Highland NHS Board 27 June 2013 Item 3.1 CRITICAL CARE CONSOLIDATION AND THEATRES REFURBISHMENT – RAIGMORE – INITIAL AGREEMENT Report by Eric Green, Head of Estates on behalf of Deborah Jones, Chief Operating Officer The Board is asked to: Approve the attached Initial Agreement for upgrading the Raigmore Theatres and combining critical care services at Raigmore. Agree that the Initial Agreement can now be submitted to the Scottish Government Capital Investment Group for their approval. 1 Background and Summary The Raigmore operating theatres are now 25 years old and have not been refurbished since new. Understandably the fabric is now worn and difficult to maintain. In addition many guidance and regulation have changed over the 25 years and the facility is no longer consistent with best practice. Critical care facilities in Raigmore have grown over the last 25 years and are in 3 different locations within the tower block. None of these facilities meet current guidance. The fire upgrade work offers a unique opportunity to locate these services on one floor and drive quality and operational benefit from doing so. This in turn facilitates other moves to further improve patient care within the tower block and improve operation of the hospital. 2 Future of Raigmore Hospital All NHS Highland facilities in Inverness are subject to the greater Inverness Masterplan currently underway. This will align clinical strategy and estate strategy and challenge the evidence underpinning both. It is intended that this project will produce a project Initial Agreement for the Greater Inverness area highlighting the projects required to enable healthcare to be delivered for the next 20 years. Raigmore Hospital will obviously be the centre of these plans, as significant work is required to upgrade this now 25 year old facility. This proposal is fully consistent with the Masterplan exercise and is being offered in advance so that the basic hub of Raigmore hospital critical services can be brought up to modern standards while taking advantage of the tower block refurbishment opportunities. Failure to do this at this time will result in additional cost. It is also recognised that this Initial Agreement does not address the capacity issues highlighted in the previous day services Business case. However the Masterplan is tasked with looking at how all assets are used in the greater Inverness area and already has identified space utilisation issues in some of our community facilities. Therefore it may be that alternative solutions can be found to address the extra capacity required, so the scope of this Initial Agreement concentrates on the established long term need for acute theatre capacity.
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Highland NHS Board27 June 2013
Item 3.1
CRITICAL CARE CONSOLIDATION AND THEATRES REFURBISHMENT – RAIGMORE –INITIAL AGREEMENT
Report by Eric Green, Head of Estates on behalf of Deborah Jones, Chief OperatingOfficer
The Board is asked to:
Approve the attached Initial Agreement for upgrading the Raigmore Theatres andcombining critical care services at Raigmore.
Agree that the Initial Agreement can now be submitted to the Scottish GovernmentCapital Investment Group for their approval.
1 Background and Summary
The Raigmore operating theatres are now 25 years old and have not been refurbished sincenew. Understandably the fabric is now worn and difficult to maintain. In addition manyguidance and regulation have changed over the 25 years and the facility is no longerconsistent with best practice.
Critical care facilities in Raigmore have grown over the last 25 years and are in 3 differentlocations within the tower block. None of these facilities meet current guidance. The fireupgrade work offers a unique opportunity to locate these services on one floor and drivequality and operational benefit from doing so.
This in turn facilitates other moves to further improve patient care within the tower block andimprove operation of the hospital.
2 Future of Raigmore Hospital
All NHS Highland facilities in Inverness are subject to the greater Inverness Masterplancurrently underway. This will align clinical strategy and estate strategy and challenge theevidence underpinning both. It is intended that this project will produce a project InitialAgreement for the Greater Inverness area highlighting the projects required to enablehealthcare to be delivered for the next 20 years.
Raigmore Hospital will obviously be the centre of these plans, as significant work is requiredto upgrade this now 25 year old facility. This proposal is fully consistent with the Masterplanexercise and is being offered in advance so that the basic hub of Raigmore hospital criticalservices can be brought up to modern standards while taking advantage of the tower blockrefurbishment opportunities. Failure to do this at this time will result in additional cost.
It is also recognised that this Initial Agreement does not address the capacity issueshighlighted in the previous day services Business case. However the Masterplan is taskedwith looking at how all assets are used in the greater Inverness area and already hasidentified space utilisation issues in some of our community facilities. Therefore it may bethat alternative solutions can be found to address the extra capacity required, so the scope ofthis Initial Agreement concentrates on the established long term need for acute theatrecapacity.
2
3 Contribution to Board Objectives
This project will contribute to achievement of”Better Health, Better Care, Better Value” atRaigmore by providing the facilities to better care for patients at the most acute phase of theircare. This project will also ensure the services at Raigmore are sustainable by providingmodern fit for purpose facilities. The improvements in layout will also facilitate better care.
4 Governance Implications
Staff Governance
Staff working in Raigmore have been fully consulted and involved in the design of the facilityby means of optioneering workshops and other formal consultations.
Patient and Public Involvement
Patient representatives were consulted and part of the decision making process around thisproject.
Clinical Governance
Raigmore Clinicians have been consulted on this proposal and have been involved at allstages of its development.
Financial Impact
The financial impact is detailed in the attached paper; however this is an Initial Agreementand further work will be done as part of OBC development to establish models of care for therevised facilities and what savings may result from that.
5 Risk Assessment
The project has its own Risk Register, the main risk are in not progressing with the project.
6 Planning for Fairness
An Equality and Impact Assessment meeting is being arranged as part of the OBCdevelopment.
7 Engagement and Communication
The project has an established governance structure with the Chief Operating Officer as theSenior Responsible Officer. The project group is chaired by the Chief Operating Officer andthe operational Unit Manager for Raigmore is also included in the group. The group includesrepresentatives of the Staff and Clinicians as well as a patient representative. The Head ofPublic Relations & Engagement is also included and a communications plan is in place toinform stakeholders including the general public and their representatives.
Eric GreenHead of Estates
20 June 2013
Inital Agreement Document
NHS Highland
Raigmore Hospital
Critical Care Consolidationand Theatres Refurbishment
(with necessary realignment ofServices)
Initial Agreement Document
Rev I
15th May 2013
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Services)
CONTENTS
Inital Agreement Document
1 SUMMARY OF PROPOSED INVESTMENT 3
2 EXECUTIVE SUMMARY 5
3 STRATEGIC CONTEXT 9
4 INVESTMENT OBJECTIVES, EXISTING ARRANGEMENTS / BUSINESS NEEDS 29
5 BUSINESS SCOPE AND KEY SERVICE REQUIREMENTS 41
6 BENEFITS / RISKS / CONSTRAINTS AND DEPENDENCIES 44
7 AGREED CRITICAL SUCCESS FACTORS 49
8 LONG LIST OF OPTIONS AND SWOT ANALYSIS 50
9 ECONOMIC CASE TO ARRIVE AT PREFERRED WAY FORWARD 55
10 AFFORDABILITY REVIEW 66
11 RECOMMENDED PREFERRED WAY FORWARD 68
A APPENDIX – SMART OBJECTIVES 71
B APPENDIX – SUMMARY OF CATEGORIES OF CHOICE ASSESSMENT 75
C APPENDIX – SWOT ANALYSIS OF LONG LIST; 79
D APPENDIX – PREFERRED TOWER BLOCK LAYOUT 88
E APPENDIX – POTENTIAL PHASING PLAN 90
F APPENDIX – POTENTIAL HIGH LEVEL SCOPE 92
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
Inital Agreement Document3
1 Summary of Proposed Investment
This Initial Agreement Document (IA) summarises the planned investment to consolidate critical
care services, and the necessary re-alignment of some other services, within the Tower Block at
Raigmore Hospital, to facilitate this. Critically, the investment will also address the current
compliance issues and deficiencies associated with the Tower Block and the Theatres on the first
floor adjacent to the Tower Block. In addition to the immediate benefits arising from these
investments, there will be ancillary functional and operational benefits arising from the
improved adjacencies for the other acute services, arising from the realignment of services.
The proposed investment is aligned with and provides a substantial platform for any future
development at Raigmore, but critically excludes any changes to the current bed capacity and
theatre capacity provision which will be the subject of wider study.
The investment will address the immediate deficiencies of the accommodation, fittings and
services infrastructure associated with the current Critical Care accommodation and the
Theatres, so that facilities are commensurate with modern standards.
The investment proposals are aligned with the wider rationalisation and coordination plans of
NHS Highland services in the Greater Masterplan area. NHS Highland is currently implementing
a “Masterplan exercise for the Greater Inverness Area”. Both clinical and non clinical facilities
are being considered with options for optimal future Healthcare provision in the Highlands linked
to clinical need over the foreseeable future. Key findings are emerging in relation to the need
for the consolidation of critical care and theatres refurbishment, at Raigmore Hospital, as is
proposed within the Initial Agreement.
The particular deficiencies in services that exist across Critical Care and the Theatres aredefined in greater detail within subsequent sections of this Initial Agreement. However some ofthe key issues are highlighted below.
Critical Care The lack of integrated critical care facilities commensuratewith modern standards and in compliance with SHTM andother guidance
Inefficient working where nursing and medicaladministrations are duplicated in some cases, andconsequently there is poor staff flexibility between HDUand CCU
Poor critical care adjacency to “front” of hospital i.e.adjacency to “accident and emergency”
Principally due to allocation approach, lack of critical carebed availability (particularly HDU beds) resulting in tooearly discharge of patients or patients wrongly located ingeneral wards, in some cases
Respiratory ward operating as informal HDU
In some cases, patients within HDU’s and CCU’s receivingtoo high a level of care resulting from lack of integratedcritical care and poor adjacencies
Poor patient flow resulting from the existing adjacencies
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
Inital Agreement Document4
Lack of isolation facilities in medical HDU
The outmoded design, and related design faults,associated with some of the existing accommodationwhich does not comply with current SHTM standards
A significant proportion of the existing accommodationand facilities are considered to be inadequate in terms ofinfection control
All of the above issues are related to the current lack ofintegrated critical care, the poor adjacencies and theinadequacies in the existing accommodation. This currently hasa significant impact on the quality of care given to critically illpatients at the hospital. Along with the care issues, it is alsoclear that the associated inefficient working practices also leadsto poorer staff moral and increased revenue spend.
Theatres Without action, NHS Highland anticipates an enforcementnotice from the Fire Authority in relation to the poorprovision for fire precautions.
There is a significant backlog in maintenance, and withplant and equipment at an age which in some cases isbeyond its design life, and therefore inefficient.Ventilation provision, in particular, fails to meet currentstandards in terms of the required number of airchanges.
Significant improvements are needed with regard to theprovision of infection control.
The space provision does not meet modern healthcarestandards and SHTM’s for Theatre accommodation.There is a particular issue with the severe lack of storagefor the increasing amount of theatre equipment.
In summary the existing operating theatre facilities fail to meetmodern standards, in terms of fire precautions, infection control,functional requirements, space provision, and compliance withcurrent clinical guidance.
The title of the project is as follows: “Critical Care Consolidation and Theatres
Refurbishment (with necessary realignment of services) at Raigmore Hospital”.
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
Inital Agreement Document5
2 Executive Summary
This Initial Agreement (IA) should be regarded as an appraisal to establish the “preferred way
forward” in respect of addressing the existing deficiencies of Raigmore’s “Tower Block”, and
adjacent Theatre facilities, including the current dispersed nature of critical care services, and
the significant compliance issues throughout. Furthermore, the scope also includes some
limited ward reconfiguration which will be necessary to facilitate these improvements. The IA
also reflects on the separate major initiative currently being undertaken by NHS Highland
comprising a substantial Masterplanning Exercise for the Greater Inverness Area where options
for optimum future Healthcare provision in the Highlands are being considered. The
development of this IA has been undertaken in close alignment with the Inverness Masterplan
so that the significant investment proposed, will not only address the immediate deficiencies
described, but also build a platform for the anticipated subsequent initiatives to allow a future
optimal healthcare model to emerge.
This IA reviews the current Tower Block “Fire Precautions Upgrade” project to highlight the
unique opportunity that has arisen, namely to undertake the much needed improvements, at a
time when existing wards will be vacated, in any case. The IA investigates NHS Highland’s
vision, aims and its principal constraints in the context of key national and local drivers including
the Local Development Plan.
Following recommendations in a report by a Working Group of the Scottish Medical and
Scientific Advisory Committee (SMASAC) NHS Highland undertook a study to review High
Dependency Unit (HDU) facilities to make recommendations on the development of a Critical
Care strategy within NHS Highland. The comprehensive study identified various deficiencies
including the care issues associated with the highly dispersed nature of critical care and high
dependency units in the Tower Block and lack of integrated critical care facilities, poor
adjacencies and various other inadequacies in the existing accommodation. The NHS Highland
study identified that these deficiencies currently have a significant impact on the quality of care
of critically ill patients at the hospital. It is also clear that the associated inefficient working
practices have led to reduced quality of patient care and staff morale.
A review has also been undertaken of the current provision and quality of Theatre facilities at
Raigmore. Fundamentally, there are various Theatre deficiencies associated with fire
precautions, infection control standards, ventilation standards and backlog maintenance. In
particular, without action, NHS Highland is facing an inevitable fire enforcement notice which
could lead ultimately to closure. The current accommodation also falls below modern healthcare
standards and SHTM’s for Theatre accommodation, including space requirements, and there is a
particular issue associated with the severe lack of storage for the increasing amount of theatre
equipment.
Section 8 summarises a long list options (a total of18 principal, and sub-options) considered to
address the identified SMART objectives and benefits, which were considered in consultation
with a wide range of stakeholders, including patient representatives. These were shortlisted
into the following options, associated with improved critical care delivery and related tower
block reconfiguration, as summarised below.
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
Inital Agreement Document6
1 Do Minimum (Retain Current Configuration)
2Consolidate Critical Care Unit with CCU at Ground floor and Medical HDU and ITU / SHDU co-located at first floor and Endoscopy retained in Tower Block (level 6)
2AConsolidate critical care with CCU & MHDU co-located at ground floor with ITU & SHDU co-located at first floor, and the addition of PACU and vascular lab, with Endoscopy moved out
2BSimilar to Option 2A but with MHDU/CCU situated at Ground floor at “A” block to facilitateintensive care adjacency, and no provision of PACU
3New Combined Assessment Unit on ground floor and consolidate critical care with CCU &MHDU also co-located on ground floor with ITU & SHDU co-located at 1st floor
3ANew Combined Assessment Unit on ground floor and consolidate critical care CCU/MHDU andITU/SHDU) completely on 1st floor
3BNew Combined Assessment Unit on ground floor and consolidate critical care (CCU/MHDU andITU/SHDU) in “A” block on ground and 1st floors, with the provision of PACU and vascular lab.
An extensive non-financial option appraisal exercise was conducted. Overall, the appraisalprocess identified that the preferred non-financial option was option 2A with 622 points,followed by option 2B with 568 points. The least favoured options, by some margin, are Option1 (Do Minimum)) and Option 2.
An economic appraisal was then undertaken to establish capital costs, recurring revenue, non-recurring revenue costs and net present costs for each option. An Option 0 (Do Nothing) hasbeen costed for baseline purposes however this option is not viable because the variouscompliance issues would not be addressed. In particular this option would result in a fireprecautions enforcement notice being issued, ultimately resulting in closure.
In addition to the critical care analysis appraisal, capital cost / revenue estimates have beenestablished based on addressing the various Theatre compliance issues. At an early stage in theprocess, it was agreed that this theatre work was common to all the options, and therefore thecombined costs, including the Theatre costs, have been used in the overall economic review.
The analysis of the net present values (NPV) indicates that Option 1 (Do minimum) has thelowest life time costs with Option 2A being the next favoured option. An analysis wasundertaken on an economic annual costs basis in line with HM Treasury guidance. The Value forMoney (VfM) analysis compared the cost per benefit point of the options as illustrated below.
Whilst Option 1 (Do Minimum) is the lowest Net Present Cost (NPC), it is the second leastfavoured option and does not fully achieve the Investment Objectives, as reflected in thescoring.
No QualitativeBenefitsScore1
QualityRank
Net PresentCost (NPC)(£k)
NPCRank
Cost perBenefitpoint (£k)
VfMEconomicRanking
1 358 6 18,013.8 1 50.3 6
2 349 7 22,687.1 7 65.0 7
2A 622 1 20,976.5 2 33.7 1
2B 568 2 21,941.4 5 38.6 2
3 511 4 21,530.3 4 42.1 3
3A 501 5 21,344.7 3 42.7 5
3B 532 3 22,641.4 6 42.6 4
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
Inital Agreement Document7
Option 2A, has been established as the highest qualitative scoring option as well as having thesecond lowest Net present Cost. Fundamentally Option 2A meets the Investment Objectives,the Critical Success Factors and achieves the lowest cost per benefit point of all the remainingoptions. This option delivers best value in terms of non-financial benefits and the actualappraisal costs. Sensitivity analysis has been undertaken to ensure the results are robust.
It is highlighted that whilst Option 2A does not include a "Combined Medical & Surgical CommonAdmissions Unit”, this option does not preclude such a development at a future date, in thescenario where further consultation established that better patient outcomes could be achieved.
The associated estimates in terms of capital costs and revenues estimates, for Option 2A, aresummarised as follows.
Costs Option 2A
Capital Costs 19,496.2k
Recurrent Revenue Impact 681.3k
Non-Recurrent Revenue Impact 15.2k
Option 2A is considered as the “preferred way forward” and it is anticipated that the OutlineBusiness Case will develop options around this preferred way forward. In recognition of thehigh complexity of this proposed reconfiguration project, detailed healthcare planning of theTower Block will be required and this will establish sub-options of Option 2A which will bereviewed and compared, at Outline Business Case stage.
As noted previously, the proposals contained within this Initial Agreement are entirelycompatible with the Greater Inverness Masterplan study review, and furthermore form aplatform for the latter’s outcomes. The Greater Masterplan review will to lead to developmentof a “Programme Initial Agreement” whereby it will build on the work proposed under this IA,and review all additional factors, relating to the optimal model for delivery of “fit for purpose”healthcare facilities, suitable for the next 25 years.
It is highlighted that due to the nature of the proposed investment, the capital outlay is likely tobe over a period of approximately 5 years, as the wards are undertaken on a phased basis andin alignment with the “fire precautions” project. The anticipated capital funding over the 5 yearperiod would therefore be as follows.
Noting the need for project objectives to relate to the key strategies previously referred to in
Section 2.2, a review was undertaken to establish key “SMART” Investment objectives for the
project based on the SCIM guidance. Following review, these SMART objectives were
established and a detailed summary of the output (including baseline data for measurement and
timing of assessment of the objectives) is provided within Appendix A.
A new project to consolidate critical care together with theatre upgrade work (and associated
realignment of acute services) is considered an essential component of achieving NHS
Highland’s vision and strategic aims. A summary of the SMART objectives is provided below:
No. SMART Objective Heading
1 To improve business effectiveness and revenue efficiency
2 To improve HEAT and other Health targets (including waiting times fortheatres / BADS targets)
3 Augment range of services and promote emerging model of care includingconsolidation of critical care
4 Make possible the introduction of new ways of working and in particulareffective collaborative working and flexibility in the workforce
5 Improved facilities / increased capacity offering a patient centred serviceincluding greater consistency of care and increased certainty foradmissions, procedures and discharge
6 Concentrate higher and lower levels of care at appropriate locations
7 Offer facilities which reduce risk of spread of infection compared to statusquo
8 To achieve optimal utilisation of space (within the constraints of existingbuildings)
9 To achieve operational and functional efficiency of physical environment
10 To deliver high quality facilities, and technical standards with a strongfocus on lifetime costs, quality and design.
11 To comply with “A Sustainable Development Strategy for NHS Scotland’, toenhance the contribution of the health sector to sustainable development
12 To enable the retention and recruitment of staff
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
Inital Agreement Document30
4.2 Existing Arrangements and Analysis
4.2.1 Raigmore Hospital
Raigmore Hospital, in Inverness, is the district general hospital (including specialist services) for
patients in the North + West, South + Mid Community Health Partnership areas, serving
patients from its own and adjacent Health Board areas. The Hospital comprises part single, part
two, part three and an eight storey block (“the Tower Block”) covering an overall foot print of
circa 94,000 m2.
The Tower Block forms part of the original “Phase 2” development of Raigmore Hospital and was
opened in 1985. It is the most prominent part of the Hospital, comprising ward and associated
accommodation on 8 floors, providing various medical and surgical services. Critical care
services, both Medical and Surgical related, are currently provided within different wards spread
around the Tower Block, arising from development over a historical period.
The Theatres are provided at first floor level, within an adjacent building, albeit they are fully
accessible at first floor level of the Tower Block.
4.2.2 Tower Block
General
Over the years, significant changes to the use of the accommodation have occurred
in terms of clinical services provided. However the basic physical ward configuration
has remained broadly the same. Ground level to level 7 of the ward block are
typically divided into 3 areas as follows:
Ward A – South Wing typically ward accommodation
Ward B – Central Core typically ward accommodation
Ward C – North Wing typically ward accommodation
“West Wing” – typically ancillary or office accommodation as well as the only lift
core area.
Fire Precautions Upgrade Project
It is highlighted that a long term construction project to significantly improve fire
precautions within the Tower Block is currently ongoing. This includes the provision
of a new fire sprinkler system, reinstatement of fire partitions and improvements to
horizontal fire evacuation across all 8 floors. To minimise disruption, these
improvements are being undertaken through a series of 3 month decants and on a
ward by ward basis. To date, the currently unoccupied Ward 7A, has been
completed and this ward is being utilised as the main “decant ward” for the majority
of the subsequent works.
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
Inital Agreement Document31
Level 7 (7C) Medical GI/Renal (30) Management (7A) Decant Ward
Level 6(6C) Cardiology/Step Down (?30) CCU (6)
AMAU/MSCU (30)
Level 5 (5C) Vasc/Urol Surgery (20) (14 closed) Derm (9)/Offices (5A) Medical (25)
Level 4 (4C) Surgical (29)SHDU (6 ) Seminar Room
and offices (4A) Surgical (29 + 5 T)
Level 3 (3C) Orthopaedics (28) Head & Neck(3A) Orthopaedics(30)
Level 2(2C) Oncology with D/C Transfusion
Therapy(2A) Stroke/YARU (22) (8)
Level 1 ITU (8)Critical Care Waiting area
1A (CAL 13) EDCU (6) SDCU (12)ITU (8)
Ground Endoscopy Paediatrics
In acknowledgement that the Wards in the Tower Block will be vacant during these
works, over the next 4 years or so, this presents a unique opportunity to undertake
the planned reconfiguration work, as described within this document, in parallel and
without further disruption to patients and clinical services.
Tower Block – Current Services
The current configuration of clinical services is best represented by a cross-section
through the Block, as illustrated below.
In conjunction with the above diagram, the following table provides an overview of
the clinical services provided by NHS Highland that are within the scope of this
project.
Current
Floor
Clinical Service Brief Summary of Services
7 Decant Ward Ward 7A was recently used for administration offices,
but was decanted to allow commencement and the
delivery of the “fire precautions” project. The ward can
be used temporarily during each phase of the works.
7 Management A suite of management offices is currently located at
Level 7B
7 Medical / GI / Renal Renal services including specialist services and renal
replacement therapy
6 AMAU Acute Medical Assessment Unit
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
Inital Agreement Document32
6 MSCU Medical High Dependency Unit (this is a 4 bed HDU)
6 CCU Medical Critical Care Unit
6 Cardiology / Step
Down
Step-Down Unit provides intermediate nursing care
5 Acute Medical Elderly For elderly patients who have complex medical, socialand sometimes mental health issues.
5 Dermatology Inpatient unit for patients with severe skin conditions
5 Vascular/Urology
surgery
Urology - medical and surgical specialty
4 General Surgery Generic Surgical ward
4 SHDU 6 Bedded Surgical High Dependency Unit for criticallyunwell surgical patients , but who do not require I.C.Ucare
4 Surgical Main Surgical Ward
3 Orthopaedics Main Orthopaedic Ward
3 Head & Neck Ward for Patients required head and neck treatment /
surgery
2 Oncology Oncology ward for the treatment of cancer treatment
2 DC Transfusion Day Case Transfusion
2 Therapy General Therapy Unit
2 YARU The Young Adult Rehabilitation Unit
2 Stroke Main Stoke Ward
1 ITU Intensive Care Unit for patients with the most serious
injuries and illnesses requiring close monitoring and
support from specialist equipment
1 Critical Care Waiting
Area
Waiting area associated CCU (Medical and Surgical)
1 CAL Common Admissions Lounge
1 EDCU The eye day care unit is a dedicated treatment unit thatundertakes all eye surgery such as cataract removal
1 SDCU Surgical Day Case Unit
G Paediatrics Child Ward In-patient and Out Patient
G Endoscopy Endoscopy services
4.2.3 Critical Care – Existing Services and Analysis
4.2.3.1 Summary of Facilities
Section 4.2.3 summarises the current configuration of critical care at Raigmore
Hospital. As noted previously, Critical Care bed provision for Level 2 and Level 3
patients at Raigmore currently comprises 24 beds as follows.
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
Inital Agreement Document33
ICU 8 bed
Level 1
The 8 bedded ICU is located on Floor 1, adjacent to Theatre.
Seven ICU beds are funded, to provide the traditional 1:1
nurse-patient ratio (BACCN 2009). Escalation above 8
patients impacts on Theatre, since these patients are
physically managed in Theatre Recovery with some
involvement of Theatre personnel. Medical management of
the ICU is provided by 5 Consultant Anaesthetists. There is
also a dedicated middle grade doctor facility during normal
hours, which continues out of hours but also includes
obstetrics. The ICU is fully equipped to include central
monitoring and modern ventilators. Adjacent to the Unit,
there is a waiting room plus a separate room where sensitive
communications with relatives can take place (as distinct
from a charge nurse’s or doctor’s office). Overnight
accommodation is also available adjacent to the Unit.
Surgical
HDU
6 bed
Level 4
The 6 bedded general surgical HDU is located on floor 4,
alongside but separate to surgical wards. It is staffed to
provide the recommended 1:2 nurse-patient ratio. Medical
management is provided by consultant surgeons who retain
responsibility for their own patients, but there is no
dedicated medical staffing for the Department. It is fully
equipped to include central monitoring. Isolation facilities
exist for 2 beds, albeit without en-suite facilities. However,
the main body of the HDU is cramped, which has implications
in terms of patient confidentiality and privacy.
Medical
HDU
4 bed
Level 6
The 4 bedded general Medical HDU is located on floor 6,
within the Acute Medical Admissions Unit (AMAU), and next
to CCU. It is staffed to provide a 1:2 nurse-patient ratio.
Medical management is provided by consultant physicians
who normally retain responsibility for their own patients. But
there is dedicated consultant physician involvement for one
session per week from a doctor with an interest in this
specialty. There is also a dedicated middle grade doctor
facility, sharing with CCU, during normal hours. The HDU is
fully equipped to include invasive but not central monitoring.
But this department is also cramped which, again, has
implications in terms of patient confidentiality and privacy.
CCU 6 bed
Level 6
The CCU is co-located with the AMAU, but also with the
Cardiac Step-Down Ward. The CCU is a 6 bedded
department, essentially a specialist HDU, providing a facility
for cardiac patients. Nurse staffing is similar to the 2 general
HDUs, with medical management being provided by
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
Inital Agreement Document34
consultant cardiologists, and middle grade doctors as already
described. The CCU is fully equipped with central
monitoring. It also provides a telemetry facility for up to 6
cardiac patients outwith the CCU. The CCU is spacious and
purpose-designed. All of its rooms are single rooms, albeit
without en-suite facilities. This is the only Critical Care Unit
within NHS Highland that is compliant with guidance that at
least 50% of Critical Care Unit beds should be single rooms
to reduce the risk of healthcare associated infection (DoH
2003b).
4.2.3.2 Study – NHS Highland Review of HDU Needs / Critical Care Strategy
As noted in Section 3.2.4, NHS Highland undertook a study to review the provision
of, and need for adult High Dependency Unit (HDU) beds in NHS Highland but also to
make recommendations to the Health Board to inform the development of Critical
Care strategy within NHS Highland. This study covered adult in-patients in Raigmore
Hospital, Belford Hospital, Caithness General Hospital and Lorn & Islands Hospital. A
full copy of the study is available on request.
Data was produced to help describe the strengths and weaknesses of current Critical
Care provision in NHS Highland plus the challenges and opportunities for future
development. The study presented a comprehensive review and analysis of the
various issues associated with the provision of critical care at Raigmore Hospital,
including various recommendations with regard to improving practices and
efficiencies within the Hospital, some of which are being implemented without the
need for significant investment. However, the following key issues and problems
have been highlighted with specific regard to the need for more fundamental change
possible, all Critical Care beds should be in adjacent locations:
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Inital Agreement Document35
‘Economies of scale and great benefits of flexibility can be
achieved by siting HDUs in or next to ICUs, with use of a
common nursing workforce. With such an arrangement, a bed
can be an HDU bed in the morning and an ICU bed in the
afternoon, or vice versa, depending on need’ (SEHD 2000).
‘Flexibility is the real key to coping with growing pressures,
especially peaks in demand’ (SEHD 2000).
Too High Levelof Occupancy
The data showed Raigmore Hospital having high occupancy, but
with much lower (but similar) occupancy in the 3 RGHs. The
high occupancy within Raigmore Hospital reflects that it is the
main provider of acute services in NHS Highland.
Lack of HDUand CCU Beds/ Too earlyDischarge
A frequently cited or recorded reason for patients that required aLevel 2 standard of care being in general wards was lack of HDUor CCU beds. A lack of available beds is directly related to levelsof occupancy. The occupancy level for the 2 HDUs and CCU, washigh. Several patients within general ward areas were assessedas requiring a Level 2 standard of care, having been dischargedtoo early from an HDU.
RespiratoryMedical WardOperating asHDU
Results reveal that 44% (12/27) of all ward-based medicalpatients assessed as requiring a Level 2 standard of care were inrespiratory medicine.
Too High aLevel of Care
Results from the Needs Assessment Audit for Raigmore Hospitalshow that 33% (29/87) of all patients in the 2 HDUs and CCUwere receiving too high a Level of Care.
Poor PatientFlow
Poor patient flow was identified. Ultimately, better management
of patient flow between areas will maximise opportunities for
critically ill patients to receive high quality care in an appropriate
setting.
InappropriateAdmissionPolicy
The study provides evidence to suggest that there is inequitable
critical care access for medical and surgical patients e.g. some
cases of medical care patients with a requirement for ward-based
Level 1 care, being placed in Medical HDU. Consequently there
will be other patients receiving too low a level of care due to lack
of critical care facilities.
Similarly there was evidence to suggest there was inappropriate
discharge policy for Surgical HDU. This was to relieve pressure
on nursing staff within the 2 step-down surgical wards by
delaying the transfer from Surgical HDU of recovering patients
who would require a high degree of Level 1 care.
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
During the data collection process, the Project Co-ordinatornoted that patients were admitted to wards with cardiacconditions that merited admission to CCU. However, atassessment these patients were no longer requiring a Level 2standard of care. This information is noted to again show theextent of need for Critical Care beds.
Lack ofIsolationFacilities
A model of care has existed over several years whereby Level 2general medical patients needing isolation facilities are admittedto CCU, even though these patients have no cardiac conditions.(A reciprocal arrangement allows for the admission of a cardiacpatient to the Medical HDU, should CCU be full in consequence ofhaving accepted a non-cardiac patient.). The Medical HDU, aspreviously described, has no single rooms. It is the only CriticalCare Unit in Raigmore Hospital that is unable to provide isolationfacilities to critically ill patients.
ITUdeficiencies
The design of the ICU has not altered in over 25 years sinceRaigmore Hospital was built. Some aspects of design arelagging. For example, the Unit has isolation facilities for just 2patients. In recent years, this has proved inadequate withinfectious patients also being managed in the 6 bedded bay area.This leads to the temporary closure of beds adjacent to theinfectious patients as part of measures to prevent cross-infection. Therefore, the out-moded design of the ICU impactson its ability to operate an efficient and cost-effective service.But there are other design faults with the ICU. For example, thevisitors’ entrance/exit to the Unit (that is, the public access)necessitates close proximity to the medical equipment andintravenous fluids store rooms. Whilst nursing staff willendeavour to escort family members to and from the Unit, thiscannot be guaranteed at times when staff are operating underextreme pressure. With regard to these issues of infectioncontrol, security and efficiency, there is clearly a requirement forthe design of the ICU to be up-graded.
Too High Levelof Care
Results from the HDU Needs Assessment Audit show that 7%(3/41) of patients in the ICU were receiving too high a Level ofCare. This, as will become evident, relates to structural deficitsnecessitating a Level 3 care requirement where the truerequirement would have been for Level 2 care.
Lack of HDUbeds
Within Raigmore Hospital, there is the need to address the
various factors that inflate demand for Critical Care beds – sub-
optimal bed management; sub-optimal care at ward level;
inappropriate admission and discharge policies; lack of CCU
‘ownership’ of cardiac triage; lack of isolation facilities in Medical
HDU and wards; uneven scheduling of surgical activity;
knowledge/skills deficit at Level 2 and lack of a co-located,
integrated Critical Care service with a single nursing and medical
administration. Therefore, additional investment in Critical Care
beds should be sequential to maximising the efficient and
effective use of existing Critical Care beds.
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That said, the findings of this report also support that there isunder provision of HDU beds, especially Medical HDU beds,within Raigmore Hospital.
Lack of HDUBeds
This also relates to too high level of care being provided (in ICU)due to lack of HDU beds to facilitate discharge from the ICUnoting that the cost of beds in ICU is approximately double thatof HDU
Therefore, it may be reasonably asserted that there is a shortfallof 4 HDU beds, especially Medical beds, within RaigmoreHospital. But having regard to the significant cost implicationsand the discussion that has taken place concerning maximisingflexibility and economies of scale, this number could belegitimately reduced by a co-located, integrated Critical Careservice
ICU Beds Consideration must also be given to ICU bed provision. The veryhigh occupancy data for 7 staffed ICU beds (86% during thisstudy; 78% according to SICSAG (2009) data) support that anadditional ICU bed should be funded. But as with the earlierdiscussion, this should be sequential to addressing the factorsthat inflate demand for ICU beds – lack of HDU beds; inequity ofaccess to Medical HDU beds; lack of CPAP provision in SurgicalHDU; and lack of a co-located, integrated Critical Care servicewith a single nursing and medical administration. If these factorsare addressed successfully then the current ICU bed provision islikely to prove adequate
4.2.4 Raigmore Theatres – Existing Services and Analysis
4.2.4.1 Existing Provision
The existing main operating department at Raigmore, where all surgical activity
takes place, includes 9 x operating theatres and 1 modular operating theatre (as well
as the Maternity theatre located separately) all with associated anaesthetic rooms,
preparation areas and recovery spaces. In summary the theatres, and associated
facilities, are utilised as follows.
Theatre No. Clinical Activity
Theatre 1 Ophthalmic Surgery 4 days, Orthopaedic half day & ENT
The Operating Department (Operating Theatres) caters for all surgical specialities,
scheduled, unscheduled, in-patient and day case procedures – resulting in a complex
and frequently inappropriate mix of patients in shared areas. The area provides
specialist facilities that enable surgeons to undertake surgical interventions
(procedures or operations) on patients whose medical condition requires the same.
It also provides accommodation for minimally invasive procedures conducted under
radiological control by either radiologists or surgeons.
Although the level of intervention will vary by patient, in general, within the
operating department, patients are received, reviewed, anaesthetised, operated
upon and recovered. The service provides for emergency and elective patients who
require surgical intervention and/or other procedures that require to be conducted
within an operating room environment and/or anaesthesia, with facilities that allow
functional groups to care for pre, intra and post-operative/anaesthesia patients in a
low risk environment.
4.2.4.2 Theatres – Condition and Physical Environment
Raigmore Hospital’s main operating theatre department has existed, along with the
Tower Block, for a period of around 30 years without any significant refurbishment.
During that period there have been significant improvements in theatre practice,
which whilst beneficial, has resulted in an increasing amount of necessary equipment
with a consequential demand for space. Furthermore, due to the lack of
refurbishment over this period, the existing fit-out and services infrastructure has
fallen well behind SHTM’s and other relevant standards. A summary of the various
issues is provided below.
4.2.4.3 Compliance with Modern Healthcare Standards
Due to the recent lack of refurbishment, the theatre accommodation currently fails to
meet modern healthcare standards in terms of level of fit-out and furnishings. The
existing installation also fails to meet full compliance in terms of compliant doors,
floors, ceiling finishes, lighting and the like. The physical condition of the premises is
of a standard that is representative of a building of approximately 30 years old. It
fails to meet modern healthcare standards in terms of functional requirements, space
needs, compliance with current clinical guidance and acoustic criteria.
The accommodation is cramped throughout and is characterised by inadequate
cluttered corridors, full of equipment and inadequate space such as the current
provision of a make-do reception, to allow a children’s waiting area to be provided.
All this compromises the provision of care for patients and similarly, staff working in
the building, are constantly frustrated by a lack of space and the poor functional
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suitability of the buildings. Inevitably this impacts upon their ability to deliver
effective and efficient services.
4.2.4.4 Infection Control
Due to the lack of refurbishment over the years, the facilities have fallen well behind
in terms of compliance with current infection control standards, in terms of suitable
layout, finishes, materials and furnishings.
4.2.4.5 Fire Precautions
Due to the age of the building, the original fire strategy has become compromised
due to the gradual change of use but in particular the application of more recent
standards by HIFRS (Highland and Island Fire & Rescue Service). Furthermore it is
likely that building services developments within these premises have weakened the
integrity of the existing fabric, in terms of maintaining the original fire separation
strategy. Accordingly, NHS Highland acknowledge that there are a number of
improvements to the existing Theatres building, which may be necessary and
consideration needs to be given to the adequacy of the existing fire strategies.
In particular fire evacuation from the theatres is provided only via the existing
stairwells (with no lifts) whereby bed-ridden patients would only escape via an
evacuation facility, one at a time.
It is highlighted that without further action, NHS Highland anticipates that an
enforcement notice from the Fire Authority would be issued, with the ultimate
sanction of closure being applied.
4.2.4.6 Mechanical and Electrical Systems
There is a significant backlog in maintenance, and with plant and equipment at an
age which is beyond their design life, is inefficient in terms of its energy use and
carbon footprint. Condition reports suggest that existing mechanical and electrical
systems fail to comply with current codes and standards.
The Ventilation systems is not currently up to the standards as identified in SHTM-
03001 “Ventilation for Healthcare premises” where there is a need for increasing air
exchange rates to theatres.
Lighting currently fails to meet CIBSE Lighting guide 2, and the electrical wiring is
likely to date back to the original build and accordingly has reached the end of its
design life.
4.2.4.7 Theatres - Space Provision
The space standards to which the department was designed to when it was
constructed nearly 30 years ago falls significantly short of the area allowances in
current Scottish Health Planning Notes. The following table presents the existing
space provision against current standards. The tables below show the existing
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accommodation for a typical theatre against those recommended in the current
SHBN Guidance.
Room HBN RecommendedArea
CurrentFloor Area
Operating Theatre 55.0sqm 36.75sqm
Anaesthetic Room 19.0sqm 15.55sqm
Scrub-up & Gowning(3places) 11.0sqm 7.5sqm
Preparation Room 12.0sqm 10.87sqm
Exit / Parking Bay 12.0sqm 11.68sqm
Store (Equipment) 1.0sqm -
Disposal Room 12.0sqm 5.2sqm
Total Net Floor Area 122.0sqm 80.05sqm
The space requirements reflect the increasing
number of developments in clinical care,
compliance issues and equipment available and
where existing space provision has been found
to be inadequate. The above demonstrates the
clear need for additional space within the
footprint of the theatres accommodation. One
of the key problem areas is the current lack of
storage for equipment both in terms of the lack
of a suitable central storage area as well space
within theatres for short term storage. In
recent years the various improvements in
theatre practice has seen an exponential
increase in equipment required. This has
resulted in the current status whereby all
corridors within the exiting Theatre department are cluttered with various equipment
(see adjacent photo).
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5 Business Scope and Key Service Requirements
5.1 Key Drivers
As noted in section 3.2.3.4, NHS Highland is undertaking a comprehensive masterplan study
which will comprise detailed consideration of an optimal model of care and providing fit for
purpose facilities for the next 25 years. A future “Programme Initial Agreement” will be
developed to address these elements, including capacity and demand issues, and accordingly,
they are excluded from the investment proposed within this IA.
The following summarises the key drivers that should influence the way forward.
The aim to comply with the national and local drivers referred to in the Strategic
section including the Scottish Government and local drivers, refer Section to 3.
Alignment with the overall healthcare Masterplanning Exercise being undertaken
by NHS Highland associated with the Greater Inverness Area
Addressing the inefficiencies in the current model of care where critical care /
high dependency services are dispersed around the Block and not at their optimal
location
Alignment with the developing policies on critical care / high dependency – refer
to Section 3.2.4.
Delivering Theatre facilities that are commensurate with modern clinical
standards
The opportunity that the fire precautions project presents where essential
decanting of clinical areas, enables an unique opportunity for appropriate re-alignment of clinical services, avoiding further disruption to patients
5.2 Potential Business Scope
5.2.1 General
The business scope is essentially the design and development of facilities that meet the
Investment Objectives described in Section 4.1. However, in order to establish project
boundaries, a review was undertaken by key stakeholders, and the following items were
established in relation to the limitations of what the project is to deliver.
Where refurbishment takes place, facilities will be developed that are
commensurate with modern healthcare standards where this is viable but within
the constraints of the existing buildings.
Similarly, new facilities, as far as possible within the existing constraints, shall
seek to comply with all relevant Health literature and guidance including, but not
limited to, Scottish Health Technical Memorandum (SHTM), Scottish Health
Planning Notes (SHPN’s) and Health Briefing Notes (HBN’s).
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The development of a design that gives high priority to minimising life cycle costs
The provision of clinical services associated with the development but limited to
that defined in Section 4.2
Within NHS Highland’s affordability criteria with respect to ongoing revenue
costs.
The development will not be designed in isolation, but should also consider the
potential for adjacent developments. This may include potential economies of
scale
Achieve good quality in design using robust materials that meets with the
general expectations of the various stakeholders. This will be measured by use
of the NHS “AEDET” system.
In conjunction with the Infection Control Team, develop a design that minimises
the risk of infection. To facilitate this, the design will be considered in
conjunction with the NHS “HAIScribe” system.
Comply with CEL 19 (2010) - A Policy on Design Quality for NHS Scotland - 2010
Revision which provides a revised statement of the Scottish Government Health
Directorates Policy on Design Quality for NHS Scotland. CEL 19 (2010) also
provides information on Design Assessment which is now incorporated into the
SGHD Business Case process.
Maximise the sustainability of the development, and meeting the mandatory
requirements under the BREEAM Healthcare assessment system.
The phasing of the project will also be in line with the ongoing Tower Block Fire
Precautions project which provides a timely opportunity for when Wards are to be
decanted in any case (this is being separately funded).
5.3 Resultant Service Requirements
Notwithstanding the identified Investment Objectives, the two principle aims are to consolidate
Critical Care at the optimal location in the tower Block and improve compliance aspects in
respect of the Theatres. As noted above, many of the existing clinical services will be ultimately
retained in their current location (albeit there will be interim moves, which are separately
funded under the “fire precautions” and “endoscopy” projects). The following summarises those
elements which could be included within this project investment.
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Critical Care Related Elements
It is anticipated that some existing clinical departments will require to be
permanently relocated, in order that the new optimal adjacencies can be
achieved.
To achieve consolidation of critical care, it is assumed the scope of work will
include refurbishment of existing ward accommodation at ground and first floor
of the Tower Block commensurate with modern standards, and including
upgrading of services infrastructure as necessary.
The project may require the re-location of services from the Tower Block into
other existing Raigmore accommodation,
The project may require the development of some existing accommodation,
within the Tower Block on a temporary basis, to facilitate the moves and phasing
works
Theatres
Following review of the deficiencies associated with the current Theatre provision as
described within Section 4.2.4, including the compliance and environmental issues,
consideration should be given to the following in relation to the potential scope of the
investment.
Upgrading existing fire precautions, and improvements
There is a clear need for the retention and some refurbishment of the existing 9
theatres (not including the Maternity theatre). It is envisaged that the existing 9
Theatres on the first floor of the Tower Block will be retained in their current
location.
Consideration should be given reconfiguring accommodation, where possible, to
better locate storage and ancillary facilities. It is envisaged that some existing
departments, including storage accommodation, may be re-located
Upgrading of existing services infrastructure, where necessary to meet modern
standards. This is likely to include the provision of new ventilation plant, at roof
level, and distribution systems.
Provision of a service waste corridor to improve waste flows (avoiding “dirty /
clean crossovers”) and to facilitate minimising disruption during future
maintenance.
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6 Benefits / Risks / Constraints and Dependencies
6.1 Benefits
The Key stakeholders have given further consideration to the Investment Objectives
(in Section 3.1) in order to establish the relative value of each objective, the key
benefits and beneficiaries, and the potential benefits criteria that may be used in the
analysis to establish the preferred way forward.
Following discussion and debate a wide range of issues were identified. These wererationalised under 7 key headings that were believed to summarise the benefitscriteria (measures) that each option should be assessed against. In summary, thesewere identified as the extent to which each option:
Benefits Criteria
1. Realised appropriate clinical adjacencies between departments
2. Realised appropriate clinical adjacencies within departments
3. Realised compliance with technical and space standards
4. Provided an optimal patient experience
5. Supported sustainable service delivery
6. Supported “strategic fit”
7. Optimised the quality of the overall physical environment
The following table summarises how the identified benefits are closely aligned with
the Investment Objectives.
Reference Investment Objectives Benefits
1 To improve businesseffectiveness and revenueefficiency
1. Clinical Adjacencies between departments
2. Clinical Adjacencies within Departments
3. Compliance with technical and SpaceStandards, as far as possible
6. Strategic Fit
7. Quality of Physical Environment
2 Improve HEAT and other Healthtargets including waiting timesfor theatres
1. Clinical Adjacencies between departments
2. Clinical Adjacencies within Departments
3. Compliance with technical and SpaceStandards, as far as possible
5. Service Sustainability
3 Augment and expand range ofservices and promote emergingmodel of care including
1. Clinical Adjacencies between departments
2. Clinical Adjacencies within Departments
6. Strategic Fit
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consolidation of critical care
4 Make possible the introduction ofnew ways of working and inparticular effective collaborativeworking and flexibility in theworkforce
1. Clinical Adjacencies between departments
2. Clinical Adjacencies within Departments
4. Patient Experience
5. Service Sustainability
6. Strategic Fit
5 Improved facilities / increasedcapacity offering a patientcentred service including greaterconsistency of care andincreased certainty foradmissions, procedures anddischarge
3. Compliance with technical and SpaceStandards, as far as possible
4. Patient Experience
6. Strategic Fit
7. Quality of Physical Environment
6 Concentrate higher and lowerlevels of care at appropriatelocations
1. Clinical Adjacencies between departments
2. Clinical Adjacencies within Departments
5. Service Sustainability
6. Strategic Fit
7 Offer facilities which reduce riskof spread of infection comparedto status quo
4. Patient Experience
6. Strategic Fit
7. Quality of Physical Environment
8 To achieve optimal utilisation ofspace (within the constraints ofan existing building)
3. Compliance with technical and SpaceStandards, as far as possible
4. Patient Experience
6. Strategic Fit
9 To achieve operational andfunctional efficiency of physicalenvironment
1. Clinical Adjacencies between departments
2. Clinical Adjacencies within Departments
5. Service Sustainability
6. Strategic Fit
10 To deliver high quality facilities,and technical standards with astrong focus on lifetime costs,quality and design.
3. Compliance with technical and SpaceStandards, as far as possible
4. Patient Experience
6. Strategic Fit
7. Quality of Physical Environment
11 To comply with “A SustainableDevelopment Strategy for NHSScotland’, to enhance thecontribution of the health sectorto sustainable development
5. Service Sustainability
6. Strategic Fit
12 To enable the retention andrecruitment of staff
4. Patient Experience
5. Service Sustainability
6. Strategic Fit
7. Quality of Physical Environment
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6.2 Main Risks
The key stakeholders have undertaken an initial Risk Workshop to establish the
principal risks associated with the proposed investment. This will be further
developed as part of the Outline Business Case. Whilst there will be many risks to
the project, the key stakeholders have considered what they perceive to be the main
risks which are considered to contribute collectively to the majority of the risk value
(approximately 80%). A summary of the key risks identified is provided below.
Business Risk
Greater Inverness Masterplan conclusions resulting in changes of scope
Changing local strategies (Raigmore) impact on the project
Demand for services higher than projected
Service Risk
Disruption to existing services during development or redevelopment
Stakeholders - contradictory aspirations
Changing statutory and NHS/HFS Guidance
“Scope Creeping” developments
Unclear strategy of Raigmore development
Capacity of Services and Infrastructure
Constraints of existing services and infrastructure
Uncertainty associated with existing building fabric
Live Acute Hospital Environment and Clinical Needs affecting delivery of project
NHS Highland and Scottish Government Approvals process
External / Environmental Risks
Statutory Approval Delays
Achievement of BREEAM Healthcare “Very Good” and complexity of scheme
(which element applies)
Financial Risk
Accuracy of Estimated Capital Cost
Revenue Cost Assumptions
VAT rules
Capital / Revenue distinction
Inflation
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Insolvency
Dependency Projects (i.e. projects upon which this investment depends)
Viability of Phasing Proposals
6.3 Constraints
Financial
NHS Highland, in line with other Boards across Scotland is facing a very
challenging financial position. This will mean a very difficult balancing act
between achieving LDP targets whilst delivering substantial cash savings.
Programme
The programme is currently dependent upon the existing “Fire Precautions”
project which is underway.
Quality
Compliance with all current health guidance, where at all possible, within
the constraints of the existing accommodation
Sustainability
Where appropriate, Achievement of BREEAM “Very Good” in the case of
any refurbishment development
Existing Clinical Services
A fundamental constraint of the project will be the need to fully maintain
existing clinical services throughout the project period. As noted previously,
the ongoing fire precautions project presents an opportunity to minimise
disruption.
6.4 “Dependency Projects”
There are a number “dependency projects” upon which this investment may rely
upon but which funding is already in place or will be required from another source.
The precise details of these are, in some cases, unable to be fully established,
however the potential relevant projects are summarised as follows.
Fire Precautions - As noted a fire precautions project is underway and is being
separately funded
The re-location of the Children’s ward (from its current location at ground floor
level) to a location outwith the Tower Block is being considered by NHS
Highland/Archie Foundation. It is envisaged that this will involve a Children’s
Ward Out-Patients Department (OPD) development and the relocation of the
Children’s Ward In-Patient facility to Ward 11. Funding will mainly be sourced
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via the Archie Foundation albeit with NHS funding required in respect of backlog
compliance issues.
A separately funded Endoscopy project is currently ongoing to provide a new
build Decontamination Unit and to re-locate the existing Endoscopy Unit to Ward
8. This will also require the amalgamation of Ward 8 into Ward 9.
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7 Agreed Critical Success Factors
7.1 Stakeholder Review
In consideration of the Investment Objectives in Section 3 and the potential benefits
summarised in Section 5, the key stakeholders have undertaken a review of those
factors which it is considered essential to the scheme.
Notwithstanding the desire that all investment objectives and resulting benefits will
be achieved, the key stakeholders have identified the following limited list of Critical
Success Factors deemed essential to the project being considered successful.
1. The achievement of the project within the available financial parameters of
NHS Highland (revenue funding). See section 9 for further information on
Funding.
2. Consolidating high dependency units and critical care in order that clinical
and administration efficiencies are delivered,
3. Achieving the position where an increased percentage of patients have the
correct level of care provided at all times during their hospital stay
4. Establishing a position whereby Theatre capacity is at a more optimal level
with a reduced number of cancellations for scheduled surgery.
5. Compliance with all relevant Health Guidance (unless otherwise agreed as
being in-appropriate) including HAIScribe guidance to ensure facilities are
commensurate with current policy and reduce the risk of health related
infection spread
6. Avoid significant disruption to existing clinical services
7. Quality – Delivery of key stakeholders (including community representatives)
expectations is critical to the success of the project. “AEDET” reviews will be
undertaken and will achieve a minimum target score of 4/6 in all categories.
8. Sustainability. The achievement of BREEAM “Very Good” for refurbishment
development
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8 Long List of Options and SWOT Analysis
8.1 General
NHS Highland has rigorously considered the SMART objectives, potential benefits and
the critical success factors previously summarised in this report. The approach
adopted for developing the options involved representatives from a range of groups,
including NHS Highland, in a series of workshops that.
Reviewed the national and global drivers for change in terms of health services
with a view to developing an understanding of the implications of these for
Health Service provision
Considered the overall objectives for the project and key success factors
Considered current procurement options available to NHS and the current
economic climate
Examined the current services and property provision at Raigmore
A summary of the key stakeholders involved in the consultation process is provided
in Section 3.1.5.
8.2 “Categories of Choice” (CoCA) Assessment to establish Long List ofOptions
Consideration has been given to a wide range of potential options in accordance with
the HM Treasury Green Book guidance. Options have been considered based on the
“SCIM” approach using the various “CoCA” assessment headings.
Appendix B presents the “CoCA” Table, developed to capture the previous views of
stakeholders on the potential options. Based on this CoCA Assessment, the options
noted in Appendix B as “discounted” were not considered further. The remainder
were developed into a long list of investment options, as follows. It was fully
recognised that there was potential for some options to be combined.
8.3 Summary of Long List of Options
Based on the assessment undertaken under Section 7.2, the following is the “Long
List of Options” that emerged. It was clear that a number of these options were not
“stand alone” (i.e. they could not address the requirement alone) but could be
“combined” with the principal options to deliver the preferred solution.
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Long List of Options Ultimatelyshort-listed(and Option)
A Do Nothing Yes (1)
B Co-locate services within the Tower Block based on speciality – Medical and
Surgical
No
C Consolidate Critical Care Unit with CCU at Ground floor and Medical HDUand ITU / SHDU co-located at first floor and Endoscopy retained in TowerBlock (level 6)
Yes (2)
D Consolidate critical care with CCU & MHDU co-located at ground floor withITU & SHDU co-located at first floor and with Endoscopy moved outwithTower Block
Yes (2A)
E Similar to Option 2A but with MHDU/CCU situated at Ground floor at “A”block to facilitate intensive care adjacency, and the addition of Vascular Laband PACU
Yes (2B)
F New Combined Assessment Unit on ground floor and consolidate criticalcare with CCU & MHDU also co-located on ground floor with ITU & SHDU co-located at 1st floor
Yes (3)
G New Combined Assessment Unit on ground floor and consolidate criticalcare CCU/MHDU and ITU/SHDU) completely on 1st floor
Yes (3A)
H New Combined Assessment Unit on ground floor and consolidate criticalcare (CCU/MHDU and ITU/SHDU) in “A” block on ground and 1st floors
Yes (3B)
I Provide additional capacity of Medical High Dependency Units No
J Consider under utilised space in Maternity Unit (first floor) as locus forservices that need close proximity to theatres e.g. Ophthalmology /Endoscopy / Surgical Day Case
No
K Create additional capacity to dialyse patients on in-patient wards with maindialyses at level 7 (close to for plant configuration
Combine
L Addition of vascular lab to meet current standards for Vascular department Combine
M Addition of post anaesthetic care unit (PACU) adjacent to intensive care unit Combine
N Move non-acute services out of the Tower Block, where adjacency is notrequired (e.g. Endoscopy, Child Ward), and to suitable existingaccommodation
Combine
O Re-locating female surgery wards (away from male wards) and intoseparate unit (outwith Ward Block) – into Ward 8
No
P Consider re-locating selected acute services at Raigmore back into theTower (e.g. Respiratory) that provide improved adjacency to GeneralMedicine
Combine
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Q Upgrade existing Theatre accommodation commensurate with modernstandards
Combine
R Eye Day Case Unit – relocation to current location of renal unit Combine
The above scoping / service solutions options would be amalgamated with the
following “implementation” and “funding” options:
Implementation Options
Phase services in – extensions and refurbishment of existing premises
Funding Options
Phased Capital funding based on traditional procurement
8.4 SWOT Analysis
Key stakeholders subsequently undertook a SWOT analysis of the long list of options
to establish a shortlist of options to be taken forward for more detailed assessment
at Outline Business Case Stage. The options selected are a combination of the
scoping service solution, implementation and funding options noted above.
A summary of the results is provided in Appendix C. In summary 6 key high level
options have been established (in addition to a “Do Minimum” option). Due to their
complexity they are represented by the following table.
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
Surgical Triage to remain at Level 4 Surgical Triage relocated to GroundLevel
Potential to move Renal Dialysis moved to Level 7 – separate Investment
Respiratory moved into Tower – Level 6
Medical Ward adjacent to Therapy
Oncology moved to Level 5
Child Ward moved out of Block (Ward 11)
Endoscopy atLevel 6
Endoscopy re-locate to Ward 8 (funded secured)
Gynae/Breast(Ward 8)into Tower -Level 5
Gynae/Breast (Ward 8) to amalgamate to Ward 9(funded secured)
- Vascular Laboratoryadded at 5C
- VascularLaboratoryadded at 5C
Potential to provide Eye Day Case into the accommodation formally occupiedby Renal (separate investment). However, this investment only to include
limited allowance for Eye Day Case, currently in 1A
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
Inital Agreement Document54
1 2 2A 2B 3 3A 3B
Theatres Refurbishment
In conjunction with the planned significant upgrading works (refer below) the
continued use of the existing 9 theatres located within the Tower Block
To improve compliance, building fabric and services upgrading of the existing 9
theatres, to meet modern clinical standards (the Theatre within the Maternity
Block is outwith the scope of this project)
Upgraded fire precautions of Theatres in Tower Block to meet horizontal fire
evacuation requirements
Services upgrade associated with achieving compliance, include ventilation
system enhancement
Where possible, potential increase in storage requirements (possible expansion
adjacent to plant room) to facilitate improved compliance with required storage
and other space standards
Provision of services / waste corridor to rear of the Theatres accommodation
Child Ward
Retain incurrentlocation
The Child Ward will involve the redevelopment of Ward 11 to facilitate
the move. A limited allocation of funding is being considered in
respect of any outstanding need to deal with the current backlog
compliance issues.
Respiratory
Retain incurrentlocation
The project will require the development of a temporary facility at
Ground Floor level involving some works. (This will require
occupation of some Children’s Ward accommodation, on a temporary
basis).
Furthermore, Level 6 will require some reconfiguration to facilitate the
permanent move to Level 6
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9 Economic Case to Arrive at Preferred Way Forward
9.1 General
This section summarises the option appraisal undertaken to arrive at the preferred
way forward in consideration of the costs, benefits and project risks of each of the
shortlisted options.
All current guidance has been followed in undertaking the option appraisal,
principally the Scottish Capital Investment Manual (SCIM), the HM Treasury Green
Book and supplementary guidance.
9.2 Qualitative Option Appraisal
9.2.1 Introduction
A non-financial option appraisal exercise was conducted with a range of key
stakeholders over 3 sessions during September and October 2012. These sessions
were facilitated by independent Healthcare Planners and included representatives
from a range of stakeholders. A copy of the full option appraisal report is available
upon request. The document summarises the process followed, along with an
analysis of the numerical outputs. The following sections summarises the key
aspects of the report.
9.2.2 Process Employed
The process employed was agreed with participants at the outset. It involved a
stakeholder group working through a series of questions with the objective of
applying a consistent and rational approach to the challenge of identifying the best
solution to meet the requirement. It was emphasised that the qualitative stage of
the option appraisal was based on non-financial qualitative criteria and that further
financial analysis of the preferred options identified would be conducted as a
subsequent component of the business case development.
9.2.3 Benefits Criteria and Weighting
As noted in Section 5, and following extensive discussion and debate a wide range of
issues were identified. These were rationalised under 7 key headings that were
believed to summarise the benefits criteria (measures) that each option should be
assessed against. These benefits criteria have already been highlighted in section
5.1. To support the process, of applying a relative “weighting” (priority) to each of
the criteria identified, a comparative matrix was used to aid the initial relative
prioritisation of benefits criteria.
To determine the actual weightings to be applied, stakeholder groups were asked to
allocate “100 points” appropriately between identified benefits criteria based on their
opinion of the relative importance of each. Scores were fed back by benefit criteria
and group in the first instance. Having agreed the relative weighted benefits criteria
of each stakeholder group, discussions took place to rationalise separate
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
Inital Agreement Document56
“weightings” into a single agreed factor that would be applied to each identified
option in the formal scoring process. The groups reached agreement over the
overall agreed weighting through consideration of the mean, median and modal
weightings, as follows.
Having agreed the benefits criteria, relative weighting and options to be assessed,
the group progressed with the formal process of applying a score to each criteria in
the context of each option. This was supported through an extensive process of
facilitated debate with the consensus agreement of all participants realised regarding
the relative merits of each option and scores to be applied.
9.2.4 Summary of Qualitative Results
The following table present a summary of the scoring of each of the 7 options (as
defined in Section 7.4).
Option Weighted Benefits Score
No. DescriptionConsensusOptimisticPessimistic
Rank
1 Do Minimum (Retain Current Configuration) 358 6
2
Consolidate Critical Care Unit with CCU atGround floor and Medical HDU and ITU /SHDU co-located at first floor and Endoscopyretained in Tower Block (level 6)
349 7
2A
Consolidate critical care with CCU & MHDU co-located at ground floor with ITU & SHDU co-located at first floor, and the addition of PACUand vascular lab, with Endoscopy moved out
622 1
2B
Similar to Option 2A but with MHDU/CCUsituated at Ground floor at “A” block tofacilitate intensive care adjacency, and noprovision of PACU
568 2
3
New Combined Assessment Unit on groundfloor and consolidate critical care with CCU &MHDU also co-located on ground floor withITU & SHDU co-located at 1st floor
511 4
3ANew Combined Assessment Unit on groundfloor and consolidate critical care CCU/MHDUand ITU/SHDU) completely on 1st floor
501 5
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3B
New Combined Assessment Unit on groundfloor and consolidate critical care (CCU/MHDUand ITU/SHDU) in “A” block on ground and 1st
floors, with the provision of PACU andvascular lab.
532 3
Overall, the non-financial option appraisal process identified that the preferred non-
financial option was option 2A with 622 points, followed by option 2B with 568
points. These 2 options represented the “leading group” with options 3B (532
points), 3 (511 points) and 3A (501 points) in 3rd, 4th and 5th place respectively.
The least favoured options by some margin are Option 1 (Do Minimum) and Option
2, with Option 2 scoring less than option 1 in some scenarios.
9.3 Economic Appraisal
9.3.1 General
This section presents the economic implications of the investment (both capital and
revenue) and also provides the economic appraisal of the short-listed options. The
outputs from the cost models identified in this section form the basis of both the
financial and economic appraisals of the short-listed options. Each of the short-listed
options has been costed with due consideration of the changes associated with each
option and any changes in cost have been clearly identified and explained. The
following categories of cost have been considered for each option.
9.3.2 Capital
The capital costs have been considered an
of each option that has been identified by
These capital costs have been calculated u
The following summarises the main capital
Costs have been calculated at January 2
Baseline costs for – Pay (workforce) Non Pay (associated with staff) Estates/Utilities (associated with
the existing building) Income Capital Charges (depreciation)
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
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It is highlighted that in order to further compare costs, and establish a baseline, an
“Option 0” (Do Nothing) was created. This had a capital cost and net present value
of £1,400k and £11,814k, respectively. However this option is not viable because
the various compliance issues would not be addressed. In particular this option
would result in a fire precautions enforcement notice being issued, ultimately
resulting in closure.
The analysis of the net present values (NPV) indicates Option 1 (Do minimum) has
the lowest life time costs with Option 2A being the next favoured option. It should
be noted that the outcome EAC for Option 2B of 897.3 which is only £40k pa
different from the first ranked Option 2A.
9.3.5 Summary of Economic Appraisal
The ‘Do minimum’ option 1 has the lowest capital requirement, recurrent and non
recurrent revenue impact and also the second lowest lifetime costs.
The second lowest recurrent revenue impact comes with Option 2A. This also has
the second lowest lifetime costs from the NPV and EAC calculations. The revenue
associated with Option 2A is an increase of £681k from current budgets – this
includes an increase of capital charges (depreciation) of £697k pa and a saving in
revenue pay of £16k pa.
Non recurrent costs are similar across all options with a range of £14,789 for Options
2, 2A and 2B to £15,210 for Options 3, 3A and 3B. This non-recurrent budget would
need to be funded at the time that the Department moves to a new location as it is
predominantly for minor equipment and staff to facilitate the move. The Outline
Business Case will give consideration to potentially significant non-recurrent costs
still to be added for Theatres. (However these are common to all the IA options).
9.4 Overall Value for Money
Value for money (VfM) is defined as the optimum solution when comparing qualitative benefits
to costs. An analysis (below) has been performed on an economic annual costs basis in line
with HM Treasury guidance. The VfM analysis compares the cost per benefit point of the
options. The option that is preferable is the option that demonstrates the lowest cost per
benefit point. The cost per benefit point is listed in the end column – VfM Economic Ranking.
No Option QualitativeBenefitsScore2
QualityRank
NetPresentCost(£k)
NPCRank
Cost/Benefitpoint(£k)
VfMEconomicRanking
1
Do Minimum(Retain CurrentConfiguration)
358 6 18,013.8 1 50.3 6
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2
Consolidate CriticalCare Unit with CCUat Ground floor andMedical HDU andITU / SHDU co-located at firstfloor andEndoscopy retainedin Tower Block(level 6)
349 7 22,687.1 7 65.0 7
2A
Consolidate criticalcare with CCU &MHDU co-locatedat ground floorwith ITU & SHDUco-located at firstfloor, and theaddition of PACUand vascular lab,with Endoscopymoved out
622 1 20,976.5 2 33.7 1
2B
Similar to Option2A but withMHDU/CCUsituated at Groundfloor at “A” blockto facilitateintensive careadjacency, and noprovision of PACU
568 2 21,941.4 5 38.6 2
3
New CombinedAssessment Uniton ground floorand consolidatecritical care withCCU & MHDU alsoco-located onground floor withITU & SHDU co-located at 1st floor
511 4 21,530.3 4 42.1 3
3A
New CombinedAssessment Uniton ground floorand consolidatecritical careCCU/MHDU andITU/SHDU)completely on 1st
floor
501 5 21,344.7 3 42.6 4
3B
New CombinedAssessment Uniton ground floorand consolidatecritical care(CCU/MHDU andITU/SHDU) in “A”block on groundand 1st floors, withthe provision ofPACU and vascularlab.
532 3 22,641.4 6 42.6 4
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
Inital Agreement Document64
The following conclusions are drawn from the value for money analysis.
Option 2A represents the best value option on the basis that it achieves the lowestcost per benefit point of all these options. This option delivers best value in termsof non-financial benefits and the actual appraisal costs.
Option 2A also achieves the highest qualitative benefits score of all the optionsbased on the “consensus”, “optimistic” and “pessimistic scores” identified duringthe appraisal workshops. Furthermore Option 2A is the highest ranking (excludingOption 1) in terms of lowest Net Present Cost although the difference from the2nd highest ranking option being only 2.6%.
It is further highlighted that whilst Option 2A does not, in itself, include a"Combined Medical & Surgical Common Admissions Unit”, this option does notpreclude such a development at a future date, subject to the Greater InvernessMasterplan review.
Based on the above analysis Option 2A, is identified as the preferred way forward
9.5 Sensitivity Analysis
A Sensitivity Analysis is defined as the effects on an appraisal/ option of varying the
programmed values of important/ selected variables. A Business Case is built upon
estimates which can lead to inaccuracies. The preparation of a Sensitivity Analysis
will help assess whether the Initial Agreement is heavily dependent on a particular
contractor’s share percentage and range, priced activity schedule review and defined
cost arrangements.
11.6 Indicative Programme and Phasing Plan
As noted earlier in this IA, the timing of proposed investment would be aligned with
the “Fire Precautions” project to exploit the unique opportunity that is presented
whereby all the wards and associated accommodation in the Tower Block will be
vacated in a phased manner, and ward by ward basis. This will therefore minimise
disruption to existing healthcare services. The phasing plan in Appendix E illustrates
the potential indicative timing of the planned works and how this fits into the other
projects at Raigmore.
As described in Section 11.6, it is envisaged that the works would be undertaken
during a 5 year period. The approximate timing to achieve an early start on site
date would be as follows.
IA CIG Meeting Date 2nd July 2013
OBC Stage / Approvals January 2014
Design and Target Price
Full Business Case development
September 2014
Full Business Case Approvals December 2014
Construction Start (Initial Phases)- based on
Frameworks Scotland
January 2015
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
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A APPENDIX – SMART OBJECTIVES
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SMART Objective Heading Objective Details Baseline Data Source Timing
To improve business effectiveness andrevenue efficiency
Both local and national objectivesrequire maximum benefit from allpublic expenditure. NHS Highlandis also required to reach a breakeven position while improvingquality of care.
Improve HEAT and other Health targets To meet both nationally stipulatedHEAT targets regarding waitingtimes and infection control, andimprove adherence to the BADStargets for day-case surgery. Alsoreduce energy-based carbonemissions as per the ClimateChange (Scotland) Act.
HEAT targets Reporting on allheat targetsalready in place
Monthly managementreviews
Augment and expand range of services andpromote emerging model of care includingconsolidation of critical care
To meet the challenges achievingthe Greater Inverness Masterplanwhich points to the need for urgentimprovements to address criticalcare deficiencies in the existingmodel of care, as well as theimportance of improving theatrecompliance at Raigmore to meetthe future needs of NHS Highland.
Service data regarding theatreutilisationCurrent performance againstBADS targets.
Service planning. Ongoing review ofservice data.
Make possible the introduction of new waysof working and in particular effectivecollaborative working and flexibility in theworkforce
To adhere to the principles set outin the Highland Quality Approachregarding new ways of working andservice redesign.
Critical Care bed daysLength of stayCurrent performance againstBADS targets.
Improved facilities / increased capacityoffering a patient centred service includinggreater consistency of care and increasedcertainty for admissions, procedures anddischarge
To adhere to the principles set outin the Highland Quality Approachregarding patient-centeredness,consistency of care and robustnessof admissions and dischargeprocedures.
Service data regarding theatreutilisation and outcomes.Better together survey results
Service planning.HealthcareImprovementScotland.
Monthly reporting inline with currentservice managementpractice.Quarterly reporting toNHS Highland board.
Concentrate higher and lower levels of careat appropriate locations
To reduce the number of patientsplaced in an inappropriate caresetting.
Service data regardingadmissions to levels 2 and 3care setting.
Service planning Monthly reporting inline with currentservice managementpractice.Quarterly reporting toNHS Highland board.
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Inital Agreement Document73
SMART Objective Heading Objective Details Baseline Data Source Timing
Offer facilities which reduce risk of spreadof infection compared to status quo
Improve ward layouts and designto assist in meeting therequirements of the HAIScribeguidance and reduces the risk ofinfection spread.
HAIScribe guidance to deliverfacilities.Existing infection control data.
Targets and definedspecificationincluded withinHAIScribedocumentation.NHS Highlandinfection controlreport.
HAIScribe reviews atstrategic times duringdesign periods.Continual monitoring ofinfection control datapost-construction asper current practice.
To achieve optimal utilisation of space(within the constraints of existingbuildings)
Refurbishment and rationalisationof existing facilities should optimisecritical care beds, and increasetheatre capacity to meetrequirements of demographictrends.
Greater Inverness Masterplan Service planning Ongoing review
To achieve operational and functionalefficiency of physical environment
Achieve a minimum target score of4/6 in relation to all the AEDETcategories in line with the AEDETreview which will be undertaken atkey stages in the project.
A technical evaluation of theproject proposals will beundertaken based on theDepartment of Health DesignEvaluation Toolkit “AEDET”(Achieving Excellence DesignEvaluation Toolkit).
AEDET review At key stages in thedesign development(as noted in the AEDETguidance) and firstpost constructionassessment within 1year after fullyoperational.
To deliver high quality facilities, andtechnical standards with a strong focus onlifetime costs, quality and design.
Where possible, to meet technicalspecifications for modern carefacilities as articulated in relevantScottish Health TechnicalMemorandum (SHTM), ScottishHealth Planning Notes (SHPN’s) andHealth Briefing Notes (HBN’s).
Comply with CEL 19 (2010) – APolicy on Design Quality for NHSScotland – 2010 Revision
Scottish Health TechnicalMemorandum (SHTM)Scottish Health Planning Notes(SHPN’s)Health Briefing Notes (HBN’s)CEL 19 (2010) – A Policy onDesign Quality for NHSScotland – 2010 Revision
Scottish HealthTechnicalMemorandum(SHTM)Scottish HealthPlanning Notes(SHPN’s)Health BriefingNotes (HBN’s)CEL 19 (2010) – APolicy on DesignQuality for NHSScotland – 2010Revision
At key stages in theplanning and designprocess.
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Inital Agreement Document74
SMART Objective Heading Objective Details Baseline Data Source Timing
To comply with “A SustainableDevelopment Strategy for NHS Scotland’,to enhance the contribution of the healthsector to sustainable development
Deliver facilities that whencompleted achieve rating ofBREEAM “Excellent” (or “VeryGood” for refurbishment) and NHSHighland’s Environmental Policy inrelation to carbon dioxide emissions
BREEAM Healthcare guidance.SCIM guide.Sustainable Buildings GuideSustainable Strategy for NHSScotlandNHS Highland’s EnvironmentalReport (2007)A sustainable DevelopmentStrategy for NHS Scotland
BREEAM Guidance BREEAM to beundertakeninitially and thensubsequent meetingstoensure criteria issatisfied
To enable the retention and recruitment ofstaff
To see an improvement in staffsurvey results in terms of absenceand staff turnover and to provide aworking environment which sustainrecruitment.
Improvement instaff surveyresults.Maintenance of lowstaff turnoverlevels.
Bi annual staff survey.Monthly absencemanagement review.
Critical Care Consolidation and Theatres Refurbishment (with necessaryrealignment of Acute Services)
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B APPENDIX – SUMMARY OF CATEGORIES OFCHOICE ASSESSMENT
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Inital Agreement Document76
Category of
Choice (Option)
Comments on Potential Options Review
Outcome
Scoping /
Capacity option
1. Reconfiguration of Beds (reduce) to achieve improved compliance with SHTM bed spacingrequirement (typically resulting in 6 beds going to 4)
2. Provide additional capacity of Medical High Dependency Units
3. Provide additional capacity of Critical Care Unit
4. Provide additional theatre capacity via the development of one or more additional theatres – day
case units
5. Consider under utilised space in Maternity Unit (first floor) Ward 8, 9 and 10 (Labour ward 10) notwithin tower block as locus for services that need close proximity to theatres e.g. Ophthalmology /Endoscopy / Surgical Day Case and Common Admission Lounge.
6. Create additional capacity to dialyse patients near/adjacent in-patient (in-patient at Level 7c) wardswith main dialyses at level 7 (close to for plant configuration)
7. Addition of vascular lab to meet current standards for Vascular department
8. Addition of post anaesthetic care unit (PACU) adjacent to intensive care unit
9. Dental Paediatric. Address current deficient accommodation within Endoscopy unit –Service provision
10. Cardio – version. Address current deficient accommodation within Endoscopy Unit – service provision
11. Addition of new build tower block (for in-patient) with existing Tower block being utilised for Out-Patient (knock down existing out-patient)
12. Day Services Project – Renal/ / Theatres and Endoscopy – creating a new build
Discount
Yes, for long list
Discount
Discount
Yes, for long list
Yes, for long list
Yes, for long list
Yes, for long list
Yes, for long list
Yes, for long list
Yes, for long list
Discount
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Inital Agreement Document77
13. Satellite – Invergordon – for Renal Dialysis Discount
Discount
Service solution 1. Co-locate intensive care and high dependency to allow acute care to be concentrated in one location
thus improving staff efficiency and flexibility
2. Moving acute Medical assessment and admission units closer to the Emergency Department or“Front Door”
3. Locate surgical & orthopaedic wards as close to Theatres as possible i.e. lower floors
4. Consider the need for an “admission assessment area” as close to the emergency department as
possible through the creation of a combined assessment area
5. Co-locate services within the Tower Block based on acuity e.g. “hot floor(s) concentrate acute
services at one level – specialist critical care staff at one level
6. Co-locate services within the Tower Block based on speciality – Medical and Surgical Departments
to be separate
7. Co-locate specialities that do not require to be on an acute site to create additional decant space
(e.g. dermatology, YARU and Aneurysm screening) Re-locating selected Day Case and OPD away
from more acute / Higher Dependency Wards
8. Move services out of the Tower Block, where adjacency is not required (e.g. Endoscopy), and to
suitable accommodation
9. Re-locating all female surgery (away from male wards) and into separate unit (outwith Ward Block) –into Ward 8 Re-locating female surgery wards (away from male wards) and into separate unit(outwith Ward Block) – into Ward 8
10. Move Child Ward services from the Tower Block into a separate Child Ward unit
11. Consider re-locating selected acute services at Raigmore back into the Tower (e.g. Respiratory) that
provide improved adjacency to General Medicine
12. Upgrade existing Theatre accommodation commensurate with modern standards
Yes, for long list
Yes, for long list
Yes, for long list
Yes, for long list
Yes, for long list
Yes, for long list
Yes for long list
Yes, for long list
Yes, for long list
Yes, for long list
Yes, for long list
Yes, for long list
Critical Care Consolidation and Theatres Refurbishment (with necessary realignment of Acute Services)
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13. Eye Day Case Unit – relocation to current location of renal unit Yes, for long list
Implementation
Options
1. Phase services in – extensions and refurbishment of existing premises
2. Single project to completion
Preferred
Discounted
Service delivery
/ Funding
Options
1. NHS Capital funding based on traditional procurement
2. PPP/PFI – private sector
3. Hub Model – private capital
4. Developer Led - private
5. Voluntary Organisation Funding
Preferred
Discounted
Discounted
Discounted
Discounted
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C APPENDIX – SWOT ANALYSIS OF LONG LIST;
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Long List of Options Summary of SWOT Analysis Results – Only Key Factors Summarised Include on
Shortlist?
Strengths Weaknesses Opportunities Threats
Scoping & Service
Solution Options
A. Do Nothing Reduced capital spend
in the short term
Less disruptive option
in the short term
Some opportunities for
efficiencies are already
being implemented
without the need for
significant investment.
Increased capital spend likely in
long term
No improvement in efficiency,
safety, or quality of care.
Continued inability to meet
modern care standards and SHTMs
for accommodation
Fire upgrade works must still go
ahead. Therefore “do nothing”
would not avoid the associated
disruption.
No increase in theatres or critical
care capacity
Ability to “wait and see”
regarding full outputs
from the Greater
Inverness Masterplan
Still requires completion of
significant and costly
maintenance backlog
Potential for increased
revenue costs given
continued inefficiencies
Decreased staff morale
Failure to capitalise on “once
in a lifetime” opportunity
given large scale fire
upgrade project
Continued use of costly
“stop gap” solutions (e.g.
the modular theatre)
Failure to fulfil significant
component of the Greater
Inverness Masterplan.
Yes, for
comparison
(Option 1)
B. Co-locate services
within the Tower Block
based on speciality –
Medical and Surgical
Improved adjacency of
some relevant services
Improved patient care
and patient flow within
the two divisions.
Relocation will allow
for significant
Not a new-build, so still restricted
by the envelope of the building
and its construction. Unlikely to
fully adhere to SHTM
specifications.
Co-location only along divisional
lines would not permit sharing and
Potential improvement in
performance against
HEAT targets (e.g. 4 hour
A&E target)
Improved accommodation
standards likely to impact
positively upon infection
Complicated decant and
transitional arrangements
without full realisation of
potential benefits in terms
of either quality or
efficiency.
Limited realisation of
potential benefits from
No
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Inital Agreement Document81
improvements to the
condition of the
accommodation, and
to the services and
facilities.
Would not disrupt
existing positive
practice within
divisions (e.g. the use
of a dedicated middle
grade doctor across
both CCU and MHDU)
flexibility of staff or administration.
Does not allow for full flexibility
between HDU/ICU beds to meet
the needs of individual patients or
of coping with peaks in demand.
control efforts.
Potential to realise some
benefits from economies
of scale.
economies of scale.
Would be contrary to
current guidance from DoH
and SEHD regarding co-
location of all HDU facilities.
C. Consolidate CriticalCare Unit with CCU atGround floor and MedicalHDU and ITU / SHDU co-located at first floor andEndoscopy retained inTower Block (level 6)
Improved adjacency of
critical care services to
“front of hospital” (i.e.
A&E), and hence
improved patient flow
Critical care no longer
spread across 3 floors
and 4 departments.
Greater ability to step
up/step down care.
Flexibility of level 2
and 3 care beds
Decreased need to
operate respiratory
ward as an informal
Not a new-build, so still restricted
by the envelope of the building
and its construction. Unlikely to
fully adhere to SHTM
specifications.
Requires dismantling of fit-for-
purpose CCU on level 6.
Would not allow space for
placement of respiratory ward on
level 6 (a much better location
than its current position outside
the tower block)
Integration of facilities
allows potential for more
efficient care and less
duplication of nursing and
administrative functions.
Improved care, improved
staff morale and
decreased revenue
spend.
Increased staff flexibility
between ITU/SHDU and
CCU/MHDU
More appropriate
placement of patients as
to care needs. Reduced
potential for either too-
Would need robust
transition arrangements for
critical care patients during
move.
Economies of scale may not
be realised if new ways of
working are not adopted.
New CCU could be less
spacious than current
purpose built facility – albeit
in an inappropriate location.
Yes
(Option 2)
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HDU.
Access to isolation
facilities in MHDU, and
improved infection
control throughout.
Compliance with
current SHTM
standards
Improved storage.
early discharge, or too
high a level of care.
Potential for improved
critical care for cardiac
patients
Potential resolution of
issue whereby MHDU
patients requiring
isolation are admitted to
CCU, despite having no
cardiac conditions.
D. Consolidate criticalcare with CCU & MHDUco-located at ground floorwith ITU & SHDU co-located at first floor andwith Endoscopy movedoutwith Tower Block
As above, but with
additional benefit that
endoscopy could
instead be sited closer
to the standalone
decontamination unit
rather than in the
tower block.
Not a new-build, so still restricted
by the envelope of the building
and its construction. Unlikely to
fully adhere to SHTM
specifications.
Requires dismantling of fit-for-
purpose CCU on level 6.
Would require alternative location
to be found for endoscopy
As above
Potential to bring
respiratory ward into the
tower block (6th floor).
As above
Potential unsuitability of
alternate locations for the
endoscopy unit.
Yes
(Option 2A)
E. Similar to Option 2Abut with MHDU/CCUsituated at Ground floorat “A” block to facilitateintensive care adjacency,and the addition ofVascular Lab and PACU
Improved adjacencies
of MHDU/CCU/PACU
Would require alternative
accommodation for either AMAU or
Cardiology step-down, thus
disrupting adjacencies of these
facilities.
Would mean moving PACU further
Potential for increased
efficiencies from better
adjacencies.
Might not be most optimum
combination of adjacent
services.
Yes
(Option 2B)
Critical Care Consolidation and Theatres Refurbishment (with necessary realignment of Acute Services)
Inital Agreement Document83
away from theatres and SHDU
F. New CombinedAssessment Unit onground floor andconsolidate critical carewith CCU & MHDU alsoco-located on groundfloor with ITU & SHDUco-located at 1st floor
Improved co-location
of services, especially
with MHDU on ground
floor and so adjacent
to radiology, A&E and
ambulance access
Co-location of critical
care services, with
associated benefits as
described above
No PACU
Separation of surgical specialities
Decide to admit paradigm
as opposed to admit to
decide
Requires increases in
medical staffing
Separation of surgical
admissions from other
surgical facilities
Potential restriction in bed
allocation for surgical admissions
Yes
(Option 3)
G. New CombinedAssessment Unit onground floor andconsolidate critical careCCU/MHDU andITU/SHDU) completely on1st floor
Improved co-location
of services
Moves MHDU away from ground
floor and reduces ease of access to
A&E/ambulances
No PACU
As above Full benefits of adjacency of
MHDU and A&E not realised.
Yes
(Option 3A)
H. New CombinedAssessment Unit onground floor andconsolidate critical care(CCU/MHDU andITU/SHDU) in “A” blockon ground and 1st floors
Improved co-location
of services
Includes PACU
No space for addition of PACU
Unable to adhere to space
regulations/requirements
As above Requires increases in
medical staffing
Separation of surgical
admissions from other
surgical facilities
Potential restriction in bed
allocation for surgical
admissions
Yes
(Option 3B)
Critical Care Consolidation and Theatres Refurbishment (with necessary realignment of Acute Services)
Inital Agreement Document84
I. Provide additional
capacity of Medical High
Dependency Units
Requirement for
increased MHDU
capacity outlined in
review of HDU in NHS
Highland (The High
Dependency Needs
Assessment of NHS
Highland Patients).
Would require both capital and
revenue expenditure.
Meets both current and
future need for increased
MHDU capacity.
Movement towards a
philosophy of Critical
care, rather than
traditional split between
ICU/HDU
Increased capacity could
increase revenue costs if
benefits of consolidation
elsewhere are not realised.
No
J. Consider under utilisedspace in Maternity Unit(first floor) as locus forservices that need closeproximity to theatres e.g.Ophthalmology /Endoscopy / Surgical DayCase?
Optimised use of
existing floor space.
Would require disruption to
Maternity services not necessary if
completion of fire works was the
sole objective.
Resolution of sub-optimal
usage of premium space.
Synergy with project to
upgrade endoscopy
services (for which
funding has been
secured)
Difficulty of releasing usable
space while ensuring quality
of
maternity/endoscopy/ophth
almic is not compromised.
Increased complexity of
decant arrangements by
bringing maternity services
into the project scope.
No
K. Create additionalcapacity to dialysepatients on in-patientwards with main dialysesat level 7 (close to forplant configuration
Fill in from day service
paper
Yes, combine
with main
options
L. Addition of vascular labto meet currentstandards for Vasculardepartment
Better adherence to
modern standards of
care
Improved patient
outcomes and satisfaction
Staff training required
Potential increased revenue
spend to staff vascular lab.
Yes, combine
with main
options
Critical Care Consolidation and Theatres Refurbishment (with necessary realignment of Acute Services)
Inital Agreement Document85
M. Addition of postanaesthetic care unit(PACU) adjacent tointensive care unit
Increased flexibility of
beds
Promotes flexibility
with staffing
Less potential for
blocking of SHDU beds
Potential to relieve
pressure on ICU and
reduce the number of
too-early discharges.
Potential to reduce the
need for delayed transfer
of patients from ICU or
HDU to ward-based care
and the inefficiencies
associated with too high a
level of care.
Space allocation Yes, combine
with main
options
N. Move non-acuteservices out of the TowerBlock, where adjacency isnot required (e.g.Endoscopy, Child Ward),and to suitable existingaccommodation
Would leave space for
improved adjacencies
of acute services.
Would require alternative
accommodation to be found for
endoscopy and children’s ward
End result of vastly
improved co-location of
relevant services.
Improved patient
outcomes
Better communication
between staff in relevant
specialties. Improved
skills and morale.
Concurrently running
projects (i.e. the Archie
Foundation) must be
managed in tandem.
Potential unsuitability of
alternative accommodation.
Increased complexity of
decant arrangements
Yes, combine
with main
options
O. Re-locating femalesurgery wards (awayfrom male wards) andinto separate unit(outwith Ward Block) –into Ward 8
Vastly improved
patient-centred care.
Not required if fire upgrade is sole
objective
Reconfiguration allows for
better use of space in
Ward 8/9/10 area.
Potential for increased
disruption and increased
complexity of decant
arrangements.
Potential difficulty of finding
alternative space for specific
functions (e.g. Parentcraft
No
Critical Care Consolidation and Theatres Refurbishment (with necessary realignment of Acute Services)
Inital Agreement Document86
room)
P. Consider re-locatingselected acute services atRaigmore back into theTower (e.g. Respiratory)that provide improvedadjacency to GeneralMedicine