Business Case for Capital Works Neonatal Unit at Daisy Hill Hospital

Business Case for Capital Works Neonatal Unit at Daisy Hill Hospital Version 0.2 Page 1 of 30

TABLE OF CONTENTS 1. INTRODUCTION AND BACKGROUND...3 2. STRATEGIC CONTEXT...6 3. CURRENT SERVICES...8 4. KEY ISSUES...13 5. PROJECT OBJECTIVES AND CONSTRAINTS...17 6. DESCRIPTION OF OPTIONS...19 7. NON-FINANCIAL EVALUATION...20 8. FINANCIAL APPRAISAL...24 9. IDENTIFICATION OF THE PREFERRED OPTION...25 10. EQUALITY AND NEW TSN...26 11. PROJECT MANAGEMENT...27 Page 2 of 30

1. INTRODUCTION AND BACKGROUND 1.1. Introduction This business case sets out a proposal to improve the Neonatal Unit (currently known as Special Care Baby Unit ) accommodation at Daisy Hill Hospital (DHH). Essential refurbishment works are needed to respond to increasing demands on the service and to address service quality and risk issues. The current condition of facilities within the Neonatal Unit is placing strains on service delivery. No improvement work has been carried out to the Neonatal Unit at DHH in recent years and it is in need of urgent refurbishment. 1.2. Existing Neonatology Accommodation at Daisy Hill Hospital The Neonatal Unit at DHH has six special care (level 3) cots. There are no intensive care (level 1) or high dependency cots (level 2). Infants requiring such care are transferred to other neonatal units, mainly at Craigavon Area Hospital (CAH). The unit has an isolation room that is used to isolate babies with infection, diarrhoea and those awaiting the results from MRSA testing, to stop the spread of infection throughout the unit. Whilst this room is called the isolation room it is not a true isolation room as defined by current design standards. The space and size constraints within the unit present limitations as rooms are often used for multiple purposes. Limitations and deficiencies of the existing accommodation are explained in this business case. 1.3. Proposed Changes to SHSCT Neonatal Service The Trust provides Neonatal services from the two acute hospital sites, CAH and DHH. The current profile of cots is detailed in the Table 1.1 below: Table 1.1 Current Profile of Neonatal Cots in SHSCT Level Care CAH DHH Total 1 Intensive 3 0 3 2 High Dependency 4 0 4 3 Special Care 8 6 14 15 6 21 The Southern Health and Social Care Trust (SHSCT) Neonatal service has come under sustained pressure in the last number of years. This is mainly attributable to the following: increasing number of births across the SHSCT. Premature infant activity and thus potential for admission to the unit can, at least, be broadly linked to activity associated with term infants; increase in the Neonatal service s catchment population; assisted reproduction with multiple pregnancies; mothers at extremes of child birth years; Page 3 of 30

increased survival of extremely low birth weight infants; and high levels of occupancy, especially in special care (level 3) cots. Improved outcomes for neonates has resulted in some of these children requiring neonatal care for up to 6 months, this has significantly reduced the capacity of the service to care for new neonates, on occasions resulting in the transfer of these babies throughout the region. These issues have prompted the Trust to review its model of service delivery. The proposed service model would provide immediate measures to alleviate the current pressures on cots especially in relation to level 3 care. The model proposes an increase in the overall complement of level 3 cots and the introduction of transitional care cots. Essentially the Trust proposes the introduction of the following: At CAH provision of one additional level 3 cot and two transitional care cots; and At DHH change in designation of one of the level 3 cots (to be used flexibly as level 2 cot approximately 25% of time) and provision of one transitional care cot. All cots within the SHSCT Neonatal Service will be used more flexibly thus promoting an integrated Neonatal service across the CAH and DHH sites. The new service model will improve patient flow and accessibility to all levels of care and will reduce the requirement for out of Trust transfers. 1.4. Capital Works Required Capital works are required to the Neonatal Unit at DHH in order to address deficiencies in the standard of the accommodation and to facilitate the implementation of the new SHSCT Neonatology service model. The Trust wishes to improve the standard of accommodation and the range of facilities available within the Neonatal Unit, whilst recognising that it is limited in terms of available space. 1.5. Project Team This business case has been prepared by the SHSCT. The members of the Project Team were as follows: Dr Bassam Aljarad Associate Medical Director - Children and Young People s Services; Mr Brian Dornan Director of Children and Young People s Services; Mrs Geraldine Maguire Assistant Director of Specialist Child Health and Disabilities; Mrs Mairead McAlinden Director of Performance & Reform; Mr Martin Kelly Assistant Director of Corporate Planning; Mrs Claire Kelly Head of Capital Planning; Mr Jim Austin Head of Estate Development and Capital Works; Page 4 of 30

Mr Dennis Quinn Assistant Head of Estate Development and Capital Works; Mrs Helen McAleavey Ward Manager, Neonatal Unit, DHH; Mrs Grace Hamilton Head of Acute Paediatrics; Mrs Jackie Gibson Finance; Mrs Josie Matthews - Infection Control Nurse. 1.6. Structure of this Document This business case is set out as follows: Section 2 the strategic and policy context for the development, outlining relevant national, regional and professional guidance; Section 3 a description of current Neonatology Services; Section 4 a summary of the key issues supporting the need to refurbish the Neonatal Unit at Daisy Hill Hospital; Section 5 a description of the project objectives and constraints; Section 6 a description of the possible options; Section 7 non-financial evaluation of options; Section 8 the capital costs associated with the options; Section 9 identification of preferred option; Section 10 discusses the equality and new TSN considerations; and Section 11 the project management arrangements. A series of appendices provide further information and detail, and are referred to as appropriate in the text. Page 5 of 30

2. STRATEGIC CONTEXT 2.1. Introduction Key strategic documents relating to the improvement of neonatal accommodation at DHH are summarised below. 2.1.1. The House of Commons Committee of Public Accounts report on Caring for Vulnerable Babies: The Reorganisation of Neonatal Services in England (June 2008) The House of Commons Committee of Public Accounts report on Caring for Vulnerable Babies: The Reorganisation of Neonatal Services in England (June 2008) states that on average, in 2006/07, each neonatal unit had to close to new admissions once a week due to a lack of baby cots. High occupancy rates could have major implications for patient safety due to increased risk of infection or inadequate staffing levels. The report also identifies Northern Ireland s neonatal mortality rate as higher than that of England. 2.1.2. The Position Paper on Specialist Neonatal Services in Northern Ireland (April 2006) The Position Paper on Specialist Neonatal Services in Northern Ireland (April 2006) which was commissioned by the Chief Medical Officer for NI states that 7% of babies born require special care (level 3 cot) and 3-4% require intensive (level 1) or high dependency (level 2) care. The paper recognises that daily or even hourly fluctuations in relatively small numbers of babies result in peaks and troughs of activity. The challenge is to maintain capacity, both in terms of cots and staff, at a level that can manage demand for the region while ensuring that the service is cost effective and value for money. 2.1.3. The British Association of Paediatric Medicine (BAPM) Designing a Neonatal Unit (May 2004) The British Association of Paediatric Medicine (BAPM) Designing a Neonatal Unit (May 2004), states that Neonatal Unit design is governed by a number of factors including: size of the population served; intensity of neonatal care anticipated; relationship with local children s hospital including paediatric surgical services; the model of care; and available finance. Page 6 of 30

The report indicates that there is a requirement for: 0.75 of an intensive care cot per 1,000 birth population; 0.70 of a high dependency cot per 1,000 birth population; and 4.4 cots per 1,000 birth population for special care. Page 7 of 30

3. CURRENT SERVICES 3.1. Introduction This section provides: an overview of services provided at DHH; a description of neonatology services provided at CAH and DHH; an overview of the trends in births and neonatal activity at CAH and DHH over recent years; and a description of existing accommodation within the DHH Neonatal Unit. 3.2. Services provided at Daisy Hill Hospital Under Developing Better Services (June 2002) DHH was designated as an acute hospital. DHH provides inpatient, out-patient and day case services across a range of specialties. The key specialties provided in DHH are: general medicine and coronary care; general surgery; obstetrics; gynaecology; paediatric medicine; paediatric surgery and ENT; geriatric medicine; and Consultant-led 24-hour accident and emergency unit. A wide range of community and Allied Health Professional services are also provided from the DHH site. There are currently 270 beds plus 6 special care baby cots, in addition 30 renal dialysis stations are provided as part of the sub-regional haemodialysis service. 3.3. Neonatology services provided at Daisy Hill Hospital The Trust currently provides neonatal services from the two acute hospital sites, CAH and DHH. The current profile of cots is detailed in Table 3.1 below. Table 3.1 Current Profile of Neonatal Cots in SHSCT Level Care CAH DHH Total 1 Intensive 3 0 3 2 High Dependency 4 0 4 3 Special Care 8 6 14 15 6 21 Page 8 of 30

The Neonatal Unit at DHH has six special care (level 3) cots. There are no intensive care (level 1) or high dependency cots (level 2). Infants requiring such care are transferred to other neonatal units, mainly at CAH. CAH Neonatal Unit provides levels 1, 2 and 3 care. 3.4. Current Activity Levels Table 3.2 below details births and neonatal activity within the SHSCT over recent years. The proposed new service model for Neonatology proposes that the service will be operating as a network across the two SHSCT acute sites, CAH and DHH. Recognising this future approach to service delivery it is considered that in order to give a more complete view of the activity experienced by the SHSCT Neonatal Service over recent years data should be presented for both CAH and DHH. 3.4.1. Births Table 3.2 Births SHSCT Births 2005/06 2006/07 2007/08 2008/09 Births - CAH 3,151 3,588 3,795 3,880 Births - DHH 1,931 2,037 2,201 2,194 5,082 5,625 5,996 6,074 The information in Table 3.2 above shows that births within SHSCT have increased by 20% over the period 2005/06 to 2008/09. The increase in the birth rate has arisen due to a number of factors including the increasing numbers of migrant workers living in the area and increase in the Trust catchment area with mothers from outside the SHSSB population coming to CAH and DHH to have their babies. In predicting birth levels for the coming years the Trust would suggest that a minimum 2008/09 level of births (circa 6,000) could be expected to be maintained. Premature infant activity and thus potential for admission to the unit can be broadly linked to activity with term infants. 3.4.2. Admissions Table 3.3 below outlines admissions to SHSCT Neonatal units. Table 3.3 - Admissions to SHSCT Neonatal Units Admissions 2005/06 2006/07 2007/08 2008/09 CAH Neonatal Unit 297 401 399 355 DHH Special Care Baby Unit 166 205 160 189 463 606 559 544 In line with the increase in birth rates, total neonatal admissions for the Southern Trust have increased by 17% over the period 2005/06 to 2008/09 (19% increase in admissions to CAH Neonatal Unit and 14% increase in admissions to DHH Neonatal Unit). 3.4.3. Occupancy Occupancy levels at CAH Neonatal Unit have remained consistently high over the last three years. Table 3.4 below shows the occupancy by level of care in the Neonatal Unit for the period 2006/07 2008/09. Page 9 of 30

Table 3.4 Occupancy Levels Level 1 Level 2 Level 3 Year Occup Avail % Occup Avail % Occup Avail % 2006/07 569 1095 52 972 1460 67 3346 2920 115 2007/08 676 1098 41 984 1464 67 2951 2928 101 2008/09 702 1095 64 1195 1460 82 2919 2920 100 The above information shows the full and over occupancy of level 3 cots from 2006/07. Annual occupancy although useful does not clearly demonstrate the extent of demand on level 3 cots in the Neonatal Unit in CAH. Level 3 occupancy plotted on a monthly basis below clearly demonstrates that cots were over occupied more often than under occupied. Chart 1 Occupancy Level 3 Cot CAH Occupancy of Level 3 Cot in CAH over a 3 year period 160 140 120 100 Percentage 80 60 40 20 0 April May June July August September October November December January February March Month 2006/07 2007/08 2008/09 Full Occupancy Annual Occupancy for level 3 cots in Daisy Hill Hospital for 2007/08 was 59%; this increased to 65% for 2008/09. Again the annual occupancy does not demonstrate demand and fluctuation in activity throughout the year. Occupancy for level 3 cots for Daisy Hill is plotted below in monthly intervals. Page 10 of 30

Chart 2 Occupancy Level 3 Cot DHH Occupancy of Level 3 Cots in the Special Care Unit Daisy Hill Hospital 100% 90% 80% 70% 60% % 50% 40% 30% 20% 10% 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2007/08 2008/09 60% Occupancy The Trust proposes to introduce a new model of working which will ensure that all neonatal cots across the CAH and DHH sites are viewed as operating within an integrated service and fully utilised. There is also a need to introduce transitional care cots so that level 3 cots are only occupied by babies actually requiring level 3 care, this will alleviate the issue of high occupancy in level 3 cots. Page 11 of 30

3.4.4. Existing Accommodation at DHH Special Care Baby Unit/Neonatal Unit The Special Care Baby Unit/Neonatal Unit at DHH is approximately 160sqm and provides the following accommodation: Incubator room; Nurses station; Isolation room as described in Section 1.2, this is not an isolation room to current design standards but a room where the a baby can be nursed until they are clear of infection, diarrhoea etc. Equipment store; Linen store; Observation room; Parent s day room; Store area; Clean and dirty utility; and Milk kitchen. Page 12 of 30

4. KEY ISSUES 4.1. Introduction This section outlines the key issues affecting the Neonatal Service at DHH: proposed changes to SHSCT Neonatology Service; and accommodation issues. 4.2. Proposed Changes to SHSCT Neonatology Service Model The Trust is seeking commissioner approval to proceed with plans to reconfigure and enhance the service model which will provide immediate measures to alleviate the current pressures on cots especially in relation to level 3 care. The model proposes an increase in the overall complement of level 3 cots and the introduction of transitional care cots. The transitional care model allows parents to care for their baby within the neonatal unit under the supervision of neonatal staff. A separate proposal has been developed which outlines the changes to the Neonatology Service Model and the associated funding requirements. Essentially the Trust proposes the introduction of the following: At CAH provision of one additional level 3 cot and two transitional care cots; and At DHH change in designation of one of the level 3 cots (to be used flexibly as level 2 cot approximately 25% of time) and provision of one transitional care cot. The introduction of these cots and the other proposed changes to the service model will: allow some babies to receive transitional care from birth (thus reducing admissions to level 3 cots); and allow babies to move from level 3 to transitional care cots and remain in hospital whilst being cared for by their parent(s). This affords time in the early weeks to bond with their child and also helps to reduce the length of stay within level 3 cots. Usually parents will care for this infant but in certain situations this may not be possible due to adoption, mother being too sick to care for baby etc. Providing transitional care cots on both sites and the implementation of the associated criteria for admission and procedure for use of these cots will reduce the length of stay of infants in level 3 cots. Some infants will be directly admitted to transitional care cots thus reducing admission to level 3 cots. The introduction of a flexible level 2/3 cot at DHH will provide additional capacity within the provision of care and will reduce pressures in level 2 and level 3 care in CAH by reducing length of stay. The Trust has determined the future assessment of need for neonatal care as the provision of 22 neonatal cots and 3 transitional care cots. Page 13 of 30

Table 4.1 below provides details of the proposed future configuration and location of cots within the Southern Trust: Table 4.1 - Proposed Future Neonatal Cot Configuration Level Care CAH DHH Total Current Future Current Future Current Future 1 Intensive 3 3 - - 3 3 2 High Dependency 4 4 - - 4 4 3 Special Care * 8 9 6 6 14 15 Transitional - 2-1 - 3 15 18 6 7 21 25 *One level 3 cot would be used flexibly as level 2/3, it is expected that it would be used as level 2 cot approximately 25% of the time. All cots within the SHSCT Neonatal Service will be used more flexibly thus promoting an integrated neonatal service across the CAH and DHH sites. The new service model will improve patient flow and accessibility to all levels of care and will reduce the requirement for out of Trust transfers. The separate proposal entitled New Service Model for Neonatology has been developed recently to support the implementation of the new Service Model, this proposal details the revenue funding required to implement the new service model. 4.3. Neonatology Department Accommodation Issues Capital investment in the Neonatal Unit is required to address deficiencies in the general standard of accommodation and to provide facilities that allow the new service model for Neonatology to be implemented. Key issues associated with the existing Neonatal accommodation include: the current neonatal unit is approximately 160 m2, falling short of the BAPM guidelines. The space and size constraints within the unit present limitations as rooms are often used for multiple purposes. The layout of the unit is poor and does not support efficient working practices; according to BAPM, a special care room requires 9.5 m2 per cot, including central walkways. This demonstrates the need for 57 m2 to accommodate 6 special care cots. The existing space constraints will need to be addressed in line with health and safety; the isolation room is used as a multi purpose room and in addition is often used for storage (for example for unused equipment and incubators). This is not ideal practice for an isolation room and does not promote the provision of safe and effective care; lack of clinical wash hand basins in the unit to facilitate the washing of nurses and parents hands. According to BAPM recommendations there should be one large wash hand basin for every 3 / 4 infants cared for; at present, the Neonatal Unit does not have its own toilet facilities for parents and is currently sharing a toilet in the Delivery Suite; the current unit is in need of redecoration. The BAPM recommends that a Neonatal Unit should be thought of as baby s first home and should promote a welcoming atmosphere, natural lighting and where possible views of surroundings outside; Page 14 of 30

the nurses station is separate from the main cot/nursery area. At present staff must leave the nursery and access the workstation via the corridor. Access to the nurses station via the nursery would enable the staff to remain within the nursery while taking phone calls etc.; limited space within the milk kitchen; parent s accommodation within the unit is limited, there is a small room with a sofabed, chairs and wash-hand basin. There is no tea/coffee making facility, ideally there would be a kitchenette for parents to use. No toilet/shower area is available to parents. The introduction of a transitional care cot will mean that parents will spend more time in the unit caring for their infant and therefore the provision of adequate parent s rest accommodation and toilet/shower facilities is essential; there is limited storage within the unit, the existing equipment store is small and as noted above the isolation room is sometimes used for storing equipment; at present there is no separate area where a very sick/dying baby can be nursed. Due to the space constraints within the unit such a baby is nursed in very close proximity to the other babies, there is no privacy for the parents and family of the very sick baby; no designated disposal hold for the Neonatal Unit; no designated preparation area; and no designated clean or dirty utility. Initial discussions with clinical staff have indicated a desire to provide (as far as possible within available space and budget) the following improvements to the accommodation within DHH Neonatal Unit: 6 level 3 cots (one as level 2 cot 25% of time); Separate area within main cot room/nursery to nurse very sick/dying baby. This would provide privacy for parents; Segregation Room: Two bedhead services to allow twins to be nursed in isolation. Preparation Room: Area to store drugs and prepare drugs. Transitional Care Cot Room: Cot; Sofabed/Fold down bed for parent(s). Parents Room: Kitchenette area; Sleeping area. Page 15 of 30

Toilet and Shower Nurses Station Milk Room: 2 sinks (one for handwash and one for bottle cleaning). General Store Room: Equipment; CSSD; Pharmacy; Laundry; Nappies; and Mailbox. Dirty Utility: 2 sinks (one for handwash and one for washing equipment) Disposal Hold Sister/Doctor s office Page 16 of 30

5. PROJECT OBJECTIVES AND CONSTRAINTS 5.1. Project Objectives This section sets out the main objectives for the project, together with the main constraints that might apply. This project is aimed at improving Neonatal accommodation at DHH to support the delivery of a high quality, safe and patient-centred service. The Trust must ensure that any developments deliver maximum value for money for Health and Social Care. Value for money will reflect a judgement on the balance of financial and economic costs set against the achievement of non-financial benefits and the levels of risk to which the Trust will be subjected. It reflects that the Trust s objective is not to minimise cost but to achieve an appropriate balance between capital investment and long term running costs, and return on that investment and expenditure. This return is ultimately in the form of benefits for patients and clients but within the business case is reflected in the form of various desirable outcomes such as space availability, standards of accommodation and other functional relationship and process improvements. Based on this focus of providing accommodation of an appropriate size and format and achievement of various functional and process benefits, a set of business case objectives have been developed. These objectives are set out below: 5.1.1. Objective One To provide a safe, clinically effective Neonatal service for patients residing within the Trust s catchment area The intensity of care within the modern hospital together with the need for highly efficient patient management requires effective clinical processes and accommodation standards which support the delivery of safe care. 5.1.2. Objective Two To ensure the provision of high quality accommodation The required accommodation should be provided to a high quality in terms of condition of the fabric and the internal and external environment and to a high level of functional suitability. 5.1.3. Objective Three To minimise disruption and disturbance to ongoing patient care activities during the construction period It is imperative that continuing care for patients is provided during the construction period. Some development options are likely to have a greater impact on the patient environment than others, and it is essential that this disruption to patients is minimised. 5.1.4. Objective Four To ensure strategic fit with future developments Page 17 of 30

Any provision of new accommodation or improvement to existing accommodation should not limit future plans to develop the Daisy Hill Hospital site. 5.2. Project Constraints A number of constraints were also agreed as the basis for limiting the choice of options to be considered. Thus selected options must be capable of overcoming the following constraints: A The selected option must be accessible and affordable in terms of capital and revenue. B The preferred option must make best use of the existing estate and service infrastructure. Page 18 of 30

6. DESCRIPTION OF OPTIONS This section examines the possible options relating to the improvement of Neonatal facilities at DHH. Options identified are detailed below. 6.1. Long List of Options The Trust considered the range of plausible options combining locations, design solutions and extent of investment to produce a long list of options, these are outlined below. There are currently no viable options for relocating the Neonatal Unit to another area within DHH building. 6.1.1. Option 1 Do Nothing This option involves continuing to provide Neonatal services using existing facilities, with no enhancement to facilities on the DHH site. There would be no additional investment above the planned capital expenditure and current baseline running costs. 6.1.2. Option 2 Refurbishment of the Existing Neonatal Unit This option involves refurbishing the existing Neonatal Unit to improve the fabric and condition of the existing accommodation. This option does not propose any reconfiguration of the available space, the layout of the unit will remain as it currently is. 6.1.3. Option 3 Refurbishment and Reconfiguration of the Existing Neonatal Unit This option involves refurbishing and reconfiguring the existing Neonatal Unit to provide the desired accommodation, outlined in Section 4.3, as far as is possible. This option does not propose any extension to the unit. 6.1.4. Option 4 Refurbishment and Extension of Existing Neonatal Unit This option involves refurbishing the existing Neonatal Unit to provide the desired accommodation outlined in Section 4.3. This option proposes re-configuration of the existing floor plan of the unit and extension of the unit via re-location of adjacent accommodation as far as is possible within the space constraints within the hospital. The desired accommodation will be provided to current design standards as far is practical and possible, however it is recognised that given the space constraints within the unit this may not be possible for all elements of the accommodation. It is estimated that the floor area of the unit will increase from 160m2 to 210m2 under this option. 6.1.5. Option 5 Provision of New Neonatal Unit This option proposes the provision of a new Neonatal Unit on the DHH site. This new Neonatal Unit will provide the desired accommodation (noted in Section 4.3) to current design standards. Page 19 of 30

7. NON-FINANCIAL EVALUATION A set of non-financial criteria were derived from the service attributes and constraints described in Sections 5.1 and 5.2 above. Each short-listed option has then been measured against these criteria. The non-financial criteria are described below. 7.1. Non-Financial Criteria 7.1.1. Clinical Effectiveness and Patient Safety An effective clinical service is defined as an integrated, appropriate service, flexible to changing needs, with good clinical outcomes. The preferred solution must ensure that the layout promotes good work flows. 7.1.2. Quality of Accommodation The Trust wishes to provide a service from a facility which is of high quality in terms of space, location and functional suitability for which it is intended. 7.1.3. Degree of Strategic Fit The proposed solution must not limit future development on the Daisy Hill Hospital site. 7.1.4. Speed of Implementation It is an objective of the Trust that this new facility should be available by April 2010. Differential timescales will be caused by varying lengths of design, procurement, construction and commissioning. 7.1.5. Continuity of Service 7.2. Weighting It is inevitable during the construction of new facilities that there will be an element of disruption to patient care. This may arise as a result of the effect of the construction on other services/departments, the environmental impact of the construction (noise etc.) or inconvenience to staff. The Trust wishes to minimise such disruption in the ongoing delivery of patient care. Neonatal services should operate as normal during the construction period. The level of importance of each of the benefit criteria was considered in relation to the objectives and constraints described in Sections 6.1 and 6.2 above. The allocation of a weighting factor to each of the criteria is a means of reflecting the relative effect of the success of each option in the scoring. The weightings agreed by the Project Team were as follows: A Clinical Effectiveness 30 per cent B Quality of Accommodation 25 per cent C Degree of Strategic Fit 15 per cent D Continuity of Service 20 per cent Page 20 of 30

E Speed of Implementation 10 per cent 7.3. Benefit Analysis Each of the options was rated on a score between 1 and 10, with 10 meaning that the option fully met the non-financial criteria. The results of this analysis are recorded in Table 7.1 below. 7.3.1. Clinical Effectiveness Option 1 has received a score of 2 as it would not provide any improvement to current facilities. Option 2 has received a score of 3 as there would be some improvement to the fabric of the unit which should slightly improve clinical effectiveness, however with no reconfiguration of the layout of the unit there would be limited scope for improving work flows. Option 3 involves refurbishing and reconfigurating the existing Neonatal Unit, there would not be any extension of the unit, however the opportunity to reconfigure the existing floor area would give some improvement to the layout and work flows. Option 4 would allow for refurbishment and some extension of the existing unit, similar to Option 3 this would allow for improvement to the layout and work flows, as this option also proposes an extension to the unit as far as possible this option has been given a score of 7. Option 5 proposes providing the desired accommodation by means of a new build on the DHH site, the provision of a new unit will provide more scope for improving the layout and work flows as the design will not be constrained by the position of existing accommodation, as such this Option has been allocated a score of 9. 7.3.2. Quality of Accommodation Option 1 has been given a score of 2 as there would be no improvement to the quality of accommodation. Option 2 would provide some improvement by means of decoration and has been given a score of 4. Option 3 would provide decoration and reconfiguration within the existing footprint of the unit and has been allocated a score of 5. Option 4 would extend the unit as far as possible, reconfigure the available space and redecorate, this has been given a score of 7. Option 5 is the new build option which would provide a higher quality of accommodation and has received a score of 9. 7.3.3. Degree of Strategic Fit Options 1, 2, 3 and 4 all propose retaining the Neonatal Unit in its current location, adjacent to Delivery Suite, this does not impact any existing plans to redevelop the DHH site. These four options have all been given a score of 4. Option 5 involves a new build on the DHH site, in the absence of any approved plans for the redevelopment of the DHH site it is possible that providing a new build Neonatal Unit now may limit future capital developments on the site. 7.3.4. Continuity of Service Option 1 has received a score of 8 as no works are proposed under this option and therefore there would be no disruption to service. Options 2, 3 and 4 would require varying degrees of decant of the Neonatal Unit for the Page 21 of 30

duration of the works. Scores allocated to these options reflect the duration of the proposed works. Option 2 involves refurbishment (redecoration) of the existing unit and has been given a score of 7. Option 3 has been given a score of 6 as it also proposes reconfiguration of the available space. Option 4 has been given a score of 5 as it proposes reconfiguring and refurbishing a larger area than the existing unit. Option 5 has been given a score of 8 as the new build option will be separate to the existing Neonatal accommodation and will not impact on continuity of existing service, the service will move to the new facility when it is complete. 7.3.5. Speed of Implementation Option 1 has received a score of 8 as no works are proposed under this option. Option 2 has received a score of 7 as the design and proposed works would be completed over 3 months. Option 3 has received a score of 6 as the design and proposed works would be completed over 6 months. Option 4 has received a score of 5 as the design and proposed works would be completed over 7 months. Option 5 has received a score of 3 as the design and proposed works would be completed over 12 months. Page 22 of 30

7.4. Option Ranking The ranking of the options is recorded in Table 7.1 as follows: 1 Option 5 Score 730 2 Option 4 Score 595 3 Option 3 Score 515 4 Option 2 Score 460 4 Option 1 Score 410 Table 7.1 - Non-Financial Evaluation Benefit Criteria Weight Option 1 Option 2 Option 3 Option 4 Option 5 Score Weighted Score Score Weighted Score Score Weighted Score Score Weighted Score Score Weighted Score Clinical Effectiveness 30 2 60 3 90 5 150 7 210 9 270 Quality of Accommodation 25 2 50 4 100 5 125 7 175 9 225 Degree of Strategic Fit 15 4 60 4 60 4 60 4 60 3 45 Continuity of Service 20 8 160 7 140 6 120 5 100 8 160 Speed of Implementation 10 8 80 7 70 6 60 5 50 3 30 Total 100 410 460 515 595 730 Page 23 of 30

8. FINANCIAL APPRAISAL 8.1. Introduction The following section outlines the capital costs associated with the improvement of the Neonatal unit at DHH. 8.2. Capital Costs The capital costs associated with each of the short-listed options are detailed in Table 8.1 below. Table 8.1 - Capital Costs Option 1 Option 2 Option 3 Option 4 Option 5 Works - 112,500 241,200 321,440 596,650 Equipment - - 20,000 30,000 50,000 Professional fees, non works costs, statutory and local authority fees and charges - 25,000 67,038 63,288 131,263 Contingency - 13,000 27,000 20,000 59,665 Total - 150,500 355,238 434,728 837,578 Detailed capital costs (works costs) are provided in Appendix 1. Page 24 of 30

9. IDENTIFICATION OF THE PREFERRED OPTION The selection of the preferred option is a process drawing on the results of both the financial and the non-financial assessment of the short-listed options. The desirable outcome of this process is a preferred option. A summary of the scoring and costing exercise is outlined in Table 9.1 below. Table 9.1 Summary of Costs and Benefits Option 1 Option 2 Option 3 Option 4 Option 5 Capital Costs ( ) - 150,500 355,238 434,728 837,578 Non-Financial Benefit Score 410 460 515 595 730 The Project Group has considered the options and has concluded that the preferred option is Option 4 Refurbishment and Extension of Existing Neonatal Unit. It is considered that this option offers the best solution in terms of capital cost and accommodation outcomes. Page 25 of 30

10. EQUALITY AND NEW TSN Section 75 of the Northern Ireland Act (1998) requires public authorities in carrying out their functions relating to Northern Ireland, to have due regard to the need to promote equality of opportunity: between persons of different religious belief, political opinion, racial group, age, martial status or sexual orientation; between men and women generally; between persons with a disability and persons without; and between persons with dependants and persons without. As part of ensuring compliance with the statutory duty, the SHSCT have produced an Equality Scheme demonstrating their commitment to equality of opportunity and to carrying out Equality Impact Assessments on policies which may have a differential impact on any of the categories noted above. The existence of a differential impact is determined by reference to the following four criteria: is there any evidence of higher or lower participation or uptake by different groups? is there any evidence that different groups have different needs, experiences issues and priorities in relation to the particular policy area? is there an opportunity to better promote equality of opportunity or better community relations by altering the policy or working with others in government or in the larger community? or have consultations in the past with relevant groups, organisations or individuals indicated that particular policies create problems that are specific to them? The developments proposed within this outline business case have been considered in terms of their equality of opportunity implications against each of the four criteria detailed above. The proposal to improve Neonatal accommodation at DHH has limited scope to impact differentially on any of the nine equality groupings, as the standard of care for all service users and staff will be improved. Page 26 of 30

11. PROJECT MANAGEMENT 11.1. Major Tasks and Timetable The table below sets out the major project stages and tasks and the envisaged timescales. Table 11.1 Project Timescales and Milestones Phase Component Target Date Formal Release of Capital Funding/Approval September 2009 Detailed Design Complete End Nov 2009 Tender Process Complete End Nov 2009 Works Commenced December 2009 Works Complete End March 2010 Page 27 of 30

Appendix 1 Capital Costs (Works) Page 28 of 30

18 th Aug 2009 Estate Development and Capital Works Southern Health and Social Care Trust Tower Block, Craigavon Area Hospital Re: New Service Model for Neonatology at Daisy Hill Hospital, Newry Budget Estimate of cost for Construction Works Options 1-5 Option 1 Do Nothing Nil Cost Option 2 Refurbishment of the Existing Neonatal Unit Works Costs 112,500.00 Contingency Sum 13,000.00 Total budget works costs 125,500.00 ========= Professional Fees, Non Works Costs, Statutory & Local Authority Fees o& Charges 25,000.00. Total budget estimated costs 150,500.00 ========== Option 3 Refurbishment and Reconfiguration of the Existing Neonatal Unit Works Costs 241,200.00 Contingency Sum 27,000.00 Total budget works costs 268,200.00 ========= Professional Fees, Non Works Costs, Statutory & Local Authority Fees o& Charges 67,038.00 Total budget estimated costs 335,238.00. ========== Page 29 of 30

Option 4 Refurbishment and Extension of Existing Neonatal Unit Item 1 : Item 2 : Item 3 : Reconfiguration of Existing Special Care Unit Neonatal DHH to provide; a. 5 No. Special Care Cots b. 1 No. Isolation Cot c. 1 No. Transitional Cot Decant Existing Special Care unit to Maternity First Floor DHH; Relocate Existing Consultants Office, Doctors On Call Room and Photocopier Room; Works Costs 321,440.00 Contingency Sum 20,000.00 Total budget works costs 341,440.00 ========= Professional Fees, Non Works Costs, Statutory & Local Authority Fees o& Charges 63,288.00 Total budget estimated costs 404,728.00. ========== Option 5 Provision of New Neonatal Unit Works Costs 596,650.00 Contingency Sum 59,665.00 Total budget works costs 656,315.00 ========= Professional Fees, Non Works Costs, Statutory & Local Authority Fees o& Charges 131,263.00. Total budget estimated costs 787,578.00 Note that these estimates are exclusive of Equipment Furniture Fixtures or Fittings Page 30 of 30