INITIAL AGREEMENT FOR CANCER SERVICES BRIDGING … · Medical Director, Cancer Services, NHS...

INITIAL AGREEMENT

FOR CANCER SERVICES BRIDGING PROGRAMME

AT THE WESTERN GENERAL HOSPITAL EDINBURGH

VERSION 3 1st July 2016

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CONTENTS I. OVERARCHING EXECUTIVE SUMMARY .................................................................... 4 II. INTRODUCTION TO THE INITIAL AGREEMENT – CANCER SERVICES BRIDGING PROGRAMME ...................................................................................................................... 6

1. Management Involvement ................................................................................... 6 2. Management Case ............................................................................................... 6 3. Design Quality Objectives ................................................................................... 7 4. Key Contractual Arrangements .......................................................................... 8 5. Overall Affordability ............................................................................................ 8

III. REDESIGN OF THE DAYCASE SYSTEMIC ANTI-CANCER THERAPY (SACT) SERVICEAT THE WESTERN GENERAL HOSPITAL IN EDINBURGH ............................... 9

1. Project Executive Summary ................................................................................ 9 2. Strategic Background ....................................................................................... 11 3. Strategic Case .................................................................................................... 13 4. The Economic Case ........................................................................................... 21 5. Commercial, Financial And Management Case ............................................... 24

5.1. Commercial Case ........................................................................................... 24 5.2. Financial Case................................................................................................ 25 5.3. Management Case ......................................................................................... 26

6. Strategic Assessment ....................................................................................... 27 7. Appendices ........................................................................................................ 28

7.1. Appendix 1: Draft Programme ...................................................................... 29 7.2. Appendix 2: Indicative Costs ........................................................................ 30 7.3. Appendix 3: Strategic Assessment .............................................................. 32 7.4. Appendix 4: Ward 1 Options Appraisal Objectives ..................................... 34 7.5. Appendix 5: Options Description & Scoring ................................................ 35

IV. UPGRADE OF WARDS 2 AND 4 AT THE WESTERN GENERAL HOSPITAL ...... 38 1. Project Executive Summary .............................................................................. 38 2. Strategic Background ....................................................................................... 40 3. Strategic Case .................................................................................................... 43 4. Economic Case .................................................................................................. 47 5. Commercial, Financial And Management Case ............................................... 50

5.1. Commercial Case ........................................................................................... 50 5.2. Financial Case................................................................................................ 51

6. Appendices ........................................................................................................ 54 6.1. Appendix 1: Draft Programme ...................................................................... 55 6.2. Appendix 2: Indicative Costs ........................................................................ 56 6.4. Appendix 4: Wards 2 & 4 Options Appraisal Objectives ............................. 59 6.5. Appendix 5: Options Appraisal Description & Scoring ............................... 60

V. REDESIGN OF THE ONCOLOGY ASSESSMENT AREA AT THE WESTERN GENERAL HOSPITAL EDINBURGH ................................................................................. 65

1. Project Executive Summary: ............................................................................ 65 2. Strategic Background ....................................................................................... 66 3. Strategic Case .................................................................................................... 69 4. Economic Case .................................................................................................. 75 5. Commercial, Financial And Management Case ............................................... 78

5.1. Commercial Case ........................................................................................... 78 5.2. Financial Case................................................................................................ 79

6. Appendices ........................................................................................................ 81 6.1. Appendix 1: Draft Programme ...................................................................... 82 6.2. Appendix 2: Indicative Costs ........................................................................ 83 6.3. Appendix 3: Strategic Assessment .............................................................. 84 6.5. Appendix 5: Options Description & Scoring ................................................ 86

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VI. LINEAR ACCELERATOR (LINAC) CAPACITY DEVELOPMENT .......................... 90 1. Project Executive Summary And Purpose ....................................................... 90 2. Strategic Case .................................................................................................... 92 3. Strategic Context ............................................................................................... 96 4. Commercial, Financial, And Management Considerations ........................... 106

4.1. Commercial Case ......................................................................................... 106 4.2. Financial Case.............................................................................................. 108 4.3. Management Case ....................................................................................... 110

5. Conclusion ....................................................................................................... 111 6. Appendices: ..................................................................................................... 112

6.1 Appendix 1 – Non Financial options considered ....................................... 113 6.2 Appendix 2 - Schematic of sites for non-financial options appraisal – numbers correspond to the numbered options considered. ................................ 114

VII. CONCLUSION.........................................................................................................115

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I. OVERARCHING EXECUTIVE SUMMARY

1. The Western General Hospital site has had a significant Master Planning exercise taking place where the centre piece involved in the development and campus modernisation being a new Edinburgh Cancer Centre. The Western General Hospital’s Master Planning team’s latest programme showed that the best possible date for a new Cancer Centre opening would be mid-2025.

2. In view of uncertainty for agreement and a timescale for the development of a new Edinburgh Cancer Centre (ECC), a number of critical areas within ECC been identified that require urgent attention. The areas that have been identified have immediate issues and will not support sustained safe service delivery until the inception of a new ECC. The areas that have been identified are:

i. Expansion of day case Systemic Anti-Cancer Therapy (SACT) Service, ward 1;

ii. Improve HEI compliance in 3 inpatient wards (wards 2, 3 and 4);

iii. Develop a new fit for purpose Oncology Assessment Area; and

iv. Increasing Linear Accelerator Bunker Capacity.

3. These four service areas that present the service with immediate pressures. Each area has been reviewed separately to identify the present risks and issues associated with each. This has enabled the development of solutions required urgently to address current issues and protect safe clinical delivery to patients until a new ECC. The review only forecast requirements to 2025 and the requirement for essential investment has been identified in all areas in order to provide a solution.

4. The resulting four projects have been linked together and are being called the “Oncology Bridging Projects”. A single Initial Agreement has been developed for progressing governance approval. To ensure focus and attention is applied to all aspects within each project, the document is split into sections with effectively separate Initial Agreements for each distinct project in the different sections (the four projects are detailed above in section 2).

5. Each Initial Agreement focuses on their relevant strategic objectives and context as well as the background issues and pressures each service is experiencing. Separate Strategic Assessments and Option Appraisals were conducted to fully demonstrate the drivers and objectives of the project and ensure that the best value for money option was selected as the Preferred Way.

6. One of the main issues that each individual project had to take account of was the increasing pressure on the service over time. The basis for these projects is a new Edinburgh Cancer Centre is not going to be opened for use until 2025 at the latest. With serious issues and concerns and severe pressure already being experienced in the project areas, the projects have been developed to not only address these immediate problems but to also plan for increased patient numbers through to 2025.

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II. INTRODUCTION TO THE INITIAL AGREEMENT – CANCER SERVICES BRIDGING PROGRAMME

1. Management Involvement

1.1. NHS Lothian is fully supportive of this proposal, with the Chief Officer for Acute Services and the WGH Site Director taking a lead role in its development.

1.2. Workshops attended by Project Board members included the Feasibility Study Oncology Workshop on 3rd February 2016, with other feasibility study meetings taking place weekly from 12th January 2016 and ad hoc meetings with the user groups as required. Engagement across the multi-disciplinary team has been vital in arriving at this point.

1.3. Clinical Service Manager (Department of Clinical Neurosciences and Cancer Services) and Clinical Nurse Manager (Department of Clinical Neurosciences and Cancer Services) have been driving this proposal supported by , Project Coordinator, and the Estates Projects Team lead by .

1.4. The case for the Linac Accelerator capacity has been supported by the SCAN Radiotherapy Short Life Working Group and through the Strategic Planning Committee requesting an Initial Agreement. The Western General Hospital Management Group and the Masterplaning Group were then tasked to develop the Initial Agreement.

1.5. The Service Directors involved in this project are , Associate Medical Director, Cancer Services, NHS Lothian and (WGH Site Director).

1.6. There were a number of consistent approaches adopted for progressing the programme of work to this stage. To avoid duplication throughout the document these processes are described in sections 2, 3, 4 and 5 below.

2. Management Case 2.1. The NHSL Governance process would be administered through the development of a

3 part business case namely: Initial Agreement, Outline Business Case and Full Business Case. These documents would seek approval at key stages by way of NHSL governance committees and the Scottish Government where required. Committee dates will inform project programming and allow for key stages of work to be funded.

2.2. Whilst the progress of the project from inception to completion is subject to NHSL governance committee approvals across its lifespan the design development will follow the RIBA plan of work. The NHSL Estates Projects team will seek to align and support these interdependent programmes whilst managing the numerous stakeholder groups which feed both.

2.3. A full Project Directory will be developed as the project develops but in the meantime the table below shows the key roles that will be undertaken at present.

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Role Manager Job Title

Project Owner WGH Site Director

Project Sponsor Clinical Service Manager

Project Sponsor

Strategic Programme Manager

Project Advisor

Acting Deputy Head of Oncology Physics

Interim Head of Oncology Physics

Project Co-ordinator Senior Clinical Research Fellow

Project Clinical Advisor

Clinical Nurse Manager

Project Medical Advisors

Consultant Oncologist

Director of Cancer Services

Consultant Haematologist

Project Director Project Team Manager

Project Manager Project Manager


Capital FinanceSupport

Capital Finance Manager

Infection ControlSupport

Senior ICPN

Estates Liaison Officer Estates Sector Manager

2.4. The use of specialist external advisors will be essential and the early release of funds will allow their appointment via Frameworks Scotland 2.

3. Design Quality Objectives

3.1. The use of AEDET will help assess the Design quality and suitability both at this early Initial Agreement stage throughout the life of the project by repeating the assessment at various key milestones including at the Business Case stage and during any Post Project Evaluation. AEDET stands for Architectural Excellence in Design Evaluation

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Toolkit and was principally developed for use with Framework Scotland and Procure 21 projects in the NHS.

3.2. The toolkit provides a methodology for evaluating the quality of design in healthcare buildings and can be used for refurbishment projects as well as for new builds plans. It is divided into 10 sections which have set questions that are weighted depending on the type of project and then scored with regards to the specific project proposals.

3.3. The option to be chosen to carry out this exercise will follow the guidance in the adoption of a workshops type arrangement. An AEDET assessment will be carried out once the Design Team has been appointed and a practical scheme design has been developed.

4. Key Contractual Arrangements

4.1. The contract will be extended in stages as the project develops and NHS Lothian approval and funds are received at each stage. The intention to use Frameworks Scotland 2 means the Principal Supply Chain Partner will be appointed in stages, with the design phase starting following the approval of the Initial Agreement by NHS Lothian and Scottish Government Capital Investment Committee (CIG). The formal appointment for the construction stage will only be made after the Business Case is approved.

4.2. The project will be managed via the approved NEC3 contract.

5. Overall Affordability

5.1. NHS Lothian operates with a delegated authority over capital schemes of less than £5m. As the estimated costs for this project are above that delegated limit, the project will be referred to the Scottish Government Capital Investment Group for approval and specific funding of capital costs. Capital affordability will be determined through prioritisation within the Scottish Government capital programme, with availability of specific capital funding a key constraint.

5.2. Should the IA be approved, revenue affordability will be assessed in detail at the OBC stage following a full review of revenue implications.

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III. REDESIGN OF THE DAYCASE SYSTEMIC ANTI-CANCER THERAPY (SACT) SERVICEAT THE WESTERN GENERAL HOSPITAL IN EDINBURGH

1. Project Executive Summary

1.1 This section of the overall Initial Agreement focuses on the day case Systemic Anti-Cancer Treatment (SACT) Service which is delivered from the Ward 1 building on the Western General Hospital site. System Anti- Cancer treatment therapies include cytotoxic chemotherapy agents, biological therapies and disease-modifying targeted agents used to treat cancer. Ward 1 provides facilities for the delivery of day case SACT and associated supportive therapies for oncology, Haematology and Trials. This building was originally the Renal Transplant Unit before being upgraded in the 1990’s to create the Outpatients SACT Service unit. The growth in demand and activity for day case SACT and associated supportive therapies (across oncology, Haematology and Trials) has led to over crowding and lack of space for essential support services (e.g. Pharmacy) which then led to a further upgrade and extension in 2006.

Although the building remains in good physical condition, it no longer provides a fit for purpose environment. The Chief Executives Letter 30 (2012) (5.1.2) sets out guidance endorsed by the Scottish Cancer Taskforce stipulates that “SACT is administered in an area which is assessed as safe and appropriate for the treatment being delivered”. Due to the increasing demand and activity the Ward 1 space is no longer considered safe and appropriate and will not sustain service delivery until a new ECC becomes available.

Overall SACT activity in the Edinburgh Cancer Centre has increased by 20% between 2010 and 2014. Annually the increase in demand for Ward 1 is approximately 2.5% for oncology and 3.5% for Haematology. This rising demand is reflective of a number of key drivers:

• An aging population • An increasing population (9% rise in Lothian 2010-2014) • Increased cancer incidence • Improved diagnostics • Increased screening • Increasing number of effective treatment options that have been licensed and SMC

approved • Increased use of multiple lines of SACT

The increase in patient numbers and treatment regimes over the last 10 years has seen a return to severe overcrowding and pressure on space. This has contributed directly to some critical clinical incidents and increased incident (DATIX) reporting. It is now considered a high risk service area. The situation urgently needs addressing to reduce the risk of clinical incidents and to improve the facility for patients, visitors and staff alike.

The increasing demand and activity is not unexpected and will continue to rise meaning an upgrade to the current facility is essential in order to sustain the service until a new ECC.

1.2 Fundamentally more space is required to address the issues within Ward 1. The Oncology Services Clinical Management Team (CMT) is committed to delivering an essential programme of quality improvement to support sustainability of the SACT

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service. Nonetheless extended working hours or alternative working practices will have minimal impact on the present space problem which affects the supporting day case treatment area and the pharmacy aseptic unit. Ward 1 currently has 58 day case chairs in a space that is designed 44 chairs, thus presenting an immediate issue. Based on the assumption that 2025 is earliest date for a new Cancer Centre opening the CMT forecast that a minimum of 80 treatment chairs will be required; an increase in 22 chairs in the next 9 years.

1.3 The current chair spacing is circa 2.0m2/chair with the recommended chair area being 10m2/chair (Health Building Note 02-01 Cancer Treatment Facilities). Within the constraints of the WGH campus it is recognised that the recommended chair spacing will not be achievable, however the plans that have been developed significantly improve the spacing. The lack of space and adequate chair numbers presents a material patient safety risk and continual “fire fighting” challenge for the multidisciplinary team. As the current accommodation is only configured for 44 chairs this means that space for an extra 36 chairs is required to enable the service to be maintained until 2025.

1.4 The Preferred Way detailed in this paper focuses on using existing vacated or soon to be vacated areas in proximal locations to ECC rather than more expensive new build options. These options have been pursued to ensure that the preferred way forward maximises the benefits realisation in recognition that the upgraded facilities will only have a limited lifespan until the new ECC opens. The areas that have been identified cannot however be safely occupied without some investment. Ward 1 will also require an upgrade once Haematology and Clinical Trials relocate to allow the remaining Pharmacy and Oncology services to be improved to enable sustainability until 2025. The proposed upgrades design is a configuration that enables effective patient flow, supports patient volume and ensures a safe and quality service delivery.

1.5 The favoured option for the day case SACT service involves:

A) Clinical Trials relocating from Ward 1 to Pentland Lodge and;

B) Haematology relocating to the MRC West Wing with further expansion into the Break Through Laboratory when it becomes available in mid-2018.

These moves release sufficient space in Ward 1 to expand the Pharmacy Aseptic Unit and to remove the overcrowding issue from for oncology day case SACT delivery as well as improving some of the supporting facilities. These changes in total deliver space for an additional 36 chairs with improved chair spacing to support the forecast increased in demand.

1.6 The overall cost of this element if carried out in isolation would be . An Early Release of funds is requested via final approval of this document. This sum would be used to appoint a Principal Supply Chain Partner and Design Team to develop the project proposals and adds up to .

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2. Strategic Background

2.1. Management Involvement

2.1.1. NHS Lothian is fully supportive of this proposal, with the Chief Officer for Acute Services and the WGH Site Director taking a lead role in its development.

2.1.2. Workshops attended by Project Board members included the Feasibility Study Oncology Workshop on 3rd February 2016, with other feasibility study meetings taking place weekly from 12th January 2016 and ad hoc meetings with the user groups as required. Engagement across the multi-disciplinary team has been vital in arriving at this point.

2.1.3. The Service Directors involved in this project are , Associate Medical Director, Cancer Services, NHS Lothian and (WGH Site Director).

2.1.4. Clinical Service Manager (Department of Clinical Neurosciences and Cancer Services) and Clinical Nurse Manager (Department of Clinical Neurosciences and

Cancer Services) have been driving this proposal supported by , Project Coordinator, and the Estates Projects Team lead by .

2.1.5. Staff affected by this proposal include: Oncology and Haematology nursing and medical staff, Pharmacy staff, Clinical Trials and support staff. Their involvement in its development includes review of the feasibility study proposals, participation in workshops and input to the project brief.

2.1.6. Staff representatives were consulted on the final version of this Initial Agreement by involvement in developing the feasibility brief and by participation in the options appraisal. Their feedback was has been incorporated into this proposal.

2.1.7. Patients and service users affected by this proposal include outpatient Oncology and Haematology SACT patients including patients taking part in Clinical Trials. Given the requirement to expedite this project service users have not been consulted with at this stage, however consultation with this group will be essential at the design stage.

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2.2. Links to NHSScotland strategic priorities

NHSScotland Strategic Investment

Priority:

How the proposal responds to this priority As measured by:

Person Centred

Improves Quality of Life through care provided (QOI).

Cancer QPIs

It improves the physical condition of the health / care estate (SAFR KPI).

Feedback from patients describing the excellent care received, however commenting on the challenging environment.

Safe Reduces adverse harmful events

Reduction in DATIX reporting relating to the day case delivery unit and pharmacy area

Effective Quality of Care

Supports the delivery of 31 days decision to treat to treatment standard for those who have SACT as first treatment

Cancer Access Standards

Value & Sustainability Increases level of staff engagement (QOI)

Percentage of staff who say they would recommend their workplace as a good place.

The strategic assessment (set out in section 6) scored this proposal 21 out of a possible score of 25. This highlights the need for change. The assessment highlights the need for change to enable delivery of NHSScotland’s strategic priorities and sets out tangible metrics to evaluate the impact of this proposal.

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3.2. Current Ward 1 Physical Environment

The Ward 1 area currently consists of:

Treatment Area- Ground Floor Pharmacy - Ground floor Lower ground floor

Area 1 – 10 Trials chairs

Area 2 - 16 chairs for oncology patients

Area 3 – 15 chairs, 2 beds and one isolation room (2 chairs may be used by Haematology)

Area 4 – 16 chairs for Haematology patients

Haematology procedure room

Pentamidine room

Each area has a SACT preparation area and there are various staff offices, a trials lab, toilets for staff and patients, and storage areas

Checking area

Diary area

Aseptic preparation area

Oral preparation area

Storage including cold-store

Prescribing offices

Offices for Trials data managers and nurses

Storage of Trials records

There are also staff toilets and changing rooms on this level

3.3. Regional and Service Planning

3.3.1. In order to maximise efficiency of SACT delivery and ensure service sustainability there is currently a review of SACT capacity being conducted across the South East Scotland Cancer Network (SCAN). The net rise in demand includes various service redesign efforts utilised over recent years to offset the underlying demographic pressures above, including repatriation of significant activity to peripheral Board SACT units, simplification and truncation of SACT regimes where this can be achieved without patient detriment, displacement of supportive activity to other areas including elective activity in the oncology assessment area, for example

3.3.2. Further opportunities to implement in house measures of this type have been largely exhausted. Some further repatriation of remaining activity to some Boards, in particular NHS Fife, is possible. This, however will be contingent on peripheral services meeting requirements to ensure safe local delivery of chemotherapy.

3.3.3. This proposal does not include options to expand the day case SATC unit at St Johns Hospital. Expansion of this unit would not address the space issues that exist in ward 1. In time the environment and space for the SACT unit at St Johns will also have to be reviewed due to the increasing demand and activity.

3.3.4. Key members from the Oncology Clinical Management Team have recently completed the NHS Lothian Quality Academy course. SACT service delivery has been the focus of much of this work with a view to implementing a total clinical quality approach to service delivery. This review will not solve the immediate capacity or space pressures, however it will support the service to achieve sustainability in the longer term. A product of this is a programme of

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improvement work for the day case SACT service. This programme is essential to ensuring the service sustainability and must be pursued in tandem with this case.

3.4. Current Accommodation Pressures

3.4.1. There are a number of different accommodation pressures which are summarised below.

• Chair Spacing

There is an insufficient number of treatment chairs to meet current and future demand. Ward 1 currently has 58 chairs in a space designed for 44. Current chair spacing is circa 2.0m2/chair with the recommended chair area being 10m2/chair (Health Building Note 02-01 Cancer treatment facilities). The lack of space and adequate chair numbers presents a continual “fire fighting” challenge for the multidisciplinary team. By 2025 it is estimated that a minimum of 80 chairs will be required to accommodate the forecast demand. This also results in a poor patient experience illustrated by the fact that return patients are no longer permitted to bring a relative or friend for support due to space constraints.

• Infection Control

Inadequate chair spacing which presents infection control and safety concerns (e.g. an incident whereby a patient was administered the wrong SACT, it was identified in the investigation that space was a significant contributory factor).

• Pharmacy Space

Essential Pharmacy support is at the limit of its capacity- evidenced by increased incidence reporting in the clinical area and in pharmacy.

• Storage Space

There is inadequate storage for pharmacy, ward supplies and linen.

• Facilities

There is a lack of facilities for relatives and patients e.g. waiting areas and toilets

• Clinical Rooms

There is an insufficient number of consulting, procedure and isolation rooms.

• Toilets

Ward 1 does not have an adequate number of toilets, nor does it have toilets that are built to a specification to meet patient needs.

• Configuration

Configuration does not support effective patient flow (i.e. no area for pre-assessment, new patient cohorting or chairs to accommodate delays) or enable safe and efficient working practices within pharmacy.

• Insufficient space to develop Trials

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There is a lack of space to develop Clinical Trials resulting in that service rejecting offers limiting the revenue benefits to the hospital and any potential clinical benefits for patients.

3.5. Need for change

3.5.1. Drivers for Change

Cause of the need for change:

Effect of the cause on the organisation: Why action now:

Non-compliant treatment area, lack of isolation rooms, lack of space in treatment area

Increased risk of infection. Risk of errors in treatment. Delayed/deferred treatments

Facility is not fit for purpose with the potential for patient harm

Lack of patient facilities including DDA compliant toilets, adequate waiting areas. Privacy issues

Complaints from users Likelihood of increasing stress in a group of ‘high risk’ patients

Lack of preparation and storage space in Pharmacy

Increased risk of prescribing errors

Pharmacy may not be able to deliver a safe service in the immediate future

Future service demand is predicted to increase

Existing capacity is unable to cope with future projections of demand

Service sustainability will be at risk if this proposal isn’t implemented now

Ineffective service arrangements because of inefficient configuration of department

Inefficient service performance

Poor patient flow

Continuation of the existing service performance is unsustainable

Service arrangements not person centred

Service is not meeting current or future user requirements

A service that isn’t meeting user requirements is unsustainable, even in the short term

Lack of space for expansion of Clinical Trials

Inability to offer new Trials to patients

Potential income generation lost

Staff moral affected

Future of Trials Unit at risk with loss of the benefits to patients and the Service

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3.6. Investment Objectives

Effect of the cause on the organisation: What needs to be achieved to

overcome this need?

(Investment Objectives)

Existing facilities do not comply with recommended treatment chair spacing

Redesign of service to produce fit-for-purpose facilities that improve treatment chair spacing

Existing space is not able to support forecast increases in demand Improve service capacity

Inefficient service performance. Current space is not conducive to supporting efficient patient flow.

Improve service performance and patient experience.

Service is not meeting current or future user requirements Meet user requirements for service

3.7. Benefits of this Proposal

3.7.1. The oncology service is faced with an immediate problem with insufficient space to accommodate day case SACT delivery safely. The existing physical space will not accommodate the future projected demand and therefore the ability to treat patients in a clinically appropriate time and in a safe environment. Over the next 12 months the CMT will be reviewing a number of different options to make immediate improvements this include:

• Use of SACT Lorries- these are mobile units which provide up to 5 chair spaces to

accommodate the delivery of SACT • Limited options to extend working day/ week • The aforementioned programme of quality improvement work to continually review

and maximise service delivery 3.7.2. Given the immediate pressures identified the pharmacy oral dispensing unit is currently

being upgraded to increase the space and configure the environment to safely accommodate the volume of dispensing. This short term action will address immediate pressures; however will not sustain delivery beyond the next 18-24 months.

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3.7.3. If this proposal is not progressed NHSL will continue to carry a risk as the demand and activity is expected to continue to grow. The issues that will persist are detailed below:

• Limited space also poses an Hospital Associated Infection (HAI) risk • Further incident reporting • Poor patient experience is compromised at what is a very difficult time in peoples

lives • Even with a quality improvement focus to improve efficiencies and review models of

care delivery the demand and activity will mean that the timely and safe treatment of patients will be compromised i.e. there will be insufficient space to book patients for their day case treatment

3.8. Benefits gained from progressing proposal

3.8.1. There are a number of clear benefits from progressing this proposal which will address the aforementioned risks and issues. The proposal will enable an essential expansion of physical space for oncology, Haematology and Trials day case delivery. For all areas this proposal will address the over crowding issue and also ensure sufficient chair space to accommodate the forecast increase in demand. The benefits that this will present for these services are detailed in the following:

3.8.1.1. Oncology Benefits

For the oncology service this proposal will provide the increased chair spacing and number of chairs required to meet demand. A redesigned environment will also support the proposal to redesign patient pathways to support efficient patient flow. The increased chair spacing will improve the patient experience and over crowding issues that currently exist.

3.8.1.2. Haematology Benefits

This proposal supports relocating the Haematology to the West Wing and the Break Through Laboratory on the Western General campus. Other than the increased treatment chair spacing and number of chairs this option also enables co-location of the Haematology day case service with the Haematology in patient wards (wards 8 and 8 unit). Co-locating the services will facilitate efficiencies in working practices. This is a model of working that will be progressed when developing a new ECC and so this is an incremental move towards achieving the longer term vision for Haematology.

3.8.1.3. Trials Benefits

Expansion of Trials into the proposed Pentland Lodge accommodation will enable Trials activity to increase by a target of 5% per annum (currently approximately 3%).

Increased space will also allow for expansion of Phase I trials which has benefits for patients, research and financially for the organisation. The table below sets out income currently generated in 2014/2015 by phase I trials for NHS Lothian compared to income received for NHS Greater Glasgow and Clyde.

2014/15 Number of Phase I Trials

Income from Phase I Trials

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Glasgow 9 £

Lothian 1 £

Table showing income generated by Phase I trials in 2014/2015 by NHS Lothian compared to NHS Greater Glasgow and Clyde (data source CRUK).

3.8.1.4. Pharmacy Benefits

This proposal would enable expansion of the pharmacy oral dispensing and aseptic unit to ensure sufficient space to operate safely and to accommodate the expected growth in demand. Improving the space will address the deficiencies that have been noted in the last two external pharmacy audits. The modernisation of the pharmacy areas will allow enable improved compliance with the Quality Assurance of Aseptic Preparation Services, 4th Edition, NHS QC Committee, Ed. A Beaney, Pharm Press 2006 and EU Guidelines to Good Manufacturing Practice Current Edition.

3.9. Measurable Benefits

3.9.1. The following measurable benefits will be gained from progressing this proposal:

• Delivery of waiting times / treatment targets now and in the future for the various tumour groups.

• Reduction in delayed or deferred treatments; reduction in unnecessary inpatient admissions.

• Improved user feedback: surveys; appraisals; reduction in complaints.

• Improved HAI and HBN guidance compliant accommodation

• Pharmacy metrics: capacity for an increased number of regimes; reduction in stock loss.

• Reduction in overtime costs due to improved space to place patients when there are unforeseen delays out of core hours.

• Increased Trials income and related recruitment and retention of staff

3.10. Risk Management Strategy

There are a number of risks which could undermine the benefits that have been described:

• Increase in patient numbers beyond forecast predicted levels over the next 10 years

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• Increase in number and complexity of new SMC approved SACT regimes above predicted levels

• Shortage of specialist trained SACT nursing staff

• Peripheral Boards unable to repatriate patients due to lack of capacity

• Revenue shortfalls

• Challenging financial landscape precipitates the requirement to review treatments available and therefore reduces demand and activity

3.11. Constraints and dependencies

The proposed solution to address the issues has a number of constraints and dependencies which are described below:

3.11.1. Constraints

• Planned New Cancer Centre and timescale for implementation • Available chair space in existing building • Extra revenue implications of moving Haematology to new area • Limited space for development of the Pharmacy Aseptic Service in Ward 1 • Limited Space for developing support accommodation in Ward 1 • Need to limit loss of Oncology car parking spaces for Pentland Lodge extension • The Day Chemotherapy Service needs to continue to be safely delivered until the

initial benefits are realised in August 2018 3.11.2. Dependencies

• Release by Edinburgh University of space in West Wing and Lab area • Dumfries and Galloway moving patients out of Pentland Lodge • Funding from Research Endowments and charities to support Trials area

development • Approval of suite of initial Agreement document covering all Oncology Bridging

Project • Prompt approval and release of funds to keep on programme • Service must be able to be delivered safely during the construction works

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4. The Economic Case

4.1. Preferred strategic / service solution

Given the immediate pressures and issues within the service, approval was given by NHS Lothian through the Lothian Capital Investment Group (LCIG) to instruct a Feasibility Study which has been completed. This led to a number of options being examined and a number of plans developed. A total of ten “Long List” options were developed and these are shown in full in Appendix 5.

For this first stage in appraising the options, a list of Primary and Secondary Objectives was drawn up that represented the aspirations of the service. These Objectives are also attached in Appendix 4. The Long List options were scored against their delivery of the Primary and Secondary Objectives allowing the list to be trimmed. The scores of the full ten options are shown in the Appendix and this step allowed a number of them to be eliminated. A Long List option had to score 75% or above to allow it to be short listed for further more detailed analysis.

This resulted in the full Option Appraisal being undertaken for the 4 options short listed from the Long List of Options, including the “Do Nothing” and “Do Minimum” options. The other two chosen options were selected from the long range of options after scoring more than the 75% required. The resulting short listed options were then evaluated during the Option Appraisal in accordance with the guidance detailed in the revised Scottish Capital Investment Manual (SCIM) including scoring benefits, risks and costs.

4.1.1. The do nothing option

Strategic Scope of Option: Do Nothing

Service provision: Continues to provide service from Ward 1 and requires to cope with increasing service demand until at least 2025

Increasingly overcrowded environment, insufficient for current and future service demands

Service arrangements: Continue to be delivered as a day service and like to be extended to 7-day working

Inadequate service unable to provide required capacity with the potential difficulty of supporting service at weekends

Service provider and workforce arrangements: Local staff delivering service out of Ward 1, supported by the Satellite Pharmacy Aseptic Unit.

Internal Staff working in very poor, overcrowded environment leading to pressure and potential for errors

Supporting assets: Present Pharmacy Aseptic Unit

Pharmacy Aseptic Unit delivered from severely overcrowded and cramped facilities

Public & service user expectations: Safe delivery of prompt service in a suitable

Overcrowded environment leading to patient dissatisfaction and potential difficulty in delivering safe service with likely delays due to lack of capacity

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environment

4.1.2. Service change proposals – Do minimum:

The “Do minimum” option involves semi-permanent hire of SACT buses and hire of pharmacy storage containers and modular units. The option would leave the service unable to cope with increasing patient numbers with Healthcare continuing to be delivered in poor and inappropriate environment and infection risks remaining considerable. This option was considered unsuitable, as it could pose health risk to patients due to unsatisfactory environment and has significant revenue implications, but was included as a reference to compare with other options.

4.1.3. Option 3

This option involves refurbishment of the Pentland Lodge to contain a new Clinical Trials Unit, upgrade of the MRC West Wing, followed by the Breakthrough Lab to house new Haematology Unit and then refurbishment of the vacated space in Ward 1 to enhance the Pharmacy and Oncology services that remain in that building. The solution relies on University giving back both the West Wing & Breakthrough Lab accommodation. The West Wing cannot provide Haematology service and protect it through to 2025, hence the need for the Lab to be developed as well. The upgrade works in Ward 1 need to allow the remaining Oncology service to continue without risk, however the Pharmacy service would need to decant and a Mobile Aseptic Unit would be required.

4.1.4. Option 6

The option involves a Modular Extension to Ward 1, built in adjacent car park to contain new Drugs Trial and Haematology Units and a refurbishment of the vacated space in Ward 1 to create expanded space for Pharmacy and Oncology Treatment area. The upgrade works in Ward 1 would have to allow the remaining Oncology service to continue without risk and the Pharmacy service would need to decant to a hired Mobile Aseptic Unit. The option would involve the loss of car parking spaces to hospital and may prevent Renal Unit expansion going ahead as planned. It would however the co-location of all Ward 1 services, although was considered to present poor Value for Money.

The methodology used to carry out the options appraisal was taken from the Scottish Capital Investment Manual (SCIM). This allows the non – monetary benefit of each option to be weighted and scored before being compared against the indicative cost for each option. This means that the option that supplies the lowest total cost per unit of weighted score comes out on top providing the best Value for Money solution

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4.2. Results of Option Appraisal

Option Indicative Costs (£)

Weighted Score

Total Cost per Unit of Weighted Score (£)

Weighted Score

increase compared

to "do nothing"

Cost per Weighted

Score increase (compared to "do nothing")

(£)

Position Risk

1 0 670 0 0 0 3 500

2 640 -30 4 450

3 1,495 825 1 150

6 1,475 805 2 170

4.2.1. Preferred strategic / service solution

Examination of the Option Appraisal process shows that there a single clear winning option when the weighted benefits scores are taken account of – Option 3. This is the combination of projects that formed the main outcome of the Feasibility Report so drawings and more accurate costs were produced as a by-product. The outcome is therefore sound and would not be affected by any sensitivity analysis. It provides the necessary change in capacity that would protect the service to 2025 and help it extend to 2030 if necessary. This option meets all the primary and secondary objectives and poses the lowest risk of all considered options.

4.3. Design Quality Objectives

The use of AEDET will help assess the Design quality and suitability both at this early Initial Agreement stage throughout the life of the project by repeating the assessment at various key milestones including at the Business Case stage and during any Post Project Evaluation. AEDET stands for Architectural Excellence in Design Evaluation Toolkit and was principally developed for use with Framework Scotland and Procure 21 projects in the NHS.

The toolkit provides a methodology for evaluating the quality of design in healthcare buildings and can be used for refurbishment projects as well as for new builds plans. It is divided into 10 sections which have set questions that are weighted depending on the type of project and then scored with regards to the specific project proposals.

The option to be chosen to carry out this exercise will follow the guidance in the adoption of a workshops type arrangement. An AEDET assessment will be carried out once the Design Team has been appointed and a practical scheme design has been developed.

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5. Commercial, Financial And Management Case

5.1. Commercial Case

5.1.1. The total indicative costs for the project at this stage are including VAT. Further work will follow to develop these costs and to identify those which are one-off revenue costs and which are capital expenditure. The procurement will be led by members of the Oncology service with support from the Estates Department and Capital Finance on behalf of NHS Lothian.

5.1.2. Procurement Strategy

The estimated value for this project and the fact that is likely to be linked to the other 3 Oncology Bridging Projects gives an overall value of circa . This means that this project will be developed using Framework Scotland 2. This means that a Design & Build approach will be used which is unfortunately the only option allowed for under the Framework.

5.1.3. The project will be subject to a competitive tender under the Framework rules for the appointment of a Principal Supply Chain Partner (Main Contractor). The Design Team will be appointed and approved via the Principal Supply Chain Partner (PSCP). The initial funds needed for this based on the Preferred Way are . These funds are being requested via this Initial Agreement document once it has been approved by both NHS Lothian and the Scottish Government. The selection process will be based on who provides the best Value for Money against the set criteria.

5.1.4. Outline of Project Programme

The project construction phase is outlined below:

Milestone

Date

Haematology Element Start Date 15th January 2018 Clinical Trials Element Start Date 15th January 2018 Ward 1 Construction Start Date 20th August 2018 Project Completion Date 28th June 2019

The timetable for the Initial Agreement approval is noted below:

The full project programme is outlined below:

Action Commence Complete

Initial Agreement Approval by NHSL 14th June 2016 13th July 2016 Initial Agreement Approval by SGHD 18th July 2016 9th September 2016


Prepare Initial Agreement April 2016 June 2016 Lothian Capital Investment Group 14th June 2016 21st June 2016 Finance and Resources Committee 4th July 2016 13th July 2016 SGHD 18th July 2016 9th September 2016

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Appointment of PSCP September 2016 November 2016 OBC Approval stage by NHS Lothian December 2016 January 2017 OBC Approval stage by SGHD January 2017 March 2017 FBC Approval stage by NHS Lothian June 2017 September 2017 FBC Approval stage by SGHD September 2017 December 2017 Project Main Construction Start Date 15th January 2018 Project Completion Date 28th June 2019

The full proposed target programme is attached as Appendix 1.

5.1.5. Key Contractual Arrangements

The contract will be extended in stages as the project develops and NHS Lothian approval and funds are received at each stage. The intention to use Frameworks Scotland 2 means the Principal Supply Chain Partner will be appointed in stages, with the design phase starting following the approval of the Initial Agreement by NHS Lothian and Scottish Government Capital Investment Committee (CIG). The formal appointment for the construction stage will only be made after the Business Case is approved.

The project will be managed via the approved NEC3 contract.

5.2. Financial Case

5.2.1. Introduction

This chapter:

• Sets out the estimated costs of the proposed development • Identifies any capital or revenue constraints on the project • Summarises the overall affordability

5.2.2. Capital affordability

The estimated overall capital costs of the project are £ . A summary of the capital costs is shown in the table below, with detailed indicative costs presented at Appendix 2

Costs Elements Option 2 £000

Construction Costs

Fees

Estates and Facilities

Equipment and IT

Risk Allowance

Sub Total

25

VAT

Total Costs

The key capital assumptions are:

• The construction costs are an indicative value, and assume no accelerated working. • Construction costs do assume the project would involve a significant level of

refurbishment & modernisation throughout. • Construction costs include an inflation allowance of £ ; • VAT at 20% has been applied to relevant costs; • VAT recovery has been assumed where appropriate. A final assessment of VAT

recovery will be given by VAT advisors on completion of the project; and • Costs include a risk allowance/ optimism bias of .

5.2.3. Revenue affordability

Although improved conditions are anticipated to bring efficiencies, the preferred option is anticipated to ultimately result in increased revenue costs. Detailed work will be undertaken at OBC stage to determine the impact on:

• Recurring staff costs • Recurring non pays • Estates, facilities and property costs • Consumables and revenue equipment • Depreciation

At this stage it is envisaged that recurring revenue for portering staff to transfer SACT from pharmacy in ward 1 to the Trials Unit and Haematology. It is estimated that 2 whole time equivalent band 2 porters will be required to enable this.

5.2.4. Overall Affordability

NHS Lothian operates with a delegated authority over capital schemes of less than £5m. As the estimated costs for this project are above that delegated limit, the project will be referred to the Scottish Government Capital Investment Group for approval and specific funding of capital costs. Capital affordability will be determined through prioritisation within the Scottish Government capital programme, with availability of specific capital funding a key constraint.

Should the IA be approved, revenue affordability will be assessed in detail at the OBC stage following a full review of revenue implications.

5.3. Management Case

5.3.1 The NHSL Governance process would be administered through the development of a 3 part business case namely: Initial Agreement, Outline Business Case and Full Business Case. These documents would seek approval at key stages by way of NHSL

26

governance committees and the Scottish Government where required. Committee dates will inform project programming and allow for key stages of work to be funded.

5.3.2 Whilst the progress of the project from inception to completion is subject to NHSL governance committee approvals across its lifespan the design development will follow the RIBA plan of work. The NHSL Estates Projects team will seek to align and support these interdependent programmes whilst managing the numerous stakeholder groups which feed both.

5.3.3 A full Project Directory will be developed as the project develops but in the meantime the table below shows the key roles that will be undertaken at present.

Role Manager Job Title

Project Owner WGH Site Director

Project Sponsor Clinical Service Manager

Project Co-ordinator Senior Clinical Research Fellow

Project Clinical Advisor Clinical Nurse Manager

Project Medical Advisors

Consultant Oncologist

Director of Cancer Services

Consultant Haematologist

Project Director Project Team Manager


Capital Finance Support Capital Finance Manager

Infection Control Support Senior ICPN

Estates Liaison Officer Estates Sector Manager

5.3.4 The use of specialist external advisors will be essential and the early release of funds will allow their appointment via Frameworks Scotland 2.

6. Strategic Assessment

6.1 The strategic assessment scored this proposal 21 out of a possible score of 25. This highlights the need for change.

6.2 The Strategic Assessment carried out for this proposal is included in Appendix 3

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7. Appendices

7.1 Appendix 1: Draft Programme

7.2 Appendix 2: Indicative Costs

7.3 Appendix 3: Strategic Assessment

7.4 Appendix 4: Options Appraisal Objectives

7.5 Appendix 5: Options Description & Scoring

28

7.1. Appendix 1: Draft Programme

29

7.2. Appendix 2: Indicative Costs

30

Redacted from the public version of the document on the basis that it contains commercially sensitive data

7.3. Appendix 3: Strategic Assessment

32

7.4. Appendix 4: Ward 1 Options Appraisal Objectives

Primary Objectives

• Allow for improved and safer healthcare delivery

• Create increased capacity to support service delivery until 2025

• Create additional pharmacy capacity to ensure they can support chemotherapy service

• Create modern, compliant facilities

• Risk – free option with regards to deliverability

Secondary Objectives

Location, Access & Services Infrastructure

• Located near supporting Oncology facilities, including pharmacy aseptic unit• Easily accessible to patients and staff• A fully serviced facility must be created including piped medical gases as needed;• IT infrastructure should be able to support all requirements;

Space Requirements

The new Treatment Areas should contain:

• Better Chair Spacing;• Associated Support Facilities;• Staff Areas;• More suitable, DDA compliant toilets• More Isolation Single Rooms• Sufficient storage space

The extended Pharmacy Aseptic Unit should contain:

• Additional storage area with drugs fridges• More desk space for producing treatment regimes• Enlarged checking area

Clinical Trials Unit will require:

• Sufficient records storage space• Phase I trial inpatient facilities• Sufficient office space

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7.5. Appendix 5: Options Description & Scoring

Option Locations Description Issues

Compliance with Primary

Objectives (%)

Compliance with Secondary Objectives

Comments Final Score

(%) Location, Access and

Services Infrastructure

Space Requirements

1 Ward 1 Do nothing

1. Leaves Service unable tocope with increasing patient numbers. 2. Healthcare would bedelivered in poor and inapproriate environment. 3. Infection risks would beconsiderable. 4.Health risk to patients due tounsatisfactory environment

20 100 0 Option not viable 35

2 Ward 1

Do Minimum: 1. Semi-permanent hire of Chemotherapy buses 2. Hire ofpharmacy storage containers and portacabins

1. Leaves Service still unableto cope with increasing patient numbers. 2. Healthcare would stillcontinue to be delivered in poor and inapproriate environment. 3. Infection risks would stillcontinue to be considerable. 4.Health risk to patients due tounsatisfactory environment 5. Significant revenue cost

40 70 20 Option not viable 42.5

3

Ward 1, Breast Unit

Building & Oncology

Block

1. UpgradePentland Lodge to house Drugs Trial Unit. 2. Upgrade WestWing to house new Haematology Treatment Unit 3. Upgrade BreakThorugh Lab when available to create extension to new Haematology Unit 4. Upgradevacated space in Ward 1 to create expanded space for Pharmacy and Oncology Treatment area.

1. Relies on University givingback both the West Wing & Break Through Lab accommodation. 2. The West Wing cannot provide Haematology service and protect it through to 2025 hence the need for the Lab to be developed as well 3. The upgrade works in Ward1 need to allow the remaining Oncology service to continue without risk. 4. The Pharmacy servicewould need to decant and a Mobile Aseptic Unit would be required. 5. Potential disruption toadjacent departments including breast unit ward/clinic/theatres

80 75 90 Shortlisted Option 81.25

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4

Ward 1, Breast Unit

Building & Oncology

Block

1. UpgradePentland Lodge to house Haematology (assume no extension required) 2. Upgrade WestWing to house Clinical Trials 3. Upgrade BreakThorugh Lab when available to accommodate the remaining Trials service 4. Upgradevacated space in Ward 1 to create expanded space for Pharmacy and Oncology Treatment area.

1. Relies on University givingback both the West Wing & Break Through Lab accommodation. 2. The West Wing cannot provide Clinical Trials service and protect it through to 2025 hence the need for the Lab to be developed as well 3. The upgrade works in Ward1 need to allow the remaining Oncology service to continue without risk. 4. The Pharmacy servicewould need to decant and a Mobile Aseptic Unit would be required. 5. Potential disruption toadjacent departments including breast unit ward/clinic/theatres 6. Loses the advantage ofadjacency of Haematology to Ward 8 7. Potential disruption toadjacent departments including breast unit ward/clinic/theatres


5

Ward 1, Breast Unit

Building & Clock Tower

Building

1. UpgradePentland Lodge to house Drugs Trial Unit. 2. Upgrade BreakThough Lab when available to house new Haematology Treatment Unit 3. Upgradevacated space in Ward 1 to create expanded space for Pharmacy and Oncology Treatment area.

1. Relies on University givingback the Break Through Lab accommodation at a time that suits the desired programme. 2. The upgrade works in Ward1 need to allow the remaining Oncology service to continue without risk. 3. The Pharmacy servicewould need to decant and a Mobile Aseptic Unit would be required. 4. Relies on Haematologybeing able to be accommodated in the lab 5. Potential disruption toadjacent departments including breast unit


6 Ward 1 & adjacent Car Park

1. Build a ModularExtension to Ward 1 in adjacent Car Park to contain new Drugs Trial Unit and Haematology Unit. 2. Upgradevacated space in Ward 1 to create expanded space for Pharmacy and Oncology Treatment area.

1. The upgrade works in Ward1 need to allow the remaining Oncology service to continue without risk. 2. The Pharmacy servicewould need to decant and a Mobile Aseptic Unit would be required. 3. Loss of Car Parking spacesto hospital. 4. Not good VFM regardingcosts. 5. Layout can be more easiliytailored to suit. 6. Colocation of all Ward 1services 7. May prevent Renal Unitexpansion going ahead as planned

90 80 90 Shortlisted Option 87.5

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7 Phase 1 of Edinburgh

Cancer Centre

1. Build a the firstphase of the new Edinburgh Cancer Centre to accommodate required day chemotherapy service. 2. Abandon Ward1

1. Full design of ECC wouldbe required before phase 1 could be constructed 2. Any buildingdecommissioning and demolition woulod be required before contrstruction 3. Services infrastructurewould have to be in place prior to build 4. Loss of clinical adjacenciesuntil 2025 5. Likely to be subjected todisruption during future construction 6. Cost and time - expensive


8

Ward 1, Clock Tower

Building and St Johns

Hospital Haematology Unit

1. UpgradePentland Lodge to house Drugs Trial Unit 2. ExpandHaematology Unit at St Johns to allow transfer out of some Oncology & Haematology Patients 3. Upgradevacated space in Ward 1 to create expanded space for Pharmacy and Oncology Treatment area 4. RepatriateWard 1 patients to their home boards as appropriate

1. Relies on sufficient spacebeing available at St Johns to create suitable expand that facility 2. Relies of suitable numbersof trained staff being available 3. Relies on vacated spacebeing sufficient at Ward 1 to protect service until 2025 4. Edinburgh patients mayhave to travel to West Lothian to receive treatment 5. This is unl kely to providesufficient capacity to see the service through to 2025. 6.Pharmacy at SJH mayrequire additional support to cope with extra patient numbers.


9

Ward 1, Clock Tower

Building and

Lauriston Building

1. UpgradePentland Lodge to house Drugs Trial Unit 2. Create newHaematology/Oncology Unit in the Lauriston Building to allow transfer out of some Oncology & Haematology Patients 3. Upgradevacated space in Ward 1 to create expanded space for Pharmacy and Oncology Treatment area

1. Relies of suitable numbersof trained staff being available to man and support service 2. No oncology service or co-located ITU/CCU currently in Lauriston 3. Relies on sufficient andsuitable space being available at Lauriston to create suitable expansion of service 4. Relies on vacated spacebeing sufficient at Ward 1 to protect service until 2025 5. Pharmacy support would berequired at Lauriston


10 Ward 1

1. Extendedworking hours 2. Using otherdaycase facilities on the WGH site

1. Leaves Service still unableto cope with increasing patient numbers. 2. Healthcare would stillcontinue to be delivered in poor and inapproriate environment. 3. Infection risks would stillcontinue to be considerable. 4.Health risk to patients due tounsatisfactory environment 5. Significant revenue cost6. Potential patient and staffresistance to extended hours 7. Recruitment, retention andtraining issues


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IV. UPGRADE OF WARDS 2 AND 4 AT THE WESTERN GENERAL HOSPITAL

1. Project Executive Summary

1.1. This section of the overall Initial Agreement focuses on wards 2 and 4 in the ECC. During the feasibility study it was identified that ward 3 should also be included in this proposal. Ward 4 is currently a 22 bedded inpatient ward accommodating oncology patients. Ward 3 is also an oncology ward comprising of 8 inpatient oncology beds. Currently the Oncology Assessment Area (OAA) occupies ward 2.

1.2. In recent HEI inspections it has been identified that the conditions and the environment in these wards are not acceptable for the provision of modern healthcare. The following issues have been identified in these wards:

• Inadequate toilet and shower facilities- unable to use hoist, lack of space for patientsneeding assistance

• Lack of en-suite facilities

• There are several two 4 bedded rooms (sometimes mixed) which share a singletoilet and a single shower between 8 patients

• Small number of single rooms

• Poor patient experience evidenced by feedback received

• The wards lack some of the rooms that a modern facility would have such as adisposal/hold room

• The wards share some facilities with adjacent wards (3 & 6) which is notrecommended or ideal

• The Radiation Treatment Rooms (ward 2, rooms 1 & 2) are no longer fit for purposebeing too small and have some design issues

• Neither ward has mechanical ventilation nor sufficient natural ventilation

• Facilities are not compliant with the Disability Discrimination Act 1995 (DDA)

• There is a lack of isolation rooms

1.4 Collectively these issues result in more patient experience and present an HAI risk. In addition these issues also present a challenge for staff and have an impact on morale.

1.5 The service is faced with an immediate issue due to the conditions of these wards. This issue will be compounded over time as the number of patients being diagnosed and treated for cancer increases. The 2016 Cancer Strategy sets out that “32,000 people in Scotland were diagnosed with cancer in 2013 - an increase of around 12% in a decade. By 2027 this is expected to reach 40,000 a year.”

1.6 The Preferred Way for these wards is a full upgrade of wards 2, 3 and 4. To enable this it is recommended that OAA is relocated to the admin corridor within ECC creating another inpatient ward. Upgrading ward 2 and transforming the area back to an inpatient area is essential to minimise the total number of beds lost and improve on the bed spacing within these wards.

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1.7 The overall cost of this element if carried out in isolation would be . It is requested that once this document completes its Governance journey that an Early Release of funds is approved once to allow for the appointment of a Design Team via a Principal Supply Chain Partner. These funds are estimated at .

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2.1. Staff and Patient Involvement


2.1.2. Patients and service users affected by this proposal include Oncology patients from within the SCAN and patients on the Western General Site. Given the need to expedite this proposal in view of the immediate pressures patients have not been consulted, however consideration has been given to patient complaints, feedback and limited patient surveys in order to ensure plans are developed to address their concerns. The intention is to ensure appropriate patient involvement at the redesign and business case stage.

2.1.3. The general public will not be affected by this proposal by .This has thus not required a public consultation.

2.2. Links to NHS Scotland strategic priorities

NHSScotland Strategic

Investment Priority:


Person Centred


Cancer QPIs


The proposal seeks to reassess and modernise the delivery of inpatient oncology care as delivered across wards 2, 3 and 4 at the Western General Hospital. This intent is driven by a fundamental need to provide fit for purpose space adequate for provision of clinical care. A functional, safe and pleasant environment underpins patient dignity and is a basic requirement of care


Safe Modernisation of the ward environment will bring with it the benefits of modern building construction with standards and

Reduces adverse harmful events

40

compliance ranging widely across all aspects of the build. In terms of impact backlog maintenance this would assume reliable building services, durable fabric and finishes and planned / ease of access as required


The re evaluation of clinical care, patient flows and working practice will generate a planning brief tailored to providing efficiency of working patterns. The re-configuration of outmoded ward space to fit current working practice is one of the key drivers for this proposal.


Improved patient and staff feedback

Value & Sustainability

The provision of improved and more efficient workflows, better healing environments and reliable infrastructure should in turn see monetary benefit.



Health of population

The provision of a modern and fit for purpose environment is essential to inpatient well being and healing. Whilst driven by patient care this brings benefit to all, patients, visitors and staff.

Enables delivery of safe, efficient care


2.3. Strategic Assessment

2.3.1. The strategic assessment scored this proposal 18 out of a possible score of 25. This assessment supports the need for change now. Also illustrated by the assessment is the need to support the proposal to enable NHSScotland’s strategic priorities to be achieved. The measurable benefits which will be realised from the change are also detailed in the assessment.

2.3.2. The Strategic Assessment carried out for this proposal is included in Appendix 3

2.4. Influence of external factors

2.4.1. An HEI inspection in 2014 found the Edinburgh Cancer Centre Wards 2 & 4 to be in poor order with a highly critical report being made on their level of cleanliness. As a result of this assessment a Health and Safety and Manual Handling risk assessment was undertaken which demonstrated that the space available in the ward areas was insufficient to deliver safe care for patients and for staff.

2.4.2. Wards 2 & 4 have failed to comply with infection prevention policy over recent years due to a deteriorating environment within the building fabric of both ward areas. This had

41

increased risk to patient safety to a vulnerable group of patients and had also led to poor patient experience. The outmoded Ward planning was also recognised as unsuitable, making many essential tasks difficult to undertake safely.

2.4.3. Also reported, were related issues for the associated Radionuclide Therapy Rooms. Deficiencies in finished surfaces which could not allow adequate decontamination, drainage issues from sanitary ware and a lack of adequate shielding were all listed as key concerns.

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3. Strategic Case

3.1. Current Service Arrangements

3.1.1. Wards 2, 3 and 4 provide inpatient provides inpatient care for patients receiving radiotherapy or chemotherapy and also for patients who require symptom control, and who cannot be managed as outpatients. The wards will also occasionally accommodate patients from other specialities on the Western General Site.

3.1.2. Ward 3 provides 8 inpatient beds and Ward 4 22 inpatient beds. There are a further two inpatient rooms with radiation protection in the ward below (ward 2) which are used for radionuclide therapy. Ward 2 is currently the Oncology Assessment Area which is the equivalent of the Medical and Surgical Acute Receiving Unit at the Western General Hospital (WGH) and is for patients who have developed acute problems while on active cancer treatment or who have recently completed therapy.

3.2. Accommodation Issues

3.2.1. The conditions and environment in wards 2 and 4 have been well documented and have been subject of critical HEI Reports, most recently in November 2014. The key accommodation issues are summarised below:

• Inadequate toilet and shower facilities- unable to use hoist, lack of space for patientsneeding assistance

• Lack of en-suite facilities

• There are several two 4 bedded rooms (sometimes mixed) which share a single toiletand a single shower between 8 patients

• Small number of single rooms

• Poor patient experience evidenced by feedback received

• The wards lack some of the rooms that a modern facility would have such as adisposal/hold room

• The wards share some facilities with adjacent wards (3 & 6) which is notrecommended or ideal

• The Radiation Treatment Rooms (ward 2, rooms 1 & 2) are no longer fit for purposebeing too small and have some design issues

• Neither ward has mechanical ventilation nor sufficient natural ventilation

• Facilities are not compliant with the Disability Discrimination Act 1995 (DDA)

• There is a lack of isolation rooms

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3.3. Need for change




Non-compliant inpatient facilities – bed spaces inadequate, toilet and showers not DDA compliant, lack of enough single en-suite rooms

Increased risk of infection in vulnerable patient population

Patient care compromised by lack of space and appropriate facilities

Risk of future unfavourable HEI report potentially leading to ward closure

Radionuclide therapy room does not comply with radiation protection and infection control requirements

Risk to patients, staff and visitors of contamination

Increased risk of infection

Inability to use room necessitating patients being sent for treatment elsewhere – expensive and inconvenient

Ineffective service arrangements in part due to poor ward layout and lack of facilities – waiting rooms, single rooms

Inefficient service performance


Service arrangements not person centred with poor patient experience, mixed toilet facilities, privacy issues



Accommodation with high levels of backlog maintenance and poor functionality

Yes - see HEI report

Increased safety risk from outstanding maintenance and inefficient service performance

Building condition, performance and associated risks will continue to deteriorate if action isn’t taken now


3.4.1. Although a new Cancer Treatment Centre is an important cornerstone of the Master Planning development at the Western General Hospital, it is not expected to be available until 2025 at least. Although a change of use for Ward 2 and transfer of inpatients to ward 11 has helped reduce the issues it has not removed all the problems Urgent redesign is therefore now required to ensure the service is fit for purpose providing a safe patient environment and able to meet infection prevention standards for the next 10 years at least.

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Effect of the cause on the organisation: What needs to be achieved to

overcome this need?


Existing inpatient facilities are non-compliant Improve and upgrade ward facilities

Radionuclide therapy facility does not fulfil radiation protection criteria Create fit-for-purpose room(s)

Inefficient service performance due to inadequate facilities

Improve service performance in improved environment

Service is not meeting current or future user requirements Meet user requirements for service


Improve safety and effectiveness of accommodation


Supporting this proposal will deliver a number of measurable benefits:

• A reduction in incident reporting and Serious Adverse Events

• HAI and HBN guidance compliant accommodation

• Improved patient feedback

• Improved staff experience

• Inpatient capacity to place oncology patients in an appropriate environment e.g.benefit from increased number of patients having access to single rooms whereclinically required

3.6. Risks Management Strategy

There are a number of risks which could undermine the benefits that have been described:

• Future increase in service requirements greater than predicted

• Delay in opening of new Cancer Centre leading to lack of space beyond 10 years

• Unpredicted increase in user population over the next 5 years

• The space constraints will mean that there will continue to be some derogations andwhilst this is an improvement there is a risk that not all of the issues described will befully addressed.

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3.7. Constraints and Dependencies

3.7.1. Constraints

• Number of beds achieved by new proposed layout is less than required

• Derogations, for example on bed spacing, not acceptable

• Appropriate decant facilities not available or require extra upgrading thus increasingcosts

• Disruption to adjacent areas including Ward 6, Teenage Cancer Centre and theadministration corridor below deemed unacceptable

• Additional revenue resources/funding not available

3.7.2. Dependencies

• Ability to identify new location for Oncology Assessment Unit if ward 2 required tocreate enough inpatient beds

• Availability of DCN Building to be used a decant facility

• Proposed new Cancer Centre completion date as agreed

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4. Economic Case

4.1. The Options Appraisal Process

A "long list" of fourteen options were drafted with each option tested against primary and secondary objectives specific to the service requirement. All of these fourteen options took cognizance of displacement and impact on adjacent services, both existing and proposed and this context formed an integral part of each proposal. Appendix 4 lists the Objectives that were used to assess the Long List of options and Appendix 5 shows the scores and description of each of these fourteen options.

Once tested and scored the process identified three favoured planning options, in addition to the “Do Nothing” and “Do minimum” options each with the same resulting layout but delivered using differing strategies.

The proposed solution in all these three favoured cases seeks to provide 2 full In-Patient Wards located on the first and second floors in place of existing Wards 2 / 3 and 4. The extended footprint would be possible through a relocation of the OAU service (described in that section of the Initial Agreement). Both floors would be stripped to their shell and rebuilt to provide a modern template. Building services, common to both floors would be reviewed and replaced as required as part of the upgrading.


• The “Do nothing” option involves delivering the inpatients wards service from itscurrent location in Wards 3 & 4

• It leaves the Wards vulnerable to closure.• Healthcare would continue to be delivered in poor and inappropriate environment.• The present layout leaves Patients vulnerable• Infection risks would continue to be considerable


• The “Do minimum” option involves improvements to en-suite facilities and increasingthe number of wash hand basins

• The option would leave the service still vulnerable to closure• Healthcare would still continue to be delivered in poor and inappropriate

environment.• Infection risks would continue to be considerable• Impact on service during any minor works• Reduced bed numbers

4.1.3. Option 06

• Decant all Wards to refurbished Ward 15 Clocktower and University Research Ward.• Upgrade vacated Wards to give two new In Patient Wards (combined 3&4)• OAU remains permanently located at Ward 15 Clocktower.

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4.1.4. Option 11

• Decant Wards 3 & 4 to Ward 15. • Upgrade vacated Wards to give two new In Patient Wards (combined 3 & 4) • OAU would be re-located to new build or upgraded GF development

4.1.5. Option 12

• Decant Wards 3 & 4 to DCN. • Upgrade vacated Wards to give two new In Patient Wards (combined 3 & 4) • OAU would be re-located to new build or upgraded GF development

4.1.6. The three options sought to score decanting arrangements and construction strategies in

tandem with the favoured planning arrangement but with the indicative nature of the costings, and the narrow resulting score band, the process was considered inconclusive.

4.1.7. The options were further developed and a further proposal of a rebuild OAU situated on the Ground floor introduced. This work was used to generate firmer budget costings and the resulting data was then subject to a second option appraisal.

4.1.8. The second OAU option appraisal favoured the development of the ground floor admin corridor for a new OAU department. This proposal would be facilitated through the temporary decanting of the Oncology Wards to DCN and ground floor office space to Ward 15, reconfigured as office space.

4.2. Service change proposals

4.2.1. The main service change associated with this upgrade is the re-profiling of the current wards. This proposal will amalgamate existing ward 3 and 4 and create a new inpatient ward 2.

4.3. Results of Option Appraisal

Option Indicative Costs (£)

Weighted Score

Total Cost per Unit of Weighted Score (£)

Weighted Score

increase compared to "do nothing"

Cost per Weighted Score

increase (compared to

"do nothing") (£)

Position Risk

1 0 0 6 355

2 840 285 5 405

3 1,215 660 4 300

6 1,465 910 3 175

11 1,465 910 2 175

12 1,520 965 1 185

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4.3.1. Preferred strategic / service solution

The preferred solution remains to provide reconfigured and fit for purpose ward space over the first and second floors of the Oncology block. The sister proposal to locate a new OAU into the ground floor of the Oncology block now allows clarity of decant options and presents a clear direction - the full decant of the Oncology block and a full single phase building programme.

The existing wards would be decanted for the duration of the work to DCN with Oncology site self contained and giving minimal impact on adjacent wards.

This proposal brings both preferred solutions, for Wards 2 and 4 and for OAU together with clear economic and logistical advantages to be gained in delivering both as a common project.

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5.1.1. The total indicative costs for the project at this stage are including VAT. Further work will follow to develop these costs and to identify those which are one-off revenue costs and which are capital expenditure. The procurement of the project will be led by members of the Oncology service with support from the Estates Department and Capital Finance on behalf of NHS Lothian.




Milestone

Date

Decant By 9th March 2018 OAU Construction Start Date 12th March 2018 Project Completion Date 3rd December 2018



Prepare Initial Agreement April 2016 June 2016 Lothian Capital Investment Group 14th June 2016 21st June 2016 Finance and Resources Committee 4th July 2016 13th July 2016 SGHD 2nd August 2016 30th August 2016

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Initial Agreement Approval by NHSL 14th June 2016 13th July 2016 Initial Agreement Approval by SGHD 2nd August 2016 30th August 2016 Appointment of PSCP September 2016 November 2016 OBC Approval stage by NHS Lothian December 2016 January 2017 OBC Approval stage by SGHD January 2017 March 2017 FBC Approval stage by NHS Lothian June 2017 September 2017 FBC Approval stage by SGHD September 2017 December 2017 Project Main Construction Start Date 15th January 2018 Project Completion Date 3rd December 2018


5.2. Financial Case

5.2.1. Introduction

This chapter:



The estimated overall capital costs of the project are . A summary of the capital costs is shown in the table below, with detailed indicative costs presented at Appendix 2.

The key capital assumptions are:

• The construction costs are an indicative value, and assume no accelerated working.

• Construction costs do assume the project would involve a significant level of refurbishment & modernisation throughout.

• Construction costs include an inflation allowance, separately identified above;

• VAT at 20% has been applied to relevant costs;

• VAT recovery has been assumed where appropriate. A final assessment of VAT recovery will be given by VAT advisors on completion of the project; and

• Costs include a risk allowance/ optimism bias of 12%.

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Construction Costs

Fees


Equipment and IT

Inflation Allowance

Risk Allowance

Sub Total

VAT

Total Costs

Summary of Capital Costs 5.2.3. Revenue affordability


• Recurring staff costs

• Recurring non pays

• Estates, facilities and property costs

• Consumables and revenue equipment

• Depreciation

At this stage it is estimated that the 15.78 whole time equivalent band 5 staff nurses will be required for the duration of the construction work. This revenue requirement presents to the splitting of the establishment for ward 3 and the Teenage and Young Adult Ward It is assumed that the Teenage and Young Adult unit will remain in the adjoining ward 3 location for the duration of the upgrade, however discussions with the Teenage Cancer Trust may be required if this is not identified as being practical. This non-recurring revenue requirement will also need to ensure that the bleep holder is supervisory at night in order to cover breaks in Teenage and Young Adult ward. The decant solution for this preferred option will also mean that non-recurring clinical support worker resource will be required to support patient transfer between DCN the radiotherapy department and other cancer services (which will remain in the current ECC). To support this non-recurring revenue for 2.62 whole time equivalent band 2 clinical support worker resource will be required.

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6. Appendices






54


55

57

The above page has been redacted from the public version of the document on the basis that it contains commercially sensitive data

6.4. Appendix 4: Wards 2 & 4 Options Appraisal Objectives

Primary Objectives

• Create modern, HEI compliant facilities• Enable staff to deliver safer healthcare• Maintain requisite inpatient bed numbers• Create new compliant radio-nuclide treatment rooms• Sustainability until 2025• Service delivery must be safely maintained for the duration of any works• Risk – free option with regards to deliverability



• Located near supporting Oncology facilities;• Find suitable decant facilities if required in an acceptable location for all Wards;• Easily accessible to patients and visitors• A fully serviced facility must be created including Piped Medical Gases as needed;• IT infrastructure should be able to support all requirements;

Space Requirements

The Inpatients Ward(s) unit should contain:

• Better bed spacing;• Associated support facilities;• Staff areas;• Overnight relatives room• En-suite facilities for each bed room• 50% single rooms• Radio-nuclide treatment rooms with lobby entrance;

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6.5. Appendix 5: Options Appraisal Description & Scoring

Options Locations Description Issues Compliance with Primary

Objectives (%)

Compliance with Secondary Objectives Comments Final Score (%)

Location, Access & Services Infrastructure Space Requirements

1 Oncology Inpatient

Wards (2, 3 &4)

Status Quo

1. Leaves Wards vulnerable toclosure. 2. Healthcare being delivered inpoor and inappropriate environment. 3. Infection risks considerable


2 Oncology Inpatient

Wards (2, 3 &4)

Do Minimum (reduce bed

numbers, improve en-suite

facilities and create compliant

radio-nuclide rooms in Ward

3)

1. Still Leaves Wards vulnerable toclosure. 2. Healthcare would continue to bedelivered in poor and inappropriate environment. 3. Infection risks would continue tobe considerable


3

Clock Tower Building & Oncology Inpatient Wards

1. Decant OAAto Ward 15. 2. Upgradevacated Ward 2 creating a new OAA. 3. ReducePatient Beds in Ward 4 4. Decant Ward4 to Ward 15 after OAA moves back. 5. UpgradeWard 4 6. Transfer Ward 4 back from Ward 15.

1. Decant arrangements takes awayWGH Winter Beds ward. 2. Loss of 12 to 16 beds toOncology and WGH site as a whole on completion. 3. Ward 15 could be used as anEmergency Winter Beds Ward on completion. 4. Cheaper Option5. Ward 15 would requireinvestment to create a suitable decant facility 6. Upgrade of Wards 2 and 4surrounded by fully occupied and operational wards

75 85 85 Shortlisted option 80

60

4


1. Permanentlydecant all wards to Ward 15 & University Research Ward. 2. UpgradeClock Tower accommodation as required. 3. UpgradeWard 3 as required. 4. AbandonWards 2 & 4.

1. Cheap Option but Ward 15 andUniversity Ward will need investment to support long term occupation. 2. Limited loss in-patient bednumbers. 3. Wards 2 & 4 could become theWinter Beds Wards for Hospital. 4. Location of OAA remote frommain entrances to Oncology. 5. Relies on University handing theaccommodation back 6. Potential risk to programme delaydue to accommodation availability.


5


1. Decant OAAto Ward 15. 2. Upgradevacated Ward 2 creating a new OAA. 3. ReducePatient Beds in Ward 4

1. Decant arrangements takes awayWGH Winter Beds ward. 2. Loss of 12 to 16 beds toOncology and WGH site as a whole on completion. 3. Ward 15 could be used as anEmergency Winter Beds Ward on completion. 4. Cheaper Option5. Ward 4 would not be modernisedand still have issues 6. Ward 15 would requireinvestment to create a suitable decant facility 7. Upgrade of Ward 2 surrounded byfully occupied and operational wards


6


1. Decant allwards to Ward 15 & University Research Ward. 2. Upgradevacated wards as appropriate to create a new inpatients wards combining Wards 3 & 4, 3. Leave OAA inClock Tower Building

1. Decant arrangements temporarilytakes away WGH Winter Beds ward. 2. Relies on University giving backtheir Clock Tower accommodation. 3. Loss of circa 4 beds to Oncologyand WGH site as a whole on completion. 4. Ward 15 would requireinvestment to create a suitable decant facility 5. Potential risk to programme dueto accommodation availability. 6. Location of OAA remote frommain entrances to Oncology

85 80 90 Shortlisted option 85

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7


1. UpgradeWard 15 to accommodate Wards 2. Decant Wards 3 & 4 to Ward 15. 3. Upgradevacated wards as a new OAA. 4. Move OAA toWard 4, abandoning Ward 2.

1. Decant arrangements takes awayWGH Winter Beds ward. 2. No loss of beds to Oncology andWGH site as a whole on completion. 3. Ward 2 could be used as anEmergency Winter Beds Ward. 4. Cheaper Option5. Ward 15 would require substantialinvestment to create a suitable facility


8


1. Decant allwards to Ward 15 & University Research Ward. 2. Upgradevacated wards as appropriate to create a single inpatients ward combining Wards 3 & 4, and a new OAA in Ward 2

1. Decant arrangements takes awayWGH Winter Beds ward. 2. Relies on University giving backtheir Clock Tower accommodation. 3. Loss of circa 16 beds to Oncologyand WGH site as a whole on completion. 4. Ward 15 would requireinvestment to create a suitable decant facility


9

DCN Building & Oncology Inpatient Wards

1. Decant allwards to DCN Inpatient Wards once it has been transferred to new DCN Building on the RIE Campus. 2. Upgradevacated wards as appropriate to create a single inpatients ward combining Wards 3 & 4, and a new OAA in Ward 2

1. Decant arrangements have towait until DCN transfers automatically delaying construction start date. 2. Assumes being able to use thevacated DCN space without investment. 3. Means that the DNC InpatientWards will still to be maintained and serviced delaying taking it out of use and demolishing it. 4. Loss of circa 16 beds to Oncologyand WGH site as a whole on completion. 5. Remote from other Oncologyservices


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10

DCN Building & Oncology Inpatient Wards

1. Permanentlydecant all wards to DCN Inpatient Wards once it has been transferred to new DCN Building on the RIE Campus. 2. UpgradeDCN as required. 3. Ward 3upgraded as required. 4. Abandonvacated wards

1. Decant arrangements have towait until DCN transfers automatically delaying any upgrades works and decant start date. 2. Relies on being able to use thevacated DCN space until a new Edinburgh Cancer Centre is built. 3. Means that the DCN InpatientWards will still to be maintained and serviced delaying taking it out of use and demolishing it. 4. No loss of beds to Oncology andWGH site and additional winter Beds Wards available. 5. New design/campus locationwould be required for new Edinburgh Cancer Centre. 6. Assumes that DCN after anyminor upgrade would provide better and more compliant facilities. 7. Remote from other Oncologyservices for an extended period resulting in some revenue consequences 8. Compromising patient experiencepathways due to physical separation of facilities and staffing cover


11

Oncology Inpatient

Wards and Oncology

Upper Ground Floor

Entrance Car Park

1. Build newOAA in Car Park area, building new Oncology Entrance, moving RVS shop and changing Car park and Entrance road as required. 2. Decant Wards 3 & 4 to Ward 15 after transferring OAA to new building. Upgrade vacated wards as inpatients wards (2, 3 & 4).

1. Costly option and unlessoccupation period rises to circa 20 years plus, does not offer good Value For Money (VFM). 2. Loss of circa 4 beds to Oncologyand Hospital on completion. 3. Causes severe disruption andimpact on Public, Patients, and staff during new build construction. 4. New build delays start of Wardsupgrade extending programme time. 5. Assumes being able to use thevacated Ward 15 space without investment.

85 75 90 Shortlisted option 83.75

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12

Oncology Inpatient

Wards and Oncology

Upper Ground Floor

Entrance Car Park

1. Build newOAA in Car Park area, building new Oncology Entrance, moving RVS shop and changing Car park and Entrance road as required. 2. Decant Wards 3 & 4 to DCN after transferring OAA to new building. Upgrade vacated wards as inpatients wards.

1. Costly option and unlessoccupation period rises to circa 20 years plus, does not offer good VFM. 2. Loss of circa 4 beds to Oncologyand Hospital on completion. 3. Causes severe disruption andimpact on Public, Patients, and staff during new build construction. 4. New build delays start of Wardsupgrade extending programme time. 5. Assumes being able to use thevacated DCN space without investment.

85 75 90 Shortlisted option 83.75

13 Various

WGH Wards and Ward 3

1. Once 80 bedsare closed around the WGH (3 Wards), use these to transfer Wards 2 & 4 at no capital cost. 2. UpgradeWard 3 as required. 3. AbandonWards 2 & 4.

1. Location of Wards may mean thatOncology service is scattered around WGH campus. 2. The OAA would still be occupyinga facility designed as an Inpatients ward, albeit a better more modern ward. 3. Cheaper option.4. Allows Wards 2 & 4 to bepotentially used as emergency Winter Beds wards. 5. Option dependent on closure of80 beds within acceptable timescales and ability to cohort Oncology beds in discrete wards 6. Ward 3 may not be viable tomanage radio-nuclide rooms in isolation


14 Various

WGH Wards and Wards 2

& 3

1. Once 80 bedsare closed around the WGH (3 Wards), use these to transfer Wards 2 & 4 at limited capital cost. 2. UpgradeWard 3 as required. 3. AbandonWard 4. 4. UpgradeWard 2 to create new purpose built OAA.

1. Location of Wards may mean thatOncology service is scattered around WGH campus. 2. The OAA would be occupying apurpose designed facility. 3. Allows Ward 4 to be potentiallyused as emergency Winter Beds ward. 4. Cheaper option.5. Option dependent on closure of80 beds within acceptable timescales and ability to cohort Oncology beds in discrete wards 6. Ward 3 may not be viable tomanage radio-nuclide rooms in isolation


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V. REDESIGN OF THE ONCOLOGY ASSESSMENT AREA AT THE WESTERN GENERAL HOSPITAL EDINBURGH

1. Project Executive Summary:

1.1 This section of the overall Initial Agreement focuses on the Oncology Assessment Area which is delivered from Ward 2 in the main Oncology block on the Western General Hospital site. This ward was originally an inpatients ward however following a poor HEI Inspection Report the Oncology Assessment Area was transferred from Ward 11 to ward 2 with the inpatients transferring from ward 2 to Ward 11. OAA was established in 2010 and comprised of a discreet area containing 3 trolleys to treat urgent patients. In the past 6 years the demand for acute oncology has risen and the area now occupies a full ward. In addition to assessing urgent cancer patients on active treatment, OAA also accommodates some ambulatory and elective patient flows. The ward also includes the radionuclide rooms for inpatient treatment. The increasing demand in OAA is correlated to the increasing demand and activity across oncology which is expected to increase.

1.2 The condition, layout and design of this former inpatient ward does not provide a fit for purpose environment. The increase in patient numbers and desired patient pathway means a inefficient service with clinical risks due a lack of observation of all patients all within an out of date design. This has contributed directly to some clinical and serious Datix incidents. It is now considered a high risk service area. The situation urgently needs addressing to reduce the risk of clinical incidents and to improve the facility for patients, visitors and staff alike.

1.3 OAA requires a layout that is configured as an assessment to their specific requirements; it is not sufficient to modernise the fabric and improve the inadequate shower and toilet accommodation. The environment of OAA needs to enable good patient pathway, providing for triaging incoming patients, good observation of patients within a range of chairs and trolleys, and sufficient isolation and counselling rooms to support the service.

1.4 The Preferred Way focuses on locating the Service in best location for patients and clinical staff. This means that the ground floor Admin Corridor sees a complete change of use leading to a specific clinical area being created that will provide a fit for purpose service for the next 10 to 15 years. The Admin corridor staff includes many Consultants and their staff and although the original option called for them to be re-located to Ward 15, it is expected that NHS Lothian will not allow Ward 15 to be used for this purpose. The costs and plans contained within this document will therefore assume that outcome and the contents will reflect that decision.

1.5 A summary of the Option is the Oncology Assessment Unit to decant along with the Admin Corridor staff and Wards 3 & 4 to the DCN Building. The works would then start to create a new Admin. Modular Building and to create a new Oncology Assessment Unit in the vacated Admin area whilst Wards 2, 3 & 4 are being upgraded above it.

1.6 The overall cost of this element if carried out in isolation would be . It is requested that once this document completes its Governance journey that an Early Release of funds is approved once to allow for the appointment of a Design Team via a Principal Supply Chain Partner. These funds are estimated at .

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2.1. Staff and Patient Involvement

2.1.1. Staff affected by this proposal includes medical, nursing and other members of the oncology multidisciplinary team. Their involvement in its development includes review of the feasibility study proposals, participation in workshops and input to the project brief.


2.1.3. Given the need to expedite this proposal in view of the immediate pressures patients have not been consulted, however consideration has been given to patient complaints, feedback and limited patient surveys in order to ensure plans are developed to address their concerns. The intention is to ensure appropriate patient involvement at the redesign and business case stage.

2.1.4. The general public will not be affected by this proposal by .This has thus not required a public consultation.

2.2. Links to NHS Scotland strategic priorities



How the proposal responds to this priority

As measured by:

Person Centred


Cancer QPIs


The proposal seeks to reassess and modernise the delivery of oncology care as delivered within OAA at the Western General Hospital. This intent is driven by a fundamental need to provide fit for purpose space adequate for provision of clinical care. A functional, safe and pleasant environment underpins patient dignity and is a basic requirement of care


Safe Reduces adverse harmful events

Modernisation of the clinical environment will bring with it the benefits of modern building construction with standards and compliance ranging widely across all aspects of the build. In terms of impact

Reduction in DATIX incident reporting

66

backlog maintenance this would assume reliable building services, durable fabric and finishes and planned / ease of access as required.


The re evaluation of clinical care, patient flows and working practice will generate a planning brief tailored to providing efficiency of working patterns. The replacement of outmoded ward space with an environment suited to current working practice is one of the key drivers for this proposal.

Reduction in DATIX incident reporting


Increases level of staff engagement (QOI)

The provision of improved and more efficient workflows, better healing environments and reliable infrastructure will support expected increase in demand.

Percentage of staff who say they would recommend their workplace as a good place

Enable service to accommodate increases in demand in a safe and efficient way.

Health of the Population

The provision of a modern and fit for purpose clinical environment is essential to patient well being and healing. Whilst driven by patient care this brings benefit to all, patients, visitors and staff.

2.3. Links to other policies and strategies

2.3.1. The whole System Patient Flow Improvement Programme

2.3.2. This strategy sets out that systems should be “designed to ensure patients receive the right care, at the right time, in the right place, by the right team” thereby ensuring an optimal patient pathway. This proposal would establish an assessment area that is designed to ensure an effective patient flow.

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2.4. Strategic assessment

2.4.1. The strategic assessment scored 21 out of a possible score of 25. This score demonstrates the need to support this change in order to address immediate service pressures and enable delivery of NHSScotland’s strategic priorities.

2.4.2. The Strategic Assessment carried out for this proposal is included in Appendix 3

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3. Strategic Case

3.1. Current Service Arrangements

3.1.1. The Oncology Assessment Area (OAA) is the Cancer Services equivalent of the Medical and Surgical Acute Receiving Unit at the Western General Hospital (WGH) and is for patients who have developed acute problems while on active cancer treatment or who have recently completed therapy. Patients are referred in from across the SCAN region although, if they self-refer through CTH, they may be asked to attend a hospital closer to home rather than WGH if appropriate. Other routes of referral into OAA include; patients from the treatment floors and the outpatient clinics, by GP’s and also from other departments and hospitals, or self-refer through a dedicated phone line (Cancer Treatment Helpline, CTH). Referrals are received in to OAA out of hours. The patients are triaged, assessed and then treated and discharged, or admitted as appropriate.

3.1.2. It is a service which has evolved and expanded over the past couple of years and is still being developed. Over a six year period OAA has expanded from an area accommodating 3 trolleys to occupying the space of a full ward inpatient. This rate in growth is related to the overall increase in demand and activity in oncology; 2016 Cancer Strategy describes that cancer diagnoses have increase by 12% in a decade. The increased demand is reflective of a number of key drivers:

• An aging population • An increasing population (9% rise in Lothian 2010-2014) • Increased cancer incidence • Improved diagnostics • Increased screening • Increasing lines • The increasing number of effective treatment options that have been licensed and

SMC approved and increasing use of multiple lines of SACT mean that it is foreseeable that demand for acute oncology will also increase.

3.1.3. Specifically for OAA the introduction of the CTH has also contributed to the increase in

demand. Due to capacity pressures in Ward 1 a proportion of supportive therapies have been displaced to OAA. If the proposal for Ward 1 is supported this would enable repatriation of selective supportive therapies in view of the expanded space.

3.1.4. In addition to the different flows of patients through OAA it is also used as “flexible capacity” to accommodate patients when the inpatient demand exceeds the bed footprint within ECC and occasionally to support flows on the WGH site.

3.1.5. Previously urgent cancer patients were referred through the Acute Receiving Unit at the WGH. When this arrangement was in place the 4 hour HEAT standard for 98 per cent of patients to wait less than 4 hours from arrival to admission, discharge or transfer for acute treatment was applicable. Following the inception of OAA this standard is no longer applicable for oncology patients, however prompt assessment and treatment of the most acutely unwell oncology patients remains a service priority to ensure a safe and quality service.

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3.2. Current Physical Environment

3.2.1. The current OAA accommodation is not configured to safely support the patient flows that have been described. OAA currently comprises of:

• radionuclide inpatient treatment rooms • 9 trolleys • 6 ambulatory chair spaces • singles rooms • Triage area • Clinical Hub

3.2.2. OAA has only been in its current form since 2014 which means that there is limited data to demonstrate activity through the department. Data analysis conducted thus far has demonstrated that there is an average of 248 emergency referrals received per month, of which an average of 137 patients are admitted as emergencies; average admission rate is 55%. The elective day case demand is approximately 170 patients per month with an average of 34 elective admissions. The graph below sets out the planned and unplanned admissions between August 2015 and May 2016. Work is also underway to understand the admission profile in order to develop a predictor for planning the workload through OAA.

Ward Admissions in OAA

050

100150200250300350400

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Month

No.

of a

dmiss

ions

Planned Unplanned

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3.3. Current Accommodation Issues

As already set out there are a number of issues with the current configuration and quality of the OAA accommodation. The key issues are:

• the layout is not conducive to efficient patient management and results in poor patient flow

• the ward layout does not allow for close observation of patients • a lack of enough isolation rooms with en suite facilities • inadequate waiting room space • non-DDA compliant toilets • radio nuclide rooms require urgent upgrade work

3.4. Service change proposals

3.4.1. The rate of growth in demand for oncology services means that redesign must feature as an essential part of service delivery. Increased activity and demand is a positive development for patients, however presents the service with a challenge to continually evolve an infrastructure at a rate to support. This issue is compounded by the financial position across NHS Scotland. Current redesign projects and service change proposals underway are detailed below.

3.4.2. A quality improvement project has been initiated to review the different flows of patients through OAA with a view to stratifying the patient pathways. A key component of this work is developing an understanding of key performance measures e.g. developing predictor tool to assess other ways to plan admissions and reviewing performance against time from referral, admission and assessment. There is also a requirement to evolve an understanding of the impact on admission rates in the context of increasing demand and activity.

3.4.3. If the proposal for Ward 1 expansion is supportive the intention is to repatriate selected supportive therapies that are currently delivered in OAA back to Ward 1.

3.4.4. In the context of increasing cancer incidence and increasing patient activity the need for acute oncology will expand. The Oncology Service is will need to further develop the acute oncology model of care to further enhance coordination of care and early decision making.

3.4.5. In line with other acute assessment areas on the WGH campus it is proposed that OAA is re-branded to the Oncology Assessment Unit (OAU).

3.5. Need for Change

3.5.1. This proposal should be progressed for two reasons:

• The service is faced with an immediate pressure as the OAA environment is not fit for purpose to accommodate the patient flows in a safe and efficient way meaning that action is required now.

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• It is expected that oncology demand and activity will continue to rise meaning which will increase patient volume through OAA. This means that the issues that are already described will become more pronounced as demand and activity increase.

3.5.2. The current accommodation is not fit for purpose now and the risks associated with the

issues described will increase over the next 9-10 years while the service waits for a new ECC. Progressing this proposal will improve the environment for patients, enable effective patient flows through the department and address the safety concerns that have been highlighted.




Inadequate facilities including lack of enough isolation rooms with en-suite facilities

Increased risk of infection and adverse events

Facilities are non-compliant

Physical space constraints and poor environment- not able to safely observe patients

Effect on staff safety and morale

Need to retain trained workforce

Future service demand predicted to increase

Existing capacity is unable to cope with future projections of demand

Service sustainability will be at risk in the future if this proposal isn’t implemented now

Inefficient layout of Unit, inadequate waiting rooms

Ineffective service arrangements

Inefficient service performance. Poor patient flow


Service arrangements not person centred – Non-DDA compliant toilets, lack of privacy and patient space



Accommodation with high levels of backlog maintenance and poor functionality


Building condition, performance and associated risks will continue to deteriorate if action isn’t taken now

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Effect of the cause on the organisation: What needs to be achieved to overcome

this need?


Increased risk of infection and adverse events

Upgrade facilities to produce compliant accommodation

Inefficient service performance and poor patient flow

Improve service performance by redesign of layout of Unit

Existing capacity is unable to cope with future projections of demand Improve and expand service capacity


Meet user requirements for service by improving the patient experience through upgrade of facilities

Poor staff morale Improve the working environment and reduce pressures through improved patient care


Improve safety and effectiveness of supporting accommodation


Supporting this proposal will deliver a number of measurable benefits:

• Reduction in incident reporting and significant adverse events

• Fit for purpose accommodation will a review of patient flows to ensure that patients are treated in the right place at the right time by the right people. The time from referral to admission to assessment is a metric that is currently being collected. Improving the accommodation will enable a review of the patient pathway and an improvement in the performance time between referral, admission and assessment. This is a vital performance measure to be monitored to ensure quality of the acute oncology service.

• Improvement in patient feedback and reduction in complaints

• Improvement against HEI and HBN standards

• Improved staff experience

• CTH performance measures will be improved

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3.8. Risks Management Strategy

There are two key risks which could undermine the benefits that have been described:

• Future increase in service requirements greater than predicted • Delay in opening of new Cancer Centre leading to lack of space beyond 10 years

3.9. Constraints and Dependencies

The proposed solution to address the issues has a number of constraints and dependencies which are set out in the table below.

3.9.1. Constraints

• Finding an appropriate site for the new unit • Appropriate decant facilities not available • Derogations on space around chairs or trolleys not accepted • Capital cost of new Unit • Revenue implications of redesigned Unit

3.9.2. Dependencies

• If new build – loss of car parking spaces • Disruption to adjacent areas during project • Date for completion of proposed new Cancer Centre delayed

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4. Economic Case

4.1. The Options Appraisal Process

A Long List of fourteen options was identified for reprovision of the OAU with each option tested against primary and secondary objectives specific to the service requirements. All of these fourteen options took cognisance of displacement and impact on adjacent services, both existing and proposed and this context formed an integral part of each proposal.

The Primary and Secondary Objectives and the full Long List of Options are shown in Appendices 4 and 5 respectively. This Long List options were scored against their delivery of the Primary and Secondary Objectives allowing the list to be trimmed. The Appendix also shows the scores that were assigned to each option, which allowed them to be reduced to 3 viable options in addition to the “Do Nothing” and the ”Do Minimum” options.

The full Option Appraisal process was then undertaken for the 5 options short listed from the Long List of Options. This was done in accordance with the guidance detailed in the revised Scottish Capital Investment Manual (SCIM) including scoring benefits, risks and costs.


• The “Do nothing” option involves delivering the OAU service from its current location in Ward 2

• It leaves Wards vulnerable to closure. • Healthcare would continue to be delivered in poor and inappropriate environment. • The present layout leaves Patients vulnerable • Infection risks would continue to be considerable


• The “Do minimum” option involves improvements to en-suite facilities and increasing the number of wash hand basins

• The option would leave the service still vulnerable to closure • Healthcare would still continue to be delivered in poor and inappropriate

environment. • Infection risks would continue to be considerable • Impact on service during any minor works • Reduced bed numbers

4.1.3. Option 05: New build OAA into Oncology car park

• Build new OAA in Car Park area, building new Oncology Entrance, moving RVS shop and changing Car park and Entrance road as required.

• Decant Wards 3 & 4 to Ward 15 after transferring OAA to new Building. • Upgrade vacated wards 2, 3 & 4 as inpatients wards.

4.1.4. Option 11: OAA located into current Ward 3 & 4

• Decant Wards 3 & 4 to Ward 15. • Upgrade vacated wards as a new OAA. • Move OAA to Ward 3&4, abandoning Ward 2.

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4.1.5. Option 13: OAA located on ground floor / main entrance

• Transfer the Admin Corridor (South) offices to Ward 15 • Upgrade Admin Corridor Offices to create new OAA. • Transfer OAA from Ward 2 to new facility • Decant Wards 3 & 4 to Ward 2 temporarily reducing bed numbers • Upgrade Wards 3 & 4 • Transfer Wards 3 & 4 back • Upgrade Ward 2 to create new inpatient ward

4.1.6. The three options sought to score decanting arrangements and construction strategies

in tandem with the favoured planning arrangement but with the indicative nature of the costings, and the narrow resulting score band, the process was considered inconclusive.

4.2. Preferred strategic / service solution

The options were re assessed and developed to allow better understanding of the impact within context of the proposed sites. This work allowed a refinement of the budget costs attached to each option. On completion of this exercise a second option appraisal was conducted to assess the following three planning alternatives:

4.2.1. Option 01 – New build OAA located within Oncology car park

• Temporary decant of wards to DCN • Construction of a new stand alone OAA building

4.2.2. Option 02 - OAA located within Oncology ground floor / admin corridor

• Temporary decant of wards to DCN • Admin office space permanently relocated to Ward 15 Clocktower • Alteration to ground floor to form new dedicated OAA

4.2.3. Option 03 - OAA located within Oncology ground floor / admin corridor

• Temporary decant of wards to DCN • Admin office space relocated to modular office space within Oncology car park • Alteration to ground floor to form new dedicated OAA

4.2.4. The second pass Option Appraisal scored clearly in favour of Option 2.

4.2.5. Option 2 seeks to reconfigure the empty Ward 15 to office accommodation and allow relocation of the Oncology ground floor Admin offices to this space. The vacated ground floor Admin corridor would then be developed in full as a dedicated front door OAA Department. This proposal was clearly favoured for a number of reasons:

• Ward 15 was seen as being better suited to office space accommodation than clinical ward space - on investigation the proposed mix (and number) of Oncology offices to be located here worked well

• The ground floor admin corridor was seen as being better suited to clinical space than office space, being related as it is to adjacent wards, supporting services and front door access.

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• The proposed OAA (wherever it would be located) required a specific footprint to accommodate its planning configuration. With a narrow entrance, linear waiting and triage area feeding into a deep plan of beds and trolley area (radiated around a central hub) the footprint is unlike typical ward space. By good fortune the ground floor admin area provides this kidney shaped footprint.

• The drop off area and south entrance could be adjusted to provide a dedicated OAA front door – this assisting patient access and efficiency of throughput.

• The development of the upper floors would have required the decanting of the ground floor throughout an extensive building programme. The expense and disruption of a part phased works may now be replaced with economy of scale and an uninterrupted, low impact programme given full building (all floors) redevelopment.

• The proposed vacating of the DCN was seen as fortuitous giving a workable and value for money decant option for the Oncology project. The programmed DCN vacation could be met and tailored to the Oncology requirement as a final use of the DCN building life. A planning exercise and condition assessment showed the DCN to be well suited for temporary occupation of Oncology Ward space.

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5.1.1. The total indicative costs for the project at this stage are including VAT. Further work will follow to develop these costs and to identify those which are one-off revenue costs and which are capital expenditure. The procurement will be led by members of the Oncology service with support from the Estates Department and Capital Finance on behalf of NHS Lothian.




Milestone

Date

Decant by 9th March 2018 OAU Construction Start Date 12th March 2018 Project Completion Date 16th November 2018




Initial Agreement Approval by NHSL 14th June 2016 13th July 2016 Initial Agreement Approval by SGHD 2nd August 2016 30th August 2016 Appointment of PSCP September 2016 November 2016 OBC Approval stage by NHS Lothian December 2016 January 2017 OBC Approval stage by SGHD January 2017 March 2017 FBC Approval stage by NHS Lothian June 2017 September 2017 FBC Approval stage by SGHD September 2017 December 2017 Project Main Construction Start Date 15th January 2018 Project Completion Date 16th November 2018



Prepare Initial Agreement April 2016 June 2016 Lothian Capital Investment Group 14th June 2016 21st June 2016 Finance and Resources Committee 4th July 2016 13th July 2016 SGHD 2nd August 2016 30th August 2016

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5.2. Financial Case

5.2.1. Introduction

This chapter:



The estimated overall capital costs of the project are . A summary of the capital costs is shown in the table below, with detailed indicative costs presented at Appendix 2.


Construction Costs

Fees


Equipment and IT

Inflation Allowance

Risk Allowance

Sub Total

VAT

Total Costs

5.2.3. The key capital assumptions are:

• The construction costs are an indicative value, and assume no accelerated working.

• Construction costs do assume the project would involve a significant level of refurbishment & modernisation throughout.

• An inflation allowance from June 2016 is separately identified • VAT at 20% has been applied to relevant costs; • VAT recovery has been assumed where appropriate. A final assessment of VAT

recovery will be given by VAT advisors on completion of the project; and • Costs include a risk allowance/ optimism bias of 12%.

5.2.4. Revenue affordability


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• Recurring staff costs • Recurring non pays • Estates, facilities and property costs • Consumables and revenue equipment • Depreciation

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6. Appendices






81


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6.4. Appendix 4: Options Appraisal Objectives

Primary Objectives • Create modern, compliant facilities • Located near front door access • Allow for improved Healthcare delivery • Improved observation of all Patients • The new OAU must be able to sustain service until 2025; • Improve the patient flow for more efficient service • New layout must improve privacy and dignity for patients • Risk – free option with regards to deliverability



• Located near supporting Oncology facilities; • Find suitable decant facilities • Easily accessible to patients and staff • A fully serviced facility must be created including piped medical gases as needed; • IT infrastructure should be able to support all requirements Space Requirements

• Better trolley and chair spacing; • Layout must enhance observation for better monitoring of all patients • Associated support and staff facilities; • Suitable, DDA compliant facilities • Some single rooms for isolation • Central staff base location • A layout that allows a Triage system; • Open Plan design with cubicles taking account of Patient Privacy; • Waiting area by the entrance; • Space to cope with a maximum of 30 patients at any one time • Patients spaces with natural daylight & external view;

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6.5. Appendix 5: Options Description & Scoring

Options Description Issues

Compliance with

Primary Objectives

(%)

Compliance with Secondary Objectives

Comments Final Score (%)

Location and

Access Space

Requirements

1 Do Nothing

1. Leaves Wards vulnerable to closure. 2. Healthcare would continue to be delivered in poor and inappropriate environment. 3. The present layout leaves Patients vulnerable 4. Infection risks would continue to be considerable

20 80 20 35

2

Do Minimum: Improve en-suite

facilities and increase sink

numbers

1. Still leaves Wards vulnerable to closure. 2. Healthcare would still continue to be delivered in poor and inappropriate environment. 3. Infection risks would continue to be considerable 4. Impact on service during any minor works 5. Reduced bed numbers

25 80 25 38.75

3

1. Decant all wards to Ward 15 & University Research Ward. 2. Upgrade vacated wards as appropriate to create a single inpatients ward combining Wards 3 & 4, and a new OAU in Ward 2

1. Decant arrangements takes away WGH Winter Beds ward. 2. Relies on University giving back their Clock Tower accommodation. 3. Loss of circa 16 beds to Oncology and WGH site as a whole on completion. 4. Some investment will be required for the decant facility

60 80 65 66.25

4

1. Decant all wards to DCN Block once it has been transferred to new DCN Building on the RIE Campus. 2. Upgrade vacated wards as appropriate to create a single inpatients ward combining Wards 3 & 4, and a new OAU in Ward 2

1. Decant arrangements have to wait until DCN transfers automatically delaying construction start date. 2. Relies on being able to use the vacated DCN space. 3. Means that the DCN block will still to be maintained and serviced delaying taking it out of use and demolishing it. 4. Loss of circa 16 beds to Oncology and WGH site as a whole on completion. 5. Some investment may be required for the decant facility

55 80 65 63.75

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5

1. Build new OAA in Car Park area, building new Oncology Entrance, moving RVS shop and changing Car park and Entrance road as required. 2. Decant Wards 3 & 4 to Ward 15 after transferring OAA to new Building. 3. Upgrade vacated wards 2, 3 & 4 as inpatients wards.

1. Costly option and unless occupation period rises to circa 20 years plus, does not offer good VFM. 2. Loss of circa 4 beds to Oncology and Hospital on completion. 3. Causes severe disruption and impact on Public, Patients, and staff during new build construction. 4. New build delays start of Wards upgrade extending programme time. 5. Loss of disabled car parking spaces

85 85 90 86.25

6

1. Upgrade Clock Tower accommodation as required. 2. Transfer all wards, including OAU to Ward 15 & University Research Ward. 3. Upgrade Ward 3 as required. 4. Abandon Wards 2 & 4.

1. Ward 15 and University Ward will need significant investment to support long term occupation. 2. Limited loss in-patient bed numbers. 3. Wards 2 & 4 could become the Winter Beds Wards for Hospital. 4. Location of OAU remote from main entrances to Oncology as well as hospital services 5. Assumes being able to use University area within required timescales 6. Leaves Ward 3 and TCU as a small ward that would need to be managed in isolation.

15 40 25 23.75

7

1. Upgrade DCN as required once it has been transferred to new DCN Building on the RIE Campus. 2. Transfer all wards, including OAU to DCN Block . 3. Ward 3 upgraded as required. 4. Abandon vacated wards

1. Decant arrangements have to wait until DCN transfers automatically delaying any upgrades works and decant start date. 2. Relies on being able to use the vacated DCN space until a new Edinburgh Cancer Centre is built. 3. Means that the DCN block will still to be maintained and serviced delaying taking it out of use and demolishing it. 4. No loss of beds to Oncology and WGH site and additional winter Beds Wards available. 5. New design/campus location would be required for new Edinburgh Cancer Centre. 6. Assumes that DCN after any minor upgrade would provide better and more compliant facilities. 7. Cancer services would be split between two centres until new ECC was opened.

60 40 60 55

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8

1. Once 80 beds are closed around the WGH (multiple wards), upgrade/redesign a freed - up ward as a new OAU. 2. Ward 4 to move to another discrete ward at a limited capital cost. 3. Upgrade Ward 3 as required. 4. Abandon Wards 2 & 4.

1. Location of Wards may mean that Oncology service is scattered around WGH campus. 2. The OAU would still be occupying a facility originally designed as an Inpatients ward, a beit redesigned as far as possible. 3. Allows Wards 2 & 4 to be potentially used as emergency Winter Beds wards. 4. Option dependent on closure of 80 beds within acceptable timescales and ability to cohort Oncology beds in discrete wards.

50 50 70 55

9

1. Once 80 beds are closed around the WGH (multiple wards), use these to decant Ward 2 and transfer Ward 4 at limited capital cost. 2. Upgrade Ward 2 to create new purpose built OAU. 3. Upgrade Ward 3 as required. 4. Abandon Ward 4.

1. Location of Wards may mean that Oncology service is scattered around WGH campus. 2. The OAU would be occupying a purpose designed facility. 3. Allows Ward 4 to be potentially used as emergency Winter Beds wards. 4. Option dependent on closure of 80 beds within acceptable timescales and ability to cohort Oncology beds in discrete wards.

60 80 65 66.25

10

1. Decant all wards to Ward 15 & University Research Ward. 2. Upgrade vacated wards as appropriate to create a new inpatients ward combining Wards 2, 3 & 4 3. Leave OAU in Clock Tower Building

1. Decant arrangements temporarily takes away WGH Winter Beds ward. 2. Relies on University giving back their Clock Tower accommodation. 3. Loss of circa 4 beds to Oncology and WGH site as a whole on completion 4. Ward 15 & University area would require significant investment to create a suitable decant facility 5. Potential risk to programme due to accommodation availability 6. Location of OAU remote from main entrances to Oncology. as well as hospital services

15 40 25 23.75

11

1. Decant Wards 3 & 4 to Ward 15. 2. Upgrade vacated wards as a new OAU. 3. Move OAU to Ward 3&4, abandoning Ward 2.

1. Decant arrangements takes away WGH Winter Beds ward. 2. Limited loss of beds to Oncology and WGH site as a whole on completion. 3. Ward 2 could be used as an Emergency Winter Beds Ward. 4. Cheaper Option, but Ward 15 would still require significant investment to create a suitable decant facility

85 85 75 82.5

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12

1. Decant OAU to Ward 15. 2. Upgrade vacated Ward 2 as a new OAU. 3. Reduce Patient Beds in Ward 4 4. Decant Ward 4 to Ward 15 after OAU moves back to Ward 2. 5. Upgrade Ward 4 6. Transfer Ward 4 back from Ward 15.

1. Decant arrangements takes away WGH Winter Beds ward. 2. Loss of 12 to 16 beds to Oncology and WGH site as a whole on completion. 3. Ward 15 could be used as an Emergency Winter Beds Ward on completion. 4. Cheaper Option, but Ward 15 would require significant investment to create a suitable decant facility 5. Upgrade of Wards 2 and 4 will be surrounded by fully occupied and operational Wards

75 80 65 73.75

13

1. Transfer the Admin Corridor (South) offices to Ward 15 2. Upgrade Admin Corridor Offices to create new OAU. 3. Transfer OAU from Ward 2 to new facility 4. Decant Wards 3 & 4 to Ward 2 temporarily reducing bed numbers 5. Upgrade Wards 3 & 4 6. Transfer Wards 3 & 4 back 7. Upgrade Ward 2 to create new inpatient ward

1. Clinical staff offices location away from wards 2. Disruption to adjacent departments and wards 3. Temporary reduction in beds 4. Potential planning and logistics issues 5. Reduced investment needed in Ward 15 6. Politically challenging to get approval 7. Loss of winter beds ward

80 85 75 80

14

1. Upgrade Pentland Lodge to accommodate OAU 2. Move Ward 2 to Pentland Lodge 3. Option available to upgrade Ward 2 as an inpatient ward

1. Impinges on critical Ward 1 solution 2. OAU would be remote from Oncology support 3. Poor clinical environment

50 65 60 56.25

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VI. LINEAR ACCELERATOR (LINAC) CAPACITY DEVELOPMENT

1. Project Executive Summary And Purpose

1.1. This case builds on the strategic commitments made in NHS Lothian’s Cancer Strategy – Better Cancer Outcomes in Lothian. The development of this proposal has been supported by regional working in South East Scotland and in particular via the regional Radiotherapy Short Life Working Group in recent years.

1.2. We know that our existing radiotherapy capacity will be increasingly unable to cope with future projected demand. In the shorter term the constraints of the current premises also threaten the department’s ability to maintain full machine capacity, particularly when managing the planned replacement of LinAcs.

1.3. Our modelling work shows that with an operational machine capacity of 6 LinAcs the radiotherapy department is estimated to be at 91% capacity utilisation in 2016. From this, we also know that:

• In the medium term, by 2018 it is forecast that the department will be at 95% capacity with 6 operational machines

• LA6 is scheduled for replacement during late 2017 / early 2018 and, with no suitable spare bunker available, requires an ‘in-room’ swap

• Commissioning an ‘in-room’ replacement in 2017/18 would create an immediate and significant capacity deficit (an estimated 114% capacity utilisation, based on 5 operational machines)

• Additional bunkers by 2018 would support the continual operation of 6 LinAcs, and potentially allow capacity expansion in the medium term

• In the medium term, across years 2017, 2018 and 2019 even with 6 operational LinAcs maintained the department is estimated to be at 94%, 95% and 97% capacity. By 2021 it is estimated that the department would be over 100% machine capacity utilisation with LinAc capacity maintenance investment alone.

• Over the term (from 2016 / 2017, and potentially until a growth in machine capacity is delivered) it is likely that extending the working day on selected LinAcs will need to be operationalised, to create additional capacity for treatment.

• The Capital Equipment Replacement Programme (CERP) picks up significantly from 2022 with a LinAc replacement scheduled each year for the next number of years thereafter. Without additional bunkers this cannot be managed. Additionally, if no longer term solution is available (a new Edinburgh Cancer Centre) then LinAc 7 would likely need to be commissioned in the period 2020 – 2022.

• Longer term, a new build department could be comfortably operating within recommended safe and effective utilisation levels if equipped with a minimum of 9 high energy bunkers (with 10 or expansion space potentially advised), and 8 operational LinAcs.

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1.4. To respond to this, key service change options have been considered (fully outlined in appendix 1). The preferred option is for a 2-bunker modular build on the car-park directly outside ECC. It is important that this preferred short-term option is viewed as intertwined and complimentary to the longer term option of re-providing the Edinburgh Cancer Centre on the Western General Hospital campus. As such, development now should be maximised in its ability to support a transition to a new department. Equally, there are currently other ‘Oncology Bridging Projects’ in development to improve Oncology facilities within the Edinburgh Cancer Centre. Proposals for these projects, and this proposal, require to be synergised. This will ensure that the Cancer Centre continues to be developed on a properly managed and phased basis for ongoing business continuity and operational effectiveness, and in a way which minimises disruption and inconvenience to staff, patients and visitors.

1.5. Capital costs for the creation of additional LinAc bunker capacity are estimated at between and depending on the construction option selected. Further costs to connect buildings and manage consequent site infrastructure requirements also need to be fully identified.

Revenue costs are minimal for the use of new bunker facilities to support LinAc replacement. The expected revenue costs of extending the working day for selected LinAc capacity is already factored into the financial plans of South East Scotland Boards.

1.6. Otherwise, growing radiotherapy capacity by increasing the number of operational LinAcs has not been agreed at this stage, and is contingent on longer term re-provision plans for the Edinburgh Cancer Centre. However, should the additional bunker facility be utilised in future for capacity expansion, via procurement and commissioning of LA7, then the additional revenue costs would be significant. An estimation of the step-up in staffing required is outlined in the financial case.

1.7. The provision of additional bunker capacity is a critical part of Western General Hospital campus masterplanning and development. This workstream is a key plank of the emerging Lothian Hospitals Plan, and in particular work which is being commissioned regarding the development of the Edinburgh Cancer Centre.

1.8. The proposal now needs to move to the briefing stage, which will be programmed to include:

• Option review and appraisal in conjunction with the other developing Oncology Bridging Projects.

• Agreement of status and operation of unit in conjunction with option development – extension or satellite.

• Operational Policies development.

• Schedules of Accommodation developed from Operational requirements.

• Room relationship diagrams.

• Technical requirements.

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2. Strategic Case

2.1. Strategic priorities

2.1.1. Edinburgh Cancer Centre provides radiotherapy for patients from across the South East of Scotland. This provision is changing rapidly, and demand for radiotherapy is set to grow significantly over the next decade, and beyond.

2.1.2. NHS Lothian’s Cancer Strategy – Better Cancer Outcomes in Lothian – outlines our strategic priorities for radiotherapy which include:

• Providing evidence on the number and location for the future provision of linear accelerators.

• Keeping pace with current technology, and ensuring that patients have timely access to the appropriate, evidence-based advancements in radiotherapy.

• To ensure optimal efficiency of the use of the machines, and to allow patients to be treated at times more suited to their needs, we will work towards the provision of extended working days, and the potential for a 7-day service, keeping in line with planned capacity requirements.

2.2. Regional Planning

Modernisation of cancer services requires a collaborative regional approach across the South East of Scotland. This must incorporate all aspects of service provision, technological development and improvement to the patient pathway. Effective local and regional arrangements to support the planning and management of cancer services in an integrated way are vital. Under the regional planning structure in the South East of Scotland, the Radiotherapy Short Life Working Group has supported collaborative working across Boards and focussed on demand, capacity, and meeting future challenges.

2.3. Service provision

2.3.1. The radiotherapy department at the Western General Hospital is part of Edinburgh Cancer Centre which, aside from radiotherapy, provides clinical assessment, systemic anti-cancer treatment, and elective and emergency care for patients from across the South East of Scotland on an out-patient, day-case, and in-patient basis.

2.3.2. All radiotherapy given in the South East of Scotland is undertaken in the department. Previous analysis of 2013 activity data shows that approximately 41% of SCAN cancer patients have at least one course of radiotherapy in the Edinburgh Cancer Centre with an average of 14.0 fractions per course. Additionally, very few patients from South East Scotland receive radiotherapy in other radiotherapy centres (circa 3% in 2013). Equally, around 4% of the department’s activity in 2013 was for non-SCAN patients.

2.3.3. For selected low volume / highly specialist treatments the department provides a designated service to patients resident in other Board areas of Scotland. The department also provides Stereotactic Radiotherapy for patients from across Scotland with benign conditions.

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2.3.4. Over the last couple of years the radiotherapy department has seen approximately 3,500 new patients per annum, generating circa 52,000 attendances (2014: 3,665 patients, 54,190 attendances & 2015: 3,484, 50,499). Following referral, patients are clinically assessed to establish if radiotherapy is the optimal choice for them. Subsequently, patients are prescribed courses of radiotherapy treatment which require detailed multi-disciplinary based preparation (scanning and planning). Delivery of external beam radiotherapy is given in fractions (of the total course). Completing treatment courses therefore requires multiple appointment visits over time to the department.

2.3.5. As well as external beam radiotherapy, brachytherapy (a procedure that involves placing radioactive material inside the body) is provided. Additionally, many patients are treated with concurrent chemo-radiotherapy, and radiotherapy synchronised with surgery (requiring specific scheduling in the patient pathway for radiotherapy delivery pre or post the surgical procedure) and indeed synchronised brachytherapy with external beam radiotherapy for some gynaecological cancers. Overall, in recent years, the department has been continually improving, developing and modernising its approach to radiotherapy delivery, particularly through the use of intensity modulated radiotherapy (IMRT), and image guided radiotherapy (IGRT).

2.4. Linear Accelerator (LinAc) and bunker capacity

2.4.1. Currently the department has an operational funded establishment of six LinAcs. These operate for 8.25hrs per day, 5 days a week, with 10 service days and 6 public holidays.

2.4.2. The LinAcs are housed within specially-constructed and radiation shielded bunkers. The department has seven bunkers, and all have LinAcs in situ (however one is a non-operational ‘mothballed’ machine). At least one spare bunker is required to be able to efficiently manage an ongoing LinAc Capital Equipment Replacement Programme, avoiding an otherwise undue disruptive affect on the rest of the radiotherapy service whilst machines are being replaced.

2.4.3. The seven current bunkers are comprised of 3 low energy bunkers built in the mid 1950’s (relatively small facilities), 2 high energy bunkers built in the 1970’s (again small facilities), and 2 medium energy bunkers built in the early 2000’s (modern rooms suitable for modern RT).

2.5. Key constraints – The bunker problem, complexity / throughput, and staffing

2.5.1. The combination and number of low, medium and high energy bunkers in the department does not always support the LinAc Capital Equipment Replacement Programme requirement and allow the department to operate all of its six LinAcs at all times. Wherever possible ‘out-of-room’ swaps are undertaken to replace LinAcs, whereby the machine being replaced is left in the bunker it occupies whilst the new machine is being installed and commissioned in the ‘spare’ (7th) bunker in the department. Occasionally, due to the limitations of current bunker provision (principally a radiation shielding level / machine energy mismatch) an ‘in-room’ swap is required. When this is necessary the department may be forced to operate with 5 operational LinAcs for the period of installation and commissioning. Limited contingencies, such as running the operational machines for longer, are used to compensate in part for the reduction in capacity.

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2.5.8. Workforce planning undertaken in support of service capacity planning in South East Scotland has also estimated the additional core number of staff in key staffing groups that would be required should the radiotherapy department grow the LinAc establishment by 1 LinAc, to become a 7 LinAc department. These increases are explained in the financial case section of this document.

2.6. Changing practice

Radiotherapy is a dynamic and rapidly developing field of medicine and clinical trials currently underway, once reported, may potentially change practice in the first half of the next decade (2020 – 2025). Whilst the impact of this work cannot yet be anticipated, and it would be unwise to plan services based on such estimated changes at this time, we are aware of the main areas of potential change and these are in high volume pathways. For breast, there is a potential reduction in the optimal radiotherapy rate and a potential reduction in the number of fractions per course for selected patients; for prostate there is a potential increase in the optimal radiotherapy rate however developments in both external beam radiotherapy and brachytherapy may in time reduce the number of fractions required for selected patients; and for lung cancer there may be a possible increase in the optimal referral rate associated with increasing capabilities to treat early stage disease potentially as an alternative to surgery.

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3. Strategic Context

3.1. Population Projections

Over the next decade the population in SE Scotland is expected to increase by 8.2%, principally in the over 65 age group, as outlined in table 1 below.

Table 1: GRO predicted change in population by age

South East Boards Population Projections 2013 to 2025

Age Years Year 0-14 15-29 30-49 50-64 65-74 75-84 85+ Total 2013 237,

977 302,22

8 407,892 286,60

2 144,835 87,013 33,568 1,500,115 2015 242,

322 300,47

8 407,699 294,25

5 152,240 90,118 35,708 1,522,820 2020 255,

558 286,82

1 412,723 314,38

9 162,635 99,698 42,504 1,574,328 2025 259,

016 284,67

1 427,907 312,25

3 168,449 119,14

3 51,419 1,622,858 Numeric Change 2013 to 2025

21,039 -17,557 20,015 25,651 23,614 32,130 17,851 122,743

% Change 2013 to 2025

8.8% -5.8% 4.9% 9.0% 16.3% 36.9% 53.2% 8.2%

1Møller B., Fekjær H., Hakulinen T., Sigvaldason H, Storm H. H., Ta bäck M. and Haldorsen T. “Prediction of cancer incidence in the Nordic countries: Empirical comparison of different approaches” (2003) Statistics in medicine, 22:2751-2766 As many cancers are age-related the incidence of cancers is predicted to increase by 27.2% (table 2). The main tumour sites which are going to increase are Breast 23.4% (from 2013 to 2025) Colon 39.3%, Head and Neck cancers 23.4%, Lung cancer 17.5%, melanoma 50.5%, Non-Hodgkin’s Lymphoma 23.4%, rectum 26.0%,prostate 46.9%. In all cases the main increase is seen in the over 75 age group due to increasing longevity.

Table 2: Forecast numeric change over coming decade for all cancers in SE Scotland Age 2011

SCR ICD10

2013 2015 2020 2025 Forecast Numeric Change 2013 to

2025

Forecast Percentage

Change 2013 to 2025

0-14 30 32 33 34 35 3 9.5% 15-29 92 119 124 129 129 10 8.7% 30-49 778 772 779 795 844 73 9.4% 50-64 2,187 2,141 2,187 2,356 2,465 324 15.1% 65-74 2,281 2,447 2,573 2,773 2,829 382 15.6% 75-84 1,936 2,026 2,128 2,455 2,913 887 43.8% 85+ 790 863 930 1,117 1,366 503 58.3% Total

8,832 9,249 9,657 10,70

3 11,76

5 2,516 27.2% Weighting 1.00 1.04 1.16 1.27

2011 = recorded cases (2012 data is released but some cases come in late so 2011 is more complete) 2013-2025 = predicted The greater number of people diagnosed with cancer will require increasing resources for diagnosis and staging (radiology, pathology, and secondary care physicians) and also treatment modalities such as surgery, radiotherapy and chemotherapy.

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3.2. What are the problems with the current arrangements?

Our existing operational capacity will be increasingly unable to cope with future projected demand. In the shorter term the constraints of the current premises also threaten the department’s ability to maintain full machine capacity, particularly when managing the planned replacement of LinAcs.

3.3. Modelling demand and our capacity requirement

3.3.1. In order to examine in detail the projected demand for radiotherapy in the South East of Scotland the region has worked with Information Services Division (ISD), commissioning a bespoke project from them to support our service capacity planning work. ISD utilised the NORDPRED software to analyse cancer incidence dating back to 1982. This software used age-period-cohort (APC) models for projecting future rates of cancer incidence, deriving the relevant parameters from the past observations. Working with this demand forecast, in order to estimate the potential future requirements we developed several models examining current and optimal use of treatment over the coming decade. This involved making an assessment of the number of people who will need a course of radiotherapy each year, the number of fractions that would need to be delivered in future years, and estimating the resources required to deliver this number of courses and fractions. A full report outlining the various models examined, and the conclusions reached, is available.

3.3.2. To utilise the modelling work and apply it to service planning and radiotherapy department operational management, a method of displaying and summarising output was developed. This is based on the selection of a derived mid-range model (from the various models examined), planned machine utilisation levels, and the use of a traffic-lights system to indicate the degree of anticipated capacity utilisation over time. The modelling work has subsequently incorporated actual activity data for recent years as this has become available, to allow a comparison of forecast and actual, and to help sharpen the use of the model. As actual activity has been at variance (under) the predicted level over the last year approximately (in the context of actual and predicted activity levels being in close agreement before this), demand estimates fed into the summary model have been reduced by 10% to compensate. This brings the model more in line with the department actual across 2015 and 2016 to date, and a mechanism is in place to monitor trends monthly. The summary model is shown below.

NHS Lothian current and future linac capacity modelling - Updated using more recent fractions per course data. 10% reduction in demand compared to predicted.Model A

Baseline Year Actual Attendances Forecasted Attendances51,354 54,190 50,499 49,790 50,944 51,901 52,859 53,816 54,787 55,759 56,730 57,701 58,672

linacs\Year 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 20255 106% 114% 109% 109% 112% 114% 116% 118% 120% 123% 125% 126% 129%6 88% 95% 91% 91% 94% 95% 97% 98% 100% 103% 104% 105% 108%7 76% 81% 78% 78% 80% 82% 83% 84% 86% 88% 89% 90% 92%8 66% 71% 68% 68% 70% 71% 73% 74% 75% 77% 78% 79% 81%9 59% 63% 60% 61% 62% 63% 65% 65% 67% 68% 70% 70% 72%

Productivity AssumptionsNo. of fractions per hour 4.8 4.7 4.6 4.5 4.5 4.5 4.5 4.5 4.5 4.5 4.5 4.5 4.5No. of operating hours per day 8.25 8.25 8.25 8.25 8.25 8.25 8.25 8.25 8.25 8.25 8.25 8.25 8.25No. of operating days per week 5 5 5 5 5 5 5 5 5 5 5 5 5No. of PH per year 6 6 6 6 6 6 6 6 6 6 6 6 6No. of Service days per year 10 10 10 10 10 10 10 10 10 10 10 10 10No. of operating days per year 245 245 245 245 244 245 245 246 245 244 244 246 245Anticipated no. of fractions available per year per machine 9,702 9,500 9,298 9,096 9,059 9,096 9,096 9,133 9,096 9,059 9,059 9,133 9,096

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3.3.3. The model uses a traffic light summary to indicate estimated LinAc utilisation levels.

• Green status is up to 90% capacity utilisation

(90% is the upper limit adopted, allowing 10% operational headroom to allow for variation and general departmental capacity and flow management. Ideally an 85% utilisation level would be planned for longer term).

• Amber status indicates 90% to 100% capacity utilisation

• Red status indicates over 100% capacity utilisation.

3.3.4. As illustrated in the model, with an operational machine capacity of 6 LinAcs the department is estimated to be at 91% capacity utilisation in 2016. This matches closely enough with departmental monthly monitoring. Key points relevant to this case from the modelling work are:

• A current 2016 estimate of 91% capacity utilisation (for comparative reference, the Beatson Cancer Centre Satellite development was triggered by the Beatson operating at 93%)

• In the medium term, by 2018 it is forecast that the department will be at 95% capacity with 6 operational machines

• LA6 is currently scheduled for replacement during late 2017 / early 2018 and, with no suitable spare bunker available, requires an ‘in-room’ swap

• Commissioning an ‘in-room’ replacement in 2017/18 would reduce the number of operational LinACs to five, creating an immediate and significant capacity deficit (an estimated 114% capacity utilisation, based on 5 operational machines)

• Additional bunkers by 2018 would support the department to continue to operate with 6 LinAcs.

• In the medium term, across years 2017, 2018 and 2019 even with 6 operational LinAcs maintained the department is estimated to be at 94%, 95% and 97% capacity. By 2021 it is estimated that the department would be over 100% machine capacity utilisation with LinAc capacity maintenance investment alone.

• Given this, over the term (from 2016 / 2017, and potentially until a growth in machine capacity is delivered) it is likely that a contingency plan to extend the working day on selected LinAcs will need to be operationalised, to create additional capacity for treatment.

• The effect of extending the working day, depending on the level of investment deployed, would increase capacity available and therefore extend the time before saturation of available capacity is reached.

• In the longer term the Capital Equipment Replacement Programme (CERP) picks up again from 2022 with a LinAc replacement scheduled each year for the next number of years thereafter. Without additional bunkers this cannot be managed. Additionally, if no longer term solution is available (a new ECC) then LinAc 7 would likely need to be commissioned in the period 2020 – 2022.

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• Longer term by 2025 a new build department would be comfortably operating within the 85% utilisation level recommended – if equipped with a minimum of 9 high energy bunkers (with 10 or expansion space potentially advised), and 8 operational LinAcs, operating a standard working day of 8.25hrs pd. Strategic options to extend operating hours would bring further future proofing, as would potentially adding a further operational LinAc 9, with due consideration to the acceptable parameters for departmental size. The recommended maximum size for radiotherapy centres is 8 LinAcs (NRAG productivity subgroup).

3.4. Increasing technology constraints and delivering world class treatment

3.4.1. Increasingly central to progressing our modernisation and quality improvement programme over the next decade is more accurate determination of the tumour location by improved imaging, so called ‘functional imaging’. This is to be used with better planning systems - ‘Biological treatment planning systems’, and the provision of more accurate ways of delivering treatment, taking into account internal organ movement - ‘4D treatments’, time being the fourth dimension, and ‘Adaptive Radiotherapy’.

3.5. Identified dependencies with radiology, and the need for more accurate pre-treatment imaging.

3.5.1. A good treatment plan maximises the radiation dose distributed uniformly to a region called the clinical target volume, while minimising the quantity of radiation dose given to normal tissues and sensitive organs. The clinical oncologist uses a variety of imaging techniques to help them define these volumes. Currently the department uses only CT scan information to define these volumes. More sophisticated functional imaging techniques are not available for treatment planning purposes. The most significant gap is access to MRI planning (both standard and spectroscopic imaging protocols). MRI is a fundamental imaging technique, and together with PET/CT scanners is becoming a routine planning tool in modern centres. There is currently no provision for additional MRI or PET/CT scanning on the WGH Site, representing a potential pathway constraint. Recent work on the diagnostic imaging contribution to the WGH site masterplan has considered oncology imaging, including the allowance of additional CT capacity to align with increased LinAc capacity. These workstreams should be kept fully aligned and co-developed in the next phase of site masterplanning and in the pending business case for the reprovision of the Edinburgh Cancer Centre. In future, there will also be greater demand on repeat imaging using various modalities to access the dynamic impact of the treatment on the tumours.

3.5.2. With the growth of functional imaging techniques and the requirement of accurate delineation of volumes, it is essential that ECC has access to high quality interpretation of these images. In the future the definition of volumes will be increasingly a more collaborative task between radiologist and clinical oncologist. Consequently the provision of greater radiology support to ECC will need to be explored across both departments, and requirements / feasibility determined.

3.5.3. The benefits of better imaging include more accurate treatment delivery. ‘4D radiotherapy’ uses a CT scanner to acquire the planning images whilst the patient’s respiratory motion is recorded. A 4D radiotherapy plan is then calculated and the

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radiotherapy can be delivered to the patient only in certain phases of the respiratory cycle (‘respiratory gating’) which can potentially decrease the radiation dose to normal tissues. There are other similar ‘gating’ techniques which restrict the delivery of the treatment only to when the tumour is in the pre-defined location. These techniques are complex to plan and deliver. Both of these key issues combine to reduce patient through-put per hour (a variable which is already assumed in our capacity utilisation projections).

3.5.4. Current LinAcs have imaging capabilities which include a CT scanner capability. This imaging allows us to perform ‘image guided radiotherapy’ whereby we can confirm the tumour is in the correct position before starting the treatment session. Images produced just prior to treatment may show that the tumour has shrunk or changed shape. Offline adaptation of the plan can be performed for subsequent fractions or online adaptation can be done for instant changes using cone beam CT. Currently, re-planning a patient would take considerable time. In future it will be necessary to do this as quickly as possible. This brings ever greater reliance on imaging and will allow the continuous modification of treatment plans whilst the patient is on the treatment couch ready for treatment. An NRIG report in 20071 recommended that 50% of all patients may benefit from 4D adaptive radiotherapy by 2017.

3.6. Dependencies between Information Technology and treatment planning system requirements.

3.6.1. Treatment planning systems mathematically model how the radiation dose is deposited. Over recent years computational power has increased dramatically (and will continue to increase) and this has led to the exploitation of more sophisticated models which have improved accuracy in the calculations. All current models predict the pattern of dose deposited in tissue but the treatment planning of the future will follow the biological consequences of this pattern of dose – ‘Biological treatment planning systems’. These imaging and treatment planning system developments for radiotherapy planning will rely heavily on fast processing of large volumes of data including image manipulation, however we do not have the IT infrastructure available in the department. Again, this dependency will require consideration in the next stage of reprovision masterplanning.

1 ‘IMRT - A Guide for Commissioners’ An National Radiotherapy Implementation Group Technology Sub-Group Report 2009

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Effect of the need for change on the organisation:

What needs to be achieved to overcome this need?


Our existing operational capacity will be increasingly unable to cope with future projected demand

Provide bunker and LinAc capacity in a way which allows demand and capacity to be matched over the next 10 years and beyond

In the shorter term the constraints of the current premises threaten the department’s ability to maintain full machine capacity

Provide additional bunker capacity to allow a) LinAc replacement and b) LinAc expansion as required by the service

Increasingly the current department arrangements are limited in both pre-treatment imaging and the growing need for adaptive radiotherapy (intra-treatment imaging and re-planning)

Provide bunker and LinAc capacity in a way which supports safe, high-quality, and sustainable service delivery

Risk that the radiotherapy department is developed in a way that is not integrated to the wider department, and supports WGH campus development

Fit with the emerging masterplan for the Western General Hospital, supporting a transition to a new ECC.

Provide capacity in a way which fits with the operational constraints both clinical and non-clinical services work within

3.8. Summary of the main constraints and dependencies

3.8.1. There is a real key risk that the project will not be delivered in time to support the necessary replacement of LA6. This risk needs to be managed alongside departmental management of the extended working day option to create capacity, and also the potential to revise the LinAC replacement programme within acceptable risk parameters.

3.8.2. The extended working day is possible to implement, however comes with its’ own risks and constraints:

• Replacement: LinAcs machine replacements may be required more frequently if machines are run for longer

• Impact of breakdowns: if a machine’s workload is increased then it is important to have capacity in the other LinAcs to accommodate more breakdowns

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• Out-of-hours servicing: Much servicing already takes place at weekend and after hours. However, if all servicing were moved to the weekends this would require the manufacturers and couriers to also be available at weekend and spare parts to be available. One approach recommended is for departments to have a spare LinAc for service days and breakdowns

• Patient specific quality assurance: for complex radiotherapy it is important to perform individual plan QA. It is important to also factor in access for dosimetry staff to the LinAcs at reasonable times of the day (usually early evening)

• Staff availability: working longer hours may make the job less attractive to an already sparse workforce.

• Patient acceptance: Surveys suggest that sufficient patients would accept treatment in early evening and over weekends but in order for departments to open longer hours and /or seven days a week it is important that the ‘whole service’ is also available – not just treating staff. For example, Oncologists, other clinical teams, clinical support services e.g. radiology, laboratories, administrative staff, porters, café services, and transport.

• Research and development: It is recommended this is at least 3% of capacity.

• Capacity to avoid waiting times: maintaining operational headroom of 15% of capacity available is recommended to ensure that waiting times do not lengthen.

3.8.3. Other constraints on the department are described at the beginning of this section

and in section 2 (bunkers, imaging, and IT). Other key constraints include the further development and approval timescale for a new Cancer Centre on the Western General Hospital campus. Investment in radiotherapy department development at this stage needs to assist with the transition and development into a new Edinburgh Cancer Centre.

3.8.4. The re-provision of car parking is a key dependency for this project, and costs and logistics need to be factored into site masterplanning. Lost car parking potentially can be re-provided on demolition of the Department of Clinical Neurosciences (DCN) in the medium term.

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3.9. How does the proposal respond to NHSScotland’s strategic priorities?




Person Centred

Improves quality of life through care provided (QOI).

Cancer QPI’s

Improves the quality of the healthcare estate (SAFR).

Proportion of estate categorised as either A or B for the Quality appraisal facet


Proportion of positive responses to the In-Patient Questionnaire on patient rating of the hospital environment

Safe Reduces adverse harmful events (QOI).

Improves statutory compliance (SAFR)

TBC

IRMER (external assessment)


Supports the delivery of 31 days decision to treat to treatment standard for those who have radiotherapy as first treatment (LDP)

Cancer Access Standards

Health of Population


Increases level of staff engagement (QOI)

Percentage of staff who they say they would recommend their workplace as a good place to work

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3.10. Options appraisal process to date

3.10.1. The Western General Masterplan has been in development for over 2 years. The plan recognises that there is a minimum requirement to construct at least one additional LinAc bunker before April 2018, in order to ensure service sustainability by at least supporting the planned replacement of Linear Accelerator 6 (LA6). The plan also recognises more significant capacity implications are present if a longer-term solution is not found by 2022. As rehearsed in section 3 above, a 7th LinAc may be required at this stage, as well as increasing capacity by extended-day working meantime.

3.10.2. An update on the masterplanning work was brought to NHS Lothian’s Strategic Planning Committee in August 2015. This update flagged up the requirement for additional bunker capacity, and Strategic Planning Committee asked for an option appraisal to be carried out. In discussion at committee, two conceptual solutions were raised:

• A “pragmatic” solution of 2 bunkers, co-located to the current ECC buildings;

• A “more ambitious” solution, whereby a suite of 8-10 LinAc bunkers would be constructed on the cleared site of the Department of Clinical Neurosciences, when this service left the site in 2017.

3.10.3. A non-financial options appraisal workshop was undertaken on 23rd October 2015, with a broad invitation list from across disciplines and including the participation of stakeholders from across SEAT. The workshop considered a short-list of 6 options including the do-nothing option. Four of these options were short-term options for a 2-bunker solution, and one was the option of a full LinAc suite on the cleared site of DCN. Following appraisal, the workshop agreed that the preferred option was for a 2-bunker modular build on the car-park directly outside ECC.

3.10.4. Various site location and construction options have therefore been evaluated on the basis of an expanded footprint for up to two bunkers. Subsequent discussion around the relationship between the new bunkers and existing facilities has also highlighted issues around potential operation that need to be clearly articulated and have an impact on more detailed development of proposals:

• If the new bunker(s) are located adjacent to the existing facilities and are physically linked then this can be treated operationally as an extension.

• If the bunker(s) are located without a physical link then they are effectively a satellite and will require to be as self-contained as possible for operational effectiveness.

• Options 2, 3 and 4 as outlined in appendix 1 can all be physically linked albeit Options 3 and 4 would require bridging structures with both stairs and lifts.

3.10.5. In the decision making process at the options appraisal stage it was clear however

that representatives of the clinical service felt the DCN ‘cleared site’ option was the best option for the centre, but that they had little confidence that it would be delivered in the tight timescale outlined. The risk to service continuation was therefore deemed

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to be too great. Nonetheless, that workshop requested that an implementation strategy should see the short-term and long-term options as intertwined and complimentary, given the different pressures coming to fruition in the early 2020’s. The workshop noted that the putative modular solution may allow transfer of the modular build to another site and hence could be part of the longer-term solution.

3.10.6. In recognition of the above, at its meeting of the 21st of January 2016, the Strategic Planning Committee duly requested the development of an initial agreement, which would see the preferred option outlined as a step on the road to delivering the full “DCN option”.

3.10.7. Options considered in the non-financial options appraisal exercise are listed in appendix 1. A schematic identifying sites on the WGH for non-financial options is also shown. Investment objectives were used in options appraisal as outlined in section 3 of this paper. Criteria for scoring, and weightings applied were all agreed by the workshop participants.

3.10.8. There are currently other ‘Oncology Bridging Projects’ in development to improve Oncology facilities within the Edinburgh Cancer Centre. Proposals for these projects and the Radiotherapy expansion facility illustrated in this document require to be synergised. This will ensure that the Cancer Centre continues to be developed on a properly managed and phased basis for ongoing business continuity and operational effectiveness, and in a way which minimises disruption and inconvenience to staff, patients and visitors.

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4. Commercial, Financial, And Management Considerations


4.1.1. Procurement

In order to deliver the project in accordance with current NHS Scotland construction procurement policy, it is anticipated that Frameworks Scotland 2 would be the best option via traditional Capital Funding.

Frameworks Scotland has been used successfully by NHS Lothian for a number of years and there is a clear organisational understanding of the process for appointment of PSCP (Contractor) and any relevant consultants that may be required.

It is anticipated that the process for appointment would be carried out on a bundled project basis with the other proposed WGH Oncology Bridging Projects which are also currently in development. The process would be staged allowing all the PSCPs on the current Frameworks Scotland 2 to submit expressions of interest in response to a High Level Information Pack (HLIP) to be issued by NHS Lothian. There would then be an evaluation and shortlisting process after which a reduced number of PSCPs with the relevant experience and supply chain would be invited to make a second stage submission, which would include further proposals and costing information. Interviews and presentations by respective shortlisted PSCPs will also take place. Appointment will be made on the basis of the highest scoring PSCP on a Quality / Cost evaluation.

It is anticipated that this process would commence in late 2016, with the appointed PSCP inputting from the OBC Stage through to completion in order to optimise programming and achieve best value from the process.

4.1.2. Construction Options

As part of the evaluation of options available for development, advice has been taken regarding the potential to have a modular type build for the new bunker(s) to address a number of key issues:

• Turnkey approach potentially – a one stop shop (reference RAD Technology proposal below).

• Potential to re-use parts of the facility.

• Shorter build time on site.

• Easier removal and/or relocation.

Modular / prefabricated Linear Accelerator bunker solutions are commonly constructed in North America and various construction options have been reviewed. The relevant construction techniques are becoming more popular in the UK though built examples are still relatively limited. Advice and costing information has been obtained from RAD Technology Medical Systems in the USA, and information provided by them formed the basis of the footprint study for a full satellite facility.

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• Interfaces with other potential construction activity.

• Minimise time on site.

• Construction options – traditional or modular.

• Lead-in time for modular components.

• Interfaces with equipment moves and commissioning periods.

4.2. Financial Case

4.2.1. Capital costs

Relatively detailed costs have been built up based on current industry data and have also been benchmarked against similar recently completed facilities across the UK. The basis for these costs are the developed layout and area schedules based on the sketch layout shown above (in the Construction Options section).

• Costs do not include any physical linkages either directly or via bridges to the existing facilities.

• Costs are based on the Preferred Option location.

• Costs for other new build options would be similar to those for the Preferred Option.

• Costs are for both traditional and modular construction options.

• Estimated costs specifically exclude the equipment costs associated with Linear Accelerators (these are managed in the Capital Equipment Replacement Programme for maintenance of established machine numbers. Any new additional capacity would require policy approval with Scottish Government, and to date this has not been discussed).

• Costs are benchmarked for comparative purposes.

Outline costs have therefore been estimated for a satellite radiotherapy facility. Summary:

• A traditional purpose built satellite radiotherapy facility with 2 bunkers, with a cost estimate of .

• A modular built satellite radiotherapy facility with 2 bunkers, with a cost estimate of .

The cost report is outlined in appendix 2. Cost benchmarks are outlined in Appendix 3.

There are also key opportunity costs for consideration in terms of construction timescales, impact on the site, and the degree to which costs are sunk or recoverable in the context of transitioning to an anticipated new Cancer Centre.

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4.2.2. Revenue costs

Identification of staffing costs depends on decision making around the location of the new bunker facility, and its short and medium term use. Assuming it is located in a nearby car-park adjacent to the existing ECC, and considering the bunker initially as a facility for LA6 replacement (i.e. a decant bunker) then radiotherapy staff would simply move across with no further radiography or physics staff required in the short term. In discussion, it has been identified that there may need to be either a Care Support Worker (unlikely to need a qualified nurse), or an assistant to help with logistics and assisting patients over from the main oncology reception area. This assumes that patients can book in at the existing ECC reception and then walk around to the new facility.

Potentially, alternative site selection for the bunker facility, or if the facility required to operate as a satellite facility (disconnected from ECC), would necessitate a reconsideration of the staffing requirement.

In the medium term, if the facility is also required to accommodate an expansion to the operational LinAc complement, via procurement and commissioning of LinAc7, then staffing numbers across most clinical groups would need to increase in proportion to the expansion. This would represent a significant step-up in costs. The estimated additional core staffing requirement to support increasing the establishment of LinAcs by one machine is:

Medical Staffing: + 1 WTE clinical oncology consultant It is difficult to predict accurately the future medical workforce demand for a number of reasons, i.e. the impact of new technology and treatment protocols. However applying the 2% year-on-year increase in radiotherapy demand to the 2013 Clinical Oncology Consultant WTE implies an additional 1 WTE consultant would be required. This is a fairly crude calculation and accounts simply for predicted increases in numbers but not the rise in complexity and the associated workload.

Radiotherapy Medical Physics: + 2.5 WTE Assuming one additional machine is commissioned, the radiotherapy medical physics workforce implications of this would be based on IPEM recommendation (IPEM 2009). These are based on an 8hr working day and are blend of equipment and patient workload related factors. An additional accelerator, fully utilised, would be a multi-mode accelerator with imaging capabilities, increasing the fleet from 6 to 7 machines. The IPEM model predicts the following increase in staffing:

• Clinical Scientists 0.9WTE

• Dosimetrists (Clinical Technologists) 0.5WTE

• Engineers 1.1WTE

The additional resource needed for additional patient workload of 2% per year would require an increase in Clinical Scientists by 0.3WTE and Dosimetrists/Clinical Technologists by 0.4WTE every 5 years. The increase in complexity would require a further increase in staffing. This is related to patient throughput per hour but is difficult to assess accurately in advance. This additional staffing would need to be experienced and competent. Engineers, Dosimetrists/Clinical Technologists and

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Clinical Scientists would all require a minimum of two years in-post training to reach a minimum level of competence.

More complex treatment will increase demand for patient specific verification QA (ie IMRT/IMAT). Traditionally done by radiotherapy medical physics staff, this requires additional work by dosimetrists and access to perform verification measurements on a surrogate phantom on the accelerator. IPEM guidelines would suggest this requires an additional 1.1WTE physics staff in the ECC. Recently this has been accommodated by physics staff working outside of clinical hours, through a combination of goodwill, lieu time and overtime but this is unsustainable. Demand for this type of work will grow. The ECC has invested in an alternate methodology which allows verification to be performed directly on the patient by radiography staff during the normal treatment visit. This is an innovative approach which optimises skill mix and maximises machine capacity but requires radiographers to acquire new skills. However in the short term additional physics resources (as yet un-quantified) will be needed to support the development phase. This innovative approach also satisfies the in-vivo Dosimetry requirement to validate treatments as required by Scottish Government in the most resource efficient way. This will reduce the physics staffing required to 0.4WTE.

Therapeutic Radiographers: + 11 WTE Therapeutic Radiiographers The Society and College of Radiographers’ guidance on core therapeutic radiography states that the staffing required per LinAc per hour is 1.33 WTE (SCoR, 2005) and therefore the ECC should have:

• 6 (LinAcs) x 8.25 (hours/day) x 1.33 (WTE guidance) = 65.8 WTE for minimum ‘core’ functions (those that are solely the domain of radiographers)

• The ECC therapeutic radiography team carries out core and advanced practice roles and to deliver this enhanced service currently has 61.14 WTE in post with a funded establishment of 65.85 WTE.

• If an additional LinAc were procured to bring the ECC funded establishment to 7 machines the minimum staff for core functions would be:

• 7 (LinAcs) x 8.25 (hours/day) x 1.33 (WTE guidance) = 76.8 WTE for core functions

4.3. Management Case

4.3.1. Programme and project management

Reports have previously been taken through the SEAT mechanism and have been discussed by the management team of the University Hospitals Division, pending discussion with Strategic Planning Committee.

Further development of the business case is remitted to the Western General Hospital Masterplanning Group, on behalf of the WGH Hospital Management Team.

A small project group will continue to take this work forward with input from strategic planning, capital planning, finance, and clinical teams.

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5. Conclusion

5.1. The provision of additional bunkers to manage immediate known pressures for the radiotherapy department remains critical to deliver as part WGH campus masterplanning and development. This workstream is a key plank of the emerging Lothian Hospitals Plan, and in particular work which is being commissioned regarding the development of the Edinburgh Cancer Centre. More detailed briefing requires to be undertaken to support development of the options. To date the layouts generated for site footprint testing and costing are based on information for a satellite centre provided by RAD Technology with very limited user group inputs. This was primarily done to test site capacity in various locations with a tried and tested satellite model and subsequently develop cost modelling.

5.2. The next stage of brief development needs to fully align with a Preferred Option as this will resolve whether there is potential for the new facility to be an extension rather than a full satellite facility or not. It is anticipated, however, that for real future proofing and resilience then the latter is the likely scenario and therefore is reflected in the options presented and high level costing.

5.3. The briefing stage will be programmed to include:

• Option review and appraisal in conjunction with the other developing Oncology Bridging Projects.

• Agreement of status and operation of unit in conjunction with option development – extension or satellite.

• Operational Policies development.

• Schedules of Accommodation developed from Operational requirements.

• Room relationship diagrams.

• Technical requirements.

5.4. The above will then be used as the brief for inclusion in the High Level Information Pack and still provide scope for innovation and value adding proposals from the PSCPs.

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6. Appendices:

6.1 Appendix 1 – Non Financial options considered & Schematic of sites for non-financial options appraisal

6.2 Appendix 2 – Cost report – Satellite Radiotherapy Facility

6.3 Appendix 3 – Capital cost benchmarks

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6.1 Appendix 1 – Non Financial options considered Option Description Discarded at which

stage? 1 Do nothing Retained for comparison

with baseline 2 Internal reconfiguration within current ECC LinAC

suite At long-list stage. Discarded due to issues with roads and with size of potential rooms.

3a 2-bunker solution – traditional construction – on current “renal” car-park

Short-list

3b 2-bunker solution – modular construction – on current “renal” car-park

Short-list

4a 2-bunker solution – traditional construction – on current “ECC” car-park

Short-list

4b 2-bunker solution – modular construction – on current “ECC” car-park

Preferred Option

5 8-10 bunker solution – traditional construction – on site of DCN, when DCN moves to RIE

To be carried forward with preferred option

6a 2-bunker solution – traditional construction – on car-park in N-W corner of WGH site

At long-list stage due to distance from current ECC

6b 2-bunker solution – modular construction – on car-park in N-W corner of WGH site


7a 2-bunker solution – traditional construction – on “RIDU” car-park


7b 2-bunker solution – modular construction – on “RIDU” car-park


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6.2 Appendix 2 - Schematic of sites for non-financial options appraisal – numbers correspond to the numbered options considered.

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VII CONCLUSION

The programme of work detailed in this initial agreement represent critical upgrades required to address immediate pressures experienced by the service and to ensure safe service delivery to patients until a new Edinburgh Cancer Centre is developed.

This paper has demonstrated that the growth across all Cancer Services which is providing many benefits for patients. This Presents a continual challenge for the service to evolve and maintain an infrastructure to support quality patient centred service delivery. The current oncology estate on the Western General Campus has significant capacity and HEI compliance issues that present material risks and cannot be addressed without capital investment.

It is recommended that NHS Lothian support the programme of work outlined in this paper.

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INITIAL AGREEMENT FOR CANCER SERVICES BRIDGING … · Medical Director, Cancer Services, NHS...

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