3Ts Hospital Redevelopment Programme Full Business Case. Strategic Case: Demand & Capacity

Transcription

1 3Ts Hospital Redevelopment Programme Full Business Case Strategic Case: Demand & Capacity February 2016

2 Contents Introduction... 4 Commissioners... 4 Approach... 5 Planning Horizon... 5 Baseline Activity... 5 Demographic Changes... 5 Epidemiology & Uptake... 5 Demand Management... 6 Inpatient Length of Stay... 6 Quality, Innovation, Prevention and Productivity (QIPP)... 7 Changes in Patient Flow... 7 Private Patients... 8 Occupancy/Utilisation... 9 Inpatient Bed Occupancy... 9 Space Utilisation - Occupancy Analytics... 9 Demand Modelling Inpatient Bed Demand Inpatient Capacity in 3Ts Scenarios/Sensitivities Mitigations Operating Theatres: Neurosurgery Interventional Radiology Radiotherapy Outpatient Model Summary of Changes to Capacity in 3Ts Changes since OBC (In-patient Beds) Summary Page 2 of 22

3 Section Strategic Case: Demand and Capacity Appendices Appendix Title Demand and Capacity Plan Page 3 of 22

4 Introduction 1. This section summarises the approach taken to assessing future service demand and the associated capacity required in the 3Ts redevelopment. Activity/capacity modelling for 3Ts has been updated from Outline Business Case (OBC) stage and is aligned with: the latest Trust Long-Term Financial Model (September 2014), which projects activity and income to 2023/24 (the year after 3Ts Stage 2 is due to open); the Trust Clinical Strategy 2014/15 to 2018/19; and commissioners planning assumptions. 2. The 3Ts Programme Office has developed and maintains the Trust-wide activity/capacity model. This ensures integrated planning across the range of Trust business processes (eg. 3Ts, Foundation Trust, Long- Term Financial Model, individual service development business cases) and alignment of activity, income, performance/efficiency and capacity assumptions. The Long-Term Financial Model and Clinical Strategy were both developed with commissioners as key stakeholders. 3. The required planning period is 2014/15 to 2027/28 (ie. five years after the completion of the development). The impact of even small changes year-on-year (growth, demand management, performance improvements, Better Care Fund etc.) is amplified when projected over 14 years. The business case therefore includes scenarios/sensitivities to show the impact of different assumptions on inpatient activity and required capacity both during and at the end of the planning period. 4. Taking an integrated, Trust-wide approach to modelling means that planning for capacity in 3Ts includes activity in both 3Ts and non-3ts specialties; this ensures that the Trust has the appropriate capacity overall. Capacity planning also needs to be undertaken at individual site level. These different dimensions are set out below. Commissioners 5. The table below shows the split in activity in 3Ts services between NHS England and Clinical Commissioning Groups. With the exception of neurosciences, the majority of the services in 3Ts are commissioned principally by the seven local Clinical Commissioning Groups. Specialty Groups (used in capacity modelling) Trust Commissioners % Spells Under % Spells CCG Specialist Treatment Groups 2% 98% General Medicine Chest Diabetes Haematology & Oncology 9% 91% Clinical Infection Service 35% 65% Interventional Radiology 1% 99% Medicine for the Elderly 1% 99% Neurosciences 99% 1% Major Trauma (VA HRGs) 12% 88% 6. Commissioning assumptions are generally set out no more than two years in advance, with broader strategic intent described for subsequent years. The assessment of future demand therefore aligns with shorter-term commissioning intentions where known and a longer-term assessment of activity as set out below. Changes to the modelling since Outline Business Case stage are noted. Page 4 of 22

5 Approach 7. In summary, capacity requirements for 3Ts are a function of: the planning horizon; demand (baseline activity, demographic changes, changes in epidemiology/uptake of services, service developments); efficiencies (eg. demand management, inpatient length of stay reductions, service changes such as the implementation of Prime Provider and Any Qualified Provider initiatives); and occupancy/utilisation. Planning Horizon 8. At Outline Business Case stage, Strategic Health Authority guidance was to continue demand/capacity modelling to five years after the completion of the development, and the planning horizon therefore extends to 2027/28. The Trust Long-Term Financial Model (LTFM) extends to 2023/24. Baseline Activity 9. Activity data from 2013/14 populates the model; the first year projection is aligned with the LTFM (October 2014), which is based on 2014/15 projected from Month 3. Demographic Changes 10. The planning model uses population growth rates projected by the Office for National Statistics (across all ages) by individual Clinical Commissioning Group area. Overall the assumed demographic growth is relatively modest: the Trust s acute catchment population is forecast to grow by 6.0% by Population Projections for Acute Catchment Area 2014 growth 2015 growth 2016 growth 2017 growth 2018 growth 2019 growth 2020 growth 2021 growth Brighton & 0.68% 0.63% 0.59%. 0.55% 0.53% 0.50% 0.47% 0.45% Hove Lewes 1.22% 1.21% 1.17% 1.15% 1.13% 1.11% 1.10% 1.08% Mid Sussex 0.73% 0.77% 0.77% 0.77% 0.78% 0.79% 0.81% 0.82% Source: Trust demographic growth model 27/9/ Trust annual activity projections are generated by applying population projections (at age and CCG level) to baseline activity and income at specialty level using a 9 year compound average growth rate. The aggregate impact on the whole of the Trust activity is just under a 1% increase in demand per year. The demand modelling undertaken for 3Ts uses this annual average and extends it for a further 6 years to 2027/ Population predictions for Sussex CCGs are appended. Epidemiology & Uptake 13. For some specialties, demand is currently growing or is expected to grow at a faster rate than demographic increase, for example because of increases in disease prevalence in the local population or other service changes. These enhanced growth rates are set out below, as assessed by KPMG using historical activity trends. This has also been factored into the modelling. Page 5 of 22

6 Enhanced Growth Specialties (2015/16 to 2023/24) (In addition to demographic growth) Clinical Specialty Avg. % Increase pa Renal 3.84% Cancer Services 2.47% Demand Management 14. Brighton & Hove and surrounding CCGs are developing strategies to change pathways for acute, elderly, respiratory and general medicine patients. The consequence of this is expected to be a reduction in unscheduled inpatient activity, which is reflected in the aligned financial and activity plans. The impact of the Better Care Fund financial adjustments on unscheduled admissions is shown below for each CCG. There is a further reduction for Brighton & Hove CCG in the subsequent three years. Currently the impact on beds has been modelled at average Length of Stay, and this will be refined as joint work with CCGs on QIPP and Better Care Fund schemes develops more detailed assumptions. The total bed reduction relating to demand management is 60 beds Trust-wide. Better Care Fund Reduction in Unscheduled Admissions (2015/16) CCG % Reduction in Unscheduled Admissions for General Medical & Elderly care services Brighton & Hove -9% Horsham and Mid Sussex -19% High Weald, Lewes and Havens -6.78% Inpatient Length of Stay 15. The Trust s Clinical Strategy has drawn on benchmarking data from 25 comparator Trusts in England to inform its efficiency assumptions this planning was supported by McKinsey & Company and specialist healthcare/public services management consultancy Carnall Farrar. 16. In the five years before 3Ts Stage 1 is due to open, Trust average Length of Stay is expected to reduce by 3% per year across all specialties. At Trust level, these assumptions equate to a reduction of 155 beds by 2019/20 and take most key specialties to top quartile performance. A number of Trust plans and developments (incl. service transformation initiatives, Cost Improvement Plans, operational resilience plans developed across the Local Health Economy, and the Better Care Fund) will contribute to the delivery of this improvement. For example, the Trust s Electronic Patient record (EPR) programme expects to contribute a 2% Length of Stay reduction. 17. As set out in the Benefits Realisation Plan, the evidence supports a further Length of Stay reduction as a result of moving into improved accommodation and a higher proportion of single inpatient rooms, in particular from reductions in falls and Healthcare-Associated Infections (HCAIs). This benefit has been estimated by assuming the specialties moving into 3Ts facilities will achieve current top quartile performance (where this not already the case). The effect is to reduce bed demand by a further 5 beds. 18. The overall impact of these assumptions on inpatient Length of Stay at Trust level is illustrated below (further detail by specialty is appended). Page 6 of 22

7 Trust Length of Stay Projections Quality, Innovation, Prevention and Productivity (QIPP) 19. The assessment of future demand and capacity requirements factors in opportunities presented by the QIPP programme, and in particular avoidance of hospital admissions. Other local QIPP plans that have a direct impact on activity projections are reflected in the Trust LTFM, which has informed the 3Ts capacity modelling. Changes in Patient Flow 20. The 3Ts development provides some additional capacity, as set out in its investment objectives. This will increase choice for patients who currently have to travel outside Sussex for their treatment, and provides capacity aligned to the development of networks across Sussex and the wider region. Downsides are considered in the Finance Chapter and include the impact of reduced growth and no 3Ts repatriated income. The table below describes the individual pathway changes that are expected once the facilities are commissioned. Description of Service Specific Changes Enabled by 3Ts HIV Service Neurosciences Rationale To centralise HIV inpatients care from across Sussex, in line with NHS England commissioning specifications. To offer a comprehensive neuroscience service to patients in Sussex:- With the development of the Sussex neurology network, the Trust would expect to manage up to 80% of inpatient activity, with outpatient/ambulatory care activity distributed across the network. Increase in inpatient neurosurgery capacity to provide choice for local patients/gps, 20% of whom currently have to travel to London for their treatment. Page 7 of 22

8 Service Haematology & Oncology Rationale To further develop as tertiary cancer centre for Sussex patients:- Consolidate Level 2 services across Sussex. This will involve transferring Level 2 chemotherapy (day case and inpatient activity) from Worthing Hospital to the Royal Sussex County Hospital. Develop a Level 3 local service, in partnership with London hospitals. For rare haematological malignancies this involves complex inpatient regimens and those that have a high incidence of complication. The aim is to bring follow-up closer to home for patients receiving bone marrow transplant this repatriates activity from London and increases choice for patients. 21. Admitted patient activity for 2013/14 from the Healthcare Evaluation Data (HED) analytics suite has been used to update estimates made in the OBC of the activity transfers that would result from repatriating Sussex patients and also other transfers between the Trust and other providers within Sussex. As set out in the table below, the associated financial transfer is c. 7m. The benefit of reduced Market Forces Factor accrues to commissioners and has been factored into the Economic Case. An estimate of the financial impact on current providers is appended. Activity and Projected Income Assumptions from Repatriation and Other Service Transfers Specialty Clinical Pathway DC & IP Spells Income ( 000s) 2014/15 Tariff HIV HIV In-patients from Sussex DGHs Neurology o London Repatriation of Sussex patients o Tertiary Transfer of Neurology patients from Sussex DGHs Neurosurgery o London Repatriation of Sussex patients o Complex Neurosurgery from ESHT o Extending Catchment W.Kent/S. Surrey o Isolated Head Injuries and other patients requiring Neurosurgery input 520 4,363 Haematology o AML/ALL Level 2 from WSHT o Transplant Patients early repatriation from London 1,209 1,681 Oncology Radiotherapy in-patients receiving treatment at RSCH currently staying in Sussex DGHs due to lack of bed capacity Total 2,674 7,168 Note: This table excludes growth Private Patients 22. It is anticipated that additional theatre and bed capacity in 3Ts Stage 1 will enable the Trust to attract additional private patient income for neurosciences and other general surgery. The income target assumes six beds worth of activity, which is considered relatively modest, and is identified in the capacity model. 3Ts Stage 2 includes shell space for a dedicated Private Patients Unit. The activity profile and facilities within this will be developed at a later stage under a separate business case; for planning purposes its assumed that it will utilise part of the Operational Capital included within the Trust s LTFM rather than be funded by Strategic Capital (eg. new loan). Page 8 of 22

9 Occupancy/Utilisation Inpatient Bed Occupancy 23. As set out in the recent Care Quality Commission inspection report, [i]t is generally accepted that when occupancy rates rise above 85%, it can start to affect the quality of care provided to patents and the orderly running of the hospital. Department of Health studies using discrete event simulation found that when bed occupancy exceeds 90%, acute hospitals experience regular bed shortages and periodic bed crises (BMJ 1999; 319:155). 24. In 2013/14 bed occupancy across the Trust averaged 89.5%, and at the Royal Sussex County Hospital site was 94.4% (Source: In-patient bed model - excluding the Royal Alexandra Children s Hospital). However, this is overnight occupancy average for the year, and there therefore will have been periods when it has been even higher than this. 25. The Trust Clinical Strategy describes the plan to reduce occupancy by freeing up capacity through reductions in inpatient Length of Stay. The current projections of inpatient demand at the opening of 3Ts Stage 1 against inpatient capacity would give the Trust the option to reduce occupancy below 90%. 26. As set out in the Commercial Case, the 3Ts building has been designed to maximise operational flexibility through the increased proportion of single rooms. On this basis, activity/capacity planning for 3Ts specialties has assumed 90% occupancy (rather than the standard 85% for newbuild facilities), which the Trust considers will maximise efficiency without compromising patient safety or quality. The model outputs below illustrate the bed demand at 100% and 90% occupancy Trust-wide. 27. Capacity modelling for other services/facilities in 3Ts (including theatres, daycase and outpatient accommodation) assumes occupancy/utilisation at the Trust target of 85% (summarised in the table below). Summary of Utilisation Assumptions Service Utilisation Assumptions Modelling. Notes Utilisation % Bed Capacity Available 24/7 90% Day Case 2 x 4 Hour Sessions 5 days a week 85% (252 days) Out-patients 2 x 4 Hours Sessions 5 days a week (252 days) 85% Some specialties already offer clinics later in the afternoon, some during the weekend. It is expected that this will increase to enhance patient choice Theatres 2 x 4 Hour Sessions 5 days a week 85% Elective Space Utilisation - Occupancy Analytics 28. As part of the work to develop sustainable/low carbon design, the 3Ts Programme Office has worked with Professor Matthew Bacon (Eleven Informatics) to consider the opportunities presented by the new science of Occupancy Analytics. This aims to right size engineering system design (eg. heating and cooling infrastructure) based on dynamic modelling of building use/occupancy and opportunities to smooth peak loads, for example by extending the work day/week. 29. This work has used the departmental operational policies developed for the 3Ts planning and design process to create a database of process activities/resources and expected inter-departmental flows. Simulation technology was used to produce a dynamic process model for the whole hospital. The model Page 9 of 22

10 then predicts the major occupancy (in particular for staff and patients) throughout the day/week within each part of the new facilities, and the impact on space and major equipment utilisation. 30. The simulation modelling suggests that there is potential to reduce the energy load on the building by smoothing demand throughout the day, and work has been undertaken with service departments to explore the impact of their operational policies on the peak occupancy of the department and for the site overall. 31. This work is expected to continue as the 3Ts programme progresses. As for standard demand/capacity modelling, the simulation modelling also relies on a set of planning assumptions, compounded over the planning period, and the results therefore require careful risk assessment. Demand Modelling Inpatient Bed Demand 32. The development of a Trust-wide inpatient bed model, of which 3Ts demand/capacity is one component, has ensured that planning encompasses the complex range and sequence of service moves over the intervening years (eg. Site Reconfiguration) and sets 3Ts planning in the wider Trust and Local Health Economy context. 33. The model starts with a representation of the number of beds and average bed occupancy for the baseline year (2013/14) and is then populated with: inpatient spells (ie. involving at least one overnight stay zero spells are excluded) and bed days for ward and critical care beds, grouped by specialty at discharge; admission type (elective or non-elective); and physical beds average number of beds used during the baseline year (average calculated from the real time bed state generated from OASIS PAS Patient Administration System). 34. The baseline bed occupancy is calculated by site and specialty groups according their ward usage this gives the number of beds used. No distinction is made between Level 2 and Level 3 critical care bed demand; the Higher Dependency Unit (HDU) is therefore not separately identified/sized in the model. 35. The model projects the demand for beds in future years using the activity assumptions, which increase or decrease the number of spells. Planning is aligned with the Trust 10-year LTFM and applies standard assumptions for the remainder of the planning timeline. The model also incorporates the service developments and efficiency assumptions described above. 36. For new activity, bed demand is calculated at 90% average occupancy. 37. Demand for critical care capacity (Level 2 and 3) is modelled in parallel with changes in inpatient admissions, based on the percentage of patients who require critical care and their average Length of Stay in critical care. 38. The activity assumptions set out above have been used to update the Trust-wide bed model. Outputs from the model shown below exclude beds which are essentially ringfenced for the majority of the activity. These include: Maternity beds; Royal Alexandra Children s Hospital; Sussex Orthopaedic Treatment Centre; and Sussex Eye Hospital. Page 10 of 22

11 39. The modelling suggests that Trust-wide demand (with above exclusions) will increase by 39 beds (at 90% occupancy) over the 14 year planning horizon (Model 86). The bridge analysis below shows the impact of the assumptions as described earlier in the chapter. Bridge Analysis of Changes in Trust Bed Demand Note: 5.5 beds for private patient activity are included in Service Developments 3Ts Page 11 of 22

12 40. These assumptions impact differentially across the campus and the increase is focussed at RSCH where the new bed capacity will be created. The figure below provides a bridge analysis of the change in bed demand for the RSCH site showing a net increase of 89 beds over the same period. Bridge Analysis of changes in Bed Demand - RSCH Page 12 of 22

13 Inpatient Capacity in 3Ts 41. The 3Ts development provides 361 inpatient beds: 261 replace existing beds and 103 are additional capacity (58 at Stage 1 and 45 at Stage 2). 3T Beds Built vs Decommissioned Physical Bed Changes Increase from 2013/14 Stage 1 - Decommission -258 Stage 1 Build Stage 2 Build Change in beds The Demand & Capacity appendix illustrates the series of moves expected on the RSCH site. In addition to the wards shown, there is potential to provide c. seven additional beds for Private Patient activity in the dedicated unit in Stage 2. This is not included in the capacity modelling. 43. The relationship between modelled bed demand and capacity over time is illustrated in the figures below. The modelling suggests that at a maximum 90% occupancy across the sites, there would be a surplus of 142 beds across the Trust in 2019/20 when Stage 1 opens, and 120 beds in 2022/23 when Stage 2 opens. This surplus narrows to 68 beds by 2027/28 and is dependent upon successful demand management across the health system and Length of Stay reductions. The surplus at the RSCH site is 92 beds in 2019/20, 79 beds in 2022/23 when Stage 2 opens, and 42 beds by 2027/28. If demographic growth were to continue at the modelled rate, demand would match capacity 11 years after opening. 44. Surplus capacity would allow the Trust to maintain additional capacity wards at both sites to accommodate peaks in demand (eg. seasonal variation - winter surges) and troughs in capacity (eg. infection outbreaks, or planned preventative maintenance). Alternatively, surplus beds could be removed in order to achieve bed spacing standards across the estate:- 110 beds Princess Royal Hospital 99 beds Royal Sussex County Hospital 32 single rooms at PRH and 10 at RSCH are non-compliant. Page 13 of 22

14 2013/14 Baseline 2014/ / / / / /20 Stage / / /23 Stage / / / / /28 Brighton & Sussex University Hospitals NHS Trust Full Business Case 3Ts Redevelopment February 2016 Inpatient Bed Demand and Capacity BSUH Note: For the purposes of modelling the occupancy has been set at 90% from the first year. The activity assumptions indicate that this will not be possible until 2015/16 and the occupancy is likely to be closer to 93% in 2014/15. Physical Beds Bed Demand 90% Occupancy Beds at 100% Page 14 of 22

15 2013/14 Baseline 2014/ / / / / /20 Stage / / /23 Stage / / / / /28 Brighton & Sussex University Hospitals NHS Trust Full Business Case 3Ts Redevelopment February 2016 Inpatient Bed Demand and Capacity RSCH Note: For the purposes of modelling the occupancy has been set at 90% from the first year. The activity assumptions indicate that this will not be possible until 2015/16 and are likely to be closer to 92% in 2014/15. Physical Beds* Bed Demand maximum 90% Occupancy Beds at 100% Further detail on the difference between predicted demand and bed capacity is appended (and summarised in the table below); and comparison between beds in the baseline and the KH03 appended. Scenarios/Sensitivities 46. Current planning assumptions include ambitious health economy-wide and Trust performance targets, the impact of which is compounded when projected to 2027/28 (ie. five years after the completion of the development). In light of the range and complexity of variables, analysis has been undertaken to consider the inpatient capacity being built in 3Ts against a range of scenarios (illustrated in the figure below). Page 15 of 22

16 Bed Demand Scenarios BSUH (modelled at 90% occupancy from 2014/15) Page 16 of 22

17 47. This modelling shows that although activity and efficiency assumptions across the Local Health Economy have changed since Outline Business Case stage, the inpatient capacity in 3Ts continues to reflect a reasonable planning assumption given the range of possible scenarios. The table below shows the consequence of each scenario for bed demand compared to capacity at the opening of Stage 2 (2022/23) and the end of the planning period (2027/28). Scenario Model output 50% reductions 1% growth 100% reductions 2% growth 0% reductions 1% growth 50% Reductions 2% Growth 0% reductions 2% growth Commentary This scenario considers that there will be all the assumed demand management, efficiencies and activity grows by the rate of circa. 1% per annum (varies slightly by specialty). This scenario considers that there will be half the demand management, efficiencies and activity grows by 1% per annum. This scenario considers that there will be all the assumed demand management, efficiencies and activity grows by 2% annum. This scenario considers that there will be no assumed demand management, efficiencies and activity grows by 1% annum. This scenario considers that there will be half the assumed demand management, efficiencies and activity grows by 2% annum. This scenario considers that there will be no assumed demand management, efficiencies and activity grows by 2% annum. Gap Between Demand and Capacity 2022/23 Excess of 120 beds for the projected activity. Excess of 15 beds for the projected activity. Excess of 58 beds for the projected activity. 78 too few beds for the projected activity. 50 too few beds for the projected activity. 142 too few beds for the projected activity. Gap Between Demand and Capacity 2027/28 Excess of 68 beds for the projected activity. 37 too few beds for the projected activity. 39 too few beds for the projected activity. 130 too few beds for the projected activity. 152 too few beds for the projected activity. 239 too few beds for the projected activity. Mitigations 48. The Trust has developed high-level contingency plans for the estate in the event that demand for inpatient beds at the Royal Sussex County Hospital is significantly greater than forecast (eg. because growth is greater and/or Better Care Fund, demand management and performance efficiencies prove less effective than planned). These include the following measures:- The Trust and commissioners would need to reassess the split of services/activity between the Royal Sussex County and Princess Royal campuses, diverting activity to available capacity. This would require clinical pathway changes and may be subject to consultation. The Trust and health and social care commissioners would need to reassess the level of capacity available in community settings (eg beds Trust-wide are currently occupied by patients who are medically fit for discharge/transfer, the majority of whom are awaiting transfer to nursing, residential or non-acute accommodation). The Trust could also apply to Brighton & Hove City Council to extend Planning Consent for the Pathology Courtyard decant building (22 beds). The modelling currently assumes that this building will close in In the event that demand for inpatient beds is significantly less than forecast (eg. because Better Care Fund, demand management and performance efficiencies all fully meet or exceed current planning assumptions), the Trust could further rationalise its own estate (eg. St Mary s Hall site) or support estate rationalisation across the Local Health Economy. It could also decompress current bed spacing in the Page 17 of 22

18 multi-bed bays in the Thomas Kemp Tower and Millennium Wing by moving some capacity into the 3Ts buildings. Operating Theatres: Neurosurgery 50. Revised modelling based on demand projections suggests that by 2027/28 c. 16 operating sessions per week will be required for elective cases, in addition to a dedicated theatre for emergency cases. Further details are appended. Interventional Radiology 51. The Interventional Radiology facilities (including three theatres) will be co-located in 3Ts (Stage 1, Level 5) to optimise operational efficiency and flexibility and provide a single base for a multidisciplinary Interventional Team. This is immediately adjacent to the major theatre and neurosurgery theatres. The three theatres within 3Ts are re-provision of current capacity, which has recently increased to accommodate activity for the Vascular Network, with capacity for future growth in demand. Radiotherapy 52. The current demand estimate based on planning assumptions set out by the Department of Health and National Radiotherapy Advisory Group (NRAG), is c. 85,000 radiotherapy attendances by 2021 for the Sussex catchment population (based on 45 minute travel time). This is close to the projections at Outline Business Case stage. Based on the expected levels of productivity and recommended resilience and flexibility to manage peak demand, the equivalent of 10 Linear Accelerators will be required for the population served by the Trust across East Sussex, West Sussex and Brighton & Hove by 2020/21. Of these, four will be provided in two linked satellite units located in East Sussex and West Sussex. 53. The 3Ts development includes seven radiotherapy bunkers: based on current activity/capacity assumptions this therefore provides one spare bunker to facilitate decant (and minimise disruption to patients) when equipment requires replacement. 54. Changes in treatment regimens may significantly impact the nature of and demand for radiotherapy in the future. If demand exceeds current projections, there is potential to develop further satellite capacity and extend the temporary decant arrangement at Preston Park. 55. The design of bunkers in 3Ts Stage 2 (principally the size and required level of shielding) will also need to be re-reviewed before plans are finalised. Developments such as stereotactic radiotherapy and Linear Accelerators that offer integrated MRI will likely be standard by the time the new Sussex Cancer Centre is commissioned, and the 3Ts designs will therefore need to be sufficiently flexible to accommodate future technological advances. Outpatient Model 56. There is currently no nationally accepted methodology for modelling outpatient capacity based on assumed demand. There is considerable variation between specialties (eg. patient dwell time within the department, number of different clinicians seen and interventions required per visit, number and service contribution of trainees) and models of care continue to evolve (eg. one-stop services, which require fewer separate visits but longer time in the department on each occasion). Simple analysis of patient attendances against appointment slots tends to significantly underestimate the outpatient accommodation required, and initial modelling assumptions for 3Ts was inconsistent with clinicians experience. 57. Capacity planning for outpatient facilities in 3Ts has therefore assumed that accommodation is currently operated at 85-90% utilisation, and that additional accommodation will be required in line with activity growth assumptions. A comparison of changes in accommodation is appended for outpatient and imaging modalities. Occupancy Analytics dynamic modelling (described above), which estimates patient dwell Page 18 of 22

19 times based on department operational policies/process flows, suggests that there may be some spare capacity for future expansion. 58. Again, the Trust has developed contingency plans in the event that actual demand for accommodation varies significantly from plan:- The Main Outpatient Department at the Royal Sussex County Hospital is outside the scope of the 3Ts redevelopment, and there is therefore a significant volume of outpatient activity that could be transferred into the 3Ts building to use any spare capacity. The Trust Clinical Strategy includes consideration of an offsite Outpatient/Ambulatory Care Hub, although a location has not yet been identified. This facility would be sized to reflect demand (including the impact of AQP initiatives) and overall utilisation of Outpatient accommodation at the Royal Sussex County Hospital site. Summary of Changes to Capacity in 3Ts 59. The table below compares the capacity for day case, imaging, theatres and outpatient activity currently provided for each service and capacity planned in 3Ts. Page 19 of 22

20 Trust Total Total with 3Ts OP Con/Exam Rm Now OP Con/Exam Rms in 3Ts Day Care Chairs Now Day case Chairs in 3Ts Theatres Now Theatres in 3Ts Brighton & Sussex University Hospitals NHS Trust Full Business Case 3Ts Redevelopment February 2016 Changes to Capacity in 3Ts Service General Medicine 0 12 Respiratory Medicine Medicine for the Elderly Haematology/Oncology* Clinical Infection Service* 8 13 Neurosurgery 2 3 Neurology 6 8 Neurosciences OPD 8 17 Major Trauma 1 1 Rheumatology* ENT/Max Fax 9 9 Fracture Clinic 6 10 CT 6 10 MRI 3 4 Fixed Fluoroscopy 4 5 X-ray Ultrasound (inc Obs) Interventional Radiology Theatres 3 3 Radiotherapy (LINACS) Shell * Current consult/exam room usage has been estimated where mixed usage, eg. Main OPD. Changes since OBC (Inpatient Beds) 60. Since the Outline Business Case was approved in 2012 (v17) there have been a number of changes to the activity/demand and efficiency assumptions underpinning the inpatient bed model. For example growth assumptions to align with commissioner planning: avg. 0% to 2016/17 and then 2.25% for five years at approved OBC vs an average 1% pa at Full Business Case. The change in modelled demand at OBC over the 11 year period projected an increase of 199 beds; this is now an overall decrease of 14 beds. 61. The table below shows the bed demand and capacity by site at OBC and FBC stages against the total number of beds allocated on each site. Page 20 of 22

21 Site OBC Approved V17 - Demand 2009/10 OBC Approved V17 - Demand 2020/21 OBC - TDA Refresh 7/13 - Demand 2012/13 OBC TDA Refresh 7/13 - Demand 2021/22 FBC - Demand 2013/14 FBC - Demand 2022/23 FBC - Physical 2022/23 Unallocated Brighton & Sussex University Hospitals NHS Trust Full Business Case 3Ts Redevelopment February It is important to note that the 61 unallocated beds, which are spread across different specialties on both sites, would all be required if annual growth in activity were to be 0.79% points above current growth assumption (1%). Bed Demand and Capacity at OBC vs FBC by Site Brighton & Neuro winter ward T Total RSCH Rest of Site RSCH & 3Ts PRH PRH total Total Excluded from Summaries Haywards Heath SOTC Sussex Eye Hospital Maternity - PRH Maternity - RSCH Children's Hospital (RAH) - RSCH Total All Beds Notes: Due to rounding, totals may not be exactly sum of part. The Trust is currently opening temporary facilities in order to accommodate seasonal variation. 30 beds were referenced as the standard ward size that would be required for use as temporary decant facilities, eg. to allow deep cleaning, or for maintenance. Page 21 of 22

22 Summary Summary Points 1. Modelling for 3Ts is fully aligned within the Trust (eg. with the Long-Term Financial Model, Clinical Strategy, Integrated Business Plan, associated business cases) and with commissioners planning (eg. demographic growth, prevalence and service uptake changes, demand management/better Care Fund). Although the Trust s Long-Term Financial Model plans to 2023/24, modelling for 3Ts has been undertaken to 2027/28 (ie. five years after the completion of the scheme), in line with national guidance. Activity, income, Trust performance/efficiency assumptions and capacity planning are also fully aligned. 2. The net impact of modelling demand from growth, service developments, occupancy assumptions and winter/decant capacity, less the impact of demand management and Trust efficiencies, is an increase of 46 beds across the Trust by 2022/23. This demand increase is 46 beds higher than at OBC. 3. Scenarios/sensitivities have been undertaken to assess the impact of both over-achieving and under-achieving against ambitious Local Health Economy utilisation targets. This suggests that the inpatient capacity being built in 3Ts continues to represent a reasonable planning assumption. The Trust has developed, at high level, mitigation strategies in the event that there is too much, or too little, capacity. Page 22 of 22