Business Case for Refurbishment/Replacement of Theatres … · Theatres 1 – 4 Craigavon Area Hospital 2 ... 40 Table 9: Surgical ... Craigavon Area Hospital is the larger of the

Business Case for Refurbishment/Replacement ofTheatres 1 – 4 Craigavon Area Hospital

Theatres 1 – 4 Craigavon Area Hospital 2

Document History Document Name: Theatres 1-4 CAH

Status: FINAL - Approved by SMT 5 May 10

Version and Date: V1.0 30 Apr 10

Origin: Acute Planning SHSCT


Contents

1 EXECUTIVE SUMMARY ..........................................................................6

1.1 Introduction........................................................................................6

1.2 Strategic Fit .......................................................................................6

1.3 Assessment of Need .........................................................................7

1.4 The Economic Case ..........................................................................8

1.5 Procurement ....................................................................................11

1.6 Project Management .......................................................................12

1.7 Project Timetable.............................................................................13

2 INTRODUCTION ....................................................................................14

2.1 Background .....................................................................................14

2.2 Current Situation..............................................................................15

2.3 Project Management Structure ........................................................16

2.4 Document Structure.........................................................................17

3 STRATEGIC CONTEXT .........................................................................18

4 ASSESSMENT OF NEED ......................................................................22

4.1 Condition of Existing Facilities .........................................................23

4.2 Clinical & Estates Risk.....................................................................28

4.3 Demand Assessment ......................................................................31

5 PATIENT PATHWAY..............................................................................45

6 OBJECTIVES AND CONSTRAINTS ......................................................47

6.1 Objectives........................................................................................47

6.2 Constraints ......................................................................................49

7 IDENTIFICATION & SHORTLISTING OF OPTIONS .............................50

7.1 Long List of Options.........................................................................50

8 NON FINANCIAL APPRAISAL OF SHORTLISTED OPTIONS ..............69

8.1 Benefit Criteria.................................................................................69

8.2 Scoring the Options .........................................................................73

9 FINANCIAL APPRAISAL OF SHORTLISTED OPTIONS .......................87

9.1 Capital Costs ...................................................................................88

9.2 Capital Charges...............................................................................88

9.3 Revenue Costs ................................................................................89

9.4 Economic Costs...............................................................................89


10 ASSESSMENT OF RISK & SENSITIVITY ANALYSIS........................90

10.1 Risks................................................................................................91

10.2 Optimism Bias Adjustment...............................................................93

10.3 Sensitivity Analysis on Non Financial Benefits ................................95

11 IDENTIFICATION OF PREFERRED OPTION....................................97

12 AFFORDABILITY ANALYSIS..............................................................99

12.1 Capital funding requirements..............................................................99

12.2 Revenue Consequences ....................................................................99

13 EQUALITY & HUMAN RIGHTS CONSIDERATIONS .......................100

14 PROCUREMENT ..............................................................................101

15 PROJECT MANAGEMENT & POST PROJECT EVALUATION .......102

15.1 Project Management .....................................................................102

15.2 Post Project Evaluation..................................................................103

15.3 Benefits Realisation Plan...............................................................104


Tables and Figures

Table 1: Surgical Services at Craigavon Area Hospital ............................................ 14

Table 2: Air Change Rates – Operating Theatres 1 – 4............................................ 24

Table 3: Risk Assessment – Operating Theatres 1 – 4............................................. 29

Table 4: Operating sessions (Theatres 1-5).............................................................. 32

Table 5: Utilisation of Operating Theatres – April to June 2009................................ 33

Table 6: Main Theatre Activity, Craigavon Area Hospital.......................................... 34

Table 7: Independent Sector Activity ........................................................................ 37

Table 8: SHSSB Projected Population Increase ....................................................... 40

Table 9: Surgical Finished Consultant Episodes & Daycases with a Procedure Projected................................................................................................................... 41

Table 10: Long List of Options .................................................................................. 51

Table 11: Short Listing of Options............................................................................. 58

Table 12: Scoring of Short Listed Options ................................................................ 74

Table 13: Capital Costs of Shortlisted Options (inclusive of MIPS inflation and Optimism Bias).......................................................................................................... 88

Table 14: Capital Charges Associated with Shortlisted Options ............................... 88

Table 15: Revenue Consequences of Shortlisted Options ....................................... 89

Table 16: Net Present Costs for Shortlisted Options ................................................ 89

Table 17: Risk Register............................................................................................. 90

Table 18: Summary of Optimism Bias Analysis ........................................................ 93

Table 19:Net Present Costs Adjusted for Optimism Bias.......................................... 94

Table 20: Effect on Ranking of Options by Adjustment of Weightings...................... 95

Table 21: Effect on Ranking of Options by Adjustment of Scores ............................ 96

Table 22: Comparison of Options ............................................................................. 97

Table 23: Affordability Analysis ................................................................................. 99

Table 24: Project Timetable for the Preferred Option ............................................. 103

Figure 1: Main Theatre Activity by Complexity.......................................................... 35

Figure 2: Surgical Finished Consultant Episodes & Daycases with a Procedure ..... 36

Figure 3: Population Projections for SHSSB 2008 - 2021......................................... 40

Figure 4: Forecast Finished Consultant Episodes (Surgical) .................................... 41


11 EEXXEECCUUTTIIVVEE SSUUMMMMAARRYY 1.1 Introduction

Craigavon Area Hospital is the larger of the Southern Health and Social Care Trust’s two acute hospitals, providing a range of acute services (both emergency and elective) to the catchment population. The hospital was opened some 27 years ago and much of the existing accommodation is still in use and is no longer fit for purpose. There are five main theatres, two trauma and orthopaedic theatres and a day surgery unit with one theatre and an endoscopy room.

The condition of the main theatres has been identified as one of the highest risks to patient safety in terms of infection control issues and also because of the likelihood of major failure due to mechanical and electrical services issues. A business case for the replacement of Theatre 5, the worst of the five main theatres, was approved by the DHSSPS in May 2007 and the new theatre was constructed and has been operational since May 2009.

This business case is for the urgent replacement/upgrading of the remaining four main theatres and support accommodation.

1.2 Strategic Fit

Craigavon Area Hospital was one of the nine acute hospitals identified in Developing Better Services (reducing the number of acute hospitals from 13), it is important that facilities as fundamental as operating theatres are of a standard consistent with the vision set out by the Acute Hospital Review Group. The proposed refurbishment/ replacement of Theatres 1 – 4 will enable the Trust to provide care to patients in line with the broad principles described in Developing Better Services.

The Trust is committed to achieving the targets set out in Priorities for Action and the provision of a modern theatre suite which complies with current estates standards is a fundamental requirement to enable the delivery of acute surgery. This project will therefore be critical to supporting the provision of a safe, timely acute hospital service which meets the targets set out in the Public Service Agreement and ministerial framework.

This project will allow Craigavon Area Hospital, as one of the nine acute hospitals in Northern Ireland, to meet its clinical responsibilities to the level required. Furthermore, improved facilities will allow the Trust to maintain and enhance the level of expertise and experience of professional staff.


1.3 Assessment of Need

An assessment of need highlights the deficiencies with the current theatre accommodation and clearly demonstrates a requirement to retain five main theatres at Craigavon Area Hospital.

Condition of Existing Facilities

! The theatre ventilation plant (including design configuration and air change rate) does not meet Departmental standards;

! Theatre design does not meet Departmental standards in terms of space, layout or quality of finishes;

! There are significant electrical services issues including only one source of electrical supply; emergency back-up is fully loaded and the distribution network contravenes standards.

Demand Assessment

! The number of allocated theatre sessions is currently 48 per week out of an available 50;

! Main theatre activity has increased over the last three years, particularly in terms of the numbers of more complex surgery. The number of surgical episodes with a procedure carried out has increased from 6,331 in 2005/06 to 9,569 in 2008/09, an increase of 51%;

! Whilst the Trust is currently meeting the Priorities for Action target of 13 weeks for inpatient and daycase treatment, this has required significant use of the independent sector to provide additional capacity. In 2008/09 826 inpatient and 3,005 day case episodes were provided by the independent sector. It is the Regional Health and Social Care Board’s (RHSCB) intent that the use of independent sector should be minimised. In the last quarter of 2009/10 the Trust made significant reductions in the use of independent sector capacity. Only 193 day cases were treated in the independent sector. This achievement resulted from the maximisation of theatre capacity, flexible use of theatres and the provision of sessions in the evening and at the weekend;

! Planned service developments will give rise to the need to increase theatre sessions further, but these can be accommodated within the existing theatre complement;

! Population demographics show a 23.8% increase in the overall number of people in the Southern area by 2021 and more significantly an increase of 43.7% in those aged 65 years and over. This increase will have a considerable impact on the requirement for theatre capacity because a large proportion of inpatient episodes are attributable to the 65+ age group;


! Projected inpatient surgical activity is forecast to increase to 12,024 finished consultant episodes by 2020/21, a substantial increase of 25% between 2008/09 and 2020/21.

1.4 The Economic Case

A long list of ten options was identified and explored by the Trust. This long list of options was sifted using agreed objectives and constraints to give a short list of five options.

The key objectives are as follows:

! To deliver operating theatre accommodation by 2012 to DHSSPS standards;

! To provide a reliable theatre environment for patients and staff to ensure consistent levels of theatre capacity;

! To provide accommodation with the flexibility/capacity to accommodate the level of emergency and complex procedures as emerging from the presenting population on completion of the project (currently 20% of procedures undertaken in the main theatre complex);

! To ensure there are no unscheduled session cancellations during the period of construction and current capacity is maintained. To minimise the disruption to theatre and other support services;

! To achieve a high satisfaction rating from theatre staff;

! To align with the Trust’s strategic direction and contribute to the development of services within the Trust.

The five short listed options are described in the paragraphs below.

The Southern Trust is currently leasing two volumetric modular theatres with support accommodation. These theatres will be vacated in May 2010 when the new trauma and orthopaedic facility has been commissioned. As the replacement of main theatres 1-4 will be a temporary solution until major redevelopment of the Craigavon Area Hospital site a number of the options considered include the purchase and upgrade of these two volumetric theatres.

Option 2 - Do Minimum – Minimal refurbishment of existing 4 theatres, replacing the ventilation system and upgrading the electrical supply.

This option proposes to conduct the minimum work required to the existing theatres to meet some of the requirements of the Department of Health building guidance. This would involve replacement of the ventilation system and upgrade of the electricity supply. Decant of two theatres at a time and also decant of recovery ward would be required for the duration of the works.


Option 3 - Purchase 2 volumetric theatres. Extend theatre block into a courtyard & refurbish to provide 2 theatres, new recovery, upgraded staff changing and support accommodation.

This option involves purchasing the 2 volumetric theatres. Two theatres and recovery facilities which comply with the Department of Health building guidance would be provided by building an extension in an adjacent courtyard and refurbishing within the existing main theatre suite. The staff changing facilities would also be upgraded and additional storage would be provided.

Option 7 - Purchase 2 volumetric theatres and construct 2 theatres. Refurbish existing theatre block to provide new recovery, upgraded staff changing and support accommodation.

This option involves purchasing the 2 volumetric theatres. Two theatres and recovery ward which fully comply with the Department of Health building guidance would be constructed. Some minor re-alignment of the hospital ring road would be required. The staff changing facilities would also be upgraded and additional storage would be provided.

Option 8 - Purchase 2 volumetric theatres, construct 1 new theatre. Refurbish existing theatre block to provide 1 theatre, new recovery, upgraded staff changing and support accommodation.

This option involves purchasing the 2 volumetric theatres. A third theatre would be constructed. The fourth theatre would be provided by refurbishing within the existing main theatre building. A new recovery ward, staff changing facilities, storage etc would be provided by refurbishing within the existing main theatre area.

Option 9 - Construct 4 new theatres and new recovery ward. Refurbish existing theatre block to provide upgraded staff changing and additional support accommodation.

This option involves the construction of four theatres and new recovery ward which fully comply with the Department of Health building guidance. The proposed site is currently occupied by the histocytology laboratory and laboratory office accommodation. These 2 units would be re-provided prior to construction commencing. The staff changing facilities would also be upgraded and additional storage would be provided.


The five short listed options were evaluated using non financial appraisal and also quantifiable costs. A summary of the scoring and costing exercise is given in the table below.

Option 2 Option 3 Option 7 Option 8 Option 9

Non Financial Appraisal Score

500 735 750 770 730

5 3 2 1 4

Capital Costs including MIPS inflation uplift but excluding Optimism Bias (£)

4,484,859 10,227,717 10,193,550 10,263,940 12,291,399

1 3 2 4 5

Baseline Average Capital Charges (including those attributable to current land, budilings and equipment)

416,413 736,346 711,182 726,321 735,574

Additional Annual recurring Revenue (£)

0 79,376 92,792 80,085 97,756

NPV Baseline (£000) 60,336 64,605 64,516 64,515 65,375

NPV Adjusted for Optimism Bias (£000)

60,883 66,010 65,934 65,951 66,973

The Project Team considered the options and has concluded that the preferred option is Option 8 – Purchase 2 volumetric theatres, construct 1 new theatre. Refurbish existing theatre block to provide 1 theatre, new recovery, upgraded staff changing and additional storage. This option has been identified as the preferred option for the following reasons:

! Option 8 has the highest non-financial benefit score of 770 and therefore will generate the greatest overall qualitative benefits in terms of providing four main theatres, recovery and associated support accommodation which meet Departmental standards; providing a clinically effective solution which has the capacity for undertaking a wide range of procedures; minimises the disruption to theatre and other support services; fits with the Trust’s strategic direction; and can be delivered within reasonable timescales;

! The capital costs (excluding Optimism Bias) associated with this option are £10,263,940. Whilst it ranks as 4 from a financial appraisal perspective the monetary difference between it and the higher ranking options 3 and 7 is not material and this will provide the Trust with theatres which will meet the current standards;


! Annual capital charges associated with Option 8 are £726,321. This is less than the capital charges associated with Options 3 and 9 and is not materially higher than those for Option 7;

! Recurring revenue costs associated with Option 8 are lower than those indicated for Option 7 and Option 9 and are not materially different to those for Option 3;

! Net Present Value of Option 8 is £64,515k (risk adjusted NPV £65,951k), given that Option 8 achieved the highest non-financial benefit score this offers the best benefit for investment required.

1.5 Procurement

In line with Health Estates recommendations on best value for money in procurement the Trust has entered into Performance Related Partnering (PRP) frameworks with a design team and a contractor for the design and construction of acute hospital facilities. The appointed Design Team and Contractor are undertaking two projects –

1. Construction of a new trauma and orthopaedics facility at Craigavon Area Hospital. This project is well underway and the building was handed over for Trust commissioning in March 2010;

2. Extension and refurbishment of maternity and neonatal facilities at Craigavon Area Hospital – works commenced in July 2009 and construction is scheduled for completion in May 2010. The Trust is satisfied with the performance of both the design team and the contractor and proposes to re-appoint both for this project.


1.6 Project Management

It is proposed to implement the organisation and management of this scheme in accordance with the guidance contained in the Capital Investment Manual entitled ‘Project Organisation and Capital Investment Manual: Management of Construction Projects’ issued by the DHSSPS. Relevant expertise and experience will be required from Trust staff and from Health Estates Investment Group.

The proposed project structure is summarised as follows:


1.7 Project Timetable

The table below summarises the major project stages along with the envisaged timescales. The target dates are dependent upon business case approval by the end of July 2010.

Phase Component *Target Date

Submission of business case to DHSSPS May 2010

Business Case Approval July 2010

Planning and Design (5 months) August – December 2010

Construction/refurbishment work commencement January 2011

Construction complete December 2012

Initial Post Project Evaluation March 2013

Full Post Project Evaluation November 2013

Assuming business case approval by July 2010, the new theatres would be completed and ready for handover to the Trust by the end of December 2012.


2 INTRODUCTION 2.1 Background

The Southern Health and Social Care Trust (SHSCT) became operational on 1 April 2007 following the amalgamation of Craigavon Area Hospital Group, Craigavon and Banbridge Community, Newry and Mourne and Armagh and Dungannon Health and Social Services Trusts. The Trust is responsible for the delivery of high quality health and social care to a resident population of 348,000, employs approximately 12,000 staff and has an annual budget in the region of £400m. The Trust delivers acute hospital care from two main sites - Craigavon Area Hospital (453 beds) and Daisy Hill Hospital (260 beds). Day surgery, outpatient and diagnostic services are also delivered at South Tyrone Hospital.

This business case focuses exclusively on the main theatre suite on the Craigavon Area Hospital (CAH) site.

The existing Craigavon Area Hospital building was opened in 1972. It provides a full range of acute services (both emergency and elective) on the site including inpatient; day case; outpatient and diagnostic services; intensive care; consultant-led and midwife-led maternity services and an accident and emergency service. The hospital also provides a number of area clinical services, including adult intensive care, neo-natal intensive care, inpatient trauma and orthopaedic services, specialist cancer services and pharmacy services.

Table 1 outlines the range of surgical services provided at Craigavon Area Hospital.

Table 1: Surgical Services at Craigavon Area Hospital

Surgical Services

Accident and Emergency Lithotripsy

Breast Surgery Oral Surgery

Colorectal Surgery Trauma & Orthopaedics

Dentistry (adult and paediatric) Orthodontics

Endoscopy including Oesophago-gastro-duodenoscopy (OGD) for GPs

Restorative Dentistry

ENT (adult and paediatric) Urology (adult and paediatric)

General Surgery (adult and paediatric) Vascular Surgery

Gastrointestinal Surgery


2.2 Current Situation

Craigavon Hospital originally had 4 theatres within its theatre suite, however due to increased demand, an endoscopy room was reconfigured in 1991 into a fifth theatre. In 2005 the Trust became concerned about the condition of the theatres and the Health Estates Agency was requested to conduct a survey assessment of the facilities. In the report the Health Estates Agency highlighted a number of areas where the conditions of the theatres were not compliant with current DHSSPS standards. The key problems were grouped as follows:

! Architectural – theatre design does not comply with space standards, layout of rooms in the suites and the quality of finishes;

! Mechanical Services – theatre ventilation plant does not comply with standards in respect of air change rates. For example, air change rates in the sterile preparation areas are approximately 24 ach (air changes per hour) compared to a requirement for 37 changes per hour; and

! Electrical Services – there is an over-dependence on a single source of electricity, the supply to theatres is fully loaded and the power distribution network throughout the theatres contravenes current standards.

Following receipt of the Health Estates report in 2005, the Trust implemented a number of measures to reduce the risks identified above. However these measures could at best be described as short term in nature until a longer term solution could be found.

This business case focuses specifically on the refurbishment/ replacement of Theatres 1 – 4. A separate business case was submitted to examine the options around the replacement of Theatre 5. This business case was approved in May 2007 and the new theatre was constructed and has been operational since May 2009.

In October 2006, the Trust submitted a business case for the refurbishment/ replacement of Theatres 1 – 4, however this previous business case also included provision for a sixth theatre. Following submission of the business case in October 2006, the Trust recognised the tightening funding environment and re-examined their capital priorities. This resulted in a revision to the options being considered and the proposal for a sixth theatre was removed.


Wider Context

Craigavon Area Hospital Group Trust submitted an Outline Business Case for major redevelopment of the Craigavon Area Hospital site, in August 2005. This was revised to incorporate comments from Departmental advisors and the Trust’s responses to those comments, and it was re-submitted in August 2006. The business case proposed the construction of a new hospital on a different part of the Craigavon Area Hospital site, to meet the acute health and social care needs of the catchment population over the longer term.

In May 2008 the Minister commissioned Health Estates Agency to lead an urgent review of the capital priorities in health, social care and public safety. The Trust submitted a high level paper setting out its capital priorities over the 10 years of the current ISNI planning period (2008/09 – 2017/18). These priorities included major redevelopment of the Craigavon Area Hospital site in 3 phases, with the first phase identified as the Trust’s highest priority for capital investment. The first phase includes the replacement of theatres.

However the deficiencies with the main theatre suite highlighted by Health Estates Agency must be addressed as a matter of urgency. The Trust is therefore progressing this business case as an interim scheme to urgently address the problems in the main theatre suite.

2.3 Project Management Structure

This business case has been developed by a multi-disciplinary Project Board under the auspices of robust and fully inclusive project management structures. The organisational structure for the project and the roles and responsibilities of the individuals and groups involved comply with the requirements of the Capital Investment Manual. The structure is illustrated in Appendix 1, along with the membership of the Project Board and the Project Team.


2.4 Document Structure

The business case has been structured to provide a clear logic for the proposed development and to explain the financial and non-financial implications. It also sets out the risks associated with the project.

The main document is set out in 14 Chapters.

In addition supporting information is given in 15 appendices.

Chapter 1 Executive Summary (Trust Board Report)

Chapter 2 Introduction

Chapter 3 Strategic Context

Chapter 4 Assessment of Need

Chapter 5 Patient Pathway

Chapter 6 Objectives & Constraints

Chapter 7 Identification and Short Listing of Options

Chapter 8 Non Financial Appraisal of Options

Chapter 9 Financial Appraisal of Options

Chapter 10 Assessment of Risk & Sensitivity Analysis

Chapter 11 Identification of the Preferred Option

Chapter 12 Affordability Analysis

Chapter 13 Equality & Human Rights Considerations

Chapter 14 Procurement

Chapter 15 Project Management & Post Project Evaluation


3 STRATEGIC CONTEXT Introduction

It is important that all Government expenditure is aligned with the relevant national and local strategic objectives. This section of the report therefore summarises the strategic context as set out in:

! Government/ Departmental Strategies;

! Southern Health and Social Services Board Strategy; and

! Southern Health and Social Care Trust (SHSCT) Principles and Strategic Development Plan.

Government and Departmental Strategies/ Policies

In recent years Government have issued a number of policy documents which impact on the refurbishment/replacement of the operating theatres in Craigavon Area Hospital. These are considered in turn below.

Developing Better Services (DBS)

The overall aim of ‘Developing Better Services’ is to put in place: “a new modern and more effective hospital service … that is set up and resourced to meet the needs of the expected number of patients it serves.”

To achieve this, nine acute hospitals would be developed across Northern Ireland that would provide a full range of care services. Importantly, Craigavon Area Hospital was one of the nine hospitals identified as a provider of acute services.

The report also highlighted that “acute services must be refocused to achieve the concentration of expertise and experience required to deliver the highest possible levels of clinical care.”

This project should therefore allow CAH, as one of the nine acute hospitals in Northern Ireland, to meet its clinical responsibilities to the level required. Furthermore, improved facilities should also allow the Trust to maintain and enhance the level of expertise and experience of professional staff.


DHSSPS – Acute Hospital Review Group

The Acute Hospital Review Group established by the Department in September 2000 set out in its vision to secure hospital services that were:

! High quality, which through clinical governance, involving audit and quality assurance processes, ensure the best outcome for patients;

! Accessible to everyone, taking full account of the urgency, nature and frequency of patients’ needs;

! Patient-centred and planned to ensure the best balance of safety, quality and convenience for patients;

! Cost-effective and offering value for money;

! Professional, delivered by staff with the right skills and experience, working under appropriate conditions, and in a well-equipped environment; and

! Integrated, as part of a seamless system including primary and secondary care allowing treatment care plans to be developed for individual patients.

As Craigavon Area Hospital (CAH) is one of the nine acute hospitals identified in DBS (reducing the number of acute hospitals from 13), it is important that facilities as fundamental as operating theatres are of a standard consistent with the vision set out by the Acute Hospital Review Group. An acute hospital is set up to deal with many types of disease and injury and includes an accident and emergency department to deal with immediate threats to health. It is typically the major health care facility in its area, and provides intensive and long-term care and specialised facilities for surgery. Therefore the proposed refurbishment/ replacement of Theatres 1 – 4 will enable the Trust to provide care to patients in line with these broad principles.

Southern Health and Social Services Board Strategy

Profile of Future Services

In January 2004, the SHSSB published its ‘Profile of Future Services within the SHSSB’ in response to DBS which outlined the following priority for CAH.

“… the reconfiguration of services across Northern Ireland and the move to make Lagan Valley into a local hospital, along with changes to Tyrone County Hospital, will mean that residents in these localities may in future be admitted for both emergency and planned surgery to Craigavon Area Hospital. As a result, this will be the key hospital for the provision of health and social services to people in a greater number of areas outside Craigavon.”


The strategic direction outlined above indicates a more prominent role for CAH and emphasises the need for investment in theatre estate to ensure that the hospital is well positioned to manage the additional demands on its service.

Legacy CAHGT Strategic Development Plan

The legacy CAHGT Strategic Development Plan was completed to address the weaknesses in the existing hospital facilities and infrastructure. The plan focuses primarily on the redevelopment of the entire CAH site which it recognises will not be complete until at least 2019/20. As a result interim schemes were proposed to ensure that the Trust could address the following strategic goals and priorities:

! Manage significant backlog maintenance issues and outdated accommodation issues in a facility over 3 decades old

! Ensure compliance with current statutes and regulations;

! Facilitate the provision of more efficient healthcare that meets patient expectations;

! Provide the capacity necessary to meet both current and future healthcare delivery requirements; and

! Improve the environment for patients, staff and the general public.

Given the condition of the existing theatre suite, it is recognised that replacement of these theatres is required to improve the facilities within which patients are treated as part of the interim scheme.

Trust Delivery Plan 2009/10

The Trust Delivery Plan gives a commitment to improving the quality of life of the local population. The Trust’s strategic direction for the development of services has a number of key themes which include:

! Providing quality of care across all dimensions – safety, timeliness, effectiveness, efficiency, equality and patient-centredness.

This project will be critical to supporting the provision of a safe, timely acute hospital service which meets the targets set out in the Public Service Agreement and ministerial framework.


Conclusion on Strategic Context

The strategic direction of Government and the SHSSB is to provide health services which are:

! Patient-centred;

! Professional and delivered under appropriate conditions;

! High quality;

! Accessible;

! Cost effective; and

! Integrated.

Furthermore, CAH is one of nine acute hospitals for Northern Ireland identified in DBS which is likely to result in increased levels of demand which would have previously been taken by Tyrone County and Lagan Valley. Therefore investment in the theatre infrastructure at Craigavon is consistent with the broad strategic direction outlined in DBS.

Finally, improved facilities should also assist the Trust in maintaining and enhancing the quality of service it provides and improving the expertise and experience of its professional staff.


4 ASSESSMENT OF NEED Introduction

This section of the appraisal considers the ‘need’ for refurbishment/ replacement of Theatres 1 – 4. The assessment considers the following factors:

! Condition of existing facilities – Health Estates completed a conditions survey of Theatres 1 – 4 in July 2005 and the results indicated a significant shortfall when compared against Departmental requirements/ standards;

! Clinical/ Estates Risk – a risk assessment was undertaken by the legacy CAHGT in terms of the relationship between the condition of facilities and the risk of infection;

! Demand assessment – through available statistical information on the following areas:

- Theatre activity and utilisation;

- Forecast analysis of usage;

- The management of waiting lists;

- Planned service developments; and

- Demographic changes.


4.1 Condition of Existing Facilities

In developing the Outline Business Case for the redevelopment of the entire hospital site, the Trust identified the need for a number of interim schemes which would be required as a matter of urgency to ensure uninterrupted service delivery until the completion of the new facilities within the site wide development. Refurbishment of the Theatre Suite was identified as one such scheme and as a result the Trust, in partnership with the Health Estates Agency, commissioned the following reports and investigations:

! Health Estates Agency Conditions Report – conducted in July 2005 (this is attached in Appendix 2);

! Independent external investigation relating to infection control – conducted in August 2005 (this is attached in Appendix 3).

These reports/ investigations are now discussed in turn.

Health Estates Agency Conditions Report (July 2005)

In respect of Theatre 1 – 4 the Health Estates Agency Conditions Report examined three areas:

! Mechanical Services;

! Architectural Non-Compliance; and

! Electrical Services.

Taking these areas in turn, the report highlighted the following issues in respect of the Mechanical Services of Theatres 1 – 4:

! The Theatre Ventilation Plant did not comply with current standards as per the DHSSPS Health Technical Memorandum (HTM) 2025. Air change rates in the theatres and sterile preparation rooms were significantly below Hospital Infection Society Guidance;

! Climate Control is limited to heating only (ie. there is no cooling or humidity control); and

! Building services are not fully compliant with the requirements for the control of legionella.

Table 2 sets out the air change rates, measured in air changes per hour (ACH), for theatres 1 – 4 and the adjacent sterile preparation rooms. This is compared to the standard as detailed in HTM 2025.


Table 2: Air Change Rates – Operating Theatres 1 – 4

Area ACHReading

(July 2005)

ACHReading

(Aug 2006)

ACHStandard

(HTM 2025)

Theatre 1 11.1 19.5 20

Theatre 2 9.2 17.2 20

Preparation Room (shared between Theatres 1 and 2)

7.2 15 37

Theatre 3 12.2 19.5 20

Theatre 4 8.3 19.5 20

Preparation Room (shared between Theatres 3 and 4)

11.7 24.5 37

As indicated in the July 2005 readings, the air change rates within the theatres and sterile preparation areas were significantly below standard, with the impact that any airborne contaminants from either patients or staff could remain in the atmosphere for an extended period of time. The impact of very low air change rates within the sterile preparation areas is significant because most airborne contaminants enter wounds after ‘landing’ on sterile instruments.

In effect, low air change rates significantly increases clinical risk (the risk of infection) and this is discussed in greater detail later in this section of the case.

On reviewing these results, the Trust undertook some remedial work on theatres 1 to 4 and their sterile preparation rooms. This work included:

! Cooling battery and moisture eliminator sections removed;

! Flanged joints on air handling unit sealed and inspected;

! Air handling unit and ductwork cleaned by specialist contractor; and

! Diverting air supply to more critical areas.

Following completion of this work, the air change rates were measured again and significant improvements noted. However as the August 2006 readings shown in Table 2 demonstrate, the air change rates, particularly in the preparation rooms, still fall well below the recommended rates.


In addition to the above analysis, the following points have been identified to address the problems with the control of legionella. These problems are due to:

! The coldwater storage turnover times.

! The design and condition of the existing Hot Water System.

! Poor temperature monitoring of both hot and cold water systems.

The installation of a new ventilation system is therefore required to resolve these problems. However the HEA has identified that to replace the ventilation system would cause significant disruption to all areas requiring mechanical ventilation as ceilings in these areas would have to be removed to accommodate new ductwork dampers and controls.

The Health Estates Agency also reported on Architectural Non-Compliance.Theatres 1 – 4 are approximately 40 sq metres, against a standard size of 55 sq metres.

Key issues highlighted are discussed below:

! Current theatre design does not meet the Department’s standards as per Health Building Note (HBN) 26 in terms of space, the layout of rooms or quality of finishes (which makes it more difficult to clean the theatre). This impacts on the ability of staff to undertake high-risk/ complex surgery because of deficiencies in theatre space; and

! These deficiencies have a direct impact on control of infection.

The final area examined by the Health Estates Agency was on ElectricalServices. These issues relate to the entire Theatre Suite and the key issues are discussed in turn below:

! Incoming electrical supply to the theatres is via one single source;

! The emergency back-up supply to the theatres is fully loaded;

! The power distribution network throughout the theatre suite contravenes current standards;

! Theatre lighting is, in places, inadequate and non-compliant; and

! The report also highlighted non-compliances for theatre control panel; use of lasers/x-rays; IT and telephone systems; security systems, and; fire detection and alarm system.


In terms of the proposed enhancements to the electrical system, the current electrical installation provides no electrical safety features as required by modern theatres. Therefore, when proposing to refurbish/ renew existing theatres, electrical safety features should be incorporated as part of any improvement works. Furthermore, HEA has advised that simply installing an additional source and extra standby is not sufficient with regard to the life safety of the patient; upgrading of the entire electrical infrastructure in the Theatre Suite is strongly recommended.

On the basis of the mechanical, architectural and electrical services findings, the Health Estates Agency report recommends that in respect of Theatres 1 to 4, “the 33 year old theatres are in need of major refurbishment in order to comply with current standards”.

Independent external investigation relating to infection control (Hoffman Report)

In addition to the ventilation investigation, by the Health Estates Agency, an independent investigation was undertaken to assess infection control across the entire Theatre Suite. The findings of the investigation are set out below:

! Air change rates were not satisfactory “from an infection control perspective … posing a ‘high’ risk of infection”;

! A higher than expected proportion of fungi were present suggesting the ingress of unfiltered air; and

! Air handling units did not comply with HTM2025 (as noted in the Health Estates Agency Report).

On the basis of these findings, the following recommendations were made:

! The ventilation supply to all theatres needs to be increased to meet the current minimum levels;

! There is substantial ingress of unfiltered air in theatres, entering via the air handling unit. In the short-term this may be decreased by inspection of the integrity of the air handling units and sealing them wherever possible. However replacement of the air handling units (to HTM 2025 standards) is required in order to address design and condition deficiencies;

! Each change to, or modification of, the air supply should be verified by assessment of engineering parameters;

! The present shared preparation configuration is unsatisfactory and there should be modifications made.

Whilst the remedial work has increased air flow throughout theatres 1 and 2, and improved the availability of ‘fresh’ air, there is still no provision for humidity control or cooling.


As previously noted by the Departmental economists, the HEA report states that the Theatres require refurbishment and the independent external investigation states that the air handling units need replaced. Neither report stated that the existing theatres need replaced. In this regard it is important to note that neither were commissioned to look at the preferred option in relation to risk, cost and continuity of the surgical service. This business case considers the options to resolve the problems highlighted in the HEA report, of which replacement of the theatres is only one option.


4.2 Clinical & Estates Risk

As noted earlier in Section 4.1 (Table 2), the Air Change Rates, generated by the Theatre Ventilation system, across the 4 theatres were significantly below Departmental standards (HTM 2025). The low air change rates have the impact of significantly increasing clinical risk (ie. increasing the risk of infection).

The Hoffman report (see Appendix 3) sets out in detail the importance of ventilation in terms of infection control, but a summary is provided below. The purpose of operating theatre ventilation is to prevent airborne microbes from entering surgical wounds. This is achieved in ventilated theatres by two approaches:

1) Preventing ingress of contaminated air from other areas in the hospital or theatre suite; and

2) Diluting airborne contamination in critical areas of the theatre suite.

The first approach is accomplished by controlling the direction of airflow between areas of the operating suite and the second by supplying sufficient clean air to critical areas, such that airborne contamination generated in these areas is diluted in turbulent airflow and carried to less critical areas. Most of this airborne contamination comprises micro-organisms dispersed from the skin of people moving around in the theatre.

Airborne contamination can enter the wound by two main routes: it can fall directly into a wound or it can fall onto exposed instruments that will later be used in the wound. The relative proportions of airborne contamination that enter a wound by each of these routes will vary according to:

! the size of the wound;

! the time it is open;

! the area of the exposed instruments; and

! the time the instruments are exposed.

Hoffman has indicated that it is generally considered that airborne contamination of the wound via instruments is more important than the direct route. For this reason, preparation rooms used for instrument layup should be at higher pressure than the operating theatre and should have high air change rates.


From Hoffman’s observations and as set out in Table 2, all theatres and preparation rooms are substantially under ventilated and there is substantial ingress of unfiltered air entering via the air handling unit. Hoffman recommended that the ventilation supply to all theatres and preparation rooms needs to be increased to meet the current levels detailed in the Standards section of this report.

Following completion of the Health Estates Agency Condition Report in July 2005, the Trust conducted a clinical and estates risk assessment. This assessment considered the risk of obtaining an infection as a result of the poor state of the operating theatres. The following four grades of risk were identified:

! Extreme Risk – immediate action is required;

! High Risk – urgent action is required;

! Moderate Risk – action is required;

! Low Risk – keep under review.

The technique employed is consistent with that used throughout the Health Service and is based on the Australian/ New Zealand Risk Management Standard AS/NZ 4360:1999.

A similar risk assessment was then completed in August 2005 following the remedial work and finally a risk classification was identified for 2010 if no further work is conducted. The results are set out in Table 3 below.

Table 3: Risk Assessment – Operating Theatres 1 – 4

Area July 2005

Aug2005

Aug2010

Theatre 1 High Moderate Extreme


Sterile Preparation room (Theatres 1 and 2)

High Moderate Extreme



Sterile Preparation room (Theatres 3 and 4)

High Moderate Extreme

Source: Legacy CAHGT


Therefore whilst the remedial work had the impact of reducing the level of risk from High to Moderate, this was only achieved through increasing air flows and cleaning of ductwork. It was not practical to improve the physical condition of the plant and theatres (without significant work being undertaken) so the risk of “age related” failure is unchanged ie. this is only a short term reprieve, if no further work is done then the level of risk is judged to increase to Extreme. The risk assessment therefore shows that a medium term solution is required to prevent the existing theatre suite from becoming an extreme risk area before the new hospital development is completed.


4.3 Demand Assessment

In this section, an overview is given of current and anticipated future demand for surgery and in turn the ‘need’ for the existing theatres to be replaced. Future demand for surgery, both elective and emergency, is considered within the context of a number of key factors including:

! Theatre utilisation;

! Increase in activity levels at Craigavon Area Hospital resulting in the need to maximise utilisation of operating theatres;

! The need to meet DHSSPS targets in relation to the management of waiting lists for elective surgery;

! Planned service developments;

! Increasing levels of day case surgery; and

! Population Projections.


Theatre Utilisation

Number of Scheduled Theatre Sessions

Table 4 below shows the typical theatre schedule over the period of a week. Where possible, sessions are not scheduled for a Friday afternoon as the number of support staff available over the week-end is typically lower.

Table 4: Operating sessions (Theatres 1-5)

Theatre 1 Theatre 2 Theatre 3 Theatre 4 Theatre 5 Total sessions

Monday AM Vascular Emergency General Gynaecology ENT 5

PM Vascular Emergency ENT Gynaecology Breast 5

Tuesday AM Gastro-intestinal

Urology Gynaecology Emergency General 5

PM Gastro-intestinal

Urology ENT Emergency General 5

Wednesday AM Gastro-intestinal

Urology ENT Emergency ENT 5

PM Gastro-intestinal

Urology ENT Emergency ENT 5

Thursday AM Breast Emergency General Gynaecology ENT 5

PM Breast Emergency General Gynaecology ENT 5

Friday AM Emergency Urology ENT Gynaecology Gynae /ENT

5

PM Emergency Urology ENT 3

There are 48 sessions allocated across all 5 theatres in CAH. This table clearly demonstrates that all 5 main theatres are still required by the Trust.

Ideally, the Trust would wish to provide the average number of procedures (list size) per theatre session per speciality, however the current database of theatre activity is unable to provide this information. The Trust is currently implementing the Regional Theatre Management System. This will allow easy extraction of this type of information in future.


Utilisation Rates

Accommodating this increased level of activity, it would be reasonable to expect increased levels of theatre utilisation. Furthermore, a high level of theatre utilisation is important in demonstrating efficient use of resources and that value for money is being achieved.

The Trust is currently implementing the Regional Theatre Management System. Although a limited amount of historical data is available at present, the theatre utilisation figures shown in Table 5 indicate a much higher rate of theatre utilisation for the 5 main theatres. The utilisation for each theatre is calculated by dividing the number of sessions which were held during the month by the number which were planned and converting to a percentage.

Table 5: Utilisation of Operating Theatres – April to June 2009

Theatre 1 Theatre 2 Theatre 3 Theatre 4 Theatre 5

April 09 84% 68% 73% 61% 50%

May 09 99% 86% 88% 67% 58%

June 09 100% 97% 87% 61% 90%


Current Activity Levels

Main Theatre Activity

Inpatient activity at CAH has been increasing over the past number of years. Most of this can be attributed to changes in demographics generally and the increase in the number of elderly people, in particular. Other factors include changes in the Trust’s catchment area, which has increased with the reduced number of acute hospitals across Northern Ireland.

When assessing activity levels, it is important to understand the breakdown in terms of the level of complexity of surgical procedures. For example a small increase in complex surgery numbers would have a much more significant impact than a small increase in the number of minor surgical procedures. Surgical procedures have been categorised as follows:

! Complex – for example radical cystectomy (removal of the bladder);

! Major+ – for example cholecystectomy (removal of the gall bladder);

! Major – for example appendectomy (removal of the appendix );

! Intermediate – for example stripping/removal of varicose veins; and

! Minor – for example surgery on ingrown toe nails.

Table 6 sets out the change in activity levels across the different types of surgery between 2001/02 and 2007/08. Figure 1 shows the activity between 2005/06 and 2007/08.

Table 6: Main Theatre Activity, Craigavon Area Hospital

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08

Minor 913 1115 1120 1064 892 799

Inter 3428 3298 3239 3326 4245 4460

Major 1608 1809 1726 1819 2153 2438

Major+ 273 264 430 402 524 438

Complex 143 150 143 132 164 145

Total 6365 6636 6658 6743 7978 8280


Figure 1: Main Theatre Activity by Complexity

Levels of Theatre Activity by Complexity

0100020003000400050006000700080009000

Type of Surgery

Number o

f Cases

2005/2006 1064 3326 1819 402 132 67432006/2007 892 4245 2153 524 164 79782007/2008 799 4460 2438 438 145 8280Minor Inter Major Major+ Complex Total

This analysis shows an uninterrupted increase year on year on the total number of cases being undertaken in main theatres, rising by 30% overall between 2002/03 and 2007/08. Of particular relevance is the fact that the numbers of Major, Major+ and Complex cases have all increased quite considerably, Major by 51%, Major+ by 60% and Complex by 1%.

Inpatient Activity

A second broad measure of surgical activity is presented in Figure 2, which shows the level of surgical ‘finished consultant episodes’ (FCEs) and day cases where a procedure was carried out at Craigavon Area Hospital over the period 2005/06 to 2008/09.

A Finished Consultant Episode (FCE) consists of the time spent in the continuous care of one consultant ie the patient has been transferred to the care of another consultant or has been discharged. Some patients may be treated by more than one consultant during a spell in hospital.


Figure 2: Surgical Finished Consultant Episodes & Daycases with a Procedure

Craigavon Area Hospital

0

2000

4000

6000

8000

10000

12000

FCEs 6331 8111 8272 9569

Daycases 4535 4662 4647 5362

2005/06 2006/07 2007/08 2008/09

Source: Business Objects Korner Surgical Specialties included are: General Surgery; ENT, Gynaecology, Urology, Trauma & Orthopaedics, Gastroenterology

Figure 2 shows a clear upward trend in surgical episodes and day cases with a procedure carried out over the 4 year period to 2008/09, with the number of surgical episodes increasing from 6331 to 9,569 (equivalent to 51%). Whilst this does not represent the number of procedures or complexity of patient workload, it is indicative of the increased level of surgical activity.


Management of Waiting Time Targets and Independent Sector Activity

Whilst the Trust is currently meeting the Priorities for Action target of 13 weeks for inpatient and daycase treatment, this has required significant use of the independent sector to provide additional capacity. This indicates capacity constraints within the Trust to meet waiting list targets on an ongoing basis. Table 7 shows the high level of independent sector usage by the Trust for 2007/08 and 2008/09.

Table 7: Independent Sector Activity

EpisodesDay Cases

2007/08 ENT 182 16

General Surgery 80 156

General Surgery (Scopes) 1 353

Urology 76 31

Oral Surgery 0 81

Pain Management 0 21

Ophthalmology 0 687

Rheumatology 0 1

Total 339 1346

2008/09 ENT 405 30

General Surgery 156 224

General Surgery (Scopes) 3 1199

Urology 187 498

Gynaecology 58 32

Orthopaedics 17 10

Oral Surgery 0 130

Pain Management 0 92

Ophthalmology 0 790

Total 826 3005

It is the Trust’s intention to reduce the level of activity which is undertaken within the independent sector and a bid has been made for recurring access target funding to increase capacity for endoscopy, orthopaedics, pain management, ENT and gynaecology. These developments will all impact on the requirement for theatre capacity but they can be accommodated within the current theatre complement.

It is the Regional Health and Social Care Board’s (RHSCB) intent that the use of independent sector should be minimised. In the last quarter of 2009/10 the Trust made significant reductions in the use of independent sector capacity. Only 193 day cases were treated in the independent sector during this 3 month period. This achievement resulted from the maximisation of theatre capacity, flexible use of theatres and the provision of sessions in the evening and weekend.


Service Developments

The Trust continually seeks to modernise current service and to introduce alternative service models such as ‘see and treat’ clinics for appropriate conditions. However, there are a number of planned service developments which will impact on the requirement for theatre capacity at the Trust:

Review of Urology Services

A regional review of Urology services has recently been undertaken and the final report is awaited. The report is expected to recommend a 3 team model for urology services within Northern Ireland. Team South will be based at Craigavon Area Hospital and will provide services for a catchment population of approximately 410,000. It will encompass the Southern area and the lower third of the Western area (Fermanagh). The number of surgeons will increase from the current three to five, with a requirement to provide a minimum of six additional operating sessions across the Trust.

Bowel Screening

PSA Target 1.11 states:

By December 2009, ensure that a comprehensive bowel screening programme for those aged 60 – 69 is in place, with a view to achieving a 10% reduction in mortality from bowel cancer by 2011.

Craigavon Area Hospital has been identified as a Bowel Screening Centre and will be required to provide a dedicated weekly colonoscopy list for bowel screening. This will be a new theatre session in addition to those which are already in place for endoscopic diagnostic procedures.

ENT

The appointment of an additional consultant surgeon is planned to meet an identified capacity gap for this service. This new post will require a further two operating sessions.

Pain Management

The Trust has submitted a proposal to the Southern Commissioning Group for an additional Consultant in Pain Management. The job plan for this post includes a weekly day case session.


Ophthalmology

The current ophthalmology service at the Southern Trust is delivered on an outreach basis by Belfast Trust. The Trust plans to develop an ophthalmology service with locally employed staff providing outpatient and day surgery sessions. The number of ophthalmology theatre sessions at South Tyrone Hospital will increase from the current 3 per week to 6 each week, giving a requirement for an additional 3 weekly day surgery theatre sessions. This increase in ophthalmology theatre sessions at South Tyrone may require existing sessions to be displaced and re-provided at Craigavon Area Hospital.

Impact of Increased Day Case Rates

PSA Target 9.1 states that:

Each Trust should secure improvements in daycase rates for a defined range of procedures in accordance with Departmental targets for March 2010 and 2011.

The Southern Trust recognises the potential benefits to be gained from optimising the number of elective procedures that can be performed as a day case both from a patient quality and efficiency perspective. The Trust has therefore put in place plans to ensure that the standard can be achieved for the 25 procedures listed in the day case basket.

A separate business case was submitted to the DHSSPS (August 2006) to extend and refurbish the Day Surgery Unit at Craigavon Hospital but funding has not been made available as yet. Therefore, although the Trust will improve its day case rates in accordance with the PSA target, day case patients will continue to be operated on in main theatre sessions until day surgery capacity can be expanded. In the interim there will be little if any reduction in main theatre activity as a result of improving day case rates.


Impact of Population Projections

The Northern Ireland Statistics and Research Agency (NISRA) provides mid year population estimates and projections within Health and Social Services Board area by age band. NISRA’s figures project an overall 23.8% increase in the total Southern area population between 2008 and 2021. Figure 3 shows the projected population changes for SHSSB residents by age band.

Figure 3: Population Projections for SHSSB 2008 - 2021

Population Projections for SHSSB 2008 - 2021

8.6% 7.5%

39.7%

7.7%

34.4% 31.8%42.0%

60.8%

28.1%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80+Age Category

Percenta

ge Chang

e

Table 8 demonstrates the very dramatic forecast increase for age 65 and above, with a projected growth of 43.7%. This has particular implications for the future demand for surgical services in the Southern Trust because a large proportion of inpatient episodes are attributed to the 65+ age group.

Table 8: SHSSB Projected Population Increase

Age!2008!Mid!Year!

Estimate!

2021!Mid!Year!

Estimate!

%!Increase!

2008!"!2021!

All!Ages! 348,892! 431,820! 23.8%!

65+! 44,218! 63,553! 43.7%!

Source: NISRA Mid Year Population Estimates for SHSSB


Projected level of Operating Theatre activity

Building on the historical picture set out above, the Trust has forecast the level of surgical ‘Finished Consultant Episodes’ and day cases with a procedure at Craigavon Area Hospital to 2020/21. These figures give an indication of the theatre capacity which will be required at the hospital. Table 9 gives the projected percentage increase in inpatient and day case surgical procedures and Figure 4 demonstrates the projected annual increase.

The methodology and assumptions used to calculate the projected figures are given as Appendix 5.

Table 9: Surgical Finished Consultant Episodes & Daycases with a Procedure Projected

To 2020/21 at Craigavon Area Hospital

2008/09 2020/21 %

Increase

FCEs 9569 12024 25.7%

Daycases 5362 6704 25.0%

Figure 4: Forecast Finished Consultant Episodes (Surgical)

0

2000

4000

6000

8000

10000

12000

14000

08/09 09/10 10/11 11/12 12/13 13/14 14/15 15/16 16/17 17/18 18/19 19/20 20/21

FCEs


The longer term demand shows a significant increase in activity. However the Trust believes that in the medium term the increase can be managed within the current theatre complement through maximisation of theatre capacity, implementing ‘The Productive Operating Theatre’ model and by extending the theatre day/week. An outline of the workstreams associated with the Productive Operating Theatre project is given as Appendix 15. The Trust has also the increased networking between its 3 hospitals (Craigavon Area Hospital, Daisy Hill Hospital and South Tyrone Hospital) and the management of patients across this network to improve theatre utilisation. Centralised theatre scheduling has been recently introduced to ensure optimum utilisation of sessions.

In order to comply with national and regional standards and guidelines1 on the care and treatment of children who require elective surgery the Trust is proposing to centralise elective surgery for patients aged 16 and under at Daisy Hill Hospital. These standards and guidelines emphasise the special requirements of paediatric patients in hospital and recommend that children should be managed in separate facilities and be looked after by staff with the appropriate paediatric training and experience.

This proposal is currently out for public consultation. If implemented, it will release some theatre sessions which will be used to absorb increases in theatre activity.

1 The National Framework for Children, Young People and Maternity Service;, The Royal College of Anaesthetists, Guidelines on the Provision of Paediatric Anaesthetic Services; DHSSPSNI proposed

new standards ‘Improving Services for General Paediatric Surgery’ and ‘Improving Services for

Paediatric ENT Surgery’


Summary of Assessment of Need

Condition of Existing Facilities

! The theatre ventilation plant (including design configuration and air change rate) does not meet Departmental standards (HTM 2025);

! Theatre design does not meet Departmental standards (HBN 26) in terms of space, layout or quality of finishes;

! There are significant electrical services issues including only one source of electrical supply; emergency back-up is fully loaded and the distribution network contravenes standards;

! Remedial works to the theatres have been successful in reducing the risk to MODERATE. However, to prevent the risk rising to EXTREME, primarily due to the failure of aging infrastructure, further significant action is required.

Demand Assessment

! The number of theatre sessions is currently at 48 per week; however usage can be higher depending on the time of the year;

! Main theatre activity has increased over the last three years, particularly in terms of the numbers of more complex surgery. Historical data on surgical FCEs with a procedure at Craigavon Area Hospital has shown a significant increase over the last four years, with the number of surgical FCEs with a procedure increasing from 6,331 in 2005/06 to 9,569 in 2008/09, an increase of 51%;

! Whilst the Trust is currently meeting the PfA target of 13 weeks for inpatient and daycase treatment, this has required significant use of the independent sector to provide additional capacity. In 2008/09 826 inpatient and 3,005 day case episodes were provided by the independent sector. It is the Regional Health and Social Care Board’s (RHSCB) intent that the use of independent sector should be minimised. In the last quarter of 2009/10 the Trust made significant reductions in the use of independent sector capacity. Only 193 day cases were treated in the independent sector. This achievement resulted from the maximisation of theatre capacity, flexible use of theatres and the provision of sessions in the evening and weekend;


! Planned service developments will give rise to the need to increase theatre sessions within the Trust. These developments include the expansion of urology with the appointment of 2 additional consultant surgeons, the commencement of bowel screening, the expansion of ENT and chronic pain management services, the development of a local ophthalmology service;

! The Trust will increase its day surgery rates in line with the PSA target 1.11. However, this will not significantly affect the level of activity in main theatres due to capacity constraints in the day surgery unit;

! Population demographics show a 23.8% increase in the overall number of people in the Southern area by 2021 and more significantly an increase of 43.7% in those aged 65 years and over. This increase will have a considerable impact on the requirement for theatre capacity because a large proportion of inpatient episodes are attributable to the 65+ age group;

! Projected inpatient surgical activity is forecast to increase to 12,024 FCEs by 2020/21, a substantial increase of 25% between 2008/09 and 2020/21.


5 PATIENT PATHWAY The operating theatre department comprises:

! 5 general theatres – 4 which are the subject of this proposal and one which has recently been replaced with a new build theatre (theatre 5);

! A dental room;

! An emergency endoscopy room (former theatre 5);

! Two new trauma and orthopaedic theatres are currently being constructed (scheduled for handover at the end of March 2010) adjacent to and linked to the main theatre suite.

All of the theatres listed above are managed as a single, integrated operating department.

There will be 4 theatres provided as part of this scheme. It is proposed that all four theatres will be 55 m2. Two will be general theatres and the remaining 2 theatres will be ultra clean with 18 m2 preparation rooms to facilitate procedures which require a large number of trolleys. This will provide flexibility within the operating theatre department eg the trauma and orthopaedic service will be able to use the two ultra clean theatres, if required. The theatres will be provided with an exit bay which is large enough to park the empty bed belonging to the patient currently in theatre.

There will be 3 main groups of patients arriving at theatres:

! Elective patients arriving straight from home;

! Elective patients coming from a surgical ward;

! Emergency cases coming from a surgical ward or A&E Department.

The majority of elective patients will arrive at the operating theatre department straight from home, having previously been pre-assessed. They will be admitted via the admissions lounge and will be assessed in the lounge by the surgeon and the anaesthetist prior to surgery. They will not go to a surgical ward until after recovery. This will reduce the pressure on surgical wards and enable the Trust to make much more effective use of its surgical bed complement. It is worthy of note that the Trust has implemented best practice in relation to admission on the day for elective procedures and compares favourably with the Northern Ireland average. The most recent figures which are available relate to the quarter ended December 2009. CHKS benchmarking data indicates a NI average of 73.6% of elective inpatients admitted on the day of their procedure compared to a Southern Trust figure of 75.1%.


Those elective and emergency patients arriving at theatre from a ward will be moved to the anaesthetic room if it is free or to a pre operative holding bay. The holding bays will be equipped with medical gases and will be provided adjacent to the recovery ward to allow for the observation of pre operative patients.

Following surgery patients are transferred from theatre to recovery ward. The recovery ward is open 24 hours, seven days per week. The recovery ward is used by:

! The 5 main theatres (theatres 1-5);

! The dental room;

! The emergency endoscopy room (‘old’ theatre 5);

! The trauma and orthopaedic theatres, out of hours. The T&O theatres do not currently provide an out of hours service and any patients requiring recovery after 9pm or an overnight stay are transferred to the main recovery ward;

! For short term high dependency care (in line with para 3.23 & 3.30 HBN 26)

As far as possible male and female patients will be segregated in recovery. Children will be separated from adults in the recovery area, and accommodation will be provided for parents of children who have to remain in recovery.

The current recovery ward can accommodate up to a maximum of 15 patients, with bed spacing which is considerably less than the recommended 3.6 m2, This is not sufficient and theatre lists have to be carefully planned around the existing recovery capacity, with patients sometimes having to be recovered in theatre, thereby delaying lists. The Trust therefore proposes an 18 bed recovery ward with this scheme.


6 OBJECTIVES AND CONSTRAINTS Introduction

This section of the business case sets out project objectives for the proposed replacement of theatres 1 to 4. It also details anticipated constraints that will impact on the achievement of the identified objectives.

6.1 Objectives

In terms of service delivery at Craigavon Area Hospital, the Trust is responsible for delivering healthcare in line with the following overarching objectives:

! Safety for patients, staff and the local community through well designed, constructed and maintained facilities that meet regulation and service standards (Measured in terms of alignment with Health Building Notes (HBN) and Health Technical Memoranda (HTM));

! Equity/Accessibility of services regardless of where services are provided (Measured through ensuring all members of the public have access to modern facilities);

! Sustainability of services, through clinical integration, networks and maximisation of synergies (Measured in terms of a full range of surgical procedures including emergency surgery being undertaken in the new facility);

! Affordability and demonstration of value-for-money (Measured in terms of option selection through business case process); and

! Quality services capable of delivering high quality healthcare incorporating best practice and fit for purpose solutions (Measured in terms of alignment with HBN and HTM).

In terms of the specific replacement/upgrading of the existing theatre suite the following overall aim has been identified:

“To provide a suitable theatre suite and associated support facilities until completion of the redevelopment of the Craigavon Area Hospital site.”


The specific objectives for this project are set out below:

Objective 1: To deliver operating theatre accommodation by 2012 to DHSSPS standards as per:

! Health Building Notes (HBN 26 – Facilities for Surgical Procedures);

! Health Technical Memoranda;

! Laser Protection Agency Guidance;

! Radiation Protection Agency Guidance.

Objective 2: To provide a reliable theatre environment for patients and staff to ensure consistent levels of theatre capacity on completion of the project::

! Provide capacity for 47 sessions per week;

! Maintain utilisation rates at above 85%;

! Meet access targets.

Objective 3: To provide accommodation with the flexibility/capacity to accommodate the level of emergency and complex procedures as emerging from the presenting population on completion of the project (currently 20% of procedures undertaken in the main theatre complex):

! Undertake 20% of emergency and complex surgery work.

Objective 4: To ensure there are no unscheduled session cancellations during the period of construction and current capacity is maintained. To minimise the disruption to theatre and other support services.

Objective 5: To achieve a high satisfaction rating from theatre staff on completion of the project::

! Achieve 95% satisfaction as determined through staff survey.

Objective 6: To align with the Trust’s strategic direction and contribute to the development of services within the Trust:

! The achievement of the day surgery standard of 75% day case rate for the ‘basket’ of 25 procedures;

! The development of bowel screening at the Trust. A key ministerial target was set for the service in 2008/09 (PSA 1.11):

‘By December 2009, a comprehensive bowel screening programme for those aged 60-69 is in place with a view to achieving a 10% reduction in mortality from bowel cancer by 2011’.

Craigavon Area Hospital has been identified as the Southern Trust bowel screening centre and will be required to provide dedicated screening colonoscopy lists;


! The expansion of the urology service in line with the current regional review of urology;

! The expansion of services including ENT, endoscopy and pain management, to meet identified capacity gaps;

! The development of an integrated ophthalmology service.

6.2 Constraints

The following constraints have been identified in respect of this project:

o Funding – the preferred option must be both accessible and affordable in terms of capital and revenue;

o Existing Estate – The preferred option must make best use of the existing estate and service infrastructure without impeding potential future development of the Craigavon Hospital site;

o Need for theatre Support at all times – in addition to having operating theatres available for use, it is also necessary that the support infrastructure is also in place. Most importantly this includes a suitable ‘Recovery Area’, but also other facilities such as changing rooms for staff. As a result sequencing will be important;

o Infection Control – the sequence of the works programme must mitigate the risk of infection during the construction phase;

o Site Constraints – any proposed replacement theatre must be located adjacent to necessary support infrastructure (eg. the Intensive Care Unit).


7 IDENTIFICATION & SHORTLISTING OF OPTIONS Introduction

This section of the business case identifies potential solutions - what is referred to as the ‘long list’ of options. A baseline option and a range of alternative options were identified by the Project Team. This long list of potential solutions was then sifted using the identified objectives and constraints to produce a short list of appropriate options for in-depth appraisal.

7.1 Long List of Options

Table 10 summarises the long list of options identified by the Project Board with further detail being provided in the paragraphs that follow.


Table 10: Long List of Options

Option Description

1 Do Nothing – continue to use existing main theatres 1 - 4, carrying out routine and essential maintenance only.

2 Do Minimum – Minimal refurbishment of existing 4 theatres, replacing the ventilation system and upgrading the electrical supply.

3 Purchase 2 volumetric theatres. Extend theatre block into a courtyard and refurbish to provide 2 theatres, new recovery, upgraded staff changing and additional storage.

4 Construct 4 new theatres, displace and re-provide hystocytology laboratory & laboratory office block. Refurbish existing theatre block to provide new recovery, upgraded staff changing and additional storage.

5 Purchase 2 volumetric theatres and construct 2 new theatres. Displace and re-provide CSSD plant room space. Refurbish existing theatre block to provide new recovery, upgraded staff changing and additional storage.

6 Purchase 2 volumetric theatres and construct 2 new theatres. Displace and re-provide the biochemistry laboratory.Refurbish existing theatre block to provide new recovery, upgraded staff changing and additional storage.

7 Purchase 2 volumetric theatres and construct 2 theatres. Minorroad re-alignment is required. Refurbish existing theatre block to provide new recovery, upgraded staff changing and additional storage.

8 Purchase 2 volumetric theatres, construct 1 new theatre. Refurbish existing theatre block to provide 1 theatre, new recovery, upgraded staff changing and additional storage.

9 Construct 4 new theatres and new recovery ward, displace and re-provide hystocytology laboratory & laboratory office block. Refurbish existing theatre block to provide, upgraded staff changing and additional storage.

10 Conversion of other buildings (Pharmacy, ICU, CSSD) to provide 4 theatres, recovery and support accommodation. Re-provide accommodation for displaced services.


Volumetric Modular Theatres

Volumetric theatres are steel framed, pre-engineered modular units manufactured within a controlled factory environment that are delivered to site as fitted-out, serviced building modules and craned into position to form a complete healthcare building. Volumetric modular buildings offer the advantages of ability to meet extremely tight programmes and to achieve installation in congested and restricted sites, e.g. over roofs of existing buildings where there is limited space at ground-floor level and within enclosed hospital courtyards. The majority of the building can be constructed off-site with plant located on the roof whilst ground works, foundations and engineering services infrastructure works are carried out on site. Standard (in terms of layout and specification) volumetric modular operating theatres can provide a fast-track, economical solution that is suited to temporary facilities.

The Southern Trust is currently leasing two volumetric modular theatres with support accommodation to enable the trauma and orthopaedic (T & O) service to commence quickly at the Trust. These theatres will be vacated when the construction of the new trauma and orthopaedic facility has been completed and the building commissioned. The new T&O facility will be handed over for Trust commissioning in April 2010. When the business case for the new T & O facility was written it was intended that the lease would be terminated and these buildings would be removed from the site when the T & O service moves to its new accommodation. However as the replacement of main theatres 1-4 will be a temporary solution until major redevelopment of the Craigavon Area Hospital site a number of the options described below include the purchase and upgrade (to the ventilation systems, nurse call and fire alarm systems) of these two volumetric theatres.


Recovery Ward

The ‘do something’ options with the exception of option 2 ‘do minimum’ all include provision of a new 18 bed recovery ward. The recovery ward is used by theatres 1-5, the dental theatre (1.5 sessions per week) and also ‘old’ theatre 5 (daily emergency endoscopy list). The current recovery ward can accommodate up to a maximum of 15 patients (with bed spacing which is considerably less than the recommended 3.6 m2), but this is not sufficient and theatre lists have to be carefully planned around the existing recovery capacity. Patients requiring post operative care overnight and also patients requiring high dependency care are frequently cared for overnight in recovery ward (the capacity in the ICU/HDU ward is very limited). This impacts on the number of recovery spaces which are available for morning lists. The table below demonstrates that the numbers of patients who need to be retained in Recovery overnight is increasing:

Overnight Stays in Recovery Ward

Post Operative HDU

2007/08 192 37

2008/09 177 87

2009/10(1 Apr 09 – 30 Sep 09)

105 87

Storage

Storage space within main theatres is very limited. There is only 1 general store, a small cupboard and a housekeeper’s store all of which are shared by all 5 main theatres. This results in equipment and supplies being stored in corridors and other inappropriate areas. The Joint Advisory Group on Decontamination visited the hospital on 22nd May 2009 and highlighted the fact that the decontamination area in theatres was shared with a storeroom and emphasised that it was inappropriate that general store items be stored alongside endoscopes. Provision of additional storage accommodation must be an essential component of this project.


Option 1 - Do Nothing

This option involves continuing to use the existing theatre suite and undertaking only planned maintenance work as necessary.


This option proposes to conduct the minimum work required to the existing theatres to meet some of the requirements of the HBN and HTM guidance. This would involve refurbishment to the existing four theatres to include the following work:

! Replacement of the ventilation system;

! Upgrade the electricity supply.

It would include removal of ceilings and tracking of walls. Two temporary decant theatres and a temporary recovery ward would be provided and the main theatres would be decanted and refurbished in pairs. Due to capital developments on the Craigavon Hospital site in the vicinity of main theatres (temporary trauma and orthopaedic theatres and ward, new theatre 5, trauma and orthopaedic phase B facility) the available locations for decant accommodation are very limited. The only potential location is on the far side of the laboratory buildings with a clean corridor through the labs reception area.

Option 3 - Purchase 2 volumetric theatres. Extend theatre block into a courtyard & refurbish to provide 2 theatres, new recovery, upgraded staff changing and additional storage.

This option involves purchasing and retaining the 2 volumetric theatres in their present location to replace 2 of the main theatres. Necessary upgrade work to the ventilation system, nurse call and fire alarm systems would be carried out.

The dental theatre, staff rest and office accommodation would be displaced and an extension would be built in an adjacent courtyard to provide a new theatre 3. The 4th theatre would be provided by refurbishing vacated accommodation along with an 18 bed recovery ward, upgraded changing facilities and additional storage. The new theatres and recovery facilities would comply with Health Building Note 26 (HBN 26) and relevant Health Technical Memoranda (HTMs). Old theatre 5 (which has recently been replaced with a new build theatre) would be utilised to provide displaced accommodation. Work would be carried out in phases and 2 theatres and recovery ward would continue to be fully functional within the main theatre block whilst building and refurbishment work is ongoing.


Option 4 - Construct 4 new theatres, displace and re-provide hystocytology laboratory & laboratory office block. Refurbish existing theatre block to provide new recovery, upgraded staff changing and additional storage.

This option involves the construction of four theatres which fully comply with HBN 26 and relevant HTMs located adjacent to the new Theatre 5 and Trauma and Orthopaedic Facility (this is under construction and will be handed over to the Trust in April 2010), to replace the four main theatres. This site is currently occupied by the Histocytology Laboratory and Laboratory office accommodation. These 2 buildings would be re-provided prior to construction commencing. A new 18 bed recovery ward would be provided by refurbishing within the existing main theatre area. The staff changing facilities would also be upgraded and additional storage would be provided.

Option 5 - Purchase 2 volumetric theatres and construct 2 new theatres. Displace and re-provide CSSD plant room space. Refurbish existing theatre block to provide new recovery, upgraded staff changing and additional storage.

This option involves purchasing and retaining the 2 volumetric theatres in their present location to replace 2 of the main theatres. Necessary upgrade work to the laminar flow, nurse call and fire alarm systems would be carried out. Two theatres which fully comply with HBN 26 and relevant HTMs would be constructed, one between the volumetric theatres and the current main theatres, taking in part of the CSSD department and the other between new theatre 5 and the Labs buildings. The space lost from CSSD would have to be re-provided.

A new 18 bed recovery ward would be provided by refurbishing within the existing main theatre area. The staff changing facilities would also be upgraded and additional storage would be provided.


Option 6 - Purchase 2 volumetric theatres and construct 2 new theatres. Displace and re-provide the biochemistry laboratory. Refurbish existing theatre block to provide new recovery, upgraded staff changing and additional storage.

This option involves purchasing and retaining the 2 volumetric theatres in their present location to replace 2 of the main theatres. Necessary upgrade work to the ventilation system, nurse call and fire alarm systems would be carried out. Two theatres which fully comply with HBN 26 and relevant HTMs would be constructed together and adjacent to the 2 volumetric theatres between the volumetric theatres and the Biochemistry Laboratory. The Biochemistry Laboratory would be displaced by the new theatres, and would be re-provided.


Option 7 - Purchase 2 volumetric theatres and construct 2 theatres. Minor road re-alignment is required. Refurbish existing theatre block to provide new recovery, upgraded staff changing and additional storage.

This option involves purchasing and retaining the 2 volumetric theatres in their present location to replace 2 of the main theatres. Necessary upgrade work to the ventilation system, nurse call and fire alarm systems would be carried out. Two theatres which fully comply with HBN 26 and relevant HTMs would be constructed, one between the volumetric theatres and the ring road and the other adjacent to the Labs and the new T&O building. Some minor re-alignment of the ring road would be required.


Option 8 - Purchase 2 volumetric theatres, construct 1 new theatre. Refurbish existing theatre block to provide 1 theatre, new recovery, upgraded staff changing and additional storage.

This option involves purchasing and retaining the 2 volumetric theatres in their present location to replace 2 of the main theatres. Necessary upgrade work to the ventilation system, nurse call and fire alarm systems would be carried out. A third theatre would be constructed adjacent to the 2 volumetric theatres and the new theatre 5. The fourth theatre would be provided by refurbishing within the existing main theatre building. Both new theatres would fully comply with HBN 26 and relevant HTMs.



Option 9 - Construct 4 new theatres and new recovery ward, displace and re-provide hystocytology laboratory & laboratory office block. Refurbish existing theatre block to provide upgraded staff changing and additional storage.

This option involves the construction of four theatres and new 18 bed recovery ward which fully comply with HBN 26 and relevant HTMs located adjacent to the new Trauma and Orthopaedic Facility on the side furthest away from current main theatres. The new T&O facility is under construction and will be handed over to the Trust for commissioning in April 2010. This site is currently occupied by the histocytology laboratory and laboratory office accommodation. These 2 units would be re-provided prior to construction commencing. The theatre staff changing facilities would also be upgraded and additional storage would be provided.

Option 10 - Conversion of another building — eg Pharmacy, Intensive Care Unit and/ or Central Sterile Service Department to provide 4 theatres, recovery and support accommodation. Re-provide accommodation for displaced services.

This option proposes the conversion of existing buildings (the Pharmacy, ICU and CSSD have been identified as possibilities) into new theatre suites. In all cases, it would be necessary to rebuild the facility/facilities which have been displaced.

The outcome of the preliminary sift of options is shown overleaf with the following symbols:

!! Fully complies with the objective/constraint

! Partially complies with the objective/constraint ? May/may not comply with the objective/constraint

X Fails to comply with the objective/constraint

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5P

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T

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Yes

10

Convers

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of oth

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build

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eg

Pharm

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No


The short listing exercise indicates that options 7, 8, and 9 comply with the majority of objectives and constraints and have therefore been carried forward for further evaluation. Option 2 would meet some of the project objectives and is being taken forward as a base case comparator, in accordance with the guidance set out in HM Treasury Green Book (The Green Book, Appraisal and Evaluation in Central Government, Treasury Guidance, 2003). Option 3 has also been short listed. Although it does not meet all of the objectives and constraints, it enables the Trust to evaluate a range of different levels of solution in line with the guidance.

Short Listed Options


This option proposes conducting the minimum work required to the existing theatres to meet some of the requirements of the HBN and HTM guidance. It would involve refurbishment to the existing four theatres to include the replacement of the ventilation system and upgrade the electricity supply. This would enable some of the theatre standards to be met however it would not address the issue of the size of theatres or preparation rooms (refurbished theatres would be 40 sq metres compared to the new HBN standard of a minimum 55 sq metres). Also preparation rooms would continue to be shared between two theatres. This option would therefore not support a full range of surgical procedures. There is no potential to upgrade the existing recovery ward with this option. The current bed spacing is considerably less than the recommended bed spacing of 3.6m for multi bed areas. There would be no upgrade to the staff changing area which is cramped and inadequate and no provision to expand the current inadequate storage.

Clinical adjacencies are good as the theatres remain adjacent to the existing support infrastructure, such as recovery ward and the intensive care unit and existing hospital estate would continue to be utilised

Of major concern to the Trust is the significant disruption which would result from the works within the main theatre suite. Two theatres would have to remain fully operational whilst works are being carried out within the same area. It would also be difficult to locate decant accommodation due to site constraints and the decant accommodation would have to be some distance from the theatre support accommodation and remaining two theatres. This arrangement would lead to operational difficulties and would inevitably impact on the Trust’s ability to provide the current level of theatre services. This would have a knock on effect to achievement of access standards or alternatively significant one-off costs would be incurred if this activity has to be displaced to the independent sector for the period of the refurbishment.


Option 2 would not release any space to support the development of services within the Trust for example the expansion of urology, ENT, gynaecology and pain management services.

Option 3 - Purchase 2 volumetric theatres. Extend the theatre block into a courtyard & refurbish to provide 2 theatres, new recovery, upgraded staff changing and additional storage.

This option meets some but not all of the project objectives and constraints. The two volumetric theatres and two refurbished theatres would enable the Trust to meet all the HBN and HTM requirements in terms of theatre environment and will support a full range of surgical procedures. The necessary support facilities would be provided. A new 18 bed recovery area would be built and would meet the current HBN/HTM requirements including compliance with new bed spacing recommendations for multi bed areas. The staff changing area would be upgraded to provide appropriate accommodation.

Existing hospital estate would continue to be utilised and good clinical adjacencies are maintained as the two volumetric theatres are linked to main theatres.

However this option would result in a high level of disruption to existing theatre services. It could impact on the Trust’s ability to provide the current level of theatre services and therefore has the potential to have an adverse impact on length of stay and the achievement of elective waiting time targets. This is a technically difficult option. It would be necessary to crane materials over occupied buildings into the courtyard to build the extension.

New plant would have to be installed on the roof (of fully functioning theatres) and the existing water tank would have to be removed. Two theatres and recovery ward would continue to be fully functional within the main theatre block whilst work is being carried out.

This option would not release any space to support the development of services within the Trust for example the expansion of urology, ENT, gynaecology and pain management services.

Option 7 - Purchase 2 volumetric theatres and construct 2 theatres. Minor road re-alignment is required. Refurbish existing theatre block to provide new recovery, upgraded staff changing and additional storage.

This option meets all of the project objectives and some of the constraints. The two volumetric theatres and two new build theatres will enable the Trust to meet all the HBN and HTM requirements in terms of theatre environment and will support a full range of surgical procedures. The necessary support


facilities will be provided. A new 18 bed recovery area will be created within the existing theatre suite after the theatre activity has moved to the two volumetric and two new build theatres. The new recovery will meet the current HBN/HTM requirements including compliance with new bed spacing recommendations. The staff changing area will be upgraded to provide appropriate accommodation and additional storage will be provided.

The disruption to theatre services will be minimal. Construction of the two new build theatres and upgrade work to the two volumetric theatres can commence when the T & O service transfers to its new facility. Upgrade work to the two volumetric theatres will be completed first and when these have been commissioned sessions from two existing theatres will transfer. The temporary volumetric staff changing and recovery ward units will be removed from the site to enable construction of the two new build theatres (these will no longer be required at that stage). Operating sessions from the two remaining theatres will transfer to the new build theatres when construction and commissioning of these has been completed. Work to construct the new recovery ward and to upgrade the staff changing will not commence until all four theatres have moved.

There is some use of existing estate – the temporary volumetric theatres will be used and recovery, staff changing and other support accommodation will continue to be located within the existing theatre block.

Clinical adjacencies are generally good with this option. However new theatre 4 is some distance from recovery and ICU. This would make monitoring of recovering patients by Anaesthetists in this theatre more difficult (at present the anaesthetists are close to recovery when in theatre and can quickly respond to an emergency situation).

Space would be released within the theatre suite which could be developed to provide other facilities such as an admissions unit to enable elective patients to be admitted to the theatre suite on the day of their procedure. This option would therefore support the development of services within the Trust for example the expansion of urology, ENT, gynaecology and pain management services.

Option 8 - Purchase 2 volumetric theatres, construct 1 new theatre. Refurbish existing theatre block to provide 1 theatre, new recovery, upgraded staff changing and additional storage.

This option meets all of the project objectives and the majority of constraints. The two volumetric theatres, the refurbished theatre and the new build theatre will enable the Trust to meet all the HBN and HTM requirements in terms of theatre environment and will support a full range of surgical procedures. The necessary support facilities will be provided. A new 18 bed recovery area will be created within the existing theatre suite. The new recovery will meet the current HBN/HTM requirements including compliance with new bed spacing recommendations for multi bed accommodation. The staff changing area will


be upgraded to provide appropriate accommodation and additional storage will be provided.

The disruption to theatre services will be minimal. Construction of the new build theatre and upgrade work to the two volumetric theatres can commence when the T & O service transfers to its new facility. Upgrade work to the two volumetric theatres will be completed first and when these have been commissioned sessions from two existing theatres will transfer. The temporary volumetric T&O recovery unit would be removed from the site to allow construction of the new build theatre. Operating sessions from a third theatre will transfer to the new build theatre when construction and commissioning of this has been completed. Work to construct the fourth theatre will be undertaken when the first three have moved and following this refurbishment to provide a new recovery ward and to upgrade the staff changing will be undertaken.

There is good use of existing estate as one theatre, recovery ward, staff changing and other support accommodation will continue to be located within the existing theatre block. The temporary volumetric theatres will also continue to be utilised.

Clinical adjacencies are good with this option. The four theatres are located together and the new build theatre adjoins new theatre 5. All are convenient to the new recovery ward and a short distance from ICU.


Option 9 - Construct 4 new theatres and new recovery ward, displace and re-provide hystocytology laboratory & laboratory office block. Refurbish existing theatre block to provide upgraded staff changing and additional storage.

This option meets all of the project objectives and partially meets some of the constraints. The four new build theatres will enable the Trust to meet all the HBN and HTM requirements in terms of theatre environment and will support a full range of surgical procedures. The necessary support facilities will be provided. A new 18 bed recovery area will be built and will meet the current HBN/HTM requirements including compliance with new bed spacing recommendations. Staff changing and additional storage will be provided in the new build accommodation.

The disruption to theatre services will be minimal as theatre sessions will not transfer until the construction of the new theatres and recovery ward has been


completed and the new facilities have been commissioned. There will be some disruption to laboratory services as the histocytology laboratory, laboratory reception, and some laboratory office accommodation occupies the proposed site for the new build theatres and recovery. This accommodation would have to be re-provided and services moved before the site could be cleared for construction. This option will therefore be slower to implement than some of the other options.

There is limited use of existing accommodation – only staff changing and some support accommodation will be located within the existing theatre footprint.

Clinical adjacencies within theatres are generally good with this option. The four new theatres are together and adjacent to recovery ward. The new recovery ward is also convenient to new theatre 5. However the new theatres are much further away from ICU than the current theatres.


Eliminated Options

Options 1, 4, 5, 6 and 10 have been eliminated at the short listing stage. The reasoning is provided in the paragraphs which follow.

Option 1 - Do Nothing

This option does not meet the majority of the project objectives. The HBN and HTM requirements in terms of theatre environment would not be met. Air change rates, theatre size standards and bed spacing in recovery ward would not be improved and therefore the clinical risk would not be reduced. The condition of the theatre suite and associated infrastructure will continue to deteriorate as time progresses, even with scheduled maintenance. The theatre suite will therefore not support more complex and high risk surgery. Ensuring an uninterrupted service would become increasingly difficult as on-going maintenance becomes necessary on a more regular basis.

Option 1 does not provide all the necessary support facilities. Separate preparation rooms would not be provided for each theatre. The current staff changing facilities would not be upgraded and there would be no space to provide additional storage so equipment and consumables would continue to be stored in inappropriate areas.


This option would not release any space to support the development of services within the Trust for example the expansion of urology, ENT, gynaecology and pain management services.

Given the critical state of the main theatres, the Trust does not consider ‘do nothing’ to be an acceptable course of action. As there is an appropriate ‘do minimum’ option which can be used as a baseline comparator, and with the agreement of the Health Economists at the DHSSPS, option 1 has not been taken forward for further analysis.

Option 4 - Construct 4 new theatres, displace and re-provide hystocytology laboratory & laboratory office block. Refurbish existing theatre block to provide new recovery, upgraded staff changing and additional storage.

This option does not meet all of the project objectives, nor comply with all of the constraints. The four new theatres would enable the Trust to meet all the HBN and HTM requirements in terms of theatre environment and will support a full range of surgical procedures. The necessary support facilities would be provided. A new 18 bed recovery area would be provided within the current main theatres block and would meet the current HBN/HTM requirements including compliance with new bed spacing recommendations. The current staff changing area would be upgraded to provide appropriate accommodation and additional storage would be provided.

There would be minimal disruption to existing theatres while the new theatres are constructed. The impact of refurbishing existing theatre accommodation to provide a new recovery ward and upgraded staff changing can also be minimised. Although disruption to theatre services would be minimised there would be disruption to laboratory services as new accommodation would have to be built for histocytology laboratory in order to clear the proposed site. This option would also take longer to implement due to the need to build laboratory accommodation first. In addition, laboratory services are currently sited together and this option would result in histocytology being located on another part of the site.

There is very little use of existing accommodation – only recovery, staff changing and some support accommodation would be located within the existing theatre footprint.

Clinical adjacencies are poor with option 4. The new theatres are much further away from recovery and ICU than at present. The distance from recovery ward is of particular concern to clinical staff as this would make monitoring of recovering patients by anaesthetists much more difficult (at present anaesthetists are close to recovery when in theatre and can quickly respond to an emergency situation).


Option 5 - Purchase 2 volumetric theatres and construct 2 new theatres. Displace and re-provide CSSD plant room space. Refurbish existing theatre block to provide new recovery, upgraded staff changing and additional storage.

This option meets some of the project objectives. The two volumetric theatres and two refurbished theatres would enable the Trust to meet all the HBN and HTM requirements in terms of theatre environment and would support a full range of surgical procedures. The necessary support facilities would be provided. A new 18 bed recovery area will be built and would meet the current HBN/HTM requirements including compliance with new bed spacing recommendations. The staff changing area would be upgraded to provide appropriate accommodation and additional storage would be provided.

There is some use of existing estate – the temporary volumetric theatres would be used and recovery, staff changing and other support accommodation would continue to be located within the existing theatre block.

Clinical adjacencies are acceptable with this option. Theatres 1 – 4 are close to the new recovery ward. The distance to ICU is acceptable. However the adjacencies between theatres 2, 3 and 4 are not as good as that provided by some of the other options.

There would be relatively little disruption to existing theatres while the new theatres are constructed. The impact of refurbishing existing theatre accommodation to provide a new recovery ward and upgraded staff changing can also be minimised. Although disruption to theatre services would be minimised the disruption to CSSD would be significant as part of the CSSD plant room would be displaced. The CSSD plant has recently been extended to enable the service to meet the decontamination needs for main theatres, day surgery and other clinical areas within the hospital. There is no other suitably located site to re-provide this plant space and therefore this option would in reality involve re-providing the sterile services department at another location. This option would also take longer to implement due to the need to re-provide and move the CSSD department.

Given that there are an acceptable number of other options which will not require such significant disruption to another key department, this option has not been short listed for further evaluation.


Option 6 - Purchase 2 volumetric theatres and construct 2 new theatres. Displace and re-provide the biochemistry laboratory. Refurbish existing theatre block to provide new recovery, upgraded staff changing and additional storage.

This option meets some of the project objectives. The two volumetric theatres and two refurbished theatres would enable the Trust to meet all the HBN and HTM requirements in terms of theatre environment and will support a full range of surgical procedures. The necessary support facilities would be provided. A new 18 bed recovery area would be built and would meet the current HBN/HTM requirements including compliance with new bed spacing recommendations. The staff changing area would be upgraded to provide appropriate accommodation and additional storage would be provided.

There is some use of existing estate – the temporary volumetric theatres would be used and recovery, staff changing and other support accommodation will continue to be located within the existing theatre block.

Clinical adjacencies are good with this option. Theatres 1 – 4 are located together and are close to the new recovery ward. The distance to ICU is acceptable.

There would be relatively little disruption to existing theatres while the new theatres are constructed. The impact of refurbishing existing theatre accommodation to provide a new recovery ward and upgraded staff changing can also be minimised. Although disruption to theatre services would be minimised the disruption to laboratory services would be significant. Part of the biochemistry laboratory occupies the proposed site for the two new build theatres. The biochemistry analyser is a large piece of equipment which along with its necessary support accommodation requires a significant footprint. This accommodation would have to be re-provided in another suitable location on the hospital site. The analyser processes approximately 750,000 laboratory samples each year. It could not be dismantled and moved either easily or quickly and the resultant downtime would have a high impact on both hospital and primary care services. This option would also take longer to implement due to the need to re-provide biochemistry. For these reasons option 6 has not been shortlisted for further consideration.


Option 10 - Conversion of another building — eg Pharmacy, Intensive Care Unit and/ or Central Sterile Service Department to provide 4 theatres, recovery and support accommodation. Re-provide accommodation for displaced services.

This option could meet some of the project objectives. Conversion of existing buildings could provide theatres and associated accommodation that would enable the Trust to meet all the HBN and HTM requirements in terms of theatre environment and would support a full range of surgical procedures. The necessary support facilities could be provided.

There is the potential to minimise disruption to existing theatres while the new theatres are constructed. However as this option involves displacing Pharmacy, ICU and/or CSSD this would cause significant disruption to these and other dependent services and would have the potential to adversely affect current clinical adjacencies (such as adjacency of theatres to ICU or CSSD). This option would also take longer to implement due to the need to re-provide displaced departments before building of the new theatre accommodation could take place. For these reasons option 10 has been eliminated.


8 NON FINANCIAL APPRAISAL OF SHORTLISTED OPTIONS In the previous chapters the long list of potential options for the project was described, the methodology employed to arrive at an appropriate short-list, and reasons for excluding options from the short-list were explained. This chapter evaluates each of the short-listed options based on a non-financial assessment using benefit criteria.

8.1 Benefit Criteria

Benefit criteria are used to select and evaluate the options that have the potential to meet the specific project objectives. Although cost is an important evaluative determinant, it represents only one of a number of issues, which will impact on the value to be provided from that particular option. In addition, it is the case that not all costs or benefits can be measured in monetary terms, as no market value exists for them. Taking into account the objectives of the proposed project, a list of salient benefits has been devised which could accrue from the project if implemented successfully. The criteria employed to select and evaluate the options are given below and explained overleaf.

! Clinical effectiveness;

! Quality of accommodation;

! Strategic fit;

! Avoidance of disruption;

! Speed of Implementation.

T

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tres

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4 C

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70

Key N

on

Fin

an

cia

l C

rite

ria

Descri

pti

on

A

ttri

bu

tes

Clin

ical e

ffectiv

eness

The

impro

vem

ent

in

clin

ica

l effectiveness

whic

h

can

be

deliv

ere

d.

A

n e

ffective c

linic

al

serv

ice i

s d

escribe

d

as a

n inte

gra

ted a

nd a

ppro

priate

serv

ice

whic

h m

eets

the n

eeds o

f th

e s

erv

ice.

!G

ood c

linic

al a

dja

cencie

s;

!S

upport

the a

chie

vem

ent of tr

eatm

ent access targ

ets

;

!R

eductio

n in

the r

isk o

f in

fectio

n;

!T

he

abili

ty

to

facili

tate

all

types

of

surg

ery

in

clu

din

g

com

ple

x a

nd h

igh r

isk n

on-e

lectiv

e s

urg

ery

;

!E

ffic

ient util

isatio

n o

f sta

ff r

esourc

es;

!S

taff s

atis

factio

n w

ith facili

ties.

Qualit

y o

f accom

modatio

n

The new

fa

cili

ties should

be of

a hig

h

qualit

y in

te

rms of

space,

location and

su

ita

bili

ty f

or

the

fu

nctio

n in

ten

de

d.

!A

ccom

modatio

n w

hic

h m

eets

Depart

menta

l sta

ndard

s (

as

deta

iled in

HB

N 2

6 a

nd a

ssocia

ted H

TM

);

!F

unctio

nal s

uita

bili

ty o

f accom

modatio

n;

!C

onfig

ura

tion

of

the

Theatr

e

Suite

to

fa

cili

tate

good

pro

cess flo

ws in

support

of best pra

ctic

e w

ork

ing;

!F

lexib

ility

to

re

sp

on

d t

o f

utu

re n

ee

ds o

f th

ea

tre

se

rvic

es;

!M

ain

tenance o

f privacy a

nd d

ignity o

f patients

.

Str

ate

gic

Fit

The s

olu

tion s

hould

alig

n w

ith t

he T

rust’s

str

ate

gic

directio

n

and

facili

tate

th

e

develo

pm

ent of serv

ices w

ithin

the T

rust.

!T

he T

rust has b

een identif

ied a

s a

scre

enin

g c

entr

e for

the

bow

el

scre

enin

g p

rogra

mm

e a

nd w

ill b

e r

equired t

o r

un

dedic

ate

d c

olo

noscopy li

sts

to s

upport

the p

rogra

mm

e;

!E

xpansio

n

of

the

uro

logy

serv

ice

catc

hm

ent

are

a

to

encom

pass th

e w

est

of

the pro

vin

ce as a re

sult

of

the

regio

nal r

evie

w o

f uro

logy s

erv

ice;

!E

xte

nsio

n of

the bre

ast

scre

enin

g pro

gra

mm

e to

cover

wom

en a

ged 5

0 t

o 7

0 a

nd t

he p

ote

ntia

l im

pact

on b

reast

surg

ery

serv

ices;

T

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!T

he n

eed t

o r

educe/e

limin

ate

independent

secto

r activ

ity -

in

2008/0

9 3

005 p

atie

nts

had d

ay c

ase t

reatm

ent

and a

fu

rther

826

had

inpatie

nt

treatm

ent

in

the

independent

secto

r.

E

NT

, gynaecolo

gy,

pain

m

anagem

ent

and

ophth

alm

olo

gy s

erv

ices w

ill e

xpand a

s a

result.

Avoid

ance o

f dis

ruptio

n

The

degre

e

of

dis

ruption

to

serv

ice

deliv

ery

during t

he c

onstr

uction p

hase o

f th

e

pro

ject

an

d/

or

an

y

on

-go

ing

essential

main

tenan

ce

whic

h

may

be

req

uire

d.

!E

ffect

on t

heatr

e c

apacity

!D

isru

ption t

o o

ther

serv

ices; and

!In

co

nve

nie

nce

to

pa

tie

nts

an

d s

taff

.

Speed o

f Im

ple

menta

tion

A f

acili

ty d

eliv

ere

d q

uic

kly

to r

ed

uce t

he

level

of

clin

ical

risk

and

pro

vid

e

ad

va

nta

ge

s t

o p

atie

nts

an

d s

taff

at

the

e

arlie

st

op

po

rtu

nity.

!F

ully

im

ple

me

nta

ble

by 2

01

2.


The benefit criteria were agreed by the Project Board. They were selected to ensure that all of the project objectives described in section 6 were tested. The Project Board applied a weighting to each criterion in recognition of its relative importance to the project. The weightings were agreed as follows:

Criterion Weighting Explanation

1 Clinical effectiveness 35 The most important criterion as it is a measure of the impact of the service on patients. The Trust is committed to providing high quality patient care through a clinically effective service.

2 Quality of accommodation

20 Quality of accommodation is also considered to be very important as good facilities enhance the patient’s experience of the service and contribute to health and well-being. A good working environment also supports staff to provide the best possible care for patients. Satisfaction of this criterion ensures that the facility meets current architectural, electrical and mechanical standards.

3 Strategic Fit 15 It is important that the project aligns with the future needs of the hospital and the Trust, and supports the development of key services.

4 Avoidance of disruption

15 Avoidance of disruption is important to ensure continuity of theatre and other hospital services. This will prevent any reduction in the current level of service and control the impact on the achievement of treatment targets. It is also important to minimise the inconvenience for patients and staff.

5 Speed of Implementation

15 Speed of implementation is important to reduce the level of clinical risk and provide benefits to patients and staff at the earliest opportunity.


8.2 Scoring the Options

Scoring of the options was carried out by the Project Board. The four short-listed options, along with the ‘do minimum’ option were evaluated using the agreed criteria and the weighted scores detailed in Table 12 were calculated. The maximum score for each criterion was 10.

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Ta

ble

12:

Sco

rin

g o

f S

ho

rt L

iste

d O

pti

on

s 2D

o M

inim

um

3 2

Volu

metr

ic &

2

inte

rnal re

furb

ishm

ent

72 v

olu

metr

ic,

2 n

ew

build

- m

inor

road r

e-

alig

nm

ent

82 v

olu

metr

ic,

1

inte

rnal re

furb

ishm

ent,

1 n

ew

build

9N

ew

build

4

theatr

es &

reco

very

, d

isp

lace

hysto

cyto

la

b &

offic

es

Cri

teri

on

W

eig

ht

Score

S

core

x

Weig

ht

Score

S

core

x

Weig

ht

Score

S

core

x

Weig

ht

Score

S

core

x

Weig

ht

Score

S

core

x

Weig

ht

1

Clin

ica

l E

ffectiveness

40

6

2

40

9

3

60

7

2

80

9

3

60

7

2

80

2

Qualit

y o

f A

ccom

mo

da

tio

n

20

4

8

0

8

16

0

8

16

0

8

16

0

9

18

0

3

Str

ate

gic

Fit

15

5

7

5

5

75

8

1

20

7

1

05

9

1

35

4

Avoid

ance o

f D

isru

ption

15

5

7

5

6

90

8

1

20

7

1

05

7

1

05

5

Sp

ee

d o

f Im

ple

menta

tion

10

3

3

0

5

50

7

7

0

4

40

3

3

0

To

tals

10

05

00

73

57

50

77

07

30

RA

NK

ING

5

32

14

T

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4 C

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rea

Ho

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75

Exp

lan

ati

on

of

the S

co

res

Cri

teri

on

1 –

Clin

ical E

ffecti

ven

ess

Op

tio

n

Sco

re

Exp

lan

ati

on

2D

o

Min

imum

–

Min

imal

refu

rbis

hm

ent

of

exis

ting

4

theatr

es,

repla

cin

g

the

ventil

atio

n

syste

m

and

upgra

din

g

the

ele

ctr

ical

supply

.

6! C

linic

al

adja

cencie

s a

re g

ood.

The t

heatr

es a

re a

dja

cent

to e

xis

ting s

upport

infr

astr

uctu

re

such a

s r

ecovery

ward

and IC

U;

! In

tegra

tion b

etw

een t

he 4

theatr

es,

new

theatr

e 5

and t

he n

ew

T&

O t

heatr

es i

s g

ood a

nd

good flo

ws w

ithin

the theatr

e c

om

ple

x a

re e

nable

d w

hic

h w

ill facili

tate

the e

ffic

ient util

isatio

n o

f sta

ff;

! T

his

optio

n s

core

d l

ow

er

than t

he o

ther

short

lis

ted o

ptio

ns b

ecause a

lthough t

he r

isk o

f in

fectio

n w

ould

be r

educed d

ue t

o t

he insta

llatio

n o

f new

ventil

atio

n e

quip

ment, e

ach p

air o

f th

eatr

es w

ould

contin

ue t

o s

hare

a p

repara

tion a

rea.

In a

dditi

on,

the 4

theatr

es w

ill s

till only

be 4

0 m

2 w

hic

h is

consid

era

bly

sm

alle

r th

an the c

urr

ent m

inim

um

recom

mended s

ize o

f 55m

2;

! A

lthough a

n im

pro

vem

ent

on t

he c

urr

ent

facili

ties,

sta

ff a

re lik

ely

to b

e less s

atis

fied w

ith t

his

optio

n than w

ith the o

ther

short

liste

d o

ptio

ns.

3P

urc

hase

2

volu

metr

ic

theatr

es.

E

xte

nd

theatr

e

blo

ck

into

court

yard

&

re

furb

ish

to

pro

vid

e

2

theatr

es,

new

re

covery

, upgra

ded sta

ff changin

g and

additi

onal s

tora

ge.

9! C

linic

al

adja

cencie

s a

re g

ood.

The t

heatr

es a

re a

dja

cent

to e

xis

ting s

upport

infr

astr

uctu

re

such a

s r

ecovery

ward

and IC

U;

! In

tegra

tion b

etw

een t

he 4

theatr

es,

new

theatr

e 5

and t

he n

ew

T&

O t

heatr

es i

s g

ood a

nd

good flo

ws w

ithin

the theatr

e c

om

ple

x a

re e

nable

d w

hic

h w

ill facili

tate

the e

ffic

ient util

isatio

n o

f sta

ff;

! R

isk o

f in

fectio

n w

ould

be s

ignifi

cantly

reduced w

ith t

his

optio

n.

In a

dditi

on t

o n

ew

ventil

atio

n

equip

ment

whic

h w

ill f

acili

tate

air c

hange r

ate

s w

hic

h a

re c

om

plia

nt

with

HB

N 2

6,

this

optio

n

will

pro

vid

e th

eatr

es w

hic

h are

com

plia

nt

in

term

s

of

siz

e

and

support

accom

modatio

n

inclu

din

g s

epara

te p

repara

tion r

oom

s for

each theatr

e;

! T

his

optio

n w

ill p

rovid

e a

facili

ty w

hic

h w

ill s

upport

the a

chie

vem

ent of access targ

ets

;

! S

taff w

ill b

e a

ble

to d

eliv

er

a s

erv

ice fro

m m

odern

, fit

for

purp

ose theatr

e a

ccom

modatio

n a

nd

T

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4 C

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Ho

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76

Cri

teri

on

1 –

Clin

ical E

ffecti

ven

ess

Op

tio

n

Sco

re

Exp

lan

ati

on

will

there

fore

be m

uch m

ore

satis

fied w

ith facili

ties than a

t pre

sent.

7P

urc

hase

2

volu

metr

ic

theatr

es

and

constr

uct

2

theatr

es.

M

ino

r ro

ad

re

-alig

nm

en

t is

re

qu

ired

.R

efu

rbis

h

exis

ting

theatr

e

blo

ck

to

pro

vid

e

new

re

covery

, upgra

ded

sta

ff

changin

g

and

additi

onal

sto

rage.

7! O

ption

7

score

d

hig

her

than

op

tio

n

2

bu

t lo

we

r th

an

o

ptio

ns

3

an

d

8.

C

linic

al

adja

cencie

s a

re f

airly

good a

s t

heatr

e 3

is i

n a

good l

ocation i

n r

ela

tion t

o t

heatr

e 5

, re

co

ve

ry a

nd

IC

U.

H

ow

eve

r, t

he

atr

e 4

is s

om

e d

ista

nce f

rom

recovery

and I

CU

;

! R

isk o

f in

fectio

n w

ould

be s

ignifi

cantly

reduced w

ith t

his

optio

n.

In a

dditi

on t

o n

ew

ventil

atio

n

equip

ment

whic

h w

ill f

acili

tate

air c

hange r

ate

s w

hic

h a

re c

om

plia

nt

with

HB

N 2

6,

this

optio

n

will

pro

vid

e th

eatr

es w

hic

h are

com

plia

nt

in

term

s

of

siz

e

and

support

accom

modatio

n

inclu

din

g s

epara

te p

repara

tion r

oom

s for

each theatr

e;

! T

his

option

will

pro

vid

e a

facili

ty w

hic

h w

ill s

upport

the a

chie

vem

ent

of

access t

arg

ets

;

! S

taff w

ill b

e a

ble

to d

eliv

er

a s

erv

ice f

rom

modern

, fit

for

purp

ose t

heatr

e a

ccom

modation

and w

ill t

he

refo

re b

e m

uch m

ore

satisfied w

ith f

acili

ties t

han a

t pre

sent.

8P

urc

hase

2

volu

metr

ic

theatr

es,

constr

uct

1

new

th

eatr

e.

Refu

rbis

h

exis

ting

theatr

e

blo

ck

to

pro

vid

e

1

theatr

e,

new

re

covery

, upgra

ded sta

ff changin

g and

additi

onal s

tora

ge.

9! O

ption 8

was a

ward

ed the h

ighest score

of 9 a

long w

ith o

ptio

n 3

. C

linic

al adja

cencie

s a

re

better

than o

ptions 7

and 9

. T

he f

our

theatr

es a

re locate

d t

ogeth

er

and t

he n

ew

build

th

eatr

e a

djo

ins n

ew

th

eatr

e 5

, enablin

g o

ptim

al utilis

ation o

f sta

ff.

All

theatr

es a

re

convenie

nt

to t

he n

ew

recovery

ward

an

d a

sh

ort

dis

tan

ce

fro

m I

CU

;

! R

isk o

f in

fectio

n w

ould

be s

ignifi

cantly

reduced w

ith t

his

optio

n.

In a

dditi

on t

o n

ew

ventil

atio

n

equip

ment

whic

h w

ill f

acili

tate

air c

hange r

ate

s w

hic

h a

re c

om

plia

nt

with

HB

N 2

6,

this

optio

n

will

pro

vid

e th

eatr

es w

hic

h are

com

plia

nt

in te

rms of

siz

e

and

support

accom

modatio

n

inclu

din

g s

epara

te p

repara

tion r

oom

s for

each theatr

e;

! T

his

optio

n w

ill p

rovid

e a

facili

ty w

hic

h w

ill s

upport

the a

chie

vem

ent of access targ

ets

;

! S

taff w

ill b

e a

ble

to d

eliv

er

a s

erv

ice fro

m m

odern

, fit

for

purp

ose theatr

e a

ccom

modatio

n a

nd

will

there

fore

be m

uch m

ore

satis

fied w

ith facili

ties than a

t pre

sent.

T

hea

tres

1 –

4 C

raig

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n A

rea

Ho

spit

al

77

Cri

teri

on

1 –

Clin

ical E

ffecti

ven

ess

Op

tio

n

Sco

re

Exp

lan

ati

on

9C

onstr

uct

4

new

th

eatr

es

and

new

re

covery

w

ard

,d

isp

lace

an

d

re-p

rovid

e

hysto

cyto

log

y l

ab

ora

tory

&

lab

ora

tory

o

ffic

e

blo

ck.

Refu

rbis

h

exis

ting

theatr

e

blo

ck

to

pro

vid

e,

upgra

ded

sta

ff changin

g and additi

onal

sto

rage.

7! C

linic

al

ad

jace

ncie

s w

ith

in t

he

atr

es a

re g

en

era

lly g

ood

with

this

op

tio

n.

Th

e f

ou

r n

ew

th

eatr

es a

re t

ogeth

er

and a

dja

cent

to r

ecovery

ward

. T

he n

ew

recovery

ward

is a

lso

re

latively

convenie

nt

to n

ew

theatr

e 5

. H

ow

ever

the n

ew

theatr

es a

re m

uch f

urt

her

aw

ay

from

IC

U t

han t

he c

urr

ent

theatr

es.

Als

o t

he

atr

e 5

is lo

ca

ted o

n t

he o

ther

sid

e o

f th

e n

ew

T

&O

theatr

es w

hic

h w

ill m

ean t

hat

main

theatr

es s

taff c

an b

e u

se

d less e

ffic

iently t

han a

t p

rese

nt;

! R

isk o

f in

fectio

n w

ould

be s

ignifi

cantly

reduced w

ith t

his

optio

n.

In a

dditi

on t

o n

ew

ventil

atio

n

equip

ment

whic

h w

ill f

acili

tate

air c

hange r

ate

s w

hic

h a

re c

om

plia

nt

with

HB

N 2

6,

this

optio

n

will

pro

vid

e th

eatr

es w

hic

h are

com

plia

nt

in

term

s

of

siz

e

and

support

accom

modatio

n

inclu

din

g s

epara

te p

repara

tion r

oom

s for

each theatr

e;

! T

his

option

will

pro

vid

e a

facili

ty w

hic

h w

ill s

upport

the a

chie

vem

ent

of

access t

arg

ets

;

! S

taff w

ill b

e a

ble

to d

eliv

er

a s

erv

ice fro

m m

odern

, fit

for

purp

ose theatr

e a

ccom

modatio

n a

nd

will

there

fore

be m

uch m

ore

satis

fied w

ith facili

ties than a

t pre

sent.

T

hea

tres

1 –

4 C

raig

avo

n A

rea

Ho

spit

al

78

Cri

teri

on

2 –

Qu

ality

of

Acco

mm

od

ati

on

Op

tio

n

Sco

re

Exp

lan

ati

on

2D

o

Min

imum

–

Min

imal

refu

rbis

hm

ent

of

exis

ting

4

theatr

es,

repla

cin

g

the

ventil

atio

n

syste

m

and

upgra

din

g

the

ele

ctr

ical

supply

.

4! T

his

optio

n a

chie

ved the lo

west score

of 4;

! T

he ventil

atio

n syste

m w

ould

be re

pla

ced and th

e ele

ctr

icity

supply

w

ould

be im

pro

ved.

How

ever

the a

ccom

modatio

n w

ill n

ot achie

ve the s

tandard

s s

et out in

Health

Build

ing N

ote

26

and a

ssocia

ted H

TM

s in r

ela

tion to s

ize o

f th

eatr

es, support

accom

modatio

n a

nd b

ed s

pacin

g

in r

ecovery

ward

eg t

he 4

theatr

es w

ill s

till only

be 4

0 m

2 w

hic

h is c

onsid

era

bly

sm

alle

r th

an

the curr

ent

min

imum

re

com

mended siz

e of

55m

2,

rendering th

em

le

ss suita

ble

fo

r m

ore

com

ple

x p

rocedure

s,

especia

lly t

hose w

hic

h r

equire a

lot

of

theatr

e i

nstr

um

enta

tion a

nd/o

r equip

ment.;

! T

his

optio

n w

ould

not im

pro

ve the c

urr

ent in

adequate

sta

ff c

hangin

g;

! T

here

were

be n

o e

xte

nsio

n t

o t

he c

urr

ent

very

lim

ited s

tora

ge,

and e

quip

ment

and s

upplie

s

would

contin

ue to b

e s

tore

d in

inappro

priate

locatio

ns;

! T

he

cra

mped

bed

spacin

g

and

absence

of

sin

gle

ro

om

s

in

recovery

w

ard

w

ould

be

unchanged a

nd there

fore

patie

nt privacy a

nd d

ignity

would

not be im

pro

ved;

! E

ach th

eatr

e w

ould

not

have a separa

te pre

para

tion ro

om

-

these w

ould

contin

ue to

be

share

d b

etw

een tw

o theatr

es.

3P

urc

hase

2

volu

metr

ic

theatr

es.

E

xte

nd

theatr

e

blo

ck

into

court

yard

&

re

furb

ish

to

pro

vid

e

2

theatr

es,

new

re

covery

, upgra

ded sta

ff changin

g and

additi

onal s

tora

ge.

8! O

ptio

ns 3

, 7, and 8

all

achie

ved the r

ela

tively

hig

h s

core

of 8;

! A

ccom

modatio

n w

ill a

chie

ve t

he s

tandard

s s

et

out

in H

ealth

Build

ing N

ote

26 a

nd a

ssocia

ted

HT

Ms in r

ela

tion t

o s

ize o

f th

eatr

es a

nd s

upport

accom

modatio

n,

air c

hange r

ate

s,

and b

ed

spacin

g in

recovery

ward

;

! T

he c

urr

ent in

adequate

sta

ff c

hangin

g w

ould

be u

pgra

ded;

! A

dditi

onal

sto

rage

would

be

pro

vid

ed,

enablin

g

equip

ment

and

supplie

s

to

be

sto

red

appro

priate

ly;

T

hea

tres

1 –

4 C

raig

avo

n A

rea

Ho

spit

al

79

Cri

teri

on

2 –

Qu

ality

of

Acco

mm

od

ati

on

Op

tio

n

Sco

re

Exp

lan

ati

on

! P

atie

nt

privacy a

nd d

ignity

would

be i

mpro

ved a

s b

ed s

pacin

g i

n r

ecovery

ward

would

be

exte

nded a

nd s

om

e s

ingle

room

s w

ould

be p

rovid

ed.

7P

urc

hase

2

volu

metr

ic

theatr

es

and

constr

uct

2

theatr

es.

M

ino

r ro

ad

re

-alig

nm

en

t is

re

qu

ired

.R

efu

rbis

h

exis

ting

theatr

e

blo

ck

to

pro

vid

e

new

re

covery

, upgra

ded

sta

ff

changin

g

and

additi

onal

sto

rage.

8! O

ptio

ns 3

, 7, and 8

all

achie

ved the r

ela

tively

hig

h s

core

of 8;

! A

ccom

modatio

n w

ill a

chie

ve t

he s

tandard

s s

et

out

in H

ealth

Build

ing N

ote

26 a

nd a

ssocia

ted

HT

Ms in r

ela

tion t

o s

ize o

f th

eatr

es a

nd s

upport

accom

modatio

n,

air c

hange r

ate

s,

and b

ed

spacin

g in

recovery

ward

;

! T

he c

urr

ent in

adequate

sta

ff c

hangin

g w

ould

be u

pgra

ded;

! A

dditi

onal

sto

rage

would

be

pro

vid

ed,

enablin

g

equip

ment

and

supplie

s

to

be

sto

red

appro

priate

ly;

! P

atie

nt

privacy a

nd d

ignity

would

be i

mpro

ved a

s b

ed s

pacin

g i

n r

ecovery

ward

would

be

exte

nded a

nd s

om

e s

ingle

room

s w

ould

be p

rovid

ed.

8P

urc

hase

2

volu

metr

ic

theatr

es,

constr

uct

1

new

th

eatr

e.

Refu

rbis

h exis

ting

theatr

e

blo

ck

to

pro

vid

e

1

theatr

e,

new

re

covery

, upgra

ded sta

ff changin

g and

additi

onal s

tora

ge.

8! O

ptio

ns 3

, 7 a

nd 8

all

achie

ved the r

ela

tively

hig

h s

core

of 8;

! A

ccom

modatio

n w

ill a

chie

ve t

he s

tandard

s s

et

out

in H

ealth

Build

ing N

ote

26 a

nd a

ssocia

ted

HT

Ms in r

ela

tion t

o s

ize o

f th

eatr

es a

nd s

upport

accom

modatio

n,

air c

hange r

ate

s,

and b

ed

spacin

g in

recovery

ward

;

! T

he c

urr

ent in

adequate

sta

ff c

hangin

g w

ould

be u

pgra

ded;

! A

dditi

onal

sto

rage

would

be

pro

vid

ed,

enablin

g

equip

ment

and

supplie

s

to

be

sto

red

appro

priate

ly;

! P

atie

nt

privacy a

nd d

ignity

would

be i

mpro

ved a

s b

ed s

pacin

g i

n r

ecovery

ward

would

be

exte

nded a

nd s

om

e s

ingle

room

s w

ould

be p

rovid

ed.

T

hea

tres

1 –

4 C

raig

avo

n A

rea

Ho

spit

al

80

Cri

teri

on

2 –

Qu

ality

of

Acco

mm

od

ati

on

Op

tio

n

Sco

re

Exp

lan

ati

on

9C

onstr

uct

4

new

th

eatr

es

and

new

re

covery

w

ard

,d

isp

lace

an

d

re-p

rovid

e

hysto

cyto

log

y l

ab

ora

tory

&

lab

ora

tory

o

ffic

e

blo

ck.

Refu

rbis

h

exis

ting

theatr

e

blo

ck

to

pro

vid

e,

upgra

ded

sta

ff c

hangin

g and additi

onal

sto

rage.

9! O

ptio

n 9

achie

ved t

he h

ighest

score

of

9 p

oin

ts a

s t

he m

ajo

rity

of

accom

modatio

n w

ill b

e

pro

vid

ed w

ithin

a n

ew

build

ing a

nd r

oom

dim

ensio

ns w

ill t

here

fore

not

be c

onstr

ain

ed b

y t

he

exis

ting m

ain

theatr

es footp

rint;

! A

ccom

modatio

n w

ill a

chie

ve t

he s

tandard

s s

et

out

in H

ealth

Build

ing N

ote

26 a

nd a

ssocia

ted

HT

Ms in r

ela

tion t

o s

ize o

f th

eatr

es a

nd s

upport

accom

modatio

n,

air c

hange r

ate

s,

and b

ed

spacin

g in

recovery

ward

;

! T

he c

urr

ent in

adequate

sta

ff c

hangin

g w

ould

be u

pgra

ded;

! A

dditi

onal

sto

rage

would

be

pro

vid

ed,

enablin

g

equip

ment

and

supplie

s

to

be

sto

red

appro

priate

ly;

! P

atie

nt

privacy a

nd d

ignity

would

be i

mpro

ved a

s b

ed s

pacin

g i

n r

ecovery

ward

would

be

exte

nded a

nd s

om

e s

ingle

room

s w

ould

be p

rovid

ed.

T

hea

tres

1 –

4 C

raig

avo

n A

rea

Ho

spit

al

81

Cri

teri

on

3 –

Str

ate

gic

Fit

Op

tio

n

Sco

re

Exp

lan

ati

on

2D

o

Min

imum

–

Min

imal

refu

rbis

hm

ent

of

exis

ting

4

theatr

es,

repla

cin

g

the

ventil

atio

n

syste

m

and

upgra

din

g

the

ele

ctr

ical

supply

.

5! O

ptio

ns 2

and 3

score

d a

low

5 p

oin

ts a

s there

would

be v

ery

litt

le fle

xib

ility

offere

d to r

espond

to f

utu

re n

eeds o

f th

e s

erv

ice –

there

would

be n

o r

ele

ase o

f space t

o r

espond t

o f

utu

re

serv

ice n

eeds,

for

exam

ple

to p

rovid

e a

n a

dm

issio

ns a

rea f

or

inpatie

nts

. T

here

would

be

limite

d s

upport

to the T

rust’s

pla

nned s

erv

ice d

evelo

pm

ents

such a

s the e

xpansio

n o

f uro

logy,

EN

T, gynaecolo

gy a

nd p

ain

managem

ent serv

ices.

3P

urc

hase

2

volu

metr

ic

theatr

es.

E

xte

nd

theatr

e

blo

ck

into

court

yard

&

re

furb

ish

to

pro

vid

e

2

theatr

es,

new

re

covery

, upgra

ded s

taff c

hangin

g a

nd

additi

onal s

tora

ge.

5! O

ptio

ns 2

and 3

score

d a

low

5 p

oin

ts a

s there

would

be v

ery

litt

le fle

xib

ility

offere

d to r

espond

to f

utu

re n

eeds o

f th

e s

erv

ice –

there

would

be n

o r

ele

ase o

f space t

o r

espond t

o f

utu

re

serv

ice n

eeds,

for

exam

ple

to p

rovid

e a

n a

dm

issio

ns a

rea f

or

inpatie

nts

. T

here

would

be

limite

d s

upport

to the T

rust’s

pla

nned s

erv

ice d

evelo

pm

ents

such a

s the e

xpansio

n o

f uro

logy,

EN

T, gynaecolo

gy a

nd p

ain

managem

ent serv

ices.

7P

urc

hase

2

volu

metr

ic

theatr

es

and

constr

uct

2

theatr

es.

M

ino

r ro

ad

re

-alig

nm

en

t is

re

qu

ired

.R

efu

rbis

h

exis

ting

theatr

e

blo

ck

to

pro

vid

e

new

re

covery

, upgra

ded

sta

ff

changin

g

and

additi

onal

sto

rage.

8! O

ptio

n 7 pro

vid

es som

e fle

xib

ility

to

re

spond to

fu

ture

serv

ice needs.

S

pace w

ould

be

rele

ased as th

e 4 th

eatr

es w

ould

be pro

vid

ed outs

ide th

e exis

ting m

ain

th

eatr

e com

ple

x

footp

rint.

Recovery

, sto

rage,

sta

ff c

hangin

g a

nd o

ther

support

accom

modatio

n w

ould

rem

ain

w

ithin

the e

xis

ting m

ain

theatr

e c

om

ple

x.

Space r

ele

ased w

ithin

the t

heatr

e s

uite

could

be

develo

ped t

o p

rovid

e o

ther

facili

ties s

uch a

s a

n a

dm

issio

ns u

nit

to e

nable

ele

ctiv

e p

atie

nts

to

be a

dm

itted t

o t

he t

heatr

e s

uite

on t

he d

ay o

f th

eir p

rocedure

. T

his

optio

n w

ould

there

fore

support

the d

evelo

pm

ent

of

serv

ices w

ithin

the T

rust

for

exam

ple

the e

xpansio

n o

f uro

logy,

EN

T, gynaecolo

gy a

nd p

ain

managem

ent serv

ices.

8P

urc

hase

2

volu

metr

ic

theatr

es,

constr

uct

1

new

th

eatr

e.

R

efu

rbis

h exis

ting

theatr

e

blo

ck

to

pro

vid

e

1

theatr

e,

new

re

covery

,

7! O

ption 8

score

d less t

han o

ption 7

as less f

loor

sp

ace

wo

uld

be

rele

ase

d f

or

oth

er

se

rvic

e

de

ve

lop

me

nts

with

th

is o

ptio

n.

One t

heatr

e a

long w

ith r

ecove

ry,

sto

rag

e,

sta

ff c

ha

ng

ing

and o

ther

support

accom

modation w

ould

rem

ain

with

in t

he

exis

tin

g m

ain

th

ea

tre

co

mp

lex

and t

here

fore

less s

pace w

ould

be r

ele

ased t

han w

ith o

ptions 7

or

9.

There

would

be

su

ffic

ien

t sp

ace

to

pro

vid

e a

n a

dm

issio

ns u

nit t

o e

nable

ele

ctive p

atien

ts t

o b

e a

dm

itte

d t

o

T

hea

tres

1 –

4 C

raig

avo

n A

rea

Ho

spit

al

82

Cri

teri

on

3 –

Str

ate

gic

Fit

Op

tio

n

Sco

re

Exp

lan

ati

on

upgra

ded s

taff c

hangin

g a

nd

additi

onal s

tora

ge.

the t

heatr

e s

uite o

n t

he d

ay o

f th

eir p

rocedure

. T

his

option w

ou

ld t

here

fore

support

the

develo

pm

ent

of

serv

ices w

ithin

th

e T

rust

for

exam

ple

th

e expansio

n of

uro

logy,

EN

T,

gynaeco

logy a

nd p

ain

managem

ent

serv

ices.

9C

onstr

uct

4

new

th

eatr

es

and

new

re

covery

w

ard

,d

isp

lace

an

d

re-p

rovid

e

hysto

cyto

log

y l

ab

ora

tory

&

lab

ora

tory

o

ffic

e

blo

ck.

Refu

rbis

h

exis

ting

theatr

e

blo

ck

to

pro

vid

e,

upgra

ded

sta

ff c

hangin

g a

nd a

dditi

onal

sto

rage.

9! O

ptio

n 9

achie

ves t

he h

ighest

score

of

all

the o

ptio

ns a

s i

t w

ill r

ele

ase t

he m

ost

space f

or

oth

er

serv

ice d

evelo

pm

ents

and t

here

fore

pro

vid

es t

he m

ost

flexib

ility

to r

espond t

o f

utu

re

needs.

All

4 t

heatr

es a

long w

ith a

new

recovery

ward

will

be b

uilt

outs

ide t

he c

urr

ent

main

th

eatr

e c

om

ple

x.

T

hea

tres

1 –

4 C

raig

avo

n A

rea

Ho

spit

al

83

Cri

teri

on

4 –

Avo

idan

ce o

f D

isru

pti

on

Op

tio

n

Sco

re

Exp

lan

ati

on

2D

o

Min

imum

–

Min

imal

refu

rbis

hm

ent

of

exis

ting

4

theatr

es,

repla

cin

g

the

ventil

atio

n

syste

m

and

upgra

din

g

the

ele

ctr

ical

supply

.

5! O

ptio

n 2

achie

ved t

he low

est

score

of

5 b

ecause t

here

will

be s

ignifi

cant

dis

ruptio

n t

o t

heatr

e

serv

ices;

! T

he

theatr

es

would

be

decante

d

in

pairs

alo

ng

with

re

covery

w

ard

to

te

mpora

ry

accom

modatio

n.

The d

ecant

of

theatr

es a

nd t

he m

ove b

ack f

ollo

win

g t

he u

pgra

de w

ork

s w

ill

itself

be very

dis

ruptiv

e and w

ill re

sult

in th

eatr

e dow

n tim

e.

In additi

on,

due to

esta

te

develo

pm

ents

aro

und th

e very

congeste

d th

eatr

e are

a,

the only

pote

ntia

l site

fo

r decant

theatr

es is o

n t

he f

ar

sid

e o

f th

e labora

tory

build

ings w

ith t

he c

onstr

uctio

n o

f a c

lean c

orr

idor

thro

ugh the la

bora

tory

receptio

n a

rea. G

iven the d

ista

nce to s

taff c

hangin

g, sta

ff r

est fa

cili

ties,

theatr

e s

tora

ge a

nd s

upport

accom

modatio

n a

nd IC

U, clin

ical adja

cencie

s w

ill b

e s

ub o

ptim

al.

In

additi

on the tw

o theatr

es r

em

ain

ing in

the m

ain

theatr

e b

lock w

ill b

e s

om

e d

ista

nce fro

m the

tem

pora

ry r

ecovery

ward

;

! T

wo t

heatr

es w

ill c

ontin

ue t

o f

unctio

n w

hils

t w

ork

is g

oin

g o

n w

ithin

the m

ain

theatr

e a

rea.

The p

ote

ntia

l for

unpla

nned d

ow

ntim

e is

consid

ere

d to b

e h

igh.

3P

urc

hase

2

volu

metr

ic

theatr

es.

E

xte

nd

theatr

e

blo

ck

into

court

yard

&

re

furb

ish

to

pro

vid

e

2

theatr

es,

new

re

covery

, upgra

ded sta

ff changin

g and

additi

onal s

tora

ge.

6! O

ptio

n 3

was a

ward

ed a

rela

tively

low

score

of

6 a

s t

here

will

be s

ignifi

cant

dis

ruptio

n t

o

theatr

e s

erv

ices, alth

ough this

is d

eem

ed to b

e le

ss than w

ith o

ptio

n 2

. W

ork

would

be c

arr

ied

out

in a

num

ber

of

phases a

nd f

or

the d

ura

tion o

f th

e p

roje

ct, t

here

would

be w

ork

goin

g o

n

while

tw

o t

heatr

es a

nd r

ecovery

ward

rem

ain

opera

tional

in t

heir c

urr

ent

locatio

n.

Theatr

e

dow

ntim

e is

inevita

ble

with

this

optio

n;

! N

ew

T

hea

tre

1

will

be

pro

vid

ed

by

a

mix

ture

of

exte

nsio

n

into

a

court

yard

an

d

refu

rbis

hm

ent

of

a s

mall

denta

l th

eatr

e a

nd s

taff r

est

and o

ffic

e a

ccom

modation.

Denta

l surg

ery

will

be r

elo

ca

ted t

o o

ld t

heatr

e 5

. S

taff r

est

are

a a

nd S

iste

rs’

offic

e w

ill b

e r

e-

pro

vid

ed i

n p

art

of

the e

xis

ting s

taff c

hangin

g.

The r

em

ain

der

of

the d

ispla

ced o

ffic

e

accom

modation w

ill b

e r

e-p

rovid

ed t

em

pora

rily

in p

ort

acabin

s.

T

hea

tres

1 –

4 C

raig

avo

n A

rea

Ho

spit

al

84

Cri

teri

on

4 –

Avo

idan

ce o

f D

isru

pti

on

Op

tio

n

Sco

re

Exp

lan

ati

on

! E

xis

ting T

heatr

e 1

will

be r

efu

rbis

hed t

o p

rovid

e a

new

theatr

e 2

.

! T

heatr

es 3

& 4

will

move t

o t

he 2

volu

metr

ic t

he

atr

es.

Exis

tin

g T

he

atr

es 2

, 3

an

d 4

will

be

re

furb

ished t

o p

rovid

e a

recovery

ward

and o

ther

support

accom

modation.

! T

he exis

ting re

covery

are

a and old

T

heatr

e 5

w

ill b

e re

furb

ish

ed

to

p

rovid

e a

d

en

tal

theatr

e,

adm

issio

ns lounge a

nd d

ispla

ced o

ffic

e a

ccom

modation.

7P

urc

hase

2

volu

metr

ic

theatr

es

and

constr

uct

2

theatr

es.

M

ino

r ro

ad

re

-alig

nm

en

t is

re

qu

ired

.R

efu

rbis

h

exis

ting

theatr

e

blo

ck

to

pro

vid

e

new

re

covery

, upgra

ded

sta

ff

changin

g

and

additi

onal

sto

rage.

8! T

he d

isru

ptio

n to theatr

e s

erv

ices w

ill b

e m

inim

al a

nd there

fore

optio

n 7

achie

ved a

hig

h s

core

of 8.

! W

hen th

e T

&

O

serv

ice tr

ansfe

rs to

its

new

facili

ty upgra

de w

ork

to

th

e tw

o volu

metr

ic

theatr

es w

ill b

e c

arr

ied o

ut

and w

hen t

hese h

ave b

een c

om

mis

sio

ned s

essio

ns f

rom

tw

o

exis

tin

g

the

atr

es

will

tr

an

sfe

r.

Th

e

tem

po

rary

vo

lum

etr

ic

T&

O

sta

ff

ch

an

gin

g

an

d

recovery

units w

ould

be re

moved fr

om

th

e site

to

allo

w constr

uction of

the new

build

th

eatr

es

and

when

constr

uction

and

com

mis

sio

nin

g

of

these

has

been

com

ple

ted

, opera

ting s

essio

ns f

rom

the t

wo r

em

ain

ing t

heatr

es w

ill t

ransfe

r to

new

theatr

e 3

and 4

;

! W

ork

to

constr

uct

the new

re

covery

w

ard

and to

up

gra

de th

e sta

ff changin

g w

ill not

com

mence u

ntil all

four

theatr

es h

ave m

oved.

8P

urc

hase

2

volu

metr

ic

theatr

es,

constr

uct

1

new

th

eatr

e.

Refu

rbis

h

exis

ting

theatr

e

blo

ck

to

pro

vid

e

1

theatr

e,

new

re

covery

, upgra

ded sta

ff changin

g and

additi

onal s

tora

ge.

7! O

ption 8

achie

ved a

low

er

sco

re t

ha

n o

ptio

n 7

be

ca

use

in

tern

al

refu

rbis

hm

en

t w

ork

to

cre

ate

the f

ourt

h t

heatr

e w

ill t

ake p

lace

wh

ile o

ne t

he

atr

e i

s s

till

opera

tion

al

within

th

e

main

theatr

e s

uite;

! In

com

mon w

ith o

ptions 3

and 7

, w

hen the T

& O

serv

ice tra

nsfe

rs to its

new

facili

ty u

pgra

de

work

to

th

e

two

volu

metr

ic

theatr

es

will

be

carr

ied

out

and

when

these

have

been

com

mis

sio

ned s

essio

ns f

rom

tw

o e

xis

tin

g t

he

atr

es w

ill t

ran

sfe

r;

! T

he

te

mp

ora

ry v

olu

me

tric

T&

O c

ha

ng

ing

un

it w

ou

ld b

e r

em

ove

d f

rom

th

e s

ite

to

allo

w

co

nstr

uctio

n o

f th

e n

ew

bu

ild (

third

) th

ea

tre

. O

pe

ratin

g s

essio

ns f

rom

a t

hird

exis

tin

g

T

hea

tres

1 –

4 C

raig

avo

n A

rea

Ho

spit

al

85

Cri

teri

on

4 –

Avo

idan

ce o

f D

isru

pti

on

Op

tio

n

Sco

re

Exp

lan

ati

on

theatr

e w

ill t

ransfe

r to

the n

ew

build

the

atr

e w

hen c

on

str

uction a

nd c

om

mis

sio

nin

g o

f th

is

has b

een c

om

ple

ted;

! W

ork

to c

onstr

uct

the f

ourt

h t

heatr

e w

ill b

e u

ndert

aken w

hen t

he

first

thre

e h

ave m

ove

d

and f

ollo

win

g t

his

, re

furb

ishm

ent

to p

rovid

e a

new

recovery

ward

and t

o u

pgra

de t

he s

taff

changin

g w

ill b

e u

ndert

aken.

9C

onstr

uct

4

new

th

eatr

es

and

new

re

covery

w

ard

,d

isp

lace

an

d

re-p

rovid

e

hysto

cyto

log

y l

ab

ora

tory

&

lab

ora

tory

o

ffic

e

blo

ck.

Refu

rbis

h

exis

ting

theatr

e

blo

ck

to

pro

vid

e,

upgra

ded

sta

ff changin

g and additi

onal

sto

rage.

7! O

ptio

n 9

sco

red

7.

Dis

rup

tio

n t

o t

he

atr

e s

erv

ices w

ill b

e m

inim

al as t

heatr

e s

essio

ns w

ill

no

t tr

an

sfe

r u

ntil

the

co

nstr

uctio

n o

f th

e n

ew

th

ea

tre

s a

nd

re

co

ve

ry w

ard

h

as b

ee

n

com

ple

ted

and

the

new

fa

cili

ties

have

be

en

co

mm

issio

ne

d.

Ho

we

ver

the

re

will

b

e

dis

ruption t

o labora

tory

serv

ices a

s t

he h

isto

cyto

log

y la

bo

rato

ry,

lab

ora

tory

re

ce

ptio

n,

an

d

som

e la

bora

tory

offic

e accom

modation occu

pie

s th

e pro

posed site fo

r th

e new

build

th

eatr

es a

nd r

ecovery

. T

his

accom

modation w

ould

have t

o b

e r

e-p

rovid

ed a

nd s

erv

ice

s

moved b

efo

re t

he s

ite c

ould

be c

leare

d f

or

constr

uction.

Curr

ently t

he labora

tory

serv

ices

are

lo

ca

ted

to

ge

the

r.

Th

is o

ptio

n w

ill r

esu

lt i

n l

ab

ora

tory

se

rvic

es b

ein

g s

plit

acro

ss t

wo

lo

ca

tio

ns o

n t

he

site

.

T

hea

tres

1 –

4 C

raig

avo

n A

rea

Ho

spit

al

86

Cri

teri

on

5 –

Sp

eed

of

Imp

lem

en

tati

on

–

This

crite

rion is

linked d

irectly

to c

onstr

uctio

n/r

efu

rbis

hm

ent tim

escale

s. T

he e

stim

ate

d p

rogra

mm

es for

the s

hort

liste

d o

ptio

ns a

re s

how

n

belo

w. F

ive m

onth

s h

as b

een in

clu

ded for

desig

n for

each o

ptio

n.

!

Optio

n 2

– 3

0 m

onth

s (

score

3)

!

Optio

n 3

– 2

8 m

onth

s (

score

5)

!

Optio

n 7

– 2

6 m

onth

s (

score

7)

!

Optio

n 8

– 2

9 m

onth

s (

score

4)

!

Optio

n 9

– 3

0 m

onth

s (

score

3)

Based o

n these tim

escale

s the s

core

s h

ave b

een a

llocate

d a

s follo

ws:

Tim

elin

e (

mo

nth

s)

0 _

_________ 2

6 _

_________ 2

7 _

_________ 2

8 _

_________ 2

9 _

_________ 3

0

Sco

re 10 _

_________ 7 _

_________ 6 _

__________ 5 _

_________ 4

__________ 3


9 FINANCIAL APPRAISAL OF SHORTLISTED OPTIONS This section of the business case assesses the quantifiable costs of the shortlisted options, as set out below.

Option Description

2 Do Minimum – Minimal refurbishment of existing 4 theatres, replacing the ventilation system and upgrading the electrical supply.

3 Purchase 2 volumetric theatres. Extend theatre block into a courtyard and refurbish to provide 2 theatres, new recovery, upgraded staff changing and additional storage.

7 Purchase 2 volumetric theatres and construct 2 theatres. Minorroad re-alignment is required. Refurbish existing theatre block to provide new recovery, upgraded staff changing and additional storage.

8 Purchase 2 volumetric theatres, construct 1 new theatre. Refurbish existing theatre block to provide 1 theatre, new recovery, upgraded staff changing and additional storage.

9 Construct 4 new theatres and new recovery ward, displace and re-provide hystocytology laboratory & laboratory office block. Refurbish existing theatre block to provide, upgraded staff changing and additional storage.

The costs of each of the options are considered under the following headings:

! Capital Costs;

! Capital Charges;

! Revenue Consequences; and

! Economic Costs (NPVs).


9.1 Capital Costs

The risk adjusted capital costs associated with each of the short-listed options are detailed in Table 13 below. The capital costs have been developed by Health Estates Agency, are stated as of quarter 2 2010 and are exclusive of VAT but include MIPS Inflation uplift. Detailed capital costs are provided in Appendix 6.

Table 13: Capital Costs of Shortlisted Options (inclusive of MIPS inflation and Optimism Bias)


£ £ £ £ £

Building Works 3,653,874 6,292,813 6,268,988 6,333,627 9,762,363

Non-works costs and fees 724,871 3,182,437 3,178,338 3,177,846 1,770,324

Optimism Bias (works) 768,032 1,657,221 1,652,337 1,663,557 2,017,067

Equipment 106,114 752,467 746,223 752,467 758,712

Optimism Bias (equipment) 55,285 392,035 388,782 392,035 395,289

Total Capital 5,167,524 12,276,974 12,234,669 12,319,533 14,703,756

9.2 Capital Charges

The total capital charges (including those attributable to the current accommodation and land) associated with each of the short-listed options are detailed in Table 14 below.

Table 14: Capital Charges Associated with Shortlisted Options


£ £ £ £ £

Baseline Average Capital Charges (including those attributable to current land, buildings and equipment) 416,413 736,346 711,182 726,321 735,574

Analysis of capital charges is included as Appendix 8.


9.3 Revenue Costs

The revenue costs associated with each of the short-listed options are detailed in Table 15.

Table 15: Revenue Consequences of Shortlisted Options


£ £ £ £ £

Baseline Revenue Costs 6,681,714 6,681,714 6,681,714 6,681,714 6,681,714

Additional Recurring Revenue Costs

Payroll Costs 0 25,139 33,100 25,558 36,032

Goods and Services 0 54,237 59,692 54,527 61,724

Total Additional Recurring 0 79,376 92,792 80,085 97,756

Total Recurring 6,681,714 6,761,090 6,774,506 6,761,799 6,779,470

9.4 Economic Costs

Discounted cash flows for each of the options are presented in Appendix 9. Table 16 gives a summary of the net present value (NPV) of each option.

Table 16: Net Present Costs for Shortlisted Options


£’000 £’000 £’000 £’000 £’000

Net Present Value - Baseline 60,336 64,605 64,516 64,515 65,375

The Trust does not currently have the necessary capital to fund this scheme. It is anticipated that this would be acquired by way of an addition to the Trust’s Capital Resource Limit and External Financing Limit.


10 ASSESSMENT OF RISK & SENSITIVITY ANALYSIS In a project of this scale and nature, a number of areas of risk have been identified that could potentially impact on the successful implementation of the refurbishment/ replacement of the theatre suite. These have been assessed using the Trust’s scoring methodology:

Consequence Likelihood

1 Insignificant 1 Rare

2 Minor 2 Unlikely

3 Moderate 3 Possible

4 Major 4 Likely

5 Catastrophic 5 Almost certain

The consequence and likelihood are combined to provide a risk rating

Risk Rating

H Red Risk - High = 20 - 25

M Amber Risk - Moderate = 12 -19

L Yellow Risk - Low = 6 - 11

VL Green Risk - Very Low = 1 - 5

The risks are set out in a risk register (see Table 17 below) and are then discussed in turn with possible mitigating factors.

Table 17: Risk Register

Description of Risk Consequence Likelihood Risk Rating

Planning Approval 4 2 L

Disruption to on-going Theatre Services (inc Theatre 5) 3 3 L

Insufficient Demand 3 1 L

Volumetric Theatres cannot be purchased/purchase price exceeds estimate.

3 3 L

Further Departmental Guidance 3 2 L


In general, the risks identified refer to all the short listed options equally, however where these risks relate to a specific option this has been highlighted. In addition mitigation factors have been discussed in respect of each risk highlighted.

It is important to recognise that whilst there may be significant risks around the construction of the project, in terms of cost overruns and delays, these are dealt with under ‘Adjustment for Optimism Bias’ which is set out after the discussion on other risks below.

10.1Risks

Planning Approval

This issue is a risk for options which require construction outside the existing hospital building, therefore this risk applies to all options. In the case of option 2, although it involves no new build, there are significant temporary structures required, in the form of modular theatres and a Recovery Suite to be used until the refurbishment work is complete.

In particular the risk is that the construction of new modular theatres and a new recovery suite would not receive planning permission. There are a number of mitigation factors which should be considered:

! The entire Craigavon Area Hospital site has been zoned for hospital use and the proposed location of the new constructions is adjacent to the existing theatre suite;

! This project represents an interim scheme before major redevelopment of the hospital on a different part of the site;

! As similar developments for the new Trauma & Orthopaedics Unit and new Theatre 5 have been granted approval, it would be highly unlikely that planning permission would not be given for this project.

Whilst the impact of not getting planning permission would be high, the likelihood of this occurring is considered to be low.

Disruption to Theatre Services

There is a risk that during the construction period, theatre services could be disrupted. Whilst this risk is largely managed across all ‘Do Something’ options, it is of greater significance to option 2 the ‘Do Minimum’ option and also with option 3. Option 2 requires two temporary theatres and recovery facilities to be erected and then refurbishment work to be undertaken in the existing theatre suite while 2 theatres remain operational. Due to recent building work to the rear of main theatres, temporary accommodation would have to be located on the far side of the laboratory buildings with a clean corridor through the laboratory reception. This would provide an operationally difficult arrangement and therefore the likelihood of disruption with option 2 is


higher than with the other short listed options. Option 3 also involves work being undertaken in the theatre suite while two theatres remain operational.

The risk of disruption is easier to manage with the other short listed options. Options 7, 8 and 9 involve new build of either one or more theatres which can be undertaken without any significant disturbance to the existing theatres as it is external to the existing suite. In addition, those options which involve purchasing the two volumetric theatres enable two existing theatres to be decanted permanently, early in the project.

Therefore options 7, 8 and 9 provide the lowest risk in this regard.

A further risk equally applicable to all options is in respect of an accidental disruption to utilities. Consultation with the Health Estates Agency has indicated that they have accurate plans of underground services around the main theatre suite therefore minimising the risk of any accidental damage.

Insufficient Demand

As with any capital project, there is a risk that demand for the new theatres may not materialise and utilisation levels could fall. In mitigation, the Assessment of Need section of this business case has highlighted an increasing trend in utilisation and numbers of procedures being completed in recent years. Furthermore, projection data has also forecast a further increase in the number of procedures being undertaken.

Volumetric Theatres Cannot be Purchased/Purchase Price Exceeds Estimate

For options 3, 7 and 8 there is a risk that the company supplying the volumetric theatres may decide not to sell or the purchase price may exceed the estimated price. This would result in the Trust having to purchase theatres from another company for these options and/or additional capital cover being required. The Trust believes this to be a low risk.

Further Departmental Guidance

Whilst Departmental guidance issued in respect of operating theatres is not applicable to theatres currently in use but only the construction of new theatres, other requirements may be issued.

This is a risk which impacts on all options equally and it is a feature of the environment in which Trusts operate and will therefore be managed as appropriate. Good communication will be maintained between the Trust and Health Estates to ensure that if new guidance is issued, then the Trust has ample time to plan for its implementation.


10.2Optimism Bias Adjustment

The Green Book and the HM Treasury Supplementary Green Book Guidance on Optimism explicitly addresses project risks following a study by Mott MacDonald2 which identified the tendency for project appraisers to be overly optimistic, overstating benefits and understating timescales and costs. To redress this tendency, HM Treasury has developed an approach which requires appraisers to make explicit adjustments to determine a suitably optimism biased adjusted capital cost and NPV for each option.

Based on this guidance, an uplift is required to the capital costs (based on HM Treasury recommended adjustment ranges). There is no specific uplift required for revenue costs.

The Green Book enables optimism bias to be reduced according to the extent to which each of the contributory factors have been managed. Appendix 10 illustrates the risk factors for this project and the extent to which the Trust considers it can mitigate against them. A summary of this evaluation is given in Table 18. The capital and equipment costs used to calculate optimism bias have been uplifted for inflation.

Table 18: Summary of Optimism Bias Analysis


Capital Cost (£) 4,378,745 9,475,250

9,447,327 9,511,473 11,532,687

Optimism Bias 17.54% 17.49% 17.49% 17.49% 17.49%

OB Adjusted Capital Cost 5,146,777 11,132,471 11,099,664 11,175,030 13,549,754

Works Duration (months) 25 23 21 24 25

Optimism Bias 13.20% 13.14% 13.14% 13.14% 13.14%

OB Adjusted Works Duration 28.3 26 23.8 27.2 28.3

Equipment Cost (£) 106,114 752,467 746,223 752,467 758,712

Optimism Bias 52.10% 52.10% 52.10% 52.10% 52.10%

OB Adjusted Equipment Cost 161,399 1,144,502 1,135,005 1,144,502 1,154,001

Discounted cash flows for each of the options were recalculated following application of these uplift factors. In applying the optimism bias percentage to capital costs, planning contingencies have been removed and the optimism bias applied to the remaining capital costs. Table 19 gives the net present value of each of the options after optimism bias adjustments.

2 Mott MacDonald (2002), Review of Large Public Procurement in the UK, Mott MacDonald (2002)


Table 19:Net Present Costs Adjusted for Optimism Bias


£’000 £’000 £’000 £’000 £’000

Baseline Net Present Value 60,336 64,605 64,516 64,515 65,375

Risk adjusted Net Present Value 60,883 66,010 65,934 65,951 66,973


10.3Sensitivity Analysis on Non Financial Benefits

The sensitivity of the benefits to risk is considered in this section, to determine if this would impact on the preferred option. The aim is to test the robustness of the ranking of the options.

Sensitivity analysis may be carried out on the weights allocated to the benefit criteria to test how the ranking of the options would respond to changes in the weighting. The most important criterion was deemed to be clinical effectiveness. As Table 20 indicates the weighting of clinical effectiveness would have to be decreased by 8 in order to change the option which is ranked first.

Table 20: Effect on Ranking of Options by Adjustment of Weightings


Weights unchanged 5 3 2 1 4

Increase clinical effectiveness by 4, decrease others by 1

5 2 2 1 4

Increase clinical effectiveness by 8, decrease others by 2 5 2 3 1 4

Decrease clinical effectiveness by 4, increase others by 1

5 4 2 1 3

Decrease clinical effectiveness by 8, increase others by 2

5 4 1 2 3

The potential risks to the project have been outlined in section 10.1. The risk associated with insufficient demand will apply equally to all of the short listed options. An inability to secure planning approval and changes to departmental guidance relating to operating theatres would affect all of the options with the exception of option 2.

The ability to deliver theatre services to both emergency and elective patients for the duration of the project is critical to the functioning of the hospital and the ‘avoidance of disruption’ criterion is deemed to have the greatest degree of uncertainty, although the uncertainty will be mitigated by appropriate planning and phasing of works. All of the options, with the exception of option 9, involve some work within the existing theatre suite while theatre and/or recovery continue to function. Table 21 shows the effect on the ranking by decreasing the score for options 2, 3, 7 and 8 by one point.


Table 21: Effect on Ranking of Options by Adjustment of Scores


Scores unchanged 5 3 2 1 4

Decrease option 2 by 1 5 3 2 1 4




Table 21 demonstrates that decreasing the score for ‘avoidance of disruption’ for options 2, 3, 7 or 8 does not change the option which is ranked first. The score for option 8 would need to be decreased by 2 points to change its ranking from first to second. This would imply that option 8 would be equally disruptive to theatre services as option 2, which is clearly not the case.


1111 IIDDEENNTTIIFFIICCAATTIIOONN OOFF PPRREEFFEERRRREEDD OOPPTTIIOONN The selection of the preferred option is a process drawing on the results of both the financial and the non-financial assessment of the short-listed options. The desirable outcome of this process is a preferred option.

A summary of the scoring and costing exercise is outlined in Table 22 below.

Table 22: Comparison of Options


Non Financial Appraisal Score

500 735 750 770 730

5 3 2 1 4

Capital Costs including MIPS inflation uplift but excluding Optimism Bias (£)

4,484,859 10,227,717 10,193,550 10,263,940 12,291,399

1 3 2 4 5

Baseline Average Capital Charges (including those attributable to current land, budilings and equipment)

416,413 736,346 711,182 726,321 735,574

Additional Annual recurring Revenue (£)

0 79,376 92,792 80,085 97,756

NPV Baseline (£000) 60,336 64,605 64,516 64,515 65,375

NPV Adjusted for Optimism Bias (£000)

60,883 66,010 65,934 65,951 66,973

The Project Team has considered the options and has concluded that the preferred option is Option 8 – Purchase 2 volumetric theatres, construct 1 new theatre. Refurbish existing theatre block to provide 1 theatre, new recovery, upgraded staff changing and additional storage. This option has been identified as the preferred option for the following reasons:

1. Option 8 has the highest non-financial benefit score of 770 and therefore will generate the greatest overall qualitative benefits in terms of providing four main theatres, recovery and associated support accommodation which meet Departmental standards; providing a clinically effective solution which has the capacity for undertaking a wide range of procedures; minimises the disruption to theatre and other support services;


fits with the Trust’s strategic direction; and can be delivered within reasonable timescales;

2. The capital costs (excluding Optimism Bias) associated with this option are £10,263,940. Whilst it ranks as 4 from a financial appraisal perspective the monetary difference between it and the higher ranking options 3 and 7 is not material and this will provide the Trust with theatres which will meet the current standards;

3. Annual capital charges associated with Option 8 are £726,321. This is less than the capital charges associated with Options 3 and 9 and is not materially higher than those for Option 7;

4. Recurring revenue costs associated with Option 8 are lower than those indicated for Option 7 and Option 9 and are not materially different to those for Option 3;

5. Net Present Value of Option 8 is £64,515k (risk adjusted NPV £65,951k), given that Option 8 achieved the highest non-financial benefit score this offers the best benefit for investment required.


12 AFFORDABILITY ANALYSIS The sections below demonstrate the affordability of the preferred option under the following headings.

12.1 Capital funding requirements

The preferred option selected in the previous section envisages purchasing 2 volumetric theatres, construct 1 new theatre. Refurbish existing theatre block to provide 1 theatre, new recovery, upgraded staff changing and additional storage.

The estimated total capital cost of this scheme (less refreshes) adjusted for Optimism Bias is £12,319,533.

12.2 Revenue Consequences

The revenue consequences of the preferred option, Option 8 - Purchase 2 volumetric theatres, construct 1 new theatre. Refurbish existing theatre block to provide 1 theatre, new recovery, upgraded staff changing and additional storage are summarised in the table below.

Table 23: Affordability Analysis

Average Annual Revenue Costs (RiskAdjusted)

Average Annual Capital

Charges (Risk

Adjusted)

Total

£ £ £

Option 2 – Base Case 6,681,714 462,789 7,144,503

Option 8 – Preferred Option 6,761,799 845,737 7,607,536

Additional Revenue Consequences 80,085 382,948 463,033


13 EQUALITY & HUMAN RIGHTS CONSIDERATIONSSection 75 of the Northern Ireland Act 1998 requires the Trust, in carrying out its functions relating to Northern Ireland, to have due regard to the need to promote equality of opportunity between persons of different religious belief, political opinion, racial group, age, marital status or sexual orientation; between men and women generally; between persons with a disability and persons without; and between persons with dependants and persons without.

Without prejudice to these obligations the Trust is also required, in carrying out its functions, to have regard to the desirability of promoting good relations between persons of different religious belief, political opinion or racial group.

As part of ensuring compliance with the statutory duty, the SHSCT have produced an Equality Scheme demonstrating their commitment to equality of opportunity and to carrying out Equality Impact Assessments on policies which may have a differential impact on any of the categories noted above. The existence of a differential impact is determined by reference to the following four criteria:

! Is there any evidence of higher or lower participation or uptake by different groups?

! Is there any evidence that different groups have different needs, experiences issues and priorities in relation to the particular policy area?

! Is there an opportunity to better promote equality of opportunity or better community relations by altering the policy or working with others in government or in the larger community? or

! Have consultations in the past with relevant groups, organisations or individuals indicated that particular policies create problems that are specific to them?

The developments proposed within this outline business case have been considered in terms of their equality of opportunity implications against each of the four criteria detailed above. The proposal to provide four theatres and associated support accommodation at Craigavon Area Hospital has limited scope to impact differentially on any of the nine equality groupings, as the standard of care and accommodation for all service users and staff will be improved. The project will provide significantly improved theatre and support accommodation which will enable the Trust to provide a safer, more clinically effective service to all patients who are operated on in the main theatres. Improved privacy and dignity will be facilitated within the new accommodation. It is therefore felt that these proposals will not have an adverse impact on the Trust’s requirement to promote equality of opportunity and good relations between the different equality groups.


The Human Rights Act 1998

Under the Human Rights Act 1998 the Trust must ensure that the way in which it carries out its functions does not breach the rights of its service users. It is felt that this proposal will not breach any of the Articles covered within the Act.

1144 PPRROOCCUURREEMMEENNTT In line with Health Estates’ recommendations on best value for money in procurement the Trust has entered into Performance Related Partnering (PRP) frameworks with a design team and a contractor for the design and construction of acute hospital facilities. The appointed Design Team and Contractor are currently undertaking two projects –

3. Construction of a new trauma and orthopaedics facility at Craigavon Area Hospital. This project is well underway and the building will be handed over for Trust commissioning in April 2010;

4. Extension and refurbishment of maternity and neonatal facilities at Craigavon Area Hospital – works commenced in July 2009 and construction is scheduled for completion by the end of March 2010.

The Trust is satisfied with the performance of both the design team and the contractor and proposes to re-appoint both for this project.


1155 PPRROOJJEECCTT MMAANNAAGGEEMMEENNTT && PPOOSSTT PPRROOJJEECCTT EEVVAALLUUAATTIIOONN HM Treasury and Department of Finance and Personnel (DFP) guidance has highlighted the importance of setting up appropriate project management and post project evaluation procedures as part of the appraisal process. In addition, the arrangements for financing the project should also be considered and detailed. These are examined in turn in this section of the report.

15.1Project Management

It is proposed that this project will be managed in line with the DHSSPS guidance ‘Project Organisation and the Capital Investment Manual: Management of Construction Projects’.

The process of document preparation will be managed by the Project Manager with input from the Directorate of Acute Services and Health Estates Agency.

The following roles have been identified:

Project Owner: Gillian Rankin (Acting Director of Acute Services)

Project Director: Martin Kelly (Assistant Director of Corporate Planning)

Trust Project Manager:

Sandra Waddell (Head of Acute Planning)

Health Estates Project Manager:

Michael McCorry (Architect)

Project Board:

Martin Kelly, Assistant Director of Corporate Planning (Chair)

Michael McCorry, Health Estates Project Manager

Sandra Waddell, Trust Project Manager

Alan Metcalfe, Assistant Director of Estates

Jim Austin, Head of Estates Development and Capital Works

Eamon Mackle, Assistant Medical Director

Gillian Rankin, Acting Director of Acute Services

Stephen Hall, Assistant Medical Director

Carol Cassells, Senior Financial Management Accountant

Heather Trouton, Assistant Director, Surgery and Elective Care Division

Ronan Carroll, Assistant Director, Cancer & Clinical Services

Mary McGeough, Head of Anaesthetics, Theatres and ICU


An outline programme for the project is given as Appendix 14. The table below summarises the major project stages along with the envisaged timescales. The target dates are dependent upon business case approval by the end of July 2010.

Table 24: Project Timetable for the Preferred Option

Phase Component *Target Date

Submission of business case to DHSSPS May 2010

Business Case Approval July 2010

Planning and Design (5 months) August – December 2010

Construction/refurbishment work commencement January 2011

Construction complete December 2012

Initial Post Project Evaluation March 2013

Full Post Project Evaluation November 2013

Assuming business case approval by July 2010, the new theatres would be completed and ready for handover to the Trust by the end of December 2012.

15.2Post Project Evaluation

This section presents the post project evaluation plan. This may be further refined as the project proceeds.

The following post-project evaluation arrangements are in place, however this may be amended as the project proceeds. The post project evaluation will be the responsibility of the Project Board and managed by the Project Director. The evaluation will be undertaken by the relevant business and clinical areas and if necessary will include staff from other HPSS organisations and/ or the DHSSPS.

Construction Phase

The initial stage of the evaluation will be undertaken on completion of the capital project and will seek to address the following questions:

! Was the project completed on time?

- Reasons sought for any delay.

! Was it completed at budget cost?

- Reason sought for any cost increase.

! Is the space and layout of the new theatre suite suitable for the purpose intended? Are there any modifications that need to be undertaken to make it fit for the purpose intended?

! Does the theatre suite meet the needs of the hospital?


! What are key issues and lessons which can be learned to ensure similar problems do not arise in future?

In addition, the Trust Estates team will also make a number of observations during the commissioning phase relating to site preparation, materials used, site management and relationships with contractors.

Post Construction Phase

Approximately 9 to 12 months following the completion of the project, an assessment will be made of the effectiveness of the proposed theatre suite for carrying out the full range of operating procedures (including high-risk and emergency surgery). The key objective of the evaluation will be to assess if the benefits that are being derived from the project are in line with the Trust’s expectations. The areas to be assessed are set out below:

! The quality of accommodation provided;

! The range of procedures which can be undertaken;

! Improved working practices;

! Clinical effectiveness of the new accommodation;

! Disruptions caused; and

! The speed with which the project was implemented.

15.3Benefits Realisation Plan

The realisation of benefits is an increasingly important aspect of completing business cases. The Benefits Realisation Plan (BRP) for this project is given overleaf. It includes the actions which will be taken, the individual or group responsible and the method by which evaluation of success should be determined.

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Documents

Business Case for Refurbishment/Replacement of Theatres … · Theatres 1 – 4 Craigavon Area Hospital 2 ... 40 Table 9: Surgical ... Craigavon Area Hospital is the larger of the