Dialysis Unit Replacement & Expansion Programme Strategic Outline Programme (SOP) 1
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CONTENTS 1. EXECUTIVE SUMMARY... 6 2. PURPOSE... 8 3. STRATEGIC CASE... 8 3.1 Organisation Overview... 8 3.2 Provision of Unit Haemodialysis... 10 3.3 Demand for Unit Haemodialysis... 12 3.4 Alternatives to Unit Haemodialysis... 16 3.5 Strategy and Programme Investment Aims... 17 3.6 National Service Framework Designed to tackle Renal Disease... 18 3.7 Existing Arrangements... 20 3.8 Business Needs... 21 3.9 Benefits, Risks, Dependencies and Constraints... 27 4. ECONOMIC CASE... 30 4.1 Critical Success Factors... 30 4.2 Main Options... 30 5. COMMERCIAL CASE... 31 5.1 Commercial & Procurement Strategy... 31 6. FINANCIAL CASE... 32 6.1 On-site capital development... 32 6.2 Off-site ISP delivered... 34 6.3 Affordability... 35 7. MANAGEMENT CASE... 35 3
7.1 Expansion Programme Management Arrangement... 35 7.2 Specific developments... 36 8. EXPECTED SCHEMES - OUTLINE... 37 8.1 Bangor and Alltwen... 37 8.2 Llandrindod Wells... 37 8.3 Gwent... 38 8.4 UHW Main Unit... 40 8.5 CRI West Wing, Cardiff... 42 8.6 Morriston Main Unit... 42 8.7 East of Swansea... 43 9 CONCLUSION... 44 4
WELSH RENAL CLINICAL NETWORK A VISION FOR DIALYSIS UNITS IN WALES To provide fit for purpose dialysis units at geographical locations across Wales, that with appropriate staffing and equipment, maximise the opportunity for local management of renal disease and specifically, the provision of chronic haemodialysis. The new and replacement units should be sited consistent with current and projected need, population centres and logistical considerations that are evidence based and prioritised collectively by the renal community. It will be achieved through the following high level requirements Sufficient capacity across Wales so that where clinically appropriate, all local patients can receive their dialysis at the nearest unit. Appropriately staffed and equipped to maximise the suitability for as many patients as possible including those with blood borne infections, mobility restrictions and advanced co morbidities. An increase in the number of cubicles in all units to meet the growing challenges of infection control. Where the spatial opportunity exists, provide additional capabilities in the units including self care 5
areas, home therapy training suites, clinical treatment rooms and outpatient suites. Such an approach raises the profile of local renal services and provides a focal point for renal services rather than solely unit based haemodialysis. 1. EXECUTIVE SUMMARY This is the second Strategic Outline Programme for the replacement and expansion of dialysis units in Wales. It builds on the success of the first which ran from 2009 through to 2013. This presided over the following developments of new and replacement units across Wales: Welshpool Llandrindod Wells Merthyr Tydfil Withybush Hospital Aberystwyth Bangor and Alltwen The next phase proposed within this document will see further additional capacity provided across Wales including new units in South Wales. If the developments are delivered as planned, based on current demand models predicting 3% growth in demand 6
per annum, Wales will have sufficient unit haemodialysis capacity until 2023. It is proposed that unless there is a specific need to develop on an NHS site, all new and replacement dialysis units be delivered as part of service contracts and involve the provision of a facility off-site of NHS grounds. This avoids central capital funding requirements. The Strategic Outline Programme objectives are consistent with the Triple Aim and Prudent Healthcare: The provision of local, fit for purpose dialysis facilities and services fits the needs and circumstances of patients requiring unit haemodialysis; Local access and improved capability removes avoidable journeys to other, distant units for the majority of patients; Enhanced patient experience through greater local access and reduced travel times; Unit haemodialysis has been subject to NICE guidance, a National Service Framework and approved through WHSSC s Prioritisation framework. Improved effectiveness of treatment is expected through maintaining treatment schedules as required by the UK Renal Association i.e. thrice weekly treatment; Optimise the value for money through targeted and prioritised use of public funds in delivering chronic haemodialysis services. The majority of the dialysis units are to be developed in partnership with the 7
Independent Sector and as a result do not require central capital funding. 2. PURPOSE The purpose of the Strategic Outline Programme is to: a. Facilitate strategic and collaborative planning and the setting of associated budgets; b. Identify and cost where appropriate key components of the Strategy and enabling deliverables; c. Provide the strategic context for subsequent investments; d. Facilitate the speedy production, and submission to Welsh Government, of subsequent Business Cases for related investment. 3. STRATEGIC CASE 3.1 Organisation Overview The Welsh Renal Clinical Network (WRCN) is the amalgamation of the former Renal Advisory Group and the former North and South Wales Renal Networks. It has a unique role as a clinical network in that it has responsibility for a discrete revenue budget for specific elements of adult renal services including Renal Replacement Therapy (RRT) which incorporates all modes of dialysis and kidney transplantation. 8
The WRCN is a sub-committee of the Welsh Health Specialised Services Committee the Joint Committee, and as such is hosted by Cwm Taf Health Board and is subject to its Standing Financial Instructions and other governance structures. The WRCN s Terms of Reference confirm that it has a commissioning role for the following service elements: Renal Transplantation Dialysis Erythropoiesis Stimulating Agents for Chronic Kidney Disease Vascular Access services for dialysis Transport for dialysis (for growth since 1 April 2008) Post-renal transplant Immunosuppressants (April 2014) The WRCN also has a qualitative and advisory role in the following service areas: Acute Kidney Injury General Nephrology Inpatient and outpatient services Transport for dialysis (pre 1 April 2008) Chronic Kidney Disease management in Primary Care 9
3.2 Provision of Unit Haemodialysis There are 17 dialysis facilities in Wales as presented in table 1 below. These consist of five main renal centres and 12 Subsidiary dialysis units which work collaboratively as per Hub and Spoke clinical model. Whilst all these services are provided through NHS Wales, some of the operational services are delivered on a day to day basis by partners from the Independent Sector (known as Independent Sector Provider or ISP ). Table 1. Current dialysis units in Wales (October 2014) Main Unit Subsidiary Unit Stations Host LHB NHS Lead Provider University Hospital of Wales 21 CVUHB CVUHB CVUHB Pentwyn, North Cardiff West Wing, Cardiff Royal Infirmary 32 16 CVUHB CVUHB ISP CVUHB CVUHB ISP St.Woolos Hospital, Newport 21 ABHB CVUHB ISP Merthyr Tydfil 30 CTHB CVUHB ISP Llantrisant 18 CTHB CVUHB ISP Morriston Hospital 23 ABMUHB ABMUHB ABMUHB 10
Morriston Annex 14 ABMUHB ABMUHB ABMUHB West Wales General Hospital, Carmarthen Withybush Hospital, Haverfordwest Bronglais Hospital, Aberystwyth 30 HDHB ABMUHB ISP 21 HDHB ABMUHB ISP 7 HDHB ABMUHB ISP Ysbyty Bangor 15 BCUHB BCUHB ISP Ysbyty Alltwen, Tremadog 9 BCUHB BCUHB ISP Glan Clwyd, Rhyl Wrexham Maelor 21 BCUHB BCUHB BCUHB 22 BCUHB BCUHB BCUHB Welshpool 12 PHB BCUHB BCUHB University of Birmingham Llandrindod Wells 4 PHB UHB ISP 316 Changes to be delivered to the above estate based on approved tendering or business cases: The replacement dialysis unit in Aberystwyth is to be operational in Spring 2015 with 12 stations (net increase of 5 stations) 11
The permanent unit for Alltwen has been provided through refurbishment of a ward space on Ysbyty Alltwen with 9 stations (net increase of 2 stations); The replacement of the Morriston Annex is to be operational by Spring 2015 with 25 stations (net increase of 11 stations). Further developments are planned including: The refurbishment of the Bangor Main unit (no net increase in capacity but resolution of quality and safety risks); The refurbishment of the Llandrindod Wells Subsidiary Unit with a net increase of 4 stations; The replacement of the West Wing Subsidiary Unit; The refurbishment of the Morriston Main; The refurbishment of the UHW Main Unit in medium and long term; Provision of a North Gwent Subsidiary Unit Provision of a larger South Gwent Subsidiary Unit (to replace St. Woolos) 3.3 Demand for Unit Haemodialysis Since 2008, the demand for unit haemodialysis has fallen from 7% to 2-3% per annum. The reasons for this decline are multi-factorial and include: 12
Enhanced anaemia management provided additional opportunities for management of chronic disease and exacerbations leading to delayed and reduced translation of patients with CKD to needing renal replacement therapy; Development of Conservative Management programmes. Evidence has proven that for certain patients, unit dialysis offers no benefit in terms of longevity and quality of life; Increased rates of transplantation. Over the five years, the number of renal transplants has risen from c100 to 140 per annum for Welsh patients; Increase in patients undertaking home haemodialysis. The UK Renal Registry provides an annual report on renal services in Wales. This routine review of the incidence and prevalence of renal replacement therapy has demonstrated repeatedly that there is very little statistical difference across Wales. There is high confidence that the numbers of patients requiring unit haemodialysis will grow but current modelling techniques are not able to predict where in Wales the growth can be anticipated. This is due to the statistical confidence levels overlapping as the population sizes shrink. The assumption is therefore that growth predictions of 2-3% per annum can be applied universally across Wales for planning purposes. 13
Future demand modelling is an inexact science. For all the positive factors listed above, there a number of factors that are expected to increase rates of Chronic Kidney Disease and the resultant numbers of patients requiring renal replacement therapy: Rates of CKD increase with age. Life expectancy is increasing resulting in a growing cohort of the population over the age of 65 (the average age for starting dialysis in Wales is 68) Increasing rates of obesity and diabetes are all linked to increased rates of CKD (as well as Cardiovascular disease) The current replacement and expansion programme is expected to be complete by 2018 depending upon availability of capital and revenue funding. The WRCN has reviewed the growth of renal replacement therapy and the graph below displays the predicted growth in unit haemodialysis over the coming four years. Graph 1. Predicted growth in demand for Unit Haemodialysis 2014-2025 14
Number of dialysis patients 1800 1600 1400 1200 1000 800 600 400 200 0 Unit Haemodialysis - Patient Growth Predictions 2014-2025 3% Growth - Patients 4% Growth - Patients 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 This suggests that to ensure sufficient national capacity, Wales requires between 295 and 307 stations operational by April 2018. Once all the schemes in phase one are complete (See Table 1 above), Wales will have 316 stations which provide a degree of head room in the short term. Attached as Appendix 1 is the expected completed unit haemodialysis estate, location and capacity based on current information and tentative discussions. This demonstrates that if all schemes progress as expected then Wales should have sufficient capacity to meet growth at 3% - 4% per annum for the next ten years. Sufficient head room will be available from an early point within the ten year programme which will allow some flexibility for organisation of patient flows to new and replacement units. This is displayed in the graph below. Graph 2: Demand for unit haemodialysis and proposed capacity developments 15
Number of dialysis stations 450 400 350 300 250 200 150 100 50 0 Unit Haemodialysis - National Demand & Capaicty Predictions 2014-2024 3% Demand - Station equivalent 4% Demand - Station equivalent Capacity 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 3.4 Alternatives to Unit Haemodialysis The WRCN has plans to increase the take up of home therapies, increasing their proportion at the expense of unit haemodialysis. However, the challenge of delivering this is significant as many patients are not suitable for home therapies due to clinical issues and co-morbidities. The impact on UHD will have to be carefully monitored over time. It remains the case that demand for UHD will remain despite increasing transplantation, home therapies and earlier management of CKD and more specifically the following: o o Circa only 30% of patients are suitable for home therapies; A significant proportion of patients present late with End Stage Renal Failure and the majority of these patients start on haemodialysis as default treatment; 16
o o The majority of patients with failing transplants are usually managed by haemodialysis; Circa 23% of peritoneal dialysis patients have to switch to haemodialysis after three to five years of treatment; o Less than 50% of patients requiring renal replacement therapy are suitable for transplantation; 3.5 Strategy and Programme Investment Aims The primary strategy is to provide sufficient local and regional capacity to meet the anticipated demand for unit haemodialysis. This will improve the overall clinical management of patients requiring dialysis as well as increasing local profile and access to, general nephrology services. The benefits of an appropriately sized and located dialysis unit extend beyond the direct provision of dialysis treatment: Local facilities improve travel times for patients and through this, treatment compliance; Reduction in mileage reduces logistical expenditure; By reducing the number of long distance journeys, and the procurement of better transport vehicles, 17
transport providers will be able to more effectively plan and operate a dedicated dialysis transport service; Each new and replacement unit will be required to include a training area for home therapies / self-care to promote growth in this area. Whilst this can be a destination treatment, it can also act as a bridge to home haemodialysis, assisting the WRCN s strategy to increase home therapies. 3.6 National Service Framework Designed to tackle Renal Disease The high level aims of the NSF are bulleted below. Italic entries demonstrate how the development of new dialysis capacity will meet these aims. o Care for All: An integrated system of patient care across all levels of the service and involving patients at every step of the way. - The development and expansion of dialysis units will improve access, providing equity across Wales regardless of where you live. o o o Prevent Renal Disease: Reducing the rate of renal disease through primary prevention; Improve detection of renal disease: Ensuring that where renal disease does occur that it is identified at an early stage; Reduce the progression of renal disease: Proactive action taken to delay its progression; 18
- The presence and profile of a dialysis unit demonstrably raises the number of referrals to nephrology to manage and advise on chronic kidney disease. This in turn provides opportunity for earlier diagnosis, management and delay in disease progression. o Improve survival rates maximise quality of life: Achieve and sustain the best quality of life and survival rates for all people receiving renal replacement therapy in Wales. - Insufficient local capacity has resulted in patients receiving sub-optimal twice weekly dialysis rather than thrice weekly. This is associated with a significant increase in morbidity and mortality. NSF Standard 11 The NSF includes a target regarding travel times for patients undertaking dialysis. This requires that a single journey should not take more than 30 minutes. Given the geographical distribution of the Welsh population, road infrastructure and ambulance resources, this presents a significant challenge. Work is ongoing with dialysis transport providers to plan and organise transport so that it is as efficient as possible, but this is reliant on sufficient local capacity. 19
3.7 Existing Arrangements The WRCN predecessors undertook a national exercise which determined priorities of schemes against agreed criteria. The Prioritisation Framework (Appendix 2) confirmed the following phases: Table 2. Phases of development of dialysis capacity First Phase Replacement of Aberystwyth unit Due for completion in March 2015 Replacement of Merthyr Tydfil unit Completed Provision of new unit in Haverfordwest Operational in September 2014 Provision of new unit in Tremadog Operational in June 2014 Provision of new unit in Welshpool Completed Second Phase Replacement of the Morriston Annex Due for completion in Spring 2015 Development of Satellite Unit in Llandrindod Wells Replacement of Cardiff Royal Infirmary Unit Completed. Expansion under consideration. To be provided within ISP contract for South East Wales Tender. Replacement of St. Woolos dialysis Unit Provision of North Gwent Unit Provision of East of Swansea Subsidiary Unit Options to be reviewed with ABMUHB following completion of the refurbishment on Morriston site and the South East Wales Tender. 20
Refurbishment of the Morriston Main Unit Subject to a capital business case. Refurbishment of the UHW Main Unit Reliant on regional capacity to be freed to allow decant. Subject to a capital business case. Refurbishment of the Bangor Unit Due for completion in January 2015 3.8 Business Needs The following are key principles for the development of new dialysis units. Unit Capacity Each scheme will have a minimum level of stations commissioned in order to open the unit. Additional stations will be commissioned as required. Given that capacity will be sufficient to meet ten years expected demand, a proportion of stations will be mothballed and not used until commissioned to meet growth. Every unit must have an agreed number of cubicles to support the management of infection control, blood borne viruses, etc. Ratio of cubicles in a unit will be dependent upon the clinical model e.g. main units would be expected to have a higher proportion of cubicles to assist the management of sicker patients. 21
Headroom provides contingency as it is not uncommon for even new dialysis units to experience temporary system failures through power and water supply problems (including activities undertaken by utility companies). It also provides the necessary flexibility to deal with peaks in activity. Conventional planning assumptions for the capacity of a unit are based around: Station numbers in multiples that are consistent with the nursing to patient ratio. For example, it is proposed to use a ratio of 1:3 and therefore the capacity of the units should be in multiples of three. The vast majority (95%<) of patients undergo thrice weekly dialysis. A much smaller number may receive unit haemodialysis twice weekly as part of symptom management in their palliative care plan. There is discussion across the renal community that more frequent dialysis would be beneficial but this needs significant evaluation before it could be considered further. Each station is therefore calculated to treat four patients a week in the following shift patterns: o Morning Monday, Wednesday and Friday o Afternoon Monday, Wednesday and Friday o Morning Tuesday, Thursday and Saturday o Afternoon Tuesday, Thursday and Saturday On this basis, a 12 station unit could therefore treat 48 patients as part of a conventional shift pattern. The NHS is moving towards seven day working and it would be a natural question to ask regarding the use of 22
such expensive assets as dialysis units. This has been actively excluded from the planning assumptions for reasons including the inclusion of sufficient downtime to enable: The safe continuation of the service is dependent upon routine planned preventative maintenance of the water treatment plant, water circuits as well as other equipment. Dialysis patients have a high risk to infection and the unit has regular deep cleans as part of infection control requirements during down time. There are also the practicalities of treatment schedules thrice weekly into seven days brings with it planning issues which would also require logistical considerations. The numbers of patients receiving twice weekly dialysis is very small at individual unit level and would not be sufficient to justify the cost of opening the unit on a Sunday. Twilight sessions are used in some units. At present, this is typically for the younger, fitter patients who may also be in employment or education and travel independently of hospital transport (This is not the average dialysis patient they typically have an average age of 69 years old when starting dialysis and a third have at least one significant co-morbidity). There is also a consideration in the longer term to the provision of nocturnal unit haemodialysis whereby patients travel to the unit and sleep overnight whilst dialysing and then leave the unit before the morning shift starts (at 7am). 23
Both such developments are potentially viable in the much longer term for future-proofing the physical capacity but they do require careful consideration. Transport at present struggles to provide an effective service to patients for the conventional morning and afternoon sessions. There are increasing numbers of complaints and clinical incidents associated with transport for unit haemodialysis patients. The service remains subject to a Modernisation Project and still may lead to even limited disaggregation. Twilight sessions are heavily reliant on effective and efficient transport arrangements. Dialysis stations Each new development should include sufficient capacity to: 1. meet existing demand; 2. provide sufficient headroom capacity to meet predicted growth for up to ten years and support self care training; 3. reflect the recommended nursing to dialysis patient ratio of 1:3 by having the number of stations in multiples of threes; 4. Provide support to neighbouring units to allow for temporary failures of a unit, or a decant facility in times of major capital works, and to allow for patients to be dialysed whilst on holiday or away from their normal dialysis unit 24
NHS Estate standards It is important to note that the need for a SOP for dialysis units owes to a number of factors, one being the changing clinical and design standards to manage infection control and health and safety and another the inevitable deterioration of buildings over time. All new and replacement units must comply with the Health Building Note 07-01 and 07-02: Dialysis Unit / Subsidiary Dialysis Unit (and successors) issued by NHS Estates. This sets out the minimum spatial and physical standards and ensures compliance with issues such as access, disability, health and safety and infection control. A group has been established in Wales incorporating Welsh Government Capital and Estates Team, NHS Wales Shared Services Partnership Estates, Health Board Estates teams and the WRCN to review the standards for dialysis facilities. This mechanism is in place to ensure that the standards applied meet the necessary requirements for the service based on the need of Welsh patients and services balanced with the availability of funding. To fully inform the SOP a review of all the Dialysis Estate was completed in 2012 and will be repeated every five years, with design guidance updated between review periods so that compliance with standards and a prioritised view of relative need for upgrading or replacement will result. As a sub set of the above, a more specific review of Water Treatment Plant is, due to the critical nature of this part of the service, being conducted across all units in 25
Wales. A first review be completed in spring 2015 and be repeated at the same time as the next Dialysis Estate Review. If it demonstrates the need for other Business Cases to be developed or the timing of some to change this will be made known to Welsh Government and Local Health Boards. Rooms In addition, the requirements for each unit must include consideration of space for use beyond the delivery solely of unit haemodialysis such as: Self care areas Treatment rooms for services such as IV Iron Home therapy training Office accommodation for members of the renal MDT or Community services. Videoconference facilities Transport Each unit must have sufficient waiting room area for patients being dropped off and collected. Each development must have a transport plan agreed by the WRCN and Health Board. All new units will be required to have sufficient care parking for 20% of the patient cohort to support independent travel to and from treatment. This is 26
consistent with the Dialysis Transport Charter developed in partnership with the Welsh Kidney Patients Association. 3.9 Benefits, Risks, Dependencies and Constraints Benefits By providing new and replacement dialysis facilities across Wales, a number of benefits will be realised: Headroom in dialysis capacity that will facilitate the sectoring of patients. This will contribute to improvements in transport and access for patients. Rather than travelling to the first available free capacity, patients will be able to go to their local capacity with appropriately planned logistics. This meets the triple aim approach: o Minimised travel time is conducive to treatment compliance and is linked to improved psychological and physical health; o Travel time is the single largest area of complaints and concerns for unit haemodialysis patients and reduced travel time will improve patient experience; o Improved logistics will result in more effective use of transport resources as a benefit of shorter, more proximal journeys. This headroom also enables the service to be resilient to catastrophic events which can render any unit unable to dialyse for short periods and require a neighbouring unit to receive and treat patients at short notice. 27
Even with successful increases in home therapies and transplantation there will still be a rise in demand for UHD. Additional capacity will meet this demand and will ensure Wales remains compliant with minimum treatment regime of thrice weekly dialysis for all patients who require it. Risks The risks to not proceeding with additional and more local unit haemodialysis capacity include: Sub-optimal logistics at higher costs and poor patient experience; Reaching the capacity limits which results in the need to reduce treatment availability (non compliance with Renal Association and NSF standards of thrice weekly dialysis). A reduction to twice weekly dialysis is linked to significant increase in morbidity and mortality; Older estate will require increasing levels of maintenance and presents a risk to service continuity e.g. older water treatment plants failing at increasing costs. Dependencies Main units need to be on an acute hospital site as they are an integral part of acute and specialist services often supporting critical care and acute kidney injury services 28
as well as the more complex chronic unit haemodialysis patients. Subsidiary dialysis units do not need to be on acute hospital sites. A review by the WRCN in 2011 concluded that off-site facilities can safely manage over 95% of chronic haemodialysis patients and only a small percentage of patients at any one time require treatment at a main unit. As the distance from a main unit grows, the argument for a Subsidiary Dialysis unit to be on a local acute site does grow stronger but should not become a rate limiting step e.g. could be provided within three miles of a District General Hospital. Constraints The following constraints are identified as associated with the proposed dialysis developments: If the agreed clinical model is for the facility to be onsite at an acute hospital setting this may be prevented by limited space or inter-twined with existing planned developments e.g. become part of a multi-storey development. Availability and profile of capital funding is not always guaranteed over the desired timeframe. 29
4. ECONOMIC CASE 4.1 Critical Success Factors The undertaking of the prioritisation process and setting of project briefs will confirm the critical success factors (CSFs) for each specific development. In general however the strategic CSFs include: The new units will provide conventional capacity based on the agreed growth model in the CDP for ten years following opening; The number of patients travelling more than 30 minutes in a single direction is 10% or less of the dialysis patient population (recognising that the current situation is approximately 40% based on WKPA and WAST survey); All new units will be compliant with the appropriate Health Building Notes with the implicit reduction in risks associated with Health & Safety and Infection Control. 4.2 Main Options It is anticipated that the delivery of the SOP could involve a combination of approaches to achieving the necessary capacity and infrastructure for the new dialysis services. The table below sets out the available options of delivery. Model A The conversion and refurbishment of commercial property by the Independent Sector as part of a competitive tender 30
process Model B Model C Model D Conversion of existing secondary care NHS estate to provide dialysis facilities New capital brick-built schemes on NHS Site Use of planned developments such as in Primary Care that have space that can be utilised, refurbished and converted to the provision of dialysis services 5. COMMERCIAL CASE 5.1 Commercial & Procurement Strategy Nearly 80% of unit haemodialysis services are provided through sub-contracts between NHS Wales and Independent Sector Providers. Benchmarking confirmed that ISP services were 30-40% cheaper than NHS provided services on a like-for-like basis. The ISPs also offered provision / refurbishment of facilities within their revenue charge thus reducing the need for capital. The WRCN strategy is to continue this approach i.e. reprovides and refurbish Subsidiary Dialysis Units through the competitive tendering process linked to the service and nursing contracts. This is most effective when these developments are away from NHS sites as they avoid i. complex lease issues, 31
increased NHS support costs and avoid capital funding requirements for the host health board. Experience and evidence confirms that off-site schemes (Model A) prove to be quickest and most economical based on revenue and capital requirements. This will not however be suitable for all developments particularly for the larger main dialysis units on NHS Wales s estate. In these instances, the Health Board owning the site will need to lead on the production and submission of a business case for the development. In these circumstance, the award of contracts to professionals such as architects, surveyors and the construction will be undertaken by the Health Board responsible for the development linked to each individual business case. 6. FINANCIAL CASE 6.1 On-site capital development Indicative Cost Each scheme will be required to complete an outline business case containing the indicative costs of the preferred scheme. Following agreement in principle with the Head of Capital and Estates Welsh Government, this will then be finalised prior to formal submission of the completed business case. 32
Appointment of professionals will be funded through agreement between Welsh Government and the respective Health Board. Funding Arrangements Whilst the capital costs of each scheme are subject to Welsh Government agreement and allocation, the revenue requirements are the responsibility of the Welsh Health Specialised Services Committee through the WRCN. The WRCN will take the following approach: All new schemes will involve the repatriation of existing activity. The funding for this activity will move with the patients to the new unit; Revenue commitment to the new unit will be based on the repatriated number which will represent the Minimum Commissioned Level ; The revenue requirements will be separately reviewed and agreed once split into the following headings: o Direct costs for dialysis treatment to include dialysis nursing, consumables, utilities, etc; o Capital depreciation for the facility and where the procurement model has agreed, dialysis equipment; o Support costs such as step increase in support services such as dieticians, pharmacy, etc. These will be reviewed against workforce and workload of the regional centres. 33
Increase above the Minimum Commissioned Level will be subject to agreement between the WRCN and the regional renal providers. It is not a critical factor to the operational opening of the new unit. 6.2 Off-site ISP delivered Indicative Cost These developments will be delivered as part of a service tender e.g. Merthyr Tydfil Dialysis Unit and the cost of providing a facility will be included in the revenue charges by the ISP to NHS Wales. The WRCN works with NWSSP Procurement and Morgan Blake Lawyers to provide the procurement technical support to the health board hosting the service contract. This approach was agreed by the WHSSC Joint Committee in 2011 and offers economies of scale, centralisation of expertise and reduction in legal and other technical costs associated with these schemes. Each scheme involves a full economic evaluation and market engagement to assess the potential costs prior to competitive dialogue tender. Funding Arrangements The contracts have been reviewed following experiences in completing the West Wales Unit Haemodialysis Tender and have been amended to ensure that central capital funding is not required as the associated building / refurbishment / water treatment plant / equipment is not treated as on-balance sheet. 34
These schemes are therefore revenue only and do not require central capital funding. 6.3 Affordability The WRCN has proactively managed its budget to ensure i. delivery of required capacity and ii. Achievement of financial balance. Further savings from the national immunosuppressant project are expected over 2014/15. Priority expenditure against this will be to maintain and grow sufficient capacity and address the high clinical risks. Each scheme will be assessed regarding its affordability against the planned investment and requirements as part of the WRCN s planning cycle. This will provide an early assessment of requirements. Each scheme will have an indicative cost allocation based on the benchmarking and workforce / workload reviews and WRCN will be informed of the operational date by the associated project board for each scheme. 7. MANAGEMENT CASE 7.1 Expansion Programme Management Arrangement Overall responsibility for monitoring the progress of the Dialysis Unit Expansion Programme will be with the Lead Clinician, Welsh Renal Clinical Network, who will report to the Director of Specialised and Tertiary Services, Welsh 35
Health Specialised Services Committee and the Deputy Chief Medical Officer, Welsh Government. Progress against the SOP expansion programme will be monitored by the WRCN Management Team and through them, the WRCN Board and WHSSC. This approach has been tightened as part of the lessons learned from the West Wales experience. 7.2 Specific developments A Project Board will be established to oversee the management of each development. The following membership and roles are proposed for that Board. : - Senior Manager / Director of host Health Board to act as Senior Responsible Officer; The Chair of each project board will be required to formally update the WRCN Board on the scheme including variance from original timetable. - Facilities representative from host Health Board; - Consultant Nephrologist and senior renal nurse from the main centre (to provide medical leadership) Member of WRCN management team; - Representative from transport services; - Patient / patient group representatives; The involvement of local patients and national patient groups has been and will continue to be key to the delivery of the new services and facilities. This will ensure that patient experience will be at the heart of each scheme. 36
The WRCN will take the lead on service user engagement and will facilitate the required option appraisal meetings. 8. EXPECTED SCHEMES - OUTLINE 8.1 Bangor and Alltwen BCUHB produced a business case which combines the permanent provision of a subsidiary dialysis unit in Ysbyty Alltwen with the refurbishment and expansion of the Bangor Main Unit. The Alltwen Subsidiary Unit component has been completed following refurbishment of a ward space at Ysbyty Alltwen. The additional space is being used to treat some patients transferred from the Bangor unit whilst it is refurbished. The current Bangor Main Unit scored badly when evaluated by the National Dialysis Estates Project. It requires a new layout and water treatment plant to address clinical governance concerns, infection control risk and service continuity issues. Work is underway and completion of the new facility is expected by January 2015. 8.2 Llandrindod Wells A small, four station unit has been provided through refurbishment of space at the Llandrindod Wells Memorial 37
Hospital. The capacity was limited due to the available space. Following a review of its estate, Powys Health Board has confirmed that additional space will be available adjacent to the current dialysis unit that could be refurbished. Initial discussions are that the new space should be used to i. provide additional capacity of up to a further four spaces including at least one cubicle and ii. To allow the relocation of the patient waiting room for dialysis. This is currently separate and poses a clinical governance concern for patients waiting in isolation pre and particularly post dialysis. The Llandrindod Wells Memorial Hospital site is subject to a large review of its function and development and any renal aspect needs to be consistent with the wider requirements. At time of writing, the WRCN is awaiting direction and guidance from Powys Health Board about timescales and engagement processes. Capital funding for the refurbishment may be sought for this scheme. Alternative option may be for a contract variation and to increase revenue costs for WRCN. 8.3 Gwent At present, Gwent patients access dialysis through the St. Woolos Subsidiary Unit in Newport or travel to the Cardiff North or Merthyr Tydfil Subsidiary Units depending upon where they live. 38
The St. Woolos Subsidiary Unit treats 84 patients and a review confirmed that circa 20 patients live in North Gwent and that there were circa 40 patients at the Cardiff North Subsidiary Unit who could repatriate to St. Woolos if there was sufficient local space. The Aneurin Bevan Health Board (ABHB) has confirmed that there is no space available for either: - Provision of a Subsidiary Unit on the Neville Hall Hospital Site - Room for expansion of the existing St. Woolos Subsidiary Unit. The commercial strategy for Gwent is linked to three other Subsidiary Dialysis Units and their services in the region. The WRCN has advised CVUHB that it should seek to batch the contracts for the Cardiff North, CRI West Wing, Llantrisant and St. Woolos Dialysis Units and replace these with a single contract that includes a North Gwent service. This approach would require the successful contractor for the service contract to provide facilities (in a similar manner to the new Merthyr Subsidiary Dialysis Unit) to replace CRI West Wing, South and North Gwent. This will be subject to market testing prior to any tender. The provision of sufficient local space and the resultant domino effect of repatriating patients back to local units would help release of space at the UHW Main Unit, allowing for it to be refurbished. This refurbishment has been identified as a high priority following the National 39
Dialysis Estates Review on the grounds of health and safety, infection control and service continuity. Capital funding is not being sought for these developments. 8.4 UHW Main Unit The following is provided as a guide in advance of any specific work undertaken by Cardiff & Vale University Health Board. Short Term (within five years) As described above, the UHW Main Unit needs a large amount of remedial work. The space is not conducive to optimal dialysis care space around the stations is too small and as such poses risks for infection control, health and safety and clinical management of emergencies. Such work will reduce the total number of stations available by approximately one third. The related activity will need to shift to other surrounding units and will be delivered within the context of a clinical model that requires the UHW Main Unit to only manage extremely unstable chronic patients, some exacerbations, acute kidney injury and crash landers. All other patients will be treated in surrounding Subsidiary Dialysis Units. This will require sufficient space in the Subsidiary Dialysis Units, staffed appropriately and with capacity and 40
equipment for more complex patients including mobile hoists and increased numbers of cubicles (for managing infections). Central capital funding will be sought for this development by CVUHB. Medium Term (5-10 years) The demographics of dialysis patients is suggesting that the patient cohort can be expected to become older and sicker with multiple co-morbidities. Increased provision of local dialysis with enhanced facilities such as cubicles, hoists, etc will help manage this demand but it is expected that a larger main unit in Cardiff will be required to appropriately manage both the more complex cases and when other patients have exacerbations. The WRCN is to work with the CVUHB to identify the medium term strategy for the reprovision of an appropriately sized main dialysis unit and this should be linked with a need for increased regional inpatient nephrology capacity to support the management of acutely unwell patients (both exacerbations and acute kidney injury). Central capital funding will be sought for this development by CVUHB. 41
8.5 CRI West Wing, Cardiff The current facility is sub-optimal and what was meant to be temporary has become a longer-term provision of chronic unit haemodialysis in South Cardiff. The associated service contract with an ISP has been extended on a number of occasions and this is to be included in the regional competitive tender and that a new facility is provided offsite by the ISP. Capital funding is not being sought for this development. 8.6 Morriston Main Unit Similarly the Morriston Main Unit needs to be refurbished and a replacement Water Treatment Plant provided. The undertaking of this will require a sequence of events linked to the Health Vision Swansea development. The current dialysis annex has 14 stations and is to be replaced by a permanent subsidiary dialysis unit with 25 stations and is expected to be operational by Spring 2015. It is proposed that the Morriston Main Unit relocates temporarily into this space allowing its current space to be refurbished. In order to comply with the health building requirements, a reduction in capacity is expected. The exact capacity is to be determined within a business case being prepared by ABMUHB. Once the refurbishment is completed, the Morriston Main Unit will move back to its original but smaller space and the 42
current annex will relocate into the new Subsidiary Dialysis Unit space. The initial net increase of 11 stations will be offset by the reduction in capacity within the Main Unit. Central capital funding will be sought for this development by ABMUHB. 8.7 East of Swansea The dialysis units on the Morriston site (Main Unit and the Annex) provide treatment for patients from the Bridgend and Neath Port Talbot areas. Local capacity in this area could alleviate demands on the Swansea service, releasing capacity for local Swansea patients. There are two approaches to the provision of an East of Swansea Subsidiary Dialysis Unit: a. Seek capital funds for the refurbishment of space on a NHS site such as the Princess of Wales Hospital. This would require a business case to be prepared by ABMUHB; b. Via a competitive tender, seek the successful contractor from a service contract to provide a facility (in a similar manner to the new Merthyr Subsidiary Dialysis Unit). Revenue funding for such a development would flow through the repatriation and transfer of patients from the Morriston units. The use of NHS Wales s estate will need to be consistent with the outcomes of the South Wales Plan for the 43
reorganisation of health services as this may have a bearing on if any space is available (and timescales). The full impact of the refurbishment of the Morriston Main Unit, the reprovision of a larger Morriston Annex and the completion of the South East Wales tender on the need of an East of Swansea unit will need to be considered before progressing with this development. 9 CONCLUSION The WRCN has successfully delivered a large expansion and replacement programme for new unit haemodialysis facilities across Wales. This SOP sets out the final phase of developments as set out in the prioritisation plan first agreed in 2009. This has included a number of units in areas of previous poor access such as Mid Wales, Pembrokeshire and Gwynedd. 44
Appendix 1 Outcome of expansion and replacement programme Main Dialysis Units Subsidiary Dialysis Units Current Next phases - Indicative University Hospital of Wales 21 15 Pentwyn, North Cardiff 32 32 West Wing, Cardiff Royal Infirmary 16 21 St.Woolos Hospital, Newport 21 30 Prince Charles Hospital, Merthyr Tydfil 30 30 Llantrisant 18 18 North Gwent 15 Morriston Hospital 23 23 Morriston Annex 14 25 West Wales General Hospital, Carmarthen Withybush Hospital, Haverfordwest Bronglais Hospital, Aberystwyth 30 30 6 21 7 12 East of Swansea 15 Ysbyty Bangor 15 15 Ysbyty Alltwen, Tremadog 9 9 Glan Clwyd, Rhyl 21 21 Wrexham Maelor 22 22 45
Welshpool 12 12 University of Birmingham Total number of stations Maximum capacity - patients Llandrindod Wells 4 8 316 368 1180 1472 46
Appendix 2. Summary Developments Model of development and Timescales Model A The conversion and refurbishment of commercial property by the Independent Sector as part of a competitive tender process Short term 1-3 years Model B Conversion of existing secondary care NHS estate to provide dialysis facilities Medium term 3-5 years Model C New capital brick-built schemes on NHS Site Long term 5-10 years Model D Use of planned developments such as in Primary Care that have space that can be utilised, refurbished and converted to the provision of 47
dialysis services Unit Actions & responsibility Timescale Procurement Model Central & West Region Llandrindod Wells Expansion of current unit ISP has confirmed expansion feasible within adjacent space to resolve capacity, waiting room and need for cubicle. Costed proposal has been prepared by ISP. Short term B Awaiting project plan and timescales from Powys Teaching Health Board to confirm availability 48
of space. Morriston Main Unit Abertawe Bro Morgannwg University Health Board has prepared a business case for the replacement of the Water Treatment Plant and refurbishment of the space. Short term B East of Swansea A new analysis is required to identify the preferred location based on need and opportunity. Medium term A WRCN to lead this with Abertawe Bro Morgannwg University Health Board. At present it is expected that this will be off-site as on-site options remain to be clarified and could be affected by the South Wales Programme 49
South East Region UHW Main Unit The regional strategy prepared by the Directorate of Nephrology and Transplantation at Cardiff & Vale University Health Board proposes a short term need for refurbishment of the main unit to manage infection control, manual handling and health and safety issues. This will require a reduction in the capacity at the unit which will need to be offset by increased capacity in the surrounding Subsidiary units. Short term B UHW Main Unit Longer term there is a need to provide a sufficient sized Main unit that is larger than current capacity reflecting the expected changes in complex cohorts. Medium term B 50
West Wing A replacement unit is needed quickly given current procurement and clinical / facility limitations. Short term A As such, it is proposed in the regional plan for a new unit to be re-provided to the South of Cardiff city South Gwent Aneurin Bevan Health Board has confirmed that there is no space into which the St. Woolos unit can expand into. Current demand and growth models suggest that a 30 station unit is required (current unit is 21 stations). Provision is therefore dependent upon pursing an off-site solution. Short term A North Gwent Aneurin Bevan Health Board has confirmed that there is no space on its sites in North Gwent that could Short term A 51
be refurbished. Provision is therefore dependent upon pursing an off-site solution. REGIONAL PLAN for South East The service contracts for the following units are all aligned to finish 31 March 2015: Short term A for Subsidiary units Cardiff North, Pentwyn Llanrisant B for Main unit CRI West Wing St. Woolos A competitive tender is required to replace these contracts and the reprovision of CRI West Wing, St. Woolos and the addition of a North Gwent facility are to be included as a requirement. Once the subsidiary units are 52
operational, the main unit refurbishment (short term) can then be completed. This will then be followed with the larger, permanent new development. 53