nhs highland · scientific advisory committee (smasac) nhs highland undertook a study to review...

Inital Agreement Document

NHS Highland

Raigmore Hospital

Critical Care Consolidation and Theatres Refurbishment

(with necessary realignment of Services)

Initial Agreement Document

Rev I

15th May 2013

Critical Care Consolidation and Theatres Refurbishment (with necessary realignment of Services)

CONTENTS


1 SUMMARY OF PROPOSED INVESTMENT 3

2 EXECUTIVE SUMMARY 5

3 STRATEGIC CONTEXT 9

4 INVESTMENT OBJECTIVES, EXISTING ARRANGEMENTS / BUSINESS NEEDS 28

5 BUSINESS SCOPE AND KEY SERVICE REQUIREMENTS 40

6 BENEFITS / RISKS / CONSTRAINTS AND DEPENDENCIES 43

7 AGREED CRITICAL SUCCESS FACTORS 48

8 LONG LIST OF OPTIONS AND SWOT ANALYSIS 49

9 ECONOMIC CASE TO ARRIVE AT PREFERRED WAY FORWARD 54

10 AFFORDABILITY REVIEW 65

11 RECOMMENDED PREFERRED WAY FORWARD 67

A APPENDIX – SMART OBJECTIVES 70

B APPENDIX – SUMMARY OF CATEGORIES OF CHOICE ASSESSMENT 74

C APPENDIX – SWOT ANALYSIS OF LONG LIST; 78

D APPENDIX – PREFERRED TOWER BLOCK LAYOUT 87

E APPENDIX – POTENTIAL PHASING PLAN 89

F APPENDIX – POTENTIAL HIGH LEVEL SCOPE 91

Critical Care Consolidation and Theatres Refurbishment (with necessary realignment of Acute Services)


3

1 Summary of Proposed Investment

This Initial Agreement Document (IA) summarises the planned investment to

consolidate critical care services, and the necessary re-alignment of some other

services, within the Tower Block at Raigmore Hospital, to facilitate this. Critically, the

investment will also address the current compliance issues and deficiencies

associated with the Tower Block and the Theatres on the first floor adjacent to the

Tower Block. In addition to the immediate benefits arising from these investments,

there will be ancillary functional and operational benefits arising from the improved

adjacencies for the other acute services, arising from the realignment of services.

The proposed investment is aligned with and provides a substantial platform for any

future development at Raigmore, but critically excludes any changes to the current

bed capacity and theatre capacity provision which will be the subject of wider study.

The investment will address the immediate deficiencies of the accommodation,

fittings and services infrastructure associated with the current Critical Care

accommodation and the Theatres, so that facilities are commensurate with modern

standards.

The investment proposals are aligned with the wider rationalisation and coordination

plans of NHS Highland services in the Greater Masterplan area. NHS Highland is

currently implementing a “Masterplan exercise for the Greater Inverness Area”. Both

clinical and non clinical facilities are being considered with options for optimal future

Healthcare provision in the Highlands linked to clinical need over the foreseeable

future. Key findings are emerging in relation to the need for the consolidation of

critical care and theatres refurbishment, at Raigmore Hospital, as is proposed within

the Initial Agreement.

The particular deficiencies in services that exist across Critical Care and the Theatres are defined in greater detail within subsequent sections of this Initial Agreement. However some of the key issues are highlighted below.

Critical Care The lack of integrated critical care facilities commensurate with modern standards and in compliance with SHTM and other guidance

Inefficient working where nursing and medical administrations are duplicated in some cases, and consequently there is poor staff flexibility between HDU and CCU

Poor critical care adjacency to “front” of hospital ie adjacency to “accident and emergency”

Principally due to allocation approach, lack of critical care bed availability (particularly HDU beds) resulting in too

early discharge of patients or patients wrongly located in general wards, in some cases

Respiratory ward operating as informal HDU

In some cases, patients within HDU’s and CCU’s receiving too high a level of care resulting from lack of integrated critical care and poor adjacencies



4

Poor patient flow resulting from the existing adjacencies

Lack of isolation facilities in medical HDU

The outmoded design, and related design faults, associated with some of the existing accommodation which does not comply with current SHTM standards

A significant proportion of the existing accommodation

and facilities are considered to be inadequate in terms of infection control

All of the above issues are related to the current lack of integrated critical care, the poor adjacencies and the inadequacies in the existing accommodation. This currently has a significant impact on the quality of care given to critically ill patients at the hospital. Along with the care issues, it is also clear

that the associated inefficient working practices also leads to

poorer staff moral and increased revenue spend.

Theatres Without action, NHS Highland anticipates an enforcement notice from the Fire Authority in relation to the poor provision for fire precautions.

There is a significant backlog in maintenance, and with plant and equipment at an age which in some cases is beyond its design life, and therefore inefficient. Ventilation provision, in particular, fails to meet current standards in terms of the required number of air changes.

Significant improvements are needed with regard to the

provision of infection control.

The space provision does not meet modern healthcare standards and SHTM’s for Theatre accommodation. There

is a particular issue with the severe lack of storage for the increasing amount of theatre equipment.

In summary the existing operating theatre facilities fail to meet

modern standards, in terms of fire precautions, infection control, functional requirements, space provision, and compliance with current clinical guidance.

The title of the project is as follows: “Critical Care Consolidation and Theatres

Refurbishment (with necessary realignment of services) at Raigmore

Hospital”.



5

2 Executive Summary

This Initial Agreement (IA) should be regarded as an appraisal to establish the “preferred way

forward” in respect of addressing the existing deficiencies of Raigmore’s “Tower Block”, and

adjacent Theatre facilities, including the current dispersed nature of critical care services, and

the significant compliance issues throughout. Furthermore, the scope also includes some limited

ward reconfiguration which will be necessary to facilitate these improvements. The IA also

reflects on the separate major initiative currently being undertaken by NHS Highland comprising

a substantial Masterplanning Exercise for the Greater Inverness Area where options for optimum

future Healthcare provision in the Highlands are being considered. The development of this IA

has been undertaken in close alignment with the Inverness Masterplan so that the significant

investment proposed, will not only address the immediate deficiencies described, but also build

a platform for the anticipated subsequent initiatives to allow a future optimal healthcare model

to emerge.

This IA reviews the current Tower Block “Fire Precautions Upgrade” project to highlight the

unique opportunity that has arisen, namely to undertake the much needed improvements, at a

time when existing wards will be vacated, in any case. The IA investigates NHS Highland’s

vision, aims and its principal constraints in the context of key national and local drivers including

the Local Development Plan.

Following recommendations in a report by a Working Group of the Scottish Medical and

Scientific Advisory Committee (SMASAC) NHS Highland undertook a study to review High

Dependency Unit (HDU) facilities to make recommendations on the development of a Critical

Care strategy within NHS Highland. The comprehensive study identified various deficiencies

including the care issues associated with the highly dispersed nature of critical care and high

dependency units in the Tower Block and lack of integrated critical care facilities, poor

adjacencies and various other inadequacies in the existing accommodation. The NHS Highland

study identified that these deficiencies currently have a significant impact on the quality of care

of critically ill patients at the hospital. It is also clear that the associated inefficient working

practices has led to reduced quality of patient care and staff moral.

A review has also been undertaken of the current provision and quality of Theatre facilities at

Raigmore. Fundamentally, there are various Theatre deficiencies associated with fire

precautions, infection control standards, ventilation standards and backlog maintenance. In

particular, without action, NHS Highland is facing an inevitable fire enforcement notice which

could lead ultimately to closure. The current accommodation also falls below modern healthcare

standards and SHTM’s for Theatre accommodation, including space requirements, and there is a

particular issue associated with the severe lack of storage for the increasing amount of theatre

equipment.

Section 8 summarises a long list options (a total of18 principal, and sub-options) considered to

address the identified SMART objectives and benefits, which were considered in consultation

with a wide range of stakeholders, including patient representatives. These were shortlisted

into the following options, associated with improved critical care delivery and related tower

block reconfiguration, as summarised below.



6

1 Do Minimum (Retain Current Configuration)

2 Consolidate Critical Care Unit with CCU at Ground floor and Medical HDU and ITU / SHDU co-located at first floor and Endoscopy retained in Tower Block (level 6)

2A Consolidate critical care with CCU & MHDU co-located at ground floor with ITU & SHDU co-located at first floor, and the addition of PACU and vascular lab, with Endoscopy moved out

2B Similar to Option 2A but with MHDU/CCU situated at Ground floor at “A” block to facilitate intensive care adjacency, and no provision of PACU

3 New Combined Assessment Unit on ground floor and consolidate critical care with CCU & MHDU also co-located on ground floor with ITU & SHDU co-located at 1st floor

3A New Combined Assessment Unit on ground floor and consolidate critical care CCU/MHDU and ITU/SHDU) completely on 1st floor

3B New Combined Assessment Unit on ground floor and consolidate critical care (CCU/MHDU and ITU/SHDU) in “A” block on ground and 1st floors, with the provision of PACU and vascular lab.

An extensive non-financial option appraisal exercise was conducted. Overall, the appraisal

process identified that the preferred non-financial option was option 2A with 622 points, followed by option 2B with 568 points. The least favoured options, by some margin, are Option 1 (Do Minimum)) and Option 2.

An economic appraisal was then undertaken to establish capital costs, recurring revenue, non-recurring revenue costs and net present costs for each option. An Option 0 (Do Nothing) has

been costed for baseline purposes however this option is not viable because the various compliance issues would not be addressed. In particular this option would result in a fire precautions enforcement notice being issued, ultimately resulting in closure.

In addition to the critical care analysis appraisal, capital cost / revenue estimates have been

established based on addressing the various Theatre compliance issues. At an early stage in the process, it was agreed that this theatre work was common to all the options, and therefore the

combined costs, including the Theatre costs, have been used in the overall economic review. The analysis of the net present values (NPV) indicates that Option 1 (Do minimum) has the

lowest life time costs with Option 2A being the next favoured option. An analysis was undertaken on an economic annual costs basis in line with HM Treasury guidance. The Value for

Money (VfM) analysis compared the cost per benefit point of the options as illustrated below.

Whilst Option 1 (Do Minimum) is the lowest Net Present Cost (NPC), it is the second least favoured option and does not fully achieve the Investment Objectives, as reflected in the scoring.

No Qualitative

Benefits

Score1

Quality

Rank

Net Present

Cost (NPC)

(£k)

NPC

Rank

Cost per

Benefit

point (£k)

VfM

Economic

Ranking 1 358 6 18,013.8 1 50.3 6

2 349 7 22,687.1 7 65.0 7

2A 622 1 20,976.5 2 33.7 1

2B 568 2 21,941.4 5 38.6 2

3 511 4 21,530.3 4 42.1 3

3A 501 5 21,344.7 3 42.7 5

3B 532 3 22,641.4 6 42.6 4



7

Option 2A, has been established as the highest qualitative scoring option as well as having the second lowest Net present Cost. Fundamentally Option 2A meets the Investment Objectives, the Critical Success Factors and achieves the lowest cost per benefit point of all the remaining options. This option delivers best value in terms of non-financial benefits and the actual appraisal costs. Sensitivity analysis has been undertaken to ensure the results are robust. It is highlighted that whilst Option 2A does not include a "Combined Medical & Surgical Common

Admissions Unit”, this option does not preclude such a development at a future date, in the scenario where further consultation established that better patient outcomes could be achieved. The associated estimates in terms of capital costs and revenues estimates, for Option 2A, are summarised as follows.

Costs Option 2A

Capital Costs

19,496.2k

Recurrent Revenue Impact

681.3k

Non-Recurrent Revenue Impact 15.2k

Option 2A is considered as the “preferred way forward” and it is anticipated that the Outline Business Case will develop options around this preferred way forward. In recognition of the high complexity of this proposed reconfiguration project, detailed healthcare planning of the Tower Block will be required and this will establish sub-options of Option 2A which will be reviewed and compared, at Outline Business Case stage. As noted previously, the proposals contained within this Initial Agreement are entirely

compatible with the Greater Inverness Masterplan study review, and furthermore form a platform for the latter’s outcomes. The Greater Masterplan review will to lead to development of a “Programme Initial Agreement” whereby it will build on the work proposed under this IA, and review all additional factors, relating to the optimal model for delivery of “fit for purpose” healthcare facilities, suitable for the next 25 years.

It is highlighted that due to the nature of the proposed investment, the capital outlay is likely to

be over a period of approximately 5 years, as the wards are undertaken on a phased basis and in alignment with the “fire precautions” project. The anticipated capital funding over the 5 year period would therefore be as follows.

Year Cost inc VAT

April 2013 – 2014 974,812

April 2014 – 2015 3,899,249

April 2015 – 2016 5,848,874

April 2016 – 2017 5,848,874

April 2017 – 2018 2,924,437

Total 19,496,246

The indicative programme for project development, based on a “HFS Frameworks 2” approach,

is provided in the following table.



8

IA CIG Meeting Date 2nd July 2013

OBC Stage / Approvals January 2014

Design and Target Price

Full Business Case development

September 2014

Full Business Case Approvals December 2014

Construction Start January 2015



9

3 Strategic Context

3.1 Organisational Overview

3.1.1 Organisation Profile

NHS Highland is one of the fourteen regions of NHS Scotland. It employs over 9,000

people, making it one of the largest employers in the region. Geographically, it is the

largest Health Board, covering an area of 32,500 km² from Kintyre in the south-west

to Caithness in the north-east, serving a population of over 300,000 people, and

sees a proportion of its patients from the influx of tourists to the Highlands, which at

certain times of the year, can double or even triple the local population.

NHS Highland provides strategic leadership and direction for NHS services and is

accountable to the public and to the Scottish Government for all elements of the NHS

system in the Highland and Argyll & Bute Council areas. As of 1st April 2012, with

the integration of health and social care in the Highland region, NHS Highland is the

lead agency for the delivery of Adult services across health and social care (The

Highland Council are the lead agency for children's services). NHS Highland works

with partners to improve the health of local people and the services they receive and

to ensure that national clinical and service standards are delivered across the NHS

system. NHS Highland is working to improve services with the involvement and

support of the public, partners in other NHS Boards, Highland Council, other

independent and voluntary agencies.

3.1.2 NHS Highland Management

NHS Highland is managed by a Board of Directors which is accountable to the

Scottish Government through the Cabinet Secretary for Health and Wellbeing. The

Board is accountable for the performance of all NHS Highland services. The Board’s

operational decision making structure is shown below.

http://en.wikipedia.org/wiki/NHS_Scotland

http://en.wikipedia.org/wiki/Kintyre

http://en.wikipedia.org/wiki/Caithness



10

3.1.3 Operational Units

The planning, coordinating and delivery of services across NHS Highland is managed

through two Partnerships:

Highland Health and Social Care Service - Covering the same area as the

Highland Council, the Partnership is made up of three operational units: North &

West Highland; South and Mid Highland; Raigmore Hospital. The Partnership is

responsible for providing a wide range of acute care, emergency care, primary

care and community based health and social care services

Argyll and Bute Community Health Partnership - Manages acute, primary,

community health and mental health services across the region. Much of the

acute and more specialist services are provided from neighbouring NHS Greater

Glasgow & Clyde. These services are purchased by the CHP through formal

contracts

NHS Highland delivers services to patients and local communities through three

operational units (which comprise the Highland Health and Social care Partnership)

and one Community Health Partnership, which is not part of the Health and Social

Care Partnership. These operational units are supported by a range of Corporate

Services including facilities, pharmacy, personnel, and finance. A summary of these

units, is provided below :



11

North and West Highland which constitutes a remote and rural area made up of

the following areas and districts:

North Area

1. Caithness (including Rural General Hospital – Caithness General in Wick)

2. Sutherland

West Area

3. Skye, Lochalsh and Wester Ross

4. Lochaber (including Rural General Hospital – Belford in Fort William)

South and Mid Highland constitutes the inner Moray Firth area, and is made up of

the following areas and districts:

Mid Area

5. East Ross

6. Mid Ross

South Area

7. Inverness West (including New Craigs)

8. Inverness East

9. Nairn & Ardersier, Badenoch & Strathspey

Raigmore Hospital

Raigmore is the single District General Hospital (including specialist services) in the

Highlands

Argyll & Bute CHP



12

Raigmore Hospital in Inverness is the district general hospital (including specialist

services) for patients in the North + West, South + Mid Community Health

Partnership areas serving patients from its own and adjacent Community Health

Partnership areas as well as those from adjacent Health Board areas.

3.1.4 Vision and Strategic Aims

NHS Highland has delivered significant achievements in recent years, treating more

patients, and providing better, faster access to diagnostic and treatment services as

well as achieving financial balance. The Board continues to seek improvement in the

quality of patient care however and, in line with other NHS Boards, has a published

Local Health Plan. This plan sets out a simple vision for the people of the Highlands:

http://en.wikipedia.org/wiki/Community_Health_Partnership

http://en.wikipedia.org/wiki/Community_Health_Partnership



13

“Quality care to every person every day”

NHS Highland, in common with all Scottish health boards, has an advantage in being

responsible for the total health needs of the population and, for integrated care. This

means it is responsible for the better health of communities through population wide

and individually focused initiatives to maximise health and prevent illness; for better

care of patients through quick access to modern services, in clean and infection free

facilities, by well trained and courteous staff; and for better value for the use of the

public money spent by ensuring there is no waste and inefficiency, money is spent

only on what is needed and has evident therapeutic benefits and variation from core

care pathways is the exception.

The importance of keeping a balance between the three components of better

health, better care and better value is fully recognised because they are intrinsically

linked and together constitute an effective health system. Any one area cannot be

prioritised over any other.

This approach is consistent with the objectives identified within the NHS Highland

Local Delivery Plan 2012/2013. The Plan sets out the strategic direction for the

Board, provides evidence of performance to date and describes the plans to address

the national targets. The key objectives associated with the Local Plan 2012/2013

are provided under Section 3.2.3.1.

3.1.5 Key Stakeholders

Key Stakeholders, involved in the consultation to date and who are associated with

the proposed investment, are highlighted as follows:

Etta Mackay – Partnership Representative

Alan Simmons – Patient Representative

Chris Lyons – Director of Operations

Stuart Lambie - Medical Directorate Clinical Lead

Claire Vincent – Consultant in Acute Medicine

Iona McGauran – Medical Directorate Nurse Manager

Morag Macleay – Service Manager Medical Directorate

Ron Coggins – Surgical Directorate Clinical Lead

William Craig MacLeman - Assistant Nurse Manager Surgical Directorate

Derek McCrae – Service Lead – Gynaecology, Urology & Breast

Andrew Ward – Assistant Surgical DGM

Angela Watt – Midwivery / Obs Gynae Manager

Kenny Clarke – Services Manager Theatres, ITU, Anaesthetics and Day Surgery

Emma Watson – Consultant Microbiologist



14

Crawford Howat– Portering & Operational Security Manager

David Mackay – Domestic Services Manager

Alison McLean – Infection Control Manager

Donna Smith – Service Performance & Partnership Manager

Doreen Bell – Clinical Advisor

Rosie McGee – Health & Safety

Iain Ross – Information Technology

Eric Green – Head of Estates

Colin McEwen – Senior Building and Fire Engineer

Brenda Dunthorne – Head of Finance

Karen Underwood – Financial Management

3.1.6 Geographical Position and Health Comparisons

The NHS Highland catchment area comprises the largest and most sparsely

populated part of the UK with all the attendant issues of difficult terrain, rugged

coastline, populated islands and a limited internal transport and communications

infrastructure. The area covers 32,518km² (12,507 square miles), which represents

approximately 41% of the Scottish land surface. The geographical nature of the

region presents particular challenges for the efficient and effective delivery of health

care services.

The area NHS Highland covers is benefiting from improved health services and so

people are now living longer. It is estimated that by 2031 the number of people aged

75 or over in Highland will double. This is important to plan for because older people

tend to make more use of health and social services. As people age it becomes more

likely that they may acquire one or more long-term condition(s) like asthma, chest

problems, depression, dementia, diabetes and heart disease as well as having a

greater risk of getting cancer. The proportion of older people is above the Scottish

average. However, levels of morbidity and deprivation are well below the Scottish

average. In total, NHS Highland will annually see and treat approximately 38,000

inpatients, 13,000 day case patients, 7,000 renal day attendances, 50,000 new

outpatients and 39,000 accident and emergency attendances. About two thirds of

inpatients are admitted as emergencies.

As noted previously, the population served by NHS Highland totals circa 310,000

people based on the GRO(S) 2008 based population statistics. This is made up of

residents of both the Highland and Argyll & Bute Council boundaries. It is anticipated

that residents of the Argyll & Bute Council area will not be significant users of any of

the services covered by this initial agreement due to the distances involved and the

Board’s objective of maintaining services as local as possible. Consequently, the

projected population figures in thousands produced by the General Registers Office

for Scotland (GRO(S)) shown below relate solely to the Highland Council area:



15

Data Source: GRO(S) 2008-based population projections (Feb 2010)

Data Source: GRO(S) 2008-based population projections (Feb 2010)

In summary, the population of Highland region has increased by around 6% over the

last 10 years and is expected to continue to grow for the foreseeable future. This

increase, past and predicted, is due mainly to net in-migration to the region, rather

than natural increase (births - deaths). The predicted increase does not take account

of any new external influences on population, such as increased inward migration

due to climate change. GRO(S) data available projects over the next 25 years within

Highland Region:

3.1.7 Epidemiological Considerations

3.1.7.1 Mortality

Cancer and circulatory diseases still account for over 60% of all deaths in NHS

Highland; this figure is in line with the rest of the UK and other developed countries.

Mortality from cardiovascular disease, the largest component of circulatory diseases,

is falling in those aged under 75 years, but the socio-economic gap remains (see

figure below).

Highland Population Shift

010203040506070

actual forecast forecast forecast forecast forecast

2008 2013 2018 2023 2028 2033

year

po

pu

lati

on

(000's

)

0-15

16-29

30-49

50-64

65-74

75+



16

Cancer incidence and number of deaths from cancer continue to increase, reflecting

the ageing of the population. Cancer survival, however, is improving and the age-

standardised death rate is falling, indicating that more people are living for longer.

The top four causes of cancer mortality remain breast, lung, bowel and prostate. Of

other major causes of death, those related to alcohol have trebled in the last 30

years.

3.1.7.2 Life expectancy

In line with falling premature mortality rates, life expectancy continues to increase,

as does healthy life expectancy, but the gap between the two is not closing,

indicating that the burden of chronic ill health in later life continues and is shifting

into older age groups. Healthy life expectancy is improving more rapidly for men

than women.

3.1.7.3 Long-term conditions

Definitions of long-term conditions (LTC’s) vary, making estimating numbers of

people with them difficult. According to local Practice Team Information, about 54%

of the population aged 16 years or over consulted their GP for a potential long-term

condition in a 1-year period; however, this figure includes many who are able to



17

manage their condition themselves. In the Scottish Health Survey, 37% of the

population reported having a long-term condition, and 11% said that their condition

limited their day-to-day activities.

The prevalence of LTCs increases with age; in the Scottish Health Survey 65% of the

over 65s reported an LTC, with 35% reporting two or more LTCs. Practice Team

Information also shows that people consulting their GPs about one LTC are more

likely than not to have at least one other LTC as well. For example, of those

consulting their GP for CHD, only 8% have no other LTC, while 67% have at least

two other LTCs.

This co-existence of multiple LTCs probably reflects the ageing population, and also

suggests that treating LTCs in isolation is no longer appropriate for the majority of

the population suffering from them.

3.1.7.4 Lifestyle risk factors

Smoking prevalence continues to fall; the latest estimates suggest that 26% of

Scottish men and 25% of Scottish women smoke regularly.

Alcohol consumption remains high at around 11.8 litres of pure alcohol per person

per year the equivalent of 570 pints of 4% beer or 42 bottles of vodka or 125 bottles

of wine. This level of consumption is enough for every adult in Scotland to exceed

the sensible drinking guidelines for men and women every week of the year.

Obesity levels continue to increase in adults: in 2008, 66% of men and 60% of

women were overweight or obese.

These changes in risk factor levels suggest that we will continue to see a reduction in

smoking-related diseases, but alcohol-related health harm, circulatory diseases,

some cancers and diabetes will continue to increase.

3.1.8 Summary Impact of Demographic and Epidemiological Data

The demographic and epidemiological changes identified in the previous sections are

likely to have two effects on those services being developed in the context of this

Initial Agreement.

1. A direct increase in demand on services based on population growth alone;

and

2. A secondary increase in demand for services based on an altered

demographic profile and epidemiological change.

The latter point here reflects a significantly increased growth in the 65+ age group

(of circa. 88%). In the face of evidence-based clinical models for each of the

services related to this Initial Agreement this demonstrates significant links between

increased age and the frequency of intervention/volume of service required.



18

3.2 Existing Business Strategies

3.2.1 Overview

The planned investment (to consolidate critical care and address compliance issues

associated with the theatres) is directly linked to delivering future hospital services in

line with, and driven by, a number of national and local strategies (described below).

Many of the local strategic objectives have been developed to meet the overall

delivery of the national strategies.

A number of factors identified in the strategies have influenced how services at

Raigmore will develop in response to such expectations and opportunities. These

factors indicate how the need for health is changing and the opportunities that are

emerging to provide services in different and better ways.

3.2.2 National Strategies

The national strategies and published guidance which have influenced the

development of the local plans, and will therefore be a key driver in the planned

investments are as follows.

The five Strategic Outcomes (the Scottish Government). These comprise

“Wealthier and Fairer; Smarter; Healthier; Safer and Stronger, and Greener”. By

investing in the redevelopment and modernisation of health services at Raigmore

Hospital, it is clear there are a large number of positive benefits to patients that

will be achieved in relation to the five “Strategic Outcomes” and relevant national

indicators.

The Healthcare Quality Strategy for NHS Scotland (the Scottish

Government 2010). This identifies the following priorities : caring and

compassionate staff and services; clear communication and explanation about

conditions and treatment; Effective collaboration between clinicians, patients and

others; A clean and safe care environment; Continuity of care; and Clinical

excellence. The planned investment is closely linked to achieving these aims.

“A Sustainable Development Strategy for NHS Scotland’ (the Scottish

Government). As with all public sector bodies in Scotland, NHS Highland must

contribute to the Scottish Government’s purpose: ‘to create a more successful

country where all of Scotland can flourish through increasing sustainable

economic growth’. The planned investment should help to enhance the

contribution of the health sector to sustainable development in respect of

procurement; facilities management, employment and skills, community

engagement, improved efficiency and energy efficient infrastructure

NHS Scotland Efficiency and Productivity Framework. The Framework’s

main purpose is to identify priority areas to improve quality and efficiency. The

Framework is a companion to the Quality Strategy and provides a baseline for

the changes that will need to be undertaken by the Scottish Government Health

Directorates (SGHD), NHS Boards and other public sector organisations.



19

The Scottish Patient Safety Programme launched in 2008. This is being

implemented in every acute hospital in the country. The initial goals are to drive

improvements in Leadership, Critical Care, General Ward, Medicines Management

and Peri-Operative. Highlighting critical care as a goal of the programme, this

investment will play a key part in helping to contribute towards the programme’s

objectives.

National Framework for Services Change in NHS Scotland (2005). This

identifies the 3 key drivers for change to be taken account of as : demographic

change, workforce pressures and developments in technology

“Building a Health Service Fit for the Future” (2005). This document sets

out the challenges facing the NHS in Scotland, in particular our ageing population

and the rising incidence of long-term or chronic conditions. The report also

recognises the particular issues facing rural communities, including access to

services and transport. Clearly this has particular relevance to NHS Highland.

“Delivering for Health” (2005). A document which describes the need to

focus more on preventing ill health and reducing the impacts of long term

conditions. This approach aims to provide as much care as possible in people’s

own communities, and to reduce acute admissions to hospital, especially

unplanned or emergency admissions.

“Better Health Better Care Action Plan” (2007). This document builds on

earlier work, and sets out a series of actions to “help people to sustain and

improve their health, especially in disadvantaged communities, ensuring better,

local and faster access to health care”

Scottish Government - Asset Management Policy. This Initial Agreement is

aligned with the Scottish Government’s Asset Management policy of bringing

more consistency to the management of the NHS Highland estate in order to

improve efficiency and effectiveness across the whole of NHS Scotland. The

development proposed is an important opportunity to consolidate and rationalise

the existing estate.

Policy for Design Quality for NHS Scotland - NHS Highland recognises and

fully supports the requirements presented in CEL 19 (2010) related to policy on

design quality for NHS Scotland.

3.2.3 Local Strategies

A number of themes embedded in the national strategies (described above) are

influencing the local strategic objectives and future models for changing the delivery

of clinical services in Highland. The key strategies are summarised as follows and

described further in the subsequent sections.

NHS Highland Local Delivery Plan 2012/2013



20

HEAT Targets (contained within the above)

Quality & Efficiency Framework

NHS Highland Greater Inverness Masterplan

Workforce Strategy

Public and Staff Engagement Strategy

3.2.3.1 Local Delivery Plan 2012 / 2013

NHS Highland’s mission is to provide patient-centered services tailored to people’s

needs in a systematic and consistent way providing quality care to every person

every day. Our approach embraces the Healthcare Quality Strategy for Scotland and

also takes account of the priorities within the NHS Scotland Efficiency and

Productivity Framework for SR10. The described vision is to :

Provide quality care at all times;

Support people and communities to maximise their own health;

Develop precisions driven services so that when people need our care they

experience timely, focused, effective services that minimise the duration and

frequency of contact;

Ensure that every health pound spent delivers maximum health gain.

The NHS Highland 2012/13 Local Delivery Plan focuses on the contributions to 4 national priority areas:

Health inequalities

Early years

Tackling poverty

Economic recovery

The investments proposed in this Initial Agreement (IA) will make a significant

contribution to the goals of the NHS Highland Local Delivery Plan by sustaining and

building upon the developments in acute care. In particular the investments will:

Provide services and facilities which meet 21st century healthcare needs and are

acceptable to both staff and patients.

Ensure that services are continuing to progress towards the achievement of

national standards.

Provide an environment which enables staff development, recruitment and

retention as well as community involvement and ownership.



21

high quality, integrated, equitable, needs and evidence-based, and cost-effective

increasing focus on hospital beds being preserved for the most acutely ill and

those with specialist needs

run by healthy, flexible, well-motivated and well-trained staff working to their

maximum potential and capability

using modern, flexible, efficient, green assets to maximum effect

reduce wastage and inefficiency across acute services

3.2.3.2 HEAT Targets

NHS Highland’s Local Delivery Plan for 2012/13 identifies and targets performance

against HEAT targets. This is, and will continue to be, monitored and reported in the

NHS Highland Balanced Scorecard. In terms of Raigmore Hospital, it is clear that the

proposed clinical service improvements will make a significant contribution to the

achievement of HEAT targets. In particular the following HEAT targets are

highlighted which will have a positive benefit from the proposed development.

NHS Scotland to reduce energy- based emissions and to continue a reduction in

energy consumption which will contribute to the greenhouse gas emissions

reduction targets set in the Climate Change (Scotland) Act 2009

No people will wait more than 28 days to be discharged from hospital into a more

appropriate care setting, once treatment is complete from April 2013, followed by

a 14 day maximum wait from April 2015.

Further reduce healthcare associated infections so that by 2012/2013 NHS

Board’s staphylococcus aureus bacteriamia (including MRSA) cases are 0.26 or

less per 1000 acute occupied bed days, and the rate of Clostridium difficile

infections in patients aged 65 and over is 0.39 cases or less per 1,000 total

occupied bed days.

3.2.3.3 NHS Highland Quality Approach

The Quality Strategy sets out NHS Scotland’s vision to be a world leader in

healthcare quality, described through 3 quality ambitions: effective, person centred

and safe. These ambitions are articulated through the 6 Quality Outcomes that

NHS Scotland is striving towards:

The Highland Quality Approach captures the spirit of how NHS Highland is working to

improve care and outcomes for people in Highland. It describes our ways of

working, values and behavior. It recognises how important it is to improve the

health of the population and get the experience of care right for individual people,

every time. We will deliver this by focusing on providing person-centred care while

at the same time eliminating waste, reducing harm and managing variation.



22

The Highland Quality framework is captured in our “blue triangle”. It has been

designed to place the individual at the top, with everything else we do supporting

this purpose. In developing our approach we have drawn from the best learning we

could find. The key elements of the Highland Quality Approach, summarised in the

blue triangle, include our Mission, Vision and Values. It also describes how services

and care will look in the future as well as how we are approaching changing the way

we deliver services and care.

NHS Highland’s vision is to provide ‘Quality Care to Every Person Every Day’. In

delivering this vision, three key elements must be delivered simultaneously:

Better Health – improving the health of the population

Better Care – enhancing the experience of care for individuals

Better Value – controlling the per capita cost of care

By reviewing the above key elements which make up the Quality Approach, it is clear

that investment (in consolidation of critical care and Theatres compliance issues) at

Raigmore Hospital, will make a significant contribution to the mission, vision and

values. In particular the investment will improve the overall care of the patient both

in terms of quality of care and an improved environment.

3.2.3.4 NHS Highland Greater Inverness Masterplan Study (On-going).

As noted previously NHS Highland are currently implementing a substantial

Masterplanning Exercise for the Greater Inverness Area. Both clinical and non clinical

facilities are being considered along with options for optimum future Healthcare

provision in the Highlands linked to clinical need over the foreseeable future. The



23

development of this Initial Agreement document has been undertaken in close

alignment with the masterplan development.

Key findings are emerging from the ongoing Masterplan Exercise work, and which

have direct relevance to driving the investment and scope described within this

Initial Agreement document. These findings are summarised as follows.

The Raigmore “component” is a major element of the emerging Masterplan

Exercise that is being utilised to achieve positive outcomes that extend beyond

the primary objective of the capital investment into a more widespread range of

benefits in support of the estate strategy

The ongoing re-development of level 7 (top floor) of the “tower block” (under the

“Fire Precautions Upgrade project”) represents the commencement of a more

widespread investment need in this important area of the estate (the Tower

Block) that is now around 30 years old

The Masterplan Exercise will build on the need for urgent improvements to

address Critical Care deficiencies in the existing model of care. This will define

the need for the integration of critical care at ground and first floor levels of the

Tower Block, together with the need for improved adjacencies for various

services

The “Fire Precautions” project presents a unique opportunity to undertake

appropriate further improvements, and reconfiguration, at a time when existing

wards will be vacated in any case, thus minimising disruption to ongoing clinical

services.

The briefing for new facilities should, wherever possible, meet the higher

standards of technical specifications defined within the latest relevant technical

guidance and/or NHS Highland Estate Strategy.

The Masterplan Exercise will define the need for a project that will facilitate the

removal of temporary buildings that have provided a “stop gap” solution to some

service needs

The location of the facilities should allow staff to utilise existing services as far as

possible rather than duplicating them in the new care structure

The Masterplan Exercise will recognise the poor condition of some

accommodation, major compliance issues and the lack of available space

associated with the Theatres

The Masterplan exercise will recognise the increasing demands on theatre

accommodation and the need for some re-alignment of operating procedures

across the existing theatre accommodation at the Hospital.



24

3.2.3.5 Workforce Strategy

The successful delivery of NHS Highland Strategic Framework requires the

contribution of the workforce to realise the vision ‘Quality Care to every patient

every day’ and delivery of the Triple Aim: Better Health, Better Care and Better

Value.

Workforce design, development and delivery, underpinned by workforce plans and

policies that support efficient, flexible working practices and are capable of

responding to current NHS challenges, are important. They will help to improve

health, reduce inequalities and deliver HEAT and efficiency targets on time; in turn

delivering safe, high quality health care services to patients in a way that is both

affordable and sustainable.

This Workforce Development Plan for NHS Highland 2012/13 incorporates Learning

and Development. This integrated approach has been underpinned by close working

with Partnership Forum through relevant sub groups.

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 .

3.2.3.6 Public and Staff Engagement Strategy

NHS organisations are under a legal duty to inform and involve service users and

staff in the design and delivery of health services. NHS Highland’s strategy is to

facilitate engagement and inform effectively. This reflects the growing evidence that

where people are given good information and involved in the right way it increases

trust and confidence in the NHS. On this basis, the consultation associated with this

investment has included public / staff engagement.

3.2.3.7 Sustainability

NHS Highland is committed to meeting the needs of the present without

compromising the ability of future generations to meet their needs in all of its

activities. NHS Highland takes cognisance of the principles laid down both locally and

nationally for the promotion of sustainability in all activities undertaken by the Public

Sector. Accordingly, the project will promote sustainability across various fields

including the following :

Use of sustainable materials in design

Passive energy service measures

Efficient services installations

Replacement of inefficient plant



25

The provision of facilities capable of sustaining growth

Provision of modern, fit for purpose and efficient NHS facilities that sustain

growth

3.2.4 Critical Care Policy and Trends

A Report by a Working Group of the Scottish Medical and Scientific Advisory

Committee (SMASAC) on High Dependency Unit (HDU) Beds (SGHD 2008) identified

that High Dependency Care in Scotland is inequitable and in many cases insufficient.

The Report recommended that all NHS Boards should undertake an assessment of

need for HDU beds (SGHD 2008). In response, the Scottish Critical Care Delivery

Group was tasked by the Chief Medical Officer to co-ordinate a needs assessment

exercise in all Health Boards to provide a national picture of the provision of, and

need for HDU beds. It was also recommended that each Health Board use an agreed

methodology previously developed in NHS Tayside (Colvin 2003).

Accordingly, NHS Highland approved the funding of a study to review the provision

of, and need for adult High Dependency Unit (HDU) beds in NHS Highland but also to

make recommendations to the Health Board to inform the development of Critical

Care strategy within NHS Highland. The Report therefore includes analysis of both

HDU and Critical Care at Raigmore Hospital.

Prospective data was collected over a 14 week period of all adult in-patients in

Raigmore Hosptial, Belford Hospital, Caithness General Hospital and Lorn & Islands

Hospital who met criteria for admission to the Critical Care Levels of Care 0 – 3. The

results and recommendations were presented in a High Dependency Needs

Assessment report, which is available upon request. This study, together with a

number of key reference documents utilised, are highlighted below.

The High Dependency Needs Assessment of NHS Highland

Patients

NHS Highland

Critical to Success: the place of efficient and effective critical

care services within the acute hospital.

Audit Commission

(1999)

Comprehensive Critical Care: a review of adult critical care

services

Department of

Health (2000)

Better Critical Care: Report of Short-Life Working Group on

ICU and HDU issues

Scottish Executive

Health Department

(2000)

It was argued that the traditional division into High Dependency and Intensive Care,

based on beds, be replaced with a philosophy of Critical Care, focussing on an

individual patient’s journey along a Critical Care continuum. This new approach to

Critical Care was concerned with the care of patients at risk of critical illness and of



26

those recovering from such an illness as well as of patients during the critical illness.

Four levels of care for Critical Care patients were identified:

Level

0

Patients whose needs can be met through normal ward care in an

acute hospital.

Level

1

Patients at risk of their condition deteriorating, or those recently

relocated from higher levels of care, whose needs can be met on an

acute ward with additional advice and support from the Critical Care

team.

Level

2

Patients requiring more detailed observation or intervention including

support for a single failing organ system or post-operative care and

those ‘stepping down’ from higher levels of care.

Level

3

Patients requiring advanced respiratory support alone or basic

respiratory support together with support of at least two organ

systems. This level includes all complex patients requiring support for

multi-organ failure.

Section 4.2.3 reviews the critical care provision, and associated services at Raigmore

Hospital, in the context of the above.

3.2.5 Theatre Policy and Trends

Operating Theatres provide specialist facilities that enable surgeons to undertake

surgical interventions (procedures or operations) on patients whose medical

condition requires the same. It also provides accommodation for minimally invasive

procedures conducted under radiological control by either radiologists or surgeons.

Although the level of intervention will vary by patient, in general, within the

operating department, patients are received, reviewed, anaesthetised, operated

upon and recovered.

The service provides for emergency and elective patients who require surgical

intervention and/or other procedures that require to be conducted within an

operating room environment and/or anaesthesia, with facilities that allow functional

groups to care for pre, intra and post-operative/anaesthesia patients in a low risk

environment. Operating theatre services are delivered from a range of hospital

locations across NHS North Highland that include:

9 x General operating theatres at Raigmore Hospital

1 x modular operating theatre (predominantly day case) at Raigmore Hospital

1 x maternity operating theatres at Raigmore Hospital

1 x General operating theatre at the Belford Hospital, Fort William



27

2 x General operating theatres at Caithness General Hospital, Wick

1 x General operating theatre at The Lawson Memorial Hospital, Golspie

2 x General operating theatre at The Dr MacKinnon Memorial Hospital, Broadford,

Skye

Increasingly stringent training standards, in combination with more complex working

environments and the difficulties associated with delivering “compliant” staff rotas in

all surgical specialties, is making it more onerous to continue to deliver these

complex services in as wide a range of locations. NHS Highland has managed to

sustain services through a combination of investment in staffing resources and

complex shift/rota planning that is designed to optimise available resources.

Surgery can be delivered on an outpatient, day-patient and in-patient basis, with an

increasing move towards non-inpatient and shorter lengths of stay in hospital. NHS

Scotland, in reflection of the global advantages associated with increased day

surgery rates, has encouraged NHS Boards to actively look at their elective

procedures and make day case surgery the default position whenever this is clinically

appropriate. They identify many benefits associated with this approach that include:

Lower risk of hospital acquired infection vis a vis inpatient treatment

Reduced time in hospital for the patient

Care that is better suited to the patients needs

Lower risk of surgery being cancelled (as long as day surgery facilities are

separate from those for emergency patients)

The British Association of Day Surgery (BADS) verifies these claims, noting that

patients overwhelmingly endorse day surgery, which generally provides timely

treatment, reduced risk of last minute cancellation, lower incidence of hospital-

acquired infections and an earlier return to normal activities. They further state that

day surgery provides better value for money overall. In order to support a move

towards day surgery, there is an ongoing commitment of NHS Boards to increase the

percentage of BADS procedures carried out as day cases or outpatients.

Section 4.2.4 reviews the theatres provision, and associated services at Raigmore

Hospital, in the context of the above.



28

4 Investment Objectives, Existing Arrangements / Business Needs

4.1 Investment Objectives (SMART)

Noting the need for project objectives to relate to the key strategies previously

referred to in Section 2.2, a review was undertaken to establish key “SMART”

Investment objectives for the project based on the SCIM guidance. Following review,

these SMART objectives were established and a detailed summary of the output

(including baseline data for measurement and timing of assessment of the

objectives) is provided within Appendix A.

A new project to consolidate critical care together with theatre upgrade work (and

associated realignment of acute services) is considered an essential component of

achieving NHS Highland’s vision and strategic aims. A summary of the SMART

objectives is provided below:

No.. SMART Objective Heading

1 To improve business effectiveness and revenue efficiency

2 To improve HEAT and other Health targets (including waiting times for

theatres / BADS targets)

3 Augment range of services and promote emerging model of care including consolidation of critical care

4 Make possible the introduction of new ways of working and in particular

effective collaborative working and flexibility in the workforce

5 Improved facilities / increased capacity offering a patient centred service

including greater consistency of care and increased certainty for admissions, procedures and discharge

6 Concentrate higher and lower levels of care at appropriate locations

7 Offer facilities which reduce risk of spread of infection compared to status quo

8 To achieve optimal utilisation of space (within the constraints of existing buildings)

9 To achieve operational and functional efficiency of physical environment

10 To deliver high quality facilities, and technical standards with a strong focus on lifetime costs, quality and design.

11 To comply with “A Sustainable Development Strategy for NHS Scotland’, to

enhance the contribution of the health sector to sustainable development

12 To enable the retention and recruitment of staff



29

4.2 Existing Arrangements and Analysis

4.2.1 Raigmore Hospital

Raigmore Hospital, in Inverness, is the district general hospital (including specialist

services) for patients in the North + West, South + Mid Community Health

Partnership areas, serving patients from its own and adjacent Health Board areas.

The Hospital comprises part single, part two, part three and an eight storey block

(“the Tower Block”) covering an overall foot print of circa 94,000 m2.

The Tower Block forms part of the original “Phase 2” development of Raigmore

Hospital and was opened in 1985. It is the most prominent part of the Hospital,

comprising ward and associated accommodation on 8 floors, providing various

medical and surgical services. Critical care services, both Medical and Surgical

related, are currently provided within different wards spread around the Tower Block,

arising from development over a historical period.

The Theatres are provided at first floor level, within an adjacent building, albeit they

are fully accessible at first floor level of the Tower Block.

4.2.2 Tower Block

General

Over the years, significant changes to the use of the accommodation have occurred

in terms of clinical services provided. However the basic physical ward configuration

has remained broadly the same. Ground level to level 7 of the ward block are

typically divided into 3 areas as follows:

Ward A – South Wing typically ward accommodation

Ward B – Central Core typically ward accommodation

Ward C – North Wing typically ward accommodation

“West Wing” – typically ancillary or office accommodation as well as the only lift

core area.

Fire Precautions Upgrade Project

It is highlighted that a long term construction project to significantly improve fire

precautions within the Tower Block is currently ongoing. This includes the provision

of a new fire sprinkler system, reinstatement of fire partitions and improvements to

horizontal fire evacuation across all 8 floors. To minimise disruption, these

improvements are being undertaken through a series of 3 month decants and on a

ward by ward basis. To date, the currently unoccupied Ward 7A, has been completed

and this ward is being utilised as the main “decant ward” for the majority of the

subsequent works.



30

Level 7 (7C) Medical GI/Renal (30) Management (7A) Decant Ward

Level 6

(6C) Cardiology/Step Down (?30) CCU (6)

AMAU/MSCU (30)

Level 5 (5C) Vasc/Urol Surgery (20) (14 closed) Derm (9)/Offices (5A) Medical (25)

Level 4 (4C) Surgical (29)

SHDU (6 ) Seminar Room

and offices (4A) Surgical (29 + 5 T)

Level 3 (3C) Orthopaedics (28) Head & Neck

(3A) Orthopaedics

(30)

Level 2

(2C) Oncology with D/C Transfusion

Therapy

(2A) Stroke/YARU (22) (8)

Level 1 ITU (8)

Critical Care Waiting area

1A (CAL 13) EDCU (6) SDCU (12)ITU (8)

Ground Endoscopy Paediatrics

In acknowledgement that the Wards in the Tower Block will be vacant during these

works, over the next 4 years or so, this presents a unique opportunity to undertake

the planned reconfiguration work, as described within this document, in parallel and

without further disruption to patients and clinical services.

Tower Block – Current Services

The current configuration of clinical services is best represented by a cross-section

through the Block, as illustrated below.

In conjunction with the above diagram, the following table provides an overview of

the clinical services provided by NHS Highland that are within the scope of this

project.

Current

Floor

Clinical Service Brief Summary of Services

7 Decant Ward Ward 7A was recently used for administration offices,

but was decanted to allow commencement and the

delivery of the “fire precautions” project. The ward can

be used temporarily during each phase of the works.

7 Management A suite of management offices is currently located at

Level 7B

7 Medical / GI / Renal Renal services including specialist services and renal

replacement therapy

6 AMAU Acute Medical Assessment Unit

6 MSCU Medical High Dependency Unit (this is a 4 bed HDU)



31

6 CCU Medical Critical Care Unit

6 Cardiology / Step

Down

Step-Down Unit provides intermediate nursing care

5 Acute Medical Elderly For elderly patients who have complex medical, social and sometimes mental health issues.

5 Dermatology Inpatient unit for patients with severe skin conditions

5 Vascular/Urology

surgery

Urology - medical and surgical specialty

4 General Surgery Generic Surgical ward

4 SHDU 6 Bedded Surgical High Dependency Unit for critically unwell surgical patients , but who do not require I.C.U care

4 Surgical Main Surgical Ward

3 Orthopaedics Main Orthopaedic Ward

3 Head & Neck Ward for Patients required head and neck treatment /

surgery

2 Oncology Oncology ward for the treatment of cancer treatment

2 DC Transfusion Day Case Transfusion

2 Therapy General Therapy Unit

2 YARU The Young Adult Rehabilitation Unit

2 Stroke Main Stoke Ward

1 ITU Intensive Care Unit for patients with the most serious

injuries and illnesses requiring close monitoring and

support from specialist equipment

1 Critical Care Waiting

Area

Waiting area associated CCU (Medical and Surgical)

1 CAL Common Admissions Lounge

1 EDCU The eye day care unit is a dedicated treatment unit that undertakes all eye surgery such as cataract removal

1 SDCU Surgical Day Case Unit

G Paediatrics Child Ward In-patient and Out Patient

G Endoscopy Endoscopy services

4.2.3 Critical Care – Existing Services and Analysis

4.2.3.1 Summary of Facilities

Section 4.2.3 summarises the current configuration of critical care at Raigmore

Hospital. As noted previously, Critical Care bed provision for Level 2 and Level 3

patients at Raigmore currently comprises 24 beds as follows.



32

ICU 8 bed

Level 1

The 8 bedded ICU is located on Floor 1, adjacent to Theatre.

Seven ICU beds are funded, to provide the traditional 1:1

nurse-patient ratio (BACCN 2009). Escalation above 8

patients impacts on Theatre, since these patients are

physically managed in Theatre Recovery with some

involvement of Theatre personnel. Medical management of

the ICU is provided by 5 Consultant Anaesthetists. There is

also a dedicated middle grade doctor facility during normal

hours, which continues out of hours but also includes

obstetrics. The ICU is fully equipped to include central

monitoring and modern ventilators. Adjacent to the Unit,

there is a waiting room plus a separate room where sensitive

communications with relatives can take place (as distinct

from a charge nurse’s or doctor’s office). Overnight

accommodation is also available adjacent to the Unit.

Surgical

HDU

6 bed

Level 4

The 6 bedded general surgical HDU is located on floor 4,

alongside but separate to surgical wards. It is staffed to

provide the recommended 1:2 nurse-patient ratio. Medical

management is provided by consultant surgeons who retain

responsibility for their own patients, but there is no

dedicated medical staffing for the Department. It is fully

equipped to include central monitoring. Isolation facilities

exist for 2 beds, albeit without en-suite facilities. However,

the main body of the HDU is cramped, which has implications

in terms of patient confidentiality and privacy.

Medical

HDU

4 bed

Level 6

The 4 bedded general Medical HDU is located on floor 6,

within the Acute Medical Admissions Unit (AMAU), and next

to CCU. It is staffed to provide a 1:2 nurse-patient ratio.

Medical management is provided by consultant physicians

who normally retain responsibility for their own patients. But

there is dedicated consultant physician involvement for one

session per week from a doctor with an interest in this

specialty. There is also a dedicated middle grade doctor

facility, sharing with CCU, during normal hours. The HDU is

fully equipped to include invasive but not central monitoring.

But this department is also cramped which, again, has

implications in terms of patient confidentiality and privacy.

CCU 6 bed

Level 6

The CCU is co-located with the AMAU, but also with the

Cardiac Step-Down Ward. The CCU is a 6 bedded

department, essentially a specialist HDU, providing a facility

for cardiac patients. Nurse staffing is similar to the 2 general

HDUs, with medical management being provided by

consultant cardiologists, and middle grade doctors as already

described. The CCU is fully equipped with central



33

monitoring. It also provides a telemetry facility for up to 6

cardiac patients outwith the CCU. The CCU is spacious and

purpose-designed. All of its rooms are single rooms, albeit

without en-suite facilities. This is the only Critical Care Unit

within NHS Highland that is compliant with guidance that at

least 50% of Critical Care Unit beds should be single rooms

to reduce the risk of healthcare associated infection (DoH

2003b).

4.2.3.2 Study – NHS Highland Review of HDU Needs / Critical Care Strategy

As noted in Section 3.2.4, NHS Highland undertook a study to review the provision

of, and need for adult High Dependency Unit (HDU) beds in NHS Highland but also to

make recommendations to the Health Board to inform the development of Critical

Care strategy within NHS Highland. This study covered adult in-patients in Raigmore

Hospital, Belford Hospital, Caithness General Hospital and Lorn & Islands Hospital. A

full copy of the study is available on request.

Data was produced to help describe the strengths and weaknesses of current Critical

Care provision in NHS Highland plus the challenges and opportunities for future

development. The study presented a comprehensive review and analysis of the

various issues associated with the provision of critical care at Raigmore Hospital,

including various recommendations with regard to improving practices and

efficiencies within the Hospital, some of which are being implemented without the

need for significant investment. However, the following key issues and problems

have been highlighted with specific regard to the need for more fundamental change

and investment.

Lack of Integrated Critical Care

with Single Nursing / Administration service

With regard to the provision of Critical Care, the historical

sequence of developments has been supported by the notion of

placing Critical Care services close to their various specialties.

Historically, the development of HDUs has been unplanned and

haphazard and largely relied on the interest of local clinicians to

drive development. Raigmore Hospital’s Critical Care service is

spread across 3 floors, 4 departments and 2 clinical directorates,

Medical and Surgical. The study confirms that this results in

increased nursing and administration costs, a lack of flexibility,

and a less patient focused service.

A major thrust of the 2 Health Department reports on Critical

Care (DoH 2000, SEHD 2000) is the need for flexibility in the

provision of service. Hugely significant is that both of these

Reports (DoH 2000, SEHD 2000) recommend that, wherever

possible, all Critical Care beds should be in adjacent locations:

‘Economies of scale and great benefits of flexibility can be

achieved by siting HDUs in or next to ICUs, with use of a



34

common nursing workforce. With such an arrangement, a bed

can be an HDU bed in the morning and an ICU bed in the

afternoon, or vice versa, depending on need’ (SEHD 2000).

‘Flexibility is the real key to coping with growing pressures,

especially peaks in demand’ (SEHD 2000).

Too High Level of Occupancy

The data showed Raigmore Hospital having high occupancy, but

with much lower (but similar) occupancy in the 3 RGHs. The

high occupancy within Raigmore Hospital reflects that it is the

main provider of acute services in NHS Highland.

Lack of HDU and CCU Beds

/ Too early Discharge

A frequently cited or recorded reason for patients that required a Level 2 standard of care being in general wards was lack of HDU

or CCU beds. A lack of available beds is directly related to levels of occupancy. The occupancy level for the 2 HDUs and CCU, was high. Several patients within general ward areas were assessed

as requiring a Level 2 standard of care, having been discharged too early from an HDU.

Respiratory Medical Ward Operating as HDU

Results reveal that 44% (12/27) of all ward-based medical patients assessed as requiring a Level 2 standard of care were in respiratory medicine.

Too High a Level of Care

Results from the Needs Assessment Audit for Raigmore Hospital show that 33% (29/87) of all patients in the 2 HDUs and CCU were receiving too high a Level of Care.

Poor Patient

Flow Poor patient flow was identified. Ultimately, better management

of patient flow between areas will maximise opportunities for

critically ill patients to receive high quality care in an appropriate

setting.

Inappropriate Admission Policy

The study provides evidence to suggest that there is inequitable

critical care access for medical and surgical patients eg some

cases of medical care patients with a requirement for ward-based

Level 1 care, being placed in Medical HDU. Consequently there

will be other patients receiving too low a level of care due to lack

of critical care facilities.

Similarly there was evidence to suggest there was inappropriate

discharge policy for Surgical HDU. This was to relieve pressure

on nursing staff within the 2 step-down surgical wards by

delaying the transfer from Surgical HDU of recovering patients

who would require a high degree of Level 1 care.

Lack of Available Critical Care Beds for Cardiac

During the data collection process, the Project Co-ordinator noted that patients were admitted to wards with cardiac conditions that merited admission to CCU. However, at assessment these patients were no longer requiring a Level 2 standard of care. This information is noted to again show the



35

Patients extent of need for Critical Care beds.

Lack of Isolation Facilities

A model of care has existed over several years whereby Level 2 general medical patients needing isolation facilities are admitted to CCU, even though these patients have no cardiac conditions. (A reciprocal arrangement allows for the admission of a cardiac patient to the Medical HDU, should CCU be full in consequence of having accepted a non-cardiac patient.). The Medical HDU, as

previously described, has no single rooms. It is the only Critical Care Unit in Raigmore Hospital that is unable to provide isolation facilities to critically ill patients.

ITU deficiencies

The design of the ICU has not altered in over 25 years since Raigmore Hospital was built. Some aspects of design are

lagging. For example, the Unit has isolation facilities for just 2

patients. In recent years, this has proved inadequate with infectious patients also being managed in the 6 bedded bay area. This leads to the temporary closure of beds adjacent to the infectious patients as part of measures to prevent cross-infection. Therefore, the out-moded design of the ICU impacts on its ability to operate an efficient and cost-effective service.

But there are other design faults with the ICU. For example, the visitors’ entrance/exit to the Unit (that is, the public access) necessitates close proximity to the medical equipment and intravenous fluids store rooms. Whilst nursing staff will endeavour to escort family members to and from the Unit, this cannot be guaranteed at times when staff are operating under extreme pressure. With regard to these issues of infection

control, security and efficiency, there is clearly a requirement for the design of the ICU to be up-graded.

Too High Level of Care

Results from the HDU Needs Assessment Audit show that 7% (3/41) of patients in the ICU were receiving too high a Level of Care. This, as will become evident, relates to structural deficits

necessitating a Level 3 care requirement where the true requirement would have been for Level 2 care.

Lack of HDU beds

Within Raigmore Hospital, there is the need to address the

various factors that inflate demand for Critical Care beds – sub-

optimal bed management; sub-optimal care at ward level;

inappropriate admission and discharge policies; lack of CCU

‘ownership’ of cardiac triage; lack of isolation facilities in Medical

HDU and wards; uneven scheduling of surgical activity;

knowledge/skills deficit at Level 2 and lack of a co-located,

integrated Critical Care service with a single nursing and medical

administration. Therefore, additional investment in Critical Care

beds should be sequential to maximising the efficient and

effective use of existing Critical Care beds.

That said, the findings of this report also support that there is under provision of HDU beds, especially Medical HDU beds, within Raigmore Hospital.

Lack of HDU This also relates to too high level of care being provided (in ICU)



36

Beds due to lack of HDU beds to facilitate discharge from the ICU

noting that the cost of beds in ICU is approximately double that of HDU

Therefore, it may be reasonably asserted that there is a shortfall of 4 HDU beds, especially Medical beds, within Raigmore Hospital. But having regard to the significant cost implications and the discussion that has taken place concerning maximising flexibility and economies of scale, this number could be

legitimately reduced by a co-located, integrated Critical Care service

ICU Beds Consideration must also be given to ICU bed provision. The very high occupancy data for 7 staffed ICU beds (86% during this study; 78% according to SICSAG (2009) data) support that an

additional ICU bed should be funded. But as with the earlier discussion, this should be sequential to addressing the factors that inflate demand for ICU beds – lack of HDU beds; inequity of access to Medical HDU beds; lack of CPAP provision in Surgical HDU; and lack of a co-located, integrated Critical Care service with a single nursing and medical administration. If these factors are addressed successfully then the current ICU bed provision is

likely to prove adequate

4.2.4 Raigmore Theatres – Existing Services and Analysis

4.2.4.1 Existing Provision

The existing main operating department at Raigmore, where all surgical activity

takes place, includes 9 x operating theatres and 1 modular operating theatre (as well

as the Maternity theatre located separately) all with associated anaesthetic rooms,

preparation areas and recovery spaces. In summary the theatres, and associated

facilities, are utilised as follows.

Theatre No. Clinical Activity

Theatre 1 Ophthalmic Surgery 4 days, Orthopaedic half day & ENT

half day

Theatre 2 (Mon - Fri 09.00 - 17.00) Gynae 3 days, Vascular 1 day

& Upper GI 1 day

(Mon - Fri 17.00 - 09.00 / Sat & Sun 24hrs) Emergency

Obstetric theatre

Theatre 3 5 days Ear Nose Throat

Theatre 4 Urology 4 days, Upper GI 1 day

Theatre 5 Upper GI 1 day, Breast 1 - 2 days, Vascular 1 day,

Paediatric 1half day

Theatre 6 Head & Neck 1 day, Colorectal 2 days, dental 1 day

Theatre 7 Orthopaedic elective 5 mornings, Orthopaedic trauma 5

afternoons, Orthopaedic emergencies

Theatre 8 Emergency theatre 24hrs/7days

Theatre 9 Orthopaedic Elective 5 days



37

Theatre 10

(Modular)

Gynae / Breast / Ortho Day Surgery

The Operating Department (Operating Theatres) caters for all surgical specialities,

scheduled, unscheduled, in-patient and day case procedures – resulting in a complex

and frequently inappropriate mix of patients in shared areas. The area provides

specialist facilities that enable surgeons to undertake surgical interventions

(procedures or operations) on patients whose medical condition requires the same. It

also provides accommodation for minimally invasive procedures conducted under

radiological control by either radiologists or surgeons.

Although the level of intervention will vary by patient, in general, within the

operating department, patients are received, reviewed, anaesthetised, operated

upon and recovered. The service provides for emergency and elective patients who

require surgical intervention and/or other procedures that require to be conducted

within an operating room environment and/or anaesthesia, with facilities that allow

functional groups to care for pre, intra and post-operative/anaesthesia patients in a

low risk environment.

4.2.4.2 Theatres – Condition and Physical Environment

Raigmore Hospital’s main operating theatre department has existed, along with the

Tower Block, for a period of around 30 years without any significant refurbishment.

During that period there have been significant improvements in theatre practice,

which whilst beneficial, has resulted in an increasing amount of necessary equipment

with a consequential demand for space. Furthermore, due to the lack of

refurbishment over this period, the existing fit-out and services infrastructure has

fallen well behind SHTM’s and other relevant standards. A summary of the various

issues is provided below.

4.2.4.3 Compliance with Modern Healthcare Standards

Due to the recent lack of refurbishment, the theatre accommodation currently fails to

meet modern healthcare standards in terms of level of fit-out and furnishings. The

existing installation also fails to meet full compliance in terms of compliant doors,

floors, ceiling finishes, lighting and the like. The physical condition of the premises is

of a standard that is representative of a building of approximately 30 years old. It

fails to meet modern healthcare standards in terms of functional requirements, space

needs, compliance with current clinical guidance and acoustic criteria.

The accommodation is cramped throughout and is characterised by inadequate

cluttered corridors, full of equipment and inadequate space such as the current

provision of a make-do reception, to allow a children’s waiting area to be provided.

All this compromises the provision of care for patients and similarly, staff working in

the building, are constantly frustrated by a lack of space and the poor functional

suitability of the buildings. Inevitably this impacts upon their ability to deliver

effective and efficient services.



38

4.2.4.4 Infection Control

Due to the lack of refurbishment over the years, the facilities have fallen well behind

in terms of compliance with current infection control standards, in terms of suitable

layout, finishes, materials and furnishings.

4.2.4.5 Fire Precautions

Due to the age of the building, the original fire strategy has become compromised

due to the gradual change of use but in particular the application of more recent

standards by HIFRS (Highland and Island Fire & Rescue Service). Furthermore it is

likely that building services developments within these premises have weakened the

integrity of the existing fabric, in terms of maintaining the original fire separation

strategy. Accordingly, NHS Highland acknowledge that there are a number of

improvements to the existing Theatres building, which may be necessary and

consideration needs to be given to the adequacy of the existing fire strategies.

In particular fire evacuation from the theatres is provided only via the existing

stairwells (with no lifts) whereby bed-ridden patients would only escape via an

evacuation facility, one at a time.

It is highlighted that without further action, NHS Highland anticipate that an

enforcement notice from the Fire Authority would issued, with the ultimate sanction

of closure being applied.

4.2.4.6 Mechanical and Electrical Systems

There is a significant backlog in maintenance, and with plant and equipment at an

age which is beyond their design life, is inefficient in terms of its energy use and

carbon footprint. Condition reports suggest that existing mechanical and electrical

systems fail to comply with current codes and standards.

The Ventilation systems is not currently up to the standards as identified in SHTM-

03001 “Ventilation for Healthcare premises” where there is a need for increasing air

exchange rates to theatres.

Lighting currently fails to meet CIBSE Lighting guide 2, and the electrical wiring is

likely to date back to the original build and accordingly has reached the end of its

design life.

4.2.4.7 Theatres - Space Provision

The space standards to which the department was designed to when it was

constructed nearly 30 years ago falls significantly short of the area allowances in

current Scottish Health Planning Notes. The following table presents the existing

space provision against current standards. The tables below show the existing

accommodation for a typical theatre against those recommended in the current

SHBN Guidance.



39

Room HBN Recommended

Area

Current

Floor Area

Operating Theatre 55.0sqm 36.75sqm

Anaesthetic Room 19.0sqm 15.55sqm

Scrub-up & Gowning(3places) 11.0sqm 7.5sqm

Preparation Room 12.0sqm 10.87sqm

Exit / Parking Bay 12.0sqm 11.68sqm

Store (Equipment) 1.0sqm -

Disposal Room 12.0sqm 5.2sqm

Total Net Floor Area 122.0sqm 80.05sqm

The space requirements reflect the increasing

number of developments in clinical care,

compliance issues and equipment available and

where existing space provision has been found

to be inadequate. The above demonstrates the

clear need for additional space within the

footprint of the theatres accommodation. One

of the key problem areas is the current lack of

storage for equipment both in terms of the lack

of a suitable central storage area as well space

within theatres for short term storage. In

recent years the various improvements in

theatre practice has seen an exponential

increase in equipment required. This has

resulted in the current status whereby all

corridors within the exiting Theatre department are cluttered with various equipment

(see adjacent photo).



40

5 Business Scope and Key Service Requirements

5.1 Key Drivers

As noted in section 3.2.3.4, NHS Highland is undertaking a comprehensive

masterplan study which will comprise detailed consideration of an optimal model of

care and providing fit for purpose facilities for the next 25 years. A future

“Programme Initial Agreement” will be developed to address these elements,

including capacity and demand issues, and accordingly, they are excluded from the

investment proposed within this IA.

The following summarises the key drivers that should influence the way forward.

The aim to comply with the national and local drivers referred to in the Strategic

section including the Scottish Government and local drivers, refer Section to 3.

Alignment with the overall healthcare Masterplanning Exercise being undertaken

by NHS Highland associated with the Greater Inverness Area

Addressing the inefficiencies in the current model of care where critical care /

high dependency services are dispersed around the Block and not at their optimal

location

Alignment with the developing policies on critical care / high dependency – refer

to Section 3.2.4.

Delivering Theatre facilities that are commensurate with modern clinical

standards

The opportunity that the fire precautions project presents where essential

decanting of clinical areas, enables an unique opportunity for appropriate re-alignment of clinical services, avoiding further disruption to patients

5.2 Potential Business Scope

5.2.1 General

The business scope is essentially the design and development of facilities that meet

the Investment Objectives described in Section 4.1. However, in order to establish

project boundaries, a review was undertaken by key stakeholders, and the following

items were established in relation to the limitations of what the project is to deliver.

Where refurbishment takes place, facilities will be developed that are

commensurate with modern healthcare standards where this is viable but within

the constraints of the existing buildings.

Similarly, new facilities, as far as possible within the existing constraints, shall

seek to comply with all relevant Health literature and guidance including, but not



41

limited to, Scottish Health Technical Memorandum (SHTM), Scottish Health

Planning Notes (SHPN’s) and Health Briefing Notes (HBN’s).

The development of a design that gives high priority to minimising life cycle costs

The provision of clinical services associated with the development but limited to

that defined in Section 4.2

Within NHS Highland’s affordability criteria with respect to ongoing revenue

costs.

The development will not be designed in isolation, but should also consider the

potential for adjacent developments. This may include potential economies of

scale

Achieve good quality in design using robust materials that meets with the

general expectations of the various stakeholders. This will be measured by use of

the NHS “AEDET” system.

In conjunction with the Infection Control Team, develop a design that minimises

the risk of infection. To facilitate this, the design will be considered in conjunction

with the NHS “HAIScribe” system.

Comply with CEL 19 (2010) - A Policy on Design Quality for NHS Scotland - 2010

Revision which provides a revised statement of the Scottish Government Health

Directorates Policy on Design Quality for NHS Scotland. CEL 19 (2010) also

provides information on Design Assessment which is now incorporated into the

SGHD Business Case process.

Maximise the sustainability of the development, and meeting the mandatory

requirements under the BREEAM Healthcare assessment system.

The phasing of the project will also be in line with the ongoing Tower Block Fire

Precautions project which provides a timely opportunity for when Wards are to be

decanted in any case (this is being separately funded).

5.3 Resultant Service Requirements

Notwithstanding the identified Investment Objectives, the two principle aims are to

consolidate Critical Care at the optimal location in the tower Block and improve

compliance aspects in respect of the Theatres. As noted above, many of the existing

clinical services will be ultimately retained in their current location (albeit there will

be interim moves, which are separately funded under the “fire precautions” and

“endoscopy” projects). The following summarises those elements which could be

included within this project investment.



42

Critical Care Related Elements

It is anticipated that some existing clinical departments will require to be

permanently relocated, in order that the new optimal adjacencies can be

achieved.

To achieve consolidation of critical care, it is assumed the scope of work will

include refurbishment of existing ward accommodation at ground and first floor

of the Tower Block commensurate with modern standards, and including

upgrading of services infrastructure as necessary.

The project may require the re-location of services from the Tower Block into

other existing Raigmore accommodation,

The project may require the development of some existing accommodation,

within the Tower Block on a temporary basis, to facilitate the moves and phasing

works

Theatres

Following review of the deficiencies associated with the current Theatre provision as

described within Section 4.2.4, including the compliance and environmental issues,

consideration should be given to the following in relation to the potential scope of the

investment.

Upgrading existing fire precautions, and improvements

There is a clear need for the retention and some refurbishment of the existing 9

theatres (not including the Maternity theatre). It is envisaged that the existing 9

Theatres on the first floor of the Tower Block will be retained in their current

location.

Consideration should be given reconfiguring accommodation, where possible, to

better locate storage and ancillary facilities. It is envisaged that some existing

departments, including storage accommodation, may be re-located

Upgrading of existing services infrastructure, where necessary to meet modern

standards. This is likely to include the provision of new ventilation plant, at roof

level, and distribution systems.

Provision of a service waste corridor to improve waste flows (avoiding “dirty /

clean crossovers”) and to facilitate minimising disruption during future

maintenance.



43

6 Benefits / Risks / Constraints and Dependencies

6.1 Benefits

The Key stakeholders have given further consideration to the Investment Objectives

(in Section 3.1) in order to establish the relative value of each objective, the key

benefits and beneficiaries, and the potential benefits criteria that may be used in the

analysis to establish the preferred way forward.

Following discussion and debate a wide range of issues were identified. These were rationalised under 7 key headings that were believed to summarise the benefits criteria (measures) that each option should be assessed against. In summary, these were identified as the extent to which each option:

Benefits Criteria

1. Realised appropriate clinical adjacencies between departments

2. Realised appropriate clinical adjacencies within departments

3. Realised compliance with technical and space standards

4. Provided an optimal patient experience

5. Supported sustainable service delivery

6. Supported “strategic fit”

7. Optimised the quality of the overall physical environment

The following table summarises how the identified benefits are closely aligned with

the Investment Objectives.

Reference Investment Objectives Benefits

1 To improve business effectiveness and revenue efficiency

1. Clinical Adjacencies between departments

2. Clinical Adjacencies within Departments

3. Compliance with technical and Space Standards, as far as possible

6. Strategic Fit

7. Quality of Physical Environment

2 Improve HEAT and other Health targets including waiting times for theatres




5. Service Sustainability

3 Augment and expand range of services and promote emerging model of care including



6. Strategic Fit



44

consolidation of critical care

4 Make possible the introduction of new ways of working and in particular effective collaborative working and flexibility in the workforce



4. Patient Experience


6. Strategic Fit

5 Improved facilities / increased capacity offering a patient centred service including greater consistency of care and increased certainty for

admissions, procedures and discharge



6. Strategic Fit


6 Concentrate higher and lower levels of care at appropriate locations




6. Strategic Fit

7 Offer facilities which reduce risk of spread of infection compared to status quo


6. Strategic Fit


8 To achieve optimal utilisation of space (within the constraints of an existing building)



6. Strategic Fit

9 To achieve operational and functional efficiency of physical environment




6. Strategic Fit

10 To deliver high quality facilities, and technical standards with a strong focus on lifetime costs, quality and design.



6. Strategic Fit


11 To comply with “A Sustainable Development Strategy for NHS Scotland’, to enhance the contribution of the health sector to sustainable development


6. Strategic Fit

12 To enable the retention and recruitment of staff



6. Strategic Fit




45

6.2 Main Risks

The key stakeholders have undertaken an initial Risk Workshop to establish the

principal risks associated with the proposed investment. This will be further

developed as part of the Outline Business Case. Whilst there will be many risks to

the project, the key stakeholders have considered what they perceive to be the main

risks which are considered to contribute collectively to the majority of the risk value

(approximately 80%). A summary of the key risks identified is provided below.

Business Risk

Greater Inverness Masterplan conclusions resulting in changes of scope

Changing local strategies (Raigmore) impact on the project

Demand for services higher than projected

Service Risk

Disruption to existing services during development or redevelopment

Stakeholders - contradictory aspirations

Changing statutory and NHS/HFS Guidance

“Scope Creeping” developments

Unclear strategy of Raigmore development

Capacity of Services and Infrastructure

Constraints of existing services and infrastructure

Uncertainty associated with existing building fabric

Live Acute Hospital Environment and Clinical Needs affecting delivery of project

NHS Highland and Scottish Government Approvals process

External / Environmental Risks

Statutory Approval Delays

Achievement of BREEAM Healthcare “Very Good” and complexity of scheme

(which element applies)

Financial Risk

Accuracy of Estimated Capital Cost

Revenue Cost Assumptions

VAT rules

Capital / Revenue distinction

Inflation



46

Insolvency

Dependency Projects (ie projects upon which this investment depends)

Viability of Phasing Proposals

6.3 Constraints

Financial

NHS Highland, in line with other Boards across Scotland is facing a very

challenging financial position. This will mean a very difficult balancing act

between achieving LDP targets whilst delivering substantial cash savings.

Programme

The programme is currently dependent upon the existing “Fire Precautions”

project which is underway.

Quality

Compliance with all current health guidance, where at all possible, within

the constraints of the existing accommodation

Sustainability

Where appropriate, Achievement of BREEAM “Very Good” in the case of

any refurbishment development

Existing Clinical Services

A fundamental constraint of the project will be the need to fully maintain

existing clinical services throughout the project period. As noted previously,

the ongoing fire precautions project presents an opportunity to minimise

disruption.

6.4 “Dependency Projects”

There are a number “dependency projects” upon which this investment may rely

upon but which funding is already in place or will be required from another source.

The precise details of these are, in some cases, unable to be fully established,

however the potential relevant projects are summarised as follows.

Fire Precautions - As noted a fire precautions project is underway and is being

separately funded

The re-location of the Children’s ward (from its current location at ground floor

level) to a location outwith the Tower Block is being considered by NHS

Highland/Archie Foundation. It is envisaged that this will involve a Children’s

Ward Out-Patients Department (OPD) development and the relocation of the

Children’s Ward In-Patient facility to Ward 11. Funding will mainly be sourced via



47

the Archie Foundation albeit with NHS funding required in respect of backlog

compliance issues.

A separately funded Endoscopy project is currently ongoing to provide a new

build Decontamination Unit and to re-locate the existing Endoscopy Unit to Ward

8. This will also require the amalgamation of Ward 8 into Ward 9.



48

7 Agreed Critical Success Factors

7.1 Stakeholder Review

In consideration of the Investment Objectives in Section 3 and the potential benefits

summarised in Section 5, the key stakeholders have undertaken a review of those

factors which it is considered essential to the scheme.

Notwithstanding the desire that all investment objectives and resulting benefits will

be achieved, the key stakeholders have identified the following limited list of Critical

Success Factors deemed essential to the project being considered successful.

1. The achievement of the project within the available financial parameters of

NHS Highland (revenue funding). See section 9 for further information on

Funding.

2. Consolidating high dependency units and critical care in order that clinical

and administration efficiencies are delivered,

3. Achieving the position where an increased percentage of patients have the

correct level of care provided at all times during their hospital stay

4. Establishing a position whereby Theatre capacity is at a more optimal level

with a reduced number of cancellations for scheduled surgery.

5. Compliance with all relevant Health Guidance (unless otherwise agreed as

being in-appropriate) including HAIScribe guidance to ensure facilities are

commensurate with current policy and reduce the risk of health related

infection spread

6. Avoid significant disruption to existing clinical services

7. Quality – Delivery of key stakeholders (including community representatives)

expectations is critical to the success of the project. “AEDET” reviews will be

undertaken and will achieve a minimum target score of 4/6 in all categories.

8. Sustainability. The achievement of BREEAM “Very Good” for refurbishment

development



49

8 Long List of Options and SWOT Analysis

8.1 General

NHS Highland has rigorously considered the SMART objectives, potential benefits and

the critical success factors previously summarised in this report. The approach

adopted for developing the options involved representatives from a range of groups,

including NHS Highland, in a series of workshops that.

Reviewed the national and global drivers for change in terms of health services

with a view to developing an understanding of the implications of these for

Health Service provision

Considered the overall objectives for the project and key success factors

Considered current procurement options available to NHS and the current

economic climate

Examined the current services and property provision at Raigmore

A summary of the key stakeholders involved in the consultation process is provided

in Section 3.1.5.

8.2 “Categories of Choice” (CoCA) Assessment to establish Long List of

Options

Consideration has been given to a wide range of potential options in accordance with

the HM Treasury Green Book guidance. Options have been considered based on the

“SCIM” approach using the various “CoCA” assessment headings.

Appendix B presents the “CoCA” Table, developed to capture the previous views of

stakeholders on the potential options. Based on this CoCA Assessment, the options

noted in Appendix B as “discounted” were not considered further. The remainder

were developed into a long list of investment options, as follows. It was fully

recognised that there was potential for some options to be combined.

8.3 Summary of Long List of Options

Based on the assessment undertaken under Section 7.2, the following is the “Long

List of Options” that emerged. It was clear that a number of these options were not

“stand alone” (i.e. they could not address the requirement alone) but could be

“combined” with the principal options to deliver the preferred solution.



50

Long List of Options Ultimately short-listed (and Option)

A Do Nothing Yes (1)

B Co-locate services within the Tower Block based on speciality – Medical and

Surgical

No

C Consolidate Critical Care Unit with CCU at Ground floor and Medical HDU and ITU / SHDU co-located at first floor and Endoscopy retained in Tower Block (level 6)

Yes (2)

D Consolidate critical care with CCU & MHDU co-located at ground floor with ITU & SHDU co-located at first floor and with Endoscopy moved outwith Tower Block

Yes (2A)

E Similar to Option 2A but with MHDU/CCU situated at Ground floor at “A” block to facilitate intensive care adjacency, and the addition of Vascular Lab and PACU

Yes (2B)

F New Combined Assessment Unit on ground floor and consolidate critical care with CCU & MHDU also co-located on ground floor with ITU & SHDU co-located at 1st floor

Yes (3)

G New Combined Assessment Unit on ground floor and consolidate critical care CCU/MHDU and ITU/SHDU) completely on 1st floor

Yes (3A)

H New Combined Assessment Unit on ground floor and consolidate critical care (CCU/MHDU and ITU/SHDU) in “A” block on ground and 1st floors

Yes (3B)

I Provide additional capacity of Medical High Dependency Units No

J Consider under utilised space in Maternity Unit (first floor) as locus for services that need close proximity to theatres eg Opthalmology / Endoscopy / Surgical Day Case

No

K Create additional capacity to dialyse patients on in-patient wards with main dialyses at level 7 (close to for plant configuration

Combine

L Addition of vascular lab to meet current standards for Vascular department

Combine

M Addition of post anaesthetic care unit (PACU) adjacent to intensive care unit

Combine

N Move non-acute services out of the Tower Block, where adjacency is not required (eg Endoscopy, Child Ward), and to suitable existing accommodation

Combine

O Re-locating female surgery wards (away from male wards) and into separate unit (outwith Ward Block) – into Ward 8 No

P Consider re-locating selected acute services at Raigmore back into the Tower (eg Respiratory) that provide improved adjacency to General Medicine

Combine



51

Q Upgrade existing Theatre accommodation commensurate with modern standards

Combine

R Eye Day Case Unit – relocation to current location of renal unit

Combine

The above scoping / service solutions options would be amalgamated with the

following “implementation” and “funding” options:

Implementation Options

Phase services in – extensions and refurbishment of existing premises

Funding Options

Phased Capital funding based on traditional procurement

8.4 SWOT Analysis

Key stakeholders subsequently undertook a SWOT analysis of the long list of options

to establish a shortlist of options to be taken forward for more detailed assessment

at Outline Business Case Stage. The options selected are a combination of the

scoping service solution, implementation and funding options noted above.

A summary of the results is provided in Appendix C. In summary 6 key high level

options have been established (in addition to a “Do Minimum” option). Due to their

complexity they are represented by the following table.



52

Do

Minimum

Option 2 – Consolidate Critical Care Option 3 – Consolidate Critical

Care + Combined Assessment Unit

1 2 2A 2B 3 3A 3B

The Current configuration

but assume - fire precautions works (ongoing)

- endoscopy development but at ground floor of Tower

- Upgrading of CCU, AMAU/MSCU, SHDU, Therapy, ITU, Critical Care

Waiting, 1A(CAL, EDCU,

SDCU, ITU - - All to be retained at

their current location

Consolidation of Critical Care on Ground and First Floor Levels –based on acuity

Consolidation of Critical Care on Ground and First Floor Levels – based

on acuity. Plus Combined Assessment Unit

Co-locate AMAU and CCU on ground floor

Combined Medical Assessment Unit on ground floor

Cardiology also co-located

on ground floor

Cardiology remains on Level 6

Co-locate ITU/SDHU on first floor

MHDU at First Floor

MHDU at Ground Floor Co-locate CCU and MHDU at Ground Floor

Co-locate CCU and MHDU at 1st Floor

Co-locate CCU and MHDU/Short stay beds at Ground Floor

No PACU Post Anaesthetic

Care at Level 1

No PACU

Post Anaesthetic

Care at Level 1

1A (CAL / Surgical DC /

Eye Day Care to Ward 8

CAL / Surgical Day Case to Level 1

CAL / Surgical

Day Case to First

Floor

CAL / Surgical

Day Case to

Ground level

CAL / Surgical Day

Case to First Floor

Surgical Triage to remain at Level 4 Surgical Triage relocated to Ground

Level

Potential to move Renal Dialysis moved to Level 7 – separate Investment

Respiratory moved into Tower – Level 6

Medical Ward adjacent to Therapy

Oncology moved to Level 5

Child Ward moved out of Block (Ward 11)

Endoscopy at Level 6

Endoscopy re-locate to Ward 8 (funded secured)

Gynae/Breast (Ward 8) into Tower -

Level 5

Gynae/Breast (Ward 8) to amalgamate to Ward 9 (funded secured)

- Vascular Laboratory

added at 5C

- Vascular

Laboratory added at 5C

Potential to provide Eye Day Case into the accommodation formally occupied

by Renal (separate investment). However, this investment only to include limited allowance for Eye Day Case, currently in 1A



53

1 2 2A 2B 3 3A 3B

Theatres Refurbishment

In conjunction with the planned significant upgrading works (refer below) the

continued use of the existing 9 theatres located within the Tower Block

To improve compliance, building fabric and services upgrading of the existing 9

theatres, to meet modern clinical standards (the Theatre within the Maternity

Block is outwith the scope of this project)

Upgraded fire precautions of Theatres in Tower Block to meet horizontal fire

evacuation requirements

Services upgrade associated with achieving compliance, include ventilation

system enhancement

Where possible, potential increase in storage requirements (possible expansion

adjacent to plant room) to facilitate improved compliance with required storage

and other space standards

Provision of services / waste corridor to rear of the Theatres accommodation

Child Ward

Retain in current location

The Child Ward will involve the redevelopment of Ward 11 to facilitate

the move. A limited allocation of funding is being considered in

respect of any outstanding need to deal with the current backlog

compliance issues.

Respiratory


The project will require the development of a temporary facility at

Ground Floor level involving some works. (This will require occupation

of some Children’s Ward accommodation, on a temporary basis).

Furthermore, Level 6 will require some reconfiguration to facilitate the

permanent move to Level 6



54

9 Economic Case to Arrive at Preferred Way Forward

9.1 General

This section summarises the option appraisal undertaken to arrive at the preferred

way forward in consideration of the costs, benefits and project risks of each of the

shortlisted options.

All current guidance has been followed in undertaking the option appraisal,

principally the Scottish Capital Investment Manual (SCIM), the HM Treasury Green

Book and supplementary guidance.

9.2 Qualitative Option Appraisal

9.2.1 Introduction

A non-financial option appraisal exercise was conducted with a range of key

stakeholders over 3 sessions during September and October 2012. These sessions

were facilitated by independent Healthcare Planners and included representatives

from a range of stakeholders. A copy of the full option appraisal report is available

upon request. The document summarises the process followed, along with an

analysis of the numerical outputs. The following sections summarises the key aspects

of the report.

9.2.2 Process Employed

The process employed was agreed with participants at the outset. It involved a

stakeholder group working through a series of questions with the objective of

applying a consistent and rational approach to the challenge of identifying the best

solution to meet the requirement. It was emphasised that the qualitative stage of the

option appraisal was based on non-financial qualitative criteria and that further

financial analysis of the preferred options identified would be conducted as a

subsequent component of the business case development.

9.2.3 Benefits Criteria and Weighting

As noted in Section 5, and following extensive discussion and debate a wide range of

issues were identified. These were rationalised under 7 key headings that were

believed to summarise the benefits criteria (measures) that each option should be

assessed against. These benefits criteria have already been highlighted in section

5.1. To support the process, of applying a relative “weighting” (priority) to each of

the criteria identified, a comparative matrix was used to aid the initial relative

prioritisation of benefits criteria.

To determine the actual weightings to be applied, stakeholder groups were asked to

allocate “100 points” appropriately between identified benefits criteria based on their

opinion of the relative importance of each. Scores were fed back by benefit criteria

and group in the first instance. Having agreed the relative weighted benefits criteria

of each stakeholder group, discussions took place to rationalise separate



55

“weightings” into a single agreed factor that would be applied to each identified

option in the formal scoring process. The groups reached agreement over the

overall agreed weighting through consideration of the mean, median and modal

weightings, as follows.

Having agreed the benefits criteria, relative weighting and options to be assessed,

the group progressed with the formal process of applying a score to each criteria in

the context of each option. This was supported through an extensive process of

facilitated debate with the consensus agreement of all participants realised regarding

the relative merits of each option and scores to be applied.

9.2.4 Summary of Qualitative Results

The following table present a summary of the scoring of each of the 7 options (as

defined in Section 7.4).

Option Weighted Benefits Score

No. Description

Consensus

Optimistic Pessimistic

Rank

1 Do Minimum (Retain Current Configuration) 358 6

2

Consolidate Critical Care Unit with CCU at Ground floor and Medical HDU and ITU / SHDU co-located at first floor and Endoscopy retained in Tower Block (level 6)

349 7

2A

Consolidate critical care with CCU & MHDU co-located at ground floor with ITU & SHDU co-located at first floor, and the addition of PACU and vascular lab, with Endoscopy moved out

622 1

2B

Similar to Option 2A but with MHDU/CCU situated at Ground floor at “A” block to facilitate intensive care adjacency, and no provision of PACU

568 2

3

New Combined Assessment Unit on ground floor and consolidate critical care with CCU & MHDU also co-located on ground floor with ITU & SHDU co-located at 1st floor

511 4

3A New Combined Assessment Unit on ground floor and consolidate critical care CCU/MHDU and ITU/SHDU) completely on 1st floor

501 5



56

3B

New Combined Assessment Unit on ground floor and consolidate critical care (CCU/MHDU and ITU/SHDU) in “A” block on ground and 1st floors, with the provision of PACU and vascular lab.

532 3

Overall, the non-financial option appraisal process identified that the preferred non-

financial option was option 2A with 622 points, followed by option 2B with 568

points. These 2 options represented the “leading group” with options 3B (532

points), 3 (511 points) and 3A (501 points) in 3rd, 4th and 5th place respectively.

The least favoured options by some margin are Option 1 (Do Minimum) and Option

2, with Option 2 scoring less than option 1 in some scenarios.

9.3 Economic Appraisal

9.3.1 General

This section presents the economic implications of the investment (both capital and

revenue) and also provides the economic appraisal of the short-listed options. The

outputs from the cost models identified in this section form the basis of both the

financial and economic appraisals of the short-listed options. Each of the short-listed

options has been costed with due consideration of the changes associated with each

option and any changes in cost have been clearly identified and explained. The

following categories of cost have been considered for each option.

9.3.2 Capital

The capital costs have been considered and prepared using the capital requirement

of each option that has been identified by the external professional cost advisors.

These capital costs have been calculated using the brief and plans for each option.

The following summarises the main capital assumptions.

Costs have been calculated at January 2013 (Q1 2013) prices

Baseline costs for –

Pay (workforce)

Non Pay (associated with staff)

Estates/Utilities (associated with the existing building)

Income

Capital Charges (depreciation)

Costs for each option –

Pay (workforce)

Non Pay (associated with staff)

Estates/Utilities (associated with the new building)

Income

Capital Charges (depreciation)

Phasing of costs

Short-listed Options Option 1 - £’s Option 2 - £’s Option 3 - £’s



57

Capital costs have been prepared using using Healthcare Premises Cost Guides

(HPCG’s) adjusted to reflect the type and nature of the works

Include building, infrastructure and service costs

Includes equipment within the estimates for group 1 & fitting of equipment in

group 2 but it has been assumed that most equipment will transfer with the staff

moving around the building

Includes estimates for all fees – Design team 10%, Professional fees 5%, Board

fees of 2.5% and an allowance for statutory fees.

Quantifiable risk contingency of 5% and Optimism Bias included

VAT has been added to the total capital cost but there may be an element that is

recoverable on certain items of refurbishment

VAT recovery is excluded from the costs with the exception of design fees which

assume 100% recovery

Having applied the costing assumptions and methodologies to the options, the

capital expenditure, was estimated firstly excluding Optimism Bias. An Optimism Bias

workshop was then convened to calculate optimism bias using the HM Treasury

guidance. The mitigated level of bias for each option was then applied to the initial

capital figures.

Details of the development of the capital costs for each option can be made available

upon request, including the procedure undertaken to calculate the optimum bias

upper levels and the mitigation levels in light of specific factors associated with this

project. In summary, and following adjusted capital costs, estimates (including VAT)

were established for each option as follows.

Capital Costs including Optimism Bias - £000’s

Option 1 – Do

Minimum £000’s

Option 2

£000’s

Option 2A

£000’s

Option 2B

£000’s

Option 3

£000’s

Option 3A

£000’s

Option 3B

£000’s

Original capital costs

13,958.8

17,734.5

16,851.1

17,445.9

17,135.5

17,056.1

17,973.5

Optimism Bias

2,439.2

(18%)

3,381.1 (19.6%)

2,645.1 (16.2%)

2,999.3 (17.7%)

3,074.0 (18.5%)

3,059.8 (18.5%)

3,224.4 (18.5%)

Revised Capital costs incl optimism bias

16,398.0

21,115.6

19,496.2

20,445.2

20,209.5

20,115.9

21,197.9



58

It is highlighted , that in order to further compare costs, and establish a baseline, an

“Option 0” (Do Nothing) was created. This had a capital cost of £1,400k.

With the exception of the ‘do nothing’ option, the lowest level of mitigated optimism

bias is associated with Option 2A, at 16.2% - this is because this option has full

clinical sign-up and agreement through the Project Board.

9.3.3 Revenue Costs (Recurrent and Non-recurrent)

9.3.3.1 General

This section identifies the recurrent and non-recurrent revenue costs associated with

each of the short-listed options. A baseline cost for the current service has been

calculated and used as a benchmark against which any changes could be considered

This is the revenue cost associated with ‘do minimum’ in Option 1. The assumptions

used in the models for revenue costs for each of the options are shown below

Costs have been calculated at 2012 prices and using 2012/13 budgets

Where relevant, whole time equivalents have been considered for staffing

Pay costs are inclusive of employer on-costs and allowances for leave.

VAT is included where appropriate

Non pay costs are based on the current cost per bed for consumables

Utility costs and non domestic rates have been excluded from all options as there

is no change to the total floor area involved and therefore no increase/decrease

in costs is expected

Capital charges are based on the capital cost inclusive of the optimism bias

calculations

There are no income streams associated with the options

9.3.3.2 Recurrent Revenue

Full details of the recurrent revenue costs are available on request. This captures

capital charges, recurrent pay costs, recurrent non-pay costs, recurrent property

costs, and recurrent property income, where applicable.

Including all of the various streams of revenue costs, the overall recurring revenue

impact of the options is shown below.



59

Summary of Recurrent Revenue Impact - £000’s

Option 1 – Do Minimum £000’s

Option 2

£000’s

Option 2A

£000’s

Option 2B

£000’s

Option 3

£000’s

Option 3A

£000’s

Option 3B

£000’s

Capital Charges

627.9 733.0 696.9 718.1 712.8 710.7 734.8

Pay costs 0 (15.6) (15.6) (15.6) (15.6) (15.6) (15.6)

Non pay costs 0 0 0 0 0 0 0

Property costs 0 0 0 0 0 0 0

Gross recurrent costs

627.9

717.4

681.3

702.5

697.2

695.1

719.2

Income 0 0 0 0 0 0 0

Net recurrent costs

627.9

717.4

681.3

702.5

697.2

695.1

719.2

The costs shown in the above table relate to the first full year of operating. After

excluding the ‘Do minimum’ option, Option 2A has the lowest net revenue cost of

£681k for capital charges and a saving of £16k for pay.

9.3.3.3 Non-Recurrent Revenue

A number of non-recurrent (transitional) revenue costs have been identified to allow

the options to go ahead. At this Initial Agreement stage, exact costs have not been

produced although the following table identifies the best estimates available at this

time. These costs will be incurred at the time of each of the Departments moving to

their new locations, or just prior to this in terms of minor equipment requirements.

One area that will require to be considered in greater detail at OBC stage is the

Theatres where there may be the potential for non recurrent revenue costs during

construction in providing alternative Theatre space/time to allow two Theatres to be

upgraded at a time. However at this stage it is envisaged that the works can be done

through a combination of extended shift work and use of the Angio-Cath theatre.

Summary of Non-Recurrent Revenue Impact - £000’s

Option 1 – Do Minimum

£000’s

Option 2

£000’s

Option 2A

£000’s

Option 2B

£000’s

Option 3

£000’s

Option 3A

£000’s

Option 3B

£000’s

Staff costs – to enable moves

0

15.2

15.2

15.2

14.8

14.8

14.8

Combined Assessment Unit – equipment

0

0

0

0

0

0

0

Total non-recurrent costs

0

15.2

15.2

15.2

14.8

14.8

14.8



60

9.3.4 Net Present Costs

A discounted cash flow for each of the seven options has been undertaken over 40

years using a discount rate of 3.5% for years 1 to 29 and 3.0% for years 30 onwards

in line with the guidance within the HM Treasury green book and from SGHD. The

Net Present Value (NPV) and Equivalent Annual Cost (EAC) have been calculated for

each option. The EAC is used as a comparison of options where there are different

life spans as the output is an annual figure which is easily compared. The elements

considered in the analysis are summarised below.

Initial capital expenditure for each option – exclusive of VAT but adjusted for

optimism bias

Any relevant lifecycle costs for building and engineering works

Any relevant equipment lifecycle costs

Total revenue costs for each option excluding capital charges

Income

Non-recurring revenue costs

The key assumptions used within the economic appraisal include :

The base year for the economic appraisal is the financial year 2012/2013

Economic appraisal period is over 40 years

Capital expenditure will be made over a maximum of five years from 2013/14 to

2017/18

Optimism bias has been included in the capital expenditure figures

All non-recurrent costs are assumed to be incurred in Yr 3 as they are required at

the time of the move to the new location for the Departments concerned

The results of the economic appraisal for the options are shown below.NPV and EAC

outcomes - £000’s

Option 1 – Do

Minimum £000’s

Option 2

£000’s

Option 2A

£000’s

Option 2B

£000’s

Option 3

£000’s

Option 3A

£000’s

Option 3B

£000’s

Net Present Value (NPV)

18,013.8

22,687.1

20,976.5

21,941.4

21,530.3

21,344.7

22,641.4

Equivalent Annual Cost (EAC)

736.6

927.8

857.8

897.3

880.4

872.9

925.9

Ranking 1 7 2 5 4 3 6



61

It is highlighted that in order to further compare costs, and establish a baseline, an

“Option 0” (Do Nothing) was created. This had a capital cost and net present value of

£1,400k and £11,814k, respectively. However this option is not viable because the

various compliance issues would not be addressed. In particular this option would

result in a fire precautions enforcement notice being issued, ultimately resulting in

closure.

The analysis of the net present values (NPV) indicates Option 1 (Do minimum) has

the lowest life time costs with Option 2A being the next favoured option. It should be

noted that the outcome EAC for Option 2B of 897.3 which is only £40k pa different

from the first ranked Option 2A.

9.3.5 Summary of Economic Appraisal

The ‘Do minimum’ option 1 has the lowest capital requirement, recurrent and non

recurrent revenue impact and also the second lowest lifetime costs.

The second lowest recurrent revenue impact comes with Option 2A. This also has the

second lowest lifetime costs from the NPV and EAC calculations. The revenue

associated with Option 2A is an increase of £681k from current budgets – this

includes an increase of capital charges (depreciation) of £697k pa and a saving in

revenue pay of £16k pa.

Non recurrent costs are similar across all options with a range of £14,789 for Options

2, 2A and 2B to £15,210 for Options 3, 3A and 3B. This non-recurrent budget would

need to be funded at the time that the Department moves to a new location as it is

predominantly for minor equipment and staff to facilitate the move. The Outline

Business Case will give consideration to potentially significant non-recurrent costs

still to be added for Theatres. (However these are common to all the IA options).

9.4 Overall Value for Money

Value for money (VfM) is defined as the optimum solution when comparing qualitative benefits

to costs. An analysis (below) has been performed on an economic annual costs basis in line with

HM Treasury guidance. The VfM analysis compares the cost per benefit point of the options. The

option that is preferable is the option that demonstrates the lowest cost per benefit point. The

cost per benefit point is listed in the end column – VfM Economic Ranking.

No Option Qualitative

Benefits

Score2

Quality

Rank

Net

Present

Cost

(£k)

NPC

Rank

Cost

/Benefit

point

(£k)

VfM

Economic

Ranking

1

Do Minimum (Retain Current Configuration)

358 6 18,013.8 1 50.3 6



62

2

Consolidate Critical Care Unit with CCU at Ground floor and Medical HDU and ITU / SHDU co-located at first floor and Endoscopy retained in Tower Block (level 6)

349 7 22,687.1 7 65.0 7

2A

Consolidate critical care with CCU & MHDU co-located at ground floor with ITU & SHDU co-located at first floor, and the addition of PACU and vascular lab, with Endoscopy moved out

622 1 20,976.5 2 33.7 1

2B

Similar to Option 2A but with MHDU/CCU situated at Ground floor at “A” block to facilitate intensive care adjacency, and no provision of PACU

568 2 21,941.4 5 38.6 2

3

New Combined Assessment Unit on ground floor and consolidate

critical care with CCU & MHDU also co-located on ground floor with ITU & SHDU co-located at 1st floor

511 4 21,530.3 4 42.1 3

3A

New Combined Assessment Unit on ground floor and consolidate critical care CCU/MHDU and ITU/SHDU) completely on 1st floor

501 5 21,344.7 3 42.6 4

3B

New Combined Assessment Unit on ground floor and consolidate critical care (CCU/MHDU and ITU/SHDU) in “A” block on ground and 1st floors, with the provision of PACU and vascular lab.

532 3 22,641.4 6 42.6 4



63

The following conclusions are drawn from the value for money analysis.

Option 2A represents the best value option on the basis that it achieves the lowest

cost per benefit point of all these options. This option delivers best value in terms of non-financial benefits and the actual appraisal costs.

Option 2A also achieves the highest qualitative benefits score of all the options based on the “consensus”, “optimistic” and “pessimistic scores” identified during the appraisal workshops. Furthermore Option 2A is the highest ranking (excluding Option 1) in terms of lowest Net Present Cost although the difference from the 2nd highest ranking option being only 2.6%.

It is further highlighted that whilst Option 2A does not, in itself, include a "Combined Medical & Surgical Common Admissions Unit”, this option does not preclude such a development at a future date, subject to the Greater Inverness Masterplan review.

Based on the above analysis Option 2A, is identified as the preferred way forward

9.5 Sensitivity Analysis

A Sensitivity Analysis is defined as the effects on an appraisal/ option of varying the

programmed values of important/ selected variables. A Business Case is built upon

estimates which can lead to inaccuracies. The preparation of a Sensitivity Analysis

will help assess whether the Initial Agreement is heavily dependent on a particular

cost or benefit.

9.5.1 Sensitivity Analysis (Weighted Benefits Score)

In order to explore the potential impact of a range of variances on the qualitative

option appraisal process, a limited sampling-based sensitivity analysis was

conducted. This attempted to understand the main effects of varying key values on

the relative prioritisation and scoring of options. The sensitivity analysis broadly fell

into 2 categories:

The general impact of including/excluding some/all identified stakeholder groups

from the weighting/scoring process

The specific impact of excluding “patient experience” as a benefits criteria based

upon discussions held and referenced previously

The detailed Option Appraisal, available upon request, summarises the sensitivity

analysis undertaken. In summary the various sensitivity scenarios resulted in no

change in the order of the options, other than the lower ranked options, in a few

cases.

9.5.2 Sensitivity Analysis (Weighted Benefits Score and Costs)

Notwithstanding the sensitivity analysis undertaken on the qualitative assessment as

described above, a sensitivity analysis has also been carried out on the preferred

option, Option 2A to assess the extent to which the weighted benefits score and the



64

costs (both revenue and capital) would have to increase before this option would no

longer be the preferred economic choice. The results are shown in the table below.

Table 20: Sensitivity Analysis

Interpretation of the sensitivity analysis shows that there would have to be a

significant movement in either WBS, capital or revenue costs relative to the total

project cost to make the next option (2B) become the preferred option.

Sensitivity % increase Outcome

Option 2B - Increase Weighted Benefits Score (WBS) by

14.5% Option 2B would

become preferred option

Option 2A – Increase Net Present Cost by

14.5% Option 2B would

become preferred option



65

10 Affordability Review

10.1 Introduction

Option 2A has been identified as the preferred option as it meets the all of the

overall benefits, affordability and economic tests to produce the best ‘Value for

Money’ solution. The preferred option 2A does not require any additional recurrent

funding and will, in fact, produce savings as a result of the economies of similar

departments being co-located and as a result the project is affordable from within

the Board’s current Revenue Resource Limit.

The overall NHS budget for the Critical Care Consolidation and Theatres

Development is in line with the proposed costs previously stated in section 9 of this

Initial Agreement for the preferred option, Option 2A and comprising.

Consolidate critical care with CCU & MHDU co-located at ground floor

with ITU & SHDU co-located at first floor and with Endoscopy moved

outwith Tower Block

Development of the Theatres at first floor

Option 2A meets the overall benefits, affordability and economic tests to produce the

best Value for Money solution.

Detailed costs showing the financial build up for each of the short listed Options and

the Optimism Bias calculations for each are available on request.

10.2 Summary of Capital and Revenue Costs

For 2013/2014, NHS Highland has an estimated Revenue Resource Limit of £510m

and an overall budget of £699m. The Capital Resource Limit for 2013/2014 is £17m.

As stated in the local delivery plan (LDP), for 2013/14 NHS Highland is expected to

achieve all of its financial targets

A summary of the capital costs and revenue cost, for the preferred option, Option

2A, is provided below.

Option 2A

£000’s

Capital Costs

19,496.2

Recurrent Revenue Impact 696.9

Non-Recurrent Revenue Impact

15.2



66

10.3 Funding Model

The preferred option would be funded from an additional specific capital allocation

from SGHD of £19.5m with the additional revenue costs funded from within the NHS

Highand’s overall revenue budget.

10.4 Impact on Balance Sheet

The Capital Cost of the development will appear on the Board’s Balance Sheet as a

Fixed Asset and will be depreciated over the life time of the asset.

10.5 Impact on Statement of Comprehensive Net Expenditure

For the preferred option of 2A, the additional recurrent revenue cost to be charged

against the Health Board’s statement of operating costs is estimated at a net figure

of £681k. This total is made up of £697k for capital charges (depreciation) less £15k

of savings as a result of the co-location of Departments

10.6 Phasing of Funding

In terms of capital outlay, the following table gives an indication of potential outlay

based on a 5 year phasing period.

Year Cost inc VAT VAT Cost exc VAT

April 2013 – 2014 974,812 - 974,812

April 2014 – 2015 3,899,249 649875 3,249,374

April 2015 – 2016 5,848,874 919,812 4,929,061

April 2016 – 2017 5,848,874 932,826 4,916,047

April 2017 – 2018 2,924,437 475,940 2,448,497

Total 19,496,246 2,978,454 16,517,792



67

Level C B A

7Medical

GI/RenalManagement Renal Dialysis

6 Respiratory RespiratoryOncology with

Day Case Trans

5Vasc/Urology

Surgery/Vasc Lab

Dermatology

Offices

EMPTY - to be

used for winter

pressures and flexi

beds for

indcidences of

Infection etc

4 Surgical Seminar Room Surgical/Triage

3 Orthopaedics Head & Neck Orthopaedics

2 Medical Therapy Unit Stroke/YARU

1 CAL/SDCU Waiting Area ITU/SHDU/PACU

GroundCardiology step-

downCCU AMAU/MHDU

OPTION 2A

11 Recommended Preferred Way Forward

11.1 Summary of Option 2A

The best value high level option that has emerged from the process is Option 2A.

This represents the “Preferred Way forward” and will be required to be the subject of

more detailed analysis at Outline Business Case.. This preferred way forward is

summarised as follows.

Option 2A

Preferred Way

Forward

Consolidate critical care with CCU & MHDU co-located at ground floor with

ITU & SHDU co-located at first floor, and the addition of PACU and

vascular lab, with Endoscopy moved out

Development of the existing Theatres to address various compliance

issues including ventilation standards, fire precautions, space

deficiencies and backlog maintenance

It is highlighted that whilst Option 2A does not, in itself, include a "Combined Medical

& Surgical Common Admissions Unit”, this option does not preclude such a

development at a future date, subject to further consultation if deemed appropriate.

11.2 Proposed Configuration of Tower Block

The configuration

of the Tower Block

as proposed under

the preferred way

forward is

illustrated as

follows (and

included as

Appendix D).



68

11.3 OBC Optioneering and Scope of Works

Given the complexity of the project, it is recognised that Option 2A only represents

the “preferred way forward”. The potential high level scope of works, based on the

preferred way forward (Option 2A) is provided within Appendix F. Clearly this will

require further development during the outline business case process.

Option 2A is considered as the “preferred way forward” and it is anticipated that the

Outline Business Case will develop options around this preferred way forward. In

recognition of the high complexity of this proposed reconfiguration project, detailed

healthcare planning of the Tower Block will be required and this will establish sub-

options of Option 2A which will be reviewed and compared, at Outline Business Case

stage.

11.4 Greater Inverness Masterplan Review

As noted previously, the proposals contained within this Initial Agreement are

compatible with the Greater Inverness Masterplan study review. The proposed

investment will not only address the immediate deficiencies described, but also build

a platform for the anticipated subsequent initiatives which will be identified to allow a

future optimal healthcare model to emerge.

The Greater Masterplan review will to lead to development of a “Programme Initial

Agreement” whereby it will build on the work proposed under this IA, and review all

additional factors, relating to the optimal model for delivery of “fit for purpose”

healthcare facilities, suitable for the next 25 years.

11.5 Commercial Review

A number of procurement options could be utilised, and these were initially

considered by NHS Highland, as referred to in the “Category of Choice” appraisal and

SWOT analysis, in Section 7. However, based on the nature of the development,

and in consultation with Scottish Government it is most likely that the project will be

most suitable, for a capital funded project, phased over a number of years, and

using the HFS “Frameworks Scotland 2” contract, and using the New Engineering and

Construction Contract (NEC 3 - Option A, C or E). Key features of the contract are:

The parties are encouraged to work together as partners in an open and

transparent approach and to ensure that this partnering ethos is maintained

There is a ‘Gain/Pain share’ mechanism to act as an incentive to the delivery

team, by rewarding good performance and penalising poor performance

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

place on prices

A level of ‘price certainty’ is determined

All price thresholds are set using quantitative risk analysis



69

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

A key principle of the NEC3 Option C contract is the payment of ‘Defined Cost’ and

an open book accounting philosophy. These require a robust, reliable and

transparent system to record staff time and manage the invoicing process.

Payments are made to the PSCP as per agreed Valuation Certificates. Costs are held

as Assets under Construction until the asset becomes operational at which point the

costs are transferred to completed assets and become subject to depreciation.

The Outline Business Case will review in more detail the proposed commercial

arrangements for delivering the proposed investment, including any analysis of key

commercial arrangements, accounting approach, commercial risk approach,

contractor’s share percentage and range, priced activity schedule review and defined

cost arrangements.

11.6 Indicative Programme and Phasing Plan

As noted earlier in this IA, the timing of proposed investment would be aligned with

the “Fire Precautions” project to exploit the unique opportunity that is presented

whereby all the wards and associated accommodation in the Tower Block, will be

vacated in a phased manner, and ward by ward basis. This will therefore minimise

disruption to existing healthcare services. The phasing plan in Appendix E illustrates

the potential indicative timing of the planned works and how this fits into the other

projects at Raigmore.

As described in Section 11.6, it is envisaged that the works would be undertaken

during a 5 year period. The approximate timing to achieve an early start on site date

would be as follows.

IA CIG Meeting Date 2nd July 2013

OBC Stage / Approvals January 2014

Design and Target Price

Full Business Case development

September 2014

Full Business Case Approvals December 2014

Construction Start (Initial Phases)- based on

Frameworks Scotland

January 2015



A APPENDIX – SMART OBJECTIVES



SMART Objective Heading Objective Details Baseline Data Source Timing

To improve business effectiveness and revenue efficiency

Both local and national objectives require maximum benefit from all public expenditure. NHS Highland is also required to reach a break even position while improving quality of care.

NHS Highland Financial framework

Financial Framework. Management accounts

Monthly management accounts. Yearly outturn. Bi-monthly improvement committee.

Improve HEAT and other Health targets

To meet both nationally stipulated

HEAT targets regarding waiting times and infection control, and improve adherence to the BADS targets for day-case surgery. Also reduce energy-based carbon emissions as per the Climate Change (Scotland) Act.

HEAT targets Reporting on all

heat targets already in place

Monthly

management reviews

Augment and expand range of services and promote emerging model of care including consolidation of critical care

To meet the challenges achieving the Greater Inverness Masterplan which points to the need for urgent improvements to address critical care deficiencies in the existing model of care, as well as the importance of improving theatre compliance at Raigmore to meet the future needs of NHS Highland.

Service data regarding theatre utilisation Current performance against BADS targets.

Service planning. Ongoing review of service data.

Make possible the introduction of new ways of working and in particular effective collaborative working and flexibility in the workforce

To adhere to the principles set out in the Highland Quality Approach regarding new ways of working and service redesign.

Critical Care bed days Length of stay Current performance against BADS targets.

Service planning Ongoing review of service data. One-off rapid action improvement cycles as per LEAN methodology.

Improved facilities / increased capacity offering a patient centred service including greater consistency of care and increased certainty for admissions, procedures and discharge

To adhere to the principles set out in the Highland Quality Approach regarding patient-centeredness, consistency of care and robustness of admissions and discharge procedures.

Service data regarding theatre utilisation and outcomes. Better together survey results

Service planning. Healthcare Improvement Scotland.

Monthly reporting in line with current service management practice. Quarterly reporting to NHS




Highland board.

Concentrate higher and lower levels of care at appropriate locations

To reduce the number of patients placed in an inappropriate care setting.

Service data regarding admissions to levels 2 and 3 care setting.

Service planning Monthly reporting in line with current service management practice. Quarterly

reporting to NHS Highland board.

Offer facilities which reduce risk of spread of infection compared to status quo

Improve ward layouts and design to assist in meeting the requirements of the HAIScribe guidance and reduces the risk of infection spread.

HAIScribe guidance to deliver facilities. Existing infection control data.

Targets and defined specification included within HAIScribe documentation. NHS Highland infection control report.

HAIScribe reviews at strategic times during design periods. Continual monitoring of infection control data post-construction as per current practice.

To achieve optimal utilisation of space (within the constraints of existing buildings)

Refurbishment and rationalisation of existing facilities should optimise critical care beds, and increase theatre capacity to meet requirements of demographic trends.

Greater Inverness Masterplan Service planning Ongoing review

To achieve operational and functional efficiency of physical environment

Achieve a minimum target score of

4/6 in relation to all the AEDET categories in line with the AEDET review which will be undertaken at key stages in the project.

A technical evaluation of the

project proposals will be undertaken based on the Department of Health Design Evaluation Toolkit “AEDET” (Achieving Excellence Design Evaluation Toolkit).

AEDET review At key stages in

the design development (as noted in the AEDET guidance) and first post construction assessment within 1 year after fully operational.




To deliver high quality facilities, and technical standards with a strong focus on lifetime costs, quality and design.

Where possible, to meet technical specifications for modern care facilities as articulated in relevant Scottish Health Technical Memorandum (SHTM), Scottish Health Planning Notes (SHPN’s) and Health Briefing Notes (HBN’s).

Comply with CEL 19 (2010) – A Policy on Design Quality for NHS Scotland – 2010 Revision

Scottish Health Technical Memorandum (SHTM) Scottish Health Planning Notes (SHPN’s) Health Briefing Notes (HBN’s) CEL 19 (2010) – A Policy on Design Quality for NHS Scotland – 2010 Revision

Scottish Health Technical Memorandum (SHTM) Scottish Health Planning Notes (SHPN’s) Health Briefing Notes (HBN’s) CEL 19 (2010) – A Policy on Design Quality for NHS Scotland – 2010 Revision

At key stages in the planning and design process.

To comply with “A Sustainable Development Strategy for NHS Scotland’, to enhance the contribution of the health sector to sustainable development

Deliver facilities that when completed achieve rating of BREEAM “Excellent” (or “Very Good” for refurbishment) and NHS Highland’s Environmental Policy in relation to carbon dioxide emissions

BREEAM Healthcare guidance. SCIM guide. Sustainable Buildings Guide Sustainable Strategy for NHS Scotland NHS Highland’s Environmental Report (2007) A sustainable Development Strategy for NHS Scotland

BREEAM Guidance BREEAM to be undertaken initially and then subsequent meetings to ensure criteria is satisfied

To enable the retention and recruitment of staff

To see an improvement in staff survey results in terms of absence and staff turnover and to provide a working environment which sustain recruitment.

Staff survey. Absence management policy and data. Staff turnover levels.

Improvement in staff survey results. Maintenance of low staff turnover levels.

Bi annual staff survey. Monthly absence management review.



B APPENDIX – SUMMARY OF CATEGORIES OF

CHOICE ASSESSMENT



Category of

Choice (Option)

Comments on Potential Options Review

Outcome

Scoping /

Capacity option

1. Reconfiguration of Beds (reduce) to achieve improved compliance with SHTM bed spacing requirement (typically resulting in 6 beds going to 4)

2. Provide additional capacity of Medical High Dependency Units

3. Provide additional capacity of Critical Care Unit

4. Provide additional theatre capacity via the development of one or more additional theatres – day

case units

5. Consider under utilised space in Maternity Unit (first floor) Ward 8, 9 and 10 (Labour ward 10) not within tower block as locus for services that need close proximity to theatres eg Opthalmology / Endoscopy / Surgical Day Case and Common Admission Lounge.

6. Create additional capacity to dialyse patients near/adjacent in-patient (in-pateitn at Level 7c) wards with main dialyses at level 7 (close to for plant configuration)

7. Addition of vascular lab to meet current standards for Vascular department

8. Addition of post anaesthetic care unit (PACU) adjacent to intensive care unit

9. Dental Paedeatric. Address current deficient accommodation within Endoscopy unit –Service provision

10. Cardio – version. Address current deficient accommodation within Endoscopy Unit – service provision

11. Addition of new build tower block (for in-patient) with existing Tower block being utilised for Out-Patient (knock down existing out-patient)

12. Day Services Project – Renal/ / Theatres and Endoscopy – creating a new build

Discount

Yes, for long list

Discount

Discount

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Discount



13. Satellite – Invergordon – for Renal Dialysis

Discount

Discount

Service solution

1. Co-locate intensive care and high dependency to allow acute care to be concentrated in one location

thus improving staff efficiency and flexibility

2. Moving acute Medical assessment and admission units closer to the Emergency Department or “Front Door”

3. Locate surgical & orthopaedic wards as close to Theatres as possible ie lower floors

4. Consider the need for an “admission assessment area” as close to the emergency department as

possible through the creation of a combined assessment area

5. Co-locate services within the Tower Block based on acuity eg “hot floor(s) concentrate acute

services at one level – specialist critical care staff at one level

6. Co-locate services within the Tower Block based on speciality – Medical and Surgical Departments

to be separate

7. Co-locate specialities that do not require to be on an acute site to create additional decant space

(eg dermatology, YARU and Aneurysm screening) Re-locating selected Day Case and OPD away

from more acute / Higher Dependency Wards

8. Move services out of the Tower Block, where adjacency is not required (eg Endoscopy), and to

suitable accommodation

9. Re-locating all female surgery (away from male wards) and into separate unit (outwith Ward Block) – into Ward 8 Re-locating female surgery wards (away from male wards) and into separate unit (outwith Ward Block) – into Ward 8

10. Move Child Ward services from the Tower Block into a separate Child Ward unit

11. Consider re-locating selected acute services at Raigmore back into the Tower (eg Respiratory) that

provide improved adjacency to General Medicine

12. Upgrade existing Theatre accommodation commensurate with modern standards

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list

Yes, for long list



13. Eye Day Case Unit – relocation to current location of renal unit

Yes, for long list

Implementation

Options

1. Phase services in – extensions and refurbishment of existing premises

2. Single project to completion

Preferred

Discounted

Service delivery

/ Funding

Options

1. NHS Capital funding based on traditional procurement

2. PPP/PFI – private sector

3. Hub Model – private capital

4. Developer Led - private

5. Voluntary Organisation Funding

Preferred

Discounted

Discounted

Discounted

Discounted



C APPENDIX – SWOT ANALYSIS OF LONG LIST;



Long List of Options

Summary of SWOT Analysis Results – Only Key Factors Summarised Include on

Shortlist?

Strengths Weaknesses Opportunities Threats

Scoping & Service

Solution Options

A. Do Nothing Reduced capital spend

in the short term

Less disruptive option

in the short term

Some opportunities for

efficiencies are already

being implemented

without the need for

significant investment.

Increased capital spend likely in

long term

No improvement in efficiency,

safety, or quality of care.

Continued inability to meet modern

care standards and SHTMs for

accommodation

Fire upgrade works must still go

ahead. Therefore “do nothing”

would not avoid the associated

disruption.

No increase in theatres or critical

care capacity

Ability to “wait and see”

regarding full outputs

from the Greater

Inverness Masterplan

Still requires completion of

significant and costly

maintenance backlog

Potential for increased

revenue costs given

continued inefficiencies

Decreased staff morale

Failure to capitalise on

“once in a lifetime”

opportunity given large

scale fire upgrade project

Continued use of costly

“stop gap” solutions (e.g

the modular theatre)

Failure to fulfil significant

component of the Greater

Inverness Masterplan.

Yes, for

comparison

(Option 1)

B. Co-locate services

within the Tower Block

based on speciality –

Medical and Surgical

Improved adjacency of

some relevant services

Improved patient care

and patient flow within

the two divisions.

Relocation will allow for

significant

Not a new-build, so still restricted

by the envelope of the building and

its construction. Unlikely to fully

adhere to SHTM specifications.

Co-location only along divisional

lines would not permit sharing and

flexibility of staff or administration.

Potential improvement in

performance against

HEAT targets (e.g. 4 hour

A&E target)

Improved accommodation

standards likely to impact

positively upon infection

Complicated decant and

transitional arrangements

without full realisation of

potential benefits in terms

of either quality or

efficiency.

Limited realisation of

potential benefits from

No



improvements to the

condition of the

accommodation, and to

the services and

facilities.

Would not disrupt

existing positive

practice within

divisions (eg the use of

a dedicated middle

grade doctor across

both CCU and MHDU)

Does not allow for full flexibility

between HDU/ICU beds to meet

the needs of individual patients or

of coping with peaks in demand.

control efforts.

Potential to realise some

benefits from economies

of scale.

economies of scale.

Would be contrary to

current guidance from DoH

and SEHD regarding

colocation of all HDU

facilities.

C. Consolidate Critical Care Unit with CCU at Ground floor and Medical HDU and ITU / SHDU co-located at first floor and Endoscopy retained in Tower Block (level 6)

Improved adjacency of

critical care services to

“front of hospital” (i.e.

A&E), and hence

improved patient flow

Critical care no longer

spread across 3 floors

and 4 departments.

Greater ability to step

up/step down care.

Flexibility of level 2

and 3 care beds

Decreased need to

operate respiratory

ward as an informal





Requires dismantling of fit-for-

purpose CCU on level 6.

Would not allow space for

placement of respiratory ward on

level 6 (a much better location

than its current position outside

the tower block)

Integration of facilities

allows potential for more

efficient care and less

duplication of nursing and

administrative functions.

Improved care, improved

staff morale and

decreased revenue spend.

Increased staff flexibility

between ITU/SHDU and

CCU/MHDU

More appropriate

placement of patients as

to care needs. Reduced

potential for either too-

early discharge, or too

Would need robust

transition arrangements for

critical care patients during

move.

Economies of scale may

not be realised if new ways

of working are not

adopted.

New CCU could be less

spacious than current

purpose built facility –

albeit in an inappropriate

location.

Yes

(Option 2)



HDU.

Access to isolation

facilities in MHDU, and

improved infection

control throughout.

Compliance with

current SHTM

standards

Improved storage.

high a level of care.

Potential for improved

critical care for cardiac

patients

Potential resolution of

issue whereby MHDU

patients requiring

isolation are admitted to

CCU, despite having no

cardiac conditions.

D. Consolidate critical care with CCU & MHDU co-located at ground floor with ITU & SHDU co-located at first floor and with Endoscopy moved outwith Tower Block

As above, but with

additional benefit that

endoscopy could

instead be sited closer

to the standalone

decontamination unit

rather than in the

tower block.





Requires dismantling of fit-for-

purpose CCU on level 6.

Would require alternative location

to be found for endoscopy

As above

Potential to bring

respiratory ward into the

tower block (6th floor).

As above

Potential unsuitability of

alternate locations for the

endoscopy unit.

Yes

(Option 2A)

E. Similar to Option 2A but with MHDU/CCU situated at Ground floor at “A” block to facilitate intensive care adjacency, and the addition of Vascular Lab and PACU

Improved adjacencies

of MHDU/CCU/PACU

Would require alternative

accommodation for either AMAU or

Cardiology step-down, thus

disrupting adjacencies of these

facilities.

Would mean moving PACU further

away from theatres and SHDU


efficiencies from better

adjacencies.

Might not be most

optimum combination of

adjacent services.

Yes

(Option 2B)



F. New Combined Assessment Unit on ground floor and consolidate critical care with CCU & MHDU also co-located on ground floor with ITU & SHDU co-located at 1st floor

Improved co-location

of services, especially

with MHDU on ground

floor and so adjacent

to radiology, A&E and

ambulance access

Co-location of critical

care services, with

associated benefits as

described above

No PACU

Separation of surgical specialities

Decide to admit paradigm

as opposed to admit to

decide

Requires increases in

medical staffing

Separation of surgical

admissions from other

surgical facilities

Potential restriction in bed

allocation for surgical

admissions

Yes

(Option 3)

G. New Combined Assessment Unit on ground floor and consolidate critical care CCU/MHDU and ITU/SHDU) completely on 1st floor


of services

Moves MHDU away from ground

floor and reduces ease of access to

A&E/ambulances

No PACU

As above Full benefits of adjacency

of MHDU and A&E not

realised.

Yes

(Option 3A)

H. New Combined

Assessment Unit on ground floor and consolidate critical care (CCU/MHDU and ITU/SHDU) in “A” block on ground and 1st floors


of services

Includes PACU

No space for addition of PACU

Unable to adhere to space

regulations/requirements

As above Requires increases in

medical staffing

Separation of surgical

admissions from other

surgical facilities

Potential restriction in bed

allocation for surgical

admissions

Yes

(Option 3B)

I. Provide additional

capacity of Medical High

Dependency Units

Requirement for

increased MHDU

capacity outlined in

Would require both capital and

revenue expenditure.

Meets both current and

future need for increased

Increased capacity could

increase revenue costs if

benefits of consolidation

No



review of HDU in NHS

Highland (The High

Dependency Needs

Assessment of NHS

Highland Patients).

MHDU capacity.

Movement towards a

philosophy of Critical

care, rather than

traditional split between

ICU/HDU

elsewhere are not realised.

J. Consider under utilised space in Maternity Unit (first floor) as locus for services that need close proximity to theatres eg Opthalmology / Endoscopy / Surgical Day Case ?

Optimised use of

existing floorspace.

Would require disruption to

Maternity services not necessary if

completion of fire works was the

sole objective.

Resolution of sub-optimal

usage of premium space.

Synergy with project to

upgrade endoscopy

services (for which

funding has been

secured)

Difficulty of releasing

usable space while

ensuring quality of

maternity/endoscopy/opth

almic is not compromised.

Increased complexity of

decant arrangements by

bringing maternity services

into the project scope.

No

K. Create additional capacity to dialyse patients on in-patient wards with main dialyses at level 7 (close to for plant configuration

Fill in from day service

paper

Yes, combine

with main

options

L. Addition of vascular lab to meet current standards for Vascular department

Better adherence to

modern standards of

care

Improved patient

outcomes and satisfaction

Staff training required

Potential increased

revenue spend to staff

vascular lab.

Yes, combine

with main

options

M. Addition of post anaesthetic care unit (PACU) adjacent to

Increased flexibility of Potential to relieve

pressure on ICU and

Space allocation Yes, combine

with main



intensive care unit beds

Promotes flexibility

with staffing

Less potential for

blocking of SHDU beds

reduce the number of

too-early discharges.

Potential to reduce the

need for delayed transfer

of patients from ICU or

HDU to ward-based care

and the inefficiencies

associated with too high a

level of care.

options

N. Move non-acute services out of the Tower Block, where adjacency is not required (eg Endoscopy, Child Ward), and to suitable existing accommodation

Would leave space for

improved adjacencies

of acute services.

Would require alternative

accommodation to be found for

endoscopy and children’s ward

End result of vastly

improved co-location of

relevant services.

Improved patient

outcomes

Better communication

between staff in relevant

specialties. Improved

skills and morale.

Concurrently running

projects (i.e. the Archie

Foundation) must be

managed in tandem.


alternative

accommodation.


decant arrangements

Yes, combine

with main

options

O. Re-locating female surgery wards (away from male wards) and into separate unit (outwith Ward Block) – into Ward 8

Vastly improved

patient-centerd care.

Not required if fire upgrade is sole

objective

Reconfiguration allows for

better use of space in

Ward 8/9/10 area.


disruption and increased

complexity of decant

arrangements.

Potential difficulty of

finding alternative space

for specific functions (e.g.

Parentcraft room)

No



P. Consider re-locating selected acute services at Raigmore back into the Tower (eg Respiratory) that provide improved adjacency to General Medicine

Safer and more

appropriate colocation

and improved

adjacencies.

Many respiratory

patients require level 2

care/emergency

transfer to ICU

Require space to be made by

transferring other services out of

the tower block.

Improved patient

outcomes.

Better communication

between staff in relevant

specialties. Improved

skills and morale.


alternative accommodation

for moved services.


decant arrangements

Yes, combine

with main

options

Q. Upgrade existing Theatre accommodation commensurate with modern standards

Improved adherence to

modern healthcare

standards and SHTMs

for theatre

accommodation

Resolution of issue

relating to severe lack

of storage for theatre

equipment

Replacement of

equipment and plant

beyond its design life

Significantly improved

infection control

Significant capital expenditure Potential for increased

efficiency, particularly in

terms of better adherence

to BADS targets and

capitalisation on the

potential of optimal short-

stay surgery.

Full refurbishment would

replace the need to

resolve the significant

maintenance backlog.

Opportunity to eliminate

need for the cost-

inefficient and unfit-for-

purpose modular theatre.

Difficulty of continuing to

provide theatre services

while refurbishment works

are ongoing.

Yes, combine

with main

options

R. Eye Day Case Unit – relocation to current location of renal unit

Allows relocation and

isolation of dedicated

day case ward

(currently includes eye

Increased distance from main

theatres.

Potential for improved

efficiency of eye theatre,

and increased flexibility

(e.g. partial lists) which

Dependent upon safe and

successful relocation of

renal unit

Would require dedicated

Yes, combine

with main

options



unit).

Improved compliance

with modern care

standards, SHTM

specifications and

infection control.

Improved adjacency to

eye OP clinic.

would improve ability to

meet TTG targets.

Would release capacity for

other specialties in main

theatres, allowing for the

introduction of LEAN

working and negating the

need for a costly

standalone modular

theatre.

staffing. Potential for some

increased revenue costs.

Dependent on the approval

of a separate outline

business case



D APPENDIX – PREFERRED TOWER BLOCK LAYOUT



Level C B A Level

7Medical

GI/RenalManagement Renal Dialysis 7

6 Respiratory RespiratoryOncology with

D/C Trans6

5Vasc/Urology

Surgery/Vasc Lab

Dermatology

Offices

EMPTY - to be used for

winter pressures and

flexi beds for

indcidences of

Infection etc

5

4 Surgical Seminar Room Surgical/Triage 4

3 Orthopaedics Head & Neck Orthopaedics 3

2 Medical Therapy Unit Stroke/YARU 2

1 CAL/SDCU Waiting Area ITU/SHDU/PACU 1

GroundCardiology step-

downCCU AMAU/MHDU Ground

OPTION 2A

*MHDU would join AMAU on the Ground floor as

opposed to the 1st floor as per Option 2.

*Ward 8 and Ward 9 would amalgamate to allow

Endoscopy ro relocate to Ward 8.

*CAL and SDCU relocate to Ward 1C and potential for

stand-alone Eye Day Case Unit could be developed

in space vacated by Renal Dialysis at a later date.



E APPENDIX – POTENTIAL PHASING PLAN



F APPENDIX – POTENTIAL HIGH LEVEL SCOPE



Do Minimum

Option 2 – Consolidate Critical Care Option 3 – Consolidate Critical Care + Combined Assessment

Unit

1 2 2A 2B 3 3A 3B

The Current configuration but assume - fire precautions

works (ongoing) - endoscopy development but at

ground floor

of Tower - Upgrading of CCU, AMAU/MSCU, SHDU, Therapy,

ITU, Critical Care Waiting, 1A(CAL, EDCU, SDCU, ITU -

- All to be retained at their

current location

Consolidation of Critical Care on Ground and First Floor Levels –based on acuity

Consolidation of Critical Care on Ground and First Floor Levels – based on acuity. Plus Combined Assessment

Unit

Co-locate AMAU and CCU on ground

floor

Combined Medical Assessment Unit

on ground floor

Cardiology also co-located on ground floor

Cardiology remains on Level 6

Co-locate ITU/SDHU on first floor

MHDU at

First Floor

MHDU at Ground Floor Co-locate

CCU and MHDU at Ground

Floor

Co-locate

CCU and MHDU at 1st Floor

Co-locate

CCU and MHDU/Short stay beds at

Ground Floor

No PACU Post Anaesthetic

Care at Level 1

No PACU

Post Anaesthetic

Care at Level 1

1A (CAL / Surgical DC / Eye Day Care to Ward 8

CAL / Surgical Day Case to Level 1

CAL / Surgical Day Case to First Floor

CAL / Surgical Day Case to Ground level

CAL / Surgical Day Case to First Floor

Surgical Triage to remain at Level 4 Surgical Triage relocated to Ground Level

Potential to move Renal Dialysis moved to Level 7 – separate Investment

Respiratory moved into Tower – Level 6

Medical Ward adjacent to Therapy

Oncology moved to Level 5

Child Ward moved out of Block (Ward 11)

Endoscopy at Level 6

Endoscopy re-locate to Ward 8 (funded secured)

Gynae/Breast

(Ward 8) into Tower - Level 5

Gynae/Breast (Ward 8) to amalgamate to Ward 9

(funded secured)

- Vascular Laboratory added at 5C

- Vascular Laboratory added at 5C

Potential to provide Eye Day Case into the accommodation formally occupied by Renal (separate investment). However, this investment only to include

limited allowance for Eye Day Case, currently in 1A



1 2 2A 2B 3 3A 3B

Theatres Refurbishment

In conjunction with the planned significant upgrading works (refer below) the

continued use of the existing 9 theatres located within the Tower Block

To improve compliance, building fabric and services upgrading of the existing 9

theatres, to meet modern clinical standards (the Theatre within the Maternity

Block is outwith the scope of this project)

Upgraded fire precautions of Theatres in Tower Block to meet horizontal fire

evacuation requirements

Services upgrade associated with achieving compliance, include ventilation

system enhancement

Where possible, potential increase in storage requirements (possible expansion

adjacent to plant room) to facilitate improved compliance with required storage

and other space standards

Provision of services / waste corridor to rear of the Theatres accommodation

Child Ward

Retain in

current location

The Child Ward will involve the redevelopment of Ward 11 to facilitate

the move. A limited allocation of funding is being considered in

respect of any outstanding need to deal with the current compliance

issues.

Respiratory


The project will require the development of a temporary facility at

Ground Floor level involving some works. (This will require occupation

of some Children’s Ward accommodation, on a temporary basis).

Furthermore, Level 6 will require some reconfiguration to facilitate the

permanent move to Level 6

nhs highland · scientific advisory committee (smasac) nhs highland undertook a study to review...

Documents