SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Meeting
Board of Directors
Date
30 March 2011
Subject
Refurbishment of Main Theatres
Business Case
Enclosure
C
Nature of item
For information
For approval
For decision

Decision
required (if any)
The Board are asked to approve option 3c and to consider solutions to address
the shortfall in available capital including the invitation of tender returns for the
scheme.
General
Information
Report Author
Lead Director
Mel Duffy, Deputy Director of Business
Development and Transformation
Matthew Butcher, Senior Finance Manager
Jayne Blacklay, Director of Development
Received or
approved by
Meeting
Date
Management Board, Capital Committee
14 January 2011, 24 March 2011
Resource
Implications
Revenue
Capital
Workforce
Use of Estate
Funding Source





Freedom of
Information
Confidential (Y/N)
(if yes, give
reasons)
Final/draft format
No
Ownership
Trust
Intended for release
to the public
Yes
Final
South Warwickshire NHS Foundation Trust
Report to Board of Directors – 30 March 2011
Refurbishment of Main Theatres Business Case
Executive Summary
This business case proposes the refurbishment of the main theatres department. It is
proposed that this includes the replacement of the air handling plant, an additional clean-air
theatre and redevelopment of the main theatre department.
This essential maintenance provides an opportunity for additional theatre developments to be
undertaken concurrently which will enable the operating theatres and anaesthetic rooms to be
updated, maximise storage space and provide a holding bay and additional changing
facilities. It is also proposed that an Integrated Theatre to facilitate laparoscopic surgery
delivery is installed as part of these developments to support patient choice, improved patient
outcomes and experience and operational efficiencies.
Although these additional developments may be viewed as less desirable on financial
evaluation, from a quality and strategic perspective, they will enable us to deliver a futureproofed theatres design which will support us to respond flexibly to market opportunities
driven by locality reconfigurations and also meet patient demand on a sustainable basis.
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
SOUTH WARWICKSHIRE
NHS FOUNDATION TRUST
Refurbishment of Main Theatres
Business Case
March 2011
South Warwickshire NHS Foundation Trust
Outline Business Case
Reference number:
Directorate:
Surgery
Outline of Proposal:
This business case proposes the refurbishment of the main theatres department. It is
proposed that this includes the replacement of the air handling plant, an additional clean-air
theatre and redevelopment of the main theatre department. The build would enable the
operating theatres and anaesthetic rooms to be updated, maximise storage space and
provide a holding bay and additional changing facilities. The upgrade would also include the
addition of a Laparoscopic theatre and we have considered 3 different integrated operating
theatre system packages.
A detailed benefit appraisal of this option has been undertaken demonstrating the quality,
efficiency and financial benefits of progressing this option.
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Proposal
Background
1. Current Theatre Capacity:
The Trust currently has five main theatres and four day surgery theatres.
The main inpatient theatres are numbered 1 to 5. Theatres 1 to 4 were built 22 years ago and
Theatre 5 was added 15 years ago. This additional theatre was squeezed into the existing theatre
department footprint and although it has provided much needed additional capacity, the theatre
does not conform to Hospital Technical Memorandum and Hospital Building Note requirements
and has caused problems with storage space and work flow through the department.
Surgical demand has increased significantly since Theatre 5 was built and the table below shows
elective theatre session utilisation in Main Theatres between November 2009 and October 2010
assuming a 4 hour session duration. This demonstrates an overall utilisation rate of 92.3% and
evidences our requirement for 5 main theatres to meet surgical demand.
Suite \ Theatre
Main Theatres
Theatre 1
Theatre 2
Theatre 3
Theatre 4
Theatre 5
Number of
Sessions
1,379
238
286
315
271
269
Number of
Operations
3,862
676
986
817
780
603
Actual Hours
Used
6,384
1,314
1,317
1,141
1,573
1,040
Avaliable Hours
Utilisation
6,920
1,312
1,532
1,344
1,604
1,128
92.3%
100.1%
86.0%
84.9%
98.1%
92.2%
2. Current issues:
Age and Condition of the Air Handling Units
Due to their age, the replacement of the air handling units has been considered within the capital
programme each year for the last 3 years.
Health Technical Memorandum (HTM) 03-01: Specialised ventilation for healthcare premises
recommends that critical ventilation systems over 20 years old be classed as having reached the
“end of useful life” and that urgent replacement is indicated.
Two years ago a full inspection was carried out by Clean Air Systems. The report stated that the
ventilation plant was in a poor condition.
One year ago a further risk assessment was carried out by the maintenance department. It was
considered that with some on-going maintenance support the air handling units could continue to
be used for a further 12 months but that the replacement would then be essential. During the past
12 months there have been 79 requests for maintenance work required to support the continued
use of these units, requiring equivalent to 4 weeks’ labour from the estate team. Throughout the
duration of the units’ problems, theatre teams have had to work in adverse conditions.
The current configuration of the air handling units is not optimal. There are only two ventilation
fans for the four theatres; one serves theatres 1 and 2, the second serves theatres 3 and 4. If any
one of the fan sections develops a fault two theatres are affected. When the system is upgraded
each theatre will have an independent unit to ensure maximum flexibility and resilience.
Issues have also occurred with the current plant due to extreme weather conditions. The design
at the time of installation was based on outside air temperatures of 28 Deg. C. in summer and
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
minus 3 Deg C in winter. In recent years we have seen summer temperatures exceeding 30 Deg
C and winter temperatures as low as minus 14 Deg. C. The recent cold spell saw the
temperature plummet to minus 8 Deg C over a prolonged period of time and weather forecasters
predict that this increased range between summer and winter temperatures, as experienced in
2010, will be sustained over future years. The new ventilation system will be designed to reflect
these conditions.
Essential Maintenance
The main theatres department is in need of redecoration and repair. In particular the flooring,
walls and doors require repair or replacement.
Department Design
There are significant issues with the design of the current theatres’ environment particularly from
an infection prevention and space perspective, conflicting with guidance detailed in Health
Building Note (HBN) 26 on facilities required for surgical procedures.
Theatre 5:
HBN 26 recommends minimum space requirements for theatre environments, however, the
additional Theatre 5, built in 1995, is non-compliant with these standards in both the theatre itself
and its anaesthetic room. The space and layout of the anaesthetic room is particularly
problematic for patients requiring ultrasound assisted anaesthesia as there is insufficient space
for the patient, equipment and clinician to administer this type of block. There is no separate
scrub room or preparation room, posing an infection risk with sterile instruments at risk of
contamination from splashing water from scrub. The Theatre 5 development has also
compromised the separate clean and dirty workflows planned for the 4 theatre environment,
resulting in an infection transmission risk due to dirty items from Theatre 5 having to be
transported along the same corridor as clean, pre-operative patients.
Holding bay:
The current department does not have a holding bay. This is an area where patients can be
brought prior to their procedure providing an opportunity to prepare patients and have them ready
for surgery as soon as the Theatre is available. This facility reduces delays between theatre
cases and reduces transfer times for ward escorts. Internal and national audits have
demonstrated that theatre productivity and utilisation can be improved with the availability of a
holding bay.
Storage:
Increased theatre capacity, increased throughput and technological advances have all increased
the storage requirements within the department beyond the available space. The current storage
shortfalls have led to equipment being left in theatre corridors resulting in damage and causing
congestion and issues with the accessibility of fire escape routes. The lack of a designated
storage area has also led to delays to theatre lists and staff time wastage as they have had to
hunt for the right equipment to match patients’ needs. This location problem is further evidenced
by EBME records documenting nearly 240 occasions over the past 3 years when they have been
unable to progress planned jobs or testing due to not being able to find devices within the
theatres’ environment.
Staff Facilities:
When originally built, staff changing and storage facilities had been designed to accommodate up
to 40 members of staff, however, due to increased theatre demand, evidenced by activity growth
and extended operating hours, we now need changing and storage facilities for up to 80
members of staff. This includes facilities to appropriately store cleaned and soiled theatre wear to
reduce infection transmission risks.
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
3. Future Requirements:
The main operating theatres are a key element of the Trust’s future plans. The Trust has an
excellent reputation for elective surgery and the Board has previously considered the growth in
market share within orthopaedics as part of previous business cases.
As changes occur across the local health economy and in neighbouring Trusts, this organisation
will require a modern and efficient theatre facility to ensure that we can
 Maintain and grow market share within specialties such as Orthopaedics and General
Surgery
 Respond quickly to opportunities that may be available due to changes at other hospitals
and consolidate facilities and expertise.
The main theatres will need to be closed during the work to replace the air-handling units and
carry out the essential maintenance. During this down time there is also an opportunity to make
additional improvements that will support future developments. The project team have considered
likely future developments in surgery and the Trust’s strategic direction. They have identified two
key developments that would support the implementation of future plans:
Increased clean air capacity
There are currently only 2 clean air theatres in Main Theatres. As orthopaedic procedures can
only be undertaken in a clean air theatre, our flexibility to schedule orthopaedic activity to meet
demand and 18 weeks’ referral to treatment standards is restricted to current clean air theatre
availability. The replacement of the air handling plant provides the opportunity for us to increase
our clean air provision to improve our capacity to meet orthopaedic demand and access
standards. We also anticipate that there may be equipment rationalisation benefits from colocating orthopaedic activity in adjacent theatres.
Integrated Theatres:
Integrated operating theatres provide an easy way of integrating and controlling theatre
equipment, within an ergonomic and uncluttered environment, at the same time as improving
visualisation and information available to the operating surgeons. It would be something that
would be of benefit within all operating theatres but this redesign and re-development provides an
opportunity to install one within the newly provided theatre 5, supporting the continued
development of laparoscopic surgery within the Trust.
Laparoscopic surgery is the best type of surgery for selected patients as it reduces tissue trauma,
post-operative hospital stay and supports an overall improved experience for the patient. As such,
it is a surgical option that we should be offering to our patients. For well informed patients,
laparoscopic surgery will be the surgery of choice and will inform which providers both GPs and
patients choose for referral. An integrated theatre will give us state of the art, upgradable and
serviceable laparoscopic equipment which will reduce operating time, improve the quality of
surgery, reduce risk for patients and staff and support our excellent reputation for training. The
key benefits of laparoscopic surgery are detailed below;
1
Future planning: Across the world and nationally there is going to be a change in
the way we perform major re-sectional bowel surgery. Currently we perform about
20% of our major cancer re-sectional surgery laparoscopically. Over the next 5 years
there will be an expectation that we will be performing approximately 80% of this
surgery laparoscopically. As this happens, standards will be developed for
undertaking this type of surgery. This is evidenced by the recent Association of
Laparoscopic Surgeons national grading of all hospitals providing laparoscopic
surgery. Unfortunately Warwick Hospital was graded as a bronze (the lowest grade)
because our equipment was deemed old and in some cases unsafe. These
standards will include a requirement for an integrated laparoscopic theatre.
Therefore, an integrated theatre will be an essential requirement to continue to
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
provide the best quality surgery and, without one, we shall rapidly fall behind
competitors, lose prestige and business and inevitably the whole service.
2
Surgical staff: We expect that it will be difficult to attract and retain the best
surgeons in the future without this equipment being available.
3
Efficiency: Set up times for integrated theatres are short and there is an opportunity
to substantially reduce current down time for set up and improve the smooth running
of operating lists with an integrated theatre.
4
Safety for patients and Staff: Automatic set up functionality available through
integrated theatres reduces potential for operator errors and consequently improves
safety for patients.
5
Training: As a premier surgical training unit we should be offering in-theatre
laparoscopic training as well as training via video link in the hospital. Integrated
theatres also offer the opportunity to deliver courses which are teleconferenced to
other national and international centres of excellence.
Proposal
A project team has been in place since April 2010 to consider the options available for theatres’
refurbishment. There are three key options:
Option 1 – Do nothing
Option 2 – Replace air handling plant, additional clean air theatre and decoration of
existing facility
Option 3 – Replace air handling plant, additional clean-air theatre and redevelopment of
main theatre department to include a laparoscopic theatre
In Option 3, the refurbishment programme would enable the operating theatres and anaesthetic
rooms to be updated, maximise storage space, provide a holding bay and provide additional
changing facilities. The upgrade would also include the addition of a Laparoscopic theatre and
steel reinforcements to support the installation of additional integrated operating rooms when
existing theatres require replacement in the future. Three different integrated operating theatre
packages, ranging from a basic to a full system, are considered within this option and evaluated
from a differential cost and benefit perspective. The higher specification systems deliver
enhanced functionality as described below.
a) Basic System - Providing ceiling mounted pendants and equipment stacks, including
camera and viewing monitors.
b)
Intermediate System - Providing ceiling mounted pendants and equipment stacks,
including camera and viewing monitors and
 the additional functionality of a theatre control system to allow automatic, custom set
up for individual operators
c) Full System Providing ceiling mounted pendants and equipment stacks, including camera
and viewing monitors and
 the additional functionality of a theatre control system to allow automatic, custom set
up for individual operators
 a networked telemedicine facility to support training and demonstrations to a remote
audience
It is proposed that the Board approve option 3c and that we proceed to tender.
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Strategic fit
This business case meets the following key objectives for the Trust:
Meeting Trust 20010/11 objectives:
1
2
3
4
5
6
7
8
Deliver safer care
Improve patients’ privacy and dignity
Deliver care at the right time in the right place
Create the capacity required to deliver our services
Listen and respond to our members
Develop our workforce
Assure that the Trust is well governed
Improve the integration of patient care across hospital and community settings
Options appraisal
Non financial appraisal
Option appraisal
Option
number
1
Do nothing
Benefits


Consequences
No capital costs
No immediate disruption
due to closure of theatres
for refurbishment



2
Replace airhandling plant,
additional
clean-air
theatre and
minor
refurbishment



Theatres are made fit for
use
Additional clean air
theatre available for
orthopaedics
Some improvement in the
environment









3 –all options
Replace air

Provision of a theatre
department that is fit for
8

Theatres become unfit for use
within a short time.
Significant loss of theatre
capacity
Trust will need to reduce
surgical activity
Loss of market share
Risk to viability of Trust
Theatres will be unavailable for
18 weeks
Significant capital investment
required
Staff will need to work flexibly
during period of scheme to
enable activity to be maintained
Opportunity to make further
improvements during closure of
theatres is lost
Continued lack of storage and
cluttered corridors
Infection prevention risks due to
storage in “dirty corridor”
Capacity constraints due to lack
of holding area
Theatres will be unavailable for
20 weeks
x
x
x
x
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
handling plant,
additional
clean-air
theatre and
redevelopment
of main
theatre
department
including
laparoscopic
theatre
installation




3a
3c


Significant capital investment
required
Staff will need to work flexibly
during period of scheme to
enable activity to be maintained

Advantages of
Laparoscopic theatre

No need to close theatre
1 at a future date to install
an integrated operating
theatre
Continuation of complex
colorectal surgery

Sustainable business continuity
following the 20 week upgrade

Minimised risk of loss of income
Reduced theatre set-up
times

Staff cost reduction
The Trust is committed to
providing
postgraduate
medical
and
nursing
training as part of an
ongoing programme for
surgical education and
the
full
integrated
operating
system
provides demonstration
and training opportunities
to a networked audience.

Income generation opportunity

3b
future use
Additional clean air
theatre available for
orthopaedics
Improved storage
facilities resulting in
improved environment,
improved work flow and
improved compliance with
infection prevention
policies.
Improved facilities for
staff
Improved efficiency due
to holding area for
patients waiting for
surgery
As 3a

As 3b

Preferred option
The preferred option is Option 3c.
Affordability
Financial Option Appraisal
Option 1: Do nothing
A true “do nothing” option would mean that we would need to close our main operating theatres
by the end of 2012/13 (as a reasonable upper estimate) as the air handling plant would no longer
be viable.
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
This would pose very significant restrictions on the type of healthcare that the Trust was able to
provide. The range of surgery offered would need to be reduced and even if our largest specialty,
orthopaedics was prioritised and maximum use made of the Day Surgery and other operating
areas, we would need to stop providing general, breast, and colorectal surgery due to the
reduction in capacity. We would lose the associated outpatient work as a consequence.
A number of other services would also come under threat. A major part of our consultant-led
maternity work would no longer be viable as it often uses main theatres. A&E would need to be
downgraded, removing certain types of non-elective emergency activity from the hospital. These
reductions in our scope of activity would have a knock-on effect on the range of services
commissioned from our Trust and on the retention of medical staff. They would also expose the
Trust to intervention from our commissioners and from Monitor for failing to provide services
which are mandatory under our terms of authorisation as an NHS Foundation Trust. So while not
all of these additional services that might be lost would be profitable, any decision to cease
providing them could be blocked by legal means.
There is therefore a very high likelihood that any attempt to close our main theatres would be
prevented by commissioners seeking to safeguard healthcare capacity for the local population
and could lead to de-regulation as an NHS Foundation Trust. The financial consequences of
such a decision would also be undesirable.
In the first three quarters of the current year, if national tariff had been applied in full, we would
have earned £8.332m from general, breast and colorectal surgery, equating to income for the full
year of £11.109m. This income would be lost if we were to close our main operating theatres.
The associated cost would also be lost. The full cost over these services calculated as part of our
in-year service line reporting for the first three quarters of 2010/11 is calculated at £8.140m,
equating to a full year full cost of £10.853m. So if we closed our main theatres, ceased to provide
general, breast, colorectal or oral surgery, and took out the full cost of these services, we would
suffer a net loss of £0.256m per year.
(We have not adjusted these figures for tariff and cost inflation as, over time, the impact of these
would tend to be offset by CIPs, so as less income was lost due to tariff inflation, so the costs
saved would fall.)
However, taking out the full cost of these services would incur additional costs. The full cost of
these services include costs of employed staff totalling £5.9m, which at a conservative estimate
would equal around 100 WTE members of staff. Even if 10% staff turnover per year were to
remove 20 of these from their posts without cost and a further 10% could be redeployed, we
would expect to pay redundancy costs on 70 WTE staff members if we were to save the full cost
of these services. This could total £2.2m as a one-off cost on the assumption of an average six
months’ pay per employee.
The second largest cost of taking out these services would be the costs of converting the space
that they were provided in. These services carry capital charges of £1.1m per year and would
continue to incur PDC dividend each year unless converted to another purpose. However, as
demand for space is high, no assumption has been made as to whether it would be cheaper to
construct new healthcare facilities in the space left by closing theatres or whether demolition and
new construction elsewhere would be cost effective.
Thirdly, we would lose the benefit from activity growth under our present maternity business case
as we would not be able to expand our consultant led maternity service as planned, but would still
incur additional costs to bring the maternity services up to desired quality standards. The net loss
as a result of this would be of £0.3m in year 3 rising to of £0.4m in year 5 and assumed to stay at
the same level thereafter. (These figures are taken from our maternity business case.)
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
The net present value of this option under these assumptions is shown in the table below. It
would give a negative discounted cash flow of £10.5m, significantly worse than the other options
considered in this business case. This, together with the fact that the “do nothing” option would
probably be blocked by legal means, leads to the conclusion that this option is not worth pursuing
further. This calculation is shown in the table below.
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Option 1: Do nothing
All figures in £'000
Net present value of incremental costs and benefits
2011/12
Year
Payments
2012/13
2013/14
2014/15
2015/16
2016/17 2017/18
2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2029/30 2030/31 2031/32
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
1
2
3
4
5
Capital expenditure
Loss of margin on general, breast and colorectal surgery
Loss of margin on maternity services
Redundancy costs
PDC dividend
0
0
0
0
0
0
0
0
0
0
0
256
331
2200
0
0
256
373
0
0
0
256
414
0
0
0
256
414
0
0
0
256
414
0
0
0
256
414
0
0
0
256
414
0
0
0
256
414
0
0
0
256
414
0
0
0
256
414
0
0
0
256
414
0
0
0
256
414
0
0
0
256
414
0
0
0
256
414
0
0
0
256
414
0
0
0
256
414
0
0
0
256
414
0
0
0
256
414
0
0
TOTAL
Discounted at 3.5%
0
0
0
0
2787
2595
629
565
670
581
670
581
670
561
670
541
670
522
670
504
670
486
670
469
670
453
670
437
670
422
670
407
670
353
670
340
670
329
670
317
Net cash inflow/ (outflow)
Cumulative cash inflow / (outflow)
0
0
0
0
-2787
-2787
-629
-3416
-670
-4086
-670
-4756
-670
-5426
-670
-6096
-670
-6766
-670
-7436
-670
-8106
-670
-8776
-670
-9446
-670
-10116
-670
-10786
-670
-11456
-670
-12126
-670
-12796
-670
-13466
-670
-14136
Net cash inflow / (outflow) (discounted)
Cumulative cash inflow / (outflow) (discounted)
0
0
0
0
-2595
-2595
-565
-3161
-581
-3742
-581
-4323
-561
-4883
-541
-5424
-522
-5946
-504
-6450
-486
-6936
-469
-7406
-453
-7858
-437
-8295
-422
-8717
-407
-9124
-353
-9477
-340
-9817
-329
-10146
-317
-10463
EBITDA
Surplus
0
0
0
0
-2787
-2787
-629
-629
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
-670
Total capital spend
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Revenue impact
Option 1: Do nothing, net present value and affordability calculations
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Options 2, 3a, 3b and 3c: Minimum refurbishment and Full upgrade with basic, intermediate and
full integrated operating rooms
The remaining options are therefore compared in terms of their return on investment over the 20
year life of the air handling works. Capital expenditure is presumed in this assessment to be
depreciated over 20 years, except for the equipment in the integrated operating room, which
would be depreciated over 7 years and then replaced. Capital expenditure is based on costings
for Options 2 and 3 prepared by the Trust’s technical advisors. These costings include VAT,
professional fees, in-house costs required to implement the works, the cost of temporary theatres
accommodation, and 6% contingency, together with a cost estimates of the integrated operating
room from the preferred supplier, Storz. (As Storz are a framework supplier, we would not need
to go out to tender for the integrated operating room.) The costing for Option 3 includes the cost
of steel reinforcements (£48,000), added to make the design suitable for further integrated
operating rooms or other modern equipment to be added in future. The costing for Option 3 also
includes some optional items which could be omitted if costs had to be reduced, including
£72,000 for media bridges to three new theatres (taking electrical fittings off the floor and making
operating safer and easier) and £36,000 for automatic doors.
The cost of Option 2 is built up as follows (including VAT but excluding recoverable VAT):
Replacement of air handling plant
Rental of temporary theatres
Other costs including fees and contingency
Backlog maintenance on theatres
£1,057,000
£ 559,000
£ 376,000
£ 400,000
TOTAL
£2,392,000
The useful economic life of these works is assumed to be 20 years.
The cost of Option 3 (apart from the integrated operating room) is built up as follows (including
VAT but excluding recoverable VAT):
Building project including air handling plant
Rental of temporary theatres
Other costs including fees and contingency
Furniture and equipment (estimate)
£2,760,000
£ 598,000
£ 662,000
£ 30,000
TOTAL
£4,050,000
The useful economic life of these works is assumed to be 20 years.
It has been assumed that 80% of the value of the capital expenditure under either option will be
lost as an impairment when the asset is brought into use. This is because the works relate
primarily to bringing the assets into their intended condition for use rather than enhancements of
the type that would add value to a building. This assumption will be revisited when we have more
information on the details of the project.
In addition, Option 3 would involve buying an integrated operating room with costs as follows
(including VAT):
Option 3a (basic integrated operating room)
£ 226,000
Option 3b (intermediate integrated operating room)
£ 382,000
Option 3c (full integrated operating room)
£ 443,000
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
The useful economic life of the integrated operating room is assumed to be 7 years and
replacement is assumed after that period at the same cost.
An option exists to purchase the integrated operating room under a managed service. The
desirability of this is still being investigated and it could lead to small cost saving on the figures
above. For this comparison, we have assumed purchase, as this is a prudent approach that does
not materially distort the comparison.
We have not built into these calculations any differences in maintenance or hotel services costs
between the two options.
Savings have been assumed under Option 3 compared to Option 2. The more efficient theatre
layout and quicker setting-up times in the integrated operating room would enable the saving
(assumed from 2012/13) of one band 6 member of staff as a result of reducing downtime and
time not spent operating, thus enabling the same workload to be delivered in a shorter space of
time.
In addition, Option 3b would generate a small saving of 40 minutes a day on staff time due to
enhanced theatre set up arrangements. This would relate to Band 2 nursing time and it has been
assumed that this saving could be achieved through rearranging rotas to take account of this time
saving.
Finally, Option 3c would allow income to be generated by training others in the use of integrated
operating room equipment. In year 2, “Lapco” funding could provide us with £800 per
laparoscopic operation, or approximately £32,000 a year, to demonstrate new techniques to other
NHS providers. After that, we have assumed that for 5 years we could run courses
demonstrating the use of integrated operating rooms for colorectal and hernia surgery. We have
assumed £35,000 of income per year for 5 years based on 2-3 courses in each area per year.
We have assumed costs associated with this of two days’ consultant time per course and 0.25
WTEs of a band 3 admin worker to coordinate the courses.
No other financial savings have been identified to set Option 3 apart from Option 2. The possible
saving on duplication of equipment in stores has been considered, but is likely to be outweighed
by the need to purchase more expensive equipment. Agency costs might have been saved by
improving recruitment and retention, but theatres have already reduced their agency costs to nil
through recruitment this year. Option 3 would enable us to avoid loss of more complex surgical
work, particularly in the area of major bowel excisions, but it seems clear from comparing the
costs of this work to the income earned under tariff that losing this work would have no significant
impact on the Trust’s financial position and we might even gain a small amount financially by
losing this work. (This is to a great extent because we are currently earning only 30% of the nonelective tariff on marginal increases or decreases in non-elective work, under the current
Operating Framework.) Finally, a best practice tariff is likely to be extended to many types of
laparoscopic work in future, but we have no information on the moment about what impact this
could have. We have therefore not assumed any revenue savings in any of these areas as a
result of Option 3.
The tables on the following four pages summarise these savings into a calculation of return on
investment for the Option 2 and all three versions of Option 3. In summary, the results are as
follows:
Option
2
3a
3b
3c
Net present value
(£2.53m)
(£4.33m)
(£4.73m)
(£4.76m)
14
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Based on current information the case for Option 3 would need to be considered as an
investment in quality and future-proofing of services, as from a financial point of view it would be
less desirable than Option 2. The same can be said for Options 3b and 3c as compared to
Option 3a. However, it is worth noting that Options 3b and 3c are very close in cost, whereas
Option 3c is significantly better from a service point of view.
15
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Option 2: Minimum refurbishment
All figures in £'000
Net present value of incremental costs and benefits
2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2029/30 2030/31 2031/32
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Year
Payments
Capital expenditure
PDC dividend
2392
8
0
16
0
15
0
14
0
14
0
13
0
12
0
11
0
10
0
9
0
9
0
8
0
7
0
6
0
5
0
4
0
4
0
3
0
2
0
1
TOTAL
Discounted at 3.5%
2401
2401
16
16
15
14
14
13
14
12
13
11
12
10
11
9
10
8
9
7
9
6
8
5
7
5
6
4
5
3
4
3
4
2
3
1
2
1
1
1
Net cash inflow/ (outflow)
Cumulative cash inflow / (outflow)
-2401
-2401
-16
-2417
-15
-2432
-14
-2446
-14
-2460
-13
-2473
-12
-2485
-11
-2496
-10
-2506
-9
-2516
-9
-2524
-8
-2532
-7
-2539
-6
-2545
-5
-2550
-4
-2554
-4
-2558
-3
-2561
-2
-2563
-1
-2564
Net cash inflow / (outflow) (discounted)
Cumulative cash inflow / (outflow) (discounted)
-2401
-2401
-16
-2416
-14
-2430
-13
-2443
-12
-2455
-11
-2466
-10
-2476
-9
-2485
-8
-2493
-7
-2500
-6
-2507
-5
-2512
-5
-2517
-4
-2521
-3
-2524
-3
-2527
-2
-2528
-1
-2530
-1
-2531
-1
-2531
Capital
Capital cost
Impairment
Depreciation
Fixed asset value
PDC dividend
2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2029/30 2030/31 2031/32
2392
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1914
0
0
0
0
0
6
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
24
472
449
425
401
377
353
329
305
281
257
233
209
185
161
138
114
90
66
42
18
8
16
15
14
14
13
12
11
10
9
9
8
7
6
5
4
4
3
2
1
Revenue impact
EBITDA
Surplus
Total capital spend
0
-14
0
-40
0
-39
0
-38
0
-38
0
-37
0
-36
0
-35
0
-34
0
-33
0
-33
0
-32
0
-31
0
-30
0
-29
0
-28
0
-27
0
-27
0
-26
0
-25
2392
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Option 2: Minimum refurbishment, net present value and affordability calculations
16
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Option 3a: Full refurbishment with basic integrated operating room
All figures in £'000
Net present value of incremental costs and benefits
2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2029/30 2030/31 2031/32
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Year
Receipts and savings Band 6 post saved through efficiency gains
Payments
0
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
TOTAL
Discounted at 3.5%
0
0
42
41
42
39
42
38
42
36
42
36
42
35
42
34
42
33
42
32
42
30
42
29
42
28
42
27
42
26
42
26
42
22
42
21
42
20
42
20
Capital expenditure
PDC dividend
4276
18
0
34
0
32
0
29
0
27
0
24
0
22
226
23
0
25
0
22
0
20
0
17
0
15
0
12
226
14
0
15
0
13
0
10
0
8
0
5
TOTAL
Discounted at 3.5%
4294
4294
34
33
32
30
29
26
27
23
24
21
22
18
249
201
25
19
22
17
20
14
17
12
15
10
12
8
240
151
15
9
13
7
10
5
8
4
5
3
Net cash inflow/ (outflow)
Cumulative cash inflow / (outflow)
-4294
-4294
8
-4286
10
-4276
13
-4263
15
-4248
18
-4231
20
-4211
-207
-4418
17
-4401
20
-4381
22
-4359
25
-4335
27
-4307
30
-4278
-198
-4476
27
-4449
29
-4420
32
-4388
34
-4354
37
-4317
Net cash inflow / (outflow) (discounted)
Cumulative cash inflow / (outflow) (discounted)
-4294
-4294
7
-4286
9
-4277
11
-4266
13
-4253
15
-4237
17
-4221
-167
-4388
13
-4375
15
-4360
16
-4344
17
-4327
18
-4308
19
-4289
-124
-4413
16
-4397
15
-4382
16
-4366
16
-4350
17
-4332
2011/12
4050
226
3240
10
8
800
218
18
2012/13
0
0
0
40
31
760
187
34
2013/14
0
0
0
40
31
720
156
32
2014/15
0
0
0
40
31
680
124
29
2015/16
0
0
0
40
31
640
93
27
2016/17
0
0
0
40
31
600
62
24
2017/18
0
0
0
40
31
560
31
22
2018/19
0
226
0
40
31
520
226
23
2019/20
0
0
0
40
31
480
195
25
2020/21
0
0
0
40
31
440
164
22
2021/22
0
0
0
40
31
400
133
20
2022/23
0
0
0
40
31
360
101
17
2023/24
0
0
0
40
31
320
70
15
2024/25
0
0
0
40
31
280
39
12
2025/26
0
226
0
40
31
240
234
14
2026/27
0
0
0
40
31
200
203
15
2027/28
0
0
0
40
31
160
172
13
2029/30
0
0
0
40
31
120
141
10
2030/31
0
0
0
40
31
80
110
8
2031/32
0
0
0
40
31
40
78
5
0
-36
42
-63
42
-61
42
-59
42
-56
42
-54
42
-51
42
-53
42
-54
42
-51
42
-49
42
-47
42
-44
42
-42
42
-43
42
-44
42
-42
42
-39
42
-37
42
-35
4276
0
0
0
0
0
0
226
0
0
0
0
0
0
226
0
0
0
0
0
Capital
Capital cost (20 year life)
Capital cost (7 year life)
Impairment
Depreciation (20 year life)
Depreciation (7 year life)
Fixed asset value (20 year life)
Fixed asset value (7 year life)
PDC dividend
Revenue impact
EBITDA
Surplus
Total capital spend
Option 3a: Full refurbishment with basic integrated operating room, net present value and affordability calculations
17
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Option 3b: Full refurbishment with intermediate integrated operating room
All figures in £'000
Net present value of incremental costs and benefits
2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2029/30 2030/31 2031/32
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Year
Receipts and savings Band 6 post saved through efficiency gains
Band 2 efficiency saving
Payments
0
0
42
2
42
2
42
2
42
2
42
2
42
2
42
2
42
2
42
2
42
2
42
2
42
2
42
2
42
2
42
2
42
2
42
2
42
2
42
2
TOTAL
Discounted at 3.5%
0
0
44
42
44
41
44
39
44
38
44
38
44
37
44
35
44
34
44
33
44
32
44
31
44
30
44
29
44
28
44
27
44
23
44
22
44
22
44
22
Capital expenditure
PDC dividend
4432
20
0
39
0
36
0
33
0
30
0
26
0
23
382
26
0
30
0
27
0
23
0
20
0
17
0
14
382
17
0
21
0
17
0
14
0
11
0
8
TOTAL
Discounted at 3.5%
4452
4452
39
38
36
34
33
29
30
26
26
23
23
19
408
330
30
23
27
20
23
17
20
14
17
11
14
9
399
251
21
13
17
9
14
7
11
5
8
4
Net cash inflow/ (outflow)
Cumulative cash inflow / (outflow)
-4452
-4452
5
-4447
8
-4440
11
-4428
14
-4414
18
-4396
21
-4376
-364
-4740
14
-4726
17
-4709
20
-4688
24
-4664
27
-4638
30
-4607
-355
-4962
23
-4939
27
-4912
30
-4883
33
-4850
36
-4813
Net cash inflow / (outflow) (discounted)
Cumulative cash inflow / (outflow) (discounted)
-4452
-4452
4
-4448
7
-4440
10
-4430
12
-4418
15
-4402
17
-4385
-294
-4679
11
-4668
13
-4655
15
-4640
17
-4624
18
-4606
20
-4586
-223
-4809
14
-4795
14
-4781
15
-4766
16
-4750
18
-4732
2011/12
4050
382
3240
10
14
800
368
20
2012/13
0
0
0
40
53
760
315
39
2013/14
0
0
0
40
53
720
263
36
2014/15
0
0
0
40
53
680
210
33
2015/16
0
0
0
40
53
640
158
30
2016/17
0
0
0
40
53
600
105
26
2017/18
0
0
0
40
53
560
53
23
2018/19
0
382
0
40
53
520
382
26
2019/20
0
0
0
40
53
480
329
30
2020/21
0
0
0
40
53
440
276
27
2021/22
0
0
0
40
53
400
224
23
2022/23
0
0
0
40
53
360
171
20
2023/24
0
0
0
40
53
320
119
17
2024/25
0
0
0
40
53
280
66
14
2025/26
0
382
0
40
53
240
395
17
2026/27
0
0
0
40
53
200
343
21
2027/28
0
0
0
40
53
160
290
17
2029/30
0
0
0
40
53
120
238
14
2030/31
0
0
0
40
53
80
185
11
2031/32
0
0
0
40
53
40
132
8
0
-44
44
-88
44
-85
44
-81
44
-78
44
-75
44
-72
44
-75
44
-79
44
-75
44
-72
44
-69
44
-66
44
-62
44
-66
44
-69
44
-66
44
-63
44
-60
44
-56
4432
0
0
0
0
0
0
382
0
0
0
0
0
0
382
0
0
0
0
0
Capital
Capital cost (20 year life)
Capital cost (7 year life)
Impairment
Depreciation (20 year life)
Depreciation (7 year life)
Fixed asset value (20 year life)
Fixed asset value (7 year life)
PDC dividend
Revenue impact
EBITDA
Surplus
Total capital spend
Option 3b: Full refurbishment with intermediate integrated operating room, net present value and affordability calculations
18
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Option 3c: Full refurbishment with full integrated operating room
All figures in £'000
Net present value of incremental costs and benefits
2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2029/30 2030/31 2031/32
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Year
Receipts and savings Band 6 post saved through efficiency gains
Band 2 efficiency saving
Course fees and training income
0
0
0
42
2
32
42
2
35
42
2
35
42
2
35
42
2
35
42
2
35
42
2
0
42
2
0
42
2
0
42
2
0
42
2
0
42
2
0
42
2
0
42
2
0
42
2
0
42
2
0
42
2
0
42
2
0
42
2
0
0
0
76
73
79
73
79
71
79
68
79
68
79
66
44
35
44
34
44
33
44
32
44
31
44
30
44
29
44
28
44
27
44
23
44
22
44
22
44
22
Capital expenditure
Costs of delivering courses
PDC dividend
4493
0
21
0
9
41
0
9
38
0
9
34
0
9
31
0
9
27
0
9
23
443
0
28
0
0
32
0
0
28
0
0
25
0
0
21
0
0
18
0
0
14
443
0
18
0
0
23
0
0
19
0
0
16
0
0
12
0
0
9
TOTAL
Discounted at 3.5%
4514
4514
50
48
47
43
43
39
40
34
36
31
33
27
471
380
32
25
28
21
25
18
21
15
18
12
14
9
461
290
23
14
19
10
16
8
12
6
9
4
Net cash inflow/ (outflow)
Cumulative cash inflow / (outflow)
-4514
-4514
26
-4489
32
-4456
36
-4421
39
-4381
43
-4338
46
-4292
-427
-4719
12
-4707
16
-4691
19
-4672
23
-4649
26
-4623
30
-4594
-417
-5011
21
-4990
25
-4965
28
-4937
32
-4905
35
-4870
Net cash inflow / (outflow) (discounted)
Cumulative cash inflow / (outflow) (discounted)
-4514
-4514
25
-4489
30
-4459
32
-4427
34
-4393
37
-4356
39
-4317
-345
-4662
9
-4652
12
-4641
14
-4627
16
-4611
18
-4593
19
-4574
-263
-4837
13
-4824
13
-4811
14
-4796
16
-4781
18
-4763
2011/12
4050
443
3240
10
16
800
427
21
2012/13
0
0
0
40
61
760
366
41
2013/14
0
0
0
40
61
720
305
38
2014/15
0
0
0
40
61
680
244
34
2015/16
0
0
0
40
61
640
183
31
2016/17
0
0
0
40
61
600
122
27
2017/18
0
0
0
40
61
560
61
23
2018/19
0
443
0
40
61
520
443
28
2019/20
0
0
0
40
61
480
382
32
2020/21
0
0
0
40
61
440
321
28
2021/22
0
0
0
40
61
400
260
25
2022/23
0
0
0
40
61
360
199
21
2023/24
0
0
0
40
61
320
138
18
2024/25
0
0
0
40
61
280
77
14
2025/26
0
443
0
40
61
240
459
18
2026/27
0
0
0
40
61
200
398
23
2027/28
0
0
0
40
61
160
337
19
2029/30
0
0
0
40
61
120
276
16
2030/31
0
0
0
40
61
80
215
12
2031/32
0
0
0
40
61
40
154
9
0
-47
67
-75
70
-69
70
-65
70
-62
70
-58
70
-55
44
-85
44
-89
44
-85
44
-82
44
-78
44
-75
44
-71
44
-76
44
-80
44
-76
44
-73
44
-69
44
-66
4493
0
0
0
0
0
0
443
0
0
0
0
0
0
443
0
0
0
0
0
TOTAL
Discounted at 3.5%
Payments
Capital
Capital cost (20 year life)
Capital cost (7 year life)
Impairment
Depreciation (20 year life)
Depreciation (7 year life)
Fixed asset value (20 year life)
Fixed asset value (7 year life)
PDC dividend
Revenue impact
EBITDA
Surplus
Total capital spend
Option 3c: Full refurbishment with full integrated operating room, net present value and affordability calculations
19
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Affordability
Affordability is an issue to be considered in relation to these proposals. The additional spend on
theatres put forward in Option 3 would reduce the Trust’s liquidity by over 2 days in 2011/12,
assuming that we have taken on Warwickshire Community Services by this point. The impact of
this on the Trust’s risk ratings could be absorbed within our current base case (where there is
forecast to be 5 days’ margin of safety on liquidity next year once additional loan repayments
have been taken into account) but would leave the Trust more vulnerable to financial downsides.
If the Trust was not willing to reduce its liquidity by this amount, it would need to consider
alternative sources of funding for this development (for instance, additional surpluses or loans) if
it was to go ahead.
In terms of the revenue impact of these cases, all would have a negative impact on the Trust’s
surplus through increased capital charges. However, an estimate of this has already been built
into the Trust’s Long Term Financial Model and the 2011/12 impact has already been estimated
as part of budget setting, so the increase in capital charges does not in itself make these options
unaffordable. In addition, Options 3a to 3c (especially Option 3c) have a positive impact on the
Trust’s EBITDA due to the savings and income that they generate. From a revenue point of view,
these cases are therefore affordable within existing budgets. The real challenge on affordability
relates to capital expenditure.
We currently have £4.0m set aside in our capital programme for 2011/12 for this expenditure.
Options 3a, 3b and 3c exceed this allocation and so would need an additional source of capital
funding to be found in order to be affordable.
20
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Achievability
This will be a highly complex and disruptive project for the organisation. If either option 2 or option
3 is approved, then main theatres will be unavailable for use for 18 to 20 weeks this year. The
Trust has liased with other organisations that have undergone a major theatre refurbishment to
benefit from their experience. All have confirmed the major disruption caused across the
organisation as a result of the scheme.
The project team have looked at the activity that may need to be provided during this time. It is
proposed that temporary theatres are located within Car Park C to maintain business continuity
during the refurbishment programme. The location of these theatres will significantly reduce car
parking capacity during the period of this scheme. Costs for re-providing this capacity have been
included.
Access to the temporary theatres will be via the radiology department. This will result in increased
traffic and disruption within this department.
Additional storage will be required on-site for all the equipment currently within the main theatres
department. Costs have been included for this.
An Operational plan has been developed (see Appendix 2 for a summary) that will require the
existing work force to work flexibly during this period to maximise utilisation of the reduced
capacity available. The current costs assume that activity will be delivered within the same pay
budget.
The capital investment required to support this proposal is significant and would account for the
majority of the capital programme during 2011/12.
Approval sought for
The Board are asked to approve option 3c and to consider solutions to address
the shortfall in available capital including the invitation of tender returns for the
scheme.
Business case approval
Approval sought from:
Capital Committee
Management Board
Trust Board
Comments:
 Included within capital programme for 2011/12
 Option 3 supported by Management Board 14 January 2011
Business case approved by: ………………………………………………………..
Date:
………………………………………………………..
21
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Business case monitoring
1. Risks that need to be added to the risk register:
Is this included in the risk register? yes
no
If yes reference number Estates risk register
Category of risk
Score on risk register
Responsible officer for monitoring:
Name:
Date:
Follow-up
2. Equality Impact Assessment
Has the proposal been assessed for any impact relating to Equality?
yes
no
Details of the assessment and any issues or concerns:
Details of any further Impact Assessment required
3: Privacy Impact Assessment (PIA)
Where a project/proposal requires the use of personal and or sensitive
information (staff or patient) a PIA may be required to be undertaken – for further
help and guidance on this please contact the Information Governance Manager
ext 4707 or email Sara.Owens@swh.nhs.uk
The guidance document can be found here – Addressing Confidentiality within
Projects
Click here for an electronic copy of the assessment questions.
Has the Privacy Impact Screening Assessment been undertaken? yes
no
What was the outcome?
Full PIA
Small PIA
No PIA required.
22
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Appendix 1
Theatres’ Development Business Case – Option 3 Benefit Appraisal
Storage
Quality Benefit
Improved
compliance with
standards around
sterile and nonsterile product
storage
Consequence
Appropriate storage
of sterile and nonsterile products.
Fit for purpose
storage facilities for
equipment
preventing;
Uncongested
storage areas with
easy access to
supplies/equipment.

Improved Health and
Safety in the
Theatres’ working
environment
Reduced risk of
equipment
breakdown due to
poor and
inappropriate
storage
Equipment available
and working ensuring
reduced delays and
increased productivity
Improved Health and
Safety environment
and reduced risk of
moving and handling
injuries
Easily and more
quickly locatable
equipment
Reduced wastage of
staff time and delays
matching equipment
to patient need
Can store enough kit
to provide back-up
systems to proceed
in event of
breakdown
Improved business
continuity
Space efficiency
gains as equipment
can be transported
between theatre
locations as needed.
Opportunity for
standardisation in all
main theatre layouts
resulting in
subsequent process

equipment being
stored openly in
corridors causing
congestion of fire
escape routes
poor access to
equipment and
high risk of
handling and
moving injuries
to staff.
Mobile and durable
storage facilities
which is accessible
for cleaning to the
required Infection
Prevention
standards
Efficiency Benefit
Reduced theatre
preparation times
due to co-located,
easily accessible kit
Equipment stored in
designated location.
Reduced risk of
infection
transmission due to
easily accessible
storage environment
23
Consequence
Released staff hours
from theatre
preparation to
undertake other
functions (NB: this is
currently undertaken
by on-call night staff
so there is not an
opportunity to reduce
staff budget)
Financial Benefit
Reduced spend on
equipment
maintenance and
repair due to
breakdown
following
inappropriate
storage
Reduced
expenditure on
duplicate
equipment as
equipment can be
stored and
transported
between theatres
as required
Consequence
Potential revenue
saving or reduced
cost pressure
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Staff Change
Holding Bay
Integrated
Theatre
Quality Benefit
Consequence
Increased facilities
for staff change
/increased number
of staff lockers to
secure individual
belongings as the
current facilities
were built to
accommodate 40
people in 1987 but
are now
accommodating
between 70 and 80.
Appropriate storage
for scrub suits clean
and soiled and
theatre footwear.
Increased toilet
facilities.
Provision of a patient
waiting area prior to
surgery facilitates
the timely sending of
patients to theatre
Improved staff
facilities, security
and morale.
Reduction in
infection risks due to
appropriate clad
staff.
Deliver optimal
outcomes for
patients
Reduced delays
between theatre
cases, and escorting
ward staff are able
to return to host
ward reducing
escorting times in
the Anaesthetic
room.
Remain provider of
choice for local
patients
Efficiency Benefit
Consequence
efficiency gains.
Reduced delays
between theatre
cases
Increased productivity
(equivalent to X)
Financial Benefit
Ward staff able to
dedicate increased
time to ward activities
Length of stay
reductions for
patients undergoing
laparoscopic surgery
80% of LGI cancers
to be operated upon
24
Reduced bed
requirements in
support of bed
reduction/right-sizing
plan (NB:
laparoscopic surgery
Maintain current
caseload/case mix
and income.
Maintain
competitive edge in
Consequence
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Quality Benefit
laparoscopically
Consequence
Efficiency Benefit
Develop
Laparoscopic
Gynaecology which
is a limited offer in
this Trust at this
time. We are
laggards on this
service
Consequence
will increase theatre
time requirements)
but this would be
minised to due the set
up and control
advantages of an
integrated theatre
Financial Benefit
local market
Consequence
UHCW will have
challenges in
implementing this
type of theatre due
to the potential
constraints of a
PFI,
GEH’s plans and
capcity unclear
going forward
Other
New layout
completely
separates the clean
and dirty corridors
from each other
reducing infection
risk to patients (and
complying with
guidelines).
Currently Theatre 5
dirty equipment,
swabs, pus etc must
be moved through
Reduced risk of
infection
transmission due to
separate clean and
dirty work flows
25
Support staff
recruitment/retentio
n with modern
facilities
Reduced
overtime/agency
expenditure
Potential
development of
best-practice tariff
for laparoscopic
work
Trust eligibility for
enhanced
payments
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Quality Benefit
the clean corridor
Consequence
The anaesthetic
room in Theatre 5 is
too small to allow the
safe conduct of
blocks requiring
ultrasound guidance
(i.e. there is not
enough space for
the patient, the
anaesthetic machine
and an ultrasound
machine). It is
anticipated that
blocks of this kind
will be used more
frequently in future.
In order to allow our
patients to benefit
from these new
techniques, the
anaesthetic room
needs to be larger
as proposed in
option 3
Remain the provider
of choice for local
patients through the
development and
implementation of
new technologies
and techniques
Efficiency Benefit
26
Consequence
Financial Benefit
Consequence
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Appendix 2
Proposed Operational plans
The Day Surgery Centre (DSC) will be required to continue to deliver all Emergency work including
NCEPOD and Trauma, out of hour’s services and cancer services. The DSC plus three additional
theatres will be available to the Trust. This space will be in the form of three Vanguard theatres
onsite linked to the rear of radiology. The level of expected elective activity is currently very difficult
to predict and the executive team are currently working with the PCT to establish agreed elective
contracts. However, we will aim to deliver increased activity both prior to and after the closure
period with the aim of minimising the effects for patients and GPs choosing to refer patients to
SWFT.
During the closure period two theatres each afternoon will be allocated to NCEPOD and Trauma to
ensure emergency services can be maintained. These theatres will have ENT and Gynae sessions
allocated to them in the mornings. In addition to this one theatre each day Monday to Friday will be
allocated to the Cancer specialties (Colorectal, Breast and Urology) for a three session day 8am –
8pm. The remaining two / three theatres will be therefore be allocated to all the smaller specialties
such as Dental and Oral Surgery and Orthopaedic elective work (joints and lower limb day case
work). Theatre 7 which is mainly Opthalmology will continue as per current timetable as will
Paediatric Friday’s and LSU sessions.
Given the reduction of theatre space and the need to maintain essential cancer and emergency
services, the usual weekly operating patterns for Surgeons and Anaesthetists will need to alter for
the 20 week shutdown period. We will need to operate in a flexible way to ensure we are able to
meet the activity requirements for all specialties, with reduced operating space. In order to achieve
this we will need to undertake alternative operating sessions potentially Saturdays and evenings
both prior to and during the close down period. Given that at times during the normal working week
we will be unable to accommodate normal operating sessions we would look to secure agreement
from clinical staff to vary their working days flexibly over this time, for no additional remuneration.
It is intended that four hour week day sessions will be exchanged for 3 hour sessions out of hours
and lists will be planned as such. If time is exchanged during normal working hours it will be
exchanged as standard 4 hour sessions. It is appreciated that this is a temporary arrangement to
enable this project to succeed and to ensure we are able to achieve this one off refurbishment
project.
If clinical staff wish to take unpaid leave during this time, or reduce PAs for a temporary period to
enable them to have additional time, this will be considered on an individual basis with AGMs, as
each specialty will have different service needs and considerations. It may also be possible for
clinical staff to undertake additional sessions prior to the shutdown period to accumulate time
which can then be taken in lieu.
We fully appreciate these arrangements are unusual and are only being implemented to facilitate
the refurbishment programme; they are not intended to create precedents, or changes to job plans.
We do however need to achieve this flexibility without incurring any additional costs, therefore if
this flexible way of working is not acceptable, the Trust may have to consider the less preferable
option and more formal method of reducing temporary additional PAs for specialties during the
shutdown period, if we have no space available to undertake elective operating procedures.
27