full business case chase farm hospital...

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ROYAL FREE LONDON NHS FOUNDATION TRUST

FULL BUSINESS CASE

CHASE FARM HOSPITAL REDEVELOPMENT

September 2015 V1.1 – REDACTED

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Document control

version date amendment description circulation author

0.1 09.04.15 Skeleton document Anna Bellamy

0.1a 11.04.15 Commercial Case edits Andrew Wildgust

0.1b 18.06.15 Economic and Management Case edits

Anna Bellamy

0.1c 01.07.15 Update of all chapters and cross reference with checklist

Anna Bellamy

0.1d 03.07.15 Including all comments from AW and HP review

OSG members, action owners

Anna Bellamy

0.2 10.07.15 Including internal trust comments

Helen Pickering

0.3 07.08.15 Including additional sections in strategic, economic, commercial and management cases

OSG members, action owners

Helen Pickering and Anna Bellamy

0.3a 18.8.15 Including additional changes / updates

Andrew Wildgust

0.4 28.8.15 Including final changes / updates but not including finalised finance case and workforce sections

Internal OSG and Programme Board members, Exec Summary to S&I

Anna Bellamy, Andrew Wildgust and Helen Pickering

0.5 17.09.15 Final draft for trust board approval, incorporating changes requested at OSG and S&I and KF comments

Exec Trust Board members

Anna Bellamy

1.0 28.09.15 Final draft (approved by the trust) for issue to Monitor, DH and Treasury.

Monitor, DH and Treasury

Anna Bellamy, Helen Pickering

1.1 04.04.16 Final draft, updated as per the approval process

Internal Anna Bellamy

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CONTENTS 1. Executive summary ......................................................................................................................... 9

1.1 Introduction ............................................................................................................................ 9

1.2 Strategic case .......................................................................................................................... 9

1.3 Strategic case – design and construction .............................................................................. 13

1.4 Economic case ....................................................................................................................... 15

1.5 Finance case .......................................................................................................................... 16

1.6 Commercial case ................................................................................................................... 17

1.7 Management case ................................................................................................................. 22

1.8 Recommendation .................................................................................................................. 26

2. Strategic case ................................................................................................................................ 27

2.1 Introduction .......................................................................................................................... 27

2.2 The strategic context ............................................................................................................ 27

2.3 Description of the trust and its services ............................................................................... 32

2.4 The case for change .............................................................................................................. 39

2.5 Programme vision and objectives ......................................................................................... 43

2.6 Scope and deliverables ......................................................................................................... 44

2.7 Services overview on the CFH site ........................................................................................ 46

2.8 Activity modelling ................................................................................................................. 53

2.9 Capacity requirements .......................................................................................................... 57

2.10 Stakeholder engagement ...................................................................................................... 63

2.11 Benefits ................................................................................................................................. 66

2.12 Constraints, dependencies and key assumptions ................................................................. 67

3. Strategic case – design and construction ...................................................................................... 68

3.1 Design quality and philosophy .............................................................................................. 68

3.2 Design compliance and reviews ............................................................................................ 73

3.3 Information technology ........................................................................................................ 78

3.4 Travel plan ............................................................................................................................. 78

3.5 Summary of changes in design since OBC ............................................................................ 79

3.6 Implementation .................................................................................................................... 82

4. Economic case ............................................................................................................................... 84

4.1 Introduction and approach ................................................................................................... 84

4.2 Results of economic appraisal .............................................................................................. 85

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4.3 Development of preferred option at FBC stage .................................................................... 85

5. Finance case .................................................................................................................................. 86

5.1 Introduction .......................................................................................................................... 86

5.2 Summary of forecast financial position of trust ................................................................... 86

5.3 Financial rationale for capital investment at CFH ................................................................. 86

5.4 Past financial performance of CFH ........................................................................................ 87

5.5 Forecast statement of comprehensive income – trust ......................................................... 88

5.6 QIPP programme ................................................................................................................... 91

5.7 Impact of capital development on Chase Farm Hospital SOCI ............................................. 91

5.8 Forecast statement of financial position – trust ................................................................... 94

5.9 Financing of capital ............................................................................................................... 95

5.10 Forecast statement of cash flows ......................................................................................... 95

5.11 Impact on continuity of services risk rating .......................................................................... 96

5.12 Risk assessment / sensitivity analysis ................................................................................... 96

5.13 Key modelling assumptions – SOCI ....................................................................................... 97

5.14 Key modelling assumptions – SOFP ...................................................................................... 97

5.15 Key modelling assumptions – SOCF ...................................................................................... 97

6. Commercial case ........................................................................................................................... 98

6.1 Procurement of built solution ............................................................................................... 98

6.2 Costs and value for money.................................................................................................. 101

6.3 Energy services contract ..................................................................................................... 108

6.4 Car parking .......................................................................................................................... 111

6.5 Key commercial and legal issues ......................................................................................... 113

6.6 IM&T ................................................................................................................................... 113

6.7 FM services ......................................................................................................................... 116

6.8 Equipment strategy ............................................................................................................. 116

6.9 Planning consent ................................................................................................................. 118

6.10 Disposal strategy ................................................................................................................. 121

7. Management case ....................................................................................................................... 123

7.1 Benefits ............................................................................................................................... 123

7.2 Programme governance ...................................................................................................... 124

7.3 Monitoring and control ....................................................................................................... 130

7.4 Resourcing strategy............................................................................................................. 131

7.5 Programme milestones ....................................................................................................... 133

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7.6 Risk management ................................................................................................................ 134

7.7 Workforce planning ............................................................................................................ 138

7.8 Change management plan .................................................................................................. 148

7.9 Communication and stakeholder engagement strategy .................................................... 149

7.10 Post project evaluation ....................................................................................................... 152

7.11 Approvals and letters of support ........................................................................................ 155

7.12 Recommendation ................................................................................................................ 155

Appendices

2. Strategic case appendices 2A Transaction Agreement clauses concerning CFH 2B Estate strategy summary 2C Existing backlog maintenance breakdown 2D Out of scope action plan 2E Service specifications 2F Activity brief 2G Schedule of accommodation and HBN derogations 2H Utilisation schedule 2I Communications log 2J Trust Medical Director and Director of Nursing support letter 2K Commissioners’ letters of support 3. Strategic case – design and construction appendices 3A Development control plan 3B 1:200 designs 3C Schedule of 1:50s 3D Elevations 3E Adjacencies matrix 3F Future expansion strategy 3G BREEAM pre-assessments 3H [not used] 3I Principles of M&E design and infrastructure 3J Highlands scope of works and backlog plan 3K DQI design review 3L HTM derogations – new build 3M Highlands lifecycle report 3N NHS authorising fire engineer letter of support 3O Construction programme 3P Outline commissioning programme 3Q Modular vs traditional construction appraisal 4. Economic case appendices 4A Economic appraisal 4B Option 11 1:500 designs 4C OB Forms for shortlisted options 4D Optimism bias calculations for shortlisted options

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4E Generic Economic Model (GEM) 4F Lifecycle costs for shortlisted options 4G Quantified risk assessment for shortlisted options 4H Cost plans for shortlisted options 4I Benefits quantification 5. Finance case appendices None 6. Commercial case appendices 6A Procurement report for Highlands 6B Cost plans and FB forms for hospital, car park and energy centre 6C Benchmarking report for hospital, car park and energy centre 6D Lifecycle costs for hospital, car park and energy centre 6E Government soft landings strategy 6F BIM strategy 6G IM&T strategy 6H Equipment strategy 6I Costed equipment schedule 6J Planning strategy 6K LB Enfield letter of comfort 6L Disposal strategy 6M Red book valuations 6N Vacant possession and legal interest management strategy 6O Value for money statement 7. Management case appendices 7A Benefits realisation plan 7B Workstream resource structures 7C Programme plan 7D Risk register for hospital, car park and energy centre 7E Gateway risk potential assessment 7F Workforce planning 7G Workforce models and assumptions 7H Communications strategy 7I Communications plan

Abbreviations

AHP Allied health professional

BCF Barnet and Chase Farm Hospitals NHS Trust

BEH Clinical Strategy Barnet, Enfield and Haringey clinical strategy

BEHMHT Barnet Enfield and Haringey Mental Health NHS Trust

BH Barnet hospital

BIM Building information modelling

BREEAM Building research establishment environmental assessment methodology

CCG Clinical commissioning group

CEF Carbon energy fund

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CFH Chase farm hospital

CHP Combined heat and power

CMG Capital management group

CSRR Continuity of services risk rating

CSSD Centralised sterile services department

CSU Commissioning support unit

DGH District general hospital

DH Department of health

DQI Design quality indicator

EAP Employee assistance programme

EBITDA Earnings before interest, tax, depreciation and amortisation

ENT Ear, nose and throat

ESCo Energy services company

FBC Full business case

FM Facilities management

FRR Financial risk rating

FTE Full time equivalent

FVA Financial viability assessment

FY Financial year, e.g. FY15 means 2014/15

GEM Generic economic model

GIFA Gross internal floor area

GMP Guaranteed maximum price

GP General medical practitioner

GSL Government soft landings

HBN Health building note

HCAS Higher cost area supplement

HDU High dependency unit

HRG Healthcare related group

HTM Health technical memorandum

HWB Health and wellbeing board

I&E Income and expenditure

IBP Integrated business plan

IESE Improvement and efficiency south east (procurement framework)

IHP Integrated health projects – the trust’s appointed PSCP

IMD Index of multiple deprivation

ITU Intensive treatment unit

LA Local authority

LIFT Local improvement finance trust

LOS Length of stay

LTFM Long term financial model

LTHW Low temperature hot water

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MFF Market forces factor

MSK Musculo-skeletal

NCL North central London CCGs

NHSE NHS England (strictly NHS Commissioning Board)

NMUH North Middlesex University Hospital

NPC Net present cost

NTE GMP Not to exceed guaranteed maximum price

OBC Outline business case

OPAU Older people’s assessment unit

OPD Out-patient department

P21+ ProCure 21+

PACE Post acute care enablement

PAU Paediatric assessment unit

PBR Payment by results

PDC Public dividend capital

PEST Political, economic, sociological and technological analysis

PFI Private finance initiative

PITU Planned investigations and treatment unit

PMO Project management office

POCU Post operative care unit

PSCM Principal supply chain member

PSCP Principal supply chain partner

QIPP Quality, innovation, productivity and prevention

RFH Royal Free Hospital

RFL Royal Free London NHS Foundation Trust

RTA Road traffic accident

SFI Standing Financial Instruction

SLR Service line reporting

SOC Strategic outline case

SOCI Statement of comprehensive income

SOCF Statement of cash flow

SOFP Statement of financial position

T&T Turner and Townsend – the trust’s appointed cost advisors

TDA NHS Trust Development Authority

TREAT Triage rapid elderly assessment team

UCC Urgent care centre

WTE Whole time equivalent

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1. Executive summary

1.1 Introduction

This full business case (FBC) confirms and details the case for investment of £203,803,377 in the

redevelopment of Chase Farm Hospital (CFH) building upon the approved outline business case

(OBC). Structured using the NHS six case model, it considers the proposals from a strategic, design,

and construction, economic, commercial, financial and management perspective.

The overarching programme objectives for the Chase Farm Hospital redevelopment are to:

to ensure that the services provided are consistent with the BEH clinical strategy providing

access to safe and sustainable elective care services that achieve required standards at

Chase Farm Hospital;

to ensure that new and refurbished facilities are designed to commissioners’ and the trust’s

models of care, improve patient experience, support best practice and to guidelines set out

in the relevant Health Building Notes and evidenced based design principles apart from

where otherwise derogated;

to develop the site in a way that is affordable to commissioners, to funders and to the trust

on both a capital and revenue basis, as quickly as possible.

to enable Chase Farm Hospital, and the trust as a whole to achieve high levels of

productivity; and

to achieve Estate Code A /B for the site.

This executive summary provides an outline of the contents of the overall document, describing

each section in order.

1.2 Strategic case

1.2.1 Context and basis of brief

The proposed redevelopment of CFH supports existing national, local and trust strategies.

The local health need and improving the experience for patients has been core to informing the

brief. The population of Enfield is projected to increase by 7% over the next 20 years, with a 42%

increase in people aged 65 and over. Therefore there will be more people in the local area (affecting

demand for all services), especially more older people (affecting demand for rehabilitation and

dementia services). It is predicted that 20% of the elderly population will be living with dementia.

Enfield has a high prevalence of lifestyle-related conditions such as obesity, coronary heart disease

(CHD) and diabetes, and the incidence and prevalence of certain diseases (particular cancers,

ischaemic heart disease, COPD, stroke and rheumatoid arthritis) are forecast to change in Enfield

over the next 10-20 years. It is likely that demand for services such as diagnostics, and especially

cancer treatment and stroke rehabilitation will increase significantly, and more of those patients will

be older. Due to increased cancer incidence and improving treatments, prevalence will increase

significantly so that many more people will be living with cancer. However these increases in

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demand are not just in the future, the principal commissioner of Chase Farm’s services, Enfield CCG,

having seen a 12% increase in GP referral rates over the last year alone.

The trust envisages CFH to be the pre-cursor of transformational change throughout the trust. By

creating a new hospital, the trust plans to manage patients with the above conditions more

effectively through a clinical model which has the following overarching principles:

to implement symptom based pathway service re-design to the benefit of the patient;

to provide an integrated hospital which promotes seamless management of elective surgery

and non acute patient care;

to increase admission avoidance and decrease lengths of stay by moving from an inpatient

to a day case / ambulatory model where appropriate; and

to provide as much care as possible outside a hospital setting where appropriate.

The redevelopment is set in the context of the acquisition by Royal Free London NHS Foundation

Trust (RFL) of Barnet and Chase Farm Hospitals NHS Trust (BCF) that was completed on 1 July 2014,

and the implementation of the Barnet Enfield and Haringey (BEH) clinical strategy in late 2013. It

remains consistent with the OBC in terms of the proposed service provision.

1.2.2 Benefits

Investment at CFH is long overdue and a redevelopment to provide modern, fit for purpose facilities

will benefit the local population of Enfield and neighbouring boroughs by ensuring the long term

future of CFH. The following benefits are envisaged from the new facility:

facilitate high quality care which supports the achievement of clinical and non clinical

standards;

increase sustainability to service delivery on site, offering greater reassurance to the

community of Enfield and North London about the safe future of Chase Farm site and the

importance the NHS strategically places upon it;

offer improvements to the local community;

improve patient experience of trust services;

help the trust to achieve sustainable financial viability after the acquisition of BCF;

eliminate backlog maintenance;

achieve land sale disposal receipts for the benefit of service improvement;

provide flexibility to enable other services to be developed on the site in future;

improve staff morale, recruitment and retention;

increase efficiency and productivity; and

improve the quality of the estate, ensuring fit for purpose accommodation.

1.2.3 Clinical engagement

Clinical engagement is essential to ensure that the redevelopment meets clinical requirements.

Since the OBC was submitted, further meetings, workshops and a clinical away day have been held

to engage staff in IM&T innovation, workforce planning and design development. All drawings and

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derogations have been signed off by departmental representatives, infection control and the trust

fire officer.

1.2.4 Activity and capacity

The role of the hospital was defined at a high level in the BEH strategy, and confirmed after public

consultation, and the core of the brief has required little new debate. The logic behind the brief

comprised the following:

the role of Chase Farm Hospital in the BEH strategy;

measures to deliver that activity content more efficiently;

some transfers of elective surgery and endoscopy from Barnet Hospital so as to enable more

efficient emergency services at that hospital, and more efficient elective services at Chase

Farm Hospital;

some limited moves of services closer to patients’ homes;

consistency with the new clinical pathways agreed with commissioners; and

growth factors for demographic structural change and access.

The activity projections, set out below, form the basic brief for the new hospital. Most of the net

increases over the current year’s projection are due to transfers, the rest being a response to

demographic change.

Table 1.1 Chase Farm Hospital activity projections summary (draft)

The capacity requirements have been reviewed and refined since OBC based upon each service’s

service specification and leading to the development of a schedule of accommodation. The table

below summarises the planned capacity proposed in this FBC.

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Table 1.2 Comparison with current provision and OBC plans

service planned service provision (2018/19) at FBC

In-patient rehabilitation and stroke

rehabilitation

44 beds

Other in-patient medical No medical beds other than rehabilitation.

Planned Investigations and

Treatment Unit (PITU) +

haematology/ oncology

20 places (PITU and haematology/ oncology day

treatment)

UCC 7 adult C/E rooms

1 minor ops room

1 plaster room

1 plain film x-ray room

GP out of hours Provision on CF site

OPAU 7 spaces , 5 consult/exam rooms and 1 treatment room

PAU / Children’s Services 3 consulting spaces for core PAU

7 consulting rooms, 1 treatment room

In-patient elective surgery

including HDU

50 beds with flexibility to accommodate up to 4 HDU

patients

Day case 14 places

Theatres 4 theatres plus 4 tables in a barn theatre for elective /

day case procedures

Theatre recovery 2 per theatre (16 in total)

Endoscopy 4 endoscopy rooms with the flexibility to extend if

required (ground floor location, ‘pod’ design’)

Out-patients All specialties currently provided on CFH site will

continue to be.

6 virtual consult booths for telemedicine.

Phlebotomy 6 booths. Children seen in children’s OP/PAU.

Anti-coagulation service

Physiotherapy and MSK service Provision for in-patients on the wards out-patients MSK

and direct access via either MSK or the OPAU

Imaging 3 x-ray rooms

6 ultrasound (4 in rooms, 2 mobile)

1 MRI plus space for 1 mobile MRI

1 CT scanner

Fluoroscopy function within one of the plain film x ray

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rooms

Ancillary facilities Café and retail space

1.2.5 Health and social care community engagement and support

The trust has held a series of stakeholder meetings in Enfield to show the developing plans to

statutory partners and members of the public. CCG staff have attended some of those events. Trust

staff attended the governing body meetings of Enfield CCG in December 2014 and September 2015,

Barnet CCG in December 2014, and East and North Hertfordshire CCG in January and June 2015, to

remind members of the scope and timetable for the development, and to answer any remaining

commissioning and other questions. The trust presented the Chase Farm redevelopment proposals

at the Enfield Health and Wellbeing Board in February 2015, where the proposals were supported.

1.3 Strategic case – design and construction

1.3.1 Design development

The trust worked with its PSCP, IHP, and its new design team to review the design to meet the

clinical brief and reduce costs whilst maintaining the fundamental design principles and optimising

benefits associated with the preferred option. The trust has sought to continue to improve the

quality of the design and the clinical benefits which can be achieved throughout the design

development process. The following changes to the design have been made:

a slight adjustment to the location of the new building to facilitate improved opportunities

for expansion and minimise the number of decants required;

the design reflects value engineering exercises to reduce the capital cost without

compromising quality;

the design incorporates improved departmental layouts;

percentage of single rooms adjusted to meet the clinical brief in the surgical and

rehabilitation wards;

retention of rehab in Highlands (as per change in preferred option – see 1.4.1).

The key elements of the scope are a new healthcare building, a refurbished ground floor of

Highlands, an additional 405 parking space multi-storey car park and a new energy centre to serve

the site.

Figure 1.1 overleaf shows the site at the completion of the redevelopment.

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Figure 1.1 Completed site development plan

1.3.2 Stakeholder support

The designs have been developed to, and signed off at, 1:50 scale by the clinical leads and other key

stakeholders such as fire safety and infection control. The design has been verified by the

Operational Steering Group.

1.3.3 Design features and quality

The design provides 57% of the beds in single bedrooms and has achieved a high score for

functionality and impact in the independent Design Quality Indicator review of the scheme.

Future flexibility and the capacity to accommodate expansion has been considered in some detail

and the new design meets this element of the brief.

New healthcare building

Energy centre

Refurbished Highlands (ground floor)

Additional car park

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The new hospital has been designed to achieve BREEAM excellent, and Highlands to achieve

BREEAM very good.

1.3.4 Implementation plans

A Development Control Plan has been prepared. This shows how the hospital redevelopment and

adjacent residential and school schemes are delivered phase by phase and demonstrates how access

around and to the site is maintained throughout.

Detailed construction and outline commissioning programmes have been prepared. An assessment

of construction methods has concluded that some elements should be constructed off site, but that

the main build should be traditional rather than modular.

1.4 Economic case

1.4.1 Changes since OBC approval

The OBC identified a preferred option (8) that provided all the healthcare facilities in a new building

The development of the OBC design led to the identification of a new option, option 11, which

involves retention of rehabilitation wards in the ground floor of Highlands, which will be partially

refurbished, and construction of a new build accommodating all other services. This new option,

retaining rehabilitation in Highlands, is strongly supported by clinicians.

1.4.2 Results of updated economic appraisal

Due to the introduction of this new option, and following consultation with DH, a new financial and

non financial options appraisal was undertaken comparing the do minimum, the OBC preferred

option (option 8), and the new option (option 11). This option appraisal was undertaken in May and

June 2015, shortly after OBC approval and before progression into detailed design of a preferred

option. The cost and design information used in the appraisal therefore represents a point in time

before the further design development reflected in the rest of this FBC.

The revised appraisal demonstrates that there is no significant difference between options 8 and 11

in terms of value for money. Option 11 achieves higher qualitative scores for clinical benefits and

has a lower cost per benefit point. It is also significantly more affordable to the trust than option 8,

and is therefore the preferred option on this basis. The results of the investment appraisal are

summarised in the table below:

Table 1.3 Option appraisal summary

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1.5 Finance case

The finance case complements the strategic direction set out in the strategic case and the economic

options appraisal.

On 1 July 2014, RFL acquired BCF to form an enlarged trust. As part of the rationale for the

acquisition to eliminate the historical deficit at Chase Farm was a plan to invest in a new healthcare

facility the Chase Farm site. This finance case sets out the financial benefit of the investment on the

trust and on Chase Farm.

The capital investment to redevelop CFH results in the elimination of the deficit at CFH by FY20. This

is due to efficiencies gained from consolidating the delivery of clinical services to a purpose build

facility, and efficiencies from reducing the footprint of the hospital site and operating a majority

brand new building. Table 1.4 sets out the forecast CFH I&E showing how the deficit is forecast to

reduce during the forecast period.

Table 1.4 CFH SOCI summary

The capital cost of the preferred option for the CFH redevelopment is £xxx (as set out in table 1.5

which includes the cost of an additional car park, energy centre, and refurbishment of an existing

building.

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Table 1.5 CFH redevelopment capital cost

This capital investment is funded by a combination of proceeds from land sales, public dividend

capital (PDC), internally generated funds, and debt as set out in table 1.6.

Table 1.6 CFH redevelopment funding table

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Table 1.7 Trust summary financials

1.6 Commercial case

1.6.1 Procurement of built solution

In accordance with the procurement strategy set out in the OBC, IHP was appointed as Principal

Supply Chain Partner (PSCP) from the Department of Health’s ProCure21+ framework following the

normal competitive selection process. Their appointment was ratified by the programme board in

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December 2014. IHP has developed designs and not to exceed (NTE) prices for the new healthcare

building (including the refurbishment of Highlands), the energy centre and the car park.

The summary NTE prices provided by IHP for these three contracts are shown in the context of the

overall project capital costs as follows:

Table 1.8 Capital cost summary

A further breakdown of the energy centre elements is shown in the table below:

Table 1.9 Breakdown of energy centre elements

The trust’s cost advisor has benchmarked the costs provided and the trust is comfortable with the

findings.

Progression into undertaking the construction works are subject to agreement of a final Guaranteed

Maximum Price (GMP) and signing the Stage 4 contract for both the hospital works and the car park,

once the full business case is approved. The contract used will be a standard Procure21+ NEC3

option C target cost with activity schedules.

The energy centre solution (which includes significant infrastructure and plant required to operate

the hospital) may or may not be procured through IHP dependant on the outcome of the process

being undertaken to procure an ESCo. IHP have been asked to include provision of the energy

centre (which include all site-wide infrastructure external to the new build and Highlands) in the

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GMP, which forms the solution presented in this FBC. The trust is also progressing procurement of

an ESCo (described in section 1.6.2), and bidders have been asked to submit three bids covering

different elements of the energy centre and associated infrastructure. The trust will compare the

GMP from IHP against the ESCo bids as part of an NPV analysis.

The FBC outlines how the works will be delivered in accordance with the Government Construction

Strategy.

1.6.2 Energy services procurement

The trust is working with the Carbon and Energy Fund to procure an energy services company (ESCo)

to provide a managed combined heat and power (CHP) energy centre. The ESCo will guarantee the

performance of the energy centre, with the trust benefitting from reduced carbon emissions,

revenue savings and compensation for any financial loss as a result of inefficiencies or down-time

over a pre-agreed limit. The procurement will be complete in summer 2016 with practical

completion due on 30 June 2017, in time to provide energy to the new healthcare building as it is

commissioned.

1.6.3 Car park

IHP will build the new car park and the trust has decided, following an option appraisal, to continue

to fund and operate the car park itself.

1.6.4 IM&T strategy

The CFH redevelopment offers the opportunity for the creation of a truly digital hospital, which

applies new technology to support all aspects of care delivery and administration with the goal of

delivering improvements to operational efficiency, health outcomes, employee and patient

satisfaction and high quality service. An IM&T strategy has been developed, which details how the

trust will deliver its vision of digital healthcare, making use of the new hospital to prove and

demonstrate the value of new IT-enabled work processes in a new, purpose built, facility and then

apply these new ways of working into other hospitals within the trust. The key IT architecture

components currently in place within the trust and which will be utilised within the new hospital are

as follows:

user workstation environments – within the new hospital a broader range of user devices

than the traditional laptops and ‘computers on wheels’ will be supported, provided by both

the trust and users themselves;

servers and hosting – a ‘cloud-based’ hosting approach will be taken, with applications

hosted in one of the trust’s own virtualised data centres, or within a secure third-party data

centre as appropriate

file storage – the trust is exploring secure cloud-based file storage options

directory services – the new single Active Directory (AD) service for the authentication of

users across the trust will be retained

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collaboration – a number of collaboration platforms implemented across the trust will be

utilised within the new hospital, including unified communications, intranet services and

medical grade video conferencing.

1.6.5 Facilities management services

Plans are in place to align the provision of hard and soft FM services at CFH with the changing

requirements on the site caused by redevelopment activities.

1.6.6 Equipment strategy

An equipment strategy has been developed to ensure that the trust has a fully equipped hospital

facility that keeps pace with technological developments, whilst also securing best value for money

once the development is completed.

During the development of the FBC the trust’s equipping advisors have:

undertaken a full audit and asset survey for all existing medical and non-medical equipment

on the Chase Farm site, inclusive of real time condition appraisal;

produced a detailed costed equipment schedule, aligned to the schedule of accommodation;

agreed responsibility for all equipment procurement with the P21+ partner, in order to

derive the trusts actual investment profile, against the equipment contained within the

project’s GMP (Group 1);

estimated transitional costs, and produced an outline commissioning programme.

The approach taken utilises the trust’s existing equipment (medical and non-medical) asset base as

far as possible and is designed to maintain continuous availability of equipment to avoid service

disruption.

The trust has assessed the options to procure the equipment via capital, lease or a Managed

Equipment Service (MES). Given the immaterial difference between the options and the flexibility a

capital solution allows, the trust has modelled that equipment is procured via capital. As part of the

next stage, the trust will consider MES and leasing for particular items or groups of items.

1.6.7 Planning consent

In addition to a reserved matters application, a Section 73 application is being made to LB Enfield to

vary the parameters of the outline planning approval for the scheme so that the redesigned

healthcare building will secure full planning permission. It is anticipated that these two matters will

be closed out by November 2015 with a 6 week judicial review period (during which time the

process could be challenged, necessitating a judicial review) concluding in December 2015 in time

for the main works to begin without planning risk.

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1.6.8 Surplus land disposal

As identified in the OBC, the redevelopment involves the disposal of parcels of land that will be

surplus to NHS requirements. The parcels are shown on the figure below together with the portion

of the site retained for healthcare use:

Figure 1.2 Land parcels for retention and disposal

The sale of parcel A is underway with bids having been received. On the basis of these bids, the red

book valuations for the other two parcels have been updated and have increased since OBC.

The table below summarises the timing and likely receipt (as per the draft red book valuation) for

each parcel.

Table 1.10 Timing and draft valuations of disposal parcels

These valuations have been factored into the financial modelling. Fees associated with the sale will

be offset against the land values, as shown in the finance case (section 5.9).

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1.6.9 Vacant possession

The trust has a number of third party commercial occupiers on the site, as well as tenants in the

residential accommodation. It has developed a strategy to obtain vacant possession of each part of

the site when required to support the redevelopment and disposals programme.

1.7 Management case

1.7.1 Benefits realisation

A benefits realisation plan has been developed. This provides details of how each benefit will be

measured. These have been identified through a benefits mapping exercise involving key clinical

and non clinical staff. Each benefit baseline has been measured and a responsible owner identified

for monitoring progress.

1.7.2 Programme governance

The programme governance structure and reporting strategy is set out in the figure below.

Figure 1.3 Programme governance and reporting structure

23

The governance structure sets out lines of accountability and reporting for the delivery of the

programme. It ensures that the proposals that have been developed are robust and are supported

by the trust. The programme is fully resourced by a combination of trust staff and external

consultants providing advisory and technical services to the trust, supported by the IHP supply chain

and the CEF. A budget has been developed to ensure the right level of resource is maintained until

completion of the programme.

1.7.3 Programme milestones

A full draft programme for the delivery of the scheme has been developed. Key milestones are

shown in the table below.

Table 1.11 Programme plan key milestones

key milestone programmed date at FBC

(September 2015)

programmed date at

GMP (February 2016)

decant works start on site June 2015 June 2015

trust sign Stage 3 contract with IHP July 2015 July 2015

decant works complete August 2015 August 2015

enabling works commence August 2015 August 2015

reserved matters planning approval

submitted

September 2015 November 2015

detailed design complete September 2015 December 2015

trust board approval of FBC, to include a ‘not

to be exceeded GMP’

September 2015 September 2015

reserved matters planning approval achieved November 2015 January 2016

final GMP to be agreed November 2015 February 2016

trust sign stage 4 contract with IHP December 2015 March 2016

main development start on site January 2016 January 2016

new hospital operational July 2018 August 2018

ground floor Highlands refurbishment

complete and operational

April 2019 June 2019

post project evaluation April 2018 – June 2020 June 2018 – July 2020

It should be noted that while the current programme shows the new hospital opening in July 2018,

the trust is working to reduce the construction programme.

1.7.4 Risk management

A full risk management strategy has been developed, where risks are logged and then scored for

their probability of occurring and their likely impact in terms of cost and time, which has then

generated a risk rating. All risks have a responsible owner and mitigating actions identified. The

risks are reviewed regularly to ensure that all reasonably practicable measures have been taken to

mitigate them. Risks are escalated as appropriate in accordance with the governance structure.

The highest level risks for the three elements of the capital project are shown in the tables below.

24

Table 1.12 Top five trust main scheme risks and mitigating actions

Ref No Risk Description

Prob. (1-5)

Impact (1-5)

Risk Rating (1-25) Mitigation

Risk Manager

302 Failure to achieve full QIPP savings as projected, which would have a negative impact on the LTFM and trust I&E position

4 5 20 Develop robust implementation plans, model downside scenarios

Katie Fisher

305 One or more of the capital financing sources fails or falls short of projections, leading to the scheme stalling or an increase in trust borrowing

3 5 15 Land sales - trust using RBVs provided by professional advisors. Parcels C and A due to complete in March 2016 and May 2016. PDC - committed in writing by DH at OBC. Cashflows showing draw-down of PDC provided to DH. Borrowing - paper approved by ITFF RFL contribution - reserves in capital programmes

Caroline Clarke

306 Delay to FBC approval by DH / Treasury, reducing future financial benefit

3 5 15 Work closely with DH/Treasury through business case approval process. Treasury have indicated they will approve within the trust's timescales.

Caroline Clarke

104 Workforce plans are not fully implemented by the time the new hospital opens, meaning that workforce savings are not delivered in full

4 4 16 Workforce workstream to manage workforce transformation and development of new roles. Implementation plan in place.

David Grantham

308 Temporary closure of beds on G floor of Highlands and permanent closure of beds on the 1st floor Highlands when the link bridge is constructed impacts trust performance.

4 4 16 Careful planning with services to manage activity and the impact of disruption during this period.

Kate Slemeck

Table 1.13 Top trust energy centre risks and mitigating actions

Ref No: Risk Description

Prob. (1-5)

Impact (1-5)


Risk Manager

33 Risk that ESCo and IHP do not coordinate delivery of supplies, delaying commissioning of Healthcare Building and potentially increasing IHP’s costs.

3 5 15 IHP have been involved throughout the ESCo bidding process. Trust to implement robust completion schedules and set clear boundaries between sites. ESCo to provide temporary supplies which can be used to commission the healthcare building if the energy centre

Nigel Walker

25

installation is delayed.

Table 1.14 Top trust car park risks and mitigating actions

There are no trust red risks currently on the car park risk register.

Depending on the nature of the risk, a capital or revenue contingency sum has been estimated for

risks and then applied as appropriate as either a capital contingency in the FB forms or in the

revenue cash flows in the GEM.

1.7.5 Workforce planning

The workforce plan for the new hospital is based upon detailed work undertaken to develop

workforce plans at service and speciality level for each division. The workforce plan builds upon the

foundations of the trust’s existing Workforce and Organisational Development Strategy 2011-2017

and the Workforce and Organisational Development Strategy for the acquisition of Barnet & Chase

Farm Hospitals NHS Trust in 2014. A full range of key stakeholders had the opportunity to contribute

to discussions to agree the workforce for these workstreams.

The strategic workforce model is activity driven – that is, based on the planned clinical activity and

the facilities in which that activity is to be delivered. Consideration was given to opportunities to

make use of efficiencies afforded by operating from a purpose built healthcare facility, clinical

adjacencies, and use of the latest IT technology. The output of the model is a detailed whole time

equivalent (WTE) requirement for each workstream based on the activity. The overall change in the

WTE staffing requirement is shown in the figure below:

Figure 1.4 Workforce planning projections


xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx. The planned WTE and skill mix

changes are described in detail in section 7.7.

The workforce strategy sets out how the trust will:

establish new ways of working, skill mix and productivity increases

implement the workforce transformation programme

build capability: education/learning and development

ensure employee engagement, communication and health and wellbeing

manage recruitment and retention

establish governance for managing the workforce changes

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1.7.6 Change management and commissioning programme

An outline plan has been develop to chart the activities and associated timelines required to

successfully implement the new ways of working and workforce plans and achieve a seamless

transition into the new hospital.

1.7.7 Communication and stakeholder engagement

A communications and stakeholder engagement project plan has been developed to provide clarity,

consistency and reassurance to all stakeholders. It contains the following key messages that are

crucial in the success of the plan:

the Royal Free London will redevelop Chase Farm Hospital to ensure it delivers care in high

quality buildings that provide a safe and pleasant environment for local people. The

current Chase Farm estate is too dispersed, in a poor state of repair and the design of

facilities are not suitable for modern healthcare.

we know that local people in Enfield are concerned about the future of Chase Farm

Hospital and we want to provide assurance that our priority is to provide excellent care

closer to patients’ homes. We want to bring services closer to where people live and work

so that they are more accessible and convenient.

the Chase Farm Hospital redevelopment is a new and exciting opportunity for existing staff

to work in a safer environment with suitable and fit for purpose buildings that helps them

provide the care they need for their patients. The new hospital will also become a more

inviting and attractive work environment, this will appeal to a high standard of new recruits

and/or staff.

we will be actively respectful in minimising disruption during the construction process.

We will communicate and engage with local people about our plans, timescales and

approach, wherever we can.

Chase Farm Hospital has faced financial challenges for over a decade. Previous attempts to

resolve these difficulties have not succeeded. We need a hospital with a smaller footprint

which is safer, more efficient and will provide better value for the taxpayer.

1.7.8 Post project evaluation

A plan to undertake the post project evaluation of the programme has been developed in

accordance with the DH guidance.

1.8 Recommendation

Following approval of this FBC by RFL trust board on 24 September, DH and HM Treasury are asked

to review and approve the case and to release the £81.8m PDC funding as agreed at OBC. Monitor is

asked to review the FBC, and to provide a risk assessment of the financial implications of the

transaction.

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2. Strategic case

2.1 Introduction

This Full Business Case (FBC) for the redevelopment of Chase Farm Hospital follows the Outline

Business Case (OBC) which was approved by the Department of Health and HM Treasury on 27

March 2015. As part of this approval, the DH committed to providing £81.8 million of Public

Dividend Capital (PDC) as a contribution to the redevelopment. The approval letter noted the

requirement for the trust to develop a detailed savings plan, provide an updated value for money

assessment and secure written confirmation of commissioner support for the FBC.

The design of the new Chase Farm hospital has developed since OBC stage to enhance flexibility, so

that, as needs change and unforeseen innovations develop, it will be readily adaptable, so reducing

future costs. For example we have recognised that the number of patients with dementia attending

the new hospital will be higher than now, and that the layout of patient circulation areas needs to be

intuitive and easily remembered. The activity brief for the new hospital is based on assumptions

about new clinical pathways having been implemented by primary, community and secondary care

providers working together in an integrated way, so saving, for example, thousands of hospital out-

patient attendances.

The strategic case also summarises the overwhelming case for change established in the OBC.

Investment at CFH is long overdue and a redevelopment to provide modern, fit for purpose facilities

will benefit the local population of Enfield and neighbouring boroughs by ensuring the long term

future of local services in sustainable buildings. The development remains consistent with the

Barnet Enfield and Haringey clinical strategy.

Finally, the case then details the future activity projections and service models that underpin the size

and scale of the proposed new CFH.

2.2 The strategic context

2.2.1 National strategy In October 2014 the Five Year Forward View was published by NHS England and its partners. It

reported that, unless determined action was taken, the gap between need and available resources

would be £30bn in 2020/21. The document summarised three scenarios showing the degree to

which that gap could be reduced. The forward view highlights several approaches which are

incorporated in the planning of the CFH redevelopment. These are:

patient needs are changing and new treatment options are emerging;

challenges in mental health, cancer and support for frail elderly patients;

new partnerships are envisaged with local communities, local authorities and employers;

the need for rapid upgrade in prevention and public health;

patients will need to gain more control of their care;

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barriers removed to care provided by family doctors, hospitals, physical and mental health

and health and social care;

in future more services delivered locally but others in specialist centres;

more support for patients with multiple health conditions;

future radically different care delivery options including integrated hospital and primary

care providers. The design of the new Chase Farm hospital has developed since OBC stage to enhance flexibility, so

that, as needs change and unforeseen innovations develop, it will be readily adaptable, so reducing

future costs. We have recognised that the number of patients with dementia attending the new

hospital will be higher than now, and that the layout of patient circulation areas needs to be intuitive

and easily remembered. The activity brief for the new hospital is based on new clinical pathways

having been implemented by primary, community and secondary care providers working together in

an integrated way, so saving, for example, thousands of hospital out-patient attendances.

The most recent national planning guidance, The Forward View into Action: planning for 2015/16

(December 2014), asked the NHS to start to fulfil the vision of the Five Year Forward View,

recognising the increasing demands from a growing and ageing population. The document restated

the operational priorities all of which are assumed for the new hospital. The national priority of

prevention is reflected in the brief of the new hospital in three ways:

a health promoting environment (eg cycle lane and parking, green gym);

staff health and wellbeing (eg new catering contract tackling obesogenic factors); and

preventative services for patients (eg stop smoking services, opportunistic vaccination). 2.2.2 Local strategy Barnet, Enfield and Haringey clinical strategy In September 2011, following at least ten years of scrutiny, support for the BEH clinical strategy was confirmed by the secretary of state for health. This strategy had the following objectives:

to develop local health services to enable the transfer of appropriate services from an

acute to a community and primary care setting;

to reorganise the provision of acute services across the Barnet, Enfield and Haringey health

communities (affecting southern Hertfordshire residents too);

to ensure the continued clinical sustainability and safety of the service configuration after

taking into account the implications of the next stage of the European Working Time

Directive (EWTD) and the Modernising Medical Careers policy; and

to address the underlying financial deficit of the health economy and BCF in particular.

The strategy set out the improvement in primary and community care across the region, the

centralisation of A&E and maternity services at BH and North Middlesex University Hospital (NMUH),

and the development of CFH as an elective centre, ambulatory and urgent care facility. These

service changes were implemented in November and December 2013. The trust is committed to

continue delivering the services as set out in that strategy in the long term and this redevelopment is

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a key step in supporting the long term provision of services at CFH on a sustainable basis. These are

shown below.

Table 2.1 Disposition of services following BEH clinical strategy implementation

Chase Farm Hospital Barnet Hospital

Urgent care centre Emergency, maternity and paediatrics

Paediatric assessment unit Accident and emergency

Older person’s assessment unit Urgent care centre

Elective in-patient surgery Emergency surgery

Day surgery Day surgery

Rehabilitation Maternity (including midwife led unit)

Out-patients Paediatrics

Critical care (HDU) Out-patients

Critical care (ITU)

Commissioners’ plans

With few exceptions the services at Chase Farm Hospital are commissioned by CCGs. Secondary

dental services (meaning in the brief for this business case the specialties of maxillo-facial surgery

and orthodontics) and some chemotherapy at the hospital are currently commissioned by NHS

England. This section therefore concentrates on CCGs’ plans.

The North Central London CCGs’ five year plans have not yet been finalised, but two main factors are

common to those and to the trust’s planning assumptions. The first is the financial outlook. All the

main commissioners of services from the hospital, especially Enfield CCG, have had better than

baseline funding growth in 2015/16, and they are all under target, meaning that they are more likely

to receive better than average allocations in the future (see table 2.2 below). The other common

factor is the strategy of pathway redesign, examples of which are now being trialled with the largest

CCG users of the secondary services.

Table 2.2 Main user CCGs’ programme allocations and financial prospects

commissioner 2014/15 adjusted

baseline, £m

2015/16 allocation

less seasonal

resilience funding,

£m

net growth

2014/15 to

2015/16¹

2015/16 distance

from target²

Barnet CCG 408.3 429.5 5.2% -2.5%

Enfield CCG 336.6 358.9 6.6% -4.3%

East and North Herts

CCG

607.0 638.9 5.3% -3.3%

Haringey CCG 314.0 323.7 3.1% -0.6%

Herts Valleys CCG 641.7 673.8 5.0% -3.3%

Source: NHS England (www.england.nhs.uk/resources/resources-for-ccgs/#finance) Notes 1 This growth calculation is (2015/16 allocation less seasonal resilience funding) / (2014/15 baseline), expressed as a percentage. 2 This is the distance from the CCGs’ allocation targets, expressed as a percentage, after the 2015/16 allocation. Negative figures mean that the CCG is below its target.

http://www.england.nhs.uk/resources/resources-for-ccgs/#finance

30

Although their numbers and their pace of development vary, local CCGs’ commissioning plans have

very similar objectives and priorities, and are based on largely the same thinking and approach.

Every CCG is investing in primary care and community services, and all their plans are well linked into

joint strategic needs assessments and the priorities of the health and wellbeing boards.

Enfield CCG, Chase Farm Hospital’s largest commissioner, expresses its quality strategy thus:

we will continue to work with people in aiming to improve their health and well-being by

focusing on preventative services, reducing health inequalities, and enabling the

population to take responsibility for their own health;

we will facilitate integration between health and social care services;

we will have an Enfield strategy that is clinically led, draws on research evidence, and uses

innovative, radical solutions to deliver the best possible care to patients and their carers;

we will focus on education and development support for clinicians to improve care and

ensure that high quality services are delivered.

Commissioners’ outcomes and affordability criteria will be met by coherent pathways with

supporting protocols for symptom defined patient groups in all the common specialities, agreed

between commissioners and providers (including GP providers and our other partners) across the

system. These pathways will be implemented through the application of highly standardised

practice across primary and secondary care (see 2.3.7 for more detail).

London Borough of Enfield (LBE) Enfield Joint Health and Wellbeing Strategy 2014-2019 has a vision which is underpinned by five supporting principles: Prevention and early intervention – The lifestyle choices that people make about diet, exercise, alcohol consumption, smoking and drug use can affect their health and wellbeing. Early diagnosis, positive interventions and good quality service delivery will lead to the people of Enfield enjoying better health and wellbeing into the future. Integration – Service users should receive a seamless service, regardless of the source of the support. The Health and Wellbeing Board (HWB) will encourage integration across all relevant health and social services, schools’ and children’s services, and the voluntary and community sector where appropriate. Integration of services is a key issue for older people. Equality and diversity – Enfield HWB initiatives will address equality and diversity, by ensuring services are accessible, high quality and tailored appropriately to the different groups in Enfield, particularly in the light of the east-west divide across the borough in health and wellbeing outcomes. Addressing health inequalities – Aim to minimise the variation in health and life expectancy between east and the west of the borough, while also improving the health and wellbeing of all Enfield residents. Ensuring good quality services – All services will be designed around the patient or user, will be safe, and will be caring and compassionate.

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LBE has consistently supported the continued provision of services at CFH. Our aim is to contribute to the strategy of LBE and the HWB by helping to achieve the principles above. 2.2.3 Local population considerations Demographic changes LB Enfield is now the fourth most populous borough in London. The catchment population of Chase Farm Hospital will continue to increase. Table 2.3 shows the population changes projected in Enfield over the next 20 years. Table 2.3 Population projections LB Enfield

1

year residents LB Enfield aged 65+ (%)

2012 317 000 39 900 (12.6)

2022 332 000 45 500 (13.7)

2032 340 000 56 400 (16.6)

The population of Enfield is projected to increase by 7% over the next 20 years, but with a 41%

increase in people aged 65 and over. Therefore there will be more people in the local area (affecting

demand for all services), especially more older people (affecting demand for rehabilitation,

dementia services and OPAU and affecting lengths of stay in hospital beds). It is predicted that 20%

of the elderly population will be living with dementia. Diversity in the Enfield population is

increasing fast, and an increase in ethnic mix of older age groups (possibly affecting system

familiarity, cultural issues and language) is likely.

Epidemiological and policy effects on demand

The 2013 Enfield Joint Strategic Needs Assessment (JSNA) identified significant health deprivation in

Enfield. Although life expectancy is better than the England average across the borough, it differs by

6-7 years (for women and men respectively) between people living in the most and least deprived

areas.

Enfield has a high prevalence of lifestyle-related conditions. Obesity presents a significant concern:

Enfield has the third highest prevalence of obese people in London (27%), with 26.5% of 4 and 5 year

olds and 38.5% of 10 and 11 year olds overweight or obese in 2009/10. An estimated 8,000 people

registered with an Enfield GP had coronary heart disease (CHD) in 2008/09, placing it third highest in

London for the condition, and a further 7,500 residents are estimated to have undiagnosed CHD.

Similarly, 12,600 people registered with a GP had diabetes in 2008/09 and a further 3000 are

thought to have undiagnosed diabetes – amongst the highest rates in London. By creating a new

hospital that is specifically designed to support new patient pathways, the trust plans to help

manage patients with these conditions more effectively.

1 LB Enfield, Joint strategic needs assessment, 2013

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The incidence and prevalence of certain diseases (particularly cancers, ischaemic heart disease,

COPD, stroke, dementia and rheumatoid arthritis) are forecast to change in Enfield over the next 10-

20 years. It is likely that demand for services such as diagnostics, and especially cancer treatment

and stroke rehabilitation will increase significantly, and more of those patients will be older. Due to

increased cancer incidence and improving treatments, prevalence will increase significantly so that

many more people will be living with cancer.

National Institute of Health and Care Excellence (NICE) guidelines, issued in June 2015, that aim to

speed up cancer diagnosis and save up to 5,000 lives a year nationally will necessarily further

increase demand on cancer services as the disease is identified earlier, therefore presenting more

treatment options.

2.2.4 Trust mechanisms for monitoring strategic direction and demographics The trust maintains a number of related mechanisms to help ensure that its strategic business planning is realistic. Amongst these mechanisms are:

a political, economic, sociological and technological (PEST) analysis of the developing

operating environment (updated annually);

the board assurance framework assessing strategic risks and recording what more needs to

be done to abate them (updated quarterly); and

quantified planning assumptions about resources, demographic change and service needs.

All the PEST factors help to inform the expected future operating context for the Chase Farm Hospital of 2019. PEST factors of special importance to this business case are:

quality expectations will rise, and quality and safety policy will continue to develop;

£30b savings need to be achieved by the English NHS by 2020/21; further austerity is

assumed in the next spending review for the period 2016/19;

inflation and cost pressures, especially related to staffing;

changing demographics and health needs;

staff culture and expectations; and

electronic sharing of information across organisational boundaries and with patients.

2.3 Description of the trust and its services 2.3.1 Trust objectives and strategy

The trust’s enduring governing objectives are:

excellent outcomes: clinical, research and teaching;

excellent experience: for patients, staff and GPs;

excellent value;

safety and full compliance;

a strong organisation.

33

These objectives provide the structure for all that the trust does – planning and annual objectives,

strategic risk management and operational delivery. Plans to redevelop CFH must and will support

these objectives.

Since 2011 the board has been pursuing an explicit strategy that will enable progress towards the

governing objectives. The six development themes that express that strategy in both service and

financial terms are:

extending the role of a major acute provider;

being a network and system leader, and the surgical hub;

being a leader in the academic health science system;

being experts in integrated care;

reducing unit costs;

gaining new markets and income sources.

The plans to redevelop CFH in this FBC will support these development themes.

2.3.2 Organisational structure

RFL has a high performing board, supported by an experienced trust executive. Below are the

current members of the trust board. The board membership has not changed since the OBC was

approved.

Dominic Dodd Chairman of the board and council of governors

Stephen Ainger Non executive director

Dean Finch Non executive director

Deborah Oakley Non executive director

Jenny Owen CBE Non executive director

Prof Anthony Schapira Non executive director

David Sloman Chief executive

Caroline Clarke Chief finance officer and deputy chief executive

Kate Slemeck Chief operating officer

Deborah Sanders Director of nursing

Prof Stephen Powis Medical director

The board is supported by a committee structure which reflects the trust’s governing objectives.

Other than the trust executive that operationally manages the trust, each is chaired by a non-

executive director to ensure appropriate oversight of the performance of the executive.

Table 2.4 Board committees

standing committee governing objective/s

audit safety and full compliance

clinical performance excellent outcomes

finance and performance excellent value for money, safety and full compliance

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integration strong organisation

patient experience excellent experience

patient safety and compliance safety and full compliance

remuneration strong organisation

strategy and investment strong organisation

trust executive all

2.3.3 Acquisition of BCF – Integrated Business Plan and Transaction Agreement

BCF board concluded in July 2012 that it could not become a sustainable independent foundation

trust, and decided to seek a partner through whom it could become part of a successful foundation

trust.

In February 2014 RFL’s five year acquisition integrated business plan (IBP) was approved by the trust

board and accepted by the NHS Trust Development Authority (TDA), acting as the vendor on behalf

of the secretary of state for health. The Transaction Agreement, the legal contract for the

acquisition, was later drawn up and signed by all parties in June 2014. RFL statutorily and

operationally acquired BCF on 1 July 2014.








Acknowledging CFH as a major contributor to the deficit, the Transaction Agreement for the

acquisition gave a commitment from all signatories, including NHS England and the CCGs, to

redevelop Chase Farm Hospital. It identified a ‘viable option’ for the Chase Farm redevelopment

which involved refurbishing Highlands Wing and the old maternity block as well as the construction

of a new building. A Strategic Outline Case (SOC) was developed on the basis of the viable option

which was approved by the trust board in July 2014. Transaction Agreement clauses relevant to the

redevelopment of Chase Farm are attached at appendix 2A.

As part of the IBP and Transaction Agreement, a level of transitional support was agreed to ensure

RFL maintained a Continuity of Services Risk Rating (CSRR) of 4 and to assure the trust board, the

council of governors, local authority scrutiny committees and other stakeholders that the short and

long term interest of patients would be protected, and that instability was not being risked.

The transitional funding included a PDC contribution of £xxx towards the redevelopment of Chase

Farm and the £xxx I&E support for 5 years from the date of the acquisition (FY15 – FY19 for the

Chase Farm site). This funding was on the basis that the trust would submit an OBC within two years

of the acquisition. The OBC was submitted to DH in January 2015 and approved on 27 March 2015.

The formal letter of approval was later received from DH on 13th May 2015.

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The anticipated high level benefits of the acquisition for all stakeholders are set out below.

Table 2.5 Anticipated benefits of acquisition

perspective Benefits

patients higher quality care through service delivery in far better premises; new service models offering greater convenience and better outcomes

Chase Farm staff an end to years of uncertainty about the hospital

other trust staff opportunity to develop and deliver a wider range of improved clinical services; practical scope for larger scale clinical research

commissioners prevents a major provider from failing, with the attendant risks to their patients; helps them to achieve their financial duties

vendor a secure path to BCF becoming part of a successful foundation trust

hospital service organisation

significant steps towards achieving our governing objectives and realising our development themes

2.3.4 Characterisation of the trust’s hospitals

The locations of the trust’s three hospitals are shown below:

Figure 2.1 Location of trust hospital sites

Royal Free Hospital

The Royal Free Hospital is a large acute hospital situated in north central London together with

networks of local services run by clinicians at other sites across north London and Hertfordshire.

Chase Farm Hospital Barnet

Hospital

Royal Free Hospital

36

World class care and expertise is provided based on a tripartite mission of service, research and

teaching excellence. As a teaching hospital, the Royal Free hosts a major campus of UCL Medical

School, some of whose research is of international status. Doctors, nurses, midwives and many

other clinical and non clinical professionals are trained.

Barnet Hospital

Barnet Hospital provides emergency and acute clinical services. Between 1994 and 2003 Barnet

Hospital was entirely rebuilt in two phases, with further extensions added in 2013 for the BEH

clinical strategy. The first phase opened in 1997, and provided surgical wards, theatres, intensive

care unit, A&E and maternity. The second phase included medical wards, coronary care and out-

patients, designed, built, financed and operated through the Private Finance Initiative (PFI) with the

PFI partner Metier. Phase 2 was officially opened in February 2003. All clinical services at BH are in

modern, purpose designed buildings.

Chase Farm Hospital

Chase Farm Hospital (CFH) is a former district general hospital situated in north Enfield. The

buildings at CFH were built over time from the 19th century to 1995 when Highlands Wing was

completed. High profile campaigns have been mounted in support of the retention of acute services

at this site. It is a focal point for the provision of health services in Enfield. Previous attempts to

redevelop parts of the site for residential housing have resulted in failed planning applications,

owing to a lack of certainty about the future of healthcare services at the site.

Barnet Enfield and Haringey Mental Health NHS Trust own the site adjacent to Chase Farm Hospital

from which they provide mental health services.

All trust sites

The full list of sites from which the trust provides clinical services is shown in the table below.

Table 2.6 Sites of RFL clinical activity, mid 2015

site main services provided populations mainly served

Barnet Hospital emergency, and complex elective in patients, out-patients, diagnostics

north Barnet, south Hertfordshire, east Harrow

Chase Farm Hospital planned and lower complexity elective, out-patients, urgent care centre, diagnostics

north Enfield, Broxbourne, Barnet

Cheshunt Community Hospital out-patients, diagnostics Broxbourne

Edgware Community Hospital out-patients, diagnostics, birth centre, day surgery

west Barnet, east Harrow, south Hertfordshire

Finchley Memorial Hospital out-patients, diagnostics, east Barnet, north-west Haringey

Kentish Town Health Centre community child health Camden

Mount Vernon Hospital plastic surgery, day cases, west Hertfordshire and

37

out-patients north west London

North Middlesex Hospital ENT, out-patients Haringey and south Enfield

Peckwater Centre community dermatology clinic

Camden

Potters Bar Community Hospital

out-patients south Hertfordshire and north Barnet

Ravenscroft Medical Centre, Golders Green

community dermatology clinic

Barnet

Royal Free Hospital emergency, specialist complex elective in- patients, out-patients, diagnostics

north Camden , south Barnet, national and international

St Albans City Hospital plastic surgery out-patients south Hertfordshire

St Michael’s Hospital ENT out-patients Enfield

St Pancras Hospital dialysis, diabetes, ophthalmology

Camden

Stephenson House, Euston adult community clinics Camden

The Vale dermatology north Barnet

Tottenham dialysis unit dialysis east Haringey and south Enfield

Watford General Hospital plastic surgery, day cases, out-patients

west Hertfordshire

Whittington Hospital ophthalmology day cases Islington

Because the services in the new hospital will be very similar to those currently provided, the CFH

development is not expected to have any significant effect on services at these other sites. Well

before the new hospital is opened, remaining non complex elective services at Barnet Hospital will

move to Chase Farm Hospital as per the BEH clinical strategy and so as to provide capacity for the

increasing emergency demands at Barnet Hospital.

2.3.5 Trust clinical strategy

The trust’s strategy is described in figure 2.2 below.

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Figure 2.2 Trust overarching strategy

The trust has a vision that it will be at the core of a health system that provides world class care and

expertise, delivering its tripartite mission of service, research and teaching excellence. The

development of integrated care is central to the realisation of this vision, and clinical pathway

redesign is a key enabler for integrated care. There is clear national, London and local commissioner

policy in favour of system integration that facilitates better patient experience, greater convenience

for the population and better use of public money.

The trust recognises GPs’ skills and experience in assessing risk and that they are excellent at

gatekeeping emergency resources. They make the most effective clinicians in urgent care centres,

and this model has therefore been implemented across sites. On the other hand specialists, always

fully up to date with current clinical standards in their field, are best placed to assess hospital

referrals, and can offer patient management advice to GPs so as to avoid referral and so speed up

treatment.

In partnership with one of the main user CCGs of the hospital, East and North Hertfordshire, a

clinical advice and navigation service is now being tested, whilst other elements of the new

pathways have been agreed for implementation with both Enfield and Barnet CCGs.

The trust recognises the opportunity presented by the Chase Farm redevelopment to act as a

catalyst for changes in working practice to reflect the principles underpinning the clinical strategy

across the whole trust. The development of service models, workforce plans, equipping and IM&T

planning undertaken have supported this approach, by identifying changes which can be

implemented across all sites.

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Equality and diversity

RFL has a longstanding commitment to ensuring that services and employment practices are fair,

accessible and appropriate for all patients, visitors and carers, as well as the talented and diverse

workforce employed.

The local population and hospital workforce is extremely diverse and is becoming more so. The trust

has a moral and ethical, as well as a legal duty, to treat everyone fairly and without discrimination.

The trust’s aim is to deliver personalised services, recognising differences to meet the needs of the

diverse patients and communities.

2.3.6 Trust estates strategy

The trust has developed an estate strategy during 2015. It aligns future estate plans across all the

trust’s assets with organisational objectives and the trust’s service strategy including a review of

backlog maintenance and the 6 facet survey. The estate strategy is consistent with the

redevelopment of CFH as set out in this FBC, identifying the progression of this project as a priority

for the trust. The estate strategy was reviewed by the trust Strategy and Investment committee in

September 2015 who gave their support, noting that it is a live document which represents a point

in time. Sections of the estate strategy that are relevant to CFH are attached at appendix 2B.

The estate strategy includes a desktop update of the 6-facet survey undertaken in 2010, covering all owner occupied areas (i.e. excluding the private health provider (Kings Oak) and Mental Health Trust occupied buildings). Key points from the 6-facet survey for Chase Farm are shown below. Table 2.7 Six facet survey summary

The current estimate of backlog maintenance across the CFH site remains at £xxx (calculated at the

time of the transaction, at 2012 prices). A breakdown is included at appendix 2C

2.4 The case for change The OBC detailed the two overarching reasons why the CFH needed investment for redevelopment.

These were and remain:

the poor condition and lack of functional suitability of CFH estate;

the requirement to improve the financial position of CFH and the local health economy.

Each of these are described below.

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2.4.1 Poor condition and lack of functional suitability of CFH estate

The Chase Farm estate dates back to 1884 and the majority of buildings cannot meet modern

standards for clinical service delivery. The clocktower, one of the oldest buildings on site, was

originally an orphanage which was converted to a hospital during the First World War. Over time

the site has been extended and the accommodation now totals approximately 65,000 square metres

in a mixture of different ages and styles of buildings in varying states of repair. 83% of the estate is

over 40 years old. The current site plan below shows the fragmented layout of the site.

As well as the issues set out in the estate strategy summarised at 2.3.6 above, clinical and

operational due diligence has identified a number of concerns related to the CFH estate. For

example poor scores in the infection control environmental audits are invariably a consequence of

the poor building fabric. In contrast, Barnet Hospital scores are normally 20% better than those on

the Chase Farm site. The ability to isolate patients at Chase Farm has been a major challenge owing

to the estate. This can require the closure of whole wards to prevent spread of infection, due to the

lack of single room facilities.

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Figure 2.3 Current CFH site plan (note: only coloured buildings are owned by RFL)

There are a high number of injury claims relating to staff at Chase Farm and the buildings are a

contributor to the level of personal injury claims.

The disparate arrangement of the buildings on the site means that patients often have to be

transported outside between departments. This gives a very poor experience for patients and is an

inefficient way to deliver care.

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2.4.2 Requirement to improve the financial position of CFH and the local health economy

Financial position of CFH

The inherent inefficiency of the site is reflected in the running costs; the long-term financial

modelling carried out in 2014 for the acquisition of BCF by RFL indicated that CFH will make a loss of

c£20m (in FY 2018 once all non-recurrent income has finished) on an income of £xxx, demonstrating

the need for radical improvement.

High level modelling undertaken during the BCF acquisition indicated that an efficiently operated

site conducting the same activity as Chase Farm in FY15 should generate a net margin rather than a

deficit. Further work has since been undertaken which is set out in the Financial Case.

Given the substantial recent investment in modern healthcare facilities at North Middlesex

University Hospital (NMUH), and bearing in mind the elective nature of the work remaining at Chase

Farm, the failure to provide modern facilities at this site would result in a starkly poorer patient

experience for local people, and a gradual but sustained loss of income in future years.

There is therefore the need for CFH to radically improve its efficiency for the benefit of the trust and

local health economy.

Financial position of local health economy

The site’s largest commissioner (Enfield CCG) is in recurrent financial deficit and is expected to

remain so for at least the next two years. See table 2.2 above.

The future operating environment within which the problem must be considered has the following

features:

reduced real terms public spending, minimal (formally 0.1% per annum) or no growth in NHS spending, and the need for real terms cost reductions in most of the next 10 years;

Barnet and Enfield CCGs will do what is necessary to achieve their financial duties early in this planning period;

a continuing significant increase in population in Barnet and Enfield, which is leading to increased referrals (for example last year GP referral rates in Enfield rose by 12% over 2013/14);

a continuing significant increase in the number of 85 year olds and older, bringing significant additional demands for complex acute and chronic condition services, outgrowing the effects of demand management; and

expectation by the public and health regulators of higher standards, and lower tolerance of poor service or outcomes.

From this it follows that in future CFH needs to be part of a system wide effort to cope with

increasing demand, whilst providing services that meet standards, and that are affordable for

commissioners in a tough financial climate.

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2.4.3 Previous commitments

It should be noted that the BCF FBC for implementation of the BEH Clinical Strategy gave a

commitment to invest in the refurbishment of the maternity block to bring together all out-patients

on the CFH site. This work was not undertaken because RFL’s due diligence prior to the acquisition

showed that wider options for CFH’s future needed to be considered.

The acquisition of BCF by RFL as set out in the IBP and Transaction Agreement identifies the need to

redevelop Chase Farm Hospital in order to remove the financial deficit by FY20 when transitional

funding stops.

2.5 Programme vision and objectives

The OBC outlined the proposal to initiate a programme with the following vision and aim:

‘to create a safe, financially sustainable elective hospital in state of the art facilities which enable excellent clinical outcomes, an excellent experience for patients, staff, visitors and GPs and value for commissioners.’

This vision and aim remains at the centre of the proposals outlined in this FBC which responds to the

same drivers identified at OBC stage and which provides additional detail on how the objectives will

be met.

The following investment objectives were described in the SOC and OBC in support of this vision and

aim and remain unchanged:

to ensure that the services provided are consistent with the BEH clinical strategy providing access to safe and sustainable elective care services that achieve required standards at Chase Farm Hospital. (supports trust’s governing objectives: excellent outcomes, excellent experience, safety and

full compliance)

to ensure that new and refurbished facilities are designed to commissioners’ and the trust’s models of care, improve patient experience, support best practice and to guidelines set out in the relevant Health Building Notes and evidenced based design principles apart from where otherwise derogated. (supports trust’s governing objectives: excellent outcomes, excellent experience, safety and

full compliance)

to develop the site in a way that is affordable to commissioners, to funders and to the trust on both a capital and revenue basis, as quickly as possible. (supports trust’s governing objectives: excellent value)

to enable Chase Farm Hospital, and the trust as a whole to achieve high levels of productivity (supports trust’s governing objectives: excellent outcomes, excellent experience, excellent

value)

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to achieve Estate Code A /B for the site.

(supports trust’s governing objectives: full compliance)

2.6 Scope and deliverables 2.6.1 Scope of CFH redevelopment The overall scope of the CFH redevelopment is largely as set out in the OBC. The clinical services to

be provided remain unaltered and the solution, based around the development of a new hospital

building and supporting energy centre and additional car parking facilities, is broadly similar to that

proposed at OBC.

This FBC is based upon updated, detailed activity and capacity modelling with a new design team

which has identified a slightly different, more affordable way of delivering the services set out in the

OBC. This includes use of the ground floor of Highlands, adjacent to the new healthcare building, for

rehabilitation beds. Further details of the preferred option and the rationale for adopting it are set

out in the economic case.

New hospital and refurbishment of Highlands ground floor

The CFH redevelopment programme encompasses the provision of new hospital facilities

concentrated on the west of the site enabling the disposal of a significant proportion of land for

housing and a primary school. The new hospital will have a physical link bridge to the existing

Highlands Wing which will have the ground floor refurbished for the rehabilitation service. All other

services in scope will be provided in the new hospital building.

Energy solution The scope of this FBC encompasses the provision of an energy solution. The current energy

provision on site is not sustainable; it is a single boiler house currently serving the whole estate

which does not meet modern NHS standards for sustainability and is a costly way to provide energy.

The redevelopment will include the provision of a combined heat and power (CHP) energy centre

which will have the flexibility to be expanded for extensions to the hospital as well as the school and

some of the new housing on the disposal site, subject to negotiations with the planners. The energy

solution also includes sufficient infrastructure to distribute around the site.

Section 6.3 of the commercial case outlines the basis upon which the energy centre will be funded,

delivered and operated.

Car park Some car parking spaces will be lost as a result of the land sales and development so capacity needs

to be provided on the retained land to meet expected demand and satisfy planning requirements.

The planners are keen to ensure that the anticipated demand for car parking provision can be

satisfied within the hospital site rather than spilling out into the surrounding neighbourhood.

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The additional car parking capacity to be provided is 405 spaces, bringing the total spaces on site to

900. The additional spaces will be provided adjacent to the existing car park as set out in the OBC,

but will be a separate structure rather than an extension as described in the OBC. Section 6.4 of the

commercial case outlines the basis upon which the car park will be funded, delivered and operated.

2.6.2 Exclusions

Services not being re-provided on site

There are some support departments which are currently located on the Chase Farm Hospital site

that will not be located there in the long term and are therefore not included within the brief for the

new hospital. These include the mortuary, some non clinical offices, switchboard and CSSD.

The trust is implementing plans for the provision of these support functions in a different way or in a

different location. The progress of these separate plans is being monitored by the programme team

to ensure they are implemented as required. Appendix 2D contains these plans.

Chase Farm improvement works

In addition to the works covered in this FBC, the trust is undertaking the following improvement

works on the site before the new hospital opens in 2018, to ensure services are provided from fit for

purpose accommodation in the interim period:

upgrades to roads, pathways and wayfinding to improve patient journeys around the site;

redecoration of the clocktower;

the installation of a new decontamination and endoscopy unit to meet additional demand.

upgrades to poor quality accommodation in pathology and out-patient physiotherapy to

improve the environment for staff and patients;

plans under development to refurbish or relocate pre-operative assessment;

new office provided for the charity to facilitate expansion of the volunteer base and provide

opportunities for greater community involvement;

development of a green gym, healthy café and fitness room (these will be available for

booking by the newly appointed health and wellbeing advisor, and for MacMillan cancer

survivorship classes);

the trust is looking at relocation of other services to improve clinical adjacencies where

possible (eg cardiology diagnostics); and

ongoing site maintenance.

Decant works

The proposed site for the new hospital accommodated services which needed to be decanted to an

alternative location whilst construction is undertaken. These services include the UCC, OPAU,

rheumatology, phlebotomy, GP out of hours and maternity clinics. Decants were successfully

completed in August 2015, details of which are as follows:

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relocation of Adelaide Ward to Highlands to provide co-location with other inpatient wards.

This has improved the patient experience by locating the ward closer to essential facilities

(e.g. by providing a direct internal route to x-ray);

relocation of the OPAU to Highlands, providing the services with expansion space and

improved quality of accommodation;

relocation of the sleep / lung function services to improved accommodation within

Highlands;

relocation of the rheumatology service to clocktower to be integrated with the out-patients

services. This provides improved clinical accommodation and supports the development of

the new out-patient models ways of working planned in the new hospital;

co-location of paediatric out-patients, paediatric urgent care, PAU and women’s services in

the Medical Block to support integrated working and reduced travel times for patients

visiting related services; and

relocation of UCC and GP out of hours service to the Medical Block, providing an

environment specifically designed for urgent care (rather than a converted A&E department)

and supporting integrated working between the two services.

2.7 Services overview on the CFH site This section sets out the proposed model of care and future specifications for each major clinical service in the Chase Farm redevelopment. Service specifications in appendix 2E provide more detail. 2.7.1 Overarching service context

The service planning principles behind the new Chase Farm Hospital are:

to implement symptom based pathway service redesign to the benefit of the patient;

to provide integrated services which promote seamless management of elective surgery and

non acute patient care;

to improve admission avoidance and decrease lengths of stay by moving from an in-patient

to a day case / ambulatory model where appropriate; and

to provide as much care as possible outside a hospital setting where appropriate.

Continuing improvement in medical technology and clinical efficiencies offer the potential to reduce

the space requirements at CFH over the next decade, meaning that capacity could be created for

expanding services or transferring activity from elsewhere. The trust therefore needs to be able to

respond to changes in clinical care pathways and has reflected this requirement in a new, more

flexible design solution so that changes in ways of working or future use can be accommodated.

More information on flexibility can be found in section 3.1.4.

2.7.2 Rehabilitation

The average lengths of stay on the CFH rehabilitation wards are higher than elsewhere, and it is

considered that by learning lessons from other units these can be reduced by as much as 50%. The

trust will implement models of good practice for both stroke and general rehabilitation and is

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committed to an agenda of integrated care to support rehabilitation, enabling patients’ needs to be

managed effectively within a community setting. Post-Acute Care Enablement (PACE) and Triage

and Rapid Elderly Assessment Team (TREAT) service models and the utilisation of community

geriatricians will focus on meeting acute rehabilitation needs out of hospital and preventing

unnecessary admissions where clinically appropriate. A community geriatrician currently operates

across Camden to proactively manage some of the trust’s most vulnerable patients in the area at

home. These service models will be rolled out across all of the RFL sites over the next three years.

The new rehabilitation and PITU units are planned under new models to absorb some activity

currently seen at Barnet Hospital, helping to reduce the pressure for additional beds. The new

models of care will see only those patients with the greatest need admitted to the in-patient beds,

with a majority being supported at home.

2.7.3 PITU

PITU will provide non-surgical procedures and treatments in order to avoid unnecessary elective and

emergency admissions. Treatments carried out in PITU will include biopsies and lumbar punctures

(which do not require a full theatre), infusions (including over a succession of days) and

administration of intravenous antibiotics for patients who do not require admission.

The trust operates a successful PITU at the Royal Free Hospital, and is applying the learning from this

to planning an equivalent unit at Chase Farm.

2.7.4 UCC, OPAU and PAU

The models of care for the UCC, the OPAU and the PAU focus on providing care and intervention in

the right place at the right time, avoiding admissions wherever possible and appropriate. Current

evidence suggests that GPs are best at assessing a patient attending an urgent care centre, which is

likely to reduce unnecessary treatments and procedures.

The OPAU provides a therapeutic environment for elderly patients, and enables multi-agency

assessments. The unit also provides some therapies and treatments at the time of assessment to

reduce admissions and repeat attendances.

The PAU delivers holistic multi-disciplinary assessments and treatments for children who are

brought in directly or are seen at paediatric out-patient clinics. The current model will be developed

in the new hospital in that it will be part of the children’s zone, a change to the functional

relationships that Enfield CCG supports.

2.7.5 In-patient elective surgery and HDU

The redevelopment will enable the bed pressures on the Barnet site to be reduced by increasing

elective in-patient surgery at CFH. Provision of the HDU beds with the right functional relationships

and increased medical cover will give clinicians the assurance to carry out a greater proportion of

surgery at CFH.

2.7.6 Endoscopy

The trust anticipates increasing activity levels across the trust due mainly to increased demand (for

example arising from the new NICE cancer referral guidelines) and starting the national bowel

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screening service from 2016. For this reason, the department has been located on the ground floor

and designed in such a way that it can easily be expanded in the future.

2.7.7 Out-patients

The out-patient activity forecasts are based on the trust’s 2% per annum growth forecast, assuming

no transfer either to or from the CFH site. This forecasted increase has then been reduced for the

modelled consequences of the new patient pathways.

2.7.8 MSK

As with out-patients, a number of factors are likely to affect the capacity requirements for MSK at

CFH in the future. The trust has an ambition to provide more therapies at CFH and it is likely that the

move towards direct-access GP referrals to therapy services will have an impact on activity. Models

of care are also changing to promote integrated provision of therapies and emerging pathways will

change patient flows, reducing the capacity requirements for therapies in the future. So as to

accommodate current uncertainties, the space provided for MSK is as generic as possible. Therapies

could be provided from other sites if demand were to increase significantly.

2.7.9 Symptom based pathways

The new symptom based patient pathways aim to ensure patients receive a diagnosis and treatment

plan at the earliest opportunity, in the most appropriate location, with minimum duplication and

excellent patient experience. As one consultant said “I’ll be spending less time on each patient,

seeing them less often in out‐patients, but will influence for the better the care of far more patients

by acting when they do need referral.” The principle underlying this are outlined below:

standardised approach to pathway delivery across CCGs and hospitals

senior clinical triage with access to multidisciplinary triage where appropriate

majority of out-patients managed within a community or primary care based service

community services supervised by senior clinicians

diagnostics ordered once and only when clinically necessary – reduce over ordering

one stop service/co-location to improve patient experience

follow-up once, and only when necessary

patient centred, safe services

payment mechanism based on whole system management and clinical outcomes

quality of GP referrals and clinical thresholds improved – protocol driven

educational support for primary care through training and development led by senior clinicians

provision of health and advice telephone lines for clinicians

integrated IT/information portal/podcasts

use of technology to deliver virtual services – Skype/telephone follow-up

decommission procedures of low clinical effectiveness.

Example pathway

Following consultation with clinical and CCG colleagues, 45 pathways across 8 specialities were

chosen in the first phase of redesign. Examples of the resulting pathways are shown overleaf.

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Figure 2.4 Example symptom based pathway – breathlessness pathway

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Figure 2.5 Example symptom based pathway – hip pain pathway

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Symptom based pathways aim to have a significant impact on patient journeys post implementation

with internal services redesigned in order to meet these new requirements. There are six

specialities in the ‘wave 1’ implementation and across the whole trust for those specialties a

reduction of 27,440 out-patient appointments is estimated from 2016/17 to 2020/21. The CFH

share of this reduction is included in the activity modelling for the new hospital. These estimates

will be continuously reviewed as experience of delivering the new pathways is gained.

Below is an actual journey for a patient experiencing hip pain. The journey lasted multiple years and

involved multiple interactions with primary and secondary care, many of which could be avoided.

Figure 2.6 Journey of a sample patient with hip pain prior to implementation of symptom based pathways

Being seen under a symptom based pathway in line with new internals models of working, the

number of interactions that the patient experienced would be significantly decreased. As a result

the patient will undertake a more efficient journey, outlined below, with a better experience for the

patient.

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Figure 2.7 Journey of a sample patient with hip pain following implementation of symptom based pathways

The implementation of symptom based pathways will transform the way patients move around the

system and are cared for within North London and the surrounding areas. Patients will be cared for

by the right person, at the right time, in the right location resulting in them experiencing the best

possible journey once a symptom begins. With increased care being carried out in primary and

community settings the trust and its hospitals will need to adapt in order to meet the changes in

demand.

In order to meet the changing demands resulting from pathways implementation and resulting

internal service redesign, the out-patient facilities at CFH will provide generic space which can be

easily adapted to see patients varying numbers of patients with certain conditions. The space will

also be amenable to seeing patients in one stop and MDT settings in order to minimise unnecessary

interaction and improve experience.

2.7.10 Integrated working

As well as the pathways described above that are integrated between primary, community and

secondary care, existing examples of integrated care at Chase Farm can be extended. The trust is

also partnering with social care, community services and the mental health service providers to

ensure integration of care for elderly patients at CFH within the OPAU.

In addition the UCC is an integrated service with the out of hours GP provider.

The Royal Free is working with a range of local providers and the CCG in order to support the

development of a new rehabilitation pathway which will be supported by the beds at Chase Farm.

2.7.11 Supporting patient choice

The new build has been designed to facilitate provision of care in the community where appropriate

and improvements in patient choice. The use of generic space in out-patients means that as more

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care is provided outside of hospital, the services in the hospital can change in accordance with the

needs of the local population. Provision of appropriate IM&T infrastructure and telemedicine pods

will support video consultations so as demand for this increases, more patients can be offered care

within their own home.

The extended hours for services provided at Chase Farm will extend the choice of times when

patients are able to attend for their intervention. Services will be open for up to seven days a week

from early morning to mid evening to improve utilisation of the building and also to make it more

convenient for patients.

2.8 Activity modelling 2.8.1 Summary

This section describes how the activity assumptions for the Chase Farm Hospital of the future have

been derived. The role of the hospital was defined at a high level in the BEH strategy, and confirmed

after public consultation, and that core of the brief required little new debate. The logic behind the

brief comprised the following:

the role of Chase Farm Hospital in the BEH strategy;

measures to deliver that activity content more efficiently;

some transfers of elective surgery and endoscopy from Barnet Hospital so as to enable

more efficient emergency services at that hospital, and more efficient elective services

at Chase Farm Hospital;

some limited moves of services closer to patients’ homes; and

growth factors for demographic structural change and access.

The trust maintains a set of evidence based corporate planning assumptions, agreed by its trust

executive that provides the logic for specialty level activity projections. These have been used for

forecasting the activity at Chase Farm Hospital up to 2020/21, and the resulting activity forecasts are

to be modelled back into the trust wide five year activity model. The trust executive has also

identified various factors that are expected to require changes in activity or role up to around 2030,

and these have been passed to the design team so that the right kind of flexibility is built into the

design concept.

The activity modelling has been updated since the OBC to incorporate an additional six months of

data. It will continue to be updated regularly to reflect both the latest actual figures and new

information about likely changes and their timing. Therefore the current forecasts will change,

including as more experience is gained of the delivery of the range of new pathways, but not such

that the functional content of the new hospital need change. The programme board is clear that the

trust has a number of other options if, for example, some category of demand increased significantly

in the medium term. If demand turned out to be significantly lower than expected, then a clinic area

for example of the new hospital could be mothballed, but current and expected trends in

demography and demand suggest that that is extremely unlikely.

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This is therefore the core of the brief, and no aspect of the brief contradicts that strategy. Not all

elements of the hospital were listed in the strategy FBC, but were implicit in it, such as theatres,

endoscopy suite and clinics.

2.8.2 Current and future usage by CCG

In 2014/15 the proportions of the services used by patients from the main user CCGs were as shown

in the next table. The dental services and oncology/chemotherapy are commissioned by NHS

England, but the referrals for those services are local as incorporated in the table. The data in the

table are based on contractual currencies, and therefore exclude or underrepresent certain services

(for example the older people’s assessment unit). Using natural currency the proportion of usage by

Enfield CCG patients would be higher, and by all other CCGs lower.

Table 2.8 Percentage of usage of Chase Farm Hospital services by patients of selected CCGs, 2014/15

CCG Enfield E&N Herts Barnet Herts Valleys Haringey

Out-patient attendances 62.1% 14.8% 10.6% 5.6% 4.1%

Day cases 50.7% 13.5% 20.1% 8.3% 3.4%

Elective in-patient spells 33.0% 11.1% 31.6% 13.0% 5.6%

Non elective spells 45.9% 7.5% 26.7% 15.0% 1.7%

Urgent care centre attendances 73.6% 8.8% 3.2% 2.6% 3.9%

In total these five CCGs account for 97% of the out-patient attendances, 96% of the spells, and 92%

of the urgent care centre attendances. Other smaller number users of the urgent care centre

include patients from West Essex and Waltham Forest CCGs. Because the services in the new

hospital will be very similar to those in the current hospital, there is no reason to assume that these

proportions of usage will change significantly.

2.8.3 Some elective transfers from Barnet Hospital to help meet national targets

Our analysis shows that sustainably reachieving some of the most important national targets in the

trust depend on improving the flow of emergency patients through Barnet Hospital and on

improving the efficiency of elective surgery through both Barnet and Chase Farm hospitals.

Sustainably achieving the accident and emergency department four hour wait target at Barnet

Hospital depends on many factors, but amongst them is the availability of the right quantity of beds,

diagnostic and treatment facilities. Currently some of those resources are devoted to elective

services, but we know that improved access for emergency patients would improve the probability

of achieving the standard. Elective patients, even day cases, booked at Barnet Hospital are

frequently cancelled because of the sheer number of emergency patients. That is why there is now

once again a high dependency unit (level 2) at Chase Farm Hospital. Therefore separating the two

groups of admitted patients largely (but not entirely) to separate sites will benefit both.

The other targets that are being missed currently are the 18 week standards. This is in the context

of the inheritance from the former BCF trust of one of the most extensive and complex long waiting

time backlogs in England. In 2016 we expect that those targets will be reachieved and we are

determined that failing them should not recur. Therefore we are planning for a clinically highly

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efficient elective operation at Chase Farm Hospital where patients are practically never cancelled,

and where the facilities are designed specifically for excellent patient experience.

The same considerations apply for the national targets on diagnostic waits, for which a modern,

compliant endoscopy suite with efficient decontamination facilities is essential.

Other than the transfers described above, few service moves are proposed as part of the

redevelopment. If there were a later phase we would consider with our partners enabling some

further consolidation of services. In this brief we are planning to provide chemotherapy for some

patients with solid tumour cancers who presently have to travel further from their homes in north

Enfield and south-east Hertfordshire for that service, recognising from local public health analysis

that the demand for this service is increasing significantly. We are especially aware how difficult

frequent travelling can sometimes be for these patients, and we are making use of our successful

experience of developing a local chemotherapy unit on a community site at Finchley Memorial

Hospital.

2.8.4 Service changes incorporated into the brief

The activity projections used in the FBC take into account projected reductions in out-patient

attendances as a result of the implementation of the new clinical pathways. Those assumptions vary

between 5% and 30% by specialty. As the pathways are in the early stages of implementation, they

will continue to be reviewed. The current projected reductions in the specialties being implemented

in wave 1 are as follows:

dermatology – 25%

orthopaedics – 25%

respiratory – 10%

cardiology – 15%

gynaecology – 5%

urology – 5%

Further symptom based pathways will be implemented in other specialties in waves 2 and 3. The

potential impact of these on activity has not been modelled because not enough is known about

which pathways will be changed. The out-patient department has been designed to incorporate a

high level of flexibility, ensuring that changes in activity projected for each specialty can be

accommodated.

2.8.5 Growth factors

For almost all the services at Chase Farm we have applied an annual growth factor of 2%, extending

that model to 2020/21. That 2% has been the subject of internal and external review, and has been

shown over recent years to have proved correct, including given demand management measures

that we and our commissioners have applied. The 2% comprises a variable factor by local authority

for population growth (ONS Census 2011 based population projections), typically more than 1%, but

also takes account of the differential growth in very elderly people with their characteristic much

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more intense use of hospital services (House of Lords, Select Committee on Public Service and

Demographic Change, Ready for ageing?, March 2013), the longer period that patients live with

complex chronic diseases, and improvement in access (for example effective treatments becoming

available for older patients).

Netted from what otherwise would be a higher growth factor are:

further adjustments, to be reviewed over time, for the new referral pathways agreed with

local GPs (per 2.8.4 above); and;

an assumption that other system level measures will be developed to abate the growth of

demand for hospital services in the five year planning period.

The draft activity projections, set out below, form the basic brief for the new hospital. Most of the

net increases over the current year’s projection are due to transfers, the rest being a response to

demographic change.

Table 2.9 Chase Farm Hospital draft activity projections summary

Activity Currency FY15 FY16 FY17 FY18 FY19

urgent care attendance 36,725 37,960 38,719 39,494 40,284

day cases spell 20,748 20,982 35,311 36,032 36,428

elective spell 5,453 5,664 7,089 7,231 7,168

non-elective spell 1,103 1,197 1,221 1,246 0

out-patients

attendance/

procedure 232,260 234,228 225,973 228,731 234,637

At this stage the CCG shares of this forecast activity have not been formally calculated, but the

working assumption is that the current shares (which vary between the main categories of activity)

will not change significantly in this planning period unless a new business case emerges from a

neighbouring health economy.

A detailed activity brief for the redevelopment has been prepared and is included in appendix 2F.

On a departmental basis it shows the changes in activity projected for FY19 and provides a

comparison between OBC and FBC, demonstrating that these changes are immaterial.

2.8.6 The period between now and the opening of the hospital

Whilst not related to the content of the FBC itself, this section is added so as to explain the

underlying activity and LTFM assumptions for the period before 2018/19. Some service moves

affecting Chase Farm Hospital are expected before the opening of the new hospital in July 2018. The

dates of almost all these moves are subject to review and most will probably change, but the

following are the current assumptions that have been incorporated in to the associated activity and

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finance model. Nothing in this list affects the activity brief for the new hospital from 2018/19

onwards, which remains entirely unchanged from that in the OBC.

elective non endoscopy transfers from Barnet Hospital to Chase Farm Hospital –

progressively from 2015

elective endoscopy transfers from Barnet Hospital to Chase Farm Hospital –

progressively from 2016

transfer of remaining relevant spells for under 19 year olds from Chase Farm Hospital to

Barnet Hospital – progressively from 2015

closure of unretained postacute wards at Chase Farm Hospital – progressively from

2015, culminating in Q4 of 2017/18

no PITU or solid organ chemotherapy at Chase Farm Hospital before Q1 of 2018/19

The closure of the postacute beds at Chase Farm Hospital that are not commissioned is a system

level issue. At the time of writing the majority are closed with no adverse effects, although whether

they will remain closed during all the following three winters depends on the epidemiology of those

winters, the utilisation of emergency beds in other hospitals (such as Barnet Hospital, the North

Middlesex Hospital, and others) from which transfers are made, and how well the wider system

responds through the various system resilience groups. Given the uncertainty we are assuming that

the beds currently closed will remain so, and that the rest will close shortly before the new hospital

opens - the buildings that they occupy will remain until that date.

There are then two scenarios for the increasing demand for emergency beds at Barnet Hospital.

Scenario A is that neither the underlying increasing demand (including the effects of continuing

problems to the west and north-west) nor the closure of the uncommissioned Chase Farm postacute

beds will require any extra beds at Barnet Hospital. Scenario B is that such pressures will require

extra beds, which would be subject to a separate business case.

2.8.7 Summary of functions not explicitly cited in the BEH clinical strategy

In summary some functions remain included in the brief that were not explicitly cited in the BEH strategy, as follows:

theatres and the endoscopy suite (not listed as a separate department in the BEH FBC, but implicit in the activity);

the specific mix of elective surgery transfer from Barnet Hospital with accompanying high dependency unit (see 2.8.4 above);

the planned investigation and treatment unit; and

the chemotherapy service for the treatment of solid tumours (see 2.8.3 above).

2.9 Capacity requirements Capacity requirements have been worked up from the activity using assumptions around utilisation,

operating hours and throughput. These are summarised in the service specifications for each service

in appendix 2E and a schedule of accommodation has been derived, attached in appendix 2G. A

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utilisation schedule has also been developed that relates both patient and facility utilisation

assumptions to the capacity provided in each department in the new build. The utilisation schedule

is attached at appendix 2H.

The table below summarises the planned capacity compared with current capacity as well as that set

out in the CFH OBC. Operationally, pressure on site car parking, waiting rooms and other ancillary

facilities will be managed through the use of appointments for all services other than UCC,

particularly essential for high throughput areas such as phlebotomy.

Table 2.10 Comparison with BEH FBC and current provision

service current service

provision (2015)

planned service

provision (2018/19)

at OBC

planned service

provision (2018/19) at

FBC

In-patient

rehabilitation and

stroke rehabilitation

44 beds

44 beds 44 beds

Other in-patient

medical

Napier - 12 beds

Capetown - 38 beds

Adelaide (part) - 16

beds

No medical beds

other than

rehabilitation.

No medical beds

other than

rehabilitation.

Planned Investigations

and Treatment Unit

(PITU) + haematology/

oncology

No PITU

Haematology /

oncology day

treatment 10 spaces

20 places (PITU and

haematology/

oncology day

treatment)

20 places (PITU and

haematology/

oncology day

treatment)

UCC 7 adult C/E rooms

2 paed C/E rooms

1 treatment / plain

film imaging room

(shared between

adults, paeds and GP

OOH)

7 adult C/E rooms

1 minor ops room

1 plaster room

7 adult C/E rooms

1 minor ops room

1 plaster room

1 x-ray room

GP out of hours Provision on CF site Provision on CF site Provision on CF site

OPAU Open 5 days per week. 9 spaces to be open 7

days per week.

7 spaces to be open

5 days per week.

Change to opening

hours has been

agreed with the

commissioner,

59

Enfield CCG, but can

be reversed if

demand requires.

PAU / Children’s Out-

patients

4 cubicles and 1

isolation space for

PAU

3 consulting spaces

for core PAU

7 consulting rooms, 1

treatment room

3 consulting spaces

for core PAU

7 consulting rooms, 1

treatment room

In-patient elective

surgery inc. HDU

64 beds

4 HDU/POCU beds

48 beds (note: bed

numbers calculated

are based on reduced

lengths of stay,

changing models of

care and pathways to

improve clinical

quality and efficiency

plus patient

experience. The

caseload is broadly

similar to current and

to BEH assumptions)

4 HDU beds in

separate department

50 beds with flexible

functionality, which

could accommodate

up to 4 HDU patients

at a time, as well as

surgical and bariatric

patients.

Day case 18 trolleys 14 places 14 places

Theatres 8 theatres in total (6

main theatres and 2

Surgicentre theatres)

8 theatres for

elective / day case

procedures.

Some additional

theatre capacity is

being included to

accommodate

elective activity from

BH.

4 theatres plus 4

tables in a barn

theatre for elective

/ day case

procedures.

Some additional

theatre capacity is

being included to

accommodate

elective activity

from BH.

Theatre recovery 11 in main theatres

4 in Surgical Centre

2 per theatre (16 in

total)

2 per theatre (16 in

total)

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Endoscopy 2 endoscopy rooms

open 6 days per week

4 endoscopy rooms

plus 2 ‘shell’ rooms

for growth

4 endoscopy rooms

with the flexibility

to extend if

required (ground

floor location, ‘pod’

design’)

Out-patients Currently provided in

disparate locations.

All specialties

currently provided on

CFH site will continue

to be.

6 virtual consult

booths for

telemedicine.

All specialties

currently provided

on CFH site will

continue to be.

6 virtual consult

booths for

telemedicine.

Phlebotomy 6 booths. Children

seen in children’s

OP/PAU.

Anti-coagulation

service

6 booths. Children


OP/PAU.

Anti-coagulation

service

6 booths. Children


OP/PAU.

Anti-coagulation

service

Physiotherapy and

MSK service

Provision for in-

patients, out-patients

and direct access

Provision for in-

patients on the

wards, out-patients

MSK and direct

access via either MSK

or the OPAU

Provision for in-

patients on the

wards out-patients

MSK and direct

access via either

MSK or the OPAU

Imaging 4 x-ray rooms

5 ultrasound

1 MRI

1 DEXA scanner

1 CT scanner

4 x-ray rooms

6 ultrasound

1 MRI plus space for

1 mobile MRI

1 CT scanner

Fluoroscopy function

within one of the 4

plain film x ray rooms

3 x-ray rooms

6 ultrasound

1 MRI plus space for

1 mobile MRI

1 CT scanner

Fluoroscopy

function within one

of the plain film x

ray rooms

The table above shows a change in functional content since the OBC from 48 surgical beds plus 4

HDU beds in a separate department, to 50 beds in surgical wards with HDU capability integrated. At

OBC, the HDU unit was co-located with theatres and was therefore sized at 4 beds, as this

represented the smallest viable HDU unit. During the subsequent detailed design development, the

HDU has been relocated to be part of the surgical ward to ensure flexible and efficient use of both

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beds and staff. The large room sizes of many of the surgical rooms mean that up to 4 HDU patients

could be accommodated at any one time in response to demand, as well as surgical and bariatric

patients. These bed numbers were supported by activity data from FY15 at CFH which shows that

on average 0.9-1.8 beds were being used per day.

The two endoscopy ‘shell’ rooms have been removed from the new build, on the basis that the

department has been designed to facilitate expansion should additional rooms be required. The

endoscopy department is located on the ground floor next to outside space earmarked for an

extension, and the rooms have been designed in ‘pods’ so additional rooms can be added without

compromising patient flow. Each ‘pod’ includes all the facilities needed for consultation, changing,

recovery and toilet facilities a patient would require, so adding additional endoscopy procedure

rooms would be accompanied by the required support space in each pod.

The OPAU and PAU have been integrated within the UCC to improve patient flows and provide all

three departments with the greater flexibility. The number of spaces in OPAU has therefore reduced,

as the department will have the ability to increase its opening hours and flex into adjacent UCC

rooms if additional capacity is required. This has been agreed with the OPAU clinicians based on

current and planned activity and ways of working.

Finally, one plain film x-ray room has been moved from the imaging department to the urgent care

centre. This will improve patient flow as a significant number of patients who attend the UCC

require a plain film x-ray. The urgent care and imaging departments are adjacent to each other on

the ground floor, so x-ray rooms can be used flexibly in response to changes in demand.

2.9.1 Bed modelling

Non-elective beds

As per the OBC it is planned that the current complement of non rehabilitation medical beds will not

be reprovided in the new hospital. The decommissioning of these beds is an objective of Enfield CCG

and their local health and social care partners, and is a subject of discussion at the joint Enfield

Integration Board (which is a sub-group of the Enfield Health and Wellbeing Board). The means by

which the need for these beds will be removed are likely to include:

closure of beds due to reducing need (currently only one of the wards is open);

reducing length of stay in the rehabilitation beds on the Chase Farm site in order that more

patients can be seen through the same number of beds;

transfer of more elective work (consistent with BEH) from the Barnet site to Chase Farm and

Royal Free sites, so enabling more available bed days for emergency patients at Barnet

Hospital and thus the achievement of the 95% national waiting time standard;

transfer of work currently undertaken as in-patient activity into planned ambulatory

episodes delivered through the proposed PITU;

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through expansion of community based initiatives such as PACE (post-acute care

enablement) and TREAT (triage rapid elderly assessment team) which focus on admission

avoidance and early facilitated discharge for mainly elderly frail patients; and

targeted work with care homes to manage patients with end of life care plans more

appropriately, avoiding conveyance to hospital and admissions wherever possible.

Elective beds

In-patient elective bed modelling was based on applying the following to current activity data:

Givens:

no overnight stay children (per BEH clinical strategy)

beds open for 350 days pa (ie closed for Christmas/New Year and Easter)

operating theatres working on Mondays to Saturdays.

The following assumptions were made.

activity quantum for in-patient work is the sum of existing Chase Farm Hospital elective in-

patient work plus certain adult elective work to be transferred from Barnet Hospital.

activity for the period 1 January 2014 to 30 June 2014 (the first post BEH clinical strategy

implementation period) was doubled to produce a full year output, and then an annual

growth factor for five years of 2% compound per the trust’s annual planning assumptions

was applied to take the activity projections to calendar year 2019. The actual activity in

subsequent periods will be kept under review.

annual growth beyond 2019 was assumed to be consumed by annual efficiency thereafter.

bed occupancy will vary between Mondays to Fridays (higher) and Saturdays and Sundays

(lower). Various combinations considered, but overall average of around 87% across all

seven days was agreed.

The table below shows how the elective activity projections are used to model the number of beds.

The most recent activity trends do not suggest that this decision needs to be changed.

Table 2.11 Elective inpatient bed modelling calculations

Inpatient bed modelling – CF FY19

LoS FY19 OBC ABD Beds

CF 1.5 6,129 9,411

BH 3.0 1,272 3,820

7,401 13,231 16,538 48

Occupancy 80%

Number of days 350

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2.10 Stakeholder engagement

2.10.1 Stakeholders

The redevelopment of CFH will affect hundreds of thousands of patients, as well as the wider health

economy in north London and south Hertfordshire. The future of CFH has been subject to

considerable debate and anxiety over the years and effective stakeholder engagement is essential to

the success of the planned hospital redevelopment. The trust is therefore implementing a

stakeholder engagement strategy and plan. These set out the trust’s approach to both internal and

external stakeholders, the strategic priorities for each stakeholder group and the objectives and key

messages to support the management of stakeholder relationships. Positive stakeholder

engagement has continued since the OBC was prepared. Each of the stakeholders will continue to

be engaged with as set out in the programme’s stakeholder communications and engagement

strategy and plan which is discussed more in section 7.9.

2.10.2 Stakeholder engagement undertaken

In order to gain support for proposals to redevelop CFH the trust has held a series of stakeholder

group meetings to share plans with them and hear their views. The summary output from these

meetings – as well as a log of other communications activities undertaken to date - is at appendix 2I.

In addition the chief executive and directors have presented plans to overview and scrutiny

committees and held individual discussions with local political leaders and local commissioners. The

trust has been clear that all services set out by the BEH clinical strategy will be provided on site with

some additional activity transferring from BH to CFH (e.g. elective surgery) which are viewed as

necessary to optimise CFH as a planned healthcare facility and to enable BH to provide emergency

services more effectively.

In undertaking engagement work with external stakeholders, the trust has taken care to ensure that

staff (particularly at CFH) are informed of the progress of redevelopment plans. Staff are regularly

kept updated on the progress of the redevelopment through a variety of channels, including:

the trust intranet (Freenet)

weekly emails to all staff (Freemail)

fortnightly emails to managers (Managers’ Briefings)

ward memos to senior staff

chief executive briefings every month

distribution of redevelopment newsletter to all wards and departments

identification of communication champions to help disseminate information.

In order to facilitate further engagement with staff, patients, visitor and residents the Chase Farm

‘redevelopment hub’ was opened in March 2015. The hub acts as a drop-in centre where people can

view the plans, ask questions and leave feedback. To date over 500 people have visited the hub,

with an almost even split between staff and members of the public. Feedback has generally been

very positive, but areas of concern commonly raised include questions around the services that will

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operate in the new build (in particular whether A&E will return to CFH) and the provision of parking

spaces.

Further public engagement events took place late in July and in September to give local residents

and stakeholders the chance to see the latest designs ahead of the submission of the reserved

matters planning application in September 2015. In July and August 2015 the trust also

implemented a communications plan to ensure that staff, patients and visitors were fully informed

of the service relocations that took place on the hospital site as part of the decant and enabling

works.

The trust continues to keep key stakeholders informed and to address concerns raised. In response

to stakeholder queries we are making clear how we have arrived at the current hospital design, and

will continue to clarify that we have enabled significant expansion space so that the future health

needs of the local population can continue to be met.

Clinical engagement is essential to ensure that the redevelopment meets clinical requirements. In

order to ensure that the clinical community is fully engaged in planning for the new hospital, an

“accelerated learning event” was held on 8 October 2014. A total of 137 clinicians and senior

managers were given the latest information on our plans to develop the site and were asked for

their input into finalising the brief and shaping the facilities. A further clinical away day was held on

16 April 2015, attended by 101 clinicians and senior managers to carry out more detailed work on

IM&T innovation, workforce planning and external communications. Since then, there has been

intensive clinical engagement in the form of 160 hours of meetings with clinical workstreams to

validate activity assumptions, develop operational policies, shape the design development and

identify future workforce models. In addition, workforce planning sessions attended by approx. 60

clinicians each were held on 26 June and 31 July to develop affordable workforce models signed off

by senior clinical staff.

Feedback from internal and external stakeholders has been taken into account where possible.

Input from staff also contributed to the consideration we have given to retaining the Highlands wing

for use of rehabilitation wards. Local concerns about traffic and parking resulted in the trust

undertaking additional surveys in order to ensure that the impact of proposals on the local transport

infrastructure is manageable.

The trust is committed to ensuring that equality and diversity groups are engaged and have

opportunities to make their views heard. An equal access group has been established at Chase Farm

Hospital, with members representing a variety of equality and diversity groups in the Enfield area.

The first meeting was on 13 July 2015 and included an overview of the project and an opportunity to

ask questions. The redevelopment will be discussed at further planned meetings of the group, and

any matters raised will be fed back to the project team. Representatives of different equality and

diversity groups have also been included on external project mailing lists and so will be periodically

kept informed and invited to stakeholder events.

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The trust presented the Chase Farm redevelopment proposals at the Enfield Health and Wellbeing

Board in February 2015, where the proposals were supported.

A letter of support for the scheme from the trust Medical Director and Director of Nursing is

attached at appendix 2J.

2.10.3 Commissioner engagement and support

As explained in 2.2.2 the natural core catchment of Chase Farm Hospital is dominated by three CCGs

(Enfield CCG, East and North Hertfordshire CCG and Barnet CCG). These three CCGs were therefore

named in the transaction agreement for the acquisition as the lead commissioners for supporting

the business case, and to act as such for all other commissioners.

The chief officer of Enfield CCG, the area within which the hospital lies, is a founding member of the

programme board for this development. Being in the best position to judge how the development

should proceed from a commissioner’s point of view having been involved also in the BEH clinical

strategy, amongst their role on the board is to act as the representative for the other two CCGs.

As stated in section 2.2.2 the three CCGs’ commissioning intentions for 2015/16 were considered in

the context of this development. No new factor was identified in them that should prompt a review

of the functional content. The trust will in the same way examine the local CCGs’ five year plans

when they become available.

The strategic outline case was forwarded to the three CCGs. The summary activity brief and

assumptions that form the basis of this outline business case, and as discussed at the programme

board, were provided to the three CCGs in October 2014. Subsequently the OBC was made available

to the lead CCG and all confirmed their support for it in writing. Successive drafts of this FBC have

subsequently been provided to the lead CCGs.

The trust has held a series of stakeholder meetings in Enfield to show the developing plans to

statutory partners and members of the public. CCG staff have attended some of those events. Trust

staff attended the governing body meetings of Enfield CCG in December 2014 and September 2015,

Barnet CCG in December 2014, and East and North Hertfordshire CCG in January and June 2015, to

remind members of the scope and timetable for the development, and to answer any remaining

commissioning and other questions.

A letter of support is attached at appendix 2K.

2.10.4 Barnet Enfield and Haringey Mental Health NHS Trust engagement

Barnet Enfield and Haringey Mental Health NHS Trust (BEHMHT) own and occupy the site adjacent

to Chase Farm Hospital. There has been regular dialogue between them and RFL during the

development of the OBC and FBC. Access to the mental health estate will be maintained throughout

the construction and post construction period in accordance with the access rights reserved…

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Both have reviewed consequences for hard and soft FM delivery, both in the construction period

and in the post redevelopment operational phase. Details of the implications and solutions are

detailed in the commercial case.

2.10.5 Impact on other service providers

No significant impact on clinical services is expected on any other NHS provider from the new

hospital. The use of chemotherapy for solid organ cancer is to deal with the forecast growth in those

cancers in the Enfield area2. However even these forecasts were calculated before NICE’s revised

“Cancer referral: recognition and referral” guidelines that were published in June 2015, and that are

expected to increase referral rates beyond those previously forecast by being based on a positive

predictive value of 3% compared with the previous 5%. All providers of cancer treatment services

will need to respond to these factors whilst still meeting the associated waiting time standards.

2.11 Benefits

A benefit realisation strategy has been adopted to set out a vision for the benefits to be gained from

the redevelopment of CFH. The benefits have been quantified wherever possible and to ensure that

they can be measured and demonstrated over time. This is consistent with the approach to benefits

realisation adopted for the integration programme.

The overall benefits of the redevelopment were identified at OBC stage as follows and remain

unchanged:


standards;


community of Enfield, north London and south Hertfordshire about the safe future of Chase

Farm Hospital and the importance the NHS strategically places upon it;










2 http://www.enfield.gov.uk/healthandwellbeing/downloads/file/116/projections_report

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2.12 Constraints, dependencies and key assumptions

The key dependencies have been reviewed during the development of the FBC. The following have

been identified as key to successful implementation of the scheme:

obtaining reserved matters planning permission;

maintaining commissioner support for proposals;

obtaining a financially acceptable agreement with a developer for the land disposal;

obtaining a commercially acceptable agreement (GMP) with IHP for the redevelopment;

obtaining a commercially acceptable agreement with an ESCo for the CHP development;

approval of FBC by trust board;

timely approval of FBC by Department of Health and Her Majesty’s Treasury;

timely review by Monitor to provide risk rating.

successful implementation of projects affecting services currently on the CFH site excluded

from the brief (summarised in appendix 2D).

Key constraints include:

consideration of other stakeholder proposals for the site within an acceptable timescale;

delivery of required savings before 30 June 2019 when transitional funding support stops;

town planning consent and conditions affecting affordability;

road access must be maintained to BEH mental health trust and Kings Oak hospital

throughout works.

The redevelopment is planned on the basis of the assumptions that:

the trust will not be acquiring land to facilitate the redevelopment;

some land disposals (parcels A and C) will commence before FBC approval;

no changes to services are taking place that would require public consultation;

land will be sold to help fund the cost of the redevelopment;

the redevelopment at CFH will be consistent with and support the BEH clinical strategy;

implementation should minimise disruption to clinical services.

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3. Strategic case – design and construction

3.1 Design quality and philosophy

3.1.1 Overarching design principles

Designs have been developed with the design team (including the trust’s healthcare planner) as well

as clinical and non-clinical working groups, and are attached at appendix 3B. HBN derogations have

been agreed and signed off concurrently, and are attached at appendix 2G. Clinical leads, infection

control, engineering, IT and fire officers have signed off these designs which were then verified at

the Chase Farm Redevelopment Operational Steering Group.

Consideration of the clinical and non clinical operational requirements has been given including:

departmental relationships and adjacencies to reflect inter-departmental movement

between each area, for patients, staff and goods;

careful planning of room and departmental relationships to maximise daily and weekly

availability throughout the working week;

creation of rooms and facilities that are multifunctional in use which offer easy opportunity

for flexibility as well as being dedicated to specific specialities;

a design which will allow clinical rooms to be well supported by non-clinical facilities,

regardless of specialty;

standards and room sizes to reflect the function and the activities for which the space is

designated;

the ability to adapt and change to meet future changing demand;

consideration of environmental impact and sensitivity to the characteristics of the local and

immediate surrounding area.

3.1.2 Development Control Plan (DCP)

A Development Control Plan has been developed for the site in conjunction with the CFH

Redevelopment Project Team (responsible for enabling works and the new build), and CFH Capital

Group (responsible for the capital programme to 2020). This is attached as appendix 3A.

The DCP sets out diagrammatically, the various phases of works required to complete the scheme,

including decant, construction logistics and disposal and development of the residual site for

residential and education use. It also demonstrates how site access, traffic routes and bus stop

provision are maintained throughout the redevelopment. The steps shown in the DCP broadly

encompass:

the existing site prior to the start of works in May 2015;

construction work in preparation for service decants (now complete);

service decants away from the construction site (now complete);

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enabling works before construction of the new hospital;

demolition of existing buildings within construction site;

site office set up;

construction work to start;

completion of first residential construction and key stage 1;

construction and completion of the new multi storey car park;

completion of the new hospital building;

phase 2 construction work;

extension of Hunters Way and development of remaining site for residential;

development of site complete.

The works undertaken to date and planned to provide vacant possession to land parcels A-C is

detailed in section 6.10.

3.1.3 Drawings

The signed off 1:200 designs, list of 1:50 designs and elevations for Highlands and the new build are

included in appendices 3B, 3C and 3D respectively.

As part of the design team, IHP has appointed a healthcare planner who has attended all design

meetings and been instrumental in developing an agreed design which supports the service model.

The trust also has a healthcare planner who has led the drawing reviews from a clinical perspective.

The adjacencies matrix is enclosed in appendix 3E. This formed part of the brief and showed the

essential clinical and non-clinical adjacencies. Additional information on the service models and

function relationships between departments can be found in the service specifications in appendix

2E.

3.1.4 Flexibility in design

An important element of the design is ensuring flexibility and providing sufficient space for future

expansion and changes in clinical usage, whilst providing a hospital which is not too large and is used

efficiently. A number of factors have been considered in determining how the building may need to

flex or expand in the future, which include demographic changes, epidemiological changes, maturity

of the new pathway models and NHS structural change.

A number of organisations have expressed an interest in being located on the CFH site. The trust is

aware of UCL's ideas for a research institute on the site, and Enfield CCG is looking with NHS England

at the potential for a GP practice integrated with the UCC. In addition, the Barnet, Enfield and

Haringey Mental Health Trust are reconfiguring their services and may wish to relocate the Magnolia

unit to Chase Farm in future. The trust may also look to expand elective surgery, subject to

commissioners’ requirements.

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In order to address the potential need for service expansion in the future, and to enable the trust to

accommodate additional services if required, the design includes high levels of flexibility. The

challenges set by the trust to the design team in the brief have been three-fold:

ensure that the design is flexible so changes can be made to the new building internally with

minimum disruption to other services and cost;

design the building in such a way that is both efficient at day one, yet enables ease of

expansion at a number of levels, either horizontally or vertically, in the medium term;

strike a balance between retaining sufficient land for long term healthcare development,

with maximising that available for disposal to fund the initial scheme.

The CFH future expansion strategy is included in appendix 3F, which sets out opportunities for

expansion (overlaid on the designs for the base scheme) and design features included in the base

scheme design to facilitate expansion. They include:

departmental layouts which give access to expansion areas via corridors or non-clinical

rooms (e.g. store rooms) to allow the existing departments to operate whilst extensions are

built

increased foundations and frame to allow expansion space to be built without complex and

expensive structural enhancements

increased structure on roofs and stub columns to accommodate vertical expansion

spatial allowance in the energy centre to enable additional plant to serve the expansion

areas

incoming building services sized for future expansion

location of external plant concentrated on the central roof to avoid plant relocations

required for expansion

3.1.5 Sustainable development

In line with LB Enfield planning policy, DH targets and national guidance, the new build has been

designed to achieved BREEAM ‘excellent’ and Highlands to achieve BREEAM ‘very good’, as

confirmed by the pre-assessments at appendix 3G. TB&A have estimated energy consumption of

the new build to be 45 GJ/100m3, which is well within the DH energy target of 35-55 GJ/100m3 for

new builds.

Measures included in the build and M&E design to achieve DH targets and Building Regulation

requirements include:

inclusion of a CHP energy centre serving the new build, Highlands and car park which will

decrease energy consumption and carbon emissions. The CHP will have the flexibility to be

extended, which would derive economies of scale and further reduce the trust’s costs and

emissions;

boilers will be high efficiency units operating at higher seasonal efficiency owing to the

district heating system;

photovoltaic panels will provide some renewable energy;

water usage on the hospital site will be minimized through tap selection;

71

LED lighting to be used in the Highlands refurbishment areas as well as the new build;

lighting control will be provided to areas of new healthcare and Highlands to ensure lighting

operation only when spaces are occupied and ambient light is insufficient;

fan energy will be reduced through lower resistance distribution system providing lower

Specific Fan Power;

the trust is using materials with low embodied carbon and which can be sourced responsibly

where possible;

fuel consumption from site transport will be monitored and minimized;

the building will meet the appropriate acoustic performance standards and testing

requirements for sound insulation, indoor ambient noise level and reverberation times;

the building fabric has been designed to maximise efficiency, incorporating A or A+ Green

Guide rated insulation material to reduce heat loss and reduce solar gain;

chillers are high SEER (Seasonal Energy Efficiency Ratio) as well as high Coefficient of

Performance;

inverter drives will reduce fan and pumping energy through lower input energy rather than

resistive restriction of flow for both constant volume systems and systems with variable,

demand-lead flow.

3.1.6 M&E design principles and energy efficiency

The approach adopted when designing the M&E elements of the scheme has been to achieve HTM

compliance wherever possible and practical within the trust’s capital affordability envelope. In

addition, the design team has made use of the P21+ standard components and rooms. The HTM

derogation schedule for the new build is included in appendix 2G, which demonstrates that there

are few significant derogations from HTMs. Areas where derogations have been made include the

selection of P21+ standard air handling units which achieve the same number of air changes as

stipulated in HTMs, but do not include additional items such as internal lighting for maintenance. In

other instances the HTMs have not been updated in line with HBNs or technological advancements,

requiring some deviation from HTM recommendations. All derogations have been signed off by the

trust.

A key element of the M&E design has been to incorporate the level of building flexibility required by

the trust. All major plant and infrastructure elements including the CHP energy centre have been

assessed and designed to either be large enough to serve future areas of hospital build and buildings

on the disposal site where applicable (e.g. primary pipework is large enough to cope with maximum

expected capacity), or are capable of being upgraded should the need arise (e.g. risers are over-

sized to accommodate additional M&E in future, standby generators can be ‘bolted on’ to the

planned provision). A full schedule of the allowances made for expansion of plant and infrastructure

can be found in the expansion strategy in appendix 3F.

Further details of the approach taken to M&E design and a summary of the plant and infrastructure

elements included in the design is included in appendix 3I.

72

3.1.7 Highlands Wing

The redevelopment programme includes works to Highlands to improve the facilities for the

rehabilitation beds. The rehab service is currently located on part of the ground floor of Highlands

and will remain there but will expand into the whole of the ground floor. The trust and IHP have

reviewed the works required on the ground floor of Highlands and developed a schedule of works

accordingly. The full scope is attached at appendix 3J but in summary includes the following:

new nurse call system

the addition of en-suite bathrooms to all bays and bedrooms, converting the 4-bed bays

into 3-bed bays

space reconfiguration to create a multi-disciplinary team meeting room, gymnasium,

treatment space and dayroom

creation of additional single en-suite bedrooms including a bariatric en-suite bedroom

works to electrical supplies

replacement of lighting in the refurbished areas

replacement of existing raw water tanks in plant rooms and booster pumps within the West

plant room

new LTHW and mains water branches will be extended from the new energy centre, into

the Highlands roof plant room.

the CT pump in the West plant room will be replaced.

a new oxygen branch will be extended from the new site wide ring main emanating from

new primary and secondary VIE plant located in the energy centre.

provision of cooling.

The works will be undertaken by IHP in 2018 following the moves of services into the new hospital.

This will free up space on the first floor of Highlands for rehab to decant into whilst the works are

undertaken to the ground floor.

Trust backlog programme of works The works detailed above will happen in 2018. As part of ongoing trust backlog works, there will be

additional works undertaken to Highlands as part of a five year plan. This is attached at appendix 3J.

Highlands first floor The assumption as part of this redevelopment is that the first floor will be vacant following

completion of works.

The decision on the best use for this will be decided as part of a separate business case by the trust

and will look at opportunities including the relocation of Magnolia Ward (a rehabilitation facility

currently at St Michael’s Hospital) to this space.

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Once the future use of the first floor is confirmed, appropriate works will be undertaken to make the

space functional and fit for purpose. The funding would need to be identified in that business case.

Phasing and co-ordination of works The refurbishment work in Highlands will take place in a number of phases which will involve

decanting rehab from the ground floor to the first floor in 2018. Following surveys of the installed

systems, a review of the refurbishment works planned and discussions with the clinical

representatives and health planners has taken place. A number of phasing options have been

identified and these are currently being analysed to phase the work in the most efficient and cost

effective manner, whilst limiting the impact of the works on operational clinical spaces. Additionally

the refurbishment works are being co-ordinated with the delivery of the trust’s backlog maintenance

plan to ensure that areas are affected for the minimum period of time possible and all works

necessary to any areas are completed in one shutdown.

3.2 Design compliance and reviews

3.2.1 Compliance with DH consumerism requirements

The table below sets out how the design addresses consumerism issues.

Table 3.1 Design response to consumerism

requirement how addressed in design of the new

build

how addressed in design of

Highlands

a. a design that provides

acceptable levels of

privacy and dignity at

all times.

separation of sexes where

applicable.

high proportion of single bedrooms

with ensuite bathrooms. Two single

sex multi bed rooms with ensuite.

patients will usually change within

oversized exam rooms not in

separate change cubicles. Where

this is necessary discrete wait areas

have been designed in.

separate waiting areas for adults,

children and the elderly where

appropriate.

glazed screens and windows will

have manifestations where

appropriate to avoid overlooking.

patient bed lifts separate from the

main visitor lifts.

increased bathroom

provision.

no leaving the bedroom to

enter bathrooms

b. gender specific day surgical patients will have a short length the model for rehabilitation is

74


build


Highlands

rooms. of stay (c.1.3 days) and specific gender

day rooms are not deemed necessary.

There is therefore one day room in each

ward, neither of which have been

designated gender specific at this point.

that patients will be expected to

be dressed in their own clothes

during the day. Gender specific

dayrooms do not align with

facilitating the social aspects of

the rehabilitation service model.

There is therefore one day room

in each ward, neither of which

have been designated gender

specific at this point.

c. high specification

fabric and finishes to

reduce lifecycle costs.

materials are HBN and P21+ compliant

for robustness and fit for purpose.

Additional protection will be provided as

deemed necessary to prevent damage.

materials are HBN and P21+

compliant for robustness and fit

for purpose.

d. natural light and

ventilation

natural light has been a

fundamental principle for the

building design to date. Double

height spaces and views out over

the landscape have helped influence

and form the building architecture.

all theatres to have windows.

all bedrooms and offices to have

windows.

the building will be fully sealed to

ensure we meet the HTM

requirements for air changes.

all rooms in the existing building

have windows which can be

opened. This functionality will be

retained.

e. zero discomfort from

solar gain.

the building has undergone full

environmental modelling and the building

will have both solar control glass and

brise soleil to the southern elevations to

counter any solar gain.

Internal blinds will be provided to

facilitate personal control of sunlight.

solar gain discomfort will be

tackled using internal window

measures; e.g. blinds. This will

be finalised during the detailed

design.

f. dedicated storage

space to support high

standards of

housekeeping and

user safety.

all departments will have their own

cleaner’s rooms. Each floor has a larger

cleaners hold to store large floor cleaning

equipment and consumables. A variety

of storage rooms is provided within each

department, supplied from the lower

ground floor FM storage area.

cleaners’ rooms, store rooms and

utility rooms provided.

g. dedicated storage for each department has its own disposal waste disposal stores c63/00/57

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build


Highlands

waste awaiting

periodic removal

hold. and 63/00/117

h. in-patient bed room

configurations of >50%

single en-suite and >5

bed bays with

separate en-suite WC

and shower facilities

with 3.6m bed centers

85% of surgical beds are accommodated

within single rooms. The two multi-bed

rooms have bedhead separation of 3.7m.

Overall, 57% of beds in the new hospital

are accommodated within single rooms.

27% of beds accommodated

within single rooms. Single, 2-

bed and 3-bed rooms all have

doors and en suite WC and

shower facilities. Multi-bed bays

achieve 3.6m bed spacing.

Overall, 57% of beds in the new

hospital are accommodated

within single rooms.

i. single sex washing and

toilet facilities

en suite washing and toilet facilities

provided to all single rooms and multi-

bed bays. All disabled/assisted WCs are

unisex.

en suite washing and toilet

facilities provided to all single

rooms and multi-bed bays.

j. safe and accessible

storage of belongings

including cash

facilities will be provided for safe storage

of patient belongings. There will be a

cashiers office for large volumes of cash

or very valuable items.

the same arrangements will be in

place for Highlands

k. immediate access for

patients to call points

for summoning

assistance

the system will be designed to meet all

relevant HTM requirements for patient

call requirements. There will be a

handset with nurse call button at each

bed location.

the same nurse call system will

be installed in the new build and

Highlands. There will be a

handset wish nurse call button at

each bed location.

l. patient control of

personal ambient

environmental

temperatures

the new build will be a fully mechanically

ventilated facility. All individual rooms

will have their own temperature control.

Multi bed or open plan zones to be

controlled by the staff.

all rooms have windows which

can be opened. These will be

retained.

m. task lighting at bed

head conducive to

reading and close

work

task lighting will be provided. task lighting will be provided.

n. patient bedside

communication and

entertainment

systems

infrastructure to support this is included

in the scheme. Hardware will be

obtained separately by IM&T.

the same patient bedside

communication and

entertainment systems will be

provided in the new build and

Highlands.

o. elimination of mixed ward accommodation consists of single ward accommodation consists of

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build


Highlands

sex accommodation

(2011).

room or gender specific multi-bed bays.

The endoscopy unit has been designed to

match the trusts current design using

‘pods’ for patients to change/wait in.

There is no requirement for separation of

the sexes each room having privacy

doors/curtains.

single room or gender specific

multi-bed bays.

Percentage of single rooms

The OBC committed to meeting the single room requirements of the surgical and rehabilitation

services in the final design. The clinical brief required a majority of single rooms for surgical wards,

and a majority of multi-bed bays in rehabilitation to reflect the patient group. This is now reflected

in the final design with 57% of beds overall being located in single rooms with 85% single rooms in

the surgical wards and 27% single rooms in rehabilitation.

Clinical review and sign off

All 1:200 and 1:50 designs have been developed in a series of user consultation meetings and then

signed off by departmental representatives. Additionally, the OSG and Programme Board have

signed off the site plans and 1:200s. 1:50 designs have also been reviewed by members of the OSG

to provide an additional level of assurance.

The service specifications and workforce plans have also been developed and signed off by the

clinical teams. This has taken place at trust wide senior clinical and operational workshops,

divisional meetings and speciality specific meetings where necessary.

3.2.2 DQI design review

As part of the design development, the trust has undertaken a stage 3 DQI process. A workshop was

held with representation from the estates department, clinical staff and the design team. Attendees

gave the design particularly high scores for functionality and impact, where they felt the scheme met

almost all of the quality indicators set. It was felt that the current design went a long way to

resolving the access and visibility issues that were concerns with the OBC design. Build quality was

also felt to be good, although at the time of the workshop the engineering services had not been

developed sufficiently to be assessed.

The DQI assessment report is included in appendix 3K.

3.2.3 Health technical memorandum (HTM) compliance

As described in section 3.1.6, the most significant derogation from HTMs in the new build is the use

of P21+ air handling units which are considered fit for purpose and more cost effective than HTM

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compliant units. The remaining derogations are in areas where the HTMs have not been updated in

line with HBNs or technological advancements. A full schedule of HTM derogations in the new build

is included at appendix 3L.

The M&E provision in Highlands wilgarl include more derogations, as it is a refurbishment rather

than a new build so elements such as the air change units which are fit for purpose but are not HTM

compliant will be retained. The HTM derogations in Highlands are included at appendix 3M.

3.2.4 Health building note (HBN) compliance

The HBN derogation schedule, which covers the new build and Highlands, is included at appendix

2G, which shows that majority of derogations from HBNs in both buildings are insignificant. The

most noteworthy derogation is that of the clean and dirty utilities in the out-patient departments,

which are significantly smaller than the HBN recommended size (8m2 as opposed to 12-14m2). This

is because the out-patient department has been designed in zones, each with a clean and dirty utility

to minimise travel times between these and clinical rooms, whereas the recommendations in HBNs

relate assume one clean and dirty utility in the whole out-patient department. All HBN derogations

have been signed off alongside the designs by clinical teams, and by FM and infection control where

appropriate.

3.2.5 NHS control of infection and decontamination

The infection control team has reviewed the 1:200 and 1:50 designs and confirmed that these are

compliant with trust standards.

3.2.6 Fire safety

A fire strategy has been completed. The NHS Authorising Fire Engineer has reviewed this along with the designs and a letter of support is attached in appendix 3N. All designs are compliant with FireCode.

3.2.7 Equality and diversity

RFL has a commitment to ensuring that services and employment practices are fair, accessible and

appropriate for all patients, visitors and carers, as well as the talented and diverse workforce

employed.

Within the design, many of the needs associated with people with mixed physical abilities, LGBT and

cultural diversity needs are being addressed through the increase of single bedrooms within both

the new build and Highlands compared to the current hospital accommodation, the elimination of

mixed sex accommodation throughout, and compliance with BS8300 code of practice for access to

buildings for disabled people, (fully on the new build and increased within Highlands). The needs of

people with dementia related conditions will be directly addressed during the detailed design

process to GMP, through light, reflection, colour and texture.

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3.3 Information technology The IM&T strategy is included at appendix 6G, and outlines the vision for a digital Chase Farm

Hospital, balancing innovation with making use of existing systems on which the trust has

intentionally standardised.

The works to the new build and Highlands provide the infrastructure and capability to support

developments in future. They will incorporate a resilient medical grade network which is capable of

supporting wireless and fixed network connections, video, data and voice services. Data points will

facilitate implementation of Cerner Smart Rooms in the future, and wireless services will enable staff

to use mobile devices throughout the hospital. Existing IM&T equipment, which is currently

undergoing a trust-wide refresh, will be transferred to administration and education facilities in the

new build. Triple monitors will also be provided in all consulting rooms to facilitate direct access to

patient records and imaging during consultations. Additional IM&T hardware and systems will be

subject to a separate trust wide business case and funded through a separate IM&T budget.

More detail on the approach to IM&T is included in section 6.6.

3.4 Travel plan

A travel plan was submitted to Enfield Council as part of the outline planning application. No

changes to this were requested as part of the resolution to grant outline planning, or have been

made subsequently.

The travel plan sets out the trust’s plans to encourage staff, patients and visitors to use sustainable

modes of transport to the hospital. Details include:

green travel noticeboards in patient areas, providing location maps of the site and plans of

walking and cycling routes to local destinations and public transport information

dedicated webpage with travel information

lockers, storage and shower facilities for staff wishing to walk or cycle to work

bike to work scheme (to enable staff to purchase a bicycle for a reduced price) and cycle

training

season ticket loans for staff wishing to travel to work by public transport

a car sharing database

increasing flexible working arrangements, reducing the need to travel to work

The travel plan addresses parking at the hospital. The trust will implement the following measures:

provision of an appropriate number of parking spaces for disabled badge holders

patient and visitor parking based on a simple tariff system

drop-off zones for patients and for staff attending emergencies, with parking for up to 20

minutes

staff parking permits for staff who meet a set of criteria, which will be paid for by a monthly

deduction from their salary.

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The travel plan will be monitored for the first five years after the building becomes operational. This

will enable the trust to review the success of the measures outlined above, and the need to amend

or introduce new measures.

Car parking

A multi-storey car park currently exists on the CFH site, providing 526 spaces. Additional surface

level parking brings the total spaces at CFH to approximately 1100 spaces. The redevelopment and

associated land disposals will result in the loss of all surface level parking. To address this reduction,

the trust, supported by its transport consultants, has undertaken a series of car parking audits to

assess the level of current demand, together with modelling of the likely impact of staff number

changes as a result of the new development. The trust is also undertaking a review of future car

parking policy for staff and patients across all its sites. The original audit, together with an

assessment of measures that would be introduced to encourage greater use of alternatives to car

use, suggested that a level of 900 spaces would be required on completion of the scheme, to be

delivered via an additional multi-storey car park. This was approved by the LB Enfield as part of the

Outline Planning Resolution to Grant.

10% of public parking will be exclusively allocated to Disabled Badge holders, and will be located as

close to the hospital entrances as possible. These marked bays will be free of charge and will allow a

maximum stay of 3 hours. The car park design will follow the principles and best practice set out in

HTM 07-03 and Secured by Design. Parking for other patients and visitors will operate with payment

on exit to avoid patients and visitors making unrealistic estimates of how long they think they will

need to park. Charges will apply 24/7 and the payment system will be advertised at pay points and

on the website. A limited number of drop-off spaces will be provided at the hospital, at which free

parking will be allowed for a maximum of 20 minutes. A weekly ticket discount will continue to be

provided to those patients who need to attend hospital frequently.

Staff attending emergencies and or loading/unloading will be entitled to use the drop off zones, for a

period of up to 20 minutes. Staff wishing to park for longer will need to apply for a permit. These

will be granted to permanent staff on site who are directly employed by the trust and meet a set of

criteria including distance from site to home, requirement for night shift work and other essential

operational need.

3.5 Summary of changes in design since OBC

The design has undergone development since OBC having brought in a new design team. The design

principles including flexibility and future expansion have not altered, however the following changes

to the design have been made:

a slight adjustment to the location of the new building to facilitate improved opportunities

for expansion and to minimise the number of decants required;

80

the design reflects value engineering exercises to reduce the capital cost without

compromising quality;

the design incorporates improved departmental layouts;

percentage of single rooms adjusted to meet the clinical brief in the surgical and

rehabilitation wards; and

retention of rehab in Highlands (as per change in preferred option – see chapter 4).

Schedule of accommodation

The FBC schedule of accommodation (SoA) has been updated based on an agreed set of recent

activity data and incorporating each service’s clinical requirements based on the planned models of

care which have themselves been subject to further development work since the OBC was

completed. A comparison of gross internal floor areas (GIFAs) is shown below:

Table 3.2 Schedule of accommodation changes between OBC and FBC

OBC m2

FBC m2

Entrance 280 216

UCC (inc GP OOH, OPAU, PAU) 1,429 1,434

Endoscopy 1,386 884

Imaging 871 784

Outpatients 3,713 3,012

PITU / Chemotherapy 519 511

MSK 239 261

Theatres 3,089 2,739

Surgical wards 2,052 2,023

Rehab wards 1,919 1,684

Sanctuary (multi-faith room) 54 49

Education, admin and staff areas 1,474 1,201

FM 909 917

Commercial 822 489

Pharmacy 194 191

Pathology 73 53

Communication (New Build) 2,853 3,094

Plant (New Build) 2,853 2,803

Wall areas and voids (New Build)

Included in departmental

measurements above 1,321

Communication, plant, walls and voids (Highlands)

Included in departmental

measurements above 835

TOTAL 24,729 24,501

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The change in floor area represents design development work to improve operational efficiency and

value for money in line with departmental requirements agreed with clinical teams. Changes to

functional content since OBC are summarised in section 2.9.

Capital cost

The summary table below shows the changes in capital cost from OBC to FBC.

Table 3.3 High level cost changes between OBC and FBC

The following three tables provide a detailed breakdown of the changes to the capital cost for each of the

three elements of the project – healthcare, car park and energy centre.

Table 3.4 Detailed cost changes between OBC and FBC - healthcare building

Table 3.5 Cost changes between OBC and FBC -car park

Table 3.6 Cost changes between OBC and FBC – energy centre

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3.6 Implementation

The summary master programme is attached at appendix 3O. This covers the main activities and

milestones to deliver the redevelopment.

Construction programme

A detailed construction programme is also attached, in appendix 3O.

Decant works have been undertaken to clear the proposed site of the new hospital. This involved

the relocation of a number of services to other locations on site, the most notable being the move of

the UCC to medical block which was successfully achieved on 4 August 2015.

Packages of enabling works are being commissioned ahead of the main construction works. These

works include:

asbestos surveys and removal to vacated buildings (UCC, ante-natal, rheumatology, OPAU

and maternity)

building services isolations and diversions to construction site

erection of site hoardings and site set up

demolition of UCC, ante-natal, rheumatology, OPAU and maternity

reduce level dig

piling mat and piling.

The main construction programme is currently due to commence in January 2016 for a period of 113

weeks. This incorporates construction of the concrete frame (March 2016-Jan 2017) and internal fit

out (Sept 2016 – Jan 2018). The new hospital building will be completed in April 2018 for handover

to the trust, following completion of the Energy Centre in April 2017. This will allow a 12 week

commissioning period, including the transfer of general surgical beds from Highlands Wing first floor.

This will facilitate the decant of rehabilitation beds to enable the refurbishment works to Highlands

ground floor to commence. From July 2018 the new hospital will operate with a temporary entrance

while works are undertaken to clear the route and construct the new main entrance plaza and road.

The scheme will be finally completed in April 2019 with the handover of Highlands and the

relocation of the rehabilitation wards to the ground floor.

It should be noted that while the current programme shows the new hospital opening in July 2018,

the trust is working to reduce the construction programme.

Outline commissioning programme

The trust has also prepared a draft outline commissioning programme for the redevelopment

(attached in appendix 3P). The purpose of this programme is to identify the interfaces with IHP for

agreement prior to contractual sign off and identify the key activities and milestones for operational

commissioning activities before and after handover for the building. This programme will be further

developed with stakeholders during construction to ensure that there is a robust plan for bringing

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the new facility into use. The outline commissioning programme demonstrates that the trust has a

grasp of the issues critical to the successful operationalisation of the new build.

Assessment of modular versus traditional construction methods

IHP has carried out an evaluation of the benefits of off-site fabrication compared to more traditional

form of procurement for this project, which is included in appendix 3Q. This concluded that, while

the trust could benefit from off-site manufacture of some components, volumetric modular

construction would increase risk and cost with no overall benefit to the construction programme.

The reasons behind this decision are:

the dissimilar shapes of the four above ground floors would have meant that there was a

reduced amount of repetition making off-site volumetric modular construction less

financially viable;

the changing layouts floor on floor would have introduced significant load transfer steelwork

which, again, would make volumetric modular construction significantly more expensive;

and

having the entire superstructure and fitting out of such a large building in one sub-contract,

potentially with an overseas supplier, would significantly increase risk – no modular

healthcare building greater than 10,000 m² has been produced in the UK.

It was concluded that the second and third floors could be constructed off-site within the time, cost

and quality parameters set by the trust, but that there would be no benefit to the overall

programme as the lower floors would be constructed traditionally.

The evaluation concluded that off-site manufacture of some components would provide high quality

finishes while reducing the programme. The not to exceed GMP therefore includes provision of:

corridor and riser service modules;

self-finished clean and dirty utility wall panels.

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4. Economic case 4.1 Introduction and approach

Summary of OBC option appraisal

A full options appraisal was undertaken at OBC in accordance with the Capital Investment Manual

and requirements of HM Treasury’s Green Book. This identified a preferred option (option 8) which

involved a new build accommodating all services, with the Highlands block being mothballed or

retained for an alternative use (subject to a separate business case). The option had an outturn

capital cost of £xxx (excluding the car park and energy centre), but the trust noted in the OBC that

this number could be significantly reduced through design development, reduction of optimism bias

and some VAT recoverability. In the options appraisal the option of utilising Highlands for out-

patient services (a significant change of use) was also evaluated, but the costs for this were

significantly higher than building a new department for this service resulting in a lower value for

money solution.

The design for the preferred option 8 at OBC was noted as requiring further design development.

This was to address the fact that the surgical and rehabilitation wards had the same layout as they

were stacked vertically in the new build design. It was acknowledged that this did not meet the

clinical brief as it did not support the service models, particularly in relation to the number of single

rooms. The trust therefore committed to achieving a solution for FBC with a majority of single

rooms for surgical wards, and a majority of multi-bed bays in rehabilitation.

Changes since OBC approval

Since approval of the OBC, the trust has appointed its PSCP, IHP, and challenged its new design team

in collaboration with the trust to review the design to meet the clinical brief and reduce costs whilst

maintaining the fundamental design principles and optimising benefits associated with the preferred

option. The trust has sought to continue to improve the quality of the design and the clinical

benefits which can be achieved throughout the design development process. This process has led to

the identification of a new option, option 11, which involves retention of rehabilitation wards in the

ground floor of Highlands, which will be partially refurbished, and construction of a new build

accommodating all other services. This new option, retaining rehabilitation in Highlands, is strongly

supported by clinicians.

Due to the introduction of this new option, and following consultation with DH, this Economic Case

provides a fully updated financial and non financial options appraisal comparing the do minimum,

the OBC preferred option (option 8), and the new option (option 11). This option appraisal was

undertaken in May and June 2015, shortly after OBC approval and before progression into detailed

design of a preferred option. The cost and design information used in the appraisal therefore

represents a point in time before the further design development reflected in the rest of this FBC.

The full economic appraisal can be found in appendix 4A.

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4.2 Results of economic appraisal

The revised appraisal demonstrates that there is no significant difference between options 8 and 11

in terms of value for money. Option 11 achieves higher qualitative scores for clinical benefits, and

alignment with the critical success factors. It is also significantly more affordable to the trust than

option 8, and is therefore the preferred option on this basis.

This decision supports achievement of the project’s critical success factors as follows:

strategic fit – Supports commissioner and trust aspirations to co-locate rehab services, while providing significant opportunities for expansion of other services on the site.

patient centred – Improves the quality of the patient experience in rehab wards due to the ground floor location and separation from the main building. Improves clinical outcomes by promoting integrated care.

value for money – Achieves the same value for money as option 8.

achievability – Some additional disruption will be incurred by refurbishing Highlands, however this will be minimised by carrying out the works after completion of the new build so services can be decanted into this facility.

affordability – This option matches the availability of capital funding significantly more closely than option 8.

The results of the investment appraisal are summarised below: Table 4.1 Option appraisal summary

4.3 Development of preferred option at FBC stage

Following selection of option 11 as the preferred option in June 2015, the design progressed to 1:50 stage and a NTE budget developed for approval in the FBC. The summary of costs for option 11 are as follows: Table 4.2 Option 11 capital cost changes between option appraisal and NTE GMP

86

5. Finance case

5.1 Introduction

The £xxx capital investment to redevelop the current hospital at CFH is a key driver for the

sustainability of the enlarged trust – as originally set out in the transaction agreement for the

acquisition of Barnet and Chase Farm Hospitals NHS Trust in 2014. The investment will deliver

recurrent cost savings which will help eliminate the recurrent deficit at CFH. The capital investment

is funded by a combination of land sales proceeds, public dividend capital (PDC), internally

generated funds, and debt.

This finance case complements the strategic direction set out in the strategic case and the economic

options appraisal. It sets out the projected financial impact of the preferred option on the trust, as

well as demonstrating how the recurrent deficit at the CFH site is eliminated.

5.2 Summary of forecast financial position of trust


Table 5.1 Summary trust forecast financial position

The key drivers of forecast EBITDA growth are clinical income growth due to increase in demand;

QIPP savings; and elimination of CFH deficit due to the capital redevelopment.


WTE are forecast to decrease at an annual compound rate of xxx% driven by delivery of QIPP

savings, and reduction in agency usage.

5.3 Financial rationale for capital investment at CFH

The transaction agreement for the acquisition of BCF sets out the proposal to invest in the estate at

CFH in order to close the historic deficit and secure the long term sustainability of the enlarged trust.

87

At the time of the acquisition of BCF, financial due diligence confirmed that CFH had a significant

recurrent deficit. This deficit was increased by the implementation of the BEH clinical strategy in

December 2013 which set out to reshape healthcare provision in North London while offering

significant benefit to patients.

Financial modelling undertaken for the acquisition business case forecast a BCF recurrent deficit of

£21.3m by FY18 – even after delivery of integration synergies, annual QIPP savings and

commissioner QIPP. This was primarily driven by CFH forecasting a deficit of £19.9m. This model

confirmed the inherent inefficiency of the site. The trust concluded that the most appropriate way

to eliminate the CFH deficit was to invest in the healthcare facility in such a way that enabled a

significant reduction in operating costs. Separately, Ernst & Young (EY) conducted high-level

modelling that indicated that, were the same volume of activity as forecast for Chase Farm in FY15

conducted at national benchmarks of performance, within an efficiently operated site such activity

should generate a net margin rather than a deficit.

The redevelopment of CFH was seen by the parties to the Transaction Agreement as fundamental to

the financial viability of CFH as part of the wider RFL trust.

As part of the transaction agreement, deficit funding cover was agreed with the DH, recognising the

time it would take for the capital investment to proceed and deliver savings. The forecast BCF deficit

is therefore funded by the DH until FY19, after which it was assumed the deficit would be eliminated

as a result of the capital investment.

5.4 Past financial performance of CFH

As part of the BCF acquisition process, Ernst and Young (EY) were engaged to conduct due diligence.

EY devised a site split analysis of all income and costs at BCF which has been used to determine the

I&E position of CFH as a standalone hospital.

CFH made a recurrent deficit in FY14 and FY15. Table 5.2 shows the deterioration in recurrent

surplus between FY13 and FY14. This was due to income loss mainly as a result of the

implementation of the BEH strategy (part year effect in FY14). In addition, some fixed costs

remained at the CFH site as parts of the estate do not provide a clinical service. Non recurrent

income was received in FY14 and FY15 in the form of BEH transitional income of £9.3m and £6.3m

respectively to compensate for the fixed costs remaining at CFH following the transfer of activity

away from the site.

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Table 5.2 CFH SOCI FY13 to FY15

5.5 Forecast statement of comprehensive income – trust

Table 5.3 Trust SOCI – historical and forecast




5.5.1 Clinical income forecast – trust Table 5.4 Trust clinical income forecast

CFH - I&E FY13 FY14 FY15

£m Actual Actual Actual

Clinical income 139.9 116.8 74.1

Other income 20.4 23.3 14.8

Total income 160.2 140.1 88.8

Pay costs (98.5) (79.4) (57.6)

Non pay costs (48.0) (52.2) (42.0)

Total operating expendtiure (146.5) (131.6) (99.7)

EBIDTA 13.8 8.5 (10.9)

Depreciation (5.9) (5.1) (4.9)

PDC dividend (3.0) (3.0) (2.9)

Surplus/(deficit) 5.0 0.4 (18.6)

Normalised surplus /(deficit) 5.0 (8.9) (24.9)

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5.5.2 Non protected income forecast - trust

Table 5.5 sets out the key sources of non protected income.

Table 5.5 Trust non protected income



5.5.3 Other income forecast

Table 5.6 sets out the key other income streams.

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Table 5.6 Other income




5.5.4 Pay forecast Table 5.7 Trust pay cost FY14 actual to FY21 forecast




5.5.5 Non pay forecast

Table 5.8 Trust non pay costs


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5.6 QIPP programme




Table 5.9 Trust forecast QIPP by high level theme




5.7 Impact of capital development on Chase Farm Hospital SOCI




Table 5.10 CFH SOCI forecast

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xxxxxxxxxxxxxxxxxxxxxxxx

5.7.1 Pay forecast




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Table 5.11 CFH pay cost forecast




Table 5.12 forecast movement in WTE at CFH

5.7.2 Non pay forecast




Table 5.13 Non pay costs detail by year




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Table 5.14 Non pay bridge FY18 to FY19 CFH




5.7.3 Activity transfers between BH and CFH




Table 5.15 Clinical income transferring between CFH and BH




Table 5.16 Surplus transferring to CFH from BH

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5.8 Forecast statement of financial position – trust



Table 5.17 Trust summary SOFP



5.8.1 Capital investment




Table 5.18 Trust forecast capital investment by scheme




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Table 5.19 CFH redevelopment capital investment




5.9 Financing of capital

The CFH redevelopment is funded by a combination of PDC, land sales proceeds, debt, and internally

generated cash as set out in table 5.20.

Table 5.20 Funding table for CFH redevelopment



5.10 Forecast statement of cash flows




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Table 5.21 Summary trust SOCF




5.11 Impact on continuity of services risk rating

Table 5.22 COSRR by year


5.12 Risk assessment / sensitivity analysis xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx



Table 5.23 I&E impact of sensitivities

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Table 5.24 Cash impact of sensitivities




5.13 Key modelling assumptions – SOCI




5.14 Key modelling assumptions – SOFP




5.15 Key modelling assumptions – SOCF




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6. Commercial case

This case describes the commercial arrangements that the trust plans to put into place to deliver and

respond to the required works. It builds upon the plans outlined at OBC stage.

6.1 Procurement of built solution

6.1.1 Procurement options

At OBC stage the trust commissioned external advisors Turner and Townsend to conduct a review of

procurement options for the redevelopment. An evaluation was undertaken with members of the

project team and was facilitated by the procurement advisors. The key drivers were identified and a

range of potential procurement options were scored against each driver. LIFT was discounted as it

was established for the delivery of primary care facilities. The options evaluated were traditional,

single and two-stage design and build, construction management, ProCure21+ (P21+),

“Improvement and Efficiency South East” (IESE), SCAPE and PFI. Subsequently, the time impact of

the partnering / framework, PFI and traditional procurement routes was assessed in detail.

The process identified P21+ as the preferred procurement option as it was deemed able to meet the

tight timescales required by the trust whilst also providing access to the greatest breadth of

appropriate health sector construction experience. The framework, which was set up and is

promoted by DH for projects such as this, also provides considerable cost certainty through the

agreement of a Guaranteed Maximum Price (GMP), encourages an integrated, collaborative

approach and involves open-book accounting with clear demonstration of activity schedules and

benchmarked costs.

The CFH programme board agreed to proceed with P21+ on 16 October 2014.

Since approval of the OBC, the trust has made the decision to refurbish the ground floor of

Highlands for the rehab wards, rather than include these in the new build. In order to ensure best

value for money of this element of the scheme, Turner and Townsend were commissioned to

conduct a further procurement review to cover the refurbishment. This concluded that these works

should be included in the existing P21+ contract to avoid duplication of design work and

preliminaries, and to avoid interface and management issues around having two contractors on site.

A copy of the report is included in appendix 6A.

6.1.2 ProCure 21+ principal supply chain partner selection process

The P21+ framework was established by the DH in accordance with EU procurement regulations.

Prospective candidates were selected through a restricted procedure process with the field being

progressively narrowed through a prequalification and then a competitive tender process.

Eventually, six Principal Supply Chain Partners (PSCP) were appointed to the framework.

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In accordance with the guidance, and taking advice from the DH’s P21+ implementation advisor, the

trust set out its requirements in a High Level Information Pack (HLIP). This was issued to all six PSCPs

on 10 November 2014. The PSCPs were invited to submit an Expression of Interest (EOI) outlining

how they would respond to the requirements set out in the HLIP by 24 November 2014. Three

expressions of interests (EoI) were received from three PSCPs. The other PSCPs noted that they

were either unable to take on this scale of scheme or had insufficient resources to submit robust

bids and meet other commitments.

Following a review of the EoIs it was agreed by the Director of Estates and Facilities that all three

PSCPs should be invited for interview. Following an open day on 3 December 2014, the three PSCPs

attended interviews with members of the trust’s project team on 8 December. The selection panel

members were:

Table 6.1 PSCP selection panel

name: position:

Andrew Panniker Director of Estates and Capital Development

Simon Gwynne Head of Project Delivery

Chris Moriarty-Baker Programme Manager, Capital & Estates

Mark Bateman Project Manager, Capital & Estates

Fiona Jackson Director of Integrated care and Chase Farm Director

Karen Kelly Head of Clinical Planning & Design

Sandy Mehta Assistant Director and Senior Procurement Business Partner for RFL

Michael Dinan Director of Finance Operations

Karen Bradley Head of Finance, Corporate Services

Steve Woodward Cost Manager (Turner and Townsend)

Each panel member completed the scoring forms individually. The mean scores from the panel

members scoring forms were entered into the DH P21+ PSCP selection tool, producing the final

result below, which has been partially anonymised.

Table 6.2 PSCP scores and ranking

The key reasons supporting IHP’s winning score were:

a balanced and robust team, who had worked successfully together on previous schemes,

such as Lister and Broadgreen hospitals.

good understanding of the likely design issues and management and engagement of the

clinical teams.

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robust and open approach to cost management

clear commitment to the trust’s challenging programme

relevant and sensible approach outlined to ensuring innovation within the scheme

development and construction.

On this basis, it was agreed by the interview panel that IHP should be recommended to the

programme board as the trust’s preferred partner subject to a number of clarifications and

reference checks. A clarification meeting took place on 9 December, where the team’s capacity and

experience was further scrutinised. This was accepted. The selection of IHP was ratified at

programme board on 11 December and IHP was subsequently appointed in accordance with

standard P21+ procedures.

Turner and Townsend has confirmed that the procurement complies with current legislation as it is a

government framework.

6.1.3 IHP Scope of Work

IHP’s scope of works is as follows:

surveys, outline and detailed design to guaranteed maximum price (P21+ Stages 2 and 3) for

a new hospital build, Highlands refurbishment, car park and a new CHP energy centre.

construction of the new hospital building, Highlands refurbishment and associated works

(P21+ Stage 4) including:

o enabling works consisting of temporary works, decanting, service and road

diversions, a reduced level dig and the reservation of a piling rig

o group 1 equipment

o IM&T cabling and sockets infrastructure.

construction of the additional car park spaces - P21+ Stage 4 (see section 6.4 for more detail

on car parking).

Stage 4 works are subject to agreement of a final GMP and signing of the Stage 4 contract for both

the hospital works and the car park, once the Full Business Case is approved.

The energy centre solution may or may not be procured through IHP dependant on the outcome of

the process being undertaken to procure an ESCo. The solution presented in this FBC is an option

which the trust will compare against the ESCo bids as part of an NPV analysis.

6.1.4 Statement of market interest

IHP is in the process of procuring the packages for the contracts and will submit a GMP to the trust

for agreement in November 2015. Response to sub-contractor enquiries has been generally

disappointing over the last year, particularly in London. Although the supply chain is always

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contacted in advance of an enquiry to describe the project, their works and to establish their level of

interest, it is frequently the case that a high proportion of enquiries are subsequently declined.

This appears to be due to a lack of supply chain capacity which is limiting the responses and also

increasing the level of cost. Forecasts from BCIS and other cost consultancies indicate that the

volume of demand will grow at a slower pace in 2016 and stabilise in 2017, which should lead to a

better response to packages tendered later in the process as the supply chain grows to address the

demand. IHP expects supply chain responses to improve as a result of this, and when it is apparent

in the market that this is a ‘real’ opportunity and not a pricing exercise. IHP will continue to contact

their supply chain partners to ensure a high level of interest is provided, and will continue to factor

market interest into their cost estimates.

6.2 Costs and value for money

A not to exceed (NTE) price has been prepared and submitted by IHP on the basis of the design and

commercial information available to date. The NTE price will be replaced with a guaranteed

maximum price (GMP) which will have a value less than or equal to the NTE price. The GMP will be

finalised once IHP has market tested the various work packages and once Turner and Townsend

have confirmed the GMP represents value for money.

6.2.1 Healthcare building costs The NTE costs for the hospital build (which includes the new build and Highlands) are shown in the

table below. A full breakdown is shown in the cost plan included at appendix 6B:

Table 6.3 Not to exceed GMP breakdown for the healthcare building

6.2.2 Healthcare building benchmarking and value for money The trust’s cost advisor, T&T, has benchmarked IHP’s NTE costs for the new healthcare building

against its own cost database. A copy of the report is included in appendix 6C. The report compared

the NTE construction costs agreed with IHP with a sample of 25 similar healthcare projects. The

exercise excluded (abnormal) on costs and adjusted the sample schemes to the same location and

inflation indices as this project.

The analysis provides a benchmark average of £xxx in comparison to £xxx for Chase Farm Hospital.

This is £xxx lower than the sample mean, which is very close to the benchmark average and within

acceptable norms.

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It is important to note that within these costs, the trust has included works for future flexibility and

future expansion. This carries an additional £xxx on the construction costs, which equates to £xxx; if

this is omitted from the cost for Chase Farm Hospital, the cost reduces to £xxx which is £xxx below

the benchmark average. It should also be noted that some of the plant and infrastructure associated

with the main hospital is included within the energy centre, in order to improve ease of maintenance

and future-proofing of the new build. If these elements were included the cost per m2 would be

increased, but this would be unlikely to push average cost outside of the benchmark range.

T&T conducted a separate analysis for the refurbishment works to be carried out in Highlands. The

analysis provides a benchmark average of £xxx across five similar healthcare refurbishment schemes

in comparison to £xxx for ground floor refurbishment of Highlands. This is £xxx higher than the

sample mean, which is close to the benchmark average and within acceptable norms

T&T therefore concluded that the costs for Chase Farm Hospital compare favourably to the

benchmark samples, and provide a value for money solution for the trust and DH.

6.2.3 Benchmarking of fees, optimism bias and risk allowances

T&T also conducted a benchmarking exercise on the PSCP fees, trust fees, optimism bias and risk

allowances. When schemes are procured via the ProCure21+ National Framework, the benchmark

norm for PSCP fees (which include all design fees) on schemes of this size and nature is xxx%, with a

range at the 25th and 75th percentile of xxx% to xxx%. On this project the PSCP fees, are at the

higher end of the normal range at xxx%. This reflects the re-design to option 11 from option 8,

additional surveys, extensive value engineering and cost planning, developing enabling GMPs,

preparing both an NTE and GMP for the main contract. Trust fee allowances provide for trust direct

appointments, and an element of capitalised fees for the trust in the delivery of the project both pre

and post contract. For these, the benchmark norm is xxx%, with a range at the 25th and 75th

percentile of xxx% to xxx%. Based on the latest cost plan, the current allowance for trust fees is

xxx%, which is higher than the upper quartile of the benchmark sample. The trust is comfortable

with this as it reflects the need to provide sufficient resources to meet the challenging

redevelopment timetable, town planning fees for the hospital and disposal sites, public engagement

expenses to ensure the public is kept aware of developments and the original OBC design fees, some

of which relate to the previous design.

The optimism bias range expected for a project of this size, nature and complexity at FBC is normally

between xxx% and xxx%, although projects do fall outside this range. The current optimism bias

calculation provides an allowance of xxx%, which is normal.

In relation to the risk contingency, dependent upon the risk transfer, at GMP Turner and Townsend

would expect the PSCP to have around xxx% risk and the trust to retain xxx% contingency for

delivery of works on site. Based on the latest cost plan, the current allowance for risk is xxx%. This is

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higher than expected at GMP, however, we are collating a ‘Not to Exceed’ budget and the level of

risk is prudent until a full GMP is provided.

6.2.4 Energy centre costs

It is anticipated that an ESCo may be able to provide the most cost effective energy solution in

capital spend terms, but the procurement of an ESCo will not be complete until after this FBC is

submitted and approved. Therefore a NTE cost for the design and construction of the energy centre

and associated infrastructure has been provided by IHP as an option for the trust. The NTE costs for

the energy centre are shown in the table below. A full breakdown is shown in the cost plan included

at appendix 6B:

Table 6.4 Not to exceed GMP breakdown for the energy centre

The table below shows a high level breakdown of the elements of the energy centre:

Table 6.5 Breakdown of energy centre elements

6.2.5 Energy centre benchmarking and value for money

Attempts have been made to benchmark elements of the energy centre plant costs by CEF but good

comparisons are difficult to obtain for the energy centre owing to the absence of directly

comparable schemes. The preliminary findings on the limited available data, based upon

commercially confidential tendered costs elsewhere, do not give cause for concern. This will be kept

under review.

CEF has modelled the likely running costs based upon its benchmarking information, the energy

requirements and energy savings. These have been incorporated in the trust’s I&E modelling.

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6.2.6 Car park costs

The NTE costs for the car park are shown in the table below. A full breakdown is shown in the cost

plan included at appendix 6B:

Table 6.6 Not to exceed GMP breakdown for the car park

Car park benchmarking and value for money

A copy of the T&T benchmarking report for the car park is included in appendix 6C. The report

compared the NTE construction costs agreed with IHP with a sample of eight similar multi-storey car

park projects. The exercise excluded (abnormal) on costs and adjusted the sample schemes to the

same location and inflation indices as this project.

The analysis provides a benchmark average of £xxx per space in comparison to £xxx for Chase Farm

Hospital (based on 405 spaces). This is £xxx/space. There a number of reasons for this:

planning conditions have dictated additional disabled and family parking, which has resulted

in larger parking bays and increased the overall car park footprint;

bridging between the new multi-storey car park and the existing car park has been included,

which has led to additional construction costs; and

the new build multi-storey car park is being built on a sloping site.

T&T concluded that, on a like for like basis, the costs for the car park falls within an acceptable

benchmark range, and provide a value for money solution for the trust and DH.

6.2.7 Lifecycle costs

IHP have provided lifecycle cost estimates for all elements of the scheme, which are included at

appendix 6D. A summary of these is shown in the table below:

Table 6.7 Summary of lifecycle cost estimates

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These will form the basis of the CFH capital plan for backlog maintenance following completion of

the new build.

6.2.8 Commitment to government construction strategy

The government construction strategy published in May 2011 seeks to encourage the reduction of

construction sector costs to the public sector whilst delivering better value outputs. The strategy

outlines a number of areas of focus for public sector construction projects. These areas and the

extent to which they have been addressed in this FBC are outlined below.

Procurement reform

The strategy states the need for ‘designers and constructors to work together to develop an

integrated solution that best meets the required outcome’ and for ‘contractors to engage key

members of their supply chain in the design process where their contribution creates value’. It

highlights the benefits of an integrated approach, engaging supply chains and incentivisation. It also

outlines the need for incentivising cost and programme efficiency via pain and gain share,

encouraging off site fabrication and genuine integration of tier 1 supply chain partners. The strategy

supports the use of frameworks noting that the benefits outlined above are most effectively

delivered via a well-structured framework environment.

These critical success factors have been fully considered in the trust’s approach to procurement. By

opting to use the P21+ framework, the associated appointment of a combined design and

construction team and, in time, through the P21+ pain/gain share mechanism the trust is able to

benefit from the benefits associated with the approaches outlined in the strategy.

The trust is therefore complying with the intentions set out in the government construction strategy

in relation to procurement.

Government soft landings

The government construction strategy identified the need to improve the alignment of the design

and construction people, decisions and implementation processes with the subsequent operational

phase. Improved integration of these phases with more overt consideration of how improved

operational performance would be achieved during design and construction was seen as a key driver

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of improved asset performance and a smoother transition into operations, leading to improved

operational performance.

This idea was subsequently developed into Government Soft Landings (GSL). GSL is a set of facilities

management-driven requirements for a good-performing building and is set to become mandatory

for central government projects in March 2016 but provides a sensible basis for all projects where

new facilities are delivered. It can be broken down into five key stages:

inception and briefing – ensuring that the client’s needs and required outcomes are clearly

defined.

design development and review – reviewing comparable projects and assessing proposals in

relation to facilities management and building users.

pre-handover – ensuring operators properly understand systems before occupation.

initial aftercare – stationing a soft landings team on site to receive feedback, fine tune

systems and ensure proper operation.

extended after care and post occupancy evaluation (POE) – outstanding issues are resolved

and POE are fed-back for changes to the working environment and for future projects.

In order to achieve this, IHP will engage end users throughout design and delivery process in order to

set and deliver clear targets and measures for the following:

functionality and effectiveness; so that the working environment is conducive to

productivity and social well-being.

operational and capital costs; to reduce costs in construction and operation.

environmental performance; to meet carbon and other sustainability targets.

commission the facility with the inclusion of training in partnership with end users.

assess performance for at least three years post completion to establish outcomes and

lessons learnt.

involve the design team in the early operating phase to tune performance and ensure target

outcomes.

Trust targets and measurements are set out in the benefits realisation plan in appendix 7A. IHP continue to implement GSL through each stage of the project as follows:

setting the brief – subject workshops to set the strategy for environmental control, P21+

standardization and expansion, the outcomes of which were reflected stage 1 and 2 reports

covering proposals for utilities, distribution, resilience, HTM and HBN derogations.

detailed design – design team meetings with trust representatives, specific workshops to

address topics such as nurse call, BMS, security, metering and expansion. IHP also plans to

provide samples and mock-ups to test the design for robustness, ease of maintenance,

physical and technical coordination, and buildability.

delivery – key staff from the trust, including estates, pharmacy and infection control will be

actively involved in the commissioning with respect to witnessing and demonstrating

systems.

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pre-handover – a programme of familiarisation visits and training in building systems will be

instigated for clinical and support staff as well as the estates team.

post-completion – the IHP Initial Aftercare Team will be available to assist with any interface

problems that may occur between the installed systems and the fit-out works and to

continue to respond to queries from hospital staff in the trust’s commissioning period.

Following this, IHP will assist with seasonal commissioning, the post project evaluation and

monitoring building energy performance.

Further details of how IHP will address each element of GSL can be found in the soft landings

strategy in appendix 6E.

Benchmarking and value for money

The government construction strategy states that benchmarking of construction costs, consultants’

fees and departmental administrative costs will be established and used to provide a consistency of

value for money across each programme. This will ensure that projects that sit outside the

benchmark range after accounting for project specific on-costs can be challenged and stopped if

necessary.

On this project the trust’s cost advisor, Turner and Townsend, has benchmarked IHP’s NTE costs for

the healthcare building against its own cost database. Details are provided in section 6.2.

The costs submitted by IHP were based upon a design that was informed by an output specification-

based brief. The trust provided high level information on the list of services to be provided, together

with the planned activity levels for each service, a schedule of accommodation and information on

the functional relationships between these services. It was left to IHP’s health planners and design

team to develop a design that met the brief, leaving scope for innovation as promoted by the

government construction strategy.

The trust has therefore complied with the intentions set out in the government construction

strategy.

Building Information Modelling (BIM)

The government has set a requirement for fully collaborative 3D Building Information Modelling

(BIM), with all project and asset information and documentation being electronic as a minimum by

March 2016. The trust is aspiring to achieve level 2 on the four levels of BIM maturity (0-3) –

providing detailed building information for major items of plant and a 3D interactive model of the

entire facility.

The trust and IHP recognise the value of developing a shared platform for the development of co-

pordinated design and construction information in line with the strategy. IHP have prepared a BIM

strategy which is included in appendix 6F, and will undertake the following tasks:

outline the current parameters of the project

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consider all stages of the project’s life - design, construction, commissioning, hand-over,

after-care, occupation, regular use, future extension, renovation, refurbishment and final

removal

define the employer’s minimum requirements for the Building Information Model

define the Employer’s Information Requirements (EIR) and the data exchanges required at

each stage of the project – concept, developed, technical, construction, handover and in-use

outline any additional aspirations and or goals for Building Information Modelling over and

above the employer’s requirements

determine the feasibility of achieving the additional aspirations and goals and schedule out

all agreed actions

provide details of the aspects of design that will utilise BIM technologies, the proposed

software and the interoperability criteria

identify the BIM standard methods and procedures for drawing standards, layer naming and

file metadata

be acknowledged, understood and agreed by all members of the design team, including

primary and secondary designers, consultants and specialist subcontractors

The 3D ‘virtual’ project model developed for this project will be constructed from fully coordinated

individual discipline models for all aspects of primary and secondary design work utilizing a common

file format. Visualisation of the site, the building facades and interior spaces will accompany the

design material submitted for final approval / sign off.

6.3 Energy services contract

6.3.1 Introduction and background

Chase Farm Hospital is currently powered by a light fuel oil fired central boiler house and site wide

steam distribution system, provided by inefficient, time expired, obsolete plant. The provision of

maintenance and operation is currently outsourced to Lorne Stewart. The redevelopment will

introduce a requirement for a new energy solution and the opportunity for improving the efficiency

and sustainability of the site. The trust has concluded that a combined heat and power (CHP)

solution will help achieve the majority of the required carbon reduction targets with which the trust

has a statutory obligation to comply. In addition, the site will require significant new and upgraded

infrastructure, and a shell to accommodate the plant equipment.

The trust made a commitment at OBC to reduce the overall capital cost of the project. The trust

sought to achieve some cost reduction by looking at alternative funding / procurement options. The

energy centre element of the project provides an opportunity to switch from a capital to revenue

based funding solution by procuring / forming an Energy Services Company (ESCo). An ESCo is a

contractor who will design, build and operate an energy centre. Depending on how the ESCo is

established, capital funding can also be obtained, with payback supported on a revenue basis.

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ESCos will typically guarantee the performance of an energy centre, with the trust benefitting from

reduced carbon emissions, revenue savings due to a cost effective solution and compensation for

any financial loss as a result of inefficiencies or down-time over a pre-agreed limit. This performance

guarantee gives the trust the security it needs that revenue costs it is anticipating will actually occur.

In addition, a design, build and operate model encourages innovation in design and significantly

reduces the risk to the trust of disputes if problems occur. This approach is familiar to the trust

having already been adopted at the Royal Free Hospital. The technology is sound having been

introduced by the Carbon and Energy Fund to a number of other hospitals.

6.3.2 ESCo procurement options

The trust appraised the procurement options in order to find the most appropriate way to establish

the ESCo to fit with the relevant programme milestones and provide the best value for money to the

trust, recognising that it requires specialist technical and legal advice to support this procurement.

Four procurement options were evaluated:




Table 6.8 ESCo procurement option cost summary

The trust concluded that using the CEF framework (option 3) is the preferred procurement option as

it has the lowest capital cost and shortest programme, and is felt to offer the best technical

expertise of all the options.

The CEF has a track record of completing similar schemes within a two year timescale and currently

have 19 schemes either operational or under construction. Additionally, option 3 does not require

the trust to commit to a deal and become liable for costs until later in the process than the other

options. It also maintains a competitive tension for longer which should contribute to a better value

for money solution.

In May 2015 the trust approved the decision to base the energy strategy for the Chase Farm

development around a Combined Heat & Power (CHP) installation and approved the proposal to

enter into an agreement with the Carbon & Energy Fund for the procurement of an ESCo. This

agreement was signed on 29 May 2015.

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6.3.3 ESCo procurement process

The timetable to complete the procurement is outlined below. It will be conducted in accordance

with the trust’s SFIs and with the involvement of the trust’s procurement department.

Table 6.9 ESCo procurement programme

milestone date

issue invitation to mini competition 03/07/15

open day with interested parties 16/07/15

trust shortlist bidders 23/07/15

technical meetings 19/08/15, 16/09/15 & 29/09/15

issue invitation to tender 30/09/15

mid-bid review between trust and bidders 28/10/15

bidders submit tenders 25/11/15

bid presentations 03/12/15

bid evaluation 15/12/15

trust shortlist preferred bidder 08/01/16

appointment of preferred bidder approved by trust board

28/01/15

negotiation with preferred bidder 28/01/15 – 27/05/15

financial close (estimated date) 27/05/16

appointment of ESCo 24/06/16

practical completion 30/06/17

At the conclusion of the evaluation, provided the trust has identified a preferred bidder, it will

complete a short business case for the delivery of energy infrastructure and services using an ESCo

and the CEF proforma Project Agreement, for the trust board and will seek approval to proceed to

contract finalisation and contract completion within the governance of the NHS CoCH Framework

and trust.

As stated above as part of the evaluation, it is anticipated that an ESCo will provide the most cost

effective energy solution. However the procurement of an ESCo will not be complete until after this

FBC is submitted and approved, and so the following approach has been taken in the estimation of

the energy centre costs for the FBC:

under P21+ a NTE GMP for the design and construction of the energy centre and associated

infrastructure has been provided by IHP as an option for the trust. This figure has been

assumed as the capital requirement for the energy solution.

CEF has modelled the likely running costs based upon its benchmarking information, the

energy requirements and energy savings. These have been incorporated in the trust’s I&E

modelling.

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Following ESCo bid evaluation and shortlisting, the trust will undertake an NPV analysis to assess

whether provision of the energy centre through an ESCo or via P21+ provides the best value for

money.

6.4 Car parking

The OBC included the provision of a car park extension for an additional 400 spaces (to total 900

spaces). The worst case scenario capital costs assumed in the OBC totalled £xxx. This included all

design, construction, fees, optimism bias, risk allowance, VAT and inflation.

The OBC noted that the trust would consider the design, build, finance and operation of the existing

and extended car park through a third party operator. This section summarises the work

undertaken and decisions made by the trust with regard to the number of car parking spaces to

provide and the best way of funding and procuring them.

6.4.1 Confirmation of the number of car parking spaces to provide

The trust’s transport advisers, TTP consulting, undertook surveys and appropriate analysis in

November 2014 as part of the outline planning application for the new hospital. It concluded that

the trust should provide 900 formal parking spaces post-development mainly within an extended

multi-storey car park (MSCP). The proposed level of parking for the hospital was deemed sufficient

to allow the efficient operation of the healthcare facility without encouraging the use of the private

car with the corresponding impact on the highway network. This was accepted by the town

planners.

The number of spaces has been reviewed since OBC approval and it was agreed to continue to plan

to provide a total of 900 spaces by CFH Programme Board in June 2015. A key reason for this is to

comply with the outline planning approval.

6.4.2 Funding and procurement option appraisal

A funding options appraisal was undertaken in June 2015. At OBC stage, a commitment was given to explore a third-party solution for the design, build, finance and operation of the car park (DBFO).

Options

The following five options were considered for the funding and procurement of the car park:

1. trust borrows to build the car park and operates it

2a. trust borrows to build the car park and outsources the operation

2b. trust borrows to build the car park, and sells the asset to a car park operator

3. trust enters into a PFI type arrangement with a car park provider to design, build, finance

and operate

4. trust leases land to a third party provider who then builds and operates the car park

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The table below summarises the different funding, asset ownership and operating model for each

option.

Table 6.10 Summary of options

asset ownership

capital funding

future revenue stream

operating model

option 1 trust trust -ITFF borrowed capital

trust trust

option 2a trust trust - ITFF borrowed capital

trust/operator share

operator

option 2b operator trust - ITFF borrowed capital

operator operator

option 3 trust DBFO trust/ operator share

operator

option 4 DBFO DBFO DBFO DBFO

Outsourced option assumptions

In order to appraise the outsourced options robustly, the trust contacted two third-party providers –

xxx and xxx. Based on the information provided, the typical features of a third-party contract are:

xxxxxxxxxxx

The timescale for the procurement of a DBFO solution was estimated by Turner and Townsend to be

xxx.

Option appraisal

The table below sets out the advantages and disadvantages of the procurement options of the car

park, including how the different options apportion risk:

Table 6.11 Review of options

Financial appraisal of options




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Table 6.12 Financial appraisal summary

Commercial market status



Preferred option

The CFH redevelopment programme considered the five options and decided to proceed on the

basis of option 1 - that the trust borrows the capital and builds and operates the car park itself,

thereby benefitting from the estimated annual income of £xxx for expenditure on clinical services.

IHP has provided a NTE cost for this which is outlined in the next section.

6.5 Key commercial and legal issues



6.6 IM&T

The CFH redevelopment offers the opportunity for the creation of a truly digital hospital, which

applies IM&T to support all aspects of care delivery and administration with the goal of delivering

improvements to operational efficiency, health outcomes, employee & patient satisfaction and high

quality service. An IM&T strategy is included at appendix 6G, which details how the trust will deliver

its vision of digital healthcare, making use of the new hospital to prove and demonstrate the value of

new IT-enabled work processes in a new, purpose built, facility and then ‘retrofit’ these new ways of

working into other hospitals within the Trust. The strategy focuses on the use of information

management and technology to support the delivery of world-class care within the hospital, and not

the delivery of technology for its own sake.

The strategy is underpinned by the following principles:

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operationally driven – IM&T systems and services within the new hospital will be driven by

clinical and operational requirements;

use of existing platforms – the trust will utilise existing IM&T systems and services as far as

possible, with new components purchased only where capability does not exist within

existing platforms;

mobility and access – the ability for staff to easily and securely access key clinical and

administrative systems from a range of devices (PCs, tablets, phones) across the hospital will

be fundamental to the delivery of our vision;

data mobility – the delivery of effective healthcare across extended, multi-organisation,

pathways will require the capability for all care providers to share data across organisational

boundaries;

retrofittable – it is critical to ensure that the new facilities and services are capable of being

retrofitted into the trust’s other hospitals. This will ensure that the benefits of common,

digitally supported working practices can be realised across all trust sites.

The standardisation of technology components reduces complexity and offers benefits such as cost

savings through economy of scale, ease of integration, improved efficiency, greater support options,

and simplification of control. The key IT architecture components currently in place within the trust

and which will be utilised within the new hospital are as follows:

user workstation environments – within the new hospital a broader range of user devices

than the traditional laptops and ‘computers on wheels’ will be supported, provided both by

the Trust and users themselves;

servers and hosting – a ‘cloud-based’ hosting approach will be taken, with applications

hosted in one of the Trust’s own virtualised data centres, or within a secure third-party data

centre as appropriate

file storage – the trust is exploring secure cloud-based file storage options

directory services – the new single Active Directory (AD) service for the authentication of

users across the trust will be retained

collaboration – the trust has implemented a number of collaboration platforms across the

Trust which will be utilised within the new hospital, including unified communications,

intranet services and medical grade video conferencing

Delivering the vision for a digital hospital

The realisation of the vision for CFH is not a technology programme per se, but rather a business

change programme underpinned by appropriate investment in technology to support clinical and

operational processes. This section outlines the process that will be followed to deliver the trust’s

vision of a digital hospital at Chase Farm

At this stage, the focus of the IM&T team has been on the core IM&T infrastructure services in the

new hospital to support future developments. A medical grade communications network will

provide a foundation to enable reliable, seamless, and secure health data exchange and

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communications across the hospital, supporting the transfer and storage of the large amounts of

data created by healthcare applications. This will be built into the fabric of the building. In addition,

when developing the 1:50 designs and RDSs the requirements for desktop devices within out-patient

consulting rooms have been documented and included in the cost plans. For inpatient areas,

discussions are underway with Cerner in relation to their ‘Smart Room’ concept, specifically in

relation to the design implications of deploying this concept within the hospital. Equipment will be

transferred from the existing hospital to the education and administration areas of the new hospital

where appropriate – the rolling refreshment programme of PCs over 4 years old will ensure that fit

for purpose equipment will be available for transfer.

Additional IM&T equipment and software will be funded separately, and will be subject to a business

case to be developed by the IM&T department. This will be carried out in accordance with the

following process:

defining requirements – the IM&T team will use the existing groups which have been

involved in developing the workforce models to understand how IM&T capabilities can

support service and workforce transformation. Once approved, the team will identify

whether the requirements can be met using systems and services currently deployed within

the trust, whether this would require enhancement of additional configuration, or whether a

new IM&T solution will need to be procured. An overarching system design will be created

from this;

prioritising investment – for each component, a business case will be developed to

articulate costs, benefits and opportunity costs. Funding will be allocated based on this

assessment from appropriate capital allocations, and the process will be managed in line

with existing policies and procedures governing IM&T investment;

sourcing – where functionality can be delivered within existing trust platforms and solutions,

these will be sourced via change control to current contracts. Where a new component is

required, this will be competitively procured in line with trust procedures;

deployment, testing and training – projects will be run in line with the trust’s programme

and project delivery function, to manage the configuration, deployment and testing of each

component. In order to ensure that operational and clinical staff can be confident that the

new IM&T facilities will be functional on day 1 of the new hospital’s operation, the trust will

consider creating model office environments to support the testing of individual

components, as well as testing the end to end process flow. This environment will include

mock-ups of clinical and operational areas to allow staff to understand how the technology

will work within the context of the new hospital. An IM&T Programme Manager will be

appointed to oversee all projects, and all systems will undergo thorough testing and

commissioning before deployment;

ongoing management and support – the IM&T directorate will review its service delivery

models to ensure sufficient site-based IM&T support will be available within CFH.

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6.7 FM services

6.7.1 Hard FM



6.7.2 Soft FM



6.8 Equipment strategy

6.8.1 Objective

An equipment strategy has been developed by the trust’s equipping advisors, MTS, and is attached

at appendix 6H. The objective of the equipping strategy is to ensure that the trust has a fully

equipped hospital facility that keeps pace with technological developments, whilst also securing best

value for money once the development is completed. There is also a need to ensure affordability

within the overall capital investment envelope. Consequently there is a commitment to review and

utilise the trust’s existing equipment (medical and non-medical) asset base where possible. The

trust also wants to maintain continuous availability of equipment to avoid service disruption.

6.8.2 Equipment requirements and costs

During the development of the FBC the trust’s equipping advisors have:

undertaken a full audit and asset survey for all existing medical and non-medical equipment

on the Chase Farm site, inclusive of real time condition appraisal;

produced a detailed costed equipment schedule, aligned to the schedule of accommodation;

agreed all equipment groupings with the P21+ partner, in order to derive the trusts actual

investment profile, against the equipment contained within the projects GMP (Group 1);

estimated transitional costs, and produced an outline commissioning programme.

The results of the 3 month validation process are summarised table 6.13, which also provide a

comparison with the equipment costs assumed at OBC.

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Table 6.13 Equipment costs at OBC and FBC

Changes since OBC

xxxxxxxxxxxx

xxxxxxxxxxxx

xxxxxxxxxxxx

Key assumptions

At FBC the following assumptions have also been made and were approved by Programme Board:

xxxxxxxxxxxx

xxxxxxxxxxxx

xxxxxxxxxxxx

The costed equipment schedule is attached at appendix 6I.

6.8.3 Equipment responsibility matrix

All equipment on the equipment schedule has been categorised into one of three groups. An

equipment responsibility matrix has been developed to identify which organisation (the trust or IHP)

is responsible for each category of equipment in terms of specification, procurement, installation,

commissioning, maintenance, replacement and finance (funding).

Table 6.14 Equipment responsibility matrix

group specify procure install / fix /

commission

maintain replace finance

1 IHP IHP IHP trust trust trust

2 IHP / trust trust IHP trust trust trust

3 trust trust trust trust trust trust

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6.8.4 Equipment procurement

The trust with foundation status has options to procure the equipment via capital, lease or a

Managed Equipment Service (MES). Listed below are these options with brief descriptions for each.

Table 6.13 Procurement option appraisal

In order to confirm the viability of the options, an assessment has been carried out by the trust’s

Equipment Advisory Group to compare the revenue cost of capital with that of leasing and MES.

This was using a selection of major medical items of equipment from the equipment schedule which

were considered suitable for lease / MES and compared to the cost of capital purchase over a term

of 10 years. A financial model has been prepared to give a high level indication of the annual

revenue costs and is based on typical replacement and lifecycles. The estimated revenue cost

comparison is shown below.

Table 6.16 Annual revenue cost of options

This demonstrates that there is a slight saving to be made by selecting a MES. However this would

be in conjunction with some capital procurement as not all items on the equipment schedule for the

new development are suitable for MES or lease. Further work would be required to test the market

to see if a MES of this size would be attractive to providers.

Given the immaterial difference between the options and the flexibility a capital solution allows, the

trust has modelled that equipment is procured via capital. As part of the next stage, the trust will

consider MES and leasing for particular items or groups of items.

6.9 Planning consent

6.9.1 Planning strategy – scope and process

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The trust has entered into a Planning Performance Agreement (PPA) with LB Enfield, which is

designed to promote a more collaborative approach to pre-application planning engagement, and

thus facilitate better quality outcomes from larger applications such as this one.

An outline planning application for the new hospital, up to 500 residential units and a three form

entry primary school was submitted on 21 November 2014 and presented to the Planning

Committee on 12 March 2015. Members of the committee resolved unanimously to grant outline

planning permission for the redevelopment of the Chase Farm Hospital site. Due to the scale and

nature of the application, it was referred to the Mayor of London who issued a Stage II report on 11

August 2015 confirming that LBE were permitted to issue the final decision notice subject to

agreement of the section 106 agreement.

The planning conditions set at outline planning have not been deemed onerous by the trust, and are

included in the planning strategy in appendix 6J. The section 106 obligations are currently being

finalised, and largely relate to the following:

safeguarding expansion space for healthcare

implementation of travel plans

highways and transport

construction management

provision of employment and training

sustainability

As previously described, the design development after submission of the OBC and outline planning

application resulted in a hospital building with a footprint outside the parameters set out in the

outline planning application. The trust is therefore preparing to submit a Section 73 application to

vary these parameters alongside the reserved matters application for the hospital, so as to secure

full planning permission. The timescales for this are as follows:

Table 6.17 Timetable for achieving full planning consent

event completion date

outline application decision notice September 2015

submission of S73 application September 2015

submission of reserved matters applications September 2015

discharge of pre-commencement conditions September 2015

discharge of S106 obligations September 2015

GLA stage 1 report (report to be issued within 6 weeks of GLA’s receipt of notification from LBE)

October 2015

officers’ report drafted early November 2015

Enfield development management committee and resolution to grant planning permission

10 November 2015

London borough of Enfield consult mayor (GLA stage 2 report issued within 14 days of receiving LBE notification of resolution to grant permission)

November 2015

S73 application decision notice issued November 2015

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reserved matters decision notices issued November 2015

judicial review period (6 weeks) December 2015

commencement of development (piling) 10 December 2015

The trust will dispose of its interest in those land parcels earmarked for housing development

(disposal of parcel A is underway, and early disposal of parcel B is being considered). The trust is

also in the process of negotiating with the Local Education Authority so that the school site (parcel C)

is purchased at on an open market value, based on a valuation as residential use. The designated

land parcels are shown below.

Figure 6.1 Land parcels for retention and disposal

Further detail of the pre-application engagement, outline planning application, reserved matters

application form and content, programme, planning conditions and section 106 obligations are

contained in the planning strategy at appendix 6J.

6.9.2 Affordable housing and keyworker units

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx


6.9.3 LB Enfield planning support

A letter of comfort from LB Enfield is provided in appendix 6K.

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6.10 Disposal strategy

6.10.1 Disposal strategy and valuations

A disposal strategy was developed at OBC stage in accordance with Health Building Note 00-08

(October 2014) to achieve best value from the disposal of sites surplus to trust healthcare

requirements and to deliver maximum receipts to fund, in part, the redevelopment of the Chase

Farm Hospital.

The disposal strategy outlined in the OBC has been pursued. The site has been divided into four

parcels for disposal. The figure below sets out the parcelling of land for disposal.

Figure 6.2 Parcelling of land for disposal

An updated disposal strategy is included at appendix 6L, which details work undertaken to date to

progress the sale of parcel A, and confirms plans for parcels B and C.



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The table below summarises the timing and likely receipt (as per the draft red book valuation) for

each parcel.

Table 6.18 Timing and draft valuations of disposal parcels

Fees associated with the sale will be offset against the land values, as shown in the finance case

(section 5.9). The detail to support the level and timing of receipt expectation and disposal can be

found in the disposal report at appendix 6L, which includes the latest draft red book valuations.

6.10.2 Vacant possession and legal title issues xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx


Figure 6.3 Third party interests at Chase Farm hospital

Table 6.19 Vacant possession plan

A full vacant possession and legal interest strategy is included in appendix 6N.

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7. Management case

This chapter sets out how the trust is managing the programme implementation through planning,

procurement, implementation and benefits realisation, into the operational and evaluation phases.

The programme structure has been developed to follow those set out in the NHS Estates Capital

Investment Manual3 and the Treasury ‘Green Book’, supported by the project management

disciplines of PRINCE24 and Managing Successful Programmes (MSP)5. The programme will also be

subject to Gateway Reviews as described later in this chapter.

7.1 Benefits

Key to the success of the implementation is that the benefits identified by the trust are realised. The

overall benefits of the redevelopment have been identified as follows. The redevelopment will:


standards;


community of Enfield, north London and south Hertfordshire about the safe future of

Chase Farm Hospital and the importance the NHS strategically places upon it;










The benefits realisation plan is included in appendix 7A and provides details of how each benefit will

be measured. These have been identified through a benefits mapping exercise involving key clinical

and non clinical staff. Each benefit has been measured and a responsible owner identified. These

individuals will be responsible for ensuring benefits are achieved. Progress will be monitored by the

programme team, and the programme board will take appropriate corrective action should delivery

be threatened.

3 1994, ISBN 0 11 321718 8

4 Project In a Controlled Environment: a structured approach to project management endorsed by the Office for Government

Commerce (OGC) as the standard for the conduct of major projects in the public sector 5 MSP is the de facto standard methodology for delivering programmes in the UK public sector. It is the programme equivalent

of PRINCE2 and is owned by the Office of Government Commerce

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Benefits identified at OBC have been reviewed to confirm that the new preferred option does not

affect the benefits targeted by the scheme. Some amendments have been made, which have been

agreed at OSG. Benefits owners have been contacted to ensure they are actively managing benefits

assigned to them.

7.2 Programme governance

The programme governance structure and reporting strategy is set out in the figure below.

Figure 7.1 Programme governance and reporting structure

The governance structure sets out lines of accountability and reporting for the delivery of the programme.

The CFH Redevelopment Programme Board oversees the programme and is chaired by David

Sloman, the CEO and SRO for the redevelopment. It reports to the strategy and investment

committee of RFL’s main board. The Operational Steering Group (clinical design and

implementation) reports to it.

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The Operational Steering Group has responsibility to ensure the progress and delivery of the

programme, and review and approve the design of clinical services. This group ensures progress in

respect of each of the workstreams, as reported by the project team.

The Project Team deals with the day-to-day management of the scheme, ensuring all workstreams

are clear as to the programme and cost position, facilitating co-ordination of activities and acting as

a forum to resolve issues. It is attended by representatives from all workstreams and the P21+ PSCP

(Principal Supply Chain Partner). It reports progress directly into the Operational Steering Group,

making recommendations as appropriate.

The Chase Farm Capital Group is supporting the development of an annual capital programme and

development control plan for the non-new build elements of the scheme, and provides updates to

the Project Team.

The workstreams have been established with a senior lead that is responsible for delivering a clear

set of terms of reference. These are shown in table 7.1 below.

Table 7.1 Workstreams

workstream workstream lead

key workstream responsibilities

operational

clinical design – Natalie Forrest, programme director

review and agree functional content; flow diagrams; functional adjacencies

identify service models and workforce models for planned changes

oversee development of the 1:500, 1:200 and 1:50 designs from a clinical perspective

ensure clinical engagement in the development of the FBC and its inputs

develop operational policies for each service, identifying how the building will facilitate new ways of working

facilitate the design of new patient pathways

liaise with clinical services to identify service requirements

non-clinical design – Karen Kelly, head of clinical planning

review and agree functional content; flow diagrams; functional adjacencies

oversee development of the 1:500, 1:200 and 1:50 designs from a non-clinical perspective

develop operational policies for each service, identifying how the building will facilitate new ways of working

facilitate the design of flows for logistics and Hard and Soft FM services

liaise with non-clinical support services to identify service requirements

service transformation

review current BEH Chase Farm model of care; patient pathways; site interfaces; clinical synergies and identify any

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– Fiona Jackson, hospital director

improvements for adopting in CFH redevelopment. identify benefits to service delivery of CFH redevelopment review options for site development oversee site improvement works to ensure services are

delivered in accommodation of an appropriate quality prior to July 2018.

contribute to communications and engagement plans so that stakeholders are informed and engaged as needed

workforce

Ragini Patel – assistant director of workforce

ensure that workforce changes are planned and provided to support FBC development

ensure that workforce input into finance and activity modelling

identify benefits from planned service changes ensure that workforce and finance plans are aligned support consultation with staff if required as a result of the

redevelopment review outputs from current workforce work streams provide sense check, evaluation and direction of travel advise on work stream development

stakeholder engagement and comms

Emma Kearney - director of corporate affairs and communications

identify stakeholders and maintain a stakeholder engagement plan.

ensure that identified organisations, groups and individuals are engaged as plans for Chase Farm Hospital are redeveloped.

ensure support from key stakeholders and champion the proposed plans.

ensure appropriate communication channels are developed for stakeholders to feedback ideas and concerns, raise issues, ask questions and find out more information.

define key communication messages. ensure consistent communication of key messages and that

stakeholders are clear about plans and implementation.

design, estates and planning

Andrew Panniker – director capital and estates

direct all design and construction aspects of the project. produce the 1:500, 1:200 and 1:50 designs for agreement

with clinical groups. manage the external advisors in relation to estates, design

and procurement. manage the commercial arrangements with the P21+ partner. develop service specifications for all non-clinical support

services in the building provide capital cost and lifecycle estimates for the design and

construction works. develop and implement the equipment and IT strategies. ensure a phasing plan is in place that meets clinical and

contractor’s requirements. manage the planning application process. manage the following sub-workstreams:

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- car park - energy centre - equipping - IM&T

disposals Maggie Robinson – head of property

develop overarching disposal strategy for the CFH site manage the sale of land parcels A and B to commercial

housing developers to achieve maximum value manage the sale of land parcel C to Enfield Council for market

value, or to commercial housing developers.

finance and activity

Kim Fleming – director of planning

set the Chase Farm finance and activity plan in the context of the trust’s plan.

document the quantitative basis of the redevelopment, and to reflect that back to the organization.

produce a five year activity output (including efficiency factors to be applied) and finance model that includes workforce numbers.

produce the finance case for the FBC, and contribute to the strategic case and the economic case.

undertake financial and activity analyses for the FBC. identify financial and activity related benefits from planned

service changes. develop financial systems and processes within the

programme to allocate and monitor expenditure against budget, escalating issues as appropriate.

manage project level issues and risks and escalate these if required.

Each workstream lead has a nominated deputy and supporting team to support the delivery of

responsibilities. The operational (clinical and non-clinical), and design, estates and planning

workstreams have a particularly large remit with a number of sub-groups, and therefore the

governance within these workstreams is set out below.

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Figure 7.2 Operational (clinical) workstream structure

Figure 7.3 Operational (non-clinical) workstream structure

Natalie Forrest

Clinical design and

engagement lead

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Figure 7.4 Design, estates and planning workstream structure

The detailed structures of each workstream are shown in appendix 7B.

Key individual roles

The key roles and responsibilities of the core programme management team are as follows:

SRO (Senior Responsible Owner) – David Sloman

owns the vision for the project and the supporting business case.

provides clear leadership and direction throughout the life of the initiative.

has full responsibility and accountability for the outcome of the programme and realisation of the benefits.

manages the interface with key senior stakeholders, keeping them engaged and informed.

maintains the alignment of the programme to the organisation’s strategic direction.

ensures that the project remains affordable and will improve the quality of care to the

target population.

establishes and ensures that the necessary resource is made available to deliver the

schemes.

Programme director – Natalie Forrest

co-ordinates all elements of the programme, shaping the overall programme of work to deliver the agreed objectives.

monitors progress, resolving issues, mitigating risks and initiating corrective action as appropriate.

provides an overall monitoring and assurance role across the programme, ensuring that programme level risks and issues and any internal or external dependencies are defined, managed and escalated where appropriate.

ensures appropriate risk, benefits and stakeholder management frameworks are in place

for the programme.

acts as the day-to-day agent on behalf of the SRO for successful delivery of the initiative.

owns and reviews the programme plan, communicating impact of any revisions in terms

of milestones, timelines and dependencies.

New build (lead: Mark

Bateman)

Hospital Build (lead: Mark Bateman) Planning (lead:

Maggie Robinson)

IM&T (lead: Andy

Dargue) Car Park

(lead: Chris

Moriarty-Baker)

Energy Centre

(lead: Martyn Jeffery / Nigel Walker)

Highlands (lead: Nigel

Walker)

Equipping and Commissioning

(lead: Karen Kelly)

Chris Moriarty-Baker

Programme

Manager

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ensures that the initiatives and projects that support the delivery of the overall

programme are initiated on a consistent basis with governance arrangements that meet

requirements.

Programme Manager – Chris Moriarty-Baker

manages allocated project(s) to deliver outputs to the required quality within the agreed time and costs constraints using the agreed project lifecycle approach.

manages project level issues and risks and escalates as required.

manages and assures the work of project team members where relevant.

reports regularly to all relevant individuals and groups using standard reporting

processes and templates.

manages relationship with IHP.

The team has been assembled to ensure the right skill mix is in place and that all team members

have relevant experience.

Procure 21+ training has been undertaken by members of the project team and IHP’s supply chain to

ensure there is appropriate understanding within the trust and the programme team for the

management of this process.

7.3 Monitoring and control 7.3.1 Monitoring progress

Control and progress monitoring of deliverables against key milestones is undertaken at workstream

level by workstream leads and project managers. Each workstream has terms of reference which

have been agreed by the workstream lead, programme director and operational steering group. The

programme plan also specified the timing of key deliverables for each workstream, as do specific

documents used at different stages of the programme (such as the FBC checklist).

Workstream progress is co-ordinated by the project team and monitored by the operational steering

group via fortnightly written reports, covering progress risks and issues. In addition, the sub-groups

of the estates workstream report progress monthly to project team, as do the contractor and trust’s

cost advisors. The programme director reports on overall progress to the programme board.

The programme board then reports into the strategy and investment committee and trust board via

the SRO. The ultimate responsibility for the progress of the programme lies with the SRO, who

monitors progress via programme board meetings and regular meetings with the programme

director.

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7.3.2 Decision making and change control

Day to day decisions are made by workstreams and the project team. Any changes against the

baseline (schedule of accommodation, capital cost, programme) are first assessed to determine their

impact on the cost plan and programme. They then go through the following approvals process:

Table 7.2 Change control

change process and approval required

design proposal / change – finalisation and any subsequent changes to the schedule of accommodation, adjacencies, room layouts or choice of finishes or equipment, or any delay to ‘sign-off’ programme dates for design stages.

1. confirmation of cost by the cost manager 2. project team define impact and review 3. OSG approval. 4. programme board for information.

any other day to day decisions / changes 1. confirmation of cost by the cost manager 2. project team approval 3. OSG and programme board for information

decisions / changes affecting clinical operations 1. confirmation at clinical workstream 2. OSG approval 3. programme board for information

significant decisions – such as directing major exceptions to the plan or halting significant elements of the plan

1. confirmation of cost by the cost manager 2. project team define impact and review 3. OSG recommendation 4. programme board approval

Any changes to IHP’s scope are instructed by the project manager via a compensation event (CE).

Requests for additional work to be undertaken by IHP outside the scope of the Stage 2 and 3

appointments are also instructed as a CE, instructed by the project manager if the value is up to

£xxx, and the programme manager if the value is up to £xxx. CEs above this figure require approval

by the Director of Capital and Estates. All CEs are recorded in the IHP monthly report which is

reviewed monthly at project team and circulated to internal OSG and programme board members.

A full monitoring and control strategy is in place.

7.4 Resourcing strategy

7.4.1 Use of external advisors

The trust has procured project management and technical advisors to take forward the project. The

external advisors have been contracted to provide the services outlined in table 7.3 below:

Table 7.3 Trust advisors

organisation role

Sweett Group programme management business case development

Turner & Townsend cost consultants procurement advisors

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Montagu Evans planning advisors

MTS equipment advisors

GE Finnamore workforce planning support

BiG Innovation away day and workshop facilitation

Berthold-Bauer VAT Consultants

VAT consultancy

Carbon Energy Fund energy centre procurement support and technical advice

Gareth Cruddace strategic advice

The programme is procured using Procure21+, and the Principal Supply Chain Partner (PSCP) is

Integrated Health Projects (IHP). Their supply chain includes the following Principal Supply Chain

Members (PSCMs):

Table 7.4 IHP supply chain

organisation role

Vinci principal contractor

IBI Group & AD Architects architects

JI Consultancy health planner

Sweett Group cost consultants

Troup, Bywaters & Anders M&E engineers

Thomasons structural engineers

All fees are controlled through a framework agreement or a fixed fee and monitored by each

workstream lead through a schedule of works and programme, reviewed on a monthly basis.

7.4.2 Costs of programme implementation

The costs of the trust resources are managed under four budgets, as set out in the table below.

Table 7.5 Resource/fee forecast

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Figures include the capital cost of some internal staff as well as external fees. IHP fees are shown in

the table below and are included

Table 7.6 IHP resource/fee forecast

Expenditure against budget is tracked by the trust finance department and reported to the

programme director on a monthly basis.

The programme director is responsible for managing resource utilisation and demands by:

analysing the resource profile and ensuring that appropriate resources have been identified

effective communication via briefings, one to one sessions and programme team meetings

obtaining regular updates to gain visibility of work progress

delegating responsibility to workstream leads to manage their own workstream resources

working closely with the finance lead to ensure that current and forecast expenditure is within the budget for the programme.

ensuring that risks relating to resource shortfalls and succession planning are monitored in the risk register

escalating resource requirements to the SRO for consideration at the monthly Programme Board if necessary.

7.5 Programme milestones

A full draft programme for the scheme is included in appendix 7C. Key milestones are shown in the

table below.

Table 7.7 Programme plan key milestones

key milestone programmed date at FBC

(September 2015)

programmed date at

GMP (February 2016)

decant works start on site June 2015 June 2015

trust sign Stage 3 contract with IHP July 2015 July 2015

decant works complete August 2015 August 2015

enabling works commence August 2015 August 2015

reserved matters planning approval

submitted

September 2015 November 2015

detailed design complete September 2015 December 2015

trust board approval of FBC, to include a ‘not

to be exceeded GMP’

September 2015 September 2015

reserved matters planning approval achieved November 2015 January 2016

final GMP to be agreed November 2015 February 2016

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trust sign stage 4 contract with IHP December 2015 March 2016

main development start on site January 2016 January 2016

new hospital operational July 2018 August 2018

ground floor Highlands refurbishment

complete and operational

April 2019 June 2019

post project evaluation April 2018 – June 2020 June 2018 – July 2020

7.6 Risk management

7.6.1 Introduction

The objective of the risk assessment is to identify risks to the successful delivery of the programme

and determine the contingency sums to be included, as well as to identify mitigating actions for the

appropriate management of the risk.

The methodology comprised the following stages, each of which is explained in detail in the

subsequent sections of this report:

risk management strategy

quantitative risk analysis

OGC Gateway risk potential assessment.

7.6.2 Risk management strategy

The trust’s approach to risk management, in accordance with the Capital Investment Manual and the

Treasury Green Book, is designed to ensure that the risks and implementation issues of a change and

construction programme of this nature have been identified, weighted, and action plans developed

in a risk management plan.

A full risk management strategy has been developed, where risks are logged and then scored for

their probability of occurring and their likely impact in terms of cost and time, which has then

generated a risk rating. All risks have a responsible owner and mitigating actions identified. The

risks are reviewed regularly to ensure that all reasonably practicable measures have been taken to

mitigate them. Workstreams and sub-groups report risks and issues to OSG and project team via

progress reports. Red risks are regularly reported to the OSG and the programme board for review,

with amendments being fed back to the IHP project manager for inclusion in the main risk register.

Red risks are also incorporated into the trust’s corporate risk register, which is reviewed quarterly by

the trust executive committee.

The risk management approach for the programme is in accordance with PRINCE2 and P21+

methodologies. Regular monthly workshops are held, attended by key trust and IHP personnel, to

assess the risks to the project in accordance with the process shown in the diagram below.

Mitigation actions are developed with action owners for each, and risk scores are updated as these

are undertaken. New risks are identified and scored, and mitigation actions identified as they arise.

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Risks are quantified in where they have a potential financial impact; the quantified risk register has

been used as the basis for the contingency sum in the not to exceed GMP, and will be updated

further for the final GMP.

This risk management process will continue to be repeated throughout the programme.

Figure 7.5 Risk management lifecycle

The highest level trust risks are shown in the tables below. All have mitigation plans in place. More

detail can be found in the full risk registers in appendix 7D.

Table 7.8 Top trust main scheme risks and mitigating actions

Ref No Risk Description

Prob. (1-5)

Impact (1-5)


Risk Manager

302 Failure to achieve full QIPP savings as projected, which would have a negative impact on the LTFM and trust I&E position

4 5 20 Develop robust implementation plans, model downside scenarios

Katie Fisher

305 One or more of the capital financing sources fails or falls short of projections, leading to the scheme stalling or an increase in trust borrowing

3 5 15 Land sales - trust using RBVs provided by professional advisors. Parcels C and A due to complete in March 2016 and May 2016. PDC - committed in writing by DH at OBC. Cashflows showing draw-down of PDC provided to DH. Borrowing - paper approved by ITFF RFL contribution - reserves in capital programmes

Caroline Clarke

306 Delay to FBC approval by DH / Treasury, reducing future financial benefit

3 5 15 Work closely with DH/Treasury through business case approval process. Treasury have indicated they will approve within the trust's timescales.

Caroline Clarke

104 Workforce plans are not fully implemented by the time the new hospital opens, meaning that workforce savings are not delivered in full

4 4 16 Workforce workstream to manage workforce transformation and development of new roles. Implementation plan in place.

David Grantham

308 Temporary closure of beds on G floor of Highlands and permanent closure of

4 4 16 Careful planning with services to manage activity and the impact of disruption during this period.

Kate Slemeck

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beds on the 1st floor Highlands when the link bridge is constructed impacts trust performance.

Table 7.9 Top trust energy centre risks and mitigating actions

Ref No: Risk Description

Prob. (1-5)

Impact (1-5)


Risk Manager

33 Risk that ESCo and IHP do not coordinate delivery of supplies, delaying commissioning of Healthcare Building and potentially increasing IHP’s costs.

3 5 15 IHP have been involved throughout the ESCo bidding process. Trust to implement robust completion schedules and set clear boundaries between sites. ESCo to provide temporary supplies which can be used to commission the healthcare building if the energy centre installation is delayed.

Nigel Walker

Table 7.10 Top trust car park risks and mitigating actions

There are no trust red risks currently on the car park risk register.

7.6.3 Quantitative risk assessment

A capital contingency sum has been estimated for risks and allocated to the owner organisation on

each of the three project risk registers which cover the healthcare building, car park and energy

centre. The risks allowances are shown as a capital contingency sum in the FB forms, with the

breakdown in the costed risk registers attached in appendix 7D.

A summary of the risk allowances assigned to each element of the scheme is shown below:

Table 7.11 Quantified risk allowances

7.6.4 OGC Gateway Risk Potential Assessment

The impact and risks associated with the project were assessed in accordance with the Health

Gateway Risk Potential Assessment (RPA) for projects. The assessment, attached in appendix 7E,

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determined the scheme remains high risk, due to the high level of public interest, the high number

of expected benefits and because it is a major contributor to the delivery of key strategic targets of

the trust.

Accordingly, an external review process has been employed on the programme in the form of a

Health Gateway Review.

OGC Gateway review process

The Gateway process has been used up until March 2015 to examine programmes and projects at

key decision points in their lifecycle. It looked ahead to provide assurance that schemes can

progress successfully to the next stage.

A Health Gateway Review 1 was carried out from 29-31 July 2014. The review concluded that “the

Programme offers the prize of delivering much needed modern elective hospital facilities at Chase

Farm and is being progressed by an experienced and committed team with strong clinical buy in.

Nevertheless, there are material risks to be overcome in achieving a financially viable design solution

and completing a robust OBC which is likely to be approved, to meet the Trust’s adopted target date

of December 2014.” The review team’s major concern was the pace at which the programme was

progressing. As a result the Delivery Confidence Assessment given was ‘Amber Red’.

A Health Gateway Review 2 was carried out from 25-27 March 2015 to assess the project at OBC

stage. The review team gave a Delivery Confidence Assessment of ‘Amber’, on the basis that ‘the

programme is being developed by a capable and experienced team, and is supported by a Trust with

a will to succeed. However, the programme’s objectives in terms of timescale and financial

efficiencies present a substantial challenge. Successful delivery is feasible as long as management

attention remains focussed on the key tasks.’ As at the Gateway 1 review, the team raised concerns

about the speed at which the programme was progressing and about the scale of the revenue

affordability gap at the time of the review. The review team gave two recommendations, which are

set out below along with the trust’s responses.

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Table 7.12 Health Gateway 2 recommendations and trust responses

ref. no.

recommendation timing trust response

1 Develop and establish plans for FBC production that include appropriate engagement and collaboration with external stakeholder / regulatory bodies to achieve prompt endorsement / approval.

by Sept 2015

Plans in place to ensure appropriate early release of information to CCGs. CCGs engaged and aware of FBC timescales. DH and Monitor engaged. Regular meetings underway with DH, and plans in place to ensure early release of information to DH reviewers where appropriate. Key stakeholder engagement milestones included in programme plan.

2 Ensure stage plans are completed for all workstreams describing the key roles and responsibilities in each case and including the timings for submission and sign off of deliverables. (Note: Deliverables would include service strategy, workforce strategy and change management plans etc.)

April 2015

Organisational structures formalised with each workstream and signed off by Programme Board on 21 April 2015. FBC action plan circulated to workstreams, with relevant items assigned to each. Progress against these monitored by the PMO. Key risks, issues and dependencies captured in fortnightly workstream updates which are reviewed by OSG. Key workstream deliverables included in an overarching governance paper, signed off at Programme Board 21 April 2015.

Since the Gateway 2 was undertaken, HM Treasury has ceased its funding of Gateway reviews and

the team has been disbanded. The decision was made by the programme board not to undertake an

independent gateway review at FBC stage partly because in its risk assessment role Monitor will be

providing significant external review.

7.7 Workforce planning 7.7.1 Context

This section outlines the workforce plan for the new hospital. This plan is based upon detailed work

undertaken to develop workforce plans at service and speciality level for each division. It outlines

the trust’s approach, the assumptions made and the plans to manage the workforce aspects of the

proposed changes.

The workforce plan builds upon the foundations of the trust’s existing Workforce and Organisational

Development Strategy 2011-2017 and the Workforce and Organisational Development Strategy for

the acquisition of Barnet & Chase Farm Hospitals NHS Trust in 2014.

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7.7.2 Methodology

Following the submission of the outline business case (OBC), a more detailed and planned approach

has been undertaken to ensure workforce plans for the Chase Farm redevelopment were produced

and agreed within the timeframe required to meet the full business case (FBC).

The trust engaged an external consultancy to support the development of a strategic workforce

modelling tool which allows different high level workforce scenarios to be modelled to test their

affordability. Appendix 7F includes a schematic which outlines the model inputs, calculations, and

outputs in further detail.

The strategic workforce model is activity driven i.e. bed based, clinic based or attendance based. The

activity used to determine the size of the building has been used to develop the workforce model.

Each workstream developed the workforce model by applying agreed assumptions of how each unit

of activity is staffed. This includes assumptions relating to both fixed and variable clinical staff, and

staffing mix. The team involved (HR Business Partners and Heads of Finance) undertook detailed

engagement with operational managers and clinicians for each workstream to discuss and agree the

workforce assumptions to be applied for each. Consideration was given to opportunities to make use

of efficiencies afforded by operating from a purpose built healthcare facility, clinical adjacencies, and

use of the latest IT technology. The output of the model is a detailed whole time equivalent (WTE)

requirement for each workstream based on the activity.

In order to develop robust workforce plans, the 18 workstreams used to undertake the clinical re-

design of the hospital were brought together to model the workforce based on the location

proposed for them in the new Chase Farm building (i.e. based on clinical adjacencies and service

mix).

The full range of key stakeholders had the opportunity to contribute to discussions to agree the

workforce for these workstreams. This process commenced in April 2015 with an away day focusing

on the redevelopment of Chase Farm. The day was successful in securing official sign off on the

clinical design of the new hospital. The afternoon session provided an introduction to the

possibilities of new technology and new roles that could be incorporated to deliver services.

Following this event, it was essential to maintain momentum and ensure clinicians were kept

thoroughly engaged. The workforce workstream initiated a workforce planning process (summarized

in appendix 7F). A number of meetings were held to debate and agree the proposed workforce,

based on the assumptions being made. All decisions made went through a process of challenge and

scrutiny by the leads of the services so that they could be assured that any changes planned were

sound.

Engagement from clinicians improved as the process went on, as people were able to focus on the

’task’ to quantify the workforce roles, numbers and skill mixes needed. The challenge was for

clinicians to look three years ahead and beyond to anticipate potential changes, linking planned

staffing levels with those assumptions (for example staffing the new patient pathways) rather than

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with current practice. A rolling programme of review and challenge has resulted in changes to

patient pathways, developments in technology and new ways of working all being considered,

against a backdrop of the requirement to make significant year on year savings and quality

improvements. The team involved has also learned from this process and built relationships which

have set the way for how workforce planning on other trust sites will be developed.

All outputs from the workstream meetings were fed into the strategic workforce planning tool to

help confirm the number of WTE staff required. The tool provided some further challenge in that

benchmarking scenarios were considered globally with a view to adopting good practice workforce

models used elsewhere. This included theatre benchmarks and nurse to patient ratios for wards.

In June 2015, a further stakeholder event was organised. All workstream attendees as well as senior

managers attended. HR Business Partners and Heads of Finance co-presented progress for each

workstream to date. The aim of the event was to encourage the cross-thinking required between the

different work streams so that key issues were either addressed or noted to be worked on further

during July.

A final progress review session took place at the end of July. This event provided the opportunity to

gain official sign off on the workforce plans at this time. The chief operating officer and divisional

management teams attended both events.

7.7.3 Workforce Plans and assumptions

The workforce modelling undertaken to date is based on the various assumptions in each of the

services, which have been discussed in depth. All assumptions are available in the work stream

summary documents at appendix 7G. Appendix 7F also confirms the proposed operational hours of

each of the services within the new hospital.

Through the approach undertaken, it has been identified that the workforce required to deliver the

clinical activity at Chase Farm, equates to 761 WTE clinical roles and 105 WTE non clinical roles when

the new hospital opens in April 2018. It is important to note that, in the main, these WTE do not

include corporate staff not directly involved in the provision of care e.g. divisional operations

management teams, governance team etc. These costs are separately accounted for in the finance

section of this case.

The breakdown of the WTE by staff group is shown in table 7.13 below.

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Table 7.13 Breakdown of overall WTE by staff group

Overall, the total WTE required to deliver clinical activity at CFH on opening in 2018 is xxx. The

proposed model shown here assumes that all posts are substantively recruited to and does not

therefore plan for bank or agency staff being used for clinical roles.

The change in WTE staffing requirement between the current financial year (ending March 2016)

and the planned staffing on the opening of the new hospital in 2018 is shown in the diagram below:

Figure 7.6 Workforce planning projections (WTE)





Table 7.14 Agenda for change banding FY16 Table 7.15 Agenda for change banding FY18

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Figure 7.7 Agenda for change banding configuration FY16

Figure 7.8 Agenda for change banding configuration 2018

The whole time equivalent changes for consultants and other medical staff are detailed in figure 7.9.

Figure 7.9 WTE changes – consultants and other medical staff

The trust will continue the process of fine tuning the workforce models via the workforce planning

workstream and for review by the programme board.

7.7.4 Workforce changes

It is expected that changes to the workforce are affordable. They account for increases and changes

to volume and type of activity anticipated, anticipated efficiencies and maintaining the safety and

quality of care.

All plans developed as part of this submission align to our financial planning assumptions.

7.7.5 New ways of working, skill mix and productivity increases

A range of new roles will be developed to support new ways of working to ensure that the most

appropriate staff with the most appropriate skill sets are working with our patients. These include

the following:

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clinical support officers

physicians associates

paediatric emergency nurse practitioners

assistant practitioners

The trust will continue to build on its values and competency based recruitment approach to ensure

that it recruits the right people, with the right skills and values and develops them for their roles.

A number of the changes will arise as a result of clinicians having identified what is needed by

undertaking a detailed review of skill mix, to support more efficient working and changes to patent

pathways.

Efficiencies and productivity will also be achieved through a continuing focus on consultant and

team job planning to ensure that job plans are always up to date and providing maximum benefit for

our patients.

Other changes will be driven by technology and from the scarcity of certain skills. For example, e-

rostering already exists at the Chase Farm hospital site, primarily for nursing and midwifery staff,

but this will be more effectively utilised to provide the benefits of better planned and more efficient

rotas ahead of the development of the new hospital. The prospect of increasing use of handheld

devices by clinicians, as well as the roll out of electronic document records management (EDRM) for

patients and ESR self-service for managers, will all be factors in making the new hospital more

efficient, paper light and provide a better experience for both patients and staff.

The trust’s preference will always be to have a low vacancy rate to ensure the highest possible levels

of world class, consistent, patient care, but it recognises that there is an important and valued role

to be played by bank workers too on occasions when staff rotas cannot be fully filled by substantive

staff. The trust will work to ensure that the use of temporary staff is minimised at all times.

Further efficiencies will accrue from the design and flows within the new building and through the

co-location of services, with staff and patient time saved. This will include the reduced number of

access points for patients, allowing for better planning of the location of reception areas and the use

of self check in facilities.

7.7.6 Workforce transformation programme

Clearly there is a lot of to do before the new hospital opens to ensure the workforce is ready. This

will include the development of new roles as outlined, but more so the development of training

programmes to upskill the existing workforce where changes to roles and responsibilities are

proposed.

Further detail in relation to extending existing roles is available at appendix 7F. This will be taken

forward to assist with recruiting to hard to fill roles.

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7.7.7 Building capability: education/learning and development

Delivering new care models

The trust has a long history of delivering high quality education and training to healthcare

professionals so is well placed to respond to the workforce demands of the new care models and

ensure it has the right workforce with the right skills. The trust is a provider of undergraduate

medical education at all of its main sites, with the Royal Free Hospital site in particular providing one

of the principal campuses of University College London Medical School (UCLMS). Following the

acquisition in July 2014, the trust is one of the largest post-graduate medical training institutions in

the country with more than 600 postgraduate medical trainees in a range of specialties and with a

large faculty of expert educationalists and committed education and clinical supervisors. The trust

has a strong history of nursing and midwifery training and strong links with a number of academic

institutions, most notably Middlesex University and the University of Hertfordshire. It has a rich pool

of expert educationalists within healthcare sciences and allied health professions and, again, a

strong history of training for these professional groups. It has a strong level of capability with regard

to the development of the unregistered workforce, including an in-house accredited diploma centre

for the delivery of level 2 and 3 diplomas in clinical health and experience of developing apprentices.

The trust also has a range of excellent education facilities, including high-fidelity simulation facilities

and an award-winning library service run by University College London (UCL), with plans to further

develop both in the future.

Following submission of this FBC, the trust will develop an education plan that will set out the

educational interventions required to respond to the changing workforce needs as part of the CFH

redevelopment. This will likely focus on those areas where education and training is required to:

support the development of new roles

support the extension of existing roles

deliver a significant increase in supply of certain roles

address existing recruitment or retention issues with certain roles

The educational responses are likely to be a mix of in-house delivery (where the trust has the

capability and a tailored, bespoke approach is needed) and external commissioning from academic

partners (where high quality accredited programmes already exist that meet the needs of the trust).

The trust will look at what educational routes have been used elsewhere, both within partner trusts

in London and further afield, and look to build on those successes (for example, where

apprenticeships have been successfully used). Where more than one educational route is available,

the trust will consider a number of factors including quality, value for money, educational capacity

and lead-in times.

The trust will work closely with Health Education North Central and East London (HE NCEL) to ensure

its changing workforce needs are fed into the regional workforce and education planning processes.

The trust will incorporate these changing workforce needs into its annual Training Needs Analysis for

post-registration commissions and use its annual Indirect and Direct Workforce Development

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Allocations where possible. It will work with HE NCEL to make the best use of opportunities for

accessing salary support funding to support the secondment of staff onto accredited programmes.

The trust will also work closely with HE NCEL on education programmes that are commissioned at a

regional level and which therefore need collaboration across the local health economy, most notably

the establishment of a physician associate training programme.

A safe workforce

The trust already places huge importance and value on the key role that individual staff appraisal

plays in providing safe services to patients and positively influencing staff engagement and

retention. The introduction of revalidation for medical and nursing staff and a strong appraisal

process also ensures that any training and development needs are picked up and can be planned for

in a structured way.

The trust also values the role that excellent induction and a rolling programme of statutory and

mandatory training plays in ensuring patient safety and staff confidence and competence. The trust

has set the target that at least 95% of all staff will have received an appraisal within the previous 12

months and similarly expects 95% of mandatory and statutory training to be complete at all times.

Developing leaders

The trust believes strongly in the importance of clinically led services and the principle of service line

reporting to enhance transparency and accountability for the benefit of our patients. The challenges

of redesigning services and planning the move into the new Chase Farm redevelopment will require

the trust to have a good supply of clinicians and managers with excellent leadership skills. A process

of talent management is due to start imminently to ensure there is a good pool of staff who are

trained and capable to be able to step into such roles identified as critical to the service.

The trust recognises the value of the NHS Leadership Competency Framework and has a range of

offerings, often of a multidisciplinary nature to grow and enhance the leadership capability of the

organisation to ensure that it is fit and ready to meet the challenges ahead. More recently a

programme of work has been undertaken to articulate the leadership framework for the trust; this is

being mapped to teams and individual roles with plans afoot to commence this programme.

In addition, the trust has recently begun to pull together its offering of coaching and mentoring to

formulate a strategy to support individuals and teams where a need is identified.

The trust will continue to run forums for the top 250 leaders within the organisation to provide a

vehicle to generate and reinforce a shared vision and to capitalise on the talent and ideas of the

workforce.

7.7.8 Employee engagement, communication and health and wellbeing

The trust recognises the importance of employee engagement, communication and health and

wellbeing in the success of the organisation. During the lead up to the redevelopment and

thereafter, the trust will continue to monitor and respond to feedback obtained both through the

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annual staff attitude survey and through the friends and families tests. The trust has now also

refreshed its exit interview survey to ensure that good intelligence is obtained as to reasons for staff

leaving.

The trust already has a Staff Engagement and Enhancement Plan which has recently been revised

following the first survey (Oct 2014) of the new organisation following the acquisition. This will help

to address issues identified which fall under five main themes: staff engagement (incorporating

world class care values, staff appraisal and development, bullying and harassment, equality and

diversity and staff health and wellbeing. Progress against this plan has senior oversight within the

organisation and the involvement and commitment of all divisions within the trust.

The trust also has a rolling programme of reviewing the policies of the organisation to ensure that

they are all current and fit for purpose.

The trust’s core values of communicating clearly, being positively welcoming, actively respectful and

visibly reassuring apply equally to all of our staff, whether they be interacting with patients, staff or

visitors.

The redevelopment presents a fantastic opportunity to engage staff on the planning of the new

hospital and services and the transition. A communications strategy is in place to ensure staff are

kept up to date with the latest developments as they unfold and to enable staff feedback.

With regards to health and wellbeing, tangible benefits are expected in the improvement of staff

morale as they move from what has largely been a poor working environment into a new modern

and purpose built facility.

Occupational Health services will continue to be available to staff to ensure that they are supported

with any health issues and access to counselling and other services is currently available via the

trust’s employee assistance programme (EAP).

Staff health is also supported by the public health team and a range of ‘Fit at the free’ programmes

which are now rolled out across all hospital sites. These programmes encourage our staff to keep fit

via various schemes on offer including the facilities for staff to cycle, run or walk to work by

providing showers, lockers and changing facilities, which will also be included in the new

redevelopment.

In addition to all of this, the trust recognises that it is essential that staff are accepting and

comfortable with the new ways of working in order for a cultural shift to take place. This will require

behavioural change as well as physical changes. Staff will be supported on the journey as

appropriate with HR Business Partner teams and the Organisational Development (OD) team

monitoring and responding to issues as they arise.

7.7.9 Recruitment and retention

The workforce plans with regards to the Chase Farm redevelopment will minimise the number of

vacancies by pro-active and rolling recruitment which capitalise on the pulling power of a brand new

hospital to give it an edge in what is a very competitive recruitment market.

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From the workforce plans generated by the individual clinical work streams referred to above, it is

already clear that there will be challenges to secure the services of certain shortage professions, for

example, emergency nurse practitioners, sonographers, occupational therapists and operating

department practitioners (ODP) etc. However, with the lead time available, we shall look at targeted

recruitment as well as any opportunities to grow our own staff. Rolling recruitment campaigns will

be maintained to ensure safe staffing levels are in place at all times.

The redevelopment of the hospital provides opportunities for local employment. During the

construction phases of both the hospital and residential developments we will work with suppliers

and contractors to encourage the engagement and development of a local workforce. There are

opportunities to create apprenticeships working with local colleges and providers to train young

people. The trust already operates apprenticeship schemes at all of its sites and is keen to extend

these creating new entry routes to NHS career pathways. We would particularly like to support

employment for people finding it hard to get into work. We will make it a requirement of

contractors to also participate in such initiatives and work with the council to see that the

redevelopment contributes as much as it can to its employment and skills strategy. The re-location

of our non-clinical support services (recruitment, finance etc) to Enfield Civic Centre has already

provided employment opportunities for local people.

An example of tackling such employment issues is our recent commitment to help ex service

personnel into work. This is a national priority as the military is reduced in scale over the next few

years. Both Enfield and the Chase Farm Hospital site have military associations so the trust's

participation and commitment seems appropriate. The scheme involves outlining all the careers and

roles available within the NHS and our own trust staff pairing with and mentoring and supporting ex-

servicemen and women, offering work experience and undertaking work trials that can lead to

employment. It builds on similar schemes run by companies such as BT. We would want companies

undertaking the re-development and supplying the trust to participate in this and other similar

schemes.

The trust runs recruitment campaigns abroad and has recently strengthened its position further by

directly recruiting staff rather than appointing via agencies. It is envisaged that continuing

international recruitment will be necessary in order to maintain safe staffing levels. The training,

induction and orientation needs of overseas recruits will also need to be addressed, an area in which

the trust has a successful track record. The trust is also currently piloting a direct hire scheme for

graduating nursing students on their final placement to give them faster track entry into positions

within the trust. It is anticipated that this will have a positive impact on the ability to recruit newly

qualified nurses.

With regards to retention, the trust has recently developed a targeted retention plan for nursing

staff and will follow suit for other staff groups identified. This will include reviewing the onboarding

process for new staff and talking to staff early on within their induction periods to identify and

resolve issues. The trust offers staff the ability to work flexibly.

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The trust offers a considerable range of staff benefits, including childcare vouchers, nursery places

and support for season ticket loans. Specifically in relation to the redevelopment staff will be able to

access new affordable accommodation, a new nursery and a new school.




To summarise, the workforce designed to support this redevelopment will be:

adequately resourced, based upon safer staffing guidance (this measure gives assurance that

appropriate staffing levels and skill mix will be in place);

based upon the roles services have identified as critical; and

appropriately skilled, competent and knowledgeable to deliver the services

The trust’s risk register for Chase Farm confirms steps and actions that are being taken to mitigate

workforce risks identified at this stage which relate to the availability of junior doctors.

7.7.10 Governance for managing the workforce changes

The trust’s process for managing organisational change is well established. The policy and

procedure incorporates best practice and legal requirements and provides a framework for common

understanding for managers, staff and trade unions/staff organisations by articulating roles and

responsibilities.

All staff affected by changes related to the implementation of the workforce for the Chase Farm will

be consulted with in accordance with this policy and best practice.

7.8 Change management plan

The success of the project will be dependent not only on the successful delivery of the construction

projects, but principally on whether the trust is able to develop and implement the new ways of

working and workforce plans set out elsewhere in this FBC, and then transfer operations seamlessly

into the new facilities from 2018.

The outline commissioning programme in appendix 3P shows the key activities and associated

timelines required to bring the new facilities into operational use. Building upon the key milestones

in IHP’s construction programme, it sets out the trust’s critical technical commissioning,

procurement (equipment, IM&T, FM) operational development, workforce roles and responsibilities.

It sets out a plan to bring the new and refurbished facilities into use with a co-ordinated post-

handover / pre-occupation period of 6 weeks followed by a move period lasting 2 weeks, both of

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which have been benchmarked against similar hospital commissioning projects. The detailed

migration plan will be worked up in detail, involving the user groups during the construction period.

7.9 Communication and stakeholder engagement strategy

7.9.1 Communication strategy

Section 2.10 sets out the stakeholder engagement undertaken to date.

A stakeholder communications and engagement project plan has been developed based upon the

following three broad strategic objectives, delivered through a combination of existing and new

methods:

1. ensure there is a robust stakeholder management structure in place for the Chase Farm

Hospital redevelopment programme.

2. develop and nurture relationships with patients, residents and stakeholders so they feel

involved, that their contributions are valued and, where possible, will influence us.

3. ensure appropriate channels are developed to feed back ideas, concerns and issues and that

there is robust evaluation of our communication and engagement.

A core narrative forms the backbone of all communications and engagement materials and provides

clarity, consistency and reassurance to all stakeholders. It contains the following key messages that

are crucial in the success of the plan:

the Royal Free London will redevelop Chase Farm Hospital to ensure it delivers care in high

quality buildings that provide a safe and pleasant environment for local people. The

current Chase Farm estate is too dispersed, in a poor state of repair and the design of

facilities are not suitable for modern healthcare.

we know that local people in Enfield are concerned about the future of Chase Farm

Hospital and we want to provide assurance that our priority is to provide excellent care

closer to patients’ homes. We want to bring services closer to where people live and work

so that they are more accessible and convenient.

the Chase Farm Hospital redevelopment is a new and exciting opportunity for existing staff

to work in a safer environment with suitable and fit for purpose buildings that helps them

provide the care they need for their patients. The new hospital will also become a more

inviting and attractive work environment, which will appeal to a high standard of new

recruits and/or staff.

we will be actively respectful in minimising disruption during the construction process.

We will communicate and engage with local people about our plans, timescales and

approach wherever we can.

Chase Farm Hospital has faced financial challenges for over a decade. Previous attempts to

resolve these difficulties have not succeeded. We need a hospital with a smaller footprint

which is safer, more efficient and will provide better value for the taxpayer.

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The above are the core key messages which will be targeted and tailored for specific stakeholders

and for specific circumstances. They will also be updated as the programme progresses, the

emphasis changes and details of some aspects become clearer.

Communications SWOT analysis

A SWOT analysis has been undertaken to inform the issues that need to be addressed through the

stakeholder communications and engagement plan. It highlights:

general public scepticism about the redevelopment of the site

a number of challenges to the successful development of the hospital

stakeholder support required for the planned changes to take place.

The full SWOT analysis is set out in the table below.

Table 7.16 SWOT analysis

Strengths local patient and resident support for the new hospital redevelopment

good reputation of trust set to run the site and services

strong political support for the development of planned services

good working relationships at various levels between LB Enfield and RFL, and

CCGs and RFL

visible site issues e.g. dispersed site, unfit facilities, provide a strong clinical

case for change

Weaknesses perception of fewer services being provided on the site

significant anecdotal cynicism at prospects for improvements

residual concern at removal of the A&E department as a result of BEH clinical

strategy

difficulty of explaining complex plans

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Opportunities ability to showcase a new way for hospitals to deliver modern services

integrated with other local healthcare services

gain public support as the building work commences and work is visible

pathway redesign will put patients first and demonstrate significant increase in

the quality of the patient experience

evidence that RFL is clinically led, excellently managed and can do difficult

things

Threats financial situation facing the local health economy

local cynicism about the providers of Enfield health services

long term sustainability of hospital that is in deficit

potential challenges to planning consents could delay the building works

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7.9.2 Stakeholder mapping and segmentation

A stakeholder is considered to be a person, group or organisation with an interest in the

development. Stakeholders in the CFH redevelopment programme fall broadly into the following

categories:

clinical leaders

NHS staff

public and patients

health partners

influencers

patients’ representatives

partner trusts

It is neither necessary nor practical to engage with all stakeholders at the same level of intensity. In

order to plan for effective and efficient communications and engagement the main stakeholders

have been identified and prioritised. By segmenting audiences, the level of engagement they want,

their views and their interests can be considered and communications tailored accordingly.

7.9.3 Communications strategy and plan

A communications strategy has been developed which identifies three key phases for the projects

from a communications and stakeholder engagement point of view:

phase 1 – ‘reassurance’ (pre-consultation engagement and formal consultation)

phase 2 – ‘building a better future for Chase Farm’ (establishment of the site and services)

phase 3 – ‘sharing the vision’ (future development after completion of new hospital)

The communications strategy also provides a list and segmentation of the project’s key stakeholders

and expands on our proposed approach. This is attached at appendix 7H.

A communications plan for each year setting out in detail activities to run alongside the programme

plan will also be developed. The communications plan for the current year (2015) is attached at

appendix 7I. Towards the end of each year the detailed plan for the next year will be developed in

consultation with the wider project team and based on upcoming milestones.

Key communications activities planned include:

continuing to keep staff fully informed about the redevelopment through newsletters, all

staff emails, chief executives briefings, ward memos, communications champions and the

intranet

publication of bimonthly Chase Farm redevelopment newsletters for staff, patients and

visitors. Copies of these will continue to be sent to local GPs

introduction of quarterly Chase Farm redevelopment community newsletter to keep local

residents informed about the redevelopment

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letter sent to local residents ahead of start of main building works to inform them about

working hours, extent of likely disruption and process for raising concerns and complaints

relating to the works

further public engagement events in September and December

communications in the run-up to Enfield Council planning committee

press work to highlight continued progress and achievement of key project milestones

attendance at the Enfield Town and Country Show to further engage with the local

community

updates on website and social media

continued running of redevelopment hub, with material on display regularly updated

publication of the redacted Full Business Case on trust website.

All feedback will be used to help steer the content of future communications and engagement as

well as determine if there is any resistance to any part of the programme. As set out in section 2.10,

we have already modified our proposals in response to stakeholder feedback and we will continue to

do so where feasible.

In response to stakeholder concerns, over the coming year we aim to provide additional reassurance

that the services at the hospital are not being downgraded and that the determination of the

hospital’s size has been a clinically-led activity to determine what space is needed to deliver the

services set out in the Barnet, Enfield and Haringey clinical strategy. We will also stress that we have

built significant flexibility into our plans to allow for future expansion space.

In respect of local concerns on issues such as traffic and parking we will continue to provide

opportunities for local residents to raise their concerns and will seek to directly address some of

these concerns through the launch of a community newsletter specifically for local residents.

7.10 Post project evaluation

The trust is committed to ensuring that a thorough and robust post project evaluation is undertaken

at key stages in the process to ensure that positive lessons can be learnt from the project. The

lessons learnt will be of benefit to:

the trust – in using this knowledge for future projects including capital schemes

other key local stakeholders – to inform their approaches to future major projects

the NHS more widely – to test whether the policies and procedures which have been used in this procurement were effective.

The project will be evaluated by undertaking the following investigations:

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a review of the project implementation to learn lessons for future

a review of the benefits detailed in the Benefits Realisation Plan and confirmation that they have been met

a review of the FBC capital and revenue costs to confirm that the capital costs were robust and adhered to and that the actual and projected revenue costs were realistic

a review of the Project Programme and adherence to it throughout the life of the project.

These investigations will focus on the perspectives of service users, staff and the project team, using

questionnaires, stakeholder consultation meetings, staff focus groups and evaluation of data around

the benefits realisation.

The arrangements for the Post Project Evaluation will be established in accordance with best

practice. In addition, as part of the P21+ process, the PSCP must have a number of post contract

activities to aid customer satisfaction and capture learning for future projects. These involve the

activities described below.

lessons learned – based on feedback and a workshop arranged for this purpose

KPI review involving analysis and the collation of a KPI workbook

satisfaction surveys will be undertaken and the results issued to the trust.

The planned participants in the evaluation and their roles will be as follows:

Table 7.17 PPE participants

participant role in post project evaluation

Evaluation Project Manager (external advisor)

To manage the evaluation in accordance with the Evaluation Plan and to provide objectivity, independence and apply other principles of good governance

Senior Responsible Officer

To provide input on: • achieving strategic objectives • achieving project objectives • project governance

Programme Manager To provide input on: • management processes • achieving strategic objectives • achieving project objectives • project governance

Director of Estates and Facilities

To provide input on: • management processes • achieving project objectives • capital costs • estates elements including building flexibility • commissioning programme • design/environmental elements • health and safety • energy performance • estates maintenance arrangements

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• site development control planning

Director of Finance To provide input on: • financial elements inc I&E sustainability • achieving financial objectives

Director of Planning To provide input on: • system flexibility / management of peaks and troughs in activity • robustness of activity modelling • continued commissioner engagement

Medical Director/Director of Nursing

To provide input on: • appropriateness of / adherence to model of care • appropriateness of design solutions • appropriateness / effectiveness of medical equipping arrangements / solutions • compliance with NHS design guidance and infection control arrangements • staffing efficiency, ergonomics, safety and security

Director of Human Resources

To provide input on: • workforce planning • recruitment and retention • sickness absence

Patients/Patients’ Representatives

To provide input on: • design / environmental elements • patient and visitor experience

In accordance with the DH’s Good Practice Guide Learning Lessons from Post Project Evaluation, the

PPE will be conducted in accordance with the following milestones:

Table 7.18 PPE key milestones

Stage Activity Timing

1 produce detailed plan for undertaking the PPE April – June 2018

2 on completion of the new hospital facility, evaluate initial outputs and undertake review of the processes followed to identify lessons learned on the next stage (Highlands)

July - September 2018

3 undertake initial evaluation of the project outputs following completion of Highlands ground floor

December 2018 to June 2019

4 evaluation of achievement of benefits and project objectives for entire project one year post completion

April – June 2020

The outcomes of the PPE will be shared within the trust and a copy will also be provided to DH.

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7.11 Approvals and letters of support

NHSE and local commissioner support in principle was obtained prior to the acquisition of BCF by RF

in July 2014. The Transaction Agreement recorded the parties’ agreement that substantial capital

expenditure was likely to be required on the Chase Farm site in order to ensure facilities at the

Chase Farm site remained at a reasonable standard and to enable greater operating efficiency and

therefore reduce the Chase Farm deficit.

In the development of the FBC, there have been various letters of support and these include:

- Trust Medical Director and Director of Nursing (appendix 2J)

- Chief officer Enfield CCG representing Enfield CCG, East and North Hertfordshire CCG and

Barnet CCG (appendix 2K)

- Planning officer (LB Enfield) (appendix 6K).

7.12 Recommendation

Following approval of this FBC by RFL trust board on 24 September, DH and HM Treasury are asked

to review and approve the case and to release the £81.8m PDC funding as agreed at OBC. Monitor is

asked to review the FBC, and to provide a risk assessment of the financial implications of the

transaction.

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