SuRNICC Full Business Case. Benefits Realisation Strategy and Framework

SuRNICC Full Business Case Benefits Realisation Strategy and Framework Purpose The purpose of this document is to set out the arrangements for the identification of potential benefits, their planning, modelling and tracking. It includes a framework that assigns responsibilities for the actual realisation of those benefits throughout the key phases of the project. The Approach to Benefits Realisation The organisation s overall approach to benefits realisation is outlined in the document Benefits Realisation for Major Capital Projects, which was endorsed by the organisation s Finance and Performance Sub-Committee in December 2015. The paper emphasises the importance of identifying clear objectives and measurable benefits from the outset of a project, and of having a robust process for their delivery. As described in that paper, the approach to identifying benefits through the business case is outlined in the organisation s Procedure Manual for Managing Capital Projects, including: Adopting the same high level investment objectives and criteria as Welsh Government Describing the process to develop a capital programme which enables the Corporate Directors Group to effectively set strategic priorities and ensure that those business cases progressing are robust, demonstrate clear linkages to the Board s priorities and have clearly defined benefits associated with the capital investment. This involves: o o Formal review of major business cases by the Finance and Performance Committee before being considered by the full Board The Capital Programme Sub-Group of the CDG overseeing the production of the Infrastructure Investment Plan as part of the IMTP, and overseeing the preparation and scrutiny of business cases. In addition to this process specific scrutiny sessions have been introduced to review major business cases at key stages in their development. These sessions are chaired by the Director of Strategy and include senior input from relevant departments and divisions. 1 P a g e

The Procedure Manual for Managing Capital Projects also outlines the process for delivering capital projects. In relation to benefits this includes: Clarity about roles and responsibilities, including those of the Senior Responsible Owner (SRO) and the Project Director (PD) for delivering the project as a whole. Specifically, the Project Director is responsible and accountable to the SRO for the delivery of benefits. The creation of a Project Execution Plan, which includes the project s objectives, scope and deliverables. The need for End Stage Reviews, which include considering any potential changes to the project s scope. Systematic reporting of progress to the Project Board, the Capital sub-group of CDG and then to F&P. The requirement for Post Project Evaluation, which includes a full consideration of the achievement of benefits as required by Welsh Government. Performance against benefits is also identified in the monthly Capital Programme Report to the Finance and Performance Committee, where the Red/Amber/Green rating of each scheme includes the achievement of benefits. Each major scheme will produce a report for F&P on progress against objectives and the delivery of benefits at appropriate stages in the project. All schemes will have a handover report when construction is completed, which will summarise the delivery of the project to that point and recommend to the F&P the benefits realisation reporting timeframe and frequency. All projects will have a formal post-project evaluation, which is typically produced 15 months after the completion of the project. SuRNICC Benefits Register The Benefits Realisation Register sets out the benefits of the project, the category of each benefit (in economic terms) how they will be measured and quantified, who benefits and who is responsible for their realisation. The benefits are as outlined in the relevant sections of the business case. This document focuses on the key benefits which the project is intended to deliver, rather than providing a comprehensive list of all benefits. This register is a management tool which addresses the specific benefits as a result of the development of the SuRNICC as a networked model across North Wales. An action plan will be developed to deliver the benefits and there will be regular progress reviews by the project team. 2 P a g e

As outlined in Welsh Government guidance an evaluation will be undertaken to review and assess the success of the project against its original objectives and success criteria. The achievement of these benefits will form the basis of that review. The initial review will be undertaken within fifteen months of the completion and handover of the project. The assurance review framework will be discussed and agreed with Welsh Government as the project progresses. Outcomes Given the very small number of patients involved in this service it is difficult to meaningfully evaluate outcomes, or to isolate the impact of the change proposed in this case. However the service is committed, as part of the all-wales Network, to developing its approach in this area. It has joined the Vermont Oxford Network benchmarking system, which is aimed at improving quality for Neonates and their families, and is collecting 2-year outcome data. National Neonatal Audit Programme It is important that the standards of care provided across North Wales as part of the SuRNICC model are robustly monitored. One of the key vehicles for doing this is via the RCPCH through the National Neonatal Audit Programme (NNAP). Since 2006 the NNAP has monitored and reported on neonatal care processes to help ensure that all babies admitted to neonatal units have the best chance of survival, optimising their full potential and achieving the best possible outcome. The NNAP looks for areas where the care of babies can be improved and makes recommendations on how those improvements can be achieved and monitored. The purpose of NNAP is to view information and monitors whether care provided matches up to the professionally agreed standards, they identify the areas which require improvement and informs action planning at local, regional and national standards. The NNAP 2015 Annual report looked at 9 areas of care, which includes specific areas identified in the benefits table below: Consultation with parents Mother s milk at discharge Clinical follow-up at 2 years of age Retinopathy of prematurity screening Antenatal steroids Temperature taken within one hour of admission 2 year outcomes Information is obtained from the Badgernet (National Neonatal Information System), which all units use. 3 P a g e

SuRNICC Benefits Register 1 Improve access to Neonatal Care in line with the All Wales Neonatal Standards, to ensure that All newborn babies who require healthcare over and above the normal birth pathway have equitable access to the appropriate level of care in a timely manner Specific Measurables Timetable for achievement Method to Review Lead Responsibility Beneficiary Class / Value 1.1 Provision of neonatal care for a minimum of 95% for babies born to women booked for delivery in one of the 3 north Wales units. There will be a reduction in the number of babies who receive care out of north Wales as part of the SuRNICC model current base line is 45 50 2018 1 ST 12 months after opening Monthly Maternity Dashboard In-utero transfer data Clinical Leads for Neonatal and Maternity Services Non-quantifiable Benefits Sufficient cots across North Wales units to allow for step up care from special care to high dependency and high dependency to Intensive care and subsequent step down. Provision of HD care in all units to support local repatriation. All babies will be cared for in the appropriate level of cot. Badgernet (National Neonatal Information System) Numbers of transfers and length of stay Provide a wider range of clinical interventions e.g Nitric Oxide in the SuRNICC and on the transport system including cerebral function CFM in all three units, reducing the need to transfer out of north Wales. Number of unit closures Datix Evidence supports that the length of stay is 4 P a g e

directly related to distance from neonatal services (YGC provides optimal access for the population) 1.2 Reduction in the number of closures or partial closures due to staffing, lack of appropriate level of cot or insufficient cots. On average we have 36 closures a year totalling 1,750 hours (73 days). We will reduce by a minimum of 60% in year 1. With further reductions in year 2 and year 3. 2018 1 st 6 months after opening Monthly Neonatal Dashboard Datix reports following closure (Escalation Policy) Clinical Leads for Neonatal Quantifiable Benefits 1.3 Reduction in the number of women who have an unplanned transfer to a unit outside of north Wales due to insufficient staffed cots at the right level. Currently 31 women a year experience unplanned transfer to another unit due to closure or partial closure. We will reduce this by 75% in year 1 with further reductions in subsequent years. 2018 1 st 6 months after opening Monthly Maternity Dashboard Datix reports following closure (Escalation Policy neonatal and maternity) Clinical Leads for Neonatal and Maternity Services Quantifiable Benefits Annual review of cot configuration WAST activity 1.4 Reduce the risk of infection outbreaks due to compliant accommodation including cot space and wash hand basins, equipment, environment and cleaning facilities. Provision of Isolation cubicle and correct staffing levels. March 18 upon opening Datix Outbreak reviews Infection Prevention and Control Neonatal Service Quantifiable Benefits 5 P a g e

Manager 2 Compliance with All Wales Neonatal Standards for all staff groups Specific Measurables Timetable for achievement Method to Review Lead Responsibility Beneficiary Class / Value 2.1 Provide a networked neonatal service across north Wales which is compliant with the standards for all staff groups, including clerical and support staff in addition to the clinical establishment Compliance is in terms of numbers of staff by profession and qualification. September 2018 Review of compliance with standards every 6 months Review of Workforce Action Plan Lead Neonatal Clinicians 2.2 Training and ongoing development of all staff across North Wales by providing Lecturer Practitioner, Practice Development Nurses, ANNPs and Designated Neonatal Consultants for the three units and Transport. Baseline and requirements will be established through a training needs analysis prior to opening the unit. Prior to Opening PDR process Medical Annual Appraisal Training needs analysis Neonatal Clinical Lead for Governance 2.3 Centre of excellence for the attraction and recruitment of neonatal and non-neonatal Medical Staff and clinical staff. Particularly supports the development of an Obstetric centre of excellence. Attractive positions for Consultants, Specialists, Researchers and Prior to unit opening Workforce information on recruitment / retention Locum / Agency Workforce information - vacancies, turnover rate etc 6 P a g e

academics. Greater potential to recruit more senior staff. usage Provides wider range of experience and opportunities for Obstetric, Paediatric Trainees at YGC and from the other two units Wider range of opportunities for Nursing and Midwifery staff including Adult branch, Paediatrics and Midwifery (including HCSW and MSWs) Wider range of opportunities for therapy and pharmacy staff to develop expertise in Neonatal care 2.4 Splitting of the Neonatal and General Paediatric Consultant rotas will support an increase in Consultant Delivered paediatric care in line with recommendations in Facing the Future RCPCH On splitting of the Paediatric and Neonatal Rota date TBC Review of Rotas Clinical Director Non-CR Non- Dedicated Neonatal Service Manager providing leadership and development of neonatal services across North Wales. This will release the three Paediatric Service managers to develop other areas of paediatric services On opening Central Area Assistant Director Children s 7 P a g e

3 Facilities for Neonatal Services, Including Equipment Specific Measurables Timetable for achievement Method to Review Lead Responsibility Beneficiary Class / Value 3.1 Sufficient cots at the required level of care for the population of north Wales. Measure numbers of closures and transfer of mother and / or baby for non-clinical reasons ref; 1.2 and 1.3 Within 12 months of unit opening Capacity Review Maternity Dashboard Neonatal Clinical Leads 3.2 Provision of sufficient Labour ward and maternity in-patient beds, including Low Dependency / Transitional Care. Provision of Bereavement Suit to support the increase in high risk Births. Increase of 1 labour room and 4 inpatient beds. The additional capacity within obstetrics will minimize delivery unit closures due to increased activity. March 2018 Maternity Dashboard SANDS audit Maternity satisfaction survey s Datix Lead Clinicians for Obstetrics and Maternity Non- In the past 12 months there have been no inutero transfers due to insufficient labour ward / maternity capacity. 3.3 Cot spaces are in line with Neonatal Units: Planning and Design Manual. March 2018 Post Project Evaluation Project Director 8 P a g e

3.4 Provision of the necessary equipment to support each cot and level of care. In the first instance only 42 of the north Wales cot capacity will be equipped March 2018 Post project evaluation Project Director 4 Care of the Baby and Family / Patient Experience Specific Measurables Timetable for achievement Method to Review Lead Responsibility Beneficiary Class / Value 4.1 Babies will be cared for in their most local unit in accordance with their care needs. 95% of babies are born where the mother is booked to deliver. Ref 1. 1 Within 6 months of unit opening Data Analysis Badgernet Datix Neonatal and Obstetric Clinical Leads Quantifiable Benefits Reduction of transfers out of North Wales will support and facilitate more families to have greater access to welsh speaking staff (ref. to Welsh Language Standards). Provision of bilingual information for mothers and families Monitor number of welsh speaker in each unit 4.2 Facilities on the unit for Rooming in to support timely and planned discharge. March 2018 Post Project Evaluation Project Director 9 P a g e

4.3 Facilities will be fit for purpose which will support the implementation of UNICEF BFI Neonatal Standards and improve the % of babies receiving Mother s milk at discharge by at least 10% by 2018 current rate is 26.8% in North Wales compared to uk average of 60% Within 12 months of opening Badgernet Maternity Dashboard Neonatal and Obstetric Clinical Leads Year on year improvements to be achieved 4.4 Consultation with Parents provide a documented consultation with parents by a senior member of the neonatal team within the first 24 hours of ALL baby being admitted. By 2018 Badgernet Senior Neonatal Team Non-quatifiable Currently this is 66% % (89% nationally). In year 1 we will achieve 100% 5 Transportation Specific Measurables Timetable for achievement Method to Review Lead Responsibility Beneficiary Class / Value 5.1 Provision of a 12 / 7 transport service and North Wales cot bureau supported by the dedicated ambulance with the provision of all levels of neonatal care during transfer e.g. Consultant, ANNP and / or Nurse. 2017 prior to opening Transport Data set requirements Datix Lead Consultant for Transport Provision of a new Transport System which will be able to provide Nitric Oxide Therapy during transfer, all modes of ventilator support and total body cooling. Badgernet 10 P a g e

5.2 Improve performance against the National Transport Dataset for all transfers. Currently 20% of all transfer activity is delayed due to non-availability of staff at the required level and are not completed in the required time scales. In year one we will reduce this by 50%, with further improvement in year 2 and achieve compliant with the target of 95% of all transfers within the agreed response times. 2018 upon opening Transport Data set requirements Badgernet Annual Transport Report Lead Consultant for Transport 6 Clinical Pathways, Protocols, Guidelines and Procedures / Clinical Governance Specific Measurables Timetable for achievement Method to Review Lead Responsibility Beneficiary Class / Value 6.1 Audit of 2 year outcomes The SuRNICC will have facilities and personnel to conduct and record neonatal follow up at 2 years of age, for those babies born before 30 weeks gestation, in order to identify neurodevelopmental and other disability. Community Paediatricians will also be involved in the assessment process to ensure continuity of care where appropriate. The SuRNICC and SCUs will arrange appropriate follow up for babies discharged home, and make arrangements for data capture through (i) identification of eligible babies at discharge, (ii) a mechanism for tracking families through transfers for neonatal care or follow up and change of address and (iii) obtaining information Commencement prior to opening March 2018 Badgernet Neonatal Clinical Leads Quantifiable Benefits 11 P a g e

for those who don't attend follow up. At present in North Wales this is not consistent in all areas and 2 year follow up is poor. 6.2 Successful implementation of NNAP recommendations eg. In North Wales 85% of babies have their temperature taken within 1 hour of admission compared to 94% UK wide. Within year 1 this should increase to 100% March 2018 Annual Report Neonatal Clinical Leads Service User Wider Economy Non CR 6.3 Strengthen the working relationship to improve practice (e.g. Competencies, training programmes, study days, Audit days) across the North Wales, All Wales Network and Cheshire & Merseyside Network including the Transport Teams and WAST Prior to opening Datix Sharing outcomes of SUI Lead consultant Service User Wider Economy Non CR 7 Education and Training / Clinical Governance Specific Measurables Timetable for achievement Method to Review Lead Responsibility Beneficiary Class / Value 7.1 All Doctors and Nurses caring for critical ill neonates should receive Newborn Life Support training. March 2018 on going Action Plan Neonatal clinical leaders Training needs analysis and action plan 12 P a g e

7.2 Competency frame work for :- Nurse post registration neonatal education is available on the matching knowledge and skills for Qualified in Speciality Transport Staff ANNPs New Staff nursing, medical, therapy Training needs analysis and action plan will be developed for current and new staff who will require training (approx 23 new staff) March 2018 on going Capacity Review Action Plan Neonatal clinical leaders 7.3 All units are working towards achieving the UNICEF BFI Neonatal Standards and receive standardised training to ensure they can support the family unit in building loving relationships and encouraging successful breastfeeding. March 2018 on going Action Plan Neonatal Service lead Training needs analysis and action plan. Increase in the % of babies receiving mother s milk by 25% in the first year. 13 P a g e

Appendix 1 F&P Paper on Benefits Realisation Benefits Realisation for Major Capital Projects Purpose This paper outlines the organisation s approach to the identification and delivery of benefits derived from capital projects. The focus is on major capital schemes which receive all-wales capital funding. The approach outlined in this paper will be adopted for all capital schemes and applied on a proportionate basis, depending on the scale and complexity of the scheme. The importance of clear objectives and measurable benefits The core of any business case is the identification of specific objectives, and the judgement that these are best achieved through a capital investment. The preferred option, which becomes the scheme to be delivered, is selected on the basis that it meets the project s objectives in a way that represents the best value for money and is both affordable and deliverable. This benefits-driven approach is important in all circumstances: it is particularly so when capital is, and is likely to remain, a scarce resource. The need to have clear objectives from the outset of a project, along with robust arrangements to ensure that they are delivered, is self-evident. However it is important to note that weaknesses in these areas are commonplace. For example the National Audit Office and the Office of Government Commerce have identified the first cause of project failure as lack of clear links between the project and the organisation s strategic priorities, including agreed measures of success. Lord Browne of Madingley, in his 2013 paper Getting a Grip: How to improve major project execution and control in government states that the detailed objectives of the project are not always explicitly stated and that a project that starts poorly never improves. Welsh Government Guidance 14 P a g e

The NHS Wales Infrastructure Investment Guidance emphasises the need for schemes to be prioritised as part of the Integrated Medium Term Plan process, and clearly aligned to organisational delivery goals which generate patient and service benefits. Schemes also have to demonstrate that they meet the investment objectives of the NHS Infrastructure Investment Programme. These are to: Support the delivery of safe, sustainable and accessible services, and facilitate high standards of patient care; Support changes to streamlining and transforming healthcare provision, with a focus on prevention and supported self management, the provision of care closer to home, and the integration and coordination of service delivery with partners; Promote the maximum efficient utilisation of assets and to improve asset condition and performance; and Promote the use of innovation to improve the quality of care, to reduce costs and to deliver the necessary service change. In order to deliver these objectives, the following investment criteria have been agreed: Health gain improving patient outcomes and meeting forecast changes in demand; Affordability given the long-term revenue assumptions, there should be an explicit reference to reducing revenue costs; Clinical and skills sustainability reducing service and workforce vulnerabilities, and demonstrating solutions that are flexible and robust to a range of future scenarios; Equity where people of highest health need are targeted first; and Value for money optimising public value by making the most economic, efficient and effective use of resources. The scrutiny of business cases by Welsh Government increasingly focuses on these objectives and criteria, and on the need to have SMART objectives (Specific, Measurable, Achievable, Relevant and Time-defined) with measurable benefits. As part of the scoping meeting held with Welsh Government prior to developing a business case the approach to benefits identification has to be explicitly stated. Welsh Government guidance also emphasises the need to have mechanisms in place to consider and review post project evaluations, in particular delivery against project objectives and benefits realisation. In terms of benefits realisation the guidance states that all infrastructure schemes receiving Welsh Government funding must be evaluated to demonstrate the benefits delivered and sustained improvements achieved in comparison to the pre-scheme situation (baseline costs and outcomes). The timing and resources to undertake the benefits exercise should be described in individual business cases These reviews should focus on the evidence to confirm the delivery of the scheme s investment objectives and benefit metrics over time to track benefits and improvements. The benefits realisation exercise is a key output in terms of assurance around investment delivered and performance, and should be shared with the organisation s Board and Welsh Government to facilitate shared learning. Benefits and the 5-case model 15 P a g e

Business cases submitted to Welsh Government use the Five Case model. Benefits are relevant to each of these cases as follows: The Strategic case sets out the strategic fit and the case for change, and outlines the high level benefits of the scheme; The Economic case analyses and values benefits, and demonstrates that the organisation has selected a preferred option that optimises public value for money. The Commercial case demonstrates that the preferred option will result in a fundable and affordable deal, and embeds benefits delivery in commercial arrangements; The Financial case demonstrates that the preferred option will result in a fundable and affordable deal, including outlining how any cash savings will support affordability; The Management case demonstrates how the scheme will be delivered, including the arrangements for delivering and monitoring benefits. Types of benefits Benefits typically fall into four main categories, and are analysed in this way in 5-case model business cases: Cash releasing benefits (CRB): These benefits reduce the costs of organisations in such a way that resources can be re-allocated elsewhere. This typically means that an entire resource is no longer needed for the task for which it was previously used. This can be staff or materials/assets. Financial but non-cash releasing benefits (non -CRB): This usually involves reducing the time that a particular resource takes to do a particular task; but not sufficiently to re-allocate that resource to a totally different area of work. Quantifiable benefits (): These benefits can be quantified, but not always easily. The extent to which s are measured will depend on their significance. However as a general rule every effort should be made to quantify benefits financially wherever possible and proportionate to do so. Non-quantifiable benefits (non-): these are qualitative benefits, which are of value to the public sector that cannot be quantified. 16 P a g e

Another useful way of considering benefits is in terms of Direct Benefits and Contributory Benefits, as outlined in the recent report on benefits arising from the Glan Clwyd project. A Direct Benefit is one that can be specifically measured and attributed entirely to the capital project. Examples would typically include an improvement in the Estates measures such as functional suitability and backlog maintenance, and the expansion or creation of a new clinical service. A Contributory Benefit arises when the scheme makes some contribution to a wider benefit, but where the specific contribution of the scheme is hard to measure because there are many other factors that will influence it. An example would be the contribution of Primary Care Resource Centres to the strategic goal of reducing the demand for acute hospital admissions and attendances at A&E. BCUHB processes for benefit identification and delivery 1. Identification of benefits through the business case The Procedure Manual for Managing Capital Projects (May 2015) outlines the organisation s business case process. This includes: Adopting the same investment objectives and criteria as Welsh Government (as described on page 1). Describing the process to develop a capital programme which enables CDG to effectively set strategic priorities and ensure that those business cases progressing are robust, demonstrate clear linkages to the Board s priorities and have clearly defined benefits associated with the capital investment. This involves: Formal review of major business cases by the Finance and Performance Committee before being considered by the full Board The Capital Programme Sub-Group of the CDG overseeing the production of the Infrastructure Investment Plan as part of the IMTP, and overseeing the preparation and scrutiny of business cases 5 Capital Development Groups assessing potential capital investments and preparing priorities for consideration by the Capital Programme Sub-Group. These are: 3 Area Estate Development Groups; the Medical Equipment Group; and the IM&T Group. In addition to this process specific scrutiny sessions have now been introduced to review major business cases at key stages in their development. These sessions are chaired by the Director of Strategy and include senior input from relevant departments and divisions. 2. Delivery of benefits through capital projects 17 P a g e

The Procedure Manual for Managing Capital Projects also outlines the process for delivering capital projects. In relation to benefits this includes: Clarity about roles and responsibilities, including those of the Senior Responsible Owner (SRO) and the Project Director (PD) for delivering the project as a whole. Specifically, the Project Director is responsible and accountable for the delivery of benefits. The creation of a Project Execution Plan, which includes the project s objectives, scope and deliverables. The need for End Stage Reviews, which include considering any potential changes to the project s scope. Systematic reporting of progress to the Project Board, the Capital sub-group of CDG and then to F&P. The requirement for Post Project Evaluation, which requires a full consideration of the achievement of benefits as required by Welsh Government. Performance against benefits is also identified in the monthly Capital Programme Report to the Finance and Performance Committee, where the RAG rating of each scheme includes the achievement of benefits. It is proposed that each major scheme should produce a report for F&P on progress against objectives and the delivery of benefits at appropriate stages in the project. All schemes will have a handover report when construction is completed, which will summarise the delivery of the project to that point and recommend to the F&P the benefits realisation reporting timeframe and frequency. All projects will have a formal post-project evaluation, which is typically produced 12 months after the completion of the project. Recommendation It is recommended that: 1. The Committee notes and agrees the approach to benefits realisation outlined in the report. 2. An update report is prepared for the Committee for all schemes completed in the last year, setting out how and when Benefits Realisation reports will be prepared. 18 P a g e