INVESTMENT PROPOSAL FOR A COMPUTED TOMOGRAPHY SCANNING SERVICE IN THE NORTH HIGHLANDS

Transcription

1 INVESTMENT PROPOSAL FOR A COMPUTED TOMOGRAPHY SCANNING SERVICE IN THE NORTH HIGHLANDS Last Revised: 19 September

2 CONTENTS Page 1 BACKGROUND 1 2 NATIONAL POSITION 2 3 HIGHLAND POSITION 3/4/5 4 REFERENCES 5 2

3 1 BACKGROUND In October 1996 a feasibility study 1 looked at the potential for a Computed Tomography (CT) Scanning Service in the North. At that time it was anticipated that a minimum of 473 CT referrals across specialties could be expected. The final report concluded that there was a need for the introduction of a local CT Service based on clinical needs. However, based on referral rates the service could not be provided on a competitive level with that of Raigmore and the project was shelved. Over the years the clinical value of CT has been proven beyond doubt and it is now regarded as a versatile and widely accepted medical investigation. The principle of CT is that x-rays are used to scan various body parts. This information is detected and converted to a digital image by a high power computer. The advantage of CT over conventional x-rays is that from one scan a wide range of body tissues can be demonstrated by manipulating the captured data. The main disadvantage is a higher radiation dose. CT is a useful technology for all body parts, but is particularly useful for head, spine, chest and abdominal pathology, for many types of cancer, and for neurological diseases including strokes, tumours and trauma. 2 NATIONAL POSITION Scottish Intercollegiate Guidelines Network Guideline No 64 Management of Patients with Stroke Part 1 2 recommends that all patients with acute stroke should undergo CT brain scanning as soon as possible, preferable within 48 hours, and no later than 7 days. The Royal College of Physician guidelines recommend that brain imaging should take place within 24 hours of onset. This is likely to be adopted by SIGN in the near future. 3 NHS Quality Improvement Scotland Clinical Standards for Stroke Services 4 states that 80% of patients have CT/MRI imaging within 48 hours of admission, unless there are documented contraindications. Scottish Intercollegiate Guidelines Network Guideline No 46 Early Management of Head Injury 5 is being reviewed and it is expected to recommend that patients with a suspected head injury should have a CT scan to confirm diagnosis or otherwise. The absence of a CT scanner in an acute general hospital is considered to be a barrier to recruitment for staff, particularly consultants and radiographers. Few consultants who have trained within the last 10 years have any experience of managing patients without readily available, on site, CT Scanning and would consider it medico-legally and professionally unwise or unacceptable to do so. 3 HIGHLAND POSITION 3.1 Capacity Currently there are 2 CT scanners available for the people of the Highlands, one in Raigmore and one in the Belford. Patients from Caithness and Sutherland who require a CT Scan have to travel to Raigmore. Depending on the degree of urgency the length of wait can be anything between 1 day and 7 weeks (as at 15 September 2006), with a return journey that can be over 200 miles and take as long as 5 6 hours travel time. Currently there are a number of patients who are too frail to travel 3

4 and as a consequence are not offered a CT Scan, but would be scanned if the service were available locally. No data has been collected on this therefore there are no accurate statistics available, but staff believe this is in the region of 30 patients per annum. 3.2 Demand Predicting the usage of a CT scanner in the North CHP has been difficult to estimate. Information has been provided by the IT Department for the periods 2002/03 and 2003/04, based on all patients in the Caithness and Sutherland post-code areas. The information indicates that the number of scans carried out is between 689 and 705 per annum. However, the number of patients suitable for scanning in Caithness would be less than this, either for geographical or medical reasons. Based on discussions with colleagues in Belford, staff in Caithness estimate that demand is likely to be in the region of 600 scans per annum. However, demand is likely to grow as new guidelines become part of routine practice, e.g. routine scanning for head injuries, and the availability of a scanner will increase demand. The availability of a CT scanner will also bring benefits to patients, their families and the Scottish Ambulance Service in reducing the number of unnecessary emergency transfers for patients with suspected head injury. 3.3 Resources Required If a CT scanner was to be based in CGH there would be a requirement for additional staff on site. A full time senior radiographer would be required who would have responsibility for the service. In addition the service would need some part time radiography assistance and all radiographers would require additional training to enable them to provide a 24 hour scanning service Timeous radiologist support to report scans is essential. There is little benefit in being able to scan a patient within the guideline time requirements if the scan cannot be reported immediately. There are a number of possible solutions to scan reporting a) utilising existing radiologists b) purchasing the service from an external agency. c) Radiographers reporting scans. There are difficulties with each of the potential solutions. The radiologists based in Raigmore are supportive of providing a reporting service and this would be the preferred solution, if timeous reporting could be achieved. Work is currently being undertaken to review practice in Raigmore to free radiology time to reduce waiting and reporting times. The implementation of a Picture Archiving Computerised system (PACs) is expected to assist with this, as will the successful recruitment into the vacant posts and role extension of radiographers. External commercial agencies can provide a reporting service at a cost of around 45 scan. However, concerns have been expressed about the quality of this service and where liability and responsibility ultimately lies. Other health service imaging departments have also expressed a willingness to undertake a reporting service, but no detailed discussions have taken place yet. 4

5 Radiographers are generally keen to expand their role and in the longer term they may be able / willing to report CT scans. However, this is generally felt to be not achievable at this point in time. 3.4 Siting of CT Scanner Several options for the siting of the scanner within Caithness General Hospital were considered. The view of the imaging staff was that the key priority was that the scanner should be sited within the imaging department. A new build attached to the imaging department is difficult to achieve, both in terms of access and size requirements. Siting the scanner elsewhere in the hospital separates the scanner from the x-ray department and contributes to increased staff travel, operating time and staff communications. Three options for siting the scanner within or adjacent to the imaging department were considered. 1) Relocated patients waiting area and decontamination area with scanner in existing waiting area. Cost 70,000. (excl VAT) 2) Relocated Physiotherapy gym with control room in X-ray records area. Existing waiting area retained and continues as decontamination receiving area. Cost 145,000. (excl VAT) 3) Relocated physiotherapy gym and X-ray office. Waiting area retained but separate decontamination receiving area created. Cost 165,000. (excl VAT) Following staff consultation and the options being costed, option 2 emerged as the preferred option. Option 1 was rejected on the basis that the new waiting area was inadequate and would not accommodate overflow from outpatients waiting area. Option 3 was rejected on the grounds of cost. Option 2 is the preferred option as this enables the physiotherapy department to be extended and locates the scanner control room within the records department of x- ray giving good staff access and security. This option also allows the continued operation and development of the decontamination facility in the waiting area, as well as enabling the physiotherapy department to retain their total space requirements. 3.5 IT Infrastructure and Costs Advice from the IT Department is that the link between Caithness General and Raigmore Hospital has recently been upgraded and should be capable of transferring images between these sites. The frequency and number of images transferred will have an effect of how much bandwidth is required for this link as well as how soon after scanning the image is required to be remotely viewed. It is expected that due to the National PACs (Picture and Archiving System) as part of the N3 contract that the IT infrastructure will be further enhanced and the cost be borne outside the CT proposal. Within CGH a number of computer sockets and connections to the existing network will be required approximate cost would be 1,000. 5

6 The CT scanner images should be fully DICOM3 compliant to enable compatibility with existing Radiology systems, web servers plus any future PACS development 3.5 Financial Appraisal Option Appraisal Two options were considered to fund a new scanner for Caithness General: Option 1 NHS Highland funds both the scanner and associated building works from its capital allocation. Option 2 NHS Highland funds the building costs from its capital allocation and a lease purchase agreement is reached for the scanner. This would save capital funds if the lease can be kept off balance sheet Capital Costs The following table summarises the capital costs of each option: Option Capital Cost 1 601, , Revenue Costs The following table summarises the impact of both options on revenue costs. The amounts detailed in this table are additional revenue costs. Option Asset Costs Additional Revenue (Pays & Non Pays) Total Recurring Revenue Costs 1 59,608 89, , , , ,618 Option 2 (Lease Purchase) costs more in revenue terms due to the effect of the lease payments NPV and Balance Sheet Test The following table summarises the Net Present Value of each option as well as the equivalent annual cost. Option Asset Value NPV Equivalent Annual cost NPV % of Fair value 1 601,013 1,418, , % 2 193,875 1,412, , % 6

7 3.5.4 Recurring Revenue Requirement Recurring Revenue from above 149,534 Less Capital Charges funded centrally -59,608 Revenue to be funded by the CHP 89,926 Sources of Funding 2006/7 Non Pay Inflation 23,000 Other CHP Funding (this will reduce further as a result of further negotiation on the Scanner maintenance contract) 66,926 Total 89,926 Conclusion from Financial Appraisal Although Option 2 is has a marginally lower Net Present Value it requires more ongoing revenue funding and therefore has a higher Equivalent Annual Cost. It also does not meet the balance sheet test and would therefore require NHS capital to offset the lease costs. In the current financial position the CHP would wish to keep the revenue requirement to a minimum and would therefore favour Option 1. The preferred option would require the Health Board to commit approximately 600k of capital funding towards this project. 4 REFERENCES 1 Independent CT Feasibility Report, Caithness and Sutherland NHS Trust October Our National Health: A plan for action, a plan for change December National Clinical Guidelines for Stroke: Second Edition RCP June NHS Quality Improvement Scotland: Draft Clinical Standards for Stroke Services (Standard 2, Essential Criteria 2) March SIGN Guideline 46 Early Management of Head Injury Ref: Investment Proposals/Caithness CT Scanner Sept 06 7