Strategic Outline Case - NHS Wales SOC Ver15.pdf · Hywel Dda Health Board Cardigan SOC March 2010 i Executive Summary 1. Introduction The purpose of this Strategic Outline Case (SOC)

Strategic Outline Case for

integrated health and social care

in Cardigan

26 March 2010

Hywel Dda Health Board

Cardigan SOC March 2010

Contents Executive Summary i

1 Introduction ........................................................................................................................1

1.1 Introduction and scope of this document ..................................................................1

1.2 Structure of this document ........................................................................................2

1.3 How this document has been produced ....................................................................2

2 Strategic Case .....................................................................................................................3

2.1 Introduction ................................................................................................................3

2.2 Strategic context .........................................................................................................3

2.2.1 Organisational context .......................................................................................3

2.2.2 National and local strategic policies and programmes ......................................6

2.2.3 Service context ................................................................................................ 10

2.2.4 The estates context ......................................................................................... 12

2.3 The Case for Change ................................................................................................ 12

2.3.1 The current model of care ............................................................................... 12

2.3.2 Current facilities .............................................................................................. 13

2.3.3 A New Model of Care....................................................................................... 15

2.4 Investment Objectives ............................................................................................. 18

2.5 Benefits .................................................................................................................... 19

2.6 Risks ......................................................................................................................... 21

2.7 Constraints ............................................................................................................... 24

2.7.1 Financial Constraints ....................................................................................... 24

2.7.2 Other Constraints ............................................................................................ 24

2.8 Dependencies .......................................................................................................... 25

3 Economic Case ................................................................................................................. 26

3.1 Introduction ............................................................................................................. 26

3.2 Critical Success Factors ............................................................................................ 26

3.3 Options .................................................................................................................... 27

3.3.1 Service solution options .................................................................................. 27

3.3.2 Scope, Implementation and Funding options ................................................. 27

3.3.3 The long list of options .................................................................................... 30

3.4 Appraisal of the long list of options......................................................................... 31

3.4.1 Appraisal of Service Solution (Site) Options .................................................... 31

3.4.2 Appraisal of Scope Options ............................................................................. 31

3.4.3 Implementation – Table 17 ............................................................................. 35

3.4.4 Funding options ............................................................................................... 35

3.5 Conclusion – the shortlisted options ....................................................................... 36

3.6 Options Shortlist ...................................................................................................... 39

4 Commercial Case ............................................................................................................. 41

4.1 Introduction ............................................................................................................. 41

4.2 Procurement strategy .............................................................................................. 41

4.2.1 Designed for Life/Building for Wales ............................................................... 41

4.2.2 Third Party Development ................................................................................ 41

4.3 Procurement Timetable........................................................................................... 41

5 Financial Case .................................................................................................................. 42

5.1 Introduction ............................................................................................................. 42

5.2 Capital Costs ............................................................................................................ 42

5.3 Assumptions made for capital estimates ................................................................ 43

5.4 Revenue Consequences ........................................................................................... 44

5.5 Assumptions made for revenue estimates .............................................................. 45



5.6 Affordability assessment ......................................................................................... 46

5.6.1 Treatment of capital charges and rental income ............................................ 46

5.6.2 Addressing the affordability gap ..................................................................... 47

6 Management Case ........................................................................................................... 49

6.1 Introduction ............................................................................................................. 49

6.2 Project Governance ................................................................................................. 49

6.3 Project Management Arrangements ....................................................................... 50

6.4 Approach to Risk Management and benefits realisation ........................................ 51

6.5 Stakeholder Engagement ........................................................................................ 51

6.6 Project Timescale..................................................................................................... 51

Appendices Appendix 1 Stakeholder Engagement

Appendix 2 Future Model of Care

Appendix 3 ABC of Integrated Community Services

Appendix 4 Letter of Commitment from Cardigan Health Centre GPs

List of Tables Table 1: Investment objectives .................................................................................................. ii

Table 2: Critical Success Factors ............................................................................................... iii

Table 3: Shortlisted options ...................................................................................................... iv

Table 4: Capital costs of shortlisted options ............................................................................ iv

Table 5: Capital spend profile of the Preferred Way Forward ................................................... v

Table 6: Revenue Consequences of the Preferred Way Forward ............................................. v

Table 7: Project Management Arrangements .......................................................................... vi

Table 8: Project milestones ...................................................................................................... vi

Table 9: Key policy drivers with direct relevance to this investment ........................................8

Table 10: Investment objectives ............................................................................................. 18

Table 11: Benefits .................................................................................................................... 19

Table 12: Risks ........................................................................................................................ 22

Table 13: Critical Success Factors ........................................................................................... 26

Table 14: Stakeholder participants ......................................................................................... 27

Table 15: Scope options - catchment and functionality ......................................................... 28

Table 16: Scope options - capacity ......................................................................................... 28

Table 17: Scope options - quality ........................................................................................... 29

Table 18: Implementation options ......................................................................................... 29

Table 19: Funding options ...................................................................................................... 29

Table 20: Long list of options .................................................................................................. 30

Table 21: Option evaluation - catchment and functionality................................................... 32

Table 22: Option evaluation - capacity ................................................................................... 33

Table 23: Option evaluation - quality ..................................................................................... 35

Table 24: Outcome of appraisal of longlist ............................................................................. 37

Table 25: Shortlisted options .................................................................................................. 38

Table 26: Description of shortlisted options .......................................................................... 39

Table 27: Procurement timetable ........................................................................................... 41

Table 28: Capital estimates ..................................................................................................... 42

Table 29: Estimated capital spend profile of preferred way forward .................................... 42

Table 30: Revenue Costs of Option A (Preferred Way Forward) ............................................ 44



Table 31: Revenue Costs of Option B ..................................................................................... 44

Table 32: Revenue costs of Option E (‘Do Minimum’) ........................................................... 45

Table 33: Impact if no capital charges and DV rental ............................................................. 46

Table 34: Impact if tapered capital charges and abated rent ................................................ 46

Table 35: Roles and Responsibilities ....................................................................................... 50

Table 36: Project Management Arrangements ...................................................................... 50

Table 37: Project Milestones .................................................................................................. 51

List of Figures Figure 1: Proposed project governance structure ..................................................................... v

Figure 2: Hywel Dda Community Services Strategic Framework and Project Relationships ....1

Figure 3: Map of main acute and community hospital facilities ...............................................5

Figure 4: The distribution of care homes in Ceredigion ............................................................6

Figure 5: Population profile, South Ceredigion ...................................................................... 11

Figure 6: Project Governance Structure ................................................................................. 49



i

Executive Summary

1. Introduction

The purpose of this Strategic Outline Case (SOC) is to set out the case for change for the

introduction of a new model of care and development of new health and social care facilities

in Cardigan. The new model of care will introduce a different approach to the integration of

primary, community and social care together with a new concept of service delivery. When

achieved, it will result in greater independence and better outcomes for all users of the

service. It will also enable a transformation in services in the acute sector.

The investment sought through this SOC is for a crucial enabling element of a larger

programme of work which when completed will deliver a new model of care for the local

population. It proposes the development of a new integrated health and social care facility

in Cardigan which will result in the closure of the existing Community Hospital and GP

Medical Centre and the relocation of the Social Services Care Teams. The estimated capital

cost of the scheme is £28.992m and requires additional revenue of between £93,000 and

£282,000 per annum to run (depending on the treatment of capital charges and rental). The

Health Board is confident that this revenue gap can be closed by actions in a number of

areas which this scheme makes possible. The project will be completed and operational by

January 2014.

2. The Strategic Case

The proposed development is fully in line with national and local policies, the strategic

direction of the Hywel Dda Health Board, and the Health Board’s five priorities for

improvement and investment. The project is a true collaborative between health and social

services organisations and is the outcome of a number of local multi agency programmes

and reviews undertaken during the last three years:

• The Ceredigion 2020 – Community Strategy.

• The Health, Social Care and Wellbeing Strategy 2008 – 2011

• Ceredigion County Council’s Accommodation Strategy for Older People 2007 – 2011

• The Ceredigion Community Services Change Programme (March 2008)

• The Alan Axford Review (May 2008)

• The Strategic Outline Programme – Ceredigion Community Services (January 2009)

• The Hwyel Dda Community Services Strategic Framework

Other work streams have been undertaken to support these various publications including a

capacity modelling exercise, a Three Counties Planning Forum and a Hywel Dda-wide clinical

framework.



ii

The case for change is driven by inadequacies in the current model of care and the current

facilities. The main problems are:

• The current system of health and social care in the Cardigan area is fragmented and

disjointed from a service user and professional perspective.

• As Cardigan is on the border of three Unitary Authority boundaries, there are gaps in

service provision and differing referral criteria which creates inequities in access to

services across geographical boundaries.

• Access to local hospital-based care is restricted to those patients who are registered

with the four GP Practices on the Cardigan Hospital bed fund scheme.

• The existing buildings are not fit for purpose, are inefficient and not capable of

expansion.

In light of this case for change, the following investment objectives have been agreed for the

project.

Table 1: Investment objectives

Investment Objective Definition

Facilitate the delivery of the

new model of care

By January 2014, to provide accommodation that will

enable multi-agency integration, single point of

assessment, rehabilitation and optimal use of health and

social care resources

Improve local access to

services

By January 2014, to extend the access for the new model

of care to include all those living within the defined

catchment area of Cardigan

Provide appropriate service

capacity

To provide accommodation that will at least meet the

needs under the new model of care of the projected 2031

defined Cardigan catchment population

Provide a high quality physical

environment

By 2014 all facilities will be at least compliant with

statutory HBN and CSIW standards for health and social

care facilities, including requirements for privacy and

dignity.

Specific benefits have been identified for a wide range of stakeholders, including service

users, the Health Board, partner organisations, staff and the public. Key risks have been

identified and assessed, and an approach to the management of each has been agreed.



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3. The Economic Case

The Economic Case sets out how the Project Board has selected the short list of options to

be taken forward to the next stages of planning (the Outline Business Case). To achieve this,

a wide range of options were generated, and then reduced to a shortlist through a rational

assessment process.

In addition to the Investment Objectives, the Project Board identified a number of factors

which, while not direct objectives of the investment, would be critical for the success of the

project, and would be relevant in judging the relative desirability of options. The agreed

Critical Success Factors are shown below.

Table 2: Critical Success Factors

Critical Success Factor The extent to which the option:

1 Flexibility Can be adapted to meet the changing needs of the local

population and the developing service model

2 Strategic Fit Takes forward the National Policy and local strategic priorities

3 Achievability Can be achieved within the 2014 planning timescale for the

project

4 Affordability - revenue Can be delivered within the overall health and social care budget

5 Acceptability Will be acceptable to stakeholders

Options have been considered in the following categories:

• Site solution (which was the subject of a detailed appraisal in November 2008)

• Scope – the scope of service to be provided by the investment; this covered:

o Geographical area/catchment population to be served, and level of

functionality

o Capacity assumptions/issues

o Quality of service provided

• Approach to implementation – e.g. phased, single contract

• Approach to funding – e.g. Third Party Development (3PD), conventional capital

funding.

Each element of scope, implementation and funding was considered against the investment

objectives and critical success factors. As a result of this process, four options have been

shortlisted to be evaluated in detail in the Outline Business Case (alongside a ‘do minimum’

comparator).



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Table 3: Shortlisted options

Option Description

Option A:

Preferred Way

Forward

A new build integrated health and social care facility developed on the

Bath House site. Facilities will include:

• A new GP medical centre

• A minor injuries unit

• An integrated day care facility and diagnostic services and

dedicated rehabilitation facilities

• 21 beds to be used for general medical care, palliative/end of life

care, respite care and rehabilitation

• An outpatient department

The new facility will have 60% of the beds in single rooms, and will be

available to all residents of the extended catchment population.

It will be delivered as a single procurement / development.

Option B As Option A, but with 25 beds.

Option C As Option A, but with a phased approach to development.

Option D As Option B, but with a phased approach to development.

Option E (Do

minimum)

Minimal upgrade of current facilities to meet statutory requirements.

4. The Commercial Case

The Commercial Case sets out the planned approach the Health Board will be taking to

ensure there is a competitive market for the supply of services. The procurement route to

be followed for this scheme is through a centrally funded approach using the Designed for

Life/Building for Wales (DFL/BFW) concept.

5. The Financial Case

The Financial Case sets out the financial impact of the investment proposal. It details the

capital costs and the revenue implications of not only the Preferred Way Forward but also

the other short-listed options. There are also details of the do minimum option to allow a

true comparison of the proposed investment. The basis on which all financial calculations

have been made including any assumptions are also set out in the Financial Case.

Table 4: Capital costs of shortlisted options

Option A

(21 beds;

single

scheme)

£m

Option B

(25 beds;

single

scheme)

£m

Option C

(21 beds,

phased)

£m

Option D

(25 beds,

phased)

£m

Option E

Do

minimum

£m

Land purchase 1.222 1.222 1.222 1.222 Nil

Building/works costs 18.214 18.574 20.035 20.629 8.734

Plant and equipment 1.160 1.173 1.160 1.173 0.200

Professional fees 3.723 3.787 4.095 4.166 1.956

Development costs [Project

Team/support, planning

contingencies)

4.673 4.757 5.140 5.233 1.862

Totals 28.992 29.513 31.652 32.423 12.752

PWF



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Table 5: Capital spend profile of the Preferred Way Forward

2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 Total

Total £2.519m £4.831m £11.669m £9.607m £0.366m £28.992m

*excludes land purchase costs

Table 6: Revenue Consequences of the Preferred Way Forward

Option A

(21 Beds, single scheme)

Preferred Way Forward

Developmental phase

(current costs)

Transition

year

Fully

operational

Year 1 Year 2 Year 3 Year 4 Year 5

Staffing Costs (Pay) 1.261 1.261 1.261 1.261 1.203

Other operating costs (Non-pay

and income) 0.259 0.259 0.259 0.366 0.473

Total Costs 1.520 1.520 1.520 1.627 1.676

Any off-setting income* (0.019) (0.019) (0.019) -0.050 (-0.082)

Full revenue consequences 1.501 1.501 1.501 1.577 1.594

The Preferred Way Forward will require additional revenue of between £93,000 and

£282,000 per annum over current costs, depending on the treatment of capital charges and

GP rentals.

6. The Management Case

This project is an integral part of the Hywel Dda Service Modernisation Programme. The

detail of that programme was set out in the Ceredigion Community Strategic Outline

Programme, (January 2009) and comprises a portfolio of projects for the delivery of schemes

in Cardigan, Aberaeron and Tregaron. The governance structure for this project is based

upon best practice. It is illustrated below and described in the table which follows.

Figure 1: Proposed project governance structure



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Table 7: Project Management Arrangements

Investment Decision

Maker


Senior Responsible Owner

and Chair of the Project

Board

Chief Executive, Trevor Purt

Project Director Director of Primary, Community and Mental Health Services -

Bernardine Rees

Other Project Board

Members

County Clinical Director, Ceredigion – To be appointed

County Director, Ceredigion - Ian Bellingham

Assistant Director of Primary, Community and Mental Health

Services – Jill Patterson

Director of Social Services – Ceredigion - Parry Davies

County Director of Health and Social Services, Pembrokeshire – Jon

Skone

Leader – Carmarthenshire County Council – Keith Evans

Deputy Director of Finance – Eldeg Rosser

Head of Capital and Estates – Rob Elliott

Major Capital Projects Manager – Jason Wood

Primary and Community Services Manager , Ceredigion

Lead General Practitioner, Cardigan Health Centre – Dr Roger Cole

Service Planning Manager – Amanda Jones

Project Support Officer – Mikki Williams

A Project Team has also been established and includes senior managers from the Health

Board and partner organisations and external advisors. The project will be managed in

accordance with PRINCE 2 methodology.

The key project milestones are as follows.

Table 8: Project milestones

Milestone Date

Submission of Strategic Outline Case (SOC )to WAG March 2010

Selection of Supply Chain Partner March 2010

Anticipated approval of SOC April 2010

Appointment of Supply Chain Partner April 2010

Development of Outline Business Case (OBC) May - December 2010

Submission of OBC December 2010

Approval of OBC March 2011

Development of Full Business Case (FBC) April - November 2011

Submission of FBC November 2011

Approval of FBC December 2011

Mobilisation of Contractors January 2012

Construction Phase January 2012 – December 2013

Commissioning December 2013 – January 2014

Services and facilities operational January 2014



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1 Introduction

1.1 Introduction and scope of this document

The purpose of this Strategic Outline Case (SOC) is to set out the case for change for the

introduction of a new model of care in Cardigan which is fully aligned with the new strategic

direction of Hywel Dda Health Board, and the recommendations contained within ‘Setting

the Direction’ and the Rural Health Plan. The proposal builds on the recommendations of the

Ceredigion Community Services Change Programme and the Alan Axford Review. It supports

the Strategic Outline Programme for Ceredigion Community Services submitted on 31

January 2009 and the subsequent SCIF application submitted in August 2009.

The investment sought through this SOC is a crucial enabling element of a larger programme

of service redesign which will deliver a new model of care for the local population. This

wider programme is illustrated below.

Figure 2: Hywel Dda Community Services Strategic Framework and Project Relationships

Hywel Dda Community Services Strategic Framework

Service Integration

Implementation of new model of care

Development of appropriate facilities

Integration of IT Operational Systems

and Programmes

Unified Assessment Process

Integrated team working

Resource management

Financial Resource Planning

Workforceredesign

The new model of care will introduce a different approach to the integration of primary,

community and social care together with a new concept of service delivery. When achieved,

it will result in greater independence and better outcomes for all users of the service.

The main element of this Strategic Outline Case is a programme of service change through

workforce redesign, which will transform the delivery of health and social care. A significant

additional benefit is an improved environment for staff and service users.



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1.2 Structure of this document

The SOC has been prepared using the agreed standards and format for Business Cases, as set

out in Welsh Health Circular WHC(2007)052: Developing and Delivering the Capital

Investment Programme.

This document follows the approved format of the Five-Case Model for business cases and

explores the proposal from five perspectives:

• The Strategic Case explores the case for change – whether the proposed investment

is necessary and whether it fits with the overall local and national strategy.

• The Economic Case asks whether the solution being offered represents best value

for money – it requires alternative solution options to be considered and evaluated.

• The Commercial Case tests the likely attractiveness of the proposal to developers –

whether it is likely that a commercially beneficial deal can be struck.

• The Financial Case asks whether the financial implication of the proposed

investment is affordable.

• The Management Case highlights implementation issues and demonstrates that the

Health Board is capable of delivering the proposed solution.

1.3 How this document has been produced

This document has been produced following extensive consultation and collaboration with a

range of stakeholders. A list of those involved is attached at Appendix 1. They have been

fully involved in the wider programme of change as well as the development of options and

concepts for this specific project referenced in this document. Further details are included

within the Economic and Management Case sections of this document.

.



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2 Strategic Case

2.1 Introduction

The Strategic Case for this SOC focuses on the introduction of a new model of care which

meets the key strategic agenda of delivering care as close to home as possible, placing less

reliance on acute inpatient beds and with a clear focus on responding to individuals’ needs.

Currently the introduction of the new model of care for the local population is constrained

by the inadequacies of the model of delivery of health and social care in Cardigan and the

facilities currently provided are totally unfit for purpose. Although Cardigan is within the

Ceredigion County Council boundary, it is strategically positioned to act as a community hub

for services in parts of Ceredigion, Carmarthenshire and Pembrokeshire. Services should be

designed to ‘pull’ patients from the acute sector into the community to enable people to be

treated and cared for as close to home as possible, for as long as possible, by the right staff.

To enable this to happen, the Strategic Outline Case presents a case for change for service

redesign, which requires investment in a new central facility to support the new service

model.

The section sets out:

• The national and local strategic context

• The case for change and the business need

• The main factors that will influence the eventual service solution. These include:

� the investment objectives

� the expected outcomes and benefits

� the main risks, constraints and dependencies

2.2 Strategic context

2.2.1 Organisational context

This case for investment is made by the Hywel Dda Health Board (the Health Board). As well

as encompassing services provided by its own clinicians, it also includes primary care and

elements of social care services provided by Carmarthenshire, Ceredigion and

Pembrokeshire County Councils. Therefore those organisations are regarded as equal

stakeholders for this investment.

Health Services

On 1st October 2009, a new Health Board was established for mid and west Wales, replacing

the three Local Health Boards in Carmarthenshire, Ceredigion and Pembrokeshire and Hywel

Dda NHS Trust. The Hywel Dda Health Board is the main provider of primary, community and

acute health care, mental health and learning disabilities services in the area, covering a

large and predominately rural area of mid and west Wales. It is one of the area’s largest



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employers, with 7,325 whole time equivalent (WTE) staff (headcount of 9,643) and an

annual turnover of approximately £565 million.

Health Board Priorities

Hywel Dda Health Board’s approach to prioritising service improvements and investments is

as follows:

• Quality First, minimising risk and harm, doing the right things by using evidence base

and improving the patient experience

• Good Governance, understanding our business and knowing that we do it well

• Reducing waste and variation by rebalancing acute services to community services,

day surgery as the norm and optimizing bed capacity

• Medicines Management – using safe, evidence based prescribing

• Service Redesign using ‘Best Evidence’ – by delivering quality based services in the

following areas:

o Care closer to home through proactive case management

o Comprehensive investment in chronic condition management

o Refocusing long-term care

o Improving urgent care

The Estate

The quality of the estate and environment varies across the Health Board, ranging from

relatively modern estate (Prince Philip Hospital) to property that pre-dates the NHS

(Cardigan Hospital). This therefore leads to significant challenges in the delivery of services

in terms of control of infection, privacy and dignity.

In Ceredigion, health services are currently provided from Bronglais Hospital in Aberystwyth;

three community hospitals, (Aberaeron, Cardigan and Tregaron); a clinic in Aberystwyth and

a health centre in Cardigan which houses a GP Practice; a health centre in Cardigan and a

clinic in Aberystwyth.

In Carmarthenshire, health services are provided from West Wales General Hospital and

Prince Philip Hospital, Llanelli (acute hospitals); community hospitals (Amman Valley,

Mynydd Mawr and Llandovery); and health centres/clinics in Carmarthen, Crosshands and

Llanelli.

In Pembrokeshire, health services are provided from Withybush Hospital in Haverfordwest;

community hospitals in Tenby and Pembroke Dock; and health centres in Fishguard, Hakin,

Haverfordwest, Milford Haven and Pembroke. The health Centre in Crymych is being

temporarily extended due to severe space shortages. The Health Board intends to provide a

permanent building either through the third party developer funding route or by partnering

with the Pembrokeshire County Council ExtraCare Housing scheme.

These facilities are all owned by the Health Board. In addition, many community nursing

teams are based within primary care in GP-owned premises.



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Figure 3: Map of main acute and community hospital facilities

Main Acute

hospitalsCardigan

HospitalCommunity

HospitalsLegend

Social Care Services

The Social Services Departments in Carmarthen, Ceredigion and Pembrokeshire are

organised into locality teams. The Ceredigion Social Services in south Ceredigion currently

has a base for the Social Services Adult Team in a converted house in Finch Square, Cardigan.

The current office accommodation will not be appropriate to provide community based

services over the longer term. In terms of housing, there is a 48 unit Extra Care

development in progress in Cardigan that will provide accommodation for 70 people.

In north Pembrokeshire, there are plans to establish a Complex Care Team in Crymych,

consisting of Social Work, Occupational Therapy, Care Management, Elderly Mentally Infirm

(EMI) and Learning Disability (LD) staff. This will be a pilot scheme that will be rolled out

across Pembrokeshire. There are also plans for the development of a 40 unit Extra Care

Housing scheme in the Crymych, linked to the Extra Care development in Cardigan.



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Figure 4: The distribution of care homes in Ceredigion

2.2.2 National and local strategic policies and programmes

National Policies

There are several national policy drivers that have been influential in developing this case for

investment:

• ‘Setting the Direction’, the Primary and Community Services Strategic Delivery

Programme for Wales, focuses on new models of care which have less reliance on

hospitalisation and where primary care is at the heart of service planning and

development. This requires whole systems redesign which needs to be built around

local needs whilst reflecting national policy.

• One Wales is the progressive agenda for the government of Wales. It has eight main

priority areas, one of which is to develop ‘A Healthy Future’. The Assembly have

committed to:-

o Developing and improving Wales health services

o Ensuring access to health care

o Improving patient experience

o Supporting Social Care

YSTRAD MEURIG

BLAENPENNAL

TREGARON

ABERAERON

LAMPETER

LLANYBYDDER

LLANRHYSTUD

LLANON

LLANDYSUL

ABERYSTWYTHPrivate nursing home

CARDIGAN

KEY

LA residential home

Private residential home

Bryntirion Care Home

Maes Y Felin Residential Home

Faerdre Care HomeBlaendyffryn Hall Care HomeGarth Ow en Care Home

Aw el Deg Residential Home

2 Roby Villa

Yr Hafod Residential Home

Brondesbury Lodge Ltd

Gelli Lon Care Home

Hafan Deg Care Home

Plas Cw mcynfelin Care Home and The Coach House

Cartref Tregerddan Residential Home

Bryn Siriol Respite Care Centre

Bodlondeb Care Home

Spring House Care HomeMin y Mor Residential Home

Cartref Henllan Care Home

Carlton House Care Home

Plas Gw yn Care Home

Plas Lluest Care Home

Abermad Care Home

Hafan Y Coed Care Home

Cysgod Y Coed Care Home

Pennal View Residential Home

Bedw Gleision Residential Home

Llw yndyrys Mansion Residential Home

Kynance Home

Rhoserchan Care Home



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• The Rural Health Plan delivers one of the key One Wales Commitments and aims to

develop rural health and rural health services in Wales. The document outlines how

community hospitals can develop with a renewed purpose and how they can bring

services closer to rural communities. The Plan outlines three themes for developing

the Rural Health Framework which are access; integration; community cohesion

and engagement.

• Making the Connections outlines four main principles:

o Citizens at the Centre: services more responsive to users with people and

communities involved in designing the way services are delivered;

o Equality and Social Justice: every person to have the opportunity to

contribute and connect with the hardest to reach;

o Working together as the Welsh Public Service: more co-ordination between

providers to deliver sustainable, quality and responsive services; and

o Value for Money: making the most of our resources.

• Wales Spatial Plan (entitled ‘People, Places, Futures’) is a 20 year plan for the

sustainable development of Wales. There are five guiding themes to the plan:

o Building sustainable communities

o Promoting a sustainable economy

o Valuing our environment

o Achieving sustainable accessibility

o Respecting distinctiveness

• Designed for Life contains a 10-year vision for creating world-class health and social

care in Wales in the 21st century. It is underpinned by three aims of lifelong health;

fast, safe and effective services; and world class care. These aims are being

implemented via three 3 year strategic frameworks.

• Fulfilled Lives Supportive Communities is the strategic document for Social Services

and sets out a renewed vision for social care. The main action over the next 3 years

in implementing this national document includes:

o Leadership and accountability

o Commissioning

o Performance management

o Partnerships



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o Workforce

• One Wales: One Planet places the promotion of sustainable development at the

heart of WAG’s work. The sustainability vision is where Wales:

o Lives within its environmental limits

o Has healthy, biologically diverse and productive ecosystems that are

managed sustainably.

o Has a resilient and sustainable economy

o Has communities which are safe, sustainable and attractive places for

people to live and work, where people have access to services, and enjoy

good health.

o Is a fair, just and bilingual nation, in which citizens of all ages and

backgrounds are empowered to determine their own lives, shape their

communities and achieve their full potential.

Table 9: Key policy drivers with direct relevance to this investment

National Policy Drivers Relevance to this investment

Setting the Direction • Shift of emphasis from acute to primary care

and community based treatment and

prevention

• Services to be planned around local needs

• Expanded and integrated model for

community services

• Health and social care partnerships

One Wales • Developing high class services and facilities

• Improving the patient experience

• Service developments that are supportive of

social care

The Rural Health Plan • Re-invigorating the role of community

hospitals

• Provision of services in rural areas closer to

the patient

• Improving access to and integration of

services

Making the Connections • Services more responsive to users

• More coordination between providers of

services

Designed for Life • High quality facilities

• Fast, safe and effective services

Local Policies and Programmes

This SOC is the outcome of a number of local multi agency programmes and reviews

undertaken during the last three years:



9 | P a g e

1. The Ceredigion 2020 – Community Strategy which set out the County’s vision for

the next 15 years. The strategy is currently being revised and updated.

2. The Health, Social Care and Wellbeing Strategy 2008 – 2011 addresses one of the

six core themes of Ceredigion 2020 and sets out how all health and social care

stakeholders will improve the services that are commissioned and provided. It builds

on the earlier (2006) Health Social Care and Wellbeing Needs Assessment.

3. Ceredigion County Council’s Accommodation Strategy for Older People 2007 – 2011

sets out a vision to provide “high quality housing, services and support which enable

older people to live as independently as possible in a suitable and safe environment

and ensure services are organised around and are responsive to their needs”.

4. The Ceredigion Community Services Change Programme (March 2008) which

proposes a new approach to partnership working and the development of an

integrated multi-agency model for community services.

5. The Alan Axford Review (May 2008) which examined the interface between

Bronglais Hospital, Aberystwyth and proposed community health facilities in

Ceredigion. One of the conclusions of that review was the development of the

integrated care centre in Cardigan.

6. The Strategic Outline Programme – Ceredigion Community Services (January 2009)

which responded to the Alan Axford Review and set out the overarching investment

framework for the development of integrated community services in Ceredigion.

7. The Hywel Dda Community Services Strategic Framework (March 2010) which sets

out the high level strategic framework for community services within the three

counties of Carmarthenshire, Ceredigion and Pembrokeshire and is linked to the 5

year strategic framework for the Health Board. Within the framework it is

recognised there is a need for close alignment of health and social care provision.

The emphasis is not on revolutionary change of organisational structure but on

breaking down barriers and defining key messages and principles to manage change,

to develop and enhance the support of people in the community.

Other work streams have been undertaken to support these various publications including a

capacity modelling exercise and a programme of work by the Three Counties Planning

Forum, which includes the development of a Hywel Dda-wide clinical framework.

The new Health Board vision and values

Finally, the new Health Board has recently approved a new organisational ethos which sets

out the vision, values, standards of governance and culture. The following extracts are of

particular relevance to this investment:

• A patient centred care approach with patients able to exercise as much or as little

influence over their care as they choose; and a focus on prevention of illness (Vision)



10 | P a g e

• A health service that changes the balance of care into people’s homes and

communities, and away from traditional hospital care (Vision)

• Services that are given equal prominence in the move from hospital to community-

based care (Values)

• Be strongly committed to partnership working (Values)

• Deliver care as close to patients homes as possible (Values)

• Innovation – to meet changing service needs (Culture)

• Partnership working – to encourage joint working of NHS staff with partner

organisations (Culture)

• Responsiveness – to ensure that future service patterns and priorities are responsive

to the needs of individuals within their communities (Culture)

To deliver this new agenda, the Health Board has invested heavily in reinforced county

and clinical leadership in primary, community and secondary care in order to rebalance

services from an acute-based focus to community services and to innovate through

pathway development with all local stakeholders.

This will be achieved by:

• GMS – More innovative local changes to philosophy of care – pro-actively

managing demand and changing care settings: by harnessing the Quality Outcomes

Framework (QOF) and enhanced services as potential modernisation levers.

• A secondary care incentivised clinical outcomes matrix: which focuses upon

reducing waste, harm and variation and rewards improved efficiency and

productivity: by harnessing CHKS, AOF Core and supporting efficiencies, to deliver

against an outcomes matrix which focuses on quality and patient safety.

• Local Authority & Third Sector: Joint budgets and joint appointments - a different

approach to management with a “County” based structure to ensure operational

delivery and robust financial management, supported by the establishment of seven

programme boards to drive the clinical modernisation of services.

2.2.3 Service context

From all of the above strategic policy drivers and supporting work, there is a clear emerging

requirement for local managers to address:

• The demand for services is going to increase as the population continues to age and

grow over the next 25 years. Across all local authorities and ages, the population of

Wales is predicted to grow by 0.5% per year over the next 25 years. Over the same

the period, Ceredigion is expected to experience slightly higher growth in population

of 0.7% per year. However, the growth in the population of Ceredigion is heavily



11 | P a g e

biased towards the elderly population, with younger elements of the population

either static or in decline. Between 2006 and 2031, the 65-74 age group is predicted

to grow 10 times more than the under-65 age group, and the 75+ age group 20 times

more. There is also a significant demographic feature in terms of the population

structure in the Cardigan area. There is a higher percentage of the population aged

over 75 in the Cardigan area when compared with the rest of Ceredigion and with

Wales as a whole.

Figure 5: Population profile, South Ceredigion

Source: National Public Health Service – Health Needs Assessment 2006

-800

-600

-400

-200

0 200

400

600

800

Number of persons

00-04

05 -09

10-14

15-19

20 -24

25 -29

30 -34

35 -39

40 -44

45 -49

50 -54

55 -59

60 -64

65 -69

70 -74

75 -79

80 -84

85+

Ag

e g

rou

p

South Ceredigion

female male



12 | P a g e

• To meet this demand, services need to be able to treat and care for more people in

their own homes (or as close to their homes as possible), thereby avoiding acute

hospital admission. Throughout Wales and the rest of the UK, there is an increasing

use of alternatives to acute hospital admission and, where these have been

implemented, there has been a decreasing need for hospitalisation. This is a key

theme of the Primary and Community Services Strategic Delivery Programme.

• There needs to be a new approach to interagency working. Any new model of care

should result in significant improvements in service integration and consistency of

service delivery to the end user.

2.2.4 The estates context

The investment sought through this SOC is to ensure that there are appropriate facilities in

place for staff from all agencies to provide the required services to the catchment

population. ‘Appropriate’ in the context of this SOC for Cardigan means that the facility:

• Enables the integration of health and social care teams and facilitates joint

assessment and working, as well as a single point of contact for service users; this is

generically referred to as a Community Resource Centre;

• Is conveniently located and provides easy access for the local population;

• Is capable of meeting the future demand for services for the next 20 years;

• Meets health and safety, infection control, privacy and dignity, Disability

Discrimination Act and all other HBN, CSSIW and Welsh Assembly Government

facilities expectations.

In Cardigan there are two key facilities owned by the Health Board – Cardigan Hospital and

Cardigan Health Centre – from which community and primary health services are provided.

Current backlog maintenance for these facilities is as follows:

Cardigan Hospital: £5,672,456

Cardigan Health Centre: £194,555

In addition, DDA compliance issues associated with Cardigan Hospital amounts to £202,331.

The Ceredigion Social Services in South Ceredigion has a base for the adult team in a

converted house in Cardigan (Finch Square).

The inadequacy of these facilities is set out in section 2.3.2.

2.3 The Case for Change

2.3.1 The current model of care

The current system of health and social care in the Cardigan area is fragmented and

disjointed from a service user and professional perspective. A clear need has been identified



13 | P a g e

in the strategic policies and reviews set out in section 2.2.2 for service integration across

health and social care and there is a commitment from front line staff to work differently

and to work together as a Community Resource Team, but this is not possible in current

facilities.

As Cardigan is on the border of three Unitary Authority boundaries, there are gaps in service

provision and differing referral criteria which creates inequities in access to services across

geographical boundaries. It is possible for a client to be resident in one county, have a GP in

another and be unable to attend a Day Unit because it is across the border managed by a

different local authority. It is clear that services could be managed more coherently.

Furthermore, access to local hospital-based care is restricted to those patients who are

registered with the four GP Practices on the Cardigan Hospital bed fund scheme. Currently,

this covers approximately 24,500 patients of whom 5,750 [24%] are aged 65 and over. A

recent study has concluded the natural catchment population for Cardigan is 39,200 of

which 8,200 [21%] are aged 65 and over. Again it is clear this broader population would

benefit from local access to community hospital facilities.

2.3.2 Current facilities

To compound the challenges and shortfalls in the current model of care, the buildings are

not fit for purpose, are inefficient and not capable of expansion.

Cardigan Hospital

Cardigan Hospital provides a range of services and facilities including:

• 21 Inpatient beds; these are GP medical beds under the care of local GPs for direct

admissions, transfers from District General Hospitals and palliative care

• Outpatient facilities for visiting consultants

• An X-ray service (Monday - Friday only)

• Rehabilitation facilities for a wide range of therapy services

• A Minor Injuries Unit (Monday – Friday 8am-6pm and Saturday am)

• Offices for community health and social care staff

The building originates from the early 1900s and has had no major programme of upgrading

in recent years. The building was not designed as a hospital and has many problems

including very small ward areas on different levels which increase staffing costs, doorways

that are too small to allow beds through, very few single rooms and no en-suite facilities.

The environment is poor from a privacy, dignity and infection control perspective.

This position is reflected in the extent to which condition category C and D building and

engineering elements have been identified through recent surveys, indicating that the

replacement of the entire facility is recommended as the way forward. The building does not

comply with a number of statutory requirements and does not meet modern healthcare



14 | P a g e

standards. The achievement of Disability Discrimination Act (DDA) compliance is also

practically unattainable as is upgrading of the functional space relationships to align with

Health Building Notes.

In the Estate and Facilities Performance Management Returns submitted between 2005 and

2008, the reported backlog position for significant risks equated to £5,479,291. An estate

condition and risk assessment was undertaken in December 2007 and again in September

2008 to highlight the building and engineering elements at Cardigan Hospital that may have

deteriorated to unsafe levels since the last comprehensive review was carried by external

consultants in 2003. A report was also commissioned to review fire compartmentalisation

across the Ceredigion and Mid Wales NHS Trust estate, which highlighted further significant

risks at Cardigan Hospital.

It was recognised that, without an urgent investment, it would become increasingly difficult

to maintain infection control standards, which could result in services provided in the clinical

areas being reduced or closed. Four beds have already been closed for this reason. In the

event of a fire, it would not be possible to ensure that an outbreak can be contained, due

the deficiencies highlighted in the fire compartmentalisation report. Also, if the lift

replacement does not proceed, there is a continued risk of breakdown, with the

consequence that supplies and food trolleys will have to be taken to the two ward areas on

the lower floors directly from the outside of the building and the staff on the two upper

floors would have to be relocated, as they would have to physically carry supplies and

equipment upstairs.

Therefore a Business Justification Case has been approved for remedial works at Cardigan

Hospital, to ensure that the building can continue to operate safely for patient care during

the development of this SOC. This programme includes a replacement lift, replacement oil

tanks and fire safety works which will address the highest prevailing estate risks and will

arrest any further deterioration in condition to unsafe levels and this work is currently in

progress.

Extensive supporting information relating to the condition of Cardigan Hospital is contained

within the Estates Annex (Appendix 3)

Cardigan Health Centre

The Cardigan Health Centre GP Practice provides General Medical Services from

accommodation deemed no longer fit for purpose. A community dental service, community

psychiatric nursing team, family planning and other agencies also operate out of the

building. The accommodation struggles to maintain DDA and health and safety standards;

infection control, confidentiality and security of patient identifiable information are also at

risk due to lack of storage and secure areas. Five GPs and 16 staff share toilet facilities with

patients and visitors from other agencies and there are no catering or meeting facilities. The

Practice is unable to expand and develop its services and current services could be at risk of

being withdrawn.



15 | P a g e

To alleviate some of the pressures the Practice utilises additional space in a nearby

portacabin and adjacent terraced house. This also has implications for confidentiality and

lone working.

The building is in poor condition and urgently needs replacement. A risk assessment has

been undertaken to assess the key risks and to enable the building to continue to function

until a new building can be obtained.

Extensive supporting information relating to the condition of Cardigan Health Centre is

contained within the Estates Annex (Appendix 3) and in the Case of Need which will

accompany this Strategic Outline case as part of this submission.

Cardigan Social Services

As already stated, the Adult Social Services team is based in a converted house in Finch

Square, Cardigan, which will not be appropriate to provide community based services over

the longer term and which does not provide any opportunity for joint working or

assessment. Future opportunities exist to work more closely with Social Care, by

considering the flexible use of inpatient beds (similar to the existing model of ‘Joint Care’

beds) and releasing this income stream into additional day care and/or rehabilitation

facilities in the new Centre. The Joint Care beds are used as a means of avoiding admission

to an acute bed.

Not for Profit Sector

A 48 unit Extra Care housing facility is under development on the Bath House site, and there

is a similar 40 unit Extra Care facility planned nearby in Crymych. These are being developed

in partnership with the Family Housing Association (FHA). It is anticipated that these

developments will present further opportunities for collaboration, and discussions are taking

place with the FHA to explore the potential for joint working through shared provision of

catering and facilities maintenance services and the flexible use of clinical areas and meeting

rooms.

2.3.3 A New Model of Care

The aim of the proposed service model is to achieve and sustain the greatest degree of

independence for people living in and around Cardigan, by providing services which are

flexible and responsive to needs. The new model of care aims to deliver care as close to

home as possible and when an acute admission is required, to only bring someone into a

health or social care setting for the shortest time possible to maintain their independence.

The consequence of these actions is that more care will be delivered in the community and

in patients’ homes.

This will be based on the establishment of:

• Acute Response Teams (ART) in the community;

• Short Stay Units with supported discharge arrangements;

• A new model of service delivery across the whole health and social care community



16 | P a g e

The model of care will be based on the principles of the Three Counties Community Services

work stream, ‘Supporting People in our Communities’, which aims to establish a single point

of contact, introduce a unified assessment process and implement a chronic conditions

service across the local health and social care communities.

In Cardigan, this will be achieved by:

• The establishment of a Community Resource Team in the Cardigan area, by bringing

together those staff already working in the community into a coherent team to

o Support primary care in improving outcomes for patients with complex

needs and

o Positively impact on the delivery of scheduled and unscheduled care as well

as improving the patient experience

• The development of a Community Resource Centre, which will act as a resource and

communications hub at the centre of the community. This will support Hywel Dda’s

service redesign proposals for acute services, which will:

o Reduce unnecessary demand on general hospital services and

o Address access and equity issues by the provision of a better balance of

services more locally

• The introduction of a single point of contact for service users

• The full implementation of the Unified Assessment Process (UAP)

• The extension of services 24/7, including a rapid response service

• The transfer of the GP Out off Hours service from Llandysul to Cardigan

• The transfer of the Reablement Team staff from Aberaeron to Cardigan and

integration with the North Pembrokeshire Reablement Team

• The development of admission avoidance schemes and supportive discharge

schemes

• Inpatient beds for slow stream rehabilitation (step-up/step-down), palliative care,

respite (for those who meet the NHS respite criteria) and continuing care

assessment

• Medicines management provision

• Pre-assessment clinics

• The provision of Telemedicine systems to provide remote access to specialist advice

and diagnostic test results

• The development of Assistive Technology to support people in living independently

at home.

• The implementation of integrated IT systems across primary, community and social

care with access for all staff

• The appointment of lead GPs for chronic conditions management to shift the focus

towards active management of high risk groups

• The engagement of all parties (including clients/citizens/patients/carers) in the self-

management of their care and the planning of services

• A focus on prevention of ill health and promotion of health and wellbeing

• The adoption of solutions that will be appropriate and effective in a rural area.

• The introduction of training packages that will support new roles for generalists and

specialists

• The rebalancing of the system away from institutional forms of care



17 | P a g e

• The pooling of budgets and resources across organisational boundaries and the

introduction of a Section 33 agreement

Cardigan Community Resource Centre will be the catalyst to bring services together and

enrich the way in which staff members work together. It will provide the opportunity to

create a future system of care that is seamless, with integrated service provision across

geographical and organisational boundaries.

Core services will include:

• GP Practice (Cardigan Health Centre GP Practice)

• GP Out of Hours service (currently based in Llandysul)

• Primary and secondary prevention services

• Specialist outreach

• Base for Community Resource Teams

• Rehabilitation Day Unit

• Reablement and rapid response

• Minor Injury Unit

• X-Ray

• Outpatient facilities for pre-assessment and outpatient consultations by visiting

Consultants, Specialist Nurses/Therapists and Social Workers

• Inpatient facilities for short stay assessment, management of exacerbation of long-

term/chronic conditions, rehabilitation, respite, palliative care and end of life care.

The new Centre will be the base for the Community Resource Team in the Cardigan area and

will provide a service in south Ceredigion, north Pembrokeshire and along the Teifi Valley

into Carmarthenshire.

The Community Resource Team will provide the following:

• Single point of contact

• Unified assessment

• Rapid response

• Specialist outreach

• Chronic conditions management

• Rehabilitation

• Management of continuing care packages

• Effective discharge planning

An integrated workforce plan is being developed, supported by a competency based training

programme with the introduction of new and extended roles, which will result in more

generic workers supporting specialist staff. A flexible and sustainable workforce will have an

increased number of staff working across professional boundaries, with opportunities for

staff to progress their careers. Levels of competence will be broadened and deepened across

the skills and qualifications spectrum.



18 | P a g e

2.4 Investment Objectives

The investment objectives for this business case are:

Table 10: Investment objectives

Investment Objective Existing arrangements Business need

1. Facilitate the

delivery of the

new model of

care

By January 2014, to

provide

accommodation that

will enable multi-

agency integration,

single point of

assessment,

rehabilitation and

optimal use of health

and social care

resources

The current system of health and

social care in the Cardigan area is

fragmented and disjointed from

a service user and professional

perspective. Inpatient,

outpatient and rehabilitation

services are separated from

primary care, community and

social services teams. None of

the existing facilities are capable

of enabling collaborative

working.

The National Primary and

Community Services Strategic

Delivery Programme requires a

shift of emphasis from acute to

primary care and community

based treatment and

prevention. It expects services

to be planned around local

needs through an expanded

and integrated model for

community services, with

health and social care providers

working in partnership.

Appropriate facilities are

required to enable this.

2. Improve local

access to

services

By January 2014, to

extend the access for

the new model of care

to include all those

living within the

defined catchment

area of Cardigan

Currently, access to local

hospital-based care is restricted

to those patients who are

registered with the four GP

Practices on the Cardigan

Hospital bed fund scheme. This

covers approximately 24,500

patients of whom 5,750 [24%]

are aged 65 and over.

The natural population of

Cardigan who would benefit

from local access to community

hospital services is 39,200 of

which 8,200 [21%] are aged 65

and over. If the Health Board is

to deliver equitable services for

its entire population this

investment needs to address

this obvious imbalance.

3. Provide

appropriate

service capacity

To provide

accommodation that

will at least meet the

needs under the new

model of care of the

projected 2031

defined Cardigan

catchment population

Over the next 25 years

Ceredigion is predicting slightly

higher than national growth in

population of 0.7% per year. The

growth in the population of

Ceredigion is heavily biased

towards the elderly population

and the 65-74 age group is

predicted to grow 10 times more

than the under-65 age group,

and the 75+ age group 20 times

more

To meet this demand, services

need to be able to treat and

care for more people in their

own homes (or as close to their

homes as possible), thereby

avoiding acute hospital

admission. This is a key theme

of the Primary and Community

Services Strategic Delivery

Programme.



19 | P a g e

Investment Objective Existing arrangements Business need

4. Provide a high

quality physical

environment

By 2014 all facilities

will be at least

compliant with

statutory HBN and

CSIW standards for

health and social care

facilities, including

requirements for

privacy and dignity.

Cardigan Hospital has numerous

deficits in terms of its facilities;

they fail to meet many HBN

standards, significant areas are in

Category C or D condition and

they do not meet privacy and

dignity or Disability

Discrimination Act requirements.

Cardigan Health Centre is

likewise in a poor state of repair

and its space restrictions is

preventing service development.

The Cardigan Adult Social

Services team is based in a

converted house which cannot

provide community based

services over the longer term

and which does not provide any

opportunity for joint working or

assessment.

The health and social services

agencies need appropriate

facilities for staff to provide the

required services to the

catchment population.

Appropriate facilities will

enable joint assessment and

working, provide a single point

of contact for service users, will

be conveniently located, will

meet future demand and

comply with health and safety,

infection control, privacy and

dignity, Disability

Discrimination Act and all other

HBN, CSSIW and Welsh

Assembly Government facilities

expectations.

2.5 Benefits

This investment is crucial to the transformation and development of community services in

Cardigan in line with the Community Services Strategic Framework for Hywel Dda Health

Board. It will bring benefits to a wide range of stakeholders and these are set out in the table

below.

Table 11: Benefits

Stakeholder Benefits and type Link to Investment

Objective

Service users • Increased and improved access to local

services, with less dependence on centralised

acute hospital services

Financially quantifiable through reduced

travel cost and time

• Equity of service provision

Qualitative – greater satisfaction

• Easier journey through health and social care

system with a single point of access


• Greater promotion of independence and well-

being


• Greater potential to avoid hospital admission

and more home and community based care

Financially quantifiable through reduced

• Objective 1, 2

and 3

• Objective 2 and

3

• Objective 1

• Objective 1

• Objective 1 and

2



20 | P a g e


Objective

travel cost and time

• Significantly improved facilities


• Objective 4

The Health

Board

• Compliant facilities

Financially quantifiable – impact assessment

of non-compliance

• Implementation of a key strategic goal

Qualitative – enhanced reputation,

achievement of goals

• Delivery of several national policy drivers for

this locality (in particular the Primary and

Community Services Strategic Delivery

Programme)

Qualitative – enhanced reputation,

achievement of goals

• Service integration and greater efficiency in

the use of resources

Financially quantifiable – cash releasing and

resource releasing

• Objective 4

• Objective 1 and

3

• Objective 1 and

2

• Objective 1

Partner

Organisations

– Local

Authorities

– Voluntary

sector

– Not for

Profit

Organisations

• Service integration and greater efficiency in

the use of resources

Financially quantifiable – cash releasing and

resource releasing

• Improved facilities for service users and staff

Financially quantifiable – improved

outcomes from more effective interventions

• Objective 1

• Objective 4

Staff • Better working conditions

Financially quantifiable – reductions in

turnover/recruitment/sickness absence

• Improved job satisfaction

Financially quantifiable – reductions in

turnover/recruitment/ sickness absence

• Greater opportunity for training and to

develop clinical practice and service scope

Financially quantifiable – improved

outcomes from more effective interventions

and shift from acute to community care

• Improved collaborative working

Financially quantifiable –increased efficiency

and improved outcomes from more effective

interventions and shift from acute to

community care

• Objective 4

• Objective 1 and

4

• Objective 1 and

4

• Objective 1 and

4



21 | P a g e


Objective

Public • Single point of access to information on all

local health and social care services

Qualitative – perceived value and greater

satisfaction

• Objective 1

As part of the overall project management and implementation control plan, a full benefits

realisation plan will be established with clear accountability and responsibility for the

attainment of these (and other emerging) benefits.

2.6 Risks

In 2007, the National Audit Office and Office of Government and Commerce (NAO/OGC)

undertook a study of recent major capital project schemes that we deemed unsuccessful in

terms of cost, time overrun or delivery of benefits. One of the eight core reasons was the

failure to properly identify and manage risk within the projects. This section takes an early

view of the key risks that could impact on the successful delivery of the project and sets out

what actions the Project Management Board can take to ensure risk is minimised and

managed. A more detailed assessment of risk will be included in the Outline Business Case

and the process of risk management will continue to be overseen by the Project Board

throughout the life of the project and then transferred to the operational management of

the organisation. The following table sets out the high level early stage assessment of risk.



22 | P a g e

Table 12: Risks

Risk Category Risk Description Impact

1 -5

Likelihood

1 - 5

Risk

Score

Approach to Risk Management

Project

development and

delivery

Funding risk – a reduction in the

level/availability of capital or

revenue funding due to the

economic downturn or changes in

health funding policy leads to

delays and reduction in scope of

project

4 3 12 No contractual commitments will be made until

firm assurances are given regarding the

affordability and availability of capital.

Planning risk – issues relating to

planning permission or planning

constraints

4 2 8 Early engagement with Local Authority planning

departments

Demand and usage risk – the size

and capacity of the scheme is not

appropriate for the eventual

needs of the population

3 3 9 The preferred option will take into consideration

future flexibility and the opportunity to ‘right-size’

at a later date to take account of emerging and

changing needs.

Build Risk – delay in the

acquisition of the site

4 1 4 Welsh Health Estates already negotiating purchase

on behalf of the Health Board and not perceived to

be a high risk; this will be reviewed at OBC stage.



23 | P a g e

Risk Category Risk Description Impact

1 -5

Likelihood

1 - 5

Risk

Score

Approach to Risk Management

Build risk – the construction of

the physical asset is not

completed on time, to

specification or within budget

3 2 6 Strong project management, (appropriately

resourced), and early engagement, robust

contracts and a mature relationship with the

supply chain partner

Service Delivery

risks

Lack of ‘buy-in’ to new clinical

model of care

5 2 10 Full involvement of clinical heads and key

stakeholders from other agencies is already

occurring through the project governance

arrangements and the wider programme

management.

Operational risk – the day-to-day

operating costs cannot be

contained within agreed budgets

3 3 9 Clear levels of accountability at local level for day-

to-day budgetary management linked with

effective financial management information

systems and reporting.

Affordability risk – the necessary

realignment of budgets following

the implementation of the new

model of care does not provide

the anticipated level of savings.

3 3 9 Clear accountability within the overall programme

for the systems-wide changes in resource

allocation and service transformation



24 | P a g e

2.7 Constraints

2.7.1 Financial Constraints

Capital

This scheme has been highlighted as a priority for Hywel Dda and has been included in

previous corporate applications for central capital funding. As a result an indicative financial

sum has been included within the All Wales Capital Programme. The overall capital

programme for health at both national and local level is oversubscribed with many schemes

competing for scarce funding. Therefore the availability of capital funding must be regarded

as an absolute constraint and reflected in this SOC and subsequent OBC/FBC documents. All

options will be rigorously tested for Value for Money in the OBC.

Revenue

Equally there are pressures on revenue spend. The additional capital charges and other

associated revenue consequences with a new build option, which has to comply with Health

Building Notes (HBNs), means that that this project will cost more than it does now to

provide services from existing facilities in revenue terms. However, the increased cost will be

met through the 10% transfer of resources from acute to community in line with the Annual

Operating Framework It is therefore expected that any additional capital charges and

revenue consequences to arise from this project will be met internally to ensure affordability

for the Health Board. There will be no increase in the workforce cost as a programme of

workforce redesign across health and social care will be implemented. The demonstration of

the affordability of this scheme will be tested fully through the overall programme

management to implement the new model of care and further details will be provided

within the OBC.

Capital charges

It has been agreed that the Health Board will be eligible to receive transitional support for

the capital charges associated with this project.

2.7.2 Other Constraints

Timescale

The new facility must be available for use within four years i.e. by 2014 due to the poor

condition of the existing premises. This is a realistic estimate on the remaining life of the

buildings without further significant capital spend and this would not result in improved

functionality.

Site availability

The new facility must be provided within the town or the immediate environs of Cardigan on

order to best serve the needs of the service users of this catchment population. A thorough

site option appraisal was undertaken in late 2008 and appropriate sites for any likely

development were found to be in short supply, but a preferred site was selected and this

site option is supported by key stakeholders. Outline Planning approval is already in place.



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2.8 Dependencies

This project is part of a wider change programme (as illustrated in Figure 1). The proposed

new model of care is described in Appendix 2. When this programme is delivered it will

result in:

• less reliance on hospitalisation

• a greater emphasis on rehabilitation

• shorter lengths of stay

• more use of home-based and community packages of care

• far greater integration of services across all agencies

This project is an enabling scheme which supports the wider transformational change

agenda across the Health Board. The programme of work is dependent on the integration of

operating systems and workforce redesign, to deliver the full benefits of the new model of

care.

At this stage there are no other known dependencies that will impact on the investment

objectives of this project being delivered.



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3 Economic Case

3.1 Introduction

The purpose of the Economic Case at SOC stage is to set out how the Project Board has

selected the short list of options to be taken forward to the next stages of planning (the

Outline Business Case). Each of the shortlisted options will be assessed then in far greater

detail to determine the best value for money (the balance of cost, benefit and risk) and

affordability (revenue and capital). This section describes:

• Critical Success Factors used to assess each option

• The long list of options

• The approach to short-listing

• The final options considered appropriate to take forward to OBC stage and the

rationale for excluding others.

3.2 Critical Success Factors

In addition to the Investment Objective set out in 2.4, the Project Board identified a number

of factors which, while not direct objectives of the investment, would be critical for the

success of the project, and would be relevant in judging the relative desirability of options.

In doing so, the Project Board considered the possible CSFs suggested in the five-case model

best practice guidance and, as recommended in the guidance, selected the CSFs that were

most applicable and relevant to this particular scheme. Two of the generic CSFs suggested in

the guidance (‘Commerciality’ and ‘Rational – VFM’) were not used in this business case.

The Commercial CSF was not relevant as it would not distinguish between options; the

‘Rational – VFM’ CSF would in this case involve detailed economic benefit modelling of the

new model of care. The wider Programme Board are continuing to develop the new model

of care and its attributes and these will be reflected in detail at OBC stage.

The agreed Critical Success Factors are shown below.

Table 13: Critical Success Factors

Critical Success Factor The extent to which the option:

1 Flexibility Can be adapted to meet the changing needs of the local

population and the developing service model

2 Strategic Fit Takes forward the National Policy and local strategic priorities

3 Achievability Can be achieved within the 2014 planning timescale for the

project

4 Affordability - revenue Can be delivered within the overall health and social care budget

5 Acceptability Will be acceptable to stakeholders



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3.3 Options

The Health Board has followed a robust process to ensure that a wide range of options were

considered to arrive at a realistic and feasible short list. The process recommended as ‘best

practice’ in the five case model guidance was followed closely.

3.3.1 Service solution options

The first stage of this process took place during 2008 and considered various ‘service

solution’ options. In the context of this business case this reflects the various sites in the

area on which any development of health / social care premises could take place if required.

An extensive survey of possible sites in the Cardigan locality was carried out on behalf of the

Health Board by Welsh Health Estates. The site search identified and assessed seven sites;

this included the current Cardigan Hospital. One of the sites (known as the Bath House

development) had two options – either one or two access points – therefore eight options in

total were considered. The conclusions of this appraisal are described in section [3.4.1]

below.

3.3.2 Scope, Implementation and Funding options

The second stage of this process was carried out at a stakeholder event in November 2009.

The participants are as detailed in the table below:

Table 14: Stakeholder participants

Stakeholder Organisation

General Practitioner Cardigan Health Centre

Practice Manager Cardigan Health Centre

Medical Director-Primary Care Hywel Dda Health Board

Director of Social Services Ceredigion County Council e

Director of Planning Hywel Dda Health Board

Director of Social Services and Housing Pembrokeshire County Council

Associate Director of Primary Care Ceredigion and Pembrokeshire

LHB/Hywel Dda Health Board

Health Planning Manager Health Planning |Mm Ceredigion and Pembrokeshire

LHB/Hywel Dda Health Board

Associate Medical Director – Community Hywel Dda Health Board

Joint Working and Flexibilities Manager Ceredigion Social Services

Service Manager – Older People Ceredigion Social Services

Service Planning Manager Hywel Dda Health Board

Chairman Cardigan Hospital and Community

League of Friends

Representative Ceredigion Community Health Council

General Manager – Community Hywel Dda Health Board

Assistant General Manager – Community Hywel Dda Health Board

Directorate Nurse – Community Hywel Dda Health Board

Sister, Cardigan Hospital Hywel Dda Health Board

Sister, Outpatients, Cardigan Hospital Hywel Dda Health Board

Head of Occupational Therapy Hywel Dda Health Board

Reablement Manager Ceredigion Social Services

Head of Speech and Language Therapy Hywel Dda Health Board



28 | P a g e

The focus of this workshop, in line with best practice guidance, was to consider options

relating to the Scope of the investment, the approach to Implementation, and the approach

to Funding. Options were put forward as follows:

• Scope – the scope of service to be provided by the investment; this was discussed in

detail and it was decided that it could cover a number of distinct elements. These

were:

o Geographical area/catchment population to be served – Scope (A)

o Level of functionality – Scope (A)

o Capacity assumptions/issues – Scope (B)

o Quality of service provided – Scope (C)

• Approach to implementation – e.g. phased, single contract

• Approach to funding – e.g. Third Party Development (3PD), conventional capital

funding.

3.3.2.1 Scope options

This project has a very broad range of scope options and to make the development of the

long list of options more manageable, options were considered in three categories.

Table 15: Scope options - catchment and functionality

SCOPE (A) OPTIONS – CATCHMENT AND FUNCTIONALITY

SCOPE (A) 1 SCOPE (A) 2 SCOPE (A) 3 SCOPE (A) 4

Current catchment1

Current services2

Extended catchment3

Dedicated

rehabilitation and day

care facilities for

therapy teams4

Extended catchment

Dedicated


care facilities

Base for all community,

rehabilitation and

social care teams.

Extended catchment

Dedicated


care facilities

Base for all teams.

New medical centre for

primary care

Table 16: Scope options - capacity

SCOPE (B) OPTIONS – CAPACITY5

6

SCOPE (B) 1 SCOPE (B) 2 SCOPE (B) 3 SCOPE (B) 4

25 beds – assumes future

demand7 under new

model of care can be


demand under new model

of care can be managed

17 beds - assumes future



No beds – use of

independent

sector beds for

1 Patients registered with the GP practices on the bed fund (currently 24,500)

2 As described at section 2.3.2

3 The natural catchment population for Cardigan, (currently 39,200). 4 As described in section 2.3.3

5 All Scope(B) options assume new catchment and future population projections

6 Whilst other functional elements could be subject to variation, bed capacity was considered to be

most significant in terms of revenue and capital implications

7 As described in section 2.2.3



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SCOPE (B) OPTIONS – CAPACITY5

6

SCOPE (B) 1 SCOPE (B) 2 SCOPE (B) 3 SCOPE (B) 4

managed with 20%

increase in beds

with no increase in beds with 20% decrease in beds community rehab

and admission

avoidance

Table 17: Scope options - quality

SCOPE (C) OPTIONS - QUALITY

SCOPE (C) 1 SCOPE (C) 2 SCOPE (C) 3 SCOPE (C) 4

Minimal upgrade to

meet basic

requirements

• New build to meet

all standards and

legislative

requirements

• 60% single rooms


all standards and

legislative

requirements



all standards and

legislative

requirements


A ‘Do nothing’ option was not considered to be viable and therefore a ‘Do minimum’ was

defined for comparative purposes. The ‘Do minimum’ revenue costs are reflective of current

revenue expenditure.

3.3.2.2 Implementation options

Implementation options for this type of scheme consider the approach to be taken in terms

of the build/construction route. A ‘do minimum’ benchmark was defined and this is defined

in the Estates Annex (Appendix 4). There were then two options possible for implementing a

development reflecting ‘Scope A4’. A fourth option would involve finding an alternative site

for redevelopment of the GP Medical Centre.

Table 18: Implementation options

IMPLEMENTATION OPTIONS

IMP1 IMP2 IMP3 IMP4

As and when

improvements to

existing facilities –

the do minimum

option

New Build on Bath

House site – single

scheme/full

implementation

New Build on Bath

House site – split

scheme/phased

implementation

New build on Bath

House and second

development on

medical centre site

3.3.2.3 Funding options

The traditional route for a capital scheme of this nature would be an application for full

funding from WAG public capital allocation for all aspects of the development. An

alternative possibility would be to finance the GP Medical Centre development through a

Third Party Development venture. This would reduce the overall project demand on the

public capital allocation.

Table 19: Funding options

FUNDING OPTIONS

FUND1 FUND2

Traditional public sector All Wales Capital

Funding

Mix of public sector capital and Third Party

Development (3PD)



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3.3.3 The long list of options

The options generated can be illustrated in an Options Framework (as recommended in best practice guidance). This is shown below.

Table 20: Long list of options

Service Scope A Current catchment, with access to

inpatients services for those

patients registered with a GP in

the GP Bed Fund.

Current services, which are

provided from Cardigan Hospital,

Cardigan Health Centre, Finch

Square (Social Services) Aberaeron

(Reablement Team) and Llandysul

(GP Out of Hours Service).

Extended catchment, with the

introduction of a new medical

model to support inpatient

activity.

Dedicated rehabilitation and day

care facilities for therapy teams




activity.


care facilities


rehabilitation and social care

teams.




activity.


care facilities

Base for all teams.

New medical centre for primary

care

Service Scope B 25 beds – assumes future demand

under new model of care can be

managed with 20% increase in

beds

21 beds – assumes future demand


managed with no increase in beds

17 beds - assumes future demand


managed with 20% decrease in

beds

No beds – use of independent

sector beds for community rehab

and admission avoidance

Service Scope C Minimal upgrade to meet

standards and legislative

requirements

• New build to meet all


requirements




requirements




requirements


Service solution Retain all existing premises: Cardigan Hospital, Cardigan Health

Centre, Finch Square (Social

Services) Aberaeron (Reablement

Team) and Llandysul (GP Out of

Hours Service). No new facilities.

Bath House site – new build for

all facilities • Alternative site for medical

centre in Cardigan

• Bath House for all other

facilities

Implementation ‘As and when’ improvements

to existing facilities

New Build on Bath House site –

single scheme/full implementation


split scheme/phased

implementation

New build on Bath House and

separate development on

medical centre site

Funding Traditional public sector All Wales

Capital Funding

Mix of public sector capital and

Third Party Development (3PD)



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3.4 Appraisal of the long list of options

From the long list of options described above, the next key step was to consider each

element against the investment objectives and critical success factors. The objective was to

reduce the long list of options down to a preferred way forward (PWF) and two or three

other feasible and realistic alternative options (SL). These would then be assessed for value

for money against the ‘Do minimum’ benchmark once SOC approval has been obtained.

3.4.1 Appraisal of Service Solution (Site) Options

At the end of November 2008, the Trust carried out a detailed weighted scoring exercise on

the eight service solution (site) options against six criteria:

• Access

• Service Development/ Future Proofing

• Achievability within 2012 – 2014 timeframe

• Acceptability to stakeholders

• Deliverability (i.e. ease of route through planning permission)

• Service co-location to support integration

The conclusion of this exercise was that the Bath House site with two access points was the

highest ranking option and the same site with single access was the second highest. The Bath

House outscored the other six options against every criterion. Full details of the Site Option

Appraisal were also included in the January 2009 SOP. This is contained within the Estates

Annex as Appendix 4. A ‘do minimum’ benchmark was defined as ‘retaining all existing

premises’. No other options were retained for shortlist because the Bath House site was

clearly preferable to all others.

There were initially some planning concerns about the Bath House site relating to access

routes. These have all now been resolved and consent for a second access road has been

granted.

3.4.2 Appraisal of Scope Options

The appraisal of the ‘Scope’ options was carried out at the stakeholder workshop described

above. A simple scoring system was used to record the consensus outcome of the

facilitated debate of each element. In each case:

• ‘N’ meant the option did not meet the investment objective or satisfy the critical

success factors

• ‘Y’ meant the option did meet or satisfy the objectives/CSFs

• ‘YY’ meant the option more than met or exceeded the objectives/CSFs



32 | P a g e

• A question mark ‘?’ has been added where there has been an element of

uncertainty.

• Not applicable (‘n/a’) where the investment objective or CSF does not apply to the

category of choice being explored.

The following tables are the outcomes of the options scoring exercise.

Table 21: Option evaluation - catchment and functionality SCOPE A 1 SCOPE A 2 SCOPE A 3 SCOPE A 4

Current catchment, Current

services

Extended catchment

Dedicated rehabilitation and

day care facilities for therapy

teams

Extended catchment,


day care facilities , Base for all

community rehabilitation,

reablement and social care

teams.

Extended catchment,


day care facilities, Base for all

community teams, New

medical centre for primary

care

Objectives

1Facilitate the delivery of the new

model of careN ?Y Y YY

2 Improve local access to services N Y Y YY

3 Provide appropriate service capacity N Y YY YY

4Provide a high quality physical

environmentN Y N Y

Criteria

1 Flexibility N Y Y YY

2 Strategic Fit N N N Y

3 Achievability Y Y Y Y

5 Affordability - revenue N Y YY YY

6 Acceptability N ?Y N Y

PWF / SL / DM / reject: DM reject reject PWF

The relative advantages and disadvantages of the four options in relation to the objectives

and CSFs are reflected in the ‘Y’ and ‘N’ scores shown above. Scope A4 which provides a full

range of dedicated rehabilitation services, inpatient beds, Minor Injury Unit, X-Ray

Department, Outpatient Department, GP Out of Hours service, accommodation to enable

maximum integration of health and social care teams and a new primary care centre was

identified as the preferred way forward. This level of functionality would be made available

to at least the extended catchment population with the ability to make the facility available

to patients from outside the catchment on a case by case basis following clinical and social

assessment. None of the other options fully met the criteria; Scope A3 was initially

considered as a shortlist option, but was eventually rejected as it did not address the

problems with primary care facilities nor give the potential opportunity for further primary

and secondary care service integration.



33 | P a g e

Table 22: Option evaluation - capacity

SCOPE B 1 SCOPE B 2 SCOPE B 3 SCOPE B 4

25 beds – assumes

future demand

under new model of

care can be

managed with 20%

increase in beds

21 beds – assumes

future demand

under new model of

care can be

managed with no

increase in beds

17 beds - assumes

future demand

under new model of

care can be

managed with 20%

decrease in beds

No beds – use of

independent sector

beds for community

rehab and

admission

avoidance

Objectives

1Facilitate the delivery of the

new model of careY Y Y N

2 Improve local access to services YY ?Y N ?

3Provide appropriate service

capacityYY ?Y N ?


environmentn/a n/a n/a n/a

Criteria

1 Flexibility y ?Y N ?Y

2 Strategic Fit Y Y Y N


5 Affordability - revenue Y Y YY ?N

6 Acceptability YY Y ?N N

PWF / SL / DM / reject: PWF SL reject reject

The relative advantages and disadvantages of the four options in relation to the objectives

and CSFs are reflected in the ‘Y’ and ‘N’ scores shown above.

There are multiple factors that impact on the number of beds required to meet the needs of

a given population. Some of these factors are relatively easy to forecast and predict e.g.

future population profiles and growth estimates. Other factors are more difficult to

determine and also have the biggest impact on the number of beds required. Not least of

these is the average length of stay.

A study commissioned in 2008 suggested that the number of community hospital beds

would have to double to meet future demand if length of stay and bed utilisation rates

remain as they are. However, at the heart of the Community Service Change Programme

and the emerging clinical service strategy is a commitment to reduce the demand on beds

and enable people to stay at home or return to their homes at the earliest opportunity. This

implies significant changes in the length of stay and throughput per bed.

The workshop took a pragmatic approach to limit the number of options considered, using

+/- 20% along with no increase and a zero-bed option.

Scope B1 which would increase the number of beds by 20% from 21 to 25 was considered to

be the preferred way forward by the workshop in November 2009. This option assumes the

future demand from the rising and ageing population will be met to a large extent through

increased emphasis on rehabilitation and reablement thereby restricting the number of

additional beds required to the minimum. However, the workshop also wanted to shortlist



34 | P a g e

Scope B2 in order to consider in more detail at OBC stage the implications of containing

demand through the new clinical service model to maintain the current bed provision.

At the time of the workshop, it was considered that the cost impact of the additional four

beds in Option B1 over Option B2 would be marginal. Subsequent financial analysis of the

options by the Health Board has shown that Option B2 is better than Option B1 against this

CSF. This has resulted in a switching of options B1 and B2. Scope B2 (21 beds) is now the

preferred way forward, with Scope B1 shortlisted.

The other options were rejected following full debate for reasons of flexibility, potential

affordability and likely acceptability to key stakeholders. Specifically, the ‘no beds’ option

was discounted on the basis that it is not in line with the Health Board’s strategic direction,

would not be acceptable to stakeholders and would not be politically acceptable. The Health

Board’s aim is to provide enhanced community and primary care based services, reducing

hospital stays to a minimum through robust and effective discharge planning and responsive

hospital at home and community hospital services.

Futhermore, its aim is to be an integrated provider with as much care delivered in a primary

care setting as possible, with a key focus on improving access to and quality of acute hospital

services. Hub and spoke models of care will be developed, blurring the traditional

boundaries between primary and secondary care, with clinicians working together across the

entire pathway. Secondary care consultants will deliver more care in out of hospital

environments in the new model of care.

Part of the blurring of boundaries between acute and community services will enable the

Health Board to look at the scale and scope of current acute bed requirements and this will

be explored further at OBC stage.



35 | P a g e

Table 23: Option evaluation - quality

Scope C 1 Scope C 2 Scope C 3 Scope C 4

Minimal upgrade to meet

basic requirements

New build to meet all


requirements, 60% single

rooms



requirements 75% single

rooms



requirements, 100% single

rooms

Objectives

1Facilitate the delivery of the

new model of careN Y Y Y

2 Improve local access to services n/a n/a n/a n/a

3Provide appropriate service

capacityn/a n/a n/a n/a


environmentN Y Y YY

Criteria

1 Flexibility N Y YY YY

2 Strategic Fit N Y Y Y


5 Affordability - revenue N Y ?Y N

6 Acceptability N YY ?Y N

PWF / SL / DM / reject: DM PWF reject reject

In this sub-element of scope, the level of single room provision (along with building

standards compliance and legislative requirements) was used as a proxy for quality of

service. In assessing the four options, clinical practice and infection control, and patient

preference and choice were also considered. The relative advantages and disadvantages of

the four options in relation to the objectives and CSFs are reflected in the ‘Y’ and ‘N’ scores

shown above.

Scope C2 which would result in a 60% level of single rooms was considered to be the

preferred way forward. This option gave a sufficient level of infection control, privacy and

dignity, met the National standard and also recognised that some patients preferred to be in

a more open environment, which supported their rehabilitation. Scope C3 (75% single

rooms) was rejected as it did not give sufficient choice to patients and may also be

unaffordable in terms of revenue costs.

3.4.3 Implementation – Table 17

This category of option was not considered at the workshop. However, since the workshop

has rejected Scope Option A3, Implementation Option 4 (development of a new Medical

Centre on a site separate from the other new facilities) is rejected as it does not allow the

full integration of services.

The remaining two options (Implementation 2 and 3) were both retained on the shortlist for

further consideration. As each option would equally meet the investment objectives and

there was no significant difference between them when compared against the CSFs, it was

agreed to defer determining a preferred option at this stage. A more detailed consideration

will be given at OBC stage when design aspects and any site constraints may result in one

approach emerging as the clear best value for money option.

3.4.4 Funding options

Following discussion with Welsh Assembly Government the Health Board has been advised

that the Third Party Development (3PD) funding route would not be considered appropriate



36 | P a g e

for this scheme. On the basis of the CSF of ‘Acceptability’ this means that public sector All

Wales Capital Funding is the only realistic option.

3.5 Conclusion – the shortlisted options

The conclusion of the appraisal of the long list of options is illustrated in the Options

Framework below. The green cells represent the Preferred Way Forward for each category

of choice. The grey cells are the do minimum. The orange cells indicate where alternative

options have been shortlisted for further consideration.



37 | P a g e

Table 24: Outcome of appraisal of longlist

Service Scope A Current catchment

Current services

Extended catchment


care facilities for therapy teams

Extended catchment


care facilities


rehabilitation and social care

teams.

Extended catchment


care facilities

Base for all teams.

New medical centre for primary

care

Service Scope B 25 beds – assumes future demand


managed with 20% increase in

beds

21 beds – assumes future demand


managed with no increase in beds

17 beds - assumes future demand


managed with 20% decrease in

beds

No beds – use of independent

sector beds for community rehab

and admission avoidance

Service Scope C Minimal upgrade to meet


requirements



requirements




requirements




requirements


Service solution Retain all existing premises Bath House site – new build for

all facilities

• Alternative site for medical

centre

• Bath House for all other

facilities

Implementation As and when improvements to

existing facilities


single scheme/full implementation


split scheme/phased

implementation

New build on Bath House and

separate development on

medical centre site

Funding Traditional public sector capital

Mix of public sector capital and

Third Party Development (3PD)



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The resulting shortlist of options is illustrated below. All permutations of Preferred Way Forward and Shortlisted variants are shown. In addition, the Do

Minimum benchmark is illustrated.

Table 25: Shortlisted options

Option A: Preferred Way

Forward

Option B: Short Listed Option C: Short Listed Option D: Short Listed Option E: Do Minimum

Service Scope A Extended catchment

Dedicated rehabilitation

and day care facilities

Base for all teams.


primary care

Extended catchment



Base for all teams.


primary care

Extended catchment



Base for all teams.


primary care

Extended catchment



Base for all teams.


primary care

Current catchment

Current services

Service Scope B 21 beds – assumes future



with no increase in beds




with 20% increase in beds




with no increase in beds




with 20% increase in beds

21 beds - Current bed state

Service Scope C • New build to meet all

standards and

legislative

requirements



standards and

legislative

requirements



standards and

legislative

requirements



standards and

legislative

requirements


Minimal upgrade to meet


requirements

Service solution Bath House site – new

build for all facilities

Bath House site – new






Retain all existing

premises

Implementation New Build on Bath House

site – single scheme/full

implementation

New Build on Bath House

site – single scheme/full

implementation


site – split scheme/phased

implementation


site – split scheme/phased

implementation

As and when

improvements to

existing facilities

Funding Traditional public sector

capital

Traditional public sector

capital


capital


capital


capital



39 | P a g e

3.6 Options Shortlist

The options that the Health Board will take forward for detailed appraisal in the OBC are

described below.

Table 26: Description of shortlisted options

Option Description

A: Preferred Way

Forward – 21

beds, single

scheme

A new build integrated health and social care facility developed on the

Bath House site. The facility will comprise a full range of dedicated

rehabilitation services, accommodation to enable maximum

integration of health and social care teams. Facilities will include:

• A new medical centre for primary care

• A minor injuries unit

• X-Ray Department

• An integrated day care facility and dedicated rehabilitation

facilities

• 21 beds to be used for rehabilitation, palliative/end of life

care, respite care. There will be 11 single rooms, two four-

bedded bays, and one two-bedded bay.

• An outpatient department

• GP Out of Hours service

The facility will be built on the Bath House site.

As well as meeting all national standards and legal requirements, the

new facility will have 60% of the beds in single rooms, with the

remainder in two and four bed bays. This offers the balance of

infection control, privacy and dignity, with choice for those patients

who do not like the isolation of single rooms.

The facility will be available to all residents of the extended catchment

population, as well as patients from outside the catchment on a case

by case basis following clinical and social assessment.

The approach to implementation would be to manage the scheme as a

single procurement/development with public sector funding.

B: 25 beds, single

scheme

This option is the same as Option A (Preferred Way Forward) but with

25 beds rather than 21.

C: 21 beds,

phased

implementation

This option is the same as Option A (Preferred Way Forward), but

envisages a phased approach to implementation. This may be

beneficial if capital funds are limited.



40 | P a g e

Option Description

D: 25 beds,

phased

implementation

This option is the same as Option B, but envisages a phased approach

to implementation.

E: Do minimum This option is included as a benchmark, although it fails to address the

investment objectives.

It comprises the current level of services (including 21 beds), provided

in existing (separate) facilities.

The catchment served by hospital services would remain as now; that

is, only the patients registered with the four GP practices in the

Cardigan Hospital bed fund.

Facilities would be upgraded to meet legal requirements. Public sector

capital would be required in addition to funding from the Health

Board’s discretionary capital programme.



41 | P a g e

4 Commercial Case

4.1 Introduction

The purpose of the Commercial Case is to set out the planned approach the Health Board

will be taking to ensure there is a competitive market for the supply of services. This in turn

will determine whether or not a commercially beneficial deal can be done and achieve the

best value for money for the development.

4.2 Procurement strategy

4.2.1 Designed for Life/Building for Wales

The most likely procurement route to be followed for this scheme is through a centrally

funded approach using the Designed for Life/Building for Wales (DFL/BFW) concept. This

relatively new method of capital procurement uses pre-competed supply chain partners to

deliver the developments on behalf of the client. It offers the Health Board the flexibility to

input into the design, speed of project delivery and a high level of quality control. Detailed

design work will need to commence as soon as the SOC is approved if the Health Board is to

achieve the timescale set out in the Management Case.

4.2.2 Third Party Development

Third Party Development (3PD) was considered as a possible procurement strategy. This

has been to date the most common route used in Wales to develop Primary Care facilities.

In 3PD, the appointed developer works with stakeholders to build the scheme and funds the

associated capital costs themselves. In return, the developer would get an annual rent

payable over a twenty year Tenant Internal Repairing Lease term.

However, the Trust has been advised by Welsh Assembly Government that this route is not

appropriate for this scheme and therefore it will not be pursued.

4.3 Procurement Timetable

Subject to SOC approval early in the New Year, the Project Board would work to the

following procurement timetable.

Table 27: Procurement timetable

Milestone Date







42 | P a g e

5 Financial Case

5.1 Introduction

The purpose of the Financial Case is to set out clearly the financial impact of the investment

proposal. It details the capital costs and the revenue implications of not only the Preferred

Way Forward but also the other short-listed options arising from the appraisal. There are

also details of the do minimum option to allow a true comparison of the proposed

investment. Finally the section also includes the assumptions that have been made at this

stage of planning from which the capital and revenue costs have been derived.

5.2 Capital Costs

The capital costs for the each of the five options are set out in the table below. Option A is

based on 21 inpatient beds and meets the investment objectives and critical success factors

agreed in the Options Framework; it is the Health Board’s Preferred Way Forward. Option B

meets and exceeds the investment objectives and critical success factors, but would increase

revenue costs. Option C is a phased variant of Option A; it would meet the objectives, albeit

in a longer timescale and at higher cost (because of the additional costs of phasing). Option

D is a phased variant of Option B, with again higher costs. Option E is the ‘do minimum’

option which does not meet any of the investment objectives but has to be included as a

benchmark comparator for the other four schemes.

Table 28: Capital estimates

Option A

(21 beds;

single

scheme)

£m

Option B

(25 beds;

single

scheme)

£m

Option C

(21 beds,

phased)

£m

Option D

(25 beds,

phased)

£m

Option E

Do

minimum

£m

Land purchase 1.222 1.222 1.222 1.222 Nil

Building/works costs 18.214 18.574 20.035 20.629 8.734

Plant and equipment 1.160 1.173 1.160 1.173 0.200

Professional fees 3.723 3.787 4.095 4.166 1.956

Development costs [Project

Team, other support, and

planning contingencies)

4.673 4.757 5.140 5.233 1.862

Totals 28.992 29.513 31.652 32.423 12.752

PWF

The table below sets out the estimated capital spend profile of Option A, the Preferred Way

Forward:

Table 29: Estimated capital spend profile of preferred way forward

2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 Total

Total £2.519m £4.831m £11.669m £9.607m £0.366m £28.992m



43 | P a g e

5.3 Assumptions made for capital estimates

The capital costs of Options A,B and E are based upon the following information.

� November 2009 Architectural Plans and Schedules of Accommodation as produced by

Powell Dobson Architects (drawing numbers G2573 (SK) Level 1, Level 2, Level 3 & G2573

(SK rev A) Level 4)

� Capital costs are reported at MIPS FP index of 530 effective at Quarter 4 20098 as

reported in DH Quarterly Briefing - Volume 18 / Number 1 / Autumn 09. There has been

a very recent (from 1st March) notification of a reduction in MIPS index for Business Case

purposes to 480, and this will be used at OBC stage.

� Equipment costs are indexed at EPI 133 also effective at Quarter 4 2009².

� The effective index for Location Factor is 0.97, as the rates and prices included in the

business case are based on market prices and not DCAGs (to which Location Factor

adjustments apply).

� Costs included for the Health Board's fees are based on typical rates assuming the

scheme is procured through WAG's Designed for Life: Building for Wales procurement

programme.

� Costs included for the Supply Chain Partner fees are based on typical rates assuming the

scheme is procured through WAGs Designed for Life: Building for Wales procurement

programme.

� Costs associated with Non-Works Costs are based on estimated capital costs that will be

incurred in developing the scheme from Feasibility through to Operational Completion.

� The costs included in the Works Cost are based upon a contractor taking vacant

occupation of the whole of the site. All work is to be undertaken during normal working

hours without interruption.

� The costs and cash flow are based on the indicative implementation programme as set

out in the Management Case. Any change to this programme will affect the capital costs

and capital spend profile.

� A provisional allowance of 15% has been included for the planning contingency at SOC

stage to reflect an indicative allowance for risk. When the scheme is approved to

progress to OBC, a detailed and quantified risk register will be developed as part of the

business case.

� VAT has been applied at the rate of 17.5% to all cost components with the exception of

professional fees. Given that the scheme is a new build solution, VAT recovery will not be

possible.

� Net Present Value (NPV) calculations have not been compiled as these will form part of

the detailed economic appraisal in the Outline Business Case, in accordance with the Five

Case Model framework.

� Optimism Bias is excluded from all costs referred to within the SOC submission, in

accordance with current WAG guidelines.

� The land purchase costs may be subject to change as negotiations with the land owners

(including the provision of a future access road) are ongoing.

8 DH Quarterly Briefing - Volume 18 / Number 1 / Autumn 09



44 | P a g e

� No provision has been made for any works costs that may arise from ecological surveys.

� It has been assumed that the Health Board will receive funding to cover any loss on

capitalisation when the building is capitalised.

� Disposal of existing premises has not yet been factored into the calculations. It is the

intention of Hywel Dda Health Board to dispose of the hospital and health centre sites on

completion.

Options C and D are based on those of Options A and B, but assume a notional 10% increase

in works cost, fees and other development costs to be indicative of the added complexity of

a phased approach. These costs will be tested fully at OBC stage if required.

Finally it needs to be noted that the requirements set out by Welsh Assembly Government

are for this investment to achieve a BREEAM 'Excellent' rating. However, WHE do not

support claims for additional costs to deliver this requirement. BREEAM cost implications will

be assessed at OBC stage when more detailed information becomes available.

5.4 Revenue Consequences

The revenue consequences of each option are detailed in the tables below. These exclude

capital charges and GP practice rental income .

Table 30: Revenue Costs of Option A (Preferred Way Forward)

Option A

(21 Beds, single

scheme)

Preferred Way Forward

Developmental phase

(current costs)

Transition

year

Fully

operational



Other operating costs

(Non-pay and income) 0.259 0.259 0.259 0.366 0.473

Total Costs 1.520 1.520 1.520 1.627 1.676

Any off-setting income* (0.019) (0.019) (0.019) -0.050 (-0.082)

Full revenue

consequences 1.501 1.501 1.501 1.577 1.594

* potential income from GPs and Social Services for services/facilities provided, and rental

income from Social services only

Table 31: Revenue Costs of Option B

Option B

(25 Beds, single

scheme)

Developmental phase

(current costs)

Transition

year

Fully

operational



Other operating costs

(Non-pay and income) 0.259 0.259 0.259 0.373 0.487

Total Costs 1.520 1.520 1.520 1.696 1.872

Any off-setting income 0.019 0.019 0.019 -0.050 -0.082

Full revenue impact 1.501 1.501 1.501 1.646 1.790



45 | P a g e

* potential income from GPs and Social Services for services/facilities provided, and rental

income from Social services only

Options C and D have not been subjected to detailed cost analysis though it is apparent that

these will mirror costs for Options A and B, with additional costs to be incurred to reflect the

phased implementation, a longer project duration overall, and the probable double running

costs of services/facilities which would have to be maintained at key points in the project.

This will be fully tested at OBC stage.

Table 32: Revenue costs of Option E (‘Do Minimum’)

Option E

‘Do Minimum’

Developmental phase

(current costs)

Transition

year

Fully

operational

Year 1 Year 2 Year 3 Year 4

Staffing Costs (Pay) 1.261 1.261 1.261 1.261

Other operating costs (Non-pay and

income) 0.259 0.259 0.259 0.245

Total Costs 1.520 1.520 1.520 1.506

Any off-setting income 0.019 0.019 0.019 0.019

Full revenue consequences 1.501 1.501 1.501 1,487

Based on the current schedule of accommodation, the Preferred Way Forward (Option A)

will require an additional £93,000 revenue per annum when compared with current costs.

This option attracts capital charges of £258,354 when the building is fully operational.

Option B will require additional £289,000 revenue per annum when compared with current

costs. This option attracts capital charges of £263,460 when the building is fully operational.

Option E (Do Minimum) would deliver revenue savings of £14,000 compared to current

costs. It would attract additional capital charges of £123,881.

Options C and D are not considered further here due to the comments made previously.

They will have a similar impact to Options A and B respectively, but with an increased

differential over current costs due to the impact of a phased approach.

5.5 Assumptions made for revenue estimates

Revenue increases are mainly attributable to capital charges and the non-clinical operating

costs of the new building, due to the increase in floor area which is required to support the

transfer of services from acute to primary/community care. The increased staffing costs

reflect the operational impact of the new facility on nurse staffing rotas (Option B – 25 beds)

and any additional pay costs for additional domestic staff , as the costs have been based on

‘Credits for Cleaning’. All other clinical staffing costs are assumed to remain as current

within the scope of this project and will be remodelled by means of a workforce redesign

programme.



46 | P a g e

5.6 Affordability assessment

An assessment of affordability of the preferred way forward (Option A) as measured against

current net costs of £1.501m shows that (excluding the impact of capital charges and rental

income), there is a shortfall of £93,000.

The estimated capital charge impact, allowing for existing capital charge funding, is

£189,000.

The total revenue impact of Option A is therefore £282,000.

5.6.1 Treatment of capital charges and rental income

Assumptions on the treatment of capital charges and rental income from the GP practice are

being reviewed in discussion with WAG and Welsh Health Estates. For the purpose of this

SOC, three methodologies have been considered to assess the indicative impact on the

preferred option.

Approach 1: capital charges funded, peppercorn rent

This approach assumes funding for capital charges is provided in full by WAG, with a

peppercorn rent payable by the GP practice.

The impact of this approach is a net revenue shortfall of £93,000 only.

Approach 2: no capital charges, DV rent

This approach assumes that no funding for capital charges provided by WAG, and that a DV

assessed rental is payable by GP practice. The impact of this approach is a net revenue

shortfall of £163,000, as shown below.

Table 33: Impact if no capital charges and DV rental

Item Impact

Net revenue shortfall £93,000

Net capital charge shortfall £189.000

Less GP Rental income (£119,000)

Revised impact £163,000

Approach 3: tapered capital charges, abated rent

This approach assumes tapered funding provided for capital charges over 3 years, with

rental payable by the GP practice abated to reflect the tapering effect. This means that by

year 4 the GP practice would pay a DV assessed rental in full. The impact of this approach is

a net revenue shortfall that increases over time from £93,000 to £163,000 as shown below.

Table 34: Impact if tapered capital charges and abated rent

Yr 1 Yr 2 Yr 3 Yr 4 and

recurring

Net revenue shortfall £93,000 £93,000 £93,000 £93,000

Net capital charge shortfall Nil £47,250 £94,500 £189,000

Less GP Rental income Nil (£29,750) (£59,500) (£119,000)

Revised impact £93,000 £110,500 £128,000 £163,000



47 | P a g e

Approach 4: no support

This approach assumes no support for capital charges, and no rent received. Its impact is a

net revenue shortfall of the full £282,000 referenced above.

Summary

Depending on the approach taken to capital charge support, the revenue consequences of

the scheme will be a minimum of £93,000 and a maximum of £282,000.

5.6.2 Addressing the affordability gap

The outcome of the costing exercise is that there remains a ‘worst case’ revenue gap of

£282,000 per annum, with a ‘best case’ of £93,000. The Health Board is confident that this

gap can be closed by action in the following areas.

• Benchmarks – The Health Board intends to push the benchmarks for length of stay

up to the best in England, fully exploiting the benefits of integrated services across

health and social care. This will create a ‘pull’ effect which will reduce length of stay

in the acute sector.

• New models of care - New models of care are being developed across the health

board, based on redesigned and strengthened services in primary, social and

community care. The Cardigan scheme will be a pilot for the implementation of

these new models.

• Blurring the boundaries – Integrated care will be significantly more effective as it

will blur the boundaries that previously existed and will re-incentivise the entire

health system.

• Minor Injury Unit – The Minor Injuries Unit (MIU) is currently operated as a nurse-

led initiative at Cardigan Hospital. The GP Practice is also commissioned to providing

a service for its own patients. There may be scope to consolidate the service within

the primary care element of the scheme, which would reduce the floor area by

155m2 and would also have an impact on staffing costs.

• Catering – There is potential to explore catering services further in order to produce

efficiencies. Costs contained within this SOC are based on providing a traditional

catering facility within the new building. However, the Health Board will assess the

potential to introduce the most modern technology available in the market place,

which is ‘cook freeze’. Previous work in this area has demonstrated beyond doubt

that this is the most efficient way forward and a more detailed analysis will be

undertaken at OBC stage. It is estimated that this could reduce floor area by 72m2

and would affect the staffing profile.

• Outpatients –The new model for Outpatient services will be based on care pathways

and treatment protocols with more diagnostic treatment services provided closer to

patient’s homes. There will be a reduction in follow up appointments, and the use of



48 | P a g e

Telemedicine will transform the way in which care is delivered. It is anticipated that

there will be a resultant transfer of services from acute to community.

• Collaboration - Additional revenue savings may also be realised through

collaboration with Family Housing Association, for example in catering and hotel

services. These are subject to further discussions which will be progressed through

the OBC stage of the project.

5.6 Conclusion

The current indicative revenue consequence of the Preferred Way Forward is a worst case

gap of £282,000 per annum and a best case gap of £93,000 (depending on treatment of

capital charges and rental). The Project Board is clear that the scheme will need to be at

least revenue neutral for the wider organisation. A range of initiatives have been identified

which will contribute to (and indeed exceed) the achievement of revenue neutrality. There

is already recognition and acceptance that the changes in primary and community based

care will enable acute hospital savings to offset additional costs in the community.

A much greater level of detail will be provided at OBC stage for the full economic analysis

and the assessment of each option. The Project Board is confident of achieving the

necessary savings to reach at least a balanced revenue position.



49 | P a g e

6 Management Case

6.1 Introduction

This section of the Five Case Model requires the organisation to describe how it will ensure

the project will be managed effectively and the investment objectives and benefits are

delivered successfully.

This project is an integral part of the Hywel Dda Service Modernisation Programme. The

detail of that programme was set out in the Ceredigion Community Strategic Outline

Programme, (January 2009) and comprises a portfolio of projects for the delivery of schemes

in Cardigan, Aberaeron and Tregaron. The relationship of this project to that programme has

been set out in Section 1 and separate governance arrangements are in place for that wider

programme. The remainder of this section describes the arrangements to be put in place

and approaches that will be used to ensure this is achieved.

6.2 Project Governance

In accordance with the Five Case Model best practice, this project will deploy the following

Governance structure:

Figure 6: Project Governance Structure

External

Advisors

Investment

Decision

Maker

Senior

Responsible

Owner

Project

Director

Project

Board

Project

Team

Stakeholder

forums and

User Groups



50 | P a g e

Table 35: Roles and Responsibilities

Role Responsibility

Investment Decision Maker Collective and final responsibility for the approval of the

Investment Proposal

Senior Responsible Owner Personal accountability and overall responsibility for the

delivery of the successful outcome

Project Director Leading managing and co-ordinating the Project Team on a

day to day basis

Project Board Provides the SRO with stakeholder and technical input to

decisions affecting the project

Project Team Takes forward the decisions of the Project Board and

develops the operational elements of the project

Stakeholder forum and user

groups

Provides the Project Board with further insight and advice on

the detailed requirements of the project

6.3 Project Management Arrangements

The following arrangements have been put in place to ensure the ongoing management and

development of the scheme.

Table 36: Project Management Arrangements

Investment Decision Maker Hywel Dda Health Board

Senior Responsible Owner

and Chair of the Project

Board

Chief Executive, Trevor Purt

Project Director Director of Primary, Community and Mental Health Services

- Bernardine Rees

Other Project Board

Members

County Clinical Director, Ceredigion – To be appointed

County Director, Ceredigion - Ian Bellingham

Assistant Director of Primary, Community and Mental

Health Services – Jill Patterson

Director of Social Services – Ceredigion - Parry Davies

County Director of Health and Social Services,

Pembrokeshire – Jon Skone

Leader – Carmarthenshire County Council – Keith Evans

Deputy Director of Finance – Eldeg Rosser

Head of Capital and Estates – Rob Elliott

Major Capital Projects Manager – Jason Wood

Primary and Community Services Manager , Ceredigion

Lead General Practitioner, Cardigan Health Centre – Dr

Roger Cole

Service Planning Manager – Amanda Jones

Project Support Officer – Mikki Williams

A Project Team has also been established and includes senior managers from the Health

Board and partner organisations and external advisors. The project will be managed in

accordance with PRINCE 2 methodology.



51 | P a g e

It should be noted that the new Hywel Dda Health Board is currently implementing a new

organisational structure and as a result the project management arrangements and

membership of the Project Board may change.

6.4 Approach to Risk Management and benefits realisation

The Project Board has already identified the key high level risks associated with this project

and these are set out in section 2.6. It also has in place a more detailed risk register which is

regularly reviewed by the Project Board and will be continually updated during the life of the

project.

As with risk management, benefits realisation will also require active management if the

benefits envisaged from this project as set out in section 2.5 are to be fully realised. A

benefits realisation plan will be established and overseen by the Project Board. This plan will

clearly describe each benefit including the success measure and will also show who has the

accountability for its realisation.

6.5 Stakeholder Engagement

There has been a high level of appropriate stakeholder engagement to date and this will

continue through the life of the project. A stakeholder group has been identified; this

membership will be kept under review to ensure appropriate representation and

engagement at all times. The Project Board will have ongoing responsibility for the active

management of communication with and involvement of stakeholders during the life of the

project.

6.6 Project Timescale

The anticipated timetable for implementation of the scheme is as follows:

Table 37: Project Milestones

Milestone Date

Submission of Strategic Outline Case (SOC )to WAG March 2010


Anticipated approval of SOC April 2010


Development of Outline Business Case (OBC) May - December 2010

Submission of OBC December 2010

Approval of OBC March 2011

Development of Full Business Case (FBC) April - November 2011

Submission of FBC November 2011

Approval of FBC December 2011



Commissioning December 2013 – January 2014

Services and facilities operational January 2014

APPENDIX 1:

STAKEHOLDER ENGAGEMENT


Cardigan SOC APPENDIX 1

List of Stakeholders Engaged in the Project

1) General Medical Services/GP Practice

a) Cardigan Health Centre GPs

b) Cardigan Health Centre Practice Manager

c) Newport Surgery GP Practice

d) Medical Director – Primary Care, Hywel Dda Health Board

e) Associate Director of Primary Care, Ceredigion and Pembrokeshire LHB/Hywel Dda

Health Board

f) Health Planning Manager, Ceredigion and Pembrokeshire LHB/Hywel Dda Health

Board

2) Inpatient Services

a) Associate Medical Director – Community, Hywel Dda Health Board

b) General Manager – Community, Hywel Dda Health Board

c) Assistant General Manager – Community, Hywel Dda Health Board

d) Directorate Nurse – Community, Hywel Dda Health Board

e) Senior Nurse – Community Hospitals, Hywel Dda Health Board

f) Sister, Cardigan Hospital, Hywel Dda Health Board

3) Outpatients

a) Senior Nurse, Outpatients, Ceredigion Locality, Hywel Dda Health Board

b) Sister, Outpatients, Ceredigion Locality, Hywel Dda Health Board

c) Staff Nurse, Cardigan Hospital Outpatients, Hywel Dda Health Board

4) Rehabilitation Services/Therapies

a) Head of Occupational Therapy, Hywel Dda Health Board

b) Head of Occupational Therapy, Ceredigion Locality, Ceredigion Locality,

c) Head of Physiotherapy, Ceredigion Locality, Ceredigion Locality,

d) Reablement Manager, Ceredigion Social Services

e) Head of Speech and Language Therapy, Ceredigion Locality, Hywel Dda Health Board

f) Head of Podiatry, Ceredigion Locality, Hywel Dda Health Board

g) Head of Dietetics, Ceredigion Locality, Hywel Dda Health Board

5) X-Ray

a) Assistant Radiology Services Manager,

b) Radiographer, Cardigan Hospital, Hywel Dda Health Board

6) Minor Injury

a) Emergency Nurse Practitioner, Cardigan Hospital, Hywel Dda Health Board

7) Hotel Services

a) Hotel Services Manager, Hywel Dda Health Board

b) Hotel Services Managers, Ceredigion Locality, Hywel Dda Health Board

c) Hotel Services Manager, Cardigan Hospital, Hywel Dda Health Board



8) Social Services

a) Joint Commissioning Manager, Ceredigion Social Services

b) Head of Adult Services, Ceredigion Social Services

c) Adult Services Team Leader, South Ceredigion, Ceredigion Social Services

d) Adult Services Team Leader, North Ceredigion, Ceredigion Social Services

9) Office Accommodation/Base for community staff

a) Assistant General Manager – Community, Hywel Dda Health Board

b) Assistant General Manager - Family Health, Hywel Dda Health Board

c) Directorate Nurse – Community, Hywel Dda Health Board

d) Senior Nurse – Community Nursing, Hywel Dda Health Board

e) Head of Speech Therapy, Ceredigion Locality Hywel Dda Health Board

f) Associate Director, Mental Health, Hywel Dda Health Board

10) Ambulance Transport

a) Locality Manager – Ceredigion, WAST

11) External Stakeholders:

a) Director of Social Services, Pembrokeshire County Council

b) Leader, Carmarthenshire County Council

c) Chairman, League of Friends

d) Representative, Ceredigion Community Health Council

APPENDIX 2

FUTURE MODEL OF CARE

Attached as separate file

APPENDIX 3

THE ABC OF INTEGRATED

COMMUNITY SERVICES

Attached as separate file

APPENDIX 4

LETTER OF COMMITMENT



Documents

Strategic Outline Case - NHS Wales SOC Ver15.pdf · Hywel Dda Health Board Cardigan SOC March 2010 i Executive Summary 1. Introduction The purpose of this Strategic Outline Case (SOC)