Replacement CT Scanners at North Manchester, Oldham and Fairfield Hospitals.

Transcription

1 Agenda Item: 11 Title of Report Executive Summary Actions requested Replacement CT Scanners at North Manchester, Oldham and Fairfield Hospitals. This business case seeks approval for the replacement of three CT scanners over the next two years at a capital cost of 2.2 million. A provision for this is in the capital programme. The Trust Board is requested to approve this business case. Corporate Objectives supported by this paper: This expenditure would support a number of the Trust objectives including: To provide a high quality service for patients. To improve the experience of patients within the Trust. Risks: Interruption to service due to machine failure. Delay in patient treatment. Increased patient transfers. Public and/or patient involvement: N/A Resource implications: Capital 2.2 million Revenue, as detailed in the report Communication: N/A Have all implications been considered? YES NO N/A Assurance * Contract * Equality and Diversity * Financial / Efficiency * HR * IM&T * Local Delivery Plan / Trust Objectives * National policy / legislation * Sustainability * Name Mr Tom Wilders Job Title Director of Strategic Planning Date September Tom.wilders@pat.nhs.uk 1

2 Replacement CT Scanners at North Manchester, Oldham and Fairfield Hospitals Introduction The Trust operates CT Scanners on each of the four sites at Fairfield, Oldham, North Manchester and Rochdale. The machine at Rochdale has been replaced recently. The three remaining CT scanners are due to be replaced over the next two years. Investment Proposal It is proposed that a replacement programme for all three aging machines is put in place. This will provide a platform to upgrade and modernise the Trust CT capacity. Business Case The attached business case sets out the case for change and the recommended way forward. Recommendation and Conclusion The Trust Board are asked to approve the purchase of three new CT scanners at a capital cost of 2.2 million. There is provision in the capital programme for this expenditure 2

3 THE PENNINE ACUTE HOSPITALS NHS TRUST SERVICE/ BUSINESS DEVELOPMENT PROPOSAL DOCUMENT 1. TITLE OF PROPOSED SERVICE / BUSINESS DEVELOPMENT 2. SERVICE LEAD & CONTACT DETAILS Replacement CT scanners at North Manchester General Hospital (NMGH), Royal Oldham Hospital (ROH) and Fairfield General Hospital, Bury (FGH). Dr Carolyn Allen & Mark Carmichael 3. OTHER SERVICES AFFECTED All acute services 4. DESCRIPTION OF PROPOSAL The purpose of this business case is to seek approval for the replacement of three CT scanners, at North Manchester, Oldham and Fairfield, at a capital cost of 2,199,200 spread over the 2010/11 and 2011/12 financial years. There is provision in the capital programme for this expenditure. 5. HEALTH NEED & CASE FOR CHANGE: Summary The CT scanners on the Oldham, North Manchester and Fairfield sites range between 8 and 9 years old with all three requiring replacement before March The Rochdale scanner was replaced with a then high spec 64-slice scanner in April The remaining sites are all 4-slice scanners. NMGH and Oldham both have a high inpatient demand base; up to 32 patients per day and the sites rely heavily on the efficient delivery of CT scanning. Healthy Futures advises that both the NMGH and Oldham sites are planned to become trauma centres, receiving all acute surgery and trauma for Bury, Rochdale and the existing workload for Oldham and North Manchester. Strategic View The current NICE guideline for 24 hour CT imaging for all stroke patients is not being met at all sites. The Directorate has agreed Internal Professional Standards and aspires to reduce the turnaround time for inpatient CT scanning to 24 hours for all inpatients not only those suffering from stroke. Healthy Futures intends all PAHNT sites to have CT scanning available on site post reconfiguration. Indeed as the designated trauma sites it is essential that the Oldham and NMGH has a reliable and robust scanning 3

4 service; this is also true for Fairfield in supporting the PSC. The continued development of the Hepatobiliary service at NMGH is dependant on the provision of enhanced imaging, particularly CT and MR. The Trust has the opportunity to develop cardiac imaging services at North Manchester and become one of the three spokes detailed in the GM Cardiac Imaging Strategy, supporting Manchester Royal; this can only be developed with a higher specification CT. The scanner at North Manchester has suffered reliability problems. This has resulted in acute inpatients being transferred to Fairfield for their scans, increasing LOS and incurring additional cost to the Trust. Remedial maintenance has been carried out to extend the life of the machine to Attracting high grade staff, both radiographers and Radiologists is often dependant on the standard of imaging equipment available. The Directorate has been fortunate in recent years in securing state of the art interventional suites at NMGH and Oldham and 1.5 Tesla MR Scanners on three sites, sadly the CT provision lags far behind. CT has become the main focus of imaging and the ability to attract and furthermore retain staff is dependant on the provision of up to date enhanced scanning and reporting tools. Service Demand Demand for CT has risen steadily (around 10% per annum) since the 1990 s; moreover the CT service must meet the imaging demands of our subspecilaity clinical services in terms of the complexity of CT imaging provided. Advances in scanning speed and technology mean that the new generation scanners vastly improve the diagnostic yield from clinical imaging and provide for better patient experience. Data Activity Period Volume Sum of Value Value % Increase Fairfield 6,156 6, , , North Manchester 9,236 10,367 1,214,919 1,367, Oldham 8,485 9,365 1,127,265 1,229, Rochdale 4,028 5, , , Further detail is at appendix 1. This level of increase is indicative of the increase year on year since the advent of CT imaging. The values depicted in the table above are the indicative tariff introduced in 2009 for clinical imaging. As clinical imaging is bundled with the PBR tariff the Directorate does not receive additional income when activity rises. Patient Experience Radiation Dose: The new generation CT scanners have significantly reduced the level of radiation dose. Patients in the 21 st century are likely to have increased numbers of CT scans in their lifetimes. The reduction of radiation dose is most significant for paediatrics; a speciality that is experiencing rapid growth at NMGH in particular. The chart below depicts the level of radiation per scanner: 4

5 Contrast usage: Faster scan times allow for a reduction in the volume of radiographic intravenous contrast required which in turn reduces the incidence of contrast related side effects; particularly contrast induced renal failure, as the majority of contrast related side effects are dose related. In addition any reduction in contrast usage will assist towards the reduction of the circa 70K over spend ( ) in this area. Patient Impact of Faster Scanning Faster scan times provide greater accuracy in diagnosis, especially for patients who experience breathlessness or who are unable to remain still; e.g. paediatrics. This reduces the number of aborted examinations in vulnerable patient groups and provides for better diagnosis and treatment. It is important to note however that faster scanning times will not significantly increase capacity as the actual scan time is only a very small proportion of the overall time taken to undertake a CT examination. Reduced requirement for other Imaging techniques 5

6 Modern CT techniques supported by enhanced software reporting tools have superseded traditional examinations such as Intravenous Urogram and Barium Enema. CT Urography and CT Colonography are now recommended by NICE as they have greater diagnostic accuracy and are less invasive for the patient. There is increasing demand for these exams across the trust, provision of modern scanners considerably improve the effectiveness of these imaging techniques. 6. HEALTH IMPACT, OUTCOMES AND DELIVERABLES Management of risk In addressing the replacement of the Trust CT scanners the following risks are relevant: Reduced risk of scanner failure on the NMGH site which impacts provision of acute services, patient safety and patient experience. Replacement in advance of reconfiguration reduces risks to the provision of trauma and acute imaging for all Trust patients. Reduced risk of failure to achieve local and national waiting time targets. Reduced risk of failure to comply with NICE guidelines such as the target for 24 hour imaging of all stroke patients Reduced risk of adverse patient incidents relating to contrast dosage. Reduced radiation dose and risk of consequences of radiation exposure for all patients especially children. Reduced requirement for alternative examinations superseded by CT. Reduced risk of failure to retain highly skilled staff and recruit consultant radiologists to existing vacancies. Extended range of imaging Interventional CT: Increased scope for interventional CT e.g. biopsy and drainage of pancreatic abnormalities which may otherwise require surgery. CT angiography: Provision of CT angiography e.g. Cardiac, Brain and abdominal, reducing the need for traditional invasive catheter angiography. This vastly improves patient experience and has no recovery period eliminating bed occupancy for these procedures. Paediatric Imaging: In addition to low dose scanning protocols which minimise radiation exposure, rapid scan times provide improved image quality making CT a more useful diagnostic tool in the paediatric population. Cardiac CT: Demand for modern cardiac imaging by means of CT is high. The new multi slice scanners can image the heart in a single cardiac cycle. Coupled with the soon to be established Radionuclide cardiac imaging service at NMGH Cardiac CT could potentially attract new business for the trust in future years and improved access to cardiac imaging for the population of the North East sector of Manchester. (Business case would be required for full development) 6

7 7. FORMULATION OF OPTIONS & IDENTIFICATION OF RISKS Statement - Clinical Director for Radiology Patient Experience Advantages of New Generation Scanners For those patients who are very ill and cannot hold their breath for more than a few of seconds and those patients who have trouble keeping still, such as children it is often very difficult to perform CT examinations. The new generation scanners with significantly reduced scan times are hugely important advances in relation to this patient cohort. Whilst faster scan times do not necessarily mean that we can scan significantly more patients, it does mean that we can perform far better quality diagnostic examinations, especially in those patients who are sickest. Furthermore, this is achieved with significant reduction in radiation dose for some examinations. Clinician s Advantage of New Generation Scanners The significant improvement in image quality means that we can see diseased organs in far greater resolution and in multiple planes. Advances in software for the processing and manipulation of images after they ve been acquired also help us to increase the accuracy of the examinations we perform. This allows us, for example to identify with much greater accuracy the spread of a cancer, which could have a huge impact on the choice of the most appropriate treatment for patients and provide a cost saving to the patient and Trust by reducing the number of unnecessary exploratory operations needed. Radiologist Advantage of New Generation Scanners In addition to the advantages detailed above the more powerful processors on the new generation scanners mean that the images are reconstructed in a fraction of the time of previous scanners making it much more efficient for radiologists when reporting; this has particular impact when hot reporting or reporting ED referrals and urgent inpatients. Dr Carolyn Allen Clinical Director 7

8 Statement of Options Considered. In formulation this business case a number of options have been considered as follows: 1. Option 1 Do nothing 2. Option 2 Replace three machines at NMGH, Oldham and Fairfield with 128 scanners. 3. Option 3 Replace one machine during 2010/11 with a 128 scanner. 4. Option 4 Replace three machines at NMGH, Oldham and Fairfield with 160 scanners. 5. Option 5 Replace three machines at NMGH, Oldham and Fairfield with 320 scanners In considering the specification of machine the Trust reviewed the position at other neighbouring trusts and the results are below: TRUST NAME NO OF SITES IN TRUST MAKE AND MODEL NO SLICES INSTALLATION DATE (APPROX) Stockport NHS FT 1 GE Light speed 8 slice 2002 Tameside 1 Toshiba Asteion Countess of Chester NHS Trust 1 Toshiba aquillion Toshiba aquillion Southport and Ormskirk 2 GE Light speed GE Light speed (GE Light speed VCT replacement ) Wrightington, Wigan and Leigh Mid Cheshire Hospitals Foundation Trust (GE Light speed VCT replacement 3 Siemens Sensation 16 Siemens Sensation Definition AS+ 2 GE lightspeed vct xte ) 16 Nov Jun Aug-09 Central Manchester University Hospitals NHS Trust 5 hospitals but all on the same central site GE Lightspeed (MRI) GE lightspeed (MRI) Siemens Somaton Definition AS (Childrens) Royal Bolton Hospitals 1 Siemens Sensation Siemens Sensation Salford Royal Hospitals FT WIRRAL UNIVERSITY TRUST Clatterbridge Centre for Oncology 1 GE Light Speed GE Lightspeed vct GE LIGHTSPEED HP60 GE LIGHTSPEED QXi 1 GE VCT Lightspeed (Philips Aqusim 1 N/K Philips Brilliancewide 16 N/K bore 8

9 In considering the appropriate machine specification in the light of experience at other nearby trusts and the view of the Clinical Director the 128 slice scanner is considered the best value for money. Option 2 is regarded to provide best value for money without significant clinical compromise. The Radiography team have worked closely with the three main suppliers to broker a competitive offer which would enable the Directorate to replace all three scanners over the next 9 10 months as part of a single deal. The directorate anticipate ordering three machines at the same time would result in a discount of 60,000 per machine, 180,000 in total. Option 3 has been discounted because of the financial savings to be gained from a multiple order for 3 machines. Options 4 and 5 have been discounted as the 128 slice machine is considered appropriate for the needs of the Trust and represents best value for money. The option appraisal for the remaining two options is set out below. (the lowest scoring option is the least favourable) Option 1 Do Nothing Improved image acquisition -2 Reduced risk of scanner failure -5 Improved cancer imaging acquisition and reporting -2 Enhanced imaging techniques 0 Reduced radiation dose for patients -5 Improved patient experience due to reduced scanning time 0 Improved access and reduced waiting times 0 Reduced contrast usage -5 Enhance radiologist retention and recruitment -2 Total -21 Option 2 Replace three machines at NMGH, ROH and FGH with 128 slice scanners Improved image acquisition 3 Reduced risk of scanner failure 3 Improved cancer imaging acquisition and reporting 3 Enhanced imaging techniques 3 Reduced radiation dose for patients 3 Improved patient experience due to reduced scanning time 3 Improved access and reduced waiting times 1 Reduced contrast usage 3 Enhance radiologist retention and recruitment 2 Total 24 The Radiology Directorate does not receive direct funding for the CT activity it undertakes; this is included in the bundled PBR Tariff. The provision of new generation scanners and new technology to support the ever increasing complex demands of clinical imaging increases the charges and the cost of maintenance. 9

10 Clinical Directors Recommendation to the Trust Executive Taking into account the risks detailed earlier Option Two is recommended. This will enable all PAHNT sites to provide modern CT scanning facilities to meet the needs of the patient population. In a very different economic environment the Directorate would be proposing the replacement of the NMGH and Oldham CT scanners with state of the art 320 slice scanners and a 128 at FGH; however realising the current financial position of the Trust and the NHS as a whole the requirements have been tailored to provide the best value for money options, whilst still delivering modern CT imaging demanded by the clinical subspeciality services. In the coming years the Directorate will assess the many clinical advantages of the 320 scanner, the most technologically advanced scanner on the market and explore the potential savings identified for some acute pathways with the other Divisions. The provision of a 5 th Trust scanner with supporting business case would then be presented to the Trust Executive. 8. INDICATION OF COSTS / INCOME: OPTION 2 - REPLACE 3 MACHINES AT NMGH, OLDHAM AND FAIRFIELD WITH 128 SCANNERS CAPITAL COSTS Year New buildings * Refurbishment (enabling works) Year Year Year Year Decommissioning Equipment Scanner(s) inc Interim solution VES (3D software trust wide) Building works Total Other e.g. IT 5 10 TOTAL CAPITAL COSTS Nil Nil Nil CAPITAL INCOME PROPOSED FUNDING SOURCE COST VS INCOME Capital programme 10/11 and 11/12 Capital programme 10/11 and 11/12 The total capital cost of this option is 2,199,200 spread over the 2010/11 and 2011/12 financial years. *Note this case does not include provision for mobile scanners to support implementation of new scanners. A separate business case is addressing necessary reconfiguration work to facilitate implementation without the need for mobile scanners. As such, there are no revenue costs needed in this case associated with provision of mobile units. 10

11 Total net maintenance cost saving Capital Charges New Scanners Year Year Year Year Year 's 000's 000's 000's 000's Depreciation for new scanners (7year life) Cost of Capital at 3.5% for New Scanners Depreciation for existing scanners (10 year life) 0 (203) (218) (218) (218) Net book value write off of existing scanners Proceeds from old scanners (24) (53) Total Capital Charges for new scanners TOTAL REVENUE COSTS

12 The Trust Executive has requested that future installations of Radiology equipment consider the provision of uninterrupted power supply (UPS) facility to prevent service downtime during loss of power. The Directorate Team has considered this option, and does not recommend this offers best value for money. The directorate has performed a risk assessment (appendix 2) and has robust contingency plans in place to deal with CT downtime. It should be noted that patients do not undergo catheterisation procedures on the CT scanners. 9. TIMESCALES AND PROJECT MANAGEMENT ARRANGEMENTS: The project will be managed by Gordon Lofthouse, Radiology Capital Manager. During 2010/11and 2011/12 all three CT scanners will be replaced. Order of replacement to be confirmed subject to completion of the work on the under croft at NMGH 10. ACTION TAKEN BY TRUST EXECUTIVE DIRECTORS - SIGN/TICK AS APPROPRIATE: Date Approved More information requested Rejected Approval to go to next stage Level 1 BC Level 2 BC Level 3 BC Capital Committee SMG Trust Board 11. CONCLUSION AND RECOMMENDATION The Trust has considered the replacement programme for CT scanners across the four hospitals. The machine at Rochdale is relatively new and therefore is not considered further in this business case. The three machines at NMGH, Royal Oldham and Fairfield General are aging and are all due to be replaced by the end of The specification of the new machines was considered and in line with the higher end specification of machines replaced in nearby Trusts it is proposed that three 128 slice machines are purchased to improve patient experience and services. The Trust Board are asked to approve the purchase of three new machines at a capital cost of approximately 2.2 million. There is provision in the capital programme for this expenditure. 12

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14 SUPPORT SERVICES IDENTIFIER PAY AND NON PAY COSTS ATTACHMENT 1 SERVICE Resource Implications Y/N SERVICE Resource Implications Y/N Laboratory Services Toxicology Haematology N Occupational Health N Histopathology/Cyto-pathology N Medical Genetics N Microbiology N Other (specify) N Biochemistry N Facilities Blood N Catering N Other (specify) N Housekeeping N Pharmacy Linen N Sterile Products N Security N Out Patients N Portering N In Patients N Estates Maintenance Y Day Case N Grounds & Gardens N Other (specify) N Patient Transport N Therapies Non Patient Transport N Physiotherapy N Communications (voice) N Speech Therapy N Communications (data) N Occupational Therapy N Energy Y Dietetics N Clinical Waste N Other (specify) N Non Clinical Waste N Rates N Other (specify) N Medical Physics & Clin Eng Corporates Medical Physics Y Human Resources N Ultrasound N Finance N Medical Electronics/Equip Maintenance N Nursing N Radiology N IM&T N Ultrasound N Other (specify) N Plain Film N Media Resources MRI N Outpatients N CT N Medical Records N Fluoroscopy N Clinical Coding N Vascular N Other (specify) N Other (specify) N Other Specify Consider:- Does the proposal change 1. The level of activity to be undertaken 2. The mix of activity to be undertaken 3. Floor area of unit used to deliver service 4. Require additional equipment 5. Increase range of tests required 6. Require new tests/services to support 7. Require other divisions/departments to change working practices If so the impact on all of the above services should be considered

15 Appendix One: CT Demand 2009/10 to 2010/11 Modality CT Site RW601 FGH Data Volume Activity Period Sum of Value Patient Type Des Value % Increas e A & E Attender ,929 66, Day Case Patient ,058 3, GP Direct Access Patient ,913 17, In Patient 2,187 2, , , Other Patient Out Patient 3,290 3, , , Grand Total 6,156 6, , , Modality CT Site RW602 NMGH Data Volume Activity Period Sum of Value Patient Type Des Value % Increase A & E Attender , , Day Case Patient GP Direct Access Patient ,160 6, In Patient 3,243 3, , , Other Patient Out Patient 5,130 5, , , Grand Total 9,236 10,367 1,214,919 1,367, Modality CT Site RW603 OLDHAM Data Volume Activity Period Sum of Value Value % Increas e Patient Type Des A & E Attender 736 1,015 88, , Day Case Patient GP Direct Access Patient In Patient 3,025 3, , , Other Patient ,

16 Out Patient 4,711 4, , , Grand Total 8,485 9,365 1,127,265 1,229, Modality CT Site RW604 RI Data Volume Activity Period Sum of Value Patient Type Des Value % Increase A & E Attender ,337 80, Day Case Patient GP Direct Access Patient ,482 2, In Patient 1,311 1, , , Other Patient Out Patient 2,109 3, , , Grand Total 4,028 5, , ,

17 Appendix 2 - Service Continuity Plan Unplanned CT Downtime In advance 1. Ensure maintenance contracts are fully maintained 2. Ensure scheduled maintenance is not delayed. 3. Ensure issues identified during routine maintenance are attended to immediately. Trigger Continuity Plans to be implemented immediately on loss of scanning facilities. Authority to trigger continuity plans and to return to normal Lead: Specialist CT Radiographer Deputy Senior Radiographer on Duty Impact on patient services Internal: Loss of emergency access to CT for ED and all wards Loss of access for Outpatients. ED and critically ill patients have to be transferred by emergency ambulance to other trust sites. ED and ward areas suffer reduced staff whilst patients are escorted to other trust sites. External NWAS are impacted due to increased journeys transferring patients across the trust. Action: 1. Staff to report problem to supplier immediately 2. Staff to report problem to ED, Radiologist, Bleep holders, Directorate manager/senior Manager on Call out of hours 3. Staff to report problem to Radiology Senior Managers 4. Staff to be notified of disruption via from Trust Communications. 5. ED to implement Continuity Plan to triage and transfer patients 6. Divisional Nurse Managers assess inpatient impact on site and if required plan for transfers to other sites. After Disruption: 1. Inpatient backlog to be prioritised 2. Urgent Outpatients to be re-scheduled immediately 3. Routine activity to be re-scheduled. Additional resources required to implement the plan: 1. Staff overtime may be needed to operate additional lists on other sites 2. Additional nursing staff to provide nurse escorts in ED/ wards 3. Additional ambulance crews 4. Loan scanner if downtime is protracted. Duration of plan: This plan is designed to provide service continuity until normal services are resumed Escalation by: CT Specialist Radiographer / Switchboard when disruption continues and it becomes difficult to maintain a service without further intervention. Escalation in hours to: 17

18 Directorate Manager or Site Manager Escalation out of hours to: On-Call Manager via switchboard Plan last implemented on August 13 th 2010 Points arising from debrief held after the event: Improved response in relation to patient flow. Plan prepared by: Radiology Management Team Plan approved by: Mark Carmichael Directorate Manager Plan due for review on: August

19 RISK ASSESSMENT FORM DIVISION/DEPARTMENT: DIVISION OF DIAGNOSTICS AND CLINICAL SUPPORT RADIOLOGY DIRECTORATE DATE: August 2010 REVIEW DATE: August 2011 RISK: Unable to provide on-site CT service due to equipment failure resulting in patient transfers, delay in diagnosis and treatment LIKELIHOOD: Possible CONSEQUENCE: Moderate RISK RATING: Significant CONTROLS IN PLACE: Fully-Comprehensive service contracts Service Continuity Plans CONTROL EFFECTIVENESS: Some Weaknesses RESIDUAL RISK RATING: Significant ACTIONS: See action plan If the residual risk is HIGH or SIGNIFICANT the action plan overleaf must be completed. The action plan should include interim actions already taken or proposed to reduce the risk; whilst working towards implementation and/or funding of the ultimate action plan to remove the risk or reduce it to an acceptable level. SIGNED: NAME: DESIGNATION: Gordon Lofthouse Radiology Quality & Governance Manager 19

20 RISK REMOVAL/REDUCTION ACTION PLAN Action No. Description of Action * Priority** Responsibility*** Cost**** Due Date Date Completed 1 Provision of 2 nd scanner on each acute site Medium Radiology Directorate Manager Equipment 1.2 million for 3 sites Estates up to 1 million for 3 sites. NMGH business case in draft to provide physical capacity; case for additional scanner not yet in draft. FGH no progress as yet. Oldham will require expansion of department into an adjacent department. * Description of actions should include interim actions already taken as well as those planned that will reduce the risk prior to the final action identified. ** Priority should be HIGH, MEDIUM or LOW. *** Responsibility is the individual, group or management team responsible for the action. **** Cost should be the estimated total cost of implementing the identified action 20