Critical Care Services

Health Outline Business Case DRAFT V 1 Critical Care Services November 2014

Critical Care OBC Contents Document Control Sheet Document Title St George s Healthcare Critical Care Outline Business Case Version 3 Status Owner Author TBC Jennifer Owen Date 20 November 2014 Further copies from Jennifer Owen Document History Version Date Issued Brief Summary of Change Author 1.0 31/10/14 Initial version J Owen 2.0 07/11/14 Submission to EMT J Owen 3.0 20/11/14 Submission to Trust Board J Owen i

Critical Care OBC Contents Purpose of this document This document provides an Outline Business Case (OBC) which sets out proposals for investment in the provision of additional capacity to Adult Critical Care at St George s Healthcare NHS Trust. It summarises key decisions and activities undertaken to develop these proposals and to provide a robust basis for investment and associated decision making. The main purpose of this OBC is to establish the need for investment; to appraise and confirm the main options for service delivery; and to provide the Trust Board with the recommended way forward. The Outline Business Case will seek to confirm the strategic context of the investment; to make a robust case for change, and to provide stakeholders with the preferred way forward, with indicative costs. ii

Critical Care OBC Contents Contents Appendix vii 1. Executive Summary 1 1.1 Introduction 1 1.2 Strategic Case 1 1.3 Economic case 3 1.4 Commercial case 4 1.5 Financial Case 5 1.6 Management Case 5 1.7 Recommendation 7 2. The Strategic Case 8 2.1 Introduction 8 2.2 Structure and content of the document 8 Part A: Strategic Context 9 2.3 Introduction 9 2.4 Organisation Overview 9 2.5 Trust Strategic Objectives 14 2.6 Trust Mission & Vision Statement 15 2.7 Strategic Context - National, Regional and Local Influences 16 2.8 Site ownership and Site Constraints 18 Site Specific Constraints 19 Background to the Redevelopment Requirement for Adult Critical Care 19 Part B - The Case for Change 21 2.9 Introduction 21 2.10 Investment Objectives 21 2.11 Background to the Redevelopment Requirement for Adult Critical Care 23 2.12 Business Needs 24 2.12.1 Key Drivers for Change 24 2.12.2 Capacity and Demand 24 2.12.3 In-Year Demand Increases Based on Service Level Agreement Proposals 25 2.12.4 Off-site Activity 25 2.12.5 Total Activity Growth Admissions and CCMDS bed days 26 2.13 Quality of Care 26 2.14 Potential Business Scope & Key Service Requirements 29 iii

Critical Care OBC Contents 2.15 Main Benefits Criteria 30 2.16 Design Quality and Philosophy 31 2.17 Summary 32 2.18 Main Risks 32 2.19 Constraints 33 3. Economic Case 34 3.1 Introduction 34 3.2 Critical Success Factors 34 3.3 Long List of Options 34 3.4 Long List: inclusions and exclusions 35 3.4.1 Determining the Capacity 37 3.5 Short-listed Options 37 3.6 Economic Appraisal 39 3.7 Options Appraisal: Financial 40 3.7.1 Capital Costs 40 3.8 The Short Listed Options 43 3.9 Qualitative Benefits Appraisal 43 3.10 Risk Appraisal Unquantifiable 46 3.11 The Preferred Option 46 4. Commercial Case 48 4.1 Introduction 48 4.2 Commercial Strategy 48 4.3 Procurement Strategy 48 4.4 Key Factors Affecting Outcomes 48 5. Financial Case 50 5.1 Introduction 50 5.2 Capital Costs 50 5.3 Impact on Balance Sheet 55 5.4 Overall affordability 55 6. Management Case 56 6.1 Introduction 56 6.2 Project Governance Arrangements 56 6.3 Project Management Arrangements 56 6.4 Project Board Role & Responsibilities 57 6.5 Membership of the Project Board 58 6.6 Internal Project Management Arrangements 58 6.7 Programme Milestones 63 6.8 Construction Programme 64 iv

Critical Care OBC Contents 6.9 Use of Special Advisors 64 6.10 Stakeholder Engagement Plan 65 6.11 Outline Arrangements for Change and Contract Management 65 6.12 Outline Arrangements for Benefits Realisation 66 6.13 Programme Quality & Assurance Management 66 6.14 Outline Arrangements for Risk Management 66 6.15 Outline Arrangements for Post Project Evaluation 68 6.16 Gateway Review Arrangements 68 6.17 Contingency Plans 68 v

Critical Care OBC Contents List of Tables Table No. Description Page No. 1 Summary of Capital Costs 4 2 Summary of Capital Expenditure 5 3 Summary of Income and Expenditure 5 4 Project Board Membership 6 5 Key Programme Milestones 6 6 Programme for OBC Approval 8 7 Trust Services 12 8 Strategic Context Summary 16 9 Investment Objectives 22 10 Critical Care Beds 23 11 Activity increase over 5 years (activity in CCMDS bed days) 24 12 Projected Activity 26 13 Standardised Mortality Rate 28 14 Potential business Scope and Key Service Requirements 30 15 Investment Objectives and Benefits 30 16 Main Risks & Counter Measures 32 17 Long Listed Options 35 18 Results of Review of Long Listed Options 35 19 Summary Assessment of Scoping Options 36 20 Capacity Requirement at 85% occupancy 37 21 Option 2 - Proposed phasing of works 37 22 Option 3 - Proposed phasing of works 38 23 Main Benefits 40 24 Summary of Capital Costs 41 25 Whole-life Costs of Short List Options 42 26 Short Listed Options and Indicative Capital Costs exclusive of VAT 43 27 Project Team 43 28 Criteria Weighting Results 44 29 Raw Score Results 45 30 Scoring Results Weighted 46 31 Summary of Economic and Value for Money Appraisal 47 32 Estates & Facilities Budget 48 33 Result of last three years & projections for Current Financial Year 50 34 Summary of Capital Expenditure 50 35 Adult Critical Care Inflation, tariff and efficiency assumptions 51 36 Divisional Income Expenditure at 2014/15 Prices 52 37 Incremental expenditure at 2014/15 prices 52 38 Summary of Revenue Income and Expenditure 53 39 Cash Flow impact of the scheme 54 40 Impact on Trust Balance Sheet 55 41 Project Board Members 58 42 Programme Milestones 63 43 Project Plan 64 44 External Advisors 65 45 Key Stakeholders 65 46 Risk Register Colour Code 67 vi

Critical Care OBC Contents Appendix Appendices are attached as separate documents and consist of the following: Appendix 1 Detailed Summary of Strategic Context Influences Appendix 2a. Preferred Option Proposed layout Appendix 2b. Phased drawing Appendix 3. Economic & Financial Case Workings Appendix 4. OB forms Appendix 5. Steering Group Terms of Reference Appendix 6. Benefits Realisation Plan Appendix 7. Risk register Appendix 8. Risk policy vii

1. Executive Summary 1.1 Introduction This OBC seeks approval to invest an estimated 13.6m in the development of 13 additional beds for Adult Critical Care at St Georges Healthcare NHS Trust, so that it addresses the demand challenges faced by the service. It focuses on identifying an option that offers an immediate solution to address short and midterm demand pressures and associated issues that would enable capacity to come on line in tandem with the increased demand. The Trust s main site is St George s Hospital in Tooting. The hospital is one of the country s principal teaching hospitals and is shared with St George s, University of London, training medical students and conducting advanced medical research. The Hospital also hosts Faculty of Health and Social Care Sciences for both University of London and Kingston University. This faculty is responsible for training a wide range of healthcare professionals from across the region. In 2010 St George s Hospital became one of the four major trauma centres, and one of the eight hyper-acute stroke units, for London. 2013 saw the opening of the new pre-operative care centre and 2014 the introduction of an air ambulance helipad. The Trust will be expanding its state-of the-art neuro-rehabilitation services, at Queen Mary s Hospital, and expects to have a large role to play in the future provision of healthcare across southwest London. The Trust has recently submitted its application for Foundation Trust status and it is hoped that Foundation Status will be awarded towards the end of 2014 calendar year. 1.2 Strategic Case The strategic context St George s Healthcare Trust is focused on becoming a successful Foundation Trust (FT) that is internationally recognised for placing quality, safety and innovation at the centre of its service provision. At the end of 2012 St George's Healthcare launched a new 10 year strategy for the trust following nearly a year of development with our staff and partners. We have developed this strategy to ensure that we deliver: Better health outcomes for all Improved patient access and experience Empowered, engaged and well-supported staff Inclusive leadership at all levels St George s Hospital s Clinical Strategy outlines the clinical service aims of the Trust for the next 10 years. The clinical strategy highlights that a key strength of the Trust is the vast range of acute and specialist services delivered from the Tooting Hospital campus. This results in a wealth of clinical expertise together on one site. The crux of the clinical strategy is to expand and develop the key specialist services; examples such as a helipad which will require fast access to critical care services and services models which will enable integrated patient flows. To ensure the best outcomes and support the delivery of this strategy, the Trust needs to have a critical care service that can provide the appropriate capacity and level of care to embrace these changes. The case for change Adult Critical Care at St George s is composed of three main units; and one satellite unit: A neurosurgical Intensive Care (NICU, 14 beds), A Cardio-thoracic Intensive Care (CTICU, 15 1

beds and 3 beds on the shared Coronary Care Unit which is linked to the main CTICU unit), a General Intensive Care (GICU 18 beds), plus a General ICU satellite unit (3 beds). GICU is located on the first floor of St James Wing, CTICU and NICU are located on the first and second floors respectively of the Atkinson Morley Wing. GICU takes the majority of non-neurosurgical and non-cardiac emergency admissions, and the majority of the major surgical elective workload. Increasing demand sentence(s) The three units work collaboratively to meet surges in demand and benefit from the ability to exchange clinical expertise and practice. This cooperation and flexibility has been responsible for managing the impact of the capacity shortage. However, this does require the non-clinical transfer of patients between units, which is both time consuming, a drain on limited resources such as cleaning, creates delays in admission to critical care from other areas such as Emergency Department and is not in the best interests of the patient being transferred. Furthermore, it has been suggested that in future, our Commissioners will financially penalise us for all non-clinical transfers of care between ICUs. The General Intensive Care Unit is over 25 years old and none of its beds comply with the HBN04-02 recommendations. This non-compliance is on the Trust Risk register recorded as individual risks which have scores that range between 9 and 20 (moderate to high risk). Should the unit be refurbished within its current footprint to comply with the current HBN04-02: recommendations, the unit would lose in excess of 50% of its current capacity. Such works would incur a significant capital spend without addressing the current, let alone future, capacity shortfall. Therefore the case for change is based on two factors, the first being the lack of capacity to deliver the Trust s Clinical Strategy and second, is the upgrading of the current infrastructure to bring it in line with the current building guidance. Critical Care at St George s Healthcare NHS Trust has a key role to play in delivering patient care pathways. The increasing number and complexity of patients within the Trust requiring this level of care creates the urgency of addressing the current need for change. Key Drivers for Change The project objectives identify the following as key drivers for change: The increasing demand for ICU services is greater than the current capacity can provide. Future demand projections identify around an 18% increase by 2019 The necessity to increase the quality of the existing bed stock in order for the service to provide the quality of care needed for future requirements. 2

1.3 Economic case The long list The following options were considered using the options framework: Options Description Cost Short Listed 1 Do Nothing baseline comparator Nil 2 A phased option is planned delivering: first an additional four bed spaces on the neuroscience intensive care unit and then a General Intensive Care Unit roof-top extension on St James s Wing and internal refurbishment totalling 2,244 sq m delivering an additional nine new compliant bed spaces plus and upgrade of nine existing bed spaces to compliant standards. 3 New Build the creation of a new two storey building including a shell only on the ground floor providing totalling 2,266 sq m, providing ten additional beds, plus refurbishment of 490 sq m accommodation displaced in Knightsbridge wing. 4 5 6 Creation of three, four bedded elective surgical critical care bays on 3 different wards Conversion of the light well in St James wing recovery into a 4 bedded elective surgical critical care unit Conversion of the General Intensive Care unit s equipment storage facilities and office space into a 4 bedded HDU X X X The preferred way forward On the basis of the above analysis, the Trust has therefore selected options 2 and 3 to financially appraise for this OBC; determining the affordability of each option in terms of the capital and revenue demand that will be placed on the Trust as a consequence of delivering. The short list On the basis that the preferred way forward is agreed, we recommend the following options for further, more detailed evaluation within the Full Business Case (FBC): Option 1 Do Nothing for baseline comparator Option 2 A phased option is planned delivering; first an additional four bed spaces on the neuroscience intensive care unit and then a General Intensive Care Unit roof-top extension on St James s Wing and internal refurbishment totalling 2,244 sq m delivering an additional nine new compliant bed spaces plus an upgrade of 9 existing bed spaces to compliant standards. Option 3 New build located adjacent to Knightsbridge Wing with maximum capacity beds numbers 10 beds taking total beds to 67 beds. 3

Consequently, the preferred option will be identified and recommended for approval within the OBC. Indicative economic costs The indicative costs for the scheme are as follows: Table 1 Summary of Capital Costs Items Option 2 GICU Option 3 New Build 000 000 Departmental Costs 4,025 5,780 On Costs 395 1,645 Total Works Cost Total 4,420 7,425 Location adjustment (9%) 398 668 Total Construction Cost 4,818 8,093 Fees (15%) 1,086 1,469 Non-works costs 300 280 Equipment Costs 1,411 1,186 Planning Contingency 761 1,103 Total for approval 8,376 12,131 Optimism Bias 921 2,036 Inflation adjustments 2,042 3,112 Total cost to outturn 11,339 17,279 VAT 2,268 3,456 Total including VAT 13,607 20,735 1.4 Commercial case Procurement strategy The scheme will be procured under EO OJEU tendering procedures. The advantages of this method of procurement are:- Trust retains control over the Design Team carrying out the detailed design. Price certainty and transfer of risk to the main contractor is achieved at contract award, provided no subsequent changes are instructed to the design. A high level of quality in design and construction is achievable. Changes to the works can be evaluated on the basis of known prices obtained in competition. OJEU was chosen due to the amount of design work that had to be completed in the feasibility stage in order to calculate the weight requirements for the roof, loading of services and whether the building would require reinforcement. 4

Required services The required products and services in relation to the preferred way forward are briefly as follows: To increase NICU capacity to 18 beds To increase GICU capacity to 30 beds by 2019/20 A new GICU facility that is compliant with modern standards of critical care delivery Potential for risk transfer and potential payment mechanisms Proposed risk transfer will be set in the contract agreed through the OJEU process 1.5 Financial Case Table 2 Summary of Capital Expenditure Capex 2014/15 2015/16 2016/17 2017/18 2018/19 Total New build - GICU 0 5,074 6,771 0 0 11,845 Refurbishment - NICU 220 1,542 0 0 0 1,762 Total capex 220 6,616 6,771 0 0 13,607 Table 3 Summary of Income and Expenditure 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 Income 0 1,035 2,145 3,297 4,410 5,544 Total Operating Costs 0-513 -2,495-2,894-2,810-4,125 EBITDA 0 523-350 404 1,600 1,419 Depreciation 0-11 -168-298 -304-311 Impairments 0-705 -2,369 0 0 0 Surplus before interest 0-193 -2,887 106 1,295 1,108 Interest on loans -16-257 -473-454 -435-415 PDC dividend payable 0 24 269 101 66 58 Surplus/(deficit) for the year -16-426 -3,092-247 927 750 1.6 Management Case This scheme is an integral part of the Trust Clinical Strategy 2012-2022, which highlights that a key strength of St George s Healthcare NHS Trust is the vast range of acute and specialist services delivered from the Tooting Hospital campus. This results in a wealth of clinical expertise together on one site. This is supported by the Trust s 10 year Strategy which sets out the Trust vision for the future, built around delivering healthcare of exceptional quality underpinned by leading edge research and teaching. The key objectives are: Redesign care pathways to keep more people out of hospital Redesign and reconfigure our local hospital services to provide higher quality care Consolidate and expand our key specialist services Provide excellent and innovative education to improve patient safety, experience and outcomes Drive research and innovation through our clinical services Improve productivity, the environment and systems to enable excellent care 5

Develop a highly skilled and motivated workforce championing our values The project will be managed using PRINCE 2 compliant methodology and project management tools such as Gantt charting and critical path analysis. Project direction and management will be determined by the Project Board. The project will be managed by the St George s Hospital Healthcare Trust. The Project Board has the responsibility to drive forward and deliver the outcomes and benefits of the project, being the provision of a expanded, modern and safe Critical Care service, compliant with NHS standards of construction and delivery. In order to ensure successful delivery of the development, the Project Board is made up as follows: Table 4 Project Board Membership Member Eric Munro Sofia Colas Dr Andrew Rhodes Sharon Welby Kevin Harbottle Anne Palmer Dr Andrew Rhodes Dr Mark Hamilton Jennifer Owen Title Director of Estates & Facilities; Chair Divisional Director of Operations Divisional Chair, Women s, Children s and Critical Care Project Manager / Deputy Director of Estates Assistant Director of Finance Senior User / Head of nursing for Adult Critical Care Senior User / Divisional Director of Adult Critical Care Senior User / Clinical Director of Adult Critical Care Senior User/ General Manager Critical Care The detailed Programme for the development is dependent on the preferred option and dates may change as a result, however indicative milestones for delivery are as follows: Table 5 Key Programme Milestones Milestone Date Preparation of Strategic Outline Case July August 2014 Detailed Design complete August 2014 Strategic Outline Case & Outline Business Case Trust Board Approval November 2014 Financial Plan complete November 2014 Strategic Outline Case & Outline Business Case to NTDA December 2014 Full Business Case submission to Trust Board February 2015 Full Business Case to NTDA March 2015 6

Full Business Case Approval (internal & external) end of May 2015 Construction commences June 2015 Handover July 2016 Trust Commissioning Period August 2016 Trust Operational September 2016 1.7 Recommendation We recommend that the Trust Board is recommended to approve this outline business case in order that the associated full business cases can be completed. Signed:... Date:... Senior Responsible Owner 7

2. The Strategic Case 2.1 Introduction This Outline Business case (OBC) is for the development of additional beds for Adult Critical Care to address the current Estate and capacity challenges and to meet the future demands of the service. This business case outlines, in this Section, the additional capacity required to meet the projected demands on adult critical care over the next 5-10 years. This business case will focus on identifying an option that offers a timely solution to address current demand and associated issues with the intention of also developing a future proof solution that will meet future demand over 5-10 years. The Trust estate strategy and current capital programme acknowledge the requirement of additional beds and is incorporated within associated planning processes. 2.2 Structure and content of the document The OBC has been produced in accordance with the principles of the Five Case Model, as set out in DH guidance and HM Treasury Green Book. This SOC and the subsequent business case process combine to fulfil the five case model, which is defined as follows: Strategic Case; this describes the strategic context and the case for change, together with the supporting investment objectives for the project. Economic Case: this demonstrates that the organisation has selected a preferred way forward, which best meets the existing and future needs of the service and is likely to optimise value for money (VFM). Commercial Case: this describes the planned procurement methodology. Financial Case: this assesses the funding arrangements and affordability and the impact on the Trust s balance sheet. Management Case: this demonstrates that the project is achievable and can be delivered successfully in accordance with accepted best practice. This document represents the first step in any proposal that involves major capital investment and aims to set the strategic need, the context of the case for change and to elicit the support of all associated stakeholders. The following is the proposed route for document review, challenge and approval. Table 6 Programme for OBC Approval OBC Programme for Approval Date Circulate document Late October 2014 Present document to FRAG W/C November 2014 Present document to BCAG W/C 10 November 2014 Present document to the Trust Executive Team W/C 10 November 2014 Papers ready for Trust Board 20 November 2014 Present document to the Trust Board 27 November 2014 Present document to the NTDA December 2014 8

Part A: Strategic Context 2.3 Introduction The strategic context provides an overview of the context in which the Trust provides its services and the strategic guiding principles, directives and policies that ensure clinical qualities standards are met. The intention is to provide an overview of the Trust, its strategic objectives and the highlight current critical care service delivery and set the context for this business case. It also provides an overview of the driving policies and guidance documents at National, Regional and Local level. 2.4 Organisation Overview St George s Healthcare NHS Trust St George s is one of the country s leading teaching hospitals with a proud history dating back to 1733. The trust is situated in south west London, having moved between 1976 and 1980 from central London to establish itself as the specialist centre for south west London, Surrey and beyond. The trust now provides community services to the people of Wandsworth, district general services to a core population of 561561 thousand inhabitants, and tertiary services to 3.4M people. To deliver care to such large populations the trust employs 7,775 people, and has 1,052 beds and 29 operating theatres. In 2010 St. George s was designated both a major trauma centre and a hyper acute stroke unit (both one of only four in London), the same year that it took over the Community Services Division of Wandsworth PCT to become a truly integrated provider, and opened the helipad in April 2014. These events marked an important stage in the development of the trust, and represent the culmination of a journey begun in 2005 to define the role of the trust and the services it wished to develop and deliver. The trust now has specialist cardiovascular, neuroscience and paediatric surgery and medicine as part of its portfolio of services, as well as renal transplantation and cancer services. Quality and patient outcomes match St George s distinguished history and the clinical quality of services at St George s is highlighted in major national audits. 1 The trust has challenges to ensure its offering to patients is consistently excellent, the trust will meet the challenges of improving the patient experience head on. Alongside the quality of the services offered, St. George s has strived to consistently improve its performance against national targets and in 2012/13 met both A&E, cancer and admitted and non-admitted 18 week targets. Infection control remains a challenge, however, as do mixed sex accommodation requirements, and the trust continues to seek ways to improve its performance against these key indicators. St. George s continues to work hard to ensure that its performance as a trust meets or exceeds all key performance indicators, as set nationally, or in local agreements. The trust is proud of its performance, but is not complacent, recognising the challenge the organisation has during financial year 2013-14, on an on-going basis, to meet the range of targets that it is required to perform against, particularly where specific issues exist, for example in meeting the A&E target. This section will look at both the trust s achievement against key national waiting time targets and also against a range of quality indicators. 1 MINAP, VSGBI, Sentinel references 9

St. George s also has a fundamental role to play, in the delivery of a vibrant research, education and academic agenda, in partnership with St. George s University of London and King s Health Partners. This work both informs the health care that the trust delivers today and supports the development of the workforce and the technologies and treatments needed for the health systems of tomorrow. The trust is well supported by commissioners, GPs and referring hospitals. It has an appropriate population base of 3.4m to sustain the range of services provided. This will be enhanced by the predicted population growth, based on the 2011 census, incremental service changes, and formal service reviews and service reconfigurations Adding together these different elements of the Trust s profile the whole of St George s is even greater than the sum of its parts. The organisation is a modern, integrated teaching provider with the staff, services, facilities, population base, track record for quality, patient safety and relationships with both commissioners and referrers to take the step up to becoming an NHS Foundation Trust. St George s Key Facts and Figures 2 St. George s is a vibrant, multi-faceted and successful organisation. The following is not an exhaustive list, but gives a flavour of the trust, its size, activity, quality and services. In 2013/14 the trust saw 641,569 outpatients, delivered 5,056 babies, undertook 43,183 elective inpatient and daycase procedures, had 131,071 attend A&E, and admitted 43,537 non-elective patients. The trust is the major centre for tertiary services, including cardiovascular, neurosciences, renal, cancer, and specialised children s services for south west London and Surrey It is one of four Major Trauma Centres in London, and received 1,860 trauma calls in 2013/14 The trust is a designated Heart Attack Centre, and was the first trust in London to provide primary angioplasty services 24 hours a day The trust is a designated large Hyper Acute Stroke Unit (HASU), providing an extremely high quality service, and received over 2,000 stroke patients in 2013/14 It offers a comprehensive range of services, including delivery of community services for the people of Wandsworth following the 2010 integration between the trust and Community Services Wandsworth The trust co-located with, and a partner of, SGUL, in Tooting in the London Borough of Wandsworth St George s is one of only 14 trusts nationally to have fewer than expected deaths under both the SHMI and HMSR methodologies It had a turnover of 665M in 2013/14, on which it delivered a 4.7M surplus. Locations & Services St. George s is a multi-layered organisation, providing community services to the people of Wandsworth, a range of local acute services to the people of Wandsworth, Merton, and Lambeth and tertiary care to the six boroughs of south west London, the county of Surrey, and 2 St George s NHS Integrated Business Plan December 2013 10

beyond. This offers the trust unique opportunities to lead and develop, in partnership with colleagues in primary, community and other acute trusts, care pathways that best utilise the skills, facilities and expertise of the whole sector. The hospital is co-located with St George s University of London, which provides unique opportunities for the Trust to make the most of its tri-partite mission of service, education and research. As with all major tertiary providers, there remains the requirement to deliver the full range of health services that the local population expects from its local hospital. St. George s Hospital is located in Tooting, a diverse, multi-ethnic and multicultural community in the London Borough of Wandsworth. As well as being ethnically and culturally diverse, the population of Wandsworth also reflects a full range of socio-economic groups with differing health needs and demands. St. George s core local catchment population is 561,790 3 from 44 electoral wards in Wandsworth, Merton and Lambeth. This population can be characterised by the following key characteristics 4 : A comparatively young age profile An ethnically and culturally diverse population, with large black and Asian minority communities A highly mobile population with high turnover in the local population Relative affluence compared to London as a whole and nationally, though this masks wide inequalities within the boroughs, which have pockets of very high deprivation The challenge to St. George s is to deliver high quality care that meets and exceeds the requirements, aspirations and expectations of these different groups. 3 2011 census data on Wandsworth, Merton and Lambeth wards 4 Population characteristics derived from ONS data sources 2009-2011 11

Organisational Structure The Trust is divided into 4 Clinical Divisions, supported by the corporate departments and governed by the Board of Directors. The divisions are as follows: Children and Women; Diagnostics; Therapeutics and Critical Care Community Services Surgery; Theatres; Neurosciences and Cancer Medicine and Cardiovascular The Corporate departments are: Operations Corporate Affairs (includes Communications) IT Strategic Development Estate & Facilities Human Resources Finance Nursing & Patient Safety Services The Trust provides a wide range of services summarised in the following table: Table 7 Trust Services Clinical Services St Georges Healthcare plays a pivotal role in providing tertiary specialist services to South West London and South East England. Many of these specialist services are provided as part of clinical networks for which the Trust acts as the clinical hub. The Trust is one of four major trauma centres, one of nine cardiac arrest centres and one of eight hyper acute stroke units in London. The local hospital services at St George s Hospital cover the catchment population of Wandsworth, Merton and the South West of Lambeth, providing the full range of medical, surgical and diagnostic services as well as maternity and children s services. At Queen Mary s Hospital in Roehampton the Trust is the largest provider of rehabilitation services for older people, amputees and people with neurological conditions. There is a minor injuries unit and through partnership with other providers, a wide range of outpatient, ambulatory and day case services. St George s Healthcare provision of community services includes community & specialist nursing, health visiting, therapies and school nursing. These services are provided from a range of sites across Wandsworth. The Trust also provides health services to Wandsworth Prison. Training and Education As well as providing clinical services, the Trust is a major provider of training and education for all health professionals, including doctors, nurses, therapists, radiographers, pharmacists and 12

biomedical scientists. St Georges Healthcare is a lead provider for postgraduate medical, nursing and Allied Health Professional training for many specialties. Research The Trust plays a key role in healthcare research with many Trust staff actively involved in undertaking research studies to enhance knowledge and improve clinical services. There are numerous joint appointments with St George s, University of London and the Joint Faculty of Health and Social Care Sciences with Kingston University Clinical Strategy 2012-2022 St George s Hospital s Clinical Strategy outlines the clinical service aims of the Trust for the next 10 years. This clinical strategy is supported by a set of enabling strategies. Some examples of these enabling strategies are: A quality improvement strategy An education strategy An Estates strategy A workforce strategy A research strategy The clinical strategy highlights that a key strength of the Trust is the vast range of acute and specialist services delivered from the Tooting Hospital campus. This results in a wealth of clinical expertise together on one site. The crux of the clinical strategy is to expand and develop the key specialist services; examples such as a helipad which will require fast access to critical care services and services models which will enable integrated patient flows. To ensure the best outcomes and support the delivery of this strategy, the Trust needs to have a critical care service that can provide the appropriate capacity and level of care to embrace these changes. The trust s tertiary services treat the most complex injuries and illnesses. Many specialist services are provided as part of clinical networks for which the trust acts as the clinical hub, for example, the trust is the inpatient centre for paediatric, ear, nose and throat, plastics and maxillo-facial surgery for south west London. 10 Year Strategy At the end of 2012 St George's Healthcare launched a new 10 year strategy for the trust following nearly a year of development with our staff and partners. We have developed this strategy to ensure that we deliver: Better health outcomes for all Improved patient access and experience Empowered, engaged and well-supported staff Inclusive leadership at all levels The 10 year strategy sets out a compelling vision for the future, built around delivering healthcare of exceptional quality underpinned by leading edge research and teaching. The success of this strategy will be determined by the strength of our partnerships with our colleagues in the healthcare, social services and the voluntary and charity sectors. 13

Existing Business Strategies St George s Healthcare Trust is focused on becoming a successful Foundation Trust (FT) that is internationally recognised for placing quality, safety and innovation at the centre of its service provision. The application was made in December 2013 and the Trust hopes to achieve Foundation Trust status later in 2014. To support its application the Trust has developed its Integrated Business Plan (IBP) which looks forward to the coming five years and describes how far the Trust will have progressed on the road to delivering its 10 year strategy. The IBP works to a five year time-frame and therefore runs in parallel with the aspirations of this OBC. The clear expectation is that by 2018/19, the Trust will, have made significant progress towards delivering this vision. The reconfiguration and expansion of critical care services is supported by and essential to the IBP. Financial and Funding Arrangements Key to the delivery of an ambitious agenda is St. George s financial strength and viability. Over each of the last 6 years St. George s has delivered a financial surplus, which includes paying off of the historic debt previously accumulated by the trust. The trust s ability to invest and develop services as outlined in the strategy is predicated on the continued delivery of financial surpluses. The Long Term Financial Model (LTFM) shows St. George s improving from a financial risk rating of 3 to 4 over the course of the LTFM, on the basis of a prudent set of assumptions. This means that St. George s will continue to deliver surpluses of between 1% and 1.5% of turnover up to 2018/19 (the period of the LTFM), which demonstrates the financial sustainability of St. George s, its ability to invest in its services and estate, and therefore deliver this strategy. 2.5 Trust Strategic Objectives Each year the Trust sets corporate objectives, identifying the key short term goals necessary in progressing towards its vision of becoming An excellent integrated care provider and a comprehensive specialist centre for South West London, Surrey and beyond with thriving programmes of education and research. The Trust s current corporate objectives are: Design pathways to keep more people out of hospital Redesign and reconfigure our local hospital services to provide higher quality care Consolidate and expand our key specialist services Provide excellent education and training opportunities for all staff, students and trainees Drive research and innovation through our clinical services Improve productivity, the environment and systems to enable excellent care Develop a highly skilled, motivated and engaged workforce Each element of the objectives and supporting strategy are performance managed through the Trust Board scorecard, regularly reported to Board through the Integrated Performance Report (IPR). The Trust believes that becoming a Foundation Trust is a crucial step in achieving its vision of being recognised as an excellent integrated acute and community care provider and a comprehensive specialist health provider for south west London, Surrey and beyond, with thriving programmes of education and research. 14

2.6 Trust Mission & Vision Statement The Trust s mission is to provide excellent clinical care, education and research to improve the health of the populations we serve. Trust Vision The Trust s Vision is to be An excellent integrated care provider and a comprehensive specialist centre for South West London, Surrey and beyond with thriving programmes of education and research. The six key components of this vision are: 1. Renowned integrated services enabling people to live at home 2. Provide the highest quality local hospital care, in the most effective and efficient way 3. A comprehensive regional hospital with outstanding outcomes 4. Thriving research, innovation and education driving improvements in clinical care 5. A workforce proud to provide excellent care, teaching and research 6. Transformed productivity, environment and systems Supporting the delivery of the overarching trust vision St. George s has developed a range of supporting strategies. Quality Improvement, Information, Communications and Technology and Estates are enabling strategies that are critical to delivering the trusts overall vision. Aligned with this scheme, the Trust set out one of its strategic visions to be a comprehensive regional hospital with outstanding outcomes. Amongst other objectives is the plan to further develop St. George s role as a major trauma centre (MTC). To support this vision is the clear need to develop and approve plans for the expansion of critical care. Trust Estate Strategy The Trust s Estates Strategy was approved at the January 2013 Trust board and a DCP plan is currently being developed commissioned by the new Director of Estates and Facilities. As part of the Trust s 10 year strategy developments including the Children s & Women s Hospital in Lanesborough Wing, improved facilities for cancer, renal, maternity, trauma and critical care services are all part of trusts future. Plan: In 2014/15 Complete ward bed capacity plans Complete hybrid theatre build Completed Neonatal Unit additional bed capacity MRI update Over the next 5 years St George s estate will need to change and is likely to have the following features 5 : Increased number of inpatient beds Fewer outpatient clinics on the Tooting site Enhanced, better utilised community facilities 5 St George s Healthcare NHS Trust: Divisional Strategy Review Estates 7 facilities 2014-15 15

Improved facilities for children, women, renal, cancer and trauma More critical care capacity A coherent approach to the use of space in association with St George's University of London A rationalised estate with fewer peripheral buildings on the Tooting campus Benefits from commercial developments such as greater provision for private patients. 2.7 Strategic Context - National, Regional and Local Influences The strategic context provides an overview of the context in which the Trust provides its services and the strategic guiding principles, directives and policies that influence best practice in clinical standards. It provides an overview of the driving policies and guidance documents at National, Regional and Local level that can provide context and support the case for change in relation to increasing capacity and providing modern accessible critical care services. These influences are summarised is the table below and in each case are the latest written document available. A more detailed summary with references can be found in Appendix 1. Table 8 Strategic Context Summary NATIONAL Health and Social Care act 2012 Standards for Intensive Care Units The Intensive Care Society 2007 Department of Health (2000) Comprehensive Critical Care A Review of Adult Critical Care Royal College of Surgeons (2011); Emergency Surgery: Standards for unscheduled care National Institute for Health and Clinical Excellence (CG50) - Acutely ill patients in hospital - Recognition of and response to acute illness in adults in hospital (2007) The National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 83 2009 The government s Health and Social Care Bill outlines the future commissioning arrangements across the NHS A guidance document to improve patient care by bringing together in one source all aspects related to the design of an intensive care unit. The document presents the minimal standards required for an intensive care unit, both for the care of patients and training of staff. This Department of Health guideline document sets out key recommendations relating to critical care service provision. The focus is to provide a service that considers the needs of patients and how they can be met through partnership between professions and specialties. The Royal College of Surgeons published a report in February 2011 outlining the standards for the care of unscheduled adult and paediatric surgical patients. The National Institute for Health and Clinical Excellence (NICE) published clinical guideline 50, in July 2007, outlining the clinical guidelines for the care of adult patients in acute hospital settings. The National Institute for Health and Clinical Excellence NICE published clinical guideline 83, in March 2009. This guideline offers best practice advice and recommendations on the care of adults with rehabilitation needs as a result of a period of critical illness that required inpatient treatment in critical care. 16

NATIONAL Developing Operational Delivery Networks The way forward Dec 2012 HBN 04-02: NHS Estates guidance for the built environment for Intensive Care (2013) Quality, Innovation, Productivity and Prevention (QIPP) The NHS Commissioning Board has outlined plans to implement Operational Delivery Networks (OPN) across the NHS to cover areas such as neonatal intensive care, adult critical care, burns and trauma. These networks are focused on coordinating patient pathways between providers over a wide area to ensure access to specialist support. HBN 04-02 provides guidance on design considerations for the built environment in critical care areas. These areas include designated intensive care units, highdependency units and other hospital locations where critically ill patients are cared for, as well as the support facilities that underpin these areas. QIPP is a large-scale transformational program for the NHS. It involves all NHS staff, clinicians, patients and the voluntary sector. The purpose is to improve the quality of care the NHS delivers and deliver 20billion of efficiency savings by 2014-15, which will then be reinvested into frontline care. The QIPP aims are: 1. To reduce cost by improving effectiveness and consistency in processes & decision-making. 2. To improve quality and effectiveness by establishing clearer clinical outcomes 3. To improve patient experience and engagement by establishing responsibilities and responsiveness to individual patient needs REGIONAL/LOCAL London Health Programmes Adult emergency Services: Acute medicine and Emergency General Surgery commissioning standards: September 2011 Draft Clinical Quality Standards - Critical Care Services: October 2012 Adult Critical Care Service Specification for critical services NHS England The commissioning standards have been developed to ensure on-going improvements in critical care service provision. These standards represent the minimum quality of care that patients should expect to receive if admitted as an emergency case to a hospital in London. London Health Programmes have published a renewed Clinical Quality Standards that relate to critical care The national commissioning standards have been developed to ensure on-going improvements in critical care service provision 17

2.8 Site ownership and Site Constraints The St Georges Hospital Site The hospital site is illustrated below in Figure 2A, highlighting the site buildings and potential site restriction for expansions. Figure 2A Aerial View of Hospital Site Ownership The land in the ownership of the Trust is the area 44,660.04sqm. 18

Figure 2B Current Site Plan Site Specific Constraints The St Georges Hospital site presents specific challenges from an estate management viewpoint. The Trust site is heavily occupied, making it difficult to identify appropriate space for future capital developments. This impacts on capital development plans as follows: There is limited available space to meet service adjacency requirements when increased capacity is needed Often solutions require capital works adjacent to current service provision. This will need to be carried out while the service remains operational with minimal disruption Background to the Redevelopment Requirement for Adult Critical Care Over the last five years there has been growing concern within the Adult Critical Care Directorate that the demands placed on the service would exceed the capacity. The initial indication of this problem was an increase in the number of refused requests for intensive care over the winter months. In July 2009 an initial business case was developed to investigate the options available to provide a solution to the increase in demand. At the time further analysis on demand projection was required. 19

CCMDS Bed Dyas forecast The Trust has undertaken demand forecasting to understand the 10 year projected demand considering, national, sector and service specific developments. The graph below outlines the conclusion of this predicted increases over the next 10 years. Demand Forecast Adult Critical Care - Activity Out Turn Estimate CCMDS Bed Days 40000 CCMDS Out Turn 35000 30000 25000 20000 15000 10000 5000 0 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 CCMDS Out Turn 21395 22122 22875 23652 24457 25288 26148 27037 27956 28907 + 3 % 22037 23447 24925 26474 28097 29796 31576 33439 35388 37429-3 % 20753 20798 20824 20830 20816 20780 20720 20635 20524 20384 Demand analysis work outlined has been initiated in order to address the on-going need for increased capacity and requirement for critical care service to be compliant with national, Regional and Local standards to provide a safe and accessible service that enhances the Trust performance plans. 20

Part B - The Case for Change 2.9 Introduction The purpose of this section of the business case is to outline the strategic case for change. Critical care has a key role to play in delivering secondary and tertiary care. The increasing complexity of care and the demands within the Trust makes the need for addressing the current need for change within Critical Care vital. The demand for Adult Critical Care at St George s has increased by 13% over the past 3 years; and 27% over the last 5 years. The Directorate has absorbed this demand through an increasing occupancy level and increase in bed numbers. The Directorate currently functions at greater than 90% occupancy during winter months, to deliver this level of activity. The expected national growth in demand for adult critical care is 50% over the next 10 years; which equates to 3-4% per year. The demand analysis performed within the trust, based on local factors and accounting for these national assumptions requires an additional 13 beds over the next 5 years. The lack of adult critical care capacity will ultimately compromise the Trust s ability to meet four essential performance targets; patient safety, the 18 week pathway (cancelling elective surgery or patients not referred to critical care), the A&E four hour target and financial viability (additional critical care capacity underpins many of the Trust s on going and future service development plans). Capacity shortfall is managed by a number of operational mechanisms, which include cancellation and postponement of electives procedures, and the provision of additional capacity in satellite units. Adult critical care is not able to support delivery of any additional activity due to the lack of capacity; therefore there is a risk of compromise to: Delivery of evidence based best practice for patient care; Patient safety Enhancing efficiencies Undertaking leading specialist research. To date significant activity increases have been operationally managed with minimal capital investment. The General Intensive Care Unit is over 25 years old and highlights no longer complies with the HBN04-02 recommendations. This non-compliance is on the Trust Risk register recorded as individual risks which have a score that ranges between 9 and 20 (moderate to high risk). Should the unit be updated to comply with all the current HBN04-02 recommendations, the unit would lose the equivalent of 4 beds for its current footprint and incur material capital spend. In summary the case for change is based on two factors, the first being the lack of the necessary capacity to deliver the Trusts Clinical Strategy and second is the upgrading of the current capacity in line with the updated building guidance. Critical Care at St George s Healthcare NHS Trust has a key role to play in delivering patient care pathways. The increasing number and complexity of patients within the Trust requiring this level of care creates the urgency of addressing the current need for change. 2.10 Investment Objectives The investment objectives for this OBC are described as follows: 21

Table 9 Investment Objectives Project Objective To implement a design/build solution that delivers 13 additional beds in order to meet anticipated capacity until 2019/20 To eliminate any further additional cost of delivering Critical Care in inefficient satellite areas by removing the satellite unit and linking it with a larger unit To ensure 100% of all new critical care beds are compliant with NHS building guidance standards (HBN 04-02:Critical care Units) To ensure annual occupancy levels remain below 90% to optimise planned/unplanned admissions To provide an environment that is in line with best practice infection prevention standards To provide sufficient space for staff education, clinical and non-clinical administration and management and storage Key Deliverables / Proposed Scope 13 additional beds by 2019/20 Improved efficiency cost per bed is reduced New beds meet NHS building guiding standards Reduced on the day cancellations, as a result of critical care capacity, to 0% Address environmental contamination issues Introduce positive / negative pressure isolation rooms Reduced staff vacancy and improved retention Link with Strategy Trust Strategy IBP QIPP CRP Critical Care Standards QIPP Critical Care Standards SIP Corporate risk register Staff satisfaction survey Audit Existing Arrangements Adult Critical Care at St George s is composed of three main units; and one satellite unit: A neurosurgical Intensive Care (NICU, 14 beds), A Cardio-thoracic Intensive Care (CTICU, 15 beds and 3 beds on the shared Coronary Care Unit and is linked to the current CTICU unit), a General Intensive Care (GICU 18 beds), plus a General ICU satellite unit (3 beds). GICU is located on the first floor of St James Wing, CTICU and NICU are located on the first and second floors respectively of the Atkinson Morley Wing. GICU takes the majority of nonneurosurgical and non-cardiac emergency admissions, and the majority of the major surgical elective workload. NICU receive local and regional secondary and tertiary, planned and emergency cases. The three units work under the structure of a single directorate with three care groups. This provides the flexibility to manage demand surges, ability to exchange clinical expertise and practice and other economies of scale. This cooperation and flexibility has been responsible for managing the impact of the lack of capacity within critical care. 22

The current location of Critical Care beds across the Trust is summarised below: Table 10 Critical Care Beds Name Service Location Capacity General Intensive Care Unit Adult Critical Care and major elective care post operative care patients St James Wing Level 1 18 Beds General ICU Satellite unit Elective post operative care St James Wing Level 5 3 beds Cardiothoracic Intensive Care Unit Cardiothoracic Intensive Care Atkinson Morley Wing Level 1 15 Beds Coronary Care Shared space Atkinson Morley Wing Level 1 3 beds Neurosurgical Intensive Care Unit Neurosurgical Intensive Care Atkinson Morley Level 2 14 Beds 2.11 Background to the Redevelopment Requirement for Adult Critical Care In order to meet the year on year increase in demand, this increase in activity has been operationally managed with no capital investment. Activity has increased in all three units, however the facilities in the Atkinson Morley Wing (Neuro ICU and Cardio Thoracic ICU) are much newer that then the General ICU comply with current building regulation and infection control guidance whereas the General UCU does not. GICU currently manages a significant number of immunosuppressed patients, in particular, neutropenic patients. These patients are especially vulnerable to opportunistic and nosocomial infections and as such, should be managed in positive pressure, isolation rooms, which are equipped with antechambers. GICU currently has no such rooms. As a result, we are putting our patients' lives at risk. As haematology and oncology services continue to expand, the numbers of such patients will continue to increase. Thus there is a pressing imperative to build these facilities within the confines of GICU. In addition, GICU also needs negative pressure isolation rooms to manage the increasing number of patients that have complex, multi-resistant infections. Within the directorate there are, 6 such rooms on CTICU and 2 on Neuro ICU. However, these are in near constant use due to current levels of patient demand. In addition, only 2 of these rooms have HEPA filtration and therefore meet the operation requirements of a negative pressure facility. 23

2.12 Business Needs This section provides a detailed account of the problems, difficulties and service gaps associated with the existing arrangements in relation to future needs. 2.12.1 Key Drivers for Change The project objectives identify the following as key drivers for change: The increasing demand for ICU services is greater than the current capacity can provide. Future demand projections identify around an 18% increase by 2019 Changes in the local and national demographics combined with the Trust s plan to remain a Trauma and emergency care centre is impacting on increased GICU demand 2.12.2 Capacity and Demand The Trust is now in the position where lack of capacity impacts the Trust business and activity on a daily basis. Activity in the three units has increased over the last 5 years by 27%. This has been absorbed through reduced length of stay (LOS), reduced Delayed Transfers of Care (DTOC) and ultimately increased occupancy levels. The increased occupancy levels have had the knock on effect of increasing the number of refused referrals. Further increases in demand will further impact the refused elective referrals, which will result in cancelled elective surgical cases or a sub-optimal post-operative patient pathway and thus and increased length of stay in the hospital. Table 11 Activity increase over 5 years (activity in CCMDS bed days) SGH Specialty Description 2009-10 2010-11 2011-12 2012-13 2013-14 NICU 4509 5055 5265 5440 5453 CTICU 4864 5163 5805 6537 6854 GICU 6552 6739 6861 7034 7841 Total 15925 16957 17931 19011 20148 Annual % increase 6.5 5.7 6.0 6.0 This demand is comprised of a number of key drivers that include: Local demographic factors: Changing age distribution and size of the population Increasing co-morbid disease burden of the population Increased prevalence of diseases such as diabetes, obesity, and alcohol related disorders. These factors compound to give an estimated increase in demand for critical care of around 18% by 2019. 24

2.12.3 In-Year Demand Increases Based on Service Level Agreement Proposals As a support service to numerous patient pathways, the increased demand for ICU capacity in 2014-15 is to a significant extent based upon the increased activity expectation of the Trust s elective and emergency work. This can be isolated into a number of discreet areas. A number of key service developments have taken place over recent years that have impacted on the demand for critical care services. The Helipad Cardiac surgery Hyper Acute Stroke Unit Out of Hospital Cardiac Arrests Neurosurgical growth Complex cancer 2.12.4 Off-site Activity This lack of critical care capacity has already led to some specialities taking some of their elective surgical work to the private sector to ensure the work is done. Re-locating this work to St George s Hospital will have an impact on the demand on adult critical care. Relocation of the Bariatric Surgical Activity from the Private Sector Currently the surgical division perform most of the bariatric surgery off-site. In 2013-14 128 cases and 64 midnight bed days were delivered off-site at St Anthony s Hospital. Relocation of the Cardiac Surgical Activity from the Private Sector Currently cardiac surgery performs a number of cases in the private sector each year. In 2013-14 there were 108 cases with 160 midnight bed days. Then planned activity for 2014-15 is 145 cases equating to 215 midnight bed days. Relocation of this work will be a step change in activity, when it happens, but is note solely dependent on ICU capacity. 25

Bed number required CCMDS Bed Dyas forecast 2.12.5 Total Activity Growth Admissions and CCMDS bed days The tables below detail the projected growth over the next 5-10 years. Table 12 Projected Activity Demand Forecast Adult Critical Care - Activity Out Turn Estimate CCMDS Bed Days CCMDS Out Turn 40000 35000 30000 25000 20000 15000 10000 5000 0 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 CCMDS Out Turn 21395 22122 22875 23652 24457 25288 26148 27037 27956 28907 + 3 % 22037 23447 24925 26474 28097 29796 31576 33439 35388 37429-3 % 20753 20798 20824 20830 20816 20780 20720 20635 20524 20384 Demand ForecastAdult Critical Care - Beds Required Beds required 100 90 80 70 60 50 40 30 20 10 0 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 Beds required 54 56 58 60 62 64 66 68 70 73-3 % 52 52 52 52 52 52 52 52 52 51 + 3 % 55 59 63 67 71 75 79 84 89 94 To deliver this activity the Trust is projected to require 66 beds in 2020. 2.13 Quality of Care In order to provide the level of high quality critical care that is expected of a tertiary referral Trust, it is essential for the Trust to ensure that its critical care service is designed to accommodate the care needs of the critically ill patient, their relatives, carers and staff. The Trust strives to ensure that patients and service users are at the heart of everything it does, and that it provides them with the highest quality services. This theme of quality improvement underpins the whole of the Trust s strategy. The trust uses the national definition of quality, which is divided into the following three domains: Patient safety quality care is care which is delivered so as to reduce or eliminate all avoidable harm and risk to the individual s safety Patient experience quality care is care which looks to give the individual as positive an experience of receiving and recovering from care as possible. Patient outcomes (clinical effectiveness) quality care is care which is delivered according to best evidence as to what is clinically effective in improving an individual s health outcomes. 26

These are affecting the quality of care provided and will be considered within the 3 domains: Patient Safety Quality care is care which is delivered so as to reduce or eliminate all avoidable harm and risk to the individual s safety All of the critical care units currently provide an excellent level of clinical care for patients, as demonstrated by their respective national quarterly reports (provided by Intensive Care Audit and Research Centre, ICNARC). It is important to highlight that when demand exceeds capacity the final action is to refuse ICU referrals for care of planned surgical cases. This is the only, means of controlling demand on the service. When this occurs there are two possible patient pathways. The first is that the elective operation is postponed; the second is that the operation proceeds and the patent does not have a post-operative ICU stay. Both of these scenarios have adverse effects on patient safety. This has been the topic of a publication by The Royal College of Surgeons, who identified that sub-optimal post operative care results in an increase in post operative morbidity, mortality and length of hospital stay. Furthermore, it creates an addition demand on critical care when these patients require preventable emergency post operative admission to ICU - which has a longer ICU length of stay than the pre-emptive / elective post-op admission. 6. The Directorate has, and continues, to strive to improve its efficiency through the measures relating to length of stay and delayed transfers of care. This information is collated and nationally bench marked by the ICNARC. ICNARC reports that all 3 units have significantly shorter ICU lengths of stay than the national bench mark and achieves this whilst maintaining expected levels of related quality of care, specially, early re-admission rates. Accordingly, it is unrealistic to achieve any further increases in ICU capacity through improvements in efficiency. To ensure that the Trust s clinical strategy and vision are achieved it is essential that there is sufficient capacity to provide access to care for all those who need it, in a timely fashion; There are also a number of environmental issues that have been raised and are on the Trust s risk register. The GICU unit experience recurrent environmental contamination with multiresistant bacteria. In addition to this the unit has no positive / negative pressure isolation rooms and is therefore compromising infection control standards. The severity of these risks is listed on the risk register and scores range from 9-20. Redevelopment of the GICU unit to ensure key standards for infection control will significantly address this issue. Patient Experience Quality care is care which looks to give the individual as positive an experience of receiving and recovering from care as possible. The Trust requires additional capacity in modern facilities and physical condition to be compliant with NHS health building guidance. If this cannot be provided the Trust runs the risk of delivering care in a suboptimal environment for patients, compromising both patient safety and experience. A new development that is compliant with the current standards of critical care environments, and capacity requirements, would ensure the delivery of high standards of quality care, 6 NCEPOD, Royal College of Surgeons (2011) 27

accommodating level 2 and level 3 patients. This development would also ensure the following is provided: Adequate space and layout to meet capacity demands Privacy and dignity Infection control requirements (provision of adequate positive/negative isolation rooms) Temperature control Sanitary requirements Access to family support services Access to adequate clinical support services e.g. storage and utility spaces At present the limited space available on the unit means that there is no dedicated relative or interview room. As such, staff have limited options to impart difficult news to patients families in a private and dignified manner. This is often attended to in either the seminar room or one of the staff offices, depending on availability. In a unit that has such a high number of critically ill patients the demand for a dedicated space to counsel concerned relatives and friends is paramount in terms of patient experience. Patient outcomes (clinical effectiveness) Quality care is care which is delivered according to best evidence as to what is clinically effective in improving an individual s health outcomes. The Standardised Mortality Ratio (SMR) is a key quality metric for critical care patients. GICU is one of the busiest in the country and consistently maintains an SMR within the expected range. (refer to Table 13 below). Table 13 Standardised Mortality Ratios for GICU for the last 4 audited quarters 2013 Q3 2013 Q4 28

2014 Q1 2014 Q2 External scrutiny re-assures the Trust of the clinical effectiveness of this unit. The use of small and remote satellite units has a significant adverse impact on the staffing costs. To ensure the safety of more critically ill patients the levels of staffing are significantly increased; sometimes up to twice the level of the main units. The efficiencies of scale and group experience and knowledge are lost which has a considerable adverse effect on cost effectiveness. In order to ensure that clinical effectiveness is not compromised by the severity of the patients conditions a financial burden is endured. To ensure that this domain of quality is improved, the redevelopment must address these issues. If the Trust wishes to retain standards such as that consistently reflected by the SMR data is essential that environmental and capacity issues are addressed. Therefore in summary the extension and refurbishment to the existing critical care facilities would allow the Trust to meet the current demand and capitalise upon the options to develop new services. Provision of an additional 13 beds through this programme would create a facility that is modern and in line with Health Building guidance (HBN 04-02), the NHS Estates guidance for the built environment for intensive care areas, which is essential in achieving other standards and efficiencies in patient pathways, clinical synergies & quality of critical care service delivery as well as efficiencies in bed management. 2.14 Potential Business Scope & Key Service Requirements The scope of this project is to provide a safe, efficient and effective service to the local (and wider) health community/economy on the St Georges Hospital site. 29

Table 14 Potential business Scope and Key Service Requirements Item Core Desirable Potential Business Scope Sufficient capacity to maintain bed occupancy to < 90% over the year Additional beds compliant with HTM/HBN/ADB standards of care Infection prevention environment 4 additional positive / negative pressure isolation rooms with HEPA filtration Sufficient capacity to maintain bed occupancy to < 85% over the year All beds compliant with Level 3 standards of care Co-located management administration, education and storage Key Service requirements 13 additional beds 18 beds compliant with HTM/HBN standards of care on GICU AND 4 additional beds on Neuro ICU 63 beds compliant with level 3 standards of care Co-located Management Administration 4 additional Isolation rooms compliant with HTM 03-01 Specialised Ventilation for Health Care Appropriate friends and relatives facilities Co-located Practice Education Officer Co-located head of nursing office Seminar room Staff rooms Changing rooms 2.15 Main Benefits Criteria This section describes the main outcomes and benefits associated with the implementation of the potential scope in relation to business needs. This investment will deliver the following highlevel strategic and operational benefits. Benefits are expressed as follows: Table 15 Investment Objectives and Benefits Investment objectives To implement a design/build solution that delivers 13 additional beds in order to meet current capacity and those until 2020 Main benefits criteria by stakeholder group Provides enough capacity to meet demand, over the next 5 years Patients Referring services 30

Investment objectives To eliminate any additional or further future cost of delivering Critical Care in inefficient satellite areas To ensure 100% of all new critical care beds are compliant with NHS building guidance standards (HBN 04-02) To ensure annual occupancy levels remain below 90% to optimise planned/unplanned admissions Main benefits criteria by stakeholder group Reduces costs and releases money for enhanced clinical care delivery Trust Wider health economy Commissioners Environment and facilities are enhanced to partially meet the requirements of modern critical care delivery Patients Clinical Staff The Trust is able to meet its 10 year strategy commitment of Improved patient access and experience Patients Emergency departments eg A&E Trust waiting time targets To provide an environment that is in line with best practice infection prevention standards Improved infection prevention within unit The Trust is able to meet its 10 year strategy commitment of Better health outcomes for all Patients Trust 2.16 Design Quality and Philosophy Design Quality The design will reflect the importance of flexibility, quality and will meet the latest design guidance where appropriate. It will be a contemporary building, respectful of locally sensitive areas. The building will not affect statutory and non-statutory designated sites. Energy Efficiency The energy efficiency of the Critical Care Unit has been assessed annually as part of the St James Wing as a whole, using HM Gov. Display Energy Certificate (DEC) system. This measures relative energy consumption on a scale from A to G, where A is best. Typical buildings perform around the D/E threshold, set at 100. The energy efficiency score for the year 2012 (St James Wing) reflects a DEC of E (120). This is an improvement on the previous year where the DEC score was F (146). The preferred option design solution will aim to enhance and improve on overall energy efficiencies, contributing to the NHS sustainability targets of reduce 2007 carbon footprint by 10% by 2015. 31

Future Flexibility Consideration of an additional 13 beds will provide opportunity for a solution that is flexible in functionality and capacity and that can provide capacity for current demand whilst enabling realisation of the 10 year capacity requirement. 2.17 Summary Drivers for Change The project objectives in this section identify the following as key drivers for change: The increasing demand for ICU services is greater than the current capacity can provide. Future demand projections identify a significant (>30%) increase over the next 10 years. Changes in the local and national demographics combined with the Trust s plan to remain a Trauma and emergency care centre is impacting on increased GICU demand The Trust requires additional capacity to be compliant with NHS health building guidance. If this cannot be provided the Trust runs the risk of compromising compliance of other standards of care such as infection control, critical care standards and commissioning standards. Refused referrals that impact on elective surgery (leading to cancellations) have a significant impact on the potential income the Trust would receive. The average surgical HRG tariff 7 for a patient admitted to critical care is 5,000. Issues that relate to patient care and safety: The current GICU have no positive / negative pressure isolation rooms and therefore compromising infection control standards. Building these additional rooms in this space (isolation rooms) would result in the reduction of current bed numbers/spaces due to increase space requirements Redevelopment and increased bed capacity will provide opportunities for the Trust to fulfil other strategic development programmes e.g. cardio vascular, neurosciences and complex cancer services. 2.18 Main Risks Risks to the project have been assessed using the Five Case Model as shown below. It will use the work streams established to support the design and development activities to identify all risks and to develop mitigation plans. The Project Board will oversee risk, and all high scoring risks will be included on the Trust Risk Register. Table 16 Main Risks & Counter Measures Risk Affordability Risk the Trust cannot afford the recommended proposals, resulting in abortive cost. Mitigation This risk is mitigated by an assessment of affordability as part of the business case process and costs in the business case that will have been 7 St Georges Healthcare NHS Trust Informatics Team 32

Risk Mitigation competitively tendered through the procurement process Service Disruption The project impacts negatively on provision of critical care services during implementation significantly affecting patient outcomes and surgical services Programme Risk the proposal is delayed by other capital development proposals, resulting in abortive cost and failure to meet strategic objectives. This risk is mitigated by an assessment of the programme and developing a project plan that limits disruption. Communication with design and project management team is essential This risk is mitigated by the delivery of the critical care project being programmed by Estate/Capital Directorate 2.19 Constraints The main constraints affecting the project are: Budget - the Trust has a limited capital budget, and must seek approval from NTDA and monitor for any expenditure of over 5m of Treasury capital (i.e. excluding funds from donations) and for any associated loans. Physical - the existing accommodation is heavily occupied, making phasing difficult, and potentially reducing the potential to comply fully with NHS Health Building Notes (HBNs) and Health Technical Memoranda (HTMs). Timeliness the hospital will see a year on year increase in demand in the coming years, both in terms of elective surgery demands and emergency admissions and must therefore have options to open additional capacity. 33

3. Economic Case 3.1 Introduction In accordance with Departmental Capital Investment Manuals and requirements of HM Treasury s Green Book (A Guide to Investment Appraisal in the Public Sector) this section of the SOC documents the range and associated development of options that have been considered in response to the case of need. 3.2 Critical Success Factors The critical success factors for this project are considered to be: Strategic fit and business needs How well the option: Meets the investment objectives Meets the requirements of the Trust s Estate Strategy Meets the Trust s strategy for Clinical services Meets the requirement of national and local directives and guidance Potential Value For Money How well the option delivers value for money by: Reducing construction risks Maximising benefits Optimises the potential return on investment Potential Achievability How well the option is likely to be delivered: In view of the Trust s capability to deliver the project; In view of the market s capability to provide and implement innovative solutions; In such a way as to preserve heritage assets on the site; In such a way as to minimise disruption to the Trust s operations during construction. Potential Affordability How well the option: Matches the likely availability of funding Enables the Trust to meet its key financial targets in the medium to long term 3.3 Long List of Options The long list of options has been generated and considered over an extended period of at least a year, in order that they could be assessed by the clinical and estate teams, to understand their viability. They are described below, identifying whether the option was shortlisted for detailed appraisal, or discounted. The extent to which each option met the project objectives was the key criterion for short listing. 34

Table 17 Long Listed Options Option Description 1 Do Nothing 2 3 4 5 6 A phased option delivering first an additional four bed spaces 270 sq m on the neuroscience intensive care unit and then a General Intensive Care Unit: roof-top extension on St James s Wing and internal refurbishment totalling 2,244 sq m delivering an additional nine new compliant bed spaces, plus an upgrade of 9 existing bed spaces to compliant standard. New Build the creation of a new two storey building including a shell only on the ground floor providing totalling 2,266 sq m, providing ten additional beds, plus refurbishment of 490 sq m accommodation displaced in Knightsbridge wing. Creation of three, four bedded elective surgical critical care bays on 3 different wards Creation of a six bedded elective surgical critical care unit within part of the endoscopy unit recovery area Conversion of the GICU s equipment storage facilities and office space into a 3 bedded HDU 3.4 Long List: inclusions and exclusions The long list has appraised a wide range of possible options. The long list of options has been generated and considered over an extended period of at least a year, in order that they could be assessed by the clinical and estate teams, to understand their viability. A summary of the review of the long listed options is set out below. Table 18 Results of Review of Long Listed Options Option Current Discounted/Shortlisted Status 1 Do Nothing Shortlisted - as a baseline comparator 2 A phased option is planned delivering: first an additional four bed spaces on the neuroscience intensive care unit and then a General Intensive Care Unit roof-top extension on St James s Wing and internal refurbishment totalling 2,244 sq m delivering an additional nine new compliant bed spaces plus an upgrade of 9 existing bed spaces, to compliant standards. 3 New Build the creation of a new two storey building including a shell only on the ground floor providing totalling 2,266 sq m, providing ten additional beds, plus refurbishment of 490 sq m accommodation displaced in Knightsbridge wing. 4 Creation of three, four bedded elective surgical critical care bays on 3 different wards. Shortlisted will not provide any further inefficient satellite beds therefore increasing capacity and enhance patient safety. This option meet all the long term objectives for this project and Trust clinical Strategy Shortlisted This option meets the long term objectives for this project and Trust clinical Strategy. Whilst not co-located to rest of unit, is co-located within itself and of sufficient size to have effective staffing levels Discounted This option does not meet strategic drivers and service standards 35

Option 5 Creation of a six bedded elective surgical critical care unit within part of the endoscopy unit recovery area. 6 Conversion of GICU equipment storage facilities and office space into a 4 bedded HDU. Current Discounted/Shortlisted Status Discounted This option has a significant impact on the Trust s ability to provide effective endoscopy services Discounted This option compromises essential patient experience standards as it provides no natural light and reduces the provision for an appropriate healing environment Overall conclusion: scoping options Table 19 Summary Assessment of Scoping Options Reference to: Option 2 Option 3 Description of option: Investment objectives To implement a design/build solution that delivers 13 additional beds by in order to meet current capacity and those until 2018/19 To ensure all critical care are geographically co-located to ensure patient safety and quality of care To eliminate the additional cost of delivering further Critical Care in inefficient satellite areas To ensure 100% of all new critical care beds are compliant with NHS building guidance standards (HBN 04-02) To ensure annual occupancy levels remain below 90% to optimise planned/unplanned admissions To provide an environment that is in line with best practice infection prevention standards Critical Success Factors Rooftop New Build Business need Strategic fit Benefits optimisation Potential achievability Supply-side capacity and capability Potential affordability Summary Preferred Possible The table above summarises the assessment of each option against the investment objectives and Critical Success Factors. 36

Bed number required 3.4.1 Determining the Capacity The approach used to determine the capacity requirements for critical care uses three components. The first is the current baseline demand, the second demand based on the SLA proposal for next year (2015-16), and the last part is the expected growth in demand beyond the SLA activity. Section 2 also outlines other potential changes that may have an effect on the demand. The baseline estimate is calculated using the Statistical Process Control methodology applied to the Run Chart with data from the last three years. Section 2.8 outlines the projected capacity and its impact on service delivery. The graph below illustrates the capacity requirements to maintain 85% occupancy, therefore 66 beds at 85% would provide enough capacity up to 2018/19 whereas 90% occupancy would provide capacity up to end of financial year 2020/21. Table 20 Capacity Requirement at 85% occupancy Demand ForecastAdult Critical Care - Beds Required 120 Beds required 100 80 60 40 20 0 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 Beds required 57 59 61 63 65 67 70 72 74 77-3 % 55 55 55 55 55 55 55 55 55 54 + 3 % 59 62 66 71 75 79 84 89 94 100 3.5 Short-listed Options The short listing took place in a project team meeting and a non-financial option appraisal agreement at a project meeting in June 2013 and refreshed in early November 2014. The revised options are detailed below: Option 1 Do Nothing: This option was shortlisted to provide a baseline comparator. Option 2 Phased approach to include: Phase 1: Additional 4 beds on Neuro ITU on the terrace Phase 2: Development of 9 beds on rooftop of St James Wing adjacent to current GICU Table 21 Option 2 - Proposed phasing of works Unit Phase 1 Total Bed Numbers NICU Q3 15-16 4 GICU Q3 15-16 9 Total 13 37

Appendix 2 highlights the proposed design solution and associated Schedule of Accommodation. Option 3 New Build New build located adjacent to Knightsbridge Wing with maximum capacity beds numbers to 10 plus the additional 4 beds on Neuro ITU Table 22 Option 3 - Proposed phasing of works Unit Phase 1 Total Beds NICU Q3 15-16 4 New Build Q3 15-16 10 Total 14 38

Figure 3A details the proposed location of Options 2 and Option 3. Figure 3A Proposed Location of Option 2 and 3 3.6 Economic Appraisal Introduction This section provides a detailed overview of the main costs, benefits and risks associated with each of the selected options. Importantly, it indicates how they were identified and the main sources and assumptions. The economic appraisal is summarised at Appendix 3. 39