NHS Highland. Endoscopy Decontamination Services for NHS Highland. Standard Business Case

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1 NHS Highland for NHS Highland Endoscopy Decontamination Unit

2 CONTENTS 1 PROJECT TITLE AND INTRODUCTION 1 2 EXECUTIVE SUMMARY 2 3 STRATEGIC CONTEXT AND CASE FOR CHANGE 4 4 STRATEGIC OPTIONS 12 5 INVESTMENT OBJECTIVES 15 6 KEY CONSTRAINTS 16 7 SUMMARY OF SCOPE AND SERVICE REQUIREMENTS 18 8 ECONOMIC CASE 21 9 DEVELOPMENT OF THE PREFERRED OPTION COMMERCIAL CASE FINANCIAL CASE MANAGEMENT CASE CONCLUSION 41 Appendix A EDU Floor Plan 42 Appendix B Accommodation schedule 43 Appendix C - Non-Financial Benefits Appraisal Weighed Scores 44 Appendix D Financial & Economic Assessment 45 Endoscopy Decontamination Unit

3 1 Project Title and Introduction This summarises the planned investment in the development of Endoscopy Decontamination Services for NHS Highland. The title of the project is as follows: for NHS Highland This Business Case has been requested by Eric Green, Head of Estates (NHS Highland) to assist NHS Highland to consider options for the provision of in the NHS Highland Region which will help to address existing compliance issues and deficiencies. In summary this Business Case seeks to consider and address the following. Consideration of the existing decontamination facilities and its context for NHS Highland Optioneering review to validate the preferred way forward for the NHS Highland region Identification of the key objectives of the planned investment Summary of the key constraints Summary of the scope An economic review of the preferred option against a do nothing Scheme development of the preferred option, including estimated costs, strategy and programme Overall affordability 1

4 2 Executive Summary This (SBC) provides a detailed report on NHS Highland s proposed investment in provided throughout the Highland region. This Business Case has been developed within the context of a separate major initiative currently being undertaken by NHS Highland comprising a substantial masterplanning exercise for the Greater Inverness Area where options for optimum future Healthcare provision in the Highlands are being considered. The investment project is titled: for NHS Highland and this Business Case demonstrates that there is currently a need on both a strategic and operational level to improve the provision of endoscopy decontamination services in NHS Highland. There are a number of areas in which the endoscopy decontamination facilities in NHS Highland are inadequate to deliver the standard of service required and comply with various healthcare stipulations. These inadequacies are noted in a broad spectrum of areas and these are detailed in Section 3.7 of this business case. To address the deficiencies referred to above, a strategic option appraisal was carried out which identified 5 options which could potentially deliver the necessary improvements to the delivery of the endoscopy service at NHS Highland. Following detailed consideration by the key stakeholders, a number of these were excluded from further consideration as they would not achieve the level of compliance necessary for the decontamination service. A weighted non-financial qualitative scoring exercise was derived for the remaining option including the do nothing option, to ascertain whether the option would achieve the qualitative benefits required. An economic appraisal was then undertaken to establish the feasibility of the options based on an assessment of capital costs, recurring revenue, non-recurring revenue costs and net present costs for each option. The Option 1 - Do Nothing has been costed for baseline purposes however this option is not viable because the various deficiencies would not be addressed. The options considered, non-financial qualitative scores, capital costs and Value for Money analysis are summarised in the table below, and additional details are provided in Sections 4 and 8. No Option Qualitati ve Benefits Score Quality Rank Net Present Cost ( k) Cost /Benefit point ( k) VfM Economic Ranking 1 Do Nothing , , Provide several compliant decontamination units with internal distribution services , ,

5 As the table indicates, the preferred option on both quantitative and qualitative outcomes is Option 5, which involves the provision of several compliant decontamination units with internal distribution services throughout the Highland region. This option requires the development of a new build Endoscopy Decontamination Unit at Raigmore Hospital which will provide a fully compliant decontamination unit, which can also provide a central supporting role to the satellite decontamination units. The proposed investment will provide a necessary improvement in Endoscopy Decontamination Services which is necessary to support the delivery of endoscopy services throughout the NHS Highland region. The preferred option, Option 5, will be delivered as detailed in Sections 8 12 of this Business Case and with consideration to the ongoing Fire Precautions project underway in the Tower Block at Raigmore Hospital, and to the Greater Inverness master planning exercise being undertaken. Subject to approval, the programme for the delivery of the Endoscopy Decontamination Unit will be in line with the dates tabulated below: Submission of Business Case August 2013 Approval of Business Case September 2013 Start on site October 2013 Completion date April 2014 Services Commencement April

6 3 Strategic Context and Case for Change 3.1 Profile of NHS Highland and Raigmore Context NHS Highland is one of the fourteen regions of NHS Scotland. It employs over 9,000 people, making it one of the largest employers in the region. Geographically, it is the largest Health Board, covering an area of 32,500 km² from Kintyre in the south-west to Caithness in the north-east, serving a population of over 300,000 people, and sees a proportion of its patients from the influx of tourists to the Highlands, which at certain times of the year, can double or even triple the local population. NHS Highland provides strategic leadership and direction for NHS services and is accountable to the public and to the Scottish Government for all elements of the NHS system in the Highland and Argyll & Bute Council areas. As of 1st April 2012, with the integration of health and social care in the Highland region, NHS Highland is the lead agency for the delivery of Adult services across health and social care (The Highland Council are the lead agency for children's services). NHS Highland works with partners to improve the health of local people and the services they receive and to ensure that national clinical and service standards are delivered across the NHS system. NHS Highland is working to improve services with the involvement and support of the public, partners in other NHS Boards, Highland Council, other independent and voluntary agencies The areas NHS Highland covers are benefiting from improved health services and so people are now living longer. It is estimate that by 2031 the number of people aged 75 or over in Highland will double. This is important to plan for because older people tend to make more use of health and social services. As people age it becomes more likely that they may acquire one or more long-term condition(s) like asthma, chest problems, depression, dementia, diabetes and heart disease as well as having a greater risk of getting cancer. 3.2 Vision Raigmore Hospital in Inverness is the district general hospital for patients in the North, Mid, and South East Community Health Partnership areas serving patients from its own and adjacent Community Health Partnership areas as well as those from adjacent Health Board areas. NHS Highland has delivered significant achievements in recent years, treating more patients, and providing better, faster access to diagnostic and treatment services as well as achieving financial balance. The Board continues to seek improvement in the quality of patient care however and, in line with other NHS Boards, has a published Local Health Plan. This plan sets out a simple vision for the people of the Highlands: Quality care to every person every day NHS Highland, in common with all Scottish health boards, has an advantage in being responsible for the total health needs of the population and, for integrated care. This means it is responsible for the better health of communities through population wide and individually focused initiatives to maximise health and prevent illness; for better 4

7 care of patients through quick access to modern services, in clean and infection free facilities, by well trained and courteous staff; and for better value for the use of the public money spent by ensuring there is no waste and inefficiency, money is spent only on what is needed and has evident therapeutic benefits and variation from core care pathways is the exception. The importance of keeping a balance between the three components of better health, better care and better value is fully recognised because they are intrinsically linked and together constitute an effective health system. Any one area cannot be prioritised over any other. This approach is consistent with the objectives identified within the NHS Highland Local Delivery Plan 2013/2014. The Plan sets out the strategic direction for the Board, provides evidence of performance to date and describes the plans to address the national targets. The key objectives associated with the Local Plan 2013/2014 are provided under Section NHS Highland Strategy General The planned investment to provide compliant decontamination services is directly linked to effective delivery of future healthcare services in line with the local NHS Highland strategies (which are described below). These local strategies, in the form of the Local Development Plan (see below) have been developed to meet the overall delivery of the national strategies in line with the Scottish Government National Strategies The national strategies and recently published guidance which have influenced the development of the Local Development Plan and are therefore of relevance to the proposed investment include: The five Strategic Outcomes of the Scottish Government. (Wealthier and Fairer; Smarter; Healthier; Safer and Stronger, and Greener) The Healthcare Quality Strategy for NHS Scotland (the Scottish Government 2010) A Sustainable Development Strategy for NHS Scotland (the Scottish Government) NHS Scotland Efficiency and Productivity Framework. The Scottish Patient Safety Programme launched in 2008 National Framework for Services Change in NHS Scotland (2005) Building a Health Service Fit for the Future The Kerr Report (2005) Delivering for Health (2005) Better Health Better Care Action Plan (2007) 5

8 Scottish Government - Asset Management Policy Policy for Design Quality for NHS Scotland 3.4 Local Delivery Plan 2013/14 NHS Highland s mission is to provide patient-centered services tailored to people s needs in a systematic and consistent way providing quality care to every person every day. Our approach embraces the Healthcare Quality Strategy for Scotland and also takes account of the priorities within the NHS Scotland Efficiency and Productivity Framework for SR10. The described vision is to: Provide quality care at all times; Support people and communities to maximise their own health; Develop precisions driven services so that when people need care they experience timely, focused, effective services that minimise the duration and frequency of contact; Ensure that every health pound spent delivers maximum health gain. The NHS Highland 2013/14 Local Delivery Plan focuses on the contributions to 4 national priority areas: Health inequalities Early years Tackling poverty Economic recovery The investments proposed in this will make a significant contribution to the goals of the NHS Highland Local Delivery Plan by sustaining and building upon the developments in acute care. In particular the investments will: Provide services and facilities which meet 21 st century healthcare needs and are acceptable to both staff and patients. Ensure that services are continuing to progress towards the achievement of national standards. Provide an environment which enables staff development, recruitment and retention as well as community involvement and ownership. High quality, integrated, equitable, needs and evidence-based, and cost-effective Increasing focus on hospital beds being preserved for the most acutely ill and those with specialist needs Run by healthy, flexible, well-motivated and well-trained staff working to their maximum potential and capability 6

9 Using modern, flexible, efficient, green assets to maximum effect Reduce wastage and inefficiency across acute services NHS Highland Quality Approach The Quality Strategy sets out NHS Scotland s vision to be a world leader in healthcare quality, described through 3 quality ambitions: effective, person centred and safe. These ambitions are articulated through 6 Quality Outcomes that NHS Scotland is striving towards, and to align their services with this, NHSH Highland have developed The Highland Quality Approach. The Highland Quality Approach captures the spirit of how NHS Highland is working to improve care and outcomes for people in the Highland Region. It describes our ways of working, values and behavior. It recognises how important it is to improve the health of the population and get the experience of care right for individual people, every time. We will deliver this by focusing on providing person-centered care while at the same time eliminating waste, reducing harm and managing variation. The Highland Quality framework is captured in the blue triangle. It has been designed to place the individual at the top, with all other activities supporting this purpose. In developing this approach NHS Highland have drawn from the best learning available, the key elements of the Highland Quality Approach, summarised in the blue triangle, include the organizational Mission, Vision and Values. It also describes how services and care will look in the future as well as how this approach is changing the way services and care is delivered. 7

10 NHS Highland s vision is to provide Quality Care to Every Person Every Day. In delivering this vision, three key elements must be delivered simultaneously: Better Health improving the health of the population Better Care enhancing the experience of care for individuals Better Value controlling the per capita cost of care By reviewing the above key elements which make up the Quality Approach, it is clear that investment in endoscopy facilities at Raigmore Hospital will make a significant contribution to the mission, vision and values. In particular the investment will improve the overall care of the patient both in terms of quality of care and an improved environment. In addition to meeting the above quality objectives, investment in Endoscopy Services, including Decontamination facilities in the Highland region will help achieve various positive outcomes which are directly related to the 6 strategic objectives described within the NHS Highland Local Delivery Plan. A summary of these positive outcomes in described below: Reduced infection rates through; adherence to improved technical & space standards; improved building fabric & servicing; improved performance against National Cleaning Standards; enhanced patient journey/flow optimisation; reduced length of stay; enhanced endoscope cleaning/storage facilities; effective pre-admission assessment and screening. Improved health for the people of the Highlands through improved access to modern endoscopy facilities that have been planned and will operate in the context of a regionwide surgical and endoscopy care delivery model, a key element of which is the provision of a compliant endoscopy decontamination service. Reduced waiting times for endoscopic review and intervention through: the creation of robustly challenged and justified additional endoscopy capacity; the optimal planning and utilisation of endoscopy activity. The capacity and optimisation of the endoscopy service is dependant on a compliant endoscope decontamination service. High quality services that are based on evidence based care and robustly evaluated through; extensive review and challenge of all care models; detailed capacity review and planning; optimal accrued benefits realisation monitoring; careful adherence to all current clinical and technical standards. Realisation of significant components of NHS Highland s service modernisation programme through; supporting/facilitating whole system re-design of all of the services involved; planning for these services in the context of region-wide care models; integrating services when it is clinically appropriate to do so; supporting the realisation of a wide range of performance and service-related targets; contributing to the development of generic models of care. 8

11 3.4.2 Greater Inverness Masterplan Whilst at an early stage in development, NHS Highland is currently considering options for the reconfiguration and rationalisation of clinical services across NHS Highland. This strategic plan will involve a review of all NHS Highland buildings in the Inverness area, and may involve some services relocating from Raigmore Hospital in their entirety. This is most likely to include reconfiguration of clinical services within the Tower Block to achieve clinical services and adjacencies at their optimal locations. NHS Highland have established that the current location of the Endoscopy services (including existing the existing decontamination facilities associated within that service) within the ground floor of the Tower Block, is not ideal and indeed there are a number of other clinical departments for which it would be more advantageous to be located in this position. Initial optioneering has established that this ground floor location could be the future position for the Medical Critical Care Unit (CCU) and Cardiology Step-down. This has been the subject of further investigation within an Initial Agreement document for the Tower Blcok which has been approved by the Scottish Government. Whilst a final decision on this aspect has yet to be taken (and will form the basis of an Outline Business Case development) the NHS Highland board are satisfied of the need to relocate the Endoscopy Services / Decontamination services away from the Tower Block. This reconfiguration forms the basis of the options identified in this document. 3.5 NHS Highland Endoscopy Decontamination Procedures Procedures The primary purpose of an Endoscope Decontamination Unit is to decontaminate flexible endoscopes between use, as any failure to adequately decontaminate the endoscope may increase the risk of transmission of infection between patients and/or compromise the quality of clinical samples. Maintaining the delivery of a high quality decontamination service is of paramount importance to the delivery of endoscopy clinical services and to ensuring patient care. Decontamination procedures in NHS Highland are carried out locally at the 6 sites which provide endoscopy procedures, and as a result of the organic growth in endoscopy procedures, often without liaison with infection control personnel, the decontamination facilities are non-compliant with current healthcare standards under the key service requirement headings noted in SHPN 13-3 which are Environment, Equipment and Management. As endoscopies are a critically important diagnostic procedures and their use is expected to increase, there will be a resultant increase in demand on the endoscopy decontamination services throughout NHS Highland Geographical Locations and Facilities 9

12 There are six sites in Highland undertaking endoscopy procedures and each site provides their own decontamination services: Raigmore Hospital, Inverness Belford Hospital, Fort William The Dr MacKinnon Memorial Hospital, Broadford, Skye Caithness General Hospital, Wick Cowal Community Hospital, Dunoon Lorn & Islands Hospital, Oban 3.6 NHS Highland Decontamination Facilities - SHPN Compliance The key area that demands investment across several facilities within the NHS Highland Region is with regard to the need to achieve compliance with modern decontamination standards including the separation of clean and dirty equipment, the associated process flow of equipment and particular ventilation requirements. The Scottish Health Planning Guidance for Endoscopy Decontamination Units (SHPN 13, Part 3, September 2010) sets out the detailed requirements for modern decontamination facilities. NHS Highland have identified that the facilities at Raigmore Hospital, Caithness, Fort William and Oban are in critical need for upgrading to meet the recognised standards. 3.7 NHS Highland Decontamination Facilities The main function of an Endoscopy Decontamination Unit is to support the work of the clinical service through the delivery of a high quality decontamination service which meets the demands of the endoscopy service. Whilst this business case considers endoscopy decontamination throughout the Highland region, it is important to highlight that although a component of a wider network of facilities conducting endoscopy, the Raigmore Hospital unit is the largest endoscopy facility within NHS Highland and therefore has a central role in supporting endoscopy throughout NHS Highland. Specifically, the Raigmore service is often used to address operational/delivery issues in other units or to conduct those investigations that are identified that should be carried out in NHS Highland s major acute facility for clinical reasons. i.e. The Raigmore Unit is often called upon to treat patients who are not attending for purely geographical reasons. In addition to the decontamination facility at Raigmore Hospital, the endoscopy facilities in the other geographical locations within NHS Highland have ancillary decontamination facilities which are not compliant standards in terms of built environment, mechanical services and decontamination equipment. Further details on these problems are provided in Section 3.8 below. 10

13 3.8 Inadequacies of the Endoscopy Decontamination Facilities There are a number of areas in which the endoscopy decontamination facilities throughout NHS Highland are inadequate to deliver the standard of service required and comply with various healthcare stipulations. Inadequacies are noted in a broad spectrum of areas and these are detailed below: The environments in which the decontamination of endoscopes is undertaken are not consistent with the room finishes described in SHPN 13 Part 3. None have physical segregation of the dirty-to-clean stages of the process with the majority having insufficient spatial segregation of dirty-to-clean stages and the process flow in most sites is unsuitable, this provides the potential for the recontamination of decontaminated endoscopes. Not all process stages are available in each site, such as there being not enough process sinks, no wash hand basin, no area for the inspection of decontaminated endoscopes, no storage cabinets Appropriate heating, ventilation and air conditioning are not present which inhibits control of the environment and provides the potential for the recontamination of decontaminated endoscopes. High standards of cleanliness are essential but the surfaces in the decontamination areas are not smooth and intact to support cleaning and plant and pipe work are exposed creating dirty areas within the rooms which are impossible to clean None of the washer disinfectors in use comply, and cannot be upgraded to comply, with SHTM 2030 and BS EN ISO , 4 and incorrect supply and microbiological quality of water is used for the final rinsing stage of the washing and disinfecting process. There is no electronic traceability system in place to provide demonstrable evidence that endoscopes have been timely and appropriately decontaminated and thereafter used within a safe period There are no storage rooms available for plant, chemicals and consumables which means chemical storage is not controlled and often excessive and on occasion unrelated consumables are stored in the decontamination area, this provides potential for the recontamination of decontaminated endoscopes due to turbulent dust when moving such items. In the main the clinical staff who undertake the decontamination of endoscopes have not undergone proper standardised training in the process of endoscope decontamination and as a result practice may provide the potential for failure and cross-contamination. Dedicated staff for endoscope decontamination are required who do not have conflicting demands on their time and practice to help ensure the validated decontamination of endoscopes. 11

14 4 Strategic Options 4.1 Overview Following the identification of the inherent inadequacies in the decontamination services in the Highland region, a strategic assessment was undertaken to identify potential solutions for the delivery of a compliant decontamination service. The strategic assessment identified 4 options for further consideration along with a baseline Do Nothing option. The 5 strategic options are detailed below, with a summary of the outcome of each, following a more detailed research. 4.2 Strategic Options Option 1: Do Nothing A Do Nothing option was considered so as to provide a baseline as per the guidance issued by HM Treasury. This is not an option given the condition of the current endoscope decontamination facilities and equipment. To Do Nothing entails the potential for future patient harm, to incur patient complaints and damage the reputation of NHS Highland. This option would leave NHS Highland out of line with the majority of Health Boards in Scotland who have introduced compliant facilities for this activity. Option 2: Purchase a compliant service from an external provider Investigations as to whether an external provider would be able to undertake endoscopy reprocessing, included approaching private partners who are interested in investing in the Highland area. This research established that none of the private suppliers were in a position to enter into contract to provide this service to NHS Highland and so this option could not be priced, and effectively could not be considered as a feasible option. It is worth noting that if this option was available, it would require considerable financial investment to purchase additional endoscopes to accommodate the extended turnaround times which would be inevitable with an external provider. Option 3: Use disposal endoscopes During early discussions on this option, the endoscopy clinicians advised that the disposable scopes available did not provide the functionality required for the delivery of the endoscopy service. Furthermore, evidence from other NHS Boards supports the view that this option would not be viable in the long terms. In addition to the limitations of the disposable scopes, research has demonstrated that disposable scopes were not widely available. These constraints result in the use of disposable endoscopes being discarded as a feasible option. 12

15 Option 4: Provide a single compliant decontamination unit and distribution service for the whole of NHS Highland A number of fundamental difficulties were encountered with this option once further research into establishing its viability was undertaken. The constraints are noted as follows: There is not currently a validated method to transport decontaminated endoscopes to the geographical locations in NHS Highland. The cost of customising vehicles would be prohibitive if a validated method was ever achieved. Road traffic incidents, road closures and inclement weather conditions in such an extensive geographical area pose significant risks. Endoscopes are disinfected between use and must be used within three hours of decontamination (which is not compatible with the large geographical spread of the NHS region) The storage cabinets used to prolong the life expectancy of disinfected endoscopes are not mobile and so are not able to be used to facilitate transporting of decontaminated endoscopes. The design and construction of an endoscope means they must be manually cleaned as soon as possible after use to prevent organic debris from hardening in the long narrow lumens (1.8mm x 2m). Notwithstanding the costs for the new facilities under this option, the capital cost alone for the additional endoscopes required to satisfy clinical activity as well as the turnaround time for off site processing is estimated to be in the region of 1.6m. In view of the above fundamental problems, and the prohibitive investment in endoscopes, this option was deemed not be be viable and was not considered further. Option 5: Provide several compliant decontamination units with internal distribution services This option would involve the development of compliant decontamination units adjacent to the endoscopy services initially at Raigmore Hospital, followed by the delivery of satellite decontamination units at including Oban, Fort William and Wick. The investment at Raigmore Hospital would be through the development of a new build decontamination unit. 4.3 Summary Consideration of the delivery of endoscope decontamination facilities in the NHS Highland region identified a number of strategic options to ensure a compliant endoscope decontamination service. However after a detailed review, as summarised above it was established that 4 of these options were clearly not a viable means of delivering a compliant, efficient and cost effective service. 13

16 The research undertaken identified that Option 5 was the only strategic option which could provide a viable and cost effective solution for delivering a compliant endoscope decontamination service for NHS Highland. Section 3.7 above notes that the Endoscopy Decontamination Unit at Raigmore Hospital Inverness is the largest facility in the Highlands region, and performs a central supporting role for the satellite facilities. Due to its strategic importance in delivering a compliant decontamination service throughout the Highlands, this document will focus on the business case for an investment in an Endoscopy Decontamination Unit at Raigmore Hospital. 14

17 5 Investment Objectives Following the assessment of the available strategic options detailed in Section 4 and the outcome being that Option 5 was the only viable strategic option, it was still necessary to establish and understand the key objectives associated with the planned investment in the. This would ensure that the development of the option was in line with the agreed objectives and so that the developed solution can be monitored against the identified benefits. A workshop with key stakeholders was convened to establish investment objectives which relate to the key strategies referred to in Section 3 and the deliverable option. Based on Option 5, the key investment objectives have been identified as follows. Reduced infection rates through the provision of local decontamination facilities which are commensurate with modern standards and fully compliant with SHPN 13 Part 3. To divorce decontamination services from clinical activity (In particular, replace the current decontamination facilities which are co-located with the Endoscopy Clinical Services). Contribute to more effective and efficient clinical services, which deliver improved health for the people of the Highlands. Comply with the detailed requirements of SHPN 13 Part 3 Endoscope Decontamination Facilities. Meet with the overall NHS strategic approach Maintain business continuity (including avoiding disruption during development and change of service) Improve potential for retention and recruitment of staff Provide high quality and functional efficiency of the physical environment. 15

18 6 Key Constraints 6.1 Financial The development of the decontamination facilities within NHS Highland is closely linked with the reconfiguration of the NHS Highland endoscopy services, as per the NHS Highland Reconfiguration of Endoscopy Services which has been submitted for consideration. A total funding package of 4m has been identified as required for the reconfiguration of the endoscopy services and the provision of compliant decontamination facilities to support this. The allocation of funding is constrained by the requirement to be expended by the end March Programme The key time constraints associated with this investment include: The improvements required by the provision of new Endoscopy Decontamination Units are a high priority and the aspiration is to have the work underway to enable a compliant facility to open at Raigmore Hospital and three satellite sites by April The satellite decontamination units are outside the scope of this business case. Procurement timescales for the endoscope washer disinfector machines mean that the guarantees on the equipment are dated from January 2014, so the machines should be operational from the earliest possible date. 6.3 Site and Associated Works In considering the site location for the proposed facility and the associated works and impact on the adjacent areas, the following points have been collated and will need to be considered as part of any decision process. Subject to the preferred location of the decontamination facilities the work areas will be adjacent to 24 hrs live acute clinical services and significant disruption to patient care and staff must be avoided. It is anticipated that the decontamination unit at Raigmore Hospital will be within new build accommodation, and access to the identified site may be constrained by adjacent buildings, services and requirements to maintain access for emergency services. This will be dependant on the final selection of the development site. Compliance with general requirements noted in the Contractors working at Raigmore Hospital NHS Highland Control of Contractors Policy. The works will need to be undertaken giving detailed consideration to Infection Control issues. As appropriate HAIScribe assessments will be undertaken. 16

19 6.4 Design and Quality Constraints Of particular note, the new decontamination facilities must comply with the Scottish Health Planning Guidance for Endoscopy Decontamination Units (SHPN 13, Part 3, September 2010). SHPN 13 Part 3 also gives advice on the providing a unit that can cope with the expected workload capacity. It is important that the Decontamination Facility provides enough space and equipment to cope for the foreseeable future. Chapter 4 of the SHPN gives detailed technical information that must be complied with such the previously mentioned capacity planning, design of the decontamination area etc and should be read carefully and fully taken account of in the design. This section also covers wall and floor finishes and the design requirements of the ventilation system. Full account of the current and predicted workloads within the unit will need to be taken to help determine the plans. Notwithstanding the above, the new decontamination facilities will require to comply with other relevant Scottish Health Planning Notes (SHPN s), Scottish Health Facilities Notes (SHFN s), Scottish Health Technical Memorandum (SHTM s) and any other relevant publications including but not limited to the following: SHPN 13 Part 3 Decontamination Facilities - Endoscope Decontamination Units SHTM 2030 Guidance for Washer Disinfectors, BS EN ISO ,4 JAG Guidance ( and NHS Highland comparison document Delivering Quality & Value, Institute for Modernisation & Improvement (2006) SHFN 30, Version 3, Infection Control in the Built Environment, Health Facilities Scotland (January 2007) Way finding: effective way finding and signing systems guidance for healthcare facilities (NHS Estates, 2005) Improving the patient experience: Welcoming Entrances and Reception Areas, NHS Estates (2004) The Disability Discrimination Act (2005) Health & Safety at Work Act (1974) COSHH Regulations (2002) as amended 17

20 7 Summary of Scope and Service Requirements 7.1 Resultant Service Requirements The provision of a new build endoscopy decontamination unit will enable the resultant service to comply with the latest health care standards as noted in Section 5.4 and particularly SHTM 13 Part 3. In complying with these standards, the following technical requirements are to be incorporated: A two room endoscope decontamination unit generally as per SHTM 13 Part 3, (but without ante room). As noted, no ante room required. This is for operational reasons and the fact that these are not seen as providing any significant benefit. An NHS Highland risk review has been undertaken to validate this. 4 pass through washers with access hatch through Separate clean / dirty flow for endoscopes Facility to clean multiple scopes at one given time Area for set down and testing General Storage for Supplies (for both Raigmore and outlying Units) Inspection area post contamination Space for transfer trolleys Space for pass through hatch Hand washing facilities Office Suitable ventilation / extraction and lighting Chemical Store DSR facilities Plant space UPS An essential requirement for endoscope decontamination facilities is an effective separation of clean and dirty processes, and this should play an integral part in the design process. 18

21 In addition to the requirements set out above, SHPN 13 Part 3 describes the requirements for services. Notwithstanding this, the following specific requirements have to be incorporated into the new facility: Reverse Osmosis treatment will be required to provide water treatment for the new facility together with the existing CDU. The design will require to take account of the RO equipment planned (being procured directly by NHS Highland) together with its integration with the CDU, including optimal pipe routing. The strategy for essential services for the proposed development in the context of establishing the on-going and proposed developments at the site. All service pipe work and cables should be concealed to minimise spread of infection. Whilst SHPN 13 Part 3 noted the general requirements for controlled environments to be heated by mechanical ventilation systems, consideration is to be given to the use of the high level radiant panels / heat exchangers in conjunction with the steam heating main which passes in close proximity to the new development. All enclosed workspaces require to be ventilated. In conjunction with SHPN 13 Part 3, whilst the ventilation system is not required to be consistent with a CDU, the ventilation supply and extract system should be chosen such as to maintain relatively clean areas at positive pressure with respect to relatively dirty areas at negative pressure to minimise risk of cross contamination. Compressed air connection into the distribution pipe work associated with the central decontamination unit. Data communications linked into existing system. The design will just include for containment. Cabling and commissioning provided by NHS Highland IT team. Requirements for connection of individual circuits and items of equipment to uninterruptible power supply (UPS) and/or standby generation systems should be discussed with users and with equipment suppliers. The UPS should be provided with a bypass for failure or maintenance purposes. Designers should undertake a risk assessment with the planning team to identify the operational impact when an electrical supply is not available. 7.2 Standard Process Flow & Service Delivery The general workflow of the decontamination process is as generally described within SHPN 13 Part 3. This process is not detailed within this document however a number of specific or exceptional issues are noted with respect to the particular location and unit being provided at Raigmore, as follows: The endoscope may have undergone preliminary removal of gross contamination by clinical staff immediately after use, within the Endoscopy Services Unit. The trolley containing the soiled endoscopes will be contained within the Endoscopy Services facility dirty store (or for other clinical services in similar units) for short periods of time for frequent pick-up by decontamination staff 19

22 EDU staff will transfer the soiled endoscopes using the trolleys and via ground levels corridors through the hospital through to the main access to the CDU security door, and then through to the EDU. The trolleys containing the soiled endoscopes are then transferred to the wash room and on arrival at the EDU, the scopes will be placed in the set-down area, dismantled and a leak test and manual cleaning of the scope is carried out the wash sink and it is then rinsed in the rinse sink. The scope is then processed through the pass-through EWD. The scope is then removed from the EWD in the inspection room, inspected and dried. Endoscope found to be soiled after processing are return for re-processing The disinfected endoscopes are placed into disinfected plastic lidded trays and into the transport trolleys for transporting to the Endoscopy Services Unit clean store where the endoscopes will be stored in HEPA filtered storage cabinets It is noted that endoscopes are heat liable and as such cannot be sterilised using moist heat. The approach is to minimise theoretical risk through disinfection with chemical. Based on this, the safe time for storage of clean scopes is 3 hours, prior to being stored in HEPA filtered cabinets, as above. 20

23 8 Economic Case 8.1 Overview This section summarises the undertaking of an economic appraisal to review the preferred option against a Do Nothing option. by establishing the potential nonfinancial benefits which could arise and the potential net present cost. 8.2 Consultations Various consultations have taken place to consider options for the proposed investment. The following representatives have been consulted: Head of Estates - Eric Green Head of Decontamination - Anne Cosh Support Manager, Decontamination Services - Claira Chisholm Senior Estates Engineering Adviser - Colin McEwen NHS Highland Clinical Adviser - Doreen Bell NHS Highland Infection Control Representative - Alison McLean NHS Highland H&S Representative - Rosie Brunton Frameworks Partners and Advisers - including Turner & Townsend and Thomson Gray The Highland Council Building Control - Angus McGruer Scottish Fire and Rescue Service - Andy Knox Scottish Fire and Rescue Service (Inverness) - Derek Wilkie 8.3 Options Background Following the strategic options exercise, as summarised in section x, and the establishment that Option 5 was the only viable, cost effective option, a further workshop was convened to review the non-financial benefits which could be realised under this option and to compare this against a do-nothing option. Whilst early consideration was given to the potential for the provision of the new decontamination facilities to be developed within accommodation adjacent to the existing Endoscopy services within the Ground Floor of the Tower Block. However this was quickly excluded from further consideration on the basis of the following: The reconfiguration exercise being undertaken at Raigmore Hospital as detailed in Section has identified the Ground Floor accommodation as being more beneficial 21

24 for other clinical services. In line with this a separate has been developed which recommends the re-location of the existing Endoscopy Services to Ward 8. Compliance with the guidance set out in the clinical design guides would prove difficult to achieve within the fabric of the existing building and prohibitive costs would be incurred. 8.4 Benefits Criteria Key stakeholders have given further consideration to the Investment Objectives (as described in Section 4) in order to establish the relative value of each objective, and to be used as a basis of review. The following is a summary of the work undertaken: Investment Objective Relative Value Main Beneficiaries Potential Benefits Criteria 1 Provide facilities which significantly reduce risk of spread of infection compared to status quo High Patients How well the option is likely to have a positive impact on infection control 2 Divorce decontamination services from Clinical Activity High Patients How well divorcing decontamination from clinical services is achieved through NHS Highland 3 Contribute to more effective and efficient clinical services High NHS Highland Population How the efficiency of the service is improved 4 Comply with the requirements of SHPN 13 Part 3 Medium Endoscopy Service How well will the option provide efficient delivery of scopes to clinical users. 5 Meet with the overall NHS strategic approach High Endoscopy Service How well does the option meet key strategic objectives as part of the NHS Highland Delivery plan 6 Maintain Business Continuity (including avoiding disruption during development and change of service Patients How well the option minimises disruption to service 7 Retention and recruitment of staff Medium Staff How well will the option improve working conditions and training capabilities. 22

25 Investment Objective Relative Value Main Beneficiaries Potential Benefits Criteria 8 Quality and functional efficiency of physical environment Medium Staff Quality of the environment for staff including functional suitability, natural light & ventilation, safety & security, statutory compliance and environmental standards. 8.5 Non-Financial Benefits Appraisal Introduction Following consultation with the project stakeholders, a set of non-financial benefits criteria was developed based on: The project objectives The benefits criteria used for similar projects The workshop identified eight benefits criteria which were then applied by the stakeholder group to score the proposed option. The six benefits criteria are illustrated in the table above. How well the option is likely to have a positive impact on infection control How well divorcing decontamination from clinical services is achieved through NHS Highland How the efficiency of the service is improved How well will the option provide efficient delivery of scopes to clinical users. How well does the option meet key strategic objectives as part of the NHS Highland Delivery plan How well the option minimise disruption to service How well will the option improve working conditions and training capabilities. Quality of the environment for staff including functional suitability, natural light & ventilation, safety & security, statutory compliance and environmental standards. The scoring of the options against these benefits criteria is designed to assess the extent to which the potential solutions meet the objectives of the proposed investment. Scoring provides a means to assess how each of the options compares both in relation to the optimal position (i.e. meeting all the criteria on its own merits as well as in 23

26 relation to the other options) provides a means by which the overall value for money delivered by the short-listed options can be assessed Scoring the Options A scoring assessment was convened on 31 st July 2013 with the Decontamination Services staff lead. The results of the assessment were subsequently submitted to key stakeholders and endorsed by all parties. The scoring assessment delivered the following results: No. Option Description Weighted Benefits Score Consensus Optimistic Pessimistic Rank 1 Do Nothing Provide several compliant decontamination units with internal distribution services Summary and Conclusion In summary, the non-financial benefits assessment has shown the following: Option 1 (no change) was included to provide a baseline and as would be expected by definition completely fails to meet the investment objectives noted in Section 4 and is not a viable option. Option 5 substantially delivers the preferred option in terms of the non-financial benefits. 8.6 Cost Estimates, including Assumptions Overview This section presents the economic implications of the investment (both capital and revenue) and also provides the economic appraisal of the short-listed options. The outputs from the cost models identified in this section form the basis of both the financial and economic appraisals of the short-listed options. Each of the short-listed options has been assessed with due consideration of the changes associated with each option and any changes in cost have been clearly identified and explained. The following categories of cost have been considered for each option Capital Cost Estimate for Each Option The capital costs have been considered and prepared using the capital requirement of each option which has been identified by the external professional cost advisors. These capital costs have been calculated using the brief and plans for each option. The following summarises the main capital assumptions. 24

27 Costs have been calculated at April 2013 (Q1 2013) prices. Capital costs have been prepared using Healthcare Premises Cost Guides (HPCG s) adjusted to reflect the type and nature of the works. Include building, infrastructure and service costs. Includes equipment within the estimates for group 1 & fitting of equipment in group 2. Includes estimates for all fees. Quantifiable risk contingency allowance. VAT has been added to the total capital cost but there may be an element that is recoverable on certain items of refurbishment. VAT recovery is excluded from the costs with the exception of design fees which is fully recoverable. Optimism Bias has been considered but due to the stage of the project has been fully mitigated Details of the development of the capital costs for the options can be made available upon request. In summary, following adjusted capital costs, estimates (including VAT) were established for each option as follows: Option 1 Do Nothing Option Option 5 - Provide several compliant decontamination units with internal distribution services Initial Capital Cost Estimate No capital cost 1,498, Recurrent Revenue Costs This section identifies the recurrent revenue costs associated with each of the shortlisted options. A baseline cost for the current service has been calculated and used as a benchmark against which any changes could be considered this is the revenue cost associated with the do nothing in Option 1. In this financial case, the recurrent revenue costs include all costs associated with running the current services with the existing staff within the constraints of the ground floor of the tower block and within Ward 11 and the Theatres. The costs include capital charges (depreciation) where appropriate. 25

28 Including all of the various streams of revenue costs, the overall recurring revenue impact of the options is shown below. The costs shown in the table relate to the first full year of operating. Summary of Recurrent Revenue Impact 000 s Option 1 - Do Nothing Option 5 - Provide several compliant decontamination units with internal distribution services Capital Charges Pay costs Non pay costs Property costs Gross recurrent costs Income 0 0 Net recurrent costs Option 1 has the lowest net revenue cost of 241.3k with Option 5 being second with a cost of 258k. The net increase of 17k between options 5 and 1 is due to the capital charge calculation of 34k less 17k of savings in recurrent non pay. This decrease in non pay results from the change from using an in-house engineer to provide the service currently provided externally to the NHS. Full details on the recurrent revenue costs are included in Appendix D financial & Economic Assessment Capital Charges The capital charges for the options in this case are based on the estimates for capital expenditure adjusted for optimism bias with a different asset life attached to each of the separate elements of the capital investment - 60 years for the building shell, 40 years for service installations and 23 years for external installations. There are no land changes in any of the options. In line with the current guidance, capital charges do not include a rate of return calculation. The results of the capital charge calculations are summarised below: 26

29 Capital Charges 000 s Option 1 Do Nothing Option 5 Provide several compliant decontamination units with internal distribution services Depreciation Risk Workshop and Assessment Overview The key stakeholders have undertaken an initial Risk Workshop to establish the principal risks associated with the proposed investment Risk Types The key stakeholders have undertaken an initial Risk Workshop to establish the principal risks associated with the proposed investment. Whilst there will be many risks to the project, the key stakeholders have considered what they perceive to be the main risks which are considered to contribute collectively to the majority of the risk value (approximately 80%). A summary of the key risks identified is provided below: Decontamination Washers - design and construction coordination will be required with the direct provider of this equipment. RO equipment will require new pipe work which will be routed through the CDU. Design & Construction coordination will be required with the direct provider Shut downs may be required for Service Connections and this will require coordination with the estates department. The standard format for the Framework Scotland Joint Project Risk Register will be implemented as a Risk Management tool and register, and this will be managed byt the project team through a series of workshops to establish, monitor and mitigate these risks as the project develops. 8.8 Economic Appraisal Overview A discounted cash flow for each of the options has been undertaken over 40 years using a discount rate of 3.5% for years 1 to 29 and 3.0% for years 30 onwards in line with the guidance within the HM Treasury green book and from SGHD. The Net Present Value (NPV) and Equivalent Annual Cost (EAC) have been calculated for each option. The EAC is used as a comparison of options where there are different life spans as the output is an annual figure which is easily compared. The elements considered in the analysis are: Initial capital expenditure for each option exclusive of VAT but adjusted for optimism bias 27

30 Any relevant lifecycle costs for building and engineering works Any relevant equipment lifecycle costs Total revenue costs for each option excluding capital charges Income Non-recurring revenue costs NPV & EAC 000 s Option 1 - Do Nothing Option 5 - Provide several compliant decontamination units with internal distribution services Net Present Value (NPV) Equivalent Annual Cost (EAC) 6, , Ranking 1 2 The analysis of the net present values (NPV) indicates that Option 1 produces the favoured option in terms of EAC. Option 5 is the second favourable and this reflects the higher capital cost associated with doing the only option that meets the non-financial criteria Value for Money Analysis (VfM) - Cost Per Benefit Point Value for money (VfM) is defined as the optimum solution when comparing qualitative benefits to costs. An analysis (below) has been performed on an economic annual costs basis in line with HM Treasury guidance. The VfM analysis compares the cost per benefit point of the options. The option that is preferable is the option that demonstrates the lowest cost per benefit point. The cost per benefit point is listed in the end column VfM Economic Ranking. No Option Qualitative Benefits Score Quality Rank Net Present Cost ( k) Cost /Benefit point ( k) VfM Economic Ranking 1 Do Nothing , , Provide several compliant decontamination units with internal distribution services , ,

31 8.8.3 Sensitivity Analysis Preferred Option A Sensitivity Analysis is defined as the effects on an appraisal/option of varying the programmed values of important/ selected variables. A Business Case is built upon estimates which can lead to inaccuracies. The preparation of a Sensitivity Analysis will help assess whether the Initial Agreement is heavily dependent on a particular cost or benefit. Interpretation of the sensitivity analysis shows that there would have to be a significant movement in either project scope, capital or revenue costs relative to the total project cost to make the alternative option become the preferred option Summary and Conclusions Section 7 has set out in detail, the method by which the potential options were identified through consultation and subsequently assessed and scored against nonfinancial benefits before the cost impact of the options was compiled. The do nothing option 1 does have the lowest capital requirement and the lowest total revenue impact but does have the highest lifecycle costs. This option is not capable of delivering the objectives of the development requirements and is only used as a baseline for measuring the other option. Option 5 has the next lowest capital requirement and the next lowest total recurrent revenue impact. The results of the Economic and Financial analysis consolidate the position of Option 5 as the preferred option, alongside that of the non-financial benefits. 29

32 9 Development of the Preferred Option 9.1 Summary Description The analysis undertaken on the potential options, as detailed in Section 7 identified that Option 5 is the preferred option. There is a clear preference in the non-financial benefits scoring, and the capital costs incurred are deemed to provide Value for Money. Option 5 is to Provide several compliant decontamination units and internal distribution services for NHS Highland. The project to deliver this option will comprise the following key elements: The development of a new build Endoscopy Decontamination Unit (EDU) at Raigmore Hospital Provision of 3 satellite decontamination units at Oban, Wick and Fort William. The further development of this preferred option through this business case will focus on the EDU to be delivered at Raigmore Hospital as this new facility must be developed in conjunction with the planned reconfigured Endoscopy Service facilities (within Ward 8/9). 9.2 The Site 30

33 The location identified for the new endoscopy decontamination unit is adjacent to the existing Central Decontamination Unit, which is illustrated in red hatching on the above extract from the Raigmore Masterplan. 9.3 Site Access, Constraints and Orientation The new EDU will be accessed internally via an access corridor/lobby created through the existing room within the adjacent Central Decontamination Unit Notable constraints associated with locating the EDU on this site include fire access for emergency services, and essential electrical supplies within the context of establishing the on-going and proposed developments at Raigmore Hospital. These constraints will be considered through the design development of the project. 9.4 Design Development The design involves a new build envelope of 257m2, based on development and integration of the entrance and access to the Central Decontamination Unit. This accommodation is subject to further design development by the appointed PSCP, to incorporate design development, consideration of building control requirements and plant & services space requirements 31

34 9.5 Clinical and Design Brief SHPN 13 Part 3 describes the requirements for decontamination services. Notwithstanding this, the following specific requirements will need to be incorporated into the new facility. Reverse Osmosis treatment will be required to provide water treatment for the new facility together with the existing CDU. The design will have to take account of the RO equipment planned (being procured directly by NHS Highland) together with its integration with the CDU, including optimal pipe routing. The PSCP will be required to review the fire strategy for the proposed development in the context of establishing the on-going and proposed developments at the site. Similarly, the PSCP will require to review the strategy for essential services for the proposed development in the context of establishing the on-going and proposed developments at the site. All service pipe work and cables should be concealed to minimise spread of infection. Whilst SHPN 13 Part 3 noted the general requirements for controlled environments to be heated by mechanical ventilation systems, consideration is to be given to the use of the high level radiant panels / heat exchangers in conjunction with the steam heating main which passes in close proximity to the new development. All enclosed workspaces require to be ventilated in conjunction with SHPN 13 Part 3. Whilst the ventilation system does not require to be consistent with a CDU, there is a specific requirement for a negative pressure environment for the washroom, this should have a supply of 7 air changes per hour and extract of 10 air changes per hour, there is a specific requirement for the inspection room to be at positive pressure with a supply of 10 AC/h and extract 7 AC/h to help minimise risk of cross contamination. Compressed air is required for the washer disinfector and for drying the internal channels of the scopes in the inspection room. Connection may be made into gas distribution pipe work associated with the central CDU Data communications linked into existing system. The design will just include for containment. Cabling and commissioning provided by NHS Highland IT team Requirements for connection of individual circuits and items of equipment to uninterruptible power supply (UPS) and/or standby generation systems should be discussed with users and with equipment suppliers. The UPS should be provided with a bypass for failure or maintenance purposes. Designers should undertake a risk assessment with the planning team to identify the operational impact when an electrical supply is not available. 32

35 9.6 Service Continuity during the construction period and migration Once agreement on the strategy for the decontamination services is reached, the planned move will require to undertaken in a very short timeframe to minimise disruption to decontamination workload and the endoscopy clinical services. 9.7 Workforce Strategy The Raigmore EDU will be staffed and managed by the Central Decontamination Unit team. The Head of Decontamination will take responsibility for the training, assessment and audit of endoscope decontamination staff as well as improvements in record keeping within the unit. Staff costs included in Section 7 include sufficient numbers of dedicated endoscope decontamination operators and decontamination engineers. 9.8 Facilities Management NHS Highland Estates have been included in the process of options appraisals and benefits analysis. Their input into the scoring process and their contribution to the design development of the preferred option ensures that the new facility will align with the facilities management standards and processes which are in place at Raigmore Hospital. 33

36 10 Commercial Case 10.1 Introduction A number of procurement options could be utilised. However, based on the nature of the development, and in consultation with NHS Highland it is proposed that the project will be most suitable, for a capital funded project using the HFS Frameworks Scotland 2 contract, and using the New Engineering and Construction Contract (NEC 3 - Option A, C or E). Key features of the 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 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. Payments are made to the PSCP as per agreed Valuation Certificates. Costs are held as Assets under Construction until the asset becomes operational at which point the costs are transferred to completed assets and become subject to depreciation Proposed Procurement Notwithstanding the above procurement strategy, there will be nominated supplier/installers, which are to be appointed directly by NHS Highland in respect of the following building elements: Pass through washers These have already been procured directly Reverse Osmosis Equipment NHS Highland are currently procuring a supplier/installer relating to the provision of the new RO equipment. In these cases, NHS Highland will appoint the supplier directly, however the PSCP will be required to develop a construction programme of works that reflects the need for these works to be integrated into the construction and commissioning & testing programme, including the following. Establish the work to be undertaken and build the works scope into the development of the Construction programme 34

37 Allow for design input and appropriate attendances during the construction period 10.3 Contractual Arrangement The contractual approach for delivery of this investment is based on the requirements of Frameworks Scotland using an NEC form of contract with the delivery of the design and construction of the scheme, by the PSCP. The PSCP would be appointed on an Option C Target Price approach where the apportionment of risks and liability thereof, will be agreed prior to the finalisation of the Target Price Risk This contractual approach has been implemented successfully on the Fire precautions upgrade project which is underway in the Tower Block at Raigmore Hospital, and the contractual arrangements for the endoscopy service relocation will reflect these arrangements. The proposed procurement route is to utilise the NEC Option C Target Price contract. This contract provides a mechanism for risk management through the joint development of a target cost by the PSCP and the PSC Cost Advisor. This Option utilises a priced risk register which is managed by the project team and is available for reference upon request Implementation Timescales Constraints with funding allocation require that the project is completed by April The environmental improvements required in Endoscopy Decontamination Units are given high priority with a plan to hopefully have the work underway to enable a compliant facility to open on the Raigmore site by April This constrained timescale requires that the design and planning stage of the project commence upon approval of the project. 35

38 11 Financial Case 11.1 Overview This section presents the financial implications of investment (both capital and revenue) and also provides the economic appraisal of the short-listed options. The methodology and assumptions applied to derive the comparative cost implications of the options are outlined below All current guidance has been followed in completing the financial and economic appraisals, principally the Scottish Capital Investment Manual (SCIM), the HM Treasury Green Book and supplementary guidance Summary of Capital Costs The capital costs have been considered and prepared using the capital spend requirement of each option, as advised by the Thomson Gray, the PSC Cost Advisor on the project. The anticipated Capital Cost for the proposed investment is 1.498m including risk allowances and VAT Revenue Impact The comparable analysis of the revenue costs associated with the preferred option demonstrates that there are no non-recurrent (transitional) costs required to allow the clinically preferred option 5 to go ahead Recurring Revenue Costs Full details of the recurrent revenue costs are available on request. This captures capital charges, recurrent pay costs, recurrent non-pay costs, recurrent property costs, and recurrent property income, where applicable Impact on Balance Sheet The Capital Cost of the development will appear on the Board s Balance Sheet as a Fixed Asset and will be depreciated over the life time of the asset Overall Affordability including VfM analysis Value for money (VfM) is defined as the optimum solution when comparing qualitative benefits to costs. The VfM analysis compares the cost per benefit point of the short listed options. The option that is preferable is the option that demonstrates the lowest cost per benefit point which in this case is Option 5 at 8,814 cost per benefit point. Option 5, the only practical option is not the most affordable option (as doing nothing is more affordable purely in financial terms) but it is the only option that is feasible. 36

39 12 Management Case 12.1 Overview This section summarises the planned management approach setting out key personnel, the organisation structure and the tools and processes that will be adopted to deliver and monitor the scheme Summary of Procurement Method As noted in Section 9, the preferred solution will be the procurement of the scheme under HFS Frameworks Project Management and Methodology The approach to the management of the project is based on the principles and requirements of Health Facilities Scotland Frameworks Scotland under an NEC 3 route. In brief, this involves the appointment of a Contractor or Principle Supply Chain Partner (PSCP) who will be responsible for delivery of the scheme (including the design and construction) using his own supply chain. NHS Highland will appoint an independent Project Manager and Cost Manager to manage the contract under NEC 3 and provide advisory services in respect of the scheme being delivered by the PSCP Project Framework 37

40 12.5 Communications and Engagement In terms of the development of the project to date, the Outline Business Case has been developed through consultations with the a number of internal and external stakeholders as listed in Section 7.2. Communication with these stakeholders will continue through the project life cycle of the investment. Communication and engagement will also extend to sub-contractors, consultants and suppliers as appropriate to help deliver the investment in line with the strategy set out within this document Project Programme A programme for the project has been developed based on assumptions regarding this Business Case approval. A summary of the identified target dates is provided as follows: Submission of Business Case August 2013 Approval of Business Case September 2013 Start on site October 2013 Completion date April 2014 Services Commencement April Reporting The Project Manager will submit monthly reports to NHS Highland for review and discussion at the Asset Management Group meetings. The report will encompass: Executive summary highlighting key project issues A review of project status including: Programme and Progress Key Issues Cost Health and Safety Project Team Meetings will be scheduled monthly to maintain clear communication amongst the stakeholders, and provide a forum to discuss any arising issues and provide enough information to allow key decision makers to direct the project. Further to this, the Cost Advisor will submit monthly cost reports to record cost movement against projected cash flow. 38

41 12.8 Change Management In line with standard project management processes, the Project Manager will be responsible for maintaining strict control of the project and managing changes as they arise. This will be managed in close communication with the NHS Highland representatives, and with reference to the Cost Adviser to ensure budgetary implications are considered. A change control process will be employed to initiate, monitor and control change (and associated costs). This will include the use of change control forms to seek approval from NHS Highland, for changes before such changes are implemented, Instructions shall be issued to the PSCP where appropriate and in accordance with the contract Risk Management The key stakeholders have undertaken an exercise to establish the key risks associated with the proposed investment. Key business, service, environmental and financial risks have been established. A risk register has been developed, based on the preferred option. It is intended that detailed consultation will take place to understand the clear allocation of risk between the parties and the required actions. The project team will manage these risks through a series of workshops to establish, monitor and mitigate these risks as the project develops. The standard format for the Framework Scotland Joint Project Risk Register will be implemented as a Risk Management tool and register Post Project Evaluation Project evaluation provides an opportunity for the project team and stakeholder groups to reflect on the lessons learnt at various stages of the project. The purpose of such evaluation is to apply the positive aspects of the project to future projects, and likewise remove where possible the negative aspects or aim to mitigate the impact where these cannot be removed. The evaluation will review the project holistically and will include discussion on the following: Comments on consultants appointments Comment on project schedule Comments on cost control Change management system Major source(s) of changes/variations Overall risk management performance Overall financial performance Communication issues 39

42 Organisational issues The post project evaluation exercise will ideally be facilitated through workshops and open and frank discussions with the project stakeholders, the outcome of which will be documented in a report to NHS Highland, following 6 months of beneficial occupation of the new facility. 40

43 13 Conclusion Independent and objective assessments of the current Endoscopy Decontamination Service being delivered throughout NHS Highland in line with the guidelines published by the Joint Assessment Group on GI Endoscopy (JAG) have highlighted that the decontamination services fall short of acceptable standards. Although the achievement of JAG standards is not a regulatory requirement or a directive issued by the NHS, it is an accurate reflection of the service delivery quality expected, and a benchmark for endoscopy decontamination units throughout the UK. Sections 1 6 of this Business Case clearly demonstrates that the current Endoscopy Decontamination service does not meet the strategic objectives of NHS Highland, and this situation will be compounded over the coming years as the anticipated population increase in the Greater Inverness area increases, with a consequential rise in demand for endoscopy procedures and the essential support required from a compliant and efficient decontamination service. Following identification of the need to improve the decontamination service, a comprehensive review of the available options was undertaken, to assess and score each potential option and form a clear and transparent consensus as to what the preferred investment would be. The preferred option is detailed within this business case document, and the process undertaken to arrive at this option whilst ensuring that value for money is delivered through the investment and the stated benefits are realised is detailed in Sections The benefits which will be delivered through the resultant investment will provide facilities which will enable the endoscopy unit to achieve compliance as per SHPN Subject to approval of this Business Case, this investment project will be initiated by NHS Highland to achieve the financial spend profile which requires that the facility is delivered by April

44 APPENDIX A EDU FLOOR PLAN 42

45 APPENDIX B ACCOMMODATION SCHEDULE Room Name Area (m2) General Store Chemical Store WC 1 WC 2 Plant RO Plant Wash Room DSR Inspection Room Office CWS Total Area

46 APPENDIX C - NON-FINANCIAL BENEFITS APPRAISAL WEIGHED SCORES 44