Annual State of NHSScotland Assets and Facilities Report for 2014

6.0 Delivering NHSScotland's 2020 Vision

Getting the right assets and facilities services in place will be central to achieving the Scottish Government's "2020 Vision" for sustainable high quality in health. Delivery of this vision will require major change to the type and distribution of facilities and the way in which future investment is prioritised across all asset groups.

The significant capital and revenue based investment plans described earlier in this report already form a key part in the delivery plans towards the 2020 vision, by focussing on improved quality in health and care services and a commitment to pursuing the three Quality Ambitions of safe, effective and person centred care, as set out in NHSScotland's Quality Strategy.

6.1 Realising the benefits from Property Asset Investment

Three of the most significant property asset investment plans over the next 5 years involve the completion of the New South Glasgow Hospitals project, the development of a new Royal Hospital for Sick Children in Edinburgh, and the re-provision of Dumfries & Galloway Royal Infirmary. Together they amount to a future investment programme of over £600m (this excludes investment already spent on New South Glasgow Hospitals).

These three investments alone will replace over 300,000 sq.m. of outdated accommodation; replace buildings in poor physical condition, reduce estate backlog maintenance risks and significantly improve the functional suitability and space utilisation of the NHSScotland estate. This investment will also deliver on the triple aims of the 2020 Vision by providing modern facilities that improve the quality of care provided, support the ability to improve the health of the population, and help to secure value and financial sustainability of health and care services.

In addition to these three major projects, a wide range of smaller but no less significant projects are being delivered across NHSScotland; including the following projects which focus on delivering new health, social and community care service models, improvements to facilities in remote and rural parts of Scotland, and patient focussed safety related to the control of blood transfusion facilities:

Stirling Care Village

The proposed Stirling Care Village is a joint development between NHS Forth Valley, Stirling Council, the Scottish Ambulance Service and Forth Valley College, to be located on the site of Stirling Community Hospital. This is an opportunity to provide a range of co-located, integrated services for the Stirling and wider communities. The Care Village concept is one which is aimed at developing the flexibility of care provision that will be needed in the future whilst introducing economies of scale that will enable these services to be affordable and sustainable in the longer term.

Over recent years, Stirling Social Care Services have worked with NHS Forth Valley to demonstrate transformational change to the delivery of care for older people over recent years. This has been achieved through the development of a broad range of large scale intermediate care services including short stay intermediate care assessment beds, reablement, Therapeutic Day Support and Falls Prevention. The successes include:

• 22% reduction in care needs through the effects of reablement.
• 50% of those admitted to intermediate care following hospital discharge return home at the end of their placement.
• Minimised delayed discharge from hospital

The current model of care is based on more intensive short term intervention resulting in reduced ongoing service as clients are enabled and more independent. This developing model of care is seeing a shift in overall trends for local authority spend with some reductions in long term care spend to increased care at home spend. Current modelling indicates that if this model can be developed to its full potential, it would have a significant effect in containing some of the cost pressures as demographic changes impact on service demand.

In order to improve outcomes for service users and to reduce the affordability gap in service delivery due to population change, further development of current service provision is required. The new service model is based on an increase in care at home delivery and a rehabilitative approach wherever possible. A natural consequence of this approach will be a reduction in the need for permanent care home beds, which will release some resources currently tied up in this provision.

The provision of care in this way is expected to ensure that people are able to stay at home longer. Preventative activity will minimise the long term interventions required for older people while the introduction of a care village approach will lead to increased flexibility in service provision and economies of scale.

The Older Peoples' Care Hub will be a 116 bed facility in which, reflective of the changing model of care, nearly 70% of these will be integrated, health & social care service provision with the ultimate aim of flexibility across the environment to cope with future change.

The proposal also incorporates the co-location of 4 of the city's Practices on the site, which would provide a number of benefits:

• More efficient and effective provision of services.
• Adjacency/integration with the proposed services for Older People.
• Adjacency with other healthcare services, including Community Nursing and others to be provided in the Community Hospital.
• More effective use of the NHS estate
• The Practices can divest themselves of their outdated/outmoded premises

The Scottish Ambulance Service is another major partner in the project with plans to relocate from their current base in Stirling and workshop facilities in Falkirk to the Care Village. In addition to enhanced facilities and learning opportunities for the SAS workforce the move to the Care Village would allow greater integration and partnership working between Scottish Ambulance Service Paramedics and other clinical colleagues in the Minor Injuries Unit and the GP out of Hours Service. The Ambulance Service is committed to supporting the wider NHS to achieve a shift in the balance of care by extending the range of pre-hospital care, working in partnership with NHS Boards to agree and implement evidence based pathways of care that will see more patients being treated in their homes or local communities. This is a focus which can only be enhanced by the proposed co-location in the Care Village.

Though not a procurement partner as such, Forth Valley College brings another dimension to the Care Village project with several potential strands to their involvement. The College will support the training and continued professional development of a future health and social care workforce through the utilisation of opportunities and facilities in the Care Village, providing employment, training, placement and volunteering opportunities for local people. There will also be the opportunity to work with the other partner organisations to foster staff training and development, utilising existing facilities on site as well as those within their Stirling Campus.

Aberdeen Health and Care Village

The NHS Grampian 2020 Vision describes a health service that seeks to support people to remain healthy and in their own communities for as long as possible. Redesign of services will help to deliver this by creating opportunities to support wellbeing and self care and provide support, investigation and treatment in community settings.

The Aberdeen Community Health and Care Village (Health Village) is a key part of delivering the 2020 Vision in the city of Aberdeen. The Health Village is an urban community hospital (without inpatient beds) delivering diagnostic and treatment services for the people of Aberdeen and Grampian.

The Health Village will support self-care with the wider community care team, by helping people to remain well, independent and in their own communities where appropriate.

It provides a wide range of services, including cardiac rehabilitation, dental, dietetics, minor procedures, out-patients, physiotherapy, podiatry, radiology, sexual health services and speech and language therapy. Additionally, there will be a healthpoint/ carerspoint information service and access to learning space for patients, carers and staff. A small number of services will be delivered from the Health Village in partnership with Aberdeen City Council and Police Scotland.

Benefits for patients include:

• Creates an environment that encourages and supports self-care that is appropriate for each individual patient and their carer(s).
• Is a friendly and welcoming place which encourages patients, potential patients and carers to make use of its services.
• Provides a wide range of diagnostic and treatment services for the people of Aberdeen and Grampian, improving access to services.
• Is centrally located with nearby parking and reasonably accessible by bus for people from throughout the city.
• Encourages multi-professional working, to improve care for patients and their families.
• Aims to reduce anxiety and ensure, as far as possible, a smooth, timely, productive and pleasant experience for patients.
• Provides patient groups and voluntary groups with access to the learning facilities for the benefit of individuals' health and care.

Care Village on the site of the current Royal Victoria Hospital, Edinburgh

A Care Village on the site of the current Royal Victoria Hospital, Edinburgh is proposed to be taken forward in line with available resources and seeks a new approach to the care of people whose discharge is delayed in their transition from acute hospital clinical care back home or to other settings more appropriate to their ongoing care requirements.

The challenge for a care village on the site of the RVH based on this approach is how to ensure that consistent and cohesive operating policies and systems, as well as high quality environmental considerations, meet the triple aims of (a) improving the quality of care and the environment for occupants, (b) creating more capacity and (c) doing so at a lower unit cost. Success will mean far fewer unacceptable delays in the discharge of patients from acute hospitals, currently characterised as a lack of available care home beds and packages of home care in Edinburgh, which has to be compensated for by the retention of old and unsuitable NHS beds. Although there are some innovative service elements already in evidence across Lothian, including step down, 'Compass' (integrated community older peoples' service), step up and 'hospital at/to home', a more comprehensive whole-system model is needed to provide a longer term solution as well as having the potential for wider application to existing hospital and other sites across Lothian.

The concept of a care village is to ensure that patients, many of whom may have been admitted to hospital in emergency circumstances but whose acute clinical episode of care has concluded, are not detained within a hospital bed when their reablement or rehabilitation can be progressed within a more relaxed and conducive environment at home or in more homely surroundings. This will also include complex packages of intensive rehabilitation for patients in need of what is sometimes referred to as intermediate or interim care, but which can still be administered within a properly designed care village setting.

The essence of flexibility and tailoring care to individual needs within a care village presents a range of other opportunities, e.g. for people requiring end stage palliative care who would otherwise be admitted to an acute hospital.

Replacement Hospital and Healthcare Facilities for NHS Orkney

The procurement for a replacement hospital and health care facilities for NHS Orkney has recently been approved by the Scottish Government. This significant hospital and healthcare facilities development will provide a range of services for the Orkney population whilst also supporting a positive patient and staff experience in the delivery of person centred, safe and effective health care and service.

The Board's ambition is to reshape the way services are provided and the provision of a new Rural General Hospital incorporating an East Hub Primary Care facility, Public Dental Service and an adjoining clinical support services/facility represents one element of a series of system wide changes.

The age, condition and functionality of the existing facilities were causing serious business continuity risk and their replacement will address:

• Overcrowding and lack of storage;
• Poor accommodation and its impact on patient experience (temporary/portable buildings added to increase toilet and wash facilities in clinical areas);
• Infection control including decontamination risks;
• Patient environment and site layout - austere interior and impersonal exterior, outdated space standards with poor clinical adjacencies;
• Deteriorating engineering infrastructure (heating, plant etc) and the risk of 'business interruption';
• Significant backlog maintenance; and
• Buildings no longer fit for purpose (care delivery) with high carbon emissions and costly to run.

This investment is expected to provide the following benefits to patients and staff:

• Improved patient and staff experience;
• Improved staff recruitment and retention;
• New ways of working and improved performance;
• Repatriations;
• Locality based health and care delivery in partnership with other providers, including the Third Sector;
• Improved adjacencies and environmental ambience; and
• Improved access.

New Scottish National Blood Transfusion Production Centre

Construction work commenced on the Scottish National Blood Transfusion Service's new Production Centre in August 2014 which will bring together in one place processing & testing, IT support, engineering, head office, selected R&D, donor administration, tissue & cells, and quality functions. The new building of circa 10,500 m² plus 1,500 m² of garaging space will provide a net reduction of 3,567 m² (18%) on current space.

Through the provision of the National Centre, the Blood Transfusion Centre (BTC) will be able to:

• Make a step change in the future sustainability of service delivery and to respond to anticipated increases in demand
• Reduce operating costs
• Continue to meet the regulatory standards required to continue to deliver its services in future years
• Maintain and invest in skills and Scotland's expertise, developing our innovative capability

The new facility will deliver the strategic objectives described above by:

• Delivering future proofed facilities that give the service the flexibility to respond to changing demographics and increasing demand, particularly the ability to deliver new cellular therapies.
• Minimising the number of buildings requiring a regulatory licence and ensuring ongoing regulatory compliance in purpose built, licensed accommodation thereby reducing regulatory risks and costs.
• Designing process improvement/lean principles into a purpose built facility to enable new ways of working that will increase levels of efficiency both in terms of operational services and the efficiency of the facility itself. Close adjacencies between related specialities and disciplines allows the design brief to maximise operational synergies.
• Consolidating onto a single manufacturing site which will also drive efficiencies and synergies through rationalisation;
• Providing an improved working environment and conditions and opportunities for staff.

The provision of a new National Centre also provides NSS with a unique opportunity to create a building which is environmentally efficient, low carbon, has an improved indoor environment and with the potential to incorporate sustainable design.

6.2 Potential benefits from a strategic approach to Office accommodation

The Smarter Offices Programme referred to earlier in this report is intended to support NHS Boards and Special Boards to develop a strategic approach to their office accommodation which will have the following benefits:

• Improving performance of the current office estate using measurement against their peer group and against target benchmarks.
• Further development of New Ways of working aimed at optimising the space efficiency of office accommodation
• Promoting and facilitating collaboration across the public sector to explore opportunities for shared use of space
• The development of case studies from successful office strategies to show the benefits of new ways of working projects from within NHS Scotland and the wider UK NHS estate.
• Further development of the Asset Performance Framework for Office Accommodation to ensure clarity in Framework KPIs and reduce target space allocation from 10sqm/FTE to 8sqm/FTE for new and refurbished office accommodation to align with changing practice in the wider public sector.

All NHS Boards recognise the importance of rationalising their office estate to maximise efficiency and reduce unnecessary space and, over recent years, the Special NHS Boards have made significant progress towards this by maximising the utilisation of their office accommodation. This has been achieved through the introduction of new ways of working, flexible working and workplace redesign.

In particular, NHS National Services Scotland (NSS) has done extensive measurement of space efficiency and costs across its own large and diverse office estate as part of implementing its Property & Asset Management Strategy which was focused on:

• Providing well designed and efficient space which is flexible towards embracing changing working practices and new technology
• Maximising the opportunity for staff to develop and deploy their knowledge, skills and personal qualities creatively to add value to the business and services
• Achieving synergies from shared use of accommodation and support services.

The Scottish Government, along with Scottish Futures Trust, will be supporting NHS Boards and Special Boards to develop strategic plans for their 2015 PAMS which consider the above opportunities for improvement, as well as further opportunities from the wider public sector office accommodation. This has the potential to bring about the following benefits:

• Provision of affordable support accommodation to the NHS that is better able to respond to future changes in strategic direction
• Improve current office accommodation performance issues, where opportunities exist, in terms of space utilisation, functional suitability and physical condition
• Improve the quality of working environment and thereby facilitate the retention and recruitment of staff
• Improve the availability of staff welfare facilities and promote positive staff morale.
• Providing flexible, well designed, efficient space that is able to cope with uncertainty around future property needs, support opportunities to change working practices, and introduce new technology
• Support Scottish Government environmental sustainability agendas through the appropriate procurement, design and operation of its property assets.
• Maximise opportunities for staff to develop and deploy their knowledge, skills and personal qualities creatively to add value to the business and service provision
• Enable more integrated/collaborative working and thereby encourage better use of skills and resources
• Achieve synergies from shared use of accommodation and support services.

6.3 Potential benefits from a more strategic approach to investment in medical equipment

Medical equipment is a valuable asset both in monetary terms and in the important role it plays in the delivery of quality healthcare across NHSScotland, with modern standards of available equipment used to support better patient care and improved efficiency and effectiveness of service delivery. The strategic management of medical equipment within each NHS Board should be aligned to its strategic aims. The strategic approach, supported by careful planning (replacement planning and, responding to changes in clinical care, procuring different additional equipment) will lead to better availability of the equipment required for patient care. Current examples of this across NHSScotland include:

• The programme of investment in new radiotherapy machines has enabled advanced treatments to be delivered in less than two minutes; rather than the 15-20 minutes needed for conventional radiotherapy treatment, and are capable of treating in excess of 40 patients per day.
• Modern imaging equipment is now designed to keep radiation dosage to as low as reasonably achievable thus reducing the associated risks to patients and staff.
• The introduction of Digital Radiology technology provides instant image results, allowing the radiology staff to verify image clarity immediately after taking the image. This avoids the wait sometimes required whilst the image quality is verified
• Medical Equipment is integral to the delivery of keyhole surgery which has significantly reduced the length of stay in hospital for patients. It has enabled complex surgery, particularly abdominal surgery, to be undertaken without the associated trauma of major open surgery.
• Examinations of the digestive and intestinal system (gastroscopy and colonoscopy) using flexible endoscopes provide minimally invasive methods of diagnosis of pathologies including cancer, with the ability to carry out some treatment. Developments including specialised imaging techniques (narrow band imaging to more clearly show abnormal cells) are improving the quality of the images.
• Modern standards of medical equipment enable cataract surgery to be carried out on a day surgery basis resulting in improved service effectiveness, patient convenience, and patient safety.
• Clinical Portals for example in cardiology where ECG recordings are wirelessly uploaded in real time to a data base where anyone can view them or use them to compare against previous recordings In the event of the patient being admitted at another hospital the recordings are immediately available.
• Cooling of patients who have had an out of hospital cardiac arrest has proven to increase recovery.
• The total number of adverse incidents related to medical devices reported centrally in Scotland is 250 per annum. This number has been fairly constant over the past few years. Of that 250, only 40 are related to medical equipment (note: the actual causes of these incidents may not necessarily be the medical equipment itself).

There are, however, opportunities to improve the strategic approach to investment in medical equipment, and the support that they provide to patient care, such as:

• Sharing knowledge and learning from good practice investment models already in place for radiotherapy and imaging equipment. This has the potential to improve the effectiveness of investment decisions in other critical medical equipment.
• Developing strategic national advice of how medical equipment could improve healthcare prevention through better / more screening equipment and thus support reduction in hospital admissions.
• Provide further advice for the 2014 SAFR on appropriate life cycle replacement periods for different categories of medical equipment.
• Improving the accuracy of reporting on the value and performance of medical equipment through the SAFR pro-forma process.
• Introducing a harmonized database across NHSScotland of medical equipment that would improve the robustness of comparable performance data and support decisions on investment priorities and resources.
• Providing national advice on the introduction of new advances in medical equipment, and forecast growth areas, such as:
  • Computerised devices and medical IT systems.
  • Robotic surgical systems.
  • Advanced imaging systems.
  • Wireless products.
  • Equipment associated with minimally invasive therapeutic procedures.
  • Home and self-care products.
  • Patient monitoring systems.

In order to take forward these opportunities, it is recommended that the SAFR Medical Equipment Group, along with other technical and strategic members, are initially tasked with investigating and reporting back on the benefits that could be gained from taking such an approach to the strategic management and investment in medical equipment. To support this it is proposed to establish a Medical Equipment Management Expert group, with a draft terms of reference submitted via the SAFR programme board for approval.

6.4 Realising the benefits from NHSScotland's eHealth Strategy

The potential of information technology to support and transform healthcare services is fully recognised across NHSScotland and eHealth has a pivotal role to play in ensuring that the 2020 Vision for Healthcare in Scotland and its Quality Ambitions are delivered.

The building blocks for future IT enabled progress are now in place following implementation of the eHealth Strategy for 2008-11, with eHealth now moving from an acquisition / development phase towards exploiting the value of the new capabilities acquired during 2008-11. The new eHealth Strategy 2011-17 is therefore a revenue based improvement programme, leveraging the IT assets to support the quality improvements that NHSScotland has committed itself to.

Progress in implementing the eHealth Strategy will be used within the SAFR domain as the basis upon which investment needs are better understood and priorities are recognised. The benefits to be gained from implementing the eHealth Strategy can then be more closely integrated with other NHSScotland investment priorities and decisions.