Children's and Women's Hospital - stgeorges.nhs.uk · dn 1. strengthen text on synergies with community children's services (jr) 2221 dn 2. insert summary of concept for institute

Children's and Women's Hospital

Strategic Outline Case

V1.4

October 2014

St George’s Healthcare NHS Trust Strategic Outline Case v1.4 Children's and Women's Hospital October 2014

WT Partnership Health Consulting Page 2

Contents

1 EXECUTIVE SUMMARY 65 1.1 Strategic Case 76 1.2 Economic Case 76 1.3 Commercial case 98 1.4 Financial case 98 1.5 Management case 109 1.1 Conclusion 109 2 INTRODUCTION 1110 2.1 The role of the document 1110 2.2 Other relevant documents 1110 2.3 Exclusions 1211 2.4 Format 1211 2.5 Next steps 1312 3 STRATEGIC CASE 1413 3.1 The Trust 1413 3.2 Foundation Trust 1514 3.3 Integrated business plan & long term financial model 1615 3.4 Stakeholders 1716 3.5 Children's Services at St George‟s 1716 3.6 Women's Services at St George‟s 1817 3.7 Strategic Direction for Children's and Women's Health 2120 3.8 Future services and model of care 2625 3.9 Current and Future Activity 2827 3.10 Private and overseas patients strategy 3029 3.11 Operating Theatres 3029 3.12 Diagnostic services 3130 3.13 Workforce issues 3130 3.14 Teaching, training and research 3130 3.15 Financial background 3231 3.16 Location of services 3433 3.17 Physical facilities 3534 3.18 Future space requirements 3635 3.19 Site development plans 3837 3.20 Children's and Women's Hospital Concept 4039 3.21 Summary of the case for change 4140 3.22 Desired benefits 4241 3.23 Constraints 4342 3.24 Stakeholder Support 4443 3.25 Further work to develop outline business case 4443 4 ECONOMIC CASE 4544 4.1 Long-list of options 4544 4.2 Short-list of options 4746 4.3 Economic analysis 4746 4.4 Risks associated with the options 4847 4.5 Further work to develop outline business case 4948 5 COMMERCIAL CASE 5049 5.1 Procurement options 5049 5.2 Statutory Consents 5049 5.3 Commercial opportunities 5049 5.4 Further work to develop the Outline Business Case 5049 6 FINANCIAL CASE 5251 6.1 Sources of capital funding 5251 6.2 Affordability 5251 6.3 Impact on finances 5453



6.4 Sensitivity analysis 5453 6.5 Further work to develop the Outline Business Case 5453 7 MANAGEMENT CASE 5554 7.1 Project management and governance 5554 7.2 Project plan 6059 7.3 Risk management 6059 7.4 Benefits realisation 6160 7.5 Post project evaluation 6261 1 EXECUTIVE SUMMARY 5 1.1 Strategic Case 6 1.2 Economic Case 6 1.3 Commercial case 8 1.4 Financial case 8 1.5 Management case 9 1.1 Conclusion 9 2 INTRODUCTION 10 2.1 The role of the document 10 2.2 Other relevant documents 10 2.3 Exclusions 11 2.4 Format 11 2.5 Next steps 12 3 STRATEGIC CASE 13 3.1 The Trust 13 3.2 Foundation Trust 14 3.3 Integrated business plan & long term financial model 15 3.4 Stakeholders 16 3.5 Children's Services at St George‟s 16 3.6 Women's Services at St George‟s 17 3.7 Strategic Direction for Children's and Women's Health 20 3.8 Future services and model of care 25 3.9 Current and Future Activity 27 3.10 Private and overseas patients strategy 29 3.11 Operating Theatres 29 3.12 Diagnostic services 30 3.13 Workforce issues 30 3.14 Teaching, training and research 30 3.15 Financial background 31 3.16 Location of services 33 3.17 Physical facilities 34 3.18 Future space requirements 35 3.19 Site development plans 37 3.20 Children's and Women's Hospital Concept 39 3.21 Summary of the case for change 40 3.22 Desired benefits 41 3.23 Constraints 42 3.24 Stakeholder Support 43 3.25 Further work to develop outline business case 43 4 ECONOMIC CASE 44 4.1 Long-list of options 44 4.2 Short-list of options 46 4.3 Economic analysis 46 4.4 Risks associated with the options 47 4.5 Further work to develop outline business case 48 5 COMMERCIAL CASE 49 5.1 Procurement options 49 5.2 Statutory Consents 49



5.3 Commercial opportunities 49 5.4 Further work to develop the Outline Business Case 49 6 FINANCIAL CASE 51 6.1 Sources of capital funding 51 6.2 Affordability 51 6.3 Impact on finances 53 6.4 Sensitivity analysis 53 6.5 Further work to develop the Outline Business Case 53 7 MANAGEMENT CASE 54 Project management and 54 7.1 governance 54 7.2 Project plan 59 7.3 Risk management 59 7.4 Benefits realisation 60 7.5 Post project evaluation 61



Appendices

1. Capital estimates

2. Optimism Bias

3. Activity estimates

4. Income estimates

5. Expenditure estimates

6. Risk register

Version Control

Ref Draft Date Distribution Author

1.0 Initial draft April 2014 Coordinating group DCW

1.1 Draft for comments June 2014 Coordinating group DCW

1.2 Draft for comments September 2014

Coordinating group DCW

SectionDrafting notes

DN 1. STRENGTHEN TEXT ON SYNERGIES WITH COMMUNITY CHILDREN'S SERVICES (JR) 2221 DN 2. INSERT SUMMARY OF CONCEPT FOR INSTITUTE OF FOETAL MEDICINE 2827 DN 3. IS THIS ENOUGH FOR DIAGNOSTICS (BRUCE) 3130 DN 1. ADD IN ANY SNIPPETS FROM CQC VISITS (BRUCE/ARIS) 17 DN 2. STRENGTHEN TEXT ON SYNERGIES WITH COMMUNITY CHILDREN'S SERVICES (JR) 21 DN 3. INSERT SUMMARY OF CONCEPT FOR INSTITUTE OF FOETAL MEDICINE 27 DN 4. IS THIS ENOUGH FOR DIAGNOSTICS (BRUCE) 30



1 EXECUTIVE SUMMARY

This document is the Strategic Outline Case (SOC) for the development of children's and women's services at St George‟s Hospital. The hospital has a long an illustrious history spanning over 250 years at the forefront of medicine. It provides many services for children and women that are highly specialist in nature, as well as caring for the needs of the its local population.

St George‟s is a leading teaching hospital, with the unique position of having St George‟s, University of London on the same site, putting the next generation of medics and researchers alongside a leading centre of clinical and medical expertise. However, this all takes place in a physical environment that does not match the cutting-edge education, research and clinical services it houses. Most of the buildings originate from the 1970s and are substantially smaller and less attractive than commissioners and patients expect of modern healthcare. In some areas, the physical capacity constraints have led to restricting access, meaning patients have had to go elsewhere.

An excellent environment is a key factor in patient choice, attracting the best staff, and maintaining accreditation and commissioner support. The Trust is now focussed on redeveloping facilities for children's and women's services to provide for a booming population.

The vision

“St George‟s Hospital is one of the largest teaching hospitals in the world and one of only a few to have a medical school on site. It has virtually every specialty on site under one roof, a major trauma centre, a stroke centre and the major tertiary centre for all specialties in South West London, Surrey and Sussex.

We are offering to build the "UK’s premier centre of excellence for the care of children, women and their unborn children” with all the crucial specialties for children and women under one roof: vital interdependencies for maternity, foetal medicine, neonatal medicine, foetal and perinatal pathology, genetics, specialised paediatric, neonatal and adolescent surgery, oncology, general paediatrics, specialist paediatrics - respiratory, metabolic, neurology, gastroenterology, endocrinology - major trauma for children, paediatric Intensive care all under one roof; all working together as one team for the benefit of children and women.

This will be provided in a state-of-the-art facility designed specifically to provide a comfortable healing family environment that puts the quality of care first for women and their children (born and unborn). This vision is unique, it is different and it is positive. Working together, we will do it.”1

1 Mr Bruce Okoye, MBBS, FRCS (Eng), FRCS (Paed), MD, Consultant Paediatric, Neonatal and

Adolescent Surgeon



1.1 Strategic Case

The strategic case for developing children's and women's services at St George‟s is based on a number of factors that can be summarised as:

The growth of the local population especially younger people has created a burgeoning demand for children's and women's services. This is accentuated at St George‟s by the trend within South West London to consolidate specialist services, especially inpatients, at the hospital, with more general and lower risk services being developed in surrounding hospitals and community locations. This growth has demanded a growth in facilities.

The facilities available largely use 1970s buildings. In terms of design these are outdated, the engineering and plant is worn out, and space inadequate. Modern NHS space standards require half as much space again as previously, which means that services are either cramped or capped in volume. The considerable growth in the volume of services since the hospital moved to the site in the 1970s means that departments now exist cheek-by-jowl, with little or no room for expansion, and with increasing use of workarounds and interim measures. It is estimated that the entire children's and women's service will require 36,000m2 of accommodation over the next ten to twenty years, which is greater than what is available within the Lanesborough Wing.

The Trust‟s vision is to remain the “go to” hospital for the primary, secondary and tertiary care in South London, offering services which stand out locally, regionally and nationally. This requires the very best facilities in terms of design for clinical use, layout, engineering, use of light, the healing environment and control of infection. The majority of wide range of stakeholders

The Trust is moving towards Foundation Trust status, which recognises the quality of services and financial stewardship in the organisation. This will bring new freedoms to raise funds, and invest in new facilities and services, and presents a new opportunity to achieve its vision.

Both the Trust and Medical School are committed to promote research, taking advantage of and building on the the core clinical services and research strengths for Children and Women‟s.

Stakeholders are being actively engaged, and initial responses to the potential development are encouraging.

1.2 Economic Case

The economic case at SOC level is concerned with demonstrating that options exist which are capable of demonstrating they are:

Suitable

Feasible

Acceptable



At this stage, a number of options have been identified which may be capable of meeting the needs of the case. The current shortlist includes:

Do minimum: “Modest refurbishment”. This option is considered for comparison and represents a “light touch” refurbishment. Services would stay roughly in situ, with no real scope for expansion (apart from minor gains due to co-locations or workflow efficiencies). This short-term solution would not be „future-proof‟ in terms of:

o quality and size of accommodation expected in a 21st century hospital (to allow privacy and dignity; optimize infection control; and comply with NHS building design guidance (HBN) and

o amount of space required to cope with the potential expansion of services expected over the next ten to fifteen years.

“Level One & Four Focus”. Under this option obstetrics, gynaecology and paediatric theatres, neonatal unit, PICU, children‟s day care and labour ward would all expand into the restaurant area on the first floor. All other floors have modest refurbishment but no major restructuring. This would deliver sufficient capacity for 7500 births and the other related increases in demand such as neonatal care.

Level 4 would be refurbished for ante- and post-natal care, with some 72 beds taking the whole floor. This would displace both gynaecology inpatients and the medical ward on Level 4.

“Full Reconfiguration”. This option would refurbish the entire wing as to the standard of the Level 5 scheme. This option considers turning the Lanesborough building, as it currently stands, into a dedicated Children and Women‟s Hospital. The scenario assumes that all non-Children and Women‟s Services would be transferred to other locations to create decanting space and expansion options. All ambulatory and outpatient activity moves to the Ground Floor, where a 24/7 facility will be established. It also assumes that all paediatric work will be repatriated to Lanesborough (apart from Paediatric A and E services).

Lanesborough as a dedicated Children and Women‟s hospital has very distinct advantages for patient care, quality and safety, public and staff perception and morale and provides the opportunity for rebranding, fundraising, research, marketing and developing an international reputation. This is significantly offset by the complexity of the refurbishment and cost of decanting other services

“Major extension and reconfiguration”. This option is the logical next step. The first stage would be to construct a completely new block on the East face of Lanesborough, increasing its capacity by some 50%. Levels would be maintained with the current wing to ensure services could be provided across the floors of the old and new blocks. This would create several thousand square metres of premium quality clinical space, allowing the step-by-step refurbishment of older areas to modern standards as services move into or expand into the new space.

The option of a separate standalone unit was discounted on the basis of previous unfavourable assessments of cost, and the lack of a suitable development plot. These options will developed further at OBC stage and subject to a systematic cost/benefit evaluation. The initial capital costs are summarised below:



Capital Do minimum Level One & Four

Refurbishment Full

Reconfiguration

Major Extension &

Reconfiguration

Capital estimates 16,000 56,500 118,500 197,000

Optimism bias 47% 51% 53% 49%

Total investment 23,520 85,315 181,305 293,530

1.3 Commercial case

The Trust is considering he best approach to procurement requirements and. These will be considered in more detail in the OBC, and tied into the overall site redevelopment requirements as set out in the development control plan.

1.4 Financial case

The key financial issue at this stage is affordability. The main issues driving affordability for the options are:

Capital outlay and the associated financing costs

Additional occupancy costs (energy, maintenance and cleaning)

Impact on productivity and contribution margin

Impact on volume of activity and income

Each option will have a different profile in this respect.

Affordability (£000) Do minimum Level One &

Four Refurbishment

Full Reconfiguration

Major Extension &

Reconfiguration

Total additional cost (1,323) (4,068) (8,644) (14,530)

Increased contribution from productivity

1,335 2,669 4,004 5,339

Contribution from other services

0 0 0 4,380

Total affordability gap at SOC stage

1,398 4,640 8,606

Additional income /activity required

15% 50% 95%

This shows that all the options have a prima facie affordability gap except the do minimum, which is not uncommon at this stage of a project. The OBC will concern itself with a more detailed assessment of the additional costs as well as measures to meet them. Whilst an 50% increase in activity is certainly feasible and indeed planned, the 95% figure will require more detailed substantiation.



1.5 Management case

Detailed project management and governance arrangements have been agreed, and detailed in the project initiation document. the Senior Responsible Officer is Miles Scott, CEO, and the project sponsor is Peter Jenkinson, Director of Corporate Affairs. The Project Board meets monthly, and includes representatives from clinical, management and finance disciplines.

The detailed project plan will be set out in detail in the OBC, once the preferred option and procurement route has been determined. The potential timeframe for completion is set out below:

Step TImescaleTimescale

Site DPC complete Late 2014

Lanesborough OBC complete Mid 2015

Lanesborough FBC complete Mid 2016

Lanesborough Level 5 scheme complete Mid 2017

Lanesborough main scheme commences Late 2017

Lanesborough main scheme complete 2020

The key risks for this scheme are:

Funding availability

Scope creep

Planning restrictions

Demand fluctuations

Staff recruitment and retention

Delays in construction

Dependency on other projects

Trust bed requirements reduce available space for children's and women's services

Their likelihood, impact, and mitigating actions will be assessed and developed at the OBC stage.

A full benefits realisation plan and post project evaluation plan will be developed as part of the OBC and FBC.

1.1 Conclusion

The Board are asked to approve this document, upon which work on the OBC can commence.



2 INTRODUCTION

2.1 The role of the document

This document is the Strategic Outline Case (SOC) for the development of children's and women's facilities at St George‟s Hospital, Tooting. The purpose of a SOC level document is to establish the preferred direction of travel, to identify options that appear to be suitable to the purpose, feasible in terms of time, money and other resource constraints, and acceptable to a range of stakeholders. The subsequent task is to identify the preferred option, which is the function of the Outline Business Case (OBC) process.

2.2 Other relevant documents

This development has been in planning for several years, and the SOC should be read in conjunction with a number of planning documents:

The 2007/2008 Strategic Outline Case (SOC), for the redevelopment of the whole of the site. This in itself was four years in the making. The following dialogue between the Strategic Health Authority (SHA) and the Trust resulted in prioritising the facilities housing women's and children's services, largely in the Lanesborough Wing.

The 2007 Estates Strategy, updated September 2010 (especially section 5.5) and again in October 2012.

The resulting 2010 “Briefing Report” (appended), which produced more detailed plans for the narrowed focus on women's and children's services, including a floor by floor layout and costings. The focus on the Lanesborough Wing was based on the disproportionate level of backlog maintenance in that wing. The phased approach to redeveloping the whole Wing was agreed with NHS London on the basis of affordability and phasing requirements. It was considered unworkable to take the entire wing out of commission at once because of the need to maintain operational services throughout the programme – thus precluding a single phase programme.

The 2013 Theatre Capacity Paper, which identified the timing of the required refurbishment of the Trust‟s theatre stock.

The 2013 Moorfields Business Case for relocating and consolidating all ophthalmology activity on the site to a new purpose build unit

The 2014 Full Business Case for the Children's Hospital Development. The OBC was approved by the Trust Board in March 2013 and by the NHS England Trust Development Authority in October 2013.

As the planning process has progressed, the scope of the project has narrowed as the detail has deepened, illustrated below:



Figure 1: Project Scope

2008 Strategic Outline Case

Whole Hospital Redevelopment

2010 Briefing Report

Children’s and Women’s

Hospital

2012 Outline

Business Case

Children’s

Services

Scope

Detail

2013 Outline

Business Case

Children’s

Inpat’s

SOC for other

elements of

Children’s and

Women’s

Hospital

2014 F

BC

Ch

ild

ren

’s In

pa

t’s

A Gateway Review will be carried out to assess in principle the SOC‟s ability to:

Address business need

Affordability

Achieve with appropriate options explored

Demonstrate value for money

Demonstrate benefits are clearly identified and measureable

2.3 Exclusions

The scheme does not address the following SPECIFIC EXCLUSIONS:

The scheme for children's inpatients on Level 5. This is subject to a separate planning process.

Developments elsewhere on the site.

2.4 Format

This document follows HM Treasury guidance on the development of business cases using the Five Case Model as follows:

The strategic case. This sets out the strategic context and the case for change together with the supporting investment objectives for the scheme.



The economic case. This demonstrates that the Trust has selected the option which best meets the existing and future demands of the service and optimises value for money.

The commercial case. This details the content and structure of the proposed procurement route and contract.

The financial case. This confirms the funding arrangements and affordability and summarises the impact on the income and expenditure account and the balance sheet.

The management case. This demonstrates that the scheme is achievable and can be delivered successfully to time, cost and quality.

The SOC concentrates on making the case for change and identifying options that are prima facie deliverable in terms of technical feasibility, suitability for purpose, affordability and acceptability to key stakeholders. The OBC will concentrate on making the case for change, and establishing the preferred option through a structured cost-benefit analysis. The FBC level submission confirms the conclusions of the OBC and concentrates on the details of procurement and project implementation.

2.5 Next steps

The next stage after the approval of this document is the development of an OBC to establish the preferred option for delivering the scheme.



3 STRATEGIC CASE

3.1 The Trust

St. George‟s Healthcare NHS Trust (St. George‟s) is the major tertiary hospital for south west London and Surrey, and parts of Kent and Sussex. The trust provides a high quality, comprehensive range of health services from leading edge tertiary and trauma care for 3.4 million people to local community services for the people of Wandsworth.

Co-located with St. George‟s, University of London (SGUL), and with both organisations now in a formal strategic alliance with King‟s Health Partners, the trust delivers with its partners high quality research and education both of which contribute to the healthcare provision of tomorrow. Acute and tertiary health services are delivered from over 1,000 beds across two sites, by 7,800 staff, delivering hundreds of thousands of episodes of care each year, care that is both of high quality and demonstrably safe.

St. George‟s is a provider of excellent integrated care and the major provider of tertiary services to south west London, Surrey and beyond. Delivering health care of exceptional quality, the trust provides a comprehensive range of health services, which patients choose for their treatment, GPs and other hospitals choose for their patients and commissioners choose for their populations.

St. George‟s is a vibrant, multi-faceted and successful organisation. The following gives a flavour of the trust, its size, activity, quality and services:

In 2012/13 it saw 533,789 outpatients, delivered 4,995 babies, undertook 41,813 elective inpatient and daycaseday case procedures, had 147,018 patients attend A&E, and admitted 44,931 non-elective patients

The trust is the major centre for tertiary services for south west London and Surrey, including high risk obstetrics, fetal medicine, paediatric surgery, neonatology and specialised children‟s services; as well as cardiovascular, neurosciences, renal, cancer, and

It is one of four Major Trauma Centres in London, and received 1,524 trauma calls in 2012/13

The trust is a designated Heart Attack Centre, and was the first trust in London to provide primary angioplasty services 24 hours a day

The trust is a designated large Hyper Acute Stroke Unit (HASU), providing an extremely high quality service, and received over 2,000 stroke patients in 2012/13

It offers a comprehensive range of services, including delivery of community services for the people of Wandsworth following the 2010 integration with Community Services Wandsworth

St George‟s is one of only 14 trusts nationally to have fewer than expected deaths under both the SHMI and HMSR methodologies

In addition to providing these enhanced tertiary services to a population of 3.4 million, the trust also provides the full range of high quality acute and community health services, integrated where appropriate with social care, which local patients deserve from their local NHS.



St. George‟s leads on and collaborates with other organisations in the development of cutting edge research, and shares the benefits of that research with other health, social and third sector organisations. Partners in this work include St. George‟s University of London, Kingston University, King‟s Health Partners, and the South London Academic and Health Sciences Network. This research has direct benefits in terms of the quality of patient care received by St. George‟s patients; financial benefits through grant funding and the national Institute for Health Research Clinical Research Network, the clinical research delivery arm of the NHS in England; and indirect benefits, such as attracting and retaining staff of the highest calibre to come and work at an organisation with a growing reputation in research.

Linked to the delivery of excellent patient care and cutting edge research, the trust, with a leadership role in Health Education South London, collaborates with other organisations to teach and develop the health professional workforce of the future.

In delivering this tripartite mission of healthcare delivery, research and education, the trust puts the needs of the patient first, such that the quality of patient care at St. George‟s is amongst the best in the country. The trust is proud of its record in delivering safe care and excellent clinical outcomes and will work tirelessly to improve the experience of patients and to build on its strengths in safety and outcomes.

The trust had an income of £636m in 2012/13 and posted a surplus of £3m on that income, the sixth year in a row of surpluses. It has no historic debt. St. George‟s will meet operational targets and deliver robust financial performance that allows the trust to reinvest in its services and estate. For the last six years, the trust has had an improving track record of delivering its financial and operational targets.

3.2 Foundation Trust

St. George‟s is proudly a centre of excellence for many services, including major trauma, cardiology, stroke and children‟s surgery. St. George‟s believes that it is an appropriate time to apply for Foundation Trust (FT) status, confident that it meets or exceeds the criteria required for authorisation and with a clear understanding of the benefits that, for the patients, staff, and the organisation as a whole, being a FT will bring. These are:

A greater say for patients and staff - St. George‟s will become a membership organisation made up of staff, patients and the local community.

Increased freedom - the ability to be able to act more quickly, helped by a different regulatory framework to deliver the trust‟s strategy. The increased financial freedoms such as retaining financial surpluses, borrowing within defined limits to progress site redevelopment plans and the possibility of innovative partnerships with other organisations will support the delivery of the trust‟s overall strategy.

Greater accountability and assurance that the organisation is well managed, meets all quality standards and uses public money efficiently and wisely

Delivery of the trust‟s vision for the future

To become a Foundation Trust, St George‟s must undergo further scrutiny by Monitor, including the assessment of four key areas:

Quality governance

Financial governance

Board governance



Historic due diligence (an independent assessment of finance and governance reporting procedures by financial advisers)

Monitor will assess each area by a combination of document submissions, interviews and staff/ patient focus groups. The assessment process will culminate in a Board-to-Board meeting, following which a recommendation will be made to Monitor‟s Board regarding authorisation. Authorisation is expected in or after October 2014.

3.3 Integrated business plan & long term financial model

The Integrated Business Plan (IBP) demonstrates that, as a thriving Foundation Trust, and through the implementation of the trust strategy and its planned service developments, St. George‟s will be well placed to meet the health needs of the various populations it serves and the clinical, financial, operational and societal challenges that the NHS faces.

Turnover has grown by 30% in three years from £489m in 2009/10 to £636m in 2012/13. The largest single change has been the integration with Community Services Wandsworth, which brought £93m of income into the organisation. There has also been increasing turnover from core service level agreements. The trust has continued to meet its other financial duties to operate within both its external financial limit and its capital resource limit and has continued to improve its financial efficiency as represented by its reference cost index.

Past performance 2010/11 (actual) 2011/12 (actual) 2012/13 (actual)

Turnover £604m £620m £636m

Fixed Assets £292m £285m £289m

Reference Cost Index ( average = 100) 102 109 102

3.5% capital absorption cost 7.2 6.9 7.2

External Financing Limit (£4.7m) (£9.3m) (£10.9m)

External Financing Requirement (£11.0m) (£16.4m) (£3.4m)

External Financing Limit Undershoot £6.2m £7.4m £7.6m

Capital Resource Limit £16.0m £17.1m £25.6m

In-year I&E surplus £5.0m £5.7m £3.1m

The trust has developed a long term financial model (LTFM) for the next five years that uses commissioner activity assumptions and Department of Health tariff and inflation assumptions.

The LTFM assumes lower levels of activity growth than in recent years, and the implementation of effective demand management programmes across the local health economy. The likely changes to tariff over the next five years will also be challenging to the trust, and require the delivery of a robustly governed, demanding but deliverable Cost Improvement Programme (CIP).

The LTFM shows that, over the next five years, the trust will continue to deliver surpluses and maintain a Continuity of Service Risk Rating (CSRR) through to 2018/19. This will result in sufficient surplus to ensure that St. George‟s can deliver its service development priorities.

Projected performance 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19

Total operating inc. £650.1m £689.6m £709.3m £721.9m £733.5m £742.7m



Projected performance 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19

Total operating exp. (£615.3m) (£649.3m) (£661.8m) (£673.4m) (£683.6m) (£690.6m)

Operational surplus £34.8m £40.3m £47.5m £48.5m £49.9m £52.1m

Non-operating surplus (£29.7m) (£32.5m) (£29.5m) (£38.5m) (£39.9m) (£42.1m)

Net Surplus £5.0m £7.8m £18.0m £10.0m £10.0m £10.0m

CSRR 3 3 3 3 3 3

3.4 Stakeholders

The Trust has a range of stakeholders that corresponds to the breadth of services it offers. These include:

Patients of the primary, secondary and tertiary services provided

Commissioners, including Clinical Commissioning Groups in the locality and the wider catchment and specialist commissioners based at NHS England

Clinical networks in South West London and beyond

The local community and its elected representatives, including thsethose involved in oversight and scrutiny

Staff and their representatives

St George‟s, University of London and Kingston University

Charitable trustees and donors

Volunteers

Arrangements are being developed to systematically include stakeholders at all relevant stages in the planning process, with a view to gaining their support for the solutions which emerge and any potential costs of implementation.

3.5 Children's Services at St George’s

St George‟s Healthcare NHS Trust provides the widest range of community, secondary and tertiary services for children in South West London. It offers:

Children‟s surgery – Specialist Paediatric surgery, Neurosurgery, ENT, Plastics, Orthopaedics

Paediatric Intensive Care (PICU)

Paediatric Anaesthesia

Paediatric Medicine (Acute Paediatrics) – Neurology, Neurodisability/ Developmental Paediatrics, Infectious Diseases, Gastroenterology, Respiratory, Allergy, Endocrinology, Haematology, Oncology

Community Child Health Services

Neonatology (intensive, high dependency, special, transitional, and community care)

Clinical Genetics



Paediatric Radiology

Paediatric Pathology

Paediatric dentistry

St Georges is a major trauma centre for children with all emergency specialties available under one roof. For specialist services, its catchment extends into Surrey, Sussex and Kent. St George‟s is part of the south Thames Tertiary Integrated Care System (ICS). This is a group of providers that come together in a formal, governed way to provide comprehensive, seamless care pathways for specialised paediatrics.

The London Specialist Paediatric Integrated Care Systems will be the significant providers of specialised paediatric care in the future: they are expected to improve outcomes and consistency of service quality across the capital. St George‟s is part of the development of a South Thames Integrated Care System providing a robust model for the provision of a comprehensive range of specialist paediatric services across south London, Kent, Sussex and Surrey but also supporting the North Thames Network. The local catchment in Wandsworth is shown below:

St George‟s recently assumed responsibility for children's community services in the area, which is a major step towards the creation of a single, integrated children's service for the locality.

3.6 Women's Services at St George’s

3.6.1 Obstetrics

We are the regional tertiary referral centre for complex maternal and fetal problems in pregnancy including

Quaternary fetal intervention service

Tertiary fetal medicine service

Dedicated multiple pregnancy service

Service for complex maternal medicine, including cardiac and neurological conditions



Referral service for bariatric pregnant women

Regional referral service for women with abnormal placental implantation (placenta accreta)

Apart from the referred population, we have seen that the complexity and risk profile of obstetrics overall is rising. This stems from multiple factors including socio-demographics (age, ethnicity, poverty, drug and alcohol use); co-morbidities (obesity, pre-existing medical conditions; past and current obstetric history, previous pregnancy complications, abnormal placentation) and factors pertaining to the unborn pregnancy (twins and multiple pregnancies, fetal abnormality, in-utero growth restriction). In addition, babies with pre-existing syndromes that are diagnosed ante-natally are usually delivered at St George‟s due to the presence of the regional paediatric surgical unit.

The map below illustrates obstetrics activity across CCGs in the south west London sector and Lambeth. Each pie chart on the map represents a GP practice, its size is relative to activity level and sections are colour coded to the acute Trusts patients attend. It is clear that patients tend to attend their local hospital. St George's tends to attract mothers from central Wandsworth and Merton predominantly as well as patients from south west Lambeth.

However, patients in Battersea choose to give birth at the Chelsea and Westminster Hospital and those in West Wandsworth are also favouring Chelsea and Westminster or Kingston Hospital. Anecdotal feedback from GPs inform us that this is attributed to factors such as facilities (accommodation, private rooms and en-suite bathrooms) and reputation of the maternity units. Maternity services at the Trust are constrained by space and facilities (including efficiencies). The high staffing ratios and excellent clinical performance at St George‟s present an opportunity to claim back market share by promoting its maternity services more aggressively.

3.6.2 Gynaecology

St George's provides a comprehensive gynaecology service for both local and regional patients. This includes:

Tertiary cancer services



Tertiary urogynaecology

Minimal access and endometriosis service

Specialist service for women with large fibroids (the Myoma service)

Outpatient gynaecological investigations unit (including outpatient hysteroscopy and colposcopy)

An internationally recognised early pregnancy and acute gynaecology unit

As illustrated on the map below, the Trust is the primary provider for patients across Wandsworth, Merton and south west Lambeth. We face competition from Chelsea and Westminster. This might be attributed to proximity, reputation and accommodation facilities provided at the latter hospital. Elective activity is also referred on to Kingston hospital as Kingston NHS Foundation Trust clinicians currently provide the gynaecology outpatient services at Queen Mary's hospital, which is located in Roehampton in West Wandsworth. The Trust wishes to reverse these flows to claim a higher market share.

Activity tends to be referred to the closest district general hospital within each CCGs as all DGH provides a gynaecology service across the sector. Patients in the northern parts of Richmond tend to be referred to the West Middlesex University Hospital NHS Trust; patients in southern Richmond and Kingston tend to attend Kingston hospital; patients in Sutton tend to attend St Helier hospital and those in Croydon tend to attend their local hospital as well. A similar trend is observed in Lambeth where patients in the northern locality are referred to Guy's and St Thomas' NHS Foundation Trust and those in the east tend to be referred to King's College Hospital NHS Foundation Trust.



Nationally there has been a shift in the case mix and care setting for gynaecology over the last few years. This shift, due to better diagnostics, medical treatments and minimally invasive surgical therapies, has resulted in less surgical management and a shift from inpatient to day case, and from day case to ambulatory care. St George‟s is in a unique position to benefit from these changes as the gynaecology unit has a strong team of experts in outpatient “one-stop” investigation and management of conditions that in most hospitals around the country still require admission; these include medical management of ectopic pregnancy and miscarriage; outpatient pregnancy termination services; and outpatient hysteroscopy and colposcopy “see and treat” services. It is predicted that the total numbers of women seen in such one-stop specialised outpatient services will continue to grow, while demand for inpatient services will reach a plateau. Nevertheless, it should be noted that the shift of more routine work into the outpatient setting will mean that the proportion of acute and complex cases seen in the inpatient setting will increase, and a higher degree of (sub)specialisation required as complex cases will be concentrated in fewer untisunits. Once more, St George‟s, with its status as tertiary level provider of care, will be able to benefit from these changes.

3.7 Strategic Direction for Children's and Women's Health

3.7.1 Children's Services

St. George‟s children‟s services have been developing steadily for the past five years, with increasing activity, improving reputation in many areas and more staff. We have been able to develop both secondary and tertiary services. We have reduced non-elective admissions whilst seeing and assessing more children. We have continued to provide a modern first class service in the secondary and tertiary care of children but working from an outdated and run down facility. The redevelopment of the inpatient facilities on the 5th floor for which the outline business case has been approved is a huge step in the right direction. However challenges remain regarding the facilities for providing care to children particularly wihhwith regard to theatre and day care facilities, and ambulatory care. It is also likely that there will be a requirement for further in patient capacity in the coming years due to the likely reorganisation of shared care centerscentres for paediatric oncology as well as an already increasing workload for specialist paediatrics.

The key challenges for the next five years are the refurbishment of physical facilities, the integration with the community and primary care, completion of our tertiary services, and fostering of an effective SW London network for children.

Integration with primary and community care. Locally, the children‟s directorate is continuing to make closer connections with primary care physicians. This is through the joint training of paediatricians with GPs, the development of more ambulatory specialist clinics and better support of GPs managing children by paediatricians. To enable more children to be cared for at home and avoid hospital admission, we will be developing „next day‟ clinics for those seen in the emergency department deemed too well to be admitted but with ongoing concerns.

With increasing integration of the children‟s directorate with the community services division, there will be more outreach care of children with complex needs in the community by children‟s staff and more joined up care of children known to the department when acutely admitted. To support these changes, community based nursing will have to be strengthened, with more staff covering more hours, allowing home care to become the default. However the integration of community care into the directorate of children‟s services will enable us to identify more clearly what the needs are, and also what expertise is available across the region to facilitate efficient use of resources, to deliver the best possible care.



DN 1. Strengthen text on synergies with community children's services (JR)

Fostering and leading a SW London network for the care of children. In recent years, there have been extensive discussions with neighbouring hospitals and local commissioners regarding the future configuration of children's services in SW London, largely under the umbrella of the ”better services, better value” (BSBV) programme. The drivers for this have been improving the health of children, reducing lengths of stay and making more efficient use of medical and nursing staffing, concentrating staff where the needs are to ensure children are cared for by the appropriately trained staff throughout the day and night. Plans to develop Short Stay Paediatric Assessment Units (SSPAUs) at sites across SW London, with a smaller number of inpatient units have been extensively discussed.

Although the BSBV programme has halted, it remains extremely likely that there will be significant developments in secondary paediatrics over the next decade. In the course of these discussions it has become crystal clear that as the lead tertiary facility for children's services in the region, St Georges hospital is expected to take a lead role in facilitating these developments. St Georges will do this by developing quality and capacity, and facilitating easy movement of expertise across the area. It will include the development of an effective managed clinical network, led by St Georges, built by building on relationships with our colleagues across the region and progressing towards the movement of staff and patients as required by clinical need. However, we cannot currently provide the lead role required from the current physical environment for the care of children at Tt Georges.

We have already created a strong general paediatric department and a PAU that is effective at treating patients without unnecessary admissions. This has freed up inpatient capacity. The physical development of the 5th floor will create an environment that will help SW London families find a trip to SGH acceptable. The next phase of network development will require joint working on patient flows, joint contracts and protocols.

Tertiary services at St Georges. Regional services also require appropriate tertiary services. Our vision is to provide those that the children of SW London need, except where substantial expertise is available elsewhere already and it is not needed immediately. Our strengths are surgery, anaesthesia, neonatology, trauma, infectious diseases, immunity and oncology, and we aspire to provide these better than any other provider in London. Other tertiary departments in gastroenterology, endocrinology, allergy, intensive care, neurology and respiratory will provide comprehensive and excellent care, with a 24/7 cover arrangement and three consultants in each area. Others, such as rheumatology, cardiology neuroscience and dermatology will function as outreach clinics with a local champion. We will continue to grow our paediatric intensive care and high dependency service, to support post surgery care, to care for children with multiple trauma and serious conditions, and to help sustain children with serious conditions at home (for example patients needing long term ventilation.

Nationally and internationally, our reputation in infectious diseases is already established, clinically and in research. Our research department needs to continue to grow and develop a succession plan.



3.7.2 Obstetrics and childbirth

Tertiary services. Whilst common fetal conditions (for example, minor malformations, late fetal growth restriction) are managed in local hospitals, more complex and rare conditions (for example, major/multiple malformations, complications of monochorionic twins and severe fetal growth restriction; and those secondary to maternal disorders, for example, alloimmunisation (where fetal blood cells are destroyed by maternal antibodies transferred across the placenta)) are managed in conjunction with one of around 16 specialist fetal centres in England2.[REFERENCE: http://www.england.nhs.uk/ourwork/commissioning/spec-services/npc-crg/group-e/e12/]

The fetal medicine unit at St George‟s has a long-standing international reputation as one of the premier clinical and research units of foetal and maternal medicine:

It is one of the 16 tertiary level fetal medicine centres in England

It is one of only 5 national centres performing intrauterine laser surgery for the management of complications of monochorionic twins

It is one of a handful of centres in Europe with a foetal surgery programme

IthasIt has a consistently high level research output

The unit is run jointly by Prof Basky Thilaganathan, Mr Amar Bhide, Mr Aris Papageorghiou and Ms Asma Khalil; Paediatric Cardiac services are led by Dr.Carvalho; and Maternal Medicine services by Dr Watt-Coote and her team of specialist midwives. The unit carries out studies on all aspects of maternal and fetal medicine, in particular pre-eclampsia, normal and abnormal fetal growth, placental function, twin to twin transfusion syndrome, fetal abnormalities, normal and abnormal maternal heart function in pregnancy and investigations into methods to prevent stillbirth.

All this is made possible by the presence of other specialist services at St George‟s, because a number of pregnancies will require joint management with other specialties including: medical genetics, radiology, virology, microbiology, neonatology, paediatric surgery, paediatric cardiology, paediatric nephrology/urology, paediatric neurology and (specialist) gynaecology. On the research side there are ongoing close collaborations with SGUL (in particular the departments of Cardiovascular & Cell Sciences and Genetics); external collaborations (Queen Mary University of London, University of Oxford), European collaborators (TRUFFLE consortium) and through the NIHR Clinical Research Network.

Our obstetric population. Apart from our tertiary fetal medicine work, we also provide a high risk pregnancy service to the region; and obstetric services to our local population. Across England, the birth rate has risen by 22% and continues to rise. At the same time the proportion of high risk and complex pregnancies continues to grow due to increased BMI, increased maternal age and long-term conditions that affect pregnancy.

The proportion of the local female population of childbearing age is considerably higher than for London as a whole, which indicates higher demand for maternity services.

This is borne out in the birth statistics which show a 38% increase in births between 2002 and 2012 in the Borough of Wandsworth.

2 Reference: http://www.england.nhs.uk/ourwork/commissioning/spec-services/npc-crg/group-e/e12/

0

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http://www.england.nhs.uk/ourwork/commissioning/spec-services/npc-crg/group-e/e12/

http://www.england.nhs.uk/ourwork/commissioning/spec-services/npc-crg/group-e/e12/



The rising birth rate is challenging many organisations as we seek to maintain safe services in terms of both appropriate staffing levels and the physical capacity to care for more women.

At the same time changes in expectations for obstetric, paediatric and neonatal staffing is driving discussions about the future configuration of maternity services.

However, the numbers of deliveries at St George‟s was “capped” in 20113, because of:

Rising number of deliveries within inadequate space and manpower were compromising safety and quality.

Rising patient complexity led to further demands on space and manpower.

Recommendations on staffing levels from CNST were not being met.

Evidence that current capacity had been overwhelmed by demand.

Best practice guidelines not been followed due to lack of resources.

There has been a demonstrable increase in the redirection of intrauterine transfers for neonatal care, due to lack of capacity on the delivery suite. Recent evidence suggests that this increases mortality in babies that are not born at a tertiary centre. This not only constitutes a risk to infants that may subsequently need to be transferred after birth4; but also means that the neonatal unit cannot fulfil its role as a regional referral centre with neonatal intensive care, and affects the paediatric surgery service, as babies requiring surgery may be transferred out of London.

The neonatal service does not have sufficient capacity for the current level of deliveries. As demand for is closely linked to the delivery rate, demand for special care now exceeds capacity, with the result that special care neonates often occupy high dependency and intensive care cots on the neonatal unit, preventing the admission of more serious cases. The demand for special care would itself be relieved to a degree by a formal transitional care service.

3 Safety and Quality of Obstetric Services, 16

th December 2010

4 Marlow N, Bennett C, Draper ES, Hennessy EM, Morgan AS, Costeloe KL. Perinatal outcomes for

extremely preterm babies in relation to place of birth in England: the EPICure 2 study. Arch Dis Child Fetal Neonatal Ed. 2014 Mar 6;

0% 1% 2% 3% 4% 5% 6% 7% 8% 9%

15 - 19

20 - 24

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Wandworth



Greater numbers of older women, women with high BMIs, and pre-existing medical conditions means that the number of women who do not experience pregnancy as „normal‟ is increasing. These women require more coordination between primary and secondary care and often specialist acute services. Almost 1 in 4 women now delivers by caesarean section with a further 10-12% delivered with the aid of forceps or ventouse. The quality of intra-partum care has a significant impact on women‟s chances of achieving a normal birth and the national variation in caesarean section rates (from 15-36%) indicated that there is much that can be done to reduce unnecessary interventions.5

Therefore, the key objectives over the next five 5 years are:

Expansion of the delivery suite to facilitate a growth in births from the current c. 5,000 to upwards of 7,500.

Continuing the growth in labour ward hours of consultant cover up to the 168 hours required in line with nationally and locally defined quality standards.

Growth and further development of the midwifery led birthing unit.

The development and establishment of an Institute of Fetal Health, which will lead the way with regards to research and development.

Expansion of the fetal medicine unit to facilitate the growing referral base and the case mix.

Expansion of the neonatal service to accommodate the increased demand from delivery suite expansion.

Consolidation of the Gynaecology Service into the „hub‟ model for all patients, incorporating outpatients‟ services, diagnostics, EPU and scanning in a service specific location.

All pregnant women will be offered choices of care that are evidence based, delivered in an appropriate environment, to ensure the physical and mental well beingwellbeing of mother and baby. High quality services will be delivered by multidisciplinary teams of professionals focused on normality with patient flows to specialist care as required, for higher risk conditions.

3.7.3 Gynaecology

The Trust does not consider itself as a competitor to DGHs in the south west London sector, but rather as the lead provider for complex and tertiary care. Therefore, it should articulate its expertise in high end complex gynaecology care and further develop relationships with local acute providers in order to establish itself as the tertiary centre in the region and capture all tertiary care.

The strategy for gynaecology is to deliver high quality care to women, working with partners in primary care and secondary hospital, to provide pathways of care that are patient centred, evaluated by patient reported outcome. This care will be delivered at a primary, secondary and tertiary level, with an aim to deliver one-stop, best practice services which offer women an all-encompassing elective and emergency gynaecology service

5 http://www.england.nhs.uk/wp-content/uploads/2012/07/comm-maternity-services.pdf



3.8 Future services and model of care

Labour ward consultant cover. By the end of 2014/15, St George‟s will be the only unit in South West London planning to achieve the gold standard of 168 hours consultant presence on the labour ward per week. It will increase the ability of the unit to cope with urgent and emergency situations in childbirth. It also means that the reduction in “elective” obstetric admissions (ege.g. for inductions) at weekends and bank holidays is likely to be counteracted, as this is fundamentally related to the presence of out of hours consultant presence. This singles it out a the major centre in the sector – units which fail to achieve this standard risk losing CQC and commissioner support in the medium to long term, resulting in an increase in births at St George‟s.

Strategic changes in configuration of services across South West London. The South West London collaborative commissioning exercise is currently re-examining the configuration of maternity services in SW London and has committed to a making its recommendations by the end of 2014/15. The previous clinically led planning exercise (Better Services Better Value - BSBV) recommended in 2012 that at least one consultant led unit in South West London should be closed, and that high complexity or high risk deliveries should be concentrated at St George‟s. These taken together could lead to a growth in the number of mothers delivering at St Georges of some 50%, taking the total number of deliveries to around 7,500. Closure of a consultant led maternity unit would also lead to closure of the neonatal unit on the same site, leading to a similar increase in neonatal activity at St George‟s to absorb a proportion of this work. Similarly, the reduction in paediatric inpatient centres could increase the requirement for inpatient beds at St George‟s by over 20 beds.

Labour ward and delivery theatre capacity. These factors taken together suggest that either by design or by default the labour ward will need to have substantially (50%) greater capacity and may require a third theatre to ensure an emergency theatre is always available. It would also require additional ante- and post-natal facilities, as well as having knock on effects on the early pregnancy service and other pre-natal services such as foetal medicine.

Midwifery Led Unit. The MLU will continue to provide an alternative setting for low risk pregnancies. The expected increase in numbers in births will also affect this service, entailing the need for greater capacity.

Neonatal Care. Reorganising maternity and neonatal services in South West London is likely to substantially increase the demand for neonatal care at St George‟s. Neonatal care is expected to expand in proportion to deliveries, as the number of babies who need specialist neonatal care remains relatively stable at around 10%. Neonatal networks were among the first managed clinical networks to be established in 2005, and have been an NHS success story. As the unit becomes increasingly the focus for tertiary referrals along established network pathways in line with national policy to manage high risk babies in tertiary centres, complex case referrals to the hospital will increase. This indicates the need for some 34 intensive care and high dependency cots and 25 special care cots6.

6 See papers: “The changing face of NNU” (2014), “Neonatal Service Specifications – E08/S/a

2013/14” (http://www.england.nhs.uk/ourwork/commissioning/spec-services/npc-crg/group-e/e08/), and “Neonatal Workflow and Space requirements” developed by SGH neonatal staff (2013)



Paediatric Intensive Care. Demand for PICU beds has increased consistently at 5% per annum. The evidence suggests that these are not sicker children but the increase is due to patients who cannot be managed in surrounding DGHs. This trend is considered likely to continue, putting pressure on current capacity and leading to adverse effects such as cancellations for planned surgery where a high dependency bed is required post-surgery. This indicates a requirement for at least 6 additional beds, taking the total to 16 (10 intensive care and 6 high dependency), with four of these being in isolation rooms7.

Children's surgery. In 2013/14 approximately 7200 children were admitted for surgery of some type across the Trust. The largest specialties by volume were paediatric surgery, urology, dentistry, ENT and trauma & orthopaedics. Of the total approximately 2700 patients were from the core local boroughs of Wandsworth, Sutton and Merton, meaning that almost 2/3rd are from further afield, reflecting the specialist nature of much of the surgery. By far the largest group of children are the 0-4 year olds. Given the anticipated concentration of obstetrics, the potential concentration of paediatric surgery following the same path, and the tendency for surgery on children, particularly infants, to go to the hospital of birth, it is anticipated that theatre requirements for children's surgery will increase.

The recent document on safe and sustainable surgery for children, drawing on best practice from the Royal Colleges, the Care Quality Commission, the Department of Health and others, identified several standards that the hospital should be working towards. The executive board approved these standards in 2011. Wherever and whenever children undergo anaesthesia and surgery, their particular needs must be recognised. They should be managed in separate facilities under the supervision of staff with appropriate experience and training. The ideal environment for the successful maintenance of these standards is a dedicated, integrated children's facility, and the full implementation of all these standards is dependent on the redevelopment of children‟s facilities.

Paediatric assessment. The children's service has introduced an emergency pathway to reduce unnecessary admissions through a paediatric assessment unit located within the emergency department. This was seen as a success and has been extended in size.

The next step is to “shorten and straighten” elective pathways. This should enable patients to be admitted on the day of operation, using the “race-track” principle. Thus they should be able to walk into the admissions lounge from reception, and go straight into the theatres complex, rather than going a bed. Post surgery and recovery, they can then either be admitted to a surgical bed, or proceed to the discharge area for same day discharge. Patients with more complex or risky surgery should be operated on in theatres with intensive care facilities close to hand.

Hub concept. The hub concept has been developed to smooth the access to obstetric and gynaecology services by providing a central referral point in the hospital. This will route patients to the appropriate diagnostic, ambulatory or other service, including:

o Early pregnancy advisory

o gynaecology

7 See paper: “The changing face of PICU” (2014) development by SGH PICU staff.



o Ultrasound

o Maternity

Institute of Fetal Health.

DN 2. Insert summary of concept for institute of foetal medicine

3.9 Current and Future Activity

The level of activity for women's and children's services is expected to rise, for the most part very significantly. The exception to this is urogynaecology, where numbers are expected to remain stable or decline as services move to more ambulatory settings in community based facilities. There are a number of factors that lead to this conclusion:

Population-driven growth. The South West London Primary Care Trusts (PCTs) assumed for several years that demand from the resident population was likely to rise at 1.5% for emergencies and 1.8% for elective treatment, giving an aggregate of c.1.5%. In fact, growth in admissions at St George‟s has outstripped this assumption. Despite this, the Clinical Commissioning Groups, which assumed commissioning responsibilities from PCTs in 2013, have maintained this assumption for the time being. This provides a steady baseline of moderate growth for the future. This is illustrated for children's inpatients below:

Spells Growth Spells Growth Spells Growth

09-10 5,211 4,584 9,795

10-11 5,184 -0.5% 5,766 25.8% 10,950 11.8%

11-12 5,608 8.2% 5,005 -13.2% 10,613 -3.1%

12-13 5,583 -0.4% 5,199 3.9% 10,782 1.6%

13-14 6,072 8.8% 5,068 -2.5% 11,140 3.3%

14-15 6,181 1.8% 5,144 1.5% 11,325 1.7%

15-16 6,293 1.8% 5,221 1.5% 11,514 1.7%

16-17 6,406 1.8% 5,299 1.5% 11,705 1.7%

17-18 6,521 1.8% 5,379 1.5% 11,900 1.7%

18-19 6,639 1.8% 5,460 1.5% 12,098 1.7%

Pla

nn

ed

ElectivesYear

Emergencies TotalBasis

Act

ual

In addition, the local birth rate is comparatively high as the population in the area younger than the national average. A total of 21,000 annual births are likely by 2016/17 in South West London including very complex births.

Market Share. Market share appears to have been constrained and indeed curtailed by capacity limitations. This is well illustrated by the graph below, which shows that market share in obstetrics in Wandsworth has declined from over 50% in 2008 to under 45% today. With referrals capped at St George‟s, this indicates that other providers are taking a growing number of referrals from the Trust‟s core catchment area – in effect “creaming off” the natural growth that would otherwise come to St George‟s.



However, early initiatives by children's consultants to inform general practitioners of the services and facilities planned for the Fifth Floor of Lanesborough have yielded an appreciable growth in referrals. This shows that there is a willingness to refer to the hospital in the GP community. Given the central position in South West London, the prospect of first class facilities and the 5% tariff advantage over central London hospitals, St George‟s has the potential to significantly expand its market share. This could take the form of consolidating market position in the core catchment, and of reversing outflows to other providers from both core and marginal areas.

30%

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SGH Obstetric Market Share in Wandsworth

Sector wide policy for obstetrics and paediatrics. The Trust and the principal commissioners in South West London expect the consolidation of specialist obstetrics and paediatrics in the medium term, either by design as a result of a planned transition through the collaborative commissioning process, or by default as services in other centre fold due to quality, recruitment or contracting difficulties. This could represent a 30-50% increase in workload for both obstetrics and paediatrics. In particular, up to 2,000 additional births from other hospitals might be expected as a result of the proposals. This would have knock on effects for neonatal care and PICU and paediatrics in general.

Specific service developments. In the medium term, specific services developments are likely to add to the overall workload of the hospital. Wherever possible these will be pursued in line with commissioner intentions and with a view to achieving best practice tariffs through high quality, innovative services. Currently, potential developments exist in the areas of cancer and trauma.

It is recommended that women are offered a choice regarding the place of birth. This not only concerns whether the birth is at home, in a midwife-led unit or in an obstetric unit, but also which obstetric unit from the range of locally available services. Experience from previous units (Manchester, University College) has demonstrated a significant “magnet” effect of a newly built unit on where women chose to give birth.



3.10 Private and overseas patients strategy

South West London has a high rate of private medical insurance, with the average for the Trust‟s immediate catchment being 26%, in places rising to 35%. There is constant demand for private and amenity beds, although women's and children's services are physically constrained and cannot consistently make rooms available.

The Trust is entering into a strategic partnership with a national private hospital provider to construct a private patients unit on the St George‟s site. This will focus primarily on adult surgical specialties. This was primarily because the unit will be located at the far end of the site from most women's and children's services, with implications for consultant and anaesthetic availability. However, the agreement also enables the provider to deliver and finance other private patients developments elsewhere in the hospital. This means that any major reconfiguration of Lanesborough, with a dedicated private patients facility, could not only offer long term financial benefit to the Trust, but also attract an independent source of capital.

The Trust is also able to offer some unique treatments such as ovarian freezing, which are truly international specialties and can attract patients from overseas.

3.11 Operating Theatres

The availability of operating theatres is a key constraint on growth. There are three main areas to consider:

Gynaecological surgery – while the mix of gynaecology is likely to change, with higher acuity work gradually replacing routine procedures, the requirement for theatre time is likely to remain at around two theatres.

Obstetric theatres – moving to over 7,000 births per annum will require an additional theatre, as the potential for two emergency obstetric procedures being undertaken simultaneously is high. In addition, Fetal Surgical procedures (60/year) are undertaken in the third theatre; although these cases are usually planned they are not “elective” in the true sense of the word, as they require to be undertaken within 12-48 hours of referral.

Paediatric surgery – the anticipated growth in deliveries will have a knock-on effect on theatre requirements. More than three theatres (31 sessions) for elective work are likely to be required (at current utilisation rates) with another theatre for emergency work under CEPOD arrangements.

Given the expense of building and maintaining theatres, innovative alternatives are being actively considered. For example, extended working arrangements will reduce the need for additional physical capacity. Three session or 12 hour days will increase capacity by 50% during the working week, and this can be further enhanced with weekend working as appropriate to create sufficient operational capacity during periods of peak demand, in a constantly changing environment.

Specialty Theatre requirement Comment

Obstetrics 3 includes 2 emergency theatres

Gynaecology 2

Paediatrics/neonatology 4 Includes 1 emergency theatre



3.12 Diagnostic services

DN 3. Is this enough for diagnostics (Bruce)

Excellent diagnostic support is a key element of providing a first class service for women and children. Diagnostic imaging is provided in several locations across the site, meaning that patients have to travel through the hospital for tests. The ideal would be for MRI, CT, ultrasound, plain film and other diagnostic modalities to be located close to the patients they serve, alongside near patient testing for a rapid diagnostic service.

3.13 Workforce issues

The overriding workforce concern relates to childbirth. The „Safer childbirth‟ and „Responsibility of the consultant on call‟ documents from the RCM and RCOG respectively, set out the minimum standards for the organisation and delivery of care in labour.

If deliveries exceed 5000 per year, we are expected to have 24 hour (168 hours per week) resident consultant presence and 3 obstetric trainees in the labour ward. The hospital currently provides 146 hours of consultant presence per week and have one obstetric trainee in the labour ward during the day and 2 during the night. By the end of 2014/15 the figure will rise to the required 168 hours – the only hospital in the sector to achieve this.

The safer childbirth document recommends a midwife to patient ratio of at least 1:28. We currently have a ratio of 1:27, again, ahead of other hospitals in the area.

There are also significant workforce issues for a neonatal unit of this size. Recent guidance suggests that this will require a minimum of four doctors or ANNPs at night – two at tier-1 and two at tier-2. A national reduction in trainee numbers will make finding sufficient junior doctors very difficult, and it is likely that resident consultant cover will be required leading to the requirement of an additional 10 consultants on a full shift rota. This has already happened in some tertiary centres in the UK. In addition there is a national shortage of neonatally trained nurses and an aging workforce, leading to recruitment problems at all levels, but particularly in more senior roles. At present we are unable to meet national service specifications of 1:1 nursing for babies requiring intensive care. While these challenges will remain with expansion, first class facilities and working conditions have a beneficial effect on recruitment and retention.

3.14 Teaching, training and research

Competition for the best students and research talent is rising, as academia becomes a global market. Medical research is becoming more complex and medicine continues to sub-specialise. One result of this is that it has become more difficult to sustain clinician-led research in a teaching hospital environment. The Trust and SGUL and mutually gain from their proximity to ramp up clinically based research activity.

Any physical development should make provision for the aspiration to increase the volume and quality of research. This requires a step change in research infrastructure such as laboratories, information technology, trial co-ordination, data management and bio-banking.

The development of a new, purpose facility could facilitate new funding partners (whether commercial, government or not-for-profit) and we would nurture an „open for business‟ approach to research which would ensure partners would find it easy and attractive to partner or invest with us. Establishing and promoting, for example, the Institute of Fetal and Maternal Health will be critical to raising the research profile of children‟s and women‟s services.



SGUL has over 1,300 medical students, as well as nursing, physiotherapy, physician assistant, paramedic and other courses that require access to patients. These courses are essential to SGUL and important to the hospital financially and professionally, with over £800,000 income into the children‟s directorate from SIFT. Current facilities fall below the level required by SGUL teaching standards and need to be upgraded.

The introduction of the new/higher fees regime will stimulate competition for the best students. This will result in increased expectations about their experience, which may take many forms including a demand for better integration between the learning experience and clinical placements. The workforce of the future is attracted to new and different ways of learning.

3.15 Financial background

The overall financial position for women's and children's services is challenging, although this hides significant variation. The service line reporting approach shows that:

Paediatric medicine has low market share and produces negative returns (£5.2m fully absorbed in 2013/14, -48% margin), in part attributable to the high fixed costs associated with running a tertiary service within a constrained physical capacity that prevents growth in activity and hence reduction in unit costs.

Gynaecology and newborn services have low market share and are in marginal deficit (£2.4m/-23% and £0.5m/-5%), for similar reasons.

Obstetrics, by contrast has moved from significant deficit towards break even (£0.7m/-2.5%). Its market share is constrained by capacity.

Community paediatrics is breaking even on a small budget.

Paediatric ITU and oncology are breaking even and have a high market share

Paediatric surgery has a high market share and has a reasonable surplus (£1m/+14%).



Adult Critical Care

Gynaecology

Pathology

Paediatric ITU

Clinical Gen

Newborn Services

Obstetrics

Radiology

Paed Medicine

Paed SurgeryBreast Screening

Therapies

Paed Onc

Community Paediatrics

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Service Line Reporting Portfolio Matrix Quarter-42013/14 - Children & Women's, Therapies & Diagnostics

Potential GrowthReview Economics

Benchmark SetterImprove Cost Position

Axis: X =Surplus/(Deficit) , Y =Market share % based on tariff Income (Source= Dr Fosters) Bubble Size = Total Costs of Specialty South W London = St Georges, ESH, Mayday and Kingston

Potential Growth

Benchmark Setter

Whilst the potential for these services to grow is high, they are constrained by capacity in some form or other – lack of beds, cots, theatres and clinics. Thus they are unable to exert leverage on what are well staffed and high quality service to increase activity and thus generate better operating margins.

The marginal costing exercise for patients under 19 years old showed that the service makes a significant contribution to the Trust for its admitted patient care. This is not reflected in the fully absorbed costs (PLICS), due to the apportionment of the Trust overheads, which consume all the surplus generated. This sets out the fully absorbed cost of the service by specialty, although it does not account for income generated by wards providing care for children under the care of non-paediatric consultants. However, when the other specialties which use paediatric wards and theatres are included, the situation is in broad balance – this is in part a function of the difficulty in fairly apportioning costs to specialties which “lodge” their patients in children's wards. When all inpatient services for children are taken into account, the contribution is £5.8m and when Trust overheads are added, the service is in balance. This is tabulated below:

Income Costs Contribution Income Costs Contribution

Emergency admissions 11,319 9,016 2,304 11,545 9,195 2,350

Elective admissions 5,393 4,357 1,036 5,279 4,265 1,014

Day cases 4,786 2,359 2,427 4,890 2,410 2,480

Other 32 11 20 32 12 20

Grand Total 21,530 15,743 5,787 21,746 15,882 5,864

2011/12 (£000) 2012/13 (£000)Point of Delivery



Women's services currently make a loss and appear not to make a contribution to overheads. A recovery plan is in place to bring the current budget deficit into balance by June 2014. However, further cost pressures are anticipated in financial 2014/5, with the tapering of CQUIN funding for nursing staff, and the need for additional consultant cover in the Labour Ward to achieve a 24/7 compliant rota. Further plans are being prepared to reduce the impact of this.

A major structural factor that affects financial performance is the physical capacity of the Labour Ward, which limits births to around 5,000 per annum, and supporting services such as neonatal care. If this cap can be lifted by the development of additional space and more efficient flows and ways of working, the number of deliveries could be extended to 7,500 birth per annum, at which 24/7 cover on the labour ward becomes efficient in terms of staff costs. This would also significantly enhance the reputation of St Georges as a maternity centre and would provide 24/7 accessible Women‟s Services in a more holistic „one-stop shop‟ approach.

When the contribution of obstetrics and gynaecology is taken into account, it can be seen that the services together make a contribution of 4% (of income) to overheads, although insufficient to cover their “fair share” of costs as calculated by the apportioning methodology adopted by the Trust.

3.16 Location of services

The Trust operates the majority of its services from the St George‟s Hospital in Tooting. This large site is well developed, and offers only a few plots for redevelopment. The hospital consists of several large wings, of which Lanesborough is one. The Trust started a strategic planning process in 2008 to develop ideas for the renewal of ageing facilities on the site, which led to a strategic outline case being developed for the whole site. However, this was seen as unaffordable and unmanageable and subsequent planning has progressively focused on the highest priority in terms of need for modern facilities – women's and children's services located in the Lanesborough wing.

The Lanesborough wing is a separate building connected to the rest of the site on the ground and first floors. The first floor is the only level that links all the building on the site and is used to move patients between sites when necessary. The Lanesborough wing has 6 floors and a total of 37,809m2.

The wing houses most of children‟s and women‟s services, with inpatients on the fourth and fifth floors. The fifth floor also has and elderly care ward and two obsolete theatres run by Moorfields Eye Hospital – Moorfields is in the process of vacating the theatres to move to new purpose built facilities elsewhere on the site. The whole floor will be developing to create state of the art facilities for children's inpatient care.

The fourth floor houses ante- and postnatal maternity, the midwifery led unit, the fetal medicine unit (ambulatory) and other adult services

The third floor is largely designated for other purposes. This includes acute medicine (winter pressure ward), oncology, elderly, neuro- and physical rehabilitation and HR offices. It also houses the obstetrics and gynaecology teaching seminar room.

The second floor is the interstitial floor for the building, housing plant and engineering, and some storage.



The first floor is the “hot” floor, with theatres, children's day care, delivery suite, neonatal care, and paediatric high dependency and intensive care. It also houses the hospital theatre stores and a large staff restaurant and servery.

The ground floor is a more mixed arrangement and includes different outpatient clinics; the acute gynaecology and early pregnancy units (ambulatory); gynaecology investigation suite; and related services and diagnostic services across a number of specialties.

3.17 Physical facilities

The Lanesborough Wing was designed and built in the 1970s and opened in 1980. It is clear that the development in standards for health facilities in the intervening decades has caught up with it – it is no longer fit for modern healthcare.

The key problems with the current facilities are:

Insufficient single rooms, and cramped four bed bays, mean there is a lack of privacy for patients.

Lack of en-suite sanitary facilities. Only few beds (less than one quarter) have access to en-suites, meaning that patients have to walk into public areas to access toilets and showers.

Lack of space, particularly between beds.

Overcrowding in outpatient areas

Labyrinthine layouts and confusing routes and wayfinding, as a result of many years of ad hoc developments.

Windows are energy inefficient and need replacement.

Overall patient experience in terms the quality of the building is poor.

Décor and aesthetics should be improved to assist patient recovery, and well-being.



Control of air temperature, ventilation and acoustics is poor.

Fire systems need to be upgraded to modern standards

Inadequate lift capacity and access frequently constrained by lift failures.

Generally poor functional suitability and sombre ambience not conducive to well beingwellbeing and healing.

Poor clinical adjacencies.

Poor separation of ambulatory care, inpatient elective care and inpatient non-elective care.

No separation of patient and public walkways / thoroughfares

Low flexibility for the inevitable further development of healthcare needs of the future.

A significant maintenance backlog – estimated at £12.3m in 2010, since when no significant improvements have been made.

In summary, the current facilities fail in terms of:

Physical space and layout.

Sanitation.

Privacy and dignity.

Infection control requirements.

Temperature control and lighting.

Being patient friendly.

3.18 Future space requirements

Space requirements and planning norms have grown substantially in recent years as a result of:

More stringent control of infection regime requiring greater spacing between beds and more hand washing facilities

An increase in the amount of medical equipment in use on the ward

The need for more single rooms to provide greater privacy – the target is at least 50% single rooms.

The need for more en-suite sanitary facilities.

The recent space planning exercise for Level 5 revealed that this means that in general only two beds can be planned for every three existing beds, reducing the effective bed capacity by one third. Similar space increases must also be planned for in theatres, day care and high/dependency/intensive care areas.

The overall space requirement will be calculated on the basis of a number of factors:



Health Building Notes (HBNs) and Health Technical Memoranda (HTMs) published by Department of Health (DH) – this suite of documents sets out the definitive guidance for the development of modern facilities, and includes clinical, support and ancillary areas. In a new build, all relevant guidance should be followed. In refurbishment, the ability to comply with all guidance will be constrained by the existing physical space, but a higher level of compliance should be striven for.

Other planning norms – such as the requirement for 50% single rooms and en-suite sanitation, which are set from time to time by the DH.

Activity forecasts – the activity forecasts, expressed in terms of inpatient beds, day beds, theatres, cots, and other key elements of physical capacity. For example, inpatient beds will be calculated on the basis of:

o The expected volume of patients, taking into account the likely growth over time.

o The expected length of patient stay, adjusted over time for reductions for greater efficiency.

o The target level of occupancy (how many days the bed may lie empty), calculated to ensure the minimum acceptable level of cancelled or refused admissions (turn-away rate).

The building is likely to be in use for 40-60 years and must be flexible enough to cope with substantial changes in the nature of healthcare delivery over that period. Flexibility must be built in to allow for changes in national, regional or local policies and commissioning intentions, for demographically and epidemiologically driven changes in demand, and for developments in clinical practice and patient pathways. The space needed to accommodate the activity predicted in facilities that meet 21st Century standards is substantially larger than is currently available. A large expansion in the labour ward, theatres, ante- and post-natal beds and paediatric beds is likely to be required.

An initial planning exercise set out a broad space requirement for the women's and children services (including children's inpatients on Level 5) at some 36,000m2:

Children's Inpatients Baseline and growth 4,000

Children's Inpatients Sector & strategic developments 2,000

Maternity Inpatients Growth up to 7500, incl staff areas 4,000

Gynaecology inpatients Steady state 1,100

Labour ward Growth up to 7500, includes MLU rooms and staff areas 2,400

Neonatal intensive care & high dependency, special care Growth up to 7500 3,800

Paediatric intensive care Growth up to 7500, plus sector & strategic developments 1,900

TheatresGrowth up to 7500, plus sector & strategic developments,

including 2 shells and 2 procedure rooms, MRI 4,100

Children's outpatients incl CDC 2,400

Children's day assessment 600

Gynaecology investigations 900

Gynaecology day assessment 400

Gynaecology hub 300

Foetal medicine 1,400

Maternity outpatients Includes EPAU 1,600

Diagnostic imaging U/S expansion, plain film and child-orientated MRI & CT 1,700

Shared space, meeting rooms, offices and education 3,600

36,200

Space (m2)Function Comment



If these requirements are set against the current locations of the services, there is a clear mismatch between the long term requirement and the current capacity.

Preferred location Needed m2 Available m2 Shortfall m2

Level 5 6,000 4,000 2,000

Level 4 5,100 4,000 1,100

Level 3 3,600 3,800 -

Level 1 12,200 7,300 4,900

Level 0 9,300 8,600 700

36,200 27,700 8,700

3.19 Site development plans

The site has developed over many years, and consists largely of clinical and academic blocks constructed in the 1970s, 80s and the early 21st century. It also has a several buildings dating to the 19th century which are in an extremely poor condition. The strategic plans for the site are in development. Key building blocks of the site strategy include:

Providing new facilities for renal services

Expanding facilities for cardiac and neuro-science

Developing a private patients facility

Accommodating the eye services provided by Moorfields Eye Hospital in new faciltiesfacilities

Developing the first floor of the clinical buildings across the site as the “integrated interventional platform” or “hot core”, focusing on theatres, diagnostics and high dependency

Replacing the dilapidated Knightsbridge Wing

Providing more rational parking, entrance and road access

These have been drawn together to create a vision for the controlled development of the site. One of the key assumptions in the current thinking is the presence of children's and women's services in the LanesborouighLanesborough Wing, based around the fixed point of the children's inpatient development on the fifth floor. This may include an extension to accommodate the additional space requirements generated by modern NHS building standards and specifications. This is visualised below, showing a major development on the southern frontage of the hospital (yellow, purple and blue), as well as developments to the Lanesborough Wing (red):



The overall plan identifies several options for the future of Lanesborough Wing, including a potential extension to provide additional space at every floor of the existing building, and a sixth storey for additional functions:



3.20 Children's and Women's Hospital Concept

The National Service Framework 2004 states: „‟Healthy mothers produce healthy babies who become healthy children and adults; much preventable adult ill health and disease has its roots during gestation, infancy and childhood. Children‟s vulnerability and the inability when young or disabled to articulate what they feel pose a challenge for all those involved in delivering health and social care services to meet their individual needs and those of their carers Improving the health and welfare of mothers and their children is the surest way to a healthier nation - the best way to achieve a fairer society for the future is to improve health and tackle inequalities in childhood.„‟

Better Healthcare for women Jan 2013 WHEC states:„ ‟Women form half the community. They have specific and different health needs from men, which need to be identified and responded to if health and care services are to be effective and deliver for everyone. Some of these differences are about different needs for clinical services; some are about different needs in terms of access. Women hold different assets, resources and play different roles within the community. They are more likely to live in poverty, but may have developed effective self-help strategies and resilience in the face of this, often at neighbourhood level. However, there are barriers to their participation in the development of health strategies – many women don‟t have a voice in decision-making.

Many parts of the developed world (and indeed the developing world) have already embraced this idea, and there are excellent examples of children and women hospitals elsewhere:

The University of South Alabama has stated that‟‟ we know that children and women have health care needs unlike anyone else. That's why we offer care that is unique in our community………Everyone who works at USA Children's & Women's Hospital is devoted to providing hope, healing and the very best care possible for children and women.„‟

In British Columbia the „‟Children‟s and Women‟s Redevelopment Project is carefully planning and building a new acute care centre at BC Children‟s Hospital and BC Women‟s Hospital + Health Centre to serve both the current and future medical needs of children, youth, women and families throughout British Columbia. Designed for patients, their families and care teams and with their well-being in mind, the Redevelopment Project blends improved and proven models of progressive care within a complex setting, with meticulous attention to every detail‟‟.

In Singapore the KK women and children hospital‟s vision is to be the healthcare leader for Women and Children. Their mission is to lead in excellent, holistic and compassionate care for Women and Children. They are committed to;

o Providing excellent, holistic and compassionate care for women and children

o Protecting the environment

o Promoting a safe and healthy environment



There is now a unique opportunity in the development of the children and women hospital to care for children and women under one roof. The health needs of women and children are linked in terms of both medical treatments and social needs. The birth of babies is intricately linked with the need for a tertiary specialist neonatal unit that can take care of the smallest and most vulnerable babies. The presence of one of the largest foetal medicine units in the country requires the colocation of neonatology, and paediatric surgery in all specialties. The specific needs of women and children mean that a state of the art unit providing all areas of world class care in all specialties all under one roof would be of great benefit to the south west of London and beyond. This would provide a beacon of excellence and a focus for clinical networks for neighbouring hospitals.

The development of a children's and women's hospital in South West London will be a major benefit to the patients, families and wider community in the local area and the wider catchment of the hospital. In particular, it can build on:

One of the largest fetal medicine units in the United Kingdom through the creation of the Institute of Fetal Health

Outstanding obstetric outcomes

Highly specialised services for expectant mothers with:

o Obesity

o Infectious diseases

o HIV and AIDS

o Heart conditions

The aim of St Georges Healthcare will be to build or refurbish the site to provide a facility to care for children and women that will be able to provide an excellence of care, and demonstrably be a leader in healthcare for children and women. The services will encompass;

Secondary services for our local population (acute and community)

Outpatient and ambulatory services for children and women

Day care services for children and women

Obstetrics and gynaecology

Tertiary services for children and women

Intensive care for neonates, children and women

3.21 Summary of the case for change

Activity is constrained by the physical limitations of the wing. This prevents the natural development of services and prevents services in financial deficit growing their way to financial viability. There is evidence that the Trust is losing market share to other hospitals who can accommodate the demand.



Significant growth is expected as a result of strategic changes in the sector. However, there is no way that the Trust can respond to the expectations of the clinical networks in the sector, nor commissioner demands, without making additional capacity available. Large scale activity streams that result from the strategic changes may go to other hospitals as a result. This risks frustrating the plans of clinicians, commissioners and the Trust, and weakening the strategic position of the Trust as the only major tertiary provider in the sector.

Facilities are out of date and no longer suitable for 21st Century care in a tertiary setting. It fails to meet modern standards in terms of layout, clinical adjacencies, privacy and dignity and patient experience. In an environment influenced by patient choice, especially in areas such as choosing where to have a baby, patients will choose to go elsewhere if they cannot access modern facilities.

3.22 Desired benefits

The proposition is as follows:

To create a future-proofed comprehensive healthcare facility for children and women

To support the urgent UK national objective of improving childhood mortality rates by providing a greater focus on interdependent services in a coherent setting

To create the quality of environment for children‟s and women‟s services to match the outstanding quality of care currently provided

To develop the skills of talented clinical staff and researchers in paediatrics and women‟s health in a first class organisation for teaching and learning

To produce a seamless pathway between the academics who lead the world in key areas such as childhood infectious diseases to those who depend on the translation of these ideas in to real treatments

To help women and their families navigate their way through what can be complex and complicated health system by creating a 24/7 Hub for women‟s health

To support newborns, those not yet born, young children and adolescents to have dedicated spaces for their specific needs

To give patients and professionals a beacon facility to be proud of, shining a light of excellence at general hospital level and for those needing life-changing tertiary level services across the region

To create a comfortable, healing family environment that puts the quality of care for women and children first and which allows for partners and fathers to be properly catered for

And to do all of this for local people with the benefits of new ideas and new practice shared nationally and internationally

The Trust aims to be the best hospital in South London with a universally acknowledge lead in terms of quality of services, teaching and research. It will provide the best possible care for patients across the region, in the best facilities and attract the best staff in the health and university sectors. For women and children this will mean:



1. 21st Century facilities for modern secondary and tertiary care delivery, which enable modern pathways and models of care to function.

2. Standout facilities that provide a high level of patient satisfaction, provide demonstrably safe services, and are attract patients exercising their choices when considering their treatment options.

3. Capacity for current and future growth so that developments in the next 5, 10, even 20 years can be accommodated

4. Facilities that are a key enabler for strategic change at a sector-wide level, so that clinical network, commissioner and trust plans to develop services for South West London can be implemented

5. Integration of clinical services, research, teaching and training to attract the best NHS and university staff

6. Flexible facilities that enable significant changes in service patterns to take place so that St George‟s stays at the forefront of innovation in health care delivery

7. Facilities that are well utilised and generate a good operating income to support reinvestment in services and facilities]

As the planning process progressively develops objectives and options in more detail, the quantitative and qualitative benefits that need to be delivered by the scheme will be formulated, with SMART characteristics to facilitate their achievement.

3.23 Constraints

There are a number of constraints which the scheme must overcome

Financial – the development must improve the financial position of the women's and children's services and the trust overall. Any capital investment must therefore be seen as a means to:

o Gain additional income streams, through new services or expansion of existing services.

o Secure current income streams which may be threatened.

o Reduce operating costs and overall unit costs.

The capital must also be within the Trust‟s means in terms of capital absorption duty and any interest/loan payments.

Physical – the site is constrained and any major development of Lanesborough will require a number of enabling measures and the development of additional space. A key issue is the location of the staff restaurant and servery, which occupies space that is the obvious area for theatres, children's day care, labour ward and neonatal care expansion.



3.24 Stakeholder Support

The program that is emerging is potentially complex, both in terms of size and scale. Initial internal stakeholder engagement has primarily been within the division and other internal stakeholders. There are a number of significant external stakeholders, including GPs, Clinical Commissioning Groups, local authorities, the local public and other healthcare providers. An analysis will be undertaken to determine the best approach to external stakeholder management and how this will support the overall development. A comprehensive Communications and Marketing work-stream plan will then be developed.

3.25 Further work to develop outline business case

Detailed activity and market share assumptions

Detailed model of care

Detailed assessment of space required



4 ECONOMIC CASE

4.1 Long-list of options

A long list of options has been drawn together from a number of sources, including the 2010 Briefing Report, earlier plans for standalone units and the recent “Wow” planning exercise for the Lanesborough Wing, which focused on reception and entrance areas amongst other things.

In any planning process, the options that are developed should be compared with a baseline which is essentially doing nothing, or if that is not feasible, doing the bare minimum, however, defined, even if this is deficient in terms of meeting the scheme‟s objectives.

The long list includes the following options:

Do nothing - “Make do and mend”

Do minimum: “Modest refurbishment”. This option represents a “light touch” refurbishment. Services would stay roughly in situ, with no real scope for expansion (apart from minor gains due to co-locations or workflow efficiencies). This short-term solution would not be „future-proof‟ in terms of:

o (a) quality and size of accommodation expected in a 21st century hospital (to allow privacy and dignity; optimize infection control; and comply with NHS building design guidance (HBN) and

o (b) amount of space required to cope with the potential expansion of services expected over the next ten to fifteen years.

In planning the 5th floor children‟s inpatient development (the first part of the refurbishment option) it has become obvious that anything more than the lightest of “light touch” refurbishments will require significantly more space and a higher building specification than originally envisaged. In addition, the limitations of such an approach due to the ageing plant, services engineering and fabric of the building have become apparent. This has resulted in a cost estimate for the fifth floor that is around half the originally proposed budget for the whole building. The emerging picture is thus that, if anything more than a very light touch refurbishment is required a more holistic and fundamental redevelopment of the building will offer the best outcome, and therefore the best value for money.

“Level One Focus”. Under this option obstetrics, gynaecology and paediatric theatres, children's day care, neonatal unit, PICU and labour ward would all expand into the restaurant area on the first floor. All other floors have modest refurbishment but no major restructuring. This means displacing the restaurant to another area, location to be decided. This would deliver sufficient capacity for 7500 births and the other related increases in demand such as neonatal care. However, it would not increase ante- or post-natal bed capacity, which also has to rise in line with births.

“Level One & Four Focus”. Under this option obstetrics, gynaecology and paediatric theatres, neonatal unit, PICU, children‟s day care and labour ward would all expand into the restaurant area on the first floor. All other floors have modest refurbishment but no major restructuring. This means displacing the restaurant to another area, location to be decided. This would deliver sufficient capacity for 7500 births and the other related increases in demand such as neonatal care.



Level 4 would be refurbished for ante- and post-natal care, with some 72 beds taking the whole floor. This would displace both gynaecology inpatients and the medical ward on Level 4.

“Full Reconfiguration”. This option would refurbish the entire wing as to the standard envisage in the previous options as well as expanding level one services into the restaurant area. This option considers turning the Lanesborough building, as it currently stands, into a dedicated Children and Women‟s Hospital. The scenario assumes that all non-Children and Women‟s Services would be transferred to other locations to create decanting space and expansion options.

This scenario assumes that the third floor becomes ward space including potentially a private patients unit. This assumption is linked to the emerging control plan for the development of the whole site, which may result in new clinical space accommodating for all the non-women‟s and children's services in the Lanesborough Wing. All ambulatory and outpatient activity moves to the Ground Floor, where a 24/7 facility will be established. It also assumes that all paediatric work will be repatriated to Lanesborough (apart from Paediatric A and E services).

Lanesborough as a dedicated Children and Women‟s hospital has very distinct advantages for patient care, quality and safety, public and staff perception and morale and provides the opportunity for rebranding, fundraising, research, marketing and developing an international reputation. This is significantly offset by the complexity of the refurbishment and cost of decanting other services

“Major extension and reconfiguration”. This option was developed by BDP architects as the logical next step. The first stage would be to construct a completely new block on the East face of Lanesborough, increasing its capacity by up to 50%. Levels would be maintained with the current wing to ensure services could be provided across the floors of the old and new blocks. This would create several thousand square metres of premium quality clinical space, allowing the step-by-step refurbishment of older areas to modern standards as services move into or expand into the new space.

“Major extension and reconfiguration with atrium”. This option was developed by BDP to show the potential to utilise the dead space between Lanesborough and Grosvenor wings to create a recognisable entrance and reception, address the vertical and horizontal access issues in the wing and resolve at least in part the catering issues raised by converting the restaurant for clinical use. The space between the two wings would be covered over to form a large atrium or “winter garden” which could house retail, dining areas, new lifts on the South face of the Lanesborough Wing and a new access point where the Hotung Centre currently stands. The rest of this option would be as for the “major extension and reconfiguration”.

Standalone Women's (or Women's and Children's) Block. This scenario would include evaluating the feasibility of using another part of the Trust site for a purpose-built Women‟s Hospital, possibly split from Children's (for example, Knightsbridge). The redevelopment of Level 5 for children's inpatients does however anchor this service in that building, and strengthens the requirement for PICU and day care to be located close by. Other displaced services would need to be re-sited either on or off site. The Trust has looked into this previously and considered it unaffordable, however, given the current state of the market, it may warrant further investigation. Key to properly evaluating this option, would be an updated and agreed Development Control Plan (DCP) at a Trust-wide level.



4.2 Short-list of options

It is not necessary at this stage to shortlist the options. However, two groups of options do not appear feasible, acceptable or affordable at this point

Do nothing. The rapid pace of change in the model of care and clinical practice, the poor state of the current facilities, the strategic changes outlines in the previous section and the burgeoning demand for women's and children's services means that doing nothing is not realistic. It would mean that the Trust continues to lose market share, and will not be able to achieve its strategic ambition as the main centre for women's and children's care in South West London.

“Level one focus”. This option would provide additional capacity on the delivery suite, but no additional ward capacity – this would constrain activity and would therefore fail in the primary objective, while incurring considerable financial cost.

“Major extension and reconfiguration with atrium”. This option was considered to expand the scope too much to the development of a major new entrance, which was considered too ambitious.

Standalone Block. This concept has been tested a number of times and found wanting in terms of capital outlay and estates strategy. There is no available plot for a building of the required size, and it would require the full range of diagnostic facilities within the development.

4.3 Economic analysis

Government investments are subject to the HM Treasury “discounted cash flow” (DCF) technique to reflect the time value of money. The combined capital and revenue cash flows associated with the options were compared to produce an overall assessment of their economic profile. The cash flow was then discounted using HM Treasury‟s standard discount rate (3.5%). This provided a comparable figure for the total cost or benefit of the investment over its economic life.

The economic analysis of the options will focus on a number of elements:

4.3.1 Capital Investment.

The capital costs of the options based on the outline design and cost plans developed by the Trust‟s architectural and cost advisers. These drive an immediate funding requirement as well as a longer term cost of financing the capital invested. The initial ball-park estimates are:

Capital Do minimum Level One & Four

Refurbishment Full

Reconfiguration

Major Extension &

Reconfiguration

Capital estimates 16,000 56,500 118,500 197,000

Optimism bias 47% 51% 53% 49%

Total investment 23,520 85,315 181,305 293,530



4.3.2 Optimism Bias

The Government‟s experience across the many thousands of investments it has funded in the NHS and elsewhere in the public sector is that that cost estimates are almost always overoptimistic at the start of a project. This reflects the tendency of the scope and timescale of projects to change rapidly in the early phases, and for the scheme itself to be more complicated than initially thought. HM Treasury therefore requires the calculation of an “optimism bias” figure to reflect likelihood of these changes over the life of the project – an upper bound figure to reflect how much the project could change. As the project proceeds and is increasingly defined, these areas of doubt are progressively driven our or mitigated. Typically at SOC stage, the upper bound will add between 25% and 75% to project costs, before mitigating actions.

The initial estimates of the current options range between 50% and 60%, with only 10% mitigation at this stage – largely due to the well-established project governance arrangements.

4.3.3 Life cycle costs

It is increasingly recognised that life cycle costs and cyclical reinvestment in facilities generates a significant proportion of the whole investment. These will be quantified, where predictable, and included in the economic assessment.

4.3.4 Activity and Income

Income estimates will be made primarily from the clinical activity that each option supports based on national or local tariffs. There may also be an element of commercial income from retail and dining outlets which each option enables.

4.3.5 Operating costs

The largest single cost element in the life of a building is the operating cost, principally staff, cleaning, energy and maintenance. A well designed and constructed building will reduce all of these. Good layouts and sensible adjacency of related clinical functions can dramatically increase overall productivity and reduce staff downtime and delays in clinical pathways. The major elements are:

Clinical staff in ambulatory, inpatient and operating theatre settings, including medical staff, nursing, and allied health professions.

Administrative and direct support staff, including receptionists, ward clerks and housekeepers.

Cleaning and maintenance.

Direct non-pay costs such as medical and surgical supplies, drugs, and patient dining.

Energy – taking the government‟s carbon reduction commitments into account.

4.4 Risks associated with the options

Each option has its own risk profile, which may stem from financial, strategic, operational, reputational or clinical grounds. These will be assessed in full for the shortlisted options.



4.5 Further work to develop outline business case

To develop the outline business case the options need to be developed in more detail across a number of headings:

Design input to 1:200 scale

Detailed capital cost estimates

Activity, income and expenditure estimates

Discounted cash flow analysis

Option shortlisting and appraisal

Identification of preferred option

Identification of enabling moves and phasing



5 COMMERCIAL CASE

5.1 Procurement options

At this stage a number of procurement options are open to the Trust. The main options that are being considered are:

Conventional OJEU process. This involves the issuing of a notice in the Official Journal of the European Union, inviting expressions of interest, pre-qualification statements and eventually bids from any suitably qualified bidder. This then results in a conventional contract for the construction or refurbishment of buildings to a design which the Trust‟s architects develop. This has the advantage of giving the Trust complete control over the process, but also exposes it to risks in terms of managing the project to cost and quality measures.

Procure 21+ (P21+). Procure 21+ is the Department of Health‟s preferred method of procurement for new builds and refurbishments in the NHS. The benefits of the process are that high quality pre-approved supply chains are available for NHS clients without having to go through EU OJEU tendering procedures. This saves an estimated 6 months in procurement time and significant consequential costs. In addition, clients and their supply chain work collaboratively to develop their scheme using common principles and tools that are proven to deliver quality schemes on time and within budget. The joint design process will be costed on an open book basis with predetermined margins for profits and overheads, and a costed risk pool. The scheme will be delivered within a Guaranteed Maximum Price (GMP), and any remaining funds in the risk pool will be shared between contractor and client.

The procurement route will be selected through a formal process against agreed criteria during the OBC stage.

5.2 Statutory Consents

Planning permission will be required for any major scheme that affects the use of the site visually, or in terms of the impact on traffic or general amenity in the area. Refurbishment options based on maintaining the existing external envelop are unlikely to require any planning permission. While the planning authority (Wandsworth Borough) has a generally helpful view of developments on the site, the process in itself is time consuming and open to challenge and judicial review.

Building control officers will be involved at all appropriate times to ensure and certify that any works are carried out to the required statutory and industry standards.

5.3 Commercial opportunities

The development of clinical facilities for women and children must also dovetail into the need for enhanced entrance, communications and public space of the Lanesborough Wing. This may produce innovative solutions for food, shopping and retail. These in tern may attract a measure of commercial finance if a viable non-clinical income stream can be identified, and this will need to fit happily with the Trust‟s overall commercial and retail strategy.

5.4 Further work to develop the Outline Business Case

Decision on procurement route



Discussions with planning officers



6 FINANCIAL CASE

6.1 Sources of capital funding

The Trust has several potential sources of funds:

Internally generated capital

Loans

Land sales

Charitable funds

Of these, no land sales are likely to be attributable to the project, and internally generated funds are generally taken up to fund the existing capital programme, including backlog maintenance. The potential for loan capital is high and FT status will undoubtedly improve the likelihood of this, and that at which funds can be borrowed from DH and other funding bodies such as the Foundation Trust Financing Facility.

The Trust has been working with St Georges Hospital Charity since 2010 considering options and potentials for fund raising. The latter is represented on the Children‟s and Women's Hospital Project Board. St George‟s Charity Trustees have made a considerable commitment to raising funds for this and related projects including the appointment of a Director of Fundraising and his team, and have set a target of £10m, plus £2m to establish a chair for the university. Of this, a portion will be made available to the Level 5 scheme for children's inpatients. The remainder would be available for use in the rest of the children's and women's developments, some of which would be very attractive to charitable donors.

6.2 Affordability

The high level affordability assessment is based on

Capital costs

Optimism bias

Capital charges

Additional hard and soft FM and energy costs for any new build

Current levels of income

Contribution from income and the impact of the project on contribution

For example, a £20m refurbishment scheme may result in capital charges of under £2m. If the services concerned increase their contribution by a moderate amount (making 50% progress towards trust average levels of contribution), this can be covered within existing income levels. By comparison, a larger scheme such as the full reconfiguration of the wing, could result in £7-8m in capital charges, which would require a 40% increase in activity & income, with substantial progress towards trust average levels of contribution – this is in line with the planned 50% expansion in activity that the scheme must enable.

The more ambitious schemes, however, with large elements of new-build, would also generate large new areas which would need to be cleaned, heated, lit and maintained. This adds a substantial addition cost which would be difficult to cover within the anticipated income levels of children's and women's services alone.



This is illustrated below:

High Level Affordability Assessment Do minimum Level One & Four

Refurbishment

Full

Reconfiguration

Major Extension

&

Reconfiguration

Capital

Capital estimates £000 16,000 56,500 118,500 197,000

Optimism bias % 47% 51% 53% 49%

Total investment £000 23,520 85,315 181,305 293,530

Depreciation Years 25 35 35 50

Impairment % 25% 25% 25% 10%

Gross Internal Area for works

Refurbishment m2 23,700 m2 11,300 m2 23,700 m2 23,700 m2

New Build m2 15,700 m2

Total m2 23,700 m2 11,300 m2 23,700 m2 39,400 m2

Gross Internal Area - endstate

Current - Children's & Women's m2 27,700 m2 27,700 m2 27,700 m2 20,400 m2

Current - Other m2 7,300 m2

New Build - Children's & Women's m2 15,700 m2

New Build - Othe m2

Total m2 27,700 m2 27,700 m2 27,700 m2 43,400 m2

Occupancy costs £/m2 £000 £000 £000 £000

Total 372 £000 - - - 3,795

Capital Charges

Depreciation £000 706 1,828 3,885 5,284

Capital absorption duty 3.50% £000 617 2,240 4,759 9,246

Total 0 1,323 4,068 8,644 14,530

(% of capital investment) % 6% 5% 5% 5%

Total additional cost £000 1,323 4,068 8,644 18,325

Increased contribution potential Low Moderate High Maximum

Increased contribution from 2013/14

income baseline£000 1,335 2,669 4,004 5,339

Remaining requirement £000 - 1,398 4,640 12,986

rate (£/m2)

Contribution from other services 600 - - - 4,380

margin

Affordability gap £000 - 1,398 4,640 8,606

Additional income required to cover costs

(at Trust average contribution margin,

rounded)

12% £000 - 11,750 39,000 72,300

Increase over 2013/4 income required (rounded) % 0% 15% 50% 95%

This indicates that any major expansion of the Lanesborough Wing facility will rely on additional income from other services in the hospital. This is feasible given that a large extension would enable significant additional income to be generated for other specialties.



6.3 Impact on finances

For the OBC, a comprehensive analysis of the preferred option on the Trust‟s financial standing will be undertaken, focussing on:

Financial risk ratio – the investment should maintain or improve the financial risk ratio.

EBITDA – the contribution to overall margin should increase, yielding a higher ratio for the surplus generated before the cost of capital is taken into account.

LTFM – the long term financial model will be adjusted to incorporate the scheme, and the integrated business plan updated accordingly.

6.4 Sensitivity analysis

The sensitivity of the preferred option to changes in the key assumptions, and risks, will be undertaken at OBC stage. The main variables are likely to be:

Higher capital costs than expected resulting from changes to scope or less favourable market conditions.

Lower operating contribution due to higher operating costs ege.g. nationally negotiated pay rises, higher inflation than budgeted for.

Higher finance costs than expected due to government borrowing costs increasing or other sources of finance costing more.

6.5 Further work to develop the Outline Business Case

The OBC will require a detailed analysis of the affordability of the preferred option in both capital and revenue terms, and of the impaction on the Trust‟s overall financial position and balance sheet.



7 MANAGEMENT CASE

7.1 Project management and governance

Trust Board and Trust Management

ExecutiveFinance &

Performance Cttee

Project Board

SOCSteering Group

Level 5 SchemeSteering Group

WorkstreamWorkstream


Workstreams



Workstreams

St George’s Charity

SOC Co-ordinating Group

7.1.1 Project Board

Chair: Peter Jenkinson

The existing Children‟s and Women's Hospital Development Project Board will act as the project board. The overall function of the project board will be to oversee and facilitate the production of the outline and full business case, design and construction of the scheme. It will also manage and key risks and decision points, referring as necessary to the Trust Board.

The Project Board will be responsible for:

Agreeing for the Children and Women‟s Hospital Development strategy

Agreeing PID, terms of reference, critical path and key timescales, risk plan and proposed clinical model

Agreeing programme of communications and stakeholder engagement activities

Agreeing overall shape of business case/consultation document and agreement of any business case/consultation document

At all stages, ensuring progress in line with the project outline milestones; make recommendations to the Trust committees and boards; setting resource limits and approving expenditure with any external third parties commissioned to undertake elements of work.



The chair will report to the Team Management Executive and Trust Board on progress and risks, and refer key decisions to the Trust Board.

The membership of the Project Board:

Role Name

Director of Estates and Facilities Eric Munroe

Children‟s Clinical Lead Bruce Okoye

Women‟s Clinical Lead Aris Papageorghiou

Divisional Director of Operations Sofia Colas

Divisional Director of Nursing Teresa Manders

Divisional Chair for WCDC Andrew Rhodes

Charity Chief Executive Martyn Willis

Charity Director of Fundraising Noel Cramer

Head of Communications Louise Halfpenny

Children's Care Group Lead Richard Chavasse

Clinical Lead – NNU Justin Richards

General Manager Women‟s Services ?

General Manager Children's Services Gavin James

Assistant Director of Finance Kevin Harbottle

PICU Consultant and clinical director for children Jonathan Round

Children‟s Hospital Specialist Nurse Adviser Ruth Meadows

Business case Don West

7.1.2 Coordinating group

Because of the importance of the project to the Trust, a small but senior group will coordinate the development of the SOC. This group will meet fortnightly and report to the project board, and commission work from the workstream leads as required. the group will consist of:

Role Name

Project sponsor Peter Jenkinson

Children‟s Clinical Lead Bruce Okoye

Women‟s Clinical Lead Aris Papageorghiou

Assistant Director, Projects Sharon Welby

Business case Don West

Strategy Director (as required) Trudi Kemp

Finance Director (as required) Steve Bolam



7.1.3 Steering Group

The existing Children's & Women's steering group will take on the role of steering this project. They will be responsible for

Stakeholder involvement internal & external

Providing direction for the project and workstreams

Interactions with networks and commissioners

Overall development budget

Escalation of relevant issues to the Project Board

The Steering Group will be responsible for managing the workstreams within its remit, and will be co-chaired by the clinical leads for women's and children's services. This may be reviewed upon the appointment of the programme director. The workstreams are:

WORKSTREAM WOMEN'S LEAD CHILDREN'S LEAD

Beacon Services Aris Papageorghiou Bruce Okoye

Equipment Kamal Ojha Ruth Meadows

Finance & Analysis Kevin Harbottle

Fundraising Noel Cramer

Innovation including "The Hub" Baskaran Thilaganathan /

Aris Papageorghiou

IT and Data Stergios Doumouchtsis Martin Gray John-Jo Campbell

Marketing & Communications Louise Halfpenny

Outpatients Gavin James

Research & Development University Asma Khalil (TBC)

Space and Design (including retail) Aris Papageorghiou Bruce Okoye

Theatres Renate Wendler

Workforce Teresa Manders Anne Walker

Further Membership:

Sharon Welby Project Manager (for time being)

(tbc) Programme director

Jenny Francis Project Manager

(tbc) Project Coordinator

Robinah Nayiga Project administrator

Don West Business case

The existing and separate steering group will continue to address the scheme to redevelop Level 5 of Lanesborough. The chair of that group is Bruce Okoye.



7.1.4 Programme Director

The programme director will lead the project through to completion and occupation of the new facilities. They will oversee the work of workstreams and steering groups for individual areas of work.

The programme director is to be appointed on a medium term contract in the Spring of 2014.

7.1.5 Project control and reporting:

Project Board will meet monthly on the second Thursday of the month. The Steering Groups will meet monthly in advance of the Project Board. Workstream meetings will take place in the intervening weeks

7.1.6 Roles and Responsibilities

The Trust Board is responsible for the overall success of the project with the Project Team retaining day to day responsibility for the project. Details of the key roles and responsibilities are set out below

Senior Responsible Owner (SRO) - the Senior Responsible Owner will:

o Maintain visible and sustainable commitment to the programme

o Resolve issues that fall outside the Project Sponsor‟s delegated authority

Project Sponsor - the Project Sponsor will:

o Ensure that the project progresses to deliver the objectives set out

o Ensure support from partner agencies to deliver their aspects of the change required to realise the vision set out in the overall Trust strategy

o Ensure that a viable and affordable Strategic Outline Business is produced

o To support and facilitate the Charities Fundraising efforts in pursuit of £10m

o Ensure commitment by all members of the board through construction phase

o Maintain visible and sustainable commitment to the programme

o Resolve issues that fall outside the Project Director‟s delegated authority, including decisions and trade-offs

Project Director - The Project Director will:

o Take the lead responsibility for risk relating to the project and for the realisation of associated benefits – balancing the acceptable level of risk against objectives and business opportunities

o Agree and direct the activity of the project

o Ensure the brief set by the Project Board is adhered to

o Investigate and develop the retail opportunities presented by this scheme

o Provide the key contact in respect of high level decisions required in order to progress work

o Overall responsibility for budget

o Ensure that proper arrangements for decant are in place



o Ensure that the Trust does not incur loss of income in as a result of decant or works associated with this scheme

o Provide overall leadership of the project through implementation and into operational use

o Provide a focal point for external interest in the project

o Manage and control change within the project

Clinical Leads - the Lead Clinicians will:

o Take the lead responsibility for the clinical aspects of the scheme

o Ensure the clinical objectives are defined and met

o Ensure that the project enables the delivery of the clinical services strategy

o Oversee the development of the clinical service model, clinical design brief, and ensure final design solution meets clinical requirements

o Provide the strategic contact for the project

o Ensure internal stakeholders are kept informed on progress including all clinicians i.e. doctors, nurses, AHPs as well as managers

o Ensure the external stakeholder support is provided and is sufficient for the purposes of the business case

o Keep the wider clinical community informed and engaged as necessary including key CCG, relevant Managed Clinical Networks and other providers as appropriate

o Report to the Project Director

Project Manager - The Project Manager will work to the project director to:

o Achieve the project objectives

o Escalate as required any delays or risks

o Provide a point of contact for all stakeholders

o Advise on any matters that may affect the programme in sufficient time that action can be taken to mitigate the risk

o Take responsibility for risk tracking, risk register and mitigation

o Monitor progress against the initial project programme and ensure that key milestones/achievements are met

o Ensure there is a clear audit trail of all works carried out, assumptions used and decisions taken

o Ensure reporting to steering group and project board is relevant and timely

7.1.7 External Advisors

The Trust has retained professional advisors for key elements of the project up to the approval of a;

Architects – (Sharon Welby to advise)

Cost consultants (Quantity Surveyors) – WT Partnership



Town Planning consultants - (Sharon Welby to advise)

Business case development – WT Partnership

7.2 Project plan

The project plan will be set out in detail in the OBC, once the preferred option has been determined. The potential timeframe for completion is set out below:

Step TImescale

Site DPC complete Late 2014

Lanesborough OBC complete Mid 2015

Lanesborough FBC complete Mid 2016

Lanesborough Level 5 scheme complete Mid 2017

Lanesborough main scheme commences Late 2017

Lanesborough main scheme complete 2020

However, this is dependent on clarity on the timescale for the Level 5 scheme and the site development control plan.

7.3 Risk management

There are many risks associated with any project, but the key risks for this scheme are:

Risk Impact Mitigation

Funding availability The scheme will stall if funding sources cannot be identified

Early discussions with funders

Scope creep Creeping scope can add significantly to cost and timescale

Discipline in governance structure to prevent unnecessary changes in scope

Planning restrictions Scheme may be red-lighted until planning consent is available

Early discussions with planning authority

Demand fluctuations Reduced or unpredictable income Continuous dialogue with commissioners and referring clinicians

Staff recruitment and retention

Inability to staff the facility Improved working environment and contract conditions

Delays in construction Delay to opening and hence income coming on stream

Tight contractual conditions and contract management, potentially using P21+

Dependency on other projects

Delays and increased cost Integration of Trust planning processes to ensure dependencies are managed

Trust bed requirements reduce available space for children's and women's services

Reduction in quantity and quality of facilities

Delay in gaining access to facilities for decant or refurbishment

Integration with Trust bed modelling process to identify and act on emerging problems



This will be developed more fully in the OBC.

7.4 Benefits realisation

An outline benefits realisation plan has been set out below, and will be expanded for the OBC submission. The key opportunity is presented by the new design for the facilities and the increased capacity.

Table 1: Benefits realisation plan summary

Name of benefit How it will be realised How it will be measured

Responsibility for delivery

Patient safety is enhanced, in terms of infection control and other safety measures.

50% single rooms and en-suite sanitation

Better patient monitoring technology

Zero MRSA/ Cdiff/ other healthcare acquired infections

Zero SUIs

Project manager

Quality of care is enhanced, in terms of the model of care, and seamless pathways of care and patient choice.

Better physical environment for patients

“Racetrack” approach to theatre management

Co-location of theatres for routine surgery and surgical ward

Consolidation of theatres for high-risk/ complex surgery with PICU

Regular audit of clinical outcomes.

Lower length of stay

Quicker transfers from theatre to ward

Project manager

Patient experience is enhanced, in terms of privacy and dignity, and the quality of environment.

Better physical environment for patients

Child friendly facilities

Parent friendly facilities

50% single rooms

100% en-suite sanitation

Higher patient satisfaction scores

Higher patient recommendation levels

Zero patient complaints

Project manager

Provides enhanced departmental relationships and clinical adjacencies that support clinical effectiveness and improved patient outcomes.

Consolidation of theatres for high-risk/ complex surgery with PICU

Regular audit of clinical outcomes.

Lower length of stay

Reduced time in transit

More efficient staffing

Project manager



Name of benefit How it will be realised How it will be measured

Responsibility for delivery

Provides a dynamic working environment that enhances recruitment and retention, training and education.

Modern ambulatory, theatre and inpatient accommodation

Reduced vacancies

Reduced sick leave

Reduced agency spend

Easier recruitment

Continued educational and training accreditation

Project manager

Provides enough capacity to meet demand, and provides flexibility, for the future and fit with the Trust‟s strategic plans

Additional beds for inpatients

Additional theatres

Local growth accommodated through reduced LOS

Increased used of PAU for emergencies

Strategic shifts in workload accommodated as required

Project manager

This will be enhanced as the project proceeds

7.5 Post project evaluation

Post-Project Evaluation (PPE) is a requirement for all projects of this scale. The trust will ensure that a thorough post-project evaluation is undertaken at key stages in the process to ensure that positive lessons can be learnt from the project. These will be of benefit to:

The trust – in using this knowledge for future capital schemes;

Other key local stakeholders – to inform their approaches to future projects;

The NHS more widely – to test whether the policies and procedures used in this procurement have been used effectively.

Contractors – to understand the healthcare environment better.

The evaluation will examine the following elements, where applicable at each stage:

The effectiveness of the project management of the scheme – viewed internally and externally.

The quality of the documentation prepared by the Trust for the contractors and suppliers.

Communications and involvement during procurement.

The effectiveness of advisers utilised on the scheme.

The efficacy of NHS guidance in delivery the scheme.

Perceptions of advice, guidance and support from the strategic health authority and NHS Estates in progressing the scheme.



Formal post project evaluation reports will be compiled by project staff with external support as required, and reported to the Board to ensure compliance to stated objectives.

Documents

Children's and Women's Hospital - stgeorges.nhs.uk · dn 1. strengthen text on synergies with community children's services (jr) 2221 dn 2. insert summary of concept for institute