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MKBC Theatres & ICU Reconfiguration and Upgrade

Outline Business Case

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Document Control

Document Name MKBC Theatres & ICU Reconfiguration and Upgrade Outline Business Case

Document Version 0.8

Author Kevin Gauld

E-mail [email protected]

Phone number 0845 287 8500

Control Status DRAFT

Document Control

Version Date Reason for issue Issued To Issued By

0.0 15th January 2013 Layout/ Content agreement CL/ RS KG

0.1 28th January Inclusion of all OBC sections CL/ RS KG

0.2 21st February Inclusive of FMcD comment and exemplars

CL/ RS KG

0.3 25th March Further drafting CL/ RS KG

0.4 26th March Further drafting CL/ RS/ BMcW KG

0.5 28th March Further drafting post 28th March OBC Meeting

CL/ RS/ BMcW/ NR/ GM KG

0.6 24th April Further drafting from team CL/ RS/ BMcW/ FMcD KG

0.7 10th June Gateway Review Gateway Review Team KG

0.8 17th June NHSL CIG review NHSL CIG KG

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Contents

1 Executive Summary

1.1 Introduction

1.2 Strategic Context

1.3 Option Appraisal Process

1.4 Commercial/ Financial Position

1.5 Conclusion and Recommendation

2 Strategic Case


2.2 Organisational Overview

2.3 Business Strategy and Aims

2.4 Other Organisational Strategies

2.5 Investment Objectives

2.6 Existing Arrangements

2.7 Business Needs – Current and Future

2.8 Desired Scope/ Service Requirements

2.9 Benefits Criteria

2.10 Strategic Risks

2.11 Constraints and Dependencies

3 Economic Case

3.1 Introduction

3.2 Critical Success Factors

3.3 Main Business Options

3.4 Preferred Way Forward

3.5 The Short Listed Options

3.6 NPC/ NPV Findings

3.7 Benefits Appraisal

3.8 Risk Assessment

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3.9 Preferred Option

3.10 Sensitivity Analysis

4 The Commercial Case

4.1 Introduction

4.2 Potential Scope and Service

4.3 Potential Risk Allocation

4.4 Potential Charging Mechanisms

4.5 Potential Key Contractual Arrangements

4.6 Potential Personnel Implications

4.7 Potential Implementation Timescales

4.8 Potential Accountancy Treatment

5 The Financial Case

5.1 Introduction

5.2 Potential Capital/ Funding Requirement

5.3 Revenue Impact

5.4 Potential Impact on Balance Sheet

5.5 Stakeholder Support

5.6 Overall Affordability

6 The Management Case

6.1 Introduction

6.2 Procurement Strategy

6.3 Project Management

6.4 Change Management

6.5 Benefits Realisation

6.6 Risk Management

6.7 Post Project Evaluation

7 Conclusion

7.1 Summary

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Appendix:

01: Design Statement

02: A&DS/ HFS Letter of Support [will be included in SGHSCD submission]

03: AEDET Workshop

04: Risk Register

05: SWOT Analysis

06: Schedule of Accommodation

07: Letter of Financial Support [will be included in SGHSCD submission]

08: PSCP Stage 1B Programme

09: Schedule of Derogations

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Glossary of Terms

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1 Executive Summary

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1.1 Introduction

This Outline Business Case (OBC) sets out the strategy for the refurbishment and upgrade of

the Theatres and ICU at Monklands District General Hospital.

The completion of the work described in this business case will address potential

environmental risks identified within the theatre and intensive care departments of Monklands

District General Hospital, as well as creating a safer environment for patients in keeping with

21st century standards, and dramatically improving the working environment for staff. These

benefits are entirely in accord with the ambitions of ‘A Healthier Future’.


Monklands District General Hospital was constructed in 1974 and the theatre areas and ICU

are typical of the age of the building.

Different elements of the Theatre/ ICU department have been upgraded at several stages in

the past, with theatres 4, 7 and Recovery having improvement works delivered more recently

however the entire department has not received a co-ordinated overall refurbishment in the

recent past.

During 2009/10 Health Facilities Scotland (HFS), as part of a Scottish Government funded

project, surveyed theatre suites and associated ventilation plant in all Scottish acute hospitals.

Using Scottish Health Technical Memorandum (SHTM) 03-01 – “Ventilation for healthcare

premises” a benchmark was created to determine performance and compliance of the

ventilation plant. Subsequently the outcome of the HFS report advised the Board that the

condition of the Theatre ventilation plant was poor.

In the review of works required to ensure the Air Handling Units’ compliance with the SHTM, it

was noted in reports provided by Capita Symonds in April and July 2012 that the disruption

caused in carrying out any replacement work would be major. The reports also noted that:

The current plant room does not lend itself to replacement with removal being very

difficult due to close proximity of plant, ductwork or building fabric.

Power supply to each theatre to be upgraded and fitted with both UPS and IPS system

along with general upgrade work to general and emergency escape lighting which is

currently non- compliant

Issues with fire compartmentation and escape signage identified in several theatres

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The overall recommendation from the Capita Symonds reports notes that due to the severe

disruption required to the theatre area in order to replace the AHUs initially, and several non-

compliances identified in the theatres regarding ventilation ductwork, fire compartmentation,

and fabric and architectural items, that a programmed theatre upgrade works package be

implemented at Monklands District General Hospital.

NHS Lanarkshire’s quality vision is to achieve transformational improvement in the provision

of safe, person centred and effective care for our patients and for our patients to be confident

that this is what they will receive, no matter where and when they access our services.

To achieve our quality vision, we are committed to transforming the quality of health care in

Lanarkshire through investment in and continuous reliable implementation of patient safety

processes. Through this we aim to:

be the safest health and care system in Scotland

have no avoidable deaths

reduce avoidable harm

deliver care in partnership with patients that is responsive to their needs

meet the highest standards of evidence based best practice

be an employer of choice

develop a culture of learning and improvement, characterised by our values of

Fairness, Respect, Quality and Working Together

The successful completion of the refurbishment and upgrade works will address the

immediate concerns with the plant and fabric of the current facilities, which in turn will allow

solid progress to be made towards both NHSL’s and SGHSCD’s vision for patient care.

1.3 Option Appraisal Process

A detailed process to determine a long list of possible options, assessment of these, and the

development of a short list of options for the refurbishment and upgrade of the Theatres and

ICU has been undertaken.

Following a non-financial benefits appraisal workshop and further financial appraisal, a

preferred option to meet service objectives has been identified. This full process is set out in

detail within this OBC.

The preferred option for the Theatres and ICU has been identified as the full refurbishment of

the existing seven theatres and the construction of a 10 bed ICU adjacent to the existing

theatre suite.

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Sensitivity testing has been carried out from both a non-financial and financial perspective to

confirm that the identified option does not change under different scenarios and this has been

clearly shown to be the case.

1.4 Commercial/ Financial Position

The refurbishment and upgrade will be delivered through the Frameworks Scotland 2

procurement route and this OBC has been developed in accordance with those requirements

and also the Scottish Capital Investment Manual.

Capital Costs of the project are as follows:

Table 01: Capital Costs of the Refurbishment and Upgrade of Theatres and ICU

Total Cost

£000’s

Works Costs 15,025

Fees 411

Irrecoverable VAT 2,470

Total Capital Cost 17,906

These capital costs will be funded initially through NHSL formula funding, with treasury

funding being noted as potentially available in 2016-17 and 2017/18. Work to define the exact

requirements will be taken forward for the submission of the Full Business Case (FBC).

Total recurring annual revenue costs of £0.23m are to be funded by the NHSL Board. Further

examination of the efficiencies and opportunities for revenue release will be undertaken in the

development of the FBC.

1.5 Conclusion and Recommendation

Providing the refurbishment and upgrade to the Theatres and ICU at Monklands General

Hospital will improve patient experience whilst offering modern services locally to where

people live. As a central element of the proposal this will enable the meeting of the challenges

of implementing NHS Scotland’s ‘Route Map to the 2020 Vision for Health and Social Care’

(2013).

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The Preferred Option, to refurbish the existing seven theatres alongside the construction of a

new build 10 bed ICU represents the best investment to provide the required services going

forward. It is the best value option, as has been demonstrated throughout this document, and

would fulfil the drivers identified in this OBC. These new facilities would provide a 21st century

environment that would meet the needs and aspirations of the patients within NHS

Lanarkshire.

Approval of this OBC will ensure that the project can move at pace towards the development

of the Full Business Case for this critical project.

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2 Strategic Case


The Scottish Government published their 2020 Vision in September 2011 which sets out the

actions required to achieve sustainable quality in Scotland’s Healthcare system. This strategic

narrative, set out by the Cabinet Secretary for Health and Wellbeing, provides the context for

taking forward the implementation of the Quality Strategy, published in May 2010, and the

actions required to improve efficiency and achieve financial sustainability. The vision is shown

in the box below.

Our ‘2020 Vision’

Our vision is that by 2020 everyone is able to live longer healthier lives at home, or in a homely

setting.

We will have a healthcare system where we have integrated health and social care, a focus on

prevention, anticipation and supported self management. When hospital treatment is required, and

cannot be provided in a community setting, day case treatment will be the norm. Whatever the

setting, care will be provided to the highest standards of quality and safety, with the person at the

centre of all decisions. There will be a focus on ensuring that people get back into their home or

community environment as soon as appropriate, with minimal risk of re-admission.

Source: Scottish Government, September 2011

In response to this vision NHSL has developed and published a framework for Strategic

Health Planning: ‘A Healthier Future 2012-2020’ to support future strategic health planning

and to facilitate definition of the actions required to achieve the Scottish Government’s 2020

Vision. This strategic framework will support NHSL to achieve the implementation of the 2020

vision and ensure that service change and developments are based upon the three Quality

ambitions of Patient Centred, Safe and Effective and enable improved efficiency and financial

sustainability within the Board.

NHS Lanarkshire’s quality vision is to achieve transformational improvement in the provision

of safe, person centred and effective care for our patients and for our patients to be confident

that this is what they will receive, no matter where and when they access our services.

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We know that following an intensive review by Healthcare Improvement Scotland of NHS

Lanarkshire’s acute adult patient services in 2013 serious failings and unacceptable practice

were identified. We also know that UK and international evidence shows that up to 25 per

cent of patients experience a safety incident while in hospital. We do not believe this is

acceptable for our patients.

To achieve our quality vision, we are committed to transforming the quality of health care in

Lanarkshire through investment in and continuous reliable implementation of patient safety

processes. Through this we aim to:

be the safest health and care system in Scotland

have no avoidable deaths

reduce avoidable harm

deliver care in partnership with patients that is responsive to their needs

meet the highest standards of evidence based best practice

be an employer of choice

develop a culture of learning and improvement, characterised by our values of

Fairness, Respect, Quality and Working Together

The completion of the work described in this business case will address potential

environmental risks identified within the theatre and intensive care departments of Monklands

District General Hospital as well as creating a safer environment for patients in keeping with

21st century standards, the working environment for staff will be dramatically improved. These

benefits are entirely in accord with the ambitions of ‘A Healthier Future’.

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2.2 Organisational Overview

NHSL serves a population of 600,000. The NHS Board is conterminous with North and South

Lanarkshire Councils. The legal entity is the Lanarkshire NHS Board. Within this, operational

delivery of all clinical services is organised around an Acute Services Division and two Health

and Social Care Partnerships (from 1st April 2015) – one for North Lanarkshire and one for

South Lanarkshire.

The principal role of the NHS Board is the protection and improvement of the health of the

resident population, and the delivery of high-quality, patient-focused services. Specifically, the

key functions of the NHS Board, for which it is accountable to the Scottish Government Health

& Social Care Directorates, on behalf of the Cabinet Secretary for Health and Wellbeing are:

Set the strategic direction of the organisation within the overall policies and priorities of

the Scottish Government and the National Health Service in Scotland

Define its annual and longer term objectives, and agree plans to achieve them

To oversee the delivery of planned results by monitoring performance against

objectives and ensuring corrective action is taken when necessary

To ensure effective financial stewardship through value for money, financial control

and financial planning and strategy

To ensure that high standards of Corporate Governance and personal behaviour are

maintained in the conduct of the business of the whole organisation

To ensure there is effective dialogue between the NHS Board, other agencies,

particularly North and South Lanarkshire Councils, and communities, on its plans and

performance, and that these are responsive to the communities’ assessed needs

The document which sets out how the NHS Board is expected to ensure the discharge of

these responsibilities is the Local Delivery Plan (LDP), constructed around the HEAT targets,

issued to the service each year by the Scottish Government Health and Social Care

Directorates (SGHSCD).

NHSL employs approximately 12, 000 staff and provides services in over 100 properties of

varying sizes. It has 3 District General Hospitals – at Wishaw, Hairmyres (East Kilbride) and

Monklands Hospital. The hospitals at Wishaw and Hairmyres were procured through the PFI

process and both opened in 2001 – the first PFI District General Hospitals in Scotland.

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The Board has an annual expenditure of £1,074m in the provision of all health services in

Lanarkshire. The NHS Board comprising of Executive and Non Executive Directors meets

monthly in public and has established a rigorous approach to performance management

across a wide range of indicators with detailed reports provided either monthly or more

frequently as appropriate.

Included in the Non Executive membership of the Board are the leaders of both North and

South Lanarkshire Councils. This is a clear demonstration at the highest level of the

commitment to integrated working between health and local authorities to improve the health

and well-being of the people of Lanarkshire.

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2.3 Business Strategy and Aims

The Scottish Government’s requirement to take forward the Quality Agenda through the 2020

Vision, the need to achieve financial sustainability and the need for improving the efficiency of

service delivery are all key drivers for NHS Boards to implement. ‘A Healthier Future 2012-

2020’ is flexible and has been developed to ensure that service changes and developments

can be assessed against a framework of strategic priorities. This will assist with prioritisation

and the approach to implementation.

This strategic framework will ensure that all service change and developments are assessed

against a clear criteria developed and will also ensure that all proposed actions move towards

the clear objectives of the 2020 vision. It is not a plan of specific service changes but a

framework against which service changes can be clearly and openly tested before

implementation. To undertake future changes without such assessment against the criteria

will not be acceptable.

The framework sets out the aims of NHSL for the period 2012-2020 and highlights the

intention of the Board to deliver the best quality of services to its patients.

The development of the framework for strategic health planning highlights a number of key

strategies and documents which set out plans and actions for developing services that

underpin the Board’s desire to improve patient care and offer improved access to services.

These plans will improve and develop clinical services within NHSL to reflect national

strategies and priorities. In particular, the strategies include:

Diagram 01: Strategies

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These are underpinned by other strategies and plans but are specifically linked to a detailed

workforce development plan, the property strategy and a five-year financial plan.

The specific detail of individual actions within plans which require to be implemented in

2014/15 is consolidated within the Board’s Local Delivery Plan (LDP) which sets out key

organisational objectives and provides a mechanism to record progress in achieving and

complying with HEAT targets.

The method of service delivery is always evolving and the key to successful investment in

property is the ability to design facilities which meet our existing needs but can be flexible to

change to meet our future needs within the confines of a defined space. Investment should

also provide the opportunity for property to be enhanced in future if services needs and

resources demand this.

NHSL is responsible for the assessment of healthcare needs and for ensuring that a full range

of services are in place to meet these needs. This is undertaken against a background of

challenges and competing priorities.

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2.4 Other Organisational Strategies

We are translating our action plan for the Healthcare Improvement Scotland Rapid Review

into a three year quality strategy, Transforming Patient Safety and Quality of Care in NHS

Lanarkshire, Healthcare Quality Assurance and Improvement Strategy 2014-17, to support the

on-going implementation of ‘A Healthier Future’ (NHS Lanarkshire’s strategic framework

taking forward the 2020 Vision) and to deliver against our quality vision. This will be a NHS

Lanarkshire wide strategy which will ensure that the initiatives and improvements commenced

in the acute hospitals are applied across all of our services.

The provision of a safe and effective healthcare environment for the provision of patient care

is an essential part of this transformational quality strategy, and is articulate with the Property

and Asset Management Strategy 2014 (PAMS).

The work of clinicians and support staff in operating theatres and intensive care can be

intense and demanding. The current facilities within Monklands do not meet the standards set

for a modern healthcare facility. The benefits to be achieved by this programme of works are

significant and will also support then ambition of NHS Lanarkshire to be an employer of choice

through providing a 21st century working environment for our staff.

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2.5 Investment Objectives

The proposed investment has a number of key objectives which can be presented in the broad

categories of:

Diagram 02: Key Objectives

At an overarching level the proposed investment will:

Strategic/ Service:

Enable NHSL to achieve the objectives set out in the Scottish Government’s 2020

vision

Enable NHSL to achieve it’s the objectives set out in ‘A Healthier Future 2012-2020’

Design:

Achieve a high design quality in accordance with the Board’s Design Action Plan and

guidance available from HFS, A+DS and CABE

Meet statutory requirements and obligations for public buildings e.g. with regards to

DDA, HEI, HAI

Follow NHS Technical Guidance where appropriate

Work towards a BREEAM Healthcare rating of ‘Good’ under the HFS BREEAM

Pragmatic scheme

Improve flexibility through increased standardisation

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Sustainability:

Deliver more energy efficient facilities within the NHSL estate contributing to a

reduction in whole life costs

Deliver facilities that provide value for money within the affordability caps set

Ensure ongoing financial sustainability in provision of services

Patient Experience:

Improved service coordination

Improved physical environment

Quality Strategy

The investment objectives have been designed to ensure that the Scottish Government 2020

vision is taken forward effectively and that the three quality ambitions are achieved. The

achievement of the three quality ambitions will ensure:

Person Centred

Implement service models which support the services’ strategic objectives by

optimising the quality of seamless care delivered for patients in Lanarkshire

Ensure that care is structured around the needs of patients and delivered through an

integrated (inpatient and community) pathway as agreed with the NHSL Strategic

Programmes

Embed integrated health and social care models of care to provide well co-ordinated,

flexible and responsive services to patients and their carers

Safe

To provide a physical environment that complies with modern standards of healthcare

and that promotes the safety, dignity, and privacy of all patients in purpose-built

facilities that significantly improve the patient experience

To create an environment which supports the improvement of HEI standards

Effective

To provide a therapeutic environment which allows the delivery of more appropriate

care that benefits patients and provides staff with improved conditions to deliver clinical

care

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To reduce costs with more efficient/ sustainable facilities and infrastructure, supporting

integrated Health & Social Care delivery

Specific investment objectives for this project are:

Table 02: Investment Objectives

Primary Objective Achieved Outcome Measured By Timescale

Safe and Compliant Theatres & ICU

Compliance with applicable SHTMs & SHFNs (SHTM 02/01; 03/01; SHFN 30) and other statutory requirements i.e. Health and Safety at Work Act/ Environmental Protection Act/ Controlled Waste Regulations/ Fire Scotland Act/ Electricity Work Regulations

Improved communication between surgical and critical care teams through provision of facilities

Compliance with Building Regulations

Design Team Due Diligence

CDMc

HAI Scribe

SHFN 30

NHSL Health and Safety Team

Specialist Consultant (Theatres)

Risk Register

Monklands Investment Board/ MKBC Project Team/ Core Group

Improved Audit Outcomes

Continual assessment

Upon completion of works

Sustainability of Service in an Energy Efficient manner

Whole life cycle costs reduced

Reduced Maintenance downtime

Redundancy built into system (duality)

BREEAM score

Whole Life Cycle costs

Reduced Carbon Footprint

Building Performance Indicator

Operation and Maintenance Manuals

Design/Technical/ Energy Team review of Design

Upon completion of works

Clinical Service maintained through Duration of Works

Minimised disruption to the Clinical teams in carrying out work

Maintaining uninterrupted clinical services

7 Operating Theatres and 6 ICU beds available throughout works

Separation of clinical and construction egress and access and monitoring of same

Throughout works

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Efficiency within the department leading to best practice and improved service delivery

Improved Patient flow from pre operative to post operative

Better bed space size

Better decontamination leads to improved productivity in endoscopy

More flexible usage of clinical spaces

Each theatre has anaesthetic room

Doubling number of laminar flow theatres

Reduced HAI Risk

Segregated paediatrics

Reduced length of stay

Improved turnover times in theatre

Design team review

On completion of works

Providing better working environment

Improved changing facilities

Improved catering facilities

Improved space utilisation and functional suitability through increased Theatre and ICU space

Improved Training facilities

Improved control over temperature and air circulation

Improved storage

Improved patient safety

Design Team Due Diligence

Compliance with Building Regulations

CDM

HAI Scribe

NHSL Health and Safety Team

Specialist Consultant (Theatres)

Risk Register

Monklands Investment Board/ MKBC Project Team / Core Group

Less down time through on- site training facilities and higher quality training environment

On completion of works

Improved facilities for carers and relatives

Segregated relative waiting and confidential interview rooms

Relative experience surveys

Ongoing

This investment will undoubtedly facilitate the modernisation of healthcare delivery at

Monklands District General Hospital. It is generally accepted that well designed health

buildings are conducive to the maintenance of good physical and mental health, and have a

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positive effect on staff performance and retention. Such facilities should also improve the

efficiency of operational relationships and provide better value for money in terms of whole-life

costs. The objectives identified in this OBC are set within this context.

Design/ Quality Objectives

NHSL is committed to the integration of design quality throughout the project. A Design

Statement has been prepared through consultation and workshops with the key project

stakeholders.

The design statement sets out in detail the specific objectives to be achieved and sets out a

series of key, non-negotiable performance criteria related to patients, staff and visitors. It

defines benchmarks for how the design will help to deliver these objectives.

The design statement is the key briefing document for the Technical Team and has been used

to inform the more detailed briefing documents such as the Schedules of Accommodation, key

adjacencies and the room data sheets as the design progresses into Stage D. The design

statement is attached as Appendix 01.

A design submission for the project was made to HFS and A+DS in line with the NHS

Scotland Design Assessment process at this Outline Business Case stage on 19th March

2014. The project team is currently engaged in an open dialogue with the HFS team in order

to achieve a supported status for the scheme.

NHS Lanarkshire is committed to developing excellence in building design and providing fit for

purpose facilities for the patients they serve in Lanarkshire.

To this end the Project is using the Achieving Excellent Design Evaluation Toolkit (AEDET) to

assess design quality throughout the procurement process and an initial Workshop was held

on Monday 10th March 2014 to review the design at Stage C. A further workshop is planned

for early July which will measure the progress made through the Stage D design.

The summary of this AEDET Workshop can be seen below, with the detailed report included

in Appendix 03.

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Diagram 03: AEDET Summary

There will be further AEDET reviews throughout the project ensuring that every category

scores higher than 4.0.

Sustainability Objective

NHS Lanarkshire is committed to developing sustainable, fit for purpose facilities for the

communities served in Lanarkshire and to that end a BREEAM Assessor was appointed early

in the planning and design process. It has been agreed with SGHSCD that the new BREEAM

Pragmatic Scheme being undertaken by Health Facilities Scotland will apply to the Project.

The design team is acutely aware of client requirements, and working in collaboration with

both NHSL and HFS throughout the process of design development, has considered all

aspects of the design throughout the life of the proposed works in order to achieve the

maximum value for money and energy efficiency that can be driven through BREEAM.

An initial BREEAM workshop, attended by HFS, was held on 14 February 2014. Through a

detailed review of all the potentially available credits against the potential maximum credits for

the projects it was recognised the project currently sits in a range which achieves a ‘GOOD’

rating through an agreed Target Score of 45.

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Diagram 04: Current BREEAM Target Score

As noted previously, early engagement has been undertaken with HFS as part of the NDAP

submission for the project. An element of ongoing discussion is to ensure that the highest

possible score is achieved under the BREEAM Pragmatic route, with a practical view being

taken as to which credits are most suitable/ cost effective for the proposed works.

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2.6 Existing Arrangements

2.6.1 Building and Fabric

Monklands District General Hospital opened in 1974 and the theatre areas are typical of the

age of the building with construction comprising of concrete floor slabs, brickwork walls and

metal stud/ plasterboard partitions, ‘waffle’ concrete soffits/ slab above ceiling voids. Corridor

and circulation areas have dated perforated steel ceiling panels spanning the width of the

corridor. Different elements of the Theatre/ ICU department have been upgraded at several

stages in the past, with theatres 4, 7 and Recovery having improvement works delivered more

recently however the entire department has not received a co-ordinated overall refurbishment

in the recent past. Alterations have been made to the original layout - some of which have

enhanced and some which have detracted from the original systems - and in some cases

these have not been fully integrated with the relevant Hospital systems or design. The central

core area is located between the two circulation corridors adjacent to the north and south

theatres and a large proportion of the core area is taken up with the TSSU.

The existing AHUs serving the Theatre and associated areas are the original units, in excess

of 35 years old and are now beyond the end of their economical lifespan.

The Theatres are served by packaged Air Handling Units located in the first floor plantroom.

These units provide conditioned supply air to the theatres. Conditioned supply air is introduced

into the theatre space via high level linear diffusers The primary supply air is drawn from a

brick built plenum chamber, which is common to all surgical unit AHU’s located in the

plantroom. Due to the age of the AHUs, spare parts are difficult to obtain and any AHU

breakdown has the potential to cause significant business continuity issues.

During 2009/10 Health Facilities Scotland (HFS), as part of a Scottish Government-funded

project, surveyed theatre suites and associated ventilation plant in all Scottish acute hospitals.

The Monklands District Hospital theatre suite was surveyed on 12th January 2010.


premises” (awaiting publication at that time) a benchmark was created to determine

performance and compliance of the ventilation plant. Subsequently the outcome of the HFS

report advised the Board that the condition of the Theatre ventilation plant was poor.

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NHS Lanarkshire placed the Theatre ventilation risk onto the Monklands Business Continuity

Risk register, and put in place interim control measures with Maintenance Services and

Infection Control to ensure that any risk exposure to patients was monitored.

In the review of works required to ensure the AHUs compliance with the SHTM, it was noted in

subsequent Capita Symonds reports of April and July 2012 that the disruption caused in

carrying out any replacement work would be major. The reports also noted that:

The current plant room does not lend itself to replacement with removal being very

difficult due to close proximity of plant, ductwork or building fabric.

Power supply to each theatre to be upgraded and fitted with both UPS and IPS system

along with general upgrade work to general and emergency escape lighting which is

currently non- compliant

Issues with fire compartmentation and escape signage identified in several theatres

The overall recommendation from the Capita Symonds reports notes that due to the severe

disruption required to the theatre area in order to replace the AHUs initially, and several non-

compliances identified in the theatres regarding ventilation ductwork, fire compartmentation,

and fabric and architectural items, that a programmed theatre upgrade works package be

implemented at Monklands District General Hospital.

2.6.2 Theatres:

The existing theatres currently provide a range of services to patients undergoing both major

and minor surgery, including two centralised services in Urology and Ear, Nose and Throat

Maxillofacial.

Since the construction of the theatres there have been many developments in associated

technologies such as laparoscopic and lasers which has led to additional items of equipment

being added to the existing space. This has impacted the theatres whereby they are no longer

of a suitable size to manage all of the required equipment, hindering flow and productivity

through the area. There has also been an impact on certain procedures e.g. certain

anaesthetic blocks due to the rooms being of inadequate size to accommodate the patient,

staff and equipment in the same space.

The flow of patients is also problematic as both male and female pre and post operative

patients are located in the same area, segregated only by a small partition which brings with it

issues around patient privacy and dignity. Similar issues exist with paediatric patients as there

is no current area where they can be segregated from adult patients.

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To compound matters the existing operating theatres are also fully utilised, leaving very limited

opportunity for planned maintenance. Loss of any operating rooms through AHU failure would

have a considerable impact on NHS Lanarkshire’s ability to provide surgical care. This would

result in cancellation of operations, an increase in waiting times and provide a potential risk to

patients.

2.6.3 ICU

2.6.3.1 Critical Care Needs Assessment:

NHSL undertook a comprehensive needs assessment in 2011, the data from which

demonstrated an inadequacy of Level 3 beds and Level 1 beds, with a satisfactory availability

of Level 2 beds.

Critical Care beds are defined as Level 1, 2 or 3. The following is the standard UK definition

for the category of patient housed in these beds:

Diagram 05: Critical Care Bed definition

The current situation in Monklands displays a disparate scattering of critical care throughout

the hospital:

Stand alone 6 bedded ICU (Level 3) situated next to the theatre complex on the

ground floor.

Stand alone 8 bedded surgical HDU within the surgical tower on the 2nd floor. Funded

for 8 HDU surgical patients from all disciplines within the surgical directorate (Level 2).

4 General medical HDU beds within ward 18 on the medical tower (Level 2). This ward

also has 6 CCU beds and step down cardiology beds.

Level 1: Patients at risk of their condition deteriorating, or those relocated from higher levels of care whose needs can be met on an acute ward with additional advice and support from the critical care team Level 2: Patients requiring more detailed observation or intervention including support for a single failing organ or postoperative care, and those stepping down from higher levels of care Level 3: Patients requiring advanced respiratory support alone, or basic respiratory support, together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure

29

2 renal HDU beds within ward 1 Renal Unit (Level 2). This ward lies separate to the

main hospital on the ground floor linked by a glass corridor.

Analysis of the 2011 study revealed that 50% of patients within surgical HDU actually required

Level 1 care. Simply translated this means that 4 out of the 8 beds effectively operate at Level

1.

Since the needs assessment was carried out, further pressure on the availability of surgical

HDU beds has arisen due to the increase in major operating on the site, particularly within

Urology.

2.6.3.2 Planned Redevelopment:

For the short to medium term, restructuring of beds within the surgical tower at Monklands, in

particular ward 4a (Emergency Surgical Receiving Unit), ward 4 (General Surgery), ward 5

(Surgical HDU), ward 6 (Urology) and ward 7 (General Surgery) has started and ongoing

discussions are underway to address the following patient centred, safe and effective

developments:

Introduction of a 4 bedded surgical GP assessment bay within the ESRU (Ward 4a)

open 08.00 – 18.00 Monday to Friday

The need for more beds providing heightened level of care post- operatively due to the

nature and volume of major surgery on the site

The launch of an enhanced recovery programme to improve the perioperative quality

of care

The requirement to expand the same day admission unit

The expansion of inpatient Urology bed numbers

2.6.3.3 Hospital Wide Operational Impact:

The CCNA suggests that a number of Level 1 beds are needed on the site and the Enhanced

Recovery Programme as applied to major urology and colorectal cases requires support. For

the surgical directorate, up to 8 Level 1 beds would satisfy these demands. If 4 of the current

Level 2 surgical HDU beds were relocated to a combined ICU/ HDU this would theoretically

leave nurse staffing for 4 Level 2 beds on ward 5. This resource would provide the basis for

safe staffing of Level 1 beds in the surgical tower.

As outlined above, existing preliminary plans to redevelop and re- designate beds within the

surgical tower would allow the development of a Level 1 surgical HDU which could house

appropriate postoperative and emergency non- operative surgical cases. The overall impact

30

is freeing up of beds within the surgical tower proportionate to the number of additional beds

provided within a combined ICU/ HDU.

Through progression of this OBC an opportunity would arise to improve the standard of critical

care delivered on the Monklands site. As part of the essential theatre refurbishment the first

major phase of the project would involve the relocation of the current Intensive Care Unit to a

10 bed ICU in a standalone building next to the current geographical locus providing the

ongoing benefits of a ground floor placement and proximity to the main operating theatre

complex.

A larger 10 bedded combined ICU/ HDU will afford greater flexibility, greater workforce

efficiencies, greater business continuity options, greater training potential and ultimately better

patient care in line with the quality ambitions of the Scottish Government Healthcare Quality

Strategy.

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2.7 Business Needs – Current & Future

Current Business Needs

The current situation with the 7 operating theatre facilities on the Monklands site is such that

scheduled cases are planned across a 6 day working week with evenings and weekends held

open for emergency cases.

The ICU service is adjacent to the theatre complex. The current service provision is 5 beds in

this area. This area is undersized in relation to the healthcare standard Scottish Health

Planning Note 27, which consequently has an impact on its operational functionality

As part of a Scottish Government-funded project Health Facilities Scotland surveyed theatre

suites and associated ventilation plant in Scottish acute hospitals in 2010. As part of that

initiative the plant serving the Monklands District Hospital theatre suites was surveyed on 12th

January 2010.


premises” a benchmark was created to determine performance and compliance of the

ventilation plant. The subsequent outcome of this report advised the Board in February 2011,

that the condition of the Theatre ventilation plant was scored as poor.

The exposure to patients and staff is further compounded through non-compliance with other

healthcare technical memorandum and healthcare standards such as Firecode, Fabric

condition and CIBSE lighting standards. However the standards of Infection Control (Scottish

Health Facilities Note (SHFN) 30) are compromised as perioperative infection, staff safety due

to the non-compliant size of the theatres and fabric condition have increased the risk rating in

conjunction with the ventilation issues to that of ‘High’.

NHS Lanarkshire placed the Theatre refurbishment onto the Monklands Business Continuity

Risk register and subsequently put in place interim control measures of additional

environmental monitoring through Maintenance Services and Infection Control to ensure that

any risk is minimised.

Future Business Needs

The number of Theatres remains the same under the refurbishment scheme as the physical

footprint available will not permit expansion, however they will be significantly improved with

regards to current healthcare guidance post works completion.

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It is also acknowledged that providing additional theatres within the envelope would also result

in smaller theatres and thus non- compliance with the healthcare standards once again.

To accommodate any expansion in theatre/ patient activity, the existing Day Surgery provision

on site will be used to take up any future increase.

ICU will be expanded into a combined ICU/HDU with the capacity of 10 beds ensuring

compliance with healthcare guidance.

The areas that require improvement to ensure that the service and the facilities comply with

legislation and healthcare guidance are as follows:

Functional suitability

Space utilisation

Physical Condition

Quality of patient care

Ventilation

HEI

Control of Infection

Fire Safety

Energy use

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2.8 Desired Scope/ Service Requirements

The Theatre suite in Monklands Hospital is now over 30 years old and no longer meets the

requirements for patient management in the 21st century. The physical infrastructure

including; air handling systems, size of theatres and anaesthetic facilities does not meet

current standards. Moreover, the current environment limits both the efficiency of theatre and

the type of surgery that can be carried out.

The theatre suite has always achieved compliance with Health Environment Inspections (HEI)

guidelines and Patient Safety Requirements. However, there are now regular issues with the

theatre environment that are cause for concern both in the short and longer term.

Maintenance of the theatre infrastructure is now proving more challenging and structural

issues are becoming more frequent with a high risk of treatment delays and list cancellations.

The main theatre suite accommodates seven theatres (Table 03). A further two Day Surgery

theatres are located in a standalone unit in a separate location. The Day Surgery Unit (DSU)

is outwith the scope of this project, although the resulting redesign of flow in main theatre will

also help improve the use of DSU.

Table 03: Theatre Specialty Allocation

Theatre Specialty

Theatre One Urology Theatre Two General Surgery Theatre Three Urology Theatre Four Orthopaedics (Laminar flow) Theatre Five Ear, Nose and Throat /Vascular Theatre Six Ear Nose and Throat / Oral and Maxillofacial Surgery Theatre Seven Emergency / Trauma

All sessions are currently allocated (Table 04) and theatres are generally view as at full

capacity (for core hours working). The theatres work flexibly to ensure that theatre sessions

run as seamlessly as possible. There are some notable restrictions; theatre four is the only

theatre with Laminar flow facilities. Theatre Seven is smaller than the other theatres and is

reserved for emergency / trauma work.

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Table 04: Allocated theatre sessions Mon – Friday by specialty based on a 42 week year. Excludes cepod and on call.

Specialty Annual Allocated Theatre Sessions Mon – Fri (based on 42 week year)

Ear, Nose and Throat 639 General Surgery 651 Oral and Maxillofacial Surgery 168 Orthopaedics 336 Urology 630 Vascular / Cardiology 33 Total: 2,457 The demand for additional operating time continues to increase and the complexity of surgery

has also grown over recent years (Table 05). Weekend and evening lists are currently

arranged on an as required basis through Waiting List Initiatives. This is to ensure full

compliance with 12 Time to Treatment Guarantees (TTG), which is now a legal right for

patients. In response to the ongoing demand the organisation is exploring both 3 session days

and 7 day working. However, the current theatre configuration is unlikely to be able to support

or sustain these developments.

This project will not provide any additional theatres, however the upgrade in space and

infrastructure will provide a stable environment that will facilitate the growing complexity of

procedures (accommodating increased number of staff and equipment in theatre) and enable

further modernisation of services.

Table 05: Number of Inpatient Procedures by Specialty and Main Theatre Utilisation April 13 – March 14. (Excludes DSU)

Specialty Annual Procedures and Theatre Utilisation Elective Main Theatre

Utilisation Emergency

Ear, Nose and Throat 1309 92% 957 General Surgery 1082 96% 2707 Oral and Maxillofacial Surgery 285 114% 244 Orthopaedics 458 93% 1376 Urology 1525 108% 1167 Vascular 42 74% 6 Cardiology 34 79% 342

Total Procedures: 4735 6799

Surgical Specialties

Three concentrated surgical specialties have their inpatient base within Monklands Hospital,

Ear, Nose and Throat (ENT), Oral and Maxillofacial Surgery (OMFS) and Urology. As a result

35

all inpatient surgery, for these specialties, is restricted to Monklands Hospital. In addition,

Urology and ENT are high volume specialties and consequently place a high demand on

theatre time. This is an important consideration as these services cannot be easily relocated

either within Lanarkshire or externally.

Urology surgical procedures range in complexity from minor surgery to complex corrective or

cancer surgery. The service has seen a major increase in cancer surgery and the incidences

of Urology cancer is predicted to increase significantly over the next three years. This includes

prostate (49%), Kidney (21%), bladder (13%) and testicular cancer (6%). This has

implications not only in terms of the volume of surgery but also in complexity and developing

surgical techniques.

The wide spread move to laparoscopic surgery has placed considerable demand on theatre

time with many Urology procedures now require anything from one to three sessions per

patient. The demographic makeup of urology referrals is an indicator for future demand with

74% of patients in the over 50 year age group. Unfortunately, these patients often have other

health issues and specific anaesthetic requirements placing additional pressure on ITU /HDU

facilities post operatively.

In contrast to Urology, Ear, Nose and Throat (ENT) patients span a wide range of ages and

Paediatric surgery is a main feature of the ENT workload. This creates additional challenges in

achieving appropriate segregation of operating lists and recovery space within the theatre suit

to comply with paediatric guidelines. The redesign of patient flow and space included in the

project proposals will resolve these issues.

One of the main issues for ENT is patient volume with a high number of routine procedures. It

is planned to reflow a proportion of ENT procedures to DSU. However, this requires a number

of elements to be put in place relating to organisation, flow and recovery space which will be

influenced by this project. In addition, 15% of referrals for patients with ear problems convert

to surgery. This is intricate surgery (including Myringoplasty and Stapedectomy) with these

procedures often taking one session and requiring the continued use of a microscope during

surgery. This has been noted as an issue during works, as excessive vibration can disturb

these procedures.

Three ENT consultants also make up part of the NHS Lanarkshire Head and Neck service.

This forms the bulk of major and complex surgery in ENT including; Thyroidectomy and

36

Laryngectomy. NHS Lanarkshire has the third highest incidence of Head and Neck Cancer in

Scotland, therefore, this type of surgery will continues to increase.

Oral and Maxillofacial Surgery (OMFS) is the third concentrated specialty on the Monklands

site. This is a much smaller specialty in terms of numbers but treats a high proportion of facial

trauma including; fractures to the malar, maxilla and mandible.

OMFS makes up the remaining part of the Head and Neck service performing complex

surgery on floor of mouth cancer including facial reconstruction. The remaining elective

procedures focus on Orthognathic surgery. The procedures undertaken in both types of

surgery require one to three sessions per patient.

The Orthopaedic department provides a range of joint surgery including knee and hip

replacements as well as revisions. This type of surgery is currently restricted within Monklands

Hospital as only theatre four contains a laminar flow system. It is proposed that this will be

expanded to a second theatre as a result of this project.

Trauma also forms a major part of the orthopaedic workload. Monday to Friday there are 5

morning theatre sessions dedicated to trauma. During their on call week the orthopaedic

surgeons elective lists are backfilled to further increase capacity.

General surgery includes a range of sub specialties including colorectal surgery and breast

surgery. The increase in colorectal cancer and resulting increase in complex bowel surgery

has been an ongoing issue in accessing theatre space.

As with other specialties there has been a move to laparoscopic surgery for Gallbladder

surgery and Hernia. The benefits in this type of surgery are well known for patients and

include a quicker recovery and reduced length of stay in hospital. However, in theatre terms

these procedures take longer, demanding more theatre time and require additional equipment

and staff in theatre.

Trauma and Emergency access is required by all surgical specialties within Monklands

Hospital. Theatre 7 accommodates emergency surgery 24 hours a day, 7 days per week.

Monday to Friday the morning sessions of the emergency lists are given to orthopaedic

trauma. In addition, each surgeon gives up a session of their allocated theatre time on a

rotational basis to provide a daily morning CEPOD list.

Critical Care

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As part of the refurbishment of theatre the first major phase requires the relocation of the

current intensive care unit (ICU). It has been agreed that a ten bedded unit will replace the

current 6 bedded ICU and 8 bedded High Dependency Unit (HDU) (Table 06). This will move

to a combined unit staffed to enable flexing up and down between levels of care depending on

site demand. The location of the replacement unit has been identified and construction can

take place with minimal disruption to the existing facilities.

Critical Care Needs Assessment

NHS Lanarkshire undertook a comprehensive needs assessment in 2011. This demonstrated

a shortfall in Level 3 and Level 1 beds. However, an over provision of Level 2 beds were also

identified with 50% of patients within the surgical HDU requiring only Level 1 care. This was

further confirmed by local audit including the day of care audit. Therefore, based on the

introduction of a minimum of 4 level 1 beds the number of HDU beds could be reduced to 4.

ICU beds are staffed to 5 beds for the most part of the year increasing to 6 beds over winter

when demand increases. Establishing a joint unit builds in flexibility around the provision of

both ICU and HDU beds in response to demand.

There has been a noted increase in pressure on HDU beds from elective surgery. This can be

found in the increasingly complex surgery performed on site and the additional ongoing health

issues which patients present. However, the expectation is that a high proportion of these

patients require Level 1 care. It is planned to establish 4 – 6 Level 1 beds in the current HDU

to meet this need.

Table 06: Activity for ICU and HDU 2013

Area Admissions Average LOS (Days) Occupancy

ICU 267 4.5 63% HDU 589 3.7 72%

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2.9 Benefits Criteria

This section describes the main benefits and outcomes associated with the project and how

these will be measured. The table below summarises the benefits identified and carried into

the appraisal of the project options:

Table 07: Benefits Criteria

Benefit Outcomes Measure

Mitigation of fire safety compliance risk

Firecode and building control requirements are improved and compliance achieved against standards

Commissioned and signed off by building control and Fire safety advisors.

Post Project Evaluation

Mitigation of AHU failure risk

Air handling units and ventilation systems refurbished to compliant standards

Commissioned and signed off by Consulting Engineers, Architects and Building Control.

Infection Control confirmation that works are satisfactory

Post project evaluation

Mitigation of infection control risk, due to building fabric

All fabric replaced/upgraded in line with SHFN 30, HAI Scribe and healthcare compliant supplied materials


Infection Control confirmation that works are satisfactory


Mitigation of risk to clinical continuity

Room relationships and space utilisation along with functional suitability are met through compliance with building, planning notes and building control


User sign off


Mitigation of risk to patient safety

Room relationships, space utilisation and HAI/Quality along with functional suitability are met through

Commissioned and signed off by Consulting Engineers, Architects and

39

compliance with building, planning notes, health technical memorandum and building control

Building Control.

User and Infection Control sign off


Initial capital Cost

Project is completed on target price

Regular financial review during project

All compensation events scrutinised through change process


Minimise works duration/impact on clinical activities

No disruption to service or duration to clinical activities

Regular User/consultant/contractor, liaison meetings

HAI Scribe and other risk assessments in place


Maintain clinical adjacencies and optimise space planning

Room relationships, space utilisation along with functional suitability are met through compliance with building, planning notes, health technical memorandum and building control.

Users engaged during phases of work to ensure this is maintained

Reduction in revenue costs (Maintenance)

Budgets are in line with new facility servicing and operating and life cycle requirements

Life cycle costs meet the requirements of the new facility

Operating and servicing costs meet the actual mode of operation


Reduction in revenue costs (staff), including costs for moving services off site

The clinical model for staffing is met and on plan

The new service models scrutinised for effective ICU/HDU integration

Theatres model is cost effective against plan


The benefits realisation plan will be fully developed as the project moves through FBC.

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2.10 Strategic Risks

The main project risks and mitigation factors have been identified at a high level within this Outline Business Case and are noted below. A Project Risk Register has been developed which details and quantifies project risk. This is included as Appendix 04 and will be maintained through progression to FBC.

Table 08: Strategic Risks

Risk Category Description Mitigation

Business Strategy Meeting the future clinical needs of the NHS Lanarkshire population

Business Continuity

Providing clinical facilities which are aligned to the clinical strategy

Redundancy of systems, robust operational policies

Service Delivery Meeting waiting times standards

Maintaining optimal use of beds through utilisation improvements

Maintaining a safe clinical environment and reducing perioperative infection

Disruption to other services on site

Failure to reach Estate Code standards

Maintaining 7 operating rooms and 6 ICU beds through Stage 3 of the project through pre- planning, ongoing communication and HAI Scribe

Planned logistical phasing of staff/ patients/ equipment

External/ Environmental Delayed statutory approvals

Adverse patient/ public reaction

Issues with neighbours – noise/ additional deliveries/ cranes etc

Failure to obtain funding

Revenue cost implications

Increase in inflation

Ongoing dialogue with NLC

Ongoing dialogue with patients/ public/ neighbours

Ongoing dialogue with SGHSCD

Continual review of revenue implications

PSCP to ensure that inflation is recognised at market testing

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This OBC details the development of risks into a formal risk register capturing individual risks within each category. The format of the risk register follows the guidance set in the Scottish Capital Investment Manual (SCIM) and has been formatted as per the guidance provided in the NHS Health Improvement Standards (NHSHIS). An initial project risk register was established at a Core Team Risk Workshop held on 14/02 2014. This Workshop was run by the PSC PM and was attended by a wide audience comprising workgroup representatives from the core team, Clinical staff, and the PSCP and their design team, which fed Risks from each sub group into the Master Register.

The risk register continues to be reviewed and updated. The latest Risk Register is attached as Appendix 04.

The NHS Health Improvement Scotland (HIS) assessment matrices were used for the scoring of risks. This allows for four categories of risk, identified as follows:

Table 09: HIS Rating

Table 10: Impact/ Likelihood

Pre- Mitigation and Post- Mitigation scores have been included on the Risk Register with an agreed Mitigation strategy. The table below highlights the current risk profile:

Table 11: Risk Summary

Risk Level

Total Number of Risks per Risk Level

(Pre- Mitigation)

Total Number of Risks per Risk Level

(Post- Mitigation)

Very High - -

High 26 -

Medium 122 83

Low 4 69

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Further details on the approach to Risk Management moving forward towards FBC are documented within Section 3.8 Risk Assessment and Section 6.6 Risk Management.

2.11 Constraints and Dependencies

There are a number of key constraints/ dependencies associated with the delivery of this project:

Constraints:

Diagram 06: Project Constraints

Dependencies:

Diagram 07: Project Constraints

Requirement to deliver a BREEAM healthcare rating of ‘Good’

Maintain current service provision whilst carrying out the works in a live environment

Lack of available land on site to build new accommodation

Requirement to deliver the project within both capital and revenue budgets

Impact on Business Continuity

Ability to carry out the works whilst continuing full current service provision

Cooperation of staff through the period of disruption

Availability of Funding

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3.0 The Economic Case

3.1 Introduction

In accordance with the Scottish Capital Investment Manual and the requirements of HM Treasury’s Green Book (A Guide to Appraisal in the Public Sector), this section of the OBC documents the process and provides evidence to show that the selection of the preferred option is derived from the most economically advantageous option whilst best meeting the service needs and optimising value for money.

The Economic Case sets out:

Critical Success Factors; Long Listed Options; Preferred Way Forward Short Listed Options; Economic Appraisal; Qualitative Benefits Appraisal; Risk Appraisal; Sensitivity Analysis; Preferred Option

44

3.2 Critical Success Factors

The following critical success factors (CSFs) have been established confirming the attributes essential to the successful delivery of the scheme. The CSFs are used in conjunction with the investment objectives to evaluate the Long List of possible options:

Diagram 08: Critical Success Factors

Supply Side Capacity and Achievability

Potential Affordability

Potential Value for Money

Potential Achievability

Strategic Fit and Business Needs

Must meet NHS Lanarkshire’s investment objectives, business needs and service requirements and allow the delivery of all relevant national and local strategies. Must result in provision of facilities for patients, relatives and staff that is functionally suitable, safe and clinically effective.

Must optimise the potential return on NHS Lanarkshire’s expenditure, business outcomes and benefits

Must meet NHS Lanarkshire’s ability to fund the required level of capital

Must deliver improved and integrated services that provide value for money in terms of clinical efficiency in support of the strategy

NHS Lanarkshire must have the ability to support the service model and maintain service continuity at all times. NHSL’s project board must have the ability to manage associated risks and establish a Project Team with the necessary level of skills (capacity and capability) to deliver the project

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3.3 Main Business Options

The path to the selection of the preferred option is explained in detail from Section 3.7 (Benefits Appraisal) onwards of this OBC. These sections provide the clear process followed for achieving the preferred option in this technically complex project, following on from the development of the Long List of Options described below.

Further to the development of investment objectives, potential benefits and the critical success factors as previously noted within this OBC, a series of discussions and workshops were undertaken with the wider stakeholder group that:

Reviewed the existing reports from Capita Symonds/ Interserve on the condition of the existing theatres and associated infrastructure

Reviewed the national and global drivers for health service change with a view to developing an understanding of the implications of these on service provision

Considered current procurement routes available to NHSL within the economic climate Examined the current services and property provision at Monklands District General

Hospital

The resultant outcome of these sessions was the following Long List of Options for the project:

Table 12: Long List of Options

Description

1 Do Nothing pending new build General Hospital: Maintain current maintenance programme

2 Do Minimum: Replace the AHUs for the Theatres as per HFS report recommendation

3 Full renovation works within the existing theatres, whilst maintaining current clinical activity

4 Renovation of a proportion of the department using 3 new operating rooms during and after the works, whilst maintaining current clinical activity

5 New Build Theatre department on site

6 Transfer a large proportion of current activity to elsewhere and renovate the current department

A SWOT analysis of the Long List was then undertaken and this is included as Appendix 05 in this OBC.

Following on from the SWOT analysis and a concurrent feasibility study to find an appropriately sized construction site within the grounds of Monklands District General Hospital it was decided to remove:

46

Option 1 as it will not address the issues currently identified within what would be considered an appropriate timescale:

Air Handling Units (AHUs) not providing air pressure differentials to current building standards which poses a theoretical risk of cross infection between clean and dirty areas.

AHUs are now 35 years old with a heightened risk of component failure which in turn poses an operational risk to business continuity.

And:

Option 5 due to the lack of availability of space within the current site to construct a new theatre block

3.4 Preferred Way Forward

In preparing the OBC all appropriate funding and procurement options have been considered including NPD. The indicative construction costs are identified as circa £15m. As detailed in SCIM, the minimum level for considering whether projects are suitable for NPD is £20m. Consequently, the guidance contained within SCIM has been followed i.e. the default procurement route for acute construction projects not suitable for NPD is Frameworks Scotland 2.

The preferred way forward is therefore to proceed under Frameworks Scotland 2 and to investigate the Short List of Options for the project highlighted in section 3.4 of this document.

3.5 Short Listed Options

Following the SWOT analysis carried out on the Long List of Options, a review against the Critical Success Factors (CSF’s) and the identification of the Preferred Way Forward, a Short List of Options was recommended to carry forward into an Option Appraisal exercise at this OBC stage:

Table 13: Short List of Options

Description

2 Do Minimum: Replace the AHUs for the Theatres as per HFS report recommendation

3 Full renovation works within the existing theatres, whilst maintaining current clinical activity

4 Renovation of a proportion of the department using 3 new operating rooms during and after the works, whilst maintaining current clinical activity

6 Transfer a large proportion of current activity to elsewhere and renovate the current department

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3.6 NPC/ NPV Findings

This section presents the economic appraisal of the shortlisted options and incorporates key elements of the Capital and Revenue implications of each which have been assessed over the anticipated life of the project and discounted to derive a Net Present Cost (NPC) for each viable option.

3.6.1 Capital Costs

The forecast capital costs for the options have been developed and are summarised in the Table below.

Table 14: Forecast Capital Costs

Option 2 £000’s

Option 3 £000’s

Option 4 £000’s

Option 6 £000’s

Works Costs 4,520 15,025 13,200 14,729

Fees 230 411 411 411

Irrecoverable VAT 800 2,470 2,178 2,422

Total 5,550 17,906 15,789 17,562

The forecast phasing of this expenditure is noted in the Table below:

Table 15: Indicative Spend Profiles

Option Description Total 2013/14 2014/15 2015/16 2016/17 2017/18 £000's £000's £000's £000's £000's £000's

2 Do Minimum: Replace AHUs for the Theatres as per HFS report recommendation

5,550 481 4,055 1,014 0 0

3 Full renovation within the existing theatres, maintaining current clinical activity

17,906 481 2,065 7,185 5,905 2,270

4

Renovation of a proportion of the department using 3 new operating rooms during and after the works, whilst maintaining current clinical activity

15,789 481 2,000 7,393 5,915 -

6

Transfer a large proportion of current activity to elsewhere and renovate the current department

17,564 481 2,000 9,426 5,657 -

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3.6.2 Revenue Costs

The high level indicative revenue costs for the project are forecast as £0.230m

Table 16: Revenue Costs

Option 2 £000’s

Option 3 £000’s

Option 4 £000’s

Option 6 £000’s

Capital Charges - 200,000 150,000 175,000

Facilities Management - 30,000 30,000 30,000

3.6.3 Lifecycle Costs

Indicative Lifecycle costs for the options have been estimated by the Cost Advisors and incorporated into the economic appraisal when calculating the net present costs.

Table 17: Life Cycle Costs

Option 2 £000’s

Option 3 £000’s

Option 4 £000’s

Option 6 £000’s

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3.6.4 Net Present Value (NPV)

The resultant Net Present Value for each viable option is summarised in the table below:

Table 18: Net Present Cost and Ranking

NPV Benefit Score Ranking

Option Description £000's

2

Do Minimum: Replace AHUs for the Theatres as per HFS report recommendation

4,577 36 127

3

Full renovation within the existing theatres, maintaining current clinical activity

14,193 58 245

4

Renovation of a proportion of the department using 3 new operating rooms during and after the works, whilst maintaining current clinical activity

13,275 43 309

6

Transfer a large proportion of current activity to elsewhere and renovate the current department

16,368

50 327

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3.7 Benefits Appraisal

A Non- Financial Benefits Appraisal Workshop was undertaken on 12th September 2012 to explore and examine the short list of options and to inform the development of the preferred option for the project. A group of stakeholders comprising clinical departmental staff, operational staff and representatives from the PSCP and their design team was present to ensure a consistency of approach and appropriate technical input was available. This Workshop took the form of a scoring exercise against the set of benefits criteria established in section 2.9 of this Outline Business Case. The Options appraised were: Diagram 09: Short List of Options

3.7.1 The Workshop

The Workshop began with an introduction to establish the outline for the session and key elements for consideration.

There was then a short presentation to refresh key project elements for the audience prior to moving to the scoring process.

Do Minimum: Replace the AHU’s for the Theatres as per HFS report

recommendation Full renovation works within the existing theatres, whilst maintaining current

clinical activity Renovation of a proportion of the department using 3 new operating rooms

during and after the works, whilst maintaining current clinical activity Transfer a large proportion of current activity to elsewhere and renovate the

current department

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3.7.2 Weighting

The next part of the process, facilitated by the PSC Project Manager, saw the undertaking of an exercise to establish a weighting of the benefits to carry forward to scoring the options.

A full description of the criteria can be found in Section 2.9 of this OBC, however a summary is provided below:

Table 19: Description of Benefits

1 Mitigation of Fire Safety Compliance risk

2 Mitigation of AHU Failure risk

3 Mitigation of Infection Control risk due to building fabric

4 Mitigation of risk to Clinical Continuity

5 Mitigation of risk to Patient Safety

6 Initial Capital Cost

7 Minimise works duration/ impact on clinical activities

8 Maintain clinical adjacencies and optimise space planning

9 Reduction in Revenue Costs (Maintenance)

10 Reduction in Revenue Costs (Staff), including costs for moving services off site

11 Ability to Future Proof / Expand

Post considered discussion the weighting to be carried into the scoring of the options was as follows:

Table 20: Benefits Weighting

1 2 3 4 5 6 7 8 9 10 11

9 14 11 10 14 8 9 6 6 6 6

This weighting reflects the relative importance of ensuring patient safety and AHU failure within the total range of benefits agreed for the project.

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3.7.3 The Scoring

Having confirmed the weighting for the criteria the short listed options were subject to scoring under a range of 1-10 as per the below guide:

Table 21: Scoring Guide

Scoring Guide

1-2 Very Poor

3-4 Poor

5-6 Satisfactory

7-8 Good

9-10 Very Good

A complete summary of the scores can be seen in Table 22 below:

Table 22: Benefit Scores

When the weighting established in the previous exercise was applied to the scores, the results were as follows:

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Table 23: Weighted Scoring Results

3.7.9 Sensitivity Analysis

In order to test the results of the Benefits Appraisal it is useful to assess the sensitivity of the scores to changes in key variables and assumptions.

This exercise provides an indication as to the elements of the evaluation that are critical to influencing the outcome.

Sensitivity Analysis should therefore be undertaken to evaluate what the ranking might be if some of the weights and/ or scores were changed as follows:

Equal weighting applied to all criteria i.e. all 11 criteria were weighted at 10 Excluding benefit scores for the top ranked criteria i.e. remove scores for criteria 2 & 5 Altering the scores of the criteria with the greatest scoring range so that all options

score the same mid- range value i.e. replace criteria 6 scores with a ‘5’ for all options

In doing so, the following results were produced:

Table 24: Non- Financial Sensitivity Analysis

equal weight remove 2 &5 replace 6 with '5' weighted

score rank weighted score rank weighted

score rank option 2 530 4 323 4 481 4 option 3 690 1 424 1 705 1 option 4 570 3 372 3 525 3 option 6 660 2 413 2 648 2

The Sensitivity Analysis shows therefore that despite changing the weights and scores, Option 3 (full renovation works) remains ranked first at all times.

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3.8 Risk Assessment

A full risk analysis was undertaken to identify and assess the impact of risks during the stages of the project. An initial project risk register was established at a Risk Workshop held on 14/02/2014.

The Register will continue to be updated and reviewed throughout the course of the project. The various workgroups will feed pertinent Risks in to the Master Register on a regular basis and Board Risk will also be captured and mitigated. An update on the very high risks will be discussed at the Core Group Meetings and the Project Board will be kept informed of the highest scoring risks via their Project Board Meeting.

Further details of the approach to Risk Management moving towards Full Business Case are documented within Section 2.10 and Section 6.6 of this OBC.

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3.9 Preferred Option

The preferred option in terms of non- financial benefits appraisal is Option 3 as can be seen from the table below.

Table 25: Non- Financial Ranking

weighted score rank

option 2: do minimum: replace AHUs only 530 4 option 3: full refurbishment and upgrade of existing theatres 690 1 option 4: partial refurbishment with new build theatres 570 3 option 6: transfer of activity through refurbishment 660 2

Under Sensitivity Analysis, Option 3 remains the preferred as per the below:

Table 26: Non- Financial Sensitivity Ranking

equal weight remove 2 &5 replace 6 with '5' weighted

score rank weighted score rank weighted

score rank option 2 530 4 323 4 481 4 option 3 690 1 424 1 705 1 option 4 570 3 372 3 525 3 option 6 660 2 413 2 648 2

3.9.1 Design Development

Further to a preferred option being achieved through the benefits appraisal workshop and the subsequent testing of this option under non- financial sensitivity analysis, Stage D design work has been undertaken to develop a construction programme and phasing for this complex project.

Through this work it became apparent that in order to achieve all clinical and technical aspirations for the project alongside the Board’s request to maintain service in all seven theatres throughout the construction phase that the option to refurbish and upgrade the theatres would require to be enhanced to include a new ICU built adjacent to the current theatre space. This addition allows the provision of a more clinically effective ICU and provides the necessary space to create theatres in line with current technical guidance.

This enhancement of the Option has been undertaken with full participation of the participants involved in the Option Appraisal exercise and has been agreed and ratified as being the preferred option to be carried forward into detailed design work at Stage D.

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The NPC has been used in conjunction with the scoring obtained during the non-financial appraisal workshop to calculate the NPC per benefit point in order to rank the viable options. The final outcomes are summarised in the table below:

3.9.1 Summary of Net Present Costs, Benefit Points and Rankings

Table 27: Summary of Financial and Non- Financial Rankings

Net Present

Cost £000’s

Benefit Points

NPC per Benefit Point

£000’s Rank

Option 2: do minimum: replace AHUs only 4,577 36 127 1 Option 3: full refurbishment and upgrade of existing theatres 14,193 58 245 2 Option 4: partial refurbishment with new build theatres 13,275 43 309 3 Option 6: transfer of activity through refurbishment 16,368 50 327 4

3.10 Sensitivity Analysis

As a Business Case is built upon various estimates, it is recommended that a sensitivity analysis is undertaken to assess to what degree the key estimates would need to change in order to alter the investment decision. Consequently sensitivities were performed in order to understand how much each of the key cost components relating to Capital and Revenue costs (excluding VAT) would need to change in order to reverse the rankings of the two viable sites.

The outcomes of the sensitivities demonstrate the following:

3.10.1 Sensitivity Analysis in respect of Net Present Cost

`3.10.2 Sensitivity Analysis in respect of Net Present Cost per Benefit Point

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4 The Commercial Case

4.1 Introduction

This section outlines the commercial transaction that the board will sign up to and will consider the following:

The scope of the services being contracted for The management and allocation of risk Potential charging mechanism Key contractual arrangements Personnel implications Implementation timescales Accountancy treatment

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4.2 Potential Scope and Services

The services to be included within the refurbished Theatres/ ICU are identified below:

Diagram 10: Services

The operating department will provide the facilities necessary to maintain surgical specialties on this site for a further 20 years. At present this includes a mix of daysurgery and inpatient surgery for orthopaedics, ENT, urology, and general surgery.

The ICU accommodates an expansion of ICU beds from 6 to 10. This sits alongside HDU beds in other parts of the hospital for medicine and surgery. All critical care beds on the site will be managed collectively and flexibly to ensure the staffing skill- mix matches the level of care required for the patients at any point in time.

The refurbishment will be provided under Frameworks Scotland 2 with the Capital Funding provided through NHSL formula funding initially and treasury funding laterally.

Group 1 equipment items, which are generally large items of permanently installed plant or equipment, will be supplied, installed by the PSCP, maintained and replaced by NHSL.

Group 2 items, which are items of fixed plant and equipment used in the delivery of engineering services and medical equipment, will be supplied by NHSL installed by PSCP and maintained and replaced by NHSL.

Group 3 items will be procured through NHSL

Group 4 items, generally smaller and moveable equipment will be supplied, installed, maintained and replaced by NHSL.

10 critical care beds which can be flexibly staffed and equipped for use for either

intensive care or high dependency 7 operating rooms (two provided with ultra– clean/ laminar flow environment) Support accommodation including staff changing, administration, training and

storage

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4.3 Potential Risk Allocation

The key features of the New Engineering and Construction Contract (NEC 3 - Option C) contract are:

The parties are encouraged to work together as partners in an open and transparent approach and to ensure that this partnering ethos is maintained

There is a ‘Gain/ Pain share’ mechanism to act as an incentive to the delivery team, by rewarding good performance and penalising poor performance

A clear and transparent system is ‘on the table’ to enable negotiation to take place on prices

A level of ‘price certainty’ is determined

All price thresholds are set using quantitative risk analysis

It is a variant of Maximum Price/ Target Cost (MPTC) approach

In accordance with the Frameworks Scotland 2 guidance notes, the NHS Client and the PSCP act as joint owners of the Joint Project Risk Register. Risks will be allocated to the party best able to manage the risk subject to value for money and responsibility for risks will be clearly identified. The table below illustrates the potential allocation of risk:

Table 28: Risk Allocation

Risk Category Potential allocation of risk

NHS Graham Shared

Design √

Development and Construction √

Transition and Implementation √

Performance √

Operating √

Revenue √

Termination √

Technology and Obsolescence √

Control √

Financing √

Legislative √

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4.4 Agreed Charging Mechanisms

This project is being procured through HFS framework Scotland 2 with design being led by the PSCP and their design team. As such there is no concession period and so no charging mechanism applied.

The PSCP shall design & build the project and upon completion hand the building over to the client (NHSL) to manage and operate the facility.

It is worth noting that during the design & construction process cognisance shall be given to the whole life costs of the facility in order that the project achieves value for money. The PSCP is also incentivised through the use of a target cost contract NEC3 Option C for Stage 2, which promotes that the PSCP look for efficiencies when carrying out the project.

4.5 Agreed Key Contractual Arrangements

The preferred solution is being procured under Frameworks Scotland 2. This framework is founded on collaborative working and the NEC3 form of contract is used to support these principles.

Following the SGHSCD’s methodology for tendering work through the new Framework for Scotland 2, Graham Construction has been appointed as Principal Supply Chain Partner (PSCP) to work with the Board to finalise design, work up the target cost for the scheme and to construct the building.

Graham Construction has been appointed to deliver multiple works task orders for NHS Lanarkshire under the new Health Facilities Overarching Scheme Contract. The Theatres/ ICU work task order is the largest and most complex project currently being delivered under the scheme

As noted above, the mechanism for ensuring that this partnership ethos is carried through to the construction of the new facility is through the use of the NEC3 form of contract. The main principles of this procurement methodology are outlined below:

4.5.1 The Priced Contract – Stage 1B Preconstruction Activity - Designing a Solution The priced contract for the Preconstruction Activity, designing a solution is fixed priced during Stage 1B and before construction is commenced (Stage 2). During Stage 1B the PSCP must deliver a design solution for a priced contract sum NEC Option A. Once agreed the priced contract sum for this stage, my only be revised upward or downward when compensation events occur under the scheme contract. Any estimated costs included within the priced contract sum must be understood together with the potential risks to the project and how they may be removed/ managed.

The likely cost consequences and the occurrence of risks that are considered likely to occur will be discussed with a view to agreeing an appropriate contingency in either the priced

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contract sum (if the PSCP is responsible for the risk) or in NHS Lanarkshire’s Budget (if NHS Lanarkshire is responsible for the risk).

The level of information that the PSCP requires to provide in support of the priced contract with activity schedule for monthly applications for payment will be agreed with the Cost Advisor.

The PSCP will provide a fully detailed priced activity schedule breakdown with their application for payment which will be verified by the Cost Advisor.

The objective is to work together to agree the completion of each activity as detailed within the priced contract activity schedule, any risk allowances; and the percentage fee (overheads and profit) applied to such sums.

The aim underpinning this approach is to reduce costs by understanding the risks that make it higher and managing/ removing those risks and at the same time seeking to plan the services/ works provided by the PSCP and its SCMs so that the Stage will be more effectively carried out.

4.5.2 Open Book Philosophy - Stage 2 Construction – Target Contract with Activity Schedule The target contract for construction following completion of the design, is a target price with activity schedule during Stage 2 construction NEC3 Option C. A key principle of the NEC3 Option C contract is the payment of ‘Defined Cost’ and an open book accounting philosophy. These require a robust, reliable and transparent system to record staff time and manage the invoicing process. This allows the Cost Advisor not only to identify costs but also to establish that the costs have been properly expended on the project and that they are allowable under the NEC3 Option C contract as defined under the “schedule of cost components”. Project costs must be referenced to items on the activity schedules with detail added against 5 main headings of; labour, plant, materials, sub contractors and preliminaries. Orders, deliveries, invoices for payment, external plant hires and sub-contracts also have to be cross-checked against Goods Received Notes.

The PSCP will be required to demonstrate that market testing has occurred at Stage 2 in the order of 80% of the priced contract sum.

The target price is key to the cost operation of the contract and is set during the pre-construction phase. This process concludes when the PSCP’s proposals are completed for costing and the risk register has been agreed. The target price costing is made up of the following elements:

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Diagram 11: Target Price Costing Elements

4.5.3 Contractor’s Share Percentage and Share Range Within clause 53 of the NEC 3 contract, the pain share/ gain share payment mechanism is set-out. This clause requires to be read in conjunction with Contract Data part 1 which defines the share percentages and share ranges. The table below outlines the share ranges on Frameworks Scotland: Diagram 12: Pain Share / Gain Share Model

4.5.4 Priced Activity Schedule The activity schedule is defined in Clause 11.2(20). Clause 54.1 states that ‘information in the activity schedule is not works or site information’. The activity schedule under NEC 3 option C is provided by the PSCP in contract data part 2 as part of the pre-construction phase conclusion. The activity schedule gives a breakdown of the work to be done under the contract and this covers the entire contract price. A key interface within NEC 3 is that the activity schedule must be related to the accepted programme as defined under Clause 31.4. The principle objective of having the activity schedule and accepted programme linked under NEC 3 option C is not to assess the contractor’s payments (these are made on defined cost), but to assist in the assessment of compensation events and contractors share.

>100%

100%

95%>100%

<95%

• Contractor takes 100% of the Pain

• Target Price

• Contractor & Employer share the gain 50:50

• Employer takes 100% of the Gain below the 95%

The key benefit of the introduction of the target price with a pain share / gain share mechanism is the incentivisation on the team and PSCP to control cost.

Contractors Overheads & Profit Within the NEC 3 Option C contact, there is provision to adjust the target price (upwards and downwards) via the compensation event process.

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4.5.5 Defined Costs Defined cost is outlined in Clause 11.2(23) and is made of up 3 key elements:

The amount of payments due to sub-contractors for work which is subcontracted without taking account of amounts deducted for; retentions, payments to employer for failure to meet key dates, correction of defects after completion, payments to others and supply of equipment etc.

The cost of components in the Schedule of Cost Components for other work Less, Disallowed cost (as defined under Clause 11.2(25))

4.5.6 Recording and Collation of Costs Information Clause 52.2 requires the PSCP to keep records of:

Accounts of payments of Defined Costs Proof of payments being made Communications about and assessments of compensation events for

Subcontractors Other records required by the works information

The PSCP will ensure that the Cost Advisor has full and unrestricted access to accounts and records that are required to be maintained in accordance with Clause 52.3. 4.5.7 Compensation Events and the Application thereof Clause 60.1 details 19 compensation events for which the PSCP is entitled to compensation if they occur. The object of the NEC 3 contract is to ensure that all compensation events are listed in one place, expressed clearly to avoid disagreement and to allocate the events in line with modern risk allocation principles. An important aspect of the compensation event (CE) process is that both the Project Manager and PSCP are required to notify them. The Project Manager raises C.E’s for instructions or changing decisions. The PSCP notifies a CE if he believes that the event is a compensation event or if the Project Manager has not notified the PSCP. Once compensation event notifications are accepted by the Project Manager, quotations are provided in accordance with Clause 62 and submitted for consideration. These quotations cover cost and time and must be linked to the accepted programme. The Project Manager makes the assessment in accordance with Clause 63 or 64 and they are then implemented in accordance with Clause 65. The key to the entire process within NEC3 is that the process has time constraints to ensure that decisions are made, preventing the process dragging on, allowing the Project to move forward without protracted negotiations. The compensation event process can be simply defined as per the diagram below:

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Diagram 13: Compensation Event Sequence

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4.6 Potential Personnel Implications

There is no major impact for staff with regard to terms and conditions as a result of the refurbishment and new build work. Some working practices will change by the time the refurbishment is complete but this is work already in progress and not as a direct result of the project. The change in flow of both HDU and theatre patients provided by the project will not only facilitate a better patient experience and a higher standard of care but also a greatly improved working environment for staff. The Intensive Care Unit (ward 26) and surgical High Dependency Unit (ward 5) as previously noted in this OBC currently occupy two separate locations within Monklands General Hospital however they are managed as one unit with staff rotating between both. The plan to establish a combined unit will require a change in base ward for some staff. The remaining beds in the existing surgical HDU will revert to Level 1 which is already staffed by nurses with the appropriate training and skills. The proposed combined unit will comprise of 10 beds with a 6:4 split of ITU to HDU. However, the unit will be staffed to enable the beds to flex up and down between dependency levels in response to site demand. Nursing staff with the required skills are currently available to facilitate this but there is also an ongoing training programme for staff working in these areas to ensure all necessary skills are met. Within the existing units the access and discharge criteria are applied quite differently with medical staff fulfilling a gate keeping role. Consultant Intensivists manage both admissions and discharge to ITU beds. The General Surgeons currently agree access to surgical HDU but discharge is left to individual consultants with considerable input from nursing staff. Within a combined unit it is proposed that the Consultant Intensivists will assume the complete role for both ITU and HDU. This role change will provide a consistent standard of care to both Level 2 and 3 patients whilst ensuring efficient bed management. Historically within the theatre suite, staff were employed to work in either the recovery area or theatre. Over the last few years this policy has changed with nursing staff now employed as cover for the complete theatre suite. This ensures flexibility in staffing for both areas as well as the same day admission lounge which is run as part of theatres. A rotational programme is currently in place for all theatre staff and this is embedded within the staff rota therefore no staffing issues are expected as a result of the redesigned flow of patients through the theatre suite. The additional available work space will also create an improved and safer working environment for staff within ITU and Theatres. This will also further promote patient safety and there will be the opportunity to provide additional work based clinical training and education.

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4.7 Potential Implementation Timescales

Following approval of this OBC, a Full Business Case (FBC) will be prepared and submitted to SGHSCD CIG for approval. An estimated 2 months has been programmed for this activity. Once the FBC has been approved, the construction works to align with the decant strategy will commence. This main construction period is estimated at 40 months culminating with completion in March 2018.

Table 29: Timescales

Stage 2: IA/ OBC Completion Date

OBC Gateway Review 16- 18 June 2014

OBC Approved by Project Board 25 June 2014

OBC Submission to CIG 08 July 2014

OBC Approval by CIG 05 August 2014

Stage 3: FBC

FBC Gateway Review TBA

FBC Approved by Project Board 24 September 2014

FBC Submission to CIG 30 September 2014

FBC Approval by CIG 28 October 2014

Stage 4: Construction

Start on Site December 2014

Completion March 2018

4.8 Potential Accountancy Treatment

The capital costs associated with the refurbished Theatres/ ICU will be capitalised in line with all appropriate accounting standards and this OBC is predicated on the appropriate level of Capital Funding being made available through NHSL formula funding.

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5.0 The Financial Case

5.1 Introduction

The financial case for the preferred option sets out the following key features:

Potential Capital/ Funding Requirement; Potential Revenue Impact; Impact on Balance Sheet; Stakeholder Support; Overall Affordability

5.2 Potential Capital/ Funding Requirement

The potential capital costs and associated funding requirement are considered in greater detail in the following sections.

The capital costs for the preferred option are shown below and are derived from cost schedules produced by the Framework PSCP Graham Construction, in conjunction with the cost advisors Currie & Brown.

5.2.1 Capital Costs

The capital costs for the preferred option are shown below and are derived from cost schedules produced by the Framework 2 PSCP Graham Construction, in conjunction with the cost advisors Currie & Brown. The Capital Costs include contingencies and allowance for out of hours working to allow the project to be delivered while the theatres remain in use.

Table 30: Forecast Capital Costs for the Preferred Option

Total Cost

£000’s

Works Costs 15,025

Fees 411

Irrecoverable VAT 2,470

Total Capital Cost 17,906

The build costs represent the cost of construction in respect of a 7 theatre facility with a 10 bed ICU which adds 1,100m2 to the current footprint of the hospital.

The departments and areas are based on Schedule of Accommodation included as Appendix 06 in this OBC.

The estimated construction costs have been prepared by the Framework PSCP partners in conjunction with the Cost Advisors using the following assumptions and allowances:

The project is planned to commence construction in November 2014 with Clinical Service commencing in January 2018;

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Costs are based on a 2014 price base;

5.2.2 Risk Allowance

A risk register has been developed and applied to the capital costs as a result of the reviews and workshops undertaken which are described in further detail within Section 6.6 Risk Management. A copy of the risk register is included within Appendix 04. This approach is reflective of the inherent risk management processes within the NEC form of contract used under Frameworks Scotland 2 and replaces an Optimism Bias allowance which previously would have been applied to the capital costs at OBC stage. In regard to inflation, this has also been included in the costed risk register and it is anticipated that in collaboration with the appointed PSCP costs in this respect will be minimised.

5.2.3 Capital Funding and Procurement

As previously noted within this OBC, the remaining construction costs fall below the de minimus level noted within Scottish Capital Investment Manual (SCIM) as being suitable for exploring potential Not for Profit Distribution (NPD) routes. As such, in order to progress the project, it will be necessary for a capital funding contribution to be made available through NHSL formula funding equating to the £17.9m capital value to allow the construction of the facility to proceed under the Frameworks Scotland 2 procurement route.

The theatre refurbishment will be constructed within the existing footprint of the current service, with the new 10 bed ICU constructed on land owned by NHS Lanarkshire directly adjacent to the current theatres.

The exact split of funding will be confirmed at Full Business Case stage however, the total projected capital spend profile for the full development is shown in the table below:

Table 31: Indicative Capital Cost Spend Profile

Option Description Total 2013/14 2014/15 2015/16 2016/17 2017/18

£000's £000's £000's £000's £000's £000's

3 Full renovation within the existing theatres, maintaining current clinical activity

17,906 481 2,065 7,185 5,905 2,270

5.3 Revenue Impact

5.3.1 Total Revenue Costs

The high level indicative revenue costs are forecast at £30,000. Further commentary on the Revenue costs by category is included below.

5.3.2 Pay Costs

There are no anticipated increase in pay costs with all cost expected to be met from existing resources.

5.3.3 Non Pay Costs

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There will be a minor increase in facilities management costs as a result of the increase the 1,100 m2 of the footprint for the ITU. This has been estimated at £30,000, p.a.

5.3.4 Depreciation

For forecasting and appraisal purposes, the building depreciation has been calculated over 25 years. Following completion of the ICU it is anticipated that the new building will be valued by the appointed valuer at which time a building specific Assessed Life will be allocated.

5.3.5 Overall Recurring Revenue Costs

These costs represent the additional recurring revenue costs associated with the refurbishment project.

As the project will be constructed on land owned by NHS Lanarkshire, ownership and responsibility for the facilities management, support services and clinical services support will rest with NHSL.

In conformance with the guidelines issued by SGHSCD, a statement of sustainable financial support for the revenue costs associated with the preferred option is contained Appendix 07.

5.4 Potential Impact on Balance Sheet

The capital costs associated with the refurbished and upgraded theatres and ICU will be capitalised in line with all appropriate accounting standards and this OBC is predicated on the appropriate level of Capital Funding being made available.

5.4.1 Major Medical Equipment

There are no costs included within this OBC for major medical equipment. There has been some recent investment in the Monklands Theatre Equipment and this will be available after conclusion of the works.

5.4.2 Construction Costs of the Facility

As responsibility for the construction and provision of the facility at Monklands District General Hospital will be the responsibility of NHSL, the capital funding for the construction, including appropriate fees etc., will need to be made available to NHSL. On completion of the ICU, it is proposed that the new building be subjected to an initial valuation by the District Valuer. As the project will result in the construction of a new building it is anticipated that the vast majority of the construction investment will add value to NHSL’s existing estate, however any impairment value will be communicated to the SGHSCD through completion of the annual AME Impairment Return.

5.4.3 Initial Expenditure up to Stage 1B of the Project

In order to progress the design and development of the facility to the current stage it has been necessary to appoint a Principal Supply Chain Partner (PSCP), Project Managers and Cost Advisors to progress the initial designs for the facility. Pending the approval of a preferred option, NHSL has progressed these aspects of the scheme and has therefore incurred some early capital costs associated with this work. As these costs are an integral

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part of the scheme, they have been included in the construction expenditure noted in this document.

5.5 Stakeholder Support

The development of the Theatres & ICU refurbishment is supported by the following:

Diagram 14: Supporting Parties

A Letter of support is provided within Appendix 07.

5.6 Overall Affordability

The Financial Case has highlighted the overall capital and revenue affordability of the preferred option and identifies a requirement for:

A total forecast Capital cost of £17.9m to be funded through NHSL formula funding through 2014-15 with additional Scottish Government capital being provided from 2016-17 to completion.

Total recurring annual revenue costs of £0.23m to be funded by NHSL.

Acute Division Operating management committee NHS Lanarkshire Capital Investment Group NHS Lanarkshire Monklands investment Board

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6.0 The Project Management Case

6.1 Introduction

This section of the OBC sets out the management arrangements that are in place to ensure the successful delivery of the MKBC Theatres project. Areas covered include:

Procurement Strategy Project Management Change Management Benefits Realisation Risk Management Post Project Evaluation

6.2 Procurement Strategy

The preferred option of refurbishment and upgrade of the theatres is to be procured under Frameworks Scotland 2. This framework is founded on collaborative working and the NEC3 form of contract is used to support these principles.

Following the methodology for tendering work through Frameworks Scotland 2, a Principal Supply Chain Partner (PSCP) Graham Construction has been appointed to work with the Core Team to finalise design, work up the target cost for the scheme and to construct the building.

6.3 Project Management

6.3.1 Project Management Approach

To successfully manage and deliver the MKBC Theatres Project, clearly defined project management arrangements have been established and experienced personnel identified to implement them.

6.3.2 Project Management Structure

The diagram below represents the current NHSL FS2 overarching scheme contract, with Graham Construction being the PSCP appointed to deliver construction. Currie & Brown provides Lead Advisor services to NHSL on their Frameworks Scotland 2 Scheme.

Diagram 15: NHSL Overarching Scheme Contract

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The below diagram provides a further breakdown which shows that due to the complexity of the Theatres and ICU project it has its own Core Group that sits outwith the main Monklands WTO Core team structure:

Diagram 16: Meeting Structure

This development will be led by the MKBC Investment Board. The Investment Board is comprised of the following representatives: Diagram 17: Investment Board The MKBC Project Team will represent the wider ownership interests of the project and maintain co-ordination of the development proposal.

Director of Acute Services (Chair): Alan Lawrie Director of Finance: Laura Ace Head of Planning & Development: Colin Lauder General Manager PSSD: John Paterson (in post 07th July 2014)

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Diagram 18: MKBC Project Team A Project Core Working Group will be formed to manage the day to day detailed information required to deliver the project. This will comprise the following representatives: Diagram 19: Core Group

Project Technical Director: Robert Spencer Project Director: Colin Lauder Project Manager NHSL: George Reid NHSL Finance: Brian McWatt PSC Project Manager: Fiona McDade NHSL PSSD: June Levick PSCP: Pat O’ Hare NHSL Users: R. Roberton/ G. McGibbon/ A. Khan/ R. McKenzie/ K. Black NHSL Clinical Interface: Nicola Ruddy NHSL Control of Infection: Richard Fox SALUS: Gordon Gray Consultant Microbiologist: Donald Inverarity CDMC Allen Dick

Head of Planning & Development (Chair): Colin Lauder General Manager PSSD: John Paterson Head of Support Services: Robert Spencer PSC Project Manager: Fiona McDade Infection Control: Richard Fox Head of Health & Safety: Gordon Gray Communications Officer: Craig McKay NHSL Finance: Brian McWatt NHSL Project Manager: George Reid NHSL Users: Rhona Roberton; Donald Spence;

Ruth Thompson NHSL Clinical Support: Nicola Ruddy PSCP: Pat O’ Hare/ Keith Barclay HFS: Stuart Brown CDMC: Allan Dick

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The project will also be supported by a series of sub groups/ task teams as required and identified in the ‘Guide to Frameworks Scotland’ published by Health Facilities Scotland. These task teams will include Technical User Group; Business Case Development; IM&T; Equipment; Commissioning and Finance. This can be simplified in the diagram below:

Diagram 20: Project Governance

6.3.3 Project Management Framework

The diagram below outlines the stages for the implementation of the project under SCIM, HFS and RIBA:

Diagram 21: Project Management Framework

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6.3.4 Programme and Milestones

The Board anticipate that the Outline Business Case will be considered by the Scottish Government Capital Investment Group in July 2014. Should approval be granted to progress to FBC at this time, the indicative project timetable is as follows:

Table 32: Indicative Project Timetable

OBC CIG Submission 08th July 2014

OBC CIG Approval 05th August 2014

FBC CIG Submission 30th September 2014

FBC CIG Approval 28th October 2014

Construction Start on Site December 2014

Construction Completion March 2018

Post Project Evaluation +12 months from occupation

Post Occupancy Evaluation +2-5 years from occupation

The dates noted in the above table will be subject to further development/ agreement as the project progresses.

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6.3.5 Stakeholder Consultation and Engagement

The MKBC project team has identified the key stakeholders with an interest this project as being:

Surgeons Anaesthetists Theatre and recovery nursing staff Control of infection team Managers within the acute division Managers within support services (estates and hotel services) Patient representatives.

Over the past two years a series of meetings and discussions has taken place with these stakeholders. This has included workshops to develop potential options and scoring of these options. Stakeholders are represented on the Core Group and as such have an active input into elements of the design of the proposed departments.

The design stages have been driven by the requirements of the clinical teams. Given that patients are generally unaware of their environment when in theatre or ICU, patient representatives have not yet been engaged with the design/ build process. It is intended that patient/ public input will be sought (via PPF’s) during the next stage.

6.4 Change Management

The project will utilise the processes from the Frameworks Scotland 2 procurement route which uses the NEC3 Engineering and Construction Contract with Activity Schedule.

This creates a structure and a discipline to manage change via the use of Early Warning Notices and Compensation Events and ensures change is identified early and is proactively managed by the project team.

6.5 Benefits Realisation

The main benefits for the MKBC Theatres Project are noted within section 2.9 of this OBC ‘Benefits Criteria’.

These will be reviewed as an integral part of the Post Project Evaluation work to ascertain if the benefits identified against the objectives of the business case have been met as a result of the project.

6.6 Risk Management

A Risk Register has been developed that is reflective of the Preferred Option and that includes contributions from all key stakeholders. The Risk Register will continue to be developed in accordance with SCIM guidance.

A Risk Workshop was held on 14/02/2014 and updated on 09/06/2014 in order to establish a project specific Register for this document.

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Each identified risk will be assessed, quantified, managed and a designated risk owner/ manager assigned.

The Register will be routinely reviewed and updated over the lifespan of the project to minimise the level of risk. It will be updated for each early warning during the construction phase.

The Risk Register will be an Agenda item at the Core Team Meetings, with all high priority risks subject to review and a general overview of all other risks to ensure that their impact on the project is not escalating.

The Risk Register will be a key tool in the ongoing management of the Project with a risk management strategy being employed to ensure:

Risks are identified in advance and mitigation strategies are agreed A process is in place to monitor risks and keep them up to date Agreement as to the right balance of control to mitigate against the adverse

consequences of the risk should it materialise A decision making process is implemented, supported by a framework of risk

analysis and evaluation

6.7 Post Project Evaluation

In order to assess the impact of the project, an evaluation of activity and performance must be carried out post completion. This is an essential aid to improving future project performance, achieving best value for money from public resources, improving decision making and learning lessons. The PPE shall follow the guidance as detailed in the Scottish Capital Investment Manual and will be implemented six months after completion, appraising all stages of the Project from preparation of the business case through construction to occupation and service.

A Post Occupancy Evaluation will be implemented 2-5 years after completion to appraise whether the project has delivered its anticipated improvements and benefits.

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7. Conclusion

Providing the refurbishment and upgrade to the Theatres and ICU at Monklands General Hospital will improve patient experience whilst offering modern services locally to where people live. As a central element of the proposal this will enable the meeting of the challenges of implementing NHS Scotland’s ‘Route Map to the 2020 Vision for Health and Social Care’ (2013).

The Preferred Option, to refurbish the existing seven theatres alongside the construction of a new build 10 bed ICU represents the best investment to provide the required services going forward. It is the best value option, as has been demonstrated throughout this document, and would fulfil the drivers identified in this OBC. These new facilities would provide a 21st century environment that would meet the needs and aspirations of both staff and patients within NHS Lanarkshire.

Approval of this OBC will ensure that the project can move at pace towards the development of the Full Business Case for this critical project.

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Appendix 01:

Design Statement

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MKBC Theatres & ICU refurbishment and upgrade: Design Statement

Introduction:

This Design Statement has been created to support the development of the above new and refurbished facilities and acts as a key briefing document for the project Technical Team. It will be used to enhance the design process to ensure that the project primary objectives are delivered. The key design principles and non- negotiable performance criteria are set out below:

Key Design Principles:

Provide Services that are safely and easily accessible

Improve and maintain retention and recruitment of staff

Provide an environment that supports service delivery, clinical effectiveness and integrated service provision

Provide a quality of clinical environment that promotes the health and wellbeing of the staff and patients

Develop theatre designs that will improve surgical services, storage and support.

Provide facilities that are both sustainable and flexible to support service provision in the future

Encourage a learning environment for staff through the provision of dedicated training facilities

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1. The Non- Negotiables for Patients

Agreed Non- Negotiable Performance Criteria

(investment objective/ customer quality expectation)

Benchmarks

The standard to be met and/ or some views of ‘what success might look like’

The experience of waiting must feel secure, pleasant and calming

Space must allow staff to provide positive distraction appropriate to different groups of people

The patient journey from entering the perioperative environment should be as streamlined as possible

Point of entry to point of treatment should flow in a linear fashion

Essential services for patients should be capable of being maintained without being openly visible to the individual

Patient front line services if taken off line have a back up provision to ensure continuation of service

Maintenance works can be carried out ‘invisibly’ as much as possible where required

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2. The Non- Negotiables for Staff



Benchmarks


The development must be efficient with rooms and circulation routes configured to allow flexibility in use.

Clear definition of patient areas from back of house/ staff areas

Design to ensure optimal flexibility and efficiency

Staff must be able to rest/ debrief/ relax away from the service provision spaces with access to daylight

Staff rest space, in addition to providing for tea/ lunch prep must provide:

• Space for coming together to chat

• Space for quiet thought

• Good daylight

• Be an attractive and restful space

Ensure the most efficient use of space and that the use of shared space is optimised. Efficient space allocation and ability to respond to future service changes effectively is to be promoted.

Office space should be shared wherever possible – limit one person offices

Space should allow long term flexibility of use without fundamental physical change

Spaces should be set out logically in relation to each other and should be capable of long term flexibility

The layout of the facility must encourage and facilitate co-ordinated working and communication between disciplines on a formal and informal basis

Staff routes should encourage interaction between services rather than isolate them

Common facilities such as staff rest and meeting rooms should be provided as a shared resource

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Working environments must promote a feeling of safety and wellbeing, aiding concentration and effective working.

The environment should have good thermal comfort, air quality and daylight (where required)

There should be good visual connections to other staff areas so as not to feel isolated or vulnerable with a route to escape attack

The development should be both easy to maintain and to clean

Consideration to be given to finishes and fixings and any proposed new products should receive NHSL approval prior to selection

Positioning of essential maintenance items should be outwith important patient areas

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3. The Non- Negotiables for Visitors



Benchmarks


Carers/ Family members accompanying patients must be able to find information and additional support to assist them

Information and signposting points available

Space should be provided to accommodate and occupy dependants while patients are being treated

Waiting areas should be attractive and restful with daylight

Carers/ Family members accompanying patients should have access to an interview room that provides a confidential environment for discussion

Interview room should be within easy access of the relative waiting area

Carers/ Family members accompanying patients should have the ability to access assistance if required

Staff should be within easy reach of Carers/ Family Members if assistance is needed

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4. Alignment of Investment with Policy



Benchmarks


Site position, massing and visual appearance of the ICU must provide a positive addition to the hospital site, setting a precedent for future development.

Building should have a suitable presence that is both welcoming and modern

Building should enable appropriate massing to achieve a coherent and economic use of space

Building should be designed with appropriate privacy in terms of overlooking and closeness

Facility should be designed to be sustainable in construction, use and decommissioning/ demolition

BREEAM Good (Assessed under HFS BREEAM Pragmatic)

Social, Economic and Technical sustainability to be considered in the design

Facility must be designed to allow future adaptation

Facilities to be designed such that they may be re-aligned to meet changes in future service

The form of construction adopted will maximise the ease of alteration

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5. The Self Assessment Process (IA Stage)

Decision Point Authority of Decision Additional Skills or other perspectives

How the above criteria will be considered at this stage and / or valued in the decision

Information needed to allow evaluation

Site Selection Decision by NHSL with advice from Project Board

Risk/ Benefit analysis considering the capacity of the sites to deliver a development that meets the criteria above.

Site feasibility studies (including sketch design to RIBA stage B) for alternate sites or completed masterplan (for site with the potential for multiple projects).

Cost estimates (both construction and running costs) based on feasibility.

Completion of brief to go to the market

Decision by Project Board with advice from Project Manager

HFS Frameworks Scotland 2

Work will progress with existing FS2 Partner Market Testing will be undertaken prior to acceptance of the Stage 2 price

Selection of Delivery/ Design team


HFS Frameworks Scotland 2

Quality cost ratio to be at upper level of guidance for complex projects contained in Annex A, para A.3.5 of Scottish Construction Procurement Manual CEL (2009) 50. Design Team selection has been in compliance with NHSL SFI’s.

Design Statement principles have been adopted by design team.

Selection of early design concept from options developed


Comment to be sought from A+DS through the NDAP process

Assessment of options using AEDET or other methodology to evaluate the likelihood of the options delivering a development that meets the criteria above

Sketch proposals developed to RIBA Stage C coloured to distinguish the main use types (bedrooms, day-space, circulation treatment, staff facilities, usable external space). Rough Model

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Approval of design proposals to be submitted to planning authority



Formal process to approve Stage D will be agreed with project board

Approval of detailed design proposals to allow construction

Decision by NHSL with advice from Project Board


Post Occupancy Evaluations

Consideration by NHSL - lessons fed to SGHSCD

Design and Healthcare advisors external to the team

Assessment of completed development by representatives of the stakeholder groups involved in establishing the above against goals they set.

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Appendix 02:

A+DS/ HFS Letter of Support

[will be included in SGHSCD submission]

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Appendix 03:

AEDET Workshop One Summary

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Appendix 04:

Risk Register

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Appendix 05:

SWOT Analysis

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TAH Phase 2 – Stage 2 report SWOT Analysis

[As at September 2012]

Option 1 – Do minimum

STRENGTHS

WEAKNESSES

• No user disruption due to construction

activity • Least capital cost • Enables clinical service to be maintained at

current standards • Minimal change in staff revenue costs to

facilitate any construction/decant works. • Adjacencies to existing theatre facilities and

support services maintained.

• The risks identified within the HFS and ICL

reports will not be addressed. • Disproportionate revenue costs associated

with maintaining theatres in current condition.

• Not able to satisfy the compliant maintenance standards/regime due to theatre pressures and waiting lists.

• None of the other theatre red risks identified within the MKBC risk register will be addressed.

• Existing theatre layout does not compliant with current basic working practice.

• Limited opportunity for future service development.

OPPORTUNITIES

THREATS

• Opportunity to deal with other small risk

items, that have no risk to infection control if stopped prior to completion, in the theatres on an interim basis (Sundays and holiday periods).

• More time to plan any future theatre works.

• Air handling unit failure risk is still open

(hence risk of theatre closure still live). • Air handling pressure regimes will still be

non compliant. • No capacity to accommodate any theatre

closures required for maintenance or failures (i.e. AHUs).

• HFS threat of department closure if do not remediate AHUs.

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Option 2 – Full scale renovation works, including the provision of 3 ‘temporary’ operating rooms. Maintain current clinical activity at Monklands

STRENGTHS

WEAKNESSES

• Full AHU compliance will be achieved. • Clinical activity levels can be maintained

throughout the construction works. • Risks identified within the HFS and ICL

reports are addressed. • Reduction in reactive maintenance required. • Airflow and pressure regimes maintained as

per current compliance standards. • Clinical adjacencies to theatre facilities and

support services maintained. • Shorter duration than option 4. • Core services (i.e. deliveries etc..)

unaffected. • Maintain ‘throughput’ of theatres.

• Duration longer than options 1, 3 & 5 • Greater capital cost than option 1 and 3 • Lead time associated with the design,

delivery and installation of temporary accommodation.

• Potential to disrupt live theatres • Non-compliant room sizes not addressed

through the works. • Increase in site traffic in theatre area (i.e.

cranes etc..) • Time/Cost and disruption associated with

strip out works for the temporary accommodation.

• Capital outlay for temporary accommodation solution.

OPPORTUNITIES

THREATS

• Opportunity to address other red risk items

within the theatres. • Opportunity to improve staff welfare facilities

(introduction of natural light to staff room/ staff WCs).

• Opportunity to relocate the theatre offices to a better location to improve department flow.

• Space planning improvement potential • Opportunity to address additional risks on

the MKBC risk register identified in the theatre area whilst theatres are decanted.

• Opportunity to improve HAI risks.

• HAI risk increased during the construction

period, within the theatres (i.e. construction site adjacent to live theatres).

• Budget being made available by NHSL to procure this option.

• Failure of the AHU ahead of works commencement.

• Potential ground remediation works required for the temporary accommodation.

• Position of the temporary accommodation may impact on environmental conditions for ICU and canteen (blocking natural light).

• Potential impact on fire assembly points/routes due to temp accommodation position.

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Option 3 – Renovation of a proportion of the department, using 3 new operating rooms during and after the works

STRENGTHS

WEAKNESSES

• Full AHU compliance will be achieved. • Clinical activity levels can be maintained

throughout the construction works. • Risks identified within the HFS and ICL

reports are addressed. • Reduction in reactive maintenance required. • Airflow and pressure regimes maintained as

per current compliance standards. • Clinical adjacencies to theatre facilities and

support services maintained. • Shorter duration than option 4. • Core services (i.e. deliveries etc..)

unaffected. • Maintain ‘throughput’ of theatres. • No cost associated with the demolition of the

modular building (as per option 2). • Opportunity to use redundant theatres for

another purpose.

• Duration longer than options 1 & 5 • Greater capital cost than option 1 • Lead time associated with the design,

delivery and installation of temporary accommodation.

• Potential to disrupt live theatres • Non-compliant room sizes not addressed

through the works (unless theatres re-configured i.e. 7 existing theatres become 4 compliant theatres)

• Increase in site traffic in theatre area (i.e. cranes etc..)

• Capital outlay for modular accommodation solution.

OPPORTUNITIES

THREATS

• Opportunity to increase the no. of theatres to

8 no. working theatres (i.e. 3 no. theatres in modular building and convert the existing 7 theatres into 5 complaint sized theatres).

• Ability to increase the ‘throughput’ at the theatres.

• HAI risk increased during the construction

period, within the theatres (i.e. construction site adjacent to live theatres).

• Budget being made available by NHSL to procure this option.

• Failure of the AHU ahead of works commencement.

• Potential ground remediation works required for the modular accommodation.

• Position of the modular accommodation may impact on environmental conditions for ICU and canteen (blocking natural light).

• Potential impact on fire assembly points/routes due to modular accommodation position.

• If the decision was made to increase the no. of theatres (i.e. refurb all 7 existing theatres and maintain the modular accommodation) the associated facilities would require expansion also (i.e. ICU and recovery).

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Option 4 – Build a new operating department

STRENGTHS

WEAKNESSES

• Reduction in the reactive maintenance

costs. • Ability to create a fully complaint theatre

department • Risks identified within the HFS and ICL

reports are fully addressed. • Ability to create a compliant ICU and

recovery area. • No disruption to clinical service during the

works. • Ability to create a future proofed facility.

• Capital cost associated with the works. • Any future redevelopment of the hospital

within the Monklands site would be dictated by the position of the new theatre block.

• Additional consideration and planning required to ensure appropriate link back to support services within the main hospital building.

• Increase in site activity and HAI risks. • Extended planning duration.

OPPORTUNITIES

THREATS

• Opportunity to tailor the department to user

requirements. • Opportunity to meet current environmental

standards. • Opportunity to consolidate theatre services

and reduce staff revenue costs associated with this.

• Opportunity to redevelop the decanted theatre space within the main building for alternative future use.

• Ability to find an area within the site with a

suitable footprint to accommodate a theatre block.

• AHU may fail prior to works being concluded.

• Risk ground remediation works would be required.

• NHSL budget availability to fund the works. • Ability to maintain clinical adjacencies may

be restricted. • Opportunity to maintain the current benefits

of the theatre block (i.e. .the ‘dirty corridor) may be limited due to current SHPN guidance and funding constraints.

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Option 5 – Transfer a large proportion of current activity to elsewhere and renovate the current department

STRENGTHS

WEAKNESSES

• Shortest programme (with the exception of

Option 1). • Overall reduced capital cost • Minimise disruption within Monklands • Enable the risks within the HFS and ICL

reports to be addressed. • No cross over between the construction

works and live clinical areas.

• Room sizes following refurbishment are still

non-compliant (to enable a minimum of 7 theatres to be retained).

• Limited opportunity to expand/future-proof the department.

• Disruption to other adjacent clinical services (i.e. limited theatre capacity).

• At least one emergency theatre would need to be retained throughout the course of the refurbishment works.

• Ability to fit all 100 theatre staff across the other sites (Wishaw and Hairmyers) unlikely.

• Ability to source alternative decant space for the recovery and ICU wards required to facilitate theatre services being decanted to other sites (and other associated critical services).

OPPORTUNITIES

THREATS

• Opportunity to rationalise surgical activities

and staffing levels across the NHSL estate. • Opportunity to address the MKBC red risks

within the theatres during the decant period.

• The other sites do not have sufficient

capacity to accommodate all surgical activities.

• It may not be possible to split all theatre staff across the other sites for the duration of the works.

• Ability for NHSL to source adequate budget.

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Appendix 06:

Schedule of Accommodation

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Schedule of Accommodation: Theatres

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Schedule of Accommodation: ICU

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Appendix 07:

Letter of Support

[will be included in SGHSCD submission]

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Appendix 08:

PSCP Programme

Stage 1B

127

Appendix 09:

Schedule of Derogations

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Schedule of Derogations: March 2014

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