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INITIAL AGREEMENT
FOR
THE MODERNISATION OF COMMUNITY AND HOSPITAL
SERVICES IN BADENOCH & STRATHSPEY
FINAL DRAFT
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ENQUIRIES Any queries directly relating to this project should be directed to: Nigel Small Project Director and Director of Operations South & Mid Operational Unit NHS Highland Alder House Cradlehall Business Park Inverness IV2 5GH Tel: 01463 704622 [email protected]
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CONTENTS 1 EXECUTIVE SUMMARY AND PURPOSE ..................................................................... 5
2 ORGANISATIONAL OVERVIEW ................................................................................... 5
3 BUSINESS STRATEGY AND AIMS ............................................................................. 15
4 PROJECT INVESTMENT OBJECTIVES ...................................................................... 19
5 EXISTING ARRANGEMENTS ...................................................................................... 21
6 MAJOR SERVICE CHANGE PROCESS ...................................................................... 24
7 BUSINESS NEED ......................................................................................................... 28
8 POTENTIAL SCOPE AND BUSINESS REQUIREMENTS ........................................... 37
9 BENEFITS .................................................................................................................... 42
10 STRATEGIC RISKS ..................................................................................................... 45
11 CONSTRAINTS AND DEPENDENCIES....................................................................... 46
12 CRITICAL SUCCESS FACTORS ................................................................................. 48
13 LONG LIST OF OPTIONS ............................................................................................ 50
14 PREFERRED WAY FORWARD AND SHORT LISTED OPTIONSERROR! BOOKMARK NOT DEFINED
14.1 OUTLINE COMMERCIAL CASE .................................. Error! Bookmark not defined. 14.2 OUTLINE FINANCIAL CASE ....................................... Error! Bookmark not defined. 14.3 OUTLINE PROJECT MANAGEMENT CASE ............... Error! Bookmark not defined.
15 APPENDICES ..................................................... ERROR! BOOKMARK NOT DEFINED.
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LIST OF APPENDICES
Appendix 1 Summary of stakeholder engagement and analysis
Appendix 2 Organisational structure
Appendix 3 Summary of high level milestones and time-line
Appendix 4 Overview of NHS service change process
Appendix 5 Option appraisal process to support site selection (qualitative)
Appendix 6 Extract from minute of board meeting held on 7th October 2014
Appendix 7 Letter of Ministerial approval 27 January 2015
Appendix 8 Summary of existing arrangements and business need
Appendix 9 Risk register
Appendix 10 Transport & Access Group: terms of reference
Appendix 11 Design statement
Appendix 12 Project programme
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1 EXECUTIVE SUMMARY AND PURPOSE
The Initial Agreement (IA) is the first of three documents which are required to be prepared as part of the Scottish Capital Investment Manual (SCIM) business case process. Once the Initial Agreement has been approved the project would progress to Outline Business case (OBC) and Full Business Case (FBC). If the IA is approved by the Asset Management Group of NHS Highland the next steps will be consideration by the board of NHS Highland on 2nd June and onwards to Scottish Government Capital Investment Group on 30th June 2015. The purpose of the IA is to clearly demonstrate a case for change and how the proposals fit with both local and national policy and priorities. In order to provide the context for the proposals some background about NHS Highland and how it is organised is briefly summarised (Section two). Section three describes the wider strategic context to support the proposed changes including the Scottish Government’s 2020 vision. This sets out the ambition that everyone is able to live longer at home or in a homely setting. The policy context which directs “all assets are used efficiently coherently and strategically” is also explained and has direct implications for this project. The re-design will build on integration of adult social care which has been operational since April 2012 in Highland. If the plans are implemented, as proposed, it would allow greater investment in community services. In turn this would allow more people to be cared for at home or in a homely setting. It is within this strategic context that the current review of services in Badenoch and Strathspey was undertaken and this Initial Agreement document prepared. There is clear alignment with the Project Investment Objectives, the Highland Quality Approach and NHS Scotland’s Quality Strategy Ambition (Section four). The services under this review fall within the locality of Badenoch and Strathspey and the existing health and social care arrangements are outlined (Section five). It points out that some services are not strategically located or adequately resourced making them not as effective or efficient as they need to be to meet future demands. In addition the two local community hospitals are old, not in good physical condition and not designed to meet modern standards. They are also no centrally locate. The current configuration of services also makes it difficult to sustain rotas, especially during out-of-hours and this is something that is predicted to become even more challenging. The proposed new arrangements would be more sustainable including supporting a more team-based approach that optimises the benefits of integration. Work has been ongoing to look at these service and workforce issues with a view to providing more sustainable solutions for the future (Section six). The scale of the changes required was considered to be major and the major service change process was followed. The process including the public consultation (21st April until 21st July 2014), and feed-back on service model, options and sites is summarised. The board considered a full consultation report at their meeting held on 7th October 2014 and endorsed the preferred way forward. All of these documents and supporting information are available on the NHS Highland website. The board recommendation was also considered by the Cabinet Secretary for Health and Wellbeing and approval was received on 27 January 2015.
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The business need including population projections, service projections and bed modelling is set out in Section seven. There is also a high-level analysis of the existing arrangements and the changes that will be required to meet the Project Investment Objectives. The stakeholder workshops to look at the issues and options used the SCIM Framework. This required the group to systematically work through available alternatives under a number of pre-set categories (scope, service solution, service delivery, implementation and funding). The overview of the new service solution is presented diagrammatically (Section eight). The benefits of the proposed service change were also developed through a series of workshops and are summarised (Section nine). This looks at each of the seven benefits criteria and summarises: i) who will benefit; ii) whether the benefits will bring cash-releasing savings and iii) whether the impacts will be delivered in the short, medium or longer term. A description of how each benefit will be measured is also included. This is important for the post-evaluation and assessing how successful the project is at delivering the expected benefits. It also provides a framework for the Project Board to work within to allow appropriate challenge on any of the assumptions being made or solutions being proposed. Strategic and project risks are considered and are underpinned by a Risk Register. Key risks include recognition that the re-design falls within the Cairngorms National Park, land purchase is required, ensuring there is the right balance between community capacity and the number of hospital beds, and having an integrated transport and access plan. The plans include closure of the two hospitals once new arrangements are in place. There may be reputational and safety risks if there were to be significant delays in delivering the new model (Section 10). The range of constraints and dependencies are considered (Section 11), as well as the critical success factors (Section 12). In line with SCIM, work on the Design Assessment Process is underway. This included two workshops which members of the Development Group took part in. A full copy of the statement is included with this document. The final version will be required to be approved by the National Design Assessment Process Team prior to consideration by Scottish Capital Investment Group. An Options Appraisal process was used to determine how best to meet the Project Objectives and in doing so address the current issues and deliver clear benefits. Initially a long list of options was considered (Section 13), followed by a short list before agreeing a preferred way forward (below and Section 14). Summary of scoring of options appraisal (scored out of 1000) Option Description Score Rank 1 Do minimum 250 3
2 Community resource centre and hospital hub and spoke 463 2
3 Community resource centre and hospital hub in a central location (Aviemore) 913 1
A site options appraisal was also carried out which looked at qualitative factors, public preference and technical considerations. Further work is required to determine the preferred site which will take all factors into consideration. The financial case for each of the options including any assumptions relating to staffing and asset related matters is provided (Section 14.2). This includes a high level financial appraisal. In summary the operational running costs of the new model are estimated to reduce from current £3.1m and will allow for re- investment of £400,000 to support additional
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community infrastructure (care-at-home, community mental health and transport) as well as financing an estimated unitary charge of circa £1.2m.
It will also eliminate the current £5.1m of back-log maintenance costs associated with both hospitals. Other considerations have been factored including future maintenance costs and associated unitary charges. Project management, governance arrangements and project plan are also considered in some detail (Section 14.3).
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2 ORGANISATIONAL OVERVIEW
2.1 Mission 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. Our overall mission is to provide quality of care to every person every day.
2.2 Strategic vision and goals
The Highland Care Strategy outlines NHS Highland’s vision for the future delivery of health and social care services for the people of Highland over the next 10 years. It is founded on the triple aim: to deliver better health, better care and better value: • delivering better health for our communities through population-wide and individually
focussed initiatives. These aim to maximise health and wellbeing and prevent illness • delivering better care through quick access to modern treatments provided in modern
facilities. Care will be delivered in the most appropriate setting and in clean and infection-free facilities by well-trained, motivated and professional staff
• delivering better value to ensure that money is spent only on what is needed and
reducing duplication, waste and errors, based on clinical evidence and improvement methodology
2.3 Overview of services and current activities
NHS Highland is responsible for overseeing the full range of services from care-at-home to acute specialist services provided from our only District General Hospital in Inverness (Raigmore). Significant effort is being sustained to look at preventing ill health and reducing inequalities led through our Public Health team. Some specialist services are provided on a regional basis such as plastic surgery and neurosurgery. We also have Service Level Agreements for tertiary services (such as specialist paediatrics and transplant surgery). Secondary care services for the population of Argyll and Bute are provided through Service Level Agreements with Greater Glasgow and Clyde. Currently around 90% of all interactions by service users with NHS Highland are through Primary Care Services. In terms of physical assets delivery of care is supported through 100 GP Practices, one District General Hospital – Raigmore (Inverness), three Rural General Hospitals – Belford (Fort William), Caithness General (Wick) and Lorn and the Islands (Oban), 20 Community Hospitals and 15 Care Homes for older adults. We also have numerous day centres and residential homes. Some services are provided through contracts with third and independent sector and partner agencies.
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NHS Highland at a glance is summarised in Box 1 and Map 1 and Map 2 on the following pages.
Box 1 - NHS Highland: at a glance
• 41% of the landmass of Scotland • 24 populated Islands • 320,000 residents • 10,000 staff (headcount) / 8,000 (WTE) • 100 GP Practices • 24 hospitals, made up of the following
– 1 District General Hospital – Raigmore (Inverness) – 3 Rural General Hospitals – Belford, Caithness General and Lorn and the Islands – 20 Community Hospitals
• 15 Care Homes (Highland Council area) • 50,000 new outpatient appointments per annum • 39,000 attendances at Raigmore Emergency Department per annum • 38,000 inpatients per annum • 13,000 day case patients per annum • 12,000 births per annum (Raigmore Hospital)
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Map 1 showing operational units and location of hospitals and GP Practices
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Map 2 Showing location of Care Homes managed by NHS Highland, since April 2012
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2.4 Key stakeholders and customers NHS Highland’s customers include residents across the council areas of Highland and Argyll and Bute who require our services, as well as a significant number of visitors to the area. We have a number of Service Level Agreements with other NHS boards who deliver services on our behalf, most notably Greater Glasgow & Clyde, Grampian, Tayside and Lothian. We also provide some specialist services to Orkney and Western Isles. Our staff are both customers and key stakeholders. Other key stakeholders are MSPs / MPs, local elected members, community councils and the wide range of local community groups, patient, carer and service user groups. We work increasingly closely with the third, voluntary and independent sector through various arrangements which are agreed through our strategic commissioning partnership. Key strategic partners include the Highland Council, Argyll & Bute Council, Scottish Ambulance Service, Scottish Fire & Rescue, Police Scotland, University of Stirling, Highlands and Islands Enterprise, University of the Highlands and Islands, North of Scotland Strategic Planning Group and Scottish Government. With respect to Badenoch and Strathspey an analysis of local stakeholder and engagement plan has been prepared and is summarised (Appendix 1).
2.5 Organisational Structure of NHS Highland NHS Highland is one of the fourteen territorial boards of NHS Scotland and employs around 10,000 people, making it one of the largest employers in the region. With an annual budget of c£700m, NHS Highland makes a very significant contribution to the local economy. Geographically, it is the largest Health Board in Scotland covering an area of 32,500 km² stretching from Kintyre in the south-west to Caithness in the north-east. The board serves a resident population of over 320,000 but due to annual influx of tourists in some areas, such as Aviemore this can double or even triple at times, both in summer and winter. The board also covers the largest remote and rural areas in Scotland including 24 populated islands. Since 1st April 2012, health and social care in the Highland region has been formally integrated with NHS Highland the lead agency for the delivery of adult services across health and social care and the Highland Council the lead agency for children's services. 2.5.1 Board and Committees NHS Highland is managed by a Board of Directors which is overseen by the Chair. The Board is accountable for the performance of all NHS Highland services and functions across the areas covered by the Highland Council and Argyll & Bute Council. The Board is underpinned by a number of committees, including: Asset Management Group, Audit, Staff Governance, Clinical Governance, Area Clinical Forum, Highland Partnership Forum, Improvement Committee, Health and Safety and Highland Health and Social Care Committee. 2.5.2 Corporate Services Highland-wide departments or functions sit within our corporate services and include Estates, Clinical Governance and Risk Management; e-Health; Finance; Human Resources;
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Infection, Prevention and Control; Nursing and Midwifery; Pharmacy; Planning and Performance; Procurement; Public Health, and the Chief Executive’s office. 2.6 Operational delivery of services Highland Health and Social Care Partnership is responsible for providing a wide range of acute care, emergency care, primary care community based health and adult social care services. Covering the same area as the Highland Council, the Partnership is made up of three operational units: South and Mid Highland; North and West Highland and Raigmore Hospital. The management structure and arrangements are set out (Appendix 2).
South and Mid Highland constitutes the inner Moray Firth area, and is made up of the following areas and districts:
South Area Nairn & Ardersier, Badenoch & Strathspey - the area relevant to this Initial Agreement Inverness West Inverness East Hosted Services, Highland-wide – directly relevant to this IA
• New Craigs psychiatric hospital • Dental Services
Mid Area East Ross Mid Ross
North and West Highland constitutes a remote and rural area made up of:
North Area Caithness (including Rural General Hospital – Caithness General in Wick) Sutherland West Area Skye, Lochalsh and Wester Ross Lochaber (including Rural General Hospital – Belford in Fort William)
Raigmore Hospital (Inverness) is our only district general hospital serving the population of the Highlands and is also directly relevant to this Initial Agreement. The Hospital covers all specialties and is a training hospital for Nursing and Medical staff in association with Stirling, Aberdeen and Dundee Universities. It is a Regional Cancer Centre. Outreach Services are provided too many sites across the Partnership area as well as to the Western Isles, Orkney and Moray for some specialties. It has close links to Tertiary Services in the central belt of Scotland and Aberdeen. The relationship between this project and the various committees, strategies and plans is summarised below:
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NHS HighlandBoard
NHS Highland Care Strategy
NHS Highland10 Year Operational Plan
Annual Local Delivery Plan
South & Mid Operataional Unit
Annual Plan
Badenoch & Strathspey
Initial Agreement
NHS HighlandAsset Managment 5 Year
Strategy
Highland Health & Social Care Committee Asset Management Group
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3 BUSINESS STRATEGY AND AIMS 3.1 National Overview The Scottish Government’s 2020 vision articulates the ambition that “everyone is able to live longer at home or in a homely setting.” This vision is underpinned by the Healthcare Quality Strategy, 2012, which calls for accelerated quality improvement which is safe, effective and person centred. The vision builds on the Commission on the Future Delivery of Public Services (Christie Report) which called for a focus on public service reform to:
• empower individuals and communities; • deliver a programme of social change; and • make best use of all assets and resources.
Other key documents include “Delivering for Remote and Rural Health”, launched by the then Cabinet Secretary for Health and Wellbeing in 2007, and Better Health, Better Care, which was an action plan also published in 2007. Both these documents set out the need to deliver a strategic change programme for the NHS in Scotland, and Delivering for Remote and Rural Health, specifically considers the role of the Rural General Hospitals. Over time this will see new models of care being developed across the country:
3.1.1 Other national building blocks The Scottish Government Health Directorate’s Capital Planning and Asset Management Division Policy CEL 35 (2010) require that all NHS Boards have a Corporate Asset Management Strategy and Plan that reflects the following policy aims:
• to ensure that NHS Scotland Assets are used efficiently, coherently and strategically • to provide, maintain and develop a high quality sustainable asset base that supports
and facilitates the provision of high quality health care and better health outcomes.
3.2 NHS Highland strategic context NHS Highland is committed to providing high quality, safe, effective care to the population of the Highlands in a safe, efficient and person centred way. This has most recently been set out in August 2014, when the board of NHS Highland endorsed “The Highland Care Strategy: NHS Highland’s Improvement and Co-production Plan”.
Existing Model of Care Future Model of Care Geared towards acute conditions Geared towards long term conditions Hospital centred Embedded in communities Doctor dependent Multi-disciplinary team based Episodic care Continuous care Disjointed care Fully integrated care Reactive care Preventative care Service user as passive recipient Service user as partner Self care infrequent Self care encouraged and facilitated Carers undervalued Low use of technology
Carers supported as partners Greater use of technology
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This document reflects that since April 2012 all adult social care services in part of our area (Highland Council) is now delivered by NHS Highland and all children’s community services are delivered by the Highland Council. This means NHS Highland is directly responsible for the operational delivery of acute care, primary care services, community services, care at home and care homes as well as public health. The Care Strategy outlines NHS Highland’s vision for the future delivery of health and social care services for the people of Highland for the next 10 years. It sets out principles which will underpin what services are required and guides any service development and redesign of services for the future. It also describes the Highland Quality Approach (HQA) which recognises how important it is to improve the health of the population and get the experience of care right for individuals. This is being delivered by focussing on providing person-centred care while at the same time eliminating waste, reducing harm and managing unwanted variation. HQA places an explicit emphasis on how we will make best use all of our resources. Further information on the Highland Quality Approach is available on NHS Highland website www.nhshighland.scot.nhs.uk. 3.2.1 Strategic Planning of services and service change NHS Highland approved a 10 Year Operational Implementation Plan in February 2015. It has been designed to direct our focus on transformational change to deliver our vision for high quality, sustainable health and social care services across NHS Highland. The financial, demographic and political climate over the next few years will change the demands for health and social care resulting in the need for some services to be delivered in a radically different way, to ensure that NHS Highland secures the best possible outcomes for our population. The redesign of services across Badenoch and Strathspey is one of the priorities highlighted in the plan. Our Local Health Plan, sets out the strategic direction for the Board, provides evidence of performance to date and describes the plans to address national targets. The investment proposed in this Initial Agreement (IA) will make a significant contribution to the goals of the NHS Highland Local Delivery Plan and in particular the investments will:
• Provide services and facilities which meet 21st century health and social care 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.
• Provide high quality, integrated and cost-effective services • Ensure care and services are equitable, needs and evidence-based, • Increase focus on acute hospital beds being used only for the most acutely ill and
those with specialist needs • Ensure services are run by healthy, flexible, well-motivated and well-trained staff
working to their maximum potential and capability • Use modern, flexible, efficient, green assets to maximum effect • Reduce waste and inefficiency across acute services
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3.2.2 Other relevant local strategic documents and plans
• Property and Assessment Management NHS Highland’s five year Assessment Management Strategy 2014 describes the implications for some of the redesign work required linked to the current state of some of NHS Highland’s assets. This most recent version was approved at NHS Highland Board Meeting held on 1st October 2014. It has been updated to reflect the transfer of assets following integration. Our five year capital plan and indicative ten year capital plan was approved by the board in April 2015 and includes the proposals to redesign services in Badenoch and Strathspey, agreed in principle by the Cabinet Secretary in January 2015. It also describes our approach and commitment to using shared services whenever possible and practical. • Workforce Through an integrated approach to financial, workforce and service planning, there are in place a number of workforce plans that respond to service redesign and service improvement programmes. In addition, specific workforce efficiency measures have been developed to scope and monitor workforce expenditure in terms of 1) reducing whole time equivalents; 2) skill mix review; and 3) reducing workforce cost base in line with the current PIN policy framework. • Communications and engagement NHS Highland board endorsed “Developing a Quality Approach to Communications and Engagement” at their meeting in February 2012. The local strategy takes full cognisance of CEL 4 (2010) “Informing, Engaging, and Consulting People in Developing Health and Community Care Services” which sets out how NHS Boards are required to involve people in designing, developing and delivering the health care services they provide for them. This document also clarifies the role of the Scottish Health Council during service change which is to quality assure the engagement process and produce a report on their findings for the Board to submit to the minister, alongside the final proposals. A review of the strategy was approved by the board in February 2015. There was significant informal and formal engagement with communities, partner agencies, service users and staff about this proposal. This is described in some detail under section six of this Initial Agreement document.
3.3 Corporate alignment and sign-off The proposed redesign for Badenoch and Strathspey reflects National and NHS Highland strategic priorities. It is one of NHS Highland’s key developments to progress during 2015/16 to support the delivery of the Scottish Government’s delivery of the 2020 vision. It will build on integration of adult social care which has been operational since April 2012 in Highland, and if the plans are implemented, as proposed, it would allow greater investment in community services allowing more people to be cared for at home or in a homely setting. A number of the facilities in the locality are old with major backlog maintenance challenges and also not strategically aligned to the future needs of the population. The proposals offer the opportunity to re-design services that would ensure NHS Highland’s Assets are used efficiently, coherently and strategically. In turn this will allow NHS Highland to provide, maintain and develop a high quality sustainable asset base that supports with better health, better care and better value.
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The current configuration of services also makes it difficult to sustain rotas, especially during out-of-hours. The proposed new arrangements would be more sustainable including supporting a more team-based approach that optimises the benefits of integration. The work has been reported through various NHS Highland committees including Asset Management Group and the Highland Health and Social Care Committee as well as other local groups and committees such as District Partnership and Council Ward Forum. There has also been overview and sign off from the board at various stages including the Options Appraisal, findings from the public consultation (and most recently this Initial Agreement)1 (Appendix 3). A similar project is also underway in Skye, Lochalsh and South West Ross and there has been consistency in approach and opportunities for shared learning. It is within this strategic context and operating environment that the current review of services in Badenoch and Strathspey was undertaken and this Initial Agreement document prepared.
1 Subject to sign-off at the meeting on 2nd June 2015
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4 PROJECT INVESTMENT OBJECTIVES 4.1 Objectives Seven project investment objectives were developed from the assessment of local needs and which align with NHS Highland’s “Highland Quality Approach” (HQA) and NHS Scotland’s Quality Strategy Ambitions as shown in Diagram 1 below: Project Quality Strategy HQA Investment Objectives Ambitions
Integrated Health and Social Care
Improve User Experience
Improve Access to Services and Care
Maximise Flexible, Responsive and
Preventative Care
Make Best Use of Resources
Improve Quality and Effectiveness of Accommodation
Improve Safety of Service Delivery
Patient/Person
Centred
Effective
Safe
To Improve the Quality of Care to Every Person,
Every Day
Create a Caring Experience
Relentlessly Pursue the Highest Quality Outcomes
of Care
Attract and Develop the Best Teams
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4.2 Description of investment objectives A description for each objective was discussed and agreed with the local development group at an initial workshop. The workshop was attended by a wide range of stakeholders and was facilitated by an independent expert; Professor Roger Tanner.
Investment objective
Description Integrated health and social care
A holistic approach which focuses on meeting all the health and social care needs of people. Aims to provide a seamless service where barriers between organisations, staffing structures and budgets are “not visible” to service users. In terms of integration this is an evolving process building on the Lead Agency model in place since April 2012.Through this business proposal integrated models will be further developed with increased co-location, integrated teams and more people looked after at home.
Improve user experience
Recognises that people are individuals with unique requirements. Develop services which focus on the individual, their preferences and choices. Respects peoples’ dignity and privacy and provides services which demonstrate compassion, continuity, clear communication and shared decision-making. Develops mutually beneficial partnerships between service users, their families/carers and those delivering health and social care services.
Improve access to services and care
To provide easy and convenient access to the optimum range of services that can be safely provided locally, with short waiting times and minimum travel distance and times. The most appropriate treatments, interventions, support and services will be provided at the right time and in the right place.
Maximise flexible, responsive and preventative care
Provides services which are responsive to individual requirements, promoting preventative and self-care. Allows services to be changed as peoples’ needs change over time. A model of service provision which proactively anticipates individual’s needs and tailors a full response to meet those needs.
Make best use of resources
Ensures that all available resources (staff, money, buildings, equipment etc.) are used effectively and efficiently to support services and provide good value for money i.e. maximises the benefits to patients from investment in staff time, buildings etc. Minimises waste, duplication and inefficient working practices.
Improve quality and effectiveness of accommodation
Provides modern, fit for purpose, well planned and designed accommodation which supports and facilitates effective and efficient service delivery and provides a pleasant and calming care environment for service users.
Improve safety of service delivery
An appropriate, clean and safe environment will be provided for the delivery of services at all times. This supports avoidable injury or harm to people from health and social care services and this will consistently be provided across the full range of service provision, wherever it is delivered.
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5 EXISTING ARRANGEMENTS The services under this review fall within the locality of Badenoch and Strathspey (Map 3) with a brief description provided in sections 5.1 to 5.4 below. This area sits within the Cairngorm National Park which has a significant influx of tourists all year round. Map 3: Location of services within Badenoch and Strathspey locality
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5.1 General Practice There are 13,472 people registered with three General Practices: Grantown-on-Spey, Aviemore and Kingussie; the Kingussie Practice also runs a practice in Laggan. 5.1.1 Grantown-on-Spey Medical Practice The Grantown practice operates from an NHS Highland owned building on the Ian Charles Hospital site and is attached to the main hospital. The GP building hosts a number of community outpatient clinics including physiotherapy.
Kingussie • St Vincent’s Hospital • Kingussie Medical
Practice • Wade Centre Care
Home Laggan • Laggan Medical Practice
Aviemore • Aviemore Health Centre
/Out of Hours Centre • Rathven House (office) • Ambulance Station • Glen Day Centre • The Mall (children’s
services)
Grantown-On-Spey • Ian Charles Hospital site
o Ian Charles Hospital o Grantown-on-Spey
Medical Practice o Ian Charles Dental Clinic
• Grant House Care Home
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5.1.2 Aviemore Health Centre / Aviemore Medical Practice The Aviemore Health Centre building is owned and managed by NHS Highland. Services
based in the building include Aviemore Medical Practice, dental services and community outpatient clinics.
The practice hosts the medical out-of-hours service for the area, providing cover to both
community hospitals. It also runs the minor injuries unit for the locality. Due to its location within the National Park
the unit treats a significant number of injuries resulting from outdoor activities such as winter sports, mountain biking, water sports and climbing.
5.1.3 Kingussie and Laggan Medical Practices
Kingussie Medical Practice is based at the Old Distillery Surgery in Kingussie and runs the Gergask Surgery in Laggan. These buildings are owned by the practice. Some community services are provided at the nearby St Vincent’s Hospital.
5.2 Community Hospitals As well as a full range of services provided by the General Practices the local communities are currently served by two community hospitals: 5.2.1 Ian Charles Hospital, Grantown-on-Spey Ian Charles Hospital is a 13 bedded, GP led hospital which is co-located with the health centre and modular dental facility. The hospital has 24 hour nursing cover but no on-site / adjacent medical cover during the out of hours period. The out of hours medical care is provided from Aviemore some 25 minutes away by car. The hospital hosts a Minor Injury service, a limited number of consultant outpatient clinics, and has part-time x-ray provision one morning per week. It holds community outpatient clinics and is an office base for some community staff.
5.2.2 St Vincent’s Hospital, Kingussie
The hospital is split into two units. The lower floor is a 10 bed GP medical unit. Upstairs is an Older Adult Psychiatry unit which has seven inpatient beds and is used for psychiatric assessment. During the in hours period GPs visit the hospital to do ward rounds and on request from the nurses. The hospital has 24 hour nursing cover however there is no on-site medical cover. This is provided from Aviemore, an 18 minute drive away. The closest x-ray facilities are also in Aviemore. The Older Adult Psychiatry Unit is led by Consultants based at New Craigs Hospital, Inverness. Day to day medical cover is provided by the Kingussie GPs.
The hospital holds physiotherapy services and some community outpatient clinics.
The beds in both hospitals are utilised for patients who require more intensive medical input than can be provided in their own home, but do not require to be admitted to Raigmore or New Craigs Hospitals. In addition care is provided for patients who have been treated in Raigmore, are ready for discharge from the acute specialties but who still require some form of medical support or inpatient rehabilitation before returning to their own home. Services at both hospitals include assessment and intensive rehabilitation provided by doctors, nurses, physiotherapists, occupational therapists, speech and language therapists
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and social workers. In addition to rehabilitation, the hospitals provide palliative care for those patients with a terminal illness who are no longer able to be treated at home.
5.3 Adult Social Care NHS Highland manages two care homes in the area; Grant House in Grantown-on-Spey and the Wade Centre in Kingussie. Although NHS Highland is responsible for the delivery of the services the buildings are owned by the Highland Council who fund their up-keep. Grant House is a modern facility and has 20 residents with 20 single en-suite rooms. It is located very close to the Medical Centre/Ian Charles Hospital site. The Wade Centre has 10 residents; eight in long term care and two respite beds. The building will be undergoing refurbishment within the next two years. In addition there are two private care homes in the locality: Mains House Care Home in Newtonmore and Grandview House Nursing Home in Grantown-on-Spey. There are proposals for the Parklands Group to build a new 40 bedded care home in Grantown. NHS Highland also manage a day care centre in Aviemore (The Glen Centre) which is also the base for adult social care and community staff. 5.4 Community based services The locality is served by multi-disciplinary teams who work out of a number of different bases across the area. These include social workers, care at home workers, physiotherapists, occupational therapists, speech and language therapists, dieticians, community nurses and community mental health teams. The office accommodation at Rathven House, Aviemore is the base for the community mental health, community nurses, community care and care at home teams. 5.5 Dental services The Public Dental Service is delivered from a modular dental facility in the grounds of Ian Charles Hospital, Grantown and a single surgery within Aviemore Health Centre. Independent Contractor practices are located in Kingussie, Aviemore and Grantown-on-Spey.
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6 MAJOR SERVICE CHANGE PROCESS 6.1 Background NHS Highland has had an ongoing engagement with local communities and staff about local services. In order to meet National and local strategies as set out in Section three it was clear some changes would be required. Initially conversations got underway in 2011/12 with discussions with all four local elected members of Highland Council, visits were made to community councils and there were presentations to local groups such as Friends of Ian Charles, Friends of St Vincent’s Hospitals, the local District Partnership and others. This initial work was supported by a communications and engagement plan. There were also regular updates to all MSPs, Scottish Government officials and the Scottish Health Council. Emerging from all this pre-work a Development Group was established in November 2012 and has had wide and continuing involvement. The make-up of the Development Group and how they have been involved was described in the consultation materials and their names and contact details were made available on the NHS Highland website. To support this work NHS Highland followed advice from the Scottish Health Council. Existing groups and community councils were approached and asked to send representatives. We were also open to include anyone who expressed an interest to get involved and to date all requests to get involved have been accommodated. This will continue to be an ongoing and evolving process. As set out in the guidance clinical staff and those who have management responsibility for its provision were also involved. There is no definitive guidance on the optimum number of people, or the proportion of the various stakeholders who should take part. The board is required to determine what is “reasonable and proportionate”. There is a general comment, however that the group should neither be too small or too large. Initially four half-day workshops were held one each in June, August, September and December 2013. All four events were attended by members of the Development Group and included a wide range of representatives including service users, elected members, community council members, Friends of St Vincent’s and Ian Charles hospitals, voluntary sector, practice managers, GPs, other clinicians and NHS Highland staff. Through this work the objectives/benefits were agreed, a long list of options considered (Section 13) and a short list of three options scored and preferred option identified (Section 14).
6.2 Major Service Change and Public Consultation At a special board meeting held on 4th March 2014, the Board of NHS Highland considered the changes being proposed to be major and endorsed the preferred option. A requirement of proposed ‘major’ service change is the need to carry out formal public consultation for a minimum period of three months (Appendix 4).
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NHS Highland worked closely with the Scottish Health Council on the communications and engagement plan, the public consultation materials and the consultation survey. In April 2014 the Scottish Health Council confirmed that they were satisfied with the arrangements NHS Highland had in place allowing the formal consultation to take place. The formal consultation was launched on 21st April and ran for a total of 14 weeks until 21st July 2014. Responses were accepted up until 28th July 2014. People were given an opportunity to feedback on the three short-listed options or to offer a view on any alternative option. Moreover, the feedback form also allowed people to comment on specific elements of the proposal including a short-list of sites within Aviemore for the new facility. The decision making process was also described in the consultation materials and at events, meetings, correspondence, media and with the Steering Group. In discussion with the Scottish Health Council a wide range of approaches were identified for use to raise awareness with the public, partners and staff about the consultation; what was being proposed, promotion of meetings and how people could make their views known. These activities were set out in a communications and engagement plan which was regularly reviewed. The process was designed to be responsive with capacity built into the plan to meet anticipated requests as they emerged during the consultation. The local Development Group was kept in regular contact throughout the consultation period through group emails and direct contact. Many members attended one or more events and also brought queries to the attention of the core team throughout the consultation and continue to do so. A well-attended mid-review meeting of the Development Group was held on 5th June. This was to get feedback from members on the process and to allow time to incorporate their suggestions. This formed part of NHS Highland’s mid-consultation review write-up. And a number of additional activities were undertaken as a result of the review and other feed-back The public consultation was also discussed at the NHS Highland Annual Review which was held on 9th June in Fort William. Two members of the steering group attended the event. Other activities included: • During the consultation staff attended over 50 meetings • Close contact was maintained with stakeholders including local groups, councillors,
community councils, partner agencies, MSPs, Scottish Government, Scottish Health Council, local GP practices and staff
• A total of 8,207 summary documents were issued (homes = 7,703 and businesses =502) via a mail drop to every home and business in the area
• NHS Highland issued regular media releases about the consultation, and paid for three adverts to be placed in the local newspaper
• A short film was prepared and promoted through social media • Hundreds of posters promoting dates of events were distributed, numerous articles
issued for local and NHS Highland publications, and websites • Two walkabouts were also carried out to check awareness within communities and
further distribute materials
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6.2.1 Feedback on the public consultation process NHS Highland undertook an extensive and wide-ranging public consultation exercise. The approach was generally well received. The reasons for the changes to services being proposed were understood and the majority of the feedback suggested that the case for major service change was accepted. There was consistency in views received through the different routes and from partner agencies. By the end of the consultation no new themes or issues had been raised. The feedback from the public meetings was fairly representative of the general feedback which emerged during the consultation. Areas of greatest concerns were raised from some residents in Grantown-on-Spey. This was also highlighted in the Highland Council response and further focussed work will be required should the proposed changes be implemented. Overall the vast majority of people who took part in the consultation, and who fed-back, were positive about the opportunities to engage with NHS Highland and there was good awareness about the consultation and how to make views known.
6.2.1.1 Feedback on the service model and site 79% of people who responded to the consultation survey agreed with the proposal to develop a community hospital and resource centre in Aviemore supported with wider development of community services. This option also received backing from all four medical practices and partner organisations (The Highland Council, Scottish Ambulance Service, Scottish Fire and Rescue Service, Highlands and Islands Enterprise and the Highland Hospice). People also had the opportunity to comment on aspects of the proposed changes. Over half the people who responded were positive about all elements. Closing in-patient beds in Ian Charles and St Vincent’s Hospitals and moving the Glen Day Centre were the least well supported. The Steering Group was also re-convened on 27th August 2014 to complete the options appraisal exercise on the potential sites for the new facility in Aviemore. This could only be completed after the consultation closed because public preference was one of the criteria being used on which to make a recommendation about the sites (Appendix 5). Both the public preference and the working group’s deliberations came up with the same conclusion on the favoured choice of site. This preference is based on qualitative factors only and will be considered alongside quantitative factors such as development costs, land purchase and the suitability of the land for construction.
6.3 Internal and external assurance process NHS Highland’s Health and Social Care Committee endorsed that the consultation process complied with Scottish Government major service change guidance. They also supported that the operational unit was in a position to present the full findings to NHS Board meeting to be held in October 2014. The Scottish Health Council carried out an independent review of the process and has also endorsed the process. They highlighted some areas of good practice as well as how the process could be improved in the future.
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6.4 Recommendation considered by NHS Highland board A paper including the detailed report on the consultation process was considered by the board at their meeting on 7th October 2014. The board was asked to: • Consider the detailed report on the feedback from the three month public consultation
into proposed major service change • Note the feedback from the Scottish Health Council endorsing the consultation
process • Endorse the recommendation in support of the preferred option – to develop a
Community hospital and resource centre in a central location (Aviemore) • Note the next steps and the requirement for any decision on proposed major service
change to be considered by the Cabinet Secretary for Health and Wellbeing The board endorsed the recommendation (Appendix 6).
6.5 Ministerial approval NHS Highland submitted the proposals to the Cabinet Secretary on 11 November 2014 and Ministerial approval was received on 27 January 2015 (Appendix 7). Specific requirements highlighted by the Cabinet Secretary were:
• Ongoing commitment to support the local transport company and to ensure workable transport solutions are in place in time for the opening of the new hospital
• Development and provision of appropriate step-up / step-down beds in both local communities will be required before closure of Ian Charles and St Vincent’s Hospitals
• Other community and care at home provision must be available before the Board proceeds to the closure of the current facilities
• Ensure that local people and all other stakeholders continue to be kept fully informed and involved in the ongoing development and delivery of these services
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7 BUSINESS NEED
7.1 Population Projections
The population in Badenoch and Strathspey has grown over the last ten years, with an 8.4% increase in the practice registered population. The Aviemore Medical Practice has had the most significant increase at 15% (Table 1). The population is ageing, with a 20.8% increase in people aged 75 years and over. All the practice populations have large population cohorts in the 45-74 age range and further population ageing is expected over the next twenty years. Table 1. GP Registered Population, Badenoch and Strathspey, April 2003 and 2013
Age Band
Aviemore Grantown Kingussie Gergask
Newtonmore Badenoch and
Strathspey 2003 2013 2003 2013 2003 2013 2003 2013 2003 2013
00-15 738 820 832 797 484 442 103 80 2157 2139
16-44 1826 1924 1536 1560 897 813 179 145 4438 4442
45-64 1135 1369 1497 1553 850 961 124 163 3606 4046
65-74 291 464 536 716 337 394 48 50 1212 1624
75-84 143 210 382 388 199 252 22 29 746 879
85+ 36 46 150 179 69 111 10 6 265 342
Total 4169 4833 4933 5193 2836 2973 486 473 12424 13472
Source: Community Health Index
The Badenoch and Strathspey population has a slightly older age profile than the Highland Council area as a whole, with 42% of the population aged 65 years and over compared to 40% in Highland overall. Population projections for the Highland Council area show that the population of Badenoch and Strathspey is projected to grow a further 7.7% by 2037. This could increase by as much as 30.7% when taking into account the proposed phased housing development at An Camus Mor, Aviemore (Figure 2). There is some uncertainty around the timetable for this and whether this population growth would be additional to the migration rates assumed in the base projection.
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Figure 2: Projected change in population of Badenoch and Strathspey and additional change resulting from phased housing developments at An Camus Mor
Source: NRS Population Projections for Scottish Areas (2012-based), NHS Highland Health Intelligence
The population projections also show an expected change in the age structure of the population with a marked increase in the number and proportion of older people (Figure 3). Figure 3: Projected population of Badenoch and Strathspey by Age Band a) Badenoch and Strathspey b) Badenoch and Strathspey + An Camus
Mor
Source: NRS Population Projections for Scottish Areas (2012-based), NHS Highland Health Intelligence
The number of people aged 75 and over is expected to double in future to 2,500 based on the current housing stock and over 3,000 with the addition of the proposed An Camas Mor development.
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7.2 Service Projections The use of health and social care services increases with age; however this is only one factor to be considered when planning future services. The population has been ageing over the last decade, yet during this time the number of hospital beds in Badenoch and Strathspey has reduced from 58 to 30 (Figure 4). This has been achieved through changing models of clinical care and improved efficiency of hospital services. Whilst there is some evidence that service change has kept pace with demographic change to date, Figure 4 also highlights that the rate of increase in people aged 75 and over is expected to exceed that observed over the last decade. Figure 4: Trend in number of inpatient beds and population aged 75 years and over, Badenoch and Strathspey, 2003 to 2037
Source: ISD(S)1, NHS Highland Service Planning
Overall admission rates and occupied bed days in the GP beds have decreased over the last five years, although this is less marked in the 85+ age group. There is a downward trend in admission and bed day rates for the psychiatry of old age beds as the locus of the service has moved away from inpatient facilities. There has been reduction in bed numbers at Ian Charles and St. Vincent’s Hospital over the last ten years. The changes are most evident at St. Vincent’s, which has seen a reduction in bed numbers from 39 to the current complement of 17. The 18 beds at Ian Charles Hospital reduced to 13 in March 2013. These reductions related to Infection Control, management of Hospital Acquired Infections, environmental compliance, Health and Safety matters and the need for some single rooms.
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7.2.1 Bed Modelling Detailed clinical modelling exercise is underway in order to estimate future service requirements for inpatient beds. It is being developed in consultation with key representatives of the operational management team and national planning guidance. It takes into consideration the changes in service provision over the last 10 years, the current profile of services in the area and benchmarking of a range of measures on service utilisation. Benchmarking suggests the area is well provided for with NHS beds and the number of care home places are on a par with the Highland average for the population aged 75 and over. Bed occupancy is below the optimal level recommended for planning services. The General Practices in Badenoch and Strathspey have historically had different admission thresholds, though these become less apparent in 2012-13. Further consideration needs to be given as to how a relocation of hospital services in the district may affect the observed admission patterns. Although the outcome of the bed modelling exercise is awaited, early indications suggest around 20 to 25 beds for the area, depending upon the forecast occupied bed day rate and population projection used. Clearly the extent to which community services are developed will significantly impact on hospital bed use. 7.3 Analysis of existing arrangements 7.3.1 Strategic location of facilities, staff and equipment The existing hospitals are historically located and not in a central location to service all communities. Over the last 100 years the population demographics have changed with Aviemore the fastest growing town in the locality. Aviemore is central to the locality and is immediately adjacent to the A9 which is the main road linking the area to the north and south. Services are being provided from a number of facilities and would benefit from being rationalised. At present staff are based in small units, in separate teams, in a variety of different buildings. The majority of staff groups are located away from in-patients, doctors and other clinical staff. For example the home care organiser is based in Kingussie and social work staff work from offices in Aviemore distant from other staff groups who are in a separate office. Currently there is no local facility to allow co-location with other third sector organisations. Current storage arrangements for aids and adaptations in Badenoch and Strathspey are very ad hoc, making things hard to track and control stock. 7.3.2 Condition of buildings and equipment The inpatient accommodation at the two hospital sites does not meet current NHS guidance on bed spacing and sanitary provision. Of the 13 beds in Ian Charles none are en-suite and only five are single rooms. There are six WCs, two shower rooms and one bathroom for 13 patients. Access for staff around the beds is poor leading to potential lifting and handling risks. St Vincent’s has eight single rooms and one twin. One of the single rooms is currently being made en-suite, the other patients share four WCs and one combined shower and bathroom. Upstairs the Older Adult Psychiatry unit has one single room and three twin rooms, none of the rooms are en-suite. There are two WCs and one bathroom with a WC.
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The cost to address backlog maintenance costs for both hospitals is currently around £5.1million. This investment would bring them up to minimum standards but would not address the lack of compliance on bed spacing or sanitary provision. During 2013/14 NHS Highland invested £100,000 in day-to-day maintenance to ensure the buildings remained safe to deliver services. Aviemore Health Centre also has a series of age-related problems and repairs that require investment. The building needs new water pipe work and repairs due to damage left by various roof leaks. The out-of-hours / ambulance entrance to the building is also in need of upgrade to make it more secure and easily accessible for disabled patients. The waiting areas are in need of upgrading to comply with modern infection control procedures and to improve access for patients with mobility problems. There are two x-ray units: one in Ian Charles Hospital and one in Aviemore. The service provided at Ian Charles is only part time. The equipment is 18 years old, well past its replacement date and no longer under maintenance contract. The equipment is likely to be withdrawn from service in the near future. The radiographer providing the service at Ian Charles Hospital is based at Aviemore Health Centre. The travelling time means the loss of three potential patient slots each way. If there is an urgent inpatient request at Ian Charles Hospital (out with Wednesday mornings) this requires the single handed radiographer in Aviemore to close the department early to travel and carry out the examination. This can have a considerable knock on effect on potential patient slots and minor injuries service provision in Aviemore. 7.3.3 Medical and nursing cover The out-of-hours medical service is located in Aviemore but the in-patient beds are located in Ian Charles Hospital in Grantown-on Spey and St Vincent’s Hospital in Kingussie. This can cause delays in the doctor seeing in-patients. On occasion the doctor is required to see patients in both hospitals at the same time which is a safety issue. During the out-of-hours period currently three nursing rotas exist - one in each hospital and one in Aviemore. There are ongoing challenges to fill the rota particularly during times of sickness and annual leave. This is neither an effective nor an efficient model. 7.3.4 Specialist out-patient clinics Currently Ian Charles Hospital holds a half day orthopaedic clinic every three months however Aviemore and St Vincent’s are unable to. Patients from Aviemore and further south often choose to travel to Raigmore Hospital, Inverness instead, a journey time of up to one hour. This results in the Grantown clinic not being well used. Even one clinic per month in Aviemore would result in around 100 fewer patients travelling to Inverness. Medicine for the Elderly, General Psychiatry and Older Adult Psychiatry clinics are held in various locations across the area and attendance figures are provided ( table 2 below). These relatively low numbers illustrate inefficient use of resource with clinics spread across a number of sites.
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Table 2: Attendance figures for outpatient clinics in 2012/13
Ian Charles Hospital, Grantown
Grantown Health Centre
Aviemore Health Centre
St Vincent’s Hospital, Kingussie
New Ret Total New Ret Total New Ret Total New Ret Total
Medicine for the Elderly
11 48 59 0 0 0 0 0 0 11 35 46
General Psychiatry
0 0 0 32 70 102 28 108 136 18 58 76
Older Adult Psychiatry
0 0 0 31 105 136 0 0 0 21 84 105
7.3.5 Adult social care Care at home requires some investment to increase capacity and the re-design will look at changes to both in-house and independent sector, including opportunities through Self Directed Support. This is part of ongoing work. Initial reviews of scheduling, allocation of care packages and review of packages, as part of the in-house service have identified the possibility of creating additional capacity within additional resource. To meet future challenges a range of solutions will be required to implemented. There are opportunities to expand how care homes are used including having step-up or step-down facilities. The location of the homes in Kingussie, Newtonmore and Grantown-on-Spey offer the opportunity to still have local ‘beds’ in the areas once both hospital close. This would maintain local access and would reduce the number of beds required in the new facility. 7.4 Analysis of existing arrangements and changes required
During the service redesign workshops a statement of business need was agreed for each of the Project Objectives and an assessment was carried out of the change required in order to meet these. Further detail is included in Appendix 8. Objective Issues with existing arrangements Changes required Integrated health and social care
The current configuration of buildings and resource allocation is hampering the opportunities to fully optimise the benefits of Lead Agency Model. Issues include: • Not enough community services
or care-at-home, • Lack of co-ordination and team
working • Not integrated with Ambulance
Service
Stop using hospital beds as a default and provide alternatives in local communities by: Facilitating new ways of working to accelerate the delivery of successful integration across health and social care, partner agencies and third and voluntary sector. New arrangements will include: • Move service into new
33
• No facility to work closely with third sector
• No step-down beds • No equipment store for aids and
adaptations
purpose-built facility in central location and benefit from staff, agencies and partner agencies co-located allowing multi- professionals input
• Investment in community services
• Centralised satellite equipment store with better tracking of equipment
Improve user experience
Users are generally very complementary about the care they receive but the condition of the buildings and location of services, across multiple sites, mean that care is not as safe as it could be and impedes privacy. Because resources are tied up in buildings this means some people need to be in hospital when they could be looked after at home or in a homely setting. Issues include: • No single room with en suite
facilities • Not enough care-at-home • Have to travel to Raigmore for
services which could be provided locally
• Increase number of single bedrooms to provide appropriate standards of privacy and dignity for patients
• Increase capacity of community services
• New approaches to reduce the need for appointments
Improve access to services and care
A failure to modernise now could result with progressive withdrawal of services and ultimately less access to local services (i.e. outside of Badenoch and Strathspey). Issues include: • Out-patient clinics not efficient or
equitable • No enough care-at-home and
community services
• Clinics held in one central location
• Better use of technology to support remote access to specialist input
• Increase responsive of community services
Maximise flexible, responsive and preventative care
Having resources tied up in multiple old buildings in close proximity offers no flexibility. Issues include: • Significant resource committed to
fixed asset and running costs
• A fundamental change in the way services are organised and where resources are invested is required to ensure flexible and responsive care
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• Strategic location of services in central location in a modern, purpose built facility reducing maintenance costs.
Make best use of resources
Under current arrangements available resources (staff, money, buildings, equipment etc.) are not used effectively nor efficiently and therefore do not provide good value for money. Issues include: • Poor condition of hospital
buildings with significant maintenance costs (£5.1m)
• Duplication of some high-cost, low volume services
• Staff and services based in a diverse range of smaller premises which increases cost
• Difficulties in filling nursing rotas • X-ray cover not efficient or
equitable and not up to date
• Close two existing hospitals releasing resources to develop modern flexible facility and invest in community services
• Relocate services and teams to a single building
• Bring three nursing teams together on a single rota
• All x-ray services provided from one site
Improve quality and effectiveness of accommodation
Existing accommodation is old and not designed for the delivery of modern health and social care. Issues include: • Poor condition of hospital
buildings, duplication of services, significant maintenance costs
• Aviemore Health Centre not fit to meet future needs of population
• Build new modern hospital in central location. Building designed to meet needs of modern service
• Close old facility and provide health centre services from new purpose-built centre compliant with all standards
Improve safety of service delivery
Significant mitigation is required to reduce safety concerns. Issues include: • Accommodation is difficult to
maintain to modern statutory compliance and health & safety standards
• Lack of single bedrooms with no en-suite WC/showers.
• Increased risk of Hospital Acquired Infections (HAI) from multi-bed wards with a lack of flexibility for isolation.
• Close existing hospitals and replace with modern, fit for purpose accommodation which is planned and designed to support contemporary models of service delivery.
• Increase number of single bedrooms to 100%.
• 24/7 on-site medical care • Bringing three nursing
teams together and having one rota
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• Poor out-of-hours medical cover for in-patients
• Difficulties in filling nursing rotas • No place of safety for people with
emergency mental health needs • X-ray equipment out of date
• New facility will provide a place of safety
• X-ray facilities to be aligned with inpatient and outpatient service provision. New state of the art X-Ray equipment utilising digital technology will give better definition imaging with a lower radiation dose
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8 POTENTIAL SCOPE AND BUSINESS REQUIREMENTS The workshops used the Scottish Capital Investment Manual Options Framework approach which required the group to systematically work through the available alternatives for the project in terms of five categories of choice as shown in table 3 below. Table 3: Scottish Capital Investment Manual Options Framework
Category of choice Description
Scope How big/small is the project? What is included, what is not included, boundaries, services?
Service Solution How do we deliver the scope? Models of service delivery, use of technology, new ways of working, centralised/de-centralised etc.
Service Delivery Who does the delivery? In-house, outsourced, mixed economy model etc.
Implementation How do we make the change happen? Roll out, big bang, phased delivery etc.
Funding How do we fund it? Capital, Hub revenue, lease etc.
The full work-shop report is available to view in the following link.
8.1 Potential business scope
The business scope is essentially the design and development of facilities and services that meet the Project Investment Objectives. To support this a review was undertaken with stakeholders to agree the boundaries and limitations of what the project is seeking to deliver: 8.1.1 Geographical The scope is as existing and defined in Map 3, page 21 The new arrangements will continue to serve the communities registered with the existing three GP Practices which covers a stretch 75 miles long and 40 miles wide. 8.1.2 Population / user base The resident population of Badenoch and Strathspey in 2012/13 was 13,500 and this is projected to increase (section 7.1). The visiting seasonal population increases this significantly. A redesigned service will need to be able to cope with demand from proposed new developments, for example the new community of up to 1,500 residential units at An Camas Mor outside Aviemore.
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8.1.3 Functionality General Medical Services (GMS), wider primary care, community health and social care including inpatient and outpatient hospital services, care homes with step-up / step-down capacity, care-at-home, dental, mental health, learning disability, alllied health professionals. district nursing and extra care housing provision are in scope. 8.1.4 Organisations NHS Highland, Local Authority, Scottish Ambulance Service, Third Sector and Independent Sector such as Badenoch and Strathspey Community Transport, Highland Home Cares, Dachaidh. 8.1.5 Hours The proposed re-design covers both in-hours and out-of-hours. 8.1.6 Locality-based staff One-hundred and fifty staff are directly impacted by the change and would relocate to the new facility. A breakdown of these staff groups is included in table 4 below. The clinical modelling work which is underway will confirm exact numbers. Table 4: Breakdown of staff groups directly impacted by service change Staff Group Headcount Portering 2 Administration 5 Physiotherapy 7 Occupational Therapy 2 General Ward 59 Pharmacy 1 Podiatry 2 Speech Therapy 2 Out of Hours 7 GP Practice (Independent Contractor) 20 District Nursing 9 Community Mental Health Team 10 Learning Disabilities Team 2 Midwifery 4 Public Health Nursing (Highland Council) 6 Adult Social Care Day Services 5 Community Care Team 7 150 Age and travel analysis for staff in both hospitals has been carried out looking at the likely opportunities through turnover and retirement. There are significant numbers in the 56 and over category as illustrated in figures 5 and 6 below.
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Figures 5 and 6: Age profiles of staff based at Ian Charles and St Vincent’s Hospitals
A large proportion of staff working at Ian Charles and St Vincent’s Hospitals live within 5 miles of their work base; 65% for Ian Charles Hospital and 71% for St. Vincent’s. A relocation of services to Aviemore would increase the travel distances for these staff by about 10 miles each way.
8.2 Service Solution Implementation of the preferred option would be a radical change from current arrangements. It would facilitate fully integrated health and social care services across all sectors including third and independent. It presents the opportunity to work more closely with other sectors in order to ensure all facilities in the area are fully utilised, for example working with Highlife Highland to maximise the use of nearby community facilities. Setting up a Hub health and social care resource centre in a central location (Aviemore) will require rationalisation of existing hospital and office based facilities. All in-patient and outpatient care will be located in the Hub including medical cover, nursing cover and diagnostic facilities. Community services including care-at-home will be maximised with a move away from hospital being the ‘safety-net’. Step up and step-down facilities will be developed in both care homes. The use of multi-professional and multi-agency peripatetic teams will be maximised. IM&T in people’s homes will be maximised including mobile devices, assistive technology and alarm-type systems. The use of technology including VC specialist clinics will also be used to reduce the need for people to travel to Raigmore for outpatient clinics.
0
5
10
15
Age
Age Band
Figure 5 - Ian Charles Hospital
0
5
10
15
20
21-2
5
26-3
0
31-3
5
36-4
0
41-4
5
46-5
0
51-5
5
56-6
0
61-6
5
66-7
0
Age
Age Band
Figure 6 - St Vincent's Hospital
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Overview of new service solution
‘Hub’Aviemore
(see page 8)
GP practices
Tele-medicine
Care-at-home
service
Day care
Care homes/
Integrated teams in
the community
AviemoreGrantown-on-SpeyKingussieLaggan
First responders in all GP practices
Grant house (Grantown) – 20-22 bedsWade centre (Kingussie) - 10 bedsPlus investment in community beds
Glen centre (Aviemore) – 20 place (moving into Hub)Grant house (Grantown) – 4 placesWade centre (Kingussie) - 15 places
Review, re-design and investment
Enhanced minor injury cover in Grantown-on-Spey via GPs
Joint working to deliver local rehab and exercise classes
Summary of services in central ‘hub’
AviemoreCommunity hospital and
resource centre
Integrated team base and
resource centre
Aviemore health centre
Day care services, out-patients and
day patients
X-ray serviceultrasound
investigations
Minor injuriesout-of-hours
treatment centreAmbulance basefirst responders
Community mental health
(including place of safety)
20-25 In-patient beds
24/7 nursing and medical and rehabilitation
Integrated teamsCommunity nursesPublic health nursesCommunity midwivesSocial workersCare-at-home staffPhysiotherapistsOccupational therapists etc
Integrated baseSingle point of contactEquipment storeTraining facilitiesBase for third sectorLearning and development
OtherLearning disabilitiesPublic Dental Service
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8.3 Service delivery Single integrated health and social care teams incorporating third and independent sector and Scottish Ambulance Service taking account local delivery for non-hospital based services. 8.4 Implementation An implementation plan will be developed for the new centralised facility and alongside this a transitions plan to move services into the new facility once ready. Enhanced community care at home, community services and integrated transport and access plan should be in place prior to closing down any of the existing services. During the development phase a business continuity plan will need to be in place to manage risks associated with any failures to building or equipment which will not be replaced.
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9 BENEFITS
The benefits of the proposed service change have been developed during the series of workshops and are described in more detail (Appendix 8) and the workshop report. A summary of the main benefits is provided in table 5. Benefits realisation workshops involving relevant stakeholders will be set up during the Outline Business Case stage. The aim of these workshops will be to further develop the project benefits and agree baseline measures.
Table 5: Main benefits of the proposed service change
Benefit Who Benefits?
Cas
h re
leas
ing?
Qua
litat
ive
/ Q
uant
itativ
e
Rea
lised
in
shor
t /
med
ium
/ lo
ng te
rm How this will be
measured
Objective 1 - Integrated health and social care
Greater numbers of people being cared in their own home
Public/Patients Yes Qual Long Emergency hospital admissions rates
Occupied bed days
Delayed discharges
Reduced hospital stays
Patients Yes Both Short As above
Objective 2 – Improve user experience
All single rooms to have en suite facilities
Patients No Qual Short Number of single rooms (From 0 to 100%)
Objective 3 – Improve access to services and care
Greater number of specialist outpatient clinics in Aviemore
Patients
Patient transport
No Qual Medium Increase in number of patients seen in clinics in the locality
Increased use of telemedicine
Patients
SAS
Patient transport
No Both Medium Increase in number of patients with remote consultation
Reduced need for travel
Equality of access to services across all patient groups (physical access)
Patients No Qual Short Compliance with disability discrimination act
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Objective 4 – Maximise flexible, responsive preventative care
Enhanced anticipatory care and community care services
Patients Yes Both Medium Number of anticipatory care plans
Increased investment in community services (+£400k)
Reduction in recurring costs
Objective 5 – Make best use of resources
Reduction in estate and corresponding reduction in utilities bills (maintenance, rent, heating etc)
NHS Highland Yes Quant Short Financial monitoring
Reduction in back-log maintenance
Reduction in recurring costs
Reduces duplication, capital replacement costs, running costs and travel
NHS Highland Yes Quant Short Financial monitoring
Reduction in recurring costs
Objective 6 – Improve quality and effectiveness of accommodation
Energy savings, reduced operating and maintenance costs.
NHS Highland Yes Quant Short Estates financial data
BREEAM score
Reduction in energy costs
Facility fully compliant with NHS guidance – control of infection
Patients No Qual Short HAIscribe
Schedule of accommodation / building design
Reduction in number of reportable infections
Improved and more efficient cleaning regimes
Patients
Staff
Yes Both Short Reduction in costs for cleaning
Infection control data
Objective 7 – Improve safety of service delivery
Safer, efficient and more sustainable nursing cover
Patients, staff, NHS Highland
Yes Qual Short Compliance with NHS HR guidelines on out of hours rotas
Reduction in short-term
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supplementary staffing
Provision of appropriate standards of privacy and dignity for patients
Patients and their families
No Qual Short Number of single rooms (From 0 to 100%)
Compliance with guidelines
Quicker medical response for urgent issues out of hours
Patients, Out of Hours teams (medical & nursing), SAS
No Both Short Medical response times to inpatient out of hours issues
On-site access to x-ray facilities for inpatients
Patients, staff No Qual Short Reduction in patients transferred for x-ray
Reduced radiation dose for patients
Patients No Qual Short Equipment data sheets, Radiation Protection data
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10 STRATEGIC RISKS
10.1 The need to close two hospitals It is recognised that the proposal to close two hospitals is major service change. In addition it is the first time that NHS Highland has built a replacement facility in a different town. The major service change process and public consultation has worked well and there is generally strong local understanding and buy-in for the proposals. Engagement will need to be ongoing and clear plans will need to be in place to manage the transition phase. In particular the feed-back we have received during our engagement is that it will be important to some local people to have influence and input as to what will happen to the hospital buildings once they are no longer required for hospital services.
Appropriate links have also been established to ensure that, once new arrangements are in place, any artefacts are archived, documented to ensure this important period of local history is not lost. This would be progressed jointly with local communities.
10.2 Development required in Cairngorms National Park
The proposals are predicated on being able to purchase affordable land in Aviemore to develop the central hospital resource centre and ‘hub’. There will be some challenges around this and close working will need to be maintained with the Park Authority, local landowners and others.
10.3 Service model
The service model, in part, depends on ensuring there is sufficient community capacity (care-at-home, community services, step-up / step-down beds) and that there is an integrated transport and access plan in place.
10.4 Project Risks
During the course of the workshops the participants identified potential risks to the project. These were themed under four sections:
• Business • Service • External / environmental • Financial
These are described alongside the likelihood, monitoring and mitigation of these in the risk register (Appendix 9). The Assurance arrangements are described in Section 14.3.
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11 CONSTRAINTS AND DEPENDENCIES 11.1 Financial It is unlikely that Scottish Government will have capital funds for this project therefore NHS Highland would need to explore the revenue route. Due to the size of the project it is possible that for financing it will need to be bundled with another project. This project has been approved as a revenue pipeline hubco project and the capital elements of equipment and land procurement are in the NHS Highland draft capital plan. There remains uncertainty of the availability of any unitary charge grant that could have an effect on the financial viability of the project. In addition, competing priorities for the use of NHS Highland capital allocation may impact on timescales and financial viability.
The sale and future use of buildings are subject to regulations on disposal in accordance with Scottish Government Policy. There is a substantial Endowment Fund associated with St Vincent’s Hospital. Transfer of fund will be subject to relevant legislation and local input. Clarification is being sought as to whether any of the buildings in the scope are subject to any listings or restrictions. The scope and potential of the Integrated Transport Plan will influence ‘parking spaces’ and non clinical elements of ‘Hub’ including costs.
Any changes required to physical assets not owned by NHS Highland (eg Care Homes)
Any proposals to review and re-design Grantown-on-Spey Medical Practice Informal discussions have also taken place for potential extended use of Kingussie Medical Practice for local delivery of service once hospital closed, such as clinic space which could be used flexibly. 11.2 Service delivery A fundamental constraint of the project will be the need to fully maintain services throughout the project period. The new resource centre and hospital ‘hub’ and reconfiguration of other services will need to be in place before the planned closure of any services. Although NHS Highland is responsible for the delivery of service in two Care Homes, the ownership and upkeep of the building is the responsibility of the Highland Council. Delivery of General Medical Services in and from the new hospital and occupation of the new centre by Aviemore GP Practice will be subject to appropriate contractual arrangements being agreed. In-patient medical care in both existing hospitals is provided by each local GP Practice which may have an impact on their income under the new arrangements. Grantown Medical Practice and Ian Charles Dental Clinic sit within the grounds of Ian Charles Hospital and currently share services such as heating and water. Closure of the hospital will have physical constraints in terms of on-going delivery of utilities to these
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buildings. There is also some shared use of space between the health centre and the hospital. There is a commitment to maintaining these services in Grantown and early work is underway to assess the options. Highland-wide reviews of out of hours, diagnostic services and delivery of the public dental service are ongoing and could influence the final model. Conclusions of the Inverness Master Plan, transforming outpatients and shape of community services may have a small influence the final clinical specification of the resource Hub in Aviemore.
Consistent with the Highland Quality Approach, application of Improvement Methodology (LEAN/3P - Production Preparation Process) will be used in the design of the new facility and any new services. Further information is available in this link.
11.3 Workforce Any change of base, location, job description will be subject to organisational change process. There are be no plans to close services until new arrangements are in place. 11.4 Planning constraints The redesign sits within the Cairngorms National Park which brings some necessary planning conditions and potential limitations on future use of existing buildings in scope. The Cairngorm National Park Authority (CNPA) representatives have been active members of the Steering Group and there has been liaison between CNPA, Scottish Futures Trust and NHS Highland regarding the potential future use of surplus sites. 11.5 Transport NHS Highland is not a transport provider but having an integrated transport plan is a key requirement as reaffirmed by the Cabinet Secretary (27 January 2015). A Transport & Access Group was established in September 2014 and has met four times, most recently in April 2015. It is chaired by Nigel Small, Director of Operations for South and Mid and includes local stakeholders such as the Badenoch & Strathspey Access Panel, Badenoch & Strathspey Transport Company, Cairngorms National Park Authority, Scottish Ambulance Service, community representatives, youth representatives and Highland Council elected members and officials. It is currently identifying the existing budgets and spend on services in the area as well as the vehicles owned and in use by the various agencies. It will look at how these can be shared and used collectively. The Group will also be liaising with commercial providers about potential new routes. Terms of Reference for the group are provided (Appendix 10). The local Transport Company have been successful in securing funding from the Bus Investment Fund for new investment and infrastructure over the next five years. NHS Highland and other partners have match funded this to provide in the region of £500,000 investment to support improved transport arrangements for the area. 11.6 Sustainability In line with Capital Investment guidance we are aiming to achieve BREEAM “Excellent” with this proposed development which will be a new build. This can be challenging on a Greenfield site and further discussion is required with the National Design Assessment team.
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12 CRITICAL SUCCESS FACTORS In addition to the Investment Objectives for the project there are a number of factors which, while not direct objectives of the investment, will be critical for the success of the project, and are relevant in judging the relative desirability of options. The five Critical Success Factors agreed at the Steering Group workshops are shown below.
Critical Success Factor Description
Strategic fit
Fits with NHS Scotland's Quality Strategy ambitions for patient centred, effective and safe services. Fits with all of NHS Highland Strategies as set out Section 2 captured in our over-arching strategic document “The Highland Care Strategy: NHS Highland’s Improvement and Co-Production Plan.”
Value for money
Will enhance service delivery, improve user experience, and achieve the project investment objectives from an efficient cost base, while at the same time reducing service delivery risks. Overall will deliver a good balance of bringing benefits, while reducing costs and risks
Achievability The key service providers are able to adapt to the proposed service changes and deliver an enhanced service from identified resources
Supply-side capacity and capability
Service providers have the resource capacity and capability to deliver the proposed service model and facilities; and the scheme will be able to attract the necessary investment.
Affordable Capital and/or revenue funds available within the Highland health and social care economy will be sufficient to deliver the proposed option.
12.1. Design Statement
In line with the Scottish Capital Investment Manual we have commenced the Design Assessment process. Two workshops were undertaken and a Design Statement has been produced and discussed with the development group. This document sets out the non-negotiable performance specifications that any new facility will need to meet and outlines some benchmarks against which this can be measured. The full copy of the Design Statement is attached (Appendix 12). The final version of this Design Statement was submitted to the National Design Assessment Process on 18 May 2015 to allow them to provide a formal report prior to consideration by the Scottish Capital Investment Group. Their report is expected at the end of May.
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Another important element of the National Design Assessment Process is the Achieving Excellence through Design Evaluation Toolkit (AEDET). This will allow evaluation of the design at key stages during the project. The first AEDET assessment was carried out by the development group in March, facilitated by Health Facilities Scotland. The outcome was a measure of the existing facilities as a benchmark to compare against future design (table 6). The group also agreed the relevant importance and weightings of each assessment criteria. The current facilities scored poorly overall, but particularly on use, access, space, performance and staff and patient environment. As well as providing a benchmark this supports the case for change. Table 6: Summary of AEDET scores for current facilities Benchmark Score Notes Use 1.0 Where the buildings are good, they are in the wrong
place. Clinical areas in many facilities are sub-standard.
Access 1.0 Some loss of local travel through facilities being relocated, but not generally realised as routes to existing facilities are poor.
Space 1.0 Need for quiet space Performance 1.3 Where there are robust materials if they had been
well maintained then would have aged well. St Vincent’s has good levels of natural light.
Engineering 1.7 Biomass and PV have been installed in some facilities
Character & Innovation 1.7 Nice grounds at St Vincent's and some good views from Ian Charles. Need to try to maintain community and views especially for sensitive areas.
Form & materials 1.7 Externally the 2 sites feel good, but are confusing inside. All confusing to new users.
Staff & patient environment 1.2
Urban & social integration 3.0
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13 LONG LIST OF OPTIONS Initially four half-day workshops were held one each in June, August, September and December 2013. All four events were attended by members of the Development Group and included a wide range of representatives including service users, elected members, community council members, Friends of St Vincent’s and Ian Charles hospitals, voluntary sector, practice managers, GPs, other clinicians and NHS Highland staff.
13.1 Long list of options During the second (August 2013) and third (September 2013) workshop a long list of options was identified. Participants went through an established process to consider advantages and disadvantages. These were compared with the way services were currently organized. Using the Options Framework approach, the workshop group undertook the following actions:
• Each of the long listed options was subjected to a Strengths Weaknesses Opportunities
and Threats (SWOT) analysis. On the basis of the outcomes from the SWOT analysis the following was undertaken:
The options within the first category of choice (scope) were assessed in terms of
how well each option met the evaluation criteria (investment objectives and CSFs) and whether each option was ‘out’, ‘in’ or a ‘maybe’; in other words, whether it should be discounted immediately or carried forward, either as the preferred choice in the category or a possibility for further consideration.
The options for the delivery of the preferred choice (scope) in relation to the next category of choice (service solution) were considered and again, options were identified either as the preferred choice or as carried forward or discounted.
The process was repeated for all other five categories of choice. The preferred way forward based on the appraisal of the main options (long list) for the successful delivery of the project is, in practice, only a ‘direction of travel’ for the delivery of the project. It should not be confused with the clearly defined preferred option for the project which will emerge from the detailed economic appraisal carried out at the Outline Business Case stage. Adopting the Options Framework approach led to the construction of a reference project from the preferred choice in each category i.e. an amalgamation of the preferred choice for the scope, service solution, service delivery, implementation and funding. It should be noted that the reference project is essentially the preferred way forward given that it is predicated upon the best assessment at this stage of the available options in each category of choice. A link to the full report is provided here.
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14 PREFERRED WAY FORWARD AND SHORT LISTED OPTIONS A shortlist of three options was drawn up and appraised in terms of: •Non-Financial Benefits •Cost (capital, revenue and Net Present Costs over 60 years) A copy of the full report is available on the website. Option 1 – Do minimum
Option 2 - Community hospital and resource centre in one town (‘hub’) and scaled-down services in the other (‘spoke’), based on existing hospital sites
Option 3 - Community hospital and resource centre in a central location (Aviemore) OPTION APPRAISAL Option 1 – Do minimum
Everything would stay the same but with some investment to address health and safety requirements around the hospitals
Main Disadvantages Main Advantages
• Missed opportunities to improve care-at-home and safety issues
• It is what people know and like
• Buildings will never be fit for modern services, even with investment
• Keeps services in existing hospital locations
• Not sustainable - may result in major loss of services in the longer term
• Easy to implement
This option scored 250 points. The low score reflects that this option would not address current or future requirements. It would not improve access to medical cover during out of hours, allow investment in care-at-home, support integration or modernise the buildings. Option 2 - Community hospital and resource centre in one town (‘hub’) and scaled-down services in the other (‘spoke’), based on existing hospital sites
Hub In either Grantown-on-Spey or Kingussie there would be a new facility which would provide in-patient beds, outpatient services, A&E, 24/7 nursing cover with a limited x-ray service. It would be very similar to the existing hospital services provided from Ian Charles with the main change being all the in-patient beds provided in one purpose-built facility. Spoke Limited out-patient clinics and base for some community nurses and social care staff.
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Other Continue to integrate services with some investment into care-at-home, service, community services and co-location of some staff. Main Disadvantages Main Advantages
• Resources still split across three main sites
• All in-patients beds on one site allowing better use of staff and other resources
• Does not address service issues such as out-of-hours medical and nursing cover, limited access to x-ray
• Improves quality of accommodation of in-patient and out-patient
• Won’t be sustainable in the future - may result in major loss of services in the longer term
• Familiar - keeps some services in existing locations
Option 2 scored 463 points. This was seen as an improvement on current services but the low score reflects that this is not a good option. Having all the in-patient beds being located on one site would bring some benefits but overall it would not improve access. It would still mean money being heavily invested in buildings rather than in community services or care-at-home service. It does not tackle any of the staffing issues associated with out-of-hours or access to x-ray. Option 3 - Community hospital and resource centre hub in a central location (Aviemore) A new community hospital and resource centre in Aviemore with good access to public transport and the A9. This purpose-built facility would allow services to be fully integrated. The centre would provide the full range of community hospital services, including in-patient beds, out-of-hours, accident and emergency, outpatient clinics. The local health centre, day care centre and NHS staff based in Aviemore would all move into the new building and Ambulance station would be relocated to the Hub. The two existing NHS Highland care homes in the area, Grant House in Grantown-on-Spey and Wade Centre in Kingussie, would remain in existing locations but with opportunities to expand some of their services. The dental unit would also stay in Grantown-on-Spey. The proposal, if implemented, would mean closing inpatient beds at Ian Charles Hospital in Grantown-on-Spey and St Vincent’s Hospital in Kingussie; re-locating the Aviemore Health Centre and Glen Day Centre, Aviemore as part of the new facility. It is important to highlight that around 90% of local NHS services that people use are through their GP Practice, dentist or pharmacist. Changes to these services are not being proposed, apart from the proposed re-location of the Aviemore Health centre as mentioned above. We may also need to consider relocation of Grantown Health Centre and Ian Charles Dental Clinic within the town.
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Other Development of care-at-home service, extended community care and community beds in care homes would all come as part of wider redesign to improve all services. Once these services were in place Ian Charles and St Vincent’s hospitals would close.
Main Disadvantages Main Advantages • Strong attachment to existing hospital
buildings
• Improves quality of many services and overall much safer, more effective and efficient
• Culture change for communities and staff to get used to
• Addresses service issues allowing better out-of-hours medical and nursing cover, access to x-ray plus investment in care-at-home and the community
• Change of location of hospital for some staff and communities
• Integrated service designed to meet the current and future needs of the population
Summary This option scored an extremely high 913. It would allow a fully integrated service to be set-up which would make better use of the resources to meet the needs of the local population.
Options appraisal of short-list and weighted criteria The non-financial benefits scores above were determined at a fifth workshop held in January 2014, also facilitated by Roger Tanner an independent expert. This was a well attended event with around 30 people. It included members of the Development Group and the majority of people who had taken part in the first four workshops. The purpose of the event was to evaluate the short list of options in terms of the benefits (non-financial) that each option would deliver, any associated risks and costs. This was achieved by: • reviewing the description of the short list options • assessing each option against key criteria agreed (as described in section 3.2 above) • scoring the options using a well established process
The group agreed the weighting for each of the criteria (i.e. relative importance), and then scored the options against the criteria.
Summary of scoring of options appraisal (scored out of 1000)
Option Description Score Rank
1 Do minimum 250 3
2 Community resource centre and hospital hub and spoke 463 2
3 Community resource centre and hospital hub in central location (Aviemore)
913 1
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Although participants at the workshop expressed their appreciation of local hospital services and staff it was clear that when all the challenges were set out the current arrangements were not considered to be fit to meet future requirements with: • patients inconvenienced • services not as efficient or as safe as they could be • resources being wasted • current arrangements counting against effective team working and integration.
Moreover, splitting some services over a number of sites posed wider challenges of maintaining safe medical and nursing rotas and skills. Quite apart from the costs it is not a sustainable model for the future. It was agreed that any redesign of services would need to provide solutions to these challenges. On this basis option 3, a new Community Hospital and Resource Centre in Aviemore was confirmed as the clear preferred option to go forward for public consultation. SITE OPTIONS APPRAISAL NHS Highland was advised by the Scottish Government to identify possible sites in Aviemore to include as part of the formal public consultation. The process from identifying sites through to selection of a preferred site is described (Appendix 5). This is based on quality factors which included access and resulted in a clear preference for Site C which is located in the Technology Park in Aviemore. A technical and financial appraisal of the three top shortlisted sites has since been carried out by Hub North Scotland who provided their report in May 2015. This was a desktop exercise to assess the sites in relation to potential development costs, land purchase and the suitability of the land for construction. Site B was excluded from this assessment due to its low qualitative score. This produced a combined weighted score for both elements: Table 6: Outcome of site options appraisal
This showed a preference for Site E, Pony Field, although the scores are very close between this and the public preferred site C, Technology Centre. It is proposed to undertake further investigations and analysis of both sites in order to determine which is most suitable. This
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was endorsed by the project development group on 12 May 2015. Cost is likely to be a significant driver in defining which of these sites is ultimately selected.
14.1 OUTLINE COMMERCIAL CASE Alongside the options appraisal exercise NHS Highland also carried out a high level financial appraisal. Both capital and revenue financing routes were considered. This resulted in a clear preference to deliver the project via a HubCo revenue solution. Hubco can deliver projects through one of the following options: • Design and Build contract under a capital cost option. • Design, Build, Finance and Maintain under a revenue cost option (land retained). • Lease Plus model for a revenue cost option under which the land is owned by Hubco. Without prejudice to commitment to any funding route, submission of a “Qualifying Projects Proforma” allows Hub North Scotland to plan resources and support participants during the pre-New Project Request stage to shape the project so that it can hit the ground running. This also allows the Territory Programme Director the opportunity to assess whether the project complies with the original OJEU notice. The Badenoch and Strathspey project has been confirmed as a pipeline project under this scheme.
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14.2 OUTLINE FINANCIAL CASE
The Initial Agreement is an early stage in the overall development of a business case for the project therefore, in accordance with SCIM guidance, these costs are indicative at this stage. 14.2.1 Capital costs Indicative capital costs for each of the shortlisted options are provided. These are estimates based on average prices for buildings similar to those in this project and are the costs shared as part of the options appraisal and public consultation:
Shortlisted Options Indicative capital costs
(£m)
Assumptions
Option 1 – Do Minimum. (primarily backlog maintenance costs)
£5.1m
Capital costs at both existing hospital sites to bring buildings up to minimum standards.
Option 2 – Community resource centre and hospital hub and spoke. (hub in one town, spoke in the other town)
£9.0m
Capital costs at both existing hospital sites. One hospital would be upgraded as a ‘spoke’ and the other would be redeveloped as a ‘hub’.
Option 3 – Community resource centre and hospital hub in central location (Aviemore) (hub in central location (Aviemore) with enhanced community services, co-location and transport)
£12m - £15m
Capital costs for a new build in a central location and closure of two existing hospitals as well as some other buildings. A range of capital costs are provided as further work at OBC stage will be required to identify cost of land, equipment and potential works required at the existing health centres sites. These health centre works may be required to accommodate services that will remain in existing communities and technical separation of the health centre and dental clinic from the hospital at Grantown.
Other assumptions The following general assumptions also apply to these indicative costs:
• 2nd quarter 2014 cost basis, excludes future cost inflation • An allowance of optimism bias has been included in accordance with SCIM • VAT is included at 20%
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14.2.2 Annual Revenue Costs Revenue costs are estimates which are generally based on existing budgets as at quarter 2 2014 and a broad assessment of unitary charge costs based on 10% of capital cost:
Annual revenue expenditure £’000 Revenue description Option 1
Do minimum Option 2 Hub and spoke
Option 3 – Community resource centre and hub
Direct Care Costs 2,545 1,500 1,220 Hotel Services Costs 382 382 163 Asset Related Costs 217 510 242 Community Infrastructure 400 Unitary Charge (Hubco) 900 1200 Total 3,144 3,292 3,225 14.2.3 Unitary charge If, as is expected, the preferred way forward is procured through a revenue solution by way of HubCo then a unitary charge will be payable. The unitary charge is the amount of money paid by the public sector procuring body to HubCo over the duration of the contract. Unitary charge payments begin once the project is fully operational or individual phases have been completed. The total unitary charge payment will comprise some or all of the following components:
• Construction costs (including VAT where applicable) • Private sector development costs (including staffing, advisory and lender’s advisory
fees) • Financing interest (which is necessary to fund the project through construction) • Financing fees • Running costs for the project’s Special Purpose Vehicle (SPV) during construction
including insurance costs and management fees. • SPV running costs during operations, including insurance costs and management
fees • Lifecycle maintenance costs • Hard facilities maintenance costs
At this early stage in the project it is difficult to accurately calculate the cost of the unitary charge. The final cost will be defined by the components shown above that will be developed as the project progresses. In order to illustrate a broad cost within the financial model, an estimated unitary charge value of 10% of capital costs has been calculated. It has been broadly assumed at this stage that the unitary charge will be included at full cost within the project. Revenue support from Scottish Government resulting from inclusion as a pipeline project has not yet been confirmed but will be developed in further detail in the Outline Business Case.
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14.2.4 Staffing and asset related costs
Shortlisted Options Assumptions
Option 1 – Do Minimum. (primarily backlog maintenance costs)
Existing services to remain on existing sites therefore the revenue costs associated with this option will remain broadly the same as existing costs. There will be a small increase in capital charges associated with the cost of capital to bring the buildings up to minimum standards.
Option 2 – Community resource centre and hospital hub and spoke. (hub in one town, spoke in the other town)
Inpatient facilities located at ‘hub’ with other site forming a ‘spoke’. Revenue costs will reduce mainly as a result of staffing reductions. Development of the ‘hub’ will be undertaken by HubCo and will be subject to a revenue unitary charge estimated at 10% of capital cost
Option 3 – Community resource centre and hospital hub in central location (Aviemore) (with enhanced community services, co-location and transport)
Both existing community hospitals will close and a new ‘hub’ will be built in a central location. Pay costs will reduce through rationalisation of 24/7 wards allowing new investment in community infrastructure such as care-at-home, Older Adult Mental Health services and Community Transport. Development of the ‘hub’ will be undertaken by HubCo and will be subject to a revenue unitary charge estimated at 10% of capital cost.
14.2.5 Backlog maintenance Investment in this project will have an impact on reducing the backlog maintenance in the existing estate by approximately £5.1m (current). Maintenance costs will also need to be built in for new facilities over their lifetime.
14.3 OUTLINE PROJECT MANAGEMENT CASE 14.3.1 Introduction The project described in this Initial Agreement is an integral part of implementing NHS Highland’s 2020 vision for the health service in Highland taking account of the direction set out in our ten year operational plan. A strong project team is in place with significant experience and understanding of both the strategic and operational overview. In addition the team are skilled in change management, service improvement methodology, integrated care and delivering capital projects. The local context, politics and relationship between communities has also been explored during the engagement process and there are solid working relationships in place. The redesign work is a priority for project members, and as a team they have the appropriate skills, experience and capacity and work constructively together.
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This section outlines the project management arrangements leading up to Contract Close and moving through design and build into the operation of the completed facility. 14.3.2 Project governance Robust project management plans will be developed to undertake the New Project Request, the production of the Outline Business Case for approval of the preferred option, Contract Close and thereafter to supervise construction and prepare for commissioning and occupation of the building. Project roles have been identified and appropriately experienced personnel have been identified. The NHS Highland Project Team will be supported by an experienced team of technical, legal and financial advisors along with colleagues from the Scottish Futures Trust as appropriate. In compliance with the Scottish Capital Investment Manual, this project will deploy a Programme & Project Management Approach (PPM) with a structure as shown in figure 7 below.
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NHSH Board
Investment decision maker
NHSH Asset Management Group
Project Board Senior Responsible Owner
Deborah Jones (Chief Operating Officer)
Project Team Project Director
Nigel Small (Director of Operations)
Highland Health and Social Care
Committee
Figure 7 Project management and reporting structure
Each group will have a chair, specified membership, clear remit with frequency of meetings specified (below). Actions agreed at the various meetings will be specified setting out owners and time-scales.
Development Group
Stakeholder forums & user groups
Design & Build Heather Cameron
(Senior Project Manager)
Clinical & Social Care
Dr Boyd Peters (Clinical Lead)
Doreen Bell (Health Care Advisor)
Transport & Access
Nigel Small (Director of Operations)
Task & Finish i) Initial Agreement
Name (Programme
Manager)
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14.3.3 External advisers
The Project Team will also have access to a range of advisors from within NHS Highland including Service Planning, Public Health, Infection Control, as well as others such as Scottish Health Council. In terms of planning there will be considerations due to the development taking place in the Cairngorms National Park and we will work closely with the Park Authority. Given the strong ties with both hospitals links have been established with researchers ‘History of Highland Hospitals’, Highlife Highland Archive Department and others such as Friends of Ian Charles and St Vincent’s. Other key organisations in relation to accessibility include Sight Action, Local Access Panel and Alzheimer Scotland. As transport links are crucial to the successful delivery of the services redesign we will be working closely with Transport Consultants. The development of this project has been supported to date by Professor Roger Tanner who has led the process of identifying, scoring and short listing the long list of options. Other work has also been supported by Hub North Scotland (site appraisal) and Aileen Walker Independent Health Care Planner. Other advisers, expertise or capacity will be commissioned as required.
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Summary of remit for various groups/committees Groups Remit NHS Highland Board
• To make final decision on business case process • Meets bi-monthly
Asset Management Group (AMG)
• To ensure board-wide co-ordination and decision making of proposed asset investment / disinvestment ensuring consistency with policy and the strategy
• Meets monthly Project Board • Supervise the specification and procurement of the
project • Make decisions on the project, manages risks and
allocates actions as required • Ensures the project is delivered on time and budget • Meets quarterly / more frequently as required
Development Group • To represent stakeholders across all elements of the re-design and business case process
• To comment on and influence proposals • To advise on communications and engagement with
stakeholders • Meets quarterly
Project Team • To oversee the successful delivery of the business case process
• To co-ordinate and deliver on all the actions required to meet the specification and delivery of the project
• To supervise the working groups, manage risks and escalate as required
• To oversee ongoing communications and engagement with stakeholders
• Meets monthly Highland Health and Social Care Committee
• To ensure board-wide co-ordination of implementation of ten year strategy and operational plan; and to internally assure major service change process
• Meets bi-monthly Working groups • Task & Finish Group
(i) Initial Agreement • Other groups to be
commissioned as required
• To oversee the preparation of the Initial Agreement document including discussions with relevant departments and stakeholders
• Clinical & social care • To co-ordinate and deliver on all the actions required to agree the detailed specification to support the strategic model of service
• To oversee ongoing communications and engagement with all health and social care professionals
• Transport & Access • To act as a partnership forum for organisations and agencies to jointly develop options and solutions to improve and sustain Transport and Access as part of the Business Case process.
• Design & Build • To co-ordinate and deliver on all the actions required to meet the specification and delivery of the building project
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Membership of Project Board Name Role Representing Deborah Jones Chair NHS Highland Eric Green Technical Lead NHS Highland Joanna MacDonald Adult Social Care Advisor NHS Highland Nigel Small Project Director Operational Unit Dr Stewart MacPherson Clinical Advisor Operational Unit Kenny Rodgers Finance Lead NHS Highland To be confirmed SFT Advisor Scottish Futures Trust Name 1 – to be confirmed Locality representative B&S Development Group Name 2 – to be confirmed Locality representative B&S Development Group Name 3 – to be confirmed Locality representative B&S Development Group At their meeting on 12 May 2015 the Badenoch & Strathspey Development Group were supportive of continuing to actively engage in the project and to provide representation on the Project Board. It is anticipated that this will include each of the three main localities (Grantown-on-Spey, Aviemore and Kingussie/Newtonmore) but cover a cross-section of stakeholder groups. Remit Project Board
The board will supervise the specification and procurement of the project, including:
• To agree the scope of the project and supervise development and delivery of the service
model consistent with NHSH strategy • To assure the project remains within the framework of the overall strategy, scope and
budget • In partnership with all stakeholders to successfully conclude Contract Close. • To review the Risk Management Plan, ensuring all risks are identified; that appropriate
mitigation strategies are actively applied and managed, and escalated as necessary, providing assurance to the NHS Board that all risks are being effectively managed.
• To supervise the functional commissioning and bring the facilities into operation in respect of the elements for which the NHS is responsible.
• To assure appropriate engagement and communications with stakeholders
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Membership of Project Team
Name (*) Role Designation Nigel Small Project Director Director of Operations
(South & Mid) To be confirmed Project Manager
(South & Mid)
Jean Pierre Sieczkarek Operational Management Area Manager (South & Mid)
Margaret MacRae Staff-side representative Staff-side Representative (South & Mid)
Kenny Rodgers Finance Lead; financial planning, business case advice and support
Finance Manager (South & Mid)
Heather Cameron Oversee and direct project management of design and build
Senior Project Manager (Estates)
Diane Forsyth Day-to-day project management of design and build
Project Manager (Estates)
Dr Boyd Peters Clinical leadership GP / Clinical Lead (Badenoch & Strathspey)
To be confirmed Clinical challenge To be confirmed (NHS Highland)
Maimie Thompson Oversee and direct communications and engagement
Head of PR and Engagement (NHS Highland)
Sue Blackhurst Administrative support to Project Administrator (South & Mid)
(*) –Individual’s, role, remit and suitability is summarised in Table 7. Remit Project Team • To coordinate the production of all Authority’s Requirement documents for the project. • To coordinate the production of all technical and financial schedules from an NHS
perspective. • To participate with the Scottish Futures Trust in Key Stage Reviews • To coordinate the production of the Initial Agreement, the OBC and the FBC. • To supervise the development of the Occupation Agreement, as appropriate, with
building users e.g. General Practice. • To ensure the development of all appropriate policies and procedures (clinical and FM)
to ensure the smooth operation of the building once operational. • To commission specific redesign work associated with the redesign of services
relocating to the new facilities. • To order and commission all group 2, 3 and 4 equipment. • To supervise the specification of all group 1equipment consistent with the Project
Agreement. • To supervise the development and implementation of functional commissioning plans
including service relocation and decommissioning, staff orientation and training etc. • To ensure appropriate stakeholder involvement including:
o To ensure that staff, partners and service end users are fully engaged in designing operating policies that inform the detailed design and overall procedures that will apply which in turn will inform the Project Agreement i.e. ensuring that the facilities are service-led rather than building-led.
o To develop, manage and review a Communication and engagement Plan ensuring appropriate involvement of, and communication with, all stakeholders, internal and external, throughout the project from conception until new arrangements are in place and any decommissioning effectively concluded.
• To plan for the post-project evaluation and ensure appropriate input from stakeholders.
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Table 7 Role, remit and suitability of key individuals involved in the project Role Remit Suitability for role Project Sponsor Elaine Mead (Chief Executive)
• To support Senior Responsible Officer, Project Director and Head of PR and Engagement
• To provide executive leadership at Board and within Scottish Government
• Strategic lead on developing lead agency model for integration
• Strategic lead on developing Highland Quality Approach
• Strategic lead for delivery of communications and engagement
• Strategic lead for linking in with SG level planning and performance
• Certified LEAN Leader Senior Responsible Officer Deborah Jones (Chief Operating Office)
• To provide corporate leadership and advice throughout the business case process including at board and SGHD
• To chair the project board
• Chief Operating Officer • Executive lead for
commissioning, greater Inverness Master Plan and Unscheduled Care
• Certified LEAN Leader Project Director Nigel Small (Director of Operations)
• To lead and co-ordinate all stages of the project in collaboration with the project team, service management team, Executive Boards and Scottish Futures Trust
• To lead on the production and approval of the SCIM compliant IA, OBC and FBC
• To keep the Project Sponsor and Senior Responsible Officer fully briefed with formal and informal updates
• To chair the project team and development group
• Oversees the budget for all health and social care resources in the locality
• Strategic and operational lead taking forward the redesign process
• Solid track record of delivering redesign (including new builds) on time and budget
• Developed constructive relationships with Scottish Government performance team and Scottish Health Council regarding major service change
• Certified LEAN Leader Technical Lead Eric Green (Head of Estates)
• To direct and oversee the co-ordination and delivery of the capital and technical elements of the project
• To direct and supervise the Senior Project Manager
• Strategic Estates lead taking forward the redesign process
• Solid track record of delivering redesign (including new builds) on time and budget
Clinical Advisor Dr Stewart MacPherson (Clinical Director)
• To provide objectivity in supporting the clinical re-design
• To oversee the leadership of clinical elements of the project including helping to resolve any clinical challenges
• Experienced clinical leader but not immersed in the specific detail for the project
Adult Social Care Advisor
• To provide objectivity in supporting the whole system
• Background in social work, previous District Manager and
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redesign • To oversee the leadership of
adult social care elements of the project ensuring fully integrated approach is taken including with 3rd and independent sector
the first Director of Adult Social Care employed by a health board
Finance Lead Kenny Rodgers (Head of Finance)
• To oversee the delivery of the financial elements of the business case process
• Solid-track record of leading the delivery of financial capital projects in the unit
• Project Manager for Nairn Hospital new build
Clinical Lead Dr Boyd Peters (GP, Grantown-on-Spey, Locality lead)
• To provide ongoing leadership to design and deliver the service change
• To inform clinical elements of communications and engagement with stakeholders
• Actively involved in the process to date
• Solid-track record as a clinical leader
• Detailed understanding
Health Care Advisor Doreen Bell (Associate Clinical Director)
• To provide clinical challenge on the specification of the new facility to support the service model
• Significant experience of working with clinicians to arrive at clinical and cost-effective solutions.
Communications & Engagement Maimie Thompson (Head of Public Relations and Engagement
• To provide advice and support to the project team to oversee the ongoing communications and engagement with stakeholders
• Actively involved in the process to date and solid track record of developing and delivering on communication and engagements plans
• Developed constructive relationships with Scottish Government’s Performance team and Scottish Health Council regarding major service change process
• Supporting a number of major service changes in Highland
Senior Project Manager Heather Cameron
• To support the Project Director in the co-ordination and production of the IA, OBC and FBC
• Day-to-day co-ordination and delivery of the capital elements of the project
• To direct and supervise the Estates project team
• Solid-track record of delivering day-to-day co-ordination and delivery of capital projects including with the operational unit
Service Lead Jean Pierre Sieczkarek (Area Manager)
• To ensure that the strategic objectives and service / clinical brief is clear and delivered by the project.
• To lead on all service re-design required to ensure that the new facility delivers the desired service benefits.
• Area Manager for Badenoch and Strathspey
• Solid track record of leading the delivery of redesign projects for the operational unit including new build projects
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Key stakeholders NHS Highland has identified key stakeholders and customers for the re-design of services across Badenoch and Strathspey including current service users, members of the public, local elected representatives (Community Councils, Councilors, MSPs, MP), local groups, local staff, GPs, senior managers and clinicians in Raigmore Hospital. In terms of partner agencies close collaboration is ongoing with Scottish Ambulance Service, The Highland Council, Fire and Rescue Service, Police Scotland, Highlands and Islands Enterprise, Cairngorms National Park Authority as well as with the third and independent sector. The proposal includes building a new hospital/GP Practice/ Resource centre in Aviemore which will require land to be purchased and so local landowners and the Cairngorm National Park planning authority are additional key stakeholders. There is significant public attachment to the existing hospital buildings (Ian Charles in Grantown-on-Spey and St Vincent’s in Kingussie) and there has been particular focused work with these communities including relevant Groups. Having strong clinical leadership and support from clinical teams and in particular GPs was considered to be very important and they were identified as key stakeholders. Similarly it was also felt that having local political support and good media relations was essential. Throughout the process there has been a significant amount of stakeholder engagement as part of the options development, appraisal and public consultation (section six and here). A summary of stakeholders affected by the proposal and details of engagement which have taken place is provided (Appendix 1). The full report on the consultation was presented to the board on 7th October 2014 and is available on this link. Engagement will continue through all phases of the development until completion. A stakeholder communication and engagement plan has been prepared for the next phase and is available on the website. High level project plan Indicative timescales for the development are as follows. A more detailed project programme is included in Appendix 12.
Appoint HubCo Oct 2015
Outline Business Case (CIG Committee) May 2016
Full Business Case May 2017
Site Commencement Jul 2017
Service commencement Jan 2019
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15 APPENDICES
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Appendix 1 Summary of stakeholder engagement and analysis
Stakeholder group
Engagement Analysis
NHS Highland Nigel Small director of operations took the lead role in developing the proposal and overseeing the consultation. Chief executive Elaine Mead is the executive sponsor and attended consultation events. The proposals are incorporated in the Boards ten year operational plan approved on date).
Board is fully supportive of the proposal and approved the preferred option and preferred location This initial Agreement was approved by the board on 2nd June 2015
Asset Management Group
The proposal has been considered by the Group at each of the key stages. The proposals are incorporated in the capital plan and Asset Management Strategy
This initial Agreement was approved by the Group on 26th May 2015
Highland Health & Social Care Committee
The Committee provided internal assurance of the consultation process.
The proposal has been considered by the committee at each of the key stages
South & Mid Operational Unit
The management team of the operational unit has been actively involved in all elements of the redesign proposals.
The Project Team includes representatives of the Unit.
Scottish Health Council (SHC)
SHC have been fully involved at all stages in the proposal. This has included the options appraisal and supporting the communications and engagement proposals to support the public consultation.
The SHC formally endorsed the consultation process. The report is available on their website
Stakeholder Development Group
A group made of a wide range of stakeholders have overseen the process to date, including developing the case for change, options appraisal and consultation materials and events. A general view was expressed about Transport and Access issues) and in response to this a local group has been established
This Initial Agreement was discussed with the Development Group at a meeting held on 12th May 2015 Members of the group have been invited to sit on the Project Board and expressions of interest have been sought
Staff – General (Badenoch & Strathspey)
Staff affected by the proposal (Note 1) and resources affected (Note 2) are listed. Staff had the opportunity to be involved in the options appraisal, public consultation, preparation of this Initial Agreement,
Staff and staff representatives are part of the Development Group and other key groups who have approved the IA.
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including clinical brief and design statement brief.
The locality staff confirmed support in a letter to Nigel Small Director of Operations
GP Practices There are three GP Practices in the area (Grantown-on-Spey, Aviemore and Kingussie). The proposal has impact on all of the practices: currently there is GO input to existing community hospitals and the location of providing that care will change in the new arrangements. The location of the Aviemore Practice will also move/ All GP Practices have been active participants of development group and clinical brief.
All three Practices confirmed support in a letter to Nigel Small Director of Operations
Patient / service users
Patients and Service users are part of the development group. Consultation materials were sent to every household in the area. Over 50 public events were held including in all the main communities
Patients and Service users are part of the development group. 79% of people who took part in the consultation supported the preferred option
Local Groups Other key local groups including Friends of St Vincent’s, Friends of Ian Charles, St Vincent’s Therapy Garden, Badenoch & Transport Co, Access Panel, Others
Patients and Service users are part of the development group
General Public Consultation materials were sent to every household in the area. Over 50 public events were held. Around 500 people took participated in the consultation.
79% of people who took part in the consultation supported the preferred option
Community Councils
There are eight community councils in the area. All are represented in the Development Group. Presentations were made with all community councils and there been ongoing dialogue (1:1, emails, phone)
Community councils are supportive of the preferred option. During the consultation four submitted responses stating their preference for the preferred option
Councillors There are four elected members who are active members of the development groups
Elective members are supportive of the proposals and have been happy to be quoted in media releases about the proposals
MSPs MSPs have been actively engaged in the process and have received regular updates
MSPs have been generally very supportive but some concerns were raised about transport issues
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Other key stake holders (Highland Council, Scottish Ambulance Service, Cairngorms National Park Authority)
Our partners are represented on the development group and have participated in the design statement and clinical brief. As the proposal is in a National Park area close working has been established.
All formally responded to the public consultation and are supportive. All sit on the Development Group and as appropriate 1:1 meetings are arranged
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Appendix 2 Organisational structure
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Appendix 3 Summary of high level milestone and time-line
Time-line High level milestones and dates of board meetings Jun 15 IA considered by Capital Investment Group, 30th June Jun 15 IA considered by NHS Highland board meeting, 2nd June May 15 IA considered by Asset Management Group, 26th May May 15 IA discussed with development group, 12th May Mar 15 Design workshops Feb 15 Cabinet Secretary approval Dec 14 Update to NHS Highland Board Nov 14 Letter and supporting reports to Cabinet Secretary Oct 14 NHS Highland Board approval Jul-Sep 14 Review responses, other information and write report for board consideration Jul 14 Final workshop to complete site options appraisal (date tbc) Jul 14 Consultation closes (21st July) Jun 14 Consultation events, meetings etc Jun 14 Mid-way review by Steering Group (5th June 2014) May 14 Mail drop of consultation summary document – w/b 9th May May 14 Consultation events, meetings etc Apr 14 Launch public consultation (21st April to 21st July) Apr 13 Confirm consultation time-table and finalise documents Mar 14 Announce move to formal public consultation for Badenoch and Strathspey Mar 14 Options appraisal workshop on sites Mar 14 Special board meeting to approve public consultation materials Feb 14 Preparation of draft consultation materials Feb 14 Discuss with SGHD sponsor to confirm major service change and next steps Jan 14 Scottish Health Council endorsement of process to date Jan 14 Preparation of consultation documents and communication and engagement materials Jan 14 Update Report to Highland Health and Social Care Committee (9th Jan) Jan 14 Hold further workshop Dec 13 Hold further workshops to carry out options appraisal to develop preferred option(s) Dec 13 Update NHS Highland Board on process, progress and next steps Dec 13 Prepare draft forward communication and engagement action plan Nov 13 Further work to develop and describe in more detail the short list of options Nov 13 Update local communities on process and likely next steps
Nov 13 Update Highland Health and Social Care Committee Nov 13 Agree plan for evaluation of initial engagement activities Oct 13 Communicate feed-back from Workshop to: i) Scottish Government, ii) Scottish Health
Council, iii) Steering Groups Oct 13 Update Asset Management Strategy to Board Oct 13 NHS Highland News distributed to all homes Jun - Jan Hold Workshops to identify long and short list of options and make recommendation on
preferred option May 13 Include redesign as part of Local Delivery Plan and Publish on Web Apr 13 Appoint Project Staff to support Operational Unit with the options appraisal process and
building the strategic case for change Sep 12 Set-up Badenoch and Strathspey Steering Group Jun 12 Board approval Property and Assessment Strategy (2012 -2017) Jan 12 Informal engagement underway about the case for change Aug 11 Different ways of providing services highlighted in NHS Highland News
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Appendix 4 Overview of the NHS service change process in Scotland
Approve formal consultation and materials
Ministerial Approval
Commence Business Case process (SCIM) if infrastructure investment case
Initial discussion with SGHD sponsor in cases of potential major change
Identify strategic options and need for service change
Proposed change considered major? Confirm with SGHD sponsor
No Yes
Proceed with proportionate public engagement as agreed
with SHC
NHS Board Decision on Service Change
NHS Highland board to consider proposal and consultation materials
Undertake formal public Consultation
No Yes
Non-Major
Major
Develop initial comms/stakeholder involvement plans in liaison with SHC
Options Appraisal in line with Green Book, SCIM and SHC guidance
SHC assurance report to NHS Board
Yes No Revisit proposals
Undertake pre-engagement activity with key stakeholders
Revisit proposals
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Appendix 5 Option appraisal process to support site selection (Qualitative) The preferred service model option included building a new community hospital in a central location (Aviemore). As part of the overall process NHS Highland was advised to identify possible sites in Aviemore to include as part of the consultation materials. The process from identifying sites through to selection of a preferred site is described. This is based on quality factors which included access. It was explained that further work would still be required to consider any technical consideration should the decision be taken to progress with the preferred option. Method The Options Appraisal work followed a well established process recommended by Scottish Government in the Scottish Capital Investment Manual – Business Case Guide. Through this process four short-listed sites (see map) were assessed against a number of quality criteria. These had been agreed by the group in advance of the consultation, and without prior knowledge of the potential sites. The five quality criteria which were selected by the steering group were:
• Access/transport • Public preference • Environmental considerations • Proximity to other services and potential for expansion • Planning acceptability •
The group also agreed that the final decision should weight the quality/cost factors as 60:40. Phase I – Identification of potential sites This involved undertaking a search of possible sites within or close to the Aviemore settlement boundary (as per Cairngorm National Park Authority plan). Sites were suggested by members of the project group, visits around Aviemore by NHS Highland staff, contact with architects and liaison with partner agencies. From this process seven sites were identified. An advertisement was also placed in the Strathspey and Badenoch Herald which produced a further three sites. This meant there were 10 sites identified for initial consideration. Phase II – Factors for assessing long list to produce shortlist A workshop with steering group members and others was held in Aviemore on 3rd April 2014. This involved 29 people, half of whom were community members and service users. The majority had participated in the earlier option appraisal events.
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The purpose of this specific event was to agree high-level factors to allow a shortlist of sites to be agreed, and then to agree criteria and weighting (relative importance of each criterion) which would be applied to the shortlist of sites to allow NHS Highland to identify a preferred site(s). This was the same methodology used for previous option appraisal and so participants were familiar with the approach.
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Process for agreeing criteria and weighting to be applied to the shortlist The discussion to consider and agree criteria and weighting took place before any of the site locations were shared. This was to avoid any bias. Participants at the workshop were asked to consider important factors for service users accessing the services. These were criteria that service users and public could reasonably have a view on and therefore could reasonably influence. After considerable discussion the following factors were agreed:
• Access / transport (such as proximity to A9, public transport, disabled access, traffic flow)
• Public preference on the shortlist of sites (to be identified as part of the consultation) • Environmental considerations (outlook, location, green space, impact of
development) • Proximity to other services/potential for expansion (current and future) • Planning acceptability (some sites will be more acceptable than others and more
easily fit or be adapted to fit with the Park Plan) Weighting Although all these criteria were important, it was also agreed that they were not all of equal importance i.e. some were more important than others and therefore the criteria were weighted to reflect this. The process to do this was to first agree the most important criterion. The group decided that this was Access and it was ranked as 100. The group then agreed that the second most important criterion - Public Preference and gave it a ranking of 85 and so on. These rankings were then converted to percentages (Table below) Assessment Criteria Ranking Weighting (%) Access 100 27.03 Public preference 85 22.97 Environmental factors 75 20.27 Proximity to other services/ Potential for expansion 65 17.57 Planning acceptability 45 12.16 The weightings would be applied later to the scores for each site. Process to determine short list Participants first agreed on two high-level exclusion factors: (i) sites have to be a minimum of three acres in size or the potential to be, and (ii) within or immediately adjacent to Aviemore settlement boundary. These were considered to be yes/no criteria and a no answer to either would exclude the site from further consideration.
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Application of process to identify shortlist From the 10 sites initially identified, six were excluded on the basis of not being big enough or were out with the Aviemore settlement boundary. The remaining four sites went forward as part of the public consultation to seek the views of the public (Box) Summary description of shortlisted sites Site A Grainish Farm On the eastern side of the B9152 travelling north leaving the village. Site B Milton Beside the A9 underpass (north side) leading to Upper Burnside. Site C Technology Park Land between the 2 rail lines beyond the closed call centre. Site D Pony Field This is beside the Macdonald Aviemore Resort and lies between the A9 and new housing to the north of the Scandinavian Village Please note A to D does NOT represent a ranking of the sites. The following additional information on the sites together with a map was made available in the public consultation document. Site Estimates of population within a 15 minute walk of each site
A 1,800 B 1,820 C 2,340 D 1,180 Phase III – Assessment of sites based on qualitative factors As public preference was one of the criteria to assess the sites this work could only be completed after the consultation had closed. The steering group held a further meeting on 27th August 2014 to complete the options qualitative appraisal process on potential sites. 29 attended the meeting and included local service users, councillors, community councillors, local access panel, Cairngorms National Park Authority, Ambulance Service, Friends of Ian Charles and St Vincent’s Hospital, Aviemore GP Practice, NHS Highland staff including partnership representative.
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Quality versus Cost
It was recognised at the 3rd April meeting of the group that in addition to the qualitative criteria regarding site selection, cost would also need to be taken into account. These were described as technical or quantitative criteria and could include such things as, site purchase cost, cost of developing the site i.e. ground conditions, availability of utilities, access arrangements, etc. This quantitative assessment and scoring would require to be completed by the Board’s technical advisors. At the meeting on 27th August the group were also asked to make a determination on the balance between quality and cost. The group agreed that the final decision should weight the quality/cost factors as 60: 40 Assessment of sites against criteria Each criterion was taken in turn to look at how the group thought each site performed relative to each other. In considering the options they were asked to consider the potential advantages for people travelling to Aviemore (i.e. hospital services) and those travelling to GP Practice. This allowed each of the sites to be scored out of 10 for each of the criteria. The previously agreed weightings were then applied to these scores to arrive at a final qualitative score for each site: Public preference Results for this were determined from the feedback during the consultation process. These results did not require input from the group and were revealed at the end after the other criteria had been scored: Site Name Votes % A Grainish Farm 18 18 B Milton 1 1 C Technology Park 64 63 D Pony Field 19 19
Notes 160 expressions of preference were noted through the consultation process including 51 “no preference” There were also seven responses which suggested other unidentified sites but for the purposes of determining the scoring “no preference” and “other” were excluded.
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Results from benefit weighting scenarios Weighted benefit scores (see notes below)
Option Description Consensus Rank
A Grainish Farm 530.54 2
B Milton 340.14 4
C Technology Park 750.14 1
D Pony Field 467.97 3 Notes Scores are out of 1000 Sensitivity Analysis In order to test the robustness of the decision, sensitivity analysis was carried out. This involved removing each of the selection criteria in turn to see if one particular criterion skewed the decision. Further analysis was carried out by scoring the preferred choice – Site C Technology Park at 0 for each of the criteria in turn. The Technology Park remained the highest scoring site in each of these scenarios. Conclusions Both the public preference and the working group’s deliberations came up with the same conclusion (site C, Technology Park) as preferred site. The sensitivity analysis also showed that this was a robust choice.
This preference is based only on qualitative factors. Other important factors such as development costs, land purchase and the suitability of the land for construction also have to be considered. This work is currently being carried out by technical advisors in Hub North Scotland and their report is expected shortly.
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Appendix 6 Extract from minute of board meeting held on 7th October 2014
Proposed Redesign of Services in Badenoch and Strathspey
Report by Nigel Small, Director of Operations (South and Mid) and Maimie Thompson, Head of Public Relations and Engagement on behalf of Deborah Jones, Chief Operating Officer
The Board a Considered the detailed report on the feedback from three-month public consultation into
proposed major service change.
b Noted the feedback from the Scottish Health Council endorsing the consultation process.
c Endorsed the recommendation in support of the preferred option – to develop Community Hospital and Resource Centre in a central location (Aviemore).
d Noted the next steps and the requirement for any decision on proposed major service change to be considered by the Cabinet Secretary for Health and Wellbeing.
The paper reflected the culmination of a huge amount of work which had taken place over the past five years as part of a comprehensive engagement exercise with communities in Badenoch and Strathspey (part of South and Mid Operational Unit). In particular it highlighted the main findings from the three-month public consultation exercise. Mr Small presented the report to the Board.
It was noted that within Badenoch and Strathspey some services were not strategically located or adequately resourced making them not as effective or efficient as they need to be to meet future demands. In addition the two local community hospitals were old, not in good physical condition and not designed to meet modern standards. Work had been ongoing to look at these issues with a view to providing sustainable solutions for the future. Through an options appraisal process a local steering group agreed a shortlist of three options:
• Option 1 – Do minimum • Option 2 – Community hospital and resource centre in one town (‘hub’) and scaled-
down services in the other (‘spoke’), based on existing hospital sites • Option 3 – Community hospital and resource centre in a central location (Aviemore)
Option 3 was identified as the steering group’s preferred option. If implemented this would mean building a new community hospital and resource centre in Aviemore, as part of a wider redesign and modernisation of health and social care services. This would also include the re-location of Aviemore Health Centre, some other services located in Aviemore and the closure of both local hospitals – Ian Charles in Grantown-on-Spey and St Vincent’s in Kingussie. Any closures would be planned to take place after the new services were in place. The Board considered these proposed changes to be ‘major’ and would therefore be subject to a period of formal public consultation. The Board approved the move to formal public consultation at a special meeting held in March 2014. The formal public consultation was launched on 21 April 2014 and ran for a total of 14 weeks until 21 July 2014. NHS Highland was consulting on the range of options including option three as the preferred option. It was
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estimated that some 500 people took part during the consultation. Of those who completed NHS Highland’s consultation response survey (176) there was widespread support for the case for change with almost 80% selecting the preferred option. Positive feedback on the consultation process and the preferred option was also received from staff, a signed letter from all three local GP Practices and partner agencies including Highland Council, Scottish Ambulance Service, Scottish Fire and Rescue Service, Highlands and Islands Enterprise and the Highland Hospice. The Scottish Health Council had endorsed that the process had been in accordance with Scottish Government Guidance. This included the options appraisal process (service model and sites), public consultation materials and the public consultation communications and engagement.
Taking everything into consideration the operational unit felt they could demonstrate broad support from the wide range of stakeholders for the preferred option (option 3) which was now being formally recommended to the Board for endorsement. Members were reminded that because the preferred option represented major service change, should the Board endorse the recommendation; the next step would be for the proposals to be considered by the Cabinet Secretary for a final decision. It was also clear from some of the feedback NHS Highland received (written correspondence, personal contact with staff and at meetings) that there were some individuals but no groups who had some strong concerns about aspects of the proposed redesign (most notably but not exclusively in Grantown-on-Spey), and some topics of wider general concern (future services, transport, future use of buildings, bed requirements and care-at-home) requiring further consideration. The report, therefore also set out some of the next steps in meeting the guidance and described some of the further work that would be required should the preferred option move to implementation. There followed a detailed discussion on the report, during which a number of issues were raised, including: • Location – Ms Mead asked if selecting the preferred location was part of the options
appraisal process Mr Small confirmed that it was. The preferred option was to develop a single site in a central location and allow for co-location. The view of the various representatives on the group had been that a central location would be the most appropriate given the geography of Badenoch and Strathspey. This narrowed it down to Aviemore being the only logical option.
• Site – During the consultation a preferred site had emerged (the Technology Park in Aviemore). Mr Small reassured the Board that the development group had considered all 10 possible sites. Public preference was one of the criteria used to determine a preferred site.
• Transport – In relation to local access and transport to services, a question was raised as to whether there had been any work done on current access to services and whether a specific group to consider transport issues had been set up. Mr Small advised that a transport survey had taken place during the consultation process. It highlighted that there were currently transport deficiencies in the Badenoch and Strathspey area and that further work would need to be taken forward relating to transport options. While NHS Highland was not a transport provider the redesign would act as a catalyst for change bringing wider benefits. The group had already been set up and had the main stakeholders round the table.
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• It was noted that while approximately 80% of those consulted had been in favour of the preferred option that 20% had not. The Chair asked Board members to reflect on this and whether they were assured that all views had been fully considered.
• Ms Wedgwood reminded members of the need for NHS Highland to provide quality services which were clinically safe. The existing facilities were not fit for purpose. She commended the team for the comprehensive engagement noting that getting approval from the Scottish Health Council is not easy to achieve.
• Mr Small also reminded the Board that the current hospitals in the area were not fit for the future and had outstanding backlog maintenance.
Following discussion the Board endorsed the recommendation in support of the preferred option – to develop Community Hospital and Resource Centre in a central location (Aviemore). The Chair thanked Mr Small and Ms Thompson and the local staff involved in the work relating to the consultation process which had been a huge amount of work. He also noted the contribution of partner agencies, members of the community and individuals involved to date. NHS Highland aimed to provide the best possible clinical care and patient experience for the local community and he hoped that the preferred option would serve the community well in the future.
Minute approved at meeting held on 2nd December 2014
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Appendix 7 Letter of Ministerial Approval – 27 January 2015
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Appendix 8 –Summary description of existing arrangements and business need for each objective
Project Investment Objective No. 1 - Integrated health and social care services
Existing Arrangements Business Need
Historic arrangements restricted opportunities for an integrated and co-ordinated approach to service provision and the potential to improve service outcomes for users. This can mean that community hospital beds sometimes used as ‘safety net’ because of a lack of community services. Equally if community hospitals beds are full there are further impacts for flow of patients between Raigmore and the locality
Different parts of the health and social care provision can operate in “silos” with limited communications between them. This can result in unclear pathways for patients and service users. The existing multi-site arrangements do not easily enable and facilitate effective patient flow management with clear care pathways and can result in patients having to access services at different locations and times.
Many people find the maze of health, social care and housing services, confusing. People with more than one long term condition, often with complex needs, may be visited or contacted by a number of different people from different departments in different organisations. Health and social care professionals in one part of the system often do not have a stake in the other parts of the service. Even in a relatively small community such as Badenoch and Strathspey, there are multiple points and locations for accessing services which can be less than ideal
Fully integrated and co-location of health and social care staff and services
Development of partnerships and co-operation between service users, their carers and families to ensure a person-centred service. A clear need to enable and facilitate the continued role of the Third Sector in encouraging people to take more care and responsibility for their own and one another’s health and wellbeing. This includes encouraging lifestyle choices
A holistic, co-ordinated approach towards preventative care is needed locally with appropriate investment in community services.
To provide care and treatment by working in partnership with other organisations (LA, voluntary & independent sectors), through extended community teams, with professionals, patients, carers and communities as full partners in improving health and managing conditions. Groups of aligned clinicians to support the development and delivery of pathways and protocols providing a mechanism for communication, information sharing and feedback on referral rates, clinical practice and the deployment of resources.
Care pathways which are clear and discussed/agreed with the patients.
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Project Investment Objective No. 2 - Improve user experience Existing Arrangements Business Need
The existing community hospitals, Ian Charles (Grantown-on-Spey) and St. Vincent’s (Kingussie) are not fit for purpose, nor strategically located and not able support the expected increasing demand for services
A lack of resources and facilities limits the ability to anticipate patient needs and provide specialist planned care close to home and often results in unplanned admissions to hospital. Telehealth and telecare technologies are not established
The Third Sector is well developed but their contribution could be maximised by ensuring that they are fully integrated into the planning processes.
Modern, fit for purpose facilities where innovation, use of technology and best practice thrive
Service users feel a positive experience of the environment in which services are provided.
Sustainable change that will make a difference to service user experience, including providing more local care
The future care provided should respect individual needs, values and preferences, and should be based on shared decision making and an inclusive planning process with all stakeholders
Project Investment Objective No. 3 Improved access to services and care
Existing Arrangements Business Need
Access to primary care is generally good in the area but access to secondary care is more challenging. Public transport is limited and in some place (e.g. Laggan) there is none. Currently, the bus service is not conducive for accessing appointments locally or at Raigmore Hospital.
People often have to travel to Raigmore Hospital for return outpatients to see a clinician for only a very short time.
If minor operations are carried out in Grantown-on-Spey, patients have to go on a round trip to Aviemore for the x-ray
Home care provision is a big challenge. There are many occasions when GPs admit patients to community hospitals due to lack of appropriate home care particularly out of hours Psychiatric emergency care is limited with no local “place of safety” provision.
Improved access to care and treatment through changes in the location of services, reduced travel time/distance and shorter waiting times. Improved access to acute clinics and specialist clinical advice accessible from patients’ homes and local community locations. Using telemedicine or telephone consultations for an increasing number of return and routine outpatients.
Local access to specialist nurses who undertake peripheral clinics e.g. diabetic/MS/ heart failure and epilepsy nurse specialists. A facility in the locality, to care for the increasing number of patients with dementia. Provision should also be made for those with learning disabilities.
Facilities and space are needed to enable a wider range of mental health services to be provided locally. Ideally, a “one-stop shop” for all MH needs.
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Project Investment Objective No. 4 Maximise flexibility, responsiveness care-
Existing Arrangements Business Need
Local service provision tends to be fairly fixed and not particularly responsive to individual patients and service users.
The lack of support for older people, particularly at night, means that they cannot maintain independence and this reduces their 'quality of life' and also contributes to an increase in emergency hospital admissions and pro-longed inpatient stay
Investment to allow people to stay at home for as long as possible, to have a service that is flexible to their changing needs, and which prevents them from staying in hospital longer than they need. Investment to allow more flexible and multi-use of space is required locally for clinics and day care procedures such as blood transfusions, infusions and chemotherapy, ultrasound, endoscopy, visiting clinics by secondary care and day surgery
Project Investment Objective No. 5 Make best use of resources
Existing Arrangements Business Need
A high degree of variation in the way that primary care and community hospital resources are used. The current lack of service integration results in less than optimal use of resources. The current arrangements with services across a number of different sites are ineffective and wasteful. More expensive interventions are having to be utilised due to the lack of support for self-care and independent living at home.
Services provided that have strong evidence of effectiveness. Patients not occupying inpatient beds who could have been cared for in other, non-inpatient, settings. Shared services and resources across the health and social care economy offer opportunities for improved effectiveness and efficiency.
Project Investment Objective No. 6 Improve quality and effectiveness of accommodation
Existing Arrangements Business Need
Buildings historically located. Old property with poor performance in terms of property maintenance, energy consumption, environmental performance, infection control and safety. Facilities that are not “fit for purpose”, have poor space planning and functional suitability result in ineffective working practices, poor use of staff time and greater risk of infection.
Strategic location of facilities (central) and co-location of facilities, reducing duplication and consolidating resources and skills
Modern facilities play a key role in supporting service delivery and enhancing user experience of services. Modern, fit for purpose facilities are needed to enable new ways of working and contemporary service models to be developed
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Project Investment Objective No. 7 Improve safety of service delivery
Existing Arrangements Business Need
There is a lack of single bedrooms with en-suite WC/showers. There is an increased risk of HAI from multi-bed wards with a lack of flexibility for isolation.
Generally, the existing, out-dated accommodation is difficult to maintain to modern statutory compliance and health & safety standards. These older properties increase the risk of harm from property related incidents due to:
• Lower fire safety standards
• Need for backlog maintenance
• HAI concerns
• Trips and falls
Modern, fit for purpose accommodation which is planned and designed to support contemporary models of service delivery. Increase number of single bedrooms (100%) used to reduce risk of infection transmission and to provide appropriate standards of privacy and dignity for patients.
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Appendix 9 Risk Register
Attached as a separate document
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Appendix 10: Terms of Reference, Badenoch & Strathspey Transport & Access Group
1. Group Purpose
• To ensure that a robust and deliverable Transport and Access Plan is developed to support the business case and planning process associated with the redesign of hospital and community health and social care in Badenoch & Strathspey.
• To ensure that transport and access are fully considered and addressed in the planning of a new hospital facility.
• To act as a partnership forum for organisations and agencies to jointly develop options and solutions to improve and sustain transport and access in Badenoch & Strathspey.
• To assist with the implementation of national local policies associated with transport and access and to strengthen existing such policies.
• To scope out existing transport arrangements and costs of the same. • To assist in identifying and addressing transport-related problems experienced
by individuals and communities in Badenoch & Strathspey with a particular emphasis on increasing economic and social inclusion opportunities.
• To feed in with wider and transport and community groups.
2. Group Composition
Chair: Nigel Small, Director of Operations, South & Mid Operational Unit, NHS Highland agreed to facilitate the meeting in the first instance.
The Group will have representation from the following:
B & S Access Panel B & S Community Transport Company
Cairngorms National Park Authority Community Representatives
NHS Highland Highlands & Islands Enterprise (as appropriate)
Scottish Ambulance Service Voluntary Action Badenoch & Strathspey
Minute Taker Youth Representatives
Highland Council (Officers and Elected Members)
(Other transport organisations to be confirmed, as required).
The Group will also consider co-opting additional members.
Ad hoc members may also be invited for specific topics.
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3. Deputies
• The Deputy Chair of the Group would be Ven. Richard Gillings. • Deputies may attend in Group member’s place.
4. Quorum
Five members of the Transport and Access Group need to be present for the meeting to make decisions or recommendations.
5. Decision-making
Decision-making will be by consensus.
6. Frequency & Venue
Approximately, every 6 weeks, with 2 hours to be the maximum length of meeting.
Meeting dates to be advised approximately two months in advance, within a reasonable time frame.
7. Work between Meetings
Work to be allocated at meetings to Transport and Access Group members and any sub-groups.
8. Communication
• Notes from meetings to be distributed to Group members for dissemination. • Team briefing paper will be issued to include updates on Group issues. • Periodic reports to relevant Boards, Committees and Management Teams of the
organisations represented. • Public Relations activity to be agreed by Group and action by nominated
organisations. • Group to communicate with local community and local community groups.
9. Potential Confidentiality of Certain Discussions
Whilst there is a need for openness and transparency with discussions at meetings; there may be occasions where members would be asked to maintain a degree of confidentially in certain subject areas. This may include commercially sensitive matters, issues relating to finance or individuals, plus situations where an approach to press / public awareness is agreed.
30 October 2014
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Appendix 11: Design Statement Attached as separate document
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Appendix 12 – Indicative Project Programme Attached as separate document
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B&S - Risk Register
Appendix 9: Risk Register
Description Possible consequence
Probabilityrating(beforemanagement)
Impactrating(beforemanagement)
Action to control risk Action byProbabilityrating(followingmitigation)
Impact rating(followingmitigation)
Closed
1 PROCUREMENT RISKS
2 Planning permission, access etc for preferredsite
Delays, increased cost Discussion with planning authority fromearly stage
NHSH
3Working within a National park Restriction on design leading to
longer planning process andincreased costs
Discussion with Cairngorm National Parkauthority from early stage
NHSH
4 Ground conditions on preferred site Increase cost, delays Surveys prior to site selection, detailedsurvey pre-construction.
NHSH
5 Utilities, drainage connections on preferred site Delay, increased costs, nonfunctionality
Ensure suitability of existing services andearly application for new/increased services.
NHSH
6Land acquisition Delay Appraisal pre- site selection to determine
any complication and early acquisition ofselected site
NHSH
7Archaeology or other items of special scientificinterest found on site
Delay, increased cost ofconstruction, additional costs ofexcavation etc, prevention ofdevelopment.
Desk-top survey of sites pre-selection,detailed survey post-selection, discussionwith National Park, Highland CouncilArchaeology Unit etc.
NHSH
8
Liquidation of construction partners (e.g.designer, contractor, supply chain)
Delay, lack of continuity Consultants and supply chain employed bydeveloper therefore passing the financialrisk, developer likely to be HUB thereforepart-public funded and lower risk ofliquidation.
NHSH
9If part of a HubCo project bundle, project maybe delayed due to delay in dependency project
Delay in project completion Continued engagement with HUB andreview of status of projects. Seekclarification on whether project can bestand-alone
NHSH/Hubco
10Insufficient project management and capitalmanagment capacity / expertise
Project fails to progress due tolack of appropriatemanagement
Ensure adequate project managementarrangements are in place, as detailed in IA
NHSH
11 Insufficient senior management capacity Delays in project, fails toprogress
Ensure adequate management resource isallocated to the project
NHSH
12Delays in NHSH / SG approval process Delay project programme Ensure adequate project management
support is in place so that all stages are fullycompleted to required level
NHSH
13 Changing statutory and NHS guidance Additional work required whichwill delay project
Early and continued engagement with SG /HFS
NHSH
14
Changes to specification post-sign off Increase in cost Ensure briefing documents are produced insufficient detail and in good time to bethoroughly reviewed by all stakeholders.Timetable showing documents produced bydeveloper to be circulated at outset detailingreview periods.
NHSH
15 FINANCIAL RISKS
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Description Possible consequence
Probabilityrating(beforemanagement)
Impactrating(beforemanagement)
Action to control risk Action byProbabilityrating(followingmitigation)
Impact rating(followingmitigation)
Closed
16
Affordability of the project will depend on theavailability of a Scottish Government UnitaryCharge Grant.
Project could be unaffordable Discussions with SG have confirmed thatthe B&S project is within the SG pipelinescheme. Once the IA has been approved itis likely that SG will be in a position toconfirm the unitary charge grant.
NHSH/SG
17
Affordability of the project may be affected bythe calculation of the unitary charge sum. Theunitary charge is calculated on a number ofcomplex variables such as size and compexityof the building, money markets, cost ofcontruction and maintenance regimes. Theseare all unknown costs at this early stage of theproject.
Project could be unaffordable After the IA has been approved, detailedwork will progress with Hubco to developthe detailed scheme costs that will form theOBC.
NHSH/Hubco
18 Availability of NHS capital to support landpurchase and procurement of equipment
Project could be unaffordable B&S project is currently in the draft Board 5year capital plan
NHSH
19There are no non recurring ringfenced revenuefunds to support project development e.g.professional fees, development costs etc.
Risk for the organisation ofrevenue overspends
Ensure that AMG is sighted on therequirement for revenue funds within the IApapers.
NHSH
20
The scope of the project may increase beyondthe construction of a new hospital as thebusiness case process progresses. Additionalproject work may develop due to GrantownHealth Centre upgrade/reprovision andreprovision of physiotherapy services atKingussie.
Project scope may widenresulting in increased cost
Progress early option appraisal and definein greater detail at OBC stage.
NHSH
21 SERVICE RISKS
22Community not supportive of preferred wayforward
Local 'buy in' may becompromised
Continue regular public engagementthrough the development group and existingmedia links
NHSH
23 Failure to deliver integrated transport plan /public transport to new site insufficient
Public unable to access site Continued engagement with local transportgroup
NHSH
24
Long term workforce plan (including medical)requires to be created and agreed that will mapchanges in staffing to match the clinical modelover time.
The required staffing modelmay not be in place when thenew service commences. Theremay not be staff 'buy in' to thechanges.
Progress the workforce plan NHSH
25 Demand for services at variance with projected Solution does not meet serviceneed
Adequate service planning / modelling toaccurately predict future service need
NHSH
26Current services collapse before projectcompletion
Reduced health services inlocal area
Ensure all necessary project arrangementsare in place to progress as quickly aspossible. Put necessary contingency /business continuity arrangements in place.
NHSH
27Stakeholders have contradictory aspirations Local buy-in may be
compromisedContinue regular public engagementthrough the development group and existingmedia links
NHSH
28 Unable to recruit to support enhancedcommunity and care-at-home plan
Unable to provide planned levelof service
Progress the workforce plan NHSH
29Ongoing requirement to make recurringsavings, reducing the resource available forservice investment
Unable to provide planned levelof care-at-home / enhancedcommunity service
Engage with AMG / NHSH Board toringfence released revenue to supportservice change
NHSH
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Description Possible consequence
Probabilityrating(beforemanagement)
Impactrating(beforemanagement)
Action to control risk Action byProbabilityrating(followingmitigation)
Impact rating(followingmitigation)
Closed
30NHSH has never closed 2 hospitals in the samearea at the same time, and closure of previouscommunity hospitals has resulted in significantadverse PR
Local buy-in may becompromised
Continue regular public engagementthrough the development group and existingmedia links. Seek to learn from experienceof other health boards
NHSH
31Stakeholder fatigue Local buy-in may be
compromised. Project may bedelayed
Robust stakeholder plan is in place, ensureregular review
NHSH
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The objectives for the new facility are as set out in Section 4 of the Initial Agreement document. • Integrated Health and Social Care • Improve user experience • Improve access to services and care • Maximise flexible, responsive and preventative care • Make best use of resources • Improve quality and effectiveness of accommodation • Improve safety of service delivery
Aviemore has been identified as the preferred location for the new development, set within the beautiful Cairngorms National Park. The design must make the most of the natural environment and cultural heritage of the area in order to satisfy the planning requirements of the Cairngorms National Park Authority. In order to realise the above, the facility must possess certain aspects and attributes.
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1 NON-NEGOTIABLES FOR SERVICE USERS
Non-Negotiable Performance Specifications Benchmarks – the criteria to be met and/or a view of what success might look like 1.1 On approaching the site, the facility (building, grounds and landscaping) must: • By its own, specific identity be something that
can be recognised from an image or be easily directed to.
• Convey the full range of services so that users will feel confident they’re coming to the right place.
• Have a calm and protective feel. • Integrate well with its Cairngorm setting
through its form, nature and orientation. • Aid familiarity and comfort for local people and
help maintain the community feel that is such an important aspect of the existing facilities.
• Be welcoming and easily accessible by all forms of transport from the main travel routes.
• Enable users to have a positive experience.
Site should be welcoming and accessible with green space on approach. The building should have a mixture of textures and materials including some that are locally available / sourced.
(No gravel please)
1.2 The arrival routes within the site must be easy and safe for all users, both in daylight and at night and taking into account the year round weather conditions. There should be convenient walking / cycle links to adjacent residential areas and main routes into Aviemore centre. The building design and landscaping must provide shelter to walking routes, entrances and outdoor spaces which will help people cope with the extremes of the year round weather conditions experienced in this locality.
• Building entrances should be easily identifiable from the site entrance and from the associated parking area(s) for all users including those with physical, sensory and mental health needs.
• The entrance(s) should provide shelter to protect more vulnerable people when transferring from vehicles and to reduce ice / snow build up. Drop-off and pedestrian areas must be designed to discourage misuse as general parking.
• Pedestrian routes from the road, bus stop and drop-off area must be as short as possible, the bus and drop off area being no more than 25m from the main entrance. They should be direct, well lit, with good observation from occupied areas and, as much as is practicable, be sheltered from the elements. Materials used should reduce ice build up / minimise slip risk.
• The parking area must be visible on arrival, though you need not see all of it, and be convenient to the entrance(s). Parking should be within 50m of entrance(s) to encourage proper use.
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• Vehicle routes should: o Be designed around the pedestrian experience so that pedestrians don’t have long
detours or have to cross vehicle areas to get where they need to go. o Be clear and efficient and minimise time and stress in finding your way around the site
and a parking space. o Minimise driver distraction and promote safe driving.
1.3 On entering there must be an obvious reception / information point where you can be checked-in and/or directed to the appropriate service and/or waiting area. The design and layout should support clear way finding for all users including those with physical, sensory and mental health needs. The reception area must be designed to allow space nearby for sensitive conversations. The relationship between reception, queues and the location of seating areas should take into account the need for patient / visitor confidentiality.
• Layout to make good use of space and natural light. • Reception desk(s) to have different heights to take account of all user needs and could be
curved. • Glass partitions should be avoided as they are unwelcoming and not conducive to face to
face interaction. • There should be clear lines of sight from the reception to the waiting area(s). • Back room staff should not be visible in the background. • Good levels of soundproofing to reduce the likelihood of discussions at the desk being
overheard. • Facility for electronic self check-in. • Visitors should not have to travel through the waiting area to get to reception. • Room for confidential / sensitive discussions.
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The entrance area(s) need to be designed to trap tracked mud / snow on shoes / clothes and to reduce the potential effects of draughts and wind.
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Glass partitions are unwelcoming
1.4 Waiting areas must provide comfort, refreshment options and positive distractions whilst waiting for appointment / treatment and when awaiting transport home.
Waiting area(s) should be visible from reception(s) but not so close as to be able to overhear private conversations. Seating areas arranged to enable the management of those with different needs, including separation of patient groups if required, e.g. large groups and the “walking wounded”
• Balance and choice of seating, not airport lounge style. • Appropriate height chairs for those who find it difficult to sit down and get back up again. • GP patients not too dispersed so it is easy for GPs to call their patients in. • Separate area suitable for young children to wait with their parents / carers and space for
prams / pushchairs. • Tables and chairs to enable patients, who need to complete forms, to have an
appropriate surface to do so. • Seating available where you can see the pickup area / bus stop and wait in the warmth
There should be clearly identifiable toilet facilities and access to refreshments, natural daylight and views maximising the local landscape. Art work can also be used. Information should be
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available on transport options to allow for decisions on whether to wait for transport or walk into town. Consideration should be given to publically available WiFi. There must be facilities to occupy children and other dependents, access to sheltered external areas to allow children to “run off steam”, fresh air and respite opportunities for others.
Not airport lounge style or rows of seats facing the reception desk (and away from the window)
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1.5 Therapy and day care spaces must have a non-clinical feel to promote interaction and relaxation.
• Treatment areas in line with appropriate guidance. • Social care provision should have a non clinical feel to promote interaction and relaxation,
although still complying with NHS guidance where required e.g. infection control • Access to appropriate external spaces and accessible paths round the site to maximise
therapeutic use. Space for sensory garden.
1.6 People arriving as an emergency, or on an Arrival may be through the same route as above by day, but should be no less clear by night.
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unplanned visit, must be able to get directly to the help they need.
The facility will cater for a high number of visitors to the area. They may arrive without appointments, generally in large or family groups, often off the surrounding mountains complete with wet / muddy gear and needing general or emergency assistance. The arrival sequence must take them directly to a reception where they can access appropriate help. The entry spaces / waiting areas must be sized to be able to cope with these groups without impacting on the environment for other service users.
1.7 Vulnerable people being brought to the facility (inpatient and potentially day care users), or to be picked up for transfer to another facility, must have their dignity and privacy maintained and feel welcome.
• Discrete and sheltered entrance leading directly into inpatient areas where those arriving are not on public view.
• Inpatient admission route to give access to treatment / diagnostic areas for tests etc on admission without going through general public routes.
1.8 The ward must convey a calm, protective, • Bedrooms to have good daylight and views of nature. The potential for views from the site
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professional impression whilst enabling independence. There should be a more private area where patients / residents can maintain contact with family and community and not feel isolated or cut-off. The inpatient areas in particular need to be designed to be dementia friendly.
should be maximised but these spaces should be protected from intrusive noise and public view.
• Good visual connections from bedrooms to shared areas, but without rooms feeling like a goldfish bowl.
• Easy access to useable, secure green space from the shared areas of the ward and from a number of bedrooms which may be used for palliative care or others who would benefit from private access to external areas.
• Ward should have an enabling ethos to support individuals who are returning home. For example an area that allows them to make their own drinks or snacks.
• Communal dining / activity area to encourage socialisation. • Quiet spaces to help meet the spiritual needs of patients and visitors. • Space in the room and social areas to allow for visitors, and ICT facilities to allow patients to
keep in touch with family and external contacts.
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2 NON-NEGOTIABLES FOR STAFF
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Non-Negotiable Performance objectives Benchmarks – the criteria to be met and/or a view of what success might look like 2.1 Staff routes must allow visiting and community outreach staff to leave and enter the building easily and with the materials they need.
• Discrete staff access / exit to allow staff to leave without encountering patients who may wish to talk to them.
• Adjacent on-call reserved parking. • Space to store materials securely, close to the appropriate staff entrance, and which will allow
pick-up / drop-off from vehicles before they are parked. • Ease of access to waste disposal areas
2.2 The layout must help staff work between areas and disciplines effectively and safely.
• Facilities that are open 24/7 (inpatient areas and emergency care) should be immediately adjacent to each other to allow nursing staff to support out of hours staff at night time and reduce the risks around lone working in public areas.
• GP Reception should be near to Outpatient and Emergency facilities to allow staff to assist patients arriving for both services.
• GP consulting areas located with easy access (under 1 minute walk) to emergency areas. • Office areas for different teams should be located together to make mixing and
communication easy. Consider placing integrated teams together in one area, including third sector colleagues.
• Staff circulation areas to be shared, allowing you to meet with people from other teams and providing space at natural meeting points for informal conversations.
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Example below of the type of layout that could support collaborative working
2.3 The layout of the ward areas must help staff deal with different patient needs and handle sensitive transfers such as moving the deceased to be done with dignity.
• Flexible arrangement of bedrooms. • Good and easy observation of the spaces between rooms and entrance / exit to ward for
passive supervision of inpatients moving around. • Enable isolation of patient(s) in the event of transmissible infection.
2.4 The facility must support the use of information technology for learning and tele-health (staff to staff and staff to patient).
• Easy access to technology and ability to utilise advances in technology. • Technology solutions designed to meet current and future demands with adaptability built in.
2.5 There must be good areas for staff to rest and be off duty (including when on call) and to rest and recuperate.
• Staff rest area to have good natural light and views. • Designed to allow for sociable space and enable individuals to have some private time. • There should be a place where staff can get a breath of fresh air during breaks. This could
include walking routes around the site so that staff have access to usable green space. • A restful room for ‘on call’ staff to sleep, close to the 24/7 areas.
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2.6 The building must be easy to clean and service without impacting on public areas.
• Durability of materials, life cycle costs, frequency of cleaning. Special consideration should be given to coping with the extremes of weather experienced within the locality (e.g. durability against salt, grit, heavy snow).
• All areas should be designed to support the control of infection. • Service areas located discretely to minimise any impact on user / visitor / staff areas. • Grounds with green space should be easy to maintain.
2.7 The building must be efficient in its use of light / heating / power in a way that is responsive to local conditions and to the needs of the different user groups.
• Building zoned to allow for different operating hours, allowing parts to be closed down and unheated overnight.
• Staff changing and rest areas should be accessible without having to go into ‘shut down’ areas. • Window placement and design, and the relationship of internal and external uses, to ensure
that where views and/or natural light are required these are not regularly lost due to the need to draw blinds for privacy / glare / overheating.
• Heating and lighting controls to allow local control of temperature. • Adequate security lighting out of hours to ensure safety of staff and visitors
2.8 The building should be designed to maximise Design should allow for:
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flexibility of use and allow future expansion. • Clinical and non-clinical spaces to be used flexibly between services. • Easy changes in use of accommodation to meet the changing health profile of the population. • Expansion or redesign of facilities to meet future service needs.
3 NON-NEGOTIABLES FOR VISITORS
Non-Negotiable Performance objectives Benchmarks - the criteria to be met and/or a view of what success might look like 3.1 Families and friends of inpatients must have a welcoming and clear arrival experience during the day and out of hours.
• The entrances to the facility should be easily identifiable from the site entrance and from the associated parking area(s).
• The site and building layouts should make way finding easy and intuitive • Clear information / signage to ensure that families and visitors can easily find where they
need to go.
3.2 The shared and central facilities (training, meeting, waiting areas and landscape) must be designed to allow the third sector to provide support and activities from the premises, including evenings and weekends.
• Work areas clearly identified and working arrangements defined to maximise participation by all appropriate groups.
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4 ALIGNMENT WITH BROADER POLICIES AND NEEDS
Non-Negotiable Performance objectives Benchmarks - the criteria to be met and/or a view of what success might look like 4.1 The changes in public transport that can be enabled by the new facility (due to increased demand in the area) must be developed with a wider view of improving public transport across the town and in the Strath generally.
Strong relationship with the Badenoch & Strathspey Transport Group, Highland Council and commercial transport providers to ensure the delivery of the appropriate transport services to and from the new facility and within the area generally.
4.2 The pathways across the site should be designed to improve pedestrian and cycle links around the town and to the local countryside to improve walking and cycling opportunities within the area.
Maintain awareness and links with Health Promotion as well as programmes like Active Cairngorms via the Cairngorms National Park Authority.
4.3 The wider site should be master planned to ensure any future developments do not detrimentally impact the nature of the facility being designed, and any opportunities for improved links with the rail station(s) are protected.
Careful planning of the NHS part of the site together with awareness of the potential developments which might happen on the wider site out with the control of NHS Highland.
4.4 The released sites should be considered not only in their monetary value but in terms of how their redevelopment can be of benefit to the needs of the local community.
Maintain close liaison with the Cairngorms National Park Planning Authority to maximise the potential for any sites to be released to ensure that their redevelopment will be of benefit to the local communities.
4.5 The facility should be sustainable in its use of energy and materials.
BREEAM “excellent” to be achieved where possible.
The above was developed through engagement with the Badenoch & Strathspey Redesign Steering Group, which included representation from:
Aviemore Community Council; Aviemore Medical Practice; Badenoch & Strathspey Access Panel; Badenoch & Strathspey Community Transport; Carrbridge Community Council; Friends of Ian Charles Hospital; Friends of St Vincent’s Hospital; Grantown Community Council; Grantown Medical Practice; Highland Council Children’s Services for Badenoch & Strathspey; Highland Council Elected Members; Highland Council Officers; Kingussie Community Council; Kingussie & Laggan Medical Practices; Laggan Community Council; NHS Highland Officers; NHS Highland Staff Side Representation; Scottish Ambulance Service and Voluntary Action Badenoch & Strathspey.
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5 SELF ASSESSMENT PROCESS
Decision Point Authority Additional Skills /
Perspectives
How the above criteria will be considered at this stage and/or valued in the
decision
Information required to allow evaluation
Site selection NHSH Board with advice from Project Board
Stakeholders, Cairngorms National Park Authority, HubCo (technical appraisal)
Risk / benefit analysis of the capacity of the sites to deliver a development that meets the criteria identified above.
Site feasibility study based on best available information
Completion of brief
NHSH Project Board with advice from Project Director
Stakeholders, including service providers and internal technical advisors. Clinical modelling supported by Independent Clinical Advisor
This Design Statement should be included in the brief.
Early engagement with HubCo to assess the affordability / deliverability of the project brief
Selection of Delivery / Design Team
HubCo Operations & Supply Chain Director with input from NHSH Project Managers
HubCo and stakeholders, including internal technical advisors
Selection process as per Hubco Method Statements, including cost and quality considerations, to ensure that the best design team is chosen from the Hubco Supply Chain.
NHSH will be involved in the selection process and can influence the outcome and, if necessary, nominate other designers for consideration
Previous experience / examples of work on similar types of development.
Interview process to include presentation and questions relating to design approach and the potential to meet the criteria set.
Consideration given to quality criteria set.
Early design concept selected from options developed
NHSH Project Board with advice from Project Director
In-house architectural team, Architecture + Design Scotland, Cairngorms National Park Authority
Use of AEDET to determine if the criteria are being met
Proposals developed to Stage 3 with enough detail to enable distinction between the main use types (including circulation and external space). Elevations/3D visuals
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Approval of Design Proposals to be submitted to the Planning Authority
NHSH Board with advice from Project Board
National Design Assessment Process.
Planning Authority within Badenoch & Strathspey is the Cairngorms National Park Authority
Use of AEDET to determine if the criteria are being met
Selected Design to Stage 4, with elevations
Approval of detailed Design to allow Construction
NHSH Project Board with advice from Project Director
In-house architectural team and technical advisors
Use of AEDET to determine if the criteria are being met
Design developed to Stage 5 with agreed specification.
Post Occupancy Evaluation
Consideration by appropriate NHS H governance and report sent to SGHD
Independent analysis by service providers / stakeholders.
Potential Third Party evaluation
Assessment of completed development by representatives of the stakeholder groups involved in establishing the assessment criteria (AEDET, Design Statement).
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B&S Project High Level Programme
Appendix 12: Project Programme
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