensive Care Society and RCN; The unit will be designated into two zones for the purposes of patient management and supervision of care; Level 1 patients should be transferred out of critical care within 4 hours; There will be no paediatric admissions; Each shift should have a supernumerary shift leader (Band 6 or 7) in line with the general principles of the RCN and Midlands Critical Care Networks Quality Standards; The shift leader will be supported by one band 6 and one band 5 nurse of differing levels of experience; Unit layout will comprise of 9 isolation cubicles and a 9 bedded open bay. These areas will be separated into 2 zones and will require a team of nurses which will be determined by the number and care level of beds included in the zone; There will be 2 critically care trained nurses supporting the supernumerary shift leader who will be team leaders for the two zones; The unit will adopt the key service characteristics outlined in Comprehensive Critical Care (DH 2000); The unit will play an active role in the teaching and training of Foundation doctors and medical students in the principles of identification and treatment of the critically ill patient as well as training specialist trainees in Intensive Care Medicine; The current level of medical workforce staffing can support the increase in bed number provided that they are in a single location; FBC ICCU

21 The Medical Workforce, which will support the Integrated Critical Care Unit, will be managed from within the wider Anaesthetic Department, however there are dedicated posts identified for each shift to directly support the Critical Care beds; Nursing workforce numbers have been benchmarked against both local Trusts which has confirmed that the proposed number of staff per shift is in line with recognised criteria and matches the numbers of surrounding Trusts, and, If the opening of extra beds is required (i.e.14 and above) and occupancy rises above the 80% average extra staffing could be supplied by the Trust s Critical Care bank or a separate business case will be developed to gain extra establishment required for each bed utilised. Nursing workforce numbers have been benchmarked against both local Trusts and peer groups Trusts adopted by the Trust when reviewing Dr Foster data Key Skills Assumptions At least 64% of current staff have the Critical Care Course (BSc Nursing Studies); At least 60% of current staff have the Mentorship Course and all qualified staff will have the opportunity to apply to complete this; and, A Band 7 Professional Development Nurse will support the education and development of trained staff and nurses in Critical Care Nursing Workforce profiles April February 2015 Based on the above assumptions, projected activity and case mix based on current experience, occupancy of 80% and skill mix requirements the establishment for the Integrated Unit is calculated to be The derived workforce is summarised in Table 1-11 below. Table 1-11: Nursing Workforce- Staffing Model Budget Budget WTE Nursing budget 2011/12 (as per OBC) ,571,860 Increase 2011/12 to 2012/13-16,500 Nursing budget 2012/ ,588,360 Increase 2012/32 to 2013/ ,988 Nursing budget 2013/ ,787,348 Savings achieved by integrating 2 units (3.58) (112,382) Budget for an Integrated Unit of 13 beds ,674,966 Increase to reflect new model, acuity, occupancy and activity ,807 Budget for the proposed Integrated Unit ,803,773 Net Change over 2013/14 Budget (0.23) 16,425 FBC ICCU

22 1.6.3 Medical Staffing Model There will be no change to the medical staffing workforce as a consequence of this development. 1.7 Financial Aspects of the Proposal and Affordability The original OBC submitted December 2012 identified a requirement for the combined ICU/HDU of 16 beds. This was later reviewed given the implications of Mid Staffordshire NHS Foundation Trust also to allow for future growth and was revised to 18 beds. An addendum was therefore submitted outlining the revised proposal and increased capital cost for the 2 additional beds. The following tables and narrative will provide a comparison of capital and revenue between the OBC and this FBC position Capital Costs The capital cost of the scheme has increased since submission of the original OBC. Although the expansion from 16 to 18 beds has had an impact on the costs, the additional works required to facilitate construction and provide the required infrastructure have resulted in a significant increase beyond the anticipated impact of the capacity changes. The additional works include: Substantially more complicated and extensive foundations following site investigations and surveys, this includes more extensive piling that originally envisaged. Replacing all floor screed within the refurbishment area and increasing thickness of screed to new build area. Skanska has included need floor screed to eliminate risk of different floor levels when walls are demolished within the existing West Wing. Increase in steelwork requirement to the frame following design. Roof scope more extensive than envisaged. Increase in the amount of glazed screens to internal partitions. Increase in internal door costs with fully encapsulated doors and associated screens. Increase in anticipated mechanical and electrical installation costs. Substantially more complicated and extensive drainage requirements following site investigations and surveys. Increase in external works to the area outside the unit. Increase in grouting of disused mineshafts. The table below provides a summary of changes from the original OBC 16 bed submission, the OBC revision to 18 beds and the FBC. It shows that costs have increased by circa 1.870m to 8.163m largely the result of increased works ( 1.110m), fees ( 0.332m), VAT (0.123m) and inflation ( 0.479m), less reduction in contingency ( 0.165m) FBC ICCU

23 Table 1-12: Capital Cost Summary OBC - 16 beds OBC - 18 beds FBC Works Costs , Non works costs Sub-total , Fees Equipment Contingency (including optimism bias) Non reclaimable VAT Approval Total , Inflation Outturn Total ,293 8, Revenue Impact However, it remains that staffing for the new unit would be as the 16 beds option, until increased demand and associated income warranted utilising increased capacity. The table below updates this addendum showing the original revenue estimated for 16 beds and the revised non pay costs based on the 18 bed proposal. Table 1-13: Comparison of revenue costs from OBC to FBC OBC 000 FBC 000 Explanation Pay - Direct Clinical The OBC identified an investment required in nurse staffing of 224k. However, since this submission there has been additional funding in nursing. The FBC therefore shows an investment of only 16k is required on current base budgets. Non Pay Soft Facilities Management Increase in costs of 3k associated with department transfers to accommodate the newly combined facility. Hard Facilities Management Confirmation of costs from PFI partner following increased costs for capital build Capital Charges Forecast using OBC methodology based on revised capital cost Sub Total Non Pay TOTAL There has been investment in nurse staffing since submission of the OBC and therefore the original estimate of increased cost is substantially reduced to 16k. The estimated increase in capital charge is calculated using the same methodology as OBC but reflecting the revised total of capital expenditure. The table below shows the components of the capital charge calculation. FBC ICCU

24 Table 1-14: Breakdown of Capital Charges Capital Cost OBC FBC Buildings Depreciation Equipment Depreciation Rate of Return Total Affordability The following Table shows a revised 5 year capital programme. The table is updated to include the forecast outturn of our 13/14 plan, the revised cost for the ICCU development and our intended A&E upgrade but also to show our bid for capital funds following the Mid Staffordshire Hospitals enquiry and the impact of patient activity referring to this Trust. As regards the latter, the assumption is an additional 14.0m capital for to assist with increased capacity by adding 2 additional wards, additional Maternity beds and improved Neo-natal facilities. For the ICCU development it is envisaged a start on site April 2014 with completion August Estimated expenditure in 2014 is fees and preliminary site preparation. Table 1-15: Summary Capital Programme 5 Year Capital Programme 13/14 14/15 15/16 16/17 17/18 18/ HSDU upgrade Maintenance & improvements A&E improvement ICCU West Wing improvement Replacement Generator 1000 Medical Equipment Information Technology Other Decant Ward New Wards 6000 Maternity theatre & delivery rooms Neo natal 2000 Office Accommodation 500 Grand Total Capital Expenditure (A) Table 1-16 below provides an updated forecast capital cashflow, from our LTFM to reflect 2013/14 forecast outturn and the impact of revisions to the capital programme. It shows our current cashholding and forecast surpluses thus demonstrating the overall affordability of the current 5 year capital programme and therefore the ICCU development Table 1-16: Capital Funding Cashflow Summary FBC ICCU

25 Capital Funding Cash flow 13/14 14/15 15/16 16/17 17/18 18/ Depreciation I&E Surplus PFI Loan Repayment Sale of Assets 310 Funding in respect of Mid Staffs Movement in Working Balances Cash generated in year (B) In year cash movement (A-B) Cash balance b/wd Closing Cash Balance Both the revenue and capital implications of the proposed investment are reflected in the Trust s Long Term Financial Model, updated for the increased capital costs and revised forecast revenue outturn. The overall LTFM delivers the required financial objectives for the Trust and therefore the scheme is considered affordable in the Trust s long term strategic plan. 1.8 Changes from the OBC As a result of the changes in both capital and revenue costs of the preferred option. The Trust has revisited the OBC option appraisal to ensure the preferred option at OBC is still valid. The results of the revised appraisal are as follows: FBC ICCU

26 Table 1-17 Summary of revised option appraisal Option 1 Option 7 Option 8 Total non financial scores (weighted) Total EAC ( 000) 5,904 5,752 5,616 Cost per benefit score Percentage score above preferred option 278% 110% 0% 1.9 Key Risks and Approach to Risk Management Risks to the Trust from the development can be categorised based on the standard categories for a major construction project: Design; Construction and development; Operating cost; Variability of revenue; Termination; Technology and obsolescence; Control; Residual value; and, Other project risks. This approach underpinned the completion of the costed Risk assessment Risk Register In line with Project Management Principles and Trust governance protocols a live risk register has been and will continue to be maintained for the Proposed Solution which includes all risks identified to date. The methodology used is in accordance with the Trust s governance structure for managing risk. This risk register identifies the following: Risk reference, description and category; Mitigation measures and current position; Risk rating in accordance with the Trust s Risk Categorisation Matrix (Probability and Impact leading to a red, amber, yellow and green rating); and, Risk lead/owner who has responsibility for monitoring, actively managing and mitigating the risk. The risk register will be reviewed on a monthly basis throughout the duration of the project by the Project Steering Group. Where risks potentially have an impact on the costs or delivery programme (time) for the Project, these have been assessed and informed the contingencies included within the capital costs. FBC ICCU

27 In terms of the current and future stages there are no areas of High Risk once mitigation measures are taken into account Project Management and Benefits Realisation Project Organisation within the Trust reflects ownership of the projects such as this at the highest level and draws not only upon the traditional roles associated with capital project management, but also upon representatives from across the Trust, to ensure that the wider business objectives of the organisation are met. The Trust has a successful history in the management and implementation of key projects and will ensure that appropriate project methodologies continue to underpin the management of the project. The proposed project structure is outlined in Figure 1-3 below and has been updated from the OBC to reflect the changing activities and outputs: Figure 1-3: Project Management Structure Trust Board Trust Management Board Estates Strategy Group Integrated Critical Care Unit Project Team Work Stream1 Equipment &IT Work Stream 2 Workforce issues including implementation of the Workforce plan recruitment Training and Communication Work Stream 3 Buildings Design, Construction & Commissioning including operational policies and procedures The objectives and benefits of the Project are set out in Sections 2.2 and 4.5 respectively. A benefits realisation plan was developed for the OBC and has been reviewed and updated to reflect changes in the operating environment of the NHS since 1 st April 2013 and the impact of Mid Staffordshire. The plan identifies, against each benefit: Who will have lead responsibility for ensuring the delivery of the benefit; Action to be taken to ensure the benefit is realised; The projected timescale for realisation of the benefit; and How the realisation of the benefit will be monitored and measured. FBC ICCU

28 Overall responsibility for ensuring that the benefits of the Project are achieved lies with the Trust Board, through the Trust Management Board. Where relevant, the performance measures identified within the benefits realisation plan will be incorporated within the relevant stage of the Post Project Evaluation plan (PPE). The PPE plan for the Integrated Critical Care Unit Project has been developed in accordance with the DH Practice Guide. The nature of this Project is such that the evaluation will follow the completion of all of the building works and the successful operation of the facilities for 2 years. This PPE Plan is based upon the four-stage model within the guidance and each stage will have both formative and summative elements within each stage: Stage 1- The scope and cost of the PPE plan; Stage 2- Evaluation of the construction phase; Stage 3- Initial operational evaluation at 6 months after commissioning; and, Stage 4- Follow up evaluation to assess longer term outcomes two years after the facility is commissioned. The PPE process which is perceived as an integral part of the Project Management process, will be led by the Director of Estates and Facilities. At each stage of the evaluation process, the Trust will be seeking to: Assess whether and how the objectives of the project are being met; Assess value for money; Assess whether the project is progressing according to plan identifying corrective actions if necessary; Identify and document lessons learned for others in the future; Take stock for the future, identifying appropriate next steps; Identify actions to consolidate current implementation; and Identify opportunities for improving current performance. The following sections outline the proposals for the evaluation process and objectives at each stage. In terms of assessment of the success criteria, the Trust proposes to incorporate the benefits realisation plan into this process as appropriate. On completion of the evaluation at each stage, a full report will be submitted to the Trust Management Board and Trust Board Request for Approval This FBC has outlined the strong clinical case for change and for the transformational investment in facilities for the delivery of Critical Care services for this Trust. The investment will act as a catalyst for the delivery of fundamental improvements in the way that the services are delivered and this will bring major benefits to patients in terms of quality and patient experience FBC ICCU

29 In completing this FBC, the Trust has completed a robust planning and appraisal exercise to establish a solution that provides all of the benefits identified whilst remaining affordable. The Business Case is supported fully by the Trust Board and local Clinical Commissioning Group. We commend this Full Business Case to you. FBC ICCU

30 2 Introduction 2.1 Background On 1 st April 2011, Walsall Community Health and Walsall Hospitals Trust became an integrated organisation called Walsall Healthcare NHS Trust, which concluded the outcome of local Transforming Community Services organisational discussions. The Trust is the provider of local general hospital and community services. It is doing this through an increasing number of integrated care pathways targeted to support the key needs of acute illness, the full range of long term conditions and increasing elderly population. This includes: Patients being included in the development of these pathways to ensure that they meet their needs. The Frail Elderly Pathway has demonstrated how, by inclusion of patient feedback the Trust has been able to develop a service, which is fit for purpose; Full consultant led, 24 hour accident and emergency service; Community based multidisciplinary services to support people to remain at home including rapid response and home based care; Intermediate care services in people own homes and in nursing homes; Full 24-hour consultant led obstetric service; Neonatal level 2 services with outreach services into the community; Full 24-hour consultant led provision of outpatient and in patients services for children; Community support for children with disabilities at home and in community settings; Universal Children s health services providing support to the families in Walsall i.e. health visiting and school nursing; Broad range of specialties for both emergency and elective care; and, Lifestyle management services Clinical Services The operational structure adopted by the Trust incorporates three Operational Divisions Table 2-1: Clinical Services Structure at Walsall Healthcare NHS Trust Divisions Care Group / Services Surgery General surgery, including bariatric and specialist weight management, colorectal surgery, breast surgery, oncoplasty, urology and community continence services and the associated specialty therapies. Musculoskeletal services, including trauma and orthopaedics, rheumatology, surgical podiatry and MSK community physiotherapy, planned physio and Orthopaedic Community Assessment Scheme (OCAS). Head and neck, including ENT, audiology, ophthalmology and orthoptics, maxillofacial, oral surgery and orthodontics. Theatres, critical care, anaesthetics, pain management and HSDU provision. Outpatient, cancer and support services including outpatient nursing, access and booking, health records, health centre and outpatient clerical and reception staff and cancer services. FBC ICCU

31 Divisions Medicine and Long Term Conditions Women, Children and Support Services Care Group / Services Emergency and Acute Care, including A&E, AMU and specialty therapies, short stay including elderly care pathways and ambulatory emergency care unit. Specialty medicine including endoscopy and gastroenterology, cardiology, medicine and specialty therapies. Long term conditions management across integrated pathways, including diabetes, respiratory, nephrology, neurology and specialist Parkinson s, MS and rehabilitation, dermatology, sexual health consultants, end of life care, district nurses, community matrons and expert patients. Elderly care, including fractured neck of femur pathway, intermediate care, rapid response services, inpatient care, stroke, falls and dementia services. Patient flow including the capacity management and integrated discharge team. Women s services, including obstetrics, gynaecology and sexual health services. Maternity services across community and acute including the midwifery led unit and breastfeeding. Children and family services, including acute and community paediatrics, hospital at home and community children s nursing and support to children with disabilities, transition services, Family Nurse Partnership, Looked After Children. Universal services for children including health visiting, school nursing, immunisation and vaccination. Adult and children s lifestyle management services including smoking, physical activity. Clinical support services including pathology, pharmacy, radiology and imaging, clinical measurement. Patient services including appliances, integrated equipment stores and wheelchairs Trust Vision and Strategic Objectives The Trust Board has set the vision and objectives for the new integrated organisation based on a number of elements which include: The assessment of benefits arising from the integration of community and acute services; The strategic consideration of the organisation s PEST and SWOT analyses; Discussions with key groups within the Trust; and, The outcome of strategic direction discussions included in our organisational development work programme For One and All: Improving Your Experience. The vision for the future of the organisation, derived from the elements listed above is expressed in the following statement: FBC ICCU First class integrated health services for the people we serve in the right place at the right time.

32 The strategic objectives underlying the vision are outlined in Figure 2-1 below, together with the ways in which we will go about achieving them. Figure 2-1: Trust Strategic Objectives The Trust has designated 2013/14 as its year of Integration and the figure below summarises the approach to achieving that element of the vision. FBC ICCU

33 Figure 2-2: Year of Integration Model Year of Integration Improving medical care across the whole organisation to safely shift care closer to home and increase patient flow UECIP Pathways Case management Productive Community Services Productive Care Closer to Home Improving surgical care to safely increase theatre throughput Timely and effective procedures Flexible and efficient scheduling Streamlined sessions Managing flow Productive Surgery Integration & Improvement Programme Productive Clinics Improving surgical care to safely increase clinic throughput Timely and effective appointments Flexible and efficient scheduling Streamlined clinics Effective discharging Managing DNAs Improving workforce management to reduce unnecessary costs Optimised capacity planning Managing vacancies Reducing premium costs Efficient Workforce Supporting Workstreams Enabling the organisation to more effectively improve Efficient Back-office Technology QIPP Improvement planning Improving back-office management to reduce unnecessary costs Lean services Partnerships and shared services Managing suppliers 2.2 Project Objectives In developing the vision for Critical Care Services it has been recognised that there are a number of key drivers for change. The team has been subject to internal assessment and service improvement input plus external scrutiny through the network and more recently the West Midlands Quality Review Service and have identified the key priorities for the delivery of a modern service, which meets the changing needs of the patients and the clinical users of the Service. Optimise Critical Care Unit bed utilisation- a key benefit of an integrated unit is the ability to flex bed utilisation between Level 2 and Level 3, and allow the team to step up or step down immediately a patient s condition changes rather than waiting for an appropriate bed to be available in the correct unit; Improved patient safety- it is essential that there are sufficient critical care facilities accessible for Level 3 and Level 2 patients within a clinically safe and appropriately staffed environment; Improved patient outcomes through improved access, reduced requirement for transfers and consistent treatment protocols; Reduction in the number of cancelled admissions and operations due to a lack of Critical Care Beds; Avoid the need for patient transfer to an alternative hospital for non clinical reasonsexpand; Improved resource utilisation- to allow more effective utilisation of the medical team and will avoid duplication of key nursing and support roles; FBC ICCU

34 Improved patient/carer experience- the treatment areas need to be in line with national guidance and be supported by the appropriate support an infrastructure. The appropriate relatives support facilities should also be available for all patients; Improved access to Critical Care- to allow the unit to operate at a lower occupancy level (currently operating at 110%-125% across Level 3 and Level 2 within ITU) which will avoid delays in access to beds, avoid cancellation of elective cases and support repatriation of inter hospital transfers; Improved access to appropriate facilities for management of immunocompromised or infected patients- within the existing units there is only 1 single room available to care for patients who require isolation or barrier nursing and this creates a significant risk to patients; Achieve compliance with key environmental standards- this reflect space, staffing and general care protocols; Improved working environment/arrangements for staff and therefore staff recruitment and retention; Improved and more efficient use of clinical supplies; will not need changing when patient steps up or down ; Provision of sufficient capacity to support any further increase in patient activity as a consequence of local service reconfiguration following on from the Francis Report; and, Improved throughput and access for the wider Trust clinical services- including time from referral to ICCU for patients on inpatient wards. It should be highlighted that a key objective has been added since submission of the Outline Business Case which recognises the potential impact on the Trust and its services of the proposed dissolution of Mid Staffordshire Hospital NHS Foundation Trust as recommended by the Special Administrator. 2.3 Scope of the Full Business Case The scope of the project has been defined as the development and commissioning of an Integrated Critical Care Unit, which will bring together the totality of adult Level 2 and Level 3 beds for the Trust into a single location. It is acknowledged that options to be considered will require decant of facilities and services to free sufficient space for this co-location to be achieved. The delivery of these enabling works has been included within the scope of the Project Steering Group- although the timeframe for completion is ahead of any FBC approval. The reconfiguration of any space released by the scheme is not considered to be part of this project. 2.4 Timetable for the Development Development of the Project and Procurement and Approvals Timetable Table 2-2 provides a brief summary of the key approval milestones of the Project to date with the detail documented in the remainder of this section. FBC ICCU

35 Table 2-2: Key Milestones for Approval Milestone Outline Business Case Submitted December 2012 Outline Business Case Approved by TDA [TBC] Market Testing for Construction works through Walsall Hospital Company September 2013 Planning Application Approved October 2013 Full Business Case Approved by Trust Board January 2014 Full Business Case Submitted to TDA February 2014 Full Business Case Approved by TDA April 2014 Start on Site May 2014 Construction Completion July 2015 Service Transfer and commencement August 2015 Date Expression of Interest, Outline Business Case and Full Business Case The timeframe between the submission of the Outline Business Case was such that there has been two significant changes in the planning assumptions which underpinned the development of the options and selection of the preferred option. This change relates to the recommendation by the Special Administrator for Mid Staffordshire Hospital NHS Foundation Trust- that the Trust be dissolved. This is expected to result in a reconfiguration of significant levels of acute activity- and it has been considered prudent to address the ability of the Trust to accommodate the Critical Care impact of this. In addition, since submission of the Outline Business Case (OBC), there has been considerable change in the strategic operating environment of the NHS with the introduction of Clinical Commissioning Groups and the establishment of NHS England. The impact of each of these changes on the planning assumptions and affordability of this case will be detailed in the relevant sections Project Construction Programme It is proposed that the development of the new facilities be in a single phase and the outline construction programme is outlined in Table 2-3: Table 2-3: Construction Programme Construction Phase Deliverable End Date Enabling Works Relocation of services from the March 2014 West Wing Template Construction New Integrated Critical Care Unit July 2015 Commissioning Decommissioning Unit tested and prepared for occupation Safe vacation of existing ITU and HDU facilities July 2015 August 2015 FBC ICCU

36 2.5 Linkages with Other Schemes This development is to be funded via the Trust s Capital Programme with no requirement for additional external funding. The scheme is part of the Trust s Estates Strategy and will release core clinical space for alternative use including the potential to reconfigure the Accident and Emergency Department. 2.6 Stakeholder Involvement and Support As part of the development of the Full Business Case the Steering Group has commissioned the preparation and delivery of full internal and external engagement plan to cover the development and commissioning of the new Unit. The Steering Group incorporates key clinical users of the Critical Care Service and also has proactive involvement of the local Clinical Commissioning Group. In addition to a Foundation Trust Member on the Steering Group there is also patient representation of the steering group and within the Design Workstream. 2.7 Structure of the Full Business Case Submission In developing this FBC document the Trust has sought to ensure that all of the relevant information is available in a format which is accessible and relevant. The document provides a clear logic for the proposed development, and explains its financial and non-financial implications and defines risks of the change and how these will be managed. The main body of the document contains all of the key facts and addresses the matters outlined in the Full Business Case Checklist as adopted by the Trust Development Authority and is supplemented, where appropriate, by further detail within relevant appendices. Other supporting documentation which has been developed to support this case but does not require inclusion in full, is cross referenced. The Outline Business Case was developed using the Capital Investment Manual structure/approach rather that the Treasury 5-Case Model. To ensure that the move from OBC to FBC can be fully mapped the Trust has opted to prepare the FBC on the same basis. FBC ICCU

37 3 Strategic Context 3.1 Planning Healthcare in Walsall and the Surrounding Areas NHS Walsall Commissioning Intentions The approach to commissioning adopted by NHS Walsall CCG embraces the National Priorities and guidance outlined in the NHS Mandate and NHS Outcomes Framework. The challenges are immense but the local plan is a plan for change and delivery and will move the CCG towards its end state ambition. By 2016 CCG believe they will have: Contributed effectively to the delivery of the strategic aims and goals of the local Health and well being strategy meeting its part of the health and well being contract with Walsall partners; A reduction in health inequalities having delivered on the agreed trajectories for priority indicators in the Quality premium and maintained recent improvements in life expectancy; Local Population approaches to commissioning and not commissioning based on one size fits all; A vibrant and engaged third sector that is much more actively supporting and engaging with health and social care in Walsall; Services commissioned and contracted that are of a constant quality and have contributed to improved outcomes; More empowered patients with greater access to personalised commissioning budgets, telehealth and telecare Choice extended and much more widely available through Any Qualified provider (AQP); Care that is accessed and provided in the right place, at the right time by those best placed to provide the care needed. Specialist services that reflect best models and practice and that have reduced duplication and costs; Integrated models of service provision established that embrace acute, primary care, community services and social care. Services commissioned and contracted reflect a strong clinical evidence base and NICE guidelines; and, QIPP plans delivered year on year enabling the CCG to continue to fund a comprehensive range of services to meet the needs of its population and to enable the CCG to remain finically viable. The incidence of Long Term Conditions have reduced Excellent Joint Commissioning arrangements with the Local Authority. Greater availability and access of local and community based services offering one stop access. In preparing and negotiating 2013/14 contracts, the CCG used the new standard NHS contract and incorporated into all contracts the applicable requirements as set out in Everyone Counts including: FBC ICCU

38 The importance of providers submitting timely and accurate data in accordance with published standards; The inclusion and application of specified national and relevant locally determined sanctions; Compliance with nationally specified requirements including emergency readmission thresholds; Zero tolerance to MRSA; Reductions in the incidence of Clostridium difficile; Adherence to waiting time and ambulance handover standards; The inclusion of CQUIN schemes to drive quality improvements and QIPP schemes to drive efficiency; and, To ensure that mental health is given the same priority as physical health Impact of Proposals For the Future of Mid Staffordshire NHS Foundation Trust The Trust has experienced the impact of the changes in patient and commissioner decisions following the reporting of events at Stafford Hospital. This has resulted in increased activity for a number of services. The Trust continues to work with Commissioners and the Special Administrator to establish an appropriate way forward for sustainable healthcare delivery for the population. The decision to accommodate the space and infrastructure to support an increase of 2 ICCU beds is a reflection of this. However there until the final configuration has been confirmed these facilities will remain unused Fit with National Priorities The proposals detailed in this case and specifically the preferred solution described in Section 7 will support the Trust in progressing the delivery of a number of national priorities and specific examples are provided in Table 3-1 below. Table 3-1: Fit of the Business Case Proposals with National NHSE Priorities Policy National Priorities How the case addresses the priorities The Outcome Framework 2013/14 and NHS Mandate Preventing people from dying prematurely. Enhancing quality of life for people with long-term conditions. Helping people to recover from episodes of ill health or following injury. Ensuring that people have a positive experience of care. Treating and caring for people in a safe environment and protecting them from avoidable harm. Ensuring patients are managed in an appropriate environment to improve patient safety and outcomes. Minimise the transfer/ movement of patients by caring for critically ill patients in a single location. Improve staffing ratios and effective use of staff through single location. FBC ICCU

39 Policy National Priorities How the case addresses the priorities Mortality Review Treating Patients and Service Users with Respect, Dignity and compassion Patient experience understanding how the views of patients and related patient experience data is used and acted upon. Safety understanding issues around the Trust s safety record and ability to manage these. Workforce understanding issues around the Trust s workforce and its strategy to deal with issues within the workforce. Clinical and operational effectiveness understanding issues around the trust s clinical and operational performance. Governance and leadership understanding the trust s leadership and governance of quality. Putting patients first in decisions about care. Helping staff to be more compassionate. Keeping Patients and service users safe. Measuring how successful services treat people with respect. WMQRS Compliance- the review team highlighted that the rotation of staff was inappropriate. The operation of the single unit and single nursing workforce will avoid the requirement for rotation and therefore achieve compliance with this standard. Staffing- the ability to flex nursing staff to reflect actual acuity will ensure that nurse staffing resources are used effectively. Under the current staffing arrangements the beds are supported to their designation not their acuity of occupancy i.e. ITU may have 6 patients, 4 level 3, 2 level 2 but they will be staffed for 6 level 3. Similarly HDU does manage Level 2 patients but may be unable to increase staffing to reflect this. Shift Co-ordinator- this supernumerary senior nurse will support all areas of the unit, providing support for the management of admissions. Under the current arrangement the shift coordinator also manages patient care and therefore in the event of support required the care of their patient is affected. Medical Cover- there will be increased access to senior medical staff advice and provision in a single location will allow quicker response times. Reduced delays for transfers from A&E patients are currently stabilised in A&E but encounter delays in transfer during peak occupancy- this will be reduced with the increased capacity and therefore transfer can be affected at the point when it is clinically safe to do so. Reduced delayed transfers from Wards when early warning signifies requirement. Ability to separate male and female patients and therefore address risks of DSSA compliance. Ensure patients treated in the most appropriate environment including single rooms if clinically or culturally required. Improves staff working environment; frees time to care appropriately. Improves carer facilities; ensures improved holistic support. FBC ICCU

40 3.1.4 Summary of the Trust s Delivery Against National Policy/Quality Requirements The table below highlights the progress the Trust has made in delivery of key national priorities and quality targets. Table 3-2: Performance Against Key National Priorities Measure Patient Safety 2009/10 (Hospital) 2010/11 (Hospital) 2011/12 (Hospital) 2011/12 (Community) 2012/13 (March 2013) (Combined) Pressure Sores 308 cases 244 cases 319 cases 296 cases 177 Hospital 286 Community Patient Falls 911 cases cases 37cases 937 cases cases Medication errors 162 events 323 events 304 events 75 events 416 events Harm Events 76 events 56 events 148 Serious 139 Serious 177 serious Incidents (including Incidents Incidents (including grade 3 and 4 (including grade grade 3 and 4 pressure ulcers) 3 and 4 pressure pressure ulcers) ulcers) Near miss reporting Clinical incident reporting Clinical Effectiveness HSMR rates N/A 90 Length of Stay - Elective - Non Elective N/A N/A % 7.2% 7.0% N/A 7.5% Re-admission rates Patient Experience MRSA cases C-difficile cases The figures for 2012/13 combine activity from both previous organisations which accounts for the increase in numbers. As can be seen, during this period, the recording and collection of data has improved, resulting in an increase in numbers recorded. The data reflects our drive to improve quality and safety. 3.2 Trust Performance Activity Levels The Trust has an annual turnover of circa 225m, with income and activity attracted from a range of Commissioners. The patient related activity delivered between 2009/ /13 and 2013/14 plan is summarised in the table below. FBC ICCU

41 Table 3-3: Trust Activity Trends Activity Type 2009/ / / / /14 Plan Elective Spells 28,796 28,939 29,597 27,605 27,389 Non Elective Spells 27,184 28,181 28,634 31,970 30,440 Outpatient Attendances 264, , , , ,823 A&E Attendances 73,059 74,689 74,025 74,552 77,634 Critical Care Bed Days 8,968 9,513 8,868 10, Community Face to Face Contacts 341, , , , ,698 Community Clinic Contacts 99, ,190 99,703 99,341 95,130 Lifestyle Services Contacts 42,344 49,760 57,392 48,760 44,550 The activity levels experienced by the Trust have increased significantly since 2011/12 largely as a consequence of changes in operational policies and public confidence in a number of clinical services in Staffordshire and the publication of the Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry (Francis Report) in February Table 3-4 shows the planned activity for the current year (2013/14) by specialty and the location of service delivery. Table 3-4: Planned Activity for 2013/14 Speciality Elective Non Elective Outpatient A&E Spells Spells Attendances Attendances Accident & Emergency Breast Surgery - - 3,232 Cardiology 1,093 1,187 11,273 Cardiothoracic Surgery Clinical Haematology 1, ,761 Chemical Pathology - - 1,368 Colorectal Surgery Dermatology ,649 Diabetic Medicine - 6 2,310 Ear, Nose And Throat 1, ,607 Endocrinology - - 1,850 Gastroenterology - - 6,579 General Medicine 7,226 9,180 3,597 General Surgery 4,393 4,415 18,945 Genito-Urinary Medicine ,055 Geriatric Medicine 25 3,083 4,246 Gynaecology 2,249 2,695 15,635 Haematology: Anti-Coag ,263 Medical Oncology 1, ,693 Midwife Episodes ,903 Nephrology - - 2,955 Neurology Obstetric - 4,723 3,864 Ophthalmology ,224 Oral Surgery 398-4,647 Orthodontics - - 4,312 Paediatrics 90 2,863 15,431 Paediatric Surgery Community Contacts Clinic Contacts Lifestyles Contacts FBC ICCU

42 Speciality Elective Non Elective Outpatient A&E Community Clinic Spells Spells Attendances Attendances Contacts Contacts Pain Management 427-3,354 Plastic Surgery Respiratory Medicine - - 4,130 Rheumatology 672-6,252 Trauma and Orthopaedics 3,633 1,421 36,034 Urology 2, ,122 Vascular Surgery Community Nursing 172,168 11,119 Services Physio / Podiatry 4,582 56,689 Inpatient Care / Rehab 73,864 1,201 Adult Specialist Nursing 6,817 20,172 Palliative / End of Life 9,976 2,513 Psychology 1,423 - Children s Specialist 26,525 3,436 Lifestyles Contacts Nursing Healthy Child ,745 - Healthy Child ,598 - Lifestyle Services ,550 TOTAL 27,390 30, , ,698 95,130 44, Income and Expenditure Profile Although there have been significant changes in commissioning arrangements nationally since the submission of the Outline Business Case, the impact locally has been limited with the vast majority of services still commissioned by the clinical commissioners within the NHS Walsall area. However, the Trust also continues to have an active commissioning relationship with both South Staffordshire and Sandwell, plus a number of services commissioned centrally via NHS England Specialist Commissioning Team. The following tables show the activity commissioned by different commissioners for 2013/14 and the value of those contracts. Table 3-5: Activity by Commissioner in 2013/14 (Plan) Commissioner Walsall CCG South Staffs CCG Sandwell CCG Wolverhampton CCG Elective Spells Non Elective Spells Outpatient Attendances A&E Attendances Community Clinic Life styles National Commissioning Board Others Grand Total The distribution of contract income between Commissioners is summarised in Table 3-6 below. FBC ICCU

43 Table 3-6: Contract Value by Commissioner 2013/14 Commissioner Population '000 Value of 2013/14 Plan '000 % of Trust SLA Income Walsall CCG 283, ,621 73% South Staffs CCG 571,154 13,337 7% Sandwell CCG 361,359 7,194 4% Wolverhampton CCG 273,568 1,338 1% National Commissioning Board 451,038 22,355 11% Others - 10,946 5% Grand Total 1,940, , % Based on an income level of 225m in 2013/14 the Trust anticipates generation of a surplus of 4.2m. Table 3-7: Historic Expenditure Profile & Financial Performance for the Trust Services Walsall Hospitals 2009/ Actual Walsall Hospitals 2010/ Actual Walsall Healthcare 2011/ Actual Walsall Healthcare 2012/ Actual Walsall Healthcare 2013/ Plan Total income 168, , , , ,200 Total costs 160, , , , ,942 EBITDA 8,000 15,300 18,390 18,890 19,258 PFI interest 0 (5,260) (7,710) (7,987) (8268) Fixed Asset Impairment (2,318) (83,200) Depreciation (3,8790) (5,900) (7,098) (7,153) (6982) Interest Receivable PDC Dividends (2,243) (931) 0 0 Other (7) Net Surplus (Deficit) (320) (79,975) 4,164 3,853 4,251 The deficit in 2010/11 was a consequence of the Trust taking occupancy of its PFI development and the subsequent valuation resulting in an impairment. Excluding this the Trust would have achieved a surplus and break-even duty. FBC ICCU

44 3.3 The Critical Care Service Current Service Provision The Trust operates Critical Care services in line with the standards issued by the Intensive Care Society and clearly differentiates between the different levels of care as defined by the society. Level 3- Intensive Care Level 2- High Dependency Care Since submission of the Outline Business Case occupancy on the units has continued to operate at a very high level with ITU operating 58% of shifts with 6 or more patients. These beds have continued to operate although not fully funded. The total overspending at Month 7 standing at 94k Workforce Profile The two areas are staffed by an integrated team of nurses. The current profiles are summarised in the table below. Table 3-8: Current Nurse Staffing Profile- Combined ITU/HDU Department Band 1 Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8a Registered Nurses CSWs A&C Total WTE In terms of medical staff the Trust provides dedicated staff from within the Anaesthetics Department to support both units. The Consultants who undertake this role do participate in the wider Anaesthetic elective and on call rotas, but only designated consultants support the critical care beds. The service is also supported by Middle Grade and Junior medical staff/trainees and the level of cover is summarised in Table 3-9 below. Table 3-9: Current Medical Staff Cover Mon-Fri Daytime Day Time ITU HDU Consultant x 1 Consultant x Specialty Doctor x SHO x 1 Overnight Specialty Doctor x1 Consultant On Call Rota x1 (off site) Weekend- Daytime Specialty Doctor x 2 Consultant On call x1 (off site) Weekend- Overnight Specialty Doctor x1 Consultant On Call Rota x1 (off site) Total FBC ICCU

45 3.3.3 Activity Levels The activity levels in the table below highlight the activity distribution between the Level 2 and Level 3 bed days. Table 3-10: Critical care Bed days by Specialty and Care Level 2010/ / /13 Specialty Level 3 Level 2 Level 3 Level 2 Level 3 Level 2 39 ENT General Medicine General Surgery Gynaecology Haematology Obs & Gynae Oral Surgery Orthopaedics & Trauma Urology Other Total bed days Combined total Income and Expenditure Profile The operating budgets for the two units are summarised in the table below. Table 3-11: Expenditure Profile 2012/13 and 2013/14 Plan Cost Budget Start 2012/13 Final Budget 2012/13 Recurrent 000 Actual Spend 2012/13 Budget 2013/14 Recurrent Budget 2013/14 (YTD M7) Actual Spend 2013/14 (YTD M7) Medical Staff Nursing Staff 2,417 2,420 2,699 2,619 1,528 1,646 Other Total Pay 3,509 3,513 3,775 3,713 2,178 2,356 Non pay Total Revenue 3,813 3,890 4,318 4,223 2,473 2,633 NB- Other includes: Matron Prof development nurse A&C staff FBC ICCU

46 The income generated by the units based on ICNARC reporting and the block contract arrangement in place with NHS Walsall is summarised in the table below. Table 3-12: Income Profile Full Year Plan Year Actual Activity Year Actual Value Activity Value Plan Actual Variance % Plan Actual Variance '000 Activity Activity Activity Activity '000 '000 ' /12 4,798 6,136 4,798 5, % 6,136 6, % 2012/13 5,153 6,287 5,153 4,711 (442) (8.6%) 6,287 5,889 (398) (6.3%) 2013/14 Month 7 4,419 5,416 2,591 2, % 3,176 3, % % 3.4 Capacity Modelling Across the Trust In terms of the Trust s projected capacity the LTFM (which underpins this case) identified the agreed activity and capacity modelling assumptions for the period 2013/14 to 2018/19. For the purposes of building this FBC cognisance has been taken of the projections for future patient activity for the Trust as a whole, as reflected in the LTFM, but of more relevance are the projections for activity for critical care, both elective and non elective. The details are in Section A fundamental issue for the development of this case has been the modelling of the impact on space and facilities of any potential reconfiguration of clinical services currently provided at Stafford Hospital. During the preparation of this case there have been a number of ongoing discussions with neighbouring Trusts but at the time of completion and submission for approval there have been no definitive changes agreed. Therefore, to fully address the planning risks and issues, a range of scenarios have been developed and modelled to assess impact on activity, space and income. 3.5 Supporting Strategies IM&T We have redefined our IMT Strategy in recognition of the need to ensure that fit for purpose IT solutions are in place. These systems must support the strategy, operation and management of our activities whilst providing opportunities to innovate within a managed risk framework. The effective use of ICT is a key component of delivering our overall vision. In compiling the strategy we have taken into account the need to support clinical decision-making, measure quality and performance, inform effective service planning and deliver efficient and cost effective business support processes. FBC ICCU

47 Our IMT Strategy builds on Lord Darzi s Next Stage Review of the NHS by describing how Informatics can support the delivery of better, safer care for patients. Improved research, planning and management, and can empower patients to make more informed choices. Our strategy describes how we will create a vibrant and innovative environment where all those who work for the Trust, and our partners in the health and social care community, will have the accurate information they need, when and where they need it, to make optimal decisions which will enhance patient care Critical Care Outreach The Critical Care Outreach within the Trust is provided by the Early Warning Response Team (EWRT) who will review patients that have been referred from ward based teams with or without changes in their early warning signs. The service is available across all seven days though the weekend service does not cover the full 24 hours. In the event that a patient requires admission to a critical care bed this will be facilitated by the EWRT. The team will also provide follow up support for patients discharged from critical care to ward areas. Care of patients with temporary tracheostomies and those with central venous catheters in situ post discharge from critical care will also be provided by this team not the Critical Care nursing team. 3.6 The Trust s Estates Strategy In the autumn of 2011 the Trust commissioned a 6-facet survey in preparation for the update of its Estates Strategy. Although much of the Trust s estate is of high quality, following the commissioning of the PFI facilities in 2010, the 6-Facet Survey highlighted the significant issues facing the both ITU and HDU in terms of: Space utilisation- both areas rated as overcrowded; Functional suitability- both areas were rated C in view of the poor infrastructure and lack of key facilities; and, Quality- although HDU rated B this reflects the redevelopment and occupation of the area in ITU was rated C. This provided key evidence that improvements in this area of the retained estate should be a key priority for the Trust. In pulling together the vision for the future of the estate, the strategy highlighted three key clinical imperatives to be addressed, including the reprovision of an Integrated Critical Care Unit. The proposal for the reprovision was designated as the initial priority as the integration would also release prime space, which the Trust would propose to refurbish to accommodate a redeveloped and extended Accident and Emergency Department. The fit with the Trust Development control plan is demonstrated in Figure 3-1 below. FBC ICCU

48 Figure 3-1: Development Control Plan Consultation with the Local Authority Health Overview and Scrutiny Committee The Trust is not obliged to consult the Overview and Scrutiny Committee but a development such as this is recognised as fundamental to the future effective operation of the Trust and it is therefore proposed to present the recommendations of the case and the proposed solution to the Committee as soon as practical. FBC ICCU

49 4 Vision for the Future, Key Planning Assumptions and Project Scope 4.1 Vision for Critical Care The establishment of a single Integrated Critical Care facility has been one of the key visions for the future of this service, which has yet to be addressed. With the changes on the site there are limited options for the achievement of this aim in the short to medium terms. The provision of a single facility would support more efficient utilisation of resources and step up/down thus supporting increased throughout as patients would move between Level 2 and Level 3 care as their condition required within a single clinical area. The unit will be designed to ensure that all of the beds were capable of accommodating a Level 3 patient but the staffing levels and equipment provision would reflect the anticipated proportions and peaks and troughs of activity. The facilities would also provide a proportion of single rooms. The requirement for full isolation facilities will also need to be considered. 4.2 Drivers for Change The Critical Care Service has sought to pursue this radical change in its structure and service pattern as a consequence of a number of physical, safety and organisational drivers for change: Compliance with National Standards Quality of the existing environment within both ITU and HDU; Management of patients in an appropriate care setting; Flexibility of resources and Capacity; and, Change in the service model Compliance with National Standards National guidance has clearly recommended that Critical Care services should, wherever practical be delivered through an integrated facility in order to ensure that patient care can be most effectively managed and that as patients move between levels of care their support and interventions are managed by a single team providing continuity and maximum flexibility. Within WHT this seamless model of care cannot be achieved due to the significant distance between units. In view of the inherent risks of moving critically ill patients as patients within HDU deteriorate and move from Level 2 to Level 3, they remain within HDU with increased nursing support. Likewise patients within ITU will improve in terms of their condition from Level 3 to Level 2, but will remain within ITU rather than transfer. In both scenarios the impact on nursing staff can be significant. The existing facilities in both ITU and HDU fall significantly below the spatial standards defined by the Department of Health estates guidance in terms of both the functional content of the areas and the overall patient bed space allowances. This does result in significant issues for the management of patients in view of the range of equipment and interventions FBC ICCU

50 required by these patients, and there is a higher risk of hospital-acquired infection as a consequence of the proximity of beds and lack of isolation facilities. The extent of the non- compliance was recently highlighted during the inspection undertaken by the West Midlands Quality Review Service in 2010, which recommended a number of extensive improvements to the facilities and patient environment. The inspection undertaken in October 2013 acknowledged the work underway to complete the business case and reiterated the importance of addressing these pressing areas of non-compliance Quality of the existing environment The existing facilities are physically separated by a distance of 150 metres, and both the existing units fall significantly below basic standards in terms of the individual bed spaces, the availability of support facilities, the inability to guarantee single sex accommodation and lack of single rooms to manage patients for either control of infection or dignity purposes. ITU- the current department accommodates up to 6 ITU beds, with one single room. Each bed space measures circa 10m 2 against the recommended standard of 24m 2.The room is not capable of operating as a full isolation room as it does not have the appropriate positive and negative air pressure balances. Within the current unit there are no relatives facilities and no private areas for the clinical teams to discuss patients with their relatives or other colleagues within the team. There are no patient WC or shower facilities and storage for both equipment and consumables is limited and not easily accessed from the bed area. The limited staff support accommodation (one office and a staff rest area) are also inadequate. The very high occupancy rate of between 110% and 126% across levels 2 and 3 and 58% of shifts operating with 6 beds or more also results in significant delays in the completion of vital repairs/ maintenance. The photographs below provide an indication of the challenge facing the team. FBC ICCU

51 HDU- the unit comprises two 4 bed bays, with no access to side room or isolation facilities. The bed bays measure 8m 2 providing an overall area per bed of 12m 2. There are no facilities for patients to toilet or wash. In addition the unit does experience issues in terms of mixed sexes within the bays. Although whilst Level 2 patients do not meet the criteria for reportable breaches, there are regular occasions when a Level 1 patient is awaiting repatriation to a general ward who is occupying a bay with members of the opposite gender. FBC ICCU

52 There are no relatives facilities and no private areas for sensitive discussion with relatives. There are inadequate staff facilities within the unit other than a single nurse station. The provision of power and medical gases for each bed is woefully inadequate which requires increased reliance upon bottled provision and use of trailing cables. The photographs below highlight the extent of the difficulties. FBC ICCU

53 4.2.3 Management of patients in an appropriate care environment The formal designation of the two units as Level 3 (ITU) and Level 2 (HDU) does not fully reflect the range of activity, which does in fact take place within the Units. ITU is also registered as a 5/6 bed unit, but does regularly manage 7-8 for an extended number of shifts and 9 patients on occasion. The table below provides a summary (for the last quarter of 2012/13) of the impact of level 3 patients managed within HDU. If it is assumed that a level 2 bed equates to 2 points, the maximum points per day within the unit should equate to 16. On the basis of each level 3 patient equating to 3 points, the table summarises the impact on the overall acuity of care within the unit and highlights the potential staffing impact of the increased dependence. Table 4-1: Acuity Levels on HDU Acuity Value of Level 3 Occupancy Maximum Planned Acuity % of Level 3 January % February % March % In view of the very limited space and infrastructure and the increased reliance of level 3 patients on mechanical support this situation presents potentially significant risks to the Trust Flexibility of resources and capacity Although managed by a single Matron, the Critical Care Service cannot operate as a single team or unit as a result of the significant physical distance between the two areas. The nursing staff operate as a Critical Care establishment and rotate between the two areas, however during shifts resources cannot be easily redirected and there is a significant reliance upon bank and agency nursing staff to support changes in acuity in HDU and the occupancy of the ITU above 5 beds. It is acknowledged that there are a number of occasions when HDU is required to care for level 3 patients when there are level 2 patients within ITU. However the impact of moving these critically ill patients between these physically separated areas can be detrimental, and therefore although patient transfers do occur to rectify this imbalance it is not always possible to operate flexibly or safely. This is further compounded by the lack of single rooms in either location. The separation of the two units does cause particular issues for the level of medical cover overnight. As highlighted in Section the medical cover for the two units during the core working week is provided by two separate teams. However at night and over much of the weekend there is only 1 on site doctor to cover both locations. This creates particular pressure for the individual doctor but can lead to delays in patient care. FBC ICCU

54 4.2.5 Change in the service model Under the current distribution of facilities the care of critically ill patients can require transfer between units or alternatively the ongoing care of patients in an inappropriate setting as highlighted by the previous sections. Although the areas are physically separated Critical Care services have operated as a single department since the creation of the combined medical and surgical HDU on Ward 19 in Although each established with a dedicated nursing workforce, the staff do rotate between the two areas to ensure appropriate distribution of skills and expertise. However, the physical separation does not support seamless care delivery and the ability to ensure continuity of care with a single clinical team. Patients within Critical Care can fluctuate between care levels during their period of admission- with a single location patients will continue to be managed on a single pathway with the same nursing and medical team. The Critical Care model which the team envisage will provide clarity of the care plan and progression of the patient and therefore minimise handoffs and support reduction in length of stay, and reduced readmissions. The unit will operate a single point of access to critical care operating clear admission criteria, and defined care protocols which will include access to multidisciplinary care and joint protocols to support the smooth transition of patients to the general ward environment, and provide the appropriate follow up and rehabilitation post discharge from Critical Care. 4.3 Key Planning Assumptions In terms of patient flows the significant clinical adjacencies are to the operating theatres, specialist imaging and A&E, and ideally the Unit would be on the same level of the hospital as those services. The key planning assumptions which have been agreed with the project team and which have been used to develop the options for appraisal are: Level 3 & Level 2 patients only to be cared for within the Unit; An occupancy rate of 80%; Patients requiring NIV or CPAP to be managed within Respiratory Care unless clinically requiring the support of the ICCU; Adjacency to major clinical referring units; Beds to be managed flexibly based on the balance of Level 3 & Level 2 care; 50% of beds to be provided in single rooms with appropriate ventilation and a minimum of 2 isolation rooms with full gowning facilities; and, Maximum observation of all beds by the clinical teams. FBC ICCU

55 4.4 Projected Activity and Capacity Requirements Trust Activity and Income Projections The Activity assumptions modelled within the LTFM reflect the expected movements in commissioned activity profiles by commissioners and also the potential price movements from adjustments to tariff income. The activity model developed jointly with the commissioners at NHS Walsall has been used as the basis for future income projections. The modelling combines: The integration of acute and community services within activity modelling; An element of growth in activity to reflect underlying changes in demographics and disease profiles as modelled by Public Health. This is offset by the QIPP schemes that identify reductions in hospital activity levels and therefore a reduction in income levels; Growth to reflect changes in referral patterns and patient choice relating to surrounding hospital providers in Staffordshire and Sandwell. The changes relating to Sandwell will have a significant impact in future years and have been modelled consistent with the regional expectations of this strategy; and, An anticipated repatriation of activity relating to areas such as cardiology and transfers of vascular services to other Black Country Trusts that reflect Black Country commissioning intentions. Table 4-2: Activity growth/casemix by point of delivery 2013/ / / / / /19 Outturn Plan Plan Plan Plan Plan '000 '000 '000 '000 '000 '000 Electives Non Electives Outpatients A&E Community Services Other CQUIN Total QIPP Net Growth The Trust has modelled receipt of non-recurrent income to support development of A&E reconfiguration and service transformation costs. These non-recurrent allocations are not contributions to support the cash requirements of servicing this business case. FBC ICCU

56 Table 4-3: Impact on Income 2013/ / / / / /19 Outturn Plan Plan Plan Plan Plan '000 '000 '000 '000 '000 '000 Baseline b/fwd Activity Growth QIPP income loss Inflation Non recurrent income Category C Income Total Income Critical Care Activity The Trusts Clinical Strategy has identified that there is no growth anticipated in Critical Care Services within the Trust. There are however a number of changes in commissioning intentions and clinical practice which will impact upon the throughput of the Critical care service: The transfer of management of appropriate NIV/BiPAP patients to the Respiratory Ward/Unit; The transfer of Vascular Surgery services to Dudley Group of Hospitals; and, Establishment of a new structure for the management of Major Trauma which designated Walsall Healthcare NHS Trust as a Trauma Unit Critical Care Capacity Modelling Having modelled the above changes on the Critical Care activity, and applied the planning assumptions for capacity calculation as summarised in Section 4.2. Table 4-4: Projected Critical Care Bed Days Specialty 2011/ /15 Level 3 Level 2 Level 3 Level 2 ENT General Medicine General Surgery Gynaecology Haematology 3 9 Included in Other Obstetrics Orthopaedics & Trauma Urology FBC ICCU

57 Specialty 2011/ /15 Level 3 Level 2 Level 3 Level 2 Other Total bed days Mid Staffs Impact N/A N/A 592 Combined total Table 4-5: Projected Activity and Capacity including Mid Staffordshire Impact Level of Care Projected Bed Days Occupancy Rate Number of beds required Level % 8.2 Level 2 (excl NIV) % 7.8 Mid Staffs Impact % Total The Impact of Mid Staffordshire NHS Foundation NHS Trust Although the Trust is looking to provide the physical capacity to accommodate 18 beds to address the projected impact of any changes as a result of the reconfiguration of Mid Staffordshire services it is conscious that during 2012/13, whilst the Trust as a whole experienced significant increases in the number of admissions from the Staffordshire catchment area, the Critical Care Unit did not experience this level of increase, indeed numbers remained relatively static. The Trust is also conscious that at the time of completion/submission of this case there are still few firm decisions in terms of service reconfiguration and therefore there is no desire to pre-empt the outcome of public consultation on this sensitive issue. The Trust has therefore opted to provide the physical capacity only. Any workforce implications will be addressed by a separate case focused on the wider service change as it becomes clearer. 3 Staffing and operation of additional beds will be subject to a separate case and will only occur should the additional activity materialise FBC ICCU

58 5 Review of the Outline Business Case 5.1 Introduction The Outline Business Case for the provision of an Integrated Critical Care Unit at Walsall Manor Hospital was submitted to the Strategic Health Authority in December With the changes in the NHS structures effective form 1 st April 2013, approval of the Business Case passed to the National Trust Development Authority (NTDA). They granted approval of the case on [xxx]. In developing the Full Business Case for this new facility there has been only one significant change in any of the underlying planning assumptions, which as summarised in Section 4.3 relates to any impact on Walsall Healthcare of likely service reconfigurations at Mid Staffordshire NHS Foundation Trust. However there have been key strategic developments at a local and national level which the Trust has sought to address in reaching the final stages of the approval mechanism. An adjustment to the OBC was therefore submitted to NTDA in July outlining the capital cost impact of providing additional capability to accommodate an increase in activity. It is, however, the clear conclusion of the Project Steering Group that these changes do not materially affect the options for delivery- although they do impact on the capital costs. The Trust faces a number of drivers for change and has identified a number of key objectives and benefits, which it is seeking from the reconfiguration of its Critical Care Services. It is clear that there is a need to physically alter or reprovide the facilities and therefore options were identified for formal appraisal by the Project Team and other key stakeholders. A number of options were identified having accounted for the overall strategic redevelopment of the service, the clinical services on the Walsall Manor Hospital site, and the delivery of the Trust s Development Control Plan. Each option in terms of its high level content and identified benefits and issues are summarised below. 5.2 Impact Of Mid Staffordshire Hospital NHS Foundation Trust The ICCU Outline Business Case was approved by the Trust Board in November This was based upon the overall complement for 16 beds in total to support the integration of ITU and HDU in the former West Wing entrance. Within the original 16 bedded solution the overall layout at the time was deemed to be clinically suitable with significant environmental improvements specifically over the high dependency unit element of the scheme. However there are a number of derogations from HBN 57 in respect of rooms being undersized. It is clear from discussions with colleagues working within the other workstreams that there is a need to consider service expansion in order to accommodate growth particularly from Staffordshire. An increase in clinical activity therefore means the layout and bedded solution FBC ICCU

59 for ICCU would need to see an increase of up to 2 additional beds in order to ensure future proofing the unit Proposed Solution In order to respond to the request for additional beds to meet growth a number of options have been considered and discussed at the Design and Construction workstream with clinicians and service leads. Two options were discounted as being practically untenable due to lack of visibility from a staff base to patients bed position and were rejected. Option 3 which accords with an optimum bed capacity for 18 generally comprising 9 single rooms for intensive treatment (incorporating 2 isolation rooms), in addition to 9 beds in the open plan area. The layout has been re-worked to establish the staff base centrally located in order to improve visibility across all areas of the clinical areas and deemed an appropriate and acceptable option. The single rooms whilst still needing derogation have now been increased in size from 21m 2 to 22.3m 2. The layout supports clinical needs and the Clinical Director for Anaesthetics, Critical Care and Theatres has signed off Cost Implications At the Project Steering Group on 17 June 2013 it was made abundantly clear that whilst the solution for the built environment should support an increase to 18 beds in total, the unit would formally open as a 16 bedded facility in keeping with current workforce competency and capacity of staff and activity demands. Any increase over and above the use of 16 beds would require a formal business case to be developed which may require Board approval of any additional staff costs, additional medical equipment costs and complete clarity on the additional income which would be received as a result of such a decision. The design team have concluded room data sheets and loaded 1:50 and 1:20 drawings and therefore the final layout is actually complete. However discussions with the design team in the initial stages indicated that by slightly expanding the footprint to accommodate the additional beds carries an accompanying capital cost increase of 827,671. This is made up as follows: Outline Business Case Project Cost (based on 16 beds) 5,466,385 Adjustment for additional beds Additional new build area say 200m 2885/m 2 577,000 Design fees 72,125 Contingencies 52,622 VAT (@20% fee excepted) 125,924 The above costs are based upon a detailed feasibility cost plan prepared by Holbrow Brookes Construction Consultants (acting for the Trust as PQS) in a report dated 14 June FBC ICCU

60 5.3 Option Appraisal Review of Options Scores In preparing the OBC the Trust confirmed the link between the project and Trust objectives and the 7 benefits criteria were agreed and weighted. It is quite clear based on current trends that the environment and capacity demands of the Trust have had an impact on the range of options originally considered. However the Trust believes that the range and nature of the benefits are sufficiently robust to accommodate the impact of the implementation of national and local guidance and priorities. These benefits therefore remain as follows: Table 5-1: Benefits Criteria and Definitions Criteria Description Impact on Clinical Services Clinical care delivered in the appropriate location and environment Ability to support improvements in patient access to key pathways Facilitates focused diagnosis and initial treatment Implementation of new models of service are supported Supports the redesign of Urgent Care Services Impact on Performance Improvement in departmental performance can be facilitated Management Improvements in performance against key clinical indicators Development of LEAN processes can be facilitated Compliance WMQRS standards Patient Experience Improved patient care environment including space and décor Improved control of infection Improved systems and processes for case management and pathway clarity Maximise Resource Utilisation Maximise efficient use of resources including staff retention Enhances recruitment, retention, and improved workforce utilisation Promotes high performance and continued development of all staff Stimulating staff environment Efficient use of staff, equipment and facilities through improved integration Potential to respond to future changes Improved resource utilisation Environmental Impact Match to the Trust Sustainability Strategy Timescale Length of time to deliver facilities Impact on Estates Strategy Impact on other services Level of decant required by other services Accessibility from other hospital departments Disruption during construction A review of the options and scores has been completed by the Project Team to account for the change in drivers and forces for change. A fundamental issue for the Trust is the need to maximise access to inpatient beds- with all available capacity currently in use. It is therefore clear that the three options which utilised ward areas currently occupied by Level 1 Inpatients were no longer feasible. However, the Trust believe that the remaining 4 options still provide a valid basis for appraisal. However given the approach to increase bed capacity to accommodate potential changes in the future the Trust has assessed how the remaining options would address this growth. As FBC ICCU

61 this did impact on the original proposals a review of the options from s non financial perspective has been undertaken with the Project team. As the team reviewed the approach to meeting the increased capacity the requirement in Option 5 to expand into the whole of West Wing Theatre Recovery was considered operationally unacceptable and potentially undeliverable. This option was therefore excluded at this point from further review. The original and revised scores of the remaining options are provided in the table below. Option 8 (West Wing) remained the preferred option. Table 5-2: Weighted Scores Criteria Option 1 Option 1 Option 7 Option 7 Option 8 Option 8 Impact on Clinical Services Impact on other services Impact on Performance management Patient Experience Maximise Resource Utilisation including staff retention Environmental Impact Do Nothing Original Scores Do Nothing Updated Scores Therapies Original Scores Therapies Updated Scores West Wing Entrance Original Scores West Wing Entrance Updated Scores Timescale Total Rank Financial, Economic and Cost Benefit Appraisal A detailed financial and economic appraisal of the identified options was undertaken as part of the development of the OBC. This has been reviewed in light of the changes in capital and revenue costs and this is summarised in the following sections Revenue Budgets The revenue cost position (excluding capital charges) for each option has been revised to reflect budget uplifts and consequent changes in the additional costs of the development. This is summarised in Table 5-3. Table 5-3: Revenue Implications Option 1 Option 7 Option Clinical Costs Baseline 4,223 4,223 4,223 FM Costs Baseline Total Critical Care Costs Baseline 4,314 4,314 4,314 FBC ICCU

62 Option 1 Option 7 Option Additional Nursing Costs Additional Medical Staff Costs Additional Soft FM costs Additional Hard FM Costs Total Additional Costs Total Revenue costs for input into GEM 4,664 4,454 4, Capital Costs Table 5-4: Capital costs for short-listed options at OBC Summary of Capital Costs Option7 Option Departmental Costs 2,218 1,608 On costs 897 1,390 Works Costs 3,115 2,998 Location Adjustment (249) (240) Sub total 2,866 2,758 Fees Non Works Costs Equipment Costs Planning Contingencies Total for approval purposes 5,455 4,503 Inflation Outturn net of VAT 5,602 4,626 VAT 1, Outturn including VAT 6,625 5,466 Although there are no capital costs for the option 1, it has been assumed that there will be additional expenditure to bring the current units up to standard starting in 2017/18. Given the requirement to accommodate 18 beds the capital costs of each shortlisted option have been revisited and these are summarised in table 5-5 below Table 5-5 Revised Capital Costs accommodating 18 beds Option7 Option 8 Summary of Capital Costs Departmental Costs 1,785 2,276 On costs 1,492 2,422 4 Additional medical staff costs are required if the Integrated Critical Care development did not proceed FBC ICCU

63 Works Costs 3,277 4,698 Location Adjustment (197) (282) Sub total 3,081 4,416 Fees Non Works Costs 2, Equipment Costs Planning Contingencies/ optimism bias Total for approval purposes 6,973 6,530 Inflation Outturn net of VAT 7,552 7,073 VAT 1,264 1,090 Outturn including VAT 8,816 8, Economic Analysis Within the OBC Equivalent capital costs included in the Generic Economic Model GEM for the shortlisted options were calculated as follows: Table 5-6: Economic capital costs for the GEM Option 1 Option 7 Option Outturn excluding VAT 5,601 4,626 Less Planning contingency (409) (269) Net Capital cost less VAT and planning contingency 0 5,192 4,357 GDP deflator 0 (250) (210) Economic Costs to input into GEM 0 4,942 4,147 The revised calculations are as follows: Table 5-7 Revised economic capital costs for the GEM Option 1 Option 7 Option Outturn excluding VAT 7,552 7,073 Less Planning contingency (977) (545) Net Capital cost less VAT and planning contingency 0 6,575 6,528 GDP deflator 0 (160) (159) Economic Costs to input into GEM 0 6,415 6, Option Risks The Trust also quantified the risk associated with each option. This has been done through separate exercises for Construction and Operational risks. FBC ICCU

64 Table 5-8: Option Risks Risk Category Option 1 Option 7 Option Design, construction and development Operating 3, Variability of revenue 8,909 8,920 8,920 Technology and obsolescence Other Total 12,714 10,408 10,244 These have been reassessed and are summarised below Table 5-9 Option Risks Risk Category Option 1 Option 7 Option Design, construction and development Operating 4, Variability of revenue 13,018 13,031 13,031 Technology and obsolescence Other Total 17,130 14,744 14,572 Variability of Revenue risks have increased as the Trust s income cost driver has been reassessed upwards Conclusion of the Financial and Economic Analysis The Trust has evaluated the options over a 60 year post construction period. Therefore the overall appraisal period is 60 to 61 years depending on the construction time. This is consistent with guidance in the Capital Investment Manual. The results of the evaluation are summarised in the table below. Table 5-10: Original Evaluation of the Financial and Economic Analysis NPC 000 NPC of Risk 000 Total NPC 000 EAC 000 EAC of Risk 000 Total EAC 000 Original Rank Adjusted Rank Option 1 119,027 12, ,741 4, , Option 7 116,068 10, ,477 4, , Option 8 114,877 10, ,120 4, , The revenue capital and risk changes have driven a revised position FBC ICCU

65 Table 5-11 Adjusted Economic Option Summary Option 1 Option 7 Option 8 NPC 000 NPC of Risk 000 Total NPC 000 EAC 000 EAC of Risk 000 Total EAC 000 Rank Adjusted OBC Ranking 137,523 17, ,653 5, , ,721 14, ,466 5, , ,322 14, ,894 5, , The ranking of the remaining options is therefore unchanged Combined Financial and Non-Financial Appraisal The financial and non-financial options have been brought forward using a cost per benefit score methodology. This divides the Equivalent Annual Cost (EAC) by the benefit points to obtain a cost per benefit point. The lowest cost per benefit point is seen to be the best option. A summary of the results is as follows: Table 5-12: OBC Summary of Financial and Non-Financial Appraisals Total non financial scores (weighted) Option 1 Option 7 Option Total EAC ( 000) 5,028 4,802 4,750 Cost per benefit score Percentage score above preferred option 218% 98% 0% The revised position using the uplifted financial and non financial appraisal scores is as follows: Table 5-13: Revised Summary of Financial and Non-Financial Appraisals Option 1 Option 7 Option 8 Total non financial scores (weighted) Total EAC ( 000) 5,904 5,752 5,616 Cost per benefit score Percentage score above preferred option 278% 110% 0% The non financial score for option 7 would need to increase by x% for it to be the preferred, alternatively the EAC would need to reduce by x% for it to be the preferred option. The sensitivity is such that the validity of option 8 as the preferred option remains,. FBC ICCU

66 5.4 Scheme Implementation and Project Plan Although the West Wing Entrance is no longer a major access point for the hospital, there are a number of functions and individuals who will need to be relocated in order to commence the refurbishment works. The affected departments/functions and proposed alternative provision are summarised in Table 5-9 below. Table 5-5: Enabling works to support ICCU reconfiguration West Wing Current Occupancy Requirements League of Friends West Wing Shop Needs to located in Retained Estate to enable current service to continue (i.e. supply of food sundries) Post Room Large lockable office Worktop / pigeon hole facilities Couriers Room Large lockable office for ISS staff (ISS) (TUPE staff) with worktop available & room for post trolleys. Possibly reception area if post process to change T&O Consultants (Currently in single person offices) X9 consultants T&O Admin support X9 Medical secretaries in open plan X1 hot desk X3 admin office Rheumatology Medical Secretaries X4 Med Secs in open plan office Rheumatology Consultants office X2 Consultants (off Hospital Street) X1 Hot desk Volunteers Office Lockable room Approx 12 lockers Space initially identified Potential new build in West Wing Courtyard Possibly relocate facilities together in Main Atrium Security Office which would require re-occupancy of x3 staff from Estates & Facilities (ID badges) (Can ID Badges work from MLCC?) Various options linked to areas vacated by other specialties- likely to be part of a chain of moves Possibly give Volunteers block of Trust facility lockers in OPDCC Query suitability on distance Head Of Nursing MLTC X1 person office in West Wing Linked to the wider Divisional Management team Community Police Office Separate office out of view from public for photo fit pictures Front desk facility for patient/ visitors Relocation of Public Seating Area Large open space for reception facilities (if required) for Inpatient visitors Seating / table facilities Link with League of Friends if possible Due to changes within the Trust a number of these moves were no longer required- however the final solutions have now been fully defined and included within Section 7.3. The project timetable for the ongoing stages of the project based on a traditional procurement route are outlined in Table FBC ICCU

67 Table 5-6: Project Timetable - Key Milestones at OBC Milestone Relevant Body Date Current Status Commence work on OBC Trust September 2011 Complete Submission of OBC Trust December 2012 Complete Approval of the OBC NTDA April 2013 Awaited Commence development of Complete Trust December 2012 FBC Submission of FBC Trust July 2013 Target February 2014 Approval of FBC NTDA September 2013 Not commenced Start on site Contractor October 2013 Not commenced Completion of Construction & Not commenced Contractor October 2014 Fit out Full operational service Not commenced Trust November 2014 commences Since the OBC there have been some changes to the programme due largely to the changes in the approval process, which are detailed in Table The updated timetable is detailed in Section 7.12 FBC ICCU

68 6 Workforce Planning 6.1 Trust Human Resources Strategy It is acknowledged that over the next 5 10 years the Trust will continue to undergo radical changes in the way it delivers services and these drivers for change will impact on the shaping of the workforce. The Trust has the following overall aims in terms of its Human Resources strategy: To facilitate effective implementation of the Trust s strategic objectives and service plans through the people we employ and who work with us maximising productivity and efficiency; To ensure that our workforce encounter a positive experience whilst employed by the Trust which gives them the commitment to maximise patient service and experience; Ensure that we have a high quality workforce in terms of: numbers appropriate skill set, in the right place at the right time, that is flexible enough to maximise delivery of service objectives in a climate of competition and where income is determined by results; Ensure that we recruit and retain staff with the values and attitudes to build the culture that reflects our values and beliefs and that we are recognised as an employer of first choice; To further develop ways of working in full partnership with staff and their representative organisations, via engagement strategies that include their contribution and commitment to decision making; The development and implementation of effective and efficient Human Resource Management processes and policies which support the development of a high performing foundation trust and minimise risk; The provision of clear strategies which define workforce role development which is aligned to our patients needs and experience with increasing flexibility and productivity; and, The Trust is committed to promoting equality and diversity and developing culturally sensitive services that recognise the diversity of those whom it cares for, and to building a workforce which is valued and whose diversity reflects the communities it serves. All of the long term planning for a restructured ICCU and related workforce has been and will continue to be completed under the umbrella of this strategy to ensure consistency and effective management of the change process. 6.2 ICCU Redevelopment Project Workforce Plan Key Workforce Planning Objectives and Assumptions In developing the integrated service proposals the key assumptions made by the team included: There will be a combined unit with appropriate adjacencies; FBC ICCU

69 The unit will comprise of 18 bed spaces beds; Nurse to patient ratios of 1:2 Level 2 patients, 1:1 Level 3 patients in line with the general principles of Critical Care Nurses, Department of Health, Intensive Care Society and RCN; The unit will be designated into two zones for the purposes of patient management and supervision of care; Level 1 patients should be transferred out of critical care within 4 hours; There will be no paediatric admissions; Each shift should have a supernumerary shift leader (Band 6 or 7) in line with the general principles of the RCN and Midlands Critical Care Networks Quality Standards; The shift leader will be supported by a band 6 and team of band 5 nurses of differing levels of experience; Unit layout will comprise of 9 isolation cubicles and a 9 bedded open bay. These areas will be separated into 2 zones and will require a team of nurses which will be determined by the number and care level of beds included in the zone; There will be 2 critically care trained nurse supporting the supernumerary shift leader who will be team leaders for the two zones. The unit will adopt the key service characteristics outlined in Comprehensive Critical Care (DH 2000); The unit will play an active role in the teaching and training of Foundation doctors and medical students in the principles of identification and treatment of the critically ill patient as well as training specialist trainees in Intensive Care Medicine; The current level of medical workforce staffing can manage the increased bed number provided that they are in a single location; The Medical Workforce, which will support the Integrated Critical Care Unit, will be managed from within the wider Anaesthetic Department, however there are dedicated posts identified for each shift to directly support the Critical Care beds; Nursing workforce numbers have been benchmarked against both local Trusts which has confirmed that the proposed number of staff per shift is in line with recognised criteria and matches the numbers of surrounding Trusts; and, If the opening of extra beds is required on an ad hoc basis if the unit is full of appropriate Level 2 and 3 patients and has no Level 1 step down patients then, extra staffing could be supplied by the Trust s Critical Care Bank or if sustain demand is demonstrated such as the impact of Mid Staffordshire NHS Trust changes, then a separate business case will be required to gain additional establishment for each bed utilised. Nursing workforce numbers have been benchmarked against both local Trusts and peer groups Trusts adopted by the Trust when reviewing Dr Foster data Key Skills Assumptions 64% of current staff have the Critical Care Course (BSc Nursing Studies). Funding is available for 4 nurses per year and all qualified staff have access to apply for the Critical Care Course. On induction to the Critical Care Unit every nurse will have access to a mentor and will be issued with the National Competency Framework to be completed and presented at regular FBC ICCU

70 appraisal interviews. There will be a supernumerary period given to all nurses to assess their safety to practice in Critical Care before joining the shift rota. 60% of current staff have the Mentorship Course and all qualified staff have the opportunity to apply. The unit also has a band 7 Professional Development Nurse to support the education and development of trained staff and nurses in Critical Care Unit Adjustments since Outline Business Case The nursing workforce in place at the time of submission of the OBC was recognised as not fully meeting the WMQRS standards in place at that time. The Trust has subsequently agreed to address this issue and in 2013/14 has funded an enhanced nursing workforce to ensure compliance of the service. This is reflected in the workforce profiles in the table below and section Table 6-1: Nursing Workforce Adjustments 2011/ / /14 Budget Budget Actual Budget Budget Actual Budget Budget Nursing WTE WTE WTE Band 8a ,435 50, ,930 Band , , , , ,510 Band , , , , ,093 Band ,556,999 1,416, ,593,089 1,580, ,752,166 Reg. bank & agency 44, ,255 7, ,965 - Band , , , , ,833 CSW bank & agency 22,275 55,886 Clerical Clerical Band 2/ ,893 66, ,993 51, ,816 Clerical bank TOTAL ,571,860 2,768, ,588,360 2,851, ,787,348 The above table shows the change in the Nursing workforce since 2011/12 (as outlined in the OBC). The budget remained unchanged in 2012/13 but the pressures on the workforce continued and at the end of the year the budget was overspent by 263k. In 2013/14 the decision was made across the Trust to base the budget on 2012/13 forecast outturn, adjusted for the premium due to bank and agency usage and address WMQRS compliance. This resulted in additional funding for the two units of 199k; the overall workforce was reviewed with the Matron and the skill mix re-aligned to produce a net increase of 3.18 WTE an increase of 5.74 WTE registered nurses and reduction of 2.52 WTE Support Workers Workforce profiles April February 2015 The workforce model reflects nursing and support staff, though excludes medical staff. The table below summarises the total workforce requirement, excluding Medical Staff for the Unit and compares it with the existing budget. FBC ICCU

71 Table 6-2: Projected Workforce Profile for ICCU Budget Budget WTE Nursing budget 2011/12 (as per OBC) ,571,860 Increase 2011/12 to 2012/13-16,500 Nursing budget 2012/ ,588,360 Increase 2012/32 to 2013/ ,988 Nursing budget 2013/ ,787,348 Savings achieved by integrating 2 units (3.58) (112,382) Budget for an Integrated Unit of 13 beds ,674,966 Increase to reflect new model, acuity, occupancy and activity ,807 Budget for the proposed Integrated Unit ,803,773 Net Change over 2013/14 Budget (0.23) 16,425 The main points to be drawn from the above table are as follows: When the current ITU and HDU are combined to form a 13 bedded unit (the current bed complement) there will be a saving of 112k pa; this is based on 5 x Level 3 beds and 8 x Level 2 beds; Increasing the unit to 16 beds (8 x Level 3 beds and 8 x Level 2 beds) and assuming an average 80% occupancy level results in a manpower saving of 0.23 WTE but a cost of 16k pa. This is because there will be a marginal skill mix change from Band 5 to Band 6 resulting in a reduction in WTE of 0.23 WTE but a minor increase in cost of 16k which will be absorbed by the Division; Based on the articulated assumptions, projected activity and case mix based on current experience, occupancy of 80% and skill mix requirements the establishment for the Integrated Unit is calculated to be Funding at this level in the event that occupancy rates or acuity changes are sustained income flow to the unit to cover the cost will be required, however it must be recognised if agency staffing is used, this is at a premium and the need to establish an internal Critical Care Nurse Bank is fundamental; and, As stated above, the staffing is based on 8 Level 3 beds and 8 Level 2 beds at 80% occupancy. Any change in this mix would impact on the manpower requirement. For example, changing 1 Level 2 Bed to a Level 3 would result in an increase of 2.79 WTE and have an increase cost of 102k pa, which will require monitoring closely and reviewed prior to budget settings annually. 6.3 Workforce Project Migration Plan Effective change management The Trust s Organisational Change Policy will form the basis of the change management ensuring that staff side are kept fully informed and engaged with the change and that staff are fully supported. Communication with staff side will be made through the monthly Joint Negotiating Committee (JNC). FBC ICCU

72 The new unit will see a reduction in the number of the band 2 Clinical Support Workers from 8.09 WTE to 5.58 WTE. This will be supported by the Trust s Management of Change process Implementation Plan During the development of the new unit, it is advised that there would be an extra transitional cost due to training and development of staff, therefore this would be supported by a 12 month secondment post for a further Professional Development Nurse (6 months 0.50 WTE followed by 6 months 1.00 WTE). 6.4 Consultation and Engagement The workstream leads for this project use the Critical Care Operational Group forums held every 6 weeks to Consult and engage with all the service stakeholders within the Trust. The project is a standing agenda item on the following monthly team meetings: Critical Care Staff; Anaesthetic Consultants; and Clinical Audit. Any issues/feedback raised at these meetings is fed to the Critical Care Operational Group whom report to the Care Group meeting and then feed into the Division of Surgery Divisional Board meeting Critical Care Services produce a newsletter for the unit on a quarterly basis for all members of staff. A noticeboard has been identified in the two current units where information will be displayed related to the new unit accordingly and is updated. FBC ICCU

73 7 The Proposed ICCU Solution 7.1 The Functional Content The proposed solution sees the establishment of an Integrated Critical Care Unit in the former West Wing Main Entrance. The current service provision for HDU is an 8 bedded facility located within the West Wing adjacent to the A&E Department. Whilst the intension of having two 4 bedded areas is to support single sex areas, from time to time within a 4 bedded area will be mixed sexes, which although compliant with the standards is contrary to maintaining dignity for patients. The current facilities within HDU therefore, are poor from the environmental perspective having limited space for relatives and visitors and storage of medical equipment. The current ITU is located on Level 02 within the West Wing and it provides No.6 beds and an isolation room. Similarly to HDU there is insufficient space to meet the modern clinical needs and has poor privacy and dignity for the patient. The outline business case proposes a 16 bedded solution for ICCU, however there are a number of derogations from HBN 57 in respect of rooms being undersized. In order to respond to the need for additional beds to meet potential predicted growth and capacity, the layout has now been agreed for an 18 bedded solution, as previously discussed. This FBC is written on the basis that the built solution will be for 18 beds however the unit will be equipped for 16 beds from point of opening. Expansion to 18 beds will only occur following Board Approval and further business case to be increasing workforce/staffing and equipment. 7.2 Design Summary The provision of a single facility for ICCU within the former Main Entrance of West Wing will support more efficient utilisation of resources as patients move between level 2 and level 3 care conditions within a single clinical area. The ICCU solution provides an 18 bedded solution with an overall footprint of 1360m 2. This area is in part a refurbishment of the former Main Entrance, but is also a significant new build extension which necessitates the demolition of the entrance canopy and uses part of the former ambulance slip road. Within the functional layout there are 9 bed bays including 2 which will be provided as isolation single en-suite rooms. In addition there are 9 open plan bays, all approximately 20m 2. The unit is accessed from the Hospital Street Corridor at Level 02, of the West Wing with a discreet access for patients and staff which will have access control. There is a further access/egress on Hospital Street Corridor intended for alternatively fire purposes only. In addition to bedded areas the accommodation include 4 clean and dirty utility rooms, equipment and storage facilities, doctors/ matron offices as well as patient and relative facilities; including interview rooms, sitting rooms and assisted toilets. FBC ICCU

74 A new link corridor is formed to provide access to the switchboard from the Hospital Street Corridor This replicates previous access arrangements between the main Hospital Street and external car park areas which have been lost due to the new development. This is illustrated in the drawing below. Figure 7-1: Proposed Development- Switchboard Access Design Context Walsall Healthcare NHS Trust currently provides critical services from a number of locations on the Manor Hospital site within the retained estate which is circa 30 years old. As a result, the design for the proposed Integrated Critical Care Unit is centred on the core principle of integrating Intensive Therapy Unit and the High Dependency Unit within one functional area where the service can benefit from the modern facilities and equipment, but also from staff benefits from the two units working together for the first time. Such integration will allow not only for increased efficiency in the delivery and quality of the service provided, but will also allow for cross fertilisation of ideas and practices leading to improved services for patients Design Layout External There are a number of physical factors which have influenced the approach to the new department s presence on site. Firstly the location proposed within the former main West Entrance of the hospital is currently not well utilised and offers the ideal platform for a development with only a small new build area to support the schedule of accommodation. Secondly it supports the overall site development plan by maximising utilisation of the former entrance and will free up space particularly the current HDU area to support further FBC ICCU

75 clinical developments; in this case specifically future development of the current A&E Department. The proposed development area is shown in Figure 7-2. This illustrates the changes to the external fabrication of the building. Figure 7-2: Proposed Developed Location- West Wing A number of site environmental factors have been taken into account to maximise natural daylight into patient areas and ensure there is suitable privacy and dignity to patient groups by careful design of external areas. Because of the close proximity to the current Accident and Emergency Department, Imaging and MRI drop off areas, significant attention to the construction methodology has been incorporated to ensure site disruption is mitigated. Pedestrian and vehicular movements have been studied to ensure the optimum approach to the building is maintained at all times. Careful attention has been given to the external facade to ensure optimum blend between the different cladding and brickwork finishes between the recent Outpatients section of the hospital and the retained estate. The assurance of the continual use of the current Blue Light Route is also provided. Both during construction and at final solution, the Blue Light Route will be undisrupted. The drawing below illustrates the red line drawing where the unit will be developed in relation to the entire site. Figure 7-2: Proposed Location on Main Hospital Site FBC ICCU

76 7.2.3 Design Layout Internal The design principles that underlie the arrangement of the accommodation of the ICCU is that there is a fully flexible working environment across the department to support the clinical stay of patients. To support this there are nine single bedded rooms two of which are isolation rooms on one half of the template all of which have natural daylight. A staff base with glazed partitions separates the remaining nine bedded bay to ensure there is optimum visibility of patient head positions for observation purposes. All bed positions have a ceiling mounted pendant to support medical equipment and monitoring units along with a range of medical gases. From the hospital street there are two entrances to the department one intended for staff and relatives which seek to provide such supporting accommodation in a discrete area away from direct patient areas. Thereafter there is access for patients direct into the bedded areas. A pictorial representation of one of the bed facilities is illustrated in Figure 7-4 and Figure 7-5. Figure 7-3: Single Bed Bay View FBC ICCU

77 Figure 7-4: View into the Unit In addition to the essential complimentary accommodation the facility also provides designated sitting room and toilets for relatives and visitors From the onset the department will be complete with 18 bed spaces all equipped with pendants and medical gases albeit the department will be staffed for 16 fully functioning Level 2/3 beds at 80% occupancy. The environment provision is such that should there be future agreement to staff the full bedded compliment of 18 beds, it will cause no disruption to the department i.e. only loose equipment will need to be purchased and commissioned. Physically beneath the ICCU floor of accommodation are other departments which will need to vacate due to construction noise/vibration notably including Ward 8 and the implications have been carefully considered in the construction programme to mitigate this impact Design Development OBC to FBC Since the submission of the Outline Business Case the design of the ICCU has changed to reflect the need for two additional beds. FBC ICCU

78 The ramifications of the Mid Staffordshire NHS Trust has been to future proof the layout with a limited degree of future flexibility and increase form the OBC 16 bedded solution to the latest 18 bedded FBC solution. Inevitably this means in terms of the building footprint it has grown during the development stages and therefore there is a cost increase in capital terms due to this factor. The key driver has been to support flexibility in the environmental solution providing appropriate space, medical equipment and medical gases to support patients throughout their stay in the unit. In moving from OBC to FBC stages, detailed design has identified a number of significant factors which have contributed to an increase in costs because of the complexities of delivering the scheme in the West Wing location. These factors include: Substantially more complicated and extensive foundations following site investigations and surveys. This includes more extensive piling than originally envisaged; Increase in steel work requirement to the frame following design; Roof scope more extensive than envisaged; Substantially more complicated and extensive drainage requirement following site investigations and survey; Increase in mechanical and electrical scope of works; and, Remedial works to grouting of disused mineshafts following detailed survey works. Overall, the capital costs submitted by the PFI Contractor reflect the design solutions provided and have largely been proven throughout market testing. To support the BREEAM assessment, it is proposed to re-commission the biofuel storage tank pump set and burner pipework, to support tri-fuel burning options to steam raising boiler plant Planning Statement The Trust has submitted a full planning application to Walsall Borough Council and has received formal written notification that the application has been successful. The conditions attached to the successful award relate to the usual planning conditions relating to submitting the materials for the faced, the soft landscaping, drainage details and access arrangements. An ecology study has already been undertaken along with trial holes adjacent to the building and previous mine shafts have been identified ready for further action ahead of a formal start on site to make necessary enhancements BREEAM and AEDET Assessments The draft BREEAM Pre-assessment indicates that the following minimum score has been targeted: 61.47% with all relevant mandatory credits also targeted; FBC ICCU

79 A further 15.59% of potential credits have also been identified which could boost the score further but also act as a back-up in case targeted credits are lost through unforeseen circumstances. The draft BREEAM Pre-assessment Estimator has been attached as part of the Estates Annex and key anticipated BREEAM provisions for the new development are summarised below under each BREEAM issue category: Management- 18 credits have been targeted here to help ensure the Very Good rating. Site works will be undertaken in accordance with the Considerate Constructors Scheme (CCS), with construction site impacts monitored and managed. Appropriate commissioning and seasonal commissioning of building services will be undertaken, and a non-technical building user guide prepared along with monitoring and recording of energy and water data 12 months after handover. Relevant consultation undertaken with the local community, hospital, Trust and building users is anticipated, along with a post occupancy assessment and access and design strategy for all types of ability and mobility. Health & Wellbeing- The hospital will want to promote a safe and secure environment where patients and staff can feel supported, and safe pedestrian and cyclist access will be encouraged. A high quality internal environment is also proposed including a good view out, occupant controls for lighting, heating, energy efficient lighting, and glare using blinds. Thermal comfort will also be considered to ensure a high standard of space. Energy- 8 credits have been targeted in this section to help ensure the Very Good rating including the mandatory credits. The development will be designed to meet 2010 Building Regulations Part L, but going beyond this to be a more efficient building. Energy consumptions will be submetered, energy lighting is proposed and on-site zero or low carbon energy technology are anticipated to reduce CO2 emissions. Transport- The location of the hospital ensures good access to public transport facilities such as bus stops and also local amenities. Cycle parking is proposed and a travel plan will be prepared for building users. We understand any new car parking spaces will be minimised. Water- Efficient fixtures and fittings will be specified to ensure low water consumption for the building, with water supplies metered and monitored. A water efficient irrigation strategy for any external planting and landscaped areas will be through native species and the use of natural precipitation topped up by manual watering when required. Materials- Construction materials including insulation (both for the buildings and the hard landscaping/boundary protection) with an appropriate Green Guide rating will be specified and sourced responsibly to help minimise their environmental impact, and the building will be designed for robustness in areas of high use. FBC ICCU

80 Waste- Construction waste will be managed and minimised under a Site Waste Management Plan and appropriate space will be provided for the storage and collection of recyclable operational waste streams for the completed building. Land Use & Ecology- A landscaping/planting strategy will be prepared to deliver ecological enhancement and longterm biodiversity benefits, where possible. Pollution- Night time light pollution will be avoided through the appropriate design and control of external lighting. The development site is at low risk of flooding, and surface water run-off will be attenuated. Lastly, any additional noise from the new development will be measured and attenuated where required. Exemplary- A number of Exemplary Credits have also been identified going beyond best practice and standard BREEAM requirements in terms of monitoring and recording energy and water data 3 years post construction, and CCS. It needs to be noted that changes to currently anticipated BREEAM credits may arise during detailed design, although the developer is committed to delivering the required BREEAM rating. Formal Design Stage and Post Construction Stage BREEAM assessments and certifications will be undertaken in due course to formally demonstrate the achieved BREEAM rating and the various contributions of the project to the sustainable development agenda and the client s requirements Effective change management As part of this project, a protocol has been developed to facilitate objective, informed submission, analysis and conscious decision making in relation to all identified Project Issues which could alter the scope of the Integrated Critical Care Unit (ICCU) Project. It is also intended to ensure that the acceptance of changes arising from Project Issues are controlled within the financial approval parameters taking due cognisance of the Project s contingencies and allowances. Throughout the design and construction process, assurance has been agreed within the ICCU Steering Group, that the requirement of a robust change control process is in place. The protocol is based on the preparation and review of a Request for Change form for requesting and documenting changes to the Project (e.g. adding new features) or to elements within the Project (such as changing a major specification of a piece of a system, product, or other deliverable). It includes fields for impact of the proposed change on the project timeline, budget etc., and on the components of the Project deliverables. Appendix 7a Change Management Process was approved by the Steering Group and ratified to manage all the listed assurances. FBC ICCU

81 7.3 Enabling Schemes In order to support the above development, the former main entrance area needs to be completely vacated which necessitates a series of enabling moves. The key areas to note include are: Trauma and Orthopaedics Consultants and Secretaries to move to office Route 109; Rheumatology Consultants and Secretaries to move to office Route 109; League of Friends Shop to move to West Wing Corridor; Post Room to move next General Office; and, To enable the list above to vacate the area, other departments across the main hospital site have had to relocate. These are tabled below: Table 7-1: Additional departmental moves Department Relocating Area From New Location Dieticians Office Room Town Wharf Trust Management Admin Team Office Route 109 Office Room Tissue Viability Office West Wing Level 01 Town Wharf From the above it can be seen that refurbishment of Town Wharf is a critical part of the enabling works - this itself taking over 2 months to complete. All the above enabling schemes need to have been concluded by January 2014 to support onsite with the main scheme. 7.4 Scheme Impact Due to the nature of the work activities, to support the ICCU scheme on Level 02 West Wing, areas beneath the contract site will also be affected either through noise and vibration or by the need to have construction activities taking place. Specifically this involves Ward 8, The Chapel and Staff Change Facilities. Construction activities within Ward 8 and The Chapel specifically, will see the need for the removal of all general lighting and suspended ceiling systems to enable new drainage systems to be installed. Furthermore in Ward 8, the gable end section of the wall will need to be removed to support the installation of new structural steel work. Preparation has been put in place to support the temporary decant of the Chapel to its secondary Prayer Room/Multi-Faith Facility adjacent to the Board Room, Route 127 By the nature of the flying link then daylight to Ward 8 and The Chapel will be severely affected. The scheme currently allows for the reinstatement of Ward 8 to its original state, however there is still an opportunity for the Trust to consider the re-provision of this space. FBC ICCU

82 7.5 Construction Programme The proposed construction programme anticipates all the enabling schemes to be completed by March This allows site set-up by way of securing the contract area during February and March During this period there will be the opportunity to see the former entrance area fully decommissioned/decontaminated and any further exploratory works (Asbestos Type 3 Intrusive Survey) to be carried out. The main construction activities will commence in April 2014 and it is anticipated that there will be a 12-month construction contract with a further month for commissioning activity. The overall completion date is scheduled for summer It is currently anticipated that Ward 8 will need to close and be de-commissioned from mid- February 2014 and not brought back into use for patient activity until September Operational Policies and Service Improvements Operational Policies Clinical teams have been developing a new operational policy which reflects new ways of working to support an integrated unit in turn, leading to an improved patient journey. The operational policy has been established with key strategic partners and includes best practice guidance supported by WMQRS Implementation & Embedding It is anticipated that the new operational policy will have strong professional support to suitably embed when the new facility becomes fully operational. Whilst the facility will be equipped for 18 beds in total (other than loose equipment), when it is commissioned, it will be staffed for 16 beds at 80% occupancy. 7.7 Equipment By connecting Clinical Leads and the Design Team, effective equipping within this clinical and specialist unit has recognised a number of outcomes that the Equipment Workstream have addressed. These include: Recognising the definition of equipment requirements; Ensuring all rooms will be fit for purpose and that the equipment will fit; Designating which equipment can be re-used (transferred) and what will need to be replaced or purchased from new; The provision of appropriate supporting services in each room, such as electrical, gas and deionised water; Obtaining predictable equipment costs; and, Management of the procurement process. FBC ICCU

83 In view of the importance of these issues, the Project Steering Group has put in place a structure to proactively manage them at an early stage via a Work Stream Project Group. As previously stated, this has members that are Clinical Leads to the unit as well as connections to Estates and Facilities Division and the Design Team. The approach to the provision of the equipment (technical/clinical and furniture) for the new development has sought to utilise appropriate funding streams including: Use of the Trusts equipment Replacement Programme; and, Equipment allocation within the Capital Costs Vision The vision for the new unit has focused particularly on the need for careful selection of the pendants and patient monitoring systems. The clinical teams have been fully involved in the selection process for both of these key items and completed the formal evaluation of a range of supplier Equipment Planning In planning for this project, the Equipment Work Stream has worked closely with the Estates and Facilities Division and Architects to ensure that the most appropriate technology will be incorporated into the new building which will facilitate ensuring efficiencies and sustainability to the organisation. The key tasks which have been addressed are as follows: Identifying the required equipment for the new unit; Identifying equipment that is suitable for transfer from existing facilities; Ensuring affordability against budget; Preparation of specifications and tenders; Planning of tender procedures; Schedule ordering and deliveries; and, Preparation of commissioning plan of complex equipment, and co-ordination of staff training. Equipment for the new Integrated Critical Care Unit has been placed into the following categories: Group 1- Equipment itemised in the building specification to be supplied and fitted by the builder or sub-contractor. Group 2- Equipment supplied by the Trust which is to be fitted in the new building by the builder or their sub-contractor. This includes fixed furniture and fixtures. Group 3- Equipment supplied by the Trust, and installed by the Trust or a Trust subcontractor. Group 3 equipment is identified as part of the Estates Annex and will be sourced in as follows: FBC ICCU

84 Equipment needs for the new unit has been reviewed by the ICCU Equipment Workstream and a list of requirements for the new unit has been produced. This list details current equipment and quantities and what additional equipment is required for the unit; and, Any additional recurring maintenance costs for additional equipment has been included against each product type. Funding for all of the medical equipment is included in the Capital Equipment allocation Equipment Project Timetable The project timetable has been drawn up to run in parallel with the construction programme as the equipment will be required for installation into the new unit in support of the extended automation and the integrated working. Through planning and reviewing, the Equipment Work Stream has been able to establish a project timetable for the purchase, installation and commissioning of equipment. This is detailed in Table 7-2. Table 7-2: Equipment Project Timetable Activity Milestones and Key Dates Invitation to Tender issued September 2013 Evaluation of Tenders and Site Visits October January 2014 Selection of preferred partner February 2014 Contract Award March 2014 Equipment design / lead time March 2014 May 2014 Installation To accord with Construction programme Commissioning To accord with Construction programme The costs of the equipment and related service contracts have been collated and are readily available. They are included in the base revenue expenditure and will not impact on the capital costs of the facility. It is anticipated that all equipment maintenance is to be managed and controlled by the Trusts Electrical Bio-Mechanical Engineers Department (EBME) within the Estates and Facilities Division Installation of Commissioning of Equipment A draft installation and commissioning programme has been produced as part of the overall construction programme. Triangulation of the Equipment Project Timetable has been carried out to ensure alignment. Confirmation will be finalised with the successful suppliers following award of the Tenders. The plan will not only cover installation of the equipment by the supplier but quality assurance. Staff familiarisation and training will also be an important aspect of the FBC ICCU

85 department and again, will be incorporated into the overall construction programme to ensure allocation of time prior to formal opening of the new unit. 7.8 Procurement Process As identified in the OBC the advice received from the Trust legal advisors highlighted that in terms of the contractual obligations of the PFI Agreement and appropriate risk distribution the appropriate procurement route for this proposal was to utilise the vehicle of Walsall Hospital Company to oversee the appointment of the main and sub contractors. This process was undertaken with the full involvement of the Trust Estates and Procurement team and included the direct market testing of a wide range of works packages. Following submission of a detailed offer, the Trust requested a Best and Final Offer, upon which the affordability of this case has been assessed. The cost submissions have been scrutinised in detail by the Trust Cost Advisors and have been subject to a variety of Value Engineering discussions which are summarised in the following section. 7.9 Capital Costs The detail of the Capital costs of 8.1m is provided in Section 9.3. A substantive report on the PFI Contractors Capital Cost has been prepared by Holbrow Brookes Construction Consultants on behalf of the Trust and is available as part of the Estates Annex. The capital costs were included within the OBC submission based upon NHS Departmental Cost Allowance Guidance (DCAG), as required by the local NHS SHA. The DCAG costs have been updated for the preferred option to reflect the proposed scheme. This is in order to provide cost data for the Trust s FBC submission, and also act as a public sector comparator against the submitted Skanska capital costs. The amendments made to the FBC capital costs are as follows: The location factor has been changed to reflect the last BCIS National Health Service Capital Planning Newsletter released in June 2013; Inflation has been changed to reflect the proposed start on site date and indexation contained in the last BCIS National Health Service Capital Planning Letter in June 2013; The on-costs have been amended to capture specific project abnormal costs identified during the design process; and, F&E has been reviewed by the Trust. To support affordability, a number of value engineering items have been considered and accounted for in the final capital cost evaluation. Having reviewed the procurement approach the Trust Cost advisor is satisfied that Skanska as the main contractor has undertaken sufficient market testing of work packages to demonstrate that based on the above adjustments- although capital costs have increased and FBC ICCU

86 the construction costs are above the capital estimates the proposal does offer value for money to the Trust Future Flexibility As detailed in Section 7.1, it is being proposed that the new development will be constructed to enable future function of a full 18 bedded unit should the need be apparent to the Trust. With this in mind, there are aspects that will be provided in the infrastructure of the expansion space. A key planning principle for the new development and the equipment procurement process is to manage future flexibility to ensure that any significant changes in demand or technology can be accommodated with minimal disruption and without recourse to physical expansion or redesign to the building. The Trust has reviewed and agreed that it is imperative to provide the unit with a full 18 pendants to avoid future disruption to the unit when the additional 2 beds are commissioned; this is also being carried out for internal works such as gas and oxygen outlets. Any other equipment and furniture however, are not being purchased and are excluded from this business case. As detailed in Section 7.1, it is being proposed that the new development will be constructed to enable future function of a full 18 bedded unit should the need be apparent to the Trust. With this in mind, there are aspects that will be provided in the infrastructure of the expansion space Key Milestones Of The Proposed Solution A key objective for the project team has been to ensure that any critical path issues are identified and managed whilst also looking to deliver the new integrated service as soon as practical. A detailed construction programme is prepared showing all the key activities (Revision 9 dated 04/09/2013). Key milestones from this programme have been extracted and detailed below in Table 7-3. Table 7-3: Key Milestones from the Construction Programme Key Milestone Start Finish Instruction To Proceed 01/01/ /01/2014 League of Friends Decanted 10/03/ /03/2014 Completion of Relocations from construction area 10/03/2014 Vacant Possession to the contractor 28/03/ /03/2015 Upgrade electrical supply 03/11/ /11/2014 FBC ICCU

87 Key Milestone Start Finish Upgrade generator available 03/11/ /11/2014 Medical Gas connecting 06/10/ /10/2014 Commence electrical integrated system 13/04/ /04/2015 Fit out Main Area 16/06/ /04/2015 Works within existing Plant Rooms 16/04/ /10/2014 Testing & Commissioning 19/03/ /07/2015 Client witness, IC and Training 09/05/ /07/2015 Commence handover process 15/07/ /07/2015 Occupation 01/08/ /08/2015 The Estates Annex contains the full detail of the proposed construction programme for the new development Match To Key Benefits and Projects Objectives The project team identified at an early stage the objectives and key benefits which the integrated project would be required to deliver. Table 7-4 provides an assessment of the fit of the proposed solution to these objectives and benefits. Table 7-4: Match of Proposed Solution to Key Benefits and Objectives Objective Integration of the ITU and HDU disciplines within a single area Re-profiling of workforce to reflect skills required for the future Key benefits Economies of scale Increased capacity for the future Improved layout and work flows Demonstration of improved efficiencies Improved accreditation compliance WMQRS Reduce wastage Value added tasks maximised Introduce new service models and operational procedures Ability to future proof the directorate with additional space for bed capacity Improved Quality Overall improved quality of the patient experience Value added tasks maximised Introduce new service models to operation procedure Ability to future proof the department Fit achieved by the proposed solution Single location and design solution provides combined integrated critical care unit Co-location will allow maximum benefit from skill mix adjustments and overall utilisation Use of combined practices will maximise process redesign benefits Space within the new facility area provides capacity for the future expansion if additional capacity is needed Co-location of support accommodation and overnight stay facilities to support improved patient care Process redesign and colocation of services will support improved care Co-location will support appropriate skill mix to ensure appropriate supervision whilst ensuring staff of the correct grade are allocated to appropriate tasks throughout 24/7 The workforce reprofiling will be FBC ICCU

88 Objective Establishment of service/facilities which can respond flexibility to internal and external changes Maximise contribution/benefit of the service to the patient experience Improved operating environment for staff Development of energy efficient buildings Key benefits Introduce new service models Ability to future proof the department Improved flow through the system Enhanced patient care Improved patient flows Reduce length of stay Greater productivity of staff Greater productivity if equipment due to reduced downtime Staff turnover/recruitment improvement Ensure value added tasks maximised Provision of a safe/secure working environment Contribution to reduction in overall carbon footprint Contribution to achievement of the DH Estates energy targets Site Rationalisation Elimination of building in poor state of repair Fit achieved by the proposed solution supported by staff redevelopment programmes including succession planning. New service models within single integrated unit will reduce duplication and eliminate non value added tasks Space within the new facility area provides capacity for the future expansion if additional capacity is needed Co-location of support accommodation and overnight stay facilities to support improved patient care Provision of Pneumatic Tube with dedicated link to Pathology Process redesign and colocation Process redesign and colocation of service/staff will reduce duplication and eliminate non-value added tasks Co-location will support appropriate skill mix to ensure appropriate supervision whilst ensuring staff of the correct grade are allocated to appropriate tasks throughout 24/7 The facilities provided will be within a purpose designed building to current standards thus providing a much improved physical environment accounting for security, training and development and general welfare. Achievement of 55GJ/100m 3 energy rating Adoption of sustainable design and construction methodologies Achievement of BREEAM Very Good Removal of buildings below condition B and require major investment to achieve condition B Reduction in Backlog Maintenance Improved energy efficiency/carbon reduction Improved functional stability FBC ICCU

89 Objective Key benefits Achievement of site Master plan Flexibility for phased site redevelopment Fit achieved by the proposed solution HDU space when available to support the A&E Redevelopment FBC ICCU

90 8 Risk 8.1 Risk Methodology The key risks of each of the short-listed options and the overall project were assessed as part of the OBC process and strategies for managing them outlined. The methodology followed is shown in Figure 8-1. Figure 8-1: Risk Assessment Methodology The process of risk analysis has therefore the following four steps: Risk identification - developing a Risk Register covering key risk areas and individual risks within these areas; Risk assessment - estimating the probability and timing of each risk occurring and the impact if it should occur; Risk quantification - putting a value to each of the risks, using the estimates of probability, impact and timing; and, Risk management - developing a plan to manage all the risks identified in the Risk Register for the preferred option, including responsible persons and monitoring mechanism. As part of the OBC process the risks relating to the preferred solution and the project as a whole have been reviewed and updated on a regular basis. FBC ICCU