Highland NHS Board CRITICAL CARE …...Highland NHS Board 27 June 2013 Item 3.1 CRITICAL CARE...

Highland NHS Board27 June 2013

Item 3.1

CRITICAL CARE CONSOLIDATION AND THEATRES REFURBISHMENT – RAIGMORE –INITIAL AGREEMENT

Report by Eric Green, Head of Estates on behalf of Deborah Jones, Chief OperatingOfficer

The Board is asked to:

Approve the attached Initial Agreement for upgrading the Raigmore Theatres andcombining critical care services at Raigmore.

Agree that the Initial Agreement can now be submitted to the Scottish GovernmentCapital Investment Group for their approval.

1 Background and Summary

The Raigmore operating theatres are now 25 years old and have not been refurbished sincenew. Understandably the fabric is now worn and difficult to maintain. In addition manyguidance and regulation have changed over the 25 years and the facility is no longerconsistent with best practice.

Critical care facilities in Raigmore have grown over the last 25 years and are in 3 differentlocations within the tower block. None of these facilities meet current guidance. The fireupgrade work offers a unique opportunity to locate these services on one floor and drivequality and operational benefit from doing so.

This in turn facilitates other moves to further improve patient care within the tower block andimprove operation of the hospital.

2 Future of Raigmore Hospital

All NHS Highland facilities in Inverness are subject to the greater Inverness Masterplancurrently underway. This will align clinical strategy and estate strategy and challenge theevidence underpinning both. It is intended that this project will produce a project InitialAgreement for the Greater Inverness area highlighting the projects required to enablehealthcare to be delivered for the next 20 years.

Raigmore Hospital will obviously be the centre of these plans, as significant work is requiredto upgrade this now 25 year old facility. This proposal is fully consistent with the Masterplanexercise and is being offered in advance so that the basic hub of Raigmore hospital criticalservices can be brought up to modern standards while taking advantage of the tower blockrefurbishment opportunities. Failure to do this at this time will result in additional cost.

It is also recognised that this Initial Agreement does not address the capacity issueshighlighted in the previous day services Business case. However the Masterplan is taskedwith looking at how all assets are used in the greater Inverness area and already hasidentified space utilisation issues in some of our community facilities. Therefore it may bethat alternative solutions can be found to address the extra capacity required, so the scope ofthis Initial Agreement concentrates on the established long term need for acute theatrecapacity.

2

3 Contribution to Board Objectives

This project will contribute to achievement of”Better Health, Better Care, Better Value” atRaigmore by providing the facilities to better care for patients at the most acute phase of theircare. This project will also ensure the services at Raigmore are sustainable by providingmodern fit for purpose facilities. The improvements in layout will also facilitate better care.

4 Governance Implications

Staff Governance

Staff working in Raigmore have been fully consulted and involved in the design of the facilityby means of optioneering workshops and other formal consultations.

Patient and Public Involvement

Patient representatives were consulted and part of the decision making process around thisproject.

Clinical Governance

Raigmore Clinicians have been consulted on this proposal and have been involved at allstages of its development.

Financial Impact

The financial impact is detailed in the attached paper; however this is an Initial Agreementand further work will be done as part of OBC development to establish models of care for therevised facilities and what savings may result from that.

5 Risk Assessment

The project has its own Risk Register, the main risk are in not progressing with the project.

6 Planning for Fairness

An Equality and Impact Assessment meeting is being arranged as part of the OBCdevelopment.

7 Engagement and Communication

The project has an established governance structure with the Chief Operating Officer as theSenior Responsible Officer. The project group is chaired by the Chief Operating Officer andthe operational Unit Manager for Raigmore is also included in the group. The group includesrepresentatives of the Staff and Clinicians as well as a patient representative. The Head ofPublic Relations & Engagement is also included and a communications plan is in place toinform stakeholders including the general public and their representatives.

Eric GreenHead of Estates

20 June 2013

Inital Agreement Document

NHS Highland

Raigmore Hospital

Critical Care Consolidationand Theatres Refurbishment

(with necessary realignment ofServices)

Initial Agreement Document

Rev I

15th May 2013

Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Services)

CONTENTS

Inital Agreement Document

1 SUMMARY OF PROPOSED INVESTMENT 3

2 EXECUTIVE SUMMARY 5

3 STRATEGIC CONTEXT 9

4 INVESTMENT OBJECTIVES, EXISTING ARRANGEMENTS / BUSINESS NEEDS 29

5 BUSINESS SCOPE AND KEY SERVICE REQUIREMENTS 41

6 BENEFITS / RISKS / CONSTRAINTS AND DEPENDENCIES 44

7 AGREED CRITICAL SUCCESS FACTORS 49

8 LONG LIST OF OPTIONS AND SWOT ANALYSIS 50

9 ECONOMIC CASE TO ARRIVE AT PREFERRED WAY FORWARD 55

10 AFFORDABILITY REVIEW 66

11 RECOMMENDED PREFERRED WAY FORWARD 68

A APPENDIX – SMART OBJECTIVES 71

B APPENDIX – SUMMARY OF CATEGORIES OF CHOICE ASSESSMENT 75

C APPENDIX – SWOT ANALYSIS OF LONG LIST; 79

D APPENDIX – PREFERRED TOWER BLOCK LAYOUT 88

E APPENDIX – POTENTIAL PHASING PLAN 90

F APPENDIX – POTENTIAL HIGH LEVEL SCOPE 92

Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)

Inital Agreement Document3

1 Summary of Proposed Investment

This Initial Agreement Document (IA) summarises the planned investment to consolidate critical

care services, and the necessary re-alignment of some other services, within the Tower Block at

Raigmore Hospital, to facilitate this. Critically, the investment will also address the current

compliance issues and deficiencies associated with the Tower Block and the Theatres on the first

floor adjacent to the Tower Block. In addition to the immediate benefits arising from these

investments, there will be ancillary functional and operational benefits arising from the

improved adjacencies for the other acute services, arising from the realignment of services.

The proposed investment is aligned with and provides a substantial platform for any future

development at Raigmore, but critically excludes any changes to the current bed capacity and

theatre capacity provision which will be the subject of wider study.

The investment will address the immediate deficiencies of the accommodation, fittings and

services infrastructure associated with the current Critical Care accommodation and the

Theatres, so that facilities are commensurate with modern standards.

The investment proposals are aligned with the wider rationalisation and coordination plans of

NHS Highland services in the Greater Masterplan area. NHS Highland is currently implementing

a “Masterplan exercise for the Greater Inverness Area”. Both clinical and non clinical facilities

are being considered with options for optimal future Healthcare provision in the Highlands linked

to clinical need over the foreseeable future. Key findings are emerging in relation to the need

for the consolidation of critical care and theatres refurbishment, at Raigmore Hospital, as is

proposed within the Initial Agreement.

The particular deficiencies in services that exist across Critical Care and the Theatres aredefined in greater detail within subsequent sections of this Initial Agreement. However some ofthe key issues are highlighted below.

Critical Care The lack of integrated critical care facilities commensuratewith modern standards and in compliance with SHTM andother guidance

Inefficient working where nursing and medicaladministrations are duplicated in some cases, andconsequently there is poor staff flexibility between HDUand CCU

Poor critical care adjacency to “front” of hospital i.e.adjacency to “accident and emergency”

Principally due to allocation approach, lack of critical carebed availability (particularly HDU beds) resulting in tooearly discharge of patients or patients wrongly located ingeneral wards, in some cases

Respiratory ward operating as informal HDU

In some cases, patients within HDU’s and CCU’s receivingtoo high a level of care resulting from lack of integratedcritical care and poor adjacencies

Poor patient flow resulting from the existing adjacencies



Lack of isolation facilities in medical HDU

The outmoded design, and related design faults,associated with some of the existing accommodationwhich does not comply with current SHTM standards

A significant proportion of the existing accommodationand facilities are considered to be inadequate in terms ofinfection control

All of the above issues are related to the current lack ofintegrated critical care, the poor adjacencies and theinadequacies in the existing accommodation. This currently hasa significant impact on the quality of care given to critically illpatients at the hospital. Along with the care issues, it is alsoclear that the associated inefficient working practices also leadsto poorer staff moral and increased revenue spend.

Theatres Without action, NHS Highland anticipates an enforcementnotice from the Fire Authority in relation to the poorprovision for fire precautions.

There is a significant backlog in maintenance, and withplant and equipment at an age which in some cases isbeyond its design life, and therefore inefficient.Ventilation provision, in particular, fails to meet currentstandards in terms of the required number of airchanges.

Significant improvements are needed with regard to theprovision of infection control.

The space provision does not meet modern healthcarestandards and SHTM’s for Theatre accommodation.There is a particular issue with the severe lack of storagefor the increasing amount of theatre equipment.

In summary the existing operating theatre facilities fail to meetmodern standards, in terms of fire precautions, infection control,functional requirements, space provision, and compliance withcurrent clinical guidance.

The title of the project is as follows: “Critical Care Consolidation and Theatres

Refurbishment (with necessary realignment of services) at Raigmore Hospital”.



2 Executive Summary

This Initial Agreement (IA) should be regarded as an appraisal to establish the “preferred way

forward” in respect of addressing the existing deficiencies of Raigmore’s “Tower Block”, and

adjacent Theatre facilities, including the current dispersed nature of critical care services, and

the significant compliance issues throughout. Furthermore, the scope also includes some

limited ward reconfiguration which will be necessary to facilitate these improvements. The IA

also reflects on the separate major initiative currently being undertaken by NHS Highland

comprising a substantial Masterplanning Exercise for the Greater Inverness Area where options

for optimum future Healthcare provision in the Highlands are being considered. The

development of this IA has been undertaken in close alignment with the Inverness Masterplan

so that the significant investment proposed, will not only address the immediate deficiencies

described, but also build a platform for the anticipated subsequent initiatives to allow a future

optimal healthcare model to emerge.

This IA reviews the current Tower Block “Fire Precautions Upgrade” project to highlight the

unique opportunity that has arisen, namely to undertake the much needed improvements, at a

time when existing wards will be vacated, in any case. The IA investigates NHS Highland’s

vision, aims and its principal constraints in the context of key national and local drivers including

the Local Development Plan.

Following recommendations in a report by a Working Group of the Scottish Medical and

Scientific Advisory Committee (SMASAC) NHS Highland undertook a study to review High

Dependency Unit (HDU) facilities to make recommendations on the development of a Critical

Care strategy within NHS Highland. The comprehensive study identified various deficiencies

including the care issues associated with the highly dispersed nature of critical care and high

dependency units in the Tower Block and lack of integrated critical care facilities, poor

adjacencies and various other inadequacies in the existing accommodation. The NHS Highland

study identified that these deficiencies currently have a significant impact on the quality of care

of critically ill patients at the hospital. It is also clear that the associated inefficient working

practices have led to reduced quality of patient care and staff morale.

A review has also been undertaken of the current provision and quality of Theatre facilities at

Raigmore. Fundamentally, there are various Theatre deficiencies associated with fire

precautions, infection control standards, ventilation standards and backlog maintenance. In

particular, without action, NHS Highland is facing an inevitable fire enforcement notice which

could lead ultimately to closure. The current accommodation also falls below modern healthcare

standards and SHTM’s for Theatre accommodation, including space requirements, and there is a

particular issue associated with the severe lack of storage for the increasing amount of theatre

equipment.

Section 8 summarises a long list options (a total of18 principal, and sub-options) considered to

address the identified SMART objectives and benefits, which were considered in consultation

with a wide range of stakeholders, including patient representatives. These were shortlisted

into the following options, associated with improved critical care delivery and related tower

block reconfiguration, as summarised below.



1 Do Minimum (Retain Current Configuration)

2Consolidate Critical Care Unit with CCU at Ground floor and Medical HDU and ITU / SHDU co-located at first floor and Endoscopy retained in Tower Block (level 6)

2AConsolidate critical care with CCU & MHDU co-located at ground floor with ITU & SHDU co-located at first floor, and the addition of PACU and vascular lab, with Endoscopy moved out

2BSimilar to Option 2A but with MHDU/CCU situated at Ground floor at “A” block to facilitateintensive care adjacency, and no provision of PACU

3New Combined Assessment Unit on ground floor and consolidate critical care with CCU &MHDU also co-located on ground floor with ITU & SHDU co-located at 1st floor

3ANew Combined Assessment Unit on ground floor and consolidate critical care CCU/MHDU andITU/SHDU) completely on 1st floor

3BNew Combined Assessment Unit on ground floor and consolidate critical care (CCU/MHDU andITU/SHDU) in “A” block on ground and 1st floors, with the provision of PACU and vascular lab.

An extensive non-financial option appraisal exercise was conducted. Overall, the appraisalprocess identified that the preferred non-financial option was option 2A with 622 points,followed by option 2B with 568 points. The least favoured options, by some margin, are Option1 (Do Minimum)) and Option 2.

An economic appraisal was then undertaken to establish capital costs, recurring revenue, non-recurring revenue costs and net present costs for each option. An Option 0 (Do Nothing) hasbeen costed for baseline purposes however this option is not viable because the variouscompliance issues would not be addressed. In particular this option would result in a fireprecautions enforcement notice being issued, ultimately resulting in closure.

In addition to the critical care analysis appraisal, capital cost / revenue estimates have beenestablished based on addressing the various Theatre compliance issues. At an early stage in theprocess, it was agreed that this theatre work was common to all the options, and therefore thecombined costs, including the Theatre costs, have been used in the overall economic review.

The analysis of the net present values (NPV) indicates that Option 1 (Do minimum) has thelowest life time costs with Option 2A being the next favoured option. An analysis wasundertaken on an economic annual costs basis in line with HM Treasury guidance. The Value forMoney (VfM) analysis compared the cost per benefit point of the options as illustrated below.

Whilst Option 1 (Do Minimum) is the lowest Net Present Cost (NPC), it is the second leastfavoured option and does not fully achieve the Investment Objectives, as reflected in thescoring.

No QualitativeBenefitsScore1

QualityRank

Net PresentCost (NPC)(£k)

NPCRank

Cost perBenefitpoint (£k)

VfMEconomicRanking

1 358 6 18,013.8 1 50.3 6

2 349 7 22,687.1 7 65.0 7

2A 622 1 20,976.5 2 33.7 1

2B 568 2 21,941.4 5 38.6 2

3 511 4 21,530.3 4 42.1 3

3A 501 5 21,344.7 3 42.7 5

3B 532 3 22,641.4 6 42.6 4



Option 2A, has been established as the highest qualitative scoring option as well as having thesecond lowest Net present Cost. Fundamentally Option 2A meets the Investment Objectives,the Critical Success Factors and achieves the lowest cost per benefit point of all the remainingoptions. This option delivers best value in terms of non-financial benefits and the actualappraisal costs. Sensitivity analysis has been undertaken to ensure the results are robust.

It is highlighted that whilst Option 2A does not include a "Combined Medical & Surgical CommonAdmissions Unit”, this option does not preclude such a development at a future date, in thescenario where further consultation established that better patient outcomes could be achieved.

The associated estimates in terms of capital costs and revenues estimates, for Option 2A, aresummarised as follows.

Costs Option 2A

Capital Costs 19,496.2k

Recurrent Revenue Impact 681.3k

Non-Recurrent Revenue Impact 15.2k

Option 2A is considered as the “preferred way forward” and it is anticipated that the OutlineBusiness Case will develop options around this preferred way forward. In recognition of thehigh complexity of this proposed reconfiguration project, detailed healthcare planning of theTower Block will be required and this will establish sub-options of Option 2A which will bereviewed and compared, at Outline Business Case stage.

As noted previously, the proposals contained within this Initial Agreement are entirelycompatible with the Greater Inverness Masterplan study review, and furthermore form aplatform for the latter’s outcomes. The Greater Masterplan review will to lead to developmentof a “Programme Initial Agreement” whereby it will build on the work proposed under this IA,and review all additional factors, relating to the optimal model for delivery of “fit for purpose”healthcare facilities, suitable for the next 25 years.

It is highlighted that due to the nature of the proposed investment, the capital outlay is likely tobe over a period of approximately 5 years, as the wards are undertaken on a phased basis andin alignment with the “fire precautions” project. The anticipated capital funding over the 5 yearperiod would therefore be as follows.

Year Cost inc VAT

April 2013 – 2014 974,812April 2014 – 2015 3,899,249April 2015 – 2016 5,848,874April 2016 – 2017 5,848,874April 2017 – 2018 2,924,437Total 19,496,246

The indicative programme for project development, based on a “HFS Frameworks 2” approach,is provided in the following table.



IA CIG Meeting Date 2nd July 2013

OBC Stage / Approvals January 2014

Design and Target Price

Full Business Case development

September 2014

Full Business Case Approvals December 2014

Construction Start January 2015



3 Strategic Context

3.1 Organisational Overview

3.1.1 Organisation Profile

NHS Highland is one of the fourteen regions of NHS Scotland. It employs over 9,000 people,

making it one of the largest employers in the region. Geographically, it is the largest Health

Board, covering an area of 32,500 km² from Kintyre in the south-west to Caithness in the

north-east, serving a population of over 300,000 people, and sees a proportion of its patients

from the influx of tourists to the Highlands, which at certain times of the year, can double or

even triple the local population.

NHS Highland provides strategic leadership and direction for NHS services and is accountable to

the public and to the Scottish Government for all elements of the NHS system in the Highland

and Argyll & Bute Council areas. As of 1st April 2012, with the integration of health and social

care in the Highland region, NHS Highland is the lead agency for the delivery of Adult services

across health and social care (The Highland Council are the lead agency for children's services).

NHS Highland works with partners to improve the health of local people and the services they

receive and to ensure that national clinical and service standards are delivered across the NHS

system. NHS Highland is working to improve services with the involvement and support of the

public, partners in other NHS Boards, Highland Council, and other independent and voluntary

agencies.

3.1.2 NHS Highland Management

NHS Highland is managed by a Board of Directors which is accountable to the Scottish

Government through the Cabinet Secretary for Health and Wellbeing. The Board is accountable

for the performance of all NHS Highland services. The Board’s operational decision making

structure is shown below.

http://en.wikipedia.org/wiki/NHS_Scotland

http://en.wikipedia.org/wiki/Kintyre

http://en.wikipedia.org/wiki/Caithness



3.1.3 Operational Units

The planning, coordinating and delivery of services across NHS Highland is managed through

two Partnerships:

Highland Health and Social Care Service - Covering the same area as the

Highland Council, the Partnership is made up of three operational units: North &

West Highland; South and Mid Highland; Raigmore Hospital. The Partnership is

responsible for providing a wide range of acute care, emergency care, primary

care and community based health and social care services

Argyll and Bute Community Health Partnership - Manages acute, primary,

community health and mental health services across the region. Much of the

acute and more specialist services are provided from neighbouring NHS Greater

Glasgow & Clyde. These services are purchased by the CHP through formal

contracts

NHS Highland delivers services to patients and local communities through three operational

units (which comprise the Highland Health and Social care Partnership) and one Community

Health Partnership, which is not part of the Health and Social Care Partnership. These

operational units are supported by a range of Corporate Services including facilities, pharmacy,

personnel, and finance. A summary of these units is provided below:



North and West Highland which constitutes a remote and rural area made up of the following

areas and districts:

North Area

1. Caithness (including Rural General Hospital – Caithness General in Wick)

2. Sutherland

West Area

3. Skye, Lochalsh and Wester Ross

4. Lochaber (including Rural General Hospital – Belford in Fort William)

South and Mid Highland constitutes the inner Moray Firth area, and is made up of the

following areas and districts:

Mid Area

5. East Ross

6. Mid Ross

South Area

7. Inverness West (including New Craigs)

8. Inverness East

9. Nairn & Ardersier, Badenoch & Strathspey

Raigmore Hospital

Raigmore is the single District General Hospital (including specialist services) in the Highlands

Argyll & Bute CHP



Raigmore Hospital in Inverness is the district general hospital (including specialist services) for

patients in the North + West, South + Mid Community Health Partnership areas serving patients

from its own and adjacent Community Health Partnership areas as well as those from adjacent

Health Board areas.

http://en.wikipedia.org/wiki/Community_Health_Partnership



3.1.4 Vision and Strategic Aims

NHS Highland has delivered significant achievements in recent years, treating more patients,

and providing better, faster access to diagnostic and treatment services as well as achieving

financial balance. The Board continues to seek improvement in the quality of patient care

however and, in line with other NHS Boards, has a published Local Health Plan. This plan sets

out a simple vision for the people of the Highlands:

“Quality care to every person every day”

NHS Highland, in common with all Scottish health boards, has an advantage in being

responsible for the total health needs of the population and, for integrated care. This means it

is responsible for the better health of communities through population wide and individually

focused initiatives to maximise health and prevent illness; for better care of patients through

quick access to modern services, in clean and infection free facilities, by well trained and

courteous staff; and for better value for the use of the public money spent by ensuring there is

no waste and inefficiency, money is spent only on what is needed and has evident therapeutic

benefits and variation from core care pathways is the exception.

The importance of keeping a balance between the three components of better health, better

care and better value is fully recognised because they are intrinsically linked and together

constitute an effective health system. Any one area cannot be prioritised over any other.

This approach is consistent with the objectives identified within the NHS Highland Local Delivery

Plan 2012/2013. The Plan sets out the strategic direction for the Board, provides evidence of

performance to date and describes the plans to address the national targets. The key

objectives associated with the Local Plan 2012/2013 are provided under Section 3.2.3.1.

3.1.5 Key Stakeholders

Key Stakeholders, involved in the consultation to date and who are associated with the

proposed investment, are highlighted as follows:

Etta Mackay – Partnership Representative

Alan Simmons – Patient Representative

Chris Lyons – Director of Operations

Stuart Lambie - Medical Directorate Clinical Lead

Claire Vincent – Consultant in Acute Medicine

Iona McGauran – Medical Directorate Nurse Manager

Morag Macleay – Service Manager Medical Directorate

Ron Coggins – Surgical Directorate Clinical Lead

William Craig MacLeman - Assistant Nurse Manager Surgical Directorate

Derek McCrae – Service Lead – Gynaecology, Urology & Breast

Andrew Ward – Assistant Surgical DGM



Angela Watt – Midwifery / Obs Gynae Manager

Kenny Clarke – Services Manager Theatres, ITU, Anaesthetics and Day Surgery

Emma Watson – Consultant Microbiologist

Crawford Howat– Portering & Operational Security Manager

David Mackay – Domestic Services Manager

Alison McLean – Infection Control Manager

Donna Smith – Service Performance & Partnership Manager

Doreen Bell – Clinical Advisor

Rosie McGee – Health & Safety

Iain Ross – Information Technology

Eric Green – Head of Estates

Colin McEwen – Senior Building and Fire Engineer

Brenda Dunthorne – Head of Finance

Karen Underwood – Financial Management

3.1.6 Geographical Position and Health Comparisons

The NHS Highland catchment area comprises the largest and most sparsely populated part of

the UK with all the attendant issues of difficult terrain, rugged coastline, populated islands and a

limited internal transport and communications infrastructure. The area covers 32,518km²

(12,507 square miles), which represents approximately 41% of the Scottish land surface. The

geographical nature of the region presents particular challenges for the efficient and effective

delivery of health care services.

The area NHS Highland covers is benefiting from improved health services and so people are

now living longer. It is estimated that by 2031 the number of people aged 75 or over in

Highland will double. This is important to plan for because older people tend to make more use

of health and social services. As people age it becomes more likely that they may acquire one or

more long-term condition(s) like asthma, chest problems, depression, dementia, diabetes and

heart disease as well as having a greater risk of getting cancer. The proportion of older people is

above the Scottish average. However, levels of morbidity and deprivation are well below the

Scottish average. In total, NHS Highland will annually see and treat approximately 38,000

inpatients, 13,000 day case patients, 7,000 renal day attendances, 50,000 new outpatients and

39,000 accident and emergency attendances. About two thirds of inpatients are admitted as

emergencies.

As noted previously, the population served by NHS Highland totals circa 310,000 people based

on the GRO(S) 2008 based population statistics. This is made up of residents of both the

Highland and Argyll & Bute Council boundaries. It is anticipated that residents of the Argyll &

Bute Council area will not be significant users of any of the services covered by this initial

agreement due to the distances involved and the Board’s objective of maintaining services as

local as possible. Consequently, the projected population figures in thousands produced by the



General Registers Office for Scotland (GRO(S)) shown below relate solely to the Highland

Council area:

Highland Population Shift

010203040506070

actual forecast forecast forecast forecast forecast

2008 2013 2018 2023 2028 2033

year

po

pu

lati

on

(000's

)

0-15

16-29

30-49

50-64

65-74

75+

Data Source: GRO(S) 2008-based population projections (Feb 2010)

Data Source: GRO(S) 2008-based population projections (Feb 2010)

In summary, the population of Highland region has increased by around 6% over the

last 10 years and is expected to continue to grow for the foreseeable future. This

increase, past and predicted, is due mainly to net in-migration to the region, rather

than natural increase (births - deaths). The predicted increase does not take account

of any new external influences on population, such as increased inward migration

due to climate change. GRO(S) data available projects over the next 25 years within

Highland Region:

3.1.7 Epidemiological Considerations

3.1.7.1 Mortality

Cancer and circulatory diseases still account for over 60% of all deaths in NHS

Highland; this figure is in line with the rest of the UK and other developed countries.

Mortality from cardiovascular disease, the largest component of circulatory diseases,

is falling in those aged under 75 years, but the socio-economic gap remains (see

figure below).



Cancer incidence and number of deaths from cancer continue to increase, reflecting

the ageing of the population. Cancer survival, however, is improving and the age-

standardised death rate is falling, indicating that more people are living for longer.

The top four causes of cancer mortality remain breast, lung, bowel and prostate. Of

other major causes of death, those related to alcohol have trebled in the last 30

years.

3.1.7.2 Life expectancy

In line with falling premature mortality rates, life expectancy continues to increase,

as does healthy life expectancy, but the gap between the two is not closing,

indicating that the burden of chronic ill health in later life continues and is shifting

into older age groups. Healthy life expectancy is improving more rapidly for men

than women.

3.1.7.3 Long-term conditions

Definitions of long-term conditions (LTC’s) vary, making estimating numbers of

people with them difficult. According to local Practice Team Information, about 54%

of the population aged 16 years or over consulted their GP for a potential long-term

condition in a 1-year period; however, this figure includes many who are able to



manage their condition themselves. In the Scottish Health Survey, 37% of the

population reported having a long-term condition, and 11% said that their condition

limited their day-to-day activities.

The prevalence of LTCs increases with age; in the Scottish Health Survey 65% of the

over 65s reported an LTC, with 35% reporting two or more LTCs. Practice Team

Information also shows that people consulting their GPs about one LTC are more

likely than not to have at least one other LTC as well. For example, of those

consulting their GP for CHD, only 8% have no other LTC, while 67% have at least

two other LTCs.

This co-existence of multiple LTCs probably reflects the ageing population, and also

suggests that treating LTCs in isolation is no longer appropriate for the majority of

the population suffering from them.

3.1.7.4 Lifestyle risk factors

Smoking prevalence continues to fall; the latest estimates suggest that 26% of

Scottish men and 25% of Scottish women smoke regularly.

Alcohol consumption remains high at around 11.8 litres of pure alcohol per person

per year the equivalent of 570 pints of 4% beer or 42 bottles of vodka or 125 bottles

of wine. This level of consumption is enough for every adult in Scotland to exceed

the sensible drinking guidelines for men and women every week of the year.

Obesity levels continue to increase in adults: in 2008, 66% of men and 60% of

women were overweight or obese.

These changes in risk factor levels suggest that we will continue to see a reduction in

smoking-related diseases, but alcohol-related health harm, circulatory diseases,

some cancers and diabetes will continue to increase.

3.1.8 Summary Impact of Demographic and Epidemiological Data

The demographic and epidemiological changes identified in the previous sections are

likely to have two effects on those services being developed in the context of this

Initial Agreement.

1. A direct increase in demand on services based on population growth alone;

and

2. A secondary increase in demand for services based on an altered

demographic profile and epidemiological change.

The latter point here reflects a significantly increased growth in the 65+ age group

(of circa. 88%). In the face of evidence-based clinical models for each of the

services related to this Initial Agreement this demonstrates significant links between

increased age and the frequency of intervention/volume of service required.



3.2 Existing Business Strategies

3.2.1 Overview

The planned investment (to consolidate critical care and address compliance issues associated

with the theatres) is directly linked to delivering future hospital services in line with, and driven

by, a number of national and local strategies (described below). Many of the local strategic

objectives have been developed to meet the overall delivery of the national strategies.

A number of factors identified in the strategies have influenced how services at Raigmore will

develop in response to such expectations and opportunities. These factors indicate how the

need for health is changing and the opportunities that are emerging to provide services in

different and better ways.

3.2.2 National Strategies

The national strategies and published guidance which have influenced the development of the

local plans, and will therefore be a key driver in the planned investments are as follows.

The five Strategic Outcomes (the Scottish Government). These comprise

“Wealthier and Fairer; Smarter; Healthier; Safer and Stronger, and Greener”. By

investing in the redevelopment and modernisation of health services at Raigmore

Hospital, it is clear there are a large number of positive benefits to patients that

will be achieved in relation to the five “Strategic Outcomes” and relevant national

indicators.

The Healthcare Quality Strategy for NHS Scotland (the Scottish

Government 2010). This identifies the following priorities: caring and

compassionate staff and services; clear communication and explanation about

conditions and treatment; Effective collaboration between clinicians, patients and

others; A clean and safe care environment; Continuity of care; and Clinical

excellence. The planned investment is closely linked to achieving these aims.

“A Sustainable Development Strategy for NHS Scotland’ (the Scottish

Government). As with all public sector bodies in Scotland, NHS Highland must

contribute to the Scottish Government’s purpose: ‘to create a more successful

country where all of Scotland can flourish through increasing sustainable

economic growth’. The planned investment should help to enhance the

contribution of the health sector to sustainable development in respect of

procurement; facilities management, employment and skills, community

engagement, improved efficiency and energy efficient infrastructure

NHS Scotland Efficiency and Productivity Framework. The Framework’s

main purpose is to identify priority areas to improve quality and efficiency. The

Framework is a companion to the Quality Strategy and provides a baseline for

the changes that will need to be undertaken by the Scottish Government Health

Directorates (SGHD), NHS Boards and other public sector organisations.



The Scottish Patient Safety Programme launched in 2008. This is being

implemented in every acute hospital in the country. The initial goals are to drive

improvements in Leadership, Critical Care, General Ward, Medicines Management

and Peri-Operative. Highlighting critical care as a goal of the programme, this

investment will play a key part in helping to contribute towards the programme’s

objectives.

National Framework for Services Change in NHS Scotland (2005). This

identifies the 3 key drivers for change to be taken account of as : demographic

change, workforce pressures and developments in technology

“Building a Health Service Fit for the Future” (2005). This document sets

out the challenges facing the NHS in Scotland, in particular our ageing population

and the rising incidence of long-term or chronic conditions. The report also

recognises the particular issues facing rural communities, including access to

services and transport. Clearly this has particular relevance to NHS Highland.

“Delivering for Health” (2005). A document which describes the need to

focus more on preventing ill health and reducing the impacts of long term

conditions. This approach aims to provide as much care as possible in people’s

own communities, and to reduce acute admissions to hospital, especially

unplanned or emergency admissions.

“Better Health Better Care Action Plan” (2007). This document builds on

earlier work, and sets out a series of actions to “help people to sustain and

improve their health, especially in disadvantaged communities, ensuring better,

local and faster access to health care”

Scottish Government - Asset Management Policy. This Initial Agreement is

aligned with the Scottish Government’s Asset Management policy of bringing

more consistency to the management of the NHS Highland estate in order to

improve efficiency and effectiveness across the whole of NHS Scotland. The

development proposed is an important opportunity to consolidate and rationalise

the existing estate.

Policy for Design Quality for NHS Scotland - NHS Highland recognises and

fully supports the requirements presented in CEL 19 (2010) related to policy on

design quality for NHS Scotland.

3.2.3 Local Strategies

A number of themes embedded in the national strategies (described above) are influencing the

local strategic objectives and future models for changing the delivery of clinical services in

Highland. The key strategies are summarised as follows and described further in the

subsequent sections.

NHS Highland Local Delivery Plan 2012/2013



HEAT Targets (contained within the above)

Quality & Efficiency Framework

NHS Highland Greater Inverness Masterplan

Workforce Strategy

Public and Staff Engagement Strategy

3.2.3.1 Local Delivery Plan 2012 / 2013

NHS Highland’s mission is to provide patient-centered services tailored to people’s needs in a

systematic and consistent way providing quality care to every person every day. Our approach

embraces the Healthcare Quality Strategy for Scotland and also takes account of the priorities

within the NHS Scotland Efficiency and Productivity Framework for SR10. The described vision is

to:

Provide quality care at all times;

Support people and communities to maximise their own health;

Develop precisions driven services so that when people need our care they

experience timely, focused, effective services that minimise the duration and

frequency of contact;

Ensure that every health pound spent delivers maximum health gain.

The NHS Highland 2012/13 Local Delivery Plan focuses on the contributions to 4 nationalpriority areas:

Health inequalities

Early years

Tackling poverty

Economic recovery

The investments proposed in this Initial Agreement (IA) will make a significant contribution to

the goals of the NHS Highland Local Delivery Plan by sustaining and building upon the

developments in acute care. In particular the investments will:

Provide services and facilities which meet 21st century healthcare needs and are

acceptable to both staff and patients.

Ensure that services are continuing to progress towards the achievement of

national standards.

Provide an environment which enables staff development, recruitment and

retention as well as community involvement and ownership.



high quality, integrated, equitable, needs and evidence-based, and cost-effective

increasing focus on hospital beds being preserved for the most acutely ill and

those with specialist needs

run by healthy, flexible, well-motivated and well-trained staff working to their

maximum potential and capability

using modern, flexible, efficient, green assets to maximum effect

reduce wastage and inefficiency across acute services

3.2.3.2 HEAT Targets

NHS Highland’s Local Delivery Plan for 2012/13 identifies and targets performance against HEAT

targets. This is, and will continue to be, monitored and reported in the NHS Highland Balanced

Scorecard. In terms of Raigmore Hospital, it is clear that the proposed clinical service

improvements will make a significant contribution to the achievement of HEAT targets. In

particular the following HEAT targets are highlighted which will have a positive benefit from the

proposed development.

NHS Scotland to reduce energy- based emissions and to continue a reduction in

energy consumption which will contribute to the greenhouse gas emissions

reduction targets set in the Climate Change (Scotland) Act 2009

No people will wait more than 28 days to be discharged from hospital into a more

appropriate care setting, once treatment is complete from April 2013, followed by

a 14 day maximum wait from April 2015.

Further reduce healthcare associated infections so that by 2012/2013 NHS

Board’s staphylococcus aureus bacteriamia (including MRSA) cases are 0.26 or

less per 1000 acute occupied bed days, and the rate of Clostridium difficile

infections in patients aged 65 and over is 0.39 cases or less per 1,000 total

occupied bed days.

3.2.3.3 NHS Highland Quality Approach

The Quality Strategy sets out NHS Scotland’s vision to be a world leader in healthcare quality,

described through 3 quality ambitions: effective, person centred and safe. These ambitions are

articulated through the 6 Quality Outcomes that NHS Scotland is striving towards:

The Highland Quality Approach captures the spirit of how NHS Highland is working to improve

care and outcomes for people in Highland. It describes our ways of working, values and

behavior. It recognises how important it is to improve the health of the population and get the

experience of care right for individual people, every time. We will deliver this by focusing on

providing person-centred care while at the same time eliminating waste, reducing harm and

managing variation.

The Highland Quality framework is captured in our “blue triangle”. It has been designed to

place the individual at the top, with everything else we do supporting this purpose. In



developing our approach we have drawn from the best learning we could find. The key elements

of the Highland Quality Approach, summarised in the blue triangle, include our Mission, Vision

and Values. It also describes how services and care will look in the future as well as how we are

approaching changing the way we deliver services and care.

NHS Highland’s vision is to provide ‘Quality Care to Every Person Every Day’. In delivering this

vision, three key elements must be delivered simultaneously:

Better Health – improving the health of the population

Better Care – enhancing the experience of care for individuals

Better Value – controlling the per capita cost of care

By reviewing the above key elements which make up the Quality Approach, it is clear that

investment (in consolidation of critical care and Theatres compliance issues) at Raigmore

Hospital will make a significant contribution to the mission, vision and values. In particular the

investment will improve the overall care of the patient both in terms of quality of care and an

improved environment.



3.2.3.4 NHS Highland Greater Inverness Masterplan Study (On-going).

As noted previously NHS Highland are currently implementing a substantial Masterplanning

Exercise for the Greater Inverness Area. Both clinical and non clinical facilities are being

considered along with options for optimum future Healthcare provision in the Highlands linked to

clinical need over the foreseeable future. The development of this Initial Agreement document

has been undertaken in close alignment with the masterplan development.

Key findings are emerging from the ongoing Masterplan Exercise work, and which have direct

relevance to driving the investment and scope described within this Initial Agreement

document. These findings are summarised as follows.

The Raigmore “component” is a major element of the emerging Masterplan

Exercise that is being utilised to achieve positive outcomes that extend beyond

the primary objective of the capital investment into a more widespread range of

benefits in support of the estate strategy

The ongoing re-development of level 7 (top floor) of the “tower block” (under the

“Fire Precautions Upgrade project”) represents the commencement of a more

widespread investment need in this important area of the estate (the Tower

Block) that is now around 30 years old

The Masterplan Exercise will build on the need for urgent improvements to

address Critical Care deficiencies in the existing model of care. This will define

the need for the integration of critical care at ground and first floor levels of the

Tower Block, together with the need for improved adjacencies for various

services

The “Fire Precautions” project presents a unique opportunity to undertake

appropriate further improvements, and reconfiguration, at a time when existing

wards will be vacated in any case, thus minimising disruption to ongoing clinical

services.

The briefing for new facilities should, wherever possible, meet the higher

standards of technical specifications defined within the latest relevant technical

guidance and/or NHS Highland Estate Strategy.

The Masterplan Exercise will define the need for a project that will facilitate the

removal of temporary buildings that have provided a “stop gap” solution to some

service needs

The location of the facilities should allow staff to utilise existing services as far as

possible rather than duplicating them in the new care structure

The Masterplan Exercise will recognise the poor condition of some

accommodation, major compliance issues and the lack of available space

associated with the Theatres



The Masterplan exercise will recognise the increasing demands on theatre

accommodation and the need for some re-alignment of operating procedures

across the existing theatre accommodation at the Hospital.



3.2.3.5 Workforce Strategy

The successful delivery of NHS Highland Strategic Framework requires the contribution of the

workforce to realise the vision ‘Quality Care to every patient every day’ and delivery of the

Triple Aim: Better Health, Better Care and Better Value.

Workforce design, development and delivery, underpinned by workforce plans and policies that

support efficient, flexible working practices and are capable of responding to current NHS

challenges, are important. They will help to improve health, reduce inequalities and deliver

HEAT and efficiency targets on time; in turn delivering safe, high quality health care services to

patients in a way that is both affordable and sustainable.

This Workforce Development Plan for NHS Highland 2012/13 incorporates Learning and

Development. This integrated approach has been underpinned by close working with Partnership

Forum through relevant sub groups.

Through an integrated approach to financial, workforce and service planning, there are in place

a number of workforce plans that respond to service redesign and service improvement

programmes. In addition, specific workforce efficiency measures have been developed to scope

and monitor workforce expenditure in terms of 1) reducing whole time equivalents; 2) skill mix

review; and 3) reducing workforce cost base in line with the current PIN policy framework.

3.2.3.6 Public and Staff Engagement Strategy

NHS organisations are under a legal duty to inform and involve service users and staff in the

design and delivery of health services. NHS Highland’s strategy is to facilitate engagement and

inform effectively. This reflects the growing evidence that where people are given good

information and involved in the right way it increases trust and confidence in the NHS. On this

basis, the consultation associated with this investment has included public / staff engagement.

3.2.3.7 Sustainability

NHS Highland is committed to meeting the needs of the present without compromising the

ability of future generations to meet their needs in all of its activities. NHS Highland takes

cognisance of the principles laid down both locally and nationally for the promotion of

sustainability in all activities undertaken by the Public Sector. Accordingly, the project will

promote sustainability across various fields including the following:

Use of sustainable materials in design

Passive energy service measures

Efficient services installations

Replacement of inefficient plant

The provision of facilities capable of sustaining growth



Provision of modern, fit for purpose and efficient NHS facilities that sustain

growth

3.2.4 Critical Care Policy and Trends

A Report by a Working Group of the Scottish Medical and Scientific Advisory Committee

(SMASAC) on High Dependency Unit (HDU) Beds (SGHD 2008) identified that High Dependency

Care in Scotland is inequitable and in many cases insufficient. The Report recommended that all

NHS Boards should undertake an assessment of need for HDU beds (SGHD 2008). In response,

the Scottish Critical Care Delivery Group was tasked by the Chief Medical Officer to co-ordinate

a needs assessment exercise in all Health Boards to provide a national picture of the provision

of, and need for HDU beds. It was also recommended that each Health Board use an agreed

methodology previously developed in NHS Tayside (Colvin 2003).

Accordingly, NHS Highland approved the funding of a study to review the provision of, and need

for adult High Dependency Unit (HDU) beds in NHS Highland but also to make recommendations

to the Health Board to inform the development of Critical Care strategy within NHS Highland.

The Report therefore includes analysis of both HDU and Critical Care at Raigmore Hospital.

Prospective data was collected over a 14 week period of all adult in-patients in Raigmore

Hospital, Belford Hospital, Caithness General Hospital and Lorn & Islands Hospital who met

criteria for admission to the Critical Care Levels of Care 0 – 3. The results and

recommendations were presented in a High Dependency Needs Assessment report, which is

available upon request. This study, together with a number of key reference documents

utilised, are highlighted below.

The High Dependency Needs Assessment of NHS Highland

Patients

NHS Highland

Critical to Success: the place of efficient and effective critical

care services within the acute hospital.

Audit Commission

(1999)

Comprehensive Critical Care: a review of adult critical care

services

Department of

Health (2000)

Better Critical Care: Report of Short-Life Working Group on

ICU and HDU issues

Scottish Executive

Health Department

(2000)

It was argued that the traditional division into High Dependency and Intensive Care, based on

beds, be replaced with a philosophy of Critical Care, focussing on an individual patient’s journey

along a Critical Care continuum. This new approach to Critical Care was concerned with the

care of patients at risk of critical illness and of those recovering from such an illness as well as

of patients during the critical illness. Four levels of care for Critical Care patients were

identified:



Level

0

Patients whose needs can be met through normal ward care in an

acute hospital.

Level

1

Patients at risk of their condition deteriorating, or those recently

relocated from higher levels of care, whose needs can be met on an

acute ward with additional advice and support from the Critical Care

team.

Level

2

Patients requiring more detailed observation or intervention including

support for a single failing organ system or post-operative care and

those ‘stepping down’ from higher levels of care.

Level

3

Patients requiring advanced respiratory support alone or basic

respiratory support together with support of at least two organ

systems. This level includes all complex patients requiring support for

multi-organ failure.

Section 4.2.3 reviews the critical care provision, and associated services at Raigmore

Hospital, in the context of the above.

3.2.5 Theatre Policy and Trends

Operating Theatres provide specialist facilities that enable surgeons to undertake surgical

interventions (procedures or operations) on patients whose medical condition requires the

same. It also provides accommodation for minimally invasive procedures conducted under

radiological control by either radiologists or surgeons. Although the level of intervention will

vary by patient, in general, within the operating department, patients are received, reviewed,

anaesthetised, operated upon and recovered.

The service provides for emergency and elective patients who require surgical intervention

and/or other procedures that require to be conducted within an operating room environment

and/or anaesthesia, with facilities that allow functional groups to care for pre, intra and post-

operative/anaesthesia patients in a low risk environment. Operating theatre services are

delivered from a range of hospital locations across NHS North Highland that include:

9 x General operating theatres at Raigmore Hospital

1 x modular operating theatre (predominantly day case) at Raigmore Hospital

1 x maternity operating theatres at Raigmore Hospital

1 x General operating theatre at the Belford Hospital, Fort William

2 x General operating theatres at Caithness General Hospital, Wick

1 x General operating theatre at The Lawson Memorial Hospital, Golspie



2 x General operating theatre at The Dr MacKinnon Memorial Hospital, Broadford,

Skye

Increasingly stringent training standards, in combination with more complex working

environments and the difficulties associated with delivering “compliant” staff rotas in all surgical

specialties, is making it more onerous to continue to deliver these complex services in as wide a

range of locations. NHS Highland has managed to sustain services through a combination of

investment in staffing resources and complex shift/rota planning that is designed to optimise

available resources.

Surgery can be delivered on an outpatient, day-patient and in-patient basis, with an increasing

move towards non-inpatient and shorter lengths of stay in hospital. NHS Scotland, in reflection

of the global advantages associated with increased day surgery rates, has encouraged NHS

Boards to actively look at their elective procedures and make day case surgery the default

position whenever this is clinically appropriate. They identify many benefits associated with this

approach that include:

Lower risk of hospital acquired infection vis a vis inpatient treatment

Reduced time in hospital for the patient

Care that is better suited to the patients needs

Lower risk of surgery being cancelled (as long as day surgery facilities are

separate from those for emergency patients)

The British Association of Day Surgery (BADS) verifies these claims, noting that patients

overwhelmingly endorse day surgery, which generally provides timely treatment, reduced risk of

last minute cancellation, lower incidence of hospital-acquired infections and an earlier return to

normal activities. They further state that day surgery provides better value for money overall.

In order to support a move towards day surgery, there is an ongoing commitment of NHS

Boards to increase the percentage of BADS procedures carried out as day cases or outpatients.

Section 4.2.4 reviews the theatres provision, and associated services at Raigmore Hospital, in

the context of the above.



4 Investment Objectives, Existing Arrangements /Business Needs

4.1 Investment Objectives (SMART)

Noting the need for project objectives to relate to the key strategies previously referred to in

Section 2.2, a review was undertaken to establish key “SMART” Investment objectives for the

project based on the SCIM guidance. Following review, these SMART objectives were

established and a detailed summary of the output (including baseline data for measurement and

timing of assessment of the objectives) is provided within Appendix A.

A new project to consolidate critical care together with theatre upgrade work (and associated

realignment of acute services) is considered an essential component of achieving NHS

Highland’s vision and strategic aims. A summary of the SMART objectives is provided below:

No. SMART Objective Heading

1 To improve business effectiveness and revenue efficiency

2 To improve HEAT and other Health targets (including waiting times fortheatres / BADS targets)

3 Augment range of services and promote emerging model of care includingconsolidation of critical care

4 Make possible the introduction of new ways of working and in particulareffective collaborative working and flexibility in the workforce

5 Improved facilities / increased capacity offering a patient centred serviceincluding greater consistency of care and increased certainty foradmissions, procedures and discharge

6 Concentrate higher and lower levels of care at appropriate locations

7 Offer facilities which reduce risk of spread of infection compared to statusquo

8 To achieve optimal utilisation of space (within the constraints of existingbuildings)

9 To achieve operational and functional efficiency of physical environment

10 To deliver high quality facilities, and technical standards with a strongfocus on lifetime costs, quality and design.

11 To comply with “A Sustainable Development Strategy for NHS Scotland’, toenhance the contribution of the health sector to sustainable development

12 To enable the retention and recruitment of staff



4.2 Existing Arrangements and Analysis

4.2.1 Raigmore Hospital

Raigmore Hospital, in Inverness, is the district general hospital (including specialist services) for

patients in the North + West, South + Mid Community Health Partnership areas, serving

patients from its own and adjacent Health Board areas. The Hospital comprises part single, part

two, part three and an eight storey block (“the Tower Block”) covering an overall foot print of

circa 94,000 m2.

The Tower Block forms part of the original “Phase 2” development of Raigmore Hospital and was

opened in 1985. It is the most prominent part of the Hospital, comprising ward and associated

accommodation on 8 floors, providing various medical and surgical services. Critical care

services, both Medical and Surgical related, are currently provided within different wards spread

around the Tower Block, arising from development over a historical period.

The Theatres are provided at first floor level, within an adjacent building, albeit they are fully

accessible at first floor level of the Tower Block.

4.2.2 Tower Block

General

Over the years, significant changes to the use of the accommodation have occurred

in terms of clinical services provided. However the basic physical ward configuration

has remained broadly the same. Ground level to level 7 of the ward block are

typically divided into 3 areas as follows:

Ward A – South Wing typically ward accommodation

Ward B – Central Core typically ward accommodation

Ward C – North Wing typically ward accommodation

“West Wing” – typically ancillary or office accommodation as well as the only lift

core area.

Fire Precautions Upgrade Project

It is highlighted that a long term construction project to significantly improve fire

precautions within the Tower Block is currently ongoing. This includes the provision

of a new fire sprinkler system, reinstatement of fire partitions and improvements to

horizontal fire evacuation across all 8 floors. To minimise disruption, these

improvements are being undertaken through a series of 3 month decants and on a

ward by ward basis. To date, the currently unoccupied Ward 7A, has been

completed and this ward is being utilised as the main “decant ward” for the majority

of the subsequent works.



Level 7 (7C) Medical GI/Renal (30) Management (7A) Decant Ward

Level 6(6C) Cardiology/Step Down (?30) CCU (6)

AMAU/MSCU (30)

Level 5 (5C) Vasc/Urol Surgery (20) (14 closed) Derm (9)/Offices (5A) Medical (25)

Level 4 (4C) Surgical (29)SHDU (6 ) Seminar Room

and offices (4A) Surgical (29 + 5 T)

Level 3 (3C) Orthopaedics (28) Head & Neck(3A) Orthopaedics(30)

Level 2(2C) Oncology with D/C Transfusion

Therapy(2A) Stroke/YARU (22) (8)

Level 1 ITU (8)Critical Care Waiting area

1A (CAL 13) EDCU (6) SDCU (12)ITU (8)

Ground Endoscopy Paediatrics

In acknowledgement that the Wards in the Tower Block will be vacant during these

works, over the next 4 years or so, this presents a unique opportunity to undertake

the planned reconfiguration work, as described within this document, in parallel and

without further disruption to patients and clinical services.

Tower Block – Current Services

The current configuration of clinical services is best represented by a cross-section

through the Block, as illustrated below.

In conjunction with the above diagram, the following table provides an overview of

the clinical services provided by NHS Highland that are within the scope of this

project.

Current

Floor

Clinical Service Brief Summary of Services

7 Decant Ward Ward 7A was recently used for administration offices,

but was decanted to allow commencement and the

delivery of the “fire precautions” project. The ward can

be used temporarily during each phase of the works.

7 Management A suite of management offices is currently located at

Level 7B

7 Medical / GI / Renal Renal services including specialist services and renal

replacement therapy

6 AMAU Acute Medical Assessment Unit



6 MSCU Medical High Dependency Unit (this is a 4 bed HDU)

6 CCU Medical Critical Care Unit

6 Cardiology / Step

Down

Step-Down Unit provides intermediate nursing care

5 Acute Medical Elderly For elderly patients who have complex medical, socialand sometimes mental health issues.

5 Dermatology Inpatient unit for patients with severe skin conditions

5 Vascular/Urology

surgery

Urology - medical and surgical specialty

4 General Surgery Generic Surgical ward

4 SHDU 6 Bedded Surgical High Dependency Unit for criticallyunwell surgical patients , but who do not require I.C.Ucare

4 Surgical Main Surgical Ward

3 Orthopaedics Main Orthopaedic Ward

3 Head & Neck Ward for Patients required head and neck treatment /

surgery

2 Oncology Oncology ward for the treatment of cancer treatment

2 DC Transfusion Day Case Transfusion

2 Therapy General Therapy Unit

2 YARU The Young Adult Rehabilitation Unit

2 Stroke Main Stoke Ward

1 ITU Intensive Care Unit for patients with the most serious

injuries and illnesses requiring close monitoring and

support from specialist equipment

1 Critical Care Waiting

Area

Waiting area associated CCU (Medical and Surgical)

1 CAL Common Admissions Lounge

1 EDCU The eye day care unit is a dedicated treatment unit thatundertakes all eye surgery such as cataract removal

1 SDCU Surgical Day Case Unit

G Paediatrics Child Ward In-patient and Out Patient

G Endoscopy Endoscopy services

4.2.3 Critical Care – Existing Services and Analysis

4.2.3.1 Summary of Facilities

Section 4.2.3 summarises the current configuration of critical care at Raigmore

Hospital. As noted previously, Critical Care bed provision for Level 2 and Level 3

patients at Raigmore currently comprises 24 beds as follows.



ICU 8 bed

Level 1

The 8 bedded ICU is located on Floor 1, adjacent to Theatre.

Seven ICU beds are funded, to provide the traditional 1:1

nurse-patient ratio (BACCN 2009). Escalation above 8

patients impacts on Theatre, since these patients are

physically managed in Theatre Recovery with some

involvement of Theatre personnel. Medical management of

the ICU is provided by 5 Consultant Anaesthetists. There is

also a dedicated middle grade doctor facility during normal

hours, which continues out of hours but also includes

obstetrics. The ICU is fully equipped to include central

monitoring and modern ventilators. Adjacent to the Unit,

there is a waiting room plus a separate room where sensitive

communications with relatives can take place (as distinct

from a charge nurse’s or doctor’s office). Overnight

accommodation is also available adjacent to the Unit.

Surgical

HDU

6 bed

Level 4

The 6 bedded general surgical HDU is located on floor 4,

alongside but separate to surgical wards. It is staffed to

provide the recommended 1:2 nurse-patient ratio. Medical

management is provided by consultant surgeons who retain

responsibility for their own patients, but there is no

dedicated medical staffing for the Department. It is fully

equipped to include central monitoring. Isolation facilities

exist for 2 beds, albeit without en-suite facilities. However,

the main body of the HDU is cramped, which has implications

in terms of patient confidentiality and privacy.

Medical

HDU

4 bed

Level 6

The 4 bedded general Medical HDU is located on floor 6,

within the Acute Medical Admissions Unit (AMAU), and next

to CCU. It is staffed to provide a 1:2 nurse-patient ratio.

Medical management is provided by consultant physicians

who normally retain responsibility for their own patients. But

there is dedicated consultant physician involvement for one

session per week from a doctor with an interest in this

specialty. There is also a dedicated middle grade doctor

facility, sharing with CCU, during normal hours. The HDU is

fully equipped to include invasive but not central monitoring.

But this department is also cramped which, again, has

implications in terms of patient confidentiality and privacy.

CCU 6 bed

Level 6

The CCU is co-located with the AMAU, but also with the

Cardiac Step-Down Ward. The CCU is a 6 bedded

department, essentially a specialist HDU, providing a facility

for cardiac patients. Nurse staffing is similar to the 2 general

HDUs, with medical management being provided by



consultant cardiologists, and middle grade doctors as already

described. The CCU is fully equipped with central

monitoring. It also provides a telemetry facility for up to 6

cardiac patients outwith the CCU. The CCU is spacious and

purpose-designed. All of its rooms are single rooms, albeit

without en-suite facilities. This is the only Critical Care Unit

within NHS Highland that is compliant with guidance that at

least 50% of Critical Care Unit beds should be single rooms

to reduce the risk of healthcare associated infection (DoH

2003b).

4.2.3.2 Study – NHS Highland Review of HDU Needs / Critical Care Strategy

As noted in Section 3.2.4, NHS Highland undertook a study to review the provision

of, and need for adult High Dependency Unit (HDU) beds in NHS Highland but also to

make recommendations to the Health Board to inform the development of Critical

Care strategy within NHS Highland. This study covered adult in-patients in Raigmore

Hospital, Belford Hospital, Caithness General Hospital and Lorn & Islands Hospital. A

full copy of the study is available on request.

Data was produced to help describe the strengths and weaknesses of current Critical

Care provision in NHS Highland plus the challenges and opportunities for future

development. The study presented a comprehensive review and analysis of the

various issues associated with the provision of critical care at Raigmore Hospital,

including various recommendations with regard to improving practices and

efficiencies within the Hospital, some of which are being implemented without the

need for significant investment. However, the following key issues and problems

have been highlighted with specific regard to the need for more fundamental change

and investment.

Lack ofIntegratedCritical Carewith SingleNursing /Administrationservice

With regard to the provision of Critical Care, the historical

sequence of developments has been supported by the notion of

placing Critical Care services close to their various specialties.

Historically, the development of HDUs has been unplanned and

haphazard and largely relied on the interest of local clinicians to

drive development. Raigmore Hospital’s Critical Care service is

spread across 3 floors, 4 departments and 2 clinical directorates,

Medical and Surgical. The study confirms that this results in

increased nursing and administration costs, a lack of flexibility,

and a less patient focused service.

A major thrust of the 2 Health Department reports on Critical

Care (DoH 2000, SEHD 2000) is the need for flexibility in the

provision of service. Hugely significant is that both of these

Reports (DoH 2000, SEHD 2000) recommend that, wherever

possible, all Critical Care beds should be in adjacent locations:



‘Economies of scale and great benefits of flexibility can be

achieved by siting HDUs in or next to ICUs, with use of a

common nursing workforce. With such an arrangement, a bed

can be an HDU bed in the morning and an ICU bed in the

afternoon, or vice versa, depending on need’ (SEHD 2000).

‘Flexibility is the real key to coping with growing pressures,

especially peaks in demand’ (SEHD 2000).

Too High Levelof Occupancy

The data showed Raigmore Hospital having high occupancy, but

with much lower (but similar) occupancy in the 3 RGHs. The

high occupancy within Raigmore Hospital reflects that it is the

main provider of acute services in NHS Highland.

Lack of HDUand CCU Beds/ Too earlyDischarge

A frequently cited or recorded reason for patients that required aLevel 2 standard of care being in general wards was lack of HDUor CCU beds. A lack of available beds is directly related to levelsof occupancy. The occupancy level for the 2 HDUs and CCU, washigh. Several patients within general ward areas were assessedas requiring a Level 2 standard of care, having been dischargedtoo early from an HDU.

RespiratoryMedical WardOperating asHDU

Results reveal that 44% (12/27) of all ward-based medicalpatients assessed as requiring a Level 2 standard of care were inrespiratory medicine.

Too High aLevel of Care

Results from the Needs Assessment Audit for Raigmore Hospitalshow that 33% (29/87) of all patients in the 2 HDUs and CCUwere receiving too high a Level of Care.

Poor PatientFlow

Poor patient flow was identified. Ultimately, better management

of patient flow between areas will maximise opportunities for

critically ill patients to receive high quality care in an appropriate

setting.

InappropriateAdmissionPolicy

The study provides evidence to suggest that there is inequitable

critical care access for medical and surgical patients e.g. some

cases of medical care patients with a requirement for ward-based

Level 1 care, being placed in Medical HDU. Consequently there

will be other patients receiving too low a level of care due to lack

of critical care facilities.

Similarly there was evidence to suggest there was inappropriate

discharge policy for Surgical HDU. This was to relieve pressure

on nursing staff within the 2 step-down surgical wards by

delaying the transfer from Surgical HDU of recovering patients

who would require a high degree of Level 1 care.



Lack ofAvailableCritical CareBeds forCardiacPatients

During the data collection process, the Project Co-ordinatornoted that patients were admitted to wards with cardiacconditions that merited admission to CCU. However, atassessment these patients were no longer requiring a Level 2standard of care. This information is noted to again show theextent of need for Critical Care beds.

Lack ofIsolationFacilities

A model of care has existed over several years whereby Level 2general medical patients needing isolation facilities are admittedto CCU, even though these patients have no cardiac conditions.(A reciprocal arrangement allows for the admission of a cardiacpatient to the Medical HDU, should CCU be full in consequence ofhaving accepted a non-cardiac patient.). The Medical HDU, aspreviously described, has no single rooms. It is the only CriticalCare Unit in Raigmore Hospital that is unable to provide isolationfacilities to critically ill patients.

ITUdeficiencies

The design of the ICU has not altered in over 25 years sinceRaigmore Hospital was built. Some aspects of design arelagging. For example, the Unit has isolation facilities for just 2patients. In recent years, this has proved inadequate withinfectious patients also being managed in the 6 bedded bay area.This leads to the temporary closure of beds adjacent to theinfectious patients as part of measures to prevent cross-infection. Therefore, the out-moded design of the ICU impactson its ability to operate an efficient and cost-effective service.But there are other design faults with the ICU. For example, thevisitors’ entrance/exit to the Unit (that is, the public access)necessitates close proximity to the medical equipment andintravenous fluids store rooms. Whilst nursing staff willendeavour to escort family members to and from the Unit, thiscannot be guaranteed at times when staff are operating underextreme pressure. With regard to these issues of infectioncontrol, security and efficiency, there is clearly a requirement forthe design of the ICU to be up-graded.

Too High Levelof Care

Results from the HDU Needs Assessment Audit show that 7%(3/41) of patients in the ICU were receiving too high a Level ofCare. This, as will become evident, relates to structural deficitsnecessitating a Level 3 care requirement where the truerequirement would have been for Level 2 care.

Lack of HDUbeds

Within Raigmore Hospital, there is the need to address the

various factors that inflate demand for Critical Care beds – sub-

optimal bed management; sub-optimal care at ward level;

inappropriate admission and discharge policies; lack of CCU

‘ownership’ of cardiac triage; lack of isolation facilities in Medical

HDU and wards; uneven scheduling of surgical activity;

knowledge/skills deficit at Level 2 and lack of a co-located,

integrated Critical Care service with a single nursing and medical

administration. Therefore, additional investment in Critical Care

beds should be sequential to maximising the efficient and

effective use of existing Critical Care beds.



That said, the findings of this report also support that there isunder provision of HDU beds, especially Medical HDU beds,within Raigmore Hospital.

Lack of HDUBeds

This also relates to too high level of care being provided (in ICU)due to lack of HDU beds to facilitate discharge from the ICUnoting that the cost of beds in ICU is approximately double thatof HDU

Therefore, it may be reasonably asserted that there is a shortfallof 4 HDU beds, especially Medical beds, within RaigmoreHospital. But having regard to the significant cost implicationsand the discussion that has taken place concerning maximisingflexibility and economies of scale, this number could belegitimately reduced by a co-located, integrated Critical Careservice

ICU Beds Consideration must also be given to ICU bed provision. The veryhigh occupancy data for 7 staffed ICU beds (86% during thisstudy; 78% according to SICSAG (2009) data) support that anadditional ICU bed should be funded. But as with the earlierdiscussion, this should be sequential to addressing the factorsthat inflate demand for ICU beds – lack of HDU beds; inequity ofaccess to Medical HDU beds; lack of CPAP provision in SurgicalHDU; and lack of a co-located, integrated Critical Care servicewith a single nursing and medical administration. If these factorsare addressed successfully then the current ICU bed provision islikely to prove adequate

4.2.4 Raigmore Theatres – Existing Services and Analysis

4.2.4.1 Existing Provision

The existing main operating department at Raigmore, where all surgical activity

takes place, includes 9 x operating theatres and 1 modular operating theatre (as well

as the Maternity theatre located separately) all with associated anaesthetic rooms,

preparation areas and recovery spaces. In summary the theatres, and associated

facilities, are utilised as follows.

Theatre No. Clinical Activity

Theatre 1 Ophthalmic Surgery 4 days, Orthopaedic half day & ENT

half day

Theatre 2 (Mon - Fri 09.00 - 17.00) Gynae 3 days, Vascular 1 day

& Upper GI 1 day

(Mon - Fri 17.00 - 09.00 / Sat & Sun 24hrs) Emergency

Obstetric theatre

Theatre 3 5 days Ear Nose Throat

Theatre 4 Urology 4 days, Upper GI 1 day

Theatre 5 Upper GI 1 day, Breast 1 - 2 days, Vascular 1 day,

Paediatric 1half day

Theatre 6 Head & Neck 1 day, Colorectal 2 days, dental 1 day



Theatre 7 Orthopaedic elective 5 mornings, Orthopaedic trauma 5

afternoons, Orthopaedic emergencies

Theatre 8 Emergency theatre 24hrs/7days

Theatre 9 Orthopaedic Elective 5 days

Theatre 10

(Modular)

Gynae / Breast / Ortho Day Surgery

The Operating Department (Operating Theatres) caters for all surgical specialities,

scheduled, unscheduled, in-patient and day case procedures – resulting in a complex

and frequently inappropriate mix of patients in shared areas. The area provides

specialist facilities that enable surgeons to undertake surgical interventions

(procedures or operations) on patients whose medical condition requires the same.

It also provides accommodation for minimally invasive procedures conducted under

radiological control by either radiologists or surgeons.

Although the level of intervention will vary by patient, in general, within the

operating department, patients are received, reviewed, anaesthetised, operated

upon and recovered. The service provides for emergency and elective patients who

require surgical intervention and/or other procedures that require to be conducted

within an operating room environment and/or anaesthesia, with facilities that allow

functional groups to care for pre, intra and post-operative/anaesthesia patients in a

low risk environment.

4.2.4.2 Theatres – Condition and Physical Environment

Raigmore Hospital’s main operating theatre department has existed, along with the

Tower Block, for a period of around 30 years without any significant refurbishment.

During that period there have been significant improvements in theatre practice,

which whilst beneficial, has resulted in an increasing amount of necessary equipment

with a consequential demand for space. Furthermore, due to the lack of

refurbishment over this period, the existing fit-out and services infrastructure has

fallen well behind SHTM’s and other relevant standards. A summary of the various

issues is provided below.

4.2.4.3 Compliance with Modern Healthcare Standards

Due to the recent lack of refurbishment, the theatre accommodation currently fails to

meet modern healthcare standards in terms of level of fit-out and furnishings. The

existing installation also fails to meet full compliance in terms of compliant doors,

floors, ceiling finishes, lighting and the like. The physical condition of the premises is

of a standard that is representative of a building of approximately 30 years old. It

fails to meet modern healthcare standards in terms of functional requirements, space

needs, compliance with current clinical guidance and acoustic criteria.

The accommodation is cramped throughout and is characterised by inadequate

cluttered corridors, full of equipment and inadequate space such as the current

provision of a make-do reception, to allow a children’s waiting area to be provided.

All this compromises the provision of care for patients and similarly, staff working in

the building, are constantly frustrated by a lack of space and the poor functional



suitability of the buildings. Inevitably this impacts upon their ability to deliver

effective and efficient services.

4.2.4.4 Infection Control

Due to the lack of refurbishment over the years, the facilities have fallen well behind

in terms of compliance with current infection control standards, in terms of suitable

layout, finishes, materials and furnishings.

4.2.4.5 Fire Precautions

Due to the age of the building, the original fire strategy has become compromised

due to the gradual change of use but in particular the application of more recent

standards by HIFRS (Highland and Island Fire & Rescue Service). Furthermore it is

likely that building services developments within these premises have weakened the

integrity of the existing fabric, in terms of maintaining the original fire separation

strategy. Accordingly, NHS Highland acknowledge that there are a number of

improvements to the existing Theatres building, which may be necessary and

consideration needs to be given to the adequacy of the existing fire strategies.

In particular fire evacuation from the theatres is provided only via the existing

stairwells (with no lifts) whereby bed-ridden patients would only escape via an

evacuation facility, one at a time.

It is highlighted that without further action, NHS Highland anticipates that an

enforcement notice from the Fire Authority would be issued, with the ultimate

sanction of closure being applied.

4.2.4.6 Mechanical and Electrical Systems

There is a significant backlog in maintenance, and with plant and equipment at an

age which is beyond their design life, is inefficient in terms of its energy use and

carbon footprint. Condition reports suggest that existing mechanical and electrical

systems fail to comply with current codes and standards.

The Ventilation systems is not currently up to the standards as identified in SHTM-

03001 “Ventilation for Healthcare premises” where there is a need for increasing air

exchange rates to theatres.

Lighting currently fails to meet CIBSE Lighting guide 2, and the electrical wiring is

likely to date back to the original build and accordingly has reached the end of its

design life.

4.2.4.7 Theatres - Space Provision

The space standards to which the department was designed to when it was

constructed nearly 30 years ago falls significantly short of the area allowances in

current Scottish Health Planning Notes. The following table presents the existing

space provision against current standards. The tables below show the existing



accommodation for a typical theatre against those recommended in the current

SHBN Guidance.

Room HBN RecommendedArea

CurrentFloor Area

Operating Theatre 55.0sqm 36.75sqm

Anaesthetic Room 19.0sqm 15.55sqm

Scrub-up & Gowning(3places) 11.0sqm 7.5sqm

Preparation Room 12.0sqm 10.87sqm

Exit / Parking Bay 12.0sqm 11.68sqm

Store (Equipment) 1.0sqm -

Disposal Room 12.0sqm 5.2sqm

Total Net Floor Area 122.0sqm 80.05sqm

The space requirements reflect the increasing

number of developments in clinical care,

compliance issues and equipment available and

where existing space provision has been found

to be inadequate. The above demonstrates the

clear need for additional space within the

footprint of the theatres accommodation. One

of the key problem areas is the current lack of

storage for equipment both in terms of the lack

of a suitable central storage area as well space

within theatres for short term storage. In

recent years the various improvements in

theatre practice has seen an exponential

increase in equipment required. This has

resulted in the current status whereby all

corridors within the exiting Theatre department are cluttered with various equipment

(see adjacent photo).



5 Business Scope and Key Service Requirements

5.1 Key Drivers

As noted in section 3.2.3.4, NHS Highland is undertaking a comprehensive masterplan study

which will comprise detailed consideration of an optimal model of care and providing fit for

purpose facilities for the next 25 years. A future “Programme Initial Agreement” will be

developed to address these elements, including capacity and demand issues, and accordingly,

they are excluded from the investment proposed within this IA.

The following summarises the key drivers that should influence the way forward.

The aim to comply with the national and local drivers referred to in the Strategic

section including the Scottish Government and local drivers, refer Section to 3.

Alignment with the overall healthcare Masterplanning Exercise being undertaken

by NHS Highland associated with the Greater Inverness Area

Addressing the inefficiencies in the current model of care where critical care /

high dependency services are dispersed around the Block and not at their optimal

location

Alignment with the developing policies on critical care / high dependency – refer

to Section 3.2.4.

Delivering Theatre facilities that are commensurate with modern clinical

standards

The opportunity that the fire precautions project presents where essential

decanting of clinical areas, enables an unique opportunity for appropriate re-alignment of clinical services, avoiding further disruption to patients

5.2 Potential Business Scope

5.2.1 General

The business scope is essentially the design and development of facilities that meet the

Investment Objectives described in Section 4.1. However, in order to establish project

boundaries, a review was undertaken by key stakeholders, and the following items were

established in relation to the limitations of what the project is to deliver.

Where refurbishment takes place, facilities will be developed that are

commensurate with modern healthcare standards where this is viable but within

the constraints of the existing buildings.

Similarly, new facilities, as far as possible within the existing constraints, shall

seek to comply with all relevant Health literature and guidance including, but not

limited to, Scottish Health Technical Memorandum (SHTM), Scottish Health

Planning Notes (SHPN’s) and Health Briefing Notes (HBN’s).



The development of a design that gives high priority to minimising life cycle costs

The provision of clinical services associated with the development but limited to

that defined in Section 4.2

Within NHS Highland’s affordability criteria with respect to ongoing revenue

costs.

The development will not be designed in isolation, but should also consider the

potential for adjacent developments. This may include potential economies of

scale

Achieve good quality in design using robust materials that meets with the

general expectations of the various stakeholders. This will be measured by use

of the NHS “AEDET” system.

In conjunction with the Infection Control Team, develop a design that minimises

the risk of infection. To facilitate this, the design will be considered in

conjunction with the NHS “HAIScribe” system.

Comply with CEL 19 (2010) - A Policy on Design Quality for NHS Scotland - 2010

Revision which provides a revised statement of the Scottish Government Health

Directorates Policy on Design Quality for NHS Scotland. CEL 19 (2010) also

provides information on Design Assessment which is now incorporated into the

SGHD Business Case process.

Maximise the sustainability of the development, and meeting the mandatory

requirements under the BREEAM Healthcare assessment system.

The phasing of the project will also be in line with the ongoing Tower Block Fire

Precautions project which provides a timely opportunity for when Wards are to be

decanted in any case (this is being separately funded).

5.3 Resultant Service Requirements

Notwithstanding the identified Investment Objectives, the two principle aims are to consolidate

Critical Care at the optimal location in the tower Block and improve compliance aspects in

respect of the Theatres. As noted above, many of the existing clinical services will be ultimately

retained in their current location (albeit there will be interim moves, which are separately

funded under the “fire precautions” and “endoscopy” projects). The following summarises those

elements which could be included within this project investment.



Critical Care Related Elements

It is anticipated that some existing clinical departments will require to be

permanently relocated, in order that the new optimal adjacencies can be

achieved.

To achieve consolidation of critical care, it is assumed the scope of work will

include refurbishment of existing ward accommodation at ground and first floor

of the Tower Block commensurate with modern standards, and including

upgrading of services infrastructure as necessary.

The project may require the re-location of services from the Tower Block into

other existing Raigmore accommodation,

The project may require the development of some existing accommodation,

within the Tower Block on a temporary basis, to facilitate the moves and phasing

works

Theatres

Following review of the deficiencies associated with the current Theatre provision as

described within Section 4.2.4, including the compliance and environmental issues,

consideration should be given to the following in relation to the potential scope of the

investment.

Upgrading existing fire precautions, and improvements

There is a clear need for the retention and some refurbishment of the existing 9

theatres (not including the Maternity theatre). It is envisaged that the existing 9

Theatres on the first floor of the Tower Block will be retained in their current

location.

Consideration should be given reconfiguring accommodation, where possible, to

better locate storage and ancillary facilities. It is envisaged that some existing

departments, including storage accommodation, may be re-located

Upgrading of existing services infrastructure, where necessary to meet modern

standards. This is likely to include the provision of new ventilation plant, at roof

level, and distribution systems.

Provision of a service waste corridor to improve waste flows (avoiding “dirty /

clean crossovers”) and to facilitate minimising disruption during future

maintenance.



6 Benefits / Risks / Constraints and Dependencies

6.1 Benefits

The Key stakeholders have given further consideration to the Investment Objectives

(in Section 3.1) in order to establish the relative value of each objective, the key

benefits and beneficiaries, and the potential benefits criteria that may be used in the

analysis to establish the preferred way forward.

Following discussion and debate a wide range of issues were identified. These wererationalised under 7 key headings that were believed to summarise the benefitscriteria (measures) that each option should be assessed against. In summary, thesewere identified as the extent to which each option:

Benefits Criteria

1. Realised appropriate clinical adjacencies between departments

2. Realised appropriate clinical adjacencies within departments

3. Realised compliance with technical and space standards

4. Provided an optimal patient experience

5. Supported sustainable service delivery

6. Supported “strategic fit”

7. Optimised the quality of the overall physical environment

The following table summarises how the identified benefits are closely aligned with

the Investment Objectives.

Reference Investment Objectives Benefits

1 To improve businesseffectiveness and revenueefficiency

1. Clinical Adjacencies between departments

2. Clinical Adjacencies within Departments

3. Compliance with technical and SpaceStandards, as far as possible

6. Strategic Fit

7. Quality of Physical Environment

2 Improve HEAT and other Healthtargets including waiting timesfor theatres




5. Service Sustainability

3 Augment and expand range ofservices and promote emergingmodel of care including



6. Strategic Fit



consolidation of critical care

4 Make possible the introduction ofnew ways of working and inparticular effective collaborativeworking and flexibility in theworkforce



4. Patient Experience


6. Strategic Fit

5 Improved facilities / increasedcapacity offering a patientcentred service including greaterconsistency of care andincreased certainty foradmissions, procedures anddischarge



6. Strategic Fit


6 Concentrate higher and lowerlevels of care at appropriatelocations




6. Strategic Fit

7 Offer facilities which reduce riskof spread of infection comparedto status quo


6. Strategic Fit


8 To achieve optimal utilisation ofspace (within the constraints ofan existing building)



6. Strategic Fit

9 To achieve operational andfunctional efficiency of physicalenvironment




6. Strategic Fit

10 To deliver high quality facilities,and technical standards with astrong focus on lifetime costs,quality and design.



6. Strategic Fit


11 To comply with “A SustainableDevelopment Strategy for NHSScotland’, to enhance thecontribution of the health sectorto sustainable development


6. Strategic Fit

12 To enable the retention andrecruitment of staff



6. Strategic Fit




6.2 Main Risks

The key stakeholders have undertaken an initial Risk Workshop to establish the

principal risks associated with the proposed investment. This will be further

developed as part of the Outline Business Case. Whilst there will be many risks to

the project, the key stakeholders have considered what they perceive to be the main

risks which are considered to contribute collectively to the majority of the risk value

(approximately 80%). A summary of the key risks identified is provided below.

Business Risk

Greater Inverness Masterplan conclusions resulting in changes of scope

Changing local strategies (Raigmore) impact on the project

Demand for services higher than projected

Service Risk

Disruption to existing services during development or redevelopment

Stakeholders - contradictory aspirations

Changing statutory and NHS/HFS Guidance

“Scope Creeping” developments

Unclear strategy of Raigmore development

Capacity of Services and Infrastructure

Constraints of existing services and infrastructure

Uncertainty associated with existing building fabric

Live Acute Hospital Environment and Clinical Needs affecting delivery of project

NHS Highland and Scottish Government Approvals process

External / Environmental Risks

Statutory Approval Delays

Achievement of BREEAM Healthcare “Very Good” and complexity of scheme

(which element applies)

Financial Risk

Accuracy of Estimated Capital Cost

Revenue Cost Assumptions

VAT rules

Capital / Revenue distinction

Inflation



Insolvency

Dependency Projects (i.e. projects upon which this investment depends)

Viability of Phasing Proposals

6.3 Constraints

Financial

NHS Highland, in line with other Boards across Scotland is facing a very

challenging financial position. This will mean a very difficult balancing act

between achieving LDP targets whilst delivering substantial cash savings.

Programme

The programme is currently dependent upon the existing “Fire Precautions”

project which is underway.

Quality

Compliance with all current health guidance, where at all possible, within

the constraints of the existing accommodation

Sustainability

Where appropriate, Achievement of BREEAM “Very Good” in the case of

any refurbishment development

Existing Clinical Services

A fundamental constraint of the project will be the need to fully maintain

existing clinical services throughout the project period. As noted previously,

the ongoing fire precautions project presents an opportunity to minimise

disruption.

6.4 “Dependency Projects”

There are a number “dependency projects” upon which this investment may rely

upon but which funding is already in place or will be required from another source.

The precise details of these are, in some cases, unable to be fully established,

however the potential relevant projects are summarised as follows.

Fire Precautions - As noted a fire precautions project is underway and is being

separately funded

The re-location of the Children’s ward (from its current location at ground floor

level) to a location outwith the Tower Block is being considered by NHS

Highland/Archie Foundation. It is envisaged that this will involve a Children’s

Ward Out-Patients Department (OPD) development and the relocation of the

Children’s Ward In-Patient facility to Ward 11. Funding will mainly be sourced



via the Archie Foundation albeit with NHS funding required in respect of backlog

compliance issues.

A separately funded Endoscopy project is currently ongoing to provide a new

build Decontamination Unit and to re-locate the existing Endoscopy Unit to Ward

8. This will also require the amalgamation of Ward 8 into Ward 9.



7 Agreed Critical Success Factors

7.1 Stakeholder Review

In consideration of the Investment Objectives in Section 3 and the potential benefits

summarised in Section 5, the key stakeholders have undertaken a review of those

factors which it is considered essential to the scheme.

Notwithstanding the desire that all investment objectives and resulting benefits will

be achieved, the key stakeholders have identified the following limited list of Critical

Success Factors deemed essential to the project being considered successful.

1. The achievement of the project within the available financial parameters of

NHS Highland (revenue funding). See section 9 for further information on

Funding.

2. Consolidating high dependency units and critical care in order that clinical

and administration efficiencies are delivered,

3. Achieving the position where an increased percentage of patients have the

correct level of care provided at all times during their hospital stay

4. Establishing a position whereby Theatre capacity is at a more optimal level

with a reduced number of cancellations for scheduled surgery.

5. Compliance with all relevant Health Guidance (unless otherwise agreed as

being in-appropriate) including HAIScribe guidance to ensure facilities are

commensurate with current policy and reduce the risk of health related

infection spread

6. Avoid significant disruption to existing clinical services

7. Quality – Delivery of key stakeholders (including community representatives)

expectations is critical to the success of the project. “AEDET” reviews will be

undertaken and will achieve a minimum target score of 4/6 in all categories.

8. Sustainability. The achievement of BREEAM “Very Good” for refurbishment

development



8 Long List of Options and SWOT Analysis

8.1 General

NHS Highland has rigorously considered the SMART objectives, potential benefits and

the critical success factors previously summarised in this report. The approach

adopted for developing the options involved representatives from a range of groups,

including NHS Highland, in a series of workshops that.

Reviewed the national and global drivers for change in terms of health services

with a view to developing an understanding of the implications of these for

Health Service provision

Considered the overall objectives for the project and key success factors

Considered current procurement options available to NHS and the current

economic climate

Examined the current services and property provision at Raigmore

A summary of the key stakeholders involved in the consultation process is provided

in Section 3.1.5.

8.2 “Categories of Choice” (CoCA) Assessment to establish Long List ofOptions

Consideration has been given to a wide range of potential options in accordance with

the HM Treasury Green Book guidance. Options have been considered based on the

“SCIM” approach using the various “CoCA” assessment headings.

Appendix B presents the “CoCA” Table, developed to capture the previous views of

stakeholders on the potential options. Based on this CoCA Assessment, the options

noted in Appendix B as “discounted” were not considered further. The remainder

were developed into a long list of investment options, as follows. It was fully

recognised that there was potential for some options to be combined.

8.3 Summary of Long List of Options

Based on the assessment undertaken under Section 7.2, the following is the “Long

List of Options” that emerged. It was clear that a number of these options were not

“stand alone” (i.e. they could not address the requirement alone) but could be

“combined” with the principal options to deliver the preferred solution.



Long List of Options Ultimatelyshort-listed(and Option)

A Do Nothing Yes (1)

B Co-locate services within the Tower Block based on speciality – Medical and

Surgical

No

C Consolidate Critical Care Unit with CCU at Ground floor and Medical HDUand ITU / SHDU co-located at first floor and Endoscopy retained in TowerBlock (level 6)

Yes (2)

D Consolidate critical care with CCU & MHDU co-located at ground floor withITU & SHDU co-located at first floor and with Endoscopy moved outwithTower Block

Yes (2A)

E Similar to Option 2A but with MHDU/CCU situated at Ground floor at “A”block to facilitate intensive care adjacency, and the addition of Vascular Laband PACU

Yes (2B)

F New Combined Assessment Unit on ground floor and consolidate criticalcare with CCU & MHDU also co-located on ground floor with ITU & SHDU co-located at 1st floor

Yes (3)

G New Combined Assessment Unit on ground floor and consolidate criticalcare CCU/MHDU and ITU/SHDU) completely on 1st floor

Yes (3A)

H New Combined Assessment Unit on ground floor and consolidate criticalcare (CCU/MHDU and ITU/SHDU) in “A” block on ground and 1st floors

Yes (3B)

I Provide additional capacity of Medical High Dependency Units No

J Consider under utilised space in Maternity Unit (first floor) as locus forservices that need close proximity to theatres e.g. Ophthalmology /Endoscopy / Surgical Day Case

No

K Create additional capacity to dialyse patients on in-patient wards with maindialyses at level 7 (close to for plant configuration

Combine

L Addition of vascular lab to meet current standards for Vascular department Combine

M Addition of post anaesthetic care unit (PACU) adjacent to intensive care unit Combine

N Move non-acute services out of the Tower Block, where adjacency is notrequired (e.g. Endoscopy, Child Ward), and to suitable existingaccommodation

Combine

O Re-locating female surgery wards (away from male wards) and intoseparate unit (outwith Ward Block) – into Ward 8

No

P Consider re-locating selected acute services at Raigmore back into theTower (e.g. Respiratory) that provide improved adjacency to GeneralMedicine

Combine



Q Upgrade existing Theatre accommodation commensurate with modernstandards

Combine

R Eye Day Case Unit – relocation to current location of renal unit Combine

The above scoping / service solutions options would be amalgamated with the

following “implementation” and “funding” options:

Implementation Options

Phase services in – extensions and refurbishment of existing premises

Funding Options

Phased Capital funding based on traditional procurement

8.4 SWOT Analysis

Key stakeholders subsequently undertook a SWOT analysis of the long list of options

to establish a shortlist of options to be taken forward for more detailed assessment

at Outline Business Case Stage. The options selected are a combination of the

scoping service solution, implementation and funding options noted above.

A summary of the results is provided in Appendix C. In summary 6 key high level

options have been established (in addition to a “Do Minimum” option). Due to their

complexity they are represented by the following table.



DoMinimum

Option 2 – Consolidate Critical Care Option 3 – Consolidate CriticalCare + Combined Assessment

Unit

1 2 2A 2B 3 3A 3B

The Currentconfigurationbut assume

- fireprecautionsworks(ongoing)

- endoscopydevelopmentbut atground floorof Tower

- Upgradingof CCU,AMAU/MSCU,SHDU,Therapy,ITU, CriticalCareWaiting,1A(CAL,EDCU,SDCU, ITU -- All to beretained attheircurrentlocation

Consolidation of Critical Care on Groundand First Floor Levels –based on acuity

Consolidation of Critical Care onGround and First Floor Levels – based

on acuity. Plus CombinedAssessment Unit

Co-locate AMAU and CCU on groundfloor

Combined Medical Assessment Uniton ground floor

Cardiology also co-locatedon ground floor

Cardiology remains on Level 6

Co-locate ITU/SDHU on first floor

MHDU atFirst Floor

MHDU at Ground Floor Co-locateCCU andMHDU atGroundFloor

Co-locateCCU andMHDU at1st Floor

Co-locateCCU andMHDU/Shortstay beds atGround Floor

No PACU PostAnaesthetic

Care atLevel 1


Care at Level1

1A (CAL /Surgical DC /Eye Day Careto Ward 8

CAL / Surgical Day Caseto Level 1

CAL /SurgicalDay Caseto FirstFloor

CAL /SurgicalDay CasetoGroundlevel

CAL /Surgical DayCase to FirstFloor

Surgical Triage to remain at Level 4 Surgical Triage relocated to GroundLevel

Potential to move Renal Dialysis moved to Level 7 – separate Investment

Respiratory moved into Tower – Level 6

Medical Ward adjacent to Therapy

Oncology moved to Level 5

Child Ward moved out of Block (Ward 11)

Endoscopy atLevel 6

Endoscopy re-locate to Ward 8 (funded secured)

Gynae/Breast(Ward 8)into Tower -Level 5

Gynae/Breast (Ward 8) to amalgamate to Ward 9(funded secured)

- Vascular Laboratoryadded at 5C

- VascularLaboratoryadded at 5C

Potential to provide Eye Day Case into the accommodation formally occupiedby Renal (separate investment). However, this investment only to include

limited allowance for Eye Day Case, currently in 1A



1 2 2A 2B 3 3A 3B

Theatres Refurbishment

In conjunction with the planned significant upgrading works (refer below) the

continued use of the existing 9 theatres located within the Tower Block

To improve compliance, building fabric and services upgrading of the existing 9

theatres, to meet modern clinical standards (the Theatre within the Maternity

Block is outwith the scope of this project)

Upgraded fire precautions of Theatres in Tower Block to meet horizontal fire

evacuation requirements

Services upgrade associated with achieving compliance, include ventilation

system enhancement

Where possible, potential increase in storage requirements (possible expansion

adjacent to plant room) to facilitate improved compliance with required storage

and other space standards

Provision of services / waste corridor to rear of the Theatres accommodation

Child Ward

Retain incurrentlocation

The Child Ward will involve the redevelopment of Ward 11 to facilitate

the move. A limited allocation of funding is being considered in

respect of any outstanding need to deal with the current backlog

compliance issues.

Respiratory


The project will require the development of a temporary facility at

Ground Floor level involving some works. (This will require

occupation of some Children’s Ward accommodation, on a temporary

basis).

Furthermore, Level 6 will require some reconfiguration to facilitate the

permanent move to Level 6



9 Economic Case to Arrive at Preferred Way Forward

9.1 General

This section summarises the option appraisal undertaken to arrive at the preferred

way forward in consideration of the costs, benefits and project risks of each of the

shortlisted options.

All current guidance has been followed in undertaking the option appraisal,

principally the Scottish Capital Investment Manual (SCIM), the HM Treasury Green

Book and supplementary guidance.

9.2 Qualitative Option Appraisal

9.2.1 Introduction

A non-financial option appraisal exercise was conducted with a range of key

stakeholders over 3 sessions during September and October 2012. These sessions

were facilitated by independent Healthcare Planners and included representatives

from a range of stakeholders. A copy of the full option appraisal report is available

upon request. The document summarises the process followed, along with an

analysis of the numerical outputs. The following sections summarises the key

aspects of the report.

9.2.2 Process Employed

The process employed was agreed with participants at the outset. It involved a

stakeholder group working through a series of questions with the objective of

applying a consistent and rational approach to the challenge of identifying the best

solution to meet the requirement. It was emphasised that the qualitative stage of

the option appraisal was based on non-financial qualitative criteria and that further

financial analysis of the preferred options identified would be conducted as a

subsequent component of the business case development.

9.2.3 Benefits Criteria and Weighting

As noted in Section 5, and following extensive discussion and debate a wide range of

issues were identified. These were rationalised under 7 key headings that were

believed to summarise the benefits criteria (measures) that each option should be

assessed against. These benefits criteria have already been highlighted in section

5.1. To support the process, of applying a relative “weighting” (priority) to each of

the criteria identified, a comparative matrix was used to aid the initial relative

prioritisation of benefits criteria.

To determine the actual weightings to be applied, stakeholder groups were asked to

allocate “100 points” appropriately between identified benefits criteria based on their

opinion of the relative importance of each. Scores were fed back by benefit criteria

and group in the first instance. Having agreed the relative weighted benefits criteria

of each stakeholder group, discussions took place to rationalise separate



“weightings” into a single agreed factor that would be applied to each identified

option in the formal scoring process. The groups reached agreement over the

overall agreed weighting through consideration of the mean, median and modal

weightings, as follows.

Having agreed the benefits criteria, relative weighting and options to be assessed,

the group progressed with the formal process of applying a score to each criteria in

the context of each option. This was supported through an extensive process of

facilitated debate with the consensus agreement of all participants realised regarding

the relative merits of each option and scores to be applied.

9.2.4 Summary of Qualitative Results

The following table present a summary of the scoring of each of the 7 options (as

defined in Section 7.4).

Option Weighted Benefits Score

No. DescriptionConsensusOptimisticPessimistic

Rank

1 Do Minimum (Retain Current Configuration) 358 6

2

Consolidate Critical Care Unit with CCU atGround floor and Medical HDU and ITU /SHDU co-located at first floor and Endoscopyretained in Tower Block (level 6)

349 7

2A

Consolidate critical care with CCU & MHDU co-located at ground floor with ITU & SHDU co-located at first floor, and the addition of PACUand vascular lab, with Endoscopy moved out

622 1

2B

Similar to Option 2A but with MHDU/CCUsituated at Ground floor at “A” block tofacilitate intensive care adjacency, and noprovision of PACU

568 2

3

New Combined Assessment Unit on groundfloor and consolidate critical care with CCU &MHDU also co-located on ground floor withITU & SHDU co-located at 1st floor

511 4

3ANew Combined Assessment Unit on groundfloor and consolidate critical care CCU/MHDUand ITU/SHDU) completely on 1st floor

501 5


Inital Agreement D57

3B

New Combined Assessment Unit on groundfloor and consolidate critical care (CCU/MHDUand ITU/SHDU) in “A” block on ground and 1st

floors, with the provision of PACU andvascular lab.

532 3

Overall, the non-financial option appraisal process identified that the preferred non-

financial option was option 2A with 622 points, followed by option 2B with 568

points. These 2 options represented the “leading group” with options 3B (532

points), 3 (511 points) and 3A (501 points) in 3rd, 4th and 5th place respectively.

The least favoured options by some margin are Option 1 (Do Minimum) and Option

2, with Option 2 scoring less than option 1 in some scenarios.

9.3 Economic Appraisal

9.3.1 General

This section presents the economic implications of the investment (both capital and

revenue) and also provides the economic appraisal of the short-listed options. The

outputs from the cost models identified in this section form the basis of both the

financial and economic appraisals of the short-listed options. Each of the short-listed

options has been costed with due consideration of the changes associated with each

option and any changes in cost have been clearly identified and explained. The

following categories of cost have been considered for each option.

9.3.2 Capital

The capital costs have been considered an

of each option that has been identified by

These capital costs have been calculated u

The following summarises the main capital

Costs have been calculated at January 2

Baseline costs for – Pay (workforce) Non Pay (associated with staff) Estates/Utilities (associated with

the existing building) Income Capital Charges (depreciation)

Short-listed OptionsOption 1 - £’sOption 2 - £’sOption 3 - £’s

Costs for each option – Pay (workforce) Non Pay (associated with staff) Estates/Utilities (associated with

the new building) Income Capital Charges (depreciation) Phasing of costs

ocument

d prepared using the capital requirement

the external professional cost advisors.

sing the brief and plans for each option.

assumptions.

013 (Q1 2013) prices



Capital costs have been prepared using Healthcare Premises Cost Guides

(HPCG’s) adjusted to reflect the type and nature of the works

Include building, infrastructure and service costs

Includes equipment within the estimates for group 1 & fitting of equipment in

group 2 but it has been assumed that most equipment will transfer with the staff

moving around the building

Includes estimates for all fees – Design team 10%, Professional fees 5%, Board

fees of 2.5% and an allowance for statutory fees.

Quantifiable risk contingency of 5% and Optimism Bias included

VAT has been added to the total capital cost but there may be an element that is

recoverable on certain items of refurbishment

VAT recovery is excluded from the costs with the exception of design fees which

assume 100% recovery

Having applied the costing assumptions and methodologies to the options, the

capital expenditure, was estimated firstly excluding Optimism Bias. An Optimism

Bias workshop was then convened to calculate optimism bias using the HM Treasury

guidance. The mitigated level of bias for each option was then applied to the initial

capital figures.

Details of the development of the capital costs for each option can be made available

upon request, including the procedure undertaken to calculate the optimum bias

upper levels and the mitigation levels in light of specific factors associated with this

project. In summary, and following adjusted capital costs, estimates (including VAT)

were established for each option as follows.

Capital Costs including Optimism Bias - £000’sOption 1

– DoMinimum

£000’s

Option 2

£000’s

Option2A

£000’s

Option2B

£000’s

Option 3

£000’s

Option3A

£000’s

Option3B

£000’sOriginalcapitalcosts

13,958.8 17,734.5 16,851.1 17,445.9 17,135.5 17,056.1 17,973.5

OptimismBias

2,439.2(18%)

3,381.1(19.6%)

2,645.1(16.2%)

2,999.3(17.7%)

3,074.0(18.5%)

3,059.8(18.5%)

3,224.4(18.5%)

RevisedCapitalcosts incloptimismbias

16,398.0 21,115.6 19,496.2 20,445.2 20,209.5 20,115.9 21,197.9



It is highlighted, that in order to further compare costs, and establish a baseline, an

“Option 0” (Do Nothing) was created. This had a capital cost of £1,400k.

With the exception of the ‘do nothing’ option, the lowest level of mitigated optimism

bias is associated with Option 2A, at 16.2% - this is because this option has full

clinical sign-up and agreement through the Project Board.

9.3.3 Revenue Costs (Recurrent and Non-recurrent)

9.3.3.1 General

This section identifies the recurrent and non-recurrent revenue costs associated with

each of the short-listed options. A baseline cost for the current service has been

calculated and used as a benchmark against which any changes could be considered

This is the revenue cost associated with ‘do minimum’ in Option 1. The assumptions

used in the models for revenue costs for each of the options are shown below

Costs have been calculated at 2012 prices and using 2012/13 budgets

Where relevant, whole time equivalents have been considered for staffing

Pay costs are inclusive of employer on-costs and allowances for leave.

VAT is included where appropriate

Non pay costs are based on the current cost per bed for consumables

Utility costs and non domestic rates have been excluded from all options as there

is no change to the total floor area involved and therefore no increase/decrease

in costs is expected

Capital charges are based on the capital cost inclusive of the optimism bias

calculations

There are no income streams associated with the options

9.3.3.2 Recurrent Revenue

Full details of the recurrent revenue costs are available on request. This captures

capital charges, recurrent pay costs, recurrent non-pay costs, recurrent property

costs, and recurrent property income, where applicable.

Including all of the various streams of revenue costs, the overall recurring revenue

impact of the options is shown below.



Summary of Recurrent Revenue Impact - £000’sOption 1 – Do

Minimum£000’s

Option2

£000’s

Option2A

£000’s

Option2B

£000’s

Option3

£000’s

Option3A

£000’s

Option3B

£000’sCapitalCharges

627.9 733.0 696.9 718.1 712.8 710.7 734.8

Pay costs 0 (15.6) (15.6) (15.6) (15.6) (15.6) (15.6)Non pay costs 0 0 0 0 0 0 0Property costs 0 0 0 0 0 0 0Grossrecurrentcosts

627.9 717.4 681.3 702.5 697.2 695.1 719.2

Income 0 0 0 0 0 0 0

Net recurrentcosts

627.9 717.4 681.3 702.5 697.2 695.1 719.2

The costs shown in the above table relate to the first full year of operating. After

excluding the ‘Do minimum’ option, Option 2A has the lowest net revenue cost of

£681k for capital charges and a saving of £16k for pay.

9.3.3.3 Non-Recurrent Revenue

A number of non-recurrent (transitional) revenue costs have been identified to allow

the options to go ahead. At this Initial Agreement stage, exact costs have not been

produced although the following table identifies the best estimates available at this

time. These costs will be incurred at the time of each of the Departments moving to

their new locations, or just prior to this in terms of minor equipment requirements.

One area that will require to be considered in greater detail at OBC stage is the

Theatres where there may be the potential for non recurrent revenue costs during

construction in providing alternative Theatre space/time to allow two Theatres to be

upgraded at a time. However at this stage it is envisaged that the works can be

done through a combination of extended shift work and use of the Angio-Cath

theatre.

Summary of Non-Recurrent Revenue Impact - £000’s

Option 1 –Do Minimum

£000’s

Option2

£000’s

Option2A

£000’s

Option2B

£000’s

Option3

£000’s

Option3A

£000’s

Option3B

£000’sStaff costs – toenable moves 0 15.2 15.2 15.2 14.8 14.8 14.8CombinedAssessment Unit –equipment 0 0 0 0 0 0 0Total non-recurrent costs 0 15.2 15.2 15.2 14.8 14.8 14.8



9.3.4 Net Present Costs

A discounted cash flow for each of the seven options has been undertaken over 40

years using a discount rate of 3.5% for years 1 to 29 and 3.0% for years 30 onwards

in line with the guidance within the HM Treasury green book and from SGHD. The

Net Present Value (NPV) and Equivalent Annual Cost (EAC) have been calculated for

each option. The EAC is used as a comparison of options where there are different

life spans as the output is an annual figure which is easily compared. The elements

considered in the analysis are summarised below.

Initial capital expenditure for each option – exclusive of VAT but adjusted for

optimism bias

Any relevant lifecycle costs for building and engineering works

Any relevant equipment lifecycle costs

Total revenue costs for each option excluding capital charges

Income

Non-recurring revenue costs

The key assumptions used within the economic appraisal include:

The base year for the economic appraisal is the financial year 2012/2013

Economic appraisal period is over 40 years

Capital expenditure will be made over a maximum of five years from 2013/14 to

2017/18

Optimism bias has been included in the capital expenditure figures

All non-recurrent costs are assumed to be incurred in Yr 3 as they are required at

the time of the move to the new location for the Departments concerned

The results of the economic appraisal for the options are shown below.NPV and EAC

outcomes - £000’s

Option 1 –Do

Minimum£000’s

Option2

£000’s

Option2A

£000’s

Option2B

£000’s

Option3

£000’s

Option3A

£000’s

Option3B

£000’sNet PresentValue (NPV) 18,013.8 22,687.1 20,976.5 21,941.4 21,530.3 21,344.7 22,641.4EquivalentAnnual Cost(EAC)

736.6 927.8 857.8 897.3 880.4 872.9 925.9

Ranking 1 7 2 5 4 3 6



It is highlighted that in order to further compare costs, and establish a baseline, an

“Option 0” (Do Nothing) was created. This had a capital cost and net present value

of £1,400k and £11,814k, respectively. However this option is not viable because

the various compliance issues would not be addressed. In particular this option

would result in a fire precautions enforcement notice being issued, ultimately

resulting in closure.

The analysis of the net present values (NPV) indicates Option 1 (Do minimum) has

the lowest life time costs with Option 2A being the next favoured option. It should

be noted that the outcome EAC for Option 2B of 897.3 which is only £40k pa

different from the first ranked Option 2A.

9.3.5 Summary of Economic Appraisal

The ‘Do minimum’ option 1 has the lowest capital requirement, recurrent and non

recurrent revenue impact and also the second lowest lifetime costs.

The second lowest recurrent revenue impact comes with Option 2A. This also has

the second lowest lifetime costs from the NPV and EAC calculations. The revenue

associated with Option 2A is an increase of £681k from current budgets – this

includes an increase of capital charges (depreciation) of £697k pa and a saving in

revenue pay of £16k pa.

Non recurrent costs are similar across all options with a range of £14,789 for Options

2, 2A and 2B to £15,210 for Options 3, 3A and 3B. This non-recurrent budget would

need to be funded at the time that the Department moves to a new location as it is

predominantly for minor equipment and staff to facilitate the move. The Outline

Business Case will give consideration to potentially significant non-recurrent costs

still to be added for Theatres. (However these are common to all the IA options).

9.4 Overall Value for Money

Value for money (VfM) is defined as the optimum solution when comparing qualitative benefits

to costs. An analysis (below) has been performed on an economic annual costs basis in line

with HM Treasury guidance. The VfM analysis compares the cost per benefit point of the

options. The option that is preferable is the option that demonstrates the lowest cost per

benefit point. The cost per benefit point is listed in the end column – VfM Economic Ranking.

No Option QualitativeBenefitsScore2

QualityRank

NetPresentCost(£k)

NPCRank

Cost/Benefitpoint(£k)

VfMEconomicRanking

1

Do Minimum(Retain CurrentConfiguration)

358 6 18,013.8 1 50.3 6



2

Consolidate CriticalCare Unit with CCUat Ground floor andMedical HDU andITU / SHDU co-located at firstfloor andEndoscopy retainedin Tower Block(level 6)

349 7 22,687.1 7 65.0 7

2A

Consolidate criticalcare with CCU &MHDU co-locatedat ground floorwith ITU & SHDUco-located at firstfloor, and theaddition of PACUand vascular lab,with Endoscopymoved out

622 1 20,976.5 2 33.7 1

2B

Similar to Option2A but withMHDU/CCUsituated at Groundfloor at “A” blockto facilitateintensive careadjacency, and noprovision of PACU

568 2 21,941.4 5 38.6 2

3

New CombinedAssessment Uniton ground floorand consolidatecritical care withCCU & MHDU alsoco-located onground floor withITU & SHDU co-located at 1st floor

511 4 21,530.3 4 42.1 3

3A

New CombinedAssessment Uniton ground floorand consolidatecritical careCCU/MHDU andITU/SHDU)completely on 1st

floor

501 5 21,344.7 3 42.6 4

3B

New CombinedAssessment Uniton ground floorand consolidatecritical care(CCU/MHDU andITU/SHDU) in “A”block on groundand 1st floors, withthe provision ofPACU and vascularlab.

532 3 22,641.4 6 42.6 4



The following conclusions are drawn from the value for money analysis.

Option 2A represents the best value option on the basis that it achieves the lowestcost per benefit point of all these options. This option delivers best value in termsof non-financial benefits and the actual appraisal costs.

Option 2A also achieves the highest qualitative benefits score of all the optionsbased on the “consensus”, “optimistic” and “pessimistic scores” identified duringthe appraisal workshops. Furthermore Option 2A is the highest ranking (excludingOption 1) in terms of lowest Net Present Cost although the difference from the2nd highest ranking option being only 2.6%.

It is further highlighted that whilst Option 2A does not, in itself, include a"Combined Medical & Surgical Common Admissions Unit”, this option does notpreclude such a development at a future date, subject to the Greater InvernessMasterplan review.

Based on the above analysis Option 2A, is identified as the preferred way forward

9.5 Sensitivity Analysis

A Sensitivity Analysis is defined as the effects on an appraisal/ option of varying the

programmed values of important/ selected variables. A Business Case is built upon

estimates which can lead to inaccuracies. The preparation of a Sensitivity Analysis

will help assess whether the Initial Agreement is heavily dependent on a particular

cost or benefit.

9.5.1 Sensitivity Analysis (Weighted Benefits Score)

In order to explore the potential impact of a range of variances on the qualitative

option appraisal process, a limited sampling-based sensitivity analysis was

conducted. This attempted to understand the main effects of varying key values on

the relative prioritisation and scoring of options. The sensitivity analysis broadly fell

into 2 categories:

The general impact of including/excluding some/all identified stakeholder groups

from the weighting/scoring process

The specific impact of excluding “patient experience” as a benefits criteria based

upon discussions held and referenced previously

The detailed Option Appraisal, available upon request, summarises the sensitivity

analysis undertaken. In summary the various sensitivity scenarios resulted in no

change in the order of the options, other than the lower ranked options, in a few

cases.

9.5.2 Sensitivity Analysis (Weighted Benefits Score and Costs)

Notwithstanding the sensitivity analysis undertaken on the qualitative assessment as

described above, a sensitivity analysis has also been carried out on the preferred

option, Option 2A to assess the extent to which the weighted benefits score and the



costs (both revenue and capital) would have to increase before this option would no

longer be the preferred economic choice. The results are shown in the table below.

Table 20: Sensitivity Analysis

Interpretation of the sensitivity analysis shows that there would have to be a

significant movement in either WBS, capital or revenue costs relative to the total

project cost to make the next option (2B) become the preferred option.

Sensitivity % increase Outcome

Option 2B - IncreaseWeighted Benefits Score(WBS) by

14.5% Option 2B wouldbecome preferred option

Option 2A – Increase NetPresent Cost by

14.5% Option 2B wouldbecome preferred option



10 Affordability Review

10.1 Introduction

Option 2A has been identified as the preferred option as it meets the all of the

overall benefits, affordability and economic tests to produce the best ‘Value for

Money’ solution. The preferred option 2A does not require any additional recurrent

funding and will, in fact, produce savings as a result of the economies of similar

departments being co-located and as a result the project is affordable from within

the Board’s current Revenue Resource Limit.

The overall NHS budget for the Critical Care Consolidation and Theatres

Development is in line with the proposed costs previously stated in section 9 of this

Initial Agreement for the preferred option, Option 2A and comprising.

Consolidate critical care with CCU & MHDU co-located at ground floor

with ITU & SHDU co-located at first floor and with Endoscopy moved

outwith Tower Block

Development of the Theatres at first floor

Option 2A meets the overall benefits, affordability and economic tests to produce the

best Value for Money solution.

Detailed costs showing the financial build up for each of the short listed Options and

the Optimism Bias calculations for each are available on request.

10.2 Summary of Capital and Revenue Costs

For 2013/2014, NHS Highland has an estimated Revenue Resource Limit of £510m

and an overall budget of £699m. The Capital Resource Limit for 2013/2014 is £17m.

As stated in the local delivery plan (LDP), for 2013/14 NHS Highland is expected to

achieve all of its financial targets

A summary of the capital costs and revenue cost, for the preferred option, Option

2A, is provided below.

Option 2A

£000’s

Capital Costs 19,496.2

Recurrent Revenue Impact 696.9

Non-Recurrent RevenueImpact 15.2



10.3 Funding Model

The preferred option would be funded from an additional specific capital allocation

from SGHD of £19.5m with the additional revenue costs funded from within the NHS

Highland’s overall revenue budget.

10.4 Impact on Balance Sheet

The Capital Cost of the development will appear on the Board’s Balance Sheet as a

Fixed Asset and will be depreciated over the life time of the asset.

10.5 Impact on Statement of Comprehensive Net Expenditure

For the preferred option of 2A, the additional recurrent revenue cost to be charged

against the Health Board’s statement of operating costs is estimated at a net figure

of £681k. This total is made up of £697k for capital charges (depreciation) less £15k

of savings as a result of the co-location of Departments

10.6 Phasing of Funding

In terms of capital outlay, the following table gives an indication of potential outlay

based on a 5 year phasing period.

Year Cost inc VAT VAT Cost exc VAT

April 2013 – 2014 974,812 - 974,812April 2014 – 2015 3,899,249 649875 3,249,374April 2015 – 2016 5,848,874 919,812 4,929,061April 2016 – 2017 5,848,874 932,826 4,916,047April 2017 – 2018 2,924,437 475,940 2,448,497Total 19,496,246 2,978,454 16,517,792



Level C B A

7Medical

GI/RenalManagement Renal Dialysis

6 Respiratory RespiratoryOncology with

Day Case Trans

5Vasc/Urology

Surgery/Vasc Lab

Dermatology

Offices

EMPTY - to be

used for winter

pressures and flexi

beds for

indcidences of

Infection etc

4 Surgical Seminar Room Surgical/Triage

3 Orthopaedics Head & Neck Orthopaedics

2 Medical Therapy Unit Stroke/YARU

1 CAL/SDCU Waiting Area ITU/SHDU/PACU

GroundCardiology step-

downCCU AMAU/MHDU

OPTION 2A

11 Recommended Preferred Way Forward

11.1 Summary of Option 2A

The best value high level option that has emerged from the process is Option 2A.

This represents the “Preferred Way forward” and will be required to be the subject of

more detailed analysis at Outline Business Case. This preferred way forward is

summarised as follows.

Option 2A

Preferred Way

Forward

Consolidate critical care with CCU & MHDU co-located at ground floor with

ITU & SHDU co-located at first floor, and the addition of PACU and

vascular lab, with Endoscopy moved out

Development of the existing Theatres to address various compliance

issues including ventilation standards, fire precautions, space

deficiencies and backlog maintenance

It is highlighted that whilst Option 2A does not, in itself, include a "Combined Medical

& Surgical Common Admissions Unit”, this option does not preclude such a

development at a future date, subject to further consultation if deemed appropriate.

11.2 Proposed Configuration of Tower Block

The configuration

of the Tower Block

as proposed under

the preferred way

forward is

illustrated as

follows (and

included as

Appendix D).



11.3 OBC Optioneering and Scope of Works

Given the complexity of the project, it is recognised that Option 2A only represents

the “preferred way forward”. The potential high level scope of works, based on the

preferred way forward (Option 2A) is provided within Appendix F. Clearly this will

require further development during the outline business case process.

Option 2A is considered as the “preferred way forward” and it is anticipated that the

Outline Business Case will develop options around this preferred way forward. In

recognition of the high complexity of this proposed reconfiguration project, detailed

healthcare planning of the Tower Block will be required and this will establish sub-

options of Option 2A which will be reviewed and compared, at Outline Business Case

stage.

11.4 Greater Inverness Masterplan Review

As noted previously, the proposals contained within this Initial Agreement are

compatible with the Greater Inverness Masterplan study review. The proposed

investment will not only address the immediate deficiencies described, but also build

a platform for the anticipated subsequent initiatives which will be identified to allow a

future optimal healthcare model to emerge.

The Greater Masterplan review will to lead to development of a “Programme Initial

Agreement” whereby it will build on the work proposed under this IA, and review all

additional factors, relating to the optimal model for delivery of “fit for purpose”

healthcare facilities, suitable for the next 25 years.

11.5 Commercial Review

A number of procurement options could be utilised, and these were initially

considered by NHS Highland, as referred to in the “Category of Choice” appraisal and

SWOT analysis, in Section 7. However, based on the nature of the development, and

in consultation with Scottish Government it is most likely that the project will be

most suitable, for a capital funded project, phased over a number of years, and

using the HFS “Frameworks Scotland 2” contract, and using the New Engineering and

Construction Contract (NEC 3 - Option A, C or E). Key features of the contract are:

The parties are encouraged to work together as partners in an open and

transparent approach and to ensure that this partnering ethos is maintained

There is a ‘Gain/Pain share’ mechanism to act as an incentive to the delivery

team, by rewarding good performance and penalising poor performance

A clear and transparent system is ‘on the table’ to enable negotiation to take

place on prices

A level of ‘price certainty’ is determined



All price thresholds are set using quantitative risk analysis

It is a variant of Maximum Price/Target Cost (MPTC) approach

A key principle of the NEC3 Option C contract is the payment of ‘Defined Cost’ and

an open book accounting philosophy. These require a robust, reliable and

transparent system to record staff time and manage the invoicing process.

Payments are made to the PSCP as per agreed Valuation Certificates. Costs are held

as Assets under Construction until the asset becomes operational at which point the

costs are transferred to completed assets and become subject to depreciation.

The Outline Business Case will review in more detail the proposed commercial

arrangements for delivering the proposed investment, including any analysis of key

commercial arrangements, accounting approach, commercial risk approach,

contractor’s share percentage and range, priced activity schedule review and defined

cost arrangements.

11.6 Indicative Programme and Phasing Plan

As noted earlier in this IA, the timing of proposed investment would be aligned with

the “Fire Precautions” project to exploit the unique opportunity that is presented

whereby all the wards and associated accommodation in the Tower Block will be

vacated in a phased manner, and ward by ward basis. This will therefore minimise

disruption to existing healthcare services. The phasing plan in Appendix E illustrates

the potential indicative timing of the planned works and how this fits into the other

projects at Raigmore.

As described in Section 11.6, it is envisaged that the works would be undertaken

during a 5 year period. The approximate timing to achieve an early start on site

date would be as follows.

IA CIG Meeting Date 2nd July 2013

OBC Stage / Approvals January 2014

Design and Target Price

Full Business Case development

September 2014

Full Business Case Approvals December 2014

Construction Start (Initial Phases)- based on

Frameworks Scotland

January 2015



A APPENDIX – SMART OBJECTIVES

Critical Care Consolidation and Theatres Refurbishment (with necessary realignment of Acute Services)


SMART Objective Heading Objective Details Baseline Data Source Timing

To improve business effectiveness andrevenue efficiency

Both local and national objectivesrequire maximum benefit from allpublic expenditure. NHS Highlandis also required to reach a breakeven position while improvingquality of care.

NHS Highland Financialframework

FinancialFramework.Managementaccounts

Monthly managementaccounts.Yearly outturn.Bi-monthlyimprovementcommittee.

Improve HEAT and other Health targets To meet both nationally stipulatedHEAT targets regarding waitingtimes and infection control, andimprove adherence to the BADStargets for day-case surgery. Alsoreduce energy-based carbonemissions as per the ClimateChange (Scotland) Act.

HEAT targets Reporting on allheat targetsalready in place

Monthly managementreviews

Augment and expand range of services andpromote emerging model of care includingconsolidation of critical care

To meet the challenges achievingthe Greater Inverness Masterplanwhich points to the need for urgentimprovements to address criticalcare deficiencies in the existingmodel of care, as well as theimportance of improving theatrecompliance at Raigmore to meetthe future needs of NHS Highland.

Service data regarding theatreutilisationCurrent performance againstBADS targets.

Service planning. Ongoing review ofservice data.

Make possible the introduction of new waysof working and in particular effectivecollaborative working and flexibility in theworkforce

To adhere to the principles set outin the Highland Quality Approachregarding new ways of working andservice redesign.

Critical Care bed daysLength of stayCurrent performance againstBADS targets.

Service planning Ongoing review ofservice data.One-off rapid actionimprovement cycles asper LEAN methodology.

Improved facilities / increased capacityoffering a patient centred service includinggreater consistency of care and increasedcertainty for admissions, procedures anddischarge

To adhere to the principles set outin the Highland Quality Approachregarding patient-centeredness,consistency of care and robustnessof admissions and dischargeprocedures.

Service data regarding theatreutilisation and outcomes.Better together survey results

Service planning.HealthcareImprovementScotland.

Monthly reporting inline with currentservice managementpractice.Quarterly reporting toNHS Highland board.

Concentrate higher and lower levels of careat appropriate locations

To reduce the number of patientsplaced in an inappropriate caresetting.

Service data regardingadmissions to levels 2 and 3care setting.

Service planning Monthly reporting inline with currentservice managementpractice.Quarterly reporting toNHS Highland board.




Offer facilities which reduce risk of spreadof infection compared to status quo

Improve ward layouts and designto assist in meeting therequirements of the HAIScribeguidance and reduces the risk ofinfection spread.

HAIScribe guidance to deliverfacilities.Existing infection control data.

Targets and definedspecificationincluded withinHAIScribedocumentation.NHS Highlandinfection controlreport.

HAIScribe reviews atstrategic times duringdesign periods.Continual monitoring ofinfection control datapost-construction asper current practice.

To achieve optimal utilisation of space(within the constraints of existingbuildings)

Refurbishment and rationalisationof existing facilities should optimisecritical care beds, and increasetheatre capacity to meetrequirements of demographictrends.

Greater Inverness Masterplan Service planning Ongoing review

To achieve operational and functionalefficiency of physical environment

Achieve a minimum target score of4/6 in relation to all the AEDETcategories in line with the AEDETreview which will be undertaken atkey stages in the project.

A technical evaluation of theproject proposals will beundertaken based on theDepartment of Health DesignEvaluation Toolkit “AEDET”(Achieving Excellence DesignEvaluation Toolkit).

AEDET review At key stages in thedesign development(as noted in the AEDETguidance) and firstpost constructionassessment within 1year after fullyoperational.

To deliver high quality facilities, andtechnical standards with a strong focus onlifetime costs, quality and design.

Where possible, to meet technicalspecifications for modern carefacilities as articulated in relevantScottish Health TechnicalMemorandum (SHTM), ScottishHealth Planning Notes (SHPN’s) andHealth Briefing Notes (HBN’s).

Comply with CEL 19 (2010) – APolicy on Design Quality for NHSScotland – 2010 Revision

Scottish Health TechnicalMemorandum (SHTM)Scottish Health Planning Notes(SHPN’s)Health Briefing Notes (HBN’s)CEL 19 (2010) – A Policy onDesign Quality for NHSScotland – 2010 Revision

Scottish HealthTechnicalMemorandum(SHTM)Scottish HealthPlanning Notes(SHPN’s)Health BriefingNotes (HBN’s)CEL 19 (2010) – APolicy on DesignQuality for NHSScotland – 2010Revision

At key stages in theplanning and designprocess.




To comply with “A SustainableDevelopment Strategy for NHS Scotland’,to enhance the contribution of the healthsector to sustainable development

Deliver facilities that whencompleted achieve rating ofBREEAM “Excellent” (or “VeryGood” for refurbishment) and NHSHighland’s Environmental Policy inrelation to carbon dioxide emissions

BREEAM Healthcare guidance.SCIM guide.Sustainable Buildings GuideSustainable Strategy for NHSScotlandNHS Highland’s EnvironmentalReport (2007)A sustainable DevelopmentStrategy for NHS Scotland

BREEAM Guidance BREEAM to beundertakeninitially and thensubsequent meetingstoensure criteria issatisfied

To enable the retention and recruitment ofstaff

To see an improvement in staffsurvey results in terms of absenceand staff turnover and to provide aworking environment which sustainrecruitment.

Staff survey.Absence management policyand data.Staff turnover levels.

Improvement instaff surveyresults.Maintenance of lowstaff turnoverlevels.

Bi annual staff survey.Monthly absencemanagement review.



B APPENDIX – SUMMARY OF CATEGORIES OFCHOICE ASSESSMENT



Category of

Choice (Option)

Comments on Potential Options Review

Outcome

Scoping /

Capacity option

1. Reconfiguration of Beds (reduce) to achieve improved compliance with SHTM bed spacingrequirement (typically resulting in 6 beds going to 4)

2. Provide additional capacity of Medical High Dependency Units

3. Provide additional capacity of Critical Care Unit

4. Provide additional theatre capacity via the development of one or more additional theatres – day

case units

5. Consider under utilised space in Maternity Unit (first floor) Ward 8, 9 and 10 (Labour ward 10) notwithin tower block as locus for services that need close proximity to theatres e.g. Ophthalmology /Endoscopy / Surgical Day Case and Common Admission Lounge.

6. Create additional capacity to dialyse patients near/adjacent in-patient (in-patient at Level 7c) wardswith main dialyses at level 7 (close to for plant configuration)

7. Addition of vascular lab to meet current standards for Vascular department

8. Addition of post anaesthetic care unit (PACU) adjacent to intensive care unit

9. Dental Paediatric. Address current deficient accommodation within Endoscopy unit –Service provision

10. Cardio – version. Address current deficient accommodation within Endoscopy Unit – service provision

11. Addition of new build tower block (for in-patient) with existing Tower block being utilised for Out-Patient (knock down existing out-patient)

12. Day Services Project – Renal/ / Theatres and Endoscopy – creating a new build

Discount

Yes, for long list

Discount

Discount

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Discount



13. Satellite – Invergordon – for Renal Dialysis Discount

Discount

Service solution 1. Co-locate intensive care and high dependency to allow acute care to be concentrated in one location

thus improving staff efficiency and flexibility

2. Moving acute Medical assessment and admission units closer to the Emergency Department or“Front Door”

3. Locate surgical & orthopaedic wards as close to Theatres as possible i.e. lower floors

4. Consider the need for an “admission assessment area” as close to the emergency department as

possible through the creation of a combined assessment area

5. Co-locate services within the Tower Block based on acuity e.g. “hot floor(s) concentrate acute

services at one level – specialist critical care staff at one level

6. Co-locate services within the Tower Block based on speciality – Medical and Surgical Departments

to be separate

7. Co-locate specialities that do not require to be on an acute site to create additional decant space

(e.g. dermatology, YARU and Aneurysm screening) Re-locating selected Day Case and OPD away

from more acute / Higher Dependency Wards

8. Move services out of the Tower Block, where adjacency is not required (e.g. Endoscopy), and to

suitable accommodation

9. Re-locating all female surgery (away from male wards) and into separate unit (outwith Ward Block) –into Ward 8 Re-locating female surgery wards (away from male wards) and into separate unit(outwith Ward Block) – into Ward 8

10. Move Child Ward services from the Tower Block into a separate Child Ward unit

11. Consider re-locating selected acute services at Raigmore back into the Tower (e.g. Respiratory) that

provide improved adjacency to General Medicine

12. Upgrade existing Theatre accommodation commensurate with modern standards

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list



13. Eye Day Case Unit – relocation to current location of renal unit Yes, for long list

Implementation

Options

1. Phase services in – extensions and refurbishment of existing premises

2. Single project to completion

Preferred

Discounted

Service delivery

/ Funding

Options

1. NHS Capital funding based on traditional procurement

2. PPP/PFI – private sector

3. Hub Model – private capital

4. Developer Led - private

5. Voluntary Organisation Funding

Preferred

Discounted

Discounted

Discounted

Discounted



C APPENDIX – SWOT ANALYSIS OF LONG LIST;



Long List of Options Summary of SWOT Analysis Results – Only Key Factors Summarised Include on

Shortlist?

Strengths Weaknesses Opportunities Threats

Scoping & Service

Solution Options

A. Do Nothing Reduced capital spend

in the short term

Less disruptive option

in the short term

Some opportunities for

efficiencies are already

being implemented

without the need for

significant investment.

Increased capital spend likely in

long term

No improvement in efficiency,

safety, or quality of care.

Continued inability to meet

modern care standards and SHTMs

for accommodation

Fire upgrade works must still go

ahead. Therefore “do nothing”

would not avoid the associated

disruption.

No increase in theatres or critical

care capacity

Ability to “wait and see”

regarding full outputs

from the Greater

Inverness Masterplan

Still requires completion of

significant and costly

maintenance backlog

Potential for increased

revenue costs given

continued inefficiencies

Decreased staff morale

Failure to capitalise on “once

in a lifetime” opportunity

given large scale fire

upgrade project

Continued use of costly

“stop gap” solutions (e.g.

the modular theatre)

Failure to fulfil significant

component of the Greater

Inverness Masterplan.

Yes, for

comparison

(Option 1)

B. Co-locate services

within the Tower Block

based on speciality –

Medical and Surgical

Improved adjacency of

some relevant services

Improved patient care

and patient flow within

the two divisions.

Relocation will allow

for significant

Not a new-build, so still restricted

by the envelope of the building

and its construction. Unlikely to

fully adhere to SHTM

specifications.

Co-location only along divisional

lines would not permit sharing and

Potential improvement in

performance against

HEAT targets (e.g. 4 hour

A&E target)

Improved accommodation

standards likely to impact

positively upon infection

Complicated decant and

transitional arrangements

without full realisation of

potential benefits in terms

of either quality or

efficiency.

Limited realisation of

potential benefits from

No



improvements to the

condition of the

accommodation, and

to the services and

facilities.

Would not disrupt

existing positive

practice within

divisions (e.g. the use

of a dedicated middle

grade doctor across

both CCU and MHDU)

flexibility of staff or administration.

Does not allow for full flexibility

between HDU/ICU beds to meet

the needs of individual patients or

of coping with peaks in demand.

control efforts.

Potential to realise some

benefits from economies

of scale.

economies of scale.

Would be contrary to

current guidance from DoH

and SEHD regarding co-

location of all HDU facilities.

C. Consolidate CriticalCare Unit with CCU atGround floor and MedicalHDU and ITU / SHDU co-located at first floor andEndoscopy retained inTower Block (level 6)

Improved adjacency of

critical care services to

“front of hospital” (i.e.

A&E), and hence

improved patient flow

Critical care no longer

spread across 3 floors

and 4 departments.

Greater ability to step

up/step down care.

Flexibility of level 2

and 3 care beds

Decreased need to

operate respiratory

ward as an informal





specifications.

Requires dismantling of fit-for-

purpose CCU on level 6.

Would not allow space for

placement of respiratory ward on

level 6 (a much better location

than its current position outside

the tower block)

Integration of facilities

allows potential for more

efficient care and less

duplication of nursing and

administrative functions.

Improved care, improved

staff morale and

decreased revenue

spend.

Increased staff flexibility

between ITU/SHDU and

CCU/MHDU

More appropriate

placement of patients as

to care needs. Reduced

potential for either too-

Would need robust

transition arrangements for

critical care patients during

move.

Economies of scale may not

be realised if new ways of

working are not adopted.

New CCU could be less

spacious than current

purpose built facility – albeit

in an inappropriate location.

Yes

(Option 2)



HDU.

Access to isolation

facilities in MHDU, and

improved infection

control throughout.

Compliance with

current SHTM

standards

Improved storage.

early discharge, or too

high a level of care.

Potential for improved

critical care for cardiac

patients

Potential resolution of

issue whereby MHDU

patients requiring

isolation are admitted to

CCU, despite having no

cardiac conditions.

D. Consolidate criticalcare with CCU & MHDUco-located at ground floorwith ITU & SHDU co-located at first floor andwith Endoscopy movedoutwith Tower Block

As above, but with

additional benefit that

endoscopy could

instead be sited closer

to the standalone

decontamination unit

rather than in the

tower block.





specifications.

Requires dismantling of fit-for-

purpose CCU on level 6.

Would require alternative location

to be found for endoscopy

As above

Potential to bring

respiratory ward into the

tower block (6th floor).

As above

Potential unsuitability of

alternate locations for the

endoscopy unit.

Yes

(Option 2A)

E. Similar to Option 2Abut with MHDU/CCUsituated at Ground floorat “A” block to facilitateintensive care adjacency,and the addition ofVascular Lab and PACU

Improved adjacencies

of MHDU/CCU/PACU

Would require alternative

accommodation for either AMAU or

Cardiology step-down, thus

disrupting adjacencies of these

facilities.

Would mean moving PACU further


efficiencies from better

adjacencies.

Might not be most optimum

combination of adjacent

services.

Yes

(Option 2B)



away from theatres and SHDU

F. New CombinedAssessment Unit onground floor andconsolidate critical carewith CCU & MHDU alsoco-located on groundfloor with ITU & SHDUco-located at 1st floor

Improved co-location

of services, especially

with MHDU on ground

floor and so adjacent

to radiology, A&E and

ambulance access

Co-location of critical

care services, with

associated benefits as

described above

No PACU

Separation of surgical specialities

Decide to admit paradigm

as opposed to admit to

decide

Requires increases in

medical staffing

Separation of surgical

admissions from other

surgical facilities

Potential restriction in bed

allocation for surgical admissions

Yes

(Option 3)

G. New CombinedAssessment Unit onground floor andconsolidate critical careCCU/MHDU andITU/SHDU) completely on1st floor


of services

Moves MHDU away from ground

floor and reduces ease of access to

A&E/ambulances

No PACU

As above Full benefits of adjacency of

MHDU and A&E not realised.

Yes

(Option 3A)

H. New CombinedAssessment Unit onground floor andconsolidate critical care(CCU/MHDU andITU/SHDU) in “A” blockon ground and 1st floors


of services

Includes PACU

No space for addition of PACU

Unable to adhere to space

regulations/requirements

As above Requires increases in

medical staffing

Separation of surgical

admissions from other

surgical facilities

Potential restriction in bed

allocation for surgical

admissions

Yes

(Option 3B)



I. Provide additional

capacity of Medical High

Dependency Units

Requirement for

increased MHDU

capacity outlined in

review of HDU in NHS

Highland (The High

Dependency Needs

Assessment of NHS

Highland Patients).

Would require both capital and

revenue expenditure.

Meets both current and

future need for increased

MHDU capacity.

Movement towards a

philosophy of Critical

care, rather than

traditional split between

ICU/HDU

Increased capacity could

increase revenue costs if

benefits of consolidation

elsewhere are not realised.

No

J. Consider under utilisedspace in Maternity Unit(first floor) as locus forservices that need closeproximity to theatres e.g.Ophthalmology /Endoscopy / Surgical DayCase?

Optimised use of

existing floor space.

Would require disruption to

Maternity services not necessary if

completion of fire works was the

sole objective.

Resolution of sub-optimal

usage of premium space.

Synergy with project to

upgrade endoscopy

services (for which

funding has been

secured)

Difficulty of releasing usable

space while ensuring quality

of

maternity/endoscopy/ophth

almic is not compromised.

Increased complexity of

decant arrangements by

bringing maternity services

into the project scope.

No

K. Create additionalcapacity to dialysepatients on in-patientwards with main dialysesat level 7 (close to forplant configuration

Fill in from day service

paper

Yes, combine

with main

options

L. Addition of vascular labto meet currentstandards for Vasculardepartment

Better adherence to

modern standards of

care

Improved patient

outcomes and satisfaction

Staff training required

Potential increased revenue

spend to staff vascular lab.

Yes, combine

with main

options



M. Addition of postanaesthetic care unit(PACU) adjacent tointensive care unit

Increased flexibility of

beds

Promotes flexibility

with staffing

Less potential for

blocking of SHDU beds

Potential to relieve

pressure on ICU and

reduce the number of

too-early discharges.

Potential to reduce the

need for delayed transfer

of patients from ICU or

HDU to ward-based care

and the inefficiencies

associated with too high a

level of care.

Space allocation Yes, combine

with main

options

N. Move non-acuteservices out of the TowerBlock, where adjacency isnot required (e.g.Endoscopy, Child Ward),and to suitable existingaccommodation

Would leave space for

improved adjacencies

of acute services.

Would require alternative

accommodation to be found for

endoscopy and children’s ward

End result of vastly

improved co-location of

relevant services.

Improved patient

outcomes

Better communication

between staff in relevant

specialties. Improved

skills and morale.

Concurrently running

projects (i.e. the Archie

Foundation) must be

managed in tandem.


alternative accommodation.


decant arrangements

Yes, combine

with main

options

O. Re-locating femalesurgery wards (awayfrom male wards) andinto separate unit(outwith Ward Block) –into Ward 8

Vastly improved

patient-centred care.

Not required if fire upgrade is sole

objective

Reconfiguration allows for

better use of space in

Ward 8/9/10 area.


disruption and increased

complexity of decant

arrangements.

Potential difficulty of finding

alternative space for specific

functions (e.g. Parentcraft

No



room)

P. Consider re-locatingselected acute services atRaigmore back into theTower (e.g. Respiratory)that provide improvedadjacency to GeneralMedicine

Safer and more

appropriate co-location

and improved

adjacencies.

Many respiratory

patients require level 2

care/emergency

transfer to ICU

Require space to be made by

transferring other services out of

the tower block.

Improved patient

outcomes.

Better communication

between staff in relevant

specialties. Improved

skills and morale.


alternative accommodation

for moved services.


decant arrangements

Yes, combine

with main

options

Q. Upgrade existingTheatre accommodationcommensurate withmodern standards

Improved adherence

to modern healthcare

standards and SHTMs

for theatre

accommodation

Resolution of issue

relating to severe lack

of storage for theatre

equipment

Replacement of

equipment and plant

beyond its design life

Significantly improved

infection control

Significant capital expenditure Potential for increased

efficiency, particularly in

terms of better

adherence to BADS

targets and capitalisation

on the potential of

optimal short-stay

surgery.

Full refurbishment would

replace the need to

resolve the significant

maintenance backlog.

Opportunity to eliminate

need for the cost-

inefficient and unfit-for-

purpose modular theatre.

Difficulty of continuing to

provide theatre services

while refurbishment works

are ongoing.

Yes, combine

with main

options

R. Eye Day Case Unit –relocation to current

Allows relocation and

isolation of dedicated

Increased distance from main Potential for improved

efficiency of eye theatre,

Dependent upon safe and

successful relocation of

Yes, combine

with main



location of renal unit day case ward

(currently includes eye

unit).

Improved compliance

with modern care

standards, SHTM

specifications and

infection control.

Improved adjacency to

eye OP clinic.

theatres. and increased flexibility

(e.g. partial lists) which

would improve ability to

meet TTG targets.

Would release capacity

for other specialties in

main theatres, allowing

for the introduction of

LEAN working and

negating the need for a

costly standalone

modular theatre.

renal unit

Would require dedicated

staffing. Potential for some

increased revenue costs.

Dependent on the approval

of a separate outline

business case

options



D APPENDIX – PREFERRED TOWER BLOCK LAYOUT



Level C B A Level

7Medical

GI/RenalManagement Renal Dialysis 7

6 Respiratory RespiratoryOncology with

D/C Trans6

5Vasc/Urology

Surgery/Vasc Lab

Dermatology

Offices

EMPTY - to be used for

winter pressures and

flexi beds for

indcidences of

Infection etc

5

4 Surgical Seminar Room Surgical/Triage 4

3 Orthopaedics Head & Neck Orthopaedics 3

2 Medical Therapy Unit Stroke/YARU 2

1 CAL/SDCU Waiting Area ITU/SHDU/PACU 1

GroundCardiology step-

downCCU AMAU/MHDU Ground

OPTION 2A

*MHDU would join AMAU on the Ground floor as

opposed to the 1st floor as per Option 2.

*Ward 8 and Ward 9 would amalgamate to allow

Endoscopy ro relocate to Ward 8.

*CAL and SDCU relocate to Ward 1C and potential for

stand-alone Eye Day Case Unit could be developed

in space vacated by Renal Dialysis at a later date.



E APPENDIX – POTENTIAL PHASING PLAN



F APPENDIX – POTENTIAL HIGH LEVEL SCOPE



DoMinimum

Option 2 – Consolidate Critical Care Option 3 – Consolidate CriticalCare + Combined Assessment

Unit

1 2 2A 2B 3 3A 3B

The Currentconfigurationbut assume

- fireprecautionsworks(ongoing)

- endoscopydevelopmentbut atground floorof Tower

- Upgradingof CCU,AMAU/MSCU,SHDU,Therapy,ITU, CriticalCareWaiting,1A(CAL,EDCU,SDCU, ITU -- All to beretained attheircurrentlocation

Consolidation of Critical Care on Groundand First Floor Levels –based on acuity

Consolidation of Critical Care onGround and First Floor Levels – based

on acuity. Plus CombinedAssessment Unit

Co-locate AMAU and CCU on groundfloor

Combined Medical Assessment Uniton ground floor

Cardiology also co-locatedon ground floor

Cardiology remains on Level 6

Co-locate ITU/SDHU on first floor

MHDU atFirst Floor

MHDU at Ground Floor Co-locateCCU andMHDU atGroundFloor

Co-locateCCU andMHDU at1st Floor

Co-locateCCU andMHDU/Shortstay beds atGround Floor


Care atLevel 1


Care at Level1

1A (CAL /Surgical DC /Eye Day Careto Ward 8

CAL / Surgical Day Caseto Level 1

CAL /SurgicalDay Caseto FirstFloor

CAL /SurgicalDay CasetoGroundlevel

CAL /Surgical DayCase to FirstFloor

Surgical Triage to remain at Level 4 Surgical Triage relocated to GroundLevel

Potential to move Renal Dialysis moved to Level 7 – separate Investment

Respiratory moved into Tower – Level 6

Medical Ward adjacent to Therapy

Oncology moved to Level 5

Child Ward moved out of Block (Ward 11)

Endoscopy atLevel 6

Endoscopy re-locate to Ward 8 (funded secured)

Gynae/Breast(Ward 8)into Tower -Level 5

Gynae/Breast (Ward 8) to amalgamate to Ward 9(funded secured)

- Vascular Laboratoryadded at 5C

- VascularLaboratoryadded at 5C

Potential to provide Eye Day Case into the accommodation formally occupiedby Renal (separate investment). However, this investment only to include

limited allowance for Eye Day Case, currently in 1A



1 2 2A 2B 3 3A 3B

Theatres Refurbishment

In conjunction with the planned significant upgrading works (refer below) the

continued use of the existing 9 theatres located within the Tower Block

To improve compliance, building fabric and services upgrading of the existing 9

theatres, to meet modern clinical standards (the Theatre within the Maternity

Block is outwith the scope of this project)

Upgraded fire precautions of Theatres in Tower Block to meet horizontal fire

evacuation requirements

Services upgrade associated with achieving compliance, include ventilation

system enhancement

Where possible, potential increase in storage requirements (possible expansion

adjacent to plant room) to facilitate improved compliance with required storage

and other space standards

Provision of services / waste corridor to rear of the Theatres accommodation

Child Ward


The Child Ward will involve the redevelopment of Ward 11 to facilitate

the move. A limited allocation of funding is being considered in

respect of any outstanding need to deal with the current compliance

issues.

Respiratory


The project will require the development of a temporary facility at

Ground Floor level involving some works. (This will require

occupation of some Children’s Ward accommodation, on a temporary

basis).

Furthermore, Level 6 will require some reconfiguration to facilitate the

permanent move to Level 6

Highland NHS Board CRITICAL CARE …...Highland NHS Board 27 June 2013 Item 3.1 CRITICAL CARE...

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Transcript of Highland NHS Board CRITICAL CARE …...Highland NHS Board 27 June 2013 Item 3.1 CRITICAL CARE...