Malvern Community Hospital. Full Business Case

Malvern Community Hospital Full Business Case Submission Draft (Version 1.2) 13 th January 2009

New Hospital and Primary Care Facility for Malvern Full Business Case TABLE OF CONTENTS 1 EXECUTIVE SUMMARY... 1 1.1 Introduction... 1 1.2 Strategic Context... 1 1.3 The Need for Change... 2 1.4 Benefits... 2 1.5 A New Community Hospital For Malvern... 5 1.6 Stakeholder and Community Involvement... 6 1.7 Procurement Process... 8 1.8 Planning Permission... 8 1.9 Workforce... 8 1.10 Financial Impact... 8 1.10.1 Capital Cost... 8 1.10.2 Annual Revenue Costs... 9 1.11 Project Plan & Timetable... 10 1.12 Conclusion... 10 2 INTRODUCTION... 11 2.1 Background... 11 2.2 Purpose of the Full Business Case... 12 3 BACKGROUND... 13 3.1 Worcestershire PCT... 13 3.1.1 Health Profile of Worcestershire and its Localities... 13 3.1.2 Demographic Trends... 14 3.1.3 Deprivation... 14 3.1.4 Rurality... 15 3.2 Malvern Hills District... 15 3.2.1 Population... 15 3.2.2 Diversity... 16 3.2.3 Health Status... 16 3.3 Malvern Hospital... 17 4 STRATEGIC CONTEXT... 19 4.1 National Policy Context... 19 4.2 NHS West Midlands Strategic Framework... 19 4.3 Local Strategic Framework... 20 4.3.1 Worcestershire Partnership... 20 4.3.2 Malvern Hills District... 21 4.3.3 Worcestershire PCT Over Arching Vision... 21 090113 Malvern FBC v1.2.docx i

New Hospital and Primary Care Facility for Malvern Full Business Case 4.3.4 Developing a Model of Care for Malvern and South West Worcestershire... 22 4.4 The Need for Change... 24 4.4.1 Services... 24 4.4.2 Estate... 25 4.4.3 Conclusions... 26 5 PROJECT OBJECTIVES AND BENEFITS... 27 5.1 Introduction... 27 5.2 Key Objectives... 28 5.2.1 Services... 28 5.2.2 Location... 29 5.2.3 Environment... 30 5.3 Key Benefits... 30 6 STAKEHOLDER & COMMUNITY INVOLVEMENT... 34 6.1 PCT Strategy... 34 6.2 Activity prior to OBC approval... 34 6.3 Strategy for the Malvern Hospital project... 35 6.4 Activity since OBC Approval... 36 6.5 Stakeholder Support... 36 7 P21 PROCUREMENT PROCESS... 38 7.1 Introduction... 38 7.2 Selection of P21 Partner... 38 7.3 Guaranteed Maximum Price (GMP)... 40 7.3.1 Process... 40 7.3.2 Progress to date... 42 8 PROPOSED SOLUTION... 43 8.1 Introduction... 43 8.2 Services... 43 8.2.1 Services... 43 8.2.2 Activity... 43 8.2.3 Care Pathways... 45 8.2.4 Healthy Lifestyle Services... 47 8.3 Location and Site... 47 8.4 Functional Content... 48 8.4.1 In patients (24 beds)... 48 8.4.2 Out patients... 48 8.4.3 Diagnostics... 48 8.4.4 Assessment Unit... 48 8.4.5 Therapies... 48 8.4.6 Day Treatments... 48 8.5 Design... 49 8.5.1 Establishing the design brief... 50 090113 Malvern FBC v1.2.docx ii

New Hospital and Primary Care Facility for Malvern Full Business Case 8.5.2 The Design Process... 51 8.5.3 Third Party consultation... 51 8.5.4 Design Details... 51 8.5.5 Design Review Panel... 52 8.5.6 AEDET assessment... 52 8.5.7 Future Flexibility... 52 8.6 Sustainability... 54 8.6.1 Environmental Management... 54 8.6.2 Internal Environment... 55 8.6.3 Transport... 55 8.6.4 Water... 56 8.6.5 Materials... 56 8.6.6 Land Use and Ecology... 56 8.6.7 Pollution... 57 8.6.8 Operational Waste... 57 8.6.9 BREEAM... 58 8.7 Planning Consent... 58 8.8 Workforce... 58 8.9 ICT... 59 8.10 Equipment... 61 8.11 Equality Impact Assessment... 62 8.12 Financial Impact... 63 8.12.1 Capital Costs... 63 8.12.2 Revenue costs and Affordability... 65 9 PROJECT MANAGEMENT, PROCUREMENT AND PROJECT PLAN... 68 9.1 Project Management... 68 9.2 Project Plan... 69 9.3 Benefits Realisation... 69 9.4 Risks... 69 9.5 Post Project Evaluation... 70 9.5.1 Aim and Scope of Evaluation... 70 9.5.2 Evaluation Stages... 70 9.5.3 Evaluation Team Structure... 71 9.5.4 Evaluation of the Project Procurement Stage... 72 9.5.5 Evaluation of the Project During Construction... 72 9.5.6 Evaluation of the Project in Use Shortly after Opening... 72 9.5.7 Evaluation of the Project Once the Hospital is Well Established... 73 9.5.8 Management of the Evaluation Process and Resources to deliver... 73 10 CONCLUSION... 74 090113 Malvern FBC v1.2.docx iii

New Hospital and Primary Care Facility for Malvern Full Business Case APPENDICES APPENDIX 1 : COMMUNICATIONS & ENGAGEMENT STRATEGY... 75 APPENDIX 2 : STAKEHOLDER SUPPORT... 83 APPENDIX 3 : SERVICES & ACTIVITY... 89 APPENDIX 4 : HEALTHY LIFESTYLE SERVICES PID... 95 APPENDIX 5 : LOCATION & SITE... 104 APPENDIX 6 : SCHEDULES OF ACCOMMODATION... 107 APPENDIX 7 : ELEVATIONS AND LAYOUTS... 118 APPENDIX 8 : AEDET ASSESSMENT... 130 APPENDIX 9 : BREEAM ASSESSMENT... 132 APPENDIX 10 : PLANNING CONSENT... 152 APPENDIX 11 : WORKFORCE PROJECTIONS... 164 APPENDIX 12 : EQUIPMENT SCHEDULE... 166 APPENDIX 13 : EQUALITY & DIVERSITY TARGETS... 175 APPENDIX 14 : CAPITAL COSTS... 178 APPENDIX 15 : REVENUE COSTS... 187 APPENDIX 16 : BENEFITS REALISATION PLAN... 189 APPENDIX 17 : RISK REGISTER... 200 090113 Malvern FBC v1.2.docx iv

New Hospital and Primary Care Facility for Malvern Full Business Case TABLE OF TABLES Table 1: Malvern Hospital Activity 2008/09... 18 Table 2: Contribution to national, regional and local policies... 31 Table 3: Projected Activity Levels... 44 Table 4: Summary of Accommodation... 49 Table 5: Summary of Accommodation comparison with OBC estimates... 49 Table 6: Group 2, 3 and 4 Equipment... 61 Table 7: Capital costs... 63 Table 8: Capital cash flow... 64 Table 9: Capital costs comparison with OBC stage... 65 Table 10: Revenue cost impact... 66 Table 11: Transfer from other hospitals... 66 Table 12: Key Project Milestones... 69 Table 13: Evaluation Team Roles and Responsibilities... 71 TABLE OF FIGURES Figure 1: Deprivation in Worcestershire... 15 Figure 2: Model of Care... 23 Figure 3 ICT Links... 60 Figure 4: Project Structure... 68 090113 Malvern FBC v1.2.docx v

New Hospital and Primary Care Facility for Malvern Full Business Case 1 Executive Summary 1.1 Introduction The existing Malvern Community Hospital was built in 1911 and was donated to serve the local community. It was initially a general hospital providing medical and surgical in patient beds, with an operating theatre and a local casualty department. An extension in the 1960s allowed the consultant and physiotherapy outpatient services to expand. Current service provision in Malvern Community Hospital comprises: 18 beds supported with GP medical care 1 ; Macmillan Nurse; 5 day X ray Service; Range of Consultant Out patient Clinics; Nurse and Therapist Led Out patient Clinics and Rehabilitation Services; Out of Hours Primary Care Centre. In December 2007, conditional approval for capital funding from the national Community Hospital Fund to build a new community hospital on the existing PCT owned Seaford Court site in Malvern for the project was secured. An Outline Business Case for the project was subsequently approved by the NHS West Midlands in July 2008. 1.2 Strategic Context The PCT is developing its commisioning strategies within the following national, regional and local context: Our Health, Our Care, Our Say; High Quality Care for All (Darzi review); NHS West Midlands Investing for Health strategic framework; The Worcestershire Partnership s Partnership towards excellence the sustainable community strategy for Worcestershire 2008 2013; The local health economy s strategy Investing in Health for Worcestershire 2008/09 2012/13 A five year local health economy plan. The PCT s vision is to deliver the highest quality, patient centred, efficient health care to local people when needed, as close to their home as possible. The major drive for the model of 1 An additional 2 beds have been opened on a temporary basis during 2008 in repsonse to increased pressure on local acute hospital beds due to an outbreak of Norovirus 090113 Malvern FBC v1.2.docx 1

New Hospital and Primary Care Facility for Malvern Full Business Case care is the need for improved patient care, better health and greater choice for Worcestershire patients. The PCT s priority is the redesign of care pathways, improving the quality of care to local people and freeing up resources to reinvest in primary care and community based services The PCT will therefore commission services which will operate around the needs of the patient, their families, and carers. The model will form the foundation of future patient care pathways, organisation, service and workforce design, new ways of working, and a framework for NHS Trust and primary care trust (PCT) business cases and implementation plans. The proposals set out in this FBC to develop a new health facility in Malvern are entirely consistent with this strategic context. 1.3 The Need for Change The imperative for change is considerable. The current Malvern hospital is no longer fit for purpose and can not deliver the future commisioning intentions of the PCT i.e. it cannot enable the delivery of modern, effective, high quality care offering real choice to local people. It is inflexible in format, serious hindering the process of development of new care pathways and treatment for an increasing proportion of the patient group who are elderly. The creation of attractive, effective services for younger residents and their families; the priority of improving local access to diagnostic and treatment services; the professional development of all the staff who work there; all of these key characteristics of modern community healthcare are not deliverable in the current Malvern Community Hospital. 1.4 Benefits Malvern Community Hospital is central to the delivery of the new care pathways being developed by the PCT. The design of Malvern Community Hospital is being undertaken with new care pathways in mind. The hospital will have suitable facilities to ensure that these services can be provided locally, and will enable the PCT to commission services that can be provided within Malvern, avoiding the need for patients to travel into Worcester and further afield to receive care. The investment will meet the needs of the PCT as a commissioner, and the new premises will provide the following significant benefits for local residents: Up to date and modern facilities, capable of delivering 21st Century healthcare in line with national and local priorities; Integrated care pathways which provide ambulatory care and step up and step down inpatient services through partnership and shared care arrangements with local secondary care providers; Flexibility to cope with demographic and demand changes; 090113 Malvern FBC v1.2.docx 2

New Hospital and Primary Care Facility for Malvern Full Business Case Improved local access to consultation, diagnosis and treatment; Reduced travelling time for a significant rural population; Reduced pressure on acute hospital services. The table below illustrates the ways in which the new hospital will assist in meeting key national, regional and local priorities: Policy Imperative Impact of New Malvern Community Hospital OUR HEALTH, OUR CARE, OUR SAY More personalised care Services closer to people s homes Better co ordination with local councils Increased patient choice Enables the development of one stop shop services, supported by the enhanced diagnostic services available; Provides 50% single rooms with en suite facilities for all in patients; Provides adequate parking facilities commensurate with need and with the hospital s role as a local flaghip project for sustainable travel. Accessible, with particular regard to people who are dependent upon public transport and to the opportunities afforded by developing good public transport services including park and ride developments, inter urban and rural bus routes, and Malvern s two railway stations; Supports the care of patients in their own homes by providing a base for community teams. Provides new opportunities for seamless health and social care; Supports integrated travel plan for Malvern. Enables the range and volume of out patient, minor injuries and diagnostic services to be considerably extended, avoiding the need for patients to travel to more remote acute hospitals. The additional capacity includes: 12,000 out patient attendances 1,100 ultrasound scans and endoscopies 1,800 MR/CT scans 3,800 A&E attendances 800 day treatment procedures A focus on prevention rather than cure Enables the care provided in a new Malvern Hospital to be integrated with other NHS and associated services in terms of logical and effective patient pathways; Enables increased focus on patient education via assessment and onstop shop services. INVESTING FOR HEALTH Inequalities widening Design offers flexibility to cope with demographic and demand 090113 Malvern FBC v1.2.docx 3

New Hospital and Primary Care Facility for Malvern Full Business Case Policy Imperative Lack of investment in upstream interventions Variable quality and safety of services Costs increasing faster than income Lack of public confidence in services Buying interventions that do not work Systems that are complex and difficult for patients to navigate. Impact of New Malvern Community Hospital changes; Tackles health inequalities by making services local and accessible. Services will focus on health and wellbeing by providing local care designed to maintain people in their home environment and help them manage their own conditions; Assists in the reduction of emergency attendances and admissions and the promotion of independent living. Up to date and modern facilities, capable of delivering 21st Century healthcare in line with national priorities. Removes need for duplication of services with associated cost benefits; Assists in the reduction of emergency attendances and admissions and the promotion of independent living; Reduces the need for hospital admissions; Provides a modern building with reduced energy and lifecycle costs. Will be acceptable to key stakeholders in the local community and wider health economy; Facilitates improvements in privacy and dignity; Reduces anxiety and stress; Increases civic pride and enhanced reputation for NHS; Provides clear evidence of integrated working across the various providers of services within the health economy. Increases the opportunity for the adoption of care pathways that are jointly developed and agreed between primary and secondary care clinicians. Provides ease of access, a familiar setting and timely care thereby encouraging uptake and compliance; Enhanced diagnostics and better co location of services will radically improve the patient experience. Dedicated purpose bult outpatient services will be designed to meet patient expectations; Includes accommodation for the GP out of hours services. There are clear advantages from the co location of this service alongside a wider range of diagnostic and minor injury/illness services. KEY NATIONAL PRIORITIES 18 week Referral to Treatment target The new Hospital will facilitate sustained delivery of the 18 week RTT target by transferring outpatient activity to the community and streamlining care pathways; Reduces pressure on acute hospital beds by increasing the capacity for patients to be admitted directly from home; The additional intermediate care beds will facilitate the management 090113 Malvern FBC v1.2.docx 4

New Hospital and Primary Care Facility for Malvern Full Business Case Policy Imperative Reduced waiting times in A&E (<4 hour target) Reduction in Hospital Associated Infections The PCT as an employer of choice Impact of New Malvern Community Hospital of step up and step down capacity thereby reducing demand on acute hospital beds e.g. reduced lengths of stay. The new hospital will act as a common portal for local people thus allowing fast tracking to the appropriate clinical setting, reducing waiting times in A&E and easing pressure on A&E waiting times. Facilitates improvements in the control of infection and the associated lengths of stay. Aids recruitment and retention particularly local employment; Will improve staff job satisfaction by enhancing patient experience; Supports multi disciplinary team working across health and social care. 1.5 A New Community Hospital For Malvern In summary, the new hospital will provide accommodation for the following: In patient facilities 24 beds Out patient facilities Radio diagnostics (including hard standing for mobile CT, MR and Mammography units) GP Out of Hours Minor Injuries Unit Day Rehabilitation & Therapies Support facilities o Administration o Training & Education o Hotel Services o Central Staff Facilities The new facility will provide the following capacity and levels of activity: Existing Hospital New Hospital Change 1. SPACE m 2 m 2 m 2 In patient areas 433 1,340 +907 Out patients, Diagnostics, Rehabilitation, Therapies, Enhanced Procedures Administration, Support Services & Shared Space 534 1,191 +657 298 976 +678 090113 Malvern FBC v1.2.docx 5

New Hospital and Primary Care Facility for Malvern Full Business Case Existing New Hospital Hospital Circulation 971 Change TOTAL 1,265 4,478 +3,213 2. ACTIVITY In patient Services (OBDs) 6,695 8,268 +1,573 Out patient Services (Attendances) Consultant 3,048 7,059 +4,011 Nurse/Therapist 608 8,391 +7,783 Ultrasound & Endoscopy 616 1,764 +1,148 Imaging X Ray (scans) 5,300 7,000 +1,700 CT/MR (scans) 1,880 +1,880 Day Treatments/Procedures 837 +837 Direct Access Therapy (contacts) 8,000 9,125 +1,125 Minor Injuries (A&E attendances) 3,800 +3,800 GP Out of Hours (attendances) 2,700 2,700 The increases in in patient, out patient and diagnostic capacity and activity are commensurate with the projected growth in the catchment population for the hospital and the aim of reducing the need for people to travel to more remote acute hospitals for diagnosis and treatment. 1.6 Stakeholder and Community Involvement The development of a new community hospital has been the subject of intense local interest and involvement since 2004. A three month formal public consultation from December 2004 to March 2005 on the core and optional services to be developed in a new hospital, and the potential location of a new facility, involved nearly 1,000 local people in discussions at 28 venues across the Malvern Hills District and 480 written communications and feedback responses. A further public meeting involving around 300 attendees in 2006 provided further opportunities for engagement with the project. Option appraisal and design review workshops involving clinicians, health and social care professionals and members of the public have underpinned the development of this OBC. In April 2008, a pre planning application consultation on the essential design features of a new Malvern hospital took place over three weeks at four venues, with exhibitions and feedback opportunities at libraries, GP surgeries, and through the local newspaper and the 090113 Malvern FBC v1.2.docx 6

New Hospital and Primary Care Facility for Malvern Full Business Case PCT s own website. This public engagement directly influenced the full planning application for the new hospital, which was submitted to the planning authority in July 2008. The design development process for the new hospital has actively engaged the views of clinicians to create a clinically robust, safe and modern building which will help in the delivery of services for patients. Local service users will be invited to come forward to participate in contributing towards the design of patient flows and care pathways within the services proposed. As well as involving service users who have used the services within the current Malvern Hospital, the project team is also actively seeking the views of those patients who have had to travel to other sites to receive services that will be repatriated to the new hospital. A wide range of communications and engagement activities have been undertaken since the OBC was approved in July 2008, including: The establishment of a Hospital Advisory Group to provide an opportunity for the local population and stakeholders to shape and influence key elements of the development of the new hospital; Close working with the League of Friends and other local community and patient groups and use of the League of Friends as project champions and advocates locally; Close liaison with the Town and District Councillors to keep local politicians informed about progress and to retain their support for the project; An ongoing programme of press releases and local media activity; The publication and wide circulation of regular project newsletters providing details of the project s progress; The launch of a Schools Competition to stimulate interest in the new hospital amongst younger age groups; Development of a dedicated page on the PCT website and the installation of a webcam so that local residents, members of the community and other stakeholders can see progress on site at first hand. There is strong support for the new Malvern community hospital from all of the key stakeholders, and both the Malvern Hills District Council and Malvern Town Council are active members of the Project Board. Letters of support from the following are attached as an appendix to the FBC: Worcestershire Acute Hospitals NHS Trust Malvern Practice Based Commissioning Cluster Malvern Hills District Council Malvern Hospital League of Friends 090113 Malvern FBC v1.2.docx 7

New Hospital and Primary Care Facility for Malvern Full Business Case 1.7 Procurement Process The new hospital is being procured under the NHS Procure 21 process and the PCT appointed Interserve Health as its P21 Primary Supply Chain Partner in July 2008. The PCT is aiming to agree the Guaranteed Maximum Price for the new hospital with Interserve Health in February 2008, and to enter into the necessary contractual arrangements for the cosntruction of the new hospital once approval to the FBC has been secured. 1.8 Planning Permission A detailed planning application was submitted to Malvern Hills District Council on 24 th July 2008 and was approved by the Council s Planning Committee on 29 th October 2008. 1.9 Workforce Details of the current and projected workforce requirements are set out in the document and show that the following numbers of additional staff will be required: Nursing o In patient services 6.43 wte o Out patient services 3.12 wte o Emergency Nurse Practitioners 3.00 wte o Emergency Practitioner Assts 3.00 wte 15.55 wte Therapists o Physiotherapy 1.64 wte o Occupational Therapy 0.36 wte 2.00 wte Admin & Clerical 4.00 wte Chaplaincy 0.05 wte Facilities & Hotel Services 7.80 wte TOTAL 29.40 wte 1.10 Financial Impact 1.10.1 Capital Cost The projected capital costs (at out turn prices) of the new hospital are as follows: 090113 Malvern FBC v1.2.docx 8

New Hospital and Primary Care Facility for Malvern Full Business Case Cost at out turn prices 000 Works Cost 12,400 Fees 1,785 F & E 733 Non Works Costs 323 Land Contingency 304 Total Cost excluding VAT 15,545 VAT 2,408 TOTAL COST INCLUDING VAT 17,953 The projected costs are in line with the estimated costs at OBC stage. 1.10.2 Annual Revenue Costs The projected annual recurring revenue costs of the new hospital are set out below: 1. Projected Annual Revenue Costs Cost 000 1.1 Clinical Services 2,731 1.2 Facilities & Support Services 717 1.3 Capital Charges 1,168 1.4 Total Gross Cost 4,617 2. Less : Existing Costs 2.1 Malvern Hospital 1,955 2.2 Services transferred from other hospitals 1,847 3. Net Additional Cost to PCT 815 The net additional cost to the PCT is estimated to be 815,000, the funding for which has already been ear marked within the Malvern PBC Cluster s financial plans from 2008/09 onwards, and will be met from the additional resource which the cluster will receive as part of the PCT s plan to move all PBC Clusters closer to its fair share target. 090113 Malvern FBC v1.2.docx 9

New Hospital and Primary Care Facility for Malvern Full Business Case 1.11 Project Plan & Timetable A detailed project plan has been prepared and the key milestones within the project plan are set out below: Start Completion Full Business Case Approval Jan 2009 Mar 2009 Construction Apr 2009 Sep 2010 Commissioning Sep 2010 Oct 2010 1.12 Conclusion The Full Business Case demonstrates that: The case for a new community hospital in Malvern has not changed since the Outline Business Case was approved in June 2008, and the new hospital remains a key priority for the PCT in meeting key national, regional and local objectives and targets; The project commands strong local community support and is supported by all of the key stakeholders within the local health economy and community; The PCT has followed a robust procurement process since approval of the OBC; The project is affordable to the PCT and the costs are in line with the estimates made at OBC stage; The design of the new hospital meets all of the requirements of the local conservation area and is likely to meet the NHS sustainability requirements; The PCT has established robust project management arrangements to ensure effective management of the project, and has achieved all of the key project milestones to date; There is a clear plan for ensuring that the planned benefits from the new hospital are realised and that a robust project evaluation is carried out at each key stage. The formal approval of the NHS West Midlands to the Full Business Case is sought in order that the PCT can enter into the necessary contractual arrangements with its appointed Principal Supply Chain Partner (Interserve Health) for the construction of the new hospital. 090113 Malvern FBC v1.2.docx 10

New Hospital and Primary Care Facility for Malvern Full Business Case 2 Introduction 2.1 Background The existing Malvern Community Hospital was built in 1911 and was donated to serve the local community. It was initially a general hospital providing medical and surgical in patient beds, with an operating theatre and a local casualty department. An extension in the 1960s allowed the consultant and physiotherapy outpatient services to expand. Current service provision in Malvern Community Hospital comprises: 18 beds supported with GP medical care 2 ; Macmillan Nurse; 5 day X ray Service; Range of Consultant Out patient Clinics; Nurse and Therapist Led Out patient Clinics and Rehabilitation Services; Out of Hours Primary Care Centre. The current hospital in Malvern is no longer fit for purpose and cannot meet the future commisioning intentions of the PCT i.e. it cannot enable the delivery of modern, effective, high quality care offering real choice to local people. It is inflexible in format and seriously hinders the process of development of new care pathways and treatment for an increasing proportion of the patient group who are elderly. In December 2007, the Department of Health granted conditional approval for capital funding for a new community hosiptal in Malvern from the national Community Hospital Fund. An Outline Business Case for the new hospital was subsequently approved by the NHS West Midlands in June 2008. Since the approval of the Outline Business Case, Interserve Health has been appointed by the PCT as its Procure 21 partner, planning approval has been granted by Malvern Hills District Council, and the detailed design of the new hospital has been developed. The PCT is aiming to agree a Guaranteed Maximum Price for the new hospital with its P21 partner in February 2009 in order that construction can commence in April 2009. 2 An additional 2 beds were opened on a temporary basis during 2008 in response to increased demands on acute hospital beds in Worcesterhire due to an outbreak of Norovirus. 090113 Malvern FBC v1.2.docx 11

New Hospital and Primary Care Facility for Malvern Full Business Case 2.2 Purpose of the Full Business Case This Full Business Case: Confirms the case for change and the project s fit with national, regional and local policies and priorities; Describes the procurement process following approval of the Outline Business Case; Confirms that the projected costs of the project are within the cost estimates set out in the Outline Business Case; Confirms that the new hospital is affordable to the PCT as a commissioner and to the PCT s provider services; Seeks approval to enter into the necessary contractual arrangements with the PCT s appointed Procure 21 Principal Supply Chain Partner Interserve Health. 090113 Malvern FBC v1.2.docx 12

New Hospital and Primary Care Facility for Malvern Full Business Case 3 Background 3.1 Worcestershire PCT Worcestershire Primary Care Trust was formed in October 2006 following the merger of Redditch and Bromsgrove PCT, South Worcestershire PCT and Wyre Forest PCT. The PCT has an annual budget of around 750m, employs approximately 2,000 wte staff, and is responsible for improving the health and well being of the 560,000 residents of Worcestershire. The PCT: Provides a range of community health services in the home and from five community hospitals in Bromsgrove, Evesham, Pershore, Malvern and Tenbury Wells; Provides a wide range of specialist services, including health visiting, district and school nursing, therapy services, specialist children s and nursing services, GP urgent out ofhours services, dentistry, sexual health, equipment loans, breast screening, and health services in prisons; Coordinates and develops family health services and commissions healthcare services from 67 GP Practices, 95 Pharmacies, 64 Dental Practices and 174 Optometrists; Commissions secondary care and specialist services from a range of NHS and other providers. The PCT s boundary is coterminous with that of Worcestershire County Council. The PCT is working with the Worcestershire partnership to agree priorities for its sustainable community strategy and indicator set for LAA to reflect local health concerns. The PCT has now entered a period of financial stability, and a 5m surplus is forecast for 2008/9. For future years, the PCT is planning to start each year with a 1% contingency reserve. 3.1.1 Health Profile of Worcestershire and its Localities While the population of Worcestershire has generally good health and life expectancy is increasing, there are a number of health issues that need to be tackled. There is a need to improve health and well being overall, and close the gap between the health of the worst off and best off in Worcestershire, where there are marked variations. There is a need to encourage and facilitate healthier lifestyles, developing projects with a focus on the most disadvantaged areas of Worcestershire. In recognising that population growth in Worcestershire will be in the older age groups, the PCT needs to support the commissioning and redesign of integrated older adults services including preventative services. 090113 Malvern FBC v1.2.docx 13

New Hospital and Primary Care Facility for Malvern Full Business Case 3.1.2 Demographic Trends Many rural areas have experienced migration patterns that have led to an ageing population, with the outward migration of young people and the inward migration of older, retired people. The population of Worcestershire is expected to increase by about 38,000 (or 7% ) by 2026 to approximately 590,000. This compares with an estimated increase of about 10% in England over the same time period. The most significant population growth will be in the older age groups. The 65 and older population is expected to rise by 56% to 151,000, with the 85+ population almost doubling to just over 24,000. In terms of limiting long term illness (LLTI) up to 2016 this is projected to rise to around 67,800, an increase of around 45% on 2001 levels. For the 85 plus age group, the increase between 2001 16 is set to rise at a rate of almost 60%. In comparison, the 0 19 population is expected to fall by 9% by 2026, whilst the corresponding projection for the 10 19 years age group predicts a 13% reduction. 3.1.3 Deprivation Overall Worcestershire is healthier than the country as a whole with a life expectancy of 77.4 for men and 81.3 for women compared to 76.2 and 80.7 for England. Parts of the County experience significant levels of deprivation. Worcester City is in the top half of most deprived local authorities in terms of education and crime. Eleven areas in Worcestershire are in the top 20% most deprived nationally, and two areas are in the top 10%. Deprivation concerns are not solely linked to the urban parts of Worcestershire. Some rural parts of the County are within the top 1% of the most deprived areas in England in terms of geographical access to services. Rural areas experience particular forms of deprivation to a greater extent than urban areas, including: low incomes and lack of housing opportunities; decline in services and employment; and difficulties in obtaining access to jobs, services and facilities. 090113 Malvern FBC v1.2.docx 14

New Hospital and Primary Care Facility for Malvern Full Business Case Figure 1: Deprivation in Worcestershire Most deprived Least deprived 3.1.4 Rurality Though agricultural land and open countryside dominate the landscape, 64% of the total population live in urban areas. Research is beginning to show that there are rural urban differences in health outcomes, and challenges the belief that rural patients have a health advantage over their urban counterparts. 3.2 Malvern Hills District 3.2.1 Population Approximately 74,000 people live in the Malvern Hills District, with nearly 30% of them living in all pensioner households, and roughly half of these being pensioners living on their own. The District has below average numbers of children and young adults, and, along with South Worcestershire in general, it has an ageing population. The new Malvern Hospital will serve the existing population of c.55,000 in the southern 16 of the District s 22 electoral wards, together constituting around 75% of the population of the District. 090113 Malvern FBC v1.2.docx 15

New Hospital and Primary Care Facility for Malvern Full Business Case Natural growth trend data indicates a 3.8% increase in the overall population by 2011. However, natural growth population data is being overtaken by the potential demographic impacts of in migration resulting from current revisions to the Regional Spational Strategy (RSS) housing and employment land allocations for the Malvern Hills District. It is expected that at least a further 4,900 homes will be built in the District which will increase the catchment population for the hospital to around 70,000. Within the overall increase in the catchment population, the number of over 65 year olds is projected to rise by 10%, and the number over 85 year olds is projected to rise by 25%. The number of under 16 year olds is expected to remain static, and the number of 16 and 17 year olds is set to rise significantly. 3.2.2 Diversity The population will be 91% white British by 2011, with Indian the largest non white group at 1.0%. There is a net inward migration of around 300 migrant workers from A8 Accession Countries annually most commonly from Poland. The Malvern Hills District has the highest proportion of its people in higher income groups in south Worcestershire. But health, wealth and success are not evenly spread among communities in the Malvern Hills. The Pickersleigh area of Malvern town has a cluster of priorities for action, including support for children and families, improving incomes and educational achievement and tackling teenage pregnancy. This neighbourhood represents a significant challenge is addressing urban disadvantage in the District. Parts of the Teme Valley, on the other hand, are remote enough to be counted among the top 10% of the wards in England where services are hard to reach, and where family incomes are low. All of these factors, in both of these localities, adversely affect the physical and mental health of the people who live there. 3.2.3 Health Status Life expectancy is 78.5 years for males, above the England average, and 82.0 years for females, similar to the England average. Death rates from heart disease and strokes among under 75 year old people in the Malvern Hills District are continuing to fall and are already below the rates for England, the West Midlands and south Worcestershire. Although the rate of decline is slightly slower than in the late 1990s, the 2010 target reduction for the District will be met. In one area alone, that of deaths from stroke among women, the District is experiencing significantly higher rates than the average for England. This relates specifically to the higher rate of deaths from stroke among older women in the District. Death rates from cancers in the under 75 year olds are below the rates for England, the West Midlands and south Worcestershire. However, the rate for the Malvern Hills District has been increasing since 1999 2001. This may be a result of increases in colorectal cancers 090113 Malvern FBC v1.2.docx 16

New Hospital and Primary Care Facility for Malvern Full Business Case across the PCT and in the Malvern Hills District, and rates of skin cancer which are higher than the English average. Death rates from accidents among the over 65s have risen steadily in Malvern since 1998, based on three year rolling averages. Death rate from suicide and undetermined injury appears to have risen markedly since 1996, although some of this may be random variation due to small numbers. There is a significant risk that Malvern Hills will not meet the Our Healthier Nation target by 2010 unless there s further work to reverse the current trend. For Chronic Obstructive Pulmonary Disease (COPD), the rate of admission to acute hospital is half that of other areas in south Worcestershire for all age groups. This can be explained by the lower prevalence of COPD in the Malvern Hills District and by the unique presence of community based preventive and care services in the area: Consultant led outpatient clinic at the current Malvern Hospital; Nurse led COPD clinic at the current Malvern Hospital; Open access spirometry; Availability of pulmonary rehabilitation; An active British Lung Foundation Breathe Easy Groups in Malvern; British Lung Foundation Exercise Study in Malvern. The 2005 West Midlands Regional Lifestyle Survey indicated that: 87% of Malvern Hills residents surveyed described their health over the last 12 months as 'good' and 'fairly good'; 22% of residents surveyed reported a limiting long term illness; Only 15% of residents achieved the minimum recommended weekly levels of physical activity; 54% of Malvern Hills residents surveyed undertook no sports related exercise; Only 1 in 3 residents surveyed reported eating the recommended daily intake of fresh fruit and vegetables; 45% of residents surveyed reported being 'overweight' and 'obese'; 52% of residents surveyed reported drinking within the recommended weekly limits for alcohol: 17% of residents reported 'binge drinking'; 82% of Malvern Hills residents surveyed described themselves as not currently smoking. 3.3 Malvern Hospital The current Malvern Hospital provides the following services to the local population: 090113 Malvern FBC v1.2.docx 17

New Hospital and Primary Care Facility for Malvern Full Business Case 18 beds supported with GP medical care 3 ; Macmillan Nursing; 5 day X ray Service; A range of Consultant Out patient Clinics; Nurse and Therapist Led Out patient Clinics and Rehabilitation Services; Minor Surgery with Local Anaesthetic; Out of Hours Primary Care Centre. The projected levels of activity for 2008/09 are summarised in Table 1 below: Table 1: Malvern Hospital Activity 2008/09 Service Activity In Patients FCEs 372 Occupied Bed Days 6,695 Bed Occupancy 92% Average Length of Stay 18.0 days Out Patients Consultant Appointments First 1,272 Follow up 1,776 Out patients Nurse/Therapist Consultations First 229 Follow up 379 Diagnostics X Ray (Plain Film) 5,300 Ultrasound 616 Direct Access Physiotherapy & Occupational Therapy 8,000 3 An additional 2 beds were opened on a temporary basis during 2008 in response to increased demands on acute hospital beds in Worcesterhire due to an outbreak of Norovirus. 090113 Malvern FBC v1.2.docx 18

New Hospital and Primary Care Facility for Malvern Full Business Case 4 Strategic Context 4.1 National Policy Context The proposed new community hospital in Malvern has been planned in the light of a number of significant developments in national policy and strategy for the NHS. These include High Quality Care for All (the Darzi Review), Choosing Health and Our Health, Our Care, Our Say and the set of changes to the way the health service operates that form System Reform and World Class Commissioning agendas. The white paper Our Health, Our Care, Our Say identified the provision of care in more local, convenient settings including the home as one of its key priorities and announced a new generation of community hospitals and facilities with strong ties to social care. High Quality Care for All reinforced this approach to deliver care outside of traditional hospital settings where possible, identifying the provision of care closer to home as one of the key elements of the clinical vision for the way the NHS will provide services in future. 4.2 NHS West Midlands Strategic Framework In November 2007, NHS West Midlands published Investing for Health a Strategic Framework for the West Midlands, setting out how health services in the West Midlands could build on the improvements already made during the previous ten years. Investing for Health identifies the following seven big challenges that need to be addressed: Challenge 1: Despite improvements in overall health status, inequalities in health have increased. People in better off areas live longer than people in more deprived areas and the gap is getting wider. Challenge 2: There remains an unjustifiable variability in the quality and safety of services and individual care, and a significant number of complaints are received about standards of fundamental care. Challenge 3: Patients expect services to be joined up and to have co ordination across teams caring for them, yet at present, patients and the public often struggle to understand how health services work. Challenge 4: The public our customers have little confidence that their local NHS will get better. Challenge 5: We are not investing enough in prevention. Challenge 6: We continue to spend substantial resources on clinical activities that, the evidence suggests, bring little or no return on the investment in terms of improved 090113 Malvern FBC v1.2.docx 19

New Hospital and Primary Care Facility for Malvern Full Business Case health, or where the evidence shows that there are other, better and more costeffective alternatives. Challenge 7: Cost pressures arising from doing more of the same. An ageing population, a rising tide of long term conditions and an accelerating pace of technological development combine to outstrip any conceivable rate of increased funding. Investing for Health also identifies five themes the strategic priorities that must guide health services now and in the years to come to enable health economies to successfully respond to the seven big challenges: Full engagement: Getting people more involved in their own healthcare for example, adopting lifestyles that promote good health, avoiding things that are a risk to health and doing more to look after themselves, with guidance from health professionals. It is also about ensuring a rich supply of information for patients on health and health services, and about extending the availability of services that can support people in managing their own health. Improving quality and safety: This is a priority, not because the quality and safety of care in the West Midlands is worse than elsewhere in the NHS, but because the ambition is higher than achieving the average the aim is to be the best. Care closer to home: The focus here is particularly on patients with long term conditions. By developing a skilled and flexible workforce, it will be possible to provide high quality, integrated care in the community. Informed patients will be true partners in their own care, while care closer to home should also mean earlier interventions for those with long term conditions. There is also a need to do more to ensure greater ease of access to a wider range of primary care services including dentistry, alongside informed choice for patients. Sustainable services: Health services need to change to respond to the changing needs of patients, staff and the public. This means making sure that services are based on clear and efficient pathways and meet the highest standards of best practice, as defined by clinical evidence. The changes made must be sustainable; they must be the right services, be affordable and make good use of resources. Organisations fit for purpose: This priority is about ensuring that health organisations in the West Midlands those who commission health services and those who provide them have the capability to deliver a high quality, accountable and safe health service. 4.3 Local Strategic Framework 4.3.1 Worcestershire Partnership The Worcestershire Partnership has recently published its Partnership towards excellence the sustainable community strategy for Worcestershire 2008 2013. This covers crime, health, housing, jobs, learning, the environment and transport. Each District and Borough 090113 Malvern FBC v1.2.docx 20

New Hospital and Primary Care Facility for Malvern Full Business Case Local Strategic Partnership has produced their community strategy, incorporating the views of 151 Town and Parish Councils, particularly those 48 that have produced or are developing Parish Plans. The Partnership has addressed in detail six themes: Communities that are safe and feel safe; A better environment for today and tomorrow; Economic success that is shared by all; Improving health and well being; Meeting the needs of children and young people; Stronger communities, including housing, culture and volunteering. 4.3.2 Malvern Hills District The Malvern Hills District Sustainable Community Strategy 2006 2021 commits the Local Strategic Partnership to enabling the development of modern and accessible healthcare services. The South Worcestershire Joint Core Strategy responds to the Regional Spatial Strategy demands for the construction of 24,500 new homes in Wychavon, Worcester City and the Malvern Hills by 2026. With a minimum allocation of 4,900 new dwellings in the Malvern Hills District, early estimates indicate a demand there for an additional 6 general practitioners over and above the current cohort of 27 although a comprehensive programme of renewal of GP premises in the area is approaching completion and incorporates significant capacity for expansion. The PCT is currently in close dialogue with planners at District and County Councils to pinpoint the centres allocated for population growth, and housing land options maps indicate signficant expansion to the north and east of Great Malvern itself. The PCT and its partners regard the RSS review estimates of in migration as a minimum position and further capacity beyond that being considered will be required. The Malvern Hills District Council Adopted Local Plan 1996 2011 allocates land for the development of a replacement community hospital and now incorporates specific recommendations for the disposal of the current hospital site. 4.3.3 Worcestershire PCT Over Arching Vision The local health economy in Worcestershire has recently developed it s strategy Investing in Health for Worcestershire 2008/09 2012/13 A five year local health economy plan for the development of health and health services in Worcestershire. The PCT s vision is to deliver the highest quality, patient centred, efficient health care to local people when needed, as close to their home as possible. The major drive for the model of care is the need for improved patient care, better health and greater choice for Worcestershire patients. The PCT s priority is the redesign of care pathways, improving the quality of care to local people and freeing up resources to reinvest in primary care and community based services. 090113 Malvern FBC v1.2.docx 21

New Hospital and Primary Care Facility for Malvern Full Business Case The overall vision is of a county of Worcestershire where: The public, the PCT, other NHS Trusts, Local Councils, the independent, voluntary and private sectors work in partnership to promote health, well being and prosperity; People live longer and enjoy a better quality of life than people in similar counties; Health inequalities are reduced, i.e. the gap between those with the best and poorest health is reduced; Health services are efficient, demonstrate good value for money, and provide patients with a high level of satisfaction; The public has confidence in the PCT, believes that it listens to public opinion and undertakes its work to the highest standards. The PCTs values include: Being transparent and open in the conduct of our business; Working to the highest standards expected of public servants; Setting an example in rejecting all forms of negative discrimination e.g.on grounds of race, religion, gender or age; Working within the laws set by Parliament, adhering to national directions and implementing them in the way which is most beneficial to local people; Only arranging health services which are safe and within which patients are treated with respect and dignity. 4.3.4 Developing a Model of Care for Malvern and South West Worcestershire The PCT is developing its commisioning strategies within the national and local context set out above. The PCT will therefore commission services which will operate around the needs of the patient, their families, and carers. The model will form the foundation of future patient care pathways, organisation, service and workforce design, new ways of working, and a framework for NHS Trust and primary care trust (PCT) business cases and implementation plans. The proposals set out in this FBC to develop a new health facility in Malvern are entirely consistent with this strategic context. 090113 Malvern FBC v1.2.docx 22

New Hospital and Primary Care Facility for Malvern Full Business Case Figure 2: Model of Care Tier 4 Acute services Tier 3 Specialist primary and community care Tier 2 Primary medical and community services Tier 1 Self help and prevention To deliver this model of care the PCT intends to commission services which improve the quality of care in a cost effective way which releases resources from secondary care to reinvest in primary care and community based services. The following principles will therefore underpin the PCT s commissioning plans for the new Malvern facility: To support local people to stay healthier and independent; To support self care by providing information, offering choice and giving control over what happens; To deliver care as locally as possible. This will include the provision of step up/step down intermediate care beds which will enable local people to have inpatient care in a community setting; To provide care, diagnostic or treatment, when it is needed, delivered by appropriately trained professionals; To improve integration between services, providing seamless care, particularly focussed on the most vulnerable; To deliver safe high quality care, supported by evidence which demonstrates improved clinical and social outcomes; To improve equity of access to services; 090113 Malvern FBC v1.2.docx 23

New Hospital and Primary Care Facility for Malvern Full Business Case To increase efficiency, reducing duplication, optimise capacity, clearly sign post services so there is clarity for patients, carers and professionals about what happens next, integrated assessment and information technology systems. The PCT's 2008/09 2011/12 Operational Plan details how the PCT's commissioning and capacity plans deliver this new model of care. The PCT's proposal to develop the new community hospital in Malvern will ensure that high quality local services can be commissioned which fully support the overall strategic direction of providing a fuller range of services closer to where people live. The new facility will allow patients to be treated locally and the plans for the new hospital recognise the need to provide facilities locally. 4.4 The Need for Change 4.4.1 Services The current hospital facilities severely restrict the capacity to shift the focus away from secondary care services into alternative community facilities and therefore many patients have to travel for care that could be provided more locally. There are a number of significant difficulties hampering the PCT s ability to commission and deliver high quality and modern clinical services within the existing hospital: The existing 18 beds are configured in male and female bays with only 3 single side rooms with no en suite accommodation. The low number of single rooms creates difficulty in isolating patients with infections as these single rooms are in regular use for patients with palliative care needs; The side rooms are focused around the nurses station and in the heart of the main hospital ward; the environment is often noisy and not conducive to caring for palliative care patients; The overall space on the main hospital ward poses daily challenges for Nurses and Therapists with the use and storage of equipment, especially equipment used for manual handling including hoists and standing frames; the ceilings are very high and therefore overhead tracking is not an option; The hospital does not have sufficient space to accommodate a day treatment facility which prevents some patients from being discharged earlier and returning to the hospital for treatments/ therapies on a day basis; hence, opportunities to reduce length of patient stay are limited; X ray is provided within the existing hospital with Picture Archiving and Communications system (PACS); however, space limitations prevent more diagnostic services including ultrasound and endoscopy, from being delivered. Thus, in patients requiring ultrasound scans are referred to secondary care. The lack of outside space also prevents mobile 090113 Malvern FBC v1.2.docx 24

New Hospital and Primary Care Facility for Malvern Full Business Case MRI/CT/Mammography scanning hence all out patients and in patients access secondary care facilities; The existing out patient facility provides a valuable service to local people but the range and choice is limited due to space limitations. New models of working have been developed involving specialist Nurses and GPSIs, including Diabetes, Heart Failure and COPD, but further developments of this nature are hindered within the existing accommodation; The current facility does not provide a Minor Injuries unit and many patients therefore have to travel to secondary care facilities; The benefits of working with partner organisations (see Section 5.2.1 below) are certainly recognised within the existing hospital however, these benefits could be further enhanced if more co location opportunities were available; Training and teaching facilities within the hospital are limited due to inadequate space; any training tends to be of a uni disciplinary nature as the facility cannot offer the space to hold seminars or workshops. 4.4.2 Estate In 2005, the physical condition of the building was surveyed and rated at level C (Major Change Needed). The cost of bringing the building up to Level B (Adequate) was assessed to be 680,000 at the time. The survey identified that major expenditure was likely to be required within the next 5 years on: Windows & Rooflights Floor coverings Heating installation Electrical installation Lift Bedpan washers Luminaires The existing building, on a site of 0.28ha, is not functionally suitable and it can no longer deliver the high quality, modern and dependable care that patients and their carers have a right to expect for the following reasons: Communications between floors are difficult and there is only one small lift, which has also to accommodate patient transfer; High ceilings and lack of natural light in some areas is detrimental to the well being of patients, carers and staff; There is a chronic lack of secure and appropriate storage space, leading to stowage of equipment in clinical areas and in the one small and narrow patient day room; 090113 Malvern FBC v1.2.docx 25

New Hospital and Primary Care Facility for Malvern Full Business Case There is no hospital reception, adequate welcoming service, or health information service; Public access to the building is poor, with inadequate definition between the out of hours facility sited there and other clinical areas; There is inadequate car parking space (only 4 disabled spaces and 3 drop off spaces) and poor access by public transport; The building is energy inefficient; The current accommodation is not compliant with the Disability Discrimination Act; Lack of privacy and dignity due to dormitory style sleeping accommodation; Lack of facilities for minor procedures and space to enhance outpatients services and to deliver extended scope therapies; Existing energy provision will not support advanced diagnostics technology 4.4.3 Conclusions The imperative for change is considerable. The current Malvern hospital is no longer fit for purpose and cannot deliver the future commisioning intentions of the PCT i.e. it cannot enable the delivery of modern, effective, high quality care offering real choice to local people. It is inflexible in format, seriously hindering the process of development of new care pathways and treatment for an increasing proportion of the patient group who are elderly. The creation of attractive, effective services for younger residents and their families; the priority of improving local access to diagnostic and treatment services; the professional development of all the staff who work there all of these key characteristics of modern community healthcare are not deliverable in the current Malvern Hospital. The present hospital has in its time served its community well, but it can simply no longer take its place as a flexible and adaptable healthcare resource, able to accommodate new services provided at the highest standards through the next two to three decades. 090113 Malvern FBC v1.2.docx 26

New Hospital and Primary Care Facility for Malvern Full Business Case 5 Project Objectives and Benefits 5.1 Introduction Chapter 4 sets out the need for change and the future models of care which need to be developed to sustain appropriate services for the residents of Malvern and South West Worcestershire. The PCT's 2008/09 2011/12 Operational Plan details how the PCT's commissioning and capacity plans deliver this new model of care. The PCT's proposal to develop a new community hospital in Malvern will ensure that high quality local services can be commissioned which fully support the overall strategic direction of providing a fuller range of services closer to where people live. Practice based commissioners will play a key role in driving services redesign and developing innovative services within community settings. Excellent facilities in new practice premises and new community hospitals developed across Worcestershire provide a major opportunity to shift activity closer to where people live from current hospitals in Worcester, Gloucester, Cheltenham and Tewkesbury. The PCT will optimise the use of these facilities. To achieve these changes the local health economy plans to: Bring care as close to home as possible by providing community based services, particularly, outpatient, diagnostic and other ambulatatory care services; Disinvest in activity which is not clinically effective or efficient; Focus on improving the safety, quality and performance of our services; Invest in programmes which support healthy lifestyles, self care and enable patients to manage their long term conditions; A new Malvern Community Hospital is central to the delivery of the new care pathways being developed by the PCT. The new facility will allow patients to be treated locally and the plans for the new hospital recognise the need to provide facilities locally. For example, a local Malvern GP has been instrumental in the development of the Diabetes care pathway, and the PCT will develop a Locally Enhanced Service to allow local GPs to use the facilities at Malvern Hospital in addition to the existing GP Surgery facilities instead of patients having to attend the acute hospital in Worcester. Patients prefer to be treated near to home and the new hospital will mean that for example: Patients with COPD can receive rehabilitation nearer to home; Stroke care and rehabilitation will be provided at the new facility; Patients at the end of life will be cared for nearer to family and friends; 090113 Malvern FBC v1.2.docx 27

New Hospital and Primary Care Facility for Malvern Full Business Case Falls clinics will be provided within easy access for those who need them; Older People will be assessed for their long term needs in a non acute hospital environment, allowing them time to recover from acute health care episodes; The incorporation of a minor injuries unit will reduce the demand on acute services and allow the rapid assessment and treatment of patients. The design of Malvern Community Hospital has been developed with these pathways in mind. The hospital will have suitable facilities to ensure that these services can be provided locally, and will enable the PCT to commission services that can be provided within Malvern, avoiding the need for patients to travel into Worcester and beyond to receive care. 5.2 Key Objectives Based on the strategic context and the PCT s commissioning intentions set out in Chapter 4 above, the PCT has identified the following key objectives for the project: 5.2.1 Services The services provided should: Be acceptable to key stakeholders in the local community and wider health economy; Enable the care provided in a new Malvern Hospital to be integrated with other NHS and associated services in terms of logical and effective patient pathways; Provide an additional 6 intermediate care/rehabilitation/palliative care beds. The additional inpatient capacity will: o Provide more opportunity for local residents to receive care closer to home; o Reduce pressure on acute hospital beds by increasing the capacity for patients to be admitted directly from home ( step up care ); o Allow more timely discharges from acute hospitals for patients requiring rehabilitation before returining to their home ( step down care ); o Provide an environment more conducive to the care of patients requiring palliative care; o Provide additional single rooms to allow patients with infections to be more carefully isolated; o Allow greater circulation space for manual handling and storage of equipment. Provide out patient facilities capable of delivering 15,000 consultations per year. The additional capacity will: o Enable the range and volume of out patient services to be considerably extended, avoiding the need for patients to travel to more remote acute hospitals; 090113 Malvern FBC v1.2.docx 28

New Hospital and Primary Care Facility for Malvern Full Business Case o Provide capacity for a range of out patient diagnostic procedures to be available, including endoscopy, sigmoidoscopy and colonoscopy; o Enable the development of one stop shop services, supported by the enhanced diagnostic services available. Examples include a falls service (incorporating nursing assessment, X Ray if required, physiotherapy assessment and advice on mobility, issuing of mobility aids to prevent further falls) and respiratory services (offering X Ray, spirometry, physiotherapy assessment, specialist nurse advice). Include a Minor Injuries/Assessment centre capable of handling 3,500 4,000 attendances per year. This new facility will: o Improve access for local residents to emergency and urgent care; o Deliver treatment and advice for patients with minor injuries and minor illnesses; o Provide assessment of patients, including those who have suffered a fall. Provide a wider range of diagnostic services, including X Ray, ultrasound scanning and endoscopy, and space and facilities to accommodate mobile MRI/CT/Mammography. The enhanced diagnostics will: o Support the provision of the increased range of out patient services, the minor injuries service and day treatments; o Reduce the need for patients to travel to acute hospitals; o Increase the speed of access to diagnosis and initial treatment. Include facilities for Day Treatments/Procedures, including Blood Transfusions, IV Fluids, IV Antibiotics, Methylprednisolone infusions, Chemotherapy, and Day Rehabilitation. These facilities will: o Avoid the need for patients to travel to acute hospitals for these services; o Reduce the need for overnight stays in hospitals; o Facilitate earlier hospital discharges and redcutions in length of stay Include accommodation for the GP out of hours services. There are clear advantages from the co location of this service alongside a wider range of diagnostic and minor injury/illness services. Enable the following activity per year to be transferred from acute and other hospitals: o 1,500 occupied bed days o 12,000 out patient attendances o 1,100 ultrasound scans and endoscopies o 1,800 MR/CT scans o 2,800 A&E attendances o 800 day treatment procedures 5.2.2 Location The site should: 090113 Malvern FBC v1.2.docx 29

New Hospital and Primary Care Facility for Malvern Full Business Case Be easily accessible, with particular regard to people who are dependent upon public transport and to the opportunities afforded by developing good public transport services including park and ride developments, inter urban and rural bus routes, and Malvern s two railway stations; Provide adequate parking facilities commensurate with need and with the hospital s role as a local flaghip project for sustainable travel; Address the travel impacts of sites allocated for significant housing development under the provisions of amendments to the Regional Spatial Strategy (RSS). Current indications from options being developed under the South Worcestershire Joint Core Strategy (SWJCS) response to the RSS are that sites to the south west of the City of Worcester and to the north of the Malvern urban area are under consideration. The Seaford Court site for Malvern s new hospital is well located to meet these potential healthcare travel impacts; Offer the potential for other developments to take place in association with the new hospital as part of the PCT s aim to promote healthy lifestyles. 5.2.3 Environment The physical environment should: Conform to formal planning regulations/requirements and conservation restrictions; Reflect the landscape attribution of the local area; Be acceptable to key stakeholders in the local community and wider health economy. 5.3 Key Benefits The investment as a provider is to meet the needs of the PCT as a commissioner which are set out in section 4.3. In meeting these needs, the new hospital will provide the following significant benefits for local residents: Up to date and modern facilities, capable of delivering 21st Century healthcare in line with national and local priorities; Integrated care pathways which provide ambulatory care and step up and step down inpatient services through partnership and shared care arrangements with local secondary care providers; Flexibility to cope with demographic and demand changes; Improved local access to consultation, diagnosis and treatment; Reduced travelling time for a significant rural population; Reduced pressure on acute hospital services. 090113 Malvern FBC v1.2.docx 30

New Hospital and Primary Care Facility for Malvern Full Business Case The table below illustrates the ways in which the new hospital will assist in meeting key national, regional and local priorities: Table 2: Contribution to national, regional and local policies Policy Imperative Impact of New Malvern Community Hospital OUR HEALTH, OUR CARE, OUR SAY More personalised care Services closer to people s homes Better co ordination with local councils Increased patient choice Enables the development of one stop shop services, supported by the enhanced diagnostic services available; Provides 50% single rooms with en suite facilities for all in patients; Provides adequate parking facilities commensurate with need and with the hospital s role as a local flaghip project for sustainable travel. Accessible, with particular regard to people who are dependent upon public transport and to the opportunities afforded by developing good public transport services including park and ride developments, inter urban and rural bus routes, and Malvern s two railway stations; Supports the care of patients in their own homes by providing a base for community teams. Provides new opportunities for seamless health and social care; Supports integrated travel plan for Malvern. Enables the range and volume of out patient, minor injuries and diagnostic services to be considerably extended, avoiding the need for patients to travel to more remote acute hospitals. The additional capacity includes: 12,000 out patient attendances 1,100 ultrasound scans and endoscopies 1,800 MR/CT scans 3,800 A&E attendances 800 day treatment procedures A focus on prevention rather than cure Enables the care provided in a new Malvern Hospital to be integrated with other NHS and associated services in terms of logical and effective patient pathways; Enables increased focus on patient education via assessment and onstop shop services. INVESTING FOR HEALTH Inequalities widening Lack of investment in upstream interventions Design offers flexibility to cope with demographic and demand changes; Tackles health inequalities by making services local and accessible. Services will focus on health and wellbeing by providing local care designed to maintain people in their home environment and help 090113 Malvern FBC v1.2.docx 31

New Hospital and Primary Care Facility for Malvern Full Business Case Policy Imperative Variable quality and safety of services Costs increasing faster than income Lack of public confidence in services Buying interventions that do not work Systems that are complex and difficult for patients to navigate. Impact of New Malvern Community Hospital them manage their own conditions; Assists in the reduction of emergency attendances and admissions and the promotion of independent living. Up to date and modern facilities, capable of delivering 21st Century healthcare in line with national priorities. Removes need for duplication of services with associated cost benefits; Assists in the reduction of emergency attendances and admissions and the promotion of independent living; Reduces the need for hospital admissions; Provides a modern building with reduced energy and lifecycle costs. Will be acceptable to key stakeholders in the local community and wider health economy; Facilitates improvements in privacy and dignity; Reduces anxiety and stress; Increases civic pride and enhanced reputation for NHS; Provides clear evidence of integrated working across the various providers of services within the health economy. Increases the opportunity for the adoption of care pathways that are jointly developed and agreed between primary and secondary care clinicians. Provides ease of access, a familiar setting and timely care thereby encouraging uptake and compliance; Enhanced diagnostics and better co location of services will radically improve the patient experience. Dedicated purpose bult outpatient services will be designed to meet patient expectations; Includes accommodation for the GP out of hours services. There are clear advantages from the co location of this service alongside a wider range of diagnostic and minor injury/illness services. KEY NATIONAL PRIORITIES 18 week Referral to Treatment target Reduced waiting times in A&E (<4 hour target) The new Hospital will facilitate sustained delivery of the 18 week RTT target by transferring outpatient activity to the community and streamlining care pathways; Reduces pressure on acute hospital beds by increasing the capacity for patients to be admitted directly from home; The additional intermediate care beds will facilitate the management of step up and step down capacity thereby reducing demand on acute hospital beds e.g. reduced lengths of stay. The new hospital will act as a common portal for local people thus allowing fast tracking to the appropriate clinical setting, reducing 090113 Malvern FBC v1.2.docx 32

New Hospital and Primary Care Facility for Malvern Full Business Case Policy Imperative Reduction in Hospital Associated Infections The PCT as an employer of choice Impact of New Malvern Community Hospital waiting times in A&E and easing pressure on A&E waiting times. Facilitates improvements in the control of infection and the associated lengths of stay. Aids recruitment and retention particularly local employment; Will improve staff job satisfaction by enhancing patient experience; Supports multi disciplinary team working across health and social care. 090113 Malvern FBC v1.2.docx 33

New Hospital and Primary Care Facility for Malvern Full Business Case 6 Stakeholder & Community Involvement 6.1 PCT Strategy A new Community Engagement and Communications Strategy was approved by the PCT Board in September 2008. A key aim of the strategy is: To establish an engagement and involvement framework that ensures all local citizens have the opportunity to contribute to decision making and maximises opportunities to build local ownership of health services The PCT intends to work with local people to engage them in developing and improving health services and ensuring that the services it commissions and delivers are done so effectively. The PCT is committed to proactively seeking the views of the public, patients, their carers and other stakeholders and to consult widely across all levels of decision making. It is important that patients and the public also understand how their views will be used, which decisions they will be involved in, when and how decisions will be made. With the additional focus on engagement work, and the challenges set by the new legislation and developments such as the LINk, the PCT has reviewed how public involvement and engagement should be undertaken and structured in the future. A new Engagement and Involvement Framework has been established that sets out the varying levels of activity. Key principles of the new framework include: Collaborative working with partners to ensure good practice is shared, duplication avoided and that we make the most of our resources. The need to identify processes systems and infrastructure that are convenient and suit the community s capacity to get involved. The need for involvement to be on an informed basis, with participants in possession of the full facts and background information. Opportunities to get involved will be flexible and will allow participation at varying levels, from armchair to formal attendance at regular meetings. There is a recognition that not everyone wants to have a view or an opinion on every issue and that the important aspect is that there should be opportunity for the local population to get involved if and when they want to do so. 6.2 Activity prior to OBC approval The Malvern Community Hospital project has been the subject of intense local interest and involvement since 2004. A three month formal public consultation from December 2004 to March 2005 on the core and optional services to be developed in a new hospital, and the 090113 Malvern FBC v1.2.docx 34

New Hospital and Primary Care Facility for Malvern Full Business Case potential location of a new facility, involved nearly 1,000 local people in discussions at 28 venues across the Malvern Hills District and 480 written communications and feedback responses. A further public meeting involving around 300 attendees in 2006 provided further opportunities for engagement with the project. In April 2008, a pre planning application consultation on the essential design features of a new Malvern hospital took place over three weeks at four venues, with exhibitions and feedback opportunities at libraries, GP surgeries, and through the local newspaper and the PCT s own website. This public engagement directly influenced the development of the full planning application for the new hospital which was submitted to the planning authority in July 2008. Option appraisal and design review workshops involving clinicians, health and social care professionals and members of the public underpinned the development of the project from an early stage. The design development process for the new hospital has actively engaged the views of clinicians to create a clinically robust, safe and modern building which will help in the delivery of services for patients. A series of meetings have been held with staff representatives from within the hospital to identify the essential layout requirements of the new building. 6.3 Strategy for the Malvern Hospital project A Communications and Engagement Strategy and Action Plan for the project was developed and approved by the Project Board in September 2008 and is attached as Appendix 1. The aims of the strategy were defined as being to: Enable a two way dialogue between the Trust, its staff, patients, GPs, stakeholders and the local population. This will help improve the services provided at Malvern hospital. Ensure staff in all NHS and partner organisations, have access to adequate information about the new Malvern Hospital. Ensure local GPs and other health professionals have access to adequate information about new developments and the impact they will have on them and their patients. Provide a recognisable identity for the new hospital and the individual developments within it. Enable members of the local community to become involved with the new hospital Build closer relationships between the partner organisations, patients, carers, public and stakeholders, providing support to patients and the public through the LINk and other means to enable them to make a difference and ensuring stakeholders such as the Strategic Health Authority, MPs and Overview and Scrutiny Committees are kept up to date with developments Ensure an appropriate reporting, monitoring and communicating mechanism for activities with accountability to deliver on targets. 090113 Malvern FBC v1.2.docx 35

New Hospital and Primary Care Facility for Malvern Full Business Case Ensure a means of identifying and responding to negative media Ensure proactive on going communications and engagement 6.4 Activity since OBC Approval A wide range of communications and engagement activities have been undertaken since the OBC was approved in July 2008, including: The establishment of a Hospital Advisory Group to provide an opportunity for the local population and stakeholders to shape and influence key elements of the development of the new hospital. Group meetings have been advertised widely in the local press and other media and have attracted attendance and interest from a broad range of people; Close working with the League of Friends and other local community and patient groups to keep them informed of project progress and encourage their input and feedback. Use of the League of Friends as project champions and advocates locally; Close liaison with the Town and District Councillors to keep local politicians informed about progress and to retain their support for the project; An ongoing programme of press releases and local media activity designed to retain a profile for the project and to keep the local community informed. Regular briefings with the editor of the local newspaper and negotiation of special features and content; The publication and wide circulation of regular project newsletters providing details of the project s progress and opportunities for members of the community to find out more and get involved; The launch of a Schools Competition to stimulate interest in the new hospital amongst younger age groups; Distribution of an introductory letter to the project, a timescale and plan and site management arrangements to 500 households living near to the Seaford Court site; An opportunity for local residents and members of the league of Friends to visit the site prior to demolition that was covered extensively by the local media; Development of a dedicated page on the PCT website and the installation of a webcam so that local residents, members of the community and other stakeholders can see progress on site at first hand. A wide range of activities will be undertaken over the period up to the opening of the new hospital, as set out in Appendix 1. 6.5 Stakeholder Support There is strong support for the new Malvern community hospital from all of the key stakeholders, and letters of support from the following are attached in Appendix 2. 090113 Malvern FBC v1.2.docx 36

New Hospital and Primary Care Facility for Malvern Full Business Case Worcestershire Acute Hospitals NHS Trust Malvern Practice Based Commissioning Cluster Malvern Hills District Council Malvern Hospital League of Friends 090113 Malvern FBC v1.2.docx 37

New Hospital and Primary Care Facility for Malvern Full Business Case 7 P21 Procurement Process 7.1 Introduction The Outline Business Case identified that the preferred procurement route for the project was the use of the NHS Procure 21 process. Following approval of the OBC, the PCT appointed Turner & Townsend to project manage the Procure 21 process on its behalf. This section describes the process followed. 7.2 Selection of P21 Partner All of the Principal Supply Chain Partners (PSCPs) on the Procure 21 contract framework were approached and all expressed interest in the potential scheme: Interserve Health BAM Balfour Beatty Costain IHP Lang O Rourke Medicinq Kier Health All of the PSCPs confirmed their potential interest in the scheme and requested a copy of the High Level Information Pack (HLIP). This provided an overview of the current scheme status, objectives, benefits and needs of the client with an indication of the current operational needs so that potential PSCPs could register their interest accordingly. All PSCPs returned an Expression of Interest (EOI) based on the criteria and the HLIP issued. Following an evaluation of the EOIs by Turner & Townsend, the following PSCPs were short listed: Costain Interserve Health Integrated Health Projects (IHP) Laing O Rourke The unsuccessful PSCPs were notified in writing. 090113 Malvern FBC v1.2.docx 38

New Hospital and Primary Care Facility for Malvern Full Business Case Prior to a formal interview, the four short listed PSCPs were invited to a project open day on the 17th June 2008. The open day included a site familiarisation tour, and. the PCT presented a more detailed explanation of its strategic direction together with the background & context of the proposed project. PSCPs were invited to ask questions in both public and private sessions. At the Open day a revised expanded version of the previously issued High Level Information Pack (HLIP) was issued to provide additional information to assist the four short listed PSCPs in the interview stage of the selection process: A PSCP Interview Pack was prepared by the Trust detailing the process and the various stages to be undertaken. An equivalent document was issued to the prospective PSCPs identifying the process, agenda and scoring criteria to support their preparation for the interview. The PSCP interviews were undertaken on Tuesday 1st July 2008, conducted in the Committee Room of the Malvern Council House. The selection panel was approved by the PCT Board and consisted of representatives from the PCT and their professional advisors. The panel comprised: Councillor Ralph Madden, Deputy Leader of Malvern Hills District Council Brian Hanford, Worcestershire PCT: Project Director Irving Steeper, Worcestershire PCT: Director of Facilities Lisa Levy, Worcestershire PCT: Associate Director of Operations Vernon Jones, NHS West Midlands: Estates Advisor Paul Elkin, Provex Consultancy: Assistant Project Director Steve Potter, Turner & Townsend: Associate Director Glenn Mackenzie, Turner & Townsend: Senior Project Manager In attendance: Andrew Mitchell, Procure 21: Implementation Advisor Observer The interview process comprised of two components; the first of which was a presentation from the PSCP teams to the selection panel responding to specific criteria. The second component was a structured Questions and Answers session aimed at exploring both behavioural and technical competencies of the proposed PSCP delivery teams. The identified questions were selected based on previous experience of this process. Based on the scoring undertaken by the Trust and Professional Advisors, a clear consensus regarding the preferred PSCP emerged, with 7 of the 8 members of the selection panel scoring Interserve highest. The panel agreed that Interserve Health should be recommended 090113 Malvern FBC v1.2.docx 39

New Hospital and Primary Care Facility for Malvern Full Business Case for appointment, and the PCT board subsequently accepted the panel s recommendation and duly appointed Interserve Health as its P21 Partner. During the PSCP selection process, the PCT indicated a strong preference to the potential PSCPs of their preference for the existing Architect to be retained. This was due to the considerable knowledge that had been obtained by Design Buro of the scheme and the PCT requirements. Interserve took due notice of this preference and appointed the following consultants to complete their team: Design Buro Architect Capita Symonds M & E Designer Capita Symonds Cost Consultant Interserve Property Services Building Construction Interserve Engineering Services M&E Installer Structural Design Partnership Structural Engineer 7.3 Guaranteed Maximum Price (GMP) The Guaranteed Maximum Price (GMP) is a fundamental principle of the Procure21 process. The GMP agreed between the PSCP and the PCT will be the maximum price the Contractor will be paid for the construction of the building, as set out within the Contractor s Proposals. The GMP does not all allow for client changes and by agreement, certain specific risk events may also be excluded from the GMP. Post contract, the PSCP is reimbursed actual costs up to the GMP value. In the event that the costs incurred exceed the GMP, these costs will be borne by the PSCP. If at the end of the project the costs are less than the GMP, the saving on the GMP will be shared equally between the PCT and the PSCP (shared savings). This provides an incentive to the PSCP to minimize the cost post contract. 7.3.1 Process The philosophy of the shared saving is that both the PSCP and the PCT will benefit from added value and reduced costs generated post contract. It is not the intention that shared savings arise from an artificially high GMP. Due to the risks involved for the PSCP of agreeing a GMP that is insufficient, coupled with the incentive of a substantial bonus for post contract savings on the GMP, it is important that a clear and transparent process is adopted by the PSCP for agreement of the GMP. The PCT appointed Turner & Townsend Cost Management as its cost advisor for the project. In order to provide assurance that the proposed GMP is commercially acceptable and represents good value for money, the following process has been adopted to agree the GMP: 090113 Malvern FBC v1.2.docx 40

New Hospital and Primary Care Facility for Malvern Full Business Case 7.3.1.1 Design Fees and Pre Construction costs Shortly after their appointment, the PSCP provided estimates of design team fees. At the request of the PCT s Cost Advisor, quotations were provided for full scheme fees, including a split between the fees incurred prior to the agreement of the GMP and post GMP approval, in order to provide greater cost certainty with regards to full scheme outturn costs. Payment of the design fees is based on actual time spent on the project against agreed framework hourly rates. In order to secure payment, full substantiated timesheets are submitted for assessment by the PCT s Cost Advisor. At the agreement of the GMP Interserve will be required to reconfirm their overall design fees costs based on the costs to date and anticipated further costs. 7.3.1.2 Site Establishment and Site Management This will be priced by Interserve based on actual cost rates against estimated resources for people, plant and materials. For validation purposes, the costs will be benchmarked by the PCT Cost Advisor against similar projects to demonstrate value for money. The majority of these costs will be directly proportionate to the duration of the construction period. Turner and Townsend Project Management will undertake an independent review of the construction programme to ensure that a reasonable base line for pricing is used. 7.3.1.3 Construction Works Packages The main works packages are being tendered by the PSCP to smaller works subcontractor organisations. In order to allow assessment of value for money and commercial reasonableness, the PSCP will prepare package documentation, comprising design and scope information, contractual information and pricing schedules. Sub contractors will be required to provide competitive prices for the works. The PCT s Cost Advsior will review the pricing schedules to ensure both accuracy and tolerances, and will review all returned tenders to ensure that the most competitively advantageous price is included as part of the GMP. Tendered prices and rates will also be independently checked by the PCT s Cost Advisor to provide assurance that the prices returned are competitive. 7.3.1.4 Risk Allowances The PSCP has undertaken an internal risk review of the project in order to be able to include financial provisions for the residual risks during the construction process. 090113 Malvern FBC v1.2.docx 41

New Hospital and Primary Care Facility for Malvern Full Business Case Risk allowances are being reviewed by the PCT s Cost Advsior to ensure that they are appropriate and are not normal construction risks that should be covered within the construction cost. The financial allowances are also being reviewed and agreed to provide assurance that the allowances are commercially acceptable. 7.3.1.5 Overhead & Profit A percentage addition to all costs will be included to cover the PSCP s overhead and profit margin the PSCP fee. The fee rate has been tendered in competition as part of the ProCure21 framework selection process and is approved by the Department for Health. The allowances within the PSCP fee element will be reviewed concurrently with the other costs included within the overall GMP to ensure that allowances forming part of the fee are not double counted as priced activities. 7.3.2 Progress to date In order to maximize the period available for the agreement of the GMP and provide a robust, market tested price, the PSCP and PCT are aiming to agree the GMP by 21 st February 2009. The PCT s Cost Advisor has reviewed the pricing schedules which have been prepared to date and have required that a number of changes are made due to discrepancies in the measure and the design information, and this process will continue up to the agreement of the contract sum. At the time of FBC submission, approximately 45% of the construction cost packages have been market tested, with the remaining 55% being priced using the PSCP s in house cost data. The in house cost data has been validated by both the PSCP and the PCT s Cost Advisor. The PCT has made it clear to the PSCP that the GMP cannot exceed the cost estimates set out in section 8.12.1 below, and the PSCP has acknowledged, and is committed to meeting, this requirement. 090113 Malvern FBC v1.2.docx 42

New Hospital and Primary Care Facility for Malvern Full Business Case 8 Proposed Solution 8.1 Introduction The Outline Business Case identified five potential options for meeting the requirements of the project, and set out the results of a detailed financial and non financial appraisal of the three short listed options. The preferred option identified through this appraisal process was Option 4 A New Build on the Seaford Court site. This chapter describes the proposed solution which has been further developed since the OBC was approved, and identifies any changes from the proposals set out in the OBC. 8.2 Services 8.2.1 Services The services and projected volumes of activity to be delivered from the new facility are set out in Appendix 3 and summarised below: 24 intermediate care/rehabilitation/palliative care beds; Out patient consultations; Minor Injuries/Emergency Assessment; Diagnostics (including imaging, facilities for mobile CT/MRI/Mammography, ultrasound, endoscopy, physiological measurement); Day treatments/procedures (non surgical); Therapy services; GP out of hours services. The range of services to be provided from the new hospital remains unchanged from that described in the Outline Business Case. 8.2.2 Activity The projected levels of patient activity in the new hospital and the impact on existing services have been re assessed since the OBC was approved to take into account: An update of the baseline levels of activity from 2007/08 to 2008/09; A more detailed analysis of the expected case mix of patients expected to be treated in the new hospital; The detailed design of the new hospital and the capacity available; 090113 Malvern FBC v1.2.docx 43

New Hospital and Primary Care Facility for Malvern Full Business Case More detailed discussions with local GPs and acute hospital clinicians regarding the range of services which can be provided in the new hospital. The projected volumes of patient activity are set out in Appendix 3 and a comparison with the estimates set out in the OBC is summarised in Table 3 below: Table 3: Projected Activity Levels OBC FBC Change % 1. In patient Services (OBDs) 8,322 8,268 54 1% 2. Out patient Services (Attendances) 2.1 Consultant 5,005 7,059 +2,054 +41% 2.2 Nurse/Therapist 1,995 8,391 +6,396 +320% 3. Ultrasound & Endoscopy 1,944 1,764 180 9% 4. Imaging 4.1 X Ray (scans) 7,000 7,000 4.2 CT/MR (scans) 1,890 1,880 10 5. Day Treatments/Procedures 836 837 +1 6. Direct Access Therapy (contacts) 8,000 9,125 +1,125 +14% 7. Minor Injuries (A&E attendances) 2,700 3,800 +1,100 +41% 8. GP Out of Hours (attendances) 2,700 2,700 The main changes from the estimates included in the OBC are as follows: 8.2.2.1 Out Patients The projected numbers of consultant led appointments in General Surgery, Orthopaedics and Breast Surgery have increased significantly as a result of further discussions with local acute hospital consultants regarding the numbers of out patient clinics which could be held at the new hospital. The projected levels of nurse and therapist activity have increased significantly as a result of: The inclusion of 1,000 Midwifery attendances not previously taken into ccount in the OBC; An additional 1,200 Orthopaedic Practitioner attendances which reflects increasing referral rates to this relatively new service; 090113 Malvern FBC v1.2.docx 44

New Hospital and Primary Care Facility for Malvern Full Business Case A more detailed analysis of the capacity which will be available in the new hospital which has identified the potential for an additional 2,400 appointments which can be used for future expansion in line with PCT commissioning intentions; The inclusion of clinics for Heart Failure, Multiple Sclerosis, Genetics and Breast Care to reflect the PCT s latest commissioning plans. 8.2.2.2 Minor Injuries The estimates used in the OBC were based upon the transfer of 60% of the activity which is currently being undertaken at the Worcester Royal Infirmary and which could safely and appropriately undertaken locally in the new hospital. The projected level of activity now includes an additional 1,000 attendances for unmet demand amongst the local population. 8.2.3 Care Pathways The Care Planning Partnership (CPP) is a health economy wide series of networks, the remit of which is to redesign and review patient pathways. The partnership is made up of representatives from Worcestershire Acute Hospital Trust, Worcestershire County Council, Worcestershire Mental Health Partnership Trust, the PCT s provider arm as well as voluntary sector and patient and public involvement representatives. The CPP provides a forum for clinicians and the public to redesign care pathways based on clinical evidence, best practice nationally and internationally and data about current resource utilisation to inform the decision making process. The main priorities for the development of care pathways are linked to the PCT s priorities and World Class Commissioning outcomes. The pathways currently under development are: Diabetes Stroke Care End of Life Care Chronic Obstructive Pulmonary Disease (COPD) Intermediate Care Falls Cardiology Urgent Care Pathway Dementia Increasing access to Psychological therapies Self management and education 090113 Malvern FBC v1.2.docx 45

New Hospital and Primary Care Facility for Malvern Full Business Case The development of the new Malvern community Hospital is an essential part of the deployment of these pathways, as it will support the function of the CPP to provide high quality integrated services, focused on prevention and care close to home, which make the best use of available resources to meet the health needs of the population. For all of the above pathways, the new Malvern Community Hospital is an integral part of the pathway design as the improved facilities will enable the PCT to deliver more of the pathway closer to patients home and in better quality environment. For example: The improved Education and Training facilities will ensure that patient education programmes can be delivered within the hospital. Programmes like XPERT, EPP programmes and other support to patients on all of the pathways to understand their condition and learn how to manage it themselves. Malvern Community Hospital will be the flagship within the PCT patient prospectus. This is essential for patients with all Long Term Conditions to halt the deterioration in health that can be a consequence of long term conditions. The facilities for education of professional staff will support the development of many of the pathways as increased competence and knowledge are key to successfully implementing many of the pathways. For example the COPD pathway has resulted in considerable additional training of practice based staff to deliver the locally enhanced service; this will also apply to Diabetes and Cardiology; The additional outpatient facilities will ensure that more patients are able to access local appointments for follow up clinics, diagnostics and on going therapies. This will result in: o A reduction in patients failing to attend follow up appointments and greater control and compliance over treatment plans; o Patients being able to receive specialist care and support from clinicians involved in, for example, the COPD and Diabetes team; o The hospital will be used for undertaking more complex multi disciplinary assessments of patients at risk of falling; o The improved in patient facilities will support the development of care closer to home for many pathways, but in particular for Stroke Care, Intermediate Care and End of Life care. Given the demographic profile of Worcestershire and Malvern in particular this is particularly important. Many of the pathways, in particular, COPD, stroke and intermediate care rely on having access to rehabilitation and therapist input to enable the patient to regain as much former function and return to independence as possible. This facility will greatly enhance the opportunities for this; The PCT is a pilot for the Map of Medicine for Diabetes, this will enable the pathway to be localised to include Malvern Community Hospital; The addition of a minor injuries unit (MIU) within the new hospital will support the development of the urgent care pathway. The focus of this pathway is to develop and 090113 Malvern FBC v1.2.docx 46

New Hospital and Primary Care Facility for Malvern Full Business Case promote the use of alternatives to A&E services. The MIU will reduce attendance at Worcestershire Royal Hospital, where achieving the emergency access target is challenging. The skill mix and case mix envisaged for the new hospital will enable individuals with minor ailments to also seek advise, further reducing the burden on other parts of the health care system, whilst being seen and assessed by a skilled competent workforce. 8.2.4 Healthy Lifestyle Services The OBC for the project signalled the PCT s aim to assess the potential for incorporating a range of additional services in the new hospital and its grounds. Following a detailed health needs assessment and discussion with external stakeholders, the PCT has concluded that the development of the new hospital creates an ideal opportunity to include healthy lifestyle services as part of the spectrum of care available to local people. A key element within the overall vision of integrated care pathways across the health spectrum is the development of preventative services with an increased focus on enabling people to make healthy lifestyle choices. A range of initiatives for utilising the hospital site to strengthen healthy lifestyles in partnership with the Malvern Hills Local Strategic Partnership s Health and Well Being Group has been considered, and the following services have been identified as immediate priorities based on the health needs assessment: A Consultant Led Falls Clinic to enable visiting Consultants to run clinics in line with the Worcestershire Falls Prevention strategy; Maximisation of the health improvement potential of the outside space, including outdoor exercise equipment for adults, a productive community garden and a school link plot; A community hub for health information; A facility for peer support and group work on health improvement areas. The accommodation needed within the new hospital and its grounds has been included within the design of the new hospital, and a project has been established to deliver the new services in partnership with all stakeholders. A copy of the Project Initiation Document for the project is attached as Appendix 4. 8.3 Location and Site The new hospital will be located on the existing Seaford Court site which is owned by the PCT. The proposed location of the new hospital on the site is shown in Appendix 5. 090113 Malvern FBC v1.2.docx 47

New Hospital and Primary Care Facility for Malvern Full Business Case 8.4 Functional Content The proposed Schedules of Accommodation for the new hospital are set out in Appendix 6. In summary the new hospital will provide accommodation for the following: 8.4.1 In patients (24 beds) The accommodation includes a mixture of single rooms (50% of the total) and 4 bedded bays with dining, bathing, en suite and lounge areas. 8.4.2 Out patients The accommodation includes space for both consultations and minor surgical procedures. 8.4.3 Diagnostics A plain film X Ray department has been located centrally in order to be accessible for patients and for transfers between the ground and first floor services. The building has been designed to allow sufficient space for visiting mobile MRI, CT and Breast Screening units. An Endoscopy suite has also been provided. 8.4.4 Assessment Unit The accommodation includes tretament rooms and plaster room. 8.4.5 Therapies Shared therapy and recreation space has been provided both internally and externally. The majority of inpatient therapy will take place on the wards, but space for large group activities has been provided, including an integrated therapy hall/gym along with a variety of external exercise, games, relaxation and contemplation spaces. 8.4.6 Day Treatments Consultation and treatment rooms and associated services. The total floor space of the proposed facility will be 4,478 m 2 as summarised in Table 4 below: 090113 Malvern FBC v1.2.docx 48

New Hospital and Primary Care Facility for Malvern Full Business Case Table 4: Summary of Accommodation Gross Internal Area m 2 In patient areas 1,340 Radio diagnostics 139 Out patients 192 Minor Injuries 222 Day Treatment 299 Therapies 339 Administration & Support Services 733 Shared space 243 Circulation & Plant 971 TOTAL 4,478 A comparison with the accommodation requirements envisaged at OBC stage shows a substantial increase in the overall size of the new hospital as a result of a signficant change in the shape and layout of the building during the design and planning process: Table 5: Summary of Accommodation comparison with OBC estimates OBC FBC Change m 2 m 2 m 2 Departmental Areas 3,071 3,507 +436 Circulation & Plant 614 971 +357 TOTAL 3,685 4,478 +793 The revised design of the building has resulted from the pre planning consultation exercise which was undertaken during April and May 2008 as part of the preparation of the detailed planning application, and from the discussions with the planning authority regarding the overall site layout. 8.5 Design The PCT appointed Margaret Jackson and Rob Parker, Non Executive Directors as the designated Co Design Champions for the project. 090113 Malvern FBC v1.2.docx 49

New Hospital and Primary Care Facility for Malvern Full Business Case 8.5.1 Establishing the design brief To ensure a successful solution to the users accommodation requirements, a managed process for developing the design of the new hospital has been adopted. The design process has been monitored by the PCT against the following key parameters: The briefing documents provided by the PCT; The Quality Plans of each individual member of the Design Team as defined by the relevant professional organisation (RIBA, ACE, ILE etc); Compliance with the requirements of the CDM Regulations; The Design Buro, as the appointed Architect since OBC stage, has taken overall responsibility for co ordinating the input of all Design Team members and agreeing the developing design brief with the PCT. The design and layout of the new hospital has been governed by the following key principles, reflecting the needs and aspirations of the PCT and other key stakeholders: Promote a more integrated service which provides effective and seamless follow up treatment and support after patients have moved on from the inpatient phase of their care; Ensure good access for patients to other non health services such as education, skilled social work, exercise and recreational activities; Exploit the natural amenities of the site to enhance the development and produce a building that both respects and enhances its wider context; Appropriately site and mass the different functions according to their specific requirements whilst considering the needs of the local environment; Provide good general access to the site, prioritising the pedestrian whilst ensuring vehicular access is available for those requiring it; Create a legible environment that aids access by employing passive way finding based on easily recognisable forms and spaces; Facilitate and maintain everyone s right to feel safe and protected from harm, including patients, staff, visitors, adjacent residents and the general public; The building shoud promote normal daily living activities; Provide care closer to the patients homes where clinically appropriate; Provide effective local health services by harmonising primary care, social care and local hospital services to prevent inefficiencies, gaps in provision, delays and duplication of effort; Provide a vibrant learning and education culture that benefits clinical services. 090113 Malvern FBC v1.2.docx 50

New Hospital and Primary Care Facility for Malvern Full Business Case 8.5.2 The Design Process The design process has involved a wide variety of inputs from a clinical planning, space planning and technical perspective. The design process has been split to cover various design aspects to ensure that manageable areas have been addressed in a logical sequence. The User Group has been at the heart of the process, and has been responsible for establishing the following technical groups to address specific design aspects: Room Data Sheets and Generic Rooms Medical Equipment and IT Operational Policies Design and Technical 8.5.3 Third Party consultation Consultation with all interested third parties has run concurrently with the design and technical development, and has dealt with the interface with local and statutory authorities and utilities companies providing services to the site. Detailed discussions have taken place on environment, flood plain risk and highways. 8.5.4 Design Details The elevations and layouts of the proposed hospital are set out in Appendix 7. The design of the new hospital enables the building and landscaping to be integrated into the context of the locality, and takes into account the topography of the site. The building and overall site have been planned to take advantage of the natural site features where possible, including the natural screening provided by the peripheral trees for privacy and shading, The building has been designed to fit the site in such a way as to minimise the need for large retaining walls and to maximise the availability of safe external recreation and therapy space that is discreetly located away from public areas. The inernal functions are also located to respect the adjacent activities of the hospital and to maximise patients views of the nearby Malvern Hills. Strategic departmental clinical adjacencies and key functional relationships have been developed with the clinical teams, and have been used, along with the schedule of accommodation and the operational policies, as the fundamental baseline for developing the internal layout of the building. 090113 Malvern FBC v1.2.docx 51

New Hospital and Primary Care Facility for Malvern Full Business Case 8.5.5 Design Review Panel A Design Review Panel was convened on 8th August 2008 in Malvern. The Panel was particularly impressed by the extent of public and stakeholder consultation and involvement in the development of the scheme. They made a number of detailed suggestions regarding the design of the building which have been taken on board by the project s Design Team. 8.5.6 AEDET assessment The design process has used an AEDET approach from the very early stages to gain the maximum design benefit. To this end, prior to any design taking place, a series of AEDET workshops were held where the AEDET headings were used to establish the Trust s design objectives. The overarching PCT requirements were used as a set of parameters against which the site analysis was completed and to inform early discussions with the planning department. They were also used to guide the 1:500 and 1:200 clinical review groups. The AEDET aspiration has been kept under constant review and an AEDET workshop was arranged to formally score the proposed design at OBC stage. A second AEDET workshop was held in December 2008 to assess the more detailed design and a summary of the results is attached as Appendix 8. This assessment resulted in scores of 5 or more for each of the AEDET criteria. 8.5.7 Future Flexibility The design has been developed with the need for future flexibility of use in mind, particularly the need to respond to increases in demand or changes in models of care in the future. A number of levels of flexibility and adaptation, which would be required in order to support the long term objectives of the hospital, have been identified: Increase in service demand (strategic) Change of use (permanent or long term) Change of use (short term) Flexibility is built into the design of this building in the following ways: 8.5.7.1 Built Form and Layout The majority of the spaces will be flexible in use. It is recognised that some spaces may not be multi use throughout a working day due to a very specific operation or the possibility of cross infection, but they can be considered flexible on a broader day to day timescale. With ample storage provision and ensuring that furniture is predominantly mobile (where clinically and practically sensible to be so), rooms can be easily cleared. The careful positioning of facilities and the ability to ensure secured areas, allows greater flexible use of the building. 090113 Malvern FBC v1.2.docx 52

New Hospital and Primary Care Facility for Malvern Full Business Case Flexibility will also be built into the construction of the building with large unobstructed floor plates, large spans steel frame, and by the use of lightweight, metal stud partitioning systems. This will enable the opportunity to remodel a large area of a floor without affecting major structural elements. 8.5.7.2 Layout Flexibility The layout has been planned to allow the plan form to remain flexible by co locating similar functions to ebb and flow between areas. Soft space has been co located to clinical areas to allow clinical areas to expand in an alternative area of the building or site e.g. co location of clinical rooms and the flexible clinical use areas. Layouts have been produced that will encourage flexible working and lead to greater integration of services to achieve economies of scale in terms of space utilisation. 8.5.7.3 Room Modules Multi purpose room modules of standard sizes, which can be assembled to generate a variety of plans suitable for different uses over time, have been designed into the layout. This will allow consulting rooms to be easily converted to treatment areas and vice versa. These modules have been developed to accommodate, for example, the range of the activities found. Larger rooms are derived by combining a number of the same modules. Room sizes have been chosen that exceed HBN recommendations and follow the most up to date clinical guidelines published, such as The Hillingdon Hospital, single room pilot ward. This allows for potential alterations to the clinical care carried out within this space provided, allowing inbuilt flexibility. 8.5.7.4 Expansion Space External soft loft space has been left immediately adjacent to a particular facility to accommodate physical expansion at some future date. Areas of the site have also been identified to provide future extension of the building. There are two other PCT owned buildings on the Seaford Court site, which offer opportunities for accommodating some of the non clinical support services (e.g. administration, staff welfare, training), which will be provided in the new hospital. This would provide capacity to expand the clinical accommodation in the new hospital in the future if demand increases. Support parking expansion has also been discussed with local authorities to ensure that, if building expansion is required, parking could equally be increased to support the expansion. 090113 Malvern FBC v1.2.docx 53

New Hospital and Primary Care Facility for Malvern Full Business Case 8.6 Sustainability The scheme is designed to ensure that the new development is environmentally sustainable to the maximum extent possible without compromising the overall need to deliver an affordable solution. As a result, use has been made of up to date techniques, materials and policies that promote this approach and aim to ensure that the new development is sustainable and efficient from the onset. Key issues addressed include: Energy and water use within the facilities; The materials used in construction; Travel plans for the new hospital; The equipment used by the Trust; All aspects of recycling and waste management. Targets will be established for each element, in line with national guidance and targets, and formal monitoring of the achievement against these targets will be built in to the overall Benefits Realisation / Post Project Evaluation plans. The environmental sustainability of the project will be benchmarked and monitored at key stages through the application of a BREEAM 2008 Healthcare Assessment. The PCT also aims to provide facilities that will benefit the local people in addition to those traditionally associated with a healthcare facility. It is most appropriate that such facilities should focus on education, illness prevention and health improvements. Feedback as a result of consultation with the local population and interested groups has been incorporated into the design. Additionally, building information and site progress concerning the new development will be publicised via the internet, newsletters, site visits and presentations. 8.6.1 Environmental Management It is the aim of the PCT to develop an environmental management system (EMS) in order to reduce the scheme s environmental impacts and increase operational efficiency. This will comprise both building management systems as well as operational management of the buildings, its services and users. The process of developing the EMS will include identification of environmental impacts, significance testing to assess priorities and a documented system to ensure that legal 090113 Malvern FBC v1.2.docx 54

New Hospital and Primary Care Facility for Malvern Full Business Case compliance is maintained, adverse impacts are minimised and opportunities for positive impacts are realised. 8.6.2 Internal Environment It is the aim of the PCT that the internal environment of the new facility should ensure that occupants and users experience a welcoming and pleasant environment that facilitates a feeling of health and well being. The design will aim to benefit wherever possible from the provision of natural light through the careful placement of windows and rooflights. It is also recognised that a balance must be struck between good natural light levels and measures to limit excessive solar heat gains which can be problematic particularly during summer months. Natural ventilation targets will be set in order to ensure that fresh air is provided at a rate to ensure high internal air quality and a good natural ventilation flow rate to remove pollutants such as carbon dioxide. Passive cooling is also to be encouraged as a means to reduce reliance on mechanical ventilation and reduce energy consumption whilst maintaining targets for fresh air rates provision. The NHS publishes Energy Performance Benchmarks for Community Hospital developments both in terms Good Practice and typical values. These values are stated within the NHS publication Health Technical Memorandum 07 02; EnCO2de, making energy work in healthcare Environment and Sustainability. It is a PCT aspiration that the development should achieve <40 GJ/100 m3 of heated volume. Dependant upon the fuel source of the primary heating plant the carbon dioxide emissions values are also fixed. Whilst it is recognised that future mandatory performance targets cannot be predicted with 100% certainty the design should be flexible to ensure that future legal requirements can be met without significant design changes. This means that where possible the design is to incorporate features that enable future improvements and/or upgrades to improve energy performance without necessarily entailing capital expenditure at this stage when such measures may not be financially viable. 8.6.3 Transport The PCT is committed to reducing car dependency and securing alternative means of transport to, from and within the site. The new development will feature a Green Travel Plan identifying a strategy for managing all travel and transport to and from the hospital site. The aim of the strategy will be to increase choice and reduce reliance on single occupancy car use by seeking to improve access to the site by public transport. The site location and the co operation of the Local Authority will play 090113 Malvern FBC v1.2.docx 55

New Hospital and Primary Care Facility for Malvern Full Business Case a significant part in realising the physical and behavioural measures targeted within the Travel Plan. 8.6.4 Water The PCT aims to minimise water consumption subject to clinical risks and requirement priorities. General specification will include (where appropriate) the provision of low volume use terminal fittings for taps, urinals, WCs and showers that consume less potable water in use than standard fittings. Water consumption will also be monitored by the Building Management System (BMS) and targets and operational maintenance established. 8.6.5 Materials Where possible, the design of the building will feature A+/A rated materials as defined within the Green Guide to Specification. The Environmental Profile of a material as defined by the Guide is assessed on the basis of a per m² functional unit over a 60 year study period and linked to Life Cycle Costs. Each material within a building element group (e.g. roof, external walls) is considered separately in order to calculate the Green Guide environmental impact ratings. For each building element, there will be a range of material specifications available for use with the lowest (minimum) and highest (maximum) impact identified. This range provides the basis from which the A+ to E ratings are determined. The design of the building will be such that robust features appropriate to the use of a given area will limit the potential for impact damage (internally and externally) and excessive wear and tear. This will also include consideration of maintenance implications in order to reduce life cycle costs and the impact of replacement materials. Specific measures may include specification of hard wearing floor and wall coverings and suitable impact protection relevant internal and external areas. 8.6.6 Land Use and Ecology It is a PCT aspiration that the site should be developed to benefit the people, environment and ecology in the locality and that where possible, the grounds should provide a degree of therapeutic benefit to the building users. The Japanese Knotweed present on site is considered a form of land contamination as a nonnative plant species. Remediation will therefore be performed as part of the site development and will enhance the long term ecology of the site. Planted areas within the development will employ a number of plants that require minimal maintenance and watering in addition to rainfall. Areas will be planted in order to further enhance site ecology with use of native species and measures to attract and sustain wildlife. 090113 Malvern FBC v1.2.docx 56

New Hospital and Primary Care Facility for Malvern Full Business Case 8.6.7 Pollution It is a PCT aspiration to limit the emission of carbon dioxide through the use of low/zero carbon energy technologies (LZC). The concept energy generation strategy for the development includes the provision of low or zero carbon technologies to address the compliance with the NHS targets and Good Practice carbon emissions criteria. In addition, credit E1 within the BREEAM for Healthcare assessment requires a Carbon Index of 40 or better on the required Energy Performance Certificate to be attained and confirmed as the design development progresses. To determine the scale and combination of LZC integration the development firstly needs to be subject to a preliminary analysis of the anticipated energy consumption, both in terms of fossil fuel and electrical power elements. This will be undertaken with consideration of the influence of Building Regulations Part L2A and the recent revision to HTM 03 (Health Technical Memorandum) that relates to the provision of ventilation in healthcare buildings. It is a PCT ambition to reduce operational pollution through the application of good practice design of the site, buildings and services. Such impacts that are to be minimised include: Pollution from refrigerants; Emissions of nitrogen oxides; Emissions of volatile organic compounds; Flooding risk; Surface water pollution; Noise; Light pollution; Social. 8.6.8 Operational Waste The minimisation of waste and maximum recycling will be a significant factor with regard to waste produced by the development. Dedicated facilities will be incorporated for storage and collection of recyclable material in conjunction with adequate segregation. This will include local non clinical area storage, subsequent centralised storage and collection provisions. The waste streams will be subject to a number of management procedures including Local Authority waste policy and strategy, waste monitoring and auditing by an appropriate individual and the required Environmental Management System (EMS). 090113 Malvern FBC v1.2.docx 57

New Hospital and Primary Care Facility for Malvern Full Business Case 8.6.9 BREEAM BREEAM Healthcare will be used to benchmark and monitor a significant proportion of the issues raised in this section of the document. It was added to the BREEAM family of assessment tools in 2008 to help reduce the environmental impact of healthcare buildings and as of 1st of July 2008, the Department of Health require that all new build health schemes achieve an Excellent rating. A post construction review is also a mandatory requirement of achieving a BREEAM Rating to ensure the design choices have been implemented in the final construction. The aim of this requirement is to help ensure that buildings are sustainable and efficient from the onset, avoiding the engineering fixes that often require significant capital expenditure and which can be time consuming and disruptive to the operation of the building. The PCT is committed to BREEAM (Building Research Establishment Environmental Assessment Method) and achieving the required Excellent rating for the new hospital. BREEAM has been embedded into the design development of the scheme with three assessments undertaken during the design process, together with the employment of a licensed assessor to ensure the process has been integrated into the design process. The results of the Preliminary BREEAM Assessment are set out in Appendix 9. 8.7 Planning Consent A detailed planning application was submitted to Malvern Hills District Council on 24 th July 2008 and was approved by the Planning Committee on 29 th October 2008. A copy of the council s decision notice is attached as Appendix 10. 8.8 Workforce Details of the current and projected workforce requirements are set out in Appendix 11 and show that the following numbers of additional staff will be required: Nursing o In patient services 6.43 wte o Out patient services 3.12 wte o Emergency Nurse Practitioners 3.00 wte o Emergency Practitioner Assts 3.00 wte 15.55 wte Therapists o Physiotherapy 1.64 wte o Occupational Therapy 0.36 wte 2.00 wte Admin & Clerical 4.00 wte 090113 Malvern FBC v1.2.docx 58

New Hospital and Primary Care Facility for Malvern Full Business Case Chaplaincy Facilities & Hotel Services TOTAL 0.05 wte 7.80 wte 29.40 wte The future workforce requirement has been assessed on the basis that the existing staff compliment will be maintained within the new hospital with a proportionate increase in staff resources based on the increase in both in patient and out patient services. In addition, there are some new services which are not currently provided within the existing hosptial, for example the Emergency Assessment Unit/ Minor Injuries. This service will require staff who have a different range of skill and qualifications. Work has already commenced in identifying the range of skills and competencies required to operate this service. Discussions with the Clinical Development Directorate within the PCT have taken place and potential training and educational programmes have been identfiified. The intention within this service is to develop two new roles Nurse Practitioner and Practitioners Assistant and to encourage staff from the existing hospital workforce to work towards these roles. Staff from within Provider Services have forged very effective working relationships with colleagues at the University of Worcester. Every Year the University has cohorts of student nurses who graduate and are seeking employment wityhin the PCT. We would wish to continue this and promote the opportunities the new hospital will present for students. Continuing professional development will continue with all our workforce as normal and individual services will be asked to identify specific training needs in preparation for delivering services within the new hospital. Discussions will also take place with other providers of services within Malvern hospital. 8.9 ICT The PCT s ICT Strategy has been developed by the Worcestershire health economy s Commissioner ICT Programme Board, which is directly linked downstream to the ICT Boards of the PCT Provider function, the Worcestershire Acute Hospital NHS Trust and the Worcestershire Mental Health Partnership NHS Trust. Upstream, the Commissioner ICT Programme Board relates directly to the NHS West Midlands ICT Programme Board. These governance arrangements ensure connectivity between national ICT programmes and the development of the infrastructure and leadership essential to their deployment across healthcare networks and care pathways in Worcestershire. The PCT s ICT Strategy sets out the ways in which a new Malvern Hospital will have 21st century technology available to it from opening day in 2010 and beyond to support patient care, patient information, and new management tools in an increasingly competitive environment. 090113 Malvern FBC v1.2.docx 59

New Hospital and Primary Care Facility for Malvern Full Business Case The present Malvern Hospital acts as a hub for eight other clinical sites and also forms part of the resilient COIN with links to both Worcestershire Royal Hospital & Pershore Hospital (see Figure 3 below): Figure 3: ICT Links These satellite sites and Malvern Hospital access numerous applications including NCRS, Radiology, PACS, Financial systems, voice & video. Integration of ICT solutions like CRS by 2010 will be at the heart of the clinical networks accessed through care at a new Malvern Hospital. The ICT Strategy also provides a road map by which other new technologies like wireless networks, medical grade networks, unified communications and data centres will create a modernised patient care and business management environment for Malvern Hospital and all of its linked care pathways and associated staff. Remote vital sign monitoring, developed by QinetiQ in Malvern for military purposes and now in the civilian domain, is an example of the technology that is expected to be available to the hospital and operating within the unified ICT framework in time. Elegant and effective information technology like that planned for delivery through the PCT s ICT strategy will place Malvern s patients at the centre of information access: SMS text alerts, 090113 Malvern FBC v1.2.docx 60

New Hospital and Primary Care Facility for Malvern Full Business Case self check in and information screens at key locations in the new hospital are likely to be the public interface of these new systems. In order to support access to these applications as well as providing business continuity, the new hospital will need a 1Gb (EES 1000) COIN connection to Worcestershire Royal Hospital and a backup 100Mb (EES 100) link for resilience to Pershore Hospital. To maintain business continuity these circuits will also have diverse routes into the building. The Communications / Server room has been sized to house two 800mm x 600mm x 42U cabinets with 1mtr clearance for maintenance access on all sides. The new building will be flood wired with CAT5e / CAT6 data cabling taking into account the need for ceiling mounted WiFi Access Points. 8.10 Equipment A detailed assessment of the equipment required for the new hospital has been undertaken, and a detailed Schedule of Equipment For Group 2, 3 and 4 equipment is attached at Appendix 12. The cost of Group 1 equipment is included within the construction costs, and the estimated cost of the Group 2, 3 and 4 equipment are set out in Table 6 below: Table 6: Group 2, 3 and 4 Equipment Estimated Cost (exc VAT) 000 Total Non Clinical Equipment ( Note 1) 293 Total Clinical Equipment (Note 1) 156 Total X Ray System (Note 2) 52 Total Desktop Equipment (Note 3) 40 Total Network and Telephony Equipment ( Note 4) 118 BT Connections (Note 4) 74 TOTAL 733 (1) This allows for the transfer of some equipment that it is expected will still be serviceable in September 2010. (2) A new X Ray facility will be required. The existing leased facility is floor mounted due to structural difficulties at the existing Hospital. To transfer this system and make the necessary modifications to allow for the more usual and practical ceiling mounted X Ray tube will not be cost effective. 090113 Malvern FBC v1.2.docx 61

New Hospital and Primary Care Facility for Malvern Full Business Case (3) All new desktop equipment will be provided. (4) This includes for the connections, hubs and switches required to provide the COIN Network as described in section 8.9 above. 8.11 Equality Impact Assessment The PCT commissioned J 2 Consultancy in 2008 to assist with a detailed Equality Impact Assessment of the proposed new hospital. Due to the nature of the local population and the local environment, it has been agreed that the scope of the assessment should be expanded to include the dimensions of disability, gender, race, age, religion, sexual orientation, and rurality and deprivation. The assessment is being undertaken in two phases, namely: Phase 1: An initial screening assessment to determine the likelihood of any adverse equality impact from the project. Phase 2: More detailed assessments of any aspects where the potential for an adverse impact is identified in Phase 1 Phase 1 has been completed and has examined the following strands: The Outline Business Case The Project Execution Plan The healthcare service package The design of the new hospital and associated access and communications A number of recurring themes have been identified as a result of the initial screening assessments, including the need to develop clear Equality & Diversity targets for the project. The PCT has determined its strategic objectives and targets for the project and these are attached as Appendix 13. These targets will be further refined by the PCT s recently appointed Equality & Diversity Lead prior to the commencement of the construction phase and will be embodied within the Project Execution Plan. Phase 2 of the assessment is about to commence and will encompass the following work: Full EIAs for existing care pathways and initial screening EIAs for new care pathways; A full EIA on the use of the building,focussing on how, through flexible use, the risk of any adverse impact on sexual orientation, race and religion or belief can be avoided. 090113 Malvern FBC v1.2.docx 62

New Hospital and Primary Care Facility for Malvern Full Business Case 8.12 Financial Impact 8.12.1 Capital Costs The projected capital costs of the project have been assessed by the PCT s appointed cost advisor and are set out in Appendix 14 and summarised in Table 7 below: Table 7: Capital costs At Approval Level prices (MIPS 530 4 ) 000 At Out turn prices (MIPS 528 5 ) 000 Works Cost 12,446 12,400 Fees 1,791 1,785 F & E 665 733 Non Works Costs 324 323 Land Contingency 304 304 Total Cost excluding VAT 15,530 15,545 VAT 2,404 2,408 TOTAL COST INCLUDING VAT 17,934 17,953 The expected capital cost of the project amounts to 17.953m at out turn prices and includes the following key features: The use of MIPS indices as per NHS Estates Quarterly Briefing Volume 17.2 and a base approvals index of MIPS 530 VOP; Outturn costs assume a Quarter 2 2009 start on site and are therefore based on a MIPS 528 index; The Works costs reflect the substantial increase in the size of the building from 3,685 m 2 at OBC stage to 4,478 m 2 ; The Works costs include On Costs at 91%, which is in line with the levels of on cost estimated by the PCT s QS at OBC stage (94%). The relatively high levels of on costs are due to the following factors: o The external building and engineering costs are at the high end of the range for this on cost element. On the Seaford court site there is a very significant change in levels across the site which will require a large amount of excavation and fill, 4 Based on NHS Estates Quarterly Briefing Volume 17.2 5 Based on NHS Estates Quarterly Briefing Volume 17.2 090113 Malvern FBC v1.2.docx 63

New Hospital and Primary Care Facility for Malvern Full Business Case necessitate retaining wall structures and also affect drainage requirements. There are also two very large sewers (one of which is 900mm in diameter) crossing the site which will require diversion around the new building. The extent of the excavation and fill for the building will therefore also require significant external works in order to achieve the required levels around the building perimeter, to car parks and external paved areas; o The site being in a conservation area and the resultant impact on design; o The high costs of the auxiliary buildings required on the site to meet planning requirements; o The high costs of abnormal works, including the cost of demolitions and the shared risk element of the design and construction risk register. The regional location factor of 5% for the West Midlands area has been excluded, based on the latest BCIS index which indicates that prices in the local area are higher than the regional average and in line with national averages; Professional Fees include the PSCP s Phase 3 fee and all relevant fees incurred by the PCT and amount to 14.4% of Works costs; The furniture and equipment cost is based upon the schedule of equipment set out in section 8.10 and Appendix 12; A Planning Contingency provision of 2% has been included to reflect the PCT owned risk within the design and construction risk register (see section 9.4 below); The anticipated cash flow based on the construction plan and a start on site in Q2 2009 is as follows: Table 8: Capital cash flow 2007/08 000s 2008/09 000s 2009/10 000s 2010/11 000s 2011/12 000s TOTAL 000s Works Cost 1,336 8,018 2,859 186 12,400 Fees 561 758 350 117 1,785 F & E 362 371 733 Non Works Costs 323 323 Planning Contingency 11 48 174 67 4 304 VAT 2 299 1,497 577 33 2,408 TOTAL AT OUT TURN PRICES 574 2,764 10,401 3,990 223 17,953 The estimated capital costs within the Outline Business Case have been updated to reflect the latest MIPS indices as per NHS Estates Quarterly Briefing Volume 17.2. A comparison of the projected capital costs with the updated OBC cost estimates is set out in Table 9 below: 090113 Malvern FBC v1.2.docx 64

New Hospital and Primary Care Facility for Malvern Full Business Case Table 9: Capital costs comparison with OBC stage OBC (MIPS 490 QB 16.4) 000 OBC UPDATED (MIPS 530 QB 17.2) 000 FBC (MIPS 530 QB 17.2) 000 DIFFERENCE Works Cost 8,571 9,292 12,446 +3,154 Fees 1,286 1,394 1,791 +397 F & E 563 563 665 +102 Non Works Costs 274 274 324 +50 Planning Contingency 1,283 1,383 304 1,079 VAT 1,871 2,015 2,404 +389 Total Cost at Approval Level MIPS 13,848 14,921 17,934 +3,013 Mitigated Optimism Bias 2,952 3,180 3,180 % Optimism Bias 21.3% 21.3% 0% 21.3% Total Cost at Approval Level MIPS including Optimism Bias 000 16,800 18,101 17,934 167 Inflation to outturn MIPS 2,420 (15) 19 +34 TOTAL COST AT OUT TURN PRICES 19,220 18,086 17,953 133 The comparison set out in Table 9 above shows that the expected overall cost of the project is in line with the costs estimated at OBC stage updated for the latest MIPS indices, despite the substantial increase in the size of the building from 3,685 m 2 to 4,478 m 2. 8.12.2 Revenue costs and Affordability Detailed estimates of the annual running costs of the new services and facilities are set out in Appendix 15 and are summarised in Table 10 below: 090113 Malvern FBC v1.2.docx 65

New Hospital and Primary Care Facility for Malvern Full Business Case Table 10: Revenue cost impact 1. Projected Annual Revenue Costs OBC (2007/08 prices) 000 OBC (2008/09 prices) 000 FBC (2008/09 prices) 000 DIFFERENCE 1.1 Clinical Services 2,118 2,167 2,731 +564 1.2 Facilities & Support Services 452 462 717 +255 1.3 Capital Charges 1,279 1,308 1,168 140 1.4 Total Gross Cost 3,849 3,937 4,617 +679 000 2. Less : Existing Costs 2.1 Malvern Hospital 1,812 1,853 1,955 102 2.2 Services transferred from other hospitals 1,317 1,347 1,847 500 3. Net Additional Cost to PCT 720 737 815 +77 The net financial impact on the PCT is estimated to be 815,000, and is based upon a transfer of the following activity from existing hospitals: Table 11: Transfer from other hospitals Activity Cost 000 1. In patient Services (OBDs) 1,573 327 2. Out patient Services (Attendances) New 2,245 698 Follow up 1,760 284 3. Ultrasound & Endoscopy 370 137 4. Day Treatments/Procedures 837 114 5. Minor Injuries (A&E attendances) 3,800 213 6. Therapies 1,125 74 7. Total 1,847 090113 Malvern FBC v1.2.docx 66

New Hospital and Primary Care Facility for Malvern Full Business Case The funding for the net additional cost to the PCT of 815,000 has already been ear marked within the Malvern PBC Cluster s financial plans from 2008/09 onwards, and will be met from the additional resource which the cluster will receive as part of the PCT s plan to move all PBC Clusters closer to its fair share target. 090113 Malvern FBC v1.2.docx 67

New Hospital and Primary Care Facility for Malvern Full Business Case 9 Project Management, Procurement and Project Plan 9.1 Project Management A Project Execution Plan (PEP) for the Procurement, Construction and Commissioning phases of the project was developed at OBC stage in June 2008 and approved by the PCT Board. The PEP sets out the scope of the project and the structure and governance arrangements which are in place to ensure that the project is delivered successfully. The project is overseen by a Project Board, the membership of which includes representation from a wide range of the PCT s external stakeholder partners including Worcestershire County Council, Malvern Hills District Council, Malvern Town Council, Malvern Hospital League of Friends, and lay members. The overall project structure is set out in Figure 4 below: Figure 4: Project Structure 090113 Malvern FBC v1.2.docx 68

New Hospital and Primary Care Facility for Malvern Full Business Case The PEP has since been updated to reflect the appointment of Interserve Health as the PSCP, and will be further updated after FBC approval once detailed construction and commissioning plans have been finalised. 9.2 Project Plan A Project Plan for the project has been prepared and is appended to the Project Execution Plan. The key milestones within the project plan are broadly unchanged from the plan approved at OBC stage and are set out in Table 12 below: Table 12: Key Project Milestones Start Completion Procurement of P21 Partner Apr 2008 Jul 2008 Full Planning Permission Jun 2008 Sep 2008 Design, Planning, GMP Jul 2008 Feb 2009 Full Business Case Jan 2009 Mar 2009 Construction Apr 2009 Sep 2010 Commissioning Sep 2010 Oct 2010 9.3 Benefits Realisation A detailed Benefits Realisation Plan is attached as Appendix 16. The Plan will be reviewed as an integral part of the Post Project Evaluation work, to ascertain if benefits identified against the objectives of the business case have been met as a result of the project. 9.4 Risks A Risk Register has been prepared detailing the key design and construction risks to be addressed by the project. Each risk has been assigned to the PCT, or PSCP, or classified as being shared and the likely cost of each risk has been assessed. The cost of all risks assigned to the PSCP or classified as being shared risks has been included within the Works cost element of the projected capital costs (see section 8.12.1 above). The register of the risks assigned to the PCT is attached as Appendix 17. The assessed cost of these risks amounts to 303,000, and this cost has been included within the Planning Contingency element of the capital costs. 090113 Malvern FBC v1.2.docx 69

New Hospital and Primary Care Facility for Malvern Full Business Case The Risk Register is reviewed on a monthly basis by the project s Design team and the results are reported to the Project Team and Project Board. 9.5 Post Project Evaluation 9.5.1 Aim and Scope of Evaluation Project evaluation is a part of the total quality process, and the PCT acknowledges its contribution towards a successful outcome in terms of: Greater assurance of total performance in terms of cost, time and quality; Clearer definitions of responsibilities; Reduced exposure to risk; and Improved value for money. Set out below is the proposed framework for carrying out the Post Project Evaluation for the project which will satisfy the requirements of the Good Practice Guide: Learning Lessons from Post Project Evaluation. 9.5.2 Evaluation Stages In line with NHS guidance, 4 stages of evaluation will take place as outlined below. Stage 1 Development of an Evaluation Plan An Evaluation Plan has been developed in close conjunction with the Benefits Realisation Plan and Risk Management Strategy which will be constantly reviewed throughout the life of the project. The Plan outlines: The objectives of the evaluation; The scope of the evaluation; The outputs to be evaluated and the success criteria against which they will be measured; The performance indicators and measures for these criteria; More detailed information about the Evaluation Steering Group; Identification of the budget and resources for this work; A dissemination plan for ensuring the evaluation results are distributed and used to reappraise the project; and Clarification on the timings for evaluation. Stage 2 Evaluation Requirements for Construction Phase 090113 Malvern FBC v1.2.docx 70

New Hospital and Primary Care Facility for Malvern Full Business Case Progress will be monitored during the construction phase, with outputs evaluated upon completion of this stage of works. Aspects to be evaluated will cover time, cost, service performance as well as management procedures, the design solution and contractors performance etc. Stage 3 Evaluation Requirement During Operational Stage An evaluation covering a wider range of project evaluation criteria and benefits will be undertaken after a suitable bedding in period after the construction phase has been completed. It is anticipated that this will take place circa 6 to 12 months following completion of construction works. Stage 4 Evaluating Longer Term Consequences Further post project evaluations will take place at a later stage, to assess the longer term outcomes of the project, when the full effects have arisen. 9.5.3 Evaluation Team Structure The evaluation will be driven and undertaken by the Evaluation Steering Group. This will be multidisciplinary and drawn from sources both within and outside the PCT, as required. It is planned that the team will have the following membership: Table 13: Evaluation Team Roles and Responsibilities Member Evaluation Project Manager Project Director Interim Director of Finance Provider Services Matron Design Team members Staff Patients / Carers Hospital Advisory Group/League of Friends Role To manage the evaluation in accordance with the Evaluation Plan Input on management processes Input on achieving strategic objectives Input on achieving project objectives Input on financial elements Input on achieving strategic objectives Input on achieving project objectives Input on achieving project objectives Input on design/environmental elements Input on design/environmental elements Input on design/environmental elements Input on design/environmental elements Input on design/environmental elements The stakeholders in the evaluation are as follows: 090113 Malvern FBC v1.2.docx 71

New Hospital and Primary Care Facility for Malvern Full Business Case Worcestershire PCT and its staff; Services users and carers; NHS West Midlands; Department of Health; Advisors. These parties will be involved in the evaluation to varying degrees either as participants or recipients of the final report. 9.5.4 Evaluation of the Project Procurement Stage In developing this stage of the evaluation, the elements evaluated include: The effectiveness of the Project Team including the robustness and skills of the team; Overall project documentation including clarity and substance; Communications and involvement during procurement including internal and external communications and effectiveness; Effectiveness of Advisors including quality of advice, accessibility and value for money; and FBC and the procurement process including production and availability of the FBC, overall costs of the P21 process and timetable to financial close. It is anticipated that in view of the evaluation criteria these aspects will be addressed largely through the use of structured questionnaires involving PCT personnel and external stakeholders including the SHA. 9.5.5 Evaluation of the Project During Construction Key elements will include: Process for design sign off, including timeliness and compliance with initial requirements; Handover of the building. including compliance with the clinical brief and statutory standards; Completion of commissioning, including clinical and operational risk assessments, costs and progress against timetable; and Management of the construction programme, including management against time scales and successful migration. 9.5.6 Evaluation of the Project in Use Shortly after Opening Assessment areas will include: 090113 Malvern FBC v1.2.docx 72

New Hospital and Primary Care Facility for Malvern Full Business Case Operational performance against the plan, including appraisal of service models and actual versus, target capacity and activity; FM performance reviews, utilising contract monitoring reports; and Review of the non financial benefits, utilising the benefits realisation plan and confirmation of any unforeseen benefits. 9.5.7 Evaluation of the Project Once the Hospital is Well Established This stage will include: Assessment of the management of the lifecycle of facilities and equipment including compliance and timing; Review of risk transfer position review against retained risk assessment; and Clarity of actual costs of service provision including assessment of value for money. 9.5.8 Management of the Evaluation Process and Resources to deliver The PPE process will be led on behalf of the PCT by the Director of Provider Services and will be supported by external assistance if required/appropriate. 090113 Malvern FBC v1.2.docx 73

New Hospital and Primary Care Facility for Malvern Full Business Case 10 Conclusion The Full Business Case demonstrates that: The case for a new community hospital in Malvern has not changed since the Outline Business Case was approved in June 2008, and the new hospital remains a key priority for the PCT in meeting key national, regional and local objectives and targets; The project commands strong local community support and is supported by all of the key stakeholders within the local health economy and community; The PCT has followed a robust procurement process since approval of the OBC; The project is affordable to the PCT and the costs are in line with the estimates made at OBC stage; The design of the new hospital meets all of the requirements of the local conservation area and is likely to meet the NHS sustainability requirements; The PCT has established robust project management arrangements to ensure effective management of the project, and has achieved all of the key project milestones to date; There is a clear plan for ensuring that the planned benefits from the new hospital are realised and that a robust project evaluation is carried out at each key stage. The formal approval of the NHS West Midlands to the Full Business Case is sought in order that the PCT can enter into the necessary contractual arrangements with its appointed Principal Supply Chain Partner (Interserve Health) for the construction of the new hospital. 090113 Malvern FBC v1.2.docx 74

New Hospital and Primary Care Facility for Malvern Full Business Case Appendix 1 : Communications & Engagement Strategy 090113 Malvern FBC v1.2.docx 75

NEW MALVERN COMMUNITY HOSPITAL COMMUNICATIONS AND ENGAGEMENT STRATEGY AND ACTION PLAN JULY 2008 1. Background Malvern s new community hospital is due to open in September 2010. It will be larger than the current hospital (24 compared to 18 beds) and will contain a greater number of services including a minor injuries unit. Although the new hospital has been generally welcomed there have been some concerns (mainly about parking and the design of the building). This Communications and Engagement Strategy sets out the vision for actively communicating with, and engaging staff, patients, stakeholders and the public. It builds on the principle that staff, patients and the public must have a significant voice in how NHS and social care is delivered. 2. AIMS The aims of this strategy have been designed to be consistent with the objectives for the Trust. It will: 1. Enable a two-way dialogue between the Trust, its staff, patients, GPs, stakeholders and the local population. This will help improve the services provided at Malvern hospital. 2. Ensure staff in all NHS and partner organisations, have access to adequate information about the new Malvern Hospital. 3. Ensure local GPs and other health professionals have access to adequate information about new developments and the impact they will have on them and their patients. 4. Provide a recognisable identity for the new hospital and the individual developments within it. 5. Enable members of the local community to become involved with the new hospital 6. Build closer relationships between the partner organisations, patients, carers, public and stakeholders, providing support to patients and the public through the LINk and other means to enable them to make a difference and ensuring stakeholders such as the Strategic Health Authority, MPs and Overview and Scrutiny Committees are kept up to date with developments 7. Ensure an appropriate reporting, monitoring and communicating mechanism for activities with accountability to deliver on targets. 8. Ensure a means of identifying and responding to negative media 9. Ensure proactive on-going communications and engagement New Malvern Hospital Comms and Engagement Strategy July 08 76

3. Key Messages The new Malvern Community Hospital will build on the excellent services at the existing hospital It will be a vibrant community hospital which will have more beds for local people It will have more services than the current hospital including a range of outpatient services, diagnostics and a minor injuries unit Patients will be treated in a clean and safe environment Maximum use will be made of its surroundings. Inpatients will have views of the Malvern Hills and be able to make use of the hospital gardens and grounds Members of the public will be involved in shaping the development of the new hospital and the services that will be within it. The Trust will need to understand better how patients wish to access healthcare at the new hospital, what information they will need and how they want to interact with the Trust and its staff. The Trust needs to build even more effective, active and market-focused communications and engagement. 4. Developing Communications and Engagement The Trust needs to build up its relationships with all its stakeholders in Malvern. Historically it has been good at telling people about its activities but, in common with many other NHS organisations, it has not been as proactive in listening to what people want. It needs to have robust feedback mechanisms which allow staff, patients, carers, GPs, opinion formers and the general public to make their voices heard. Traditional routes, such as through complaints or PALs, need to be supplemented with new mechanisms such as a new hospital user group (HUG), planned and proactive engagement with community groups on their own territory, interactive pages on the internet, competition for school children and innovative new ways of engaging hard to reach groups. The Trust must enable a range of views from patients, staff and the public to be gathered and fed into the decision making process. The PCT has been challenged by West Midlands Strategic Health Authority to produce a wow factor for the new hospital. The wow relates to what will take place in the building rather than its design. Members of the public should be invited to suggest what constitutes the wow factor. There should be a planned, annual programme for communicating and engaging with partners and stakeholders. This will include letters, face-toface briefings, newsletters and site visits. There needs to be an active engagement process with the Trust reaching out to embrace the community rather than expecting the community to come to it.. New Malvern Hospital Comms and Engagement Strategy July 08 77

Once this Strategy and Action Plan are implemented stakeholders, patients and the public will: Be able to access enough information about the new Malvern hospital and the services it offers to enable them to make an informed choice about where they wish to be treated Feel the hospital belongs to the community 5. Media Relations The Trust has a good relationship with BBC Hereford and Worcester and the Malvern Gazette. This must be maintained. 6. Public Information Campaign for the move It will be important to have a sustained public awareness campaign about the new hospital and the timetable for the move. Under the strapline we re moving this could include Posters Briefing of GPs Team Talk Bus, radio, street and newspaper advertising Billboards at both the old and new hospital sites during development work Proactive PR campaign concentrating on patient stories Continued communication with the groups and individuals already in contact with the Trust Websites (including intranets) Adverts in patient/community magazines Regular updates in Council publications Regular attendance at organised meetings (internal and external) Briefing MPs (at least quarterly) Regular dialogue with OSC and Link Team briefing for staff 7. Conclusion This strategy is not a one-off tick box exercise. It needs to be a living document which evolves to support the Trust s changing priorities. Methods of communication which will be used to deliver the strategy are outlined in detail in the Action Plan. The purpose of this strategy is to set out a plan for the positive development of the Communication and Engagement function for the new Malvern hospital over the next two years. It will be important to review the plan carefully and to generate any new, specific approaches in response to identified opportunities and threats. New Malvern Hospital Comms and Engagement Strategy July 08 78

New Malvern Hospital Communications and Engagement Strategy Action Plan Date Action Resp Comments June 2008 Press Release - SHA CA Complete approval of outline business case July 2008 Identify stakeholders and RB Already in hand draw up contact list for both e-mail and hard copies Prepare template for a RB Complete regular newsletter for stakeholders and neighbours Brief Malvern Gazette on RB Complete process Press Release RB Complete Appointment of P21 Partner 1 st Newsletter RB Press Release - Planning RB Application submitted Identify opportunities for presenting information about the new hospital to local groups RB/SH August 2008 Send report of preconsultation to everyone who responded Aim to get on the agenda of local community groups including the Civic Society, Rotary, Church groups, WI etc (cross reference with stakeholders). Need to identify all the potential groups and the frequency you will need to meet with them. Can also be sent the PCT s regular stakeholder brief New Malvern Hospital Comms and engagement action plan 1 79

Date Action Resp Comments September Establish Hospital User 2008 Group (HUG) October 2008 December 2008 January 2009 Feb 2009 March 2009 ST/RB/SH to facilitate Start of planned RB/SH programme of engagement with local groups Identify expert patients/service users to help improve services Launch of competition for RB schoolchildren Press Release Planning RB application decision Newsletter published RB 1 st HUG meeting ST/RB/SH Press Release submission of full business case to SHA Results of Competition for RB schools Press Release SHA RB approval of full business case Newsletter published Press Release and Photo RB Opportunity start of construction Install web cams on site to show the public what s going on Put information boards about the project on the perimeter walls Newsletter published Membership to include patients, users, carers, local residents, neighbours, league of friends etc. Group to select a Chair and decide frequency, Lin Ingles to be key member of the group. See separate action plan Already in hand Get Miss France (former matron) to cut the first sod with Lin Ingles and a student nurse RB June 2009 Three Counties Show Part of the PCT s display New Malvern Hospital Comms and engagement action plan 2 80

Date Action Resp Comments August 2009 Newsletter published RB November 2009 Newsletter published RB February 2010 Invite Royal to perform opening ceremony Produce communications ST and engagement action plan for the move Use the strapline we re moving March 2010 Topping out ceremony Marks completion of the roof get key stakeholder to perform ceremony Identify patient stories to be used as part of the public information campaign around the move RB April 2010 Newsletter published RB May 2010 Start of orientation tours for staff Small groups to be shown around the new hospital June 2010 Three Counties Show Part of the PCT s August 2010 September 2010 November 2010 November 2010 Completion Newsletter published Re-issue key pieces of patient information RB display Maps, coming into hospital leaflets, patient letters etc. Follow the patient s journey Listen with a patient s ears to everyone you come into contact with and look at the hospital through a patient s eyes. Move of services Thanksgiving Service for old hospital Official Opening Newsletter published RB Need to recognise that people are very attached to the current hospital and will feel grief at the move Official opening by Royal, celebratory party for patients, stakeholders and staff New Malvern Hospital Comms and engagement action plan 3 81

In addition at each Project Board the team should decide what messages they want to be communicated internally and externally. New Malvern Hospital Comms and engagement action plan 4 82

New Hospital and Primary Care Facility for Malvern Full Business Case Appendix 2 : Stakeholder Support 090113 Malvern FBC v1.2.docx 83

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Upton Surgery Tunnel Hill Upton-upon_Severn Worcs 28/3/08 Dear Alec, I am writing as Chair of the Malvern Practice based Commissioning cluster to support the proposals for a new Malvern Community Hospital. This will be a great opportunity to expand the out-patient facilities currently provided at MCH and also to offer an extensive range of diagnostic tests and surgical and day-case procedures closer to people s homes saving them a trip to Worcester or beyond. Local GPs are very supportive of the development of the new MCH and feel this will significantly enhance the medical care that local residents receive. The Malvern PBC cluster wishes to be very closely involved at all stages of development of the new Malvern Community Hospital. Yours sincerely, Andy Havercroft PBC chair for Malvern Hills PBC cluster 85

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New Hospital and Primary Care Facility for Malvern Full Business Case Appendix 3 : Services & Activity 090113 Malvern FBC v1.2.docx 89

Malvern Community Hospital Existing capacity on sites to be developed Elective services Shift from other providers % PCT shift potential addressed Total capacity following redevelopment Comments Outpatients First 1,501 6,273 3% 7,774 Includes Nurse & Therapist appointments attendances per Includes Nurse & year Follow up 2,155 5,521 2.60% 7,676 Inpatients Day procedures Diagnostics procedures per year (including nonelective) Intermediate care/ step down beds Assessment beds 5,966 844 6,810 0 0 0 Therapist appointments 18 beds in current facility, 24 beds in proposed new hospital to deal with growth in elderly population GP beds 0 0 0 Maternity beds 0 0 0 Other (please give details) 729 729 1,458 End of Life Care Total 6,695 1,573 8,268 Procedures per year Day surgery beds/trolleys X ray Ultra sound MRI CT Pathology 0 837 837 0 0 0 5,300 1,700 0 7,000 Chemotherpy and Minor Surgical Procedures Site will be connected to the NHS data spine and will be PACS-compliant Including maternity 616 778 1,394 ultrasound Existing mobile capacity currently dispersed 0 1,661 1,661 across the Malvern Hills district 0 219 219 0 0 0 Endoscopy Other (please give details) Total 0 370 370 8,000 1,125 9,125 13,916 5,853 19,769 Physio and Occ Therapy direct access 90

Worcestershire PCT Malvern Community Hospital OBC Out Patient Activity Projections PROJECTED ACTIVITY EXISTING ACTIVITY (2008/09 FORECAST OUT TURN) INCREASE 1. OUT PATIENTS NEW FOLLOW UP TOTAL NEW FOLLOW UP TOTAL NEW FOLLOW UP TOTAL 1.1 Consultant Pain Management 380 190 570 0 380 190 570 Rheumatology 380 190 570 0 380 190 570 General Surgery 665 371 1,036 212 122 334 453 249 702 Vascular Surgery 190 190 380 0 190 190 380 Breast Surgery 380 190 570 122 122 244 258 68 326 Orthopaedics 627 912 1,539 420 288 708 207 624 831 Gynaecology 257 266 523 100 146 246 157 120 277 Clinical Haematology 0 247 247 242 242 0 5 5 Paediatrics 200 437 637 152 150 302 48 287 335 General Medicine 190 456 646 74 418 492 116 38 154 Urology 152 190 342 192 288 480 40 98 138 3,420 3,639 7,059 1,272 1,776 3,048 2,148 1,863 4,011 1.2 Nurse/Therapist Diabetes 240 433 673 Dietetics 12 48 60 Urology 192 240 433 Continence 288 192 481 Heart Failure 192 192 385 Multiple Sclerosis 24 72 96 Genetics 24 48 72 Breast Care 12 36 48 Orthopaedic Practitioner 1,250 577 1,827 Orthotics 192 192 385 COPD 48 192 240 Midwifery 592 444 1,036 Speech Therapy 84 168 252 Capacity not yet specified 1,202 1,202 2,404 4,354 4,037 8,391 229 379 608 4,125 3,658 7,783 1.3 Total Out patients 7,774 7,676 15,450 1,501 2,155 3,656 6,273 5,521 11,794 91

Worcestershire PCT Malvern Community Hospital FBC Inpatient Activity Projections v5, sensitivity analysis (this verion incorporates changes outlined in Notes / Assumptions section below) Excludes step down patients currently treated at the Malvern Homeward Bound Unit or other units not listed below Current Hospital site of treatment Malvern Existing Cases (2008/09 Projected) Malvern Existing Bed Days (2008/09 Projected) Malvern Potential New Cases Malvern Potential New Bed Days Total Projected Cases Total Projected Bed Days MALVERN COMMUNITY HOSPITAL 324 5,966 0 0 324 5,966 EVESHAM COMMUNITY HOSPITAL 0 0 21 331 21 331 PERSHORE COTTAGE HOSPITAL 0 0 8 54 8 54 TENBURY AND DISTRICT HOSPITAL 0 0 2 7 2 7 PRINCESS OF WALES COMMUNITY HOSPITAL 0 0 1 14 1 14 WORCESTERSHIRE ROYAL HOSPITAL 0 0 76 273 76 273 ALEXANDRA HOSPITAL 0 0 6 15 6 15 KIDDERMINSTER HOSPITAL 0 0 0 0 0 0 GLOUCESTERSHIRE ROYAL HOSPITAL 0 0 6 24 6 24 CHELTENHAM GENERAL HOSPITAL 0 0 5 20 5 20 TEWKESBURY GENERAL HOSPITAL 0 0 11 106 11 106 Grand Total 324 5,966 136 844 460 6,810 End of Life Care 48 729 48 729 96 1,458 Total Inpatient Requirement 372 6,695 184 1,573 556 8,268 Notes / Assumptions: This sensitivity analysis uses the projected outturn for MCH for 08/09 as its baseline (FCEs 13% higher than 07/08, bed days 16% higher) One outlier has been removed from the dataset (a patient treated for depression at PoWCH with a length of stay of 2,082 days) Key assumptions used in this version are itemised below - for the sensitivity analysis, the % occupancy has been reduced from 95% to 90% Stepdown potential has been identified as bed days in excess of the trim point for each HRG. End of Life Care has been estimated based on existing activity at Malvern, with an assumption about a potential increase in demand. Key assumptions used in the inpatient model: StepDownatMalvern The proportion of potential step down cases / bed days from each geograhical locality that could be stepped down at Malvern Locality % Step Down at Malvern Bromsgrove Droitwich Malvern & Upton 100% Martley, Witley, Tenbury 10% Pershore & Evesham Redditch Worcester 5% Wyre Forest StepDownEfficiencyAndFacilities Used in calculating indicative bed requirements Proportion of Step Down (post Trim) Care that 60% could be Undertaken at Malvern * % Occupancy** 90% Available Bed Days 365 Potential increase in demand for end of life care at 100% Malvern * Takes account of post acute care that requires secondary or tertiary setting, and care provided in other settings eg patients' home, day hospital, nursing home etc ** 95% occupancy also assessed 081231 FBC Activity Appendix.xlsx 92 IP Proj sensitivity analysis 12/01/2009

Malvern Community Hospital GP and social care provision Number of new practices on site 0 Number of practices relocated to site 0 Extended GP surgery hours? 0 Out of hours GP cover based on site? Yes - 2,700 attendances per annum Social care teams based on site? 0 Comments GP practice located in two newbuild facilities nearby in Malvern 93

Malvern Community Hospital Type of staffing (eg nurse/consultant led) Services available Urgent care Existing attendances per year Attendances Total expected attendances on site following redevelopment Expected shift from other providers Comments Walk in centre 0 0 0 Minor injury unit Nurse-led Emergency Assessments 0 3,800 Reduction in attendances at 2,800 A&E dept Urgent care centre 0 0 0 94

New Hospital and Primary Care Facility for Malvern Full Business Case Appendix 4 : Healthy Lifestyle Services PID 090113 Malvern FBC v1.2.docx 95

Malvern Community Hospital Healthy Lifestyles Initiatives Project Initiation Document Date: 09 Jan 2009 PROJECT DOCUMENTATION PROJECT INITIATION DOCUMENT Malvern Community Hospital Healthy Lifestyles Initiatives Release: For Business Case Date: 09 January 2009 PRINCE 2 Author: Philip Siegert Owner: Frances Howie Client: WPCT, Malvern Community Hospital Document Number: MCH/HLI/PID/v0.2 96

Malvern Community Hospital Healthy Lifestyles Initiatives Project Initiation Document Date: 09 Jan 2009 Project Initiation Document History Document Location This document is only valid on the day it was printed. The source of the document will be found on the project's PC in location Revision History Date of this revision: 9 Jan 2008 Revision Version Summary of Changes Changes date marked 09.01.09 0.2 Comments incorporated, plan added No Approvals This document requires the following approvals. Signed approval forms are filed in the Management section of the project files. Name Signature Title Date of Version Issue Frances Howie Public Health Director 17.12.08 0.2 HLI Project Lead Teresa French CEO, Provider 17.12.08 0.2 Services Lisa Levy Associate Director MCH Clinical Lead Linda Ingles Modern Matron Distribution This document has been distributed to Name Title Date of Version Issue Frances Howie Public Health Director - HLI Project Lead 17.12.08 0.1 Teresa French CEO, Provider Services 17.12.08 0.1 97

Malvern Community Hospital Healthy Lifestyles Initiatives Project Initiation Document Date: 09 Jan 2009 Project Initiation Document Purpose of Document The purpose of this document is to define the project, to form the basis for its management and the assessment of overall success. Background The Malvern Community Hospital replacement project is underway and is expected to complete in Autumn 2010. As part of the project, as well as the reprovision of the existing beds and outpatient services in a new and efficient building, a wide range of new services will be provided. Some of these services are grouped under the working title of Healthy Lifestyle Services A Health Needs Assessment has been developed which identifies the need and opportunity to deliver health improvement initiatives for the population of Malvern and its surroundings. The following is identified as being of immediate consideration and likely to generate a set of requirements for the hospital building project. Consultant led falls clinics Use of the outside space of the hospital for exercise, rehabilitation and community activities Provision of static and interactive health information Facilities for community use, peer support and group work. This project will feed into the overall project development project communicating requirements and needs at a timely fashion as well as designing and initiating the new services for handover to the operational teams to coincide with the hospital opening. Project Definition Project Objectives The project objectives are to: Convert the finding of the Health Needs Assessment into tangible, resourced, workable services in time for the opening of the new hospital the Healthy Lifestyles Initiatives. Work with local PCT management and clinical staff to develop a package of patient focused services that complement the overall objectives of the new community hospital 98

Malvern Community Hospital Healthy Lifestyles Initiatives Project Initiation Document Date: 09 Jan 2009 Communicate the needs of the Healthy Lifestyles Initiatives to the overall project and the developer to ensure that all necessary physical implementation is defined, managed and co-ordinated. Manage the transition from design and development into operational services Engage with and involve the local community and voluntary sectors in appropriate aspects of the Healthy Lifestyles Initiatives Project Scope The Health Needs Assessment identifies the following areas for initial consideration: A Consultant Led Falls Clinic o Provision of a suitably equipped room to enable visiting Consultants to run clinics o Commission Consultant involvement in line with the Worcestershire Falls Prevention strategy Maximisation of the health improvement potential of the outside space, including outdoor exercise equipment for adults, a productive community garden and a school link plot o Specify and procure, through the Design and Build Contractor, an appropriate exercise facility (Trim trail or similar) o Engage with clinicians and local horticultural organisations to design and implement hospital and schools based garden projects. o Provide input to the procurement of wider hospital gardening services as appropriate o Co-ordinate with the needs and aspirations of the Malvern in Bloom initiative as appropriate A community hub for health information o Design, specify and procure health information to be disseminated o Design and specify the access methodology, technical equipment and user support for the health information. Procure as necessary. o Provide a design brief to the Design and Build Contractor to ensure all necessary enabling works are included within the Building project A facility for peer support and group work on health improvement areas o Engage with clinicians and voluntary services to establish what groups are required in the Malvern Area o Liaise with health care professional and the like to design and deliver sessions. o Work with Hospital managers to ensure fit with core clinical objectives and co-ordination with other hospital users 99

Malvern Community Hospital Healthy Lifestyles Initiatives Project Initiation Document Date: 09 Jan 2009 Method of Approach Project Deliverables and/or Desired Outcomes Set Up and resource a Healthy Lifestyles Project Team Provide a specialist falls clinic room within the hospital Engage Consultant(s) to deliver clinics Prepare and deliver a Specification for an outdoor exercise facility, review design proposals and approve Design and implement garden based projects with hospital management, local horticultural bodies and schools Procure and install as necessary the equipment and structures required to support gardening projects Design a Health Information facility including written materials and access portals Procure health information systems Set up peer group training and support sessions Exclusions The project will not be responsible for the operational management of the Healthy Lifestyles Initiatives this will be the responsibility of the hospital management team. Constraints The project must adhere to the overall New Malvern Community Hospital Project Plan Interfaces The project interfaces with: The New Malvern Community Hospital Project (of which this is a sub-project) o The Project Board and Project Team o The Design and Build Contractor The hospital management team The local stakeholders The Malvern Hills Practice Based Commissioning Cluster Assumptions It is assumed that the findings and recommendations described in the Health Needs Assessment represent an accurate interpretation of the needs of the users of the New Malvern Community Hospital Initial Business Case Refer to the Outline and Full Business Cases for the New Malvern Community Hospital 100

Malvern Community Hospital Healthy Lifestyles Initiatives Project Initiation Document Date: 09 Jan 2009 Project Organisation Structure The Healthy Lifestyles Initiatives Project Team will report to the Overall Project Team and input its needs into the technical teams are required. The Team will be made up as follows: Chair - Teresa French, CEO WPCT Provider Services Project Lead - Melanie Whistance Public Health Hospital Rep - Lin Ingles, Malvern CH Matron Community Representation - Malvern In Bloom, Malvern Hospital League of Friends etc Schools Representation - tba Malvern Hills PBC Cluster - tba Clinical Input - Malvern CH, Physiotherapy Team Leader Technical Input - Interserve, Ad Hoc as required Communications Plan The Healthy Lifestyles Project will communicate with its immediate stakslhplde4rsv directly and through the main project. Detailed plan tbc Project Quality Plan tbd Initial Project Plan See attached Draft Implementation Plan Project Controls The Healthy Initiatives project team will meet on a regular basis. Meetings will be minuted and issues and risks recorded. A representative will attend the Hospital Project Board and Team meetings. An initial scoping document will be prepared and this will be used to control, the scope of the project A project plan will be prepared and signed off and this will be used to manage progress A project budget will be prepared in line with the overall project budget and this will be used to expenditure against budget 101

Malvern Community Hospital Healthy Lifestyles Initiatives Project Initiation Document Date: 09 Jan 2009 Deviations from scope, time and/or budget will be escalated to the New Hospital Project Team Initial Risk Log The main risks are: Failure to meet the timescales demanded by the hospital project Failure to encourage suitably qualified clinicians to use the facilities as expected Poor take up of outside space equipment Lack of support from local community and schools for the gardening initiatives Information access portals not user friendly 102

ID Task Name 1 MALVERN HOSPITAL - HEALTHY LIFESTYLES INITIATIVES 2 Initiation/Specification 3 Prepare Health Needs Assessment 4 Design and Agree Service Mix/Offering 5 Provide Performance Specification for Interserve 6 Service Design 7 Prepare Outline Service Specifications 8 Specialist Clinics 9 Use of Outside Space 10 Clinical Uses 11 Community Uses 12 Health Information 13 Shared Use of Facilities 14 Agree with Hospital User Group and main stakeholders 15 Approve Main Contractor Equipment Designs 16 Community Engagement 17 Commence Full HLI Community Involvement Programme 18 Management Design 19 Sign Up Schools 20 Clinical Service Design 21 Confirm Health Needs Assessment 22 Stakeholder Sessions 23 Clinical Specifications 24 Clinical Approval - PCT 25 Clinical Implementation 26 Recruitment 27 Promote new Sessions 28 Engage with Hospital Commissioning Activities 29 Commence Sessions 30 Early Feedback and Review 31 Confirm Service Operational 32 Business as Usual 33 Health Information Design 34 Agree Content 35 Prepare Specification - content, management 36 Procure Technical Provider 37 Appoint Provider 38 Implementation 39 Witness and sign off content 40 Site Installation 41 Test 42 Go Live 43 Review Performance - Hand Over 44 Outside Space Usage 45 tbc Malvern Community Hospital - Healthy Lifestyles Initiatives DRAFT Implementation Plan 46 PROJECT CLOSURE AND HAND TO HOSPITAL BOARD 2009 2010 2011 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 02/12 27/01 11/01 11/01 01/06 04/01 16/07 Mon 12/01/09 01/10 10/09 29/10 29/10 29/10 08/10 29/10 Project: Healthy Lifestyles Implementatio Date: Mon 12/01/09 Task Split Progress Milestone Summary Rolled Up Task Rolled Up Split Rolled Up Milestone Rolled Up Progress External Tasks Project Summary External Milestone Deadline Page 1 103 DRAFT

New Hospital and Primary Care Facility for Malvern Full Business Case Appendix 5 : Location & Site 090113 Malvern FBC v1.2.docx 104

Osborne Road Hospital Site Malvern Link Rail Station Worcester Road 105

1:12 stone retaining wall (ht 1.60) GARDENS brick & stone wall (ht 1.30) 73.43 73.24 73.08 72.99 concrete 73.00 72.86 lp 72.93 72.84 72.62 72.555 72.62 72.40 72.53 b t 72.43 72.25 72.36 stone wall (ht 1.25) GARDENS 74.37 74.19 100.236 74.18 73.99 73.95 73.77 73.82 73.74 73.64 73.60 99.952 73.59 73.67 73.39 73.40 73.50 99.610 73.09 99.483 73.15 73.233 stone wall (ht 1.70) 73.05 O S B O R N E R O A D 73.20 72.57 72.85 72.99 Existing masonry wall 72.65 72.82 72.17 72.47 72.65 71.91 (2)0.15Ø 72.32 72.49 72.15 72.33 71.86 72.15 72.03 72.30 72.22 72.07 stone wall (ht 1.0) 72.01 375mm FWS 72.22 GARAGES G2 5.080 RG2 101.272 74.14 74.08 74.21 73.78 100.109 73.91 73.76 99.971 73.55 GARDEN 72.54 EOT WATER PIPE 72.05 GARDEN slope 72.26 (3)0.15Ø 72.19 74.40 71.72 0.30Ø acer 0.25Ø acer (2)0.30Ø 72.29 0.20Ø 72.18 71.98 71.95 72.13 101.5 102.134 RG13 102.205 919 102.934 101.253 101.234 102.404 102.5 re 101.159 101.378 NHS DENTAL CENTER PROPERTY ramp 0.25Ø 73.76 0.25Ø 0.30Ø 100.641 74.12 brick wall remains New 1.8m high close boarded timber fence E 74,120 73.28 73.75 Stone wall 73.98 73.25 73.75 P 72,350 72.77 72.85 72.67 73.07 Staff garden 72.72 72.26 Medical gas store Wall Site of mobile facilities Hard standing 72.55 Oxygen compound for deliveries 72.04 72.20 150mm ic EOT 71.69 71.69 71.90 The basin 0.20Ø (3)0.20Ø 71.40 0.25Ø 71.56 71.77 WATER PIPE 71.42 72.04 0.30Ø (2)0.35Ø st 0.45Ø 72.06 71.94 72.11 71.78 71.58 71.82 71.89 72.09 lp 71.89 71.90 stone wall (ht 1.70) stone wall (ht 1.0) 72.09 72.04 71.84 g Gate to be locked out of hours 71.94 71.98 03.501 ARDENS 3.507 103.5 103.476 IC cl 103.57 il 102.29 g y 103.704 103.718 103.457 103.562 103.401 103.5 103.769 103.678 wooden slatted fence 1.70m high 101.142 225mm FWS Patient garden 0.25Ø 0.25Ø 74.55 multi 100.283 74.02 73.79 ramp 99.981 100.437 door 73.63 conc H O S P I T A L 73.53 73.72 73.67 FFL 72,500 275 canopy multi conifer 73.85 T2 73.74 P 72,500 Cycle parking with overhead canopy Bridge over 73.14 72.78 Wall 72.87 T4 Bin Store 72.48 G3 72.42 P 72,500 Deliveries Pergola 72.25 3 spaces 71.94 71.90 multi 0.15Ø s/birch Generator and Fuel Tank 72.07 71.54 71.31 multi 71.43 71.77 71.57 72.13 71.46 72.00 0.40Ø 71.82 0.40Ø 71.57 72.18 0.10Ø 72.01 O S B O R N 72.45 72.29 71.9 72 72.23 103.412 103.638 103.518 3.596 103.692 103.818 104.455.483 104.463 76 100mm SWS 225 FWS 104.0 77.13 76.44 77.01 lp GARDENS brick wall (ht2.50) block ret wall (ht 0.50) multi GARDENS 104.0 76.41 77.09 76.40 area of foliage brick wall (ht 2.50) 76.37 76.41 New 1.8m high close boarded timber fence 103.5 102.956 103.5 103.0 76.40 0.20Ø 102.5 102.514 102.483 103.007 102.594 (ht 1.80) 0.15Ø 0.15Ø 0.10Ø 76.40 76.37 76.81 77.10 76.10 0.20Ø (2)0.20Ø 0.40Ø (3)0.20Ø 102.106 0.40Ø trunk Ramp (2)0.15Ø 76.44 76.54 0.20Ø 1ST 76,500 Upper terrace 75.77 (3)0.15Ø 75.65 Patient first floor garden Heat pump enc 76.61 0.20Ø 76.08 76.81 ST14 0.20Ø (2)0.20Ø 76.13 (2)0.15Ø (2)0.10Ø 0.20Ø Stone wall 75.83 75.90 76.17 75.54 75.95 Malvern stone wall RAMP RAMP Gravel border RAMP 76.23 Feature lawn 75 spaces Drop off 10 spaces 26 spaces Canopy over 1:15 Crossing Crossing Crossing 1:20 74.98 74.62 75.34 73.96 iron mesh fence (ht 3.50) 73.76 EOT 74.63 Drop off 76.05 0.20Ø 0.15Ø Feature lawn 75.38 RAMP 76.23 75.84 Gravel border (3)0.15Ø 73.61 G30 75.11 75.77 Stone wall 75.87 73.61 1:20 Security 72.87 Dropped kerb 74.90 Seat Dropped kerb Barrier 75.43 75.63 Gated barrier 72.89 Stone wall Seat 73.85 Assumed boundary line 1:20 G30 75.49 75.48 0.70Ø 72.45 75.44 0.25Ø fruit 73.92 0.20Ø 74.04 72.39 0.40Ø multi 73.32 73.86 73.93 75.37 75.17 73.09 73.76 73.89 73.70 73.62 73.72 73.89 74.53 12 spaces 74.85 0.20Ø 73.73 72.58 72.60 73.79 brick wall (ht 1.50) lp EOT 74.81 (3)0.30Ø acer 72.58 72.49 74.93 72.53 73.82 72.53 72.42 72.59 up 73.80 74.63 74.93 72.48 74.17 0.30Ø 74.47 74.93 74.27 72.48 74.56 72.33 72.51 73.67 b t 72.54 73.72 72.45 post b t cl 72.47 74.10 73.07 74.32 74.20 72.81 72.13 72.46 72.44 SEAFORD LODGE 72.15 brick wall (ht 1.50) 74.29 74.53 tp ST05 72.60 72.46 74.13 74.00 72.3 72.6 7 (2)0.30Ø 0.20Ø 78.14 77.60 (2)0.30Ø 76.86 Bike parking 77.57 (2)0.20Ø 76.99 76.66 77.08 28 spaces 0.20Ø 76.64 Crossing tp 76.72 76.48 76.47 RAMP 76.08 76.09 Dropped kerb 76.31 76.11 75.73 ENTRANCE 75.79 Dropped kerb 75.42 75.48 Visibility splay Visibility splay 75.08 W O R C E S T E R R O A D 75.54 74.94 s v 75.09 75.00 brick setts 74.77 78.42 78.40 GARDENS brick wall (ht 2.50) private property pit 77.99 78.23 79.10 s/birch 0.20Ø 77.31 0.20Ø 77.82 0.15Ø 11 spaces 0.15Ø 0.15Ø 77.55 77.73 76.93 Visitor Contemplation Garden Gas meter housing 77.58 stone wall (ht 1.50) 77.42 76.94 g 76.79 76.70 0.55Ø 76.28 g 76.29 lp76.40 75.90 0.70Ø P6 05/11/08 Gas meter housing relocated IB P5 22/07/08 Revised overhead walkway to bin store, wall beneath EKLW P4 18/07/08 Parking revised, trees revised. HRW P3 08/07/08 Parking area revised, path added. M and E information added. Pond added. Rev No. Date Revision HRW P2 06/06/08 Delivery areas revised HRW Author 0.35Ø 78.26 78.13 Gate to be locked out of hours 79.61 0.20Ø 0.50Ø 78.53 lp 78.35 77.97 b t 77.45 0.65Ø 77.27 a r c h i t e c t s The Design Büro (Coventry) Ltd The Stables, Newtown Grange Farm Business Park, Desford Road 79.14 77.99 grass Newtown Unthank, LE9 9FL Telephone: 01455 828986 Fax: 01455 828987 www.designburo-architects.co.uk KEY Grass seed or turf Site boundary. Exact boundary to be clarified. New gravel edge New soft landscaping beds New Tarmac footpath with granite set edging New block paving Existing tree to remain Existing tree to be felled. P 00,000 E 00,000 Proposed level Existing level to remain New Pergola New stainless steel glazed canopy New stainless steel lighting bollard - 70W SON PLEASE REFER TO LANDSCAPE DRAWING NO 0765 002 A N Client Job Ref Dwg Title Malvern Community Hospital Site Plan Drawn Date Checked Date HRW 22/05/08 ---- ---- Job Number DBC610 1:250 A1 DBC610 Scale Dwg Number P005 Drawing Size Revision P6 New yorkshire stone feature circle New red brick running bond path Hinged lighting 106 column. 70W SON - T Indus IP65 lantern mounted on 5 m column. The copyright of this drawing is vested in the Architect/ Designer and must not be copied or reproduced without his written consent. Figured dimensions only to be taken from this drawing. All contractors and / or specialists must visit the site and be responsible for taking and checking all dimensions relative to this work.

New Hospital and Primary Care Facility for Malvern Full Business Case Appendix 6 : Schedules of Accommodation 090113 Malvern FBC v1.2.docx 107

Malvern Community Hospital Room Number Facility Size - SQM Cumulative Total GIFA Adjusted Floor Area DCAG Area ON COST Area AD-GF-003 Reception: 3 staff 23.3 23.3 24.4 24.4 0.0 AD-GF-112 Corridor 44.0 44.0 46.2 46.2 0.0 AD-GF-113 Admin Staff Office: 2 staff 12.0 12.0 12.6 12.6 0.0 AD-GF-115 Cleaners cupboard (wet) 5.7 5.7 6.0 6.0 0.0 AD-GF-117 Beverage, snack preparation room 8.0 8.0 8.4 8.4 0.0 AD-GF-118 Office: 4 staff 34.0 34.0 35.7 35.7 0.0 AD-GF-119 Printer/photocopier room 9.0 9.0 9.4 9.4 0.0 AD-GF-120 Store: records 12.5 12.5 13.1 13.1 0.0 AD-GF-121 Office: Medical Secretaries, 4 staff 31.0 31.0 32.5 32.5 0.0 AD-GF-122 Post Room 15.7 15.7 16.5 16.5 0.0 AD-GF-124 Store: equipment 7.5 7.5 7.9 7.9 0.0 AD-GF-125 Store: general 28.7 28.7 30.1 30.1 0.0 231.4 242.7 242.7 0.0 Room Number Facility SCHEDULE OF ACCOMMODATION MALVERN COMMUNITY HOSPITAL GROUND FLOOR ADMINISTRATION DAY TREATMENT Size - SQM Cummulati ve Total GIFA Adjusted Floor Area DCAG Area ON COST Area DT-GF-056 Corridor 61.5 61.5 64.5 64.5 0.0 DT-GF-059 Activities of daily living 22.0 22.0 23.1 23.1 0.0 DT-GF-060 Recreation room 23.5 23.5 24.7 24.7 0.0 DT-GF-062 Consulting, examination, treatment room: doublesided couch access 12.8 0.0 12.2 12.2 12.8 DT-GF-063 Consulting, examination, treatment room: doublesided couch access 12.8 0.0 12.2 12.2 12.8 DT-GF-064 Consulting, examination, treatment room: doublesided couch access 12.8 0.0 12.2 12.2 12.8 DT-GF-065 WC & handrinse: ambulant / semi assisted 7.2 7.2 7.6 ambulant patient. 7.6 0.0 DT-GF-068 Beverage, snack preparation room 5.5 5.5 5.8 5.8 0.0 DT-GF-069 Dirty utility 11.3 11.3 11.9 11.9 0.0 DT-GF-070 Clean utility 10.0 10.0 10.5 10.5 0.0 DT-GF-071 Office: 4 staff 17.5 17.5 18.4 18.4 0.0 DT-GF-072 Store: general 6.8 6.8 7.1 7.1 0.0 DT-GF-073 Store: linen 2.0 2.0 2.1 2.1 0.0 DT-GF-074 Cleaners cupboard (wet) 5.7 5.7 6.0 6.0 0.0 209.6 220.1 219.9 0.0 Design Buro SOA Page 1 of 8 108

Malvern Community Hospital Room Number Facility Size - SQM Cummulati ve Total GIFA Adjusted Floor Area DCAG Area ON COST Area EN-GF-105 Corridor 9.8 9.8 10.3 10.3 0.0 EN-GF-105a Recovery Chairs 3.6 3.6 3.8 3.8 0.0 EN-GF-106 Recovery 21.0 21.0 22.0 22.0 0.0 EN-GF-106a Changing Cubicle 3.0 3.0 3.1 3.1 0.0 EN-GF-107 Major treatment 23.0 23.0 24.1 24.1 0.0 EN-GF-108 Scope Clean 14.6 14.6 15.3 15.3 0.0 75.0 78.7 78.7 0.0 Room Number Facility Size - SQM Cummulati ve Total GIFA Adjusted Floor Area DCAG Area ON COST Area FA-GF-024 Corridor / Holding bay 45.5 45.5 47.7 47.7 0.0 FA-GF-025 Locker room: 5 places 4.8 4.8 5.0 5.0 0.0 FA-GF-026 WC & handrinse: ambulant / semi assisted 5.6 5.6 5.9 ambulant patient. 5.9 0.0 FA-GF-027 Staff sanitary facility: 1 shower 4.8 4.8 5.0 5.0 0.0 FA-GF-028 Store: equipment 5.7 5.7 6.0 6.0 0.0 FA-GF-029 Regen Kitchen 38.2 38.2 40.1 40.1 0.0 FA-GF-030 Store: general 12.0 12.0 12.6 12.6 0.0 FA-GF-031 Central wash-up 17.0 17.0 17.8 17.8 0.0 FA-GF-032 Office: 2 staff 8.3 8.3 8.7 8.7 0.0 FA-GF-033 Cleaners cupboard (wet) 13.5 13.5 14.2 14.2 0.0 FA-GF-034 Store: general 18.3 18.3 19.2 19.2 0.0 FA-GF-035 Store: linen 13.0 13.0 13.6 13.6 0.0 186.7 195.8 195.8 0.0 Room Number Facility GROUND FLOOR ENDOSCOPY FACILITIES GROUND FLOOR MINOR INJURIES Size - SQM Cummulati ve Total GIFA Adjusted Floor Area DCAG Area ON COST Area MI-GF-010 Subwait area: 3 persons including 1 wheelchair 8.1 8.1 8.5 user 8.5 0.0 MI-GF-010a Triage 6.1 6.1 6.4 6.4 0.0 MI-GF-011 Office nursing: 1 staff 8.1 8.1 8.5 8.5 0.0 MI-GF-012 Corridor 71.7 71.7 75.2 75.2 0.0 MI-GF-012a Linen Store 1.0 1.0 1.0 1.0 0.0 MI-GF-013 Consulting, examination, treatment room: doublesided couch access 15.6 0.0 14.9 14.9 15.6 MI-GF-014 Consulting, examination, treatment room: doublesided couch access 14.9 0.0 14.2 14.2 14.9 MI-GF-015 Consulting, examination, treatment room: doublesided couch access 15.1 0.0 14.4 14.4 15.1 MI-GF-016 Resuscitation bay: 1 place 14.5 14.5 15.2 15.2 0.0 MI-GF-017 Treatment room: Plaster 15.0 15.0 15.7 15.7 0.0 MI-GF-018 Decontamination: 1 shower 5.5 5.5 5.8 5.8 0.0 MI-GF-019 WC & handrinse: ambulant / semi assisted 5.6 5.6 5.9 ambulant patient. 5.9 0.0 MI-GF-020 Store: equipment 4.0 4.0 4.2 4.2 0.0 MI-GF-021 Dirty utility 8.2 8.2 8.6 8.6 0.0 MI-GF-022 Beverage, snack preparation room 4.0 4.0 4.2 4.2 0.0 MI-GF-023 Clean utility 8.9 8.9 9.3 9.3 0.0 MI-GF-038 Hold: disposal 7.5 7.5 7.9 7.9 0.0 211.7 222.1 222.1 0.0 Design Buro SOA Page 2 of 8 109

Malvern Community Hospital Room Number Facility OUT PATIENTS Size - SQM Cummulati ve Total GIFA Adjusted Floor Area DCAG Area ON COST Area OP-GF-092 Corridor 46.0 46.0 48.3 48.3 0.0 OP-GF-093 Consulting, examination, treatment room: doublesided couch access 15.9 0.0 15.2 15.2 15.9 OP-GF-094 Consulting, examination, treatment room: doublesided couch access 15.2 0.0 14.5 14.5 15.2 OP-GF-095 Consulting, examination, treatment room: doublesided couch access 15.2 0.0 14.5 14.5 15.2 OP-GF-096 Consulting, examination, treatment room: doublesided couch access 15.2 0.0 14.5 14.5 15.2 OP-GF-097 Consulting, examination, treatment room: doublesided couch access 15.2 0.0 14.5 14.5 15.2 OP-GF-098 Consulting, examination, treatment room: doublesided couch access 15.2 0.0 14.5 14.5 15.2 OP-GF-099 Consulting, examination, treatment room: doublesided couch access 16.0 0.0 15.3 15.3 16.0 OP-GF-100 Trolley Store 2.7 2.7 2.8 2.8 0.0 OP-GF-101 WC & handrinse: ambulant / semi assisted 5.5 5.5 5.8 ambulant patient. 5.8 0.0 OP-GF-102 Store 2.5 2.5 2.6 2.6 0.0 OP-GF-103 Clean utility 8.7 8.7 9.1 9.1 0.0 OP-GF-104 Dirty utility 9.5 9.5 10.0 10.0 0.0 OP-GF-114 Store: linen 2.6 2.6 2.7 2.7 0.0 OP-GF-116 Store (orthotics) 2.8 2.8 2.9 2.9 0.0 183.3 192.3 192.3 0.0 Design Buro SOA Page 3 of 8 110

Malvern Community Hospital Room Number Facility Size - SQM Cummulati ve Total GIFA Adjusted Floor Area DCAG Area ON COST Area PH-GF-066 WC & handrinse: ambulant / semi assisted 6.2 6.2 6.5 ambulant patient. 6.5 0.0 PH-GF-067 Interview/counselling/advisory room: 4 persons 11.5 11.5 12.1 12.1 0.0 PH-GF-075 Corridor 58.0 58.0 60.8 60.8 0.0 PH-GF-076 Office; 3 staff 11.6 11.6 12.2 12.2 0.0 PH-GF-077 Treatment Room, double sided couch access. 11.3 11.3 11.9 11.9 0.0 PH-GF-078 Treatment Room, double sided couch access. 11.5 11.5 12.1 12.1 0.0 PH-GF-079 Treatment Room, double sided couch access. 11.5 11.5 12.1 12.1 0.0 PH-GF-080 Treatment Room, double sided couch access. 11.5 11.5 12.1 12.1 0.0 PH-GF-081 Treatment Room, double sided couch access. 11.8 11.8 12.4 12.4 0.0 PH-GF-082 Store: general 8.0 8.0 8.4 8.4 0.0 PH-GF-083 Activities area: Physiotherapy, 10 places 58.0 58.0 60.8 60.8 0.0 PH-GF-083a Activity space 26.0 26.0 27.3 27.3 0.0 PH-GF-084 Store: general 4.9 4.9 5.1 5.1 0.0 PH-GF-085 Store: general 4.9 4.9 5.1 5.1 0.0 PH-GF-086 Treatment Room, double sided couch access. 12.0 12.0 12.6 12.6 0.0 PH-GF-087 Treatment Room, double sided couch access. 11.9 11.9 12.5 12.5 0.0 PH-GF-088 Office: 5 staff 22.6 22.6 23.7 23.7 0.0 PH-GF-089 Treatment Room, double sided couch access. 11.9 11.9 12.5 12.5 0.0 PH-GF-090 Treatment Room, double sided couch access. 11.9 11.9 12.5 12.5 0.0 PH-GF-091 Interview/counselling/advisory room: 4 persons 6.0 6.0 6.3 6.3 0.0 323.0 338.8 338.8 0.0 Room Number Facility GROUND FLOOR PHYSIOTHERAPY RADIOLOGY Size - SQM Cummulati ve Total GIFA Adjusted Floor Area DCAG Area ON COST Area RA-GF-044 Corridor 30.7 30.7 32.2 32.2 0.0 RA-GF-045 WC & handrinse: ambulant / semi assisted 5.9 5.9 6.2 ambulant patient. 6.2 0.0 RA-GF-046 Scan Room 11.5 11.5 12.1 12.1 0.0 RA-GF-047 Patient changing cubicle: ambulant person 3.1 3.1 3.3 3.3 0.0 RA-GF-048 Patient changing cubicle: ambulant person 3.1 3.1 3.3 3.3 0.0 RA-GF-049 Patient changing cubicle: ambulant person 3.1 3.1 3.3 3.3 0.0 RA-GF-050 Patient changing cubicle: ambulant person 3.1 3.1 3.3 3.3 0.0 RA-GF-051 Processing, viewing room 8.2 8.2 8.6 8.6 0.0 RA-GF-052 Parking, waiting bay: patient trolley (x-ray top) 4.7 4.7 4.9 4.9 0.0 RA-GF-053 X-ray room 30.8 30.8 32.3 32.3 0.0 RA-GF-054 Scan Room 13.3 13.3 14.0 14.0 0.0 RA-GF-055 Office: 2 staff 15.0 15.0 15.7 15.7 0.0 132.5 139.0 139.0 0.0 Design Buro SOA Page 4 of 8 111

Malvern Community Hospital Room Number Facility Size - SQM Cummulati ve Total GIFA Adjusted Floor Area DCAG Area ON COST Area SH-GF-001 Main entrance draught lobby 11.5 11.5 12.1 12.1 0.0 SH-GF-002 Waiting area: 40 persons including 4 wheelchair 192.0 192.0 201.4 users 201.4 0.0 SH-GF-004 WC & handrinse: ambulant / semi assisted 4.1 4.1 4.3 ambulant patient. 4.3 0.0 SH-GF-004a WC Lobby 5.4 5.4 5.7 5.7 0.0 SH-GF-005 Nappy change room with handwash 6.5 6.5 6.8 Baby/infant 6.8 0.0 SH-GF-006 WC & handrinse: ambulant / semi assisted 4.2 4.2 4.4 ambulant patient. 4.4 0.0 SH-GF-007 Lobby to stairwell / lift 9.0 9.0 9.4 0.0 9.4 SH-GF-008 Stairwell 23.0 23.0 24.1 0.0 24.1 SH-GF-009 Lift 7.5 7.5 7.9 0.0 7.9 SH-GF-036 Store: community disability equipment 8.0 8.0 8.4 8.4 0.0 SH-GF-039 Lobby to stairwell / lift 12.0 12.0 12.6 0.0 12.6 SH-GF-040 Lift 7.5 7.5 7.9 0.0 7.9 SH-GF-041 Stairwell 20.2 20.2 21.2 0.0 21.2 SH-GF-042 Lobby to stairwell / lift 12.0 12.0 12.6 0.0 12.6 SH-GF-043 Lift 7.5 7.5 7.9 0.0 7.9 SH-GF-057 Lobby to stairwell / lift 5.8 5.8 6.1 0.0 6.1 SH-GF-058 Stairwell 19.8 19.8 20.8 0.0 20.8 SH-GF-061 Stairwell 18.0 18.0 18.9 0.0 18.9 SH-GF-110 Lobby to stairwell / lift 3.7 3.7 3.9 0.0 3.9 SH-GF-111 Stairwell 21.0 21.0 22.0 0.0 22.0 SH-GF-123a Lobby 6.0 6.0 6.3 0.0 6.3 404.7 424.5 243.1 181.5 Room Number Facility GROUND FLOOR SHARED FIRST FLOOR ADMINISTRATION Size - SQM Cummulati ve Total GIFA Adjusted Floor Area DCAG Area ON COST Area AD-FF-058 Corridor 69.5 69.5 72.9 72.9 0.0 AD-FF-058a Store 3.8 3.8 4.0 4.0 0.0 AD-FF-058b Store 4.0 4.0 4.2 4.2 0.0 AD-FF-059 Meeting Room 30.0 30.0 31.5 31.5 0.0 AD-FF-060 Beverage, snack preparation room 31.0 31.0 32.5 32.5 0.0 AD-FF-061 Office: 1 staff 17.6 17.6 18.5 18.5 0.0 AD-FF-062 Office: 1 staff 7.4 7.4 7.8 7.8 0.0 AD-FF-063 Stairwell 18.0 18.0 18.9 0.0 18.9 AD-FF-064 Office: 1 staff 8.1 8.1 8.5 8.5 0.0 AD-FF-065 Office: 1 staff 11.2 11.2 11.7 11.7 0.0 AD-FF-066 Office: 1 staff 13.0 13.0 13.6 13.6 0.0 AD-FF-067 Office: 1 staff 11.6 11.6 12.2 12.2 0.0 AD-FF-068 Lobby to stairwell / lift 5.8 5.8 6.1 0.0 6.1 AD-FF-069 Stairwell 19.7 19.7 20.7 0.0 20.7 AD-FF-071 Computer communication: IT hub room 22.5 22.5 23.6 23.6 0.0 AD-FF-072 Staff sanitary facility: 1 shower; Male 16.0 16.0 16.8 16.8 0.0 AD-FF-073 Library / Study room 10.0 10.0 10.5 10.5 0.0 AD-FF-075 Staff sanitary facility: 1 shower: Female 25.0 25.0 26.2 26.2 0.0 324.2 340.2 294.5 45.6 Design Buro SOA Page 5 of 8 112

Malvern Community Hospital Room Number Facility Size - SQM Cummulati ve Total GIFA Adjusted Floor Area DCAG Area ON COST Area WA-FF-001 Waiting area: 5 persons including 1 wheelchair 127.5 127.5 133.7 user 133.7 0.0 WA-FF-002 Reception: 1staff 6.5 6.5 6.8 6.8 0.0 WA-FF-003 Staff base: 4 staff 21.5 21.5 22.6 22.6 0.0 WA-FF-004 Bath, WC & Wash: ambulant / semi assisted 15.0 15.0 15.7 ambulant patient. 15.7 0.0 WA-FF-005 Store: general 9.7 9.7 10.2 10.2 0.0 WA-FF-006 Doctors Office 10.3 10.3 10.8 10.8 0.0 WA-FF-007 Laundry room 10.0 10.0 10.5 10.5 0.0 WA-FF-008 Clinic 11.0 11.0 11.5 11.5 0.0 WA-FF-009 Office: 1 staff 10.5 10.5 11.0 11.0 0.0 WA-FF-010 Store: equipment 4.0 4.0 4.2 4.2 0.0 WA-FF-011 Store: equipment 5.2 5.2 5.5 5.5 0.0 WA-FF-012 Dining room: 15 patients 35.5 35.5 37.2 37.2 0.0 WA-FF-013 WC & handrinse: ambulant / semi assisted 5.3 5.3 5.6 ambulant patient. 5.6 0.0 WA-FF-014 WC & handrinse: ambulant / semi assisted 5.2 5.2 5.5 ambulant patient. 5.5 0.0 WA-FF-015 Lounge: 5 patients 25.0 25.0 26.2 26.2 0.0 FIRST FLOOR WARDS (cont) Room Number Facility WARDS Size - SQM Cummulati ve Total GIFA Adjusted Floor Area DCAG Area ON COST Area WA-FF-016 Interview/counselling/advisory room: 4 persons 10.0 10.0 10.5 10.5 0.0 WA-FF-017 Corridor 74.5 74.5 78.2 78.2 0.0 WA-FF-018 Store: linen 7.3 7.3 7.7 7.7 0.0 WA-FF-019 Pantry 17.8 17.8 18.7 18.7 0.0 WA-FF-020 Clean utility 12.3 12.3 12.9 12.9 0.0 WA-FF-021 Multi-bed room: Adult acute, 4 beds 65.4 65.4 68.6 With clinical support. 68.6 0.0 WA-FF-021a Shower, WC & wash: assisted wheelchair 12.2 12.2 12.8 accessible 12.8 0.0 WA-FF-021b WC Ensuite 6.0 6.0 6.3 6.3 0.0 WA-FF-022 Corridor 36.7 36.7 38.5 38.5 0.0 WA-FF-023 Hold: disposal 2.5 2.5 2.6 2.6 0.0 WA-FF-023a Dry Cleaners 2.6 2.6 2.7 2.7 0.0 WA-FF-024 Dirty utility 14.2 14.2 14.9 14.9 0.0 WA-FF-025 Lobby to stairwell / lift 12.0 12.0 12.6 0.0 12.6 WA-FF-026 Lift 7.5 7.5 7.9 0.0 7.9 WA-FF-027 Stairwell 17.5 17.5 18.4 0.0 18.4 WA-FF-028 Lobby to stairwell / lift 12.0 12.0 12.6 0.0 12.6 WA-FF-029 Lift 7.5 7.5 7.9 0.0 7.9 WA-FF-030 Single bedroom: Adult acute 22.5 22.5 23.6 With clinical support. Relative overnight stay 23.6 0.0 WA-FF-030a Shower, WC & wash: assisted wheelchair 8.2 8.2 8.6 accessible 8.6 0.0 WA-FF-031 Single bedroom: Adult acute 22.5 22.5 23.6 With clinical support. Relative overnight stay 23.6 0.0 WA-FF-031a Shower, WC & wash: assisted wheelchair 8.2 8.2 8.6 accessible 8.6 0.0 WA-FF-032 Day space: 4 patients 21.0 21.0 22.0 Part of multi bedroom 22.0 0.0 WA-FF-033 Single bedroom: Adult acute 22.5 22.5 23.6 With clinical support. Relative overnight stay 23.6 0.0 WA-FF-033a Shower, WC & wash: assisted wheelchair 8.2 8.2 8.6 accessible 8.6 0.0 WA-FF-034 Single bedroom: Adult acute 22.5 22.5 23.6 With clinical support. Relative overnight stay 23.6 0.0 WA-FF-034a Shower, WC & wash: assisted wheelchair 8.2 8.2 8.6 accessible 8.6 0.0 WA-FF-035 Multi-bed room: Adult acute, 4 beds 64.4 64.4 67.6 With clinical support. 67.6 0.0 WA-FF-035a Shower, WC & wash: assisted wheelchair 12.8 12.8 13.4 accessible 13.4 0.0 WA-FF-035b WC Ensuite 6.2 6.2 6.5 6.5 0.0 WA-FF-036 Cleaners cupboard (wet) 5.3 5.3 5.6 5.6 0.0 WA-FF-037 Lobby to stairwell / lift 15.0 15.0 15.7 0.0 15.7 WA-FF-038 Stairwell 23.0 23.0 24.1 0.0 24.1 WA-FF-039 Lift 7.5 7.5 7.9 0.0 7.9 WA-FF-040 Corridor 58.7 58.7 61.6 61.6 0.0 Design Buro SOA Page 6 of 8 113

Malvern Community Hospital Room Number Facility Size - SQM Cummulati ve Total GIFA Adjusted Floor Area DCAG Area ON COST Area WA-FF-041 Store: linen 7.0 7.0 7.3 7.3 0.0 WA-FF-042 Dirty utility 12.0 12.0 12.6 12.6 0.0 WA-FF-043 Clean utility 14.5 14.5 15.2 15.2 0.0 WA-FF-044 Single bedroom: Adult acute 23.0 23.0 24.1 With clinical support. Relative overnight stay 24.1 0.0 WA-FF-044a Shower, WC & wash: assisted wheelchair 7.0 7.0 7.3 accessible 7.3 0.0 WA-FF-045 Single bedroom: Adult acute With clinical support. 23.0 23.0 24.1 Relative overnight stay 24.1 0.0 WA-FF-045a Shower, WC & wash: assisted wheelchair 7.0 7.0 7.3 accessible 7.3 0.0 WA-FF-046 Single bedroom: Adult acute With clinical support. 23.0 23.0 24.1 Relative overnight stay 24.1 0.0 WA-FF-046a Shower, WC & wash: assisted wheelchair 7.0 7.0 7.3 accessible 7.3 0.0 WA-FF-047 Single bedroom: Adult acute 23.0 23.0 24.1 With clinical support. Relative overnight stay 24.1 0.0 WA-FF-047a Shower, WC & wash: assisted wheelchair 7.0 7.0 7.3 accessible 7.3 0.0 WA-FF-048 Corridor 41.2 41.2 43.2 43.2 0.0 WA-FF-049 Lobby to stairwell / lift 5.1 5.1 5.3 0.0 5.3 WA-FF-050 Day space: 4 patients 25.0 25.0 26.2 Part of multi bedroom 26.2 0.0 WA-FF-051 Stairwell 20.5 20.5 21.5 0.0 21.5 WA-FF-052 Cleaners cupboard (wet) 2.7 2.7 2.8 2.8 0.0 WA-FF-053 Single bedroom: Adult acute 23.0 23.0 24.1 With clinical support. Relative overnight stay 24.1 0.0 WA-FF-053a Shower, WC & wash: assisted wheelchair 7.0 7.0 7.3 accessible 7.3 0.0 WA-FF-054 Single bedroom: Adult acute 23.0 23.0 24.1 With clinical support. Relative overnight stay 24.1 0.0 WA-FF-054a Shower, WC & wash: assisted wheelchair 7.0 7.0 7.3 accessible 7.3 0.0 WA-FF-055 Single bedroom: Adult acute 23.0 23.0 24.1 With clinical support. Relative overnight stay 24.1 0.0 WA-FF-055a Shower, WC & wash: assisted wheelchair 7.0 7.0 7.3 accessible 7.3 0.0 WA-FF-056 Single bedroom: Adult acute 22.0 22.0 23.1 With clinical support. Relative overnight stay 23.1 0.0 WA-FF-056a Shower, WC & wash: assisted wheelchair 7.0 7.0 7.3 accessible 7.3 0.0 WA-FF-057 Multi-bed room: Adult acute, 4 beds 66.5 66.5 69.8 With clinical support. 69.8 0.0 WA-FF-057a Shower, WC & wash: assisted wheelchair 9.0 9.0 9.4 accessible 9.4 0.0 WA-FF-057b FIRST FLOOR WARDS (cont) Shower, WC & wash: assisted wheelchair accessible 6.0 6.0 6.3 6.3 0.0 1,405.4 1,473.8 1,340.4 133.9 Room Number Facility GROUND AND FIRST FLOOR RISERS Size - SQM Cummulati ve Total GIFA Adjusted Floor Area DCAG Area ON COST Area R1-GF-057a Riser 1 7.9 7.9 8.3 0.0 8.3 R2-GF-118a Riser 2 4.8 4.8 5.0 0.0 5.0 R3-GF-117a Riser 3 5.8 5.8 6.1 0.0 6.1 R4-GF-091a Riser 4 0.8 0.8 0.8 0.0 0.8 R1-FF-068a Riser 1 7.9 7.9 8.3 0.0 8.3 R2-FF-043a Riser 2 4.9 4.9 5.1 0.0 5.1 R3-FF-043b Riser 3 10.3 10.3 10.8 0.0 10.8 R4-FF-009a Riser 4 0.2 0.2 0.2 0.0 0.2 42.6 44.6 0.0 44.6 Design Buro SOA Page 7 of 8 114

Malvern Community Hospital Summary of Areas Size - SQM Cumulative Total GIFA AdjustedFloor Area DCAG Area ON COST Area Ground Floor - Administration 231.4 231.4 242.7 242.7 0.0 Ground Floor - Day Treatment 209.6 209.6 220.1 219.9 0.0 Ground Floor - Endoscopy 75.0 75.0 78.7 78.7 0.0 Ground Floor - Facilities 186.7 186.7 195.8 195.8 0.0 Ground Floor - Minor Injuries 211.7 211.7 222.1 222.1 0.0 Ground Floor - Outpatients 183.3 183.3 192.3 192.3 0.0 Ground Floor - Physiotherapy 323.0 323.0 338.8 338.8 0.0 Ground Floor - Radiology 132.5 132.5 139.0 139.0 0.0 Ground Floor - Shared 404.7 404.7 424.5 243.1 181.5 First Floor - Administration 324.2 324.2 340.2 294.5 45.6 First Floor - Wards 1405.4 1,405.4 1473.8 1,340.4 133.9 Risers Ground Floor and First Floor 44.6 44.6 44.6 0.0 44.6 Stairwell - Wing A - Roof / Plant 24.1 24.1 24.1 0.0 24.1 Stairwell - Wing B - Roof / Plant 18.9 18.9 18.9 0.0 18.9 Lift - Roof / Plant 7.9 7.9 7.9 0.0 7.9 Plant Room ( Excluding walkways ) 514.0 514.0 514.0 0.0 514.0 Plant Room walkways ( excluded from area calculations. 0.0 0.0 0.0 0.0 0.0 Total 4,297.0 4,297.0 4,477.5 3,507.2 970.5 4,477.7 Design Buro SOA Page 8 of 8 115

Malvern Community Hospital Schedule of On Cost Areas SPACE Area Circulation GF110 lobby 3.90 GF 123a lobby 6.30 GF 07 Lobby 9.40 GF 57 Lobby 6.10 GF 42 Lobby 12.60 GF 39 Lobby 12.60 FF 49 Corridor 5.30 FF 37 Lobby 15.70 FF 68 Lobby 6.10 FF 25 Lift lobby 12.60 FF 28 Lift lobby 12.60 103.20 103.20 Stairs GF 111 22.00 GF 08 24.10 GF 58 20.80 GF 61 18.90 GF 41 21.20 FF 51 21.50 FF 38 24.10 FF 69 20.70 FF 63 18.90 FF 27 18.40 Roof / Plant Room Wing A 24.10 Roof / Plant Room Wing B 18.90 253.60 253.60 On cost areas 116

Malvern Community Hospital Schedule of On Cost Areas Lift GF 09 7.90 GF 43 7.90 GF 40 7.90 FF 39 7.90 FF 26 7.90 FF 29 7.90 Lift Roof / Plant 7.90 55.30 55.30 Risers GFR 2 5.00 GFR 3 6.10 GFR 1 8.30 GFR 4 0.80 FFR 2 5.10 FFR3 10.80 FFR1 8.30 FFR 4 0.20 44.60 44.60 Plant Room Plant Room ( excluding walkways ) 514.00 Plant Room Walkway ( excluded from area calcs ) 0.00 ON COST AREA TOTAL 970.70 On cost areas 117

New Hospital and Primary Care Facility for Malvern Full Business Case Appendix 7 : Elevations and Layouts 090113 Malvern FBC v1.2.docx 118

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New Hospital and Primary Care Facility for Malvern Full Business Case Appendix 8 : AEDET Assessment 090113 Malvern FBC v1.2.docx 130

Achieving Excellence Design Evaluation Toolkit (AEDET Evolution) Project details: Title Malvern Community Hospital Workshop details: Location Date Kidderminster Hospital 11/12/08 Results summary: A: Character and innovation 5.0 7 of 5 scored B: Form and materials 5.6 5 of 5 scored C: Staff and patient environment 5.5 8 of 8 scored D: Urban and social integration 6.0 4 of 4 scored E: Performance 6.0 4 of 4 scored F: Engineering 6.0 5 of 5 scored G: Construction 6.0 7 of 7 scored H: Use 6.0 7 of 7 scored I: Access 5.9 7 of 7 scored J: Space 6.0 6 of 6 scored 1 2 3 4 5 6 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'. 131

New Hospital and Primary Care Facility for Malvern Full Business Case Appendix 9 : BREEAM Assessment 090113 Malvern FBC v1.2.docx 132

Worcester Primary Care Trust Malvern Community Hospital BREEAM Healthcare 2008 Preliminary Assessment Report Revision 1 Reference: CS/028873-01-02 Date: 18 th December 2008 Report prepared for: Interserve 133

DOCUMENT VERIFICATION/REVISION SHEET Revision: 0.00 Date: 27.10.08 Prepared by Checked by Approved By GC JT MW Revision: 1.00 Date 18.12.08 Prepared by Checked by Approved By RL JT JT Revision Date Prepared by Checked by Approved By 1 st Floor, York House, 38 Great Charles Street, Birmingham. B3 3JY. Tel 0121 212 9394 Fax 0121 212 3545 www.capitasymonds.co.uk Capita Symonds Ltd Registered office: 71 Victoria Street, Westminster, London SW1H 0XA. Registered in England No. 2018542 Part of The Capita Group Plc. www.capita.co.uk 134 i

Contents 1. INTRODUCTION 1 1.1 BREEAM 2008 Mandatory Requirements 2 1.2 BREEAM 2008 Innovation Credits 3 2. DEVELOPMENT BACKGROUND 4 3. BREEAM RATING TARGETED 5 4. ASSESSOR COMMENT AND RECOMMENDED IMPROVEMENTS 7 5. APPENDIX 1 DETAILED CREDITS TARGETED 11 Copyright Information The BREEAM name and logo are registered trademarks of the Building Research Establishment Limited. Copyright exists on BREEAM and it may not be used or reproduced in any form and for any purpose without prior written consent of BRE. Disclaimer Capita Symonds and its staff shall not be liable, whether in contract or in tort or otherwise, for any loss or damage sustained as a result of using or relying on the information given in this report, or the final certificate from BRE on which it is based. 135

Malvern Community Hospital Preliminary BREEAM Assessment 1. Introduction This report concerns the Design and Procurement stage BREEAM assessment of the forthcoming development of the new Malvern Community Hospital. BREEAM (Building Research Establishment Environmental Assessment Method) is a tool that allows designers to review and improve the environmental performance of a building. It is a widely accepted and respected scheme that sets a benchmark for environmental performance and provides a wide range of benefits. It is independent and authoritative, being based on many years of construction and environmental research carried out at BRE together with the input and experience of the construction and property industries, Government and building regulators. As the development is a new build there is a formal requirement to achieve an Excellent rating. This report follows an initial design team meeting held on the 20 th October 2008, the completion of predicted credit awards in the BREEAM Healthcare Assessment Tool and subsequent revision of the credits awarded at a meeting on the 15 th December 2008. It is stressed that at this stage, the award of the credits is subject to the outcome of the final design of the building. Therefore, the credits and rating awarded are a prediction and are not guaranteed at this stage. BREEAM awards an environmental label after assessing buildings against a range of environmental issues covering impacts on the environment at global, local and indoor levels. For each issue, there are a number of credits available. Where buildings have attained or exceeded various benchmarks of performance, an appropriate number of credits are awarded. The relative importance of the credits awarded under each issue is taken into account in the final score, which is interpreted in the form of an overall rating of: Outstanding (>85%) Excellent (70% to 85%) Very Good (55% to 70%) Good (45% to 55%) Pass (30% to 45%) 136 1

Malvern Community Hospital Preliminary BREEAM Assessment 1.1 BREEAM 2008 Mandatory Requirements The new BREEAM Healthcare 2008 scheme includes the introduction of Mandatory Credits that are required in order to achieve different BREEAM ratings. For example, in order to achieve a PASS rating, one credit must be achieved for Man 1, Hea 4 and Hea 12. The mandatory credits that are required in order to achieve an Excellent rating have been highlighted in the table below: BREEAM Rating / Minimum number of credits BREEAM issue PASS GOOD VERY GOOD EXCELLENT OUTSTANDING Man 1 Commissioning 1 1 1 1 2 Man 2 Considerate Constructors 1 2 Man 4 Building User Guide 1 1 Hea 4 High Frequency Lighting 1 1 1 1 1 Hea 12 Microbial Contamination 1 1 1 1 1 Ene 1 Reduction of CO2 Emissions 6 10 Ene 2 Sub-metering of Substantial Energy Uses 1 1 1 Ene 5 Low or Zero Carbon Technologies 1 1 Wat 1 Water Consumption 1 1 1 2 Wat 2 Water Meter 1 1 1 1 Wst 3 Storage of Recyclable Waste 1 1 LE 4 Mitigating Ecological Impact 1 1 1 137 2

Malvern Community Hospital Preliminary BREEAM Assessment 1.2 BREEAM 2008 Innovation Credits Another feature of the new Healthcare 2008 scheme is the introduction of Innovation credits. The award of these credits provides additional recognition for a building that leads in the field of sustainable performance, above and beyond the level that is currently recognised and rewarded within standard BREEAM issues. Innovation credits can be achieved by meeting levels of exemplary performance requirements. Each innovation credit amounts to an additional percentage point added to the overall score and is not effected by any weighting. There is also the opportunity to build your own credit. Here, an application is made to BRE by the assessor to have a particular building feature, system or process recognised as innovative and if successful a further innovation credit can be awarded. The table below shows all the items which have new exemplary criteria to meet for the Healthcare scheme: Man 2 Hea 1 Ene 1 Ene 5 Wat 2 Mat 1 Mat 5 Wst 1 Considerate Constructors Daylighting Reduction of CO 2 Emissions Low or Zero Carbon Technologies Water Meter Materials Specification Responsible Sourcing of Materials Construction Site Waste Management 138 3

Malvern Community Hospital Preliminary BREEAM Assessment 2. Development Background The development is anticipated to provide accommodation upon two floors with a total GRA of approximately 4,200m 2 to replace the existing Community Hospital located at Lansdowne Crescent, Great Malvern. The new site is located between Worcester Road and Osborne Road, Malvern in close proximity to Malvern Link Rail Station and will provide greater accessibility for users as well as improved functionality. A BREEAM Rating is required to ensure the best possible environmental performance both during and after construction, and to ensure the environmental sustainability of the individual aspects of the development. This report results from the information available at this stage of the development and presents a preliminary rating. Given that the project is in the early stages of development the assessment is therefore subject to confirmation of the information used to assess individual credits. Also presented are recommendations for improving the BREEAM rating and a prediction of the rating should those recommendations be implemented. The inclusion of some credits in a BREEAM Healthcare assessment is dependent on the presence of various items in the design. The following table details what criteria are assumed or excluded for this assessment. Facility Food preparation, servery and/or dining areas Lifts Cold storage plant and enclosures Soft Landscaping/Planting Inclusion/Exclusion 139 4

Malvern Community Hospital Preliminary BREEAM Assessment 3. BREEAM Rating Targeted Figure 1 summarises the revised target score for the development based on discussion held between members of the design team on 15 th December 2008. It can be seen that following re-assessment with the inclusion of a number of Priority 1 and 2 credits a score of 70.70% has now been predicted. This would allow the award of a BREEAM rating Excellent for the development on the condition that the required supporting evidence is submitted by the design team. Figure 1: Output from the BREEAM Healthcare 2008 scheme assessment tool Environmental weighting Building Performance by Section Credits available Credits achieved % Achieved Weighted Score Management 12% 18.00 16.00 88.89% 10.67% Health & Wellbeing 15% 17.00 14.00 82.35% 12.35% Energy 19% 26.00 19.00 73.08% 13.88% Transport 8% 13.00 9.00 69.23% 5.54% Water 6% 9.00 6.00 66.67% 4.00% Materials 13% 15.00 7.00 46.67% 5.83% Waste 8% 7.00 6.00 85.71% 6.43% Land Use & Ecology 10% 10.00 7.00 70.00% 7.00% Pollution 10% 12.00 6.00 50.00% 5.00% Total 70.70% Exemplary Level credits achieved 0.00% Approved and/or pre-approved Innovation credits 0.00% Total Innovation credits achieved 0.00% Total BREEAM Score 70.70% In addition, the mandatory requirements within the assessment for an Excellent (as detailed on page 2) have been met, as indicated within the Minimum BREEAM Standards table in Figure 2. Figure 2: Minimum BREEAM Standards Output - BREEAM Healthcare 2008 Assessment Tool Minimum BREEAM Standards Rating Level Pass Good Very Good Excellent Outstanding Minimum Standards Achieved YES YES YES YES NO Full details of the credits and those targeted are provided in Appendix A Detailed Credits Targeted. 140 5

Malvern Community Hospital Preliminary BREEAM Assessment The score predicted is situated only 0.70% over the boundary mark required for a BREEAM Excellent. As a result it is advised that options for achieving further credits are investigated so as to further improve the environmental performance of the building and increase the likelihood of achieving an Excellent rating in the final assessment. 20% 18% 16% 14% Assessed Building's BREEAM Performance by Section Management 12% 11% Health &Wellbeing 15% 12% Energy 19% 14% Transport 8% 6% Water 6% 4% Materials 13% 6% Waste 8% 6% Land Use & Ecology 10% 7% Pollution 10% 5% Innovation 10% 0% 12% 10% 8% 6% 4% 2% 0% Management Health &Wellbeing Energy Transport Water Materials Waste Land Use & Ecology Pollution Innovation Score Available Score Achieved Figure 3 above provides a visual representation of the preliminary assessment output following re-assessment with the award of a number of Priority 1 and 2 credits previously not targeted. It can be seen that the areas with significant number of credits outstanding are in the following sections: Energy Materials Pollution Innovation Credits The following section will discuss the credits that have currently not been targeted and the feasibility of implementing them into the assessment. 141 6

Malvern Community Hospital Preliminary BREEAM Assessment 4. Assessor Comment and Recommended Improvements It is recommended that the remaining available credits are fully investigated in order to achieve an Excellent rating and improve the environmental performance of the building. The following table details each of the credits that have not been targeted. The potential for achieving them is described along with the percentage increase they will give the score should they be achieved. Also given for each of the credits discussed is a priority rating from 1 to 3 as follows: Priority 1 credits: No/low cost inclusions to the design Priority 2 credits: Outcome unclear OR significant investment and/or work required Priority 3 credits: Unlikely to be achieved due to high cost and/or large changes to design Additionally, those marked - are impossible to achieve given the site and its attributes Credit Reference Title Potential for Achievement Potential Additional Percentage Priority Man 12 Life Cycle Costing The award of this credit requires life cycle costing to be carried out at the early stages of the design. Due to the stage of development these credits cannot be achieved. 1.50 (0.75/credit) - Hea 1 Daylighting 1of 2 credits are targeted. A second credit is available where 80% of patient occupied spaces and consulting rooms have an average daylight factor of 3%. It is likely that significant changes to the existing design would be required in order to achieve this in all the required spaces. 1.76 3 Hea 7 Potential for Natural Ventilation 1 credit is available where opening window areas of 5% of the floor plate are provided. As a result of the presence of internal windowless rooms in the design this credit is unachievable without extensive investment and design alteration. 0.88 - Hea 8 Indoor Air Quality This credit is unachievable due to the proximity of access roads and car parking to opening windows and vents. 0.88 - Ene 1 Reduction in CO 2 Emissions 0.73/credit (max 7) 3 142 7

Malvern Community Hospital Preliminary BREEAM Assessment Credit Reference Title Potential for Achievement Potential Additional Percentage Priority 8 of 15 credits are currently targeted. Credits are awarded on the basis of the buildings CO2 index (EPC rating) taken from the Energy Performance Certificate. Credits are awarded on a benchmark scale as per the table provided. It may be possible for the development to achieve further credits but it is difficult to predict at this stage (i.e. without an EPC) as the rating is calculated via approved software and is influenced by a number of factors. It is clear however, that buildings with a more passive strategy for heating and cooling will perform significantly better than buildings that are fully sealed and highly serviced. Tra 2 Proximity to Amenities Due to the lack of key amenities within the required distance this credit is unachievable for the development. 0.62-1 credit is available where the site layout is designed in accordance with best practice regarding cyclists and pedestrian access. Tra 4 Pedestrian & Cyclist Safety The credit may be possible if changes to the design can be incorporated to allow deliveries to be made without access through car parking areas, cycle routes can be provided on the carriageways to a minimum width of 1.5m and Lighting design of pedestrian pathways and cycle paths on site are in compliance with CIBSE Lighting Guide 6, 1992 (LG6) and BS5489 Part 1. 0.62 3 Tra 6 Maximum Car Parking Capacity 1 credit is available where a maximum number of car parking spaces are provided depending on the number of beds, staff and treatment/consulting rooms. The room data sheets, floor plans and building occupancy will be confirmed with the design team and the maximum number of space determined by the BREEAM Assessor. 1 1 Tra 8 Deliveries & manoeuvring 1 credit is available where delivery routes avoid sharing car parking area access. The current design does not meet this requirement and therefore prevents the award of this credit. 0.62 - Wat 3 Major Leak Detection 1 credit is available where a major leak detection system is specified. 0.66 2 Wat 5 Water Recycling Up to 2 credits are available where a greywater or rainwater harvesting system is specified for WC use. 1.32 (0.66/credit) 2 Mat 1 Materials Specification Major Building Elements 3 of 6 credits are currently targeted. Further credits are available where further A+/A rated materials (as defined in the Green Guide to Specification) are used in the building construction. 2.52 (0.84/credit) 2 Mat 2 Materials Specification Hard Landscaping and Boundary Protection 1 credit is available where A-rated materials are specified for at least 80% of hard landscaping and boundary protection. 0.84 1 Mat 3 Reuse of Building Façade The development consists of 100% new build. As a result this credit cannot be achieved. 0.84 - Mat 4 Reuse of Building Structure The development consists of 100% new build. As a result this credit cannot be achieved. 0.84-8 143

Malvern Community Hospital Preliminary BREEAM Assessment Credit Reference Title Potential for Achievement Potential Additional Percentage Priority Mat 5 Responsible Sourcing of Materials 3 credits are available where a significant amount of timber is specified and responsibly sourced. 1 credit may be possible where other materials are sourced from suppliers with an environmental management system. 0.84 1 Wst 2 Recycled Aggregates 1 credit is available where 25% of aggregate use is recycled or secondary aggregate. This credit cannot be achieved given the small amount of aggregate available on site for reuse and quality issues associated with recycled aggregate structural purposes. 1.07 - LE1 Reuse of Land 1 credit is available where 75% of the development footprint is on previously developed land. It is unclear without further investigation if the site meets the credit requirements as75% of the new building footprint may not fall on previously developed areas of the site. 1.00 2 LE3 Protection of Ecological Features 1 credit is available where the site has low ecological value and ecological features are protected. The removal of trees prevents the award of this credit. 1.00 - LE5 Enhancing Site Ecology 2 of 3 credits have been targeted for the appointment of an ecologist to advise on enhancing site ecology and an increase in the site species count. An additional credit is available where a increase of 6 or more is made. 1.00 1 Pol 1 Refrigerant GWP Building Services This credit is unachievable due to the refrigerants used in the cooling system having a GWP of higher than 5. 1.00 - Pol 2 Preventing Refrigerant Leaks Up to 2 credits are available where a compliant refrigerant leak prevention system is specified for building services containing refrigerants. 1 credit may be achievable at cost as the second credit requires automatic pump down and attenuation of the refrigerant and is not likely to be achieved within budgetary constraints. 1.00 2 Pol 4 NO X Emissions From Heating Source These credits are not available where grid electricity or biomass are utilised to heat the building or power heat pumps. It should be noted however that the loss of these credits is more than made up for in other areas of the assessment on which the biomass proposed has a positive impact. 3.00 (1.00/credit) - Innovation Man 2 Considerate Constructors 1 innovation credit is available where a score of 36 is achieved under the Considerate Constructors Scheme. 1.00 2 Innovation Hea 1 Daylighting As the building is multi-storey, 1 credit is available where 80% of the floor area has and average daylight factor of 3%. This is only achievable where all Hea 1 credits have been awarded. 1.00 - Innovation Ene 1 Reduction of CO 2 emissions Up to 2 credits are available where the building has a zero carbon rating or is true zero carbon. This is only achievable where all Ene 1 credits have been awarded. 2.00-9 144

Malvern Community Hospital Preliminary BREEAM Assessment Credit Reference Title Potential for Achievement Potential Additional Percentage Priority Innovation Ene 5 Low or Zero Carbon Technologies 1 innovation credit is available where A local LZC energy technology has been installed in line with the recommendations of a feasibility study and this method of supply results in a 20% reduction in the building s CO2 emissions. 1.00 1 Innovation Wat 2 Water Meters 1 innovation credit is available where, in addition to achieving the Wat 2 credit, additional water meters are provided for separate departments. 1.00 2 Innovation Mat 1 Materials Specification 1 additional credit is available where the performance requirements for Mat 1 are exceeded. This is only achievable where all Mat 1 credits have been awarded. 1.00 - Innovation Mat 5 Responsible Sourcing of Materials 1 additional credit is available where the performance requirements of Mat 5 are exceeded. This is only achievable where all Mat 5 credits have been awarded. 1.00 - Innovation Wst 1 Construction Site Waste Management 1 innovation credit is available where, in addition to achieving all Wst1 credits, at least 95% by weight of nonhazardous demolition and construction waste can be diverted from landfill. 1.00 1 The following list details the scores that could be achieved with the inclusion of the recommended credits (providing all other targeted credits are achieved on certification by BRE): Should all of the remaining/re-assessed Priority 1 credits be achieved (including innovation credits) the assessment result will potentially be improved to 75.82% (EXCELLENT); Should all of the remaining/re-assessed Priority 1 and 2 credits be achieved (including the innovation credits) the assessment result will potentially be improved to 81.15% (EXCELLENT). In addition, if the priority 3 credits are included the score can potentially be increased to 84.11%. However, it should be noted that this is the maximum score possible for the development and it is likely this would be achieved only if there was an unlimited budget. A score significantly above the required rating should be targeted in order to allow flexibility in the latter stages of the assessment and to plan against the loss of credits during the QA phase. It is therefore recommended that a number of the remaining (or reassessed) priority 1 and 2 credits are targeted so as to achieve a score in the region of 74%. In addition, the inclusion of more credits of any priority will also help improve the score and improve the environmental performance of the building. 145 10

Malvern Community Hospital Preliminary BREEAM Assessment 5. Appendix 1 Detailed Credits Targeted Number of BREEAM credits available Total BREEAM credits achieved Management Man 1 Commissioning One credit where evidence provided demonstrates that an appropriate project team member has been appointed to monitor commissioning on behalf of the client to ensure commissioning will be carried out in line with current best practice. Two credits where, in addition to the above, evidence provided demonstrates that seasonal commissioning will be carried out during the first year of occupation, post construction (or post fit out). 2 2 Man 2 Considerate Constructors One credit where evidence provided demonstrates that there is a commitment to comply with best practice site management principles. Two credits where evidence provided demonstrates that there is a commitment to go beyond best practice site management principles. One credit where evidence provided demonstrates that 2 or more of items a-g (listed below) are achieved. 2 2 Two credits where evidence provided demonstrates that 4 or more of items a-g (listed below) are achieved. Man 3 Construction Site Impacts Three credits where evidence provided demonstrates that 6 or more of items a-g are achieved: a. Monitor, report and set targets for CO2 or energy arising from site activities b. Monitor, report and set targets for CO2 or energy arising from transport to and from site c. Monitor, report and set targets for water consumption arising from site activities d. Implement best practice policies in respect of air (dust) pollution arising from the site e. Implement best practice policies in respect of water (ground and surface) pollution occurring on the site f. Main contractor has an environmental materials policy, used for sourcing of construction materials to be utilised on site g. Main contractor operates an Environmental Management System. 4 4 One additional credit where evidence provided demonstrates that at least 80% of site timber is responsibly sourced and 100% is legally sourced. Man 4 Building user guide One credit where evidence provided demonstrates the provision of a simple guide that covers information relevant to the tenant/occupants and non-technical building manager on the operation and environmental performance of the building. 1 1 Man 6 Consultation One credit where evidence provided demonstrates that consultation has been, or is being, undertaken and feedback given to the local community and building users. In addition, advice should also have been sought from any relevant national and local history, archaeological bodies or military history groups regarding the heritage value of the building/site/surroundings. Two credits where, in addition to the above, evidence provided demonstrates that changes to the design and/or action has been taken as a result of the above consultation process. This should include the protection of any parts of the building (or site) having historic or heritage value in accordance with independent advice from the relevant body. 2 2 Man 7 Shared Facilities One credit where evidence provided demonstrates that shared facilities have been provided as a consequence of consultation feedback. Two credits where, in addition to the above, evidence provided demonstrates that these facilities can be accessed without compromising the safety and security of the building and its occupants. 2 2 Man 8 Security One credit where evidence provided demonstrates that an Architectural Liaison Officer (ALO) or Crime Prevention Design Advisor (CPDA) from the local police force has been consulted at the design stage and their recommendations incorporated into the design of the building and its parking facilities (if relevant). 1 1 Man 11 Ease of Maintenance One credit where evidence provided demonstrates that specifications for the building and the building services/systems and landscaping have considered ease and efficiency of maintenance in line with best practice. 1 1 Man 12 Life Cycle Costing One credit where evidence provided demonstrates that a Life Cycle Cost (LCC) analysis based on the feasibility study proposals has been undertaken on the building design at a strategic and system level. Two credits where, in addition to the above, evidence provided demonstrates that the results of the feasibility study and consideration of LCC have been implemented. 2 0 Man 13 Good Corporate Citizen One credit where evidence provided demonstrates that the Good Corporate Citizen model has been used to assess the development and that there is a commitment to continue to use the model to re-assess the development regularly. 1 1 11 146

Malvern Community Hospital Preliminary BREEAM Assessment Health & Wellbeing Hea 1 Daylighting Two credits where at least 80% by floor area of occupied staff and public spaces have an average daylight factor of 2% or more. And at least 80% by floor area of occupied patient spaces (dayrooms, wards) and consulting rooms have an average daylight factor of 3% or more. 2 1 Hea 2 View Out One credit where evidence provided demonstrates that all workstations/benches and desks and at least 80% by floor area of public areas have an adequate view out. Second Credit. 1 1 One credit where evidence provided demonstrates that all patient-occupied spaces have an adequate view out. Hea 3 Glare Control One credit where evidence provided demonstrates that an occupant-controlled shading system (e.g. internal or external blinds) is fitted in relevant building areas. 1 1 Hea 4 High frequency lighting One credit where evidence provided demonstrates that high frequency ballasts are installed on all fluorescent and compact fluorescent lamps. 1 1 Hea 5 Internal and external lighting levels One credit where evidence provided demonstrates that all internal and external lighting, where relevant, is specified in accordance with the appropriate maintained illuminance levels (in lux) recommended by CIBSE. 1 1 Hea 6 Lighting zones & controls One credit where evidence provided demonstrates that, in all relevant building areas, lighting is appropriately zoned and occupant controllable. 1 1 Hea 7 Potential for natural ventilation One credit where evidence provided demonstrates that fresh air is capable of being delivered to the occupied spaces of the building via a natural ventilation strategy, and there is sufficient user-control of the supply of fresh air. 1 0 Hea 8 Indoor air quality One credit where air intakes serving occupied areas avoid major sources of external pollution and recirculation of exhaust air. 1 0 Hea 9 Volatile Organic Compounds One credit where evidence provided demonstrates that the emissions of VOCs and other substances from key internal finishes and fittings comply with best practice levels. 1 1 Hea 10 Thermal comfort One credit where evidence provided demonstrates that thermal comfort levels in occupied spaces of the building are assessed at the design stage to evaluate appropriate servicing options, ensuring appropriate thermal comfort levels are achieved. 1 1 Hea 11 Thermal zoning One credit where evidence provided demonstrates that local occupant control is available for temperature adjustment in each occupied space to reflect differing user demands. 1 1 Hea 12 Microbial contamination One credit where evidence provided demonstrates that the risk of waterborne and airborne legionella contamination has been minimised. 1 1 Hea 13 Acoustic Performance One credit where evidence provided demonstrates that indoor ambient noise levels and airborne and impact sound insulation levels achieve the recommended performance benchmarks outlined HTM 08-01 Part A. One credit where evidence provided demonstrates that reverberation times are compliant with the recommended performance benchmarks outlined HTM 08-01 Part A. 2 2 Hea 15 Outdoor Space One credit where evidence provided demonstrates the provision of an adequate outdoor amenity space accessible for use by the building s occupants. 1 1 Hea 19 Arts in health One credit where evidence provided demonstrates that an art co-ordinator has been appointed or an art strategy and policy have been prepared for the development. 1 1 12 147

Malvern Community Hospital Preliminary BREEAM Assessment Energy Ene 1 Reduction of CO2 Emissions Up to fifteen credits where evidence provided demonstrates an improvement in the energy efficiency of the building s fabric and services and therefore achieves lower building operational related CO2 emissions. 15 8 Ene 2 Sub-metering of Substantial Energy Uses One credit where evidence provided demonstrates the provision of direct submetering of energy uses within the building. Two credits where, in addition to the above, evidence provided demonstrates that sub meters are connected to a BMS or other type of automated control device. 2 2 Ene 3 Sub-metering of high energy load Areas and Tenancy One credit where evidence provided demonstrates sub-metering of energy consumption by tenancy/building function area is installed within the building. 1 1 Ene 4 External Lighting One credit where energy-efficient external lighting is specified and all light fittings are controlled for the presence of daylight. 1 1 One credit where evidence provided demonstrates that a feasibility study considering local (on-site and/or near site) low or zero carbon (LZC) technologies has been carried out and the results implemented. Two credits where evidence provided demonstrates that the first credit has been achieved and there is a 10% reduction in the building s CO2 emissions as a result of the installation of a feasible local LZC technology. Ene 5 Low zero carbon technologies Three credits where evidence provided demonstrates that the first credit has been achieved and there is a 15% reduction in the building s CO2 emissions as a result of the installation of a feasible local LZC technology. 3 3 Or alternatively: A maximum of one credit where evidence provided demonstrates that a contract with an energy supplier is in place to provide sufficient electricity used within the assessed building/development to meet the above criteria from a 100% renewable energy source. (Note: a standard Green Tariff will not comply) Ene 8 Lifts Up to two credits are available where evidence provided demonstrates the installation of energy-efficient lift(s). 2 2 Ene 15 Provision of Energy Efficient Equipment One credit where evidence provided demonstrates procurement of office and domestic scale equipment on the basis of energy-efficient performance over the product life cycle. 1 1 Ene 16 CHP Community Energy One credit where evidence provided demonstrates that a feasibility study has been carried out on the potential for the building to set up, contribute to or benefit from a local CHP community energy scheme. 1 1 Transport Tra 1 Provision of public transport Up to five credits are awarded on a sliding scale based on the assessed buildings accessibility to the public transport network. 5 5 Tra 2 Proximity to amenities One credit where evidence provided demonstrates that the building is located within 500m of accessible local amenities appropriate to the building type and its users. 1 0 Tra 3 Cyclist Facilities One credit where evidence provided demonstrates that covered, secure and well-lit cycle storage facilities are provided for all building users. Two credits where, in addition to the above, adequate changing facilities are provided for staff use. 2 2 Tra 4 Pedestrian and cycle safety Small healthcare buildings e.g. GP surgery, NHS walk-in centres One credit where evidence provided demonstrates that the site layout has been designed in accordance with best practice to ensure safe and adequate pedestrian and cycle access. 1 0 Tra 5 Travel plan One credit where evidence is provided to demonstrate that a travel plan has been developed and tailored to the specific needs of the building users. 1 1 Tra 6 Maximum car parking capacity One credit where evidence provided demonstrates that the number of parking spaces provided for the building has been limited. 1 0 Tra 7 Travel information point One credit where evidence provided demonstrates there is a dedicated space within the development for the provision of real-time public transport information. 1 1 Tra 8 Deliveries & manoeuvring One credit where evidence provided demonstrates that vehicle access areas have been designed to ensure adequate space for manoeuvring delivery vehicles and provide space away from manoeuvring area for storage of refuse skips and pallets. 1 0 13 148

Malvern Community Hospital Preliminary BREEAM Assessment Water Wat 1 Water Consumption Up to three credits where evidence provided demonstrates that the specification includes taps, urinals, WCs and showers that consume less potable water in use than standard specifications for the same type of fittings. 3 3 Wat 2 Water meter One credit where evidence provided demonstrates that a water meter with a pulsed output will be installed on the mains supply to each building/unit. 1 1 Wat 3 Major leak detection One credit where evidence provided demonstrates that a leak detection system is specified or installed on the building's water supply. 1 0 Wat 4 Sanitary supply shut off One credit where evidence provided demonstrates that proximity detection shut-off is provided to the water supply to all toilet areas. 1 1 Wat5 Water recycling Up to two credits where evidence provided demonstrates the specification of systems that collect, store and, where necessary treat, rainwater or greywater for WC and urinal flushing purposes. 2 0 Wat 6 Irrigation systems One credit where evidence provided demonstrates that a low-water irrigation strategy/system has been installed, or where planting and landscaping is irrigated via rainwater or reclaimed water. 1 1 Materials Mat 1 Materials Specification (major building elements) Up to six credits are available, determined by the Green Guide to Specification ratings for the major building/finishing elements. 6 3 Mat 2 Hard landscaping and boundary protection One credit where evidence provided demonstrates that at least 80% of the combined area of external hard landscaping and boundary protection specifications achieve an A or A+ rating, as defined by the Green Guide to Specification. 1 0 Mat 3 Re-use of building façade One credit is awarded where evidence provided demonstrates that at least 50% of the total façade (by area) is reused and at least 80% of the reused façade (by mass) comprises in-situ reused material. 1 0 Mat 4 Re-use of building structure One credit is awarded where evidence provided demonstrates that a design reuses at least 80% of an existing primary structure and for part refurbishment and part new build, the volume of the reused structure comprises at least 50% of the final structure s volume. 1 0 Mat 5 Responsible sourcing of materials Up to 3 credits are available where evidence provided demonstrates that 80% of the assessed materials in the following building elements are responsibly sourced: a. Structural Frame b. Ground floor c. Upper floors (including separating floors) d. Roof e. External walls f. Internal walls g. Foundation/substructure h. Staircase 3 1 Additionally 100% of any timber must be legally sourced. Mat 6 Insulation One credit where evidence provided demonstrates that thermal insulation products used in the building have a low embodied impact relative to their thermal properties, determined by the Green Guide to Specification ratings. One credit where evidence provided demonstrates that thermal insulation products used in the building have been responsibly sourced. 2 2 Mat 7 Designing For Robustness One credit where protection is given to vulnerable parts of the building such as areas exposed to high pedestrian traffic, vehicular and trolley movements. 1 1 149 14

Malvern Community Hospital Preliminary BREEAM Assessment Waste Wst 1 Construction Site Waste Mangement Up to three credits are available where evidence provided demonstrates that the amount of non-hazardous construction waste (m3/100m2 or tonnes100m2) generated on site by the development is the same as or better than good or best practice levels. One credit where evidence provided demonstrates that a significant majority of nonhazardous construction waste generated by the development will be diverted from landfill and reused or recycled. 4 4 Wst 2 Recycled aggregates One credit where evidence provided demonstrates the significant use of recycled or secondary aggregates in high-grade building aggregate uses. 1 0 Wst 3 Recyclable waste storage One credit where a central, dedicated space is provided for the storage of the building s recyclable waste streams. 1 1 Wst 5 Composting One credit w here evidence provided demonstrates there is a vessel on site for composting food waste, and adequate storage for such waste generated by the building s users and operation. OR 1 1 Where space or access is limited, there is a dedicated space for compostable food waste to be stored prior to removal and composting at an alternative site. Land Use & Ecology LE1 Re-use of land One credit where evidence provided demonstrates that the majority of the footprint of the proposed development falls within the boundary of previously developed land. 1 0 LE2 Contaminated land One credit is awarded where evidence provided demonstrates that the land used for the new development has, prior to development, been defined as contaminated and where adequate remedial steps have been taken to decontaminate the site prior to construction. 1 1 LE3 LE4 LE5 Ecological value of site AND Protection of ecological features Mitigating Ecological impact Enhancing Site Ecology One credit is awarded where evidence provided demonstrates that the construction zone is defined as land of low ecological value and all existing features of ecological value will be fully protected from damage during site preparation and construction works. One credit where evidence provided demonstrates that the change in the site s existing ecological value, as a result of development, is minimal. Two credits where evidence provided demonstrates that there is no negative change in the site s existing ecological value as a result of development. One credit where the design team (or client) has appointed a suitably qualified ecologist to advise and report on enhancing and protecting the ecological value of the site; and implemented the professional s recommendations for general enhancement and protection of site ecology. Two credits where, inaddtion to the above, there is a positive increase in the ecological value of the site of up to (but not including) 6 species. 1 0 2 2 3 2 Three credits where, inaddition to the above, evidence is provided to demonstrate a positive increase in the ecological value of the site of 6 species or greater. LE6 Long term impact on biodiversity One credit where the client has committed to achieving the mandatory requirements listed below and at least two of the additional requirements. Two credits where the client has committed to achieving the mandatory requirements listed below and at least four of the additional requirements. 2 2 Pollution Pol 1 One credit where evidence provided demonstrates the use of refrigerants with a Refrigerant GWP - Building services global warming potential (GWP) of less than 5 or where there are no refrigerants specified for use in building services. 1 0 One credit where evidence provided demonstrates that refrigerant leaks can be detected or where there are no refrigerants specified for the development. Pol 2 Preventing refrigerant leaks One credit where evidence provided demonstrates that the provision of automatic refrigerant pump down is made to a heat exchanger (or dedicated storage tanks) with isolation valves. Or where there are no refrigerants specified for the development. One credit where evidence provided demonstrates that the maximum dry NOx emissions from delivered space heating energy are 100 mg/kwh (at 0% excess O2). 2 0 Pol 4 NOx emissions from heating source Two credits where evidence provided demonstrates that the maximum dry NOx emissions from delivered space heating energy are 70 mg/kwh (at 0% excess O2). Three credits where evidence provided demonstrates that the maximum dry NOx emissions from delivered space heating energy are 40 mg/kwh (at 0% excess O2) and 3 0 150 15

Malvern Community Hospital Preliminary BREEAM Assessment Two credits where evidence provided demonstrates that the assessed development is located in a zone defined as having a low annual probability of flooding. Pol 5 Flood risk One credit where evidence provided demonstrates that the assessed development is located in a zone defined as having a medium or high annual probability of flooding AND the ground level of the building, car parking and access is above the design flood level for the site s location. 3 3 One further credit where evidence provided demonstrates that surface water runoff attenuation measures are specified to minimise the risk of localised flooding, resulting from a loss of flood storage on site due to development. Pol 6 Minimising watercourse pollution One credit here evidence provided demonstrates that effective on site treatment such as Sustainable Drainage Systems (SUDs) or oil separators have been specified in areas that are or could be a source of watercourse pollution. 1 1 Pol 7 Reduction of Night Time Light Pollution One credit where evidence provided demonstrates that the external lighting design is in compliance with the guidance in the Institution of Lighting Engineers (ILE) Guidance notes for the reduction of obtrusive light, 2005. 1 1 Pol 8 Noise Attenutaion One credit where evidence provided demonstrates that new sources of noise from the development do not give rise to the likelihood of complaints from existing noisesensitive premises and amenity or wildlife areas that are within the locality of the site. 1 1 Innovation Man 2 Considerate Constructors Where post construction, a Considerate Constructors Scheme certificate can be provided demonstrating that the site achieved CCS Code of Considerate Practice with a score of at least 36. OR Where post construction, the site has complied in full with the alternative, independently assessed scheme, and the alternative scheme addresses all the mandatory and optional items in Checklist A2. 1 0 Hea 1 Daylighting At least 80% of the floor area (for the building spaces/room identified above in the standard requirements) has an average daylight factor of 3% in multi-storey buildings and 4% in single-storey buildings. 1 0 Ene 1 Reduction of CO2 emissions One additional innovation credit can be awarded where evidence provided demonstrates the building is designed to be a carbon neutral building as defined by the NCM (i.e. in terms of building services energy demand), as follows: a. A new building achieves a CO2 index less than 0 on the benchmark scale. b. A refurbished building achieves a CO2 index equal to or less than 0 on the benchmark scale. 2 0 Two additional innovation credits can be awarded where evidence provided demonstrates the building is designed to be a True zero carbon building (in terms of building services and operational energy demand). Ene 5 Low or Zero Carbon Technologies A local LZC energy technology has been installed in line with the recommendations of a compliant feasibility study and this method of supply results in a 20% reduction in the building s CO2 emissions. 1 0 Where sub meters are fitted to allow individual water-consuming plant or building areas to be monitored such as cooling towers, car washes, catering areas, etc. If the building does not have any major water consuming plant this exemplar credit is not available. Each sub meter has a pulsed output to enable connection to a Building Management System (BMS) for the monitoring of water consumption. Wat 2 Water Meter In addition to the above, for sites with multiple departments e.g. large health centres or acute hospitals, separate pulsed sub meters are fitted on the supply to the following areas where present: 1 0 a. Staff and public areas b. Clinical areas and wards c. Letting areas: On the water supply to each tenant unit d. Laundries e. Main production kitchen f. Hydrotherapy pools g. Laboratories h. CSSD/HSDU, pathology, pharmacy, mortuary and any other major process water user. One exemplary BREEAM credit can be awarded as follows: Mat 1 Materials Specification a. Where assessing four or more applicable building elements, the building achieves at least two points additional to the total points required to achieve maximum credits under the standard BREEAM requirements. 1 0 b. Where assessing fewer than four applicable building elements, the building achieves at least one point additional to the total points required to achieve maximum credits under the standard BREEAM requirements. Mat 5 Responsible Sourcing of Materials Where, in addition to the standard BREEAM requirements, 95% of the applicable materials, comprised within the applicable building elements, have been responsibly sourced. 1 0 Where non-hazardous construction waste generated by the building s development meets or exceeds the resource efficiency benchmark required to achieve three credits (as outlined in the guidance). Wst 1 Construction Site Waste Management Where at least 90% by weight (80% by volume) of non-hazardous construction waste and 95% of demolition waste by weight (85% by volume) (if applicable) generated by the build has been diverted from landfill and either: a. Reused on site (in-situ or for new applications) b. Reused on other sites c. Salvaged/reclaimed for reuse d. Returned to the supplier via a take-back scheme e. Recovered from site by an approved waste management contractor and recycled. 1 0 Where all key waste groups are identified for diversion from landfill at pre-construction stage SWMP. 16 151

New Hospital and Primary Care Facility for Malvern Full Business Case Appendix 10 : Planning Consent 090113 Malvern FBC v1.2.docx 152

Malvern Hills District Council Name and Address of Applicant Worcestershire Primary Care Trust Ground Floor West Wing Wildwood Wildwood Drive Worcester Town and Country Planning Act 1990 PLANNING PERMISSION Name and Address of Agent (if any) Miss C Knight Design Buro The Stables Newtown Grange Farm Business Park Desford Road Newtown Unthank Part I - Particulars of Application Date of Application: 11th August 2008 Application No: 08/01097/FUL Grid Ref: Easting: 378139 Northing: 247431 PROPOSAL: LOCATION: Proposed Community Hospital Land At A449 Worcester Road Malvern Summary of Reasons for Approval This decision to grant planning permission takes into account the provisions of the Development Plan comprising the Regional Spatial Strategy, the Worcestershire County Structure Plan and the Malvern Hills District Local Plan and, in particular, the key policies set out below, and all other material considerations. It was considered that, on balance, the development was generally in accordance with the Development Plan and was not outweighed by any other material consideration. DS01 The Location of Development DS02 Sustainable Development DS03 General Development Requirements DS16 Development and Flood Risk DS18 Planning Obligations QL01 Design of New Development QL0 Walls, Gates, Fences or Other Means of Enclosure QL07 New Development in Conservation Areas QL08 Demolition of Buildings in Conservation Areas QL28 Surface Water Drainage 08/01097/FUL Page 1 of 11 PEFULZ 153

QL19 Protection of Wider Biodiversity QL20 Creation of Habitats QL21 Landscaping QL24 Landscape Character QL22 Protection of Trees, Woodland & Hedgerows QL26 Pollution Control QL27 Foul Drainage QL28 Surface Water Drainage QL29 Contaminated Land ST02 Public Transport, Walking and Cycling ST03 Parking, Servicing and Commuted Parking Requirements ST04 Minimising Travel Impacts CN16 Provision of New Community Facilities SD2 Care for the Environment SD3 Use of Previously Developed Land SD4 Minimising the Need to Travel CTC1 Landscape Character CTC8 Flood Risk and Surface Water Drainage CTC20 Conservation Areas D43 Crime Prevention and Community Safety T1 Location of Development T4 Car Parking T10 Cycling and Walking UR4: Social Infrastructure QE1: Conserving and Enhancing the Environment QE3: Creating a high quality built environment for all QE5: Protection and enhancement of the Historic Environment QE6: The conservation, Enhancement and restoration of the Region's Landscape T2: Reducing the need to travel 08/01097/FUL Page 2 of 11 PEFULZ 154

Part II - Particulars of Decision The Malvern Hills District Council hereby give notice in pursuance of the provisions of the Town and Country Planning Act, 1990 that permission has been granted for the carrying out of the development referred to in Part I hereof in accordance with the application and plans submitted subject to the following the following condition(s) (if any): 1 The development to which this permission relates must be commenced not later than the expiration of three years from the date of this permission. Reason: To conform with the requirements of Section 91 of the Town and Country Planning Act 1990 as amended by Section 51 of the Planning and Compulsory Purchase Act 2004. 2 The development hereby approved shall be carried out in accordance with the following plans and drawings - DBC610/ P005 Rev. P6, 8136/ 103/ Rev.B, 8136/ DBC610/ 27 Rev. P2, DBC610/ PO28 Rev.01, DBC610/ PO29 Rev. 01, DBC610/ PO30 Rev. 01, DBC610/ 26 Rev. P2, DBC610/ 25 Rev. P2, DBC610/ P008 Rev. P4, DBC610/ P007 Rev P4, DBC610/ P009 Rev P4, DBC610/ P010 Rev P2, DBC610/ 11 Rev P1, DBC610/ 31 Rev. P1, 32182-01(M) 10 Rev. P0, 0765 401, 0765 401 -, 8136- SK1, 8136-103 Rev C and 0765 004 Rev. A, unless otherwise agreed in writing by the Local Planning Authority. The development shall also be carried out in accordance with the Design and Access Statement unless otherwise required by conditions attached to this permission. Reason: To define the permission and to ensure that the development meets the design quality and environmental requirements of the Development Plan. 3 The building hereby approved shall only be used as a community hospital and for the provision of health care services and/or purposes ancillary to the provision of healthcare and for no other use within Class C2 of the Town and Country Planning (Use Classes) Order 1987 and its subsequent amendments. Reason: To define the permission. The Local Planning Authority would wish to be able to consider any other uses against relevant policies in the development Plan and in terms of their impact on the locality. 4 The development hereby permitted shall not be brought into use until the access, pedestrian access, access road, barrier, parking facilities and service yard shown on the approved plan have been properly consolidated, surfaced, drained and otherwise constructed in accordance with details to be submitted to and approved in writing by the Local Planning Authority and these areas shall thereafter be retained and kept available for those uses at all times. Reason: In the interests of highway safety and to ensure the free flow of traffic using the adjoining highway. 5 The development hereby permitted shall not be brought into use until secure covered parking for at least 20 cycles (for staff and patients/visitors) has been provided in accordance with details to be submitted to and approved in writing by the Local Planning Authority. Reason: To encourage the use of alternative modes of transport in the interests of sustainability, in accordance with Policy T10 of the Worcestershire County Structure Plan and Policy ST02 and EP20 of the Malvern Hills District Local Plan. 6 The development hereby permitted shall not be first brought into use until a travel plan that promotes sustainable forms of access to the site for all users of the hospital (informed by the Framework Travel Plan submitted with the application) has been submitted to and approved in writing by the Local Planning Authority. The approved Travel Plan shall be reviewed annually by the Hospital management and updated to meet the Travel Plan modal shift targets. 08/01097/FUL Page 3 of 11 PEFULZ 155

Reason: To reduce vehicle movements and promote sustainable access in accordance with Policies DS1, DS2 and DS3 of the Malvern Hills District Local Plan. 7 Means of access for construction traffic to the development hereby approved shall be from Worcester Road, A449, only. Routing details including a road map, shall be submitted to and approved in writing by the Local planning Authority. All contractors/ sub-contractors shall be provided with a copy of the agreed routing details. Reason: In the interests of highway safety. The narrow residential streets in the locality are not suitable to take heavy construction/delivery vehicles for extended periods. 8 A specification for the treatment of all hard surfaced areas and samples of materials to be used for the final surfacing shall be submitted to and approved in writing by the Local Planning Authority before any of these areas are laid out, or within an alternative timescale which has previously been agreed in writing by the Local Planning Authority. Permeable surfacing shall be used wherever practicable. The building shall not be first brought into use until the hard surfaced areas have been constructed as approved. Reason: The treatment of the hard surfaced areas is an essential element in the detailed design and effective drainage of this development and the application is not accompanied by sufficient details to enable the Local Planning Authority to give proper consideration to these matters in accordance with Policies DS3 and QL1 of the Malvern Hills District Local Plan. 9 The development shall not begin until parking for site operatives and visitors has been provided within the application site in accordance with details to be submitted to and approved by the Local Planning Authority and such provision shall be retained and kept available during the construction phase of the development. Reason: To reduce the potential for indiscriminate parking on the public highway in the interests of highway safety in accordance with Policy DS3 of the Malvern Hills District Local Plan. 10 Prior to being discharged into any watercourse, surface water sewer or soakaway system, all surface water drainage from parking areas shall be passed through an oil interceptor designed and constructed to have a capacity and details compatible with the site being drained. Roof water shall not pass through the interceptor. Reason: To prevent pollution of the water environment in accordance with Policy QL26 of the Malvern Hills District Local Plan. 11 The development shall not begin until wheel cleaning apparatus has been provided in accordance with details to be submitted to and approved in writing by the Local Planning Authority, and this equipment shall be operated and maintained during the construction of the development hereby approved. Reason: To ensure that the wheels of vehicles are cleaned before leaving the site in the interests of highway safety. 12 Ground works/construction work shall not take place outside the following hours: Monday to Friday 07.30-18.00 hrs Saturdays 08.30-13.00 hrs Reason: There shall be no such work on Sundays or Public Holidays Reason: To protect the residential amenity of adjacent occupiers and the general amenity of the area in accordance with Policies DS3 and QL26 of the Malvern Hills District Local Plan. 08/01097/FUL Page 4 of 11 PEFULZ 156

13 Prior to the commencement of development, or within an alternative timescale which has previously been agreed in writing by the Local Planning Authority, samples and/or trade descriptions of all the external facing materials to be used in the construction of the development hereby permitted shall be submitted to and approved in writing by the Local Planning Authority. In the case of the randomly laid stone walling a sample panel shall be constructed on site for approval by the Local Planning Authority. The development shall be carried out in accordance with the approved details. Reason: To ensure that the new materials are of an appropriate appearance and quality, in keeping with the surroundings in accordance with Policies DS3 and QL1 of the Malvern Hills District Local Plan. 14 Before development commences, or within an alternative timescale which has previously been agreed in writing by the Local Planning Authority, architectural details of window sections, door sections, eaves, verges, window cills and heads, stone banding and other feature details, ballustrading, pergola and glazed canopy shall be submitted to and approved in writing by the Local Planning Authority. The development shall thereafter be carried out in accordance with the approved details. Reason: To ensure that the design quality of the building is appropriate in the conservation area end enhance s its character and appearance in accordance with Policy QL7 of the Malvern Hills District Local Plan. 15 Prior to the commencement of the development or within an alternative timescale that has been agreed in writing by the Local Planning Authority, details of all external seating and bollards shall be submitted to and approved in writing by the Local Planning Authority. The development shall be carried out in accordance with the details so agreed. Reason: To ensure that these features are of an appropriate design quality in the conservation area in accordance with Policy CTC20 of the Worcestershire County Structure Plan and Policy QL07 of the Malvern Hills District Local plan. 16 Prior to the commencement of development, or within an alternative timescale which has previously been agreed in writing by the Local Planning Authority, details of the rooflights to be utilised in the development shall be submitted to and approved in writing by the Local Planning Authority. The development shall be carried out in accordance with the details so approved. The rooflights so approved shall not thereafter be changed without the prior written approval of Local Planning Authority. Reason: To ensure that the building is of an appropriate design quality and enhances the character and appearance of the conservation area in accordance with Policy QL7 of the Malvern Hills District Local Plan and Policy CTC20 of the Worcestershire County Structure Plan. 17 Prior to the commencement of any other part of the development hereby approved, the existing stone gate piers shall be taken down and stored for re-use. The gate piers shall be reconstructed at the proposed dedicated pedestrian/cycle entrance to the site in accordance with drawing no. DBC610/ 31 Rev. P1 before the building is first brought into use. However, notwithstanding the details of a gate on this drawing, gate/railing/fence details shall be submitted to and approved in writing by the Local Planning Authority and the development shall be carried out in accordance with the agreed details before the building is first brought into use. Reason: To ensure that the development is of an appropriate design quality in the Conservation Area in accordance with Policy CTC20 of the Worcestershire County Structure Plan and Policy QL7 of the Malvern Hills District Local Plan. 18 Development shall not begin until drainage details, incorporating sustainable drainage principles and an assessment of the hydrological and hydrogeological context of the development have been submitted to and approved in writing by the Local Planning Authority (in consultation with Severn Trent Water Ltd). The development shall be carried out in accordance with the details so agreed and 08/01097/FUL Page 5 of 11 PEFULZ 157

the building shall not be brought into use until the drainage system is completed. The drainage scheme shall include at least 415m3 of cellular storage and 45m3 of open pond storage on site for storm water. Reason: To ensure that the development is provided with a satisfactory means of drainage as well as to reduce the risk of creating or exacerbating a flooding problem and to minimise the risk of pollution. 19 Prior to the commencement of the development or within a timescale previously agreed in writing by the Local Planning Authority, details of external levels and kerbs to ensure that any overland flood flows do not affect the building (informed by the drainage strategy drawing 103 Rev.B shall be submitted to and approved in writing by the Local Planning Authority. the development shall be carried out in accordance with the details so agreed. Reason: To safeguard the building from overland flood flows in accordance with Policy CTC8 of the Worcestershire County Structure Plan and Policies DS16 and QL28 of the Malvern Hills District Local Plan. 20 Before any work on the site commences, or within an alternative timescale which has previously been agreed in writing by the Local Planning Authority, a detailed scheme of landscaping (informed by the landscaping proposals submitted with the application) shall be submitted to and approved in writing by the Local Planning Authority. The approved scheme shall be carried out concurrently with the development and completed within one year of substantial completion of the development. Any trees or shrubs dying or becoming seriously diseased within five years of planting shall be replaced by trees or shrubs of similar size and species to those originally required to be planted. The landscaping/planting required to be carried out shall thereafter be retained in accordance with the approved scheme. Reason: To ensure the environment of the development is improved and enhanced in accordance with Policies DS3 and QL24 of the Malvern Hills District Local Plan and Policy CTC1 of the Worcestershire County Structure Plan. 21 Notwithstanding the details submitted with the application, no site clearance or building operations shall be commenced until a protective fence of at least 2 metres in height, (or other suitable alternative which accords with BS5837:2005 and previously approved in writing by the Local Planning Authority), has been erected around the trees to be retained, on a line concurrent with the perimeter of the crown on the trees (or in the case of fastigiate trees, in a position agreed in writing by the Local Planning Authority). Reason: To secure the well being of the trees to be retained in accordance with Policies DS3 and QL22 of the Malvern Hills District Local Plan. 22 No materials shall be stored, or temporary buildings erected beneath the canopy of any tree and no alteration of ground levels shall occur beneath the canopy of any tree to be retained. Reason: To prevent unnecessary damage to trees in accordance with Policies DS3 and QL22 of the Malvern Hills District Local Plan. 23 A landscape management plan, including long term design objectives, management responsibilities and maintenance schedules for all landscape areas within the site, shall be submitted to and approved in writing by the Local Planning Authority prior to the building hereby approved being first brought into use or within an alternative timescale that has been agreed in writing by the Local Planning Authority. The landscaping shall be managed thereafter in accordance with the approved landscape management plan. Reason: In the interests of visual and residential amenity in accordance with Policies DS3 and QL24 of the Malvern Hills District Local Plan and Policy CTC 1 of the Worcestershire County Structure Plan. 08/01097/FUL Page 6 of 11 PEFULZ 158

24 There shall be no burning of any materials or substances on site unless otherwise agreed in writing by the Local Planning Authority. Reason: To safeguard the residential amenity of adjacent occupiers in accordance with Policy DS3 of the Malvern Hills District Local Plan. 25 Prior to the commencement of the development hereby approved, a specification (including methodology and programme of implementation) for the enhancement of biodiversity through the provision of features including bat boxes/roosting structures and bird nesting boxes shall be submitted to and approved in writing by the Local Planning Authority. The works so approved, shall be carried out in accordance with the approved programme of implementation. Reason: To enhance biodiversity in accordance with Policies QL19 and QL20 of the Malvern Hills District Local Plan and PPS9 - Biodiversity and Geological Conservation. 26 Prior to the commencement of development, or within an alternative timescale which has previously been agreed in writing by the Local Planning Authority, details of the boundary treatment to be erected and/or repairs to be carried out to existing boundary treatments shall be submitted to and approved in writing by the Local Planning Authority. These details shall include a plan at a minimum scale of 1:500 detailing the position of all proposed boundary treatment and annotated or accompanied by a schedule specifying the type, height, composition and appearance of boundary treatment throughout the site. In the case of Malvern stone walling and extract drawing at a scale of 1:50 shall be submitted showing how the stone is to be laid and capped. The approved boundary treatment shall be erected and existing boundary treatments repaired before the development is first brought into use and thereafter retained in that form, notwithstanding the provisions of Schedule 1, Part 2 of the Town and Country Planning (General Permitted Development) Order 1995 (or any Order revoking and re-enacting that Order with or without modification) Reason: In the interests of visual amenity in accordance with Policies DS3, QL1 and QL7 of the Malvern Hills District Local Plan and Policy CTC1 and CTC20 of the Worcestershire County Structure Plan. 27 Any facilities for the storage of oils, fuels or chemicals must be sited on impervious bases and surrounded by impervious bund walls. The size of the bunded compound should be at least equivalent to the capacity of the tank plus 10%. If there is multiple tankage, the compound should be at least equivalent to the capacity of the largest tank plus 10%. All filling points, vents and sight glasses must be located within the bund. There must be no drains through the bund floor or walls. Reason: To minimise the risk of pollution of surface waters in accordance with Policy CTC9 of the Worcestershire County Structure Plan and Policies QL26 and DS3 of the Malvern Hills District Local Plan. 28 Notwithstanding the details submitted with the application a detailed external lighting scheme for the building and external car park/ amenity areas shall be submitted to and approved in writing by the Local Planning Authority before any external lighting is erected on the site. The development shall be carried out in accordance with the approved details. Notwithstanding the provisions of the Town and Country Planning (General Permitted Development) Order 1995 (or any Order revoking or reenacting that Order with or without modification) there shall be no other external illumination of the development. Reason: To safeguard local amenities in accordance with Policy CTC1 of the Worcestershire County Structure Plan and Policies DS3 and QL26 of the Malvern Hills District Local Plan. 29 Prior to the commencement of the development hereby approved or within an alternative timescale agreed in writing by the Local Planning Authority, details of the design and appearance of all 08/01097/FUL Page 7 of 11 PEFULZ 159

ancillary buildings and structures such as gas meter housings, generator and fuel tank enclosures, medical gas storage compounds and oxygen compounds shall be submitted to and approved in writing by the Local Planning Authority. The development shall be carried out in accordance with the details so agreed and no other ancillary buildings or structures shall be erected on the site. Reason: To ensure that these buildings and structures are of an appropriate design quality in the conservation area in accordance with Policy CTC20 of the Worcestershire County Structure Plan and Policy QL07 of the Malvern Hills District Local Plan. 30 There is a public sewer which crosses the site. No buildings shall be erected or trees planted within 2.5 metres of the (225 FWS) or any diversion made to that sewer. Reason: To maintain essential access for maintenance, repair, renewal, and to protect the structural integrity of the public sewerage system. 31 Prior to the building hereby approved being first brought into use, details of public art to be included in the external areas of the site shall be submitted to and approved in writing by the Local Planning Authority. Reason: To visually enhance the development in accordance with the District Council's Supplementary Planning Document "Developer Contributions and Planning Obligations". 32 No development shall begin until a Renewable Energy Plan (REP) (informed by details contained within the Design and Access Statement) has been submitted to and approved in writing by the Local Planning Authority. The REP shall include details of sufficient on-site renewable energy production to reduce Carbon Dioxide emissions by at least 10% from the energy use of the building(s) hereby approved. It shall demonstrate that all renewable energy options and energy conservation measures have been explored, and that for each option, carbon emission calculations, a feasibility study including details of the system sizes, locations, costs and carbon savings have been undertaken. The approved scheme shall be implemented concurrently with the development and shall thereafter be retained Reason: To reduce carbon dioxide emissions in accordance with Policy QL1 of the Malvern Hills District Local Plan, PPS22 - Renewable Energy, Draft PPS1 Supplement - Climate Change, and the District Council's - Developer Contributions and Planning Obligations SPD. 33 Notwithstanding the provisions of the Town and Country Planning (General Permitted Development) Order, 1995 (or any Order revoking or re-enacting that Order with or without modification), no new windows or other openings shall be made in the external elevations of the building and no additions, extensions or external alterations shall be made without planning permission being granted by the Local Planning Authority. Reason: To ensure the character and appearance of the building is maintained to protect the amenities of the area and the residential amenity of adjacent occupiers in accordance with Policies DS3 and QL1 of the Malvern Hills District Local Plan. 34 Details of any external signage to be erected on the site shall be submitted to and approved in writing by the Local Planning Authority before the signage is erected on site. The development shall be carried out in accordance with the approved details. Notwithstanding the provisions of Circular 03/07: Town and Country Planning (Control of Advertisements) (England) Regulations 2007, there shall be no other external signage within the site Reason: To safeguard local amenities in accordance with Policy CTC1 of the Worcestershire County Structure Plan and Policies DS3 and QL26 of the Malvern Hills District Local Plan. 35 External mechanical and electrical services shall only be laid within the service corridors shown on drawing no.32182-01(m)10 Rev. P0 unless otherwise agreed in writing by the Local Planning Authority. 08/01097/FUL Page 8 of 11 PEFULZ 160

Reason: To safeguard trees to be retained on site that positively contribute to the character and appearance of the Conservation Area in accordance with Policy CTC20 of the Worcestershire County Structure Plan and Policy QL7 of the Malvern Hills District Local Plan. 36 The developer shall afford access at all reasonable times to any archaeologist nominated by the local planning authority, and shall allow him to observe the excavations and record items of interest and finds. Reason: To enable expert investigation of this site of archaeological interest during the excavation of the site in accordance with Policy QL13 of the Malvern Hills District Local Plan and Policies CTC.16 and CTC.17 of the Worcestershire County Structure Plan. 37 Notwithstanding the details submitted with the application, details of the design of the barrier system to be installed at the main vehicular entrance/exit of the site shall be submitted to and approved in writing by the Local Planning Authority. The development shall be carried out in accordance with the details so approved. No other barrier system shall be erected on this site without the prior written approval of the Local Planning Authority. Reason: To safeguard the character and appearance of the Conservation Area in accordance with Policy CTC 20 of the Worcestershire County Structure Plan and Policy QL7 of the adopted Malvern Hills District Local Plan. INFORMATIVES 1 a) The attention of the applicant is drawn to section 175 A(3) of the Highways Act, 1980, within which the Highway Authority shall have regard to the needs of disabled persons when considering the desirability of providing ramps at appropriate places between carriageways and footways. b) The attention of the applicant is drawn to the need to keep the highway free from any mud or other material emanating from the application site or any works pertaining thereto. c) The attention of the applicant is drawn to Section 59 of the Highways Act, 1980, which allows the Highway Authority to recover additional costs of road maintenance due to damage by extraordinary traffic. Before any work is commenced on the development hereby approved, representatives of Worcestershire County Council, as Highway Authority, and the applicant shall carry out a joint road survey/inspection of the roads (including footways) leading to the site. Any highlighted defects shall be rectified to the specification and satisfaction of the Highway Authority, before work is commenced on the development hereby approved. A further joint survey/inspection shall be undertaken following completion of the development and any necessary remedial works shall be completed to the specification and satisfaction of the Highway Authority within 1 month or other agreed timescale. d) This permission does not authorise the applicant to carry out works within the publicly maintained highway, since such works can only be carried out by the County Council s Approved Contractor, following the issue of a License under Section 184 and 278 of the Highways Act, 1980. The applicant should contact Worcestershire County Council s Highways Network Control Manager, Environmental Services, County Hall, Spetchley Road, Worcester WR5 2NP (Tel: 0845 607 2005), regarding the issue of the necessary License authorising the access works to be carried out by the County Council s Approved Contractor at the applicant s expense. 08/01097/FUL Page 9 of 11 PEFULZ 161

2 All species of bats and their roosts (whether the bats are present or not) are protected from reckless killing, disturbance or destruction under both national and European legislation. Cracks, cavities and holes in trees and buildings can provide suitable places for bats to rest or hibernate; these should be carefully inspected prior to carrying out any works. If bats are discovered during work on trees or are suspected of being present, the relevant work should be halted and English Nature notified and further advice sought. 3 All wild bird species are legally protected under the Wildlife and Countryside Act 1981 (as amended) from any form of disturbance between the onset of nest building and until such time as any dependent young have left the nest, principally from the end of March to the end of August. 4 Great Crested Newts are protected under both UK and European legislation and it is an offence to kill, injure or disturb them or obstruct access to places used for shelter. Work should be undertaken with due care and if Great Crested Newts are discovered during work on the development, all work should be halted and English Nature should be notified and further advice sought. 5 The verge to opposite side The A449 Worcester Road is common land. No vehicles whatsoever should be parked on this common land. 6 Trees on this site are within a designated Conservation Area where there is a requirement to give the Council a period of 6 weeks advance notice of any works affecting those trees. Date: 7th November 2008 Development Control Manager (Planning Services) The Council House Avenue Road Malvern Worcs WR14 3AF (See Notes Attached) Note: This permission refers only to that required under the Town and Country Planning Acts and does not include any consent or approval under any other enactment, byelaw, order or regulation. In particular consent may be required under The Building Regulations - please Tel: 01684 862151 to check. This document is also available in large print upon request 08/01097/FUL Page 10 of 11 PEFULZ 162