An Outline Business Case for the New Emergency Centre (Phase 1) at New Cross Hospital

Transcription

1 An Outline Business Case for the New Emergency Centre (Phase 1) at New Cross Hospital FINAL OCTOBER

2 Purpose of this document This document is the Outline Business Case (OBC) in support of the first phase of an investment in a New Emergency Centre at New Cross Hospital. This is part of a wider development of the New Cross site which will provide modern facilities which are fit for purpose. The proposals outlined in this case focus on the provision of redesigned services within a new facility which will support significant operational benefits for Emergency Services within the Trust and across Wolverhampton. This case will outline the context, both national and local, against which the proposals have been planned and will detail the key drivers for change and therefore the objectives and benefits that the proposals will deliver for Emergency Services, the organisation as a whole and the local patient population. It will also confirm the affordability of the proposals for the development both in capital and revenue terms. This OBC has been prepared using the agreed standard and format for business cases using the Five Case Model, which comprises the following key components: the strategic case section. This sets out the strategic context and the case for change, together with the supporting investment objectives for the scheme the economic case section. This demonstrates that the organisation has selected the choice for investment which best meets the existing and future needs of the service and optimises value for money (VFM) the commercial case section. This outlines the content and structure of the proposed project the financial case section. This confirms funding arrangements and affordability and explains any impact on the balance sheet of the organisation the management case section. This demonstrates that the scheme is achievable and can be delivered successfully to cost, time and quality. The Trust believes that the development of this OBC and contents therein comply with Monitor s governance proposals for major investments outlined in the document Risk Evaluation for Investment Decisions by Foundation Trusts (REID). 2

3 VERSION HISTORY Version No. Issue Date Issued to Purpose 1.0 Not issued Author only Drafting th January 2013 Project Board Members Review and Amendment th February 2013 Project Board Members Review and Amendment th April 2013 Project Board Members Review and Amendment nd April 2013 Project Board Members Review and Amendment nd May 2013 Project Board Members Review and Amendment (JMcK & EW only) th May 2013 Project Board Members Review and Amendment th June 2013 Project Board Members Review and Amendment st August 2013 Project Board Members Review and Amendment and reformatting to 5 Case Model th September Project Board Members Review and Amendment th September Project Board Members Review and Amendment 2013 JMcK/EW/RM 12.0 September/ Project Board Members Review and Amendment October 2013 Final Draft 4 th October 2013 Trust Board Review (Executive Summary only) Final October 2013 Trust Board WCCG Approval 3

4 1 EXECUTIVE SUMMARY INTRODUCTION STRATEGIC CASE THE STRATEGIC CONTEXT OVERVIEW OF THE TRUST, LOCAL HEALTH ECONOMY AND KEY COMMISSIONERS OVERVIEW OF EMERGENCY SERVICES EMERGENCY SERVICES ACTIVITY PERFORMANCE WORKFORCE INCOME AND EXPENDITURE NATIONAL & LOCAL DRIVERS CASE FOR CHANGE VISION FOR THE FUTURE, CAPACITY PLANNING AND PROJECT SCOPE VISION FUTURE SERVICE MODEL FUTURE ACTIVITY PROJECT SCOPE WORKFORCE PLANNING WORKFORCE MIGRATION PLAN EFFECTIVE TRAINING AND DEVELOPMENT ECONOMIC CASE THE LONG LIST SHORT LIST NON-FINANCIAL OPTION APPRAISAL FINANCIAL & ECONOMIC APPRAISAL GENERIC ECONOMIC MODEL (GEM) CAPITAL COSTS ECONOMIC APPRAISAL

5 SENSITIVITIES CONCLUSION OF ECONOMIC APPRAISAL COMBINING THE FINANCIAL AND NON-FINANCIAL APPRAISALS THE PREFERRED OPTION COMMERCIAL CASE DESCRIPTION OF THE WORKS PROJECT TIMETABLE PROCUREMENT STRATEGY REQUIRED SERVICES POTENTIAL FOR RISK TRANSFER & POTENTIAL PAYMENT MECHANISM FINANCIAL CASE IMPACT ON REVENUE POSITION CAPITAL AFFORDABILITY MANAGEMENT CASE PROJECT MANAGEMENT ARRANGEMENTS PROJECT STRUCTURE BENEFITS REALISATION POST PROJECT EVALUATION ARRANGEMENTS RISK MANAGEMENT CONCLUSION AND RECOMMENDATION STRATEGIC CASE PART A: THE STRATEGIC CONTEXT INTRODUCTION AN OVERVIEW OF THE TRUST CLINICAL SERVICES ACTIVITY EMERGENCY SERVICES

6 2.3.1 WORKFORCE PROFILE EMERGENCY SERVICES ACTIVITY INCOME AND EXPENDITURE THE NATIONAL CONTEXT NHS OUTCOMES FRAMEWORK 2013/ A&E CLINICAL QUALITY INDICATORS THE COLLEGE OF EMERGENCY MEDICINE - CONSULTANTS, WORKFORCE RECOMMENDATIONS, APRIL NHS NHS PATIENT EXPERIENCE FRAMEWORK PUBLIC INQUIRY INTO STANDARDS OF CARE AT MID STAFFORDSHIRE NHS FOUNDATION TRUST 2005 & AMBULANCE SERVICE QUALITY INDICATORS NATIONAL REVIEW OF A&E SERVICES IN ENGLAND LOCAL CONTEXT URGENT & EMERGENCY CARE STRATEGY FOR WOLVERHAMPTON SURGE PLAN (A&E SUSTAINABILITY PLAN) FOR WOLVERHAMPTON HEALTH ECONOMY 2013/ RWT PRIORITIES FOR IMPROVEMENT 2012/13 AND 2013/ RWT HUMAN RESOURCES STRATEGY RWT PATIENT EXPERIENCE STRATEGY REGIONAL REVIEW OF STROKE SERVICES OVERNIGHT CLOSURE OF MID STAFFORDSHIRE EMERGENCY DEPARTMENT RWT ICT STRATEGY HOSPITAL SITE RATIONALISATION AND REDEVELOPMENT MARKET ASSESSMENT SWOT ANALYSIS PORTERS MARKET FORCES PART B: THE CASE FOR CHANGE

7 2.7 INVESTMENT OBJECTIVES CURRENT EMERGENCY SERVICE MODEL ACTIVITY AND PERFORMANCE TRENDS ISSUES IMPACTING THE EMERGENCY SERVICES PROVISION DEMAND ON THE EMERGENCY CARE SYSTEM INEFFICIENCIES IN CARE PATHWAYS AND SERVICE MODEL PHYSICAL CAPACITY AND ENVIRONMENT WORKFORCE EQUIPMENT & ICT GOVERNANCE, OPERATIONAL AND FINANCIAL INEFFICIENCIES ESTATES STRATEGY THE VISION FOR EMERGENCY SERVICES BENEFITS FUTURE DEMAND JOINT URGENT CARE STRATEGY AND ACTIVITY MODELLING EMERGENCY SERVICES ACTIVITY RADIOLOGY IN THE NEW EMERGENCY DEPARTMENT FUTURE CAPACITY REQUIREMENTS WORKFORCE KEY WORKFORCE PLANNING ASSUMPTIONS INTRODUCTION OF ADDITIONAL MAJORS CAPACITY AND CLINICAL DECISIONS UNIT ADJACENT TO THE EXISTING DEPARTMENT HOUR CONSULTANT COVER FOR THE EMERGENCY DEPARTMENT FUTURE WORKFORCE ESTABLISHMENT WORKFORCE MIGRATION PLAN EFFECTIVE CHANGE MANAGEMENT RECRUITMENT PLAN AND MANAGEMENT OF TEMPORARY STAFFING EFFECTIVE TRAINING AND DEVELOPMENT 81 7

8 2.17 PROJECT SCOPE FUNCTIONAL CONTENT AND SCHEDULES OF ACCOMMODATION CONSULTATION AND ENGAGEMENT STAKEHOLDERS PATIENT AND PUBLIC INVOLVEMENT HEALTH & WELLBEING BOARD KEY RISKS CONSTRAINTS DEPENDENCIES ECONOMIC CASE OPTION DEVELOPMENT LONG LIST SHORTLISTING OF OPTIONS SHORT LIST NON-FINANCIAL OPTION APPRAISAL BENEFITS CRITERIA OPTION SCORING SENSITIVITY ANALYSIS FINANCIAL OPTION APPRAISAL INTRODUCTION CAPITAL COSTS OPTIMISM BIAS UPPER BOUND ASSESSMENT MITIGATION OF OPTIMISM BIAS ECONOMIC APPRAISAL APPRAISAL PERIOD EQUIVALENT CAPITAL COSTS

9 3.5.3 SENSITIVITIES SUMMARY OF GEM AND RISK CONCLUSION OF ECONOMIC APPRAISAL COMBINING THE FINANCIAL AND NON-FINANCIAL APPRAISALS THE PREFERRED OPTION COMMERCIAL CASE INTRODUCTION REQUIRED SERVICES DESCRIPTION OF THE WORKS FUNCTIONAL CONTENT AND ADJACENCIES DESIGN PRINCIPLES EQUIPMENT ICT FUTURE FLEXIBILITY DESIGN REVIEW PANEL PLANNING STATUS EQUALITY IMPACT ASSESSMENT PROJECT TIMETABLE BENEFITS OF THE PREFERRED OPTION PROCUREMENT STRATEGY AND RISK TRANSFER ASSESSMENT OF PROCURE 21+ AND TRADITIONAL TENDERING FINANCIAL CASE INTRODUCTION CHANGES IN REVENUE POSITION REVENUE AFFORDABILITY SENSITIVITIES CAPITAL AFFORDABILITY OVERALL CONCLUSION

10 6 MANAGEMENT CASE INTRODUCTION OVERALL PROJECT MANAGEMENT STRUCTURE AND METHODOLOGY PROJECT BOARD MEMBERSHIP PROJECT RESPONSIBILITIES PROJECT BOARD PROJECT SPONSOR PROJECT DIRECTOR PROJECT CLOSEDOWN REPORT POST PROJECT EVALUATION BENEFITS REALISATION RISK MANAGEMENT KEY RISK AREAS MANAGEMENT OF RISK GATEWAY REVIEW CONCLUSION AND RECOMMENDATION

11 TABLES Table 1a: Emergency Services Activity 2007/8 to 2012/13 Table 1b: Emergency Department Attendance Shift Table 1c: Workforce 2013/14 to 2025/26 Table 1d: Impact of National Drivers on the Emergency Services Table 1e: Impact of Local Drivers on Emergency Services Table 1f: Principles of the New Service Table 1g: Future Emergency Services Activity 2013/ /26 Table 1h: Benefit Criteria and Option Scores - Weighted Table 1i : Capital costs for short-listed options Table 1j: Equivalent Capital Costs for the Generic Economic Model Table 1k: Summary of revenue costs for each option Table 1l: Summary of Economic appraisal Table 1m: Summary of Financial and Non-Financial Appraisals Table 1n: Key Milestones Table 1o: 5 year Capital Programme Table 2a: Clinical Services Table 2b: Acute Hospital Activity Profile (Spells) 2010/11 to 2013/14 Table 2c: Community Activity Profile 2011/12 to 2013/14 Table 2d (i):workforce Establishment (WTE) for Clinical Staff in Emergency Department Table 2d (ii)workforce Establishment (WTE) for Nursing Staff in Emergency Department Table 2d (iii)workforce Establishment (WTE) for Clinical & Non-Clinical Support Staff Table 2e: Emergency Services Activity 2007/8 to 2012/13 Table 2f: Emergency Department Activity 2013/14 by Commissioner Table 2g: Radiology Activity related to the Emergency Department 2007/08 to 2012/13 Table 2h: Radiology Activity split between Emergency Department & Main Radiology Department for 2012/13 Table 2i: SWOT Analysis Table 2j: Emergency Department Attendance Shift Table 2k: Emergency Department Activity Change and Performance against the 4 hour wait target for Type 1 and Type 1 and 3 combined Table 2l: Current Estates Performance Indicators Table 2m: Principles of the New Service Table 2n: Key Benefits Table 2o Emergency Services Activity 2012/ /26 Table 2p: Anticipated changes to Workforce 2013/14 to 2025/26 Table 2q: Key Risks and Mitigations Table 3a: Benefits Criteria Definitions Table 3b: Benefit Criteria Weighting Table 3c: Option Scores- Un-weighted Table 3d: Option Scores- Weighted Table 3e Inputs to GEM Table 3f: Summary of revenue costs for each option Table 3g: Capital costs for short-listed options Table 3h: Optimism bias for short-listed options Table 3i: Equivalent capital costs for the GEM Table 3j : Evaluation results Table 3k: Table 4a: Summary AEDET Scores Table 4b: Key Milestones Table 5a: Full Impact of Additional Annual Costs Summary of Financial and Non-Financial Appraisals Table 5b: Summary of I&E Impact in first full year of operation (2016/17) Table 5c: Breakdown of Capital Charges for each Option 11

12 Table 5d: Affordability Statement for Preferred Option (2013/14 pay and prices) Table 5e: Affordability Statement for Preferred Option (including inflation and staff deflator) Table 5f: Affordability Statement for the Sensitivity Scenario less potential primary care activity (2013/14 pay and prices) Table 5g: Affordability Statement for the Sensitivity Scenario of increased activity for Stafford and surrounding areas (2013/14 pay and prices) Table 5h: Affordability Statement for the Sensitivity Scenario less potential primary care activity and increased activity for Stafford and surrounding areas (2013/14 pay and prices) Table 5i: Affordability Statement for the Sensitivity Scenario of capital costs increasing by 10% Table 5j: Income less direct expenditure for each sensitivity compared to base case for Option 5 Table 5k: 5 year Capital Programme FIGURES Figure 1a: Current Service Model Figure 1b: Emergency Department Attendances Figure 1c: RWT Emergency Department Position against 95% achievement of 4 hour turnaround target since 2004 Figure 1d: Future Service Model Figure 1e: Project Management Structure Figure 2a: RWT Human Resources Strategy Figure 2b: Current Service Model Figure 2c: Emergency Department Attendances Figure 2d: Emergency Department 4 hour Performance against 95% target since 2004 Figure 2e: Number of Ambulances Monthly 2011/12 and 2012/13 Figure 2f: Future Service Model Figure 4a: Site Context for the Preferred Option Figure 4b: ICT Framework Figure 6a: Project Management Structure 12

13 GLOSSARY OF TERMS Abbreviation AEDET AMU BREEAM CDU CQUIN CSU CT EAC ED FBC GEM GMP HBN HTM I&E IBP KPI LOS LTFM MES MRI NPC NPV OBC OJEU PAU PCT PFI PSCP PUBSEC.BIS FP QIPP RWT SAU SES & SPCCG WCCG Full Title Achieving Excellence Design Evaluation Tool Acute Medical Unit Building Research Establishment Environmental Assessment Clinical Decisions Unit Commissioning for Quality and Innovation Commissioning Support Unit Computed Tomography Equivalent Annual Cost Emergency Department Full Business Case Generic Economic Model Guaranteed Maximum Price Health Building Note Health Technical Memorandum Income and Expenditure Integrated Business Plan Key Performance Indicator Length of Stay Long Term Financial Model Managed Equipment Service Magnetic Resonance Imaging Net Present Cost Net Present Value Outline Business Case Official Journal of the European Union Paediatric Assessment Unit Primary Care Trust Private Finance Initiative Principal Supply Chain Partner Public Sector, Dept. for Business Innovation & Skills Firm Price (Tender Price Index of Public Sector Buildings (Non-housing) Quality, Innovation, Productivity and Prevention Royal Wolverhampton NHS Trust Surgical Assessment Unit South East Staffordshire and Seisdon Penninsula Clinical Commissioning Group Wolverhampton Clinical Commissioning Group 13

14 1 EXECUTIVE SUMMARY 1.1 Introduction This Outline Business Case (OBC) outlines the Trust s intention to invest 28.7 million in the provision of a new Emergency Centre and the associated redevelopment of its Emergency Department. This case will outline the context, both national and local, against which the proposals have been planned and will detail the key drivers for change and therefore the objectives and benefits that the proposals will deliver for Emergency Services, the organisation as a whole and the local patient population. It will also confirm the affordability of the proposals for the development both in capital and revenue terms. 1.2 Strategic Case The strategic context New Cross Hospital is operated by The Royal Wolverhampton NHS Trust and is located in the Heath Town area of the city of Wolverhampton. The Trust operates a full range of clinical services at community, secondary and tertiary levels. The New Cross hospital site comprises a range of clinical and support facilities which vary significantly in terms of age and functional suitability. The organisation s key objective is to deliver high quality, effective and efficient patient care. In order to achieve this, the Trust has established a strategic vision for the reconfiguration of a number of core clinical services plus the redevelopment of the New Cross Hospital site to provide modern facilities which are fit for purpose. To this end a Planning Application for the redevelopment of the New Cross site was submitted to Wolverhampton City Council and received approval in This included outline planning approval for a new Emergency Centre. The proposals outlined in this case focus on the provision of redesigned services within a new facility which will support significant operational benefits for Emergency Services within the Trust and across Wolverhampton. As the Trust intends to fund this development from internally generated funds the new facility will be provided on a phased basis. Consequently, this Business Case supports Phase 1 of the development but will also outline the Trust s vision for the transformation of Emergency Services and provide details on subsequent phases of development. Phase 1 includes a new Emergency Department and supporting ambulatory and diagnostic facilities together with a new primary care centre to ensure patients receive the right care, at the right time by the right clinician Overview of the Trust, Local Health Economy and Key Commissioners The Royal Wolverhampton NHS Trust was established in 1994 and is a major acute Trust providing a comprehensive range of services for the people of Wolverhampton, the wider Black Country, South Staffordshire, North Worcestershire and Shropshire. It gained Cancer Centre status in 1997, was designated as the 4 th Regional Heart & Lung Centre during 2004/05 and became one of the first wave Bowel Screening Centres in The Trust is the largest teaching hospital in the Black Country providing teaching and training to around 14

15 130 medical students on rotation from the University of Birmingham Medical School. It also provides training for nurses, midwives and allied health professionals through wellestablished links with the University of Wolverhampton. With an operating budget of circa 385 million the Trust is one of the largest acute providers in the West Midlands having more than 800 beds on the New Cross site including intensive care beds and neonatal intensive care cots and 82 rehabilitation beds at West Park Hospital. As the second largest employer in Wolverhampton the Trust employs more than 6,500 staff. In April 2011 the Trust completed a successful transaction to integrate with the community services from Wolverhampton City PCT. The Trust adopted a model of full integration within the existing clinical and corporate structures to ensure that models of service delivery drive quality of service, patient experience and efficient use of resources. The integration also ensures the long term sustainability of a wide range of services for local people. The Trust serves a core catchment population of around 335,000 for its secondary care services and around 1,000,000 for its tertiary services. The Trust provides a comprehensive range of community, acute and specialist/tertiary services from the following locations: New Cross Hospital secondary and tertiary services, Maternity, Accident & Emergency, Critical Care, Outpatients West Park Hospital rehabilitation inpatient and day care services, Therapy services, Outpatients More than 20 Community sites community services for children and adults, Walk in Centre, Therapy and Rehabilitation services Wolverhampton Clinical Commissioning Group (WCCG) are the Trust s main commissioner of services and the coordinating commissioner for acute and community services on behalf of other local associate commissioners Overview of Emergency Services The current Urgent Care system in Wolverhampton includes the following services: One hospital provider (Royal Wolverhampton NHS Trust) providing emergency care at New Cross Hospital; Two walk in centre providers across the city: Phoenix Walk In Centre, provider RWT; Showell Park, provider Docs on Call; One out of hours provider (Primecare); Forty eight (48) GP practices. Currently there are several emergency portals provided by RWT to which patients can present, depending on the mode of referral. These emergency portals are: Royal Wolverhampton NHS Trust Emergency Department: (self-referrals; 999 ambulance referrals; some GP referred patients; Trauma and Orthopaedic referrals; Ophthalmology referrals and self-presenters) 15

16 Acute Medical Unit (AMU): (GP referred medical patients; referrals for urgent Haematology/Oncology admissions from other specialty outpatients e.g. referrals; Renal referrals; A/E referred medical patients for admission) Surgical Assessment Unit (SAU) Paediatric Assessment Unit: (GP referred children; A/E referred children; some selfreferrals). In addition to the above, emergency obstetrics and gynaecology (GP referred) is provided for in the Women s Hospital. Urgent ENT/Maxillo-facial assessment is available in the Outpatient Department during normal working hours. Hot clinics e.g. Respiratory, Cardiac, Ambulatory Assessment Area; Heart & Lung Centre Phoenix Walk In Centre These emergency portals are generally staffed by their own dedicated nursing and medical teams and have their own 24 hour emergency medical rotas. For the purposes of this project the re-provision of emergency care relates to the following specialties: Emergency Department Acute Medical Unit General Medicine (all specialties including oncology/haematology) Ophthalmology The Emergency Department is the first step in the pathway of emergency care often for patients who have complex needs and are at their most vulnerable. It is the shop window of the Trust for the emergency patients and their carer s. 16

17 Figure 1a shows diagrammatically the patient flows within the current service. Figure 1a: Current Service Model EMERGENCY DEPARTMENT (A&E) GPs Walk In URGENT CARE SERVICE Social Care SERIOUS ILLNESS & INJURY Ambulance Minor Illness Minor injuries Out of hours face to face Psychiatric Care Limited Diagnostics Specialty Wards/Stroke Heart & Lung Centre Ambulatory Assessment Units Medical, Surgical & Paediatrics (AMU, SAU, PAU) DISCHARGE +/- FOLLOW UP The current model can be defined as:- Traditional; Slow with time wasted between steps; Leads to duplication; Collaborative working difficult due to poor adjacencies; Care plan and investigations developed following transfer from ED. 17

18 Emergency Services Activity Table 1a shows the historical change in emergency services activity across the health economy since 2007 Table 1a: Emergency Services Activity 2007/8 to 2012/13 Year New Cross ED Attendances Walk-in Centre Attendances New Cross Assessment Unit Activity Phoenix Centre Showell Park Acute Medical Unit Surgical Assessment Unit Acute Medical Unit Ambulatory 2007/8 98,510 14,224 6, /9 99,944 24,223 7, /10 98,898 32,441 9,720 7, /11 98,288 29,137 21,395 4,059 1,888 2, /12 101,303 29,848 25,479 3,987 2,732 2, /13 106,836 36,186 29,009 3,192 2,730 2,417 Figure 1b and Table 1b show the shift in attendances to the New Cross Emergency Department from 2004 to Since 2004 monthly attendance has increased from 5816 (January 2004) to 8718 (January 2013). ED attendances have increased by more than 5% between financial years 2011/12 and 2012/13. Figure 1b: Emergency Department Attendances A&E Attendances since

19 Table 1b:- Emergency Department Attendance Shift January 2004 January 2013 Increase Monthly attendances (patients) Average daily attendances (patients) Since October 2012, the number of ambulances conveyed to RWT has also increased by over 5.8% against a West Midlands average of 1.1% Performance Until two years ago ED performance at RWT against the 4 hour turnaround target was consistently amongst the best in the Country. However, since this time, RWT performance, in common with other Trusts, has fallen. Figure 1c shows the RWT performance against the 95% target for 4 hour turnarounds since Figure 1c: Emergency Department Position against 95% achievement of 4 hour turnaround target since % 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% 84.00% A&E 4 hr % Performance since Workforce Table 1c includes the workforce numbers (Whole Time Equivalents) by band and discipline for 2013/14. These numbers include the planned expansion for 2013/14 which has been approved to support interim additional majors capacity and Clinical Decisions Unit (CDU) planned to be open by November

20 Table 1c: Workforce 2013/14 to 2025/26 Post April /14 Planned 2014/ / / / / / / / / / / /26 Total ED - Consultants ED - Other Medical Staff ED-ACP's (8a, 8b & 7) ED - ENP ED - Nursing ED - Nursing (Ophthalmology) ED - Ancilliary ED - Admin AAA - Nursing 5.28 (5.28) 0.00 AAA - Admin 1.13 (1.13) 0.00 Therapies Radiology - Consultants Radiology - Other Medical Staff Radiology - Nursing Radiology - Radiographer Radiology - Sonographer Radiology - Technician Radiology - Admin Porters (0.80) Domestics Med Physics TOTAL (4.41)

21 Income & Expenditure The Trust s baseline (2014/15) income and expenditure associated with the provision of emergency services is as follows: Income million Pay million Non Pay million This equates to a contribution of 3.456m before capital charges at 2014/ National & Local Drivers The strategic drivers for this investment and associated strategies, programmes and plans are as follows: The need to redevelop the New Cross site. This represents part of Stage 1 of the Trust s redevelopment plan; The need to address local strategies and developments in relation to: o Modernisation of emergency services; o Integration of emergency services; o o Demand for emergency services; Flexibility to changes in demand (e.g. increases as a result of developments in the hyper acute stroke service and Stafford); and, The need to ensure that the Emergency Department can deliver national priorities and indicators. Those national drivers and priorities of particular relevance to the model of emergency service delivery are included in Table 1d. This table shows where these drivers impact the emergency service. Table 1d: Impact of National Drivers on the Emergency Services Driver NHS Outcomes Framework Activity Clinical Performance Patient Experience A&E Quality Indicators Staffing Facilities College of Emergency Medicine Consultants Workforce NHS 111 Francis Report NHS Patient Experience Framework Ambulance Service Quality Indicators National Review of A&E Services in England 21

22 Against the national background there are also a significant range of local drivers for changes at a regional, health economy, Trust and departmental level which underpin the proposals for the future of the Emergency Services. These are listed again along with their impact on Emergency Services in Table 1e. Table 1e: Impact of Local Drivers on Emergency Services Driver Activity Clinical Performance Patient Experience Staffing Facilities Joint Urgent & Emergency Care Strategy Trust Priorities for Improvement Surge Plan (A&E Sustainability Plan) for Wolverhampton Health Economy 2013/14 Regional Review of Stroke Services Overnight Closure of Stafford General Hospital Trust ICT Strategy Hospital Site Rationalisation and Redevelopment Case for Change As previously stated there are several emergency portals at New Cross Hospital which have their own dedicated staff and have their own 24 hour emergency medical rotas. The model of care varies from portal to portal resulting in unnecessary duplication of work including duplication of diagnostic tests when patients are referred between portals as part of the current pathway process. Different access times to diagnostics are also experienced. Multiple access points result in duplication of skill base, and there is a high level of complaints regarding excessive waiting times in some of the portals. Patient safety is compromised with patients often having to wait in corridors. At a time of growing emergency activity (8% increase in ED attendances over 5 years excluding walk in centres and 5% increase in the last year), capacity is limited and will not be able to continue to cope with the increasing demand. The existing ED is no longer fit for purpose with the key issue for the department being the lack of space for reorganising services and physical size of cubicles and diagnostic space. This results in compromised patient safety, privacy and sub-optimal/poor patient and staff environment and consequently poor experience. 22

23 The Project Board has identified a number of key priorities for the delivery of a modern service within the context of the wider Urgent and Emergency Care Strategy for Wolverhampton which meet the changing needs of patients and commissioners of the service. These are: To provide high quality clinical care for emergency patients that is timely, accessible and consistently available and enables delivery of quality targets; To deliver closer integration of Emergency Services improving communication between clinical teams and reducing movement and travel distances between departments; To deliver closer integration with Primary Care ensuring patients see the right clinician at the right time, 24/7; To modernise Emergency Services and facilities which will ensure the most appropriate use of resources and improve the overall patient, visitor and staff experience; To establish services/facilities which can respond flexibly to internal and external changes; To maximise the use and availability of technology to support internal service model and interface with internal and external stakeholders/users; To develop good quality, energy efficient and low carbon buildings. In agreeing these objectives the team has also identified measurable benefits which will be derived by patients, the Emergency Services Directorate, the organisation as a whole and the local health economy. These are detailed in Section Vision for the Future, Capacity Planning and Project Scope Vision The Trust has developed a long-term vision for Emergency Services which is outlined below: An Emergency Service which puts patients needs at the core of its provision; An Emergency Service which achieves high quality and safe care provision, which is measured both by external and internal KPI s; An Emergency Service where staff ask to work; An Emergency Department which is perceived as the best in the West Midlands; one which staff from other organisations visit as a source of ideas and leadership; An Emergency Service which has education, research and innovation at the heart of its provision; An Emergency Service which is affordable for the local health economy. This vision underpins the cohesive vision of the local health economy in relation to urgent and emergency care: Our vision is for an improved, simplified and sustainable 24/7 urgent and emergency care system that supports the right care in the right place at the right time for all of our population. Our patients will receive high quality and seamless care from easily accessible, appropriate, integrated and responsive services. Self-care will be promoted at all access points across the 23

24 local health economies and patients will be guided to the right place for their care and their views will be integral to the culture of continuous improvement. The principles underpinning the new service model for Emergency Services are described in Table 1f Table 1f: Principles of the New Service Focus on patient need Right care, right time, right location Emergency Services Directorate Service Smoother pathways of care and streaming patients effectively Avoid duplication Improved diagnostics Admission avoidance Reduced length of stay (LOS) where admission is required 24/7 service Integration of primary and secondary care Staff Appropriately trained personnel, grade and number to support 24/7 A flexible multidisciplinary workforce Maintain teaching and training focus Consistent and appropriate staffing structure for all services provided Best and appropriate technology Flexibility for expansion and development Facility for in-house training and teaching Building & Equipment Providing a safe, secure and healthy environment for patients and staff Appropriate clinical and non-clinical support space Use of sustainable technologies which are low carbon, energy efficient. Meet patient expectations with regard to privacy and dignity and equality Paper light Best use of IT Improved IT interface with external stakeholders e.g. GPs IT 24

25 Future Service Model Figure 1d shows the revised and future intended patient flows through the Urgent Care System. The key improvements to the current service model are: Patient is seen at the right time, in the right place, given the right treatment, by the right person; 24/7 Decision Maker cover with involvement earlier in the process; Single portal for the majority of patients including primary care 24/7; One Stop Shop for diagnostics; Definitive care plan before leaving ED; Reduction in admissions and length of stay for those admitted; Shared pool of Junior Doctors; Improved learning and sharing of knowledge and experience. Figure 1d: Future Service Model GPs Assessment Wards/Specialty Wards Future Activity The Trust has agreed its future activity projections with commissioners following joint activity modelling work undertaken by the Birmingham, Black Country and Solihull Commissioning Support Unit to inform the Wolverhampton Urgent and Emergency Care Strategy. The future 25

26 projections are summarised in Table 1g in line with Capital Investment Manual requirements (baseline, operational year, plus 5 years and plus 10 years). Table 1g: Future Emergency Services Activity 2013/ /26 Year Emergency Department Primary Care within ED ED Review Outpatients Clinical Decisions Unit 2013/14 109,804 5,737 3,697 Potential additional Primary Care Centre Activity 2016/17 94,901 23,074 4,815 6,568 21, /21 104,508 25,410 5,303 7,360 22, /26 117,895 28,665 5,982 8,302 25,363 The underpinning assumptions which drive this activity modelling are: Emergency Department Activity baseline is 2013/14 plan. This activity includes activity gained as a result of the Stafford overnight closure of ED in December 2011; Growth of 2.45% in 2013/14 and 2014/15 and 2.44% thereafter; 3.8% transfer of New Cross Emergency Department activity to an alternative primary care setting from 2015/16 e.g. GPs; 20% reassignment of New Cross Emergency Department activity to primary care activity but to be delivered in/alongside the New Cross ED; 22,000 potential new primary care attendances transferred into New Cross ED in 2016/17; RWT gains Hyper Acute Stroke Unit status from April 2014; Assumes no further activity gain from Stafford. Clinical Decisions Unit Activity in 2013/14 is part year impact and includes activity which currently goes to Medical and Surgical Assessment Units and other areas with a Length of Stay of less than 24 hours for a number of identified conditions and patients waiting longer than 4 hours for breach reason of investigations, transport, mental health assessment and admission avoidance; From the opening of the new facility the full impact of activity transfers from AMU are included; Growth is factored in at the same rate as ED. Emergency Department Review Outpatients The 2013/14 baseline is based on current activity in ED and Acute Medical Unit review clinics; Growth is factored in at the same rate as ED. The Trust has also undertaken scenario modelling around specific uncertainties relating to reductions in primary care activity and Stafford emergency activity. 26

27 These include: Scenario Change from Base Model Impact at base year 1 Base Model plus further Stafford activity +9,234 ED attendances 2 Base Model less potential primary care activity -22,000 ED attendances 3 Base Model less potential primary care activity but plus Stafford activity -12,766 ED attendances The impact of these scenarios is that the worst case will result in a reduction in potential activity of 25,264 attendances by 2025/26 affecting income and capacity. In terms of the potential income loss the Trust will work closely with partners to mitigate this impact. Any reduction in capacity needs will be reallocated to other use to support further site rationalisation. A further scenario relating to a potential increase in capital costs by 10% has also been modelled and is included in Appendix 2c Project Scope In taking forward the vision for remodelled Emergency Services the Trust s aspirations for new facilities are outlined below: Phase 1 Phase 2 Phase 3 Re-provision and expansion of Emergency Department facilities; Expansion of a clinical decisions unit (CDU) as a care component of the Emergency Department providing protocol driven periods of investigation, observation and review for patients up to 24 hours who would otherwise be admitted to hospital beds or wait on trolleys for first line treatment which takes over four hours; Co-location with the Heart and Lung Centre to provide better and faster access to Critical Care; Co-location with medical assessment facilities/acute medical unit (AMU) and medical beds to support greater integration, co-operation and rapid deployment of appropriate expertise to improve patient care and throughput; Alongside or integrated primary care provision 24/7; Ambulatory care for medical minor illness (currently seen in both ED and AMU); Provision of a multi-purpose hot clinic area for patients referred for example by GP s and who need a specialist urgent opinion but not a hospital bed e.g. respiratory patients; Unrestricted access to imaging (CT, Ultrasound and plain film) to allow immediate diagnosis of life threatening conditions. Relocation of Acute Medical Unit (assessment beds); and/or Relocation of Paediatric Inpatients and Paediatric Assessment Unit. Provision of new in-patient beds. 27

28 However, the project scope for this Outline Business Case is only those works described in Phase Workforce Planning Table 1c (Page 19) shows the year by year workforce changes required to deliver the new service model and to support the increased capacity within the facilities on opening in 2016/17 and then to 2025/26. Employment of manpower has been phased between 2016/17 and 2025/26 to coincide with the phased opening of ED capacity as activity increases Workforce Migration Plan There is no expectation that the new build will in itself increase the current risk of appointment to vacancies and to the costs associated with recruitment and employment of temporary staffing. The Trust already has a robust plan to manage the challenge of recruitment that occurs nationally in the area of Emergency services. These include use of attractions such as welcome packages, joint working with other clinical disciplines and university establishments, participation in regional nurse practitioner development programmes and overseas recruitment. These programmes will continue and will mitigate the risk of a deficit in staff Effective Training and Development A multidisciplinary workstream will be established at least one year prior to the opening of the new build which will consider the training and development requirements. The role will be to identify the implications of new equipment and pathways. An implementation timeline will be produced in conjunction with existing Trust resources such as practice nurse development teams, the post graduate doctor training teams and medical equipment training. 1.3 Economic Case The long list The Trust has identified a number of key objectives and benefits which it is seeking from the redevelopment of its Emergency Services. It is clear from these objectives and the Trust s current position that there is a need to physically alter or re-provide the existing facilities. Consequently five options have been developed for review by the Project Board and other key stakeholders. These options were identified having considered the overall strategic redevelopment of the emergency service, the need for co-location of clinical services on the New Cross Hospital site, and the delivery of a cohesive Estates Strategy. Each option in terms of its high level descriptor is summarised in the following text. Option 1 - Do Nothing Option 2 Downgrade the existing Emergency Department to an Emergency Care Centre Option 3 Do Minimum relocate administrative accommodation and reconfigure the existing Emergency Department 28

29 Option 4 - Extend and reconfigure the existing Emergency Department and use adjacent accommodation as expansion space Option 5 - New Build on the site of the former Catering Building Short List These options have been reviewed by the Project Board and it has been agreed that Option 2 - Downgrade the existing Emergency Department and Option 3 Do Minimum - should be discounted at this stage for the following reasons: Option 2 The impact that this would have on neighbouring Trusts who do not have the capacity to cope with increased activity; The potential activity impact on RWT and neighbouring Trusts from changes in Mid Staffordshire; The impact that this would have on other RWT clinical services and provision of tertiary services; Does not support the Urgent and Emergency Care Strategy. Option 3 The disruption to the department significantly outweighs the benefits likely to be achieved; Capacity increases are minimal and issues will only be relieved in the short term; Co-location with other key departments will never be achieved. The detailed financial and non-financial appraisal was therefore completed on the following shortlisted options: Option 1 - Do Nothing (retained as a benchmark only); Option 4 Extend and reconfigure the existing Emergency Department; Option 5 New Build on the site of the former catering building Non-financial Option Appraisal In accordance with Capital Investment Manual and Department of Health Estates guidance on appraisal, a formal non-financial appraisal of the 3 short listed options has been undertaken. This was carried out by a multidisciplinary group of stakeholders and involved a sequential and systematic approach covering: Criteria selection; Weighting of criteria to reflect their relative importance; Consideration of the options and scoring against the identified criteria; and, Analysis of the results and sensitivity testing to establish the robustness of the conclusions. The benefits criteria which the Project Board agreed, the relative weighting applied to this criteria and weighted scores determined at the Option Appraisal Workshop are summarised in Table 1h. 29

30 Table 1h: Benefit Criteria and Option Scores - Weighted Agreed Weighting % Option 1 Do Nothing Option 4 Extend & Reconfigure Existing Option 5 New Build Strategic Fit Clinical Effectiveness Access to Services Staff Experience Patient Experience Environmental Quality Disruption Timescales Flexibility Total Rank These results show that Option 5 is the preferred option from a non-financial perspective. Sensitivity analysis applied to these weightings did not affect the ranking of the options Financial & Economic Appraisal Generic Economic Model (GEM) The Trust has used the Department of Health s Generic Economic Model to appraise the short listed options. The key inputs into the GEM are summarised in the following sections Capital Costs The capital costs for the shortlisted options are included in Table 1i. 30

31 Table 1i: Capital costs for short-listed options Option 4 Extend and Reconfigure Existing 000 Option 5 New Build 000 Works cost 16,565 16,372 Location adjustment -1,159-1,063 Non Works cost Fees 1,460 1,460 Equipment 1,340 1,271 Contingency 1,838 1,848 Optimism bias 3,412 2,345 VAT 4,434 4,241 Total cost (PUBSEC BIS FP 173) 28,065 26,910 Inflation 1,869 1,787 Outturn Cost (PUBSEC BIS FP 185) 29,934 28,697 The equivalent capital costs for input into the Generic Economic Model are shown in Table 1j. These exclude VAT, inflation and planning contingencies. Table 1j:- Equivalent capital costs for the GEM Extend and Reconfigure Existing Option 4 Option 5 New Build Outturn cost 29,934 28,696 Less VAT 4,746 4,539 Less planning contingencies 1,838 1,848 Outturn economic cost 23,350 22,309 Less RPI inflation 1,558 1,489 Economic current prices 21,792 20,820 Note: There are no capital costs associated with Option Revenue impact Table 1k summarises the revenue consequences of each of the options: Table 1k: Summary of revenue costs for each option Option 1 Do Nothing Option 4 Extend and Reconfigure Existing Option 5 New Build Baseline 11,998,565 11,998,565 11,998,565 Changes in 15/16-20,044 20,044 Changes in 16/17-1,506,036 1,451,338 Changes in 17/18 196, ,564 Total 11,998,565 13,721,182 13,661,511 31

32 Economic Appraisal Table 1l summarises the economic appraisal in Net Present Cost (NPC) and Equivalent Annual Cost (EAC) terms: Table 1l: Summary of Economic appraisal Total NPC 000 Total EAC 000 Option 1 275,348 10,330 Option 4 412,926 15,491 Option 5 409,493 15, Sensitivities The Trust has considered the impact of the scenarios on the options to test the robustness of the preferred option. The Trust considers (given that both options provide the capacity to deliver the projected activity to 2025/26) that the activity and resultant income impacts affect both options in the same way. In terms of capital impacts, the capital cost of the Preferred Option 5 would need to increase by 16% or 3.64million for Option 4 to become the least cost option, with no increase in the capital costs of Option 4. Alternatively the Capital costs of Option 4 would need to reduce by 16% or 3.71m (including VAT and contingency) for it to become the least cost option. It is considered however that any increase in capital costs which may be brought about by inflation indices, market conditions, site conditions are also likely to be similar for both options Conclusion of Economic Appraisal From the economic analysis Option 5 is the preferred option Combining the Financial and Non-Financial Appraisals In order to determine the preferred option from both the economic analysis and the nonfinancial appraisal, the EAC for each option has been divided by the point scores from the non-financial appraisal to provide a cost per benefit point score. The outcome of this process is shown in Table 1m. The option with the lowest cost per benefit score is the preferred option. Table 1m: Summary of Financial and Non-Financial Appraisals Option 1 Do Nothing Option 4 Extend and Reconfigure Existing Option 5 New Build Total non-financial scores (weighted) Total EAC ( 000) 10,330 15,491 15,362 Cost per benefit score ( 000) Percentage score above preferred option 24% 63.5% - 32

33 The Preferred Option The outcome of both the non-financial and economic appraisals is that the preferred option for the delivery of the project objectives is Option 5 New Build on the site of the former Catering Department. 1.4 Commercial Case Description of the Works The proposed development will provide Phase One of a fully integrated Emergency Centre within a single building situated to the North/East of the New Cross Hospital site. The proposed construction site is currently being used for staff car parking. The new building will consist of three storeys of 9232m 2 including plant space. The Emergency Department and satellite radiology will be located at ground floor level. The entrance to the new Emergency Department will be collocated with the existing but reconfigured East Entrance to the hospital. The Clinical Decisions Unit and Outpatient clinic space and integrated Primary Care Facility will be located at 1 st floor, as will staff and other support accommodation. Shell space will be provided at 1 st and 2 nd floor levels to facilitate further development in Phase 2. The building will be directly linked to the Heart & Lung Centre for the Critical Care Unit and the main Hospital Street for access to the Acute Medical Unit and Medical beds. The construction site has been cleared with the following exceptions: electrical substation and generator; concrete slab left from the former catering department; relocation of departments and demolition of small sections of accommodation to the north side of the existing main corridor. This work will be packaged into an Enabling Works contract to be delivered out-with the main construction works in order to minimise the risk of unforeseen issues delaying the project. The Trust Board gave approval on 23 rd September 2013 for the Enabling Works to commence. Figure 1e provides a graphical representation of the proposed solution within the context of the hospital site. 33

34 Figure 1e: Site Context for the Preferred Option Project Timetable The key milestone programme for the on-going stages of the project based on a traditional procurement route is outlined in Table 1n. Table 1n: Key Milestones Milestone Relevant Body Target Date Approval of SOC Trust, CCG s July 2013 Approval of SOC NHSTDA September 2013 Approval of the OBC Trust, CCG s October/November 2013 Approval of OBC NHSTDA January 2014 Enabling Works Trust October 2013 to March 2014 Commence development of FBC Trust October 2013 Detailed Planning Approval Trust December 2013 Approval of FBC Trust, CCG s March 2014 Approval of FBC NHSTDA April 2014 Construction start on site Trust/Construction Partner November 2014 Completion of Construction & Fit out and commissioning Trust/Construction Partner April 2016 Full operational service commences Trust May

35 1.4.2 Procurement Strategy The Trust intends to fund the scheme through a combination of operational capital and surplus and will procure the main construction contract through a single stage traditional procurement route. It has allowed for sufficient time to deliver this successfully and it believes it will achieve better value for money through procuring the main contract in this way. However, to enable timely delivery of a complex package and to de-risk the project, the Trust intends to procure an Enabling Works package through Procure Required Services The Trust intends only to procure the design and construction of the new Emergency Centre. The provision of Soft and Hard Facilities Management services will be managed through the Trust s existing arrangements Potential for risk transfer and potential payment mechanisms The traditional form of procurement targets the removal of all risk prior to tender. This is done by the early establishment of a Risk Register, and the Trust and Design Team managing either the removal or mitigation of items in the Register as the design develops. The Management of Risk in the traditional process is cost beneficial to the Client for two reasons: 1. The contractor does not include a cost premium for risk in his tender. 2. Any saving resulting from the removal of risk is to the Trust s benefit. 1.5 Financial Case Impact on Revenue position The revenue impact of the preferred option is shown in the affordability statements in Section 5. These include: The Base Model at 13/14 prices; The Base Model including inflation and staff deflator; The baseline revenue position at 2014/15 shows a contribution of 3,455,708 before capital charges. Additional costs in 2016/17 and future years associated with the operational costs of the new building which are only partly offset by increased income means that the current level of contribution is not recovered until 2021/22. However during affordability discussions with WCCG, the Commissioners have agreed to underwrite this shortfall on a non-recurrent basis until this position is recovered. The capital charge implications of the build are funded within the Trust s LTFM which has previously been agreed by the Trust Board. The Trust has also modelled the impact of the scenarios referred to in Section 1.2 and affordability statements have also been included in Section 5 for the respective increases and reductions in activity and increase in capital charges. 35

36 1.5.2 Capital Affordability The Trust has allowed for the total cost of the Project in its 5 year Capital Programme. Table 1o identifies the total capital commitment for the five years 2013/14 to 2017/18 and identifies the allocation for the Emergency Centre Project. This assumes additional DH PDC capital of 3million in 2014/15. The Trust has already invested a significant amount of its own capital in 2013/14 to provide facilities to cope with additional activity from Stafford and is currently in discussions with the Trust Special Administrators and the NHSTDA regarding funding for this additional capacity. Should this additional funding be provided in 2013/14 or early 2014/15 then the Trust would be in a position to accelerate the delivery programme for the project. Table 1o: 5 year Capital Programme 2013/ / / / /18 m m m m m CRL 18,676 18,676 18,820 15,720 15,700 Charitable Funds Additional DH PDC funding Total CRL 19,076 21,676 18,820 15,720 15,700 Medical Equipment IM&T Statutory Standards Improvement of Retained Estate New Schemes - Pharmacy Adult Cystic Fibrosis facility Linacs Replacement Theatre refurbishment Other miscellaneous Emergency Centre New Build Emergency Centre Phase Multi-Storey Car Park Pathology New build Welcome Centre/OPD Reconfiguration Carbon Reduction Other Schemes GRAND TOTAL VARIANCE (1.530) (1.400) 36

37 1.6 Management Case Project Management Arrangements Project Structure The scheme is an integral part of stage 1 of the New Cross Site Redevelopment programme. The delivery programme for the project is set out in Table 1n. The following arrangements have been put in place to ensure the successful development of the scheme and production of the OBC. The Project Organisation reflects ownership of the project at the highest level and draws not only upon the traditional roles associated with capital project management, but also upon a number of multi-disciplinary representatives from across the Trust, to ensure that the wider business objectives of the organisation are met. A number of WCCG members are members of the Emergency Centre Project Board. The primary objectives of the project organisation are to ensure: The delivery of the new patient-centred service model and associated patient pathways; Effective clinical engagement; Input from an extensive range of stakeholders; Smooth implementation of the workforce changes; Construction of the building on time, and in accordance with the design brief; The operational commissioning of the building. The Trust has a successful history in the management and implementation of key projects and will ensure that appropriate project methodologies are put in place. The project structure for the project is outlined in Figure 1f: 37

38 Figure 1f: Project Management Structure Trust Board Trust Management Committee Capital Review Group Emergency Centre Project Board Urgent and Emergency Care Board Work Stream Work Stream Work Stream Work Stream Activity & Service Model Design (inc equipment & ICT) Workforce Planning Finance and Risk The Trust Medical Director is the Project Sponsor and Project Lead. The Head of Estates Development is the Project Director and Technical Lead. There has also been regular scrutiny and support (throughout the development of the proposals contained within this outline business case) from the Executive Team and Trust Board Benefits Realisation As part of the business case process the benefits to patients, staff, the Trust and the Health Economy, have been quantified. The Trust has developed a Benefits Realisation Plan which outlines the benefits that will be delivered as a result of this project. Specific Indicators have been assigned for each of these anticipated benefits, and the current and target performance will be recorded against each heading. This plan is work in progress and will be fully developed for FBC. The assessment and monitoring of the realisation of these benefits will form a key part of the Post Project Evaluation process. 38

39 1.6.3 Post project evaluation arrangements The Trust is committed to the full evaluation of all major schemes and projects through the formal evaluation methodology, with involvement as necessary from local commissioners. In order to facilitate this process a Project Evaluation Team will be put in place by the Capital Review Group post project delivery Risk Management It has been assumed that the revenue risks associated with activity increases and reductions apply to all options. The planning contingencies value included within the capital costs represents the capital risk values for each of the options 4 and 5. A project risk register has been developed for the preferred option which includes all risks identified to date. This risk register is included in Appendix 6c. 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 Risk rating in accordance with the Trust s Risk Categorisation Matrix (Probability and Impact leading to a red, amber, yellow and green rating) 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 life of the project by the Project Board. Where risks potentially have an impact on the capital costs or delivery programme (time) for the Project these will inform the contingency value included within the capital costs. 1.7 Conclusion and Recommendation The Royal Wolverhampton NHS Trust is committed to a vision for the redevelopment of the clinical services provided on the New Cross Hospital site to ensure that it can appropriately address the demand on its services from its local population. A key milestone in the delivery of that vision is the modernisation of Emergency Services and the provision of a new Emergency Department co-located with assessment, diagnostic and primary care facilities and operating within a purpose built, state of the art environment with the aim of improving the patient and staff experience, improving quality and efficiency of care and patient safety and future proofing capacity to meet demand. This development enables the delivery of the Joint Urgent and Emergency Care Strategy for the city of Wolverhampton and patients using our services. Approval of this case will be a significant step in the development of the New Cross Hospital site and will form a key enabler for the future development of the Emergency Services and other key services on the site. The proposal is fully supported by the clinical and operational teams within the Trust, external stakeholders and by the local Commissioners. This case has demonstrated the drivers for change and the key objectives and benefits which can be realised by this project. The case has also demonstrated that the proposed 39

40 development is in line with the Trust and local health economy overall clinical and strategic vision and is affordable without recourse to external financing. On the basis of this we recommend this case for approval. 40

41 2 STRATEGIC CASE The purpose of this section is to explain how the scope of the Emergency Centre Project fits within the existing business strategies of the Trust and outlines a compelling case for change, in terms of existing and future operational needs. Part A: The strategic context 2.1 Introduction and Background New Cross Hospital is operated by The Royal Wolverhampton NHS Trust and is located in the Heath Town area of the city of Wolverhampton. The Trust operates a full range of clinical services at community, secondary and tertiary levels. The hospital site comprises a range of clinical and support facilities which vary significantly in terms of age and functional suitability. The organisation s key objective is to deliver high quality, effective and efficient patient care. In order to achieve this the Trust has established a strategic vision for the reconfiguration of a number of core clinical services plus the redevelopment of the New Cross Hospital site to provide modern facilities which are fit for purpose. To this end a Planning Application for the redevelopment of the New Cross site was submitted to Wolverhampton City Council and received approval in This included outline planning approval for a new Emergency Centre. The proposals outlined in this case will focus on the provision of redesigned services within a new facility which will support significant operational benefits for Emergency Services with the Trust and across Wolverhampton. As the Trust intends to fund this development from internally generated funds the new facility will be provided on a phased basis. Consequently, this Business Case supports Phase 1 of the development but will also outline the Trust s vision for the transformation of Emergency Services and provide details on subsequent phases of development. Phase 1 includes a new Emergency Department and supporting ambulatory and diagnostic facilities together with a new primary care centre to ensure patients receive the right care at the right time by the right clinician. 2.2 An Overview of the Trust The Royal Wolverhampton NHS Trust was established in 1994 and is a major acute Trust providing a comprehensive range of services for the people of Wolverhampton, the wider Black Country, South Staffordshire, North Worcestershire and Shropshire. It gained Cancer Centre status in 1997, was designated as the 4 th Regional Heart & Lung Centre during 2004/05 and became one of the first wave Bowel Screening Centres in The Trust is the largest teaching hospital in the Black Country providing teaching and training to around 130 medical students on rotation from the University of Birmingham Medical School. It also provides training for nurses, midwives and allied health professionals through wellestablished links with the University of Wolverhampton. With an operating budget of circa 385 million the Trust is one of the largest acute providers in the West Midlands having more than 800 beds on the New Cross site including intensive care beds and neonatal intensive care cots and 82 rehabilitation beds at West Park Hospital. As the second largest employer in Wolverhampton the Trust employs more than 6,500 staff. 41

42 In April 2011 the Trust completed a successful transaction to integrate with the community services from Wolverhampton City PCT. The Trust adopted a model of full integration within the existing clinical and corporate structures to ensure that models of service delivery drive quality of service, patient experience and efficient use of resources. The integration also ensures the long term sustainability of a wide range of services for local people. Serving a catchment population of around 330,000 for secondary care services and up to 1,000,000 for tertiary services the Trust has an extensive natural boundary within which it delivers healthcare. The Trust has grown its specialist service portfolio and its income significantly over the last few years as part of a business strategy to increase tertiary services both directly and as a driver to secure secondary service referrals from PCTs on our geographical boundaries. The year on year growth now forms part of our base contracts for activity moving forward. The Trust has an excellent reputation for its clinical services and for whole system transformation in the delivery of clinical care, service reform and partnership working. Delivering its services from hospital and community sites across Wolverhampton in addition to a number of outreach clinics in other provider organisations, it fulfils two main roles: The provision of high quality emergency, community and secondary care services for our local population Tertiary and specialist services both independently and through clinical networks to the wider population of West Midlands and beyond The Trust s excellent transport links with close access to the M6, M6 Toll, M5, M42, and M54, national and local rail networks, national and local bus networks and international airports mean that it is ideally positioned to fulfil its two main roles in the future. The Trust s vision and values play an important role in describing the principles and beliefs that underpin the way in which it does business. They provide the checks and balances to make sure that all plans improve the experience for patients. Our vision An NHS organisation that continually strives to improve patients experiences and outcomes. Our values Patients are at the centre of all we do: We maintain a professional approach in all we do. We are open and honest at all times. We involve patients and their families and carers in decisions about their treatment and care. Working together we deliver top quality services: We work in partnership with others. Working in teams we will recognise and respect our differences. We support each other as members of the Trust. We will be innovative in how we work: We make it easy to do the right thing. We continue to improve the experiences of those who use our services. We encourage and support people who lead change. 42

43 We create an environment in which people thrive: We empower people to explore new ideas. We act as positive role models. We work hard for our patients. We recognise achievements Clinical Services The Trust provides a comprehensive range of community, acute and specialist/tertiary services from the following locations: New Cross Hospital Secondary and Tertiary Services, Maternity, Accident & Emergency, Critical Care, Outpatients West Park Hospital Rehabilitation Inpatient and Day Care Services, Therapy Services, Outpatients More than 20 Community sites Community Services for children and adults, Walk in Centre, Therapy and Rehabilitation Services The clinical services are currently managed through two divisions led by divisional Medical Directors. The mix of specialities within the divisions has been chosen to facilitate the integration across hospital and community services and to forge complementary clinical relationships ensuring investment and development is addressed in every area. Table 2a shows the split of services across the two clinical divisions: Table 2a: Clinical Services Division 1: Division 2: Radiology Pathology ITU/Anaesthetics/Theatres Cardiothoracic General Surgery Urology Trauma & Orthopaedics Obstetrics and Gynaecology Ophthalmology Head and Neck Paediatrics Adult Community Services Rehabilitation Care of the Elderly Stroke Neurology Rheumatology Sexual Health Dermatology Respiratory Diabetes Gastroenterology Renal Emergency Services Therapy Services Pharmacy Oncology/Haematology Activity The Trust s activity profile for the last 3 years (where applicable) and plan for 2013/14 are outlined in Tables 2b and 2c. The detailed specialty breakdown is provided in Appendix 2a. 43

44 Table 2b: Acute Hospital Activity Profile 2010/11 to 2013/14 Activity Type 2010/ / / /14 Plan Electives 9,916 10,128 9,143 9,342 Non Electives 45,925 44,245 44,883 44,518 Day cases (including chemotherapy day cases) 42,033 44,074 45,552 46,037 New Outpatients 119, , , ,246 Follow up Outpatients 323, , , ,356 Outpatient Procedures 33,222 36,583 37,324 37,441 A&E Attendances 98, , , ,178 Notes: - AMUAMB patients included as New outpatients from 11/12 - Regular day attenders and Births excluded - Outpatient activity included only where plan exists for New and Follow ups - Source of data is SLAM Table 2c: Community Activity Profile 2011/12 to 2013/14 Currency 2011/ / /14 Plan Contacts e.g. District Nursing 534, , ,260 Community Units (wheelchairs) 2,117 1,910 2,158 Group Contacts e.g. phlebotomy 98,632 95,997 97,037 Inpatients OBD's 32,159 31,043 30,796 Outpatients Attendances 6,377 6,089 6,918 Walk In Centre Attendances 28,551 36,186 28,286 Key Commissioners From 1 st April 2013, the commissioning environment has changed, with the abolition of Primary Care Trusts and Strategic Health Authorities. Primary commissioning responsibilities now rest with Clinical Commissioning Groups and locally, Wolverhampton CCG are the coordinating commissioner for acute and community services on behalf of local associate commissioners. Outside of CCGs, Specialised Services have seen an increase in the size of their commissioning portfolio, and the movement of the Public Health function from PCTs into Local Authorities has taken commissioning of some services away from health commissioners, leading to the need to develop key relationships with local Councils. The Trust is working hard to establish new and mutually beneficial relationships with these partners. Progress to date includes: Trust attendance at CCG forum for Wolverhampton and South Staffordshire; CCG board member has a place at the Trust Board; CCG members for Wolverhampton and South Staffordshire attend the contract clinical quality review meetings; CCG members undertake a programme of planned and short notice visits to wards and departments; 44

45 A modernisation Board has been established to oversee implementation of QUIPP/CIP schemes; CCG members for Wolverhampton and South Staffordshire sit with the Trust on the Local Health Economy Urgent & Emergency Care Board and will join other groups linked to the delivery of the Trust s priorities. The Trust is a key player in the context of NHS West Midlands having a unique market place as the only acute provider with a catchment population larger than its host population between Birmingham and North Staffordshire. 2.3 Emergency Services Workforce Profile The current workforce profile for Emergency Services is summarised in Tables 2d(i), (ii) and (iii). Table 2d(i): Workforce Establishment (WTE) for Clinical Staff in Emergency Department (ED) 2013/2014 (includes planned expansion in 2013/14) Posts & AfC Bands 6 8a 8b Other Total Consultants Middle Grades: Associate Specialists Specialist Registrar (ST Level) Trust Grade ACP's Junior Doctors (CT grades) ENP's GP's Radiology - Consultant Radiology - Registrar Total Table 2d(ii): Workforce Establishment (WTE) for Nursing Staff in Emergency Department 2013/14 (includes planned expansion in 2013/14) Department & AfC Bands a Total ED (incl. Ophthalmology Nursing) Ambulatory Assessment Area Radiology Total

46 Table 2d(iii): Workforce Establishment (WTE) for Clinical &Non-Clinical Support Staff 2013/14 (includes planned expansion in 2013/14) Posts & AfC Bands a 8c Total ED Health Recs/Ward Clerks/Receptionists ED Medical Secretaries ED A&C ED Ancillary AAA Health Records Porters Housekeeping Radiographers Radiology - Technicians Radiology-Clerical/Helpers Therapists Therapies A&C Medical Physics Technicians Total Emergency Services Activity Table 2e includes the historical Emergency Services activity since 2007/08. Table 2e: Emergency Services Activity 2007/8 to 2012/13 Year New Cross ED Attendances Walk-in Centre Attendances New Cross Assessment Unit Activity Phoenix Centre Showell Park Acute Medical Unit Surgical Assessment Unit Acute Medical Unit Ambulatory 2007/8 98,510 14,224 6, /9 99,944 24,223 7, /10 98,898 32,441 9,720 7, /11 98,288 29,137 21,395 4,059 1,888 2, /12 101,303 29,848 25,479 3,987 2,732 2, /13 106,836 36,186 29,009 3,192 2,730 2,417 Notes : Phoenix centre opened in 2007 Showell Park opened in 2009 (shown for completeness but not RWT activity) Surgical Assessment Unit (SAU) previously within AMU prior to 10/11 and known as EAU (Emergency Assessment Unit) Acute Medical Unit, SAU and AMUAMB (ambulatory) are discharges from these wards 46

47 Table 2f shows the Emergency Department Activity Plan for 2013/14 split by Commissioner volume and value. Table 2f: Emergency Department Activity 2013/14 by Commissioner Emergency Department PbR Attendances Activity Finance NHS Wolverhampton CCG 75,398 7,427,053 NHS Cannock Chase CCG 4, ,315 NHS East Staffordshire CCG 51 5,403 NHS South East Staffordshire & Seisdon CCG 6, ,109 NHS Stafford and Surrounds CCG 2, ,923 NHS Birmingham South & Central CCG ,125 NHS Birmingham Crosscity CCG 27 2,298 NHS Shropshire CCG ,545 NHS Walsall CCG 10,907 1,077,438 NHS Telford & Wrekin CCG ,773 NHS Sandwell & West Birmingham CCG 1, ,569 NHS Dudley CCG 3, ,300 NHS North Staffs CCG 45 4,148 NHS Stoke on Trent CCG 85 8,371 NHS Redditch and Bromsgrove CCG 40 3,974 NHS South Worcestershire CCG 39 4,006 NHS Wyre Forest CCG 60 5,791 Total 107,061 10,662,142 Note: excludes small amount of non-contract activity A 24/7 radiology service is provided in the Emergency Department for Plain film examinations and CT Heads. A small number of examinations are also performed in the main Radiology Department for CT, MR and Ultrasound. Tables 2g and 2h show the activity growth 2007/08 to 2012/13 and how this activity is apportioned between the two areas at 2012/13. Table 2g: Radiology Activity related to the Emergency Department 2007/08 to 2012/13 Emergency Department 2007/ / / / / /13 Plain Film Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Ultrasound Total

48 Table 2h: Emergency Radiology Activity split between Emergency Department & Main Radiology Department for 2012/13 Radiology Activity 2012/13 ED Main Total Plain Film Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Ultrasound Total Many of the patients that are admitted through ED have additional diagnostic tests (particularly CT and Ultrasound) as inpatients either as referrals from AMU or specialty wards Income and Expenditure The Trust s income and expenditure associated with the provision of emergency services for 2014/15 (after implementation of planned changes in 2013/14) is as follows: Income million Pay million Non Pay million 2.4 The National Context In establishing the drivers impacting on the model of Emergency Service delivery the following are of particular relevance:- NHS Outcomes Framework 2013/14; A&E clinical quality indicators; The College of Emergency Medicine Emergency Medicine Consultants Workforce Recommendations, 2010; Public Inquiry into Standards of Care at Mid Staffordshire NHS Foundation Trust between 2005 and 2008 (Francis Report); NHS 111; NHS Patient Experience Framework; Ambulance Service Quality Indicators; National Review of A&E Services in England NHS Outcomes Framework 2013/14 Everyone Counts: Planning for Patients 2013/14 The principles supporting the new approach to planning clinical-led commissioning from April 2013 outlined in this framework are: Empowered local clinicians delivering better outcomes; Increased information for patients to make choices; Greater accountability to the communities the NHS serves. 48

49 The framework provides for a number of financial levers/rewards which commissioners can use to secure better patient outcomes including the NHS Standard Contract, CQUIN, Quality Premium. The Outcomes Framework measures are grouped around five domains which set out the high-level national outcomes that the NHS should be aiming to improve. Domain 1 Domain 2 Domain 3 Domain 4 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. This includes the use of friends and family test. This was rolled out nationally starting with adult inpatient and Accident & Emergency Services from April RWT however started collecting this data ahead of the proposed start date as part of a West Midlands initiative. Domain 5 Treating and caring for people in a safe environment; and protecting them from avoidable harm. All domains will impact the work of the Emergency Services Directorate and underpin the proposed service model A&E Clinical Quality Indicators 2011/12 saw the introduction of a set of clinically led indicators to allow a rounded view to be taken of the performance of Accident and Emergency Services. Whilst the full set of indicators are no longer used to benchmark nationally, WCCG monitors performance against a number of these criteria. In judging performance nationally the operational standard of 95 per cent of patients being seen within four hours continues to be used The College of Emergency Medicine Emergency Medicine Consultants, Workforce Recommendations, April 2010 This document recommends an agenda of consultant expansion in response to the failure of demand management to limit Emergency Department attendances. It recommends Consultant presence in the ED for 16 hours per day, 7 days per week as a minimum; and suggests there is a strong argument for 24/7 Emergency Medicine consultant presence in hospitals even when they are not operating as major trauma centres. The benefits from this investment are outlined as: Improving the quality of patient care; Enhancing patient safety; Developing Emergency Care; Cost efficiencies. 49

50 2.4.4 NHS 111 This service has being rolled out from April 2013 as part of the wider revision to the Urgent Care System with the aim of:- Improving public access to urgent healthcare services; Increasing public satisfaction and confidence in the NHS; Increasing efficiency of the NHS; Enabling the commissioning of more effective and productive healthcare services; Reducing the non-emergency calls received by the 999 Emergency Ambulance Service. NHS 111 was introduced in Wolverhampton in line with the national roll out to make it easier for patients to access local health services and to direct patients to the most appropriate service when they are unsure where to go. Monitoring of the impacts of this service will be undertaken locally to ensure that the 111 service sends people to the right services at the right time and identifies any gaps in service NHS Patient Experience Framework Improving patient experience is a key aim for the NHS. The NHS Patient Experience Framework developed in conjunction with The King s Fund is significant for healthcare organisations because it provides a common evidence-based list of what matters to patients, and can be used to direct efforts to improve services. Other policy drivers include the NHS Constitution and NICE Quality Standards for Patient Experience in Adult NHS Services. Since the Darzi review of 2008 to the present day NHS organisations have been driven to afford the same level of importance to patient experience as they do clinical effectiveness and safety. In terms of patient experience specifically focus needs to be placed on the human interactional and environmental aspects of a patient s care and treatment as well as the functional aspects. Research about what matters to patients, which has shaped policy and thinking in today s NHS, highlights quality consistent information and involvement about decision making in care as key themes in enhancing experience. Providing assurance and treating people as individuals with courtesy and respect are also important. Other critical elements can be categorised as: 1. Respect of patient-centred values 2. Co-ordination and integration of care 3. Information, communication and education 4. Physical comfort 5. Emotional support 6. Welcoming the involvement of family and friends 7. Transition and continuity 8. Access to care The NHS has tended to concentrate on improving functional aspects of care yet the research clearly reveals that the relational aspects, such as feeling listened to or informed matter much more to patients than the functional aspects. Applying these principles directly to an Emergency Department requires the relational or human aspects to be factored in, taking the 50

51 patient journey into consideration. For example, the process of arrival at hospital can in a patient s or relative s mind, induce heightened senses of anxiety around traveling to the hospital, parking, and booking in at reception. The patient s expectation is that they will receive safe and effective treatment (functional). The things that take place on the other side of the line, before any care or treatment has been administered, have a profound effect on how they view their experience Public Inquiry into Standards of Care at Mid Staffordshire NHS Foundation Trust between 2005 and 2008 The Public Inquiry led by Robert Francis QC published 6 th February 2013 made 290 recommendations. The Public Inquiry called for a change of culture within the healthcare system on the basis that the patient is the priority in everything done. In summary the main recommendations of the Report included:- Improvement to complaints handling making it easier for patients to complain; Statutory duty of candour for providers and clinicians requiring them to speak out when a potential harmful error has occurred; Improvement to cultural training standards and leadership of nursing professions with a clear focus on care, compassion and clear visible distinction between support workers and registered nursing staff; Improvement to the provision of elderly care; Improvement to patient information systems, public and patient use of patient feedback and access to information about the quality of care. This report has implications for all provider organisations and for all services provided by them. RWT has been involved in discussions regarding provision of clinical services at Stafford and Cannock with the Trust s Special Administrators during the public consultation on changes at Mid Staffordshire NHS Foundation Trust. Whilst the impact is not yet known the Trust has modelled the potential impacts on emergency department activity within its scenario planning contained within this outline business case Ambulance Service Quality Indicators Ambulance Quality Indicators were introduced in April The Quality Indicator which has particular relevance for Emergency Departments is the requirement for a 30 minute turnaround for ambulance crews. Fines have been introduced from April 2013 for exceeding these turnaround times and have cost implications for both Acute and Ambulance Trusts. RWT performance against these quality indicators is detailed in Section National Review of A&E Services in England The national review of A&E Services launched by the NHS Commissioning Board in January 2013 and led by Sir Bruce Keogh, Medical Director has been tasked with developing a national framework of the best way of organising A&E Services to meet the needs of patients and to ensure high quality, consistent standards are offered across the Country. Whilst the 51

52 final report is awaited, the Trust has been working with member organisations within the health economy to develop the A&E Sustainability Plan for 2013/14 to put initiatives in place at all stages of the emergency care system to meet rising demand and improve performance against quality indicators. The national agenda for urgent and emergency care services highlights the need to ensure services are more responsive to people, use resources more efficiently and use developments in medical and technological advances to deliver better care to support people. 2.5 Local Context Against the national background there are also a significant range of local drivers for changes at a regional, health economy, Trust and departmental level which underpin the proposals for the future of the Emergency Services Urgent & Emergency Care Strategy for Wolverhampton A Joint Urgent Care Strategy Board was set up in 2012 by RWT and WCCG and has more recently evolved into the Local Health Economy Urgent and Emergency Care Board. Continuous increases in activity and increased costs in the system together with an uncoordinated approach to urgent care has resulted in a need to set out the strategy for urgent and emergency care within Wolverhampton and for patients using the services within the City to 2016/17. The Urgent and Emergency Care Strategy for /17 aims to: o o o Ensure improved and simplified arrangements for urgent and emergency care by developing a simply designed and rationalised system supported by easy telephone and web access - by reducing the confusion in the system and reducing and by making the entry points more efficient to reflect a new and sustainable 24/7 system. Ensure strong patient-centred clinical leadership in all access points of the urgent and emergency care system - Senior clinical decision makers will be a fundamental part of the system and their decisions will be made early and regularly in a patients care pathway. Provide better value for money and sustainability Improving appropriate use of urgent care facilities and services. Reducing inappropriate use of NHS services, to deliver better value for the taxpayer, for local organisations and to provide a financially sustainable system for the future. A reduction in unnecessary ED, ambulance and emergency admissions are a focus of the strategy. o Provide greater consistency and openness, transparency and candour by providing consistently high quality, integrated care led by our Clinical Commissioning Group delivering the best outcomes and experience 24/7, with no noticeable differences out of normal office hours. A culture of openness 52

53 and insight will be developed and action taken where honest concerns about the standards or safety of services are made. o o o o Ensure improved quality, safety and standards - Deliver up-to-date, high quality services which are clearly focused on meeting the clinical needs of the patient and putting the patient s needs first, with less variation across the city and ingrained in a culture of continuous improvement. NHS standards will be applied. Ensure improved patient experience - Ensuring a greater focus on the patient journey. Compassionate, caring and continuous improvement in response to patient and carer feedback; Provide greater integration & information - Services working together to provide a seamless service, irrespective of the provider organisations which operate them. Sharing of information and regular reporting of the outcomes of the patient pathway will be ingrained in the system using the latest IT facilities where possible; No blame culture - The strategy will support a No Blame Culture with clinicians, managers and services working together to improve the services offered to patients. The new Emergency Centre build is closely linked to the emerging Urgent & Emergency Care strategy. As part of the strategy work, WCCG and RWT have been working collaboratively on the development of a primary care facility within the new ED. It is the intention that the Primary care facility will see and treat primary care patients who have attended the ED but also affords the opportunity to merge the out of hours and daytime services together at the front door of the Emergency Department to provide a 24/7 service. The emerging strategy describes the direction of travel for urgent and emergency care within Wolverhampton and the new Emergency Centre will provide the local health economy the opportunity to improve and simplify Urgent Care by providing both a primary and secondary care resource in one place. The Urgent & Emergency Care Strategy is evolving and will be available for public consultation in Surge Plan (A&E Sustainability Plan) for Wolverhampton Health Economy 2013/14 The Surge Plan (A&E and Sustainability Plan) 2013/14 developed by the Wolverhampton health economy details the commitment stakeholder organisations have made to ensuring capability and capacity to deliver a safe, sustainable and quality service which is responsive to patient demand throughout periods of pressure. This plan sets out the local health economy governance structure relating to urgent care, communication and escalation plans both internally within organisations and across the health economy, sharing of learning, knowledge and best practice, mitigation of risk and assurance that safeguarding measures are in place in compliance with the Francis Report. The plan puts into context the issues faced by the health economy and details actions to be put in place to address these including timescales, responsibility and expected outcomes. The plan is aimed at the following three priority areas: prior to ED, within ED and flow out of the hospital. The organisations within the health economy will continually review the benefits of the interventions identified within the plan. 53

54 2.5.3 RWT Priorities for Improvement 2012/13 and 2013/14 The Trust chose Urgent Care as one of its three priorities for improvement in 2012/13 as this service impacts on everyone at their most vulnerable and is where the Trust can really make a difference to patients through the best use of community services. Urgent and Emergency Care also drives demand for a number of other services both within the hospital and in the community. The Trust goals echo national indicators and are as follows:- 1. Patients who arrive by ambulance will be assessed by a nurse within 15 minutes; 2. The average time to be seen by a doctor will be 1 hour; 3. Accurate information will be available for patients on their waiting time and the treatment they can expect; 4. Pathways of care will be available for the top 10 conditions; 5. The number of children attending Accident and Emergency Department and Paediatric Assessment Unit will be reduced. The Trust has the following plans for 2013 /14: Develop an agreed and signed off Joint Urgent & Emergency Care Strategy encompassing the needs of the respective organisations and requirements of the local health economy. Anticipated date for completion; Summer 2013; Commence public and partner engagement with the wider community in relation to the Urgent Care discussions and options for Wolverhampton and South East Staffordshire & Seisdon Peninsula. Commenced March 2013; Continue to forge strong working relationships with our partner organisations in order to continue to work in a productive and cohesive manner; Expansion of majors area in the Emergency Department by November 2013; The opening of a Clinical Decisions Unit by September 2013; Commence (in liaison with partner organisations) a full public consultation on the joint Urgent and Emergency Care Strategy encompassing the emergency portal. Due to commence in January Implementation of the strategy will be overseen by the Urgent and Emergency Care Strategy Board and will be delivered through project groups and work streams. Monitoring of outcomes will include reporting of: Numbers of attendances and admissions through the emergency department(s) in secondary care; Availability and utilisation of urgent care services in the Community; Reporting of and compliance with achievement of quality standards of care; Patient and relative satisfaction surveys for quality of care and experience. 54

55 2.5.4 RWT 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: Alignment of community staff into an integrated organisational form. To ensure the provision of clear strategies which enable effective workforce planning which is aligned to our patients needs and increases the flexibility and productivity of our workforce. To ensure that we recruit and retain staff with values, attitudes and beliefs that are appropriately aligned to those of the Trust and that therefore enable the further development of the commitment based culture. To 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. To ensure that our workforce encounter a positive experience whilst employed by the Trust that enables us to be recognised as an employer of choice and, more importantly, leads to our employees acting as advocates of the Trust as both an employer and a service provider. To develop the culture of the organisation so that our employees are committed to maximising productivity, efficiency and the quality of patient service. To further develop ways of working in full partnership with all staff and their representative organisations, via engagement strategies described, that ensures their contribution and commitment to decision making. To develop and implement effective and efficient HRM processes and policies which support the development of a high performing foundation trust and minimise risk. All of the long term planning for a restructured Emergency Service 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. The Trust s Human Resources Strategy and how this has been developed is illustrated in Appendix 2e. This Strategy underpins the service redesign and implications for staffing in Emergency Services. 55

56 2.5.5 RWT Patient Experience Strategy The key pillars of the Trust s Strategy are: Patient involvement and feedback; Staff involvement; Generating insight; Making improvements; Feeding back to patients; Monitoring performance. The Strategy contains 11 objectives against which the Trust measures its progress Regional Review of Stroke Services In May 2012, it was announced that the NHS Midlands and East will be undertaking a review of stroke services, including the provision of Hyper Acute Stroke Services. The purpose of the review is to achieve a step change improvement in the quality of stroke services and stroke outcomes. The Trust is engaging in this review process to develop a proposal to deliver stroke services across the whole pathway including Hyper Acute Services. The Hyper Acute Service has been established in Wolverhampton for a number of years and provides a service to 600+ stroke patients. In 2009, the Trust doubled its stroke catchment area to provide Hyper Acute and Acute Stroke Services to a wider catchment area, which increased the number of stroke patients to 1033, 692 of whom were confirmed patients. Should the Trust be awarded Hyper Acute Stroke status, it is anticipated that patient numbers will increase. The success of achieving Hyper Acute Status is extremely important for local patients and the Trust s extended border areas; it will bring untold benefits to patients, e.g. faster treatment, better outcomes and improved standards of care but will increase the input through the Emergency Department as patients will be required to follow a pathway for suspected stroke through the paramedic alert system to the Emergency Department. The Stroke Service working with the ED have already a strongly established service which is recognised by Commissioners and with the opportunity of a new Emergency Department this will further enhance the stroke care that is provided to patients and our ability to offer this to more patients who badly need this care Overnight closure of Mid Staffordshire Emergency Department In December 2011 Mid Staffordshire NHS Foundation Trust decided to close its Emergency Department at Stafford General Hospital from 10.00pm to 8.00am, seven days per week. This closure remains in place today. In response to this closure RWT assessed the impact that this might have on the Emergency Department and admissions at New Cross Hospital and put coping strategies in place. Over the 12 months January to December 2012 the Trust has seen an average increase in attendances of 135 South Staffordshire patients each month. This has also translated into increased average admission rates of this cohort of patients of 1.1% or 455 patients over the same time period. 56

57 2.5.8 RWT ICT Strategy The importance of technology has increased as has its strategic value to the organisation with a growing dependence on ICT by all Trust services both clinical and non-clinical. Information handling and business transformation form the key objectives that the ICT strategy looks to address. The ICT strategy for the Trust is therefore based on the development of a single corporate processing environment with a single physical shared technical infrastructure. This will result in a move away from the frontline services logging on to different application systems to process different stages of the patient journey. Specific activities and events for ICT for the Trust in general include: Development of a clinical Electronic Document and Records Management system; Integration of all Trust Patient Systems through the use of Middleware software (BizTalk); Development of workflow transactions for all patient processes, enabling the patient journey through the Trust to be as smooth as possible; Development of a Fibre Wide Area Network (WAN); Implementation of mobile technology infrastructure within the network; and, Enablement of links to domestic residences to support home working and telemedicine where possible; Improved links with primary care Hospital Site Rationalisation and Redevelopment The Trust commenced the building of the first stage of the new hospital development in This first stage is part of a journey culminating in the delivery of a Master Plan approved by Wolverhampton City Council in Within this Masterplan, the Trust proposes that the site is zoned according to the proposed clinical models for: Women and children s services; Cancer; Cardiothoracic services; Emergency services; Elective services; Clinical support accommodation including diagnostics; and, Business support functions. A major challenge for the Trust is the establishment of a single integrated hospital, reducing the quantity of peripheral buildings on the site, and concentrating clinical services at the core. This involves maximising the use of the better quality existing buildings on the site, refurbishing where appropriate and cost effective, and providing new buildings linked to the existing facilities to achieve the required clinical adjacencies and design to be fit for purpose into the future. The key objectives can be summarised as: To provide an integrated Emergency Centre that maximises linkages with the existing Heart and Lung Centre and inpatient beds; and, 57

58 Provide new Inpatient and Outpatient accommodation that addresses Privacy, Dignity and Choice agenda. The projected works are extensive and are increased in complexity by the need to plan and deliver on a live hospital site. Although this Masterplan is now under review, the Trust is committed to completing the first stage of this which includes a new Emergency Centre. 2.6 Market Assessment In establishing the need for significant developments within Emergency Services, the Project Board has undertaken a market assessment including: SWOT analysis; and, NHS Adapted Porters 5 Forces Model SWOT Analysis In this analysis the Emergency Services Group has set out the current strengths and weaknesses of the service, the opportunities afforded by a new facility and the threats to the service if improvements are not made. This analysis has focused upon four key areas: Quality; Efficiency; Performance; Delivery. Table 2i therefore differentiates for each SWOT category the main issues under each heading. Table 2i: SWOT Analysis STRENGTHS Quality High calibre cohesive senior clinical team Good relationship with Key Stakeholders e.g. Commissioning Teams, Ambulance Service Trauma Unit Commended for Advanced Life Support Training Family & Friends feedback which commends the care provided and commitment of staff WEAKNESSES Quality Poor facilities & environment in ED Number of patient complaints Lack of capacity to meet demand Friends & Family feedback which suggests waiting times in minors and quality of the environment are generally sub-standard 58

59 Efficiency Recruitment to Advanced Clinical Practitioner role Good access to some Radiology modalities Performance History of achieving ambulance turnaround times Low admission rates from A&E Consistently in the top 3 for ED performance in West Midlands Delivery Manage Type 1 and 3 patients through the Walk In Centre and Emergency Department at New Cross Emergency Services delivered by one directorate OPPORTUNITIES Quality Improved Patient Environment Improved Staff Environment Greater Patient & Staff satisfaction Provide opportunities to rationalise estate & improve quality of building stock Efficiency Potential to integrate & reduce number of portals More integrated working between Primary & Secondary Care both in and out of hours Improved access to Pathology Reduce 24 hr LOS Reduce admissions Achieve low carbon & energy targets Performance Enhanced staff involvement Potential to improve turnaround times Improved patient outcomes Delivery of quality targets Delivery Space available on site for further associated development Improved facilities for training Continued recruitment of high calibre staff Development of robust relationships through delivery of Urgent Emergency Care Strategy Efficiency Several portals across health economy & hospital Lack of co-location on site with assessment units and medical beds Lack of latest technology e.g. IT and some diagnostic equipment Poor access to Pathology Performance Some inefficiency in reporting Radiology test results Inconsistent achievement of 4 hr wait target & quality indicators over last 12 months Number of admissions & <24 hr stays on AMU Delivery Duplication of resources Different pathways dependent on referral route THREATS Quality Potential for increase in complaints Deteriorating Environment Efficiency Lack of capacity will impact patient safety Performance Limited capacity which will eventually impact on performance Potential fines if unable to meet ambulance turnaround times Delivery Static tariff New commissioning environment and the need to build stable robust relationships 59

60 2.6.2 Porters Market Forces Although originally developed as a model for the assessment of industrial markets/environments to quantity the level of competitive intensity and consequent impact on profitability and potential attractiveness of a specific market, the approach has been adapted in recent times to support Trusts as they develop a business strategy for the mapping of a robust future when establishing the benefits of Foundation Trust status. This exercise which has been undertaken across all services within the Trust provides a market assessment of the alignment with strategic issues within the NHS. The five forces taken into account are: Power of the Commissioners; Power of the patients; Power of the workforce; Degree of rivalry; and, Competitive Advantage. The first four forces take into account the degree of influence upon a specific service, with the higher the degree of influence the more vulnerable the service may be in the future. The competitive advantage score acts to mitigate influence from other factors. The Project Board believes that for Emergency Services at the Trust the scores are as follows (1 low importance; 5 high importance): Power of the Commissioners - 4; Power of the patients - 4; Power of the workforce - 3; Degree of rivalry - 3; and, Competitive Advantage - 3. Part B: The case for change 2.7 Investment objectives The Project Board has identified the key priorities for the delivery of a modern service within the wider context of the Wolverhampton Urgent & Emergency Care Strategy for Wolverhampton which meets the changing needs of patients and commissioners of the service. These objectives are: To provide high quality clinical care for emergency patients that is timely, accessible and consistently available and enables delivery of quality targets; To deliver closer integration of Emergency Services improving communication between clinical teams and reduce movement and travel distances between departments; To deliver closer integration with Primary Care ensuring patients see the right clinician at the right time, 24/7; 60

61 To modernise Emergency Services and facilities which will ensure the most appropriate use of resources and improve the overall patient, visitor and staff experience; To establish services/facilities which can respond flexibly to internal and external changes; To maximise the use and availability of technology to support internal service model and interface with internal and external stakeholders/users; To develop good quality, energy efficient and low carbon buildings. In agreeing these objectives the team has also identified measurable benefits which will be derived by patients, the Emergency Services Directorate, the organisation and the health economy. These are detailed in Section 2.13 and Appendix 4e. 2.8 Current Emergency Service Model The current Urgent Care system in Wolverhampton includes the following services: One hospital provider (Royal Wolverhampton NHS Trust) providing emergency care at New Cross Hospital; Two walk in centre providers across the city: Phoenix Walk In Centre, provider RWT; Showell Park, provider Docs on Call; One out of hours provider (Primecare); Forty eight (48) GP practices. Currently there are several emergency portals provided by RWT to which patients can present, depending on the mode of referral. These emergency portals are: Royal Wolverhampton NHS Trust Emergency Department: (self-referrals; 999 ambulance referrals; some GP referred patients; Trauma and Orthopaedic referrals; Ophthalmology referrals and self-presenters) Acute Medical Unit (AMU): (GP referred medical patients; referrals for urgent Haematology/Oncology admissions from other specialty outpatients e.g. Renal referrals; ED referred medical patients for admission) Surgical Assessment Unit (SAU) (GP referred and ED referred surgical patients) Paediatric Assessment Unit: (GP referred children; ED referred children; some selfreferrals). In addition to the above, emergency obstetrics and gynaecology (GP referred) is provided for in the Women s Hospital. Urgent ENT/Maxillo-facial assessment is available in the Outpatient Department during normal working hours. Hot clinics e.g. Respiratory, Cardiac, Ambulatory Assessment Area; Heart & Lung Centre Phoenix Walk In Centre These emergency portals are generally staffed by their own dedicated nursing and medical teams and have their own 24 hour emergency medical rotas. For the purposes of this project the re-provision of emergency care relates to the following specialties: 61

62 Emergency Department Acute Medical Unit General Medicine (all specialties including oncology/haematology) Ophthalmology The Emergency Department is the first step in the pathway of emergency care often for patients who have complex needs and are at their most vulnerable. It is the shop window of the Trust for the emergency patients and their carer s. Figure 2b shows diagrammatically the flows within the current service. Figure 2b Current Service Model EMERGENCY DEPARTMENT (A&E) GPs Walk In URGENT CARE SERVICE Social Care SERIOUS ILLNESS & INJURY Ambulance Minor Illness Minor injuries Out of hours face to face Psychiatric Care Limited Diagnostics Specialty Wards/Stroke Heart & Lung Centre Ambulatory Assessment Units Medical, Surgical & Paediatrics (AMU, SAU, PAU) The current model can be defined as:- DISCHARGE +/- FOLLOW UP 62

63 The current model can be defined as: Traditional; Slow with time wasted between steps; Leads to duplication; Collaborative working difficult due to poor adjacencies; Care plan and investigations developed following transfer from ED. 2.9 Activity and Performance Trends Since 2004 monthly attendance has increased at the New Cross Emergency Department from 5,816 in January 2004 to 8,718 in January This increase is demonstrated in Figure 2c and Table 2j. Figure 2c: Emergency Department Attendances A&E Attendances since Table 2j: Emergency Department Attendance Shift January 2004 January 2013 Increase Monthly attendances (patients) Average daily attendances (patients) The increase in ED attendees between financial year 2011/12 and 2012/13 was over 5%. Until two years ago ED performance against the 4 hour turnaround target was consistently amongst the best in the country, since this time ED performance in common with many other Trusts has fallen. See Figure 2d. 63

64 Figure 2d:- Emergency Department 4 hour Performance against 95% target since % 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% 84.00% A&E 4 hr % Performance since 2004 RWT has never previously failed to achieve this target in any one year or in a quarter. Whilst the Trust achieved the contractual target for the year 2012/13, it did not achieve the target for Quarter 4 attendances. Performance in Type 1 A&E has faced considerable challenge throughout 2012/13. Table 2k shows the performance for Type 1 and Type 1 and 3 combined. Table 2k: Emergency Department Activity Change and Performance against the 4 hour wait target for Type 1 and Type 1 & 3 combined ED Activity ED Performance 2012/13 Quarter 2011/ /13 % Activity Change All Type ,838 26, % 95.08% 93.49% 2 25,355 27, % 96.46% 95.35% 3 24,630 26, % 95.18% 93.53% 4 25,475 26, % 94.01% 91.92% Total 101, , % 95.71% 94.26% Performance is also consistently below that of 11/12. This can in large parts be explained by the increase in attendances that the department has seen. However, the actions taken to date have started to see an improvement in performance with the 2013/14 performance showing an improving trend. Quarter 1 performance for Type 1 patients was 93.56% and 95.12% for all patients. Quarter 2 performance was 95.63% for Type 1 and 96.63% for all Types. 64

65 2.10 Issues Impacting the Emergency Services Provision The current issues relating to Emergency Services can be grouped under the following headings: Demand on the Emergency Care System; Inefficiencies in Care Pathways and Service Model; Sub-optimal physical capacity and environment; Workforce issues; Equipment and ICT requirements; Governance, Operational and Financial inefficiencies Demand on the Emergency Care System Wolverhampton Health Economy has experienced unprecedented demand on its urgent care services which is reflective of trends across the country. The demand has steadily grown over recent years resulting in winter pressure wards remaining open during summer 2012/13. The number of attendances at ED has continued to increase despite the introduction of two Walk In Centres in the city. Work is on-going with community teams to develop care pathways in an attempt to provide alternative services but numbers are still expected to increase in response to an increase in demand at all stages of the patient interaction with the NHS. Fifty per cent (50%) of ED attendances are classed as major/resuscitation, the other 50% are minor cases. Usually demand rises each morning from 9.00am with a constant flow of attendances arriving each hour until 9.00pm. Attendances per hour then reduce overnight although the ratio of majors patients to minors tends to rise during this time period. Children under the age of 16 years account for 18% of ED activity. The impact of the increases in demand described in Section 2.9 on patient care has been significant with patients experiencing long waits to see a doctor for initial assessment, for treatment and where necessary, admission to an inpatient bed. As the number of patients requiring admission increases, the pressure on in-patient beds intensifies. There has been subsequent impact on bed pressures, increased cancellations and loss of elective income and overall poor patient experience. Increased activity and the arrival times of patients and ambulances, has caused further capacity pressures and resulted in the need to open an Ambulance Off-load Area during This area does not provide a suitable environment for the initial assessment or treatment of patients and affords little privacy and dignity. Figure 2e shows that, in excess of 2,051 more ambulances were conveyed to the ED when compared to the previous year, an increase of over 5.4%. The % increase into RWT Type 1 A&E is consistently higher than the WMAS average. Since October 2012 ambulance conveyances have increased by 5.8% into RWT against a 1.1% WMAS average. This equates to an extra 43 ambulances per week. The increase in ambulance conveyances has a disproportionate impact on emergency services given that the admission rates for patients arriving by ambulance in Q1 2013/14 was 45.7% compared to a standard admission rate of 18.6%. 65

66 Figure 2e: Number of Ambulances Monthly 2011/12 and 2012/13 Number of Ambulances monthly (11/12 v 12/13) May June July August September October November December January February March April Ambulances (Actual) 12/13 Ambulances (Actual) 11/12 To summarise the key issues are: Increases in ambulance conveyances; Increases in ED attendances; Increases in admission rates from ED; Some evidence of increase in attendances/admissions in out of hours periods (after 6pm and weekends) Inefficiencies in Care Pathways and Service Model The Model of Emergency Care varies from portal to portal resulting in unnecessary duplication of work including duplication of diagnostic tests when patients are referred between portals as part of the current pathway process. Different access times to diagnostics are also experienced. Multiple access points results in duplication of skill base. In the past there has been: Tendency by the management team and ED staff to focus on the 4 hour wait target with little buy in to on-going care; An inward focus and lack of engagement with other services who could support including community teams and primary care A culture that all patients who attend are assessed and treated rather than referred on/deflected to other supportive services. Provision of care in ED and AMU has predominantly been from medical clinicians against a background of reducing availability of doctors (static junior docs through the training system and desire for expansion across the majority of Trusts). A reliance on individually acquired knowledge of clinical and management ways of doing things rather than a culture of consistent and available pathways. The result is inconsistency, repetition, gaps and un-auditable practice. This also means that individuals and teams and therefore the service do not have a basis on which to 66

67 develop and progress. There is a high level of patient complaints regarding excessive waiting times in some of the portals and Friends and Family Test results from patients visiting ED have been disappointing both in terms of return rate and scoring. The survey was introduced in ED in early 2013 ahead of the national rollout using a token system given to patients at reception who were asked to register their response on leaving. In order to obtain more information and establish the issues in more detail, the token system has been replaced with comment cards in recent weeks. These results have shown particularly good results for majors patients who comment on excellent clinical care and staff commitment but are less positive for minors patients with the main issues relating again to long waits and poor environment including lack of privacy Physical Capacity and environment The Emergency Services are currently provided from a number of disparate buildings on site. The Emergency Department (ED) has been located in the same accommodation footprint for over 15 years and is no longer fit for purpose. The Emergency Department is located to the North West of the site and is at the opposite end of the site to the Acute Medical Unit and the medical wards which are accessed by long public corridors and steep ramps. This results in long and difficult travel distances for medical patients requiring further assessment and/or admission. The disparate geographic location of portals results in logistical difficulties with patient management. The physical capacity of the Emergency Department is limited to the building footprint with little room for expansion either to the North or West of the site, and without relocating other adjacent departments. A key issue for the department is lack of space for re-organising services and physical size of cubicles and diagnostic space resulting in compromised patient safety, privacy and dignity issues and sub-optimal patient and staff environment. Reference to DH Building capacity guidance: Health Building Note 22, indicates that the current ED has insufficient capacity (by circa 10 cubicles) to cope with the current levels of activity. The current capacity shortage in ED also leaves no room for service provision should Trusts in the surrounding areas change their patient emergency pathways. For example should Stafford ED stop taking Type 1 ED patients (usually ambulance transported patients), the ED at RWT would have no room to take on the added demand which would undoubtedly flow to Wolverhampton without the planned expansion. Table 2l identifies the estates performance of the current ED. Table 2l: Current Estates Performance Indicators Area Year of Construction Functional Suitability Space Utilisation Quality Emergency Department Building constructed in 1974: Ground floor accommodation refurbished in 1996 for ED CX Overcrowded CX Notes: CX this category indicates that nothing but a total rebuild or relocation will suffice (i.e. improvements to existing are either impracticable or too expensive (Ref: HBN 00-08) 67

68 Whilst the department has undergone a facelift in the last 18 months to maintain the environment, this has had little effect on physical capacity. Do Nothing is no longer an option for the Trust. The Trust therefore plans to further enhance the current department in 2013/14 by adding a modular extension to create additional majors cubicle space to cope with increasing demand and to convert an adjacent clinic area to a small Clinical Decisions Unit. These enhancements have commissioner support and are identified as RWT actions in the local A&E Sustainability Plan. These developments however are considered only sufficient to plug the capacity gap between now and 2015/16 when a new department can be provided. These additional facilities will do nothing to improve the patient or staff environment, increase the capacity for paediatric or resus patients, improve the lack of space in existing patient areas or improve diagnostic capability. Neither will they improve adjacencies, both internally within the department or with other key departments such as assessment and inpatient medical beds. Concern about the sustained rise in activity and resultant pressure together with safety issues particularly where patients are waiting in corridors due to lack of space has focussed the need for a new facility Workforce A review of the workforce in the Emergency Department has already taken place and the Trust is actively recruiting medical staff to move towards 24 hour consultant cover. It has within the last 18 months established an Advanced Clinical Practitioner role and is looking to add further staff to this unit. Whilst the service has been successful in recruiting to existing posts, the Trust believes there are opportunities for cross specialty working e.g. Acute Medicine with Emergency clinicians. The current geographical gap between these areas makes it difficult to introduce or sustain this model of working efficiently and therefore opportunities for staff training and improved patient care are lost Equipment & ICT Some equipment replacement within the Emergency Department has taken place in the last 18 months particularly in relation to patient monitoring equipment in individual cubicles. Radiology equipment currently consists of: two plain film machines; one OPG (dental) machine; one CT scanner which is currently used for head scans; This equipment is located in dedicated Radiology rooms within the ED. Other equipment consists of: one plain film machine mounted on overhead gantry which serves the four resuscitation cubicles in the ED; one ultrasound machine. 68

69 The radiology equipment is either owned by the Trust or is supplied through a managed equipment service (MES) linked to the Radiology PFI. Links with Pathology until April 2013 involved samples being transported by pneumatic tube system through three zones to four separate Pathology departments. Although this will be improved when the new Integrated Pathology Building is fully operational, there will still be no direct link from the Emergency Department to Pathology. The current IT system and data capture relies heavily on paper and there is little use of mobile devices. The A&E department is working with the existing manufacturers of the software (MSS, Patient first) in an effort to upgrade the current model to one that will support paper free clinical and demographic data capture. Once upgraded within A&E it is planned to implement the application within AMU ahead of the new build and integration of the 2 services. This will help to inform the decision on final ICT requirements, particularly the mix between mobile and worktop devices. The Trusts PAS system is the source of all master patient data and is interfaced with the existing MSS application utilising the PAS HL7 messaging interface to ensure a single and consistent view of patient data. The existing MSS system supports the use of the National NHS Number. Significant progress has been achieved over recent years on delivering a clinical web portal which provides a consolidated single view of patient data within the Trust. Whilst this is available to GP s via their desktop, more work on integration with GP systems needs to be undertaken and this will be a key driver in delivering the new integrated department. Work is already underway to access summary care information by patient via the trusts clinical portal to support this going forward Governance, Operational and Financial Inefficiencies Governance issues arise due to patients receiving different management for the same condition depending on which portal they present to. For example, patients with suspected DVT can present to 3 different portals depending upon who has referred. The number of portals leads to financial inefficiencies. Separation of clinical teams by geography, management and governance means that there is a lack of opportunity for learning and development between the various workforces and whilst some roles are shared, there is a repetition of information collected or processes across the emergency and then the on-going urgent care journey (e.g. history/bloods in Emergency Department, history/bloods in AMU, history/bloods on the ward). Alternatively there is a risk of assuming that the other team will follow through an action Estates Strategy The Trust s Estates Strategy has been developed to create the quality of environment and facilities required to support the Clinical Services Strategy. The Strategy identifies how the Trust will use and support its existing buildings, which buildings will become obsolete and demolished and where new buildings are required to underpin the Models of Care and service delivery. This objective is therefore reflected in this business case. The provision of new facilities for Emergency Services is a key pillar of the Trust s Estates Strategy. See Appendix 2b and Section 5 for the site Masterplan and 5 year Capital Programme. 69

70 2.12 The Vision for Emergency Services The Trust has developed a long-term vision for Emergency Services which is outlined below: An Emergency Service which puts patients needs at the core of its provision; An Emergency Service which achieves high quality and safe care provision, which is measured, both by external and internal KPI s; An Emergency Service where staff ask to work; An Emergency Department which is perceived as the best in the West Midlands, one which staff from other organisations visit as a source of ideas and leadership; An Emergency Service which has education, research and innovation at the heart of its provision; An Emergency Service which is affordable to the local health economy. This vision underpins the cohesive vision of the local health economy in relation to urgent and emergency care: Our vision is for an improved, simplified and sustainable 24/7 urgent and emergency care system that supports the right care in the right place at the right time for all of our population. Our patients will receive high quality and seamless care from easily accessible, appropriate, integrated and responsive services. Self-care will be promoted at all access points across the local health economies and patients will be guided to the right place for their care and their views will be integral to the culture of continuous improvement. The principles underpinning the new service model for Emergency Services are therefore as described in Table 2m. Table 2m: Principles of the New Service Emergency Services Directorate Focus on patient need Right care, right time, right location Service Smoother pathways of care and streaming patients effectively Avoid duplication Improved diagnostics Admission avoidance Reduced length of stay (LOS) where admission is required 24/7 service Integration of primary and secondary care Staff Appropriately trained personnel, grade and number to support 24/7 A flexible multidisciplinary workforce Maintain teaching and training focus Consistent and appropriate staffing structure for all services provided 70

71 Building & Equipment Best and appropriate technology Flexibility for expansion and development Facility for in-house training and teaching Providing a safe, secure and healthy environment for patients and staff Appropriate clinical and non-clinical support space Use of sustainable technologies which are low carbon, energy efficient. Meet patient expectations with regard to privacy and dignity and equality IT Paper light Best use of IT Improved IT interface with external stakeholders e.g. GPs Figure 2f shows the revised and future intended patient flows through the Urgent Care System. The key improvements to the current service model are: Patient is seen at the right time, in the right place, given the right treatment, by the right person; 24/7 Decision Maker cover with involvement earlier in the process; Single portal for the majority of patients including primary care, 24/7; One Stop Shop for diagnostics; Definitive care plan before leaving ED; Reduction in admissions and length of stay for those admitted; Shared pool of Junior Doctors; Improved learning and sharing of knowledge and experience. 71

72 Figure 2f: Future Service Model GPs Assessment Wards/Specialty Wards The new service model will include the provision of a Clinical Decisions Unit. Clinical Decision Units are nationally/internationally recognised clinical models for treating patients. A Clinical Decision Unit (CDU) is a designated area where patient conditions can be managed in circumstances where more than 4 hours is required for further investigation/treatment. Patients remain under the care of the ED consultants while in the CDU. Use of an ambulatory care service such as a CDU is in line with the recent directive published by NHS England aimed at advising Trusts on how to manage the surge in demand experienced by all Trusts across the country (NHS England: Improving A&E Performance Gateway ref 00062, May 2013) The CDU will provide a suitable environment for patients who require observation, investigation and treatment that will take longer than the 4 hour standard, but do not require an admission. Historically these patients have either breached the 4 hour standard or been admitted to an assessment and/or an in-patient bed thus impacting on patient flow. The benefits include: Reducing admissions to an inpatient from ED; Freeing room on AMU and SAU for GP referred patients who sometimes have to wait hours in the adjoining clinic space for admission; Freeing room in ED thereby providing room for other patients to be assessed and treated within the 4 hour turnaround; Reducing the number of 4 hour breaches. 72

73 The following groups of patients, if clinically appropriate, will be moved to the CDU: Diagnostic Evaluation o Low risk chest pain on the Troponin I pathway; o Pulmonary embolism awaiting further test like CTPA; o Renal colic awaiting CT KUB - to rule out aneurysm; o Awaiting blood results. Short Term Treatment o Allergic reaction; o Asthma - mild to moderate requiring nebuliser; o Dehydration/vomiting for first line IV; o Cellulitis; o Head injury, with normal CT Scan Head, requiring less than 24 hours admission, (for example: alcoholic, elderly living alone); o Post Sedation monitoring; o Elderly patients awaiting Occupational Therapy/Physiotherapy/Social Services assessment (Admission Avoidance). The following exclusions will be applied: Patients likely to require admission; Patients requiring social admissions or placement in long-term care; Palliative patients; 16 years of age or under; Not listed in the Inclusion Criteria. The Urgent & Emergency Care Strategy previously referred to has been developed for the residents of Wolverhampton and for those using services within the city. A major development within the strategy is a new Primary Care Centre (PCC) that will provide a high quality, efficient urgent primary care service for patients accessing the new service both in and out of hours. Local residents have told us that the current system is complex and difficult to navigate, they are confused on how and where to go and often resort to A&E as a default. These difficulties are reflected in the changes in activity seen at the Emergency Department with rising ED attendances for primary care conditions. To ensure the future system delivers care in the right place, at the right time, the local health economy have developed the vision for a PCC. Patients will enter the department through one door and will be triaged through to the most appropriate service for their care either the PCC or ED. The aim of the PCC is to enable patients who attend with minor illness and injury, to be seen, treated and discharged or signposted to alternative services depending on their need. A patients GP will still remain the first point of contact for patients, but the PCC will provide urgent access to the right service at times when the patients own GP is not open or unable to see patients quickly. The PCC will also be responsive to telephone contacts for patients needing GP/Primary Care advice as a result of being triaged through the NHS 111 service. The new Primary Care Centre will include a multi-faceted approach: 73

74 Clinical Triage whereby Primary Care clinicians will triage patients who attend the ED. Patients will then be diverted to the appropriate service within the emergency portal; See and Treat - patients will be seen in a timely manner by an appropriately trained clinician according to clinical need; Telephone based clinical triage - for those patients who require a clinical discussion with a GP/Health Care Professional as a result of calling NHS111; Outreach service aimed at keeping patients out of the urgent care system where possible by providing a rapid response service to care/residential home, working closely with the patients registered GP and Emergency Ambulance Services (WMAS) The detailed plans for the PCC are currently in development and will be detailed within the Full Business Case 2.13 Benefits The key benefits to be derived from the new service model and re-provided Emergency Department facilities are described in Table 2n. Table 2n: Key Benefits Objective Provision of high quality Clinical Care Key Benefits Improved Patient satisfaction Achievement of quality targets Closer Integration of Emergency Services Improved outcomes for patients right treatment, right time, right service Increased clinical efficiency Improved access to services primary and secondary care Reduced travel distances for patients and staff Less duplication Improved teaching and shared learning Co-location physically and mentally Modernisation of Services & Facilities Improved environment Reduction in violence & aggression Improved privacy & dignity Improved staff satisfaction and recruitment and retention Improved patient satisfaction Capacity of right type and scale to cope with demand Improved Service Models & Patient Pathways Improved Patient Experience Less duplication 74

75 Objective Key Benefits Achievement of quality targets Single Portal/one stop shop Earlier intervention Definitive care plan before patient leaves ED Workforce Re-profiling Flexibility of workforce Improved skill mix Improved outcomes for patients Availability of senior decision makers earlier in the process 24/7 cover provided by appropriate clinicians Flexibility to respond to change Increased capacity Flexibility of capacity Improved adjacencies with dependent/related services Maximisation of Technology to support Service Model Improved diagnostics and reporting Improved monitoring Reduced Length of stay (LOS) Reduced admissions Energy efficient/low carbon buildings Improved quality, condition and functional suitability of estate Energy & carbon reduction targets achieved Lower energy costs/m Future Demand Joint Urgent Care Strategy and Activity Modelling RWT and WCCG (also representing SES&SP CCG) commissioned the Birmingham, Black Country & Solihull Commissioning Support Unit in January 2013 to facilitate and conduct a joint activity modelling exercise to determine future activity levels and associated costs for differing ways forward for Urgent Care within the City. In advance of the finalisation of this Joint Urgent and Emergency Care Strategy and to reflect the activity work underpinning this strategy, the Trust has agreed its future activity projections for this Outline Business Case with Commissioners. 75

76 Emergency Services Activity Table 2o provides a summary of the anticipated projected activity levels for Emergency Services delivered by RWT. In line with the capital planning guidance the projections have been taken to the planning horizon of 2016/17 and then plus 5 years and 10 years. A detailed year by year analysis is included in Appendix 2c. Table 2o: Future Emergency Services Activity 2013/ /26 Year Emergency Department Primary Care within ED ED Review Outpatients Clinical Decisions Unit 2013/14 109,804 5,737 3,697 Potential additional Primary Care Centre Activity 2016/17 94,901 23,074 4,815 6,568 21, /21 104,508 25,410 5,303 7,360 22, /26 117,895 28,665 5,982 8,302 25,363 The activity figures included in Table 2o have been based on the following assumptions which have been agreed with Commissioners:- Emergency Department Activity baseline is 2013/14 Plan. This activity includes activity gained as a result of the Stafford overnight closure of ED in December 2011; Growth of 2.45% in 2013/14 and 2014/15 and 2.44% thereafter; 3.8% transfer of New Cross Emergency Department activity to an alternative primary care setting from 2015/16 e.g. GPS; 20% reassignment of New Cross Emergency Department activity to primary care activity but to be delivered in/alongside the New Cross ED; 22,000 potential new primary care attendances transferred into New Cross ED in 2016/17; RWT gains Hyper Acute Stroke Unit status from April Clinical Decisions Unit Activity in 2013/14 is part year impact and includes activity which currently goes to Medical and Surgical Assessment Units and other areas with a Length of Stay of less than 24 hours for a number of identified conditions and patients waiting longer than 4 hours for breach reason of investigations, transport, mental health assessment and admission avoidance; Growth is factored in at the same rate as ED. Emergency Department Review Outpatients The 2013/14 baseline is based on current activity in ED and Acute Medical Unit review clinics; Growth is factored in at the same rate as ED. Further detail underpinning the activity figures is included in Appendix 2c. 76

77 The Trust has also undertaken scenario modelling around specific uncertainties relating to potential additional primary care activity and Stafford emergency activity. These include: Scenario Change from Base Model Impact at base year 1 Base Model plus further Stafford activity +9,234 ED attendances 2 Base Model less potential primary care activity 3 Base Model less potential primary care activity but plus Stafford -22,000 ED attendances -12,766 ED attendances The impact of these scenarios is that the worst case will result in a reduction in activity of 25,264 attendances by 2025/26 which will impact income and capacity. In terms of the potential income loss the Trust will work closely with partners to mitigate this impact and any reduction in capacity needs will be reallocated to other use to support further site rationalisation Radiology in the New Emergency Department It is proposed to provide an enhanced diagnostic service in the new Emergency Department. The majority of diagnostic tests will be requested from ED, performed and reported before a decision is made to admit the patient. This will reduce the number of admissions and reduce the length of stay for those admitted. A service will be provided in the new Emergency Department for patients currently referred from the Emergency Department, AMU (Ambulatory), SAU and PAU Future Capacity Requirements The activity projections as at 2025/26 have been used to derive the capacity requirements of the departments included within the scope of this OBC. Reference has been made to Health Building Notes and the Schedules of Accommodation have been benchmarked with a number of other Trusts with similar activity levels and who have recently built new emergency departments. A further capacity exercise has been undertaken by external consultants to support the Trust s capacity projections. The main capacity requirements are: 6 Resuscitation spaces 17 Majors cubicles 16 Minors cubicles 10 CDU spaces 6 Clinic cubicles 1 CT Scanning room 3 Plain Film rooms (including dental) 1 Ultrasound Scanning room Integrated/alongside primary care facility 77

78 2.16 Workforce The introduction of the new service model for Emergency Services will affect all staff disciplines. The current Workforce profile is summarised in Tables 2d (i), (ii) and (iii) Key Workforce Planning Assumptions Between 1 st April 2013 and the opening of the new department in 2016, it is anticipated that there will be a number of workforce changes within the Emergency Department. Some Business Cases supporting service developments have already been approved and implementation and recruitment is underway. Other initiatives are currently being scoped for which business cases are under development. These include: Introduction of additional majors capacity and Clinical Decisions Unit adjacent to the existing department A business case to provide nine additional cubicles and a small CDU (six beds) was approved by the Trust Board in May 2013 to plug the short term capacity gap and deal with current performance issues. The workforce changes associated with this development have been included in the 2013/14 baseline workforce figures provided in Tables 2d (i), (ii) and (iii) hour Consultant Cover for the Emergency Department The Trust has identified that it needs additional consultants to provide 24/7 cover in the Emergency Department. One additional consultant has been approved as part of the Business Case for Majors and CDU capacity described in but a number of additional consultants are required to support a full 24/7 rota. The current consultant workforce allows for 8.00 to shop floor presence. Any further increases in posts will be the subject of a separate Business Case at the appropriate time Future Workforce Establishment The details of the future workforce requirements for all disciplines to 2025/26 to support the new service model and changes in activity and capacity are provided in Table 2p Workforce Migration Plan The required changes will be managed within the Trust s Human Resources (HR) Framework. Service operational plans will be produced containing relevant HR information and HR will be informed of all implications so that the appropriate aspects of the Framework are implemented. In doing so the Trust needs to ensure that it; Employs sufficient levels of staff with the right skills and knowledge to deliver the services it is planning to provide; and, The criteria it uses to select staff for transfer, redeployment and/or redundancy are robust, fair and consistently applied across the Trust. 78

79 Where redeployment is required the Trust will identify a specific senior individual with overall responsibility for ensuring that consultation takes place in accordance with the framework Effective Change Management The workforce plan will effect change management through the use of necessary protocols, particularly the HR framework. The approach will facilitate changes to workforce structures in a partnership approach with Staff Side, to enable the adjustment for new ways of working and changes to working patterns to ensure the Trust continues to be working time compliant. Although the process of implementation will start immediately the change management process needs to be flexible to assist with the uncertainty of transformational change as well as the more predictable transitional change. 79

80 Table 2p: Anticipated changes to Workforce 2013/14 to 2025/26 Post April /14 Planned 2014/ / / / / / / / / / / /26 Total ED - Consultants ED - Other Medical Staff ED-ACP's (8a, 8b & 7) ED - ENP ED - Nursing ED - Nursing (Ophthalmology) ED - Ancilliary ED - Admin AAA - Nursing 5.28 (5.28) 0.00 AAA - Admin 1.13 (1.13) 0.00 Therapies Radiology - Consultants Radiology - Other Medical Staff Radiology - Nursing Radiology - Radiographer Radiology - Sonographer Radiology - Technician Radiology - Admin Porters (0.80) Domestics Med Physics TOTAL (4.41)

81 Recruitment Plan and Management of Temporary Staffing There is no expectation that the new build will in itself increase the current risk of appointment to vacancies and to the costs associated with recruitment and employment of temporary staffing. The Trust already has a robust plan to manage the challenge of recruitment that occurs nationally in the area of Emergency services. These include use of attractions such as welcome packages, joint working with other clinical disciplines and university establishments, participation in regional nurse practitioner development programmes and overseas recruitment. These programmes will continue and will mitigate the risk of a deficit in staff Effective Training and Development A multidisciplinary workstream will be established at least one year prior to the opening of the new build which will consider the training and development requirements. The role will be to identify the implications of new equipment and pathways. An implementation timeline will be produced in conjunction with existing Trust resources such as practice nurse development teams, the post graduate doctor training teams and medical equipment training Project Scope In taking forward the vision for remodelled Emergency Services the Trust s aspirations for an Emergency Centre are outlined below: Phase 1 Re-provision and expansion of Emergency Department facilities; The Emergency Department should have two portals for urgent care serving adults and children but with both areas being linked operationally and geographically; Development of a clinical decisions unit (CDU) as a care component of the Emergency Department providing protocol driven periods of investigation, observation and review for patients up to 24 hours who would otherwise be admitted to hospital beds or discharged potentially unsafely; Co-location with the Heart and Lung Centre to provide access to Critical Care; Co-location with medical assessment facilities/acute medical unit (AMU) and medical beds to support greater co-operation and rapid deployment of appropriate expertise to improve patient care and throughput; Alongside or integrated primary care provision; Facilities for medical minor illness (currently seen in ED and AMU); Provision of a multi-purpose outpatient clinic for patients currently seen in ED and AMU to facilitate discharge and review of patients. Unrestricted access to imaging (CT, Ultrasound and plain film) to allow immediate diagnosis of life threatening conditions; Phase 2 Relocation of Acute Medical Unit (assessment beds) and/or Relocation of Paediatric Inpatients Phase 3 Provision of new in-patient beds. However, the project scope for this Outline Business Case is only those works described in Phase 1. 81

82 2.18 Functional Content and Schedules of Accommodation The functional content required for Phase 1 accommodation is as follows: Main Entrance Ambulance Entrance Reception and waiting areas adults Reception and waiting areas children Primary/ambulatory care facilities Triage Majors cubicles Minors cubicles including specialist requirements for Ophthalmology and ENT Resuscitation Children s triage and cubicles Body viewing rooms and relatives waiting area Trolley waiting area Radiology (CT, MRI, Ultrasound, plain film) Major Incident facilities De-contamination facilities Clean and dirty utility Storage Staff facilities Clinical Decisions Unit Outpatient Clinic Administrative accommodation Externally the facility will need to be supported by ambulance parking, public drop-off and accessible parking. The full Schedule of Accommodation against which the options have been assessed and the preferred solution developed is included in Appendix 2d Consultation and Engagement Stakeholders The key external stakeholders in relation to this scheme are patients and their representatives, Wolverhampton Clinical Commissioning Group (WCCG), South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group (SES&SPCCG) and other local commissioners, the GPs within Wolverhampton and Wolverhampton City Council. Approval for the strategic site redevelopment for New Cross Hospital including the proposals for the Emergency Centre received outline planning approval from the City Council in The Clinical Commissioning Groups have been involved in the development of the proposals outlined in this Business Case through the Joint Urgent and Emergency Care Board and the Emergency Centre Project Board. A number of meetings and presentations have been held with commissioners during the development and finalisation of this Outline Business Case. The potential impact on the Emergency Services staff is significant. In order to ensure that the nature of the changes is understood the Project Board has included senior clinicians and managers from the 82

83 Emergency Services Directorate and key clinical and support staff have been involved in a number of design development workshops Patient and Public Involvement The Estates Development Team have reported regularly to patients and public and other stakeholders (including commissioners, partner organisations and the voluntary sector) and Trust staff on the major site development plans and specifically concerning Stage 1 projects which includes the Emergency Centre. A Stakeholder Event was held by the Trust in January 2011 to discuss stakeholder expectations in relation to Emergency Services. Follow-up events were held in early 2013 to inform and gain feedback from stakeholders on proposals for a potential new Emergency Centre. These included a Patient and Public Event on 18 th February 2013 and a Stakeholder and Partners Event on 11 th March In December 2012 social research and behaviour change experts, ICE Creates were commissioned by WCCG to deliver a study to explore the local populations current use of urgent care services in Wolverhampton. This included exploring experiences, perceptions and attitudes as well as behaviours relating to the use of urgent care services. This research included feedback from seven in-depth insight groups and questionnaires and provided recommendations which will be used to inform the emerging urgent and emergency care strategy. WCCG, SES&PCCG and RWT have also jointly organised a number of presentations and engagement events from December 2012 to October 2013 to further seek stakeholder views on urgent care provision in the City. The consultation process for the Joint Urgent and Emergency Care Strategy will also include plans for the new emergency department. A number of events have also been held for Trust and CCG staff. Communication with all Stakeholders will be on going throughout the introduction of new service models and provision of associated facilities Health & Wellbeing Board The Trust is extremely conscious of its obligations in terms of public consultation and the involvement of the Health & Wellbeing Boards. In line with the national requirements, the Trust site redevelopment Masterplan was subject to public consultation undertaken by Wolverhampton City PCT as far back as 2006 and specific presentations have been made by the Chief Executive and senior staff on the key proposals on a continuous basis since that date to the Health Scrutiny Panel and more recently to the Wolverhampton Health and Wellbeing Board. The Draft Urgent and Emergency Care Strategy was also presented to the Health and Wellbeing Board in July 2013, with the next iteration being presented to the Board in November

84 2.20 Key risks The main business and service risks associated with this project are shown in Table 2q, together with their counter measures. Table 2q: Key Risks and mitigations Risk Business Case Approval Mitigation Business Case Delays/Rejection Financial Lack of capital funding to support project/pdc funding is not available Scheme is unaffordable from Trust revenue perspective Scheme is unaffordable from Commissioners expenditure perspective Capital costs increase Increases or decreases in activity due to service reviews (locally or regionally) Design and Planning Planning issues Increases or decreases in activity due to service reviews (locally or regionally) Change in clinical scope to that briefed Ensure that both OBC and FBC are robust and that joint financial modelling is undertaken to ensure both commissioner & provider are satisfied with the Business Case and that the proposals are financially affordable for the Local Health Economy. Minimise cost commitment until FBC approved. Ensure that proposed sign off dates are communicated with WCCG. Investigation of alternate sources of funding and procurement model. Reprofile spend on other projects within capital programme. Ensure that affordability is fully understood, that efficiencies are maximised and that joint financial modelling is undertaken to ensure both commissioner & provider are satisfied with the FBC. Ensure that affordability is fully understood, that efficiencies are maximised and that joint financial modelling is undertaken to ensure both commissioner & provider are satisfied with the FBC. Contingencies included in capital costs. Model capital cost increase as a sensitivity. Re-profile spend on other projects within capital programme. Dialogue with Users to ensure maximum flexibility of design. Close working with Administrators and Commissioners. Scenario planning undertaken. Outline Planning achieved. Close working with Wolverhampton City Council on detailed planning to close down issues in a timely manner Dialogue with Users to ensure maximum flexibility of design and close working with commissioners. Scenario planning undertaken. Ensure all requirements including primary care elements are picked up at Design Workshops and refer any potential issues to Project Board for agreement Failure to involve all stakeholders Human Resources Trust does not resource project sufficiently Trust to co-ordinate stakeholders and develop engagement strategy to ensure all areas are covered. On-going review of staffing requirement through Trust Project Board 84

85 2.21 Constraints The main constraints associated with this scheme are as follows: The Trust has a limited amount of capital available to deliver the scheme; The Trust has to deliver the scheme in an environment of increasing pressure on ED departments from both a demand and performance perspective and also in the context of reducing income to deliver this; The Trust will need to deliver the scheme whilst delivering a comprehensive ED service; Interface with the infrastructure on the New Cross site, including the Tug Way, the links into the Heart and Lung Centre and the main hospital corridor; Patient staff and visitors access to the hospital site during construction Dependencies The main dependencies associated with this scheme are as follows: Availability of capital from the Trust s internal capital programme and external funding; Emerging Urgent & Emergency Care Strategy for Wolverhampton; Recruitment and availability of key operational and project staff; Competitiveness of suppliers to enable the scheme to be delivered within budget; Transfer of ED activity to New Cross; Trust s continued strong financial position. 85

86 3 ECONOMIC CASE In accordance with the Capital Investment Manual and requirements of HM Treasury s Green Book (A Guide to Investment Appraisal in the Public Sector), this section of the OBC documents the wide range of options that have been considered in response to the requirements identified within the strategic case. 3.1 Option Development Long List The Trust has identified a number of key objectives and benefits which it is seeking from the redevelopment of its Emergency Services. It is clear from these objectives and the Trust s current position that there is a need to physically alter or re-provide the existing facilities. Consequently five options have been developed for review by the Project Board and other key stakeholders. These options were identified having considered the overall strategic redevelopment of the emergency service both within the Trust and within the context of the Wolverhampton Urgent Care Strategy, the need for co-location of clinical services on the New Cross Hospital site, and the delivery of a cohesive Estates Strategy. Each option in terms of its high level descriptor and identified benefits and issues is summarised in the following text. Option 1- Do Nothing This would involve no reconfiguration or refurbishment works to any of the existing departments. Benefits No disruption to existing services as no construction required. Issues Disruption to delivery of clinical services in the short to medium term due to lack of capacity; No opportunity to re-profile workforce as critical mass of services through co-location would not be achieved; The physical and environmental issues facing the current Emergency Department would remain unresolved; There would be significant limitations in providing the necessary capacity, improved significant adjacencies and workflow within the department to cope with current and future demand; Co-location with the Acute Medical Unit and Medical Beds would not be achieved resulting in long and difficult travel distances for patients and staff; No or little opportunity to improve the patient experience e.g. patients waiting in corridors during busy periods; No or little opportunity to improve the staff experience; No opportunity to expand diagnostics within the department; Estates issues relating to the building condition and access remain e.g. ramps; Financial penalties possible through non-achievement of targets. 86

87 Option 2 Downgrade the existing Emergency Department to an Emergency Care Centre Benefits No physical disruption to existing Emergency Services as no construction needed. Issues Potential redundancy/redeployment of clinical staff; Does not fit with Trust s status as a Tertiary Centre for several specialties; Does not fit with the Urgent and Emergency Care Strategy for Wolverhampton; Implications for other Black Country and Staffordshire Emergency Centres; Consultation required and likelihood of adverse public/stakeholder reaction; Loss of income; Impact on/and potential down grading of other Trust services; Estates issues with building condition and access remain e.g. steep ramps. Option 3 Do Minimum relocate administrative accommodation and reconfigure the existing Emergency Department Benefits Would enable some expansion to the department e.g. co-location of the ambulatory clinic space or the provision of some additional cubicles for minors/majors or expansion for diagnostics; Issues Although limited re-profiling of the workforce would be possible the benefits associated with sharing of knowledge and experience achieved through co-location would be reduced; Key co-location with AMU and Medical Beds would not be achieved; Estates issues relating to building condition and access remain e.g. steep ramps; Space is required elsewhere e.g. upper floor for displaced administrative accommodation. This will potentially lead to loss of winter capacity beds on 1 st floor; Little opportunity to improve patient and staff experience; Sub-optimal environment will remain; Financial penalties possible through non-achievement of targets. Option 4 - Extend and reconfigure the existing Emergency Department and use adjacent accommodation as expansion space Benefits Provides accommodation to meet current and future demand; Improved patient and staff experience in the short to medium term; Co-location with AMU possible in future phases by moving AMU to existing Emergency building. Issues Will not deliver fit for purpose facilities for the long term; Requires relocation of other services to new build e.g. Fracture Clinic, Durnall Unit (Cancer Services), Orthodontics; Co-location with AMU only possible by displacing other accommodation at a later date e.g. Paediatric Inpatients, OPD and ENT/MaxFax OPD; Co-location with Medical Beds will never be achieved; 87

88 Does not fit with site Master Plan and gives no opportunity for site rationalisation; Estates issues relating to the building condition and access remain e.g. steep ramps. Option 5 - New Build on the site of the former Catering Building This option would provide a purpose-built facility linked to the main hospital via the East/West corridor and Heart & Lung Centre at 1 st floor level in an area currently designated as temporary car parking. Benefits The new department would be designed specifically to meet the needs of the Emergency Service; The new build is supportive of the Urgent and Emergency Care Strategy for Wolverhampton; The design could be developed to ensure in built flexibility for the future and will incorporate shell space at 1st and 2nd floor levels; Affords the opportunity to integrate primary and secondary care in and out of hours; In the long term the proposed location provides much closer links with the key clinical users; The capacity and environmental issues regarding the current Emergency Department would be resolved; Benefits of workforce re-profiling (including out of hours) can be maximised through colocation; Single point of access achieved for medical patients; Space available would support extended use of diagnostics; There would be a significant contribution to the quality and functional suitability of the Estate; Design changes would improve adjacencies and workflow and address current limitations; The redevelopment fits with the site Masterplan; Site available; Better co-location and links with new Pathology improving specimen transport and turnaround times. Issues Due to the phased completion of this project, some clinical adjacencies could be made worse in the short-term e.g. PAU/Paediatric In Patients and ED; Short-term solutions may be needed in the interim which may require some investment. 3.2 Shortlisting of Options Short List These options have been reviewed by the Project Board and it has been agreed that Option 2 - Downgrade the existing Emergency Department and Option 3 Do Minimum, should be discounted at this stage for the following reasons: Option 2 The impact that this would have on neighbouring Trusts who do not have the capacity to cope with increased activity; 88

89 The potential activity impact on RWT and neighbouring Trusts from changes in Mid Staffordshire; The impact that this would have on other RWT clinical services and provision of tertiary services; Does not support the Urgent and Emergency Care Strategy for Wolverhampton. Option 3 The disruption to the department significantly outweighs the benefits likely to be achieved; Capacity increases are minimal and issues will only be relieved in the short term; Co-location with other key departments will never be achieved. The detailed financial and non-financial appraisal has therefore been completed on the following shortlisted options: Option 1 - Do Nothing (retained as a benchmark only); Option 4 Extend and reconfigure the existing Emergency Department; Option 5 New Build on the site of the former catering building. 3.3 Non-Financial Option Appraisal In accordance with Capital Investment Manual and Department of Health Estates guidance on appraisal, a formal non-financial appraisal of the 3 short listed options has been undertaken. This was carried out by a multidisciplinary group of stakeholders and involved a sequential and systematic approach covering: Criteria selection; Weighting of criteria to reflect their relative importance; Consideration of the options and scoring against the identified criteria; and, Analysis of the results and sensitivity testing to establish the robustness of the conclusions Benefits Criteria The benefits criteria which the Project Board agreed and Appraisal Team supported are summarised and defined in Table 3a: 89

90 Table 3a: Benefits Criteria Definitions Criteria Strategic Fit Clinical Effectiveness Access to services Staff Experience Patient Experience Environment Disruption Timescales Flexibility Description/Definition Fit with regional and local health economy plans Commissioner and stakeholder support Meets the needs of local people Fit with development strategy for hospital site Assists delivery of national, health economy and Trust targets Improved service model and patient pathways Efficient use of clinical resources High quality clinical care for patients Improves access to emergency services Improved access to diagnostic services leading to increased speed and accuracy of diagnosis Improved integration with other services internal and external to Trust Single portal Improved job satisfaction Promotes recruitment and retention of high calibre staff Promotes provision of high quality training and education Provides secure, healthy and safe working environment Creates supportive multidisciplinary team working Seen by right person with right skills, in right place at right time Meets patient expectations with regards to privacy and dignity Reduction in movement and travel distances between departments Increases patient confidence/reduces complaints Healing environment Promotes reduction in violence and aggression Meets Privacy and Dignity agenda User of latest/best technology Contributes to improvements in overall quality and condition of estate Meets sustainability agenda natural light, natural ventilation, sustainable technology Facilitates improved infection prevention Reduces anxiety/stress for patients including children Evidence of local regeneration New services and facilities can be provided with minimum disruption to service users and staff delivering the services New services and facilities can be provided with minimum disruption to other service users and staff delivering other Trust services Can be delivered within the timescales defined for the project Can provide flexibility for future changes in service delivery and/or demand The relative weighting of the benefits criteria which was agreed at the Option Appraisal Workshop is summarised in Table 3b. 90

91 Table 3b: Benefit Criteria Weighting Criteria Agreed Weighting Agreed Ranking % Strategic Fit Clinical Effectiveness Access to Services Staff Experience Patient Experience Environmental Quality Disruption Timescales Flexibility Total Option Scoring The raw and weighted scores and consequent rankings for each of the options are summarised in Tables 3c and 3d. Table 3c: Option Scores Not Weighted Option 1 Do Nothing Option 4 Extend & Reconfigure Existing Option 5 New Build Strategic Fit Clinical Effectiveness Access to Services Staff Experience Patient Experience Environmental Quality Disruption Timescales Flexibility Total Rank

92 Table 3d: Option Scores- Weighted Option 1 Do Nothing Option 4 Extend & Reconfigure Existing Option 5 New Build Strategic Fit Clinical Effectiveness Access to Services Staff Experience Patient Experience Environmental Quality Disruption Timescales Flexibility Total Rank These results show that Option 5 is the preferred option from a non-financial perspective Sensitivity Analysis A range of sensitivity tests have been applied including reversed weighting and average weighting scores. None of the changes in weighting altered the ranking order of the options. Appendix 3a provides details of this assessment. 3.4 Financial Option Appraisal Introduction This section appraises the financial implications, both capital and revenue of the short-listed options. Option 1 - Do Nothing (retained as a benchmark); Option 4 Extend and reconfigure the existing Emergency Department; Option 5 New Build on the site of the former catering building. All current guidance has been followed in constructing the financial and economic appraisal, principally the Capital Investment Manual. The DH Generic Economic Model (GEM) has been used to develop the economic appraisal of each option. The GEM uses standard discounted cash flow techniques, using a 3.5% discount rate to year 30 and a discount rate of 3% after year 30. A summary of the Discounted Cash Flow for each option is included in Appendix 3b. A full copy of the GEM in electronic format is available and will be provided as an addendum to this business case. Inputs to the GEM are driven by work carried out in revenue modelling and the capital costing. In addition to this, assumed lifecycle costs have been included in the GEM. The inputs are outlined in Table 3e. 92

93 Table 3e: Inputs to GEM Inputs Revenue costs/ savings Capital costs Lifecycle costs Residual value Description Based on costs identified in Section 5. This does not include capital charges The costs for each option reflect outturn cost deflated by RPI. They include planning contingencies as the capital risk element and optimism bias is shown separately. Lifecycle costs have been calculated on a standard profile reflecting the life of different elements of the new and refurbished buildings. Where no refurbishment is assumed in existing buildings lifecycle has been calculated on the relative age of the current building Detailed lifecycle costs for each option are shown in Appendix 3c No residual values have been assumed as each option has been assessed on the assumed life of the investment/asset The revenue cost position (excluding capital charges) for each option is summarised in Table 3f: Table 3f: Summary of revenue costs for each option Option 1 Do Nothing Option 4 Extend and Reconfigure Existing Option 5 New Build Baseline 11,998,565 11,998,565 11,998,565 Changes in 15/16-20,044 20,044 Changes in 16/17-1,506,036 1,451,338 Changes in 17/18 196, ,564 Total 11,998,565 13,721,182 13,661, Capital costs The capital costs for the shortlisted options (option 4 and 5) have been provided by the Quantity Surveyor and include the following assumptions: construction costs are calculated at PUBSEC BIS FP 173 for approval purposes and PUBSEC BIS FP 185 for outturn; VAT is at 20% except for the professional fee element which is assumed to be recoverable; fees have been included at 10.34% of the works cost for Option 5 and 9.48% for Option 4. These are based on known costs; equipment costs are based on generic room data sheet information and assume 100% new equipment. It is assumed that all radiology equipment will be procured through the Radiology PFI and the resultant Unitary Payment has been included as a revenue cost; a contingency of 10% has been assumed for both options. This has been calculated on location adjusted works costs, non-works costs, equipment costs and fees; optimism bias has been included. Further details on optimism bias are provided in Section

94 Table 3g: Capital costs for short-listed options Option 4 Extend and Reconfigure Existing 000 Option 5 New Build 000 Works cost 16,565 16,372 Location adjustment -1,159-1,063 Non Works cost Fees 1,460 1,460 Equipment 1,340 1,271 Contingency 1,838 1,848 Optimism bias 3,412 2,345 VAT 4,434 4,241 Total cost (PUBSEC BIS FP 173) 28,065 26,910 Inflation 1,869 1,787 Outturn Cost (PUBSEC BIS FP 185) 29,934 28,697 Note: There are no capital costs associated with Option Optimism Bias In line with HM Treasury guidance, the Green Book and DH template, the Trust has assessed the level of optimism bias associated with each of the short-listed options. This has been done through consultation with the Project Board and the Design Team and then reviewed and confirmed following the risk workshop. In assessing optimism bias, the Trust has sought to base the assessment on evidence from other NHS schemes. The optimism bias tool tailored by the DH in England to reflect the key contributions to optimism bias in health build projects has been used. The spread sheets used to identify the upper bound and the levels of mitigation are included in Appendix 3d. Table 3h summarises the upper bound assessment, degree of mitigation and residual optimism bias for each of the short-listed options where relevant. Table 3h: Optimism bias for short-listed options Upper Bound Assessment Degree of Mitigation Residual Optimism Bias Option 4 40% 47% 18.56% Option 5 27% 47% 12.69% Note: There are no capital costs associated with Option Upper bound assessment The upper bound assessment identified an upper bound of 27% for Option 5 and 40% for Option 4. Option 4 includes a higher level of Optimism Bias due to the number of phases and level of refurbishment involved Mitigation of optimism bias The Trust has assessed the mitigation of optimism bias that can be applied at this stage in the design development expected at OBC. Significant mitigation factors have been allowed for both options, particularly in respect of output specifications, planning and policy environment. 94

95 3.5 Economic Appraisal Appraisal Period Each option has been appraised over its estimated useful economic life. This has resulted in Option 1, 4 and 5 being appraised over 63 years (3 years construction including enabling works plus 60 year life). To enable a like for like comparison Equivalent Annual Costs (EAC) have been calculated for each option Equivalent Capital Costs Equivalent capital costs for the GEM have been calculated as follows: Table 3i: Equivalent capital costs for the GEM Option 4 Extend and Reconfigure Existing Option 5 New Build Outturn cost 29,934 28,696 Less VAT 4,746 4,539 Less planning contingencies 1,838 1,848 Outturn economic cost 23,350 22,309 Less RPI inflation 1,558 1,489 Economic current prices 21,792 20,820 Note: There are no capital costs associated with Option Sensitivities The Trust has considered the impact of the scenarios on the options to test the robustness of the preferred option. The Trust considers that given that both options provide the capacity to deliver the projected activity to 2025/26 that the activity and resultant income impacts affect both options in the same way. In terms of capital impacts, the capital cost of the Preferred Option 5 would need to increase by 16% or 3.64million for Option 4 to become the least cost option, with no increase in the capital costs of Option 4. Alternatively the Capital costs of Option 4 would need to reduce by 16% or 3.71m (including VAT and contingency) for it to become the least cost option. It is considered however that any increase in capital costs which may be brought about by inflation indices, market conditions, site conditions are also likely to be similar for both options Summary of GEM and Risk The results of the evaluation are as follows: Table 3j: Evaluation results: Total EAC 000 Option 1 10,330 Option 4 Option 5 15,491 15,362 95

96 3.5.5 Conclusion of Economic Appraisal From the economic analysis, given that Option 1 was included for benchmarking purposes only and was therefore not considered as a viable option, then Option 5 is the preferred option. 3.6 Combining the Financial and Non-Financial Appraisals In order to determine the preferred option from both the economic analysis and the nonfinancial appraisal, the EAC for each option has been divided by the point scores from the non-financial appraisal to provide a cost per benefit point score. The outcome of this process is shown in Table 3k. The option with the lowest cost per benefit point is the preferred option. Table 3k: Summary of Financial and Non-Financial Appraisals Option 1 Do Nothing Option 4 Extend and Reconfigure Existing Option 5 New Build Total non-financial scores (weighted) Total EAC ( 000) 10,330 15,491 15,362 Cost per benefit point score ( 000) Percentage score above preferred option 24% 63.5% The Preferred Option The outcome of both the non-financial and economic appraisals is that the preferred option for the delivery of the project objectives is Option 5 New Build on the site of the former Catering Department. Section 4 will describe in more detail what this option will entail in terms of the works required, the programme and the extent to which this option addresses the key objectives set out in Section 2. 96

97 4 COMMERCIAL CASE 4.1 Introduction This section of the OBC outlines the proposed development in relation to the preferred option outlined in the economic case. 4.2 Required services Description of the Works The proposed development will provide Phase One of a fully integrated Emergency Centre within a single building situated to the North/East of the New Cross Hospital site. The functional content of the new building and schedule of accommodation are detailed in Section 4 and Annexe 1 Design Proposals. The proposed construction site is currently being used for staff car parking. The new building will consist of three storeys of 9232m 2 including plant space. The Emergency Department and satellite radiology will be located at ground floor level. The entrance to the new Emergency Department will be collocated with the existing but reconfigured East Entrance to the hospital. The Clinical Decisions Unit and Outpatient clinic space and integrated Primary Care Facility will be located at 1 st floor, as will staff and other support accommodation. Shell space will be provided at 1 st and 2 nd floor levels to facilitate further development in Phase 2. The building will be directly linked to the Heart & Lung Centre for the Critical Care Unit and the main Hospital Street for access to the Acute Medical Unit and Medical beds. The construction site has been cleared with the following exceptions: electrical substation and generator; concrete slab left from the former catering department; relocation of departments and demolition of small sections of accommodation to the north side of the existing main corridor. This work will be packaged into an enabling works contract to be delivered out-with the main construction works. The Trust Board gave approval on 23 rd September 2013 for this work to commence. Figure 4a provides a graphical representation of the proposed solution within the context of the hospital site. Further detail is included in Annex 1 Design Proposals. 97

98 Figure 4a: Site Context for the Preferred Option The Trust is committed to the development of sustainable facilities which contribute positively to improvements in the overall carbon footprint and specific targets for energy and environmental efficiency. Achievement of the national agenda for sustainable development has been incorporated into the design solution. Detailed proposals are included in Annex 1 Design Proposals which accompanies this business case Functional Content and Adjacencies The proposed distribution of the key functions and adjacencies within the building including proposed floor layouts are detailed in Annex 1 Design Proposals which accompanies this business case. The capacity and functional content provided by the proposed development are as specified in Sections 2.15 and The net impact on the Trust s Estates portfolio is an increase of 8732m² after the demolition of buildings on the North side of the existing main corridor. However, in order to clear the site footprint the Trust demolished the former Catering Building which occupied this site, in 2011/12. This building was 3617m 2 in size and had a backlog maintenance liability of 2.5million. The relocation of the existing Emergency Department to new facilities will free up circa 2,000m 2 of space which will be used for the relocation of other clinical services e.g. outpatients. This relocation in turn will facilitate further site rationalisation and potential demolition of 8385m 2 of a partly occupied building which has a backlog maintenance liability of circa 10million. This Emergency Centre development will also result in the removal of 500m 2 of Victorian buildings adjacent to the main corridor. This development will consequently result in an overall improvement in the condition, quality and functional suitability of the Estate. 98

99 Design Principles As part of the design evaluation an initial BREEAM assessment has been completed and the credits to date support achievement of an Excellent rating with a score of 76.5%. There are however on-going design activities which will require further assessment. This Preassessment was carried out using BREEAM Healthcare Units. The Pre-assessment summary is attached at Appendix 4a. An initial multi-disciplinary AEDET Workshop was held in April The AEDET scores are summarised in Table 4a Table 4a: Summary AEDET Scores Criteria Score Character & Innovation 4.7 Form & Materials* 2.4 Staff & Patient Environment* 3.6 Urban & Social Integration 5.0 Performance* 2.0 Engineering* 2.8 Construction* 3.3 Use 5.1 Access 4.3 Space 4.3 Due to the early stage of design development the team were unable to score all indicators in those categories marked* hence the lower scores in these areas. A detailed analysis of the scores is included in Appendix 4b. The building will be designed and built to meet the relevant D.H. Estates standards including Hospital Building Notes, (HBNs) and Hospital Technical Memorandum (HTMs) where appropriate. In moving forward with the detailed design, the Trust will pay particular attention to the following design guidance: Equipment Health Building Note 15-01: Accident and Emergency Departments Planning and Design Guidance; Design Council Toolkit for Reducing Violence and Aggression in A&E; Kings Fund Enhancing the Healing Environment Programmes including the recent programme relating to Dementia Care. In developing the design solution the team will take full account of the range of equipment needed to support the new service model and a full list including any equipment identified to transfer and that to be provided new will be developed for the Full Business Case. Existing radiology equipment which is provided under the Radiology PFI Managed Equipment Service will be refreshed and installed to coincide with the commissioning of the new building. This includes: 99

100 2 x plain film machines 1 x OPG dental machine 1 x plain film machine (gantry mounted) The following radiology equipment is currently owned by the Trust and will be at the end of its operational life by CT Scanner 1 Ultrasound machine This equipment will be replaced through the Radiology PFI and will be again procured to coincide with the commissioning of the new building. An additional in-situ plain film machine and a portable plain film machine will be required to support additional capacity within the new Emergency Department. This equipment will also be procured through the Radiology PFI to the same timescales. Whilst capacity within the building has been provided for either MRI or a second CT Scanner, this equipment will not be installed in Phase 1 and this equipment has therefore not been included in this business case ICT The basic principles of the Trust s ICT strategy approved July 2013 are: 1. Continue to move in the direction established over the last 2-3 years; 2. Deliver the electronic patient record: A desire to move from where we are today to an environment where all patient data is available to those who need it in a timely manner where-ever they need it to ensure a safe and effective patient experience that our staff would view as an indispensable asset; 3. Deliver applications that support decision-making using timely and consistent information; 4. ICT systems that are seamless to the user, fit for purpose and efficient to run As few systems as possible; Robust and secure infrastructure; An ICT department that is appropriately skilled, structured and focused to deliver the appropriate support and SLA s. The ICT Framework in Figure 4b has been produced to summarise the component parts of the ICT Strategy. It is made up of the key outcomes, enablers and foundation stones required. All of which are essential to ensure success. Detail for each outcome, enabler and foundation can be found within the ICT Strategy , which provides the direction of travel for ICT for the next 5 years if required. 100

101 Figure 4b: ICT Framework The key priority for RWT, as it is for all healthcare organisations in England & Wales, is to deliver an integrated electronic patient record (EPR). The conceptual model of an EPR is shown below. The key ambitions being to provide secure information that can be shared both internally and externally to ensure both improved and integrated care for all patients. This priority will be applied to the new integrated service and will see a move to a paperless system including both electronic patient records and electronic recording of patient observations. The roll-out of the patient tracking system will take place ahead of the new building to ensure a fully integrated system is in place at the time of the move. ICT infrastructure is a critical foundation stone for any ICT provision at service level and as a result, the new building will include a wireless network allowing for the use of any appropriate device to access patient information in a timely and secure manner. A working group is in the process of being established to identify plans for integration of systems with primary care. These plans will be fully developed and included in the final proposals Future Flexibility Phase 1 of this development has been designed to create maximum flexibility in relation to capacity. Shell space of 797m² has been provided at first floor adjacent to the clinic space and Clinical Decisions Unit. This will allow the capacity of this floor to be flexed to allow expansion or contraction in any of the departments on this floor should the need arise including primary care facilities and provision of space for a paediatric assessment unit in Phase 2. Space has been provided at ground floor to accommodate an additional CT Scanner or MRI Scanner at a later date. Similarly this space if not needed for radiology investigations could be used as additional resuscitation space, majors cubicles or clinical support space. Cubicles have been sized and will be equipped to allow flexing of capacity between minors and majors. 101