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
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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
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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
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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.
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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
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.
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:
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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)
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• 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
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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
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• 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
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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
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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.
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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
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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
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• 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.
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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.
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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
Qualitative – greater satisfaction
• Greater promotion of independence and well-
being
Qualitative – greater satisfaction
• 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
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Stakeholder Benefits and type Link to Investment
Objective
travel cost and time
• Significantly improved facilities
Qualitative – greater satisfaction
• 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
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Stakeholder Benefits and type Link to Investment
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.
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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.
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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
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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
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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
rehabilitation and day
care facilities
Base for all community,
rehabilitation and
social care teams.
Extended catchment
Dedicated
rehabilitation and day
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
21 beds – assumes future
demand under new model
of care can be managed
17 beds - assumes future
demand under new model
of care can be managed
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
• New build to meet
all standards and
legislative
requirements
• 75% single rooms
• New build to meet
all standards and
legislative
requirements
• 100% single rooms
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
Extended catchment, with the
introduction of a new medical
model to support inpatient
activity.
Dedicated rehabilitation and day
care facilities
Base for all community,
rehabilitation and social care
teams.
Extended catchment, with the
introduction of a new medical
model to support inpatient
activity.
Dedicated rehabilitation and day
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
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
Service Scope C Minimal upgrade to meet
standards and legislative
requirements
• New build to meet all
standards and legislative
requirements
• 60% single rooms
• New build to meet all
standards and legislative
requirements
• 75% single rooms
• New build to meet all
standards and legislative
requirements
• 100% single rooms
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
New Build on Bath House site –
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
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• 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,
Dedicated rehabilitation and
day care facilities , Base for all
community rehabilitation,
reablement and social care
teams.
Extended catchment,
Dedicated rehabilitation and
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.
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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 ?
4Provide a high quality physical
environmentn/a n/a n/a n/a
Criteria
1 Flexibility y ?Y N ?Y
2 Strategic Fit Y Y Y N
3 Achievability Y Y Y Y
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
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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.
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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
standards and legislative
requirements, 60% single
rooms
New build to meet all
standards and legislative
requirements 75% single
rooms
New build to meet all
standards and legislative
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
4Provide a high quality physical
environmentN Y Y YY
Criteria
1 Flexibility N Y YY YY
2 Strategic Fit N Y Y Y
3 Achievability Y 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
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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.
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Table 24: Outcome of appraisal of longlist
Service Scope A Current catchment
Current services
Extended catchment
Dedicated rehabilitation and day
care facilities for therapy teams
Extended catchment
Dedicated rehabilitation and day
care facilities
Base for all community,
rehabilitation and social care
teams.
Extended catchment
Dedicated rehabilitation and day
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
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
Service Scope C Minimal upgrade to meet
standards and legislative
requirements
• New build to meet all
standards and legislative
requirements
• 60% single rooms
• New build to meet all
standards and legislative
requirements
• 75% single rooms
• New build to meet all
standards and legislative
requirements
• 100% single rooms
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
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
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.
New medical centre for
primary care
Extended catchment
Dedicated rehabilitation
and day care facilities
Base for all teams.
New medical centre for
primary care
Extended catchment
Dedicated rehabilitation
and day care facilities
Base for all teams.
New medical centre for
primary care
Extended catchment
Dedicated rehabilitation
and day care facilities
Base for all teams.
New medical centre for
primary care
Current catchment
Current services
Service Scope B 21 beds – assumes future
demand under new model
of care can be managed
with no increase in beds
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
25 beds – assumes future
demand under new model
of care can be managed
with 20% increase in beds
21 beds - Current bed state
Service Scope C • New build to meet all
standards and
legislative
requirements
• 60% single rooms
• New build to meet all
standards and
legislative
requirements
• 60% single rooms
• New build to meet all
standards and
legislative
requirements
• 60% single rooms
• New build to meet all
standards and
legislative
requirements
• 60% single rooms
Minimal upgrade to meet
standards and legislative
requirements
Service solution Bath House site – new
build for all facilities
Bath House site – new
build for all facilities
Bath House site – new
build for all facilities
Bath House site – new
build for all facilities
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
New Build on Bath House
site – split scheme/phased
implementation
New Build on Bath House
site – split scheme/phased
implementation
As and when
improvements to
existing facilities
Funding Traditional public sector
capital
Traditional public sector
capital
Traditional public sector
capital
Traditional public sector
capital
Traditional public sector
capital
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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.
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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.
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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
Selection of Supply Chain Partner March 2010
Appointment of Supply Chain Partner April 2010
Mobilisation of Contractors January 2012
Construction Phase January 2012 – December 2013
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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
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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
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� 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
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
* 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
Year 1 Year 2 Year 3 Year 4 Year 5
Staffing Costs (Pay) 1.261 1.261 1.261 1.323 1.385
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
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* 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.
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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
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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
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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.
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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
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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.
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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
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
APPENDIX 1:
STAKEHOLDER ENGAGEMENT
Hywel Dda Health Board
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
Hywel Dda Health Board
Cardigan SOC APPENDIX 1
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
Hywel Dda Health Board
Cardigan SOC APPENDIX 4