State of the NHSScotland Estate 2011

Annex A: Case Studies

This annex of the report provides short summaries of a number of best practice case studies covering different aspects of managing property and assets in NHSScotland. In addition to the benefits to participating NHS Boards, there are outputs from these case studies that are of value to a wider audience in NHSScotland. The case studies are aimed at promoting the sharing of good practice and provide the reader with information on actions being taken elsewhere in NHSScotland to deliver improvements in the performance, efficiency and sustainability of property and assets. It is envisaged that this will be a key feature of this annual State of the Estate Report, aimed at helping NHSScotland to develop capability and capacity to deliver a high performing, efficient and sustainable property and asset base. They have been selected on the basis of whether they are innovative and making a difference and whether they could be easily replicated more widely across NHSScotland.

Best Practice Case Study 1: NHS Forth Valley

In May 2010, NHS Forth Valley instigated an initiative to form a joint approach to property and asset management with other publicly supported bodies in Forth Valley.

The partners in the initiative include the NHS, three Local Authorities, Police, Fire and Rescue Service and Further Education. These organisations have a combined property portfolio comprising over 1,000 individual buildings with a building area in excess of 1 million sq.m.

The aim of the initiative was to tackle a number of well known challenges faced, to a greater or lesser extent, by all of the partner organisations. This includes fragmentation and duplication of property assets within the different organisations, the potential for more space efficient ways of working, the accumulated value of backlog maintenance and the need for a combined and overall property and asset database.

As part of the work undertaken on this initiative, a scenario planning exercise helped the participating organisations to develop the concept of a "Continuum of Ambition for Change" which, in essence, conceives change as a continuous process rather than specifically defined steps. The process map opposite helps to describe the confirmed approach for examining the different levels of future change from "minimum" to "more ambitious" to "very ambitious".

The outcome from this initiative has led to a general acceptance by the partners that a joint approach to property and asset strategy is essential to achieving more ambitious changes and associated benefits.

A Partnership Agreement and a Next Steps Action Plan have been developed and these will form the basis for taking forward the initiative. The Next Step Action Plan is a detailed plan which sets out what needs to be done to confirm the initiative's ongoing governance arrangements, how opportunities for joint collaboration will be identified, communicated and managed, what core of information will be collated and how performance improvement will be monitored. Implementing the Action Plan will move the partner organisations towards a standardised approach to the way in which all properties and assets are managed across the publicly supported bodies in Forth Valley.

Best Practice Case Study 2: NHS National Services Scotland

NHS National Services Scotland (NSS) has been implementing a programme of property rationalisation to support its strategic model of property provision since the year 2000.

Subsequent versions of its Property Strategy have continued to build on the successful theme of consolidation and rationalisation of the estate to align it to NSS Corporate Strategy and to continue to improve the overall quality and efficiency of the property portfolio.

The impact of implementing its current proposals for further consolidation and rationalisation up to 2014, (compared with 2008 figures), include:

• Reducing the number of properties held from 33 to 19.
• Reducing its occupied floor area by over 30%
• Eliminating its backlog maintenance from its current financial burden of £12.3m.
• Reducing revenue costs by £2.7m

Introducing new ways of working

In developing the first NSS Property Strategy it was recognised that opportunities existed to introduce innovative solutions to workplace planning, including "new ways of working". Hence, this became a key decision-making benefit criteria which has been consistently used in the development of business cases for implementing the Property Strategy. The results of this are evident in the workspaces and environments provided in new NSS office accommodation provided since 2004 and clearly demonstrates a move towards open plan, flexible space within high quality visual, aural and thermal environments.

Benefits

NSS has shown a strong commitment to strategic property planning for more than a decade and is now able to demonstrate that this has delivered significant benefits, including:

• NSS estate consolidated, rationalised and aligned to NSS Corporate Strategy.
• Improved building performance.
• Improved quality of working environment & thereby facilitating the retention and recruitment of staff.
• Availability of 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 & support services.

Best Practice Case Study 3: NHS Greater Glasgow & Clyde

In 2009, NHS Greater Glasgow & Clyde undertook a review of its central laundry facilities at Hillington in Renfrewshire with the intention of developing more efficient processes for the recycling of the trade effluent. By adopting state of the art technology it has managed to achieve 70% water and 95% heat recovery from these processes.

The central laundry unit consumes in excess of 193,000cu.m of potable mains water per annum through its laundry wash processes. Previously, the waste water from the laundry wash process was discharged to drain as trade effluent at approximately 55 degrees Celsius.

The new plant cost £800,000 to install and there have been some further costs associated with remedial works.

The financial model indicates that if the target minimum water saving of 70% is achieved the NHS Board will realise savings in the following aspects of the laundry wash process:

• Water consumption savings of 135,331,000 litres per annum
• Energy savings (Heat recovery) of 2,992,694 KWh's per annum.
• Total carbon emissions reduced by 450 Tonnes CO_²/annum
• Financial savings of £312,000/annum.

The financial savings indicated will provide a simple pay back of 2.7 years. This saving is guaranteed within the contract, with the NHS Board compensated for any shortfall in the projected savings within the financial model.

Further potential Trade Effluent cost savings of approximately £60,000 per annum are potentially achievable, by reducing consent levels once operational reliability has been confirmed and confidence in plant has been established.

The new filtration and recycling plant was installed in 2009/10 and has now been operational for one year, and, whilst there have been some technical problems with the implementation and operation of the plant, it continues to provide substantial benefits of significant water recovery, reduced environmental impact, and reduced costs.

This innovative solution addresses the growing need for sustainable use of both water and gas energy resources within a healthcare laundry production environment. In addition, this is a technological advance which could be replicated across all NHSScotland production laundry units which, although involves a reasonably significant investment, has a relatively low payback period.

Best Practice Case Study 4: NHS Tayside

Ninewells Hospital in Dundee has been implementing an ongoing programme of investment in energy efficient lighting schemes which has not only contributed significantly to energy, carbon and financial savings but has also enhanced the comfort levels for patients and staff.

The main objective of this scheme was to reduce energy waste, improve the patient, staff and visitor healthcare environment, and raise the profile of energy and environmental issues amongst hospital staff.

Many of the individual upgrade schemes include the installation of efficient fluorescent fittings with high frequency control and incorporation of presence detection. Back up 'pilot lights' were also installed to prevent areas plunging into complete darkness. These schemes have enabled significant savings in energy consumption, carbon reduction and financial efficiencies with a payback often between 7 to 10 years.

The Estates Department is also working alongside clinical colleagues to install a lighting control philosophy, which is a 'bolt on' to new installations via the BMS. This approach has been adopted within existing ward accommodation and will become standard across all 40 wards of similar design / layout. The outcome of this has seen a far more pleasant ward area where lighting levels now conform to lighting legislation and it also achieves a 50% reduction in electricity consumption with a payback of just over 9 years.

Further schemes across the 40 year old hospital have included locations such as service corridors, main circulation corridors, staff residences, estates administration office, and the engineering plant room area.

The ongoing programme of investment in energy efficient lighting schemes will not only contribute significantly to further efficiencies but it will also enhance the comfort levels for patients and staff. It is also recognised that this is a continuous improvement process requiring ongoing refinement of lighting levels and controls, as well as constantly reviewing and evaluating new lighting technology as it appears on the market. Staff communication, engagement and raising awareness are seen as key to the success of this scheme.

The main outcomes of this scheme are considered to be as follows:

• Lighting installations best suited to specific service needs.
• Increased staff awareness of energy and environmental issues.
• NHS Estates staff educated on the subject of new lighting technology.
• Improved lighting levels and lighting controls.
• Reduced energy consumption which in turn reduces the carbon footprint which also reduces operational costs.

Best Practice Case Study 5: NHS Greater Glasgow & Clyde

NHS Glasgow & Clyde's Acute Service Review (ASR) aims to modernise services across the city by renewing its acute healthcare facilities in tandem with a redesign of patient service delivery. The expected investment to fully implement the strategy is circa £850m and is expected to enable modern healthcare to be provided in fit for purpose buildings and clinical environments, with resulting improvements to the patient experience and the working environment for staff.

The overarching strategy is to reduce the number of adult inpatient sites from six to three (two with A&E), supported by two Ambulatory Care Hospitals and one children's hospital. Implementation of this strategy has been taking place over the last 8 years, with around two thirds of it being completed by the beginning of 2011.

The proposals for the redevelopment of the Southern General Campus forms the pivotal phase of the ASR strategy. It includes a new 1,100 bed inpatient facility with theatres and clinical support as well as a new Accident and Emergency Department. In addition, there will be a new 240 bedded Children's Hospital which is thus co-located with maternity services in the adult acute hospital.

Upon completion in 2015, the proposals for the three site inpatient configuration of adult services in Glasgow will be achieved and the NHS Board will be able to implement the following:

• Transfer inpatient services from the Victoria Infirmary and the Mansion House Unit to the New South Glasgow Hospitals.
• Inpatient services housed in outdated buildings on the Southern General Hospital and Western Infirmary sites will be relocated to the New South Glasgow Hospitals.
• Transfer of A&E services and associated beds from the Victoria Infirmary, the Western Infirmary and the Southern General Hospital to the New South Glasgow Hospitals allowing closure of the Western and Victoria Infirmary and older parts of the Southern General.

The challenges faced, and successes achieved, whilst implementing this ambitious change programme has enabled NHS Glasgow & Clyde to reflect on its experience of service rationalisation and make the following recommendations:

• The patient journey needs to be at the heart of any service redesign.
• A clinical strategy must inform the level of service provision required.
• Service provision needs to reflect the national context and strategic direction.
• The current provision of the estate needs to be understood along with its strengths and weaknesses.
• All options must be considered, including service redesign and reviewing the number and locations of where services are delivered, and maximise opportunities for co-location and streamlined patient flow.

Best Practice Case Study 6: NHS Ayrshire & Arran

The development of Girvan Community Hospital is proof that a wide range of environmental, sustainable and renewable technologies can be relatively easily integrated into a new building in order to minimise environmental impact and reduce future revenue consequences without compromising quality or functional suitability.

It is estimated that the building performance will lead to a reduction of 3% of NHS Ayrshire and Arran's current CO₂ emissions.

The sustainability objectives of the project included the aspiration of a BREEAM "Excellent" rating for the building through the introduction of renewable and sustainable technologies, including the use of recycled construction materials where appropriate. Another key objective was to minimise CO₂ emissions that the new facility would add to the estate.

Sustainability and energy considerations were, therefore, key aspects that informed the design process from the start leading to the provision of a wide range of environmentally efficient and sustainability features, such as:

• Biomass boiler 700 kW
• Wind turbine 100 kW
• Natural ventilation
• Rain water recovery for flushing toilets
• Under floor heating thermal mass
• Infra red auto sensor taps and toilet flushing
• Food waste vacuum & composting system
• PIR and daylight control energy efficient lighting
• Motor room-less lift
• Green Travel Plan
• Local indigenous materials
• Recycled aggregate in all concrete block work
• Forest stewardship council (FSC) sourced timber products
• Enhanced thickness of recycled newspaper insulation
• Zinc cladding (largely recycled and will not corrode hence less potential for leaks)

The various environmentally efficient and sustainability features have allowed this building to achieve a BREEAM "Very Good" and an Energy Performance Certificate (EPC) "A" rating.

The wind turbine after running for 4809 hours had produced 117 MW of electricity and has subsequently saved 50.3 Tonnes of CO₂ emissions. The income from the wind turbine is £28,200 over a measured 7 month period.

The biomass boiler after running for 2750 hours had produced consumed approximately 100 tonnes of pellets equating to 480MW of heat and a saving of 91.2T of CO₂ emissions.

The savings realised from rain water harvesting and waste disposal costs have not yet been accurately quantified however on water savings and waste disposal costs alone the savings are expected to be considerable.

Following an extensive public consultation exercise, 'Right for Fife', undertaken in 2002, NHS Fife identified the need for the existing provision of in-patient mental health services to be changed from provision in three geographical areas to two - namely West Fife and North East Fife. The Elmview Ward and Muirview Unit represent two phases of this Best Practice Case Study 7: NHS Fife strategic change within the North East Fife area at Stratheden Hospital near Cupar.

The Elmview Ward proposal was to provide a stand-alone 18 bed dementia unit for the elderly situated in the beautiful rural grounds of the existing Stratheden Hospital. The unit replaces an existing ward facility in Kirkcaldy which had an artificially lit deep plan corridor known as the 'dreaded corridor', very typical of hospital buildings of its age and type, and was the type of design which the project team was determined to avoid in the new facility.

The Muirview Unit project was to re-provide clinical services accommodation for in-patients from the existing Whyteman's Brae Hospital Site in Kirkcaldy to a new purpose built unit. The existing facilities were designed and built in the 1960's containing conventional long, artificially lit double loaded corridors and multi-bayed ward accommodation with shared toilet facilities and no access to external gardens or facilities. The existing facilities were in poor physical condition and functionally unsuitable in relation to the key mental health design principles of encouraging social activity and interaction. The design challenge to create an improved, patient focussed, innovative and sustainable environment was clear.

Both projects benefited immensely from a fresh collaborative, inclusive and participatory user focused design approach, which augmented AEDET and ASPECT design evaluations and resulted in functional designs which promote improved mental health and wellbeing.

The design approach was firmly based on a conceptual model of 'User-Centred Design' (UCD), developed from on-going research within NHS Fife in which from the outset of the project a significant amount of effort was put into encouraging staff, public patient representatives and the design team to collaborate and participate closely together. UCD seeks to promote key understanding beyond evaluating the designs and to build relationships. These relationships and understanding were extended to beneficial effect into the construction and commissioning phases and will be used again in the forthcoming post-occupancy evaluation.

The new Muirview Unit has been recognised for its architectural excellence by the Royal Institute of British Architects (RIBA) and will now be considered for the RIBA Stirling Prize. The unit also won the Best Mental Health Design Award at the Building Better Healthcare Awards held in London.

Best Practice Case Study 8: Hub Initiative

The Scotland-wide hub initiative reflects a national approach to the delivery of new community infrastructure. It brings community planning partners; including NHS Boards, local authorities, police, and fire and rescue services, together with a private sector development partner to increase joint working and deliver best value.

From small GP practices to large combined community, health and sports centres, the hub initiative is set to revolutionise the way Scotland's public bodies plan new facilities and deliver their services.

The potential savings possible by procuring an infrastructure project through hub, as opposed to conventional procurement are estimated as follows:

• Procurement cost savings - 2% of capital costs.
• Construction inflation savings - 3% of capital costs.
• Cost efficiencies and economies of scale - 3% of capital costs.
• Risk transfer - 2% of capital costs.

The programme divides the country into five geographical 'territories', each with a population of approximately one million. The South East and North hubco's are now operational and East Central Territory is due to complete its competitive dialogue phase at the end of July 2011 with preferred bidder announced in October and financial close in December. The West Territory has just commenced competitive dialogue and is due to reach financial close on March 2012 and the South West is due to issue its OJEU notice in summer 2011.

The first project, the Drumbrae Library project in Edinburgh, started on site in January 2011 with four more schemes due to start elsewhere in late summer 2011.

The hub programme received a major boost in the 2011-2012 Budget with a portfolio of healthcare projects to the value £200 million earmarked for development through hub over the next five years. This demonstrates just some of the tangible benefits arising from the flexibility of the hub model. These are projects that may otherwise not have happened because of the decline in available capital.

Another positive outcome of recent work is that public sector organisations can, through their hubCo partner, secure an appropriate designer and contractor for their project a lot more quickly than in the past.

As the initiative progresses, hub will become a key mechanism for delivering and managing assets more effectively, with continuous improvement leading to better value for money, which will be measured through detailed key performance indicators.

Best Practice Case Study 9: Frameworks Scotland

Frameworks Scotland continues to deliver excellent value for money with approximately £400m worth of projects being progressed and 11 projects completed, all successfully delivered on time and under budget.

Frameworks Scotland is a strategic and flexible partnering/collaboration approach to the procurement of publicly funded construction work and complements other procurement initiatives, including hub, for the delivery of new build and refurbishment health facilities in Scotland.

It provides NHS Boards with the ability to readily appoint accredited Principal Supply Chain Partners (PSCPs) alongside a pre-agreed commercial arrangement. This enables the team to immediately focus on the needs of the NHS Board rather than be involved in a protracted advertisement, selection and appointment process.

The PSCPs act as 'solution providers' and can offer a wide and diverse range of services. They are very different to traditional contractors as their supply chains contain a wealth of expertise from construction professionals through to specialist members of the supply chain. This provides NHS Boards with the unique opportunity of engaging the PSCP to undertake a wide variety of duties from service strategies, estates strategies, business planning, developing the brief and design development through to major and minor construction works.

These frameworks have been established to achieve the following key benefits:

• Earlier and faster delivery of projects.
• Certainty of time, cost and quality.
• Value for money.
• Well designed buildings procured within a positive collaborative working environment.

Frameworks Scotland is, however, not just a construction solution. A key benefit is the diverse range of management and construction services it can offer, and there are Frameworks for the following Professional Services Consultants (PSCs):

• Project Manager.
• NEC Supervisor.
• Cost Advisor.
• CDM Co-ordinator.
• Healthcare Planner.

Best Practice Case Study 10: Automated Guided Vehicles

Automated Guided Vehicles (AGVs) have been incorporated into the new Forth Valley Royal Hospital in order to separate out staff and patient flows from visitor and FM services

The intention is to reduce opportunities for cross infection, improve the hospital environment, enhance the patient experience, and promote a calmer, more therapeutic atmosphere. In addition, by keeping patient flow separate from visitor and FM traffic, patients can be moved between wards or to theatre in a more controlled environment.

The use of AGVs to provide flow separation was an innovative solution proposed by the successful PPP/PFI partner for the new hospital development.

In order to incorporate this system into the overall design of the hospital, early planning and the involvement of FM staff at the design stage was essential. In particular, given the space requirements for this approach, carefully consideration needs to be given to the provision, location and efficiency of dedicated corridors, lifts and location specific hubs.

AGVs are controlled by wireless connection which also allows them to call lifts when required and to communicate with fire doors, to avoid any damage in the event of a fire alarm. They are also fitted with detectors to prevent collision with anything within the AGV areas

There are a number of charging points located within the basement area. Where an AGVs charge drops to 60% or they have time not otherwise occupied they automatically go to a charging point.

The cost of the AGV system is approximately £1m, with each AGV costing around £50k. At present Forth Valley Royal Hospital use 13 AGVs but depending on demand may order additional units. This gives a payback period of between three and four years.

It is estimated that the AGVs are covering the work of around 12 staff; however, at Forth Valley Royal Hospital those staff have been moved to other duties, including tasks which the AGVs could not perform.

In terms of contingency, in the event of system fail, trolleys can be pulled by hand or electric vehicle with the redeployment of portering staff.

In 2010, NHS Lothian undertook a Clinical Accommodation Release Strategy (CARS) which was an essential pre-requisite to the delivery of the NHS Best Practice Case Study 11: NHS Lothian

Lothian's clinical strategy by ensuring that scarce and valuable clinical accommodation is freed up and that resources are directed towards front line service delivery. The strategy unlocked the opportunities to deliver the Board's objectives to improve efficiency, reduce energy consumption and maximise the benefits from good estate rationalisation.

NHS Lothian's property strategy highlighted the need to create additional clinical accommodation on hospital sites, i.e. RIE, WGH, REH, and RHSC.

It was noted that the Board's strategic HQ was located within Deaconess House, a period building which was inflexible to evolving business demands and required significant investment to maintain its condition and achieve partial compliance with statutory compliance, particularly, the Disability Discrimination Act.

The strategic HQ involved the relocation of the services from Deaconess House to a central Edinburgh location by securing a commercial lease on very favourable terms. The central Edinburgh Premises provides modern office accommodation which is accessible for people with disabilities, provides Boardroom and support accommodation facilities for the Board, public and staff, enables flexible single and multi-person office arrangements, and promotes new ways of working such as open plan, hot desking and home working.

The move to a central Edinburgh location enhanced NHS Lothian's commitment to the green agenda, with its location being fully accessible by public transport and in the vicinity of Scottish Government, City of Edinburgh Council offices etc. The building's energy profile is a considerable improvement on the existing estate, and allowing for energy and CO₂ savings to be achieved and further enhanced through the implementation of the Board's Green Travel Plan and Sustainability Strategy. The project has produced a reduction in energy and of 2,374kWh (65%) and CO₂ emissions by 538 tonnes (50%).

The Corporate Office involved the relocation of a number of corporate support functions from clinical accommodation to shared office accommodation in a Scottish Government leased building. As with the strategic headquarters accommodation, the premises provide a flexible open plan working environment with hot desking and the ability for remote working arrangements.

The release of the accommodation in clinical areas has enabled the Board to implement clinical strategies and free up accommodation linked to re-provision projects.

The rationalisation of the estate allowed Deaconess House to be marketed and disposed with the receipt expected this financial year. The closure of other areas has released revenue budgets associated with the estate, i.e. rates, property maintenance, utility costs.

The project has seen benefits being realised for staff and the Board in terms of efficiencies, improved environment for the staff and implementation of the Board's Green Travel Plan and Sustainability Strategy.

The Board is now embarking on phase 2 of the rationalisation of the estate which will concentrate on relocation of staff from sites which are linked to re-provision projects and from properties which are deemed unfit for purpose.

Best Practice Case Study 12: Supply Voltage Optimiser

Installation of Electrical Supply Voltage Optimiser technology is demonstrating potential electrical energy consumption savings of between 9 - 12%.

In 2009, NHS Lothian prepared a Carbon Management Programme in partnership with the Carbon Trust. This CMP targets a reduction of 20% of CO₂ emissions from NHS Lothian's building energy consumption and waste disposal. The savings are measurable against an investment programme which when funded will achieve the target.

The CMP includes a wide variety of projects and methods to reduce energy consumption including renewable energy schemes associated with new buildings, LED and automatic lighting, electric motor variable speed drives, high efficiency heat exchangers, boiler replacement programme with condensing heat exchangers. The programme is ambitious in its range of technologies and includes investment in electric supply voltage optimisation.

A pilot scheme to install a 1,000kVA Varmatic Voltage Optimiser at Royal Edinburgh Hospital was introduced which provided a supplier performance guarantee based on a 9% kWh consumption saving.

The technology basically reduces electricity and operating costs by reducing incoming power to more accurately match the electrical loading of the equipment on site thus reducing the carbon foot print. Tests at the Royal Edinburgh Hospital have indicated that supply can be in excess of 247 volts which can be reduced to 230 volts and permit a saving of 11.1%. In terms of monetary saving it is estimated that the savings based on the 9% performance guarantee would be circa £15,000 for an investment of £42,000.

Performance measuring has determined the guaranteed savings of 9% will be achieved and the chart below demonstrates this by comparing daily consumption between this year and previous year. Weekly savings have varied between a minimum of 4.4% and a maximum of 11.7%. The higher savings have been achieved latterly while moving to higher resistive electric loads in the winter period. Analysis of the electricity supply accounts during the 4 summer months reveals that cost savings have been equivalent to £16,000 in a full year.