Day Surgery Centre,
Raigmore Hospital, Inverness
Outline Business Case
Version No: 20
5th September 2006
Working with you to make Highland the healthy place to be/ Headquarters:
NHS Highland, Assynt House, Beechwood Park, Inverness
Chairman: Mr Garry Coutts
Chief Executive: Dr Roger Gibbins, BA, MBA, PhD
Contents
Ref / Section Heading / Page1.0 / Title of Project / 3
2.0 / Executive Summary / 3
3.0 / Introduction/Purpose / 9
4.0 / Background and Strategic Context / 12
5.0 / Service Specification / 14
6.0 / Project Objectives / 16
7.0 / Options / 17
8.0 / Exploration of PPP/PFI / 18
9.0 / Appraisal Process / 20
10.0 / Preferred Option / 24
11.0 / Personnel Issues / 25
12.0 / Timetable / 26
13.0 / Project Management / 26
14.0 / Confirmation of Required Specific Statements / 28
15.0 / Appendices / 29
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1. THE TITLE OF THE PROJECT
Day Surgery Centre, Raigmore Hospital (previously titled Ambulatory Care Centre in Initial Agreement).
2. EXECUTIVE SUMMARY
2.1 Background
Highland Health Board is the only mainland Health Board area in Scotland, which does not have a dedicated Day Surgery Centre. This proposed development would allow the population presently served by Raigmore Hospital to enjoy the accepted benefits of modern surgical day care.
2.2 Introduction
The Initial Agreement for the creation of a dedicated Day Surgery Centre comprising three theatres and a Treatment Room and supporting areas with dedicated Day Surgical nursing and ancillary staff was approved by the NHS Highland Board at its meeting on 4th April. Subsequently the Capital Investment Group also approved the Initial Agreement at its meeting on 16th May and authorised NHS Highland to produce the Outline Business Case for the development.
A dedicated Day Surgery Centre will provide NHS Highland with a modern high throughput, clinically effective and cost effective service for dealing with 52% of elective surgical patients who do not need to use more expensive in-patient facilities.
· The Day Surgery Centre will provide a dedicated service separate from the inpatient service. Day case patients will not have their stay disrupted by delays and cancellations because of other clinical priorities.
· Patients will be given a mutually convenient date for surgery at pre-assessment, allowing them to plan ahead for their admission.
· Patients will get accurate information on the arrangements for the day of surgery, including admission and discharge details.
· Staff will be dedicated to the Day Surgery Centre. They will be available to respond to patients questions and concerns both before and after the procedure, and will be able to guide the patient safely and efficiently through the day. It is important that staff in the Day Surgery Centre do not have other duties, which would interfere with this primary function.
· Scheduling of lists should be such that the patient will spend less time in hospital.
· Reduced waiting times through a reduction in DNA rates and increased throughput.
2.3 Key Attributes of the Preferred Option
The Outline Business Case demonstrates that a new Day Surgery Centre is the preferred option as it is the option which is:
· Most clinically effective.
· Most cost effective.
· Least costly in revenue terms.
· Provides the greatest non-financial benefits.
· Lowest risk.
· Least disruptive.
2.4 Project Objectives
a) To bring Raigmore Hospital into line with the other District General Hospitals in Scotland by providing a separate facility for day surgery for the patient population currently served by the hospital.
b) To address, in the longer term the issue of maintaining the present Surgical Waiting Times and cope with future targets (18 weeks by December 2006).
c) To aid recruitment to Raigmore Hospital as most surgical and anaesthetic staff will have been trained in modern day surgical procedures.
d) To comply with advice on Day Surgery from
· The Audit Commission 2005
· The Department Of Health --- NHS Plan (2000)
· The NHS Modernisation Board advising that day surgery should be the norm in terms of patient experience clinical quality, length of stay and cost.
e) To comply with recent advice from the CMO Scotland, stating that “Day Surgery was to be the norm in Scotland”.
2.5 Summary of the Short Listed Options
A number of options for achieving the project objectives were considered and the short listed options have been subjected to a rigorous appraisal in terms of their expected benefits, costs and risks.
The short listed options were:
· Do Nothing
· Extend the Working Day to 3 Sessions
· A Modern Day Surgery Centre
2.6 Economic and Financial Appraisal
An option appraisal was undertaken on the three short listed options looking at the following parameters:
· Non-Financial Benefits
· Financial
· Economic
· Risks
The results of this appraisal for each of these parameters are as follows:
Non-Financial Benefits
A set of non-financial benefits criteria was developed based on:
· The Project Objectives
· The Benefits Criteria used for most projects of this type.
Six criteria were identified and designed to be clear and capable of being consistently applied by the stakeholder group involved in the option appraisal. The six benefits criteria were then ranked and assigned weights to reflect their relative importance. The result of the scoring exercise for each of the options is:
Option / ScoreDo Nothing / 370
Extend Working Day / 500
Modern Day Surgical Facility / 875
In order to test the robustness of the ranking of options a sensitivity analysis was carried out. The results of the original benefits appraisal were not sensitive to even significant changes in the parameters and were therefore considered to be robust. Full details of the benefits appraisal are contained in Section 9.1 and Appendix 4.
Financial Appraisal
Each of the short listed project options was financially appraised in accordance with the Scottish Capital Investment Manual (SCIM). The results of that appraisal are summarised below. A full breakdown of the estimated cost consequences for each of the options can be found in Appendix 1.
Option / Asset Cost / Pay & Non Pay / Revenue Cost / Capital Cost£000 / £000 / £000 / £000
Do Nothing / 0 / 4,950 / 4,950 / 0
Extend Working Day / 164 / 3,443 / 3,607 / 0
Day Surgery Centre (New Build) / 812 / 0 / 812 / 11,867
The revenue cost figures shown above and highlighted in bold are the net recurring revenue consequences of each of the options.
Economic Appraisal
Each short listed option was economically appraised and both cost benefit and cost effectiveness analysis was undertaken. This takes into account the Net Present Value (allows for discounted cost & revenue) of each of the options. This has been summarised below with further detail to be found in Appendix 2.
Option / NPV Revenue Costs / NPV Capital Costs / Estimated NPV Total£000 / £000 / £000
Do Nothing / 110,657 / 0 / 110,657
Extend Working Day / 80,637 / 0 / 80,637
Day Surgery Centre (New Build) / 19,893 / 12,283 / 32,176
Taking the Net Present Value for each option and using the base score results from the Benefits appraisal (see Section 9.1) to determine economic benefit, it is clear to see that the option of providing a Modern Day Surgery Centre gives the best value for money, as it has both the lowest Net Present Value of the three options and the highest level of non-financial benefits.
Description / Do Nothing / Extend to 3 Sessions / Day Surgery Centre (New Build)Net Present Value / £110.7mill / £80.6mill / £32.2mill
Benefits Criteria Scoring / 370 / 500 / 875
Cost per Benefit Score / 299,075 / 161,274 / 36,772
Value for Money Ranking / 3 / 2 / 1
Capital Affordability
The Board’s five year capital plan presently has unallocated sums of £6.5 million in 2008/09 and £6.7 million in 2009/10 giving a total available over the two years of £13.2 million. Capital requirements for this project are £6.2 million in 2008/09 and £5.6 million in 2009/10. Clearly the Board will be unable to finance the whole of this project without potential detriment to other priorities.
The Director of Delivery in SEHD has indicated his strong support for this project and the Board would welcome SEHD providing additional capital funds to meet the cost of this project.
Risks and Uncertainty Appraisal
The project risks for each of the options were identified and examined by the Project Team and are shown in detail in Appendix 5.
The risks that could not be quantified financially were then scored for probability and impact. In summary this analysis showed that the Day Surgery Centre option was the lowest risk option. The highest risk for this option is that the service cost turns out higher than planned which was assessed as a MEDIUM risk overall.
The weighted risk scores for the three options are:
Option / ScoreDo Nothing / 61
Extend Working Day / 74
Modern Day Surgical Centre / 28
Full details of risk assessment for the risks that can be quantified financially and those which cannot are shown in Appendix 5.
2.7 Effect On Existing Assets
Main Theatres
There will be no reduction in the number of theatres presently in use in Raigmore Hospital for the following reasons:
· Presently the theatres are used at 99% of their capacity. The recommended rate is 85%. Theatre capacity released by transfer of patients from the main theatres to the Day Surgery Centre will in part be used to reduce the rate to the recommended 85%.
· Demographics of the area indicate that the increase in the population over 50 will be 30% in the next 8 years. Individuals over 50 years old place greater demands on surgical facilities generally including the requirement for emergency surgery. This is expected to have a significant effect on surgical workload in the next decade.
· In its paper “Increase in general surgical workload as a result of changing demographics – can we cope?” The Association of Surgeons of Great Britain and Ireland stated that the expected increase in the following procedures in the next twenty years would be:
Colorectal – 29.1%
Upper GI Cancer – 30.9%
Vascular surgery – 41.5%
Inpatient Beds
A minimum of 6 beds will be released from the in patient surgical words based on 1,100 patients presently being treated as in patients being transferred to day case care.
In addition there will be 12 beds released from the Day Case Unit and 6 beds from Ward 1A which are currently used for Ophthalmology Day Cases.
The beds released will in the first instance be used to create a temporary Day Surgery area in Raigmore and will subsequently be closed or used for Day Surgery patients who require 23 hour care.
Hotel Beds
The current patient lodge does not provide sufficient capacity to fully support the Day Surgery Centre. Increased provision of hotel facilities is being worked on by the Facilities Directorate and is not part of this bid.
2.8 Future Proofing
To provide the maximum ability to cope with future growth in demand, higher day case rates and/or shorter waiting time targets the following flexibility has been built into the development:
1. One of the three theatres in the proposed Day Surgery Centre will be dedicated to Ophthalmology. This theatre could be re-provided elsewhere in future if necessary.
2. The building will be constructed so that it will be strong enough for a second floor to be added if required in the future.
2.9 Child Friendly Facilities
We are aware of the advice given by the Association of Anaesthetists and others relating to the provision of care for children. However, we do not feel that the additional cost of providing an area completely devoted to children is justified. There will be some facilities, which will be set aside for the exclusive use of children e.g., a consulting room, recovery areas and a play area.
Wherever possible children will be segregated from adults by scheduling sessions for Paediatrics and adult surgery at different times.
2.10 Timetable
The proposed development of a Day Surgery Centre is based on the following key milestones:
Approval of OBC September 2006
Approval of FBC April 2007
Start on site June 2008
Start of service March 2010
The assessment of PFI/PPP Potential in Section 8 indicates that we should proceed on the basis of a publicly funded project. This timetable has therefore been drawn up on that basis.
2.11 Support from NHS Highland Board
This project is supported by NHS Highland Board. The Initial Agreement for this development was approved by the Board at its meeting on 4th April 2006.
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3. INTRODUCTION/PURPOSE – ASSESSMENT OF NEED
3.1 Clinical Need & Benefits to Patients
Present arrangements are inconvenient for patients in that day cases are not separated from inpatients or emergencies. Day Cases can be subject to delays and cancellations because they are not seen as a priority on mixed day case/elective inpatient/emergency operating lists.
NHS Highland is the only mainland Health Board in Scotland without a dedicated Day Surgery Centre. The Day Case Unit in Raigmore Hospital has no theatre and is used as a holding area for day cases, which are treated in Main Theatres, on lists, which often include Elective and Emergency in-patients. There are few dedicated day case lists. In this setting, day cases may be seen as a low priority and are subject to postponements or cancellations when major surgery or emergency surgery has to be accommodated. If Day Case patients are delayed in theatre they may be transferred back to inpatient wards rather than the Day Case Unit resulting in a disrupted and unpredictable length of stay. As major cases and emergencies may be accommodated on the same list as day cases, lists may overrun and result in day cases being cancelled.
Some day cases use the general wards and are accommodated in a variety of locations including side rooms, patient sitting rooms, inpatient beds and corridors.
The pressure on surgical inpatient beds has been such that elective cases, which have come to the ward for admission, have had to be cancelled on the day and rescheduled. This is poor patient care and wasteful of resources. The demoralising effect of this type of care on the patient should not be underestimated. The patient may well have been anxious about coming for a surgical procedure for weeks beforehand. This problem was particularly highlighted when the issue of a day surgical facility was discussed with the Patients Council.