Trust Board Meeting: Wednesday 13 May 2015
TB2015.56
Title
Proposal for the Relocation of Respiratory Inpatient and
Cystic Fibrosis Services to the John Radcliffe Site
Status
For decision
History
Considered by the Trust Management Executive at its meeting
on 23 April 2015, and supported for submission to the Trust Board
Board Lead(s)
Mr Paul Brennan, Director of Clinical Services
Key purpose
Strategy
TB2015.56 Proposal for Respiratory Relocation
Assurance
Policy
Performance
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TB2015.56
Executive Summary
1. This business case is to outline the proposed reconfiguration of respiratory services to
move inpatient services to the John Radcliffe site in line with the Trust agreed strategy
for the configuration of its services.
2. A plan has been developed to move the Respiratory in-patients from Geoffrey Harris
Ward at the Churchill to a 21-bedded respiratory ward on Level 7 at the JR as a result
of the vacation of the Community Hospital ward and 6 dedicated Cystic Fibrosis beds
on 5C/D. The relocation plan also includes the move of the Cystic Fibrosis and
Bronchiectasis outpatient and treatment unit which currently operates out of the
Respiratory Day Case Unit which was condemned in December 2011. This service will
relocate to a dedicated area within Blue outpatients with access to gym facilities on
Level 2. The location of the Respiratory inpatient ward on the John Radcliffe Hospital
site will improve the pathway for acute respiratory inpatient admissions and support the
implementation of the Acute General Medicine Review from 2012. The services will
also join the Respiratory interventional unit (bronchoscopy and thoracoscopy) and
overnight sleep studies services which moved to the JR during 2014.
3. The capital investment required for the reconfiguration of the ward on Level 7 is
estimated as £1,958k which includes extensive refurbishment, installation of medical
gases, removal of asbestos and installation of ducting to allow future installation of
mechanical ventilation. Derogation in place for a period of 2 years following which a
further assessment will need to be made re the installation of the mechanical
ventilation. It also includes the purchase of equipment for the move including
replacement monitoring for the service’s high care beds; bedside EPR computers and
the location of a lung function testing room within blue outpatients to support
comprehensive lung function studies on respiratory patients but also other patients
such as cardiothoracic who require these tests prior to surgery. Provision has been
made for this proposal in the Trust capital programme.
4. In addition, there is a requirement for £330k revenue investment as this move will
result in a number of staff and teams needing to work on a split-site basis. It will also
require investment in consultant time to maintain outpatient clinics and junior doctors to
enable the provision of robust out-of-hours rotas for respiratory medical cover. The
Division is committed to reducing the additional costs over time as other efficiencies
are realised as a result of the new configuration and closer working between
Respiratory and Acute General Medicine
5. Following this move, the configuration of Respiratory Medicine will be as follows:
 The Churchill site will maintain most general and sub-specialist outpatients; Sleep
and Ventilation set-ups; lung function tests; Radiology exams including overnight
admission for respiratory radiology procedures. Some pleural procedures will also
continue at the Churchill site in Radiology.
 The John Radcliffe site will host general and Cystic Fibrosis Respiratory
inpatients; Cystic Fibrosis outpatients and day case treatments; Interventional
procedures including bronchoscopy and pleural procedures; inpatient sleep
studies.
 In addition, the Horton hospital also provides respiratory outpatients,
bronchoscopy procedures and lung function tests.
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6. To approve this business case and the capital and revenue investment required to
support the delivery of the relocation of Respiratory inpatient services and adult cystic
fibrosis services to the John Radcliffe site.
7. To support the continued work of the MRC division to realise efficiencies associated
with improvements to patient flow as a result of the new location of services.
8. Recommendation
The Trust Board is asked to:
 To approve this business case and the capital and revenue investment required to
support the delivery of the relocation of Respiratory inpatient services and adult
cystic fibrosis services to the John Radcliffe site.
 To support the continued work of the MRC division to realise efficiencies
associated with improvements to patient flow as a result of the new location of
services.
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Proposal for the Relocation of Respiratory Inpatient and Cystic Fibrosis Services to
the John Radcliffe Site
Trust Management Executive Reference
TME2015.107
Appendices
Appendix A – Financial Pro Forma
Appendix B – Ward Refurbishment Works
costing assessment
Appendix C – Risk and Action log for the
Relocation Plan
Appendix D – Equality Impact Assessment
TBC
Background papers (if any)
Action/decision required from SPC
To approve the plans for relocation of
respiratory services to the John Radcliffe
Site
To approve the additional resources
required to facilitate this move which are:
Capital:£1,958k
Revenue:£330k p.a.
To acknowledge the risk associated with the
remaining respiratory services remaining in
their current location at the Churchill site
and to support finding a solution for these
issues
To acknowledge the risks associated with
relocation and to support the organisation in
managing these risks
Strategic Objective(s) that the case will SO1
To be a patient-centred
help deliver
organisation, providing high quality and
compassionate care, with integrity and
respect for patients and staff – “delivering
compassionate excellence”
SO4 To provide high quality general
acute healthcare services to the
population of Oxfordshire, including
more joined-up care across local health
and social care services – “delivering
integrated healthcare”
SO5 To develop extended clinical
networks that benefit our partners and
the people they serve. This will support
the delivery of safe and sustainable
services throughout the network of care
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that we are part of and our provision of
high quality specialist care for the
people of Oxfordshire and beyond –
“excellent secondary and specialist care
through sustainable clinical networks.”
Proposed date that revenue spend will October 2015
begin:
Proposed date that capital spend will May 2015
begin:
Conclusion of Equality Analysis
The relocation of Respiratory inpatient
services will increase the availability of
respiratory expertise in the management of
acute hospital medical admissions and
improve the overall delivery of care for
these patients
The relocation doesn’t address the
accommodation needs for respiratory
outpatients and solutions will need to be
found to address this.
Review Date
April 2016
Acronyms and abbreviations used
BTS – British Thoracic Society
OCDEM – Oxford Centre for Diabetes,
Endocrine and Metabolism
NIV – Non-invasive Ventilation
CPAP –
Pressure
Author (s)
Continuous
Mrs Kathryn
Manager
Positive
Airway
Hall, Operational Service
Dr Maxine Hardinge, Clinical Lead for
Respiratory Services
Lead Finance Manager
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Mr Andrew Hall, Interim Senior Business
Partner, MRC Division
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Proposal for the Relocation of Respiratory Inpatient and Cystic Fibrosis Services
to the John Radcliffe Site
1.
Strategic Context and Case for Change
1.1. The Trust’s Two Year Business Plan 2014/15-15/16 (TB2014.58) as part of the
delivery of its clinical strategy stated the requirement to “Optimise the
configuration of services across the Trust’s four sites”. This would be delivered
through a number of actions including “Support the strengthening of acute
services by the transfer of medical sub-specialities to the JR site to provide
enhanced and more responsive support”. For respiratory services and
Infectious Diseases, this would be achieved through:
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Agreement of strategy and location
Completion and approval of business case
Completion of necessary works
Relocation of services.
1.2. The Respiratory Service produced a Strategy document which was approved by
TME in the autumn of 2014. This strategy outlined the long term goal for the
location and development of all Respiratory services. This business case is a
step in the delivery of that strategy.
2.
Current Service Configuration
2.1. The Oxford Centre for Respiratory Medicine is currently located on the old
Churchill Hospital site. The service comprises of the following departments:
2.1.1.
A 24-bedded ward located in the OCDEM (Oxford Centre for Diabetes,
Endocrine and Metabolism) building which is shared with Diabetes and
Endocrine patients. The ward is nominally split with 18 beds for
Respiratory and 6 beds for Endocrine/Diabetes but the bed usage is
flexible according to the demand. Respiratory patients frequently
exceed 18 beds and will also outlie on John Warin ward (Infectious
Diseases), and the Renal ward. There is an average of 4 outliers per
day on the Churchill site and there is also an average of 5 patients per
day awaiting transfer /admission from the John Radcliffe site for
Respiratory management.
2.1.2.
A 10-bedded day case unit which is located on the east side of the
hospital site down the corridor from the old east entrance. The day
case unit is used by a number of services including:
 A rapid access service which is designed for patients who are known
to the respiratory service and may be deteriorating. GPs are able to
access this service for urgent intervention to avoid admission (NB
this service has not been operating during 2014/15 due to the
inability to recruit to the nursing posts required to support the unit).
 Cystic Fibrosis day case assessment and treatment for patients who
require support and intervention, e.g. IV infusions.
 Day case set-up of Non-Invasive Ventilation (NIV) or Continuous
Positive Airways Pressure (CPAP) for sleep and ventilation patients
who are going home to continue their treatment. This is an
alternative to hospital admission which is standard care in many
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other large sleep centres. There is also space for a group education
session for patients and their carers to provide them with advice and
guidance for their on-going treatment.
A base for the collection and deposit of equipment for home-based
sleep studies for the sleep and ventilation service.
Day case IV infusion treatments with Omalizumab (severe asthma
patients) and Infliximab (Dermatology patients with complex
psoriasis) which have to be administered under medical supervision.
(NB this service relocated to a side-room on the Respiratory ward
due to a lack of nursing staff as a result of recruitment and retention
problems in 2014).
Respiratory physiotherapy out-patients including a gym and exercise
area for general Respiratory patients and Cystic Fibrosis patients.
A long-term oxygen therapy and ambulatory oxygen therapy
assessment service provided by the Home Oxygen Service, part of
the Oxford Health Respiratory nursing team OUH provide Consultant
supervision for this service and facilities (arterial blood gas machine)
which are not available in the community.
A two-bedded research area for patients currently undergoing clinical
trials through research projects with the University and the BRC.
2.1.3.
A Lung Function Laboratory which is the only OUH diagnostic lung
function facility. Lung function tests support the diagnosis and
monitoring of respiratory patients but also forms part of the range of
assessments needed for patients who are having surgery or
chemotherapy and radiotherapy treatment for Cancer. This service is
almost in continuous use and sees approximately 130 patients per
week.
2.1.4.
An Outpatient department with 9 clinic rooms and a reception area. This
provides out-patient facilities for approximately 20,000 patients per
annum.
2.1.5.
An office area for the following staff:
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2.1.6.
12 consultants in shared offices
1 unit manager
4 SPRs
14 A&C staff
3 Lung Cancer Specialist Nurses, MDT Co-ordinator and Tracker
4 Oxford Health Community TB nurses
4 Oxford Health Community Respiratory Nurses
Notes Storage.
The offices are mostly shared except those which are too small to
accommodate any more than 1 person. There is a staff coffee room
and seminar room for medical/nursing education which is used by many
other services on site.
 The Oxford Clinical Trials Department which coordinates regional
and national respiratory trials is located in the old Occupational
Health suite at the bottom of the corridor on the East side.
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2.2. During 2014, two services within Respiratory Medicine successfully relocated to
the John Radcliffe site. In February 2014, the inpatient sleep study service
moved to the Geratology Day Unit (Lionel Coisins) and uses the outpatient and
treatment rooms overnight. In July 2014, the Interventional service which
supports the provision of bronchoscopy, thoracoscopy and pleural procedures,
moved to JR Theatres. This followed a previous move to Churchill Radiology
after the procedure room within the old Respiratory Day Unit was condemned
for interventional use in 2013 due to problems with oxygen and suction. The
move to the JR has greatly improved the available capacity for procedures and
has supported a reduction in the diagnostic part of the lung cancer pathway as
the original relocation to Churchill Radiology was very limited due to limited
access to recovery space.
3.
Estate Issues for the Existing Accommodation
3.1. There are significant problems with the existing accommodation for Respiratory
Medicine at the Churchill:
3.1.1.
The ward (Geoffrey Harris ward) is located in newer accommodation in
the OCDEM building which was opened circa 2004 but this ward is not
without problems. The fabric of the building means that it can be very
hot in the summer and very cold in the winter. There have been regular
problems with leaks in the roof during heavy rain. In addition, the ward
fails to comply with appropriate standards for evacuation in the event of
a fire. One end of the ward is accessible for escape but the other will
not support the evacuation of bed-bound patients. Patients are also not
able to evacuate vertically due to the lack of back-up power supply for
the lifts in the building and the ward is located on the first floor. During
a power failure in 2014, there was a significant delay to the transfer of a
patient to Critical Care due to the inability to move the patient down a
flight of stairs.
3.1.2.
With the exception of the ward, all Respiratory services are supported
by power cables which date back to the Second World War and are of a
particularly specialist nature (wrapped in oiled paper) and there are a
very limited number of people who are able to work with such cables.
The last power failure was in March 2012 and Estates have advised
that the service can expect another power failure at any time. The
March 2012 power failure lasted 4 days and was significantly disruptive
to the service resulting in patients being cancelled where they could not
be safely relocated. The power failure effected all departments and
there is only one back-up power supply plug in the entire area.
3.1.3.
The existing accommodation does not comply with current infection
control standards for cleaning:
 The day case area has poor building fabric particularly around the
windows, edges of the side-rooms, the sluice room and kitchen area.
There are large areas of wood which cannot be cleaned to the
recommended standard. In the autumn of 2011, following an
executive walk-round, it was recommended that the department
should close by Christmas 2011 as it was considered unsafe for
patients. To date, it has not been possible to achieve this closure
due to the significant disruption to existing patient services and the
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difficulty in finding alternative clinical space. The department is
regularly audited for cleaning standards and monitored for any
incidents associated with hygiene or the environment to ensure that
patients remain safe. To date, there have been no incidents in
respect of this matter.
The outpatient accommodation has similar building fabric problems
with windows that cannot be opened and closed appropriately and
does not comply with current infection control standards for cleaning.
Demand for outpatient clinics has increased in the last few years and
on busy clinic days there is insufficient space for patients to wait
comfortably for their appointment.
The outpatient department is located on the old side of the hospital
whereas the Radiology department is located in the new Cancer
Centre. This distance is very difficult for patients who are suffering
with breathing problems and there is consistent patient feedback
from Outpatient Surveys regarding this. There is no space to provide
a plain film x-ray facility for Chest x-rays within the respiratory
outpatient department.
None of the departments have been redecorated for several years
and this contributes to the shabby appearance of the area and also
adds to the difficulties in presenting an environment that is clinically
clean.
The main corridor and the lung function corridor are similarly shabby
with inappropriate fabric for a clinic area and more recently several
species of pests have been spotted in the main corridor area which
again contributes to a poor environmental appearance for the
services as well as concerns for cleanliness and infection control
standards.
Impact and Risk of the Split between Respiratory and Acute General Medicine
4.1. The site split between Acute General Medicine based at the John Radcliffe
Hospital site and Respiratory at the Churchill site causes significant problems
with the patient pathway.
4.1.1.
Emergency admissions present at the John Radcliffe hospital site. A
significant percentage of these admissions will have a respiratory
problem as part of their primary diagnosis. There are insufficient
specialist respiratory beds to transfer all these patients across to the
Churchill and often the patients require input from a number of
specialists many of whom are located at the JR.
4.1.2.
The separate site configuration and the fact that the Respiratory service
has an extensive outpatient population and a commitment to the
Respiratory ward and immediate outliers on the Churchill site means
that within current staffing levels, it is difficult to provide a timely
response for Respiratory patients at the John Radcliffe site.
4.1.3.
The split-site configuration means that it is not easy to ‘exchange’
patients – in effect, to take the more acutely unwell respiratory patients
onto the respiratory ward and move a more able respiratory patient to
another ward prior to discharge.
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4.1.4.
Respiratory medicine is consistently busy but also suffers seasonal
spikes in demand, particularly during winter.
4.1.5.
The split site configuration also has a potential impact on the length of
stay for patients with respiratory conditions and ‘frequent flyers’ are not
always able to receive immediate intervention that could send them
home without the need for admission.
4.1.6.
The split-site configuration does not ably support the new model for
Medicine with the timely intervention of a specialist opinion to facilitate
effective and efficient patient management for patients admitted via
Acute General Medicine.
Case for Change – Relocation of Respiratory Services
5.1. There is an opportunity to relocate the Respiratory ward to the John Radcliffe
site through the vacation of Ward 7E following the departure of the City
Community Ward. This would create a 21-bedded ward which would include 2
High care beds for patients who are on basic or advanced Respiratory support.
This ward alone would not accommodate all of the Respiratory patients
including its outliers but there is also the opportunity to accommodate the Cystic
Fibrosis patients on Ward 5C/D and to do so within that ward’s existing
establishment. Ward 5C/D used to be the Private Patient ward and each bed is
in a single room with an en-suite and this would be ideal for the Cystic Fibrosis
patients. This is supported by the Cystic Fibrosis Peer review who visited the
Trust and the proposed location for inpatients.
5.2. There have been several changes in Blue Outpatients that mean it would be
possible to accommodate the Cystic Fibrosis and Bronchiectasis outpatient and
day case services where there is a much higher chance that patients will need
to be admitted to a bed from clinic. This would mean that Cystic Fibrosis
services could be accommodated on one site and would also promote a
stronger link with the Paediatric Cystic Fibrosis service to enable a more
positive transition for patients and would particularly address the environmental
disappointment that is currently experienced by patients moving from the new
Children’s hospital to the dilapidated Churchill site.
5.3. The Diabetes and Endocrine patients who would remain on the Churchill site
could be accommodated on John Warin ward on a cost-neutral basis within the
existing nursing establishment and bed base. Although it would present some
difficulties with regards the distance from OCDEM and the timing of some
endocrine diagnostic tests, these issues should be able to be resolved with
clear guidelines and specific identification of staff to take responsibility for those
patients when they are on the ward.
5.4. The vacation of Geoffrey Harris ward at the Churchill presents other
opportunities to facilitate the relocation of other services that need to remain on
the Churchill site. This could include Respiratory outpatients and sleep and
ventilation services as detailed above.
6.
Objectives and Benefit Criteria
6.1. The objectives for a relocation of Respiratory services are set out below:
 To relocate Respiratory inpatient services to the John Radcliffe Hospital site
to facilitate a more timely intervention of respiratory specialist expertise in the
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management of acute respiratory referrals to ED and EAU and to meet
national quality standards e.g. NICE COPD standards.
To support the Acute General Medicine review from 2012 and the model for
specialist input at an early stage.
To support patients who need a higher level of respiratory intervention such
as Non-invasive Ventilation.
To move clinical services to better accommodation and vacate poor estate
which has a high risk of power failure and does not meet current standards
for an appropriate clinical environment.
To ensure that Cystic Fibrosis patients, who have a high risk of being
admitted, are co-located with inpatient services to reduce the on-going risk of
patients needing to travel between sites.
6.2. The benefit criteria for a move of respiratory services are as follows:
 The opportunity for a more timely intervention from a respiratory specialist in
the acute general medicine pathway.
 A reduced length of stay for patients with respiratory conditions being looked
after by Respiratory medicine.
 Increased ability to move the most acute respiratory patients to the
respiratory ward to maximise the expertise available.
 A reduction in delays to the pathway of care for complex patients who require
multiple specialist opinions including respiratory.
 Delivery of the service specification for Cystic Fibrosis services as
determined by patients and commissioners and monitored by the Cystic
Fibrosis Trust through peer review.
 An increase in teaching and education for nurses and doctors in the
management of respiratory conditions on other wards.
7.
Options
7.1. Do Nothing
7.1.1.
The option to do nothing has been discounted as doing nothing will
deliver none of the objectives listed above and the option to remain in
the existing configuration is not going to be possible in the long term
due to problems with the estate and infrastructure on the Churchill site
and the continued split between respiratory and acute general medicine
which does not facilitate an effective pathway for patients admitted with
an acute respiratory condition.
7.2. Relocation of All Respiratory Services
7.2.1.
The option to put all Respiratory services on the John Radcliffe site has
been discounted as there is insufficient space for the volume of
ambulatory respiratory patients both within the hospital premises itself
and also within the parking facilities for patients. This will mean that
some services have to remain in sub-standard accommodation at the
Churchill for the time being but it is important not to lose the opportunity
to move some services and further the links and integration with Acute
General Medicine.
7.3. Recommended Option: Move Respiratory Inpatients and Cystic Fibrosis
Services
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8.
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7.3.1.
The opportunity to move the Respiratory Ward and the Cystic Fibrosis
services to vacated ward space on Level 7 and Level 5 and to Blue
Outpatients on Level 2 will meet all the objectives and benefit criteria
set out in sections 9 and 10 above and fits with the Trust strategy for
the relocation of Respiratory services to facilitate the Acute Medical
pathway.
7.3.2.
In addition to the relocation of the Cystic Fibrosis and Bronchiectasis
service to Blue Outpatients, it is recommended that a Lung Function
testing room is also established alongside that facility. This will not only
support Cystic Fibrosis patients but will also facilitate Cardiothoracic
patients being tested without the need to be transferred to the Churchill
site. It will also facilitate advanced diagnostic tests on acute respiratory
patients that might help to avert an admission to hospital as part of the
enhanced input of respiratory medicine to the acute medical flow.
7.3.3.
Although this option does not address all of the accommodation
problems for Respiratory services at the Churchill site, it does allow the
service to move a further step forward in accommodating its services in
a facility that meets the standard of twenty first century healthcare in a
world class University Hospital.
Financial Analysis of Preferred Option
8.1. Capital Costs
8.1.1.
The cost of reconfiguring Level 7 is £1.774 million and the detailed
costing is attached as Appendix B. The costs are high as they include
some extensive works to install medical gases to all the bed-heads,
removal of asbestos, a number of configuration changes on the ward to
open the space out from its current configuration to enable improved
observation of patients, and installation of ducting to allow future
installation of mechanical ventilation. Derogation in place for a period of
2 years following which a further assessment will need to be made re
the installation of the mechanical ventilation.
8.1.2.
As the works are largely the reconfiguration of space within the existing
footprint, the capital cost will not be added at 100% to the Depreciated
Replacement Cost. The exception will be the Mechanical and
Engineering (M&E) costs, where real value is added to the asset, in
particular through the installation of medical gases to all bed-heads and
installation of ducting to allow future installation of mechanical
ventilation. M&E costs are estimated at £665k (including ducting).
Assuming a 30 year life this gives depreciation of £22k/per annum and
cost of capital of a further £19k/per annum.
8.1.3.
There are some equipment costs as follows:
 Replacement monitoring for High care / HDU patients which will
include a centralised monitoring station at the nurses base for
maximum patient support:
£90,000.
The present monitoring
equipment is old and it has been recommended that it should be
replaced due to the likelihood of failure if it is transferred to the new
facility.
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 14 EPR computers and wall-mounted arms for bed spaces on the
main respiratory ward on Level 7. The costs for this have not been
confirmed at the time of writing this case and are estimated at
£20,000.
 Additional Lung Function testing facility within Blue Outpatients to
support Cystic Fibrosis patients, admission avoidance for acute
admissions and diagnostic tests for Cardiothoracic patients:
£34,000.
 Some minor equipment requirements for the relocation of services
and duplication of equipment that will be needed on the two sites.
This is estimated as £10,000 for the purposes of the business case.
8.1.4.
The estimated total for equipment is £154k. At an economic life of 5
years, this gives depreciation of £31k p.a. and cost of capital of £5k.
8.1.5.
In addition to the above capital costs there will be some set-up costs
that will be required to support the relocation – in particular the physical
move of the ward and additional staff time to support packing and
transfer of patients during the move itself. This is estimated at £30k.
These costs will be treated as enabling costs for the capital works and
therefore as capital in nature. They will not add to the Depreciated
Replacement Cost so there are no capital charge implications.
8.1.6.
Provision has been made in the Capital Programme to support the
capital costs of this proposal.
8.1.7.
Procurement will be via the Managed Term Contract (MTC).
8.2. Revenue Costs
8.2.1.
Staffing a split site clinical unit introduces unavoidable inefficiencies
which have been minimised as far as possible and are detailed below:
Service Area
Reason
Resource
Required
Cost
Occupational
and
Physiotherapy
Currently the teams are configured to work
flexibly according to patient need between
the medical wards at the Churchill. The split
site configuration will require additional staff
to support timely intervention for the
respiratory ward in its new location without
loss of service to Renal and Infectious
Diseases
1WTE across
the services
£33,800
Pharmacy
Pharmacy input is already under pressure
due to the split support required in Cystic
fibrosis, outpatients and the ward and also
the growth in homecare prescriptions to be
dispensed in respiratory services. Pharmacy
have found funding for half a post for the
antimicrobial service and would put this with
funding to make a full-time post which,
together with the existing post would provide
full cover for the ward and the outpatient
services within the Churchill team across the
two sites.
0.5 Band 7
£24,400
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Service Area
Reason
Resource
Required
Cost
Respiratory
SHOs
This post will be required to support the
increase in respiratory beds and split
configuration for the Cystic Fibrosis patients
who will be based on level 5. This post will
also improve the workload within the existing
team and protect the compliance of the rota
1 WTE CMT
Post with 1A
banding
£58,500
Respiratory
Middle Grades
This post will enable the creation of a single
Respiratory middle grade rota which will
support Respiratory at the JR and remove
the current shared requirement between ID
and Respiratory which will not work across
the split sites. The rota will also include
some contribution to Acute General Medicine
1WTE clinical
fellow with
1A banding
£87,000
Respiratory
Consultants
To reinstate specialty outpatient activity that
will be lost. Currently consultants are able to
maintain their 2 clinics per week whilst also
providing ward cover. This will not be
possible due to split-site working.
3PAs
£39,000
Total Staffing
£242,700
Capital charges - building
£41,000
Capital charges - equipment
£36,000
Estates operational costs
£10,000
Total
8.2.2.
£329,700
Radiology and Pathology have been consulted during the development
of the relocation proposal and have not identified any resource issues.
There will be some operational matters that will need to be addressed
including the switch in scanning requirements from the Churchill to the
JR and reporting of these but the assessment of the workload has
indicated that the total number of CT scans requested by the
Respiratory ward is relatively minimal and the greatest pressure on
radiology comes from Respiratory outpatients which will be remaining at
the Churchill site.
8.3. Income
8.3.1.
There may be a change in income as a result of moving more
respiratory work to be managed on an ambulatory basis but there are
opportunities for best practice tariff in some of these cases and the
continued, anticipated increase in acute admissions is likely to offset the
gains in ambulatory management. There is a potential risk to tertiary
income for non-invasive ventilation referrals from other hospitals and
cystic fibrosis patients within the local catchment area if those patients
cannot be admitted. The proposed scheme mitigates this risk with the
establishment of separate dedicated beds for Cystic Fibrosis patients.
TB2015.56 Proposal for Respiratory Relocation
Page 14 of 18
Oxford University Hospitals
9.
TB2015.56
Contribution
9.1. Chest Medicine made a contribution of £2,626k to end of Q3 of 2014/15.
Grossing up to full year effect gives £3,502k. The revenue costs noted above
would reduce this to £3,172k. The contribution margin reduces from 26.2% to
23.7%.
10. Impact on Profitability
10.1. Chest Medicine makes a profit of £1,113k to end of Q3 of 2014/15. Grossing up
to full year effect gives £1,484k The revenue costs noted above would reduce
this to £1,155k. The profit margin reduces from 11.1% to 8.6%.
11. Market Assessment (including commissioner discussions)
11.1. Commissioners are very keen to have more specialist respiratory expertise
available to support medical admissions and in the past have identified socalled “frequent fliers” and also drawn attention to the length of stay for some
patients, particularly when they are admitted over the weekend.
12. Benefits Realisation
12.1. The table below shows the quantifiable benefits of the proposal and the plan for
achieving them.
Benefit
Performance
Measure
Current Value
Target Value
Reduced length of stay
for patients admitted
with Respiratory
Conditions
Length of stay
Reduction in
readmissions for
patients with COPD
Readmissions within Assessment of baseline will be
28 days for COPD
undertaken to inform a
Divisionally agreed target
Earlier intervention of a
Respiratory specialist
opinion in acute medical
admissions
Number of patients
referred to and seen
by the Respiratory
team
Delivery of BTS and
NICE guidelines for
Respiratory conditions
eg Asthma,
Bronchiectasis, COPD,
NIV,
Compliance
with
guidelines
and
improvement
in
current gap analysis
Avoidance of admission
of patients with
Respiratory conditions
Number of patients
discharged from
EAU with
Respiratory condition
on same day of
admission.
TB2015.56 Proposal for Respiratory Relocation
Target Date
Assessment of baseline will be
undertaken to inform a
Divisionally agreed target
Assessment of baseline will be
undertaken to inform a
Divisionally agreed target
Assessment of baseline will be
undertaken to inform a
Divisionally agreed target
Page 15 of 18
Oxford University Hospitals
TB2015.56
13. Management of Risks of Implementation of Proposal
13.1. An extensive Risk and Action Log has been produced as part of the project
management arrangements for the relocation of service and this is attached as
Appendix C. Many of the risks will be resolved by agreement for funding and
recruitment to the additional posts identified.
13.2. There will be some risks associated with the management of respiratory
patients as inpatients on the Churchill site – particularly patients who are post a
radiology procedure such as a lung ablation or guided biopsy. These patients
will be accommodated on John Warin ward and will need to be subject to clear
protocols for management and agreed medical staffing responsibility.
13.3. The Respiratory service remains extremely concerned that there is no agreed
solution for the remaining services on the Churchill site which continue to
operate from sub-standard facilities.
14. Implementation Plan
14.1. If approval is given for this scheme to proceed, it is anticipated that the building
refurbishment of Level 7 will take approximately 20 weeks. Enabling works
have already begun which has reduced the risk of the programme being even
longer. Detailed discussion on room requirements have already taken place
which has also helped with reducing the length of the build programme.
14.2. A project team has been set up with a detailed action plan for all the work that
will need to take place prior to the relocation. This group is chaired by the
Clinical Director for Ambulatory Medicine and the Project is being managed by
the Operational Service Manager for Ambulatory. This group had been meeting
weekly during the development of this proposal and some of the initial work to
discuss the operational arrangements for the future configuration and to
mitigate against the risks associated with the planned move. This group is
currently meeting monthly but will increase the frequency of the meetings
pending approval of the business case to ensure that all actions to support the
move are completed. The group has accountability to the MRC division for
delivery of this project. Staff have been kept fully informed of the relocation
plans for the service but a formal consultation for staff would be issued in June
for to ensure that all issues are considered and staff are supported with plans
for relocation.
14.3. Recruitment for additional staff would commence pending approval of this case
to proceed. A meeting has been arranged between Respiratory, JR and Horton
Acute General Medicine to look at the best configuration of consultant job plans
that will work between Oxford and Banbury and across Respiratory and
Medicine. Locum posts will be advertised alongside substantive posts to
support maintaining service cover on an interim basis. This is a particularly
acute issue due to the resignation of both the substantive and locum
consultants for Respiratory at the Horton.
14.4. There will need to be some more detailed pathway work between Respiratory
and Acute General Medicine to consider the model of care and to agree how
patients will be managed that are across the specialties given that the total
number of respiratory patients will regularly exceed the number of respiratory
beds available. This work will be led by Dr Maxine Hardinge as the Clinical
Lead for Respiratory and Dr Sudhir Singh as the Clinical Lead for Medicine.
TB2015.56 Proposal for Respiratory Relocation
Page 16 of 18
Oxford University Hospitals
TB2015.56
14.5. The options for out-of-hours rotas will be finalised and an implementation date
agreed in order to communicate with the junior staff who will be affected and to
allow time for services to consider the impact on day time capacity.
Contingency plans for delays and/or overlap of the rotas and project will be
drawn up to ensure that there are no gaps in cover. The work on doctors’ rotas
is being led by Professor Tim Peto who led the work to establish the out-ofhours rotas for the Churchill site when the Cancer Centre opened in 2008.
14.6. A detailed operational policy will be written to fully document which services are
working in which location and what contingency arrangements are in place if
patients need to transfer.
15. When and how will the impact and intended effect be reviewed and reported
on?
15.1. The relocation will be reported on in December 2015 through the MRC Division
following the initial move. A formal review of the move and the impact will be
provided in a report to TME in April 2016 once the service has settled and it is
easier to assess how the service is working and what the impact has been.
16. Conclusion
16.1. The decision to relocate respiratory inpatient services to the John Radcliffe site
has already been made as part of the Trust’s strategy for configuration of
services. There are a number of quality benefits associated with this
reconfiguration, with increased efficiency in the support of the patient pathway
for patients admitted with acute respiratory conditions. There are also other
opportunities such as the closer liaison and development of thoracic services in
partnership with the Thoracic surgeons which will also support and strengthen
the cancer pathway as there are increasing efforts to encourage more patients
to have a surgical intervention for their cancer.
16.2. There are a number of difficult implications for the move which include the lack
of resolution for remaining services in the old accommodation on the Churchill
site. The move of inpatient services will result in a different split in services that
will have risks associated with it such as the reduction in support for patients on
the Churchill site in terms of both medical input for cancer, surgical and
diagnostic patients, and potentially a different break in the patient pathway for
respiratory diagnostic and outpatients who may require acute admission and
may need to transfer to the John Radcliffe site. These risks will continue to be
considered and actively addressed through the work of the project team that
has been established to support the move.
16.3. Delivery of this business case will result in the following configuration of
services in Respiratory Medicine within the Trust:
Respiratory Service
Location
Inpatient Ward
John Radcliffe Hospital
Cystic Fibrosis Inpatients
John Radcliffe Hospital
Cystic Fibrosis Day Case and Outpatients
John Radcliffe Hospital
Interventional work – Bronchoscopy and
Pleural
John Radcliffe Hospital
TB2015.56 Proposal for Respiratory Relocation
Page 17 of 18
Oxford University Hospitals
TB2015.56
Respiratory Service
Location
Inpatient Sleep Studies
John Radcliffe Hospital
Respiratory Day Treatments
John Radcliffe Hospital
Respiratory Outpatients including remaining
sub-specialties and lung cancer
Churchill Hospital
Respiratory Outpatient Radiology
Investigations – CT and Plain Film X-ray
Churchill Hospital
Sleep and Ventilation Outpatients and Sleep
Apnoea and Ventilator set-ups
Churchill Hospital
Lung Function Testing
Churchill Hospital
Interventional Radiology procedures for Lung
Cancer patients
Churchill Hospital
Radiology admissions
Churchill Hospital (John Warin
Ward)
17. Recommendations
17.1. The Trust Board is asked to:
 Approve the proposed reconfiguration of Respiratory services and to note the
associated risks and to support the services to minimise the risks as a result
of the move.
 The Trust is asked to support either a reconfiguration or some investment in
infrastructure to improve the environment for services remaining on the
Churchill site whilst a final Churchill site strategy is developed.
 The Trust is asked to approve the additional revenue and capital resources
required to facilitate the reconfiguration of services.
Paul Brennan, Director of Clinical Services
Authors:
Dr Hywel Jones, Divisional Director, Emergency, Medicine, Therapies and Ambulatory
Dr Maxine Hardinge, Clinical Lead for Respiratory Services
Mrs Kathryn Hall, Operational Services Manager
Mr Andrew Hall, Interim Senior Business Partner
May 2015
TB2015.56 Proposal for Respiratory Relocation
Page 18 of 18
Business Case:
EXPENDITURE
Relocation of Respiratory Services
Baseline/
budget
Proposal
2014/15
WTE
2014/15
WTE
2015/16
WTE
2016/17
WTE
2017/18
WTE
2018/19
WTE
2019/20
WTE
Baseline/bud
get
Proposal
2014/15
2015/16
£000s
2014/15
£000s
£000s
2016/17
£000s
2017/18
£000s
2018/19
£000s
2019/20
£000s
A. Direct revenue costs
Staff (specify grade & wte)
Consultants
0.30
0.30
0.30
0.30
0.30
19
39
39
39
39
Sub total
0.00
0.00
0.30
2.00
0.30
2.00
0.30
2.00
0.30
2.00
0.30
2.00
0
0
19
73
39
146
39
146
39
146
39
146
Sub total
0.00
0.00
2.00
2.00
2.00
2.00
2.00
0
0
73
146
146
146
146
Sub total
0.00
0.00
0.00
1.50
0.00
1.50
0.00
1.50
0.00
1.50
0.00
1.50
0
0
0
29
0
58
0
58
0
58
0
58
Sub total
0.00
0.00
1.50
1.50
1.50
1.50
1.50
0
0
29
58
58
58
58
Sub total
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
0
Sub total
0.00
0.00
0.00
0.00
0.00
3.80
0.00
3.80
0.00
3.80
0.00
3.80
0.00
3.80
0
0
0
0
0
121
0
243
0
243
0
243
0
243
10
10
10
10
Junior Medical
Nursing
Scientific & Therapeutic
Other Clinical
Non Clinical
Total Staff
Non-Staff (inc VAT)
Estates operatinal costs
Total non staff
Total Direct Revenue costs
A
0
0
0
10
10
10
10
0
0
121
253
253
253
253
B. Indirect revenue costs
Staff (specify grade & wte)
Radiological Sciences
Sub total
Pharmacy
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0
0
0
0
0
0
0
Sub total
Therapies
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0
0
0
0
0
0
0
Sub total
Laboratory Medicine
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0
0
0
0
0
0
0
Sub total
Theatres/Anaesthetics
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0
0
0
0
0
0
0
Sub total
Critical Care
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0
0
0
0
0
0
0
Sub total
Others
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0
0
0
0
0
0
0
Sub total
Total Staff
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Non Staff (please insert lines and descriptions)
Radiological Sciences
Pharmacy
Laboratory Medicine
Theatres/Anaesthetics
Critical Care
Equipment servicing
Revenue set up costs (e.g. IT, Furniture, fittings etc)
Outpatient costs
Facillities Costs (e.g. catering, linen)
Others
Total non staff
Total Indirect Revenue costs
B
C. Capital Expenditure
Building
Equipment
Relocation
1,774
154
30
C. Capital Expenditure
D. Capital Charge & Depreciation
C
D
0
0
1,958
38
0
77
0
77
0
77
0
77
E. Contribution to Corporate Overheads @ 15%
E
0
0
0
0
0
0
0
F. TOTAL REVENUE COST
F
0
0
159
330
330
330
330
Appendix A - Financial Pro forma Respiratory Relocation Business Case re... 05/05/2015
Business Case:
Activity & Income
G. Activity (specify HRGs)
A & E attendances
Emergency HRGs
Relocation of Respiratory Services
Baseline/
budget
Proposal
2014/15
2015/16
2014/15
2016/17
2017/18
2018/19
2019/20
Subtotal emergency
Elective HRGs
0
0
0
0
0
0
0
Subtotal elective
Day Case HRGs
0
0
0
0
0
0
0
Subtotal daycase
Outpatient new
Outpatient follow-up
Subtotal outpatient
Other
Other
0
0
0
0
0
0
0
0
0
0
0
0
0
0
H. Income
A & E attendances
Emergency HRGs
Elective HRGs
Day Case HRGs
Outpatient new
Outpatient follow-up
Other
Other
£000s
£000s
£000s
£000s
£000s
£000s
£000s
Subtotal NHS/PCT
0
0
0
0
0
0
0
Total Income
0
0
0
0
0
0
0
Private Patient
R&D
Other non NHS clinical
Charitable Funds
Other
Analysis of income by Specialised/Non-Specialised Commissioner
The following table is to indicate changes to current Commissioner income flows. If future years will alter significantly from this
please make clear reference in your business case narrative. For non-specialised services, please analyse by CCG.
2015/16
Activity
Spells
Source of Income
A&E
Emergency
Other
OP- New/Fup
Day case
Elective
Commissioner
Sub total NHS/PCT
0
0
0
0
0
0
Total
0
0
0
0
0
0
Private Patient
R&D
Other non NHS clinical
Charitable Funds
Other
2015/16
Income
Source of Income
Commissioner
Spells
A&E
Emergency
Elective
Day case
OP- New/Fup
£000s
£000s
£000s
£000s
£000s
Other
£000s
Sub total NHS/PCT
0
0
0
0
0
0
Total
0
0
0
0
0
0
Private Patient
R&D
Other non NHS clinical
Charitable Funds
Other
Appendix A - Financial Pro forma Respiratory Relocation Business Case re... 05/05/2015
Business Case:
Relocation of Respiratory Services
Baseline/
budget
SUMMARY
2014/15
WTE
Baseline/
budget
Proposal
2014/15
WTE
2015/16
WTE
2016/17
WTE
2017/18
WTE
2018/19
WTE
2019/20
WTE
Proposal
2014/15
2015/16
£000s
2014/15
£000s
£000s
2016/17
£000s
2017/18
£000s
2018/19
£000s
2019/20
£000s
A. Direct revenue costs
Staff
Consultants
Junior Medical
Nursing
Scientific & Therapeutic
Other Clinical
Non Clinical
0.00
0.00
0.00
0.00
0.00
0.00
Total Staff
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.30
2.00
0.00
1.50
0.00
0.00
3.80
0.30
2.00
0.00
1.50
0.00
0.00
3.80
0.30
2.00
0.00
1.50
0.00
0.00
3.80
0.30
2.00
0.00
1.50
0.00
0.00
3.80
0.30
2.00
0.00
1.50
0.00
0.00
3.80
Non-Staff
Subtotal Direct costs
A
0
0
0
0
0
0
0
0
0
0
0
0
19
73
0
29
0
0
39
146
0
58
0
0
39
146
0
58
0
0
39
146
0
58
0
0
39
146
0
58
0
0
0
0
121
243
243
243
243
0
0
0
10
10
10
10
0.00
0.00
3.80
3.80
3.80
3.80
3.80
0
0
121
253
253
253
253
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
B. Indirect revenue costs
Staff
Radiological Sciences
Pharmacy
Therapies
Laboratory Medicine
Theatres/Anaesthetics
Critical Care
Others
Total Staff
Non Staff
Subtotal Indirect costs
B
0.00
0.00
0.00
0.00
0.00
0.00
0.00
C. Capital Expenditure
D. Capital Charge & Depreciation
C
D
0
0
0
0
1,958
38
0
77
0
77
0
77
0
77
E. Contribution to Corporate Overheads @ 15%
E
0
0
0
0
0
0
0
F. TOTAL REVENUE COST
F
0
0
159
330
330
330
330
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
H. Income
Total PCT
Private Patient
R&D
Other non NHS clinical
Charitable Funds
Other
Total Income
H
SURPLUS (DEFICIT)
Appendix A - Financial Pro forma Respiratory Relocation Business Case re... 05/05/2015
0
0
0
0
0
0
0
0
0
-159
-330
-330
-330
-330
Business Case:
Relocation of Respiratory Services
Baseline/
budget
INCREMENTAL SUMMARY
2014/15
WTE
Baseline/
budget
Proposal
2014/15
WTE
2015/16
WTE
2016/17
WTE
2017/18
WTE
2018/19
WTE
2019/20
WTE
2014/15
£000s
Proposal
2015/16
£000s
2014/15
£000s
2016/17
£000s
2017/18
£000s
2018/19
£000s
2019/20
£000s
A. Direct revenue costs
Staff
Consultants
Junior Medical
Nursing
Scientific & Therapeutic
Other Clinical
Non Clinical
0.00
0.00
0.00
0.00
0.00
0.00
Total Staff
0.00
0.30
2.00
0.00
1.50
0.00
0.00
3.80
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Non-Staff
Subtotal Direct costs
A
0
0
0
0
0
0
19
73
0
29
0
0
20
73
0
29
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
121
122
0
0
0
0
0
10
0
0
0
0.00
3.80
0.00
0.00
0.00
0.00
0
121
132
0
0
0
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
B. Indirect revenue costs
Staff
Radiological Sciences
Pharmacy
Therapies
Laboratory Medicine
Theatres/Anaesthetics
Critical Care
Others
Total Staff
Non Staff
Subtotal Indirect costs
B
0.00
0.00
0.00
0.00
0.00
0.00
C. Capital Expenditure
D. Capital Charge & Depreciation
C
D
0
0
1,958
38
-1,958
39
0
0
0
0
0
0
E. Contribution to Corporate Overheads @ 15%
E
0
0
0
0
0
0
F. TOTAL REVENUE COST
F
0
159
171
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
H. Income
Total PCT
Private Patient
R&D
Other non NHS clinical
Charitable Funds
Other
Total Income
SURPLUS (DEFICIT)
H
0
0
0
0
0
0
0
-159
-171
0
0
0
BUDGET
ESTIMATE
Detailed
Design
Project Number
2014.203
Capital Programme Capital Code: 7189
Project Name
Project Option
Ward 7E Respiratory Refurbishment
With ducting only for mech vent
Outturn 13/14
Allocation 14/15
£0
£400,000
Project Manager
DATE:
Mark Bristow
6th March 2015
Total
Charitable Fund
£400,000
£0
Work Stage
Completion of det design
Overall Capital Programme Allocation
£400,000
Procurement Strategy
MTC therefore no allowance for prelims
Initial Estimate base docs~
GBS drawings 6514.200-701, Method
drawings Medical gases & M&E services.
Please note that this Estimate is a preliminary cost based upon outline sketch proposals
and is subject to change during the detailed design stages.
Cost per m2 (£/m2)
Construction
Notes/ Qualification
%
Construction costs
-Building Costs
-M&E Costs
Ducting only for future vent
-Phasing Cost
Sub- Total
Construction contingencies
Total Construction
m2 cost based on HPCG's plus
allowances for abnormals
10.00%
£
breakdown below
£251,022
£465,174
£200,000
£0
£916,196 Excludes: Construction Contingency
£91,620
£1,007,816 Includes: Construction Contingency
Professional Fees (VAT 100% recoverable)
Assumed 15% of Construction Costs
15.00%
£151,172 Includes: Design, Professional, Building Contol, Planning and Survey Fees
5%
£50,391 Includes: Trust Signage, Cleaning, Trust Project Team and Decant Costs.
Non Works
5% of Total Construction Costs
Group 2 & 3 Equipment
£0 none allowed for included separately in business case
none
Sub Total
£1,209,379 Includes: Total Construction, Professional Fees, Non-Works and Group 2&3 Equipment Costs
Planning Contingencies
Assumed 10% of Total Construction
Cost
10.00%
Total Cost
Applied to Sub-Total. Includes: Cost Overruns not contained within building contract contingencies, claims for
£120,938 disruption and loss and expense, cost overruns on equipment budget, claims for additional professional fees
£1,330,317
Optimism Bias
Estimated 17.01% of Overall Construction
and Contingencies Cost
14.03%
Applied to Total Cost. Includes: changes to scope of project incl. for example developments in national policy,
changes in local priorities and strategies, changes in medical technology, changes in how services are
£186,643 delivered.
Inflation to 2Q2015
2.20%
£33,373 Cost at date of issue
VAT % (Excluding Fees)
20.00%
Applied to Total Construction, Non-works, Group 2 & 3 Equipment, Planning Contingency, Optimisim Bias and
£279,832 Inflation Costs
Recoverable VAT 20,40 or 75%.
20.00%
Total Scheme Cost
£55,966 No independent objective assessment of VAT abatement has been undertaken
£1,774,199
\\OXNETORHESTFS01\Estates&Facilities\Estates Planning & Development\Development\Jr Projects\2014.203 Ward 7E Geoffrey Harris Ward\1.Costs\InEsts\2014.203 ward 7E
detailed design estimate mech vent ducting only
11/03/2015
1
Other ward equipment required to be
confirmed.
Current options:
 Small room utilised by Estates
services as a kitchen / staff room.
 Sharing the relative’s area on the
Post-Acute Unit (PAU), however this
is not ideal.
Current options:
 Office in Blue Outpatients.
 Divisional Nurses office on Level 7,
C/D corridor.
 To obtain update on room options.
Resource requirements:
 Centralised monitoring system for
high-care patients: four monitors plus
a central console costing £90,000 is
included in the business case
Risk
Rating
(Feb-15)
L
C
1
5
5
20
5
1
↔
5
2
10
5
Risk
Rating
(Apr-15)
L
C
5
2
10
4
5
20
Trend
Updated 24/02/2015
5
Immediate
Principal Risk 1: Ward Accommodation
Lack of relative’s room:
1.1 L’OC
Cause: Insufficient space within the
current ward plans to incorporate a
relative’s room.
Effect: Lack of dedicated space for
visitors to the ward, and to have
private conversations with relatives
and carers about patient care.
Impact: Poor experience for patient
relatives and carers.
Lack of Consultant’s office:
1.2 L’OC
Cause: Insufficient space within the
current ward plans to incorporate a
Consultant’s office.
Effect: Lack of dedicated space for
Consultants who do not have an office
on the JR site.
Impact: Consultants not set up to
facilitate
cross-site
working.
Consultant proximity to the ward
important for patient safety / junior
staff supervision.
Provision of monitoring equipment:
1.3
Cause: Lack of monitoring equipment
for high-care patients.
Effect:
Ward
environment
not
currently
suitable
for
high-care
patients.
Impact: Compromising patient safety
for high-care patients.
Immediate
RISK DESCRIPTION
KEY CONTROLS & CONTINGENCY
PLANS
Proximity
Respiratory Relocation – Risk & Action Log
Immediate
Source
Risk
Owner
RISK ID
Oxford University Hospitals
4
Last
Review
Target
L
C
3.2
Senior House Officers:








Provisional plan for inpatients to be
located on ward 5C / 5D. This needs
to be confirmed including identified
area for these patients
Training and Development plans
need to be agreed and delivered for
staff on 5C/5D
The use of the pre-assessment space
and five rooms in Blue Outpatients
has been requested.
Office space to support the Cystic
Fibrosis team has also been
requested.
A room for lung function has been
requested
Provision of the post has been agreed
with MRC Division Education Lead
Doctors have been interviewed for the
posts although no doctor has been
specifically allocated to the post
The additional CMT post will help
Risk
Rating
(Feb-15)
L
C
3
Risk
Rating
(Apr-15)
L
C
4
3
↔
12
12
4x3=
12
4x3=
12
4
4
16
3
2
4
8
4
3
Trend
Updated 24/02/2015
4
Immediate
Principal Risk 2: Cystic Fibrosis Patients
Plan for Cystic Fibrosis inpatients:
2.1 L’OC
Cause: No confirmed plan for
accommodation of Cystic Fibrosis
inpatients.
Effect: The provision of inpatient beds
for Cystic Fibrosis patients is unknown.
The skill mix and training for relevant
nursing staff needs to be discussed.
Impact: Cystic Fibrosis service cannot
function without an agreement for the
management of inpatients.
Cystic Fibrosis in Blue Outpatients:
2.2 L’OC
Cause: No confirmed plan for provision
KH
of accommodation for the Cystic
Fibrosis Service.
Effect: The provision of Cystic Fibrosis
outpatients is unknown.
Impact: Cystic Fibrosis service cannot
function without an agreement for the
management of outpatients.
Principal Risk 3: Staffing
Junior medical staff:
3.1
Cause: An additional CMT post is
required to support the increase in
Respiratory beds and also the separate
ward support that will be required for
the Cystic Fibrosis patients.
Effect: Lack of agreed funding and
time taken to recruit.
Impact: Gaps in service provision with
impact on daytime workload and outof-hours on-call
Immediate
RISK DESCRIPTION
KEY CONTROLS & CONTINGENCY
PLANS
Proximity
Respiratory Relocation – Risk & Action Log
Immediate
Source
Risk
Owner
RISK ID
Oxford University Hospitals
4
Last
Review
Target
L
C
Cause: There is no agreed plan to
cover the SHO night rota.
Effect: Lack of agreed funding and
time taken to recruit.
Impact: Gaps in service provision.
3.3


Middle grade medical staff:
Cause: Three additional Clinical
Fellows are required to cover a
separate Respiratory Medicine middle
grade rota. There is a lack of funding
for one of these posts.
Effect: Lack of agreed funding and
time taken to recruit.
Impact: Gaps in service provision.


3.4
Consultants:
Cause: There is no agreed plan for
Churchill ward cover.
Effect: Gap in Service Provision

address rota issues and workload
within the existing team and protect
compliance of the rota.
There are ongoing discussions with
Geratology
and
Gastro
about
reconfiguring their SHO rotas to fit
with the contribution of respiratory
medicine
These posts will be added to the
current Specialist Registrar rota to
create a single Respiratory middle
grade rota to support Respiratory at
the JR. It will also remove the current
shared
requirement
between
Infectious Diseases and Respiratory
which will not work across the split
sites.
The remaining post that is required to
support the rota is also required to
deliver activity within the ILD service
due to loss of research fellow
contribution. The post is currently
being advertised at risk to avoid other
financial consequences and impact
on income and contract performance
The
removal
of
Respiratory
Registrars from the Churchill site is
not expected to have a detrimental
impact on the Churchill Hospital at
Night
rota
due
to
additional
contributions from doctors at the
Churchill
This is to facilitate the maintenance of
Respiratory outpatient capacity to
meet the 18 week target. Currently
Risk
Rating
(Feb-15)
L
C
3
12
4
12
2
4
Risk
Rating
(Apr-15)
L
C
3
4
12
2
2
4
2
Trend
Updated 24/02/2015
12
Immediate
RISK DESCRIPTION
KEY CONTROLS & CONTINGENCY
PLANS
Proximity
Respiratory Relocation – Risk & Action Log
Immedi
ate
Source
Risk
Owner
RISK ID
Oxford University Hospitals
Last
Review
Target
L
C
3.7
3.8
Nursing:
Cause: The ward establishment in line
with the number of beds and acuity of
patients has not yet been agreed. The
ward also currently has vacancies for





Consultants
maintain
outpatient
clinics whilst on-call for the ward. This
will not be possible when split across
2 sites. This usually amounts to 2
clinics in the week which is a total of 3
PAs per week including clinical admin
time.
The provision of a daily referrals
service at the JR on the medical
wards and EAU will require 4 hours
per day therefore 5PAs. In addition it
has been requested that a daily
urgent clinic is provided which will
require further resource
The service requirement has been
identified as 10 hours of Band 6 nurse
time.
The Sleep & Ventilation Nurses
currently provide a predominantly
outpatient based service but also
need to visit the ward daily to support
inpatients on NIV treatment and help
with discharge home for those
patients.
The Directorate will review the
establishment across all nursing
budgets and consider options for how
to
address
the
acuity
and
dependency of the patients in the
Risk
Rating
(Feb-15)
L
C
4
20
5
3
20
4
5
3
15
3
15
5
5
20
15
5
Risk
Rating
(Apr-15)
L
C
5
3
15
4
5
20
4
Trend
Proximity
Updated 24/02/2015
5
Immediate
Impact: Delay to receiving timely
advice
for
ongoing
patient
management.
Consultants:
Cause: There is no agreed plan for
split site working and the cover of
Outpatients clinics.
Effect: Gap in service provision
Impact: Increase in waiting time which
may impact on delivery of the 18 week
target as well as the management of
more urgent patients
Consultants:
Cause: There is no agreed plan or
agreed funding for the JR referrals
service.
Effect: Gap in service provision
Impact: Delay to delivery of advice and
care plan for patients which may also
impact on length of stay
Sleep & Ventilation Service:
Cause: Additional hours are required
for Sleep & Ventilation Nurses to
attend cross-site ward visits.
Effect: Gap in service provision
Impact: Delay in patient care and
increased length of stay
Immediate
Source
RISK DESCRIPTION
KEY CONTROLS & CONTINGENCY
PLANS
Immediate
3.6
Respiratory Relocation – Risk & Action Log
Immediate
3.5
Risk
Owner
RISK ID
Oxford University Hospitals
Last
Review
Target
L
C
3.1
1
five Band 5 nurses and one Band 6
nurse.
Effect: Gap in service provision
Impact: Inability to maintain safe level
of staffing for the acuity of the patient
and delay to treatment and increased
length of stay
Physiotherapy:
Cause: Additional Physiotherapists are
required for split site working and
workload in respiratory outpatients
Effect: Gap in service provision
Impact: Delay to rehabilitation of
patients and increased length of stay
Occupational Therapy:
Cause:
Additional
Occupational
Therapists are required for split site
working.
Effect: Gap in service provision
Impact: Delay to rehabilitation and
increased length of stay
Pharmacy:
Cause: Additional Pharmacists are
required for split site working.
Effect: Gap in service provision
Impact:
 Failure to meet Trust quality
standards – Medicines
reconciliation completed within
24 hours of admission
 Failure to meet Trust TTO
turnaround target
 Significant increase in risk
related to medicine errors,
omissions and drug related
readmissions
Resource requirements:
 0.8 WTE Band 6 to provide
supervision and support for complex
Respiratory patients at the JR site
and
to
protect
Respiratory
Physiotherapy outpatient capacity.

Resource requirements:
 Minimum staffing required will be
0.5WTE Band 6.
 0.5 Band 3 to support both
Occupational
Therapy
and
Physiotherapy.
Resource requirements:
 Additional 0.5 Band 7 Pharmacist and
1.0 WTE Pharmacy Technician.
 Pharmacy have found funding for half
a post for antimicrobial service and
would put this with funding to make a
full-time post which would provide full
cover for the ward and the outpatient
services within the Churchill team.
 The Technician post will support rapid
discharge and TTOs in line with the
new electronic prescribing system.
Updated 24/02/2015
Risk
Rating
(Feb-15)
L
C
5
3
15
5
15
5
3
15
3
15
5
Risk
Rating
(Apr-15)
L
C
5
3
15
3
5
15
3
Trend
Proximity
current and future bed configuration
Immediate
Source
RISK DESCRIPTION
KEY CONTROLS & CONTINGENCY
PLANS
Immediate
3.1
0
Respiratory Relocation – Risk & Action Log
Immediate
3.9
Risk
Owner
RISK ID
Oxford University Hospitals
Last
Review
Target
L
C



Significant cost pressures due
to un-reviewed and nonformulary medications and
medication waste
No pharmacy support for
nursing and medical training
Ward stock management
failures
Gap in service provision
Principal Risk 4: Critical Care
Loss of Critical Care capacity at the
4.1
HB
Churchill site:
MH
Cause: Withdrawal of Respiratory
high-care beds.
Effect: Reduced high-care capacity at
the Churchill site, e.g. tracheostomy
patients, weaning ventilator-dependent
patients
Impact: Reduced service access for
critically unwell patients and potential
delay to surgery or cancellation of
transplant procedures
Principal Risk 5: Radiology Procedures at Churchill Site
Patients post-Radiology procedure:
5.1
Cause: Patients being admitted postRadiology procedure at the Churchill
site will no longer be admitted to a
Respiratory ward with the immediate
availability of Respiratory trained staff.
Effect: Patients to be managed on
John Warin ward.
Impact: Potential compromise to
patient safety without support and
expertise readily available.




If ablations and biopsies remain on
the Churchill site (John Warin ward)
then there is a need to ensure
support is provided by a Respiratory
Consultant for advice.
Patients should also be admitted
under an Infectious Disease doctor to
ensure timely medical management
and responsibility.
Draft protocol for the management of
these patients.
Risk
Rating
(Feb-15)
L
C
5
Critical Care Capacity is the subject
of a separate business case
Immediate

Updated 24/02/2015
3
5
15
5
20
Risk
Rating
(Apr-15)
L
C
3
↔
15
4
5
15
Trend
RISK DESCRIPTION
KEY CONTROLS & CONTINGENCY
PLANS
Proximity
Respiratory Relocation – Risk & Action Log
Immediate
Source
Risk
Owner
RISK ID
Oxford University Hospitals
3
Last
Review
Target
L
C

Principal Risk 6: Pathways
Daycase patients:
6.1
MH
Cause: No agreed process for the
admission
and
management
of
Daycase patients at the JR such as
xolair treatment for chronic asthma and
methalprenisalone .
Effect: Delay to treatment of patients
Impact: Reduction in ward capacity if
patients need to be admitted to the
Respiratory ward
Principal Risk 7: Endocrine Bed Relocation
Management of Endocrine pathway:
7.1
GT
Cause: Endocrine inpatients will
KH
primarily be managed on John Warin
ward rather than Geoffrey Harris ward.
Effect: Additional training required for
medical and nursing staff on John
Warin ward to manage Endocrine
patients.
Impact:
Care
requirements
of
Endocrine inpatients not fulfilled.
Principal Risk 8: Lung Function
Lung function testing:
8.1
KH
Cause: Lack of lung function testing
L’OC
equipment at the JR site.
Effect: Patients will have to travel to
the Churchill site in an ambulance for
lung function tests.
Impact: Logistical issues associated






Nurse skills and competencies need
to be considered and training
provided.
Some of these patients are already
being accommodated on John Warin
ward
Plan is for patients to attend DDU on
Level 4.
Additional meeting required to start
documenting pathways of care and
back-up support for patients at the JR
site.
Training plan to be developed and
delivered for nursing staff
A plan is required for Infectious
Diseases
SHO
allocation
for
Endocrine patients.
A training plan is required for nursing
staff
Documented protocols for complex
testing regimes to be drawn up
Current options:
 Discussed requirement for lung
function
equipment
based
in
outpatients
to
support
rapid
assessment of patients attending
hospital through the Emergency
Assessment Unit and other direct
3
Risk
Rating
(Apr-15)
L
C
4
15
Trend
Risk
Rating
(Feb-15)
L
C
5
Immediate

Updated 24/02/2015
3
12
5
Immediate
RISK DESCRIPTION
KEY CONTROLS & CONTINGENCY
PLANS
Proximity
Respiratory Relocation – Risk & Action Log
3
5
15
5
Immediate
Source
Risk
Owner
RISK ID
Oxford University Hospitals
↔
15
3
15
3
5
3
15
↔
Last
Review
Target
L
C
KEY CONTROLS & CONTINGENCY
PLANS
with the above.

pathways.
This would positively
impact upon patient diagnoses and
reduce the number of Thoracic
patients sent to the Churchill site for
lung function tests.
To obtain update on room availability
in Blue Outpatients at the JR.
Updated 24/02/2015
Risk
Rating
(Feb-15)
L
C
Risk
Rating
(Apr-15)
L
C
Trend
RISK DESCRIPTION
Respiratory Relocation – Risk & Action Log
Proximity
Source
Risk
Owner
RISK ID
Oxford University Hospitals
Last
Review
Target
L
C
Oxford University Hospitals
Respiratory Relocation – Risk & Action Log
Updated 24/02/2015
Key Risk Owners:
MH
HB
GT
KH
SP
RL
Maxine Hardinge – Clinical Lead, Respiratory Medicine
Henry Bettinson – Clinical Governance Lead, Respiratory Medicine
Garry Tan – Clinical Lead, OCDEM
Kathryn Hall – Operational Service Manager, Ambulatory Medicine Clinical Directorate
Sarah Poole – Pharmacist, Respiratory Medicine
Rachel Lardner – Physiotherapist, Respiratory Medicine
Trend
↑
↔
↓
variable
risk score increasing
risk score remains static for rolling 12
months
risk score reducing
risk score changes up and down overtime
L’OC
IB
LP
PJ
CJ
WF
Lily O’Connor – Divisional Nurse, Medicine, Rehabilitation & Cardiac Division
Ivor Byren – Clinical Director, Ambulatory Medicine Clinical Directorate
Lisa Priestley – Lead Nurse, Cystic Fibrosis
Philippa Jeffcock – Clinical Unit Manager, Respiratory Medicine
Cicy Jose – Ward Sister, Geoffrey Harris ward
William Flight – Consultant, Cystic Fibrosis
Oxford University Hospitals NHS Trust.
Please include this in the preparation to write a policy and refer to the “Policy on Writing
Policies.” Full guidance is available:
http://ouh.oxnet.nhs.uk/Equality/Pages/EqualityImpactAssessment.aspx
Equality Analysis
Plan / proposal name:
Relocation of Respiratory ward and Cystic Fibrosis day case and outpatient unit from
Churchill to John Radcliffe site
Date of Plan
April 2015
Date due for review
April 2018
Lead person for policy and equality analysis
Kathryn Hall, Operational Service Manager, Ambulatory Directorate
Does the policy /proposal relate to people? If yes please complete the whole form.
YES
The only policies and proposals not relevant to equality considerations are those not involving
people at all. (E.g Equipment such as fridge temperature)
1.
Identify the main aim and objectives and intended outcomes of the policy.
Who will benefit from the policy? How is the policy likely to affect the promotion of equality
and minimize discrimination considering: age, disability, sex/gender, gender re-assignment, race,
religion or belief, sexual orientation, pregnancy and maternity, marriage or civil partnerships or human
rights?
Patients admitted to the John Radcliffe site with acute respiratory problems will benefit from
the proposal through improved colocation and integration with AGM, supporting improved
management of their pathway of care
Patients treated within the Cystic Fibrosis service will benefit from improved accommodation
and opportunities to enhance the transition from paediatric to adult services by being on the
same site.
2. Involvement of stakeholders.
List who has been involved in the policy/proposal development?
The multi-disciplinary team within Respiratory Medicine including consultants, nurses,
administrative staff, therapists, etc.
The Cystic Fibrosis peer review team are also supportive of the proposal to relocate the service
and there is also patient feedback to support the relocation.
The Trust Equality Plans can be found on the website and on the Equality intranet site.
Equality analysis version 8 February 2013.
1
Oxford University Hospitals NHS Trust.
3. Evidence.
Population information on www.healthprofiles.info search for Oxfordshire.
Disability Have you consulted with someone who has a physical or sensory impairment? How will this
policy affect people who have a disability?
There should be no impact on patients with a disability other than to reduce the requirement for these patients to
move between sites as part of their inpatient pathway when admitted with an acute respiratory problem.
Disability: learning disability
There should be no impact
Sex: How will this policy effect people of different gender?
There should be no impact
Age: How will this policy affect people of different ages?
There should be no impact
Race: How will this policy affect people of different race?
There should be no impact
Sexual orientations How will this policy effect people of different sexual orientation?
There should be no impact
Pregnancy and maternity
There should be no impact
Religion or belief.
There should be no impact
Gender re-assignment.
There should be no impact
Marriage or civil partnerships:
There should be no impact
Carers Remember to ensure carers are fully involved, informed, supported and they can express their concerns.
Consider the need for flexible working.
Carers for patients on the ward and the Cystic Fibrosis service should be supported through
the reduction in requirement for patients to be transferred during their admission. Carers have
also complained about the quality of the existing accommodation for Cystic Fibrosis patients
and this move should address that.
Safeguarding people who are vulnerable: How has this policy plan or proposal ensured that the
organisation is safeguarding vulnerable people? (E.g. by providing communication aids or assistance
in any other way.)
The Trust Equality Plans can be found on the website and on the Equality intranet site.
Equality analysis version 8 February 2013.
2
Oxford University Hospitals NHS Trust.
Communication for patients and carers regarding the relocation will be undertaken in advance of the
service move.
Other potential impacts e.g. culture, human rights, socio economic e.g. homeless people
There should be no impact
Section 4 Summary of Analysis
Does the evidence show any potential to discriminate? If your answer is no – you need to give
the evidence for this decision.
There is no evidence that this relocation shows any potential to discriminate. This should
improve the pathway and the patient experience for patients who are admitted to the John
Radcliffe with a respiratory condition. It should also improve the quality of the
accommodation for Cystic Fibrosis outpatients and day cases as well as ensure they have
access to fully-equipped side rooms when they are particularly unwell on the site of their
admission.
How does the policy advance equality of opportunity?
This should improve access to a Respiratory Expert Opinion for Medical patients admitted to
the John Radcliffe Hospital site and reduce delays in transferring acutely unwell patients to
the respiratory ward.
How does the policy promote good relations between groups? (Promoting understanding)
The Trust Equality Plans can be found on the website and on the Equality intranet site.
Equality analysis version 8 February 2013.
3