LINEAR ACCELERATOR and CT SIMULATOR PROCUREMENT
Report by Derek Leslie, Director of Planning and Performance, Malcolm Iredale, Director of Finance, Dr David Whillis, Head of Service, Department of ClinicalOncology, and Mr Steve Colligan, Head of Radiotherapy Physics
RR
1.Background
RaigmoreHospital is one of five cancer centres serving the population of Scotland. Cancer is treated by three main modalities – surgery, radiotherapy and chemotherapy. Increasing cancer incidence, an aging population, increasing indications for the use of radiotherapy and improved techniques are all contributing to a pressure for more radiotherapy. Despite the high capital investment required for equipment, radiotherapy is the most cost-effective of the three modalities.
The continuation of Radiotherapy Services at Raigmore forms part of the Scottish Executive Health Department’s (SEHD) national strategy for cancer. The SEHD have stated that a second linear accelerator in Inverness is essential to ensure a sustainable radiotherapy service and secure non-surgical oncology services in the northwest of Scotland. The equipment and building work will be funded by the SEHD as part of the national strategic review of radiotherapy equipment if NHS Highland approve the business case.
2.Equipment
The Department of Clinical Oncology at RaigmoreHospital, Inverness currently has one modern linear accelerator. This machine was installed in 2000 to replace a machine which is now 18 years old. Although linear accelerators have a life expectancy of only 10 years, it was decided to keep this machine as a backup machine when the new machine was installed.
While it is accepted that unusual treatments cannot be offered at a centre the size of Raigmore, it is important to ensure that Inverness can offer the majority of modern radiotherapy techniques. Intensity Modulated Radiotherapy (IMRT) and Image Guided Radiotherapy (IGRT) techniques allow the high dose region to be shaped to the tumour, increasing the chance of cure, while minimising side effects in normal tissues. These techniques must be available in Inverness to treat patients’ common disease sites such as prostate and head and neck cancers.
A second modern staffed linear accelerator is essential to:
- ensure that the current waiting time of six weeks can be reduced to meet national targets.
- reduce the number of interruptions to treatment, which cause a reduction in local tumour control by 1% for every day of interruption.
- increase the capacity of the department, which now delivers more than double the number of treatment fractions compared with 1988, but still has the same number of machines.
- allow the introduction of modern treatment techniques such as IMRT and IGRT to ensure that NHS Highland patients are offered the same quality of treatment as at other centres.
Four companies tendered for the linear accelerator through Scottish Healthcare Supplies. The evaluation process has concluded that a TomoTherapy unit provides the best option for Raigmore at this time, as it is felt that this is the only machine that will allow the introduction of IMRT and IGRT techniques within a realistic timescale. It is also believed that this machine will minimise the staff requirements, and the associated revenue requirements.
Historically, imaging for radiotherapy treatment planning has been provided by the combination of a simulator (a simple fluoroscopy device) and a CT scanner. To be able to deliver modern techniques such as IMRT and IGRT the treatment plan must be based on a CT planning scan. Currently, less than 18% of Raigmore’s radiotherapy is planned using the CT scanner in the Radiology Department. However, many technical requirements for radiotherapy planning cannot be met by diagnostic CT scanners, including both the old and new CT scanners at Raigmore. Because these issues are common in radiotherapy departments, the Royal College of Radiologists and the Scottish Radiotherapy Advisory Group have recommended that all cancer centres should have a CT Simulator. Glasgow and Edinburgh currently have machines installed, Aberdeen is installing a unit this year, and Dundee’s machine is in the planning stages.
The fluoroscopic simulator which is currently in the Department of Clinical Oncology is due for replacement in 2009. However, because the techniques offered by the new linear accelerator are so dependent on CT-based data and the removal of the old linear accelerator will create an ideal location for the CT Simulator in late 2008, it is recommended that a CT Simulator be purchased for installation at that time. This will also free some capacity on the Radiology CT Scanner.
3.Building Work
Linear accelerators are housed within radiation “bunkers” which are designed to shield the radiation generated by the machines from the surrounding area. The current bunker which houses the backup machine is too small for a modern linear accelerator, and the radiation protection it offers is insufficient to meet the modern legislation. Because of this, and to ensure service continuity during the building and commissioning period, a new bunker must be built for the new machine. The current location of the backup machine will be suitable to house the CT simulator.
The linear accelerator which currently provides most of the treatments is due for replacement in 2010. Because of service continuity issues, this replacement machine will also have to be housed in a new bunker. Restricted space at the back of the Clinical Oncology Department will make the future provision of this problematic. In addition, the construction of this bunker would have to begin less than two years after the completion of this project. Consideration has therefore been given to the building of the second bunker within this project.
The building work proposed within this project will also address some of the existing issues relating to the department’s infrastructure. Current limitations in the patients’ waiting area and treatment planning area will be corrected and an additional clinic room and accommodation for the additional staff will be constructed.
4.Options Appraisal
The options considered in this business case were:
- Retain the Status Quo,
- Refer Patients to Other Centres,
- Extend the Working Day,
- Use the old Mevatron machine for less complex treatments,
- Provide a 2nd, modern staffed linear accelerator with
- installation in an existing room,
- a single new bunker,
- two new bunkers or
- two new bunkers built using a phased approach.
- Provide a 2nd, modern staffed linear accelerator and CT simulator with
- installation in existing rooms,
- a single new bunker,
- two new bunkers or
- two new bunkers built using a phased approach.
The preferred option is the provision of a 2nd staffed linear accelerator and CT simulator and two new bunkers using a phased building approach.
The building work is expected to commence in December 2006 and be completed by December 2009. The linear accelerator and CT simulator would be available for clinical use by June 2008 and November 2008 respectively.
5.Contribution to Corporate Objectives
This project will contribute in a major way to:
- Delivering treatment within national waiting time guidelines,
- Reducing the number of interruptions to treatment,
- Continuously improving the quality of services delivered,
- Improving the clinical outcomes for individual patients,
- Ensuring equity of access to radiotherapy services for the population served, and
- Increasing the treatment capacity of the department.
6.Governance Implications
6.1Staff Governance
Staff will be fully trained to provide a high quality radiotherapy service with modern equipment, which will improve staff morale and assist with recruitment and retention.
6.2Patient Focus and Public Involvement
The aim of this project is to ensure that Raigmore can offer treatment for the most common cancers in Inverness, thereby avoiding patients being sent to the central belt for treatment. The new facilities will also reduce waiting times, which currently do not meet national targets.
A representative from the Patients’ Council has attended project team meetings.
6.3Clinical Governance
This proposal has already received support from the Clinical Planning Group.
The facilities provided by this project would ensure that the best radiotherapy practice could be followed in Inverness, allowing the best chance of cure, and minimising side effects.
Waiting times, which are currently outside national targets will be reduced.
6.4Financial Impact
Capital funding for both the equipment and the building is to be provided by SEHD from resources specifically earmarked for this purpose. This funding will be made available following the support and approval by NHS Highland of this business case. For the preferred option, the indicative costs are:
£2.5m incl VAT for the purchase of the linear accelerator
£705,000 incl VAT for the purchase of the CT Simulator
£4.5m incl VAT for the building cost estimate.
The cost of the building work will be funded through SEHD capital. The equipment will be purchased using SEHD capital, or by funding the lease payments, depending which option demonstrates better value for money. It is understood hat SEHD would meet any associated leasing costs although not capital charges, which would fall to be met by NHS Highland. There is currently a provision within the Financial Plan of additional capital charges for such purposes.
The project started in 2005/06 following the approval of the outline business case by NHS Highland. Appendix 1 summarises the financial situation for the preferred clinical option. Year 1 costs for 2005/06 have already been funded. Appendix 2 summarises the funding requirement and availability, and highlights the need for an additional £100,000 as well as requiring significant commitment of the additional capital charge provision.
Further work will be undertaken on the financing options for the equipment since it is understood that SEHD will reimburse appropriate lease charges, but not capital charges. If this is not confirmed then there will be further capital charge pressures of approximately £300,000.
Any decision to progress with this initiative must recognise that additional cost pressures of £100,000 will be added to the existing Board savings target,
7.Impact Assessment
This project will ensure that the population served the Raigmore Hospital Cancer Centre will continue to receive treatment in a local setting. Waiting times and interruptions to treatment will be minimised, which when combined with modern techniques will ensure that the best possible treatment is provided.
- Conclusion
The project has been developed over some months, and has evolved as clinical preferences and opportunities, such as the inclusion of a dedicated CT Scanner have been identified. This is reflected in the financial costs through the addition of the associated Scanner costs and some increased staffing costs.
Derek Leslie, Director of Strategic Planning
Malcolm Iredale, Director of Finance
Dr David Whillis, Head of Service, Department of ClinicalOncology
Steve Colligan, Head of Radiotherapy Physics
26 May 2006
Appendix 1 : Financial Summary
Initial Investment / 07/08 - Yr 3 Additional Investment / Year 4 – Additional Investment / Total Investment
£000’s / £000’s / £000’s / £000’s
Capital Investment / 2,967 / 1,550 / 4,517
Recurrent Revenue (Pay Costs) / 199 / 30 / 254 / 483
Recurrent Revenue (Lease Payments) / 291 / 0 / 0 / 291
Capital Charges / 175 / 0 / 88 / 263
Non-Recurrent Revenue / 0 / 25 / 96 / 121
Recurrent Revenue – CT simulator / 0 / 60 / 0 / 60
Capital Charges – CT simulator / 0 / 95 / 0 / 95
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APPENDIX 2
LINEAR ACCELERATOR AND CT SIMULATOR
FUNDING REQUIREMENT / AVAILABILITY
1.CAPITAL
1.1Requirement / £(000) / £(000)Building Work / 4,517
Linear Accelerator / 2,500
CT Simulator / 700 / 7,717
1.2Availability
Building – SEHD – Provisionally Agreed / 4,517
Linear Accelerator – Provisionally Agreed / 2,500
CT Simulator – yet to be agreed but in line with national strategy / 700 / 7,717
2.REVENUE
£(000) / £(000)
2.1Requirement
Recurrent Revenue (pay) / 483
Capital Charges (Building) / 263
Lease Charges (Accelerator) / 291
Recurrent Revenue (CT Simulator) / 60
Capital Charges (CT Simulator) / 95 / 1,192
Non Recurrent Revenue over 4 years / 121
1,313
2.2Potentially Available
Already in Financial Plan (pa) / 444
Capital Charges - Building / 263
Commit Cap. Charge. Flexibility - CT Simulator / 95
Lease Payment (from SEHD) (Provisional) / 291
1,093
Non Recurrent Resource (over 4 years in Plan) / 120
1,213
Additional Resource Required / 100,000
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