Emergency Centre Outline Business Case

Transcription

1 Emergency Centre Outline Business Case Agenda Item No: 12.4

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3 The Royal Wolverhampton NHS Trust Trust Board Report Meeting Date: 28 th October 2013 Title: Executive Summary: Action Requested: Report of: Author: Contact Details: Resource Implications: Public or Private: (with reasons if private) References: (eg from/to other committees) Appendices/ References/ Background Reading NHS Constitution: (How it impacts on any decision-making) New Emergency Centre This report contains the Outline Business Case for the New Emergency Centre. Approval. Medical Director Dr Jonathan Odum Tel This project has both capital and revenue funding implications for the Trust. Details are provided within the business case and appendices. Public Session Emergency Centre Project Board Attachment 1 Outline Business Case and Appendices In determining this matter, the Board should have regard to the Core principles contained in the Constitution of: Equality of treatment and access to services High standards of excellence and professionalism Service user preferences Cross community working Best Value Accountability through local influence and scrutiny Background Details 1 See Attachment 1 Outline Business Case and Appendices.

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

5 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

6 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

7 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

8 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

9 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

10 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

11 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

12 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

13 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

14 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

15 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

16 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

17 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

18 130 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

19 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

20 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

21 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

22 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

23 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)

24 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

25 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

26 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

27 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

28 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

29 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

30 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

31 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

32 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

33 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

34 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

35 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

36 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

37 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

38 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

39 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

40 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

41 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

42 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

43 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

44 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

45 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

46 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

47 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

48 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

49 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

50 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

51 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

52 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

53 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

54 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

55 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

56 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

57 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

58 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

59 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

60 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

61 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

62 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

63 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

64 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

65 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

66 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

67 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

68 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

69 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

70 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

71 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

72 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

73 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

74 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

75 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

76 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

77 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

78 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

79 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

80 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

81 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

82 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

83 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)

84 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

85 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

86 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

87 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

88 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

89 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

90 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

91 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

92 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

93 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

94 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

95 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

96 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

97 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

98 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

99 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

100 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

101 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

102 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

103 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

104 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

105 2459m² of shell space at second floor is intended to provide in patient bed accommodation for either medical assessment or paediatrics in Phase 2 of the development. Again this shell space could alternatively, be used for additional support accommodation to the Emergency Department should demand exceed expectations in the future. This business case assumes that all shell space will remain empty until future phases Design Review Panel Department of Health guidance published 2007 confirms that the threshold for panel reviews is 35million total outturn. Therefore the value of this project falls below the formal threshold and a submission for Design Review Panel review is not required. However, in recognition of the significance of the investment a full information pack has been developed and is included in Annex 1 Design Proposals to this Business Case Planning Status The Trust submitted a Hybrid Planning Application in June 2008 for the overall Masterplan and was granted conditional outline planning permission for redevelopment of the hospital site in This included planning permission for the erection of a three storey Emergency Centre building on the proposed site and associated ancillary works. The Conditions relating to the detailed planning permission include the customary need to submit and have approved the materials of the façade, the soft landscaping proposals, drainage details, plant noise attenuation measures, parking and access arrangements. Other Conditions, such as the requirement to investigate the site for contamination has now been addressed by completion of full geotechnical Site Investigations (SI). From the findings of the intrusive SI contamination levels were found to be low, thus anticipating no requirement for remediation, and the summary of the SI Report states that no significant constraints to the construction of the proposed Emergency Centre have been identified. The Lead Architect and Planning colleagues are in dialogue with the local Planning Authority and all planning obligations are anticipated to be discharged in advance of the approval of the Full Business Case Equality Impact Assessment In line with the Trust s Single Equality Scheme an Equality Impact Assessment has been completed and this has identified there is no adverse impact on any group anticipated. The assessment outcome is attached at Appendix 4c Project Timetable The key milestone programme for the on-going stages of the project based on a traditional procurement route is outlined in Table 4b. The detailed project plan is attached at Appendix 4d: 102

106 Table 4b: 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 Trust/Construction Partner April 2016 commissioning Full operational service commences Trust May Benefits of the Preferred Option Sections 2.7 and 2.13 set out the key objectives and benefits which this project seeks to address. Appendix 4e details how the preferred option achieves these benefits. 4.4 Procurement strategy and risk transfer The Trust has reviewed the different options available in terms of the procurement routes for the capital elements of this proposal. It is recognised that there are still options available for the development of a partnership with the private sector. However, in the light of existing uncertainties in the market place, the absence of definitive central guidance on the preferred nature of such arrangements for the Acute sector and the likely impact on the project timetable the Trust Board concluded that the most appropriate way forward for this project would be public funding through the Trust 5 year Capital Programme. The scope and nature of the project was considered along with the key drivers that will impact on the final product, namely: Cost Tender Cost v Final Cost; Risk/Cost Management who takes it and at what cost; and, Programme/Contractor appointment delivery on time is critical once dates are set. In view of the estimated costs the options available to the Trust were considered to be either a traditional construction contract (single stage or two stage) or a development under the ProCure 21 initiative. For the two options in the traditional procurement route of selective tender list with a competitive lump sum tender there are two options: Single Stage Lump sum; and, 103

107 Two Stage Lump sum. The question of which traditional tender route to choose may be assessed on the merits of the particular schemes, the quality and complexity of the work, the programme requirements. There may be benefits for the use of a two stage tendering option, but there are particular disadvantages which may also outweigh the benefits. The use of a two stage tender, by competitively tendering the preliminaries and profit elements of the scheme would bring an early appointment of the contractor. In doing so this may bring forward the completion date of the project; however, the emphasis of the two stage tender is to promote a specific focus during the later stages of design on issues of buildability and economic construction which is important in particularly complex or unusual design systems. The two stage approach provides an opportunity to obtain contractor buy-in to the client s viability model through agreement of not to be exceeded costs at end of stage one. Unfortunately this buy in is not binding on the contractor. Improved identification of project risks within a timescale where action can be undertaken. In respect of commitment before full knowledge of the tender sum is in place, the Client has no contractual commitment beyond the Pre Commencement Stage prior to the completion of stage two and can withdraw should the second stage tender not fulfil the budget expectations. There would be a fee agreed at first stage tender for the pre commencement service agreement. To use a single stage tender process in lieu of two stage process will provide the Trust with an early contractual commitment on price without the confusion of a preferred bidder stage. The discipline of a single-stage tender with proper controls and approval periods will prevent the project team from proceeding to construction without a complete design which would otherwise undermine the accuracy of the fixed price tender. The single stage tender tends to provide Clients and funders greater security to an application for loans or grants. By utilising a single stage tender route, there is no opportunity for the preferred contractor to escalate the cost of the scheme during the second-stage tendering process and the contractor is not given an opportunity to revisit the pricing of the scheme. The two stage process typically provides a fully competitive bid for only the preliminaries and on costs, with the majority of the remaining works priced on a downstream partnered supply chain which may have benefits in construction reliability and quality but is likely to have a reduced benefit in cost. For a fully designed and tendered scheme such as with single stage tendering, there is no risk for confusion between contractor and client with respect to the demarcation of responsibility for design. The design for the scheme will be fully completed and so there will be less opportunity for extended negotiation during the tender period than with a two-stage approach. Selection of the right contractor is most important because this involves ensuring that the contractor s proposal can be delivered as well as identifying the most advantageous offer. In principle, if the prequalification of contractors is effective, and good practice is followed, the Trust should be able to accept either the lowest tender without hesitation or the one providing the greatest assurance of outcome combining cost and programme certainty with quality. Prequalification and the post-tender evaluation are critical to ensure that a bid offers the client the basis for cost and time certainty. Steps that have been taken include: Investing in pre-tender briefing and mid-bid consultation to ensure that contractors understand the project requirements, have all necessary information and are willing to complete the bid; Use of quality criteria in the bid evaluation, administered in accordance with published standards; 104

108 Proper management of tendering documentation to provide managed circulation of all information including correspondence, tender addenda etc; and, Building enough time into the programme to allow for the post-tender evaluation of tenders, including the confirmation of the contractor s correct interpretation of client requirements, design intent, risk identification and project constraints. For the scheme which we are assessing at this point we have highlighted particular aspects for consideration: There is sufficient time in the pre-contract programme for the completion of design work and any production information; The construction requirements of the scheme are reasonably standard and the requirements are not overly complex; Early start on site is not advantageous for overall capital cash flow; Fully market tested tendering of all elements is to the Trust s benefit; The design and project management team will produce detailed programming and track the progress of design completion; and, The project management team will rigorously apply design-stage reviews and design freezes. The programming process, the projected timescales and the type of construction that is anticipated for this scheme indicate that there is no advantage to utilising a two stage tendering process instead of a single stage tender. The programme allows for sufficient design and tendering periods and forms a part of the Trust 10 year plan; The construction is not significantly complex to require early buildability input from specialist sub-contractors; The capital project management team are aware of the requirement for rigorous monitoring of the design programme; and, The single stage tender will introduce a quality test for individual assessment of tenders for quality not just the lowest price Assessment of ProCure 21 + and Traditional Tendering Each of these has been assessed against the three key drivers. Cost Both ProCure 21+(P21 + ) and traditional procurement routes result in a competitively tendered scheme. The P21+ Principal Supply Chain Partner (PSCP) will generally tender through their supply chain and the traditional contractor will tender through the current market, using a pre-qualification and tender process. The PSCP will provide a Guaranteed Maximum Price (GMP) which will be inclusive of design reserve. In essence the PSCP is taking the major risk and as such will include in his price the cost premium for doing so. The traditional route, if managed correctly, removes the majority of the risk prior to tender, by developing the design progressively with regular scope and cost appraisals. The Traditional tender will provide a fixed lump sum price for the works, which could if required be developed into a GMP. 105

109 In the light of current trends in construction cost inflation the ability to benefit from the spot testing of the wider local and national market, rather than a restricted supply chain, was considered to have significant cost advantages. Risk Management The PSCP will include within their price all allocated risks and will seek to manage the risk out of the scheme as the design progresses. Savings against the GMP will be shared between the Trust and the P21 Contractor in an agreed proportion; should the cost of the works exceed the GMP then the P21 Contractor would bear the extra cost. 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. In both procurement options the management of Risk is important and the Client and Design team should target the management of the risk register through the design process as a priority. Programme/Contractor Appointment The use of ProCure 21 + allows a Trust to immediately go to the market place and select from a previously tendered group of PSCP. These contractors have been market tested in their own right to provide a competitive price and a preselected team for the management of the scheme. The design team would usually be an element of the PSCP team. There should be a programme benefit but often it is seen by the Trust as an additional period to develop the brief and, as such does not produce the time benefit that it should against other forms of procurement. Where time is not a major criterion this perceived saving in time is not a benefit. The traditional form of procurement allows a separate competitive appointment of a design team to provide a full design and a main contractor who will then provide a firm price for the works. Similarly, a GMP may be obtained by the Contractor pricing out any outstanding risk items. The big advantage in the current market is that you can tender the project at a moment in time which should be cost beneficial to the Trust. Within the programme for the Emergency Centre scheme, due allowance has been made for the traditional procurement route time periods, the external approval periods, the Trust approval periods and OJEU tender periods. The overall conclusion has therefore been that a single stage traditional procurement route would be the most appropriate for this particular scheme. However, due to the complexity of the works included in the Enabling Package and the short timescales for delivery, the Trust intends to procure these works through the P21+ route. The Trust Board gave approval for these works to proceed in September

110 5 FINANCIAL CASE 5.1 Introduction This section assesses the overall affordability of the scheme. The analysis assumes that the scheme is financed through the Trust s operational capital programme. The development will account for capital charges, and the analysis accounts for them in the context of the scheme s overall affordability. The Trust has reviewed direct and indirect budgets related to the Emergency Services Directorate. It has identified costs as a result of the development relating to the following: ED in relation to nursing and reception staff; Radiology in relation to an enhanced service need in the new building and to support the new Emergency Services Model; Estates and Facilities in relation to energy costs and cleaning associated with the increased area. Costs relating to the anticipated activity growth in emergency services have also been included in the case as they are a driver for the Emergency Centre in terms of size, costs and overall affordability. 107

111 5.2 Changes in Revenue Position Table 5a provides a summary of the full impact of the costs identified for the preferred option. Table 5a: Full Impact of Additional Annual Costs Area of Savings Amount of Recurrent Annual Savings / (Additional costs) '000s Commentary Direct Staff Costs Emergency Department (815,105) Due to requirements of new build and activity Ambulatory Assessment Area 211,037 Transferred into EC Therapies 0 Radiology (153,597) Requirements of enhanced service Sub Total (757,665) Direct Non Pay Costs Emergency Department (35,079) Activity driven Radiology (53,183) Requirements of enhanced service Therapies 0 Radiology PFI Maintenance (191,655) Increased facilities, plain film Sub Total (279,917) Indirect Costs Estates & Facilities Pay (107,293) Increase to domestics due to increased area & facilities, partly offset by porters savings Estates & Facilities Non Pay (510,571) Energy increase, maintenance and rates IT Non Pay (7,500) Sub Total (625,364) Income Rapid response from CCG 0 Sub Total (1,662,946) Capital Charges (1,458,792) Total (3,121,738) 108

112 Table 5b: Summary of I&E Impact in first full year of operation (2017/18) 2014/15 Option 1 Do Nothing Option 4 Extend and Reconfigure Existing Option 5 New Build Direct Pay 10,097,717 10,097,717 10,097,717 Direct Non Pay 853, , ,135 Other Non Pay Indirect Pay and Non Pay 1,047,714 1,047,714 1,047,714 Capital Charges 0 90, ,137 Income 15,454,273 15,454,273 15,454,273 Sub Total 3,455,708 3,365,633 3,213, /18 Direct Pay 10,097,717 10,855,381 10,855,381 Direct Non Pay 853, , ,397 Other Non Pay 0 0 Indirect 1,047,714 1,924,404 1,864,733 Capital Charges 0 1,771,813 1,700,929 Income 15,454,273 16,422,657 16,422,657 Sub Total 3,455, ,662 1,060,217 Increase/(Decrease) in Revenue Costs 0 2,435,971 2,153,353 Capital Charges for each option in 2017/18 are broken down and detailed in Table 5c. Table 5c: Breakdown of Capital Charges for each Option Option 4 Option 5 Extend and Reconfigure Existing New Build Buildings Depreciation 424, ,557 Equipment Depreciation 379, ,909 Sub total 804, ,466 Rate of Return 967, ,462 Total 1,771,813 1,700,929 Note: There are no capital costs associated with Option

113 5.3 Revenue Affordability The revenue impact of the preferred option is shown in the affordability statement in Table 5d. 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. Table 5e shows the base case Option 5 including the impact of inflation and staff deflator. The percentages used are as included in the LTFM. Income is deflated by 1.3% per annum; pay costs have been inflated by 1% per annum; energy costs inflated by 5.5% and PFI costs by 2.5%. As in the LTFM annual efficiency savings have been included at the required 4% and also, a level of inflation for Trust support departments, methodologies are as per the LTFM. 110

114 Table 5d: Affordability Statement for Preferred Option (2013/14 pay and prices) Emergency Centre New Build OBC Affordability Statement - as at 13/14 Income and Costs Base Model Base Year 2014/ / / / / / / / / / / /26 Income ED 11,397,385 11,850,448 9,765,293 10,003,566 10,247,653 10,497,696 10,753,840 11,016,233 11,285,029 11,560,384 11,842,457 12,131,413 Primary care in ED 0 0 1,153,696 1,181,846 1,210,683 1,240,224 1,270,485 1,301,485 1,333,241 1,365,772 1,399,097 1,433,235 PAU ( Excluded ) EAU Amb 741, , A&E Outpatients 509, , , , , , , , , , , ,953 CDU 2,524,880 2,586,338 3,283,940 3,423,033 3,506,555 3,592,115 3,679,762 3,769,548 3,861,525 3,955,747 4,052,267 4,151,142 Additional primary care activity in ED 0 0 1,099,340 1,098,680 1,098,021 1,097,362 1,124,138 1,151,567 1,179,665 1,208,449 1,237,935 1,268,141 Rapid Response Income 281, , , , , , , , , , , ,831 Patient Care Income 15,454,273 15,991,572 16,007,471 16,422,657 16,789,026 17,164,351 17,576,285 17,998,270 18,430,551 18,873,380 19,327,013 19,791,716 Expenditure Direct Pay: Emergency Department 7,770,358 7,770,358 8,517,537 8,585,463 9,003,768 9,073,110 9,153,782 9,234,370 9,308,475 9,357,878 9,438,467 9,698,630 PAU AMU AMB 211, ,037 17, Radiology 1,706,340 1,706,340 1,847,137 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 Estates and Facilities -Pay 581, , , , , , , , , , , ,640 Therapies Pay 409, , , , , , , , , , , ,981 Direct Non Pay: Maintenance - Radiology CT , , , , , , , , , ,366 Maintenance - Radiology Plain Film ,541 36,335 37,244 38,175 39,129 40,107 41,110 42,138 43,191 44,271 Maintenance - Radiology US Machine ,928 14,671 15,038 15,414 15,799 16,194 16,599 17,014 17,439 17,875 Emergency Department Non Pay and Drugs 606, , , , , , , , , , , ,047 PAU Non Pay and Drugs Radiology Non Pay 227, , , , , , , , , , , ,847 Therapies Non Pay 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 Estates and Facilities Non Pay 466, , , , , , , , , , , ,076 IT 0 0 6,875 7,500 7,500 7,500 7,500 7,500 7,500 7,500 7,500 7,500 Sub total Expenditure 11,998,565 12,018,609 13,469,947 13,661,511 14,119,145 14,228,657 14,329,900 14,427,999 14,536,053 14,624,183 14,744,413 15,037,371 Patient Income Less Direct Expenditure 3,455,708 3,972,963 2,537,524 2,761,146 2,669,882 2,935,694 3,246,385 3,570,270 3,894,498 4,249,197 4,582,600 4,754,345 Capital Charges on New Building 242, ,137 1,317,505 1,366,182 1,345,888 1,325,595 1,305,301 1,285,007 1,264,714 1,271,112 1,277,511 1,257,217 Capital Charges on Radiology Equipment , , , , , , , , , ,484 Charges for Extra Floor ( 2nd Floor Shell) - Not Used for Emergency Services , , , , , , , , , ,558 Patient Income less direct expenditurre and capital implications 3,213,571 3,345,826 1,023,119 1,060, ,095 1,289,048 1,626,880 1,977,907 2,327,554 2,680,980 3,014,833 3,192,086 Change in Position from 2014/14 Baseline (before Capital Charges) 517,255 (918,183) (694,561) (785,826) (520,013) (209,323) 114, , ,489 1,126,893 1,298,638 Contribution from the CCG 918, , , , ,323 Revised Change in Position from 2014/14 Baseline (before Capital Charges) 517, , , ,489 1,126,893 1,298,638 Change in Position from 2014/15 (after capital charges) 132,255 (2,190,452) (2,153,353) (2,217,476) (1,924,522) (1,586,690) (1,235,664) (886,016) (532,591) (198,738) (21,484) Impairment (MEA Valuation) 0 0 2,717, NOTES: Excludes pay award, inflation and tariff deflator from 14/15 (1) Includes 2.5 % inflation from 14/15 on PFI costs Contribution Before Capital charges 22.4% 24.8% 15.9% 16.8% 15.9% 17.1% 18.5% 19.8% 21.1% 22.5% 23.7% 24.0% After capital charges 20.8% 20.9% 6.4% 6.5% 5.9% 7.5% 9.3% 11.0% 12.6% 14.2% 15.6% 16.1% 111

115 Table 5e: Affordability Statement for Preferred Option (including inflation and staff deflator) Emergency Centre New Build OBC Affordability Statement - Adjusted for Pay Award, Inflation & Tariff Deflator Base Model Base Year 2014/ / / / / / / / / / / /26 Income ED 11,249,219 11,544,339 9,389,376 9,493,437 9,598,650 9,705,030 9,812,589 9,921,340 10,031,296 10,142,471 10,254,878 10,368,531 Primary care in ED 0 0 1,109,284 1,121,578 1,134,008 1,146,576 1,159,284 1,172,132 1,185,122 1,198,257 1,211,537 1,224,964 PAU ( Excluded ) EAU Amb 731, , A&E Outpatients 502, , , , , , , , , , , ,524 CDU 2,492,057 2,519,530 3,157,524 3,248,476 3,284,478 3,320,879 3,357,684 3,394,896 3,432,521 3,470,563 3,509,027 3,547,917 Additional primary care activity in ED 0 0 1,057,021 1,042,653 1,028,481 1,014,502 1,025,746 1,037,114 1,048,608 1,060,229 1,071,980 1,083,860 Rapid Response Income 281, , , , , , , , , , , ,831 Patient Care Income 15,257,031 15,585,774 15,402,109 15,599,560 15,743,596 15,889,577 16,062,555 16,237,450 16,414,283 16,593,075 16,773,850 16,956,627 Expenditure Direct Pay: Emergency Department 7,848,061 7,926,542 8,775,627 8,934,067 9,463,051 9,631,289 9,814,093 9,999,500 10,180,542 10,336,920 10,530,199 10,928,659 PAU AMU AMB 213, ,279 17, Radiology 1,723,404 1,740,638 1,903,107 1,935,458 1,954,813 1,974,361 1,994,104 2,014,045 2,034,186 2,054,528 2,075,073 2,095,824 Estates and Facilities -Pay 587, , , , , , , , , , , ,245 Therapies Pay 414, , , , , , , , , , , ,977 Direct Non Pay: Maintenance - Radiology CT , , , , , , , , , ,366 Maintenance - Radiology Plain Film ,541 36,335 37,244 38,175 39,129 40,107 41,110 42,138 43,191 44,271 Maintenance - Radiology US Machine ,928 14,671 15,038 15,414 15,799 16,194 16,599 17,014 17,439 17,875 Emergency Department Non Pay and Drugs 612, , , , , , , , , , , ,171 PAU Non Pay and Drugs Radiology Non Pay 227, , , , , , , , , , , ,847 Therapies Non Pay 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 Estates and Facilities Non Pay 478, ,613 1,000,684 1,098,647 1,145,035 1,188,857 1,216,505 1,240,670 1,284,405 1,334,639 1,386,895 1,431,386 IT 0 0 6,875 7,500 7,500 7,500 7,500 7,500 7,500 7,500 7,500 7,500 Trust Inflation - Support Departments 276, , ,372 1,040,486 1,264,532 1,496,939 1,723,577 1,945,275 2,158,850 2,439,654 2,630,095 2,808,746 Sub total Expenditure 12,400,332 12,818,761 14,721,987 15,318,823 16,184,053 16,699,998 17,204,982 17,705,684 18,215,051 18,775,111 19,293,610 19,983,068 4% Trust Efficiency on Total Income as above Current Year Efficiency Savings (599,008) (612,158) (604,811) (612,709) (618,471) (624,310) (631,229) (638,225) (645,298) (652,450) (659,681) (666,992) Prior Years Efficiency Savings 0 (599,008) (1,211,166) (1,815,977) (2,428,686) (3,047,157) (3,671,466) (4,302,695) (4,940,920) (5,586,218) (6,238,668) (6,898,349) CIP Total (599,008) (1,211,166) (1,815,977) (2,428,686) (3,047,157) (3,671,466) (4,302,695) (4,940,920) (5,586,218) (6,238,668) (6,898,349) (7,565,341) Patient Income Less Direct Expenditure & Effeciency 3,455,708 3,978,179 2,496,099 2,709,423 2,606,699 2,861,046 3,160,268 3,472,686 3,785,450 4,056,632 4,378,589 4,538,900 Capital Charges on New Building 242, ,137 1,317,505 1,366,182 1,345,888 1,325,595 1,305,301 1,285,007 1,264,714 1,271,112 1,277,511 1,257,217 Capital Charges on Radiology Equipment , , , , , , , , , ,484 Charges for Extra Floor ( 2nd Floor Shell) - Not Used for Emergency Service , , , , , , , , , ,558 Patient Income less direct expenditurre, CIP & capital implications 3,213,571 3,351, ,693 1,008, ,912 1,214,400 1,540,763 1,880,323 2,218,506 2,488,416 2,810,821 2,976,641 Change in Position from 2014/15 Baseline (before Capital Charges) 522,471 (959,609) (746,285) (849,009) (594,662) (295,439) 16, , , ,881 1,083,192 Contribution from the CCG 959, , , , ,439 Revised Change in Position from 2014/14 Baseline (before Capital Charges) 522, , , , ,881 1,083,192 Change in Position from 2014/15 (after capital charges) 137,471 (2,231,877) (2,205,076) (2,280,659) (1,999,171) (1,672,807) (1,333,248) (995,065) (725,155) (402,749) (236,929) Impairment (MEA Valuation) 0 0 2,717, NOTES: Includes tariff deflator of 1.3% from 14/15 Includes inflation on E&F non pay of 2% from 14/15 Includes pay award of 1% from 14/15 Includes inflation on ED non pay of 1% from 14/15 Contribution Before Capital charges 22.6% 25.5% 16.2% 17.4% 16.6% 18.0% 19.7% 21.4% 23.1% 24.4% 26.1% 26.8% After capital charges 21.1% 21.5% 6.4% 6.5% 5.9% 7.6% 9.6% 11.6% 13.5% 15.0% 16.8% 17.6% 112

116 5.4 Sensitivities Tables 5f, 5g, 5h and 5i highlight the impact of the three sensitivity scenarios. Table 5j shows the impact of the sensitivities compared to the base case for Option 5. This table shows the impact of patient income less direct expenditure (excluding capital charges), for each sensitivity: Table 5j: Income less direct expenditure for each sensitivity compared to base case for Option / / / /26 Base Case 3,455,708 2,537,524 3,246,385 4,754,345 Base Case plus further Stafford activity (impact 2014/15) Base Case less potential primary care activity (impact 2016/17) Base Case less potential primary care activity (impact 2016/17) but plus Stafford activity increase (impact 2014/15) 3,890,244 2,923,838 3,720,361 5,289,671 3,455,708 1,605,177 2,327,551 3,716,212 3,890,244 1,991,492 2,801,512 4,251,812 With regard to each of the sensitivities and their impact on income, the Trust is actively managing the options. Direct discussions are taking place with the administrators at Stafford and the Trust is in continuous dialogue with the CCG. 113

117 Table 5f: Affordability Statement for the Sensitivity Scenario of reduction in primary care activity (2013/14 pay and prices) Emergency Centre New Build OBC Affordability Statement - as at 13/14 Income and Costs MODEL - Base less potential primary care activity 2014/ / / / / / / / / / / /26 Income ED 11,397,385 11,850,462 9,765,305 10,003,578 10,247,665 10,497,709 10,753,853 11,016,247 11,285,043 11,560,398 11,842,472 12,131,428 Primary care in ED 0 0 1,153,697 1,181,847 1,210,685 1,240,225 1,270,487 1,301,487 1,333,243 1,365,774 1,399,099 1,433,237 PAU ( Excluded ) EAU Amb 741, , A&E Outpatients 509, , , , , , , , , , , ,954 CDU 2,524,880 2,586,338 3,283,940 3,423,033 3,506,555 3,592,115 3,679,762 3,769,548 3,861,525 3,955,747 4,052,267 4,151,142 Additional primary care activity in ED Rapid Response Income 281, , , , , , , , , , , ,831 Patient Care Income 15,454,273 15,991,587 14,908,145 15,323,991 15,691,020 16,067,004 16,452,162 16,846,718 17,250,902 17,664,947 18,089,095 18,523,592 Expenditure Direct Pay: Emergency Department 7,770,358 7,770,358 8,350,544 8,403,288 8,821,593 8,867,821 8,948,493 9,029,081 9,078,485 9,127,888 9,208,476 9,468,639 PAU AMU AMB 211, ,037 17, Radiology 1,706,340 1,706,340 1,848,830 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 Estates and Facilities -Pay 581, , , , , , , , , , , ,640 Therapies Pay 409, , , , , , , , , , , ,981 Direct Non Pay: Maintenance - Radiology CT , , , , , , , , , ,366 Maintenance - Radiology Plain Film ,541 36,335 37,244 38,175 39,129 40,107 41,110 42,138 43,191 44,271 Maintenance - Radiology US Machine ,928 14,671 15,038 15,414 15,799 16,194 16,599 17,014 17,439 17,875 Emergency Department Non Pay and Drugs 606, , , , , , , , , , , ,047 PAU Non Pay and Drugs Radiology Non Pay 227, , , , , , , , , , , ,847 Therapies Non Pay 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 Estates and Facilities Non Pay 466, , , , , , , , , , , ,075 IT 0 0 5,197 7,500 7,500 7,500 7,500 7,500 7,500 7,500 7,500 7,500 Sub total Expenditure 11,998,565 12,018,609 13,302,968 13,479,336 13,936,969 14,023,369 14,124,611 14,222,711 14,306,062 14,394,192 14,514,423 14,807,380 Patient Income Less Direct Expenditure 3,455,708 3,972,978 1,605,177 1,844,656 1,754,051 2,043,635 2,327,551 2,624,008 2,944,840 3,270,754 3,574,672 3,716,212 Capital Charges on New Building 242, ,137 1,317,505 1,366,182 1,345,888 1,325,595 1,305,301 1,285,007 1,264,714 1,271,112 1,277,511 1,257,217 Capital Charges on Radiology Equipment , , , , , , , , , ,484 Charges for Extra Floor ( 2nd Floor Shell) - Not Used for Emergency Service , , , , , , , , , ,558 Patient Income less direct expenditure and capital implications 3,213,571 3,345,841 90, ,727 80, , ,046 1,031,644 1,377,895 1,702,538 2,006,905 2,153,953 Change in Position from 2013/14 Baseline (before Capital Charges) 517,270 (1,850,531) (1,611,052) (1,701,657) (1,412,073) (1,128,157) (831,700) (510,868) (184,954) 118, ,504 Change in Position from 2013/14 (after capital charges) 132,270 (3,122,799) (3,069,844) (3,133,308) (2,816,582) (2,505,525) (2,181,927) (1,835,676) (1,511,033) (1,206,666) (1,059,618) Impairment (MEA Valuation) 0 0 2,717, NOTES: Excludes pay award, inflation and tariff deflator from 14/15 Includes 2.5 % inflation from 14/15 on PFI costs Contribution Before Capital charges 22.4% 24.8% 10.8% 12.0% 11.2% 12.7% 14.1% 15.6% 17.1% 18.5% 19.8% 20.1% After capital charges 20.8% 20.9% 0.6% 0.9% 0.5% 2.5% 4.3% 6.1% 8.0% 9.6% 11.1% 11.6% 114

118 Table 5g: Affordability Statement for the Sensitivity Scenario of increased activity from Stafford and surrounding areas (2013/14 pay and prices) Emergency Centre New Build OBC Affordability Statement - as at 13/14 Income and Costs MODEL - Base BUT Includes Stafford Activity 2014/ / / / / / / / / / / /26 Income ED 12,332,153 12,823,825 10,562,995 10,820,732 11,084,758 11,355,226 11,632,294 11,916,122 12,206,875 12,504,723 12,809,838 13,122,398 Primary care in ED 0 0 1,250,598 1,281,113 1,312,372 1,344,394 1,377,197 1,410,801 1,445,224 1,480,488 1,516,612 1,553,617 PAU ( Excluded ) EAU Amb 741, , A&E Outpatients 550, , , , , , , , , , , ,917 CDU 2,524,880 2,586,338 3,283,940 3,423,033 3,506,555 3,592,115 3,679,762 3,769,548 3,861,525 3,955,747 4,052,267 4,151,142 Additional primary care activity in ED 0 0 1,099,340 1,098,680 1,098,021 1,097,362 1,124,138 1,151,567 1,179,665 1,208,449 1,237,935 1,268,141 Rapid Response Income 281, , , , , , , , , , , ,831 Patient Care Income 16,430,236 17,007,150 16,936,660 17,374,518 17,764,113 18,163,230 18,599,536 19,046,488 19,504,346 19,973,375 20,453,849 20,946,046 Expenditure Direct Pay: Emergency Department 8,240,784 8,240,784 8,987,964 9,055,889 9,474,153 9,543,495 9,624,166 9,704,755 9,778,860 9,828,263 9,908,852 10,228,638 PAU AMU AMB 211, ,037 17, Radiology 1,706,340 1,706,340 1,847,138 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 Estates and Facilities -Pay 581, , , , , , , , , , , ,640 Therapies Pay 409, , , , , , , , , , , ,981 Direct Non Pay: Maintenance - Radiology CT , , , , , , , , , ,366 Maintenance - Radiology Plain Film ,541 36,335 37,244 38,175 39,129 40,107 41,110 42,138 43,191 44,271 Maintenance - Radiology US Machine ,928 14,671 15,038 15,414 15,799 16,194 16,599 17,014 17,439 17,875 Emergency Department Non Pay and Drugs 677, , , , , , , , , , , ,043 PAU Non Pay and Drugs Radiology Non Pay 227, , , , , , , , , , , ,847 Therapies Non Pay 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 Estates and Facilities Non Pay 466, , , , , , , , , , , ,075 IT 0 0 6,875 7,500 7,500 7,500 7,500 7,500 7,500 7,500 7,500 7,500 Sub total Expenditure 12,539,992 12,560,036 14,012,822 14,205,870 14,664,985 14,776,053 14,879,175 14,979,199 15,089,224 15,179,375 15,301,674 15,656,375 Patient Income Less Direct Expenditure 3,890,244 4,447,114 2,923,838 3,168,648 3,099,128 3,387,177 3,720,361 4,067,289 4,415,122 4,794,001 5,152,175 5,289,671 Capital Charges on New Building 242, ,137 1,317,505 1,366,182 1,345,888 1,325,595 1,305,301 1,285,007 1,264,714 1,271,112 1,277,511 1,257,217 Capital Charges on Radiology Equipment , , , , , , , , , ,484 Charges for Extra Floor ( 2nd Floor Shell) - Not Used for Emergency Service , , , , , , , , , ,558 Patient Income less direct expenditure and capital implications 3,648,107 3,819,977 1,409,433 1,467,719 1,425,340 1,740,531 2,100,857 2,474,926 2,848,178 3,225,784 3,584,407 3,727,412 Change in Position from 2013/14 Baseline (before Capital Charges) 556,870 (966,405) (721,596) (791,116) (503,067) (169,883) 177, , ,757 1,261,931 1,399,427 Change in Position from 2013/14 (after capital charges) 171,870 (2,238,674) (2,180,387) (2,222,766) (1,907,576) (1,547,250) (1,173,181) (799,929) (422,323) (63,699) 79,306 Impairment (MEA Valuation) 0 0 2,717, NOTES: Excludes pay award, inflation and tariff deflator from 14/15 Includes 2.5 % inflation from 14/15 on PFI costs Contribution Before Capital charges 23.7% 26.1% 17.3% 18.2% 17.4% 18.6% 20.0% 21.4% 22.6% 24.0% 25.2% 25.3% After capital charges 22.2% 22.5% 8.3% 8.4% 8.0% 9.6% 11.3% 13.0% 14.6% 16.2% 17.5% 17.8% 115

119 Table 5h: Affordability Statement for the Sensitivity Scenario of reduction in primary care activity but increased activity from Stafford and surrounding areas (2013/14 pay and prices) Emergency Centre New Build OBC Affordability Statement - as at 13/14 Income and Costs MODEL - Base BUT less primary care activity and plus Stafford Activity 2014/ / / / / / / / / / / /26 Income ED 12,332,153 12,823,825 10,562,995 10,820,732 11,084,758 11,355,226 11,632,294 11,916,122 12,206,875 12,504,723 12,809,838 13,122,398 Primary care in ED 0 0 1,250,598 1,281,113 1,312,372 1,344,394 1,377,197 1,410,801 1,445,224 1,480,488 1,516,612 1,553,617 PAU ( Excluded ) EAU Amb 741, , A&E Outpatients 550, , , , , , , , , , , ,917 CDU 2,524,880 2,586,338 3,283,940 3,423,033 3,506,555 3,592,115 3,679,762 3,769,548 3,861,525 3,955,747 4,052,267 4,151,142 Additional primary care activity in ED Rapid Response Income 281, , , , , , , , , , , ,831 Patient Care Income 16,430,236 17,007,150 15,837,320 16,275,838 16,666,092 17,065,868 17,475,398 17,894,921 18,324,681 18,764,926 19,215,914 19,677,905 Expenditure Direct Pay: Emergency Department 8,240,785 8,240,785 8,820,971 8,873,715 9,291,979 9,338,206 9,418,878 9,499,467 9,548,870 9,598,273 9,678,862 9,998,356 PAU AMU AMB 211, ,037 17, Radiology 1,706,340 1,706,340 1,847,138 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 Estates and Facilities -Pay 581, , , , , , , , , , , ,640 Therapies Pay 409, , , , , , , , , , , ,981 Direct Non Pay: Maintenance - Radiology CT , , , , , , , , , ,366 Maintenance - Radiology Plain Film ,541 36,335 37,244 38,175 39,129 40,107 41,110 42,138 43,191 44,271 Maintenance - Radiology US Machine ,928 14,671 15,038 15,414 15,799 16,194 16,599 17,014 17,439 17,875 Emergency Department Non Pay and Drugs 677, , , , , , , , , , , ,043 PAU Non Pay and Drugs Radiology Non Pay 227, , , , , , , , , , , ,847 Therapies Non Pay 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 Estates and Facilities Non Pay 466, , , , , , , , , , , ,075 IT 0 0 6,875 7,500 7,500 7,500 7,500 7,500 7,500 7,500 7,500 7,500 Sub total Expenditure 12,539,992 12,560,036 13,845,828 14,023,696 14,482,811 14,570,765 14,673,887 14,773,911 14,859,234 14,949,384 15,071,684 15,426,093 Patient Income Less Direct Expenditure 3,890,243 4,447,114 1,991,492 2,252,142 2,183,281 2,495,103 2,801,512 3,121,011 3,465,447 3,815,542 4,144,230 4,251,812 Capital Charges on New Building 242, ,137 1,317,505 1,366,182 1,345,888 1,325,595 1,305,301 1,285,007 1,264,714 1,271,112 1,277,511 1,257,217 Capital Charges on Radiology Equipment , , , , , , , , , ,484 Charges for Extra Floor ( 2nd Floor Shell) - Not Used for Emergency Service , , , , , , , , , ,558 Patient Income less direct expenditure and capital implications 3,648,106 3,819, , , , ,457 1,182,007 1,528,647 1,898,503 2,247,325 2,576,462 2,689,554 Change in Position from 2013/14 Baseline (before Capital Charges) 556,870 (1,898,752) (1,638,101) (1,706,962) (1,395,140) (1,088,732) (769,233) (424,797) (74,702) 253, ,569 Change in Position from 2013/14 (after capital charges) 171,870 (3,171,020) (3,096,893) (3,138,613) (2,799,649) (2,466,099) (2,119,459) (1,749,604) (1,400,781) (1,071,644) (958,553) Impairment (MEA Valuation) 0 0 2,717, NOTES: Excludes pay award, inflation and tariff deflator from 14/15 Includes 2.5 % inflation from 14/15 on PFI costs Contribution Before Capital charges 23.7% 26.1% 12.6% 13.8% 13.1% 14.6% 16.0% 17.4% 18.9% 20.3% 21.6% 21.6% After capital charges 22.2% 22.5% 3.0% 3.4% 3.1% 5.0% 6.8% 8.5% 10.4% 12.0% 13.4% 13.7% 116

120 Table 5i: Affordability Statement for the Sensitivity Scenario of Capital Costs increasing by 10% Emergency Centre New Build OBC Affordability Statement - as at 13/14 Income and Costs Base Model plus 10% increase in capital costs Base Year 2014/ / / / / / / / / / / /26 Income ED 11,397,385 11,850,448 9,765,293 10,003,566 10,247,653 10,497,696 10,753,840 11,016,233 11,285,029 11,560,384 11,842,457 12,131,413 Primary care in ED 0 0 1,153,696 1,181,846 1,210,683 1,240,224 1,270,485 1,301,485 1,333,241 1,365,772 1,399,097 1,433,235 PAU ( Excluded ) EAU Amb 741, , A&E Outpatients 509, , , , , , , , , , , ,953 CDU 2,524,880 2,586,338 3,283,940 3,423,033 3,506,555 3,592,115 3,679,762 3,769,548 3,861,525 3,955,747 4,052,267 4,151,142 Additional primary care activity in ED 0 0 1,099,340 1,098,680 1,098,021 1,097,362 1,124,138 1,151,567 1,179,665 1,208,449 1,237,935 1,268,141 Rapid Response Income 281, , , , , , , , , , , ,831 Patient Care Income 15,454,273 15,991,572 16,007,471 16,422,657 16,789,026 17,164,351 17,576,285 17,998,270 18,430,551 18,873,380 19,327,013 19,791,716 Expenditure Direct Pay: Emergency Department 7,770,358 7,770,358 8,517,537 8,585,463 9,003,768 9,073,110 9,153,782 9,234,370 9,308,475 9,357,878 9,438,467 9,698,630 PAU AMU AMB 211, ,037 17, Radiology 1,706,340 1,706,340 1,847,137 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 1,859,937 Estates and Facilities -Pay 581, , , , , , , , , , , ,640 Therapies Pay 409, , , , , , , , , , , ,981 Direct Non Pay: Maintenance - Radiology CT , , , , , , , , , ,366 Maintenance - Radiology Plain Film ,541 36,335 37,244 38,175 39,129 40,107 41,110 42,138 43,191 44,271 Maintenance - Radiology US Machine ,928 14,671 15,038 15,414 15,799 16,194 16,599 17,014 17,439 17,875 Emergency Department Non Pay and Drugs 606, , , , , , , , , , , ,047 PAU Non Pay and Drugs Radiology Non Pay 227, , , , , , , , , , , ,847 Therapies Non Pay 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 19,201 Estates and Facilities Non Pay 466, , , , , , , , , , , ,076 IT 0 0 6,875 7,500 7,500 7,500 7,500 7,500 7,500 7,500 7,500 7,500 Sub total Expenditure 11,998,565 12,018,609 13,469,947 13,661,511 14,119,145 14,228,657 14,329,900 14,427,999 14,536,053 14,624,183 14,744,413 15,037,371 Patient Income Less Direct Expenditure 3,455,708 3,972,963 2,537,524 2,761,146 2,669,882 2,935,694 3,246,385 3,570,270 3,894,498 4,249,197 4,582,600 4,754,345 Capital Charges on New Building 242, ,137 1,405,649 1,502,800 1,480,477 1,458,154 1,435,831 1,413,508 1,391,185 1,398,223 1,405,262 1,382,939 Capital Charges on Radiology Equipment , , , , , , , , , ,484 Charges for Extra Floor ( 2nd Floor Shell) - Not Used for Emergency Services , , , , , , , , , ,214 Patient Income less direct expenditurre and capital implications 3,213,571 3,345, , , ,732 1,142,874 1,482,896 1,836,111 2,187,948 2,540,893 2,874,266 3,053,709 Change in Position from 2014/14 Baseline (before Capital Charges) 517,255 (918,183) (694,561) (785,826) (520,013) (209,323) 114, , ,489 1,126,893 1,298,638 Contribution from the CCG 918, , , , ,323 Revised Change in Position from 2014/14 Baseline (before Capital Charges) 517, , , ,489 1,126,893 1,298,638 Change in Position from 2014/15 (after capital charges) 132,255 (2,287,123) (2,303,905) (2,365,839) (2,070,696) (1,730,675) (1,377,459) (1,025,623) (672,677) (339,304) (159,862) Impairment (MEA Valuation) 0 0 2,988, NOTES: Excludes pay award, inflation and tariff deflator from 14/15 (1) Includes 2.5 % inflation from 14/15 on PFI costs Contribution Before Capital charges 22.4% 24.8% 15.9% 16.8% 15.9% 17.1% 18.5% 19.8% 21.1% 22.5% 23.7% 24.0% After capital charges 20.8% 20.9% 5.8% 5.5% 5.0% 6.7% 8.4% 10.2% 11.9% 13.5% 14.9% 15.4% 117

121 5.5 Capital Affordability The Trust has allowed for the total cost of the Project in its 5 year Capital Programme. Table 5k 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 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 will accelerate the delivery programme for the project. Table 5k: 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) 118

122 5.6 Overall conclusion Both the revenue and capital implications of the proposed investment have been considered and reflected in the Trust s latest Long Term Financial Model. The overall LTFM delivers the required financial objectives for the Trust and the scheme is therefore considered affordable from a capital and revenue perspective. 119

123 6 MANAGEMENT CASE 6.1 Introduction This section of the OBC addresses the achievability of the scheme. It builds on the SOC by setting out in more detail the actions that will be required to ensure the successful delivery of the scheme in accordance with best practice. 6.2 Overall Project Management Structure and Methodology The Project Organisation within the Trust 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 representatives from across the Trust, to ensure that the wider business objectives of the organisation are met. 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, the most recent large project being the delivery of a new Pathology Centre at a cost of 16 million which opened in April The Trust will ensure that appropriate project methodologies are put in place. The proposed project structure is outlined in Figure 6a. The project delivery will be in accordance with the requirements of the Capital Investment Manual and PRINCE 2 project methodologies as appropriate. 120

124 Figure 6a Project Management Structure: Trust Board Trust Management Team Capital Review Group Emergency Centre Project Board Urgent & Emergency Care Board Work Stream Work Stream Work Stream Work Stream Activity & Service Model Design (including equipment & ICT) Workforce Planning Finance and Risk Project Board Membership The membership of the Emergency Centre Project Board is as follows: Jonathan Odum, Medical Director; Mike Goodwin, Head of Estates Development; Tim Powell, Deputy Chief Operating Officer Division 2; Charlotte Hall, Deputy Chief Nurse; Divisional Medical Director- Division 2; Caroline Marshall, Deputy Human Resources Director; Elaine Williams, Deputy Chief Finance Officer; Jin Kalkat, Trust Governor; Andy Morgan, Clinical Director Emergency Services; Jane McKiernan, Group Manager - Emergency Services; Rose Baker, Head of Nursing Division 2; 121

125 Diane Preston, Head of Emergency Preparedness; Louise Landucci, Service Development Redesign Manager; Carolyn Robinson Team Manager Projects & Estates; Kay Cantrill, Head of Portfolio and Programme Services ICT; Anthony Leese, Head of Imaging and Diagnostics; Ed Callaghan, Team Manager, Capital Projects; Roxana Modiri Urgent Care Programme Manager; Andrea Smith WCCG Urgent Care management lead; Dr Julian Morgans WCCG Urgent Care Clinical Lead Project Responsibilities The Medical Director is the Project Sponsor and Executive Lead. The Head of Estates Development is the Project Director and Technical Lead Project Board The Project Board includes senior Trust representatives and stakeholders (internal and external to the Trust) affected by the development and will remain in place until the new facilities are complete and become operational. It will be responsible for the overall management of the scheme and will be accountable to the Capital Review Group. The Project Board is chaired by the Medical Director and meets on a monthly basis or more frequently at key points in the programme as required. Although the membership of the team may alter throughout the project the responsibilities of the Project Board include: To oversee the development of the new facility on behalf of the Capital Review Group, Trust Management Team and Trust Board; To receive a monthly report from the four workstreams; To receive regular reports from the Technical Team Lead for the project in respect of progress with the Design and Construction elements of the scheme; To advise the Capital Review Group, Trust Management Team and Trust Board of issues arising from the project. A number of workstream sub groups have been formed to support the Project Board Project Sponsor The Project Sponsor s responsibilities will be as follows: To establish the Project Board specifically focussing on preparation of the Business Case, design development, construction and transition issues; To ensure the Capital Review Group, Trust Management Team, the Trust Board and all clinical users are fully briefed on the progress of the Project and act as a source of information for the scheme both internally and externally; To lead and direct the efforts of the Project Board towards the successful delivery of the project objectives. 122

126 Project Director The Project Director s responsibilities will be as follows:- Design and construction of the new facility; Provision of the necessary resources (internal and external) to ensure delivery to stakeholder requirements, quality standards, programme and budget; Reporting progress and issues to the Project Board. The Project Director is supported by an internal Capital Development Team with a history of delivering successful projects and who have the requisite skills and experience to support this project. The Project Management Lead for the project is the Capital Development Team Manager. A team of external advisors have been appointed to support the in-house team. These include:- Keppie Architects (Lead) Arup Mechanical and Electrical Design Consultants Ramboll Structural Consultants Faithfull & Gould Quantity Surveyors The Trust has also independently appointed a number of additional consultants. Details of all Trust key personnel and advisors are included in Appendix 6a. The appointment of the main Design Team (Architects, Mechanical & Electrical and Structural Consultants) was approved by the Trust Board on 23 rd July 2012 following an OJEU procurement process. The Design Team and other advisors have been appointed for the duration of the project from initial design to project delivery (stage to stage). However, the Trust has reserved the right to terminate the contract at any stage of the project. The Design Team and Trust have commissioned independent surveys of the site as required. Internal advice on the design to date has been sought from the following Trust teams: Emergency Services Clinical & Management Teams Clinical support Teams e.g. Radiology, Therapies, Pharmacy, Pathology Non-clinical support Teams.e.g Estates & Facilities Health & Safety Advisor Infection Prevention Team Radiation Protection Advisor Fire Safety Advisors IT Team Funding for both external and internal teams has been included in the professional fees section of the Capital Cost Forms. See Appendix 3d. 123

127 6.2.3 Project Closedown Report The Closedown Report will be compiled for this development which will review the construction delivery and functional suitability of the facility. It will address: Completion against schedule; Achievement of forecast budget; Rationale for any variations, and mitigating action taken; Recommendations for future projects; Functional suitability of the facility; and, Review of working relations between Trust, Main Building Contractor and any other contractors. The Closedown Report will be signed off by the Capital Review Group and submitted to the Trust Management Team and Trust Board Post Project Evaluation 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 the Capital Review Group will designate a Project Evaluation Team consisting of: Project Team members including Evaluation Manager; Representatives of the Clinical Users; Independent Technical Consultants (if required); and, Stakeholder interests. The role of the Evaluation Manager will be to: Define in detail the Evaluation Processes for sign off by the Capital Review Group; Chair the Evaluation Team; Identify members of the Evaluation Team, ensuring that all interest are represented; and, Manage the Evaluation Programme and ensure that the results are communicated within specified timescales. Detailed records will be maintained on Project Files in formats approved by the Capital Review Group 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 identified in Appendix 6b the benefits that will be delivered as a result of the development of a new Emergency Service and the construction of the new facility. Specific Indicators have been assigned for each of these anticipated benefits, and the current and 124

128 planned 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. 6.3 Risk Management The key risks of the preferred option have been assessed and strategies for managing them outlined. The process of risk analysis has therefore the following four steps: Risk identification - developing a Risk Register covering key risk areas and individual risks within these areas; Risk assessment - estimating the probability and timing of each risk occurring and the impact if it should occur; Risk quantification - putting a value to each of the risks, using the estimates of probability, impact and timing; and, Risk management - developing a plan to manage all the risks identified in the risk register for the preferred option, including responsible persons and monitoring mechanism Key Risk areas Risks to the Trust from the development can be categorised based on the standard categories for a major construction project: Design; Construction and development; Operating cost; Variability of revenue; Termination; Technology and obsolescence; Control; Residual value; and, Other project risks. Likely financial impact i.e. if the risk occurs what percentage of the cost identified above will be borne under a minimum, likely and maximum scenario; The number of years for which the risk will be present; and, Where the risk will be borne Management of Risk An initial risk register included at Appendix 6c has been developed for the preferred option which includes all risks identified to date. The methodology used is in accordance with the Trust s governance structure for managing risk. This risk register identifies the following: 125

129 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 be costed and will inform the contingencies included within the capital costs. Risks associated with the Project deemed to have an impact on the Trust s business will be escalated by the Project Sponsor and/or Project Director as Corporate risks to the Trust s Assurance Framework in Datix which is reported through the Board Assurance Committee to the Trust Board. 6.4 Gateway Review All significant public sector projects are required to complete the OGC process of detailed peer review and assessment at key stages or gateways. The requirement to register a project for formal review is based upon an initial risk potential assessment (RPA). The assessment for this project scored 37 which identifies this as a medium risk project which means that Gateway review is discretionary. The assessment is attached at Appendix 6d. The Trust has however commenced discussions with the DH Gateway Team with the intention of undertaking reviews from OBC stage onwards. 126

130 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 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. 127

131 An Outline Business Case for the New Emergency Centre (Phase 1) at New Cross Hospital APPENDICES FINAL OCTOBER 2013

132 Index of Appendices Appendix Title 2a RWT Activity Profile 2010/11 to 2012/13 Specialty Breakdown 2b Masterplan 2c Future Emergency Services Activity and Scenario Modelling 2d Schedule of Accommodation 2e RWT Human Resources Strategy 3a Non-Financial Option Appraisal Sensitivity Analysis 3b Generic Economic Model Discounted Cash Flow Summary Extract for all options (Full Generic Economic Model available on request) 3c Lifecycle Calculations for Options 4 and 5 3d Capital Cost Forms including Optimism Bias Calculations and Cash Flow for Options 4 and 5 4a BREEAM Pre-Assessment Summary 4b AEDET Results 4c Equality Impact Assessment 4d Project Programme 4e Key Benefits of the Preferred Solution 6a Project Responsibilities 6b Benefits Realisation Plan 6c Risk Register for Preferred Option 6d Risk Potential Assessment (Gateway)

133 2a RWT Activity Profile 2010/11 to 2012/13 Specialty Breakdown

134 Trust Activity 2010/2011 Year 1011 Sum of Total Activity Category Daycases (inc Follow up New Outpatient Specialty A&E Attendances chemo daycases) Electives Outpatients Outpatients Non Electives Procedures Grand Total Accident & Emergency 98, ,565 3, ,991 Breast Surgery 2,147 1, ,397 Cardiac Catheters ,128 Cardiac Surgery , ,885 Cardiac Surgery Pre Op Cardiac Surgery War Attender 2, ,029 Cardiology ,260 5, ,781 18,114 Clinical Neuro-Physiology 0 0 Clinical Oncology 5, ,398 2, ,448 25,934 Colorectal Surgery 2,429 1, ,118 Cystic Fibrosis - Child Cystic Fibrosis Adult - Band Cystic Fibrosis Adult - Band Cystic Fibrosis Adult - Band Other 2 2 Cystic Fibrosis Child - Band Cystic Fibrosis Child - Band Cystic Fibrosis Child - Band Cystic Fibrosis Child - Band Dermatology 3 10,726 4, ,167 18,164 Dermatology Treatments 9, ,277 Diabetic Medicine 4, ,328 Dietetics 1,789 1, ,990 Electrophysiology Endocrinology 3, ,093 ENT ,848 5, ,387 19,708 Fetal Med 2, ,042 Gastroenterology 5,551 2, ,463 General Medicine 1, , , ,942 General Medicine INR 0 0 General Surgery 2,272 1,979 13,747 4,772 3, ,714 Genito-urinary Medicine 1 4,136 7,023 11,160 Geriatric Medicine 2, ,587 Gynaecological Oncology ,983 Gynaecology 1,555 1,361 7,809 3,370 1,625 3,151 18,871 Haematology (Clinical) 5, , ,328 Head and Neck Surgery Interventional Radiology Medical Endoscopy 4, ,989 Medical Oncology 3, , ,175 Medical Ophthalmology 5,784 2, ,873 Nephrology ,974 1, ,465 Neurology ,497 2, ,909 Obstetrics using Bed or Delivery 0 16,747 5,609 9,261 1,396 33,013 Occupational Therapy 3, ,006 Ophthalmology 3, ,199 21, ,348 70,095 Oral Surgery 1, ,262 3, ,814 13,833 Orthodontics ,652 2,485 Orthoptics 13, ,696 Paediatric Dentistry Paediatrics ,395 3,744 6, ,159 Pain Management , ,393 Palliative Medicine PCI ,582 Physiotherapy 27,366 7, ,907 Plastic Surgery , ,475 Respiratory Medicine 6,022 2, ,340 Rheumatology 1, ,826 2, ,267 Sleep Studies Surgical Endoscopy Thoracic Surgery Thoracic Surgery Ward Attender TIA TOE's Trauma & Orthopaedics 3,542 1,678 20,699 8,040 1, ,824 Trauma & Orthopaedics - Fracture 13,221 4, ,287 Upper Gastrointestinal Surgery Urology 3,231 1,241 10,313 2, ,272 19,649 Vascular Surgery 2,108 1, ,422 Vascular Surgery INR 0 0 Grand Total 98,281 42,033 9, , ,915 45,925 33, ,243 Notes: - Regular day attenders and Births excluded - Outpatient activity included only where plan exists for New and Follow ups - Source of data is SLAM

135 Trust Activity 2011/2012 Year 11/12 Sum of Total Activity Category Specialty A&E Attendances Daycases (inc chemo daycases) Electives Follow up Outpatients New Outpatients Non Electives Outpatient Procedures Grand Total Accident & Emergency 101,297 1,787 3, ,428 Anaesthetics Breast Surgery 1,602 1, ,917 Cardiac Catheters ,055 Cardiac Surgery ,290 1, ,860 Cardiac Surgery Pre Op Cardiac Surgery War Attender Cardiology ,681 5, ,433 18,911 Cardiology Coding Block 0 0 Clinical Haematology 5, ,558 1, ,711 Clinical Haematology Coding Block 0 0 Clinical Oncology 6, ,283 2, ,986 27,971 Colorectal Surgery 1, ,847 Critical Care Medicine 5 5 Dermatology 11 11,521 5, ,845 20,848 Dermatology Treatments 9, ,276 Diabetic Medicine 1 5, ,659 Dietetics 1,808 1, ,882 Endocrinology 3, ,128 ENT ,792 5, ,483 19,405 EPS Fetal Med 3, ,735 Gastroenterology 5,735 2, ,871 General Medicine ,648 2,519 14, ,096 General Surgery 2,289 2,030 17,846 5,839 4, ,089 General Surgery Coding Block Genitourinary Medicine 4,011 7,343 11,354 Geriatric Medicine 1 1, ,736 Gynaecological Oncology ,697 Gynaecology 1,566 1,414 7,923 3,805 1,447 2,838 18,993 Gynaecology Coding Block ICD Interventional Radiology Medical Endoscopy 5,354 5,354 Medical Oncology 3, , ,378 Medical Ophthalmology 5,104 1, ,882 Nephrology ,620 1, ,030 Neurology ,701 2, ,232 Obstetrics 1 17,408 6,203 9,198 1,980 34,790 Occupational Therapy 3, ,022 Ophthalmology 3, ,321 19, ,904 63,235 Oral & Maxillo Facial Surgery Oral Surgery 1, ,840 3, ,684 13,075 Oral Surgery Coding Block Orthodontics ,703 2,408 Orthoptics 22,133 1,652 23,785 Paediatrics ,795 3,541 6, ,821 Pain Management ,694 1, ,481 Pain Management Coding Block 0 0 Palliative Medicine PCI ,418 Physiotherapy 27,772 8, ,622 Plastic Surgery , ,955 Podiatry 2, ,993 Respiratory Medicine 1 6,199 2, ,661 Respiratory Physiology Rheumatology 1, ,307 2, ,829 Surgical Endoscopy T&O Coding Block Thoracic Surgery TIA TOE's Trauma & Orthopaedics 3,538 1,880 20,961 8,543 1, ,760 Trauma & Orthopaedics - Fracture 12,618 4, ,987 Upper Gastrointestinal Surgery Urology 4,161 1,101 8,752 2, ,468 19,270 Urology Coding Block Vascular Surgery 1, ,815 Grand Total 101,297 44,074 10, , ,876 44,245 36, ,149 Notes: - EAUAMB 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

136 Trust Activity 2012/2013 Year 12/13 Sum of Total Activity Category Specialty A&E Attendances Daycases (inc chemo daycases) Electives Follow up Outpatients Non Electives Outpatient Procedures Grand Total Accident & Emergency 106,836 5, ,583 Breast Surgery 2, ,625 Cardiac Catheters Cardiac Surgery , ,035 Cardiology , ,257 19,537 Clinical Haematology 6, , ,416 Clinical Oncology 6, , ,916 27,405 Colorectal Surgery 1, ,695 Critical Care Medicine Dermatology 19 27, ,214 31,590 Dermatology Treatments Diabetic Medicine 6, ,533 Dietetics 2,538 2,538 Endocrinology 4, ,223 ENT , ,943 18,910 EPS Gastroenterology 9, ,357 General Medicine 1, ,418 15, ,976 General Surgery 2,015 1,709 23,164 3,942 1,221 32,051 Genitourinary Medicine 11,222 11,222 Geriatric Medicine 1 0 2, ,230 Gynaecological Oncology ,685 Gynaecology 1,430 1,313 12,635 1,257 2,613 19,248 ICD Interventional Radiology Medical Endoscopy 5,597 5,597 Medical Oncology 3, , ,077 Medical Ophthalmology 6, ,212 Midwife Episode Nephrology , ,550 Neurology , ,618 Obstetrics ,577 8,972 1,485 37,037 Occupational Therapy 3,846 3,846 Ophthalmology 4, , ,266 74,105 Oral & Maxillo Facial Surgery Oral Surgery 1, , ,627 13,587 Orthodontics ,644 2,467 Orthoptics 27, ,970 Paediatric Trauma And Orthopaedics Paediatrics ,233 7, ,385 Pain Management , ,312 Palliative Medicine PCI ,418 Physiotherapy 37, ,665 Plastic Surgery , ,793 Podiatry 2, ,503 Respiratory Medicine 0 10, ,410 Respiratory Physiology Rheumatology 1, , ,389 Surgical Endoscopy Thoracic Surgery ,006 TIA TOE's Trauma & Orthopaedics 3,066 1,652 44,611 1, ,117 Upper Gastrointestinal Surgery 0 0 Urology 3,817 1,012 10, ,605 18,268 Vascular Surgery 1, ,286 Grand Total 106,836 45,552 9, ,583 44,883 37, ,321 Notes: - EAUAMB 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

137 2b Masterplan

138

139 2c Future Emergency Services Activity and Scenario Modelling

140 Projected Emergency Services Activity 2012/ /26: Base Model - No Stafford activity, HASU inclusion A B C D E F G H I J L M N O P Q Modelling Assumptions Year ED Attendances + growth + HASU Adj E.D Attendances adjusted with assumptions Primary Care Front end (20%) Total E.D + internal Primary Care AMU admissions from E.D AMUAMB ED Review Outpatients CDU Potential additional primary care activity transfer to E.D Total E.D E.D Annual demographic growth Staffordshire Primary Care Front end GP Primary care trasnfer HASU E.D Admmission Conversion Rate to AMU 2012/13 106, , ,836 9,743 2,365 5, , % 2013/14 109, , ,804 8,774 2,423 5,737 3, , % 9.12% 2014/15 114, , ,112 9,137 2,483 5,790 5, , % 1, % /16 112, , ,165 9,202 2,543 5,844 5, , % 20.00% 3.80% -4, % /17 115,370 94,901 23, ,975 7,322 4,815 6,568 21, , % 20.00% 9.12% /18 118,185 97,216 23, ,853 7,500 4,933 6,846 21, , % 20.00% 9.12% /19 121,068 99,588 24, ,802 7,683 5,053 7,013 21, , % 20.00% 9.12% /20 124, ,018 24, ,823 7,871 5,177 7,184 21, , % 20.00% 9.12% /21 127, ,508 25, ,917 8,063 5,303 7,360 22, , % 20.00% 9.12% /22 130, ,058 26, ,087 8,260 5,432 7,539 23, , % 20.00% 9.12% /23 133, ,670 26, ,335 8,461 5,565 7,723 23, , % 20.00% 9.12% /24 136, ,346 27, ,661 8,668 5,701 7,911 24, , % 20.00% 9.12% /25 139, ,087 27, ,069 8,879 5,840 8,105 24, , % 20.00% 9.12% /26 143, ,895 28, ,560 9,096 5,982 8,302 25, , % 20.00% 9.12% Notes & Assumptions This are total number of E.D patient = Column D+I 12/13 figures based upon 12/13 outturn This Column adjusts Column A with AMUMB inclusion from 15/16. Also this excludes 20% primary care figures in Column F 20% of E.D attendances to change tariff due to primary care front end FROM 16/17. 20% is taken from Column A (which excludes AMUAMB) transfers This Column includes all E.D attendances including 20% primary care figures. This factors in all adjustments E.D Attendances to include AMUAMB from 2015/16 ED outpatient activity growth each year linked to 12/13 % proportion of ED attendances (column A) Potential additional primary care activity of 22,000 taken from CSU modelling. Between 2017/18 and 2019/20 there is a reduction of 2.5% 6,216 12/13 CDU Activity comprised of: *Transfer from ED to AMU and less than 24 Hrs los with conditions identified by clinicians (1240) * Discharged from AMUAMB and less than 24 Hrs los with conditions identified by clinicians (1287) * Patients who are clinically appropriate in ED with breach reasons of investigations, transport, mental health assessments and admission avoidance (3,450) * Transfer from E.D to SAU and less than 24 Hrs los with CDU pathway conditions (152) * Transfer from E.D to Discharge Lounge with 12 Hrs los (87) *CDU annualgrowth based upon previous year % proportion of ED attendances E.D Wolverhampton demographic growth increase taken from Stafford CPT modelling (2.44%). This has been applied to: - ED attendances - AMUAMB admissions (changed to ED in 15/16) - primary care 3.8 % of E.D attendances reduced in 2015/16 for transfer of activity to GP practices Increase of E.D attendances from 2014/15 of 1,618 attendances if HASU status is achieved (from CSU modelling) Current admission conversion rate to AMU of 9.12% applied each year. AMU figures to be reduced with CDU element of patients that are currently discharged from AMU

141 Projected Emergency Services Activity 2012/ /26: Scenario 1 - Base Model plus Stafford activity here A B C D E F G H I J L M N O P Q Modelling Assumptions Year ED Attendances + growth + HASU Adj E.D Attendances adjusted with assumptions Primary Care Front end (20%) Total E.D + internal Primary Care AMU admissions from E.D AMUAMB ED Review Outpatients CDU Potential additional primary care activity transfer to E.D Total E.D E.D Annual demographic growth Staffordshire Primary Care Front end GP Primary care trasnfer HASU E.D Admmission Conversion Rate to AMU 2012/13 106, , ,836 9,743 2,365 5, , % 2013/14 109, , ,103 8,710 2,423 5,536 3, , % 9.12% 2014/15 122, , ,629 9,913 2,483 6,222 5, , % , % /16 121, , ,916 10,000 2,543 6,288 5, , % 20.00% 3.80% -4, % /17 124, ,073 24, ,940 7,976 5,179 6,568 21, , % 20.00% 9.12% /18 127, ,563 25, ,037 8,171 5,306 6,846 21, , % 20.00% 9.12% /19 130, ,115 26, ,210 8,370 5,435 7,013 21, , % 20.00% 9.12% /20 133, ,728 26, ,460 8,574 5,568 7,184 21, , % 20.00% 9.12% /21 136, ,406 27, ,790 8,783 5,704 7,360 22, , % 20.00% 9.12% /22 140, ,148 28, ,201 8,998 5,843 7,539 23, , % 20.00% 9.12% /23 143, ,958 28, ,695 9,217 5,985 7,723 23, , % 20.00% 9.12% /24 147, ,836 29, ,274 9,442 6,131 7,911 24, , % 20.00% 9.12% /25 150, ,785 30, ,941 9,672 6,281 8,105 24, , % 20.00% 9.12% /26 154, ,805 30, ,697 9,908 6,434 8,302 25, , % 20.00% 9.12% Notes & Assumptions This are total number of E.D patient = Column D+I 12/13 figures based upon 12/13 outturn This Column adjusts Column A with AMUMB inclusion from 15/16. Also this excludes 20% primary care figures in Column F 20% of E.D attendances to change tariff due to primary care front end FROM 15/16. 20% is taken from Column A (which excludes AMUAMB) transfers This Column includes all E.D attendances including 20% primary care figures. This factors in all adjustments E.D Attendances to include AMUAMB from 2015/16 ED outpatient activity growth each year linked to 12/13 % proportion of ED attendances (column A) Potential additional primary care activity of 22,000 taken from CSU modelling. Between 2017/18 and 2019/20 there is a reduction of 2.5% 6,216 12/13 CDU Activity comprised of: *Transfer from ED to AMU and less than 24 Hrs los with conditions identified by clinicians (1240) * Discharged from AMUAMB and less than 24 Hrs los with conditions identified by clinicians (1287) * Patients who are clinically appropriate in ED with breach reasons of investigations, transport, mental health assessments and admission avoidance (3,450) * Transfer from E.D to SAU and less than 24 Hrs los with CDU pathway conditions (152) * Transfer from E.D to Discharge Lounge with 12 Hrs los (87) *CDU annualgrowth based upon previous year % proportion of ED attendances E.D Wolverhampton demographic growth increase taken from Stafford CPT modelling (2.44%). This has been applied to: - ED attendances - AMUAMB admissions (changed to ED in 15/16) - primary care 3.8 % of E.D attendances reduced in 2015/16 for transfer of activity to GP practices Increase of E.D attendances from 2014/15 of 1,618 attendances if HASU status is achieved (from CSU modelling) Current admission conversion rate to AMU of 9.12% applied each year. AMU figures to be reduced with CDU element of patients that are currently discharged from AMU

142 Projected Emergency Services Activity 2012/ /26: Scenario 2 - Base Model minus potential additional primary care activity A B C D E F G H I J L M N O P Q Modelling Assumptions Year ED Attendances + growth + HASU Adj E.D Attendances adjusted with assumptions Primary Care Front end (20%) Total E.D + internal Primary Care AMU admissions from E.D AMUAMB E Review Outpatients CDU Potential additional primary care activity transfer to E.D Total E.D E.D Annual demographic growth Staffordshire Primary Care Front end GP Primary care trasnfer HASU E.D Admmission Conversion Rate to AMU 2012/13 106, , ,836 9,743 2,365 5, , % 2013/14 109, , ,103 8,710 2,423 5,536 3, , % 9.12% 2014/15 113, , ,395 9,071 2,483 5,754 5, , % 1, % /16 111, , ,457 9,137 2,543 5,808 5, , % 20.00% 3.80% -4, % /17 114,645 94,321 22, ,250 7,269 4,786 6, , % 20.00% 9.12% /18 117,442 96,622 23, ,111 7,446 4,903 6, , % 20.00% 9.12% /19 120,307 98,980 24, ,041 7,628 5,022 7, , % 20.00% 9.12% /20 123, ,395 24, ,043 7,814 5,145 7, , % 20.00% 9.12% /21 126, ,869 25, ,119 8,005 5,270 7, , % 20.00% 9.12% /22 129, ,403 25, ,269 8,200 5,399 7, , % 20.00% 9.12% /23 132, ,000 26, ,497 8,400 5,531 7, , % 20.00% 9.12% /24 135, ,659 27, ,803 8,605 5,666 7, , % 20.00% 9.12% /25 139, ,384 27, ,190 8,815 5,804 8, , % 20.00% 9.12% /26 142, ,175 28, ,659 9,030 5,946 8, , % 20.00% 9.12% Notes & Assumptions This are total number of E.D patient = Column D+I 12/13 figures based upon 12/13 outurn This Column adjusts Column A with AMUMB inclusion from 15/16. Also this excludes 20% primary care figures in Column F 20% of E.D attendances to change tariff due to primary care front end FROM 15/16. 20% is taken from Column A (which excludes AMUAMB) transfers This Column includes all E.D attendances including 20% primary care figures. This factors in all adjustments E.D Attendances to include AMUAMB from 2015/16 ED outpatient activity growth each year linked to 12/13 % proportion of ED attendances (column A) no additional primary care activity to RWT 6,216 12/13 CDU Activity comprised of: *Transfer from ED to AMU and less than 24 Hrs los with conditions identified by clinicians (1240) * Discharged from AMUAMB and less than 24 Hrs los with conditions identified by clinicians (1287) * Patients who are clinically appropriate in ED with breach reasons of investigations, transport, mental health assessments and admission avoidance (3,450) * Transfer from E.D to SAU and less than 24 Hrs los with CDU pathway conditions (152) * Transfer from E.D to Discharge Lounge with 12 Hrs los (87) *CDU annualgrowth based upon previous year % proportion of ED attendances E.D Wolverhampton demographic growth increase taken from Stafford CPT modelling (2.44%). This has been applied to: - ED attendances - AMUAMB admissions (changed to ED in 15/16) - primary care 3.8 % of E.D attendances reduced in 2015/16 for transfer of activity to GP practices Increase of E.D attendances from 2014/15 of 1,618 attendances if HASU status is achieved (from CSU modelling) Current admission conversion rate to AMU of 9.12% apllied each year. AMU figures to be reduced with CDU element of patients that are currently discharged from AMU

143 Projected Emergency Services Activity 2012/ /26: Scenario 3 - Base Model minus potential additional primary care activity but plus Stafford activity A B C D E F G H I J L M N O P Q Modelling Assumptions Year E Attendances + growth + HASU Adj E.D Attendances adjusted with assumptions Primary Care Front end (10%) Total E.D + internal Primary Care AMU admissions from E.D A UAMB E Review Outpatients CDU Potential additional primary care activity transfer to E.D Total E.D E.D Annual demographic growth Staffordshire Primary Care Front end GP Primary care trasnfer HASU E.D Admmission Conversion Rate to AMU 2012/13 106, , ,836 9,743 2,365 5, , % 2013/14 109, , ,103 8,710 2,423 5,536 3, , % 9.12% 2014/15 122, , ,629 9,913 2,483 6,222 5, , % , % 2015/16 121, , ,916 10,000 2,543 6,288 5, , % 20.00% 3.80% -4, % 2016/17 124, ,073 24, ,940 7,976 5,179 6, , % 20.00% 9.12% 2017/18 127, ,563 25, ,037 8,171 5,306 6, , % 20.00% 9.12% 2018/19 130, ,115 26, ,210 8,370 5,435 7, , % 20.00% 9.12% 2019/20 133, ,728 26, ,460 8,574 5,568 7, , % 20.00% 9.12% 2020/21 136, ,406 27, ,790 8,783 5,704 7, , % 20.00% 9.12% 2021/22 140, ,148 28, ,201 8,998 5,843 7, , % 20.00% 9.12% 2022/23 143, ,958 28, ,695 9,217 5,985 7, , % 20.00% 9.12% 2023/24 147, ,836 29, ,274 9,442 6,131 7, , % 20.00% 9.12% 2024/25 150, ,785 30, ,941 9,672 6,281 8, , % 20.00% 9.12% 2025/26 154, ,805 30, ,697 9,908 6,434 8, , % 20.00% 9.12% Notes & Assumptions This are total number of E.D patient = Column D+I 12/13 figures based upon 12/13 outurn This Column adjusts Column A with AMUMB inclusion from 15/16. Also this excludes 20% primary care figures in Column F 20% of E.D attendances to change tariff due to primary care front end FROM 15/16. 20% is taken from Column A (which excludes AMUAMB) transfers This Column includes all E.D attendances including 20% primary care figures. This factors in all adjustments E.D Attendances to include AMUAMB from 2015/16 ED outpatient activity growth each year linked to 12/13 % proportion of ED attendances (column A) No additional primary care activity to ED 6,216 12/13 CDU Activity comprised of: *Transfer from ED to AMU and less than 24 Hrs los with conditions identified by clinicians (1240) * Discharged from AMUAMB and less than 24 Hrs los with conditions identified by clinicians (1287) * Patients who are clinically appropriate in ED with breach reasons of investigations, transport, mental health assessments and admission avoidance (3,450) * Transfer from E.D to SAU and less than 24 Hrs los with CDU pathway conditions (152) * Transfer from E.D to Discharge Lounge with 12 Hrs los (87) *CDU annualgrowth based upon previous year % proportion of ED attendances E.D Wolverhampton demographic growth increase taken from Stafford CPT modelling (2.44%). This has been applied to: - ED attendances - AMUAMB admissions (changed to ED in 15/16) - primary care % of E.D attendances reduced in 2015/16 for transfer of activity to GP practices Increase of E.D attendances from 2014/15 of 1,618 attendances if HASU status is achieved (from CSU modelling) Current admission conversion rate to AMU of 9.12% apllied each year. AMU figures to be reduced with CDU element of patients that are currently discharged from AMU

144 2d Schedule of Accommodation

145 NEW CROSS HOSPITAL EMERGENCY DEPARTMENT WOLVERHAMPTON Rev OBC The following Schedule of Accommodation is based on the Emergency Centre Phase 1 - Accident & Emergency briefing document Version 1.2. Individual room areas are noted together with Departmental Circulation, Public Zone Clinical Zone Staff Zone GROUND FLOOR DEPARTMENT & ROOM DESCRIPTION Qty Drawn Room Area Net Drawn Room Area Notes Entrance/Main Waiting Main entrance/draught lobby Entrance/Main Waiting Draught lobby ambulance entrance Lobby at entrance between majors and resus Parking for wheelchairs and trolleys Reception (In Patients / east-west) Not accounted for in original brief Reception Waiting area 80 place inc 4 wheelchairs Porters base/security Breast feeding room Nappy change room WC WHB's visitors WC WHB wheelchair Relocation of WH Smith Not accounted for in original brief Records store Children's Area Children's wait/play area - 10 place Exam treatment rooms - children WC - children's WC - children's WC - children's disabled Nurse base Drs room Relatives room Clean utility Dirty utility Linen store Triage Triage rooms Therapies assessment area Minor injuries Exam treatment rooms Exam treatment rooms Ambulatory Care Centre Bays Added August 2012 Nurse base Drs room Exam treatment rooms - ENT Exam treatment rooms Eyes Clean utility (shared with triage) Dirty utility (shared with triage) Linen store Accessable WC WC Major injuries Exam treatment rooms Nurse base Drs room Clean utility (shared with resus) Dirty utility (shared with resus) Storage Linen store

146 Resuscitation Resus room 6 spaces Resus room 4 spaces Resus room Linen store Plaster & Manipulation Plaster room - 3 trolleys Enhanced procedure suite Store crutch & splint Specimen WC Specimen WC WHB WC ambulant WC accessible Support services Interview room person office Relatives Relatives sitting room Relatives sitting room toilet Visiting room/viewing room Visiting room/viewing room Utilities & Services Near patient testing Cleaners room Cleaners room Disposal hold Disposal hold Disposal hold Switch cupboard Included within 'Engineering' UPS room/it servers Included within 'Engineering' Parking bay - equipment Included within 'Engineering' 56.1 Major Incidents Major Incident Room Patient decontamination room To be provided externally Decontamination Area To be provided externally Major incident store provided on first floor adjacent to Heart & Lung link 12.7 Satellite Radiology Parking bay - mobile x-ray unit Waiting area - 15 place inc 2 w.ch Reception Patient changing cubicle - ambulant Patient changing cubicle - wheelchair W.C. handwash - ambulant W.C. handwash - wheelchair Imaging room - general x-ray Processing & viewing room Scanner room - CT Control room - Shared Imaging reporting room Ultrasound Linen bay Clean Utility Dirty Utility Radiology shell space (MRI or second CT) Scanner room - MRI Control room - Shared Shared with Satellite Radiology Recovery Exam Treatment MRI Equipment Room Sub Wait MRI Trolley bay

147 Total Net Room Areas Planning 5.00% Engineering 5.48% Circulation 41.16% Communication 11.40% Includes stairs, lifts, lobbies and links Internal Walls 3.49% Gross Internal Floor Area 3, External Sub Station LV Switchgear HV Switchgear Transformer Generator Oil Tank Tugway Stairs Entrance Lobby

148 FIRST FLOOR DEPARTMENT & ROOM DESCRIPTION Qty Drawn Room Area Net Drawn Room Area Notes Offices Office single person Office - 4 place permanent base Office 4 place touch down Staff Change & Showers Staff change - female x Staff change - male x Staff restroom Beverage bay Staff WC WHB Staff WC (Accessible) Staff shower Staff Shower (Accessible) Teaching & Training Seminar room Teaching/resource room Out Patients Clinic Reception / Staff Base Cons/exam Treatment Room Mobile Equipment Waiting area 30 person Shared with Clinical Decisions Unit WC ambulant WC ambulant WC accessible Clean utility Dirty utility Clinical Decisions Unit Waiting 0 Shared with Outpatients Reception / Staff Base Combined staff base / reception 4 Bed Room Assisted En-suite (patient) Ambulant WC (Patient) Single Bedroom Assisted En-suite (patient) Ambulant WC (Patient) Doctors Room Clean Utility Dirty Utility Store Linen Store Mobile Equipment Bay Resus Trolley Bay Disposal Hold Pantry Store Paediatric Assessment Unit Waiting Reception Exam Treatment Rooms Staff Base Doctors Room Clean Utility Dirty Utility Store Store Linen Store Mobile Equipment Bay Resus Trolley Bay Disposal Hold Assisted WC (patient) Ambulant WC (Staff)

149 Assisted WC (visitor) Pantry Shell Space Shell Space Clinical Decisions Unit M.I. Store Located on first floor instead of ground 16.3 Services Cleaners Room Cleaners Room Total Net Room Areas Planning 5.00% Engineering 3.84% Circulation 34.20% Communication 15.38% Includes stairs, lifts, lobbies and links Internal Walls 1.62% Gross Internal Floor Area 2,658.80

150 SECOND FLOOR DEPARTMENT & ROOM DESCRIPTION Qty Drawn Room Area Net Drawn Room Area Notes Shell Space 2, Planning Engineering Circulation - Communication Includes stairs, lifts, lobbies and links Gross Internal Floor Area 2, THIRD FLOOR DEPARTMENT & ROOM DESCRIPTION Qty Drawn Room Area Net Drawn Room Area Notes Shell Space - Plant Planning 2.40 Engineering - Circulation - Communication Includes stairs, lifts, lobbies and links Gross Internal Floor Area Total Gross Internal Floor Area 9, Includes external sub-station

151 2e RWT Human Resources Strategy

152 RWT Human Resource Strategy WHITE PAPER TRANSFORMING COMMUNITY SERVICES TRUST OBJECTIVES + + HR IN THE NHS PLAN TRUST VISION & VALUES INTEGRATED BUSINESS PLAN TRUST HR WORKFORCE STRATEGY Planning & Adapting Our workforce Valuing & Engaging our/the Workforce Developing our Workforce Recruitment Promoting Employability Retention Flexibility Equality & Diversity Workforce Planning Productivity Employee Engagement People Mgmt Processes Communication Occupational Health & Well Being Staff Pay, Pensions and Reward Education & Training Commissioning & Funding Leadership & Talent Management Future Roles HR Work Plan Monthly Corporate Business Plan Monitoring Directorate KPIs

153 3a Non-Financial Option Appraisal Sensitivity Analysis

154 Baseline Option 1 - Do Nothing Option 4 - Reconfiguration and Extension of Existing A&E Option 5 - New Build Benefits Criteria Strategic Fit Clinical Effectiveness Access to Services Staff Experience Patient Experience Environmental Quality Disruption Timescales Flexibility Weighted Scores Option Ranking Reverse weighting Option 1 - Do Nothing Option 4 - Reconfiguration and Option 5 - New Build Benefits Criteria Extension of Existing A&E Strategic Fit Clinical Effectiveness Access to Services Staff Experience Patient Experience Environmental Quality Disruption Timescales Flexibility Weighted Scores Option Ranking 3 2 1

155 Equal/Average weighting applied to all options Option 1 - Do Nothing Option 4 - Reconfiguration and Extension of Existing A&E Option 5 - New Build Benefits Criteria Strategic Fit Clinical Effectiveness Access to Services Staff Experience Patient Experience Environmental Quality Disruption Timescales Flexibility Weighted Scores Option Ranking Adding a 1 point score for all scores to option 4 (ranked 2nd) Option 1 - Do Nothing Option 4 - Reconfiguration and Extension of Existing A&E Option 5 - New Build Benefits Criteria Strategic Fit Clinical Effectiveness Access to Services Staff Experience Patient Experience Environmental Quality Disruption Timescales Flexibility Weighted Scores Option Ranking 3 2 1

156 3b Generic Economic Model Discounted Cash Flow Summary Extract for all Options

157 ROYAL WOLVERHAMPTON NHS TRUST Discounted Cashflow Summary OBC D Year 63 Years Property & Opp.Cost Capital Revenue Total Cashflow NPC Cashflow NPC Cashflow NPC Cashflow NPC '000 '000 '000 '000 '000 '000 '000 ' / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , ,434.8 TOTAL 16, , , , , ,348.1 NPC 275,348.1 Price Base EAC 10, /14

158 ROYAL WOLVERHAMPTON NHS TRUST Discounted Cashflow Summary OPTION 4 Year EXTEND AND RECONFIGURE 63 Years Property & Opp.Cost Capital Revenue Total Cashflow NPC Cashflow NPC Cashflow NPC Cashflow NPC '000 '000 '000 '000 '000 '000 '000 ' / , , , , /15 1 4, , , , , , / , , , , , , /17 3 4, , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , ,047.1 TOTAL 51, , , , , ,926.1 NPC 412,926.1 Price Base EAC 15, /14

159 ROYAL WOLVERHAMPTON NHS TRUST Discounted Cashflow Summary OPTION 5 Year NEW BUILD 63 Years Property & Opp.Cost Capital Revenue Total Cashflow NPC Cashflow NPC Cashflow NPC Cashflow NPC '000 '000 '000 '000 '000 '000 '000 ' /14 0 2, , , , , , /15 1 6, , , , , , / , , , , , , /17 3 3, , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , / , , , , / , , , , / , , , , / , , , , / , , , , , / , , , , / , , , , / , , , , / , , , , / , , , ,041.5 TOTAL 49, , , , , ,492.9 NPC 409,492.9 Price Base EAC 15, /14

160 3c Lifecycle Calculations for Options 4 and 5

161 NEW CROSS HOSPITAL EMERGENCY DEPARTMENT PHASE 1 OPTION 5 YEAR NEW BUILD Lifecycle Costs 624,750 2,289,775 1,494,760 1,820,000 2,122,300 10,195,700 All costs based upon current values and current cost levels Assumptions: - Fabric items only require replacement at year 5 First replacement of any M&E items at year 10 Both fabric and M&E at 5 yearly intervals after year 10 Virtually total replacement at year 30 Costs exclude Cleaning, utilities, administrative costs and inflation

162 NEW CROSS HOSPITAL EMERGENCY DEPARTMENT PHASE 1 OPTION 4 REFURBISHMENT YEAR TOTAL Lifecycle Costs 764,249 3,035, ,000 1,822,835 2,906,410 1,854,546 12,740, ,398 1,845, , , , ,304,262 Approx cost M&E New build 3, = 2,178,150 Block 14 3, = 1,489,625 Block 78 1, = 713,150 New build Minor plant 5,000 5, ,000 5,000 5,000 5,000 5,000 5,000 5,000 Major plant 250, , , , ,000 General installations 5,000 10,000 5, ,000 5,000 10,000 5, ,000 5,000 10,000 5,000 Block 14 Minor plant 5,000 5,000 5,000 5,000 50, ,000 Major plant 500,000 General installations 5,000 1,000,000 5,000 5,000 5,000 5,000 Block 78 Minor plant 5,000 5,000 5,000 5,000 5,000 5,000 5,000 Major plant 200,000 40,000 40,000 General installations 5,000 5, ,000 5,000 5,000 5, ,000 5,000 Approx cost Building New Build 3,351 2,850.= 9,550,350 Refurb 5,183 2,000.= 10,366,000 Block 14 3,505 m2 Block78 1,678 m2 Fabric New Build 263, , , , ,200 9,550, , , , , ,200 Fabric Refurb 470, , ,334 1,013,045 1,114,346 2,575, ,506 0 Check All costs based upon current values and current cost levels Assumptions: - Fabric items only require replacement at year 5 First replacement of any M&E items at year 10 Both fabric and M&E at 5 yearly intervals after year 10 Virtually total replacement at year 30 Block 14 Remaining Life Expectancy 33 years for Building & 11 years for Services Block 78 Remaining Life Expectancy 40 years for Building & 13 years for Services Costs exclude Cleaning, utilities, administrative costs and inflation

163 3d Capital Cost Forms including Optimism Bias Calculations and Cash Flow for Options 4 and 5

164 EMERGENCY CENTRE COST FORM OB1 TRUST/ORGANISATION: The Royal Wolverhampton NHS Trust SCHEME: New Emergency Centre STRATEGIC HA: PHASE: PROJECT DIRECTOR: CAPITAL COSTS SUMMARY ORGANISATIONAL CODE: Cost Excl. VAT Cost Incl. VAT VAT 1 Departmental Costs (from Form OB2) 11,211,775 2,242,355 13,454,130 2 On Costs (from Form OB3) (35.48% of Departmental Cost) 3,977, ,523 4,773,129 3 Works Cost Total (1+2) at 173 PUBSEC Calculations Based upon FBC Submission 3Q ,189,383 4 Provisional location adjustment (if applicable) planning contingency -(7.00 % of Works Cost) (b) 1,063, ,651 1,275,907 (where detail allows this should be based upon quantified risk analysis) 5 Sub Total (3+4) 14,126,126 2,825,225 16,951,352 14,126,126 location adjusted works cost 6 Fees (from Form OB4) (c) (d) 1,460,000 fees 7 Enabling works (from OB4) One - Three Storey - Option 5 New Build Revised (10.34% of sub-total 5) 1,460,000 XXXXXXXXXXX 1,460,000 1,618,154 non-works costs 1,182, ,511 1,419,065 8 Non-Works Costs (from Form OB4) (e) 1,271,049 equipment cost LAND 18,475,329 SUM SUBJECT TO PLANNING CONTINGENCY OTHER 435,600 87, ,720 9 Equipment Costs (from Form OB2) 1,847,533 CONTINGENCY SUM 10% (11.34% of Departmental Cost) 1,271, ,210 1,525, Planning Contingency 1,847, ,507 2,217,039 inflation adjustment 11 TOTAL (for approval purposes) ( ) 20,322,862 3,772,572 24,095,435 22,667,382 sub total (line 30) at PUBSEC Optimism Bias 2,344, ,904 2,813,423 (1,271,049) less equipment cost (purchased toward end of construction - inflation accounted for below) 13 Sub Total (10+11) 22,667,382 4,241,476 26,908,858 (127,105) less planning contingency for equipment costs 14 Inflation adjustments (f) 1,489, ,812 1,786,873 (161,296) less optimism bias for equipment costs 15 FORECAST OUTTURN BUSINESS CASE (1,460,000) less Fees - Client cost at completion level TOTAL (12+13) 24,156,442 4,539,288 28,695,731 19,647,931 SUM SUBJECT TO CONSTRUCTION CONTRACT INFLATION ADJUSTMENT Proposed start on site (g) 1st Quarter 2014 Proposed completion date (g) 3rd Quarter Cash Flow:- Year yy/yy EFL BUSINESS CASE SUBMISSION BIS 173 PUBSEC BIS FP (Base) SOURCE BUSINESS CASE SUBMISSION EPI 173 PUBSEC BIS FP (Base) OTHER GOVERNMENT PRIVATE TOTAL 795,003 construction contract Inflation - start on site 180 PUBSEC BIS FP (1Q14).. 567,859 construction contract Inflation - mid point of construction 185 PUBSEC BIS FP (4Q14) 126,198 equipment cost inflation (assume 1Q 2015) 187 PUBSEC BIS FP (1Q15) 1,489,061 TOTAL INFLATION ON FP CONTRACT INCLUDING EQUIPMENT Optimism Bias Total Cost (as 10 above) 27% Upper Bound 47% Mitigating Factor Total (for approval purposes) match against Cashflow ERROR EQUIPMENT COST ONLY CALC 1,271,049 equipment cost Notes : 127,105 ADD: planning contingency for equipment costs * Delete as appropriate 161,297 ADD: optimism bias for equipment costs (a) On-costs should be supported by a breakdown of the percentage or a brief description of their scope ( form OB3 may be used if appropriate ) 1,559,450 TOTAL EQUIPMENT COST (b) Adjustments of national average DCA price levels & on-costs for local market conditions (c) Fees include all resource costs associated with the scheme e.g. project sponsorship, clerk of works, building regulation & planning fees etc. (d) Not applicable to professional fees - VAT reclaimable EL (90 ) P64 refers (e) Non-works costs should be supported by a breakdown & include such items as contributions to statutory & local authorities ; land costs & associated legal fees (f) Estimate of tender price inflation up to proposed tender date ( plus construction cost for VOP contracts only ) (g) Overall timescale including any preliminary works Name (capitals) KEITH WOOLDRIDGE Authorised for issue Position Managing Surveyor Project Director Address Faithful+Gould The Axis 10 Holliday Street Birmingham Date Telephone

165 EMERGENCY CENTRE COST FORM OB2 TRUST/ORGANISATION: The Royal Wolverhampton NHS Trust SCHEME: New Emergency Centre PHASE: One - Three Storey - Option 5 New Build Revised PROJECT DIRECTOR: CAPITAL COSTS: DEPARTMENTAL COSTS AND EQUIPMENT COSTS Functional Content.. Functional Units/Space Requirements (1) N/A/C (2) Cost Allowance Version Equipment Cost Version. HCI 2.1 HCI 2.1 Ground Floor Total N 4,892,768 First Floor Total N 3,472,514 Second Floor Total N 2,077,771 Roof Plant Room Total N 481,131 First Floor Link structure to Heart and Lung Centre including breaking through and alterations N 287,591 Equipment Costs Ground Floor N 824,491 First Floor N 196,559 Allowance for fittings provided but not covered in CIM allowances N 250,000 Departmental Costs and Equipment Costs Carried Forward 11,211,775 1,271,049

166 OUTLINE BUSINESS CASE FOR PREFERRED OPTION COST FORM OB2 (CONT) CAPITAL COSTS : DEPARTMENTAL COSTS AND EQUIPMENT COSTS Functional Content Functional Units/Space N/A/C (2) Cost Allowance Equipment Cost Requirements (1) Brought Forward 11,211,775 1,271,049 Less abatement for transferred 1,271,049 equipment if applicable % ( 4 ) Departmental Costs and Equipment Costs To Summary 11,211,775 1,271,049

167 COST FORM OB2 (CONT) Cost allowances should be based on Departmental Cost Allowances where appropriate and include allowances for essential complementary accommodation and optional accommodation and services where details not available. Identify separately any proposed adjustment (over or under cost allowances) justifiable in value for money terms (details to be provided). * Delete as appropriate 1. State area and rate if departmental cost allowance not available. 2. Insert: N for new build. A for adaptions for alternative use or C for upgrading existing building retaining current use. 3. Insert relevant version number of HCI listing of Departmental Cost Allowances and Equipment Cost allowances. 4. Provide details where appropriate. Completed by Name (capitals) KEITH WOOLDRIDGE Authorised for issue Position Managing Surveyor Project Director Address Faithful+Gould The Axis 10 Holliday Street Birmingham Telephone Date

168 EMERGENCY CENTRE COST FORM OB3 TRUST/ORGANISATION: The Royal Wolverhampton NHS Trust SCHEME: New Emergency Centre PHASE: One - Three Storey - Option 5 New Build Revised CAPITAL COSTS: ON COSTS Estimated Cost (exc. VAT) Percentage of Departmental Cost 1 Communications % a. Space (Covered within Floor Costings) - b. Atria at First and Second Floor (Building cost only) 302,832 c. Allowance for plant rooms etc associated with services - (Covered within Floor Costings) d. Lifts and staircases (stairs Covered within Floor Costings) 410, , ''External'' Building Works (1) a. Drainage 354,118 b. Attenuation 147,782 c. Roads, paths, parking, including enhanced landscaping 369,499 d. Site layout, walls, fencing, gates 38,587 e. Builders work for engineering 273,814 f. Allowance for minor alterations to East/West corridor access and associated works 53,728 g. Major Incidents Decontamination Areas (not in building footprint) 24,422 h. Canopies to Main Entrance and Ambulances 106,968 j. Allowance for building over Tugway and associated works 60,195 1,429, ''External'' Engineering Works (1) a. Steam, condensate, heating, hot 568,108 water and gas supply mains b. Cold water mains and storage 183,414 c. Electricity mains, sub-stations, 655,173 stand-by generating plant d. Calorifiers and associated plant 81,118 e. Local Chiller to MRI/CT Scanners 18,643 f. Diversion of steam main within Tugway 33,844 g. Additional services to Atrium 8,242 h. Relocate existing IT Node in East/West Corridor 19,538 j. Moving of substation and generator; work to relocate 11kVA mains (see OB4) - 1,568, Auxiliary Buildings a. New external Substation & Generator (see OB4) - 5 Other on-costs and abnormals (2) a. Building allowance for abnormals including building demolition and - demolition of existing slabs etc ( see OB4) b. Abnormal foundations due to ground conditions 218,450 c. Engineering 48,844 e. Decant Costs (See OB4) - 267, Total On-Costs to Summary OB1 Notes: 3,977, Must be based on scheme specific assessments/measurements; attach details to define scope of works as appropriate. Identify separately any proposed additional capital expenditure justifiable in value for money terms (details to be provided). * (1) (2) Delete as appropriate. ''External'' to Departments Identify any enabling or preliminary works to prepare the site in advance e.g. demolitions; service diversions; decanting costs; site investigation and other exploratory works. Completed by Name (capitals) KEITH WOOLDRIDGE Authorised for issue Position Managing Surveyor Project Director Address Faithful+Gould The Axis 10 Holliday Street Birmingham Date Telephone

169 EMERGENCY CENTRE COST FORM OB4 TRUST/ORGANISATION: The Royal Wolverhampton NHS Trust SCHEME: New Emergency Centre PHASE: One - Three Storey - Option 5 New Build Revised CAPITAL COSTS: FEES AND NON-WORKS COSTS Percentage of Works Cost % 1 Fees (including "in-house" resource costs) 1,460,000 a. Architects b. Structural Engineers c. Mechanical Engineers d. Electrical Engineers e. Quantity Surveyors f. Project Management g. Project Sponsorship h. Legal fees i. Site Supervision j. Building Regulations and Planning Fees k. Other Total Fees to Summary (OB1) 1,460, Fee allowance as discussed with Trust - includes external professional fees and internal Trust costs 2 Enabling works a. Substation construction 101,678 b. Substation and generator installation 463,770 c. Demolitions 342,443 d. Site clearance 205,268 e. Enabling works preliminaries 69,395 Total enabling works to Summary (OB1) 1,182, Non-Works Costs a. Land purchase costs and associated legal fees b. Statutory and Local Authority charges c. Other (Decant Costs) 285,600 d. Other (IT Works Costs) 150,000 Non-Works Costs to Summary (OB1) 435, Notes: * Delete as appropriate. Completed by Name (capitals) KEITH WOOLDRIDGE Authorised for issue Position Managing Surveyor Project Director Address Faithful+Gould The Axis 10 Holliday Street Birmingham Date Telephone

170 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Three Storey - Option 5 New Build Revised Appendix 1: - DCAG and ECAG Calculations Ref Functional Content Functional Units Area (m2) DCAG ( / M2) Total ( ) at (2Q02) BIS FP Total ( ) at BIS FP reporting Level Equipment Total ( ) at (2Q97) BIS FP Equipment Total ( ) at BIS FP GROUND FLOOR All base DCAG rates have 3% added for BREEAM increase Accident & Emergency A&E Department Department Costs below are based upon a throughput of 110,000 attendances Entrance/Main Waiting Main entrance/draught lobby 1 Room , , ,333 1,250 2,088 Pro rata allowance for fittings Draught lobby ambulance entrance 1 Room 7.3 1,345 9,822 12,769 1,250 2,088 Pro rata allowance for fittings Reception (grid 12/G) 1 Area ,307 28,999 3,988 6, Parking for wheelchairs and trolleys 1 Area ,579 24,323 31,620 18,498 30,892 Wheelchair hold - Pro rata allowance for fittings Reception (grid K/12) 1 Room ,974 15,567 3,988 6, Waiting area 80 place inc 4 wheelchairs 1 Area , ,365 23,204 38, Porters base/security 1 Room ,839 10, ,253 Assessed fitting requirements Breast feeding room 1 Room 6.5 1,200 7,797 10, Nappy changing room 1 Room 6.5 1,205 7,834 10, WC WHB's visitors 2 Toilets 5.8 2,258 13,095 17,023 1,500 2, WC WHB's wheelchair 2 Toilets ,773 21,633 28, Records Store 1 Room ,651 8,646 2,685 4,484 - Relocate existing W H Smiths 1 Area ,838 72,777 94, Children's Area Children's wait/play area - 10 place 1 Area ,100 27,952 36, Pro rata allowance for fittings Exam treatment rooms - children 6 Rooms ,069 76, ,084 13,260 22, WC - children's 2 Toilets 6.8 2,258 15,352 19, Assessed fitting requirements WC - children's disabled 1 Toilet 6.5 1,773 11,526 14, Assessed fitting requirements Nurse base 2 Rooms ,054 14,857 19,314 5,330 8, Drs room 1 Room ,548 15,013 1,088 1, B.13 Relatives room 1 Room ,021 14,197 18, ,535 Relatives overnight stay Clean utility 1 Room ,302 16,536 21,497 2,375 3, Dirty utility 1 Room ,349 17,940 23, B.25 Store - Linen 1 Store 3.5 1,040 3,641 4, Triage 04.09B.20 Triage rooms 4 Rooms ,265 45,551 59,216 4,195 7,006 Day Assessment - Pro rata allowance for fittings 04.09B.20 Therapies assessment area 1 Area ,265 13,159 17,107 1,398 2,335 Day Assessment - Pro rata allowance for fittings Minor injuries Exam treatment rooms 8 Rooms ,108 83, ,631 12,064 20, Ambulatory Care Centre Bays 6 Bays ,354 73,138 95,079 18,096 30, Nurse base 1 Room ,054 16,543 21,506 2,665 4, Drs room 1 Room ,778 14,012 1,088 1,817 Overnight stay room Exam treatment rooms - ENT 1 Room ,092 19,320 25,116 2,500 4,175 Assessed fitting requirements Exam treatment rooms - Eyes 1 Room ,092 16,155 21,001 2,500 4,175 Assessed fitting requirements Clean utility (shared with Triage) 1 Room ,302 22,916 29,791 2,375 3, Dirty utility (shared with Triage) 1 Room 8.6 1,349 11,600 15, B.25 Store - Linen 1 Store 3.7 1,040 3,849 5, WC hand wash - ambulant 1 Item 5.9 2,258 13,321 17,317 1,000 1,670 Assessed fitting requirements WC hand wash - accessible 1 Item 4.3 2,258 9,708 12, Assessed fitting requirements Major injuries Exam treatment rooms 17 Rooms , , ,795 25,636 42, Nurse base 1 Room ,054 16,964 22,053 2,665 4, Drs room 1 Room ,778 14,012 1,088 1,817 Overnight stay room Clean utility (shared with Resus) 1 Room ,302 23,958 31,145 2,375 3, Dirty utility (shared with Resus) 1 Room ,349 16,186 21, B.20 Storage - major incident 1 Store ,112 15,229 19,797 50,829 84,884 Pro rata allowance for fittings 04.09B.25 Store - Linen 1 Store 3.7 1,040 3,849 5, Notes

171 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Three Storey - Option 5 New Build Revised Appendix 1: - DCAG and ECAG Calculations Ref Functional Content Functional Units Area (m2) DCAG ( / M2) Total ( ) at (2Q02) BIS FP Total ( ) at BIS FP reporting Level Equipment Total ( ) at (2Q97) BIS FP Equipment Total ( ) at BIS FP Notes Resuscitation Resus room 4 spaces 1 Room , , ,549 25,264 42,191 Rate of 1,002 is for 1 bay + enhancement as bay normally only 3m Resus room 2 spaces 1 Room , , ,434 12,632 21,095 Rate of 1,002 is for 1 bay + enhancement as bay normally only 3m B.25 Store - Linen 1 Store 0.0 1, Plaster & Manipulation Plaster room - 3 trolleys 1 Room ,174 40,971 53,263 6,217 10, Enhanced Procedure Suite 2 Rooms ,296 93, ,351 6,288 10,501 Used Plaster facilities - Pro rata allowance for fittings Store - crutch & splint 1 Store 0.0 2, Specimen WC Specimen WC WHB 1 Toilet 6.1 1,393 8,500 11, WC hand wash - ambulant 4 Items ,258 26,190 34,046 1,000 1,670 Assessed fitting requirements WC hand wash - accessible 2 Items ,258 27,544 35, Assessed fitting requirements Support Services Interview Room 2 Rooms ,110 26,652 34,647 1,226 2, Person Office 2 Rooms ,057 29,974 8,284 13,834 Relatives Relatives sitting room 2 Rooms ,801 34,842 3,638 6, Toilet 2 Toilets 0.0 1, Assumed disabled toilet 01.04B.13 Visiting room/viewing room 2 Rooms ,021 17,261 22,440 1,838 3,069 Major Incidents Major incident room 1 Room ,133 14,386 18,702 8,371 13,980 Major treatment room Patient decontamination room 1 Room 0.0 1, Assessed fitting requirements Decontamination Area 1 Area 0.0 1, Assessed fitting requirements Major Incident Store 1 Room 0.0 1, ,750 6,263 General store -Assessed fitting requirements Satellite Radiology Parking bay - mobile x-ray unit 1 Area 2.4 1,579 3,791 4, Waiting area - 15 place inc 2 w.ch. 1 Area ,167 36,617 1,812 3, Reception 1 Area ,043 13,056 3,988 6, Patient changing cubicle - ambulant 3 Cubicles 8.7 1,176 10,235 13,306 2,643 4,414 Use enhanced rate for wheelchair additional cubicle size Patient changing cubicle - wheelchair 1 Cubicle 5.5 1,176 6,471 8, ,471 Use enhanced rate for wheelchair additional cubicle size WC hand wash - ambulant 3 Items 8.7 2,258 19,642 25, ,253 Assessed fitting requirements WC hand wash wheelchair 1 Item 5.8 1,773 10,285 13, Assessed fitting requirements Imaging room - general x-ray 2 Rooms ,192 85, ,551 5,000 8, Processing & viewing room 1 Room ,000 15,503 20,154 82, ,082 Assessed fitting requirements Scanner room - CT 1 Room ,630 63,388 82, Control room - CT 1 Room ,630 35,035 45,545 18,500 30,895 Pro rata allowance for fittings Imaging reporting room 1 Room ,201 18,611 24,194 5,449 9, A.02 Imaging room - ultra sound 1 Room ,548 20,212 67, , B.25 Linen bay 1 Area 3.0 1,040 3,121 4, Clean utility 1 Room ,302 13,541 17,604 2,375 3, Dirty utility 1 Room 9.0 1,349 12,140 15, Radiology (MRI or Second CT) - Shell Only (Allow for shell only but all main services to Scanner Rooms) Scanner Room - MRI 1 Room ,361 61,113 79, Average of internal glazed and external glazed corridors; main services Control Room - MRI 1 Room 0.0 1, Average of internal glazed and external glazed corridors; main services Recovery 1 Room ,493 20, Average of internal glazed and external glazed corridors Exam Treatment 1 Room ,729 15, Average of internal glazed and external glazed corridors MRI Equipment 1 Room ,361 15,925 20, Average of internal glazed and external glazed corridors; main services Sub Wait 1 Room ,824 3, Average of internal glazed and external glazed corridors 01.01B.14 MRI Trolley bay 1 Room Average of internal glazed and external glazed corridors

172 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Three Storey - Option 5 New Build Revised Appendix 1: - DCAG and ECAG Calculations Ref Functional Content Functional Units Area (m2) DCAG ( / M2) Total ( ) at (2Q02) BIS FP Total ( ) at BIS FP reporting Level Equipment Total ( ) at (2Q97) BIS FP Equipment Total ( ) at BIS FP Notes Utilities & Services Near patient testing 1 Room 9.4 1,026 9,643 12, ,134 Used urine test room Cleaners room 2 Rooms ,266 21,149 27,494 1,538 2, B.12 Disposal hold 3 Rooms ,391 41,735 54,255 4,500 7,515 Assessed fitting requirements 01.04B.20 Switch cupboard 1 Cupboard 0.0 1, B.20 UPS room/it servers 2 Rooms 0.0 1, B.20 Parking bay - equipment 2 Areas 0.0 1, Total Nett Area 1, Planning (Design Flexibility) 1 Area ,806 92,047 Assessed cost Engineering (Plant & Risers) 1 Area , ,989 Assessed cost Circulation (Corridors etc) 1 Area , ,732 1,150,152 Assessed cost Communication (Stairs, Lift Lobbies etc) 1 Area , , ,662 Assessed cost Internal walls 1 Area Total Area 3, ,763,668 4,892, , ,491

173 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Three Storey - Option 5 New Build Revised Appendix 1: - DCAG and ECAG Calculations Ref Functional Content Functional Units Area (m2) DCAG ( / M2) FIRST FLOOR Accident & Emergency Total ( ) at (2Q02) BIS FP Total ( ) at BIS FP reporting Level Equipment Total ( ) at (2Q97) BIS FP Equipment Total ( ) at BIS FP Notes All base DCAG rates have 3% added for BREEAM increase Offices Office - single person 6 Offices ,064 70,204 91,265 6,102 10,190 Assessed fitting requirements Office - 4 place permanent base 2 Offices ,135 50,847 66,101 5,222 8, Office - 4 place touch down 6 Offices , , ,155 15,666 26,162 Staff Change & Showers Staff change - female x 25 1 Room ,012 24, ,471 Pro rata allowance for fittings Staff change - male x 15 1 Room ,012 24, ,471 Pro rata allowance for fittings 04.09B.21 Staff restroom 1 Room ,187 37,876 49,239 7,536 12,585 Pro rata allowance for fittings 04.09B.21 Beverage bay 1 Area 9.5 1,187 11,280 14,664 3,768 6, Staff WC WHB 4 Toilets ,024 11,874 15, , Staff WC hand wash - accessible 3 Toilets ,258 41,316 53,711 1,500 2, Staff shower 2 Showers 4.8 1,229 5,897 7, , Staff shower (accessible) 2 Showers 9.4 1,843 17,322 22,519 1,000 1,670 Pro rata allowance for accessible enhancement Teaching & Training Seminar room 1 Room ,016 45,914 59,689 2,974 4,967 Pro rata allowance for fittings Teaching/resource room 1 Room ,474 30,516 3,000 5,010 Assessed fitting requirements Out Patients Clinic Staff base/reception 1 Area ,345 19,241 25,013 4,634 7,738 Pro rata allowance for fittings Cons/exam 6 Rooms , , ,600 9,048 15, Treatment room 1 Room ,155 20,675 26,878 2,612 4, Waiting area - 30 person 1 Area ,248 73,123 3,624 6,052 Pro rata allowance for fittings Mobile equipment store 1 Area ,471 7, WC hand wash - ambulant 2 Items 7.8 2,258 17,610 22, Assessed fitting requirements WC hand wash - accessible 1 Item 6.1 2,258 13,772 17, Assessed fitting requirements Clean utility 1 Room ,302 22,526 29,283 2,375 3, Dirty utility 1 Room ,349 16,860 21, Clinical Decisions Unit Sub Waiting 1 Area 0.0 1, Staff base 1 Room ,330 18,629 2,265 3,783 Used Pro-rata Nurse base 04.09B.37 4 Bed room 2 Rooms , , ,745 9,692 16,186 Fittings Pro-rata 6 bed Single bedroom 2 Rooms ,100 47,099 61,229 6,860 11, Assisted en-suite 2 Items ,899 28,106 36, ,169 Assessed fitting requirements WC hand wash - ambulant 3 Items ,258 24,383 31, Assessed fitting requirements Assisted en suite patient 2 Items ,899 25,068 32,588 3,500 5,845 Assessed fitting requirements Doctors room 1 Room ,971 14,262 1,088 1, Clean utility 1 Room ,302 22,135 28,775 2,375 3, Dirty utility 1 Room 8.7 1,349 11,735 15, Store 1 Store ,573 30, B.25 Linen store 1 Store 4.1 1,040 4,265 5, B.20 Mobile equipment bay 1 Area 3.8 1,389 5,280 6,864 3,500 5,845 Use equipment store enhanced rate/ assessed fittings requirement Resus trolley bay 1 Area 3.8 1,116 4,241 5,513 6,316 10, B.12 Disposal hold 1 Area ,391 20,450 26,585 4,500 7,515 Assessed fitting requirements 01.04A.09 Pantry 1 Store ,115 13,379 17, ,263 Used milk kitchen store M I Store 1 Store ,213 21, Store 1 Store ,887 27,

174 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Three Storey - Option 5 New Build Revised Appendix 1: - DCAG and ECAG Calculations Ref Functional Content Functional Units Area (m2) DCAG ( / M2) Total ( ) at (2Q02) BIS FP Total ( ) at BIS FP reporting Level Equipment Total ( ) at (2Q97) BIS FP Equipment Total ( ) at BIS FP Notes Paediatric Assessment Unit (Shell Only) Waiting 1 Area 0.0 1, Reception 1 Area Exam treatment rooms 7 Rooms 0.0 1, Assessed fitting requirements Staff base 1 Room Used Pro-rata Nurse base Doctors room 1 Room Clean utility 1 Room 0.0 1, Dirty utility 1 Room 0.0 1, Store 1 Store Store 1 Store B.25 Linen store 1 Store 0.0 1, B.20 Mobile equipment bay 1 Area 0.0 1, Resus trolley bay 1 Area 0.0 1, B.12 Disposal hold 1 Area 0.0 1, Assessed fitting requirements Staff WC 2 Items 0.0 1, Assisted WC (patient) 2 Items 0.0 2, Assessed fitting requirements 01.04A.09 Pantry 1 Store 0.0 1, Used milk kitchen store Assisted WC (visitor) 2 Items 0.0 2, Assessed fitting requirements General Cleaners Room 2 Rooms ,266 19,883 25, /04 Shell Space 1 Area , ,931-0 Average of internal glazed and external glazed corridor Mitigated for shell space only by 50% Total Nett Area 1, Planning (Design Flexibility) 1 Area ,141 78,184 Assessed cost Engineering (Plant & Risers) 1 Area ,190 60,047 Assessed cost Circulation (Corridors etc) 1 Area , , ,074 Assessed cost Communication (Stairs, Lift Lobbies etc) 1 Area , , ,819 Assessed cost Internal walls 1 Area Total Area 2, ,671,165 3,472, , ,559

175 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Three Storey - Option 5 New Build Revised Appendix 1: - DCAG and ECAG Calculations Ref Functional Content Functional Units Area (m2) SECOND FLOOR DCAG ( / M2) Total ( ) at (2Q02) BIS FP Total ( ) at BIS FP reporting Level Equipment Total ( ) at (2Q97) BIS FP Equipment Total ( ) at BIS FP Notes Accident & Emergency /04 Shell Space 1 Area 2, ,598,285 2,077, Average of internal glazed and external glazed corridor Total Nett Area 2, Planning (Design Flexibility) 1 Area Engineering (Plant & Risers) 1 Area Circulation (Corridors etc) 1 Area Communication (Stairs, Lift Lobbies etc) 1 Area Total Area 2, ,598,285 2,077,

176 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Three Storey - Option 5 New Build Revised Appendix 1: - DCAG and ECAG Calculations Ref Functional Content Functional Units Area (m2) ROOF PLANT ROOM DCAG ( / M2) Total ( ) at (2Q02) BIS FP Total ( ) at BIS FP reporting Level Equipment Total ( ) at (2Q97) BIS FP Equipment Total ( ) at BIS FP Notes Accident & Emergency Plant Room 1 Area , , Average of internal glazed and external glazed corridor Total Nett Area Planning (Design Flexibility) 1 Area ,368 1,778 Assessed cost Engineering (Plant & Risers) 1 Area Assessed cost Circulation (Corridors etc) 1 Area Assessed cost Communication (Stairs, Lift Lobbies etc) 1 Area ,704 64,615 Assessed cost Total Area , ,

177 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Three Storey - Option 5 New Build Revised Appendix 1: - DCAG and ECAG Calculations Ref Functional Content Functional Units Area (m2) FIRST FLOOR LINK TO HEART AND LUNG AND GROUND FLOOR/FIRST FLOOR LINKS TO EXISTING EAST/WEST CORRIDOR DCAG ( / M2) Total ( ) at (2Q02) BIS FP Total ( ) at BIS FP reporting Level Equipment Total ( ) at (2Q97) BIS FP Equipment Total ( ) at BIS FP Notes Link structure Link Space per latest Keppie proposals) 4 Areas , , ,591 Area requirements as discussed with Keppie Design & Trust DCAG moderated as 75% of total allowance Allowance for breaking through into existing building 4 Nr 80, , Planning (Internal Walls) 1 Area Not required for link areas Engineering (Plant & Risers) 1 Area Not required for link areas Circulation (Corridors etc) 1 Area Not required for link areas Communication (Stairs, Lift Lobbies etc) 1 Area Not required for link areas Total Area , ,

178 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Three Storey - Option 5 New Build Revised Accommodation Business Case Optimism Bias - Upper Bound Calculation for Build Lowest % Upper Bound 13% Mid % 40% Upper % 80% Actual % Upper Bound for this project 27% Build complexity Scope of scheme Choose 1 category X Choose 1 category X Length of Build < 2 years x 0.50% 0.50% Facilities Management Hard FM only or no FM x 0.00% 0.00% 2 to 4 years 2.00% 0 Hard and soft FM 2.00% Over 4 years 5.00% 0 0 Choose 1 category Choose 1 category Equipment Group 1 & 2 only 0.50% 0 Number of phases 1 or 2 Phases x 0.50% 0.50% major Medical equipment x 1.50% 1.50% 3 or 4 Phases 2.00% 0 All equipment included 5.00% 0 More than 4 Phases 5.00% 0 Choose 1 category Choose 1 Category IT No IT implications 0.00% 0 Number of sites involved (i.e. before and after Single site* x 2.00% 2.00% Infrastructure x 1.50% 1.50% 2 Site 2.00% 0 Infrastructure & systems 5.00% 0 More than 2 site 5.00% 0 change) * Single site means new build is on same site as existing facilities Choose more than 1 category if applicable External Stakeholders 1 or 2 local NHS organisations 1.00% 0 Location 3 or more NHS organisations x 4.00% 4.00% Universities/Private/Voluntary sector/local government 8.00% 0 Choose 1 Category New site - Green field New build 3% 0 Service changes - relates to service delivery e.g. NSF's New site - Brown Field New Build 8% 0 Existing site New Build x 5% 5.00% Choose 1 category or Stable environment, i.e. no change to service 5% 0 Existing site Less than 15% Refurb 6% 0 Identified changes not quantified x 10% 10.00% Existing site 15% - 50% Refurb 10% 0 Longer time frame service changes 20% 0 Existing site Over 50% Refurb 16% % Gateway Choose 1 category RPA Score Low 0% 0 Medium x 2% 2.00% High 5% %

179 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Three Storey - Option 5 New Build Revised Accommodation Business Case Contributory Factor to Upper Bound Progress with Planning Approval Other Regulatory % Factor Contributes 4 4 % Factor Contributes after mitigation 1 1 Explanation for rate of mitigation Outline Planning Approval gained for Site Redevelopment Master Plan in Emergency Centre of similar size and on same site included in Stage 1 of this Master Plan. Discussions commenced to secure detailed planning approval circa November 2013 Most regulatory issues included in capital costs Depth of surveying of site/ground information 3 2 All necessary surveys now undertaken. includes ground works Enabling work to commence in October 2013 which Detail of design 4 3 1:200 completed. 1:50's under development Innovative project/design (i.e. 3 has this type of project/design been undertaken before) Design complexity Basic design but will include sustainable elements Only design complexity relates to interface with existing buildings on site and site infrastructure i.e. subterranean service tugway Likely variations from Standard Contract 2 1 Procure 21+ for Enabling Package, Traditional Procurement for main contract with no variations from standard contract Design Team capabilities 3 1 External Design Team have experience of delivering similar projects and were selected on this basis Contractors capabilities (excluding design team covered above) Contractor Involvement Yet to be appointed but will be selected on basis of experience and track record in delivering similar projects To be involved at the appropriate stage Client capability and capacity (NB do not double count with design team capabilities) Robustness of Output Specification 6 2 Trust internal project management team have experience of delivering similar projects. Clinical users have been heavily involved in the design and will continue to be throughout the design development process and construction Capacity requirements and functional content are known Involvement of Stakeholders, including Public and Patient Involvement Agreement to output specification by stakeholders A number of patient and stakeholder events have been held to date on both this project and its interface with the Wolverhampton Urgent and Emergency Care strategy. Presentations to Health and Wellbeing Board and staff also held. CCG members on Project Board. Output specification developed with stakeholders involvement. Large equipment requirements known. New service or traditional 3 1 Mainly traditional with some new elements Local community consent 3 2 Local health economy and patient support Stable policy environment 20 Likely competition in the market for the project Project will be affected by National Review into ED Services, Wolverhampton Urgent and Emergency Care Strategy but outcome of Consultation on Stafford but all impacts have either been included in base model or as sensitivities. Expect there to be a good level of competition but not marketed. TOTAL % Note: Across all contributory factors, mitigation would be expected to be greater the greater the extent of risk quantification and risk management.

180 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 30,500, New Build - Cumulative Costs 25,500, ,500, ,500, Cumulative Costs 10,500, ,500, ,000.00

181 New Build - Year End Expenditure Mar-17 3,777, Mar-16 14,000, Mar-15 8,000, Year End Expendature Mar-14 2,381, Mar ,000, ,000, ,000, ,000, ,000, ,000,000.00

182 New Cross Hospital - New Emergency Centre New Build - Cashflow Contract Sum 1,801, ,200, Contract Perio 5 17 Retention (%) : 3 3 Start on site: 3rd Quarter ,381, Enabling Works Main Works Val.Nr. Date Predicted Gross Cumulative Retention Predicted In the Month Predicted Gross Cumulative (inc Enabling Works) Predicted In the Month Excluding Enabling Works Cumlative Total Of All Works Year End Totals Mar Apr-13 0 May-13 0 Jun-13 0 Jul-13 0 Aug-13 0 Sep-13 0 Oct Nov , , ,377 2 Dec , , ,754 3 Jan , ,377 1,429,131 4 Feb , ,377 1,905,508 5 Mar , ,377 2,381,885 2,381, Apr-14 2,381,885 May-14 2,381,885 Jun-14 2,381,885 Jul-14 2,381,885 Aug-14 2,381,885 Sep-14 2,381,885 Oct-14 2,381,885 Nov-14 2,381,885 Dec-14 2,381,885 1 Jan-15 2,666,667 2,666,667 5,048,552 2 Feb-15 2,666,667 2,666,667 7,715,219 3 Mar-15 2,666,666 2,666,666 10,381,885 8,000, Apr-15 1,083,413 1,083,413 11,465,298 5 May-15 1,083,413 1,083,413 12,548,711 6 Jun-15 1,083,413 1,083,413 13,632,124 7 Jul-15 1,083,413 1,083,413 14,715,537 8 Aug-15 1,083,413 1,083,413 15,798,950 9 Sep-15 1,083,412 1,083,412 16,882, Oct-15 1,083,412 1,083,412 17,965, Nov-15 1,083,412 1,083,412 19,049, Dec-15 1,083,412 1,083,412 20,132, Jan-16 1,083,412 1,083,412 21,216, Feb-16 1,582,937 1,582,937 22,798, Mar-16 1,582,938 1,582,938 24,381,885 14,000, Apr-16 1,888,765 1,888,765 26,270, May-16 1,888,765 1,888,765 28,159,415 Jun-16 Jul-16 1,083, Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 3,777,530.00

183 EMERGENCY CENTRE COST FORM OB1 TRUST/ORGANISATION: The Royal Wolverhampton NHS Trust SCHEME: New Emergency Centre STRATEGIC HA: PHASE: PROJECT DIRECTOR: CAPITAL COSTS SUMMARY ORGANISATIONAL CODE: Cost Excl. VAT Cost Incl. VAT VAT 1 Departmental Costs (from Form OB2) 10,848,428 2,169,686 13,018,114 2 On Costs (from Form OB3) One - Option 4 Extension and Reconfiguration of Existing Emergency Department (52.70% of Departmental Cost) 5,716,758 1,143,352 6,860,109 3 Works Cost Total (1+2) at 174 PUBSEC Calculations Based upon FBC Submission 3Q ,565,186 4 Provisional location adjustment (if applicable) planning contingency -(7.00 % of Works Cost) (b) -1,159, ,913-1,391,476 (where detail allows this should be based upon quantified risk analysis) 5 Sub Total (3+4) 15,405,623 3,081,125 18,486,747 15,405,623 location adjusted works cost 6 Fees (from Form OB4) (c) (d) 1,460,000 fees (9.48% of sub-total 5) 1,460,000 xxxxxxxxxxxx 1,460, ,000 non-works costs 7 Non-Works Costs (from Form OB4) (e) 1,339,782 equipment cost LAND 18,380,405 SUM SUBJECT TO PLANNING CONTINGENCY OTHER 175,000 35, ,000 8 Equipment Costs (from Form OB2) 1,838,040 CONTINGENCY SUM 10% (12.35% of Departmental Cost) 1,339, ,956 1,607,738 9 Planning Contingency 1,838, ,608 2,205,649 inflation adjustment 10 TOTAL (for approval purposes) ( ) 20,218,445 3,751,689 23,970,134 23,630,767 sub total (line 12) at PUBSEC Optimism Bias 3,412, ,464 4,094,788 (1,339,782) less equipment cost (purchased toward end of construction - inflation accounted for below) 12 Sub Total (10+11) 23,630,767 4,434,153 28,064,921 (133,978) less planning contingency for equipment costs 13 Inflation adjustments (f) 1,557, ,554 1,869,324 (248,731) less optimism bias for equipment costs 14 FORECAST OUTTURN BUSINESS CASE (1,460,000) less Fees - Client cost at completion level TOTAL (12+13) 25,188,537 4,745,707 29,934,245 20,448,277 SUM SUBJECT TO CONSTRUCTION CONTRACT INFLATION ADJUSTMENT Proposed start on site (g) 1st Quarter 2014 Proposed completion date (g) 3rd Quarter Cash Flow:- Year yy/yy EFL BUSINESS CASE SUBMISSION BIS 173 PUBSEC BIS FP (1Q13) SOURCE BUSINESS CASE SUBMISSION EPI 173 PUBSEC BIS FP (1Q13) OTHER GOVERNMENT PRIVATE TOTAL 827,387 construction contract Inflation - start on site 180 PUBSEC BIS FP (1Q14).. 590,991 construction contract Inflation - mid point of construction 185 PUBSEC BIS FP (4Q14) 139,392 equipment cost inflation (assume 1Q 2015) 187 PUBSEC BIS FP (1Q15) 1,557,770 TOTAL INFLATION ON FP CONTRACT INCLUDING EQUIPMENT Optimism Bias Total Cost (as 10 above) 40% Upper Bound 47% Mitigating Factor Total (for approval purposes) match against Cashflow ERROR EQUIPMENT COST ONLY CALC 1,339,782 equipment cost Notes : 133,978 ADD: planning contingency for equipment costs * Delete as appropriate 248,731 ADD: optimism bias for equipment costs (a) On-costs should be supported by a breakdown of the percentage or a brief description of their scope ( form OB3 may be used if appropriate ) 1,722,491 TOTAL EQUIPMENT COST (b) Adjustments of national average DCA price levels & on-costs for local market conditions (c) Fees include all resource costs associated with the scheme e.g. project sponsorship, clerk of works, building regulation & planning fees etc. (d) Not applicable to professional fees - VAT reclaimable EL (90 ) P64 refers (e) Non-works costs should be supported by a breakdown & include such items as contributions to statutory & local authorities ; land costs & associated legal fees (f) Estimate of tender price inflation up to proposed tender date ( plus construction cost for VOP contracts only ) (g) Overall timescale including any preliminary works Name (capitals) KEITH WOOLDRIDGE Authorised for issue Position Managing Surveyor Project Director Address Faithful+Gould The Axis 10 Holliday Street Birmingham Date Telephone

184 EMERGENCY CENTRE COST FORM OB2 TRUST/ORGANISATION: The Royal Wolverhampton NHS Trust SCHEME: New Emergency Centre PHASE: One - Option 4 Extension and Reconfiguration of Existing Emergency Department PROJECT DIRECTOR: CAPITAL COSTS: DEPARTMENTAL COSTS AND EQUIPMENT COSTS Functional Content.. Functional Units/Space Requirements (1) N/A/C (2) Cost Allowance Version Equipment Cost Version. HCI 2.1 HCI 2.1 Phase 1 Total N 5,234,113 Phase 2 Total A 773,169 Phase 3 Total A 1,869,307 Phase 4 Total A 693,691 Phase 5 Total A 2,278,148 Equipment Costs Equipment costs taken as same as provided for New Build Option N/A 1,339,782 Departmental Costs and Equipment Costs Carried Forward 10,848,428 1,339,782

185 OUTLINE BUSINESS CASE FOR PREFERRED OPTION COST FORM OB2 (CONT) CAPITAL COSTS : DEPARTMENTAL COSTS AND EQUIPMENT COSTS Functional Content Functional Units/Space N/A/C (2) Cost Allowance Equipment Cost Requirements (1) Brought Forward 10,848,428 1,339,782 Less abatement for transferred 1,339,782 equipment if applicable % Departmental Costs and Equipment Costs To Summary 10,848,428 1,339,782

186 COST FORM OB2 (CONT) Cost allowances should be based on Departmental Cost Allowances where appropriate and include allowances for essential complementary accommodation and optional accommodation and services where details not available. Identify separately any proposed adjustment (over or under cost allowances) justifiable in value for money terms (details to be provided). * Delete as appropriate 1. State area and rate if departmental cost allowance not available. 2. Insert: N for new build. A for adaptions for alternative use or C for upgrading existing building retaining current use. 3. Insert relevant version number of HCI listing of Departmental Cost Allowances and Equipment Cost allowances. 4. Provide details where appropriate. Completed by Name (capitals) KEITH WOOLDRIDGE Authorised for issue Position Managing Surveyor Project Director Address Faithful+Gould The Axis 10 Holliday Street Birmingham Telephone Date

187 EMERGENCY CENTRE COST FORM OB3 TRUST/ORGANISATION: The Royal Wolverhampton NHS Trust SCHEME: New Emergency Centre PHASE: One - Option 4 Extension and Reconfiguration of Existing Emergency Department CAPITAL COSTS: ON COSTS Estimated Cost (exc. VAT) Percentage of Departmental Cost 1 Communications % a. Space 108,484 d. Lifts and staircases (stairs Covered within Floor Costings) - 108, ''External'' Building Works (1) a. Drainage 500,000 b. Roads, paths, parking 225,000 c. Site layout, walls, fencing, gates 149,535 d. Builders work for engineering 200,000 e. Services outside buildings 50,000 1,124, ''External'' Engineering Works (1) a. Steam, condensate, heating, hot 75,000 water and gas supply mains b. Cold water mains and storage - c. Electricity mains, sub-stations, 120,000 stand-by generating plant d. Calorifiers and associated plant - e. Miscellaneous services - 195, Auxiliary Buildings - 5 Other on-costs and abnormals (2) a. Building - b. Electrical Upgrade Works to Ground, Second and Third Floors 998,453 c. Mechanical Upgrade Works to Ground, Second and Third Floors 1,747,293 d. Medical gases etc. 145,124 e. Backlog maintenance 757,384 f. Alterations to bedhead trunking to suit new layouts 117,000 g. Works to IPS/UPS and PACS 80,000 h. Pneumatic Tube system from Pathology to A&E 35,000 j. IT Wiring Closets 165,000 k. Phasing requirements 100,000 l. Structural works in association with steel beams to 'Ice tank' 35,000 m. Asbestos 108,484 4,288, Total On-Costs to Summary OB1 5,716, Notes: Must be based on scheme specific assessments/measurements; attach details to define scope of works as appropriate. Identify separately any proposed additional capital expenditure justifiable in value for money terms (details to be provided). * Delete as appropriate. (1) ''External'' to Departments (2) Identify any enabling or preliminary works to prepare the site in advance e.g. demolitions; service diversions; decanting costs; site investigation and other exploratory works. Completed by Name (capitals) KEITH WOOLDRIDGE Authorised for issue Position Managing Surveyor Project Director Address Faithful+Gould The Axis 10 Holliday Street Birmingham Date Telephone

188 EMERGENCY CENTRE COST FORM OB4 TRUST/ORGANISATION: The Royal Wolverhampton NHS Trust SCHEME: New Emergency Centre PHASE: One - Option 4 Extension and Reconfiguration of Existing Emergency Department CAPITAL COSTS: FEES AND NON-WORKS COSTS Percentage of Works Cost % 1 Fees (including "in-house" resource costs) 1,460,000 a. Architects b. Structural Engineers c. Mechanical Engineers d. Electrical Engineers e. Quantity Surveyors f. Project Management g. Project Sponsorship h. Legal fees i. Site Supervision j. Building Regulations and Planning Fees k. Other Fee allowance as discussed with Trust - includes external professional fees and internal Trust costs Total Fees to Summary (OB1) 1,460, Non-Works Costs a. Land purchase costs and associated legal fees b. Statutory and Local Authority charges c. Other - Decant of Durnall Unit, Fracture Clinic, Orthodontics and Part Emergency Department 175,000 Non-Works Costs to Summary (OB1) 175,000 Notes: * Delete as appropriate. Completed by Name (capitals) KEITH WOOLDRIDGE Authorised for issue Position Managing Surveyor Project Director Address Faithful+Gould The Axis 10 Holliday Street Birmingham Date Telephone

189 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Option 4 Extension and Reconfiguration of Existing Emergency Department Appendix 1: - DCAG and ECAG Calculations Ref Functional Content Functional Units Area (m2) PHASE1 - NEW BUILD DCAG ( / M2) Total ( ) at (2Q02) BIS FP Total ( ) at BIS FP reporting Level Equipment Total ( ) at (2Q97) BIS FP Equipment Total ( ) at BIS FP Notes Accident & Emergency Relocate existing Fracture and Orthopaedic Clinic (Block 78) 1 Area 1, ,164 1,953,192 2,539, Taken rate as plaster facilities Relocate Orthodontics Department 1 Area , , , Taken rate as mid range - 5 chairs Relocate Durnall Unit and adjacent accommodation 1 Area ,475 1,032,500 1,342, Taken as average rate for radiology Total Nett Area 2, Planning (Design Flexibility) 1 Area , ,005 Assessed cost Engineering (Plant & Risers) 1 Area ,076 65,099 Assessed cost Circulation (Corridors etc) 1 Area Assessed cost Communication (Stairs, Lift Lobbies etc) 1 Area , ,729 Assessed cost Total Area 3, ,026,241 5,234,

190 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Option 4 Extension and Reconfiguration of Existing Emergency Department Appendix 1: - DCAG and ECAG Calculations Ref Functional Content Functional Units Area (m2) PHASE 2 - ALTERATIONS AND REFURBISHMENT DCAG ( / M2) Total ( ) at (2Q02) BIS FP Total ( ) at BIS FP reporting Level Equipment Total ( ) at (2Q97) BIS FP Equipment Total ( ) at BIS FP Notes Accident & Emergency Reconfigure and refurbish existing Durnall Unit to form CDU and support accommodation (Block 14) 1 Area , , rate modified for Refurb Upgrading and Reconfiguration of Mechanical & Electrical 1 Area See Cost on OB3 Form Total Nett Area Planning (Design Flexibility) 1 Area Assessed cost Engineering (Plant & Risers) 1 Area Assessed cost Circulation (Corridors etc) 1 Area Assessed cost Communication (Stairs, Lift Lobbies etc) 1 Area Assessed cost Total Area , ,

191 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Option 4 Extension and Reconfiguration of Existing Emergency Department Appendix 1: - DCAG and ECAG Calculations Ref Functional Content Functional Units Area (m2) PHASE 3 - ALTERATIONS AND REFURBISHMENT DCAG ( / M2) Total ( ) at (2Q02) BIS FP Total ( ) at BIS FP reporting Level Equipment Total ( ) at (2Q97) BIS FP Equipment Total ( ) at BIS FP Notes Accident & Emergency Reconfigure and refurbish existing Fracture Clinic to form ED Accommodation (Block 78) 1 Area 1, ,437,929 1,869, Accident & Emergency Dept rate modified for Refurb - Upgrading and Reconfiguration of Mechanical & Electrical 1 Area 1, See Cost on OB3 Form Total Nett Area 1, Planning (Design Flexibility) 1 Area Assessed cost Engineering (Plant & Risers) 1 Area Assessed cost Circulation (Corridors etc) 1 Area Assessed cost Communication (Stairs, Lift Lobbies etc) 1 Area Assessed cost Total Area 1, ,437,929 1,869,307-0

192 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Option 4 Extension and Reconfiguration of Existing Emergency Department Appendix 1: - DCAG and ECAG Calculations Ref Functional Content Functional Units Area (m2) PHASE 4 - ALTERATIONS AND REFURBISHMENT DCAG ( / M2) Total ( ) at (2Q02) BIS FP Total ( ) at BIS FP reporting Level Equipment Total ( ) at (2Q97) BIS FP Equipment Total ( ) at BIS FP Notes Accident & Emergency / Reconfigure and refurbish existing Orthodontics/A23 to form OPD Clinic and PAU (Block 14) 1 Area , , Average of Out-Patient/Children costs rate modified for Refurb Upgrading and Reconfiguration of Mechanical & Electrical 1 Area See Cost on OB3 Form Total Nett Area Planning (Design Flexibility) 1 Area Assessed cost Engineering (Plant & Risers) 1 Area Assessed cost Circulation (Corridors etc) 1 Area Assessed cost Communication (Stairs, Lift Lobbies etc) 1 Area Assessed cost Total Area , ,

193 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Option 4 Extension and Reconfiguration of Existing Emergency Department Appendix 1: - DCAG and ECAG Calculations Ref Functional Content Functional Units Area (m2) PHASE 5 - ALTERATIONS AND REFURBISHMENT DCAG ( / M2) Total ( ) at (2Q02) BIS FP Total ( ) at BIS FP reporting Level Equipment Total ( ) at (2Q97) BIS FP Equipment Total ( ) at BIS FP Notes Accident & Emergency Reconfigure and refurbish existing A&E to form ED Accommodation (Block 14) 1 Area 2, ,752,422 2,278, Accident & Emergency Dept rate modified for Refurb - Upgrading and Reconfiguration of Mechanical & Electrical 1 Area 2, See Cost on OB3 Form Total Nett Area 2, Planning (Design Flexibility) 1 Area Assessed cost Engineering (Plant & Risers) 1 Area Assessed cost Circulation (Corridors etc) 1 Area Assessed cost Communication (Stairs, Lift Lobbies etc) 1 Area Assessed cost Total Area 2, ,752,422 2,278,148-0

194 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Option 4 Extension and Reconfiguration of Existing Emergency Department Accommodation Business Case Optimism Bias - Upper Bound Calculation for Build Lowest % Upper Bound 13% Mid % 40% Upper % 80% Actual % Upper Bound for this project 40% Build complexity Scope of scheme Choose 1 category X Choose 1 category X Length of Build < 2 years x 0.50% 0.50% Facilities Management Hard FM only or no FM x 0.00% 0.00% 2 to 4 years 2.00% 0 Hard and soft FM 2.00% Over 4 years 5.00% 0 0 Choose 1 category Choose 1 category Equipment Group 1 & 2 only 0.50% 0 Number of phases 1 or 2 Phases 0.50% 0 major Medical equipment x 1.50% 1.50% 3 or 4 Phases x 2.00% 2.00% All equipment included 5.00% 0 More than 4 Phases 5.00% 0 Choose 1 category Choose 1 Category IT No IT implications 0.00% 0 Number of sites involved (i.e. before and after Single site* x 2.00% 2.00% Infrastructure x 1.50% 1.50% 2 Site 2.00% 0 Infrastructure & systems 5.00% 0 More than 2 site 5.00% 0 change) * Single site means new build is on same site as existing facilities Choose more than 1 category if applicable External Stakeholders 1 or 2 local NHS organisations 1.00% 0 Location 3 or more NHS organisations x 4.00% 4.00% Universities/Private/Voluntary sector/local government 8.00% 0 Choose 1 Category New site - Green field New build 3% 0 Service changes - relates to service delivery e.g. NSF's New site - Brown Field New Build 8% 0 Existing site New Build 5% 0 Choose 1 category or Stable environment, i.e. no change to service 5% 0 Existing site Less than 15% Refurb 6% 0 Identified changes not quantified x 10% 10.00% Existing site 15% - 50% Refurb 10% 0 Longer time frame service changes 20% 0 Existing site Over 50% Refurb x 16% 16.00% 20.50% Gateway Choose 1 category RPA Score Low 0% 0 Medium x 2% 2.00% High 5% %

195 The Royal Wolverhampton NHS Trust New Emergency Centre Phase One - Option 4 Extension and Reconfiguration of Existing Emergency Department Accommodation Business Case Contributory Factor to Upper Bound Progress with Planning Approval Other Regulatory % Factor Contributes 4 4 % Factor Contributes after mitigation 1 1 Explanation for rate of mitigation Outline Planning Approval gained for Site Redevelopment Master Plan in Therefore site for new building has outline approval. Detailed planning approval required for new build and potentially for any external adaptions to existing buildings Most regulatory issues included in capital costs Depth of surveying of site/ground information 3 2 All necessary surveys now undertaken on site for new build. Minimal surveys required in existing buildings. Historical information available Detail of design 4 Innovative project/design (i.e. 3 has this type of project/design been undertaken before) Design complexity Less than would be expected at OBC. Capacity and functional requirement check only. Schedules of accommodation developed. Basic design but will include sustainable elements Complex due to number of phases and working in live service environment Likely variations from Standard Contract 2 1 Standard Contract Design Team capabilities 3 1 External Design Team have experience of delivering similar projects and were selected on this basis Contractors capabilities (excluding design team covered above) Contractor Involvement Yet to be appointed but will be selected on basis of experience and track record in delivering similar projects To be involved at the appropriate stage Client capability and capacity (NB do not double count with design team capabilities) Robustness of Output Specification Trust internal project management team have experience of delivering similar projects. Clinical users will be heavily involved in the design and will continue to be throughout the design development process and construction. Capacity requirements and functional content are known Involvement of Stakeholders, including Public and Patient Involvement Agreement to output specification by stakeholders A number of patient and stakeholder events have been held to date on both this project and its interface with the Wolverhampton Urgent and Emergency Care strategy. Presentations to Health and Wellbeing Board and staff also held. CCG members on Project Board. Output specification developed with stakeholders involvement. Large equipment requirements known. New service or traditional 3 1 Mainly traditional with some new elements Local community consent 3 2 Local health economy and patient support for reprovided service Stable policy environment 20 Likely competition in the market for the project Project will be affected by National Review into ED Services, Wolverhampton Urgent and Emergency Care Strategy but outcome of Consultation on Stafford but all impacts have either been included in base model or as sensitivities. Expect there to be a good level of competition but not marketed TOTAL % Note: Across all contributory factors, mitigation would be expected to be greater the greater the extent of risk quantification and risk management.

196 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 35,500, Refurbishment- Cumulative Costs 30,500, ,500, ,500, Series1 15,500, ,500, ,500, ,000.00

197 Refurbishment - Year End Expenditure 6,286,192 Jan-17 Jan-16 18,500,929 Series1 5,147,124 Jan ,000, ,000, ,000, ,000, ,000, ,000,000.00

198 Phase 5&6 Phase 2&3 Phase 1 New Cross Hospital New A&E Refurbishment Cashflow Per Phase Val.Nr. Date Proportion of Contract Elapsed Predicted Gross Cumulative Retention Predicted Nett Cumulative Predicted In the Month Cumulative Total Over All Phases Year End Costs 1 Jan ,019,170 1,019,170 1,019,170 1,019,170 2 Feb ,836,615 2,836,615 1,817,446 2,836,615 3 Mar ,147,123 5,147,123 2,310,508 5,147,123 5,147,123 4 Apr ,645,480 7,645,480 2,498,357 7,645,480 5 May ,026,473 10,026,473 2,380,992 10,026,473 6 Jun ,984,886 11,984,886 1,958,414 11,984,886 7 Jul ,730,583 13,730,583 1,745,697 13,730,583 8 Aug ,443,273 14,443, ,690 14,443,273 1 Sep , , ,462 14,924,735 2 Oct ,619,911 1,619,911 1,138,449 16,063,184 3 Nov ,116,762 3,116,762 1,496,851 17,560,035 4 Dec ,673,432 4,673,432 1,556,670 19,116,705 5 Jan ,242,090 6,242,090 1,568,658 20,685,363 6 Feb ,291,982 7,291,982 1,049,892 21,735,255 Phase 4 1 Mar ,912,798 1,912,798 1,912,798 23,648,053 18,500,929 1 Apr , , ,973 24,517,026 2 May ,686,864 2,686,864 1,817,891 26,334,917 3 Jun ,850,238 4,850,238 2,163,374 28,498,291 4 Jul ,286,191 6,286,191 1,435,954 29,934,245 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 6,286,192

199 4a BREEAM Pre-Assessment Summary

200 Emergency Portal - A&E - Phase I New Cross Hospital, Wolverhampton BREEAM New Construction 2011 Pre-assessment Mark Pendry Gleeds Advisory Town Centre House Merrion Centre Leeds LS2 8ND mark.pendry@gleeds.co.uk Tel: Mob: Version: 4_0 Date: 15/04/2013

201 BREEAM New Construction 2011 Pre-assessment Report Client: Project: Gleeds Project Number: The Royal Wolverhampton NHS Trust Emergency Portal - Accident and Emergency - Phase I GASA0066 Date of Report: 15th April 2013 Prepared by: Mark Pendry - Associate Reviewed by: Jerry Percy - Head of Sustainability Revision History Issue Date Reason for Change 1_0 10/10/2012 n/a - First issue 2_0 21/02/2013 Updated Assessment 3_0 05/03/2013 Updated Assessment to Support OBC 4_0 15/04/2013 Revision to meet Excellent Rating

202 BREEAM New Construction 2011 Pre-assessment Report Project Name: Client: Emergency Portal - Accident & Emergency - Phase I The Royal Wolverhampton NHS Trust OVERVIEW Performance Summary: % Required Rating: EXCELLENT 70% Predicted Rating EXCELLENT 76.5 Commentary: The following document provides an overview of the progress of Phase I of the Emergency Portal building against BREEAM. The building will be a three storey building hosting a range of medical functions. BREEAM is a method of benchmarking the environmental performance of a building, and involves assessing a building against a range of environmental criteria ranging from Biodiversity through to Energy Performance Not Sought, 19.4 The Royal Wolverhampton NHS Trust is proposing to achieve a BREEAM EXCELLENT rating for the Emergency Portal building. This requires more than 70% of BREEAM credits to be achieved. It also requires a number of mandatory requirements to be met for certain credits (e.g. 6 credits or more must be achieved under Credit Ene 01) Required for Oustanding, 14.1 The building has been reviewed during a number of design development meetings and through BREEAM specific workshops. These meetings have involved input from representatives of the Trust, from Keppie (the Architects and Landscape Architects), Arup (the M&E Consultant), Ramboll (the Structural, Civils, Ecology and Acoustic Consultants), Faithful and Gould (the Cost Managers) and Rona Harper Associates (the CDM co-ordinator). Mark Pendry of Gleeds has been the represented BREEAM Assessor. Mark is also a BREEAM Accredited Professional Threshold for Excellent Required for Excellent 19.8 During these various meetings, the scheme has been reviewed against the BREEAM New Construction Criteria, and each credit has been reviewed for its feasibilty. In this instance an assessment has been made of which credits would be required to achieve a Very Good, Excellent or Outstanding rating. The results of this categorisation are detailed in the BREEAM Pre-assessment Scoring Tool contained in this report. It should be noted that the scheme is still in the early stages of design - and there are a considerable number of issues to resolve. This will mean that some credits may end up being recategorised Required for Very Good, 56.7 The results of the pre-assessment are summarised in the table overleaf and the graph opposite. These show that the scheme is 0.0 1

203 Scoring Breakdown Awarded Targeted Difficult Not Sought Section Total Credits Weighting Credit Value Credits % score Credits % score Credits % score Credits % score Management Health and Wellbeing Energy Transport Water Materials Waste Landuse and Ecology Pollution Innovation Total Assumptions The following assumptions have been made about the scheme so far: - Building is a Healthcare Building and forms part of a General Acute Hospital - Building will be fully fitted out - Building will not have a cold storage or laboratory facilities - Building will have soft landscaping and a lift

204 BREEAM New Construction 2011 Emergency Portal - A - Phase 1 Royal Wolverhampton NHS Trust BREEAM Pre-assessment Scoring Tool Management Man 01 Sustainable Procurement Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Gleeds to review final output. Letter of commitment will be developed Credit 1 Meeting held to identify project team roles and responsibilities over the life of building Keppie for training schedule - and requirements for training will be built into Schedule of Training developed for building occupier / premises manager Trust preliminaries. Credit 2 BREEAM AP appointed to facilitate setting of BREEAM performance target Trust BREEAM performance target contractually agreed with client and design/project team Trust Appointment made. Performance target will be Outstanding. Confirm Target achieved at Design Stage Certification All this is included within the brief. Credit 3 Credit 2 achieved Trust AP to monitor and report progress on BREEAM during feasibility and design Gleeds AP to provide written progress reports for client and project team Gleeds Letter to be provided. Credit 4 AP to monitor and report progress on BREEAM during RIBA F to L Gleeds BREEAM target is a contract requirement on principal contractor Gleeds AP to provide written progress reports for client and project team Gleeds Target achieved at Final Stage Certification All Letter to be provided. Credit 5 Thermographic study allowed for within project budget and programme F&G Thermographic study undertaken post-construction Contractor Defects identified in study are rectified Contractor Requirement will be put into prelims. Credit 6 Project team member appointed to monitor and programme commissioning Trust All building services identified in commissioning schedule Arup Commissioning undertaken in line with BSRIA and CIBSE guidelines Arup Main contractor accounts for commissioning in main programme of works Arup Confirmation will be required of proposed commissioning monitor and proposed specialist commissioning manager. Arup to build Specialist commissioning manager appointed during design stage for complex systems Arup requirements into spec. Credit 7 Seasonal Commissioning undertaken over a minimum 12 month period Arup Requirements to be built into spec. Credit 8 Energy and Water Consumption to be monitoring and reviewed for at least 12 months Trust Trust to confirm monitoring/review. Requirement for aftercare Contract/Commitment to provide aftercare support F&G support to be built into prelims. Minimum Standard Check - One credit required PASS to EXCELLENT, Two for OUTSTANDING Man 02 Responsible Construction Practices Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 CCS Score 24 to 31.5 Contractor To be addressed in prelims Credit 2 CCS Score 32 to 35.5 Contractor To be addressed in prelims Minimum Standard Check - One for Excellent, Two for Outstanding Man 03 Construction Site Impacts Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Pre-requisite Responsibility assigned to individual for monitoring, recording and reporting Contractor To be addressed in prelims. Credit 1 Monitor Site Energy and Carbon Consumption Contractor To be addressed in prelims. Credit 2 Monitor Site Water Consumption Contractor To be addressed in prelims. Credit 3 Monitor material delivery and waste disposal mileage and CO2 emissions Contractor To be addressed in prelims. Credit 4 Confirm all Site Timber sourced in line with UK Government's Timber Procurement Policy Contractor To be addressed in prelims. Credit 5 Principal Contractor is ISO equivalent certified Contractor Implement best practice pollution prevention policies and procedures on site Contractor To be addressed in prelims.

205 BREEAM New Construction 2011 Emergency Portal - A - Phase 1 Royal Wolverhampton NHS Trust Man 4 Stakeholder Participation Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Relevant parties and bodies identified and consulted with Trust Date for consultation workshop needs to be established. Compliant consultation plan prepared Trust Archaeological Desk Top Study undertaken in 2009, covers affected Feedback provided to all consultees Trust area and includes consultation with key bodies. NOTE: Scheme has Areas of historic/heritage value are protected Keppie scope to impact on a historical building - Building 52 (albeit this is not listed). Further discussion with the Conservation Officer required. AEDET review to be undertaken by a suitably 'independent' individual. Good corporate citizen requirement removed in latest edition of the Consultation uses AEDET Keppie manual. Credit 2 Building design to meet needs of all potential users Keppie Access statement developed in line with CABE requirements Keppie Shared facilities can be separately secured Keppie Credit 3 Compliant Building User Guide provided All Assume contractor will co-ordinate this document. To be included within preliminaries. Credit 4 Commitment to undertake a Post Occupancy Evaluation one year after occupation Trust POE findings are shared Trust Commitment required that this will be done. Minimum Standard Check - Credit 3 required for Excellent and Outstanding Man 05 Life Cycle Cost and Service Life Planning Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 LCC Cost analysis undertaken F&G Critical Appraisal of Service Life Estimations and Maintenance Implications of different design options F&G Critical Appraisal document will need to be undertaken early on in design (RIBA B/C) Credit 2 Credit 1 achieved F&G LCC analysis undertaken on different element options (2 of: envelope, services, finishes or external spaces) F&G Option meets LCC and sustainability requirements Trust Credit 3 Credit 1 and 2 achieved n/a RIBA C/D LCC model updated during D/E F&G Results of study are implemented Trust Maintenance strategy developed Keppie/Arup TOTAL CREDITS SCORE EQUIVALENT

206 BREEAM New Construction 2011 Emergency Portal - A - Phase 1 Royal Wolverhampton NHS Trust Health and Wellbeing Hea 01 Visual Comfort Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Pre-requisite All Fluorescent and Compact Fluorescent lamps are fitted with High Frequency Ballasts Arup Requirement to be built into specification. Building meets Daylight requirements (80% to meet 2% ADF staff/public areas, 3% ADF occupied Credit 1 to 2 spaces and consulting rooms) Keppie/Arup Credit 3 Disabling Glare has been designed out of all relevant building areas Keppie Glare control strategy has been developed in tandem with the lighting strategy Keppie/Arup View out requirements have been met Keppie Moved to difficult - layout unlikely to achieve Lighting specified in line with the CIBSE Code for Lighting 2009 and other relevant industry Credit 4 standards Arup Where computer screens are used lighting complies with CIBSE LG7 Arup External lighting levels meet the requirements of BS5489-1:2003 Arup Lighting zones and controls are appropriate for the different spaces in the building Arup To be integrated into spec. Credit 5 Arts Co-ordinator appointed or Arts Policy in place (during RIBA B) Trust Natalie Lewis appointed as Arts Co-ordinator Minimum Standard Check : pre-requisite must be met by all schemes Hea 02 Indoor Air Quality Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Indoor Air Quality Plan has been produced Arup/Keppie (Air Con/Mixed Mode) Intakes and Exhausts are 10 m apart - and 20 m from source of air pollution Arup (nat vent) openeable windows/ventilators are 10 m from a source of external pollution Arup Building designed to meet ventilation requirements for relevant industry standard Arup Areas of large/unpredictable occupancy equipped with CO2/air quality sensors Arup Credit 2 Indoor Air Quality Plan has been produced Arup/Keppie All decorative paints and varnishes meet VOC requirements Keppie VOC requirements for 5 out of the remaining 8 areas are met Keppie Credit 3 Indoor Air Quality Plan has been produced Arup/Keppie Formaldehyde levels measured post construction and are <100 micrograms/m3 Contractor TVOC levels measured post construction and are less than 300 micrograms/m3 Contractor Where exceedance found measures taken to reduce levels within the above limits Contractor Testing of Formaldehyde and TVOC in line with required standards Contractor Assumed cannot be achieved given proximity of ambulance road next to proposed openeable windows. Requirements for testing will need to be built within the prelims. Credit 4 Occupied spaces are designed to provide fresh air through a natural ventilation strategy Arup Natural ventilation strategy provides two levels of user control Arup Will be reviewed further - may be able to achieve this through a review of the exemptions detailed in the manual. Hea 03 Thermal Comfort Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Thermal Model uses CIBSE AM11 compliant software and provides fully dynamic thermal analysis Arup Modelling shows that thermal comfort levels meet CIBSE Guide A levels or other appropriate standard Arup Building complies with any Time Out of Range (TOR) metric Arup Credit 2 Credit 1 achieved Arup Thermal model has been used to inform temperature control strategy Arup Strategy for heating/cooling addresses efficient zoning, occupant control provision, interaction between proposed system and need for manual overrides Arup Note consultation with end user required regarding end user controls. Hea 04 Water Quality Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 All water systems designed to meet HSE COP Arup If humidification provided this is a failsafe system Arup Drinking water provision has been made Arup / Keppie Minimum Standard Check - HSE COP Requirement required for any rating

207 BREEAM New Construction 2011 Emergency Portal - A - Phase 1 Royal Wolverhampton NHS Trust Hea 05 Acoustic Performance Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Pre-requisite Suitably Qualified Acoustician has been appointed at pre-bid/briefing stage Trust Ramboll have been appointed Credit 1 to 2 Building meets acoustic performance standards (HTM 08-01). Ramboll/Keppie/ Arup Appropriate testing requirements have been undertaken Ramboll/Keppie/ Arup Principles' report provided. Background noise testing understood to have been undertaken. Hea 6 Safety and Security Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Cycle lanes are provided where relevant and are designed to DoT/NCN requirements Keppie Cycle lanes provide direct access to cycle storage facilities Keppie Footpaths provide direct access to site and connect to off site pedestrian footpaths Keppie Where provided, drop off areas designed next to access road and give direct access to pedestrian footpaths Keppie Pedestrian crossings of vehicle roads are provided at pavement level Keppie For large developments, signposting provided Keppie Lighting of access roads, pathways and cycleways meets levels set out in BS5489: Arup Delivery areas are not accessed through parking Keppie Separate parking/waiting area provided for goods vehicles away from delivery area Keppie Parking/turning areas designed for simple manoeuvring Keppie Dedicated space for refuse skips/pallets is away from delivery area Keppie Credit 2 Consultation held with ALO during RIBA Stage C Keppie Design incorporates recommendations of ALO Keppie / Arup Design meets the principles and guidance of Secure by Design / Safer Parking Scheme Keppie / Arup To be incorporated into design of external areas Consultation will need to be scheduled during RIBA C. TOTAL CREDITS SCORE EQUIVALENT

208 BREEAM New Construction 2011 Emergency Portal - A - Phase 1 Royal Wolverhampton NHS Trust Energy Ene 01 Reduction of CO2 emissions Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 to 15 Confirm likely carbon reduction of the building above Building Regulation Part L requirements Arup / Keppie Will require revision to existing strategy Minimum Standard Check - Six credits required for EXCELLENT, Ten for OUTSTANDING Ene 02 Energy Monitoring Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Major Energy Consuming Systems are monitored via a BMS or separate energy sub-meters Arup Credit 2 End energy consumption is identifiable to building user through labelling or data output Arup Accessible BEMS or sub meters cover the energy supply to all tenanted or function areas/departments Arup Minimum Standard Check - First credit required for VERY GOOD, EXCELLENT and OUTSTANDING Ene 03 External Lighting Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments 1st Credit External light fittings meet efficacy requirements Arup External light fittings controlled via time switch or daylight sensor Arup Ene 04 Low and Zero Carbon Technologies Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments 1st Credit Feasibility study by energy specialist to identify most appropriate LZC technology at RIBA C Arup LZC technology has been specified Arup OR: Contract in place with an energy supplier to provide 100% renewable energy for 3 years n/a nd Credit LZC reduces regulated CO2 by 10% OR Feasibility study includes LCA of carbon impact of technology Arup rd Credit LZC reduces regulated CO2 by 20% or LZC reduces life cycle CO2 by 10% Arup th Credit LZC reduces life cycle CO2 by 20% Arup th Credit First Credit in Hea 03 has been awarded Arup Building utilises a free cooling strategy Arup To be reviewed. Minimum Standard Check - One credit required for EXCELLENT and OUTSTANDING Ene 06 Energy Efficient Transportation Systems Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Analysis of transportation demand and usage patterns to confirm optimal number and size of lifts Keppie / escalators / moving walks 1st Credit Comparative energy study of two different systems Arup/Lift Provider System with the lowest energy consumption has been specified Trust Lift influenced by Helipad. 1st Credit awarded n/a 2nd Credit Lifts have three of four energy efficient features Arup/Lift Provider Escalators/Movings walks has one of two energy efficient features n/a Assume available for a bed lift. Ene 08 Energy Efficient Equipment Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Major unregulated energy consuming area identified and equipment procured in line with credit 1st Credit requirements Trust nd Credit Equipment in second largest area of unregulated energy use procured in line with guidelines Trust TOTAL CREDITS SCORE EQUIVALENT

209 BREEAM New Construction 2011 Emergency Portal - A - Phase 1 Royal Wolverhampton NHS Trust Transport Tra 01 Public Transport Accessibility Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 to 5 Awarded on the basis of the schemes Accessibility Index Gleeds Tra 02 Proximity to Amenities Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments 1st Credit Where the building is within 500 metres of required amenities Gleeds Tra 03 Cycle Facilities Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Compliant number of cycle storage facilities will be provided Keppie Credit 2 2 of 3 compliant facilities provided (showers/changing & locker/drying space) Keppie Tra 04 Maximum Car Parking Capacity Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Number of car parking spaces meet BREEAM criteria Trust Information from Pathology to be provided. Tra 05 Travel Plan Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Travel plan developed as part of the feasibility and design stage Trust Travel plan structured to meeting the needs to the site and addresses BREEAM requirements Travel plan incorporates a range of measures aimed at reducing car based travel Travel plan addresses deliveries (if applicable) Occupant confirms they will implement the travel plan Trust Trust Trust Trust Travel Plan will need to be provided or prepared. TOTAL CREDITS SCORE EQUIVALENT

210 BREEAM New Construction 2011 Emergency Portal - A - Phase 1 Royal Wolverhampton NHS Trust Water Wat 01 Water Consumption Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Determined by provision of low consumption sanitary ware - credit includes assessment of WC's, Urinals, Taps, Showers, Baths, Dishwashers and Washing Machines Keppie Credits 1 to 5 For Healthcare - baths must be fitted with an overflow device and flushing controls for WCs/Urinal must be appropriate for patients with frail or infirm hands. Keppie Assumes low flush/flow sanitary specification. Minimum Standard Check - 1 Credit required for GOOD and above, 2 for OUTSTANDING Wat 02 Water Monitoring Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Specification of a water metering on incoming mains Where areas consume >10% sub-meters must be fitted Meters must be able to connect to a BMS - or to a site wide existing BMS Arup Note requirement for sub-metering. Minimum Standard Check - water meter must be fitted to achieve a GOOD and ABOVE Wat 03 Water Leak Detection and Prevention Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Leak detection system fitted to mains water supply Leak detection system meets specific credit requirements Arup Assume that proposed tie into water main will meet requirements. Credit 2 Measures fitted to each WC/Facility to ensure water is supplied only when needed (e.g. Sanitary supply cut off controlled by a PIR, time controllers, volume controllers etc.) Arup Will require sign off by infection control / estates Wat 04 Water Efficient Equipment Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 External planting does not use irrigation - and is drought tolerant, dependent on rainfall and/or relies on manual watering only. If vehicle wash system is specified it reclaim all or part of the used water Keppie TOTAL CREDITS SCORE EQUIVALENT

211 BREEAM New Construction 2011 Emergency Portal - A - Phase 1 Royal Wolverhampton NHS Trust Materials Mat 01 Life Cycle Impacts Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credits awarded on green guide rating of external walls, windows, roof, upper floor slab, internal Credit 1 to 6 walls and floor finishes Keppie / Ramboll Mat 02 Hard Landscaping and Boundary Protection Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Where at least 80% of all external hard landscaping and boundary protection is A or A+ rated Keppie Mat 03 Responsible Sourcing of Materials Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments MANDATORY Confirmation that all timber used on the project is sourced in accordance with the Governments Timber Procurement Policy Gleeds / Keppie Requirements to be built into prelims / NBS Credit 1 to 3 Credits are awarded dependent upon how they have been sourced. Credit looks at the following building elements: structural frame; ground floor; upper floors; roof; external walls; internal walls; foundation/substructure; fittings (including staircase, windows, doors, floor finishes) and Hard Landscaping. Contractor Will need further review once more details on materials is provided Minimum Standard Check - Timber requirement must be met for ANY rating to be achieved Mat 04 Insulation Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Pre-requisite Any new insulation specified for use within the external walls, ground floor, roof or building services must be assessed. Credit 1 Embodied impact of the insulation is assessed and the Insulation Index for the building is greater than 2 Keppie / Arup Credit 2 At least 80% of the volume of thermal insulation is responsibly sourced (i.e. Between Tier 1 and 6 of the responsible sourcing hierarchy). Keppie / Arup Mat 05 Designing for Robustness Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Areas of building identified where vehicular, trolley and pedestrian movement occurs. Keppie Design incorporates suitable durability and protection measures Keppie TOTAL CREDITS SCORE EQUIVALENT

212 BREEAM New Construction 2011 Emergency Portal - A - Phase 1 Royal Wolverhampton NHS Trust Waste Wst 01 Construction Waste Management Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 to 3 Building's design and construction meets or exceeds established resource efficiency benchmarks Design Team / Contractor Compliant SWMP in place Contractor Pre-demolition/Pre-refurbishment waste audit undertake prior to construction Contractor Will be built into preliminaries Credit 4 Buildings construction meets or exceeds the diversion from landfill targets set out of demolition and non-demolition waste Contractor Waste materials are sorted into separate waste groups either on or off site Contractor Will be built into preliminaries Minimum Standard Check - One credit for OUTSTANDING Wst 02 Recycled Aggregates Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Total amount of recycled/secondary aggregate is greater that 25% of the total high-grade aggregate specified for the building. Ramboll Individual aggregated uses (e.g. Structural frame, floor slabs, pipe bedding etc.) meets an established recycled content Ramboll Will need further review. Ramboll to confirm what likely aggregates Aggregates are obtained on site, from a site within 30 km or are post industrial/consumer aggregates Ramboll can be used, where available sources of recycled aggregates are etc. Requirements to then be passed onto Contractor. Wst 03 Operational Waste Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Dedicated space provided to cater for recyclable wastes Keppie Dedicated space is labelled, accessible to occupants and collections and is of an appropriate capacity Keppie Where consistent generation of waste is likely to be produced appropriate facilities are provided for (e.g. Compactor, baler, composting vessels, composting storage) Keppie Requirements of HTM07-01 are met Keppie Currently assumed will be provided within the site boundary. Minimum Standard Check - One credit for EXCELLENT and ABOVE TOTAL CREDITS SCORE EQUIVALENT

213 BREEAM New Construction 2011 Emergency Portal - A - Phase 1 Royal Wolverhampton NHS Trust Landuse and Ecology LE 01 Site Selection Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 At least 75% of development footprint is on previously developed land Keppie Clear historical use. Credit 2 Site is deemed to be significantly contaminated and appropriate investigation has been undertaken Ramboll Client/Contractor confirms remediation has been undertaken in line with remediation strategy Ramboll SI will confirm if any contamination present on the site. LE 02 Ecological Value of the Site Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Land in the construction zone is of low ecological value Ramboll Existing features of ecological value surrounding the construction zone and site boundary are adequately protected Ramboll Ecologist has been commissioned and site survey is due imminently. Ecological protection measures are provided prior to construction starting Ramboll Currently assumed land is of low ecological value. LE 03 Mitigating Ecological Impact Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Where there is a small negative change in biodiversity value Ramboll Minimal biodiversity present Credit 2 Where there is no change or an increase in biodiversity value Ramboll Minimal biodiversity present Minimum Standard Check - One credit for VERY GOOD and above LE 04 Enhancing Site Ecology Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Suitably Qualified Ecologist appointed Trust General recommendations of Ecologist are implemented Keppie (landscape) Credit 2 Development will lead to a small improvement in biodiversity value Keppie (landscape) Will need looking at in more detail. Credit 3 Development will lead to a significant increase in biodiversity value Keppie (landscape) Will need looking at in more detail. LE 05 Long term impact on Biodiversity Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 and 2 SQE has been appointed Trust SQE confirms that all relevant legislation has been complied with during design and construction Where relevant, a Landscape and Management plan has been produced Principal Contractor nominates a biodiversity champion Training on protection of ecology provided to site staff Measures taken to protect ecology are recorded New, ecological valuable, habitat created Contractor programmes works to avoid impact on ecology Ramboll Ramboll Contractor Contractor Contractor Contractor Contractor Contractor requirements to be built into prelims. TOTAL CREDITS SCORE EQUIVALENT

214 BREEAM New Construction 2011 Emergency Portal - A - Phase 1 Royal Wolverhampton NHS Trust Pollution Pol 01 Impact of Refrigerants Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments 3 credits - where no refrigerants used OR 2 credits where Direct Effect life cycle CO2 equivalent emissions of 100 kg DELC CO2e/kW used Credit 1 to 3 1 credit where Direct Effect life cycle CO2 equivalent emissions of 1000 kg DELC CO2e/kW used AND 1 additional Credit where leak detection and pump down facilities provided BRE have responded on this issue. Refrigerant associated with process load can be excluded from the assessment. This includes refrigerant associated with any medical equipment. Pol 02 Nox Emissions Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Nox emissions from space heating are <100 mg/kwhr Assume majority of space heating will be through connection to on site steam. Credit 2 Nox emissions from space heating are <70 mg/kwhr Credit 3 Nox emissions from space heating are <40 mg/kwhr - and water heating is 100 mg/kwh Pol 03 Surface Water Runoff Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit credit if in medium flood risk, 2 credits if low flood risk Ramboll Needs confirmation - currently assumed. Agency map shows no flood risk. Need confirmation on other sources of flooding. Prerequisite Appropriate Consultant appointed to assess following three credits Ramboll Credit 3 Where peak rate of run off from site to watercourses is no greater for the developed site that the pre-developed site. This should be for 1 year and 100 year return periods. Ramboll Needs further review Credit 4 Flooding of property will not occur in the event of a local drainage system failure AND EITHER Ramboll - post development runoff volume over development lifetime is no greater than it would have been prior to the assessed site's development Ramboll - And additional runoff for the 100 year, 6 hour return event must be prevented from leaving the site by infiltration/runoff Ramboll OR - Justification provided by consultant stating why above criteria cannot be met. Ramboll - post development runoff is reduced to a limited discharge (as set out in manual) Ramboll Credit 5 Appropriate Consultant confirms that there is no discharge from site for rainfall up to 5 mm Ramboll SUDS has been specified for relatively low risk areas Ramboll Oil/petrol interceptors specified for areas where high risk of contamination/spillage of hydrocarbons Ramboll Water pollution prevention systems designed in line with PPG 3 and SUDS manual Ramboll Drainage plan will be provided to occupants upon completion Ramboll Shut off valves provided where chemical/liquid gas storage areas provided Ramboll All external storage and delivery areas designed in line with PPF guidance (and PPG 25 for Hospitals) Ramboll Needs further review Pol 04 Reduction of Night Time Pollution Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 External lighting complies with the ILE Guidance Note on Obtrusive Light Arup External lighting can be switched off between 2300 and 0700 hrs via a timer Arup Safety and Security lighting used between 2300 and 0700 hrs meets with lower levels of lighting set out in the ILE guidance note - e.g. By use of automatic switch to reduce lighting levels Arup Illuminated advertisements must comply with ILE technical report 5 Arup Requirements to be built into specification.

215 BREEAM New Construction 2011 Emergency Portal - A - Phase 1 Royal Wolverhampton NHS Trust Pol 05 Noise Attenuation Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments Credit 1 Credit given by default if no noise sensitive development within 800 metres Ramboll Where development, noise assessment should be undertaken in line with BS 7445 Ramboll Assessment must be undertaken by a suitable qualified acoustician Ramboll noise level from the building is no greater than +5db during the day and +3db during the night than background levels Ramboll / Arup Attenuation must be provided if noise level is greater Arup TOTAL CREDITS SCORE EQUIVALENT

216 BREEAM New Construction 2011 Emergency Portal - A - Phase 1 Royal Wolverhampton NHS Trust Innovation Man 01 Sustainable Procurement Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments EXEMPLARY Quarterly collection of occupant satisfaction, energy and water consumption - and establishing targets Trust Provide yearly data to BRE Global Trust Man 02 Responsible Construction Practices Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments EXEMPLARY CCS Score > 36 Trust Hea 01 Visual Comfort Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments EXEMPLARY Building meets Exemplary Daylight requirements Ene 01 Reduction of CO2 emissions Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments EXEMPLARY Building is Carbon Negative EXEMPLARY Reductions achieved in unregulated energy emissions Ene 04 Low and Zero Carbon Technologies Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments EXEMPLARY LZC reduces regulated CO2 by 30% or LZC reduces life cycle CO2 by 30% Mat 01 Life Cycle Impacts Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments EXEMPLARY Where a high proportion of materials are A or A+ rated Mat 03 Responsible Sourcing of Materials Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments EXEMPLARY Where 70% of the available responsible sourcing points have been achieved Wst 01 Construction Waste Management Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments EXEMPLAR Scheme achieves highest level of performance for resource efficiency and diversion from landfill Wst 02 Recycled Aggregates Responsibility Credits Value (%) Very Good Excellent Outstanding Not Sought Comments EXEMPLARY Total amount of recycled/secondary aggregate is greater that 35% of the total high-grade aggregate specified for the building. Individual aggregated uses (e.g. Structural frame, floor slabs, pipe bedding etc.) meets an the exemplary recycled content Needs further review TOTAL CREDITS SCORE EQUIVALENT OVERALL SCORE

217 4b AEDET Results

218 Achieving Excellence Design Evaluation Toolkit (AEDET Evolution) Project details: Title Emergency Portal Phase 1 Workshop details: Location Date New Cross Hospital, Wolverhampton Results summary: A: Character and innovation of 5 scored B: Form and materials of 5 scored C: Staff and patient environment of 8 scored D: Urban and social integration of 4 scored E: Performance of 4 scored F: Engineering of 5 scored G: Construction of 7 scored H: Use of 7 scored I: Access of 7 scored J: Space of 6 scored NOTE: A filled traffic light dot [ ] in the table above indicates a valid average score, a hollow dot [ ] indicates that one or more statements have been marked as 'unable to score'.