Argyll and Bute CHP Future Bed Modelling requirements – Stage 1

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					                                                           Argyll & Bute CHP Committee
                                                   Date of Meeting : 25 September 2008
                                                                            Item No.5.1

Argyll and Bute CHP Future Bed Modelling requirements – Stage 1 LIRGH

Report by Stephen Whiston Head of Planning, Performance and Contracting

    The Argyll and Bute CHP Committee is asked to:

        1. Consider the findings of the Bed modelling work and the review of
           facilities and services undertaken to identify the future configuration
           and complement of inpatient, day case and theatre facilities at LIRGH.
        2. Consider the assessment of the CHP Management Team of the
           modelling exercise re 1
        3. Decide whether the option of locating the New Dental access centre into
           the hospital is viable and appropriate.
        4. Note the implications of this work to inform the infrastructure
           modernisation plan for LIRGH
        5. Note the use of this bed modelling tool to inform decision making on
           future proposals in line with the CHP priorities

    1   Introduction

The CHP management team in 2007 commissioned consultants to produce a dental
modernisation strategy for the CHP. A solution for Oban was fast tracked as the
dental service was in crisis at that time due to the closure of one of the independent
surgeries in the town.

An option appraisal process was conducted, which resulted in a recommendation to
site the new facility within the vacant Nelson Ward on the hospital site. The CHP
management team considered this recommendation at its meeting on the 30/01/08
and it was agreed that a bed modelling scenario exercise be undertaken to assess
future demand for ward, day case and theatre accommodation. The outcome of this
work would create a more accurate understanding of the future service and facility

The CHP commissioned consultants to undertake this work and over the last 6
months local management, clinicians and staff from the planning and information
services department have been involved in assessing, reviewing and refining the
outcomes. The results were presented and considered at Septembers CHP
management team meeting and the following recommendation is made for the
committees approval

2       Context

The papers and information presented to the management team today need to be
seen as work at a point in time but of a status to inform the CHPs decision making

2.1         Modelling and current performance statistics

The best guide to future performance is previous performance. This section will
review recent performance and compare and contrast that with peer RGH’s and
national trends. Following on from this review the scenario model will be introduced
along with results and analysis of its findings.

The current average inpatient occupancy rate in 2006/07 and to date is around 64%.
This trend at LIRGH bucks the trend nationally where the occupancy rates have been
increasing. On average 74 inpatient beds were occupied, out of a capacity of 96.

Table 1 Bed occupancy rates by speciality

                                                                            2007-08   to
                                          2004-05       2005-06   2006-07
General Surgery                           60%           64%       57%       58%
General Medicine                          66%           73%       65%       62%
Geriatric Assessment                      94%           68%       100%      85%
Continuing Care                           105%          100%      77%       100%
GP Obstetrics                             12%           5%        1%        0.5%
Total Inpatient                           69%           59%       64%       61%
Total Day Case                            84%           99%       88%
    Clarifying day case numbers for 2007-08

Bed Modelling

The bed modelling process and outcomes need to be understood within the context
that the models outcome will vary dependent upon the changes in the scenarios
introduced. The advantage of such a tool is that over time one can see how ones
assumptions played out in reality as well as enable the CHP to refine its scenarios
over time.

The following scenarios were considered:

       Increasing Day Case Rate - Review performance against British Association of
       Day Surgery (BADS) standards
       Reducing Length of Stay - Moving current Length of Stay (LOS) for LIRGH to
       the upper quartile performance i.e. assumes patients will have a LOS not
       exceeding 3.9 days for surgery and 6.2 days for medicine.
       Removal of Continuing Care Beds – closure of remaining continuing care and
       resource transfer to the council.
       Admission Avoidance - Using the Institute for Innovation & Improvement
       Ambulatory Emergency Care for Adults report to identify and reduce the need for
       emergency Finished Consultant Episodes (FCEs)
       Repatriation of services from GG&CHB - Modelling repatriation of selected
       procedures from NHS GG&C . Repatriation would allow some of the 1800
       admissions currently treated in GG&CHB to be carried out in LIRGH. We have
       categorised these procedures into 1, 2 and 3. Categories 1 are the simplest to
       start performing in LIRGH, 3 the most difficult required capital expenditure
       (Addendum 2).

                                                                         Argyll & Bute CHP Committee
                                                                 Date of Meeting : 25 September 2008
                                                                                          Item No.5.1

             The bed modelling results are illustrated below

             Table 2 Bed Modelling Results

             Scenario                                Type            Now             2021-22
             Population & Occupancy Rates            Day Case        6               7
                                                     Inpatient       96              121
                                                     Total           102             128
             Increasing Day case Rates               Day Case        6               8
                                                     Inpatient       96              120
                                                     Total           102             128
             Reducing LOS / Removal               of Day Case        6               7
             Continuing Care Beds                    Inpatient       96              52
                                                     Total           102             59
             Admission Avoidance                     Day Case        6               7
                                                     Inpatient       96              110
                                                     Total           102             117
             Repatriation                            Day Case        6               9
                                                     Inpatient       96              129
                                                     Total           102             138
             All scenarios combined                  Day Case        6               10
                                                     Inpatient       96              55
                                                     Total           102             65

             2.2    Sensitivity Analysis

             It is appropriate to consider additional scenarios that were not in the original model.
             Discussion in LIRGH with senior clinicians and management suggested two
             additional variations. The first excludes all scenarios except population changes.
             The model is not based on all patients coming down to the average number of days
             for LIRGH, but based on 10 and 20% improvements in average length of stay, over a
             13 year period.

             Table 3: Sensitivity Analysis
             Variation using increased efficiency on LOS for 2021

Speciality             Average        2008 Beds     2021 Beds          2021 Beds      2021
                       LOS                          10% more efficient 20%       more 30%               more
                                                                       efficient      efficient
General Surgery        3.9            43            46                 41             36
General                5.1            29            29                 26             23
Geriatric              25.1           10            13                  12                  10
Other                                 20            11                  11                  11
Total                                 102           99                  90                  80

      As can be seen from table 3, the number of beds required by LIRGH reduces from
      the current level to 99, 90, and 80 for improved efficiencies of 10, 20, and 30 %
      respectively. These performance improvement targets are small equating to 1, 1.5 or
      2.5% p.a. and in line with expectations of potential efficiency savings without any
      breakthrough technology.

      Table 4 - Sensitivity Analysis
      Variation using increased occupancy for 2021

                   2008          Existing        Model         Revised Model Revised Model
                   Beds          Model           Forecast      Occupancy 80% Occupancy 90%
General Surgery    43            69%             53            46                  41
General Medicine   29            69%             30            26                  23
Geriatric          10            63%             27            21                  19
Other              20                            18            12                  12
Total              102                           128           105                 95

      Table 4 gives variation of the modelling in occupancy rates with underlying
      population increases. This table demonstrates that better use of existing facilities
      would reduce bed numbers. The Scottish Government’s requirement for a DGH to
      achieve 85% occupancy. If the CHP were able to reach an agreement with a hotel or
      hostel to house pre or post op patients it should be entirely possible to increase bed
      occupancy levels significantly.

      However, the model is based on a total occupancy of 69% and therefore at any given
      time almost a third of the hospital is available for patients that stay longer than the
      average Tribal has made an underlying assumption within their calculations that 95%
      of events would be catered for with a 69% bed occupancy.

      The current performance information presented for LIRGH clearly shows there is
      under utilisation of the existing asset as demonstrated by the bed occupancy figures
      by specialty. This is supported by the fact that the hospital is operating relatively
      efficiently re its LoS and turnover intervals by specialty are good against its peer
      hospitals. In addition the activity conducted in the last year has increased probably as
      a result of the efficiency gains derived from the third surgeon post and the new
      physician at the hospital. The CHP forecast is for this trend to continue.

      This is illustrated in the tables below:

                                                                                      Argyll & Bute CHP Committee
                                                                              Date of Meeting : 25 September 2008
                                                                                                       Item No.5.1

            Table 5 - Peer Group RGH’s Length of Stay 2007/08

                                                                                   Lorn     &
                                                                    Gilbert                      Western
                        Balfour,                     Caithness                     Islands                                  Upper
SPECIALTY                              Belford                      Bain,                        Isles,           Average
                        Kirkwall                     General                       District                                 Quartile
                                                                    Lerwick                      Stornoway
General Medicine                       5.9           5.2            5.9            5.1           10.2             6.5       5.9
General Surgery         3.6            4.4           3.9            3.6            3.9           3.6              3.8       3.8
Medicine                                                                           25.1                           25.1      25.1
GP Obstetrics           2.6                                         2.9            0.4                            2.0       2.3
Oral Surgery            1.0                          0.2                           0.8           0.9              0.7       0.8
Medical Oncology        8.7                                                        4.0                            6.4       6.4

            Table 6 – Activity trends 2004/05 – Forecast data 2008/09

            * Data from CHP Information Services   ** Forecast Data from CHP Information Services based on April to July

            2.3       Operational Assessment

            Of equal importance is Operational management’s assessment of the modelling and
            existing performance measures and management processes. Interpretation of this
            against actual operating parameters, service plans and aspirations, when placed
            alongside building and technical guidance provides a key reality check for the
            modelling theory.

            The key points made in this regard are:

                  •   Changing demography and likely increase the elderly and very elderly
                      population requiring more complex acute interventions
                  •   New ward design standards reflecting that a minimum of 50% of all beds
                      should be single rooms with ensuite facilities

      •   Palliative care standards of accommodation fall well short of CHP policy and
      •   Training and educational facilities
      •   Repatriation of activity from Glasgow providing more services locally could
          result in a maximum estimated increase of 1200 in and day patients.
      •   Maintaining the core service profile expected of RGH – standards, service
          portfolio etc
      •   Control of infection, increase in single room requirements
      •   Impact of redesign on ground floor services within the overall hospital site
          development plan, particularly the need to develop RGH as a diagnostic hub
          networked and outreaching with the western spine.
      •   Compromising possible future developments in service – e.g. haemodialysis
      •   Modernisation and Reconfiguration requirements Maternity, HDU, Day

Oban Lorn & Isles Locality Management Team Consideration

Having reviewed this analysis, both the Locality Management Team and the Senior
Medical staff remain extremely doubtful about some of the modelling assumptions
and also the practical possibility of achieving the levels of occupancy identified. As a
result they lack confidence in how robust the model analysis is.

In particular

•     The assumption relating to continuing care activity is overstated.
•     The assumption relating to reduced length of stay is very significantly overstated.
•     The overall bed requirement identified for 2021/22 is less than any of the
      individual scenarios received.

Several meetings have taken place with the clinicians and management of the
LIRGH. The model was refined; the scenarios were broken down further to take
account of the extra levels of detail that the hospital team required to become
comfortable with the model and how it could be altered. In all cases the clinicians
and management team were happy with the outcome of the modelling except for one
important area. The assumption that all patients could be moved to the peer
group average of having a length of stay not greater than the average. This
assumption was not felt to be logical, practical or achievable.

2.4       LIRGH- Ward accommodation footprint – 50% single room standard

A high level assessment of the impact of the single room standard on the wards
currently occupied is detailed in the floor plan and supporting information in
Addendum 1. This diagram illustrates the number of inpatient, day case and HDU
beds that could be provided assuming the proposed dental facility was placed in
Nelson ward.

This work has identified that between 76- 80 beds could be provided which would still
allow the proposed dental facility to be located in the hospital. Members should also
note a detailed architectural review may result in a small increase to these figures.

The management team also pointed out that parts of the vacant Nelson ward had
been reused to house physiotherapy, regular use of a training venue and the

                                                             Argyll & Bute CHP Committee
                                                     Date of Meeting : 25 September 2008
                                                                              Item No.5.1

temporary housing of decontamination unit, offices etc. The Dental development
would result in these functions being relocate

2.5    Strategic Issues

The CHPs still has a significant underlying recurring deficit. The scale of resources
tied up in our buildings can be viewed as a wasted resource if we are not utilising our
assets to at or near their maximum capacity. Using LIRGH for dental would assist in
maximising asset utilisation and reducing this recurring deficit.

Reviewing the bed occupancy in all our wards across the CHP, shows significant
under utilisation, frequently in the order of 30% in some specialties. Yet we are also
clearly sending significant activity to Glasgow. Notwithstanding local variation this is
not something we can continue to afford and hence the CHP repatriation programme.

The CHP needs to start looking across its whole patient care system particularly its
western spine – Campbeltown, Mid Argyll and LIRGH, but also to the Belford in Fort
William. All of these are within 1 hour drive time of each other and if we are full in one
site, then should not the option of patient transfer to another appropriate acute facility
in the CHP/Fort William be considered prior to transfer to Glasgow? Further the
western spine must look to maximise the use of LIRGH by referring all appropriate
activity accordingly.

Our partnership working with the council sees the NHS transferring its continuing
care resources to the Council. Whilst the exact timetable for this transfer continues to
remain unclear, clearly we will continue to tie up resources inappropriately, clarity
over this direction and timescale is urgently needed.

Making a reality the rhetoric of “Shifting the Balance of Care”, directly challenges the
CHP to disinvest in acute services and reinvest in primary care/community services.
There is however a real risk and tension in delivering this notably:
   • Increasing very elderly population with complex morbidity
   • Loss of primacy care safety net of hospital beds
   • Requirement for transition funding re invest in community before transfer
       acute resources

2.6    Achievement of waiting times targets

It is clear that LIRGH theatre and day case accommodation are below 21st century
design standards and this constrains their operating efficiency. They require
modernising to support the delivery of an accessible, fast and efficient elective
service meeting the needs of patients. Unless we invest in these facilities providing a
designated day surgery suite etc, then we are at risk of compromising our ability to
achieve waiting time targets which by March 2010 will be 9 weeks for treatment and
4 weeks for diagnostic tests.

2.7    CHP Capital planning implications

It is clear that the decision made today will have implications for the CHP with regard
to its capital resource. If we select a different option to proceed, than the current
preferred option, the dental access centre for Oban will tie up more capital from our
programme and possibly other developments will not proceed. In addition members
should note the timing issue of the Oban dental development as this facility is

urgently required. (Addendum 2 details the cost of the various alternative options
identified for the dental access centre in Oban)

Running concurrently as an outcome of this is the fact that we can now also predict
significant capital implications for the scale of works required to modernise LIRGH
infrastructure over a 1-5 year period regardless of whether the dental access centre
is located in the hospital or not. This is recognised within the planning priorities
document and has been endorsed by the CHP Management Team.

The proposed development of Palliative Care will also bring forward a significant
capital contribution from Oban Hospice.

Further if we do site the Dental Development in the hospital the CHP would have to
put in place a significant transformational change project over a 2/3 year period. This
would see all of its capital and project management resource focused on Oban to the
significant detriment of other localities and services.

This ramification would skew the investment priorities of the CHP, possibly deferring
mental health modernisation for example

3       Assessment

The information presented to the CHP committee illustrates the complexity of the
issues with regard to planning, modeling and forecasting future bed and theatre
Requirements at LIRGH. The table below attempts to distil the issues into top level
broad risk/advantage comparison.

Locality clinical and management assessment has concluded that the risk is too high
and there is too much uncertainty in housing the dental development in the hospital.
The Locality team feels that there is a real risk of compromising the hospital’s future.
In addition a number of additional service accommodation requirements have been
identified as important to ensure the sustainability of core services and at present
these can only be housed in Nelson ward.

The top level floor plan analysis of the impact of achieving the 50% standard of single
beds and still house the dental centre would provide the hospital with around 76-80
beds to deliver its core service.

The scenario modeling of beds and subsequent sensitivity analysis illustrates a range
of bed numbers from 65-138 depending upon the assumptions modeled. However,
all of these scenarios would require:

    •   a continuous improvement in performance (a figure of 2.5% p.a. would seem
    •   proactive bed management and cross CHP working
    •   Capital investment to modernise facilities.
    •   Recognition new building standards re single rooms will restrict bed numbers

                                                                                                                      Argyll & Bute CHP Committee
                                                                                                              Date of Meeting : 25 September 2008
                                                                                                                                       Item No.5.1

Topic         Advantage                                                 Disadvantage/risk                                 Observation
Dental centre • Modern facility and service for locality                • Significant financial and resource implication • Building
housed     in • Build time frame assessed as quicker – 14                  for CHP                                           standards
LIRGH            months                                                        o Skew CHP capital invest priorities 1-3      guidance will
              • Fully utilized asset offering best VFM in revenue                 years – development blight in rest of      result        in
                 costs for CHP                                                    CHP                                        reduced beds
              • Capital cost lower (1.8m) – frees up capital for               o Require         significant      change     in hospital –
                 other CHP projects                                               management project and performance         circa 80 - 85
              • Greater/immediate focus on performance and                        management focus resource               • Importance of
                 utilisation of surplus capacity in “Western spine”     • Scale of service disruption very significant as    implementing
                 of CHP & Fort William                                     decant capacity Nelson ward not available         partnership
              • Would act as immediate catalyst to put in place         • Could compromise future core service               plan          to
                 modernisation developments in a 2/3 year time             development of RGH                                provide older
                 frame from 09/10.                                      • Car parking limitations                            peoples long
                                                                        • Physical constraints of existing building          term       care
                                                                           envelope                                          needs.

Dental centre •     Modern facility and service for locality – if new   •   Other dental option more expensive and take
housed              build design not constrained.                           longer e.g. Est. build – 17-20months, Costs
elsewhere     •     If Harbour Bowl selected, site central to Oban          2.186-2.763m
                    with transport and possible parking advantages      •   Risk in 2 years time still being faced with
                •   No immediate change implication for LIRGH 1 /2          partially empty ward/accommodation
                    year time frame                                     •   Maintaining inappropriate facilities re efficient
                •   Not potentially constrain future requirements of        operation as time line of investment to
                    RGH                                                     modernise is constrained by absence of
                •   More time to work up site and service                   capital
                    rationalization/development plan                    •   More of CHP capital resource tied up in dental
                •   Immediate possibility of realignment of some            although this is mitigated by the opportunity to
                    accommodation to meet care standards e.g.               bid for resource from the Primary Care
                    palliative, single beds                                 Modernisation Initiative

4      Conclusion

There is now sufficient information to consider and make a transparent decision and
recommendation to the CHP committee on the suitability or not of locating Oban’s
new dental access centre in the RGH.

The CHP management team review of the issues has led it to recommend that it the
new Dental access centre should not be housed in the hospital and an alternative
option should be pursued. In coming to its conclusion the key elements were:
    • Level of service disruption
    • Tying up a significant proportion of the CHPs project and capital resource in
        Oban for the next 1-3 years
    • Potentially compromise of the future ability of the hospital to develop its role
        as the RGH for Argyll and Bute.

If the CHP committee approves this recommendation then an assessment of the
other options will be undertaken and recommendations made to the CHP
management team for approval and immediate implementation.

The CHP committee should note that the management team has endorsed this bed
modeling methodology and process for application across all its future planning
proposals to inform its decision making process and to monitor outcomes over time.


 Financial:                  Impact on the CHPs revenue and capital allocations
 Staff Governance            Implications across the projects identified
 Patient Focus & Public      Implications of outcomes have service change implications requiring
 Involvement                 public involvement processes
 Clinical                    QIS standards are relevant
 Equality   &   Diversity    Modernisation projects will require to have EQIA assessment to
 Impact:                     ensure access is enhanced for all socially excluded groups

Stephen Whiston Head of Planning Contracting and Performance
25th August 2008

                                                      Argyll & Bute CHP Committee
                                              Date of Meeting : 25 September 2008
                                                                       Item No.5.1

Addendum 1

50% Single Use Bed Standard assessment on impact of existing Bed/Day Case

                  Opt. 1 Bed
Ward Area         No's       6 Bay      4 Bay      Single
Ward A            18         1          -          12
Ward B + HDU      18         1          1          8
Ward C            22         1          1          12
Maternity         1          -          -          1
Ward E            21         1          -          15
                  Available area 626.23 sq M - Dental Access
                  centre requires 599 sq M, therefore leaving 27
Vacant Wd D       sq M for other requirements.
TOTAL (Excl. Wd
D)              80                                 48

                  Opt. 2 Bed
Ward Area         No's          6 Bay 4 Bay         Single
Ward A            18            1        -          12
Ward B + HDU      18            1        1          8
Ward C            22            1        1          12
Maternity         1             -        -          1
Ward E            17            1        -          11
                  Available area 679 sq M - Dental Access
                  Centre requires 599 sq M, therefore leaving 71
Vacant Wd D       sq M for other requirements.
TOTAL (Excl. Wd
D)              76                                 44

        Addendum 2
        Repatriation of Selected localities -Activity sent to GG&CHB

Group    HRG                                                                     No.   %
3        Phakoemulsification Cataract Extraction with Lens Implant               260   7.9
2        Arthroscopies                                                           108   3.3
1        Bladder Minor Endoscopic Procedure w/o cc                               106   3.2
         Chemotherapy with a Haematology, Infectious Disease, Poisoning, or Non-
1        specific Primary Diagnosis                                              94    2.9
1        Vasectomy Procedures                                                    72    2.2
1        Chemotherapy with a Digestive System Primary Diag                       52    1.6
1        Chemotherapy with a Skin, Breast or Burn Primary Diag                   50    1.5
1        Chemotherapy - Female Reproductive Sys Primary Diag                     44    1.3
1        Haematological Disorders with Minor Procedure                           41    1.2
1        Oesophagus - Diagnostic Procedures                                      40    1.2
2        Muscle, Tendon or Ligament Procedures - Category 1                      24    0.7
1        Bladder Intermediate Endoscopic Procedure w/o cc                        23    0.7
1        Stomach or Duodenum - Diagnostic Procedures                             23    0.7
n/a      Planned Procedures Not Carried Out                                      21    0.6
2        Red Blood Cell Disorders >69 or w cc                                    21    0.6
1        Fibreoptic Bronchoscopy                                                 21    0.6
1        Bladder Minor Endoscopic Procedure w cc                                 18    0.5
1        Hand Procedures - Category 1                                            17    0.5
1        Prostate or Bladder Neck Minor Endoscopic Procedure (Male and Female)   17    0.5
1        Chemotherapy - Urinary Tract or Male Reproductive Sys Primary Diag      17    0.5
1        General Abdominal - Endoscopic or Intermediate Procs <70 w/o cc         16    0.5
3        Other Ophthalmic Procedures - Category 5                                14    0.4
2        Minor Procedures to the Musculoskeletal System                          11    0.3
2        Malignant Disorders of Lymphatic or Haematological Systems w cc         10    0.3
1        Intermediate Pain Procedures                                            8     0.2
1        Chemotherapy with a Hepato-Biliary or Pancreatic Sys Primary Diag       8     0.2
3        Other Ophthalmic Procedures - Category 4                                7     0.2
2        Red Blood Cell Disorders <70 w/o cc                                     6     0.2
1        Varicose Vein Procedures                                                3     0.1
1        Ureter Intermediate Endoscopic Procedure                                2     0.1
1        Malignant Disorders of Lymphatic or Haemo Sys w/o cc                    80    2.4
1        Large Intestine - Endoscopic or Intermediate Procedures                 73    2.2
1        Upper Genital Tract Intermediate Procedures                             43    1.3
1        Lower Genital Tract Major Procedures                                    22    0.7

                                                                Argyll & Bute CHP Committee
                                                        Date of Meeting : 25 September 2008
                                                                                 Item No.5.1

Group   HRG                                                                         No.        %
n/a     Other Admissions                                                            49         1.5
1       Minor Skin Procedures - Category 1 w/o cc                                   32         1.0
n/a     Cardiac Catheterisation without Complications                               66         2.0
3       Mouth or Throat Procedures - Category 3                                     38         1.2
2       Upper Genital Tract Major Procedures                                        33         1.0
3       Surgical Termination of Pregnancy                                           39         1.2
3       Mouth or Throat Procedures - Category 2                                     23         0.7
2       Foot Procedures - Category 2                                                16         0.5
2       Soft Tissue or Other Bone Procs - Category 1 <70 w/o cc                     18         0.5
3       Medical Termination of Pregnancy                                            28         0.9
3       Nose Procedures - Category 3                                                16         0.5
3       Soft Tissue or Other Bone Procs - Category 1 >69 or w cc                    13         0.4
2       Inflammatory Bowel Disease – Endo or Inter Procs <70 w/o cc                 20         0.6
3       Inflammatory Spine, Joint or Connective Tissue Disorders <70 w/o cc         7          0.2
2       Lower Genital Tract Intermediate Procedures                                 9          0.3
3       Biliary Tract - Major Procedures <70 w/o cc                                 12         0.4
3       Ear Procedures - Category 1                                                 7          0.2
1       Inguinal Umbilical or Femoral Hernia Repairs <70 w/o cc                     12         0.4
1       Sleep Disordered Breathing                                                  9          0.3
1       Penis Minor Open Procedure <70 w/o cc                                       14         0.4
3       Non-Inflammatory Back, Bone, or Joint Disorders <70 w/o cc                  17         0.5
1       Ureteric or Bladder Disorders                                               9          0.3
2       Other Ophthalmic Procedures - Category 2                                    5          0.2
1       Upper Genital Tract Minor Procedures                                        13         0.4
3       Therapeutic Pancreatic or Biliary Procedures                                5          0.2
2       Foot Procedures - Category 1                                                3          0.1
3       Neoplasms                                                                   7          0.2
3       Inflammatory Spine/Joint or Connective Tissue Dis >69 or w cc               15         0.5
3       Multiple Sclerosis or other CNS Demyelinating Conditions                    5          0.2
3       Other Ophthalmic Procedures - Category 3                                    9          0.3
3       Hand Procedures - Category 2                                                6          0.2
3       Ear Procedures - Category 4                                                 4          0.1
2       Intermediate Breast Surgery <50 w/o cc                                      7          0.2
3       Mouth, Head, Neck or Ear Diagnoses - Category 1 <70 w/o cc                  4          0.1


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Description: Argyll and Bute CHP Future Bed Modelling requirements – Stage 1