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					     FULL BUSINESS CASE




 DEVELOPMENT OF WOMENS AND
 CHILDRENS SERVICES AT NORTH
MANCHESTER GENERAL HOSPITAL




                      VERSION 1.3
                                                       Development of Women &
                                                       Children’s Services at North
                                                       Manchester General Hospital



                                                  CONTENTS

EXECUTIVE SUMMARY
SECTION 1 :              INTRODUCTION ...................................................................... 1
  1.1 .................. Purpose of this Document ......................................................... 1

   1.2 .................. Purpose of the FBC .................................................................. 2

   1.3 .................. Document Structure and Content .............................................. 2

SECTION 2 :              STRATEGIC CONTEXT ........................................................... 4
  2.1 .................. Pennine Acute Hospitals NHS Trust ......................................... 4

   2.2 .................. National Strategies for Women and Children's Services ......... 10

   2.3 .................. Local Strategies for Women and Children's ............................ 13

   2.4 .................. Models of Care – Regional...................................................... 29

   2.5 .................. Models of Care – Local ........................................................... 29

   2.6 .................. Profile of Current Services ...................................................... 33

   2.7 .................. Estates Context ...................................................................... 35

   2.8 .................. Activity and Performance ........................................................ 36

   2.9 .................. Interim Arrangements ............................................................. 40

   2.10 ................ Staffing ................................................................................... 41

   2.11 ................ Recruitment Initiatives............................................................. 44

   2.12 ................ Financial Context .................................................................... 45

   2.13 ................ Summary of Case for Change ................................................. 45

SECTION 3 :              OBJECTIVES, BENEFITS & CONSTRAINTS ........................ 46
  3.1 .................. Objectives ............................................................................... 46

   3.2 .................. Benefits Criteria ...................................................................... 46

   3.3 .................. Relative Importance ................................................................ 47

   3.4 .................. Constraints ............................................................................. 47

SECTION 4 :              OPTIONS ............................................................................... 49




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   4.1 .................. Developing a long list of options ............................................. 49

SECTION 5 :              OPTION APPRAISAL ............................................................ 52
  5.1 .................. Introduction ............................................................................. 52

   5.2 .................. Description of Business Case Objectives ................................ 52

   5.3 .................. Identification of Benefits .......................................................... 54

   5.4 .................. Benefits Appraisal ................................................................... 54

SECTION 6 :              FINANCIAL AND ECONOMIC APPRAISAL .......................... 59
  6.1 .................. Background ............................................................................ 59

   6.2 .................. Revenue and Affordability Impact ........................................... 59

   6.3 .................. Capital Investment Assumptions and Requirements ............... 61

   6.4 .................. Revenue assumptions ............................................................ 63

   6.5 .................. Sensitivity Analysis ................................................................. 64

   6.6 .................. Economic Appraisal – Value for Money Analysis .................... 69

SECTION 7 :              THE OVERALL PREFERRED OPTION ................................. 70
  7.1 .................. Process Followed to Determine the Preferred Solution ........... 70

   7.2 .................. Summary of Key Data ............................................................. 71

SECTION 8 :              RISK ASSESSMENT.............................................................. 72
  8.1 .................. Overview................................................................................. 72

   8.2 .................. Identification of Key Risk AreasError!                        Bookmark                 not
   defined.Error! Bookmark not defined.

   8.3 .................. Assessment of RisksError!                 Bookmark            not      defined.Error!
   Bookmark not defined.

   8.4 .................. Risk Management StrategiesError!                             Bookmark                  not
   defined.Error! Bookmark not defined.

   8.5 .................. ConclusionsError! Bookmark not defined.Error! Bookmark
   not defined.

SECTION 9 :               TIMESCALE, PROCUREMENT AND & PROJECT
                          MANAGEMENT ...................................................................... 81
   9.1 .................. Timetable ................................................................................ 81




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                                                        Manchester General Hospital



   9.2 .................. Procurement ........................................................................... 82

   9.3 .................. Project Management Arrangements........................................ 92

   9.4 .................. Stakeholder Involvement ........................................................ 95

SECTION 10 : POST-PROJECT EVALUATION ............................................ 96
  10.1 ................ Introduction ............................................................................. 96

   10.2 ................ Framework for Post-Project Evaluation ................................... 96

   10.3 ................ Evaluation Process ................................................................. 96

   10.4 ................ Conclusions .......................................................................... 100

SECTION 11 :             CONCLUSION...................................................................... 101


                                                 List of Tables

Table 1 : Summary of Content ................................................................................... 3
Table 2 : Patient Population Socio-demographic Trends by PCT ........................... 5
Table 3 : Health Statistical Overview – Geographical Area Served by
Pennine Acute ............................................................................................................... 6
Table 4 : Sector Statistics by PCT – Geographical Area Served by Pennine
Acute      ...................................................................................................................... 7
Table 5 : Sector Statistics by Hospital – Geographical Area Served by
Pennine Acute ............................................................................................................... 8
Table 6 : National Guidance for Women and Children’s Services ........................ 12
Table 7 : Greater Manchester Reviews of Paediatric Services .............................. 13
Table 8 : Proposed New Service Model .................................................................. 15
Table 9 : Making it Better Clinical and Service Model ............................................ 25
Table 10 : Additional Options Following Public Consultation................................. 28
Table 11 : 2005-6 Actual v Targets for Relevant Specialties ................................... 36
Table 12 : Summary of High Level Calculated Activity ............................................ 39
Table 13 : Summary of Capacity Requirements ....................................................... 39
Table 14 : HR in the NHS Plan “More Staff Working Differently" ............................ 42
Table 15 : Women & Children’s Business Case - Benefits Criteria ......................... 47
Table 16 : Overview of Benefits Appraisal Approach Followed .............................. 52
Table 17 : Women & Children’s Development - Project Objectives ....................... 53
Table 18 : Scoring of Shortlisted Options by Option Appraisal Team .................... 55
Table 19 : Women & Children’s Services – Comments on Shortlist Scores .......... 56
Table 20 : Income and Expenditure Position of Preferred Option .......................... 60
Table 21 : Trust Cost Pressures by Year .................................................................. 61




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                                                      Manchester General Hospital



Table 22 : Women & Children’s Development - Space Requirements of
Options .................................................................................................................... 62
Table 23 : Women & Children’s Development – Capital Costs................................ 63
Table 24 : Sensitivity Analysis – Changes to Activity Levels .................................. 66
Table 25 : Sensitivity Analysis – Case Mix ............................................................... 67
Table 26 : Sensitivity Analysis – Cost Behaviours................................................... 68
Table 27 : Discounted Cash Flow of Options ........................................................... 69
Table 28 : Summary of Benefits and Financial Appraisal ........................................ 71
Table 29 : Four Step Process of Risk Analysis Undertaken .................................... 73
Table 30 : Design, Construction and Revenue Risks ............................................... 76
Table 31 : Key Individual Risks in Terms of Value ................................................... 77
Table 32 : Range of Values for each of the top Seven Risks, as Output from
the @Risk Model ......................................................................................................... 78
Table 33 : Risk Register Strategies ........................................................................... 79
Table 34 : Timetable for Procurement and Implementation .................................... 81
Table 35 : Qualitative Assessment ............................................................................ 82
Table 36 : Qualitative Assessment – Inclusion of Soft Services ............................. 87
Table 37 : Methodology for Evaluating the Project .................................................. 97

APPENDICES
APPENDIX 1                         PCT HEALTH PROFILES
APPENDIX 2                         HEALTH IMPACT AND RACE IMPACT ASSESSMENT
APPENDIX 3                        TRANSPORT AND ACCESSIBILITY ANALYSIS,
                                  CORPORATE CITIZENSHIP AND SUSTAINABILITY
APPENDIX 4                        MODEL OF CARE – CHILDREN, YOUNG PEOPLE’S
                                  AND FAMILIES NETWORK
APPENDIX 5                         2006-07 KEY PERFORMANCE INDICATORS
APPENDIX 6                         ACTIVITY AND CAPACITY ASSUMPTIONS
APPENDIX 7                         WORKFORCE PLAN
APPENDIX 8                         BENEFITS APPRAISAL & REALISATION PLAN
APPENDIX 9                         CAPITAL AND REVENUE COST ASSUMPTIONS
APPENDIX 10                        NET PRESENT COST CALCULATIONS AND VALUE
                                   FOR MONEY MODEL RESULTS
APPENDIX 11                        RISK ASSESSMENT MATRIX
APPENDIX 12                        PROJECT STRUCTURE




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    Executive Summary
1   Purpose of this Business Case

    This document is the full business case for capital investment at the North
    Manchester General Hospital. The investment will be needed to:

          Enable the further development of children’s services at North
           Manchester. Most inpatient children‟s services for the North Manchester
           General Hospital catchment population served by the Pennine Acute
           Hospitals NHS Trust (the Trust) are currently provided at Booth Hall and
           the Royal Manchester Children‟s Hospital. The outcome of the Making it
           Better consultation was the decision to support Option A. Option A
           ensures that in future children from the North Manchester General
           hospital catchment area will have all but the most specialist care provided
           at North Manchester General Hospital. As Booth Hall and Pendlebury
           Children‟s hospitals will be closed in June 2009 it is essential that these
           services can be accommodated on the North Manchester General site by
           that date. The business case also allows for the consolidation and
           development of other paediatric services at North Manchester (particularly
           inpatient paediatric services from Bury and to a lesser extent, Rochdale).
           This is also in line with the full implementation of Option A.

          Support the development of obstetric and neonatal services. The
           preferred option (Option A) in Making it Better, Making it Real is that in-
           patient neonatal and obstetric services will no longer be provided at Bury
           or Rochdale and those services at North Manchester General and Royal
           Oldham Hospital are developed to provide additional capacity. This
           business case relates to the North Manchester component of this change.

    The purpose of this business case is to set out the case for change, to
    demonstrate the feasibility of the development, and to record the key activity and
    affordability issues and the assumptions made by the Trust.

    This is one of three business cases that the Trust will prepare in relation to the
    implementation of the preferred option (Option A) within Making it Better.. The
    other two will deal with the development of paediatric (including Observation and
    Assessment), obstetric and neonatal services at Oldham and the development of
    paediatric Observation and Assessment facilities at Fairfield.




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2   Key issues on activity

    The Trust has developed this business case using the activity and capacity
    assumptions developed by the Greater Manchester, East Cheshire and High
    Peak Children, Young People and Families‟ Network (the Network).

    The Trust has updated the Network‟s figures to reflect the Trust‟s current and
    planned performance. For example:

            The business case assumes higher bed occupancy figures than those
             suggested by the Network, as we wish to ensure maximum value for
             money.

            In many cases, shorter more challenging HRG lengths of stay than those
             suggested by the Network have been used.

    For the purposes of this business case the Trust has formulated estate options
    based on the above assumptions as they relate to the preferred option (Option A)
    within Making it Better.

    The activity that is associated with this option is shown in the table below.

                Assumed Activity at North Manchester General Hospital

                                Description                               Activity


           Paediatrics – Inpatients                                           5,941
           Paediatrics – Day Cases                                            1,937
           Obstetrics – Inpatients                                           10,653
           Gynaecology – Inpatients                                           1,559
           Gynaecology Day Cases                                              2,269
           Outpatient & Attendances
           Paediatric                                                        15,005
           Maternity                                                          4,785
           Gynaecology                                                        8,009
           Paediatrics - A & E and O & A Attendances                         21,114




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3     Options

      In addition to a “Do Nothing” option two different estate options have also been
      identified that would provide the capacity to deliver the requisite activity.

3.1   Preferred Estate Option: Combination of Refurbishment and New
      Build

      The preferred option (Option 1) includes the refurbishment of space within the
      existing adult A&E department to provide a dedicated paediatric A&E. This
      facility will be located on the ground floor with close access to expanded
      diagnostic facilities. It will also provide accommodation for child and adolescent
      mental health services and the existing fracture clinic will be relocated to enable
      the expansion of the adjacent radiology facility.

      This option will include the provision of a new 4 storey facility close to the A&E
      department. The ground floor will include 300m2 of paediatric outpatient facilities
      and re-provided office and storage accommodation. A paediatric inpatient facility
      of 32 beds will be located on the first floor providing inpatient (20 beds), day case
      (6 beds) and observation and assessment beds (6 beds). One operating theatre
      undertaking paediatric surgery and day cases will be located on the second floor.
      There will be a lift access to the theatres.

      Initially in-patient obstetrics, neonatal and special care services will be transferred
      from existing accommodation at North Manchester, and subsequently from
      Fairfield Hospital, to the new unit. This facility will have 19 special care cots
      (adjacent to the paediatric inpatient facility on the first floor), with 13 LDRP
      (labour, delivery, recovery/ post-partum care) rooms/delivery suites on the
      second floor. Two obstetric theatres will also be provided on the second floor. On
      the top floor there will be two wards comprising 46 obstetric beds. This
      reconfiguration will enable the aligned services of paediatrics, obstetrics, and
      neonatology (including the special care and high dependency care baby unit) to
      be co-located on site.

3.2   Functional Content

      The outline functional content of the facility for the preferred option is as follows:




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                                                                           Preferred
                               Description                                  Option
    Capacity for Booth Hall, RMCH and Fairfield Activity
    Paediatric Beds                                                                  20
    Observe & Assessment Beds                                                         6
    Paediatric Day Case Beds                                                          6
    Total Paediatric Beds                                                            32

    Paediatric Theatres                                                               1

    Capacity for Women and Children's Reconfiguration
    Maternity Beds                                                                   46

    Delivery Rooms                                                                   13
    Special Care Cots                                                                19
    Obstetric Theatres                                                                2


4   Finance/Affordability

    The table below shows the affordability of the preferred option, (Option A of
    Making it Better) for Pennine.

    Revenue
                                 Description                             Option 1
      INCOME                                                              £’000
      Paediatrics
      Current Trust Income                                                        5,255
      Changes to Income from Internal and External Inpatient Transfers
      Inpatients                                                                  3,787
      Day cases                                                                     403
      Outpatients                                                                 6,095
      Neonates                                                                      522
      Accident & Emergency                                                     1,441
      Observe & Assess                                                         1,447
      Total Paediatric Income                                                 18,950


      Obstetrics and Gynaecology
      Current Trust Income                                                    17,948
      Changes to Income from Internal and External Inpatient Transfers




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 Inpatients                                                              (1,438)
 Outpatients                                                              (322)
 Total Obstetrics and Gynaecology Income                                 16,188


 TOTAL INCOME                                                            35,138


 EXPENDITURE
 Paediatrics
 Current Trust Expenditure                                                5,255
 Changes to Expenditure from Internal and External Transfers
 Inpatients, day cases and O&A                                            5,538
 Outpatients                                                              4,012
 Neonates                                                                   522
 Accident & Emergency                                                     1,540
 Total Paediatric Expenditure                                            16,868
 Obstetrics and Gynaecology
 Current Trust Expenditure                                               17,948
 Changes to Expenditure from Internal and External Transfers
 Inpatients and day cases                                                -1,428
 Outpatients                                                               -242
 Total Obstetrics and Gynaecology Expenditure                            16,278


 Capital Charges                                                          2,263
 Estate Costs                                                               608
 TOTAL EXPENDITURE                                                       36,017
 (Excess)/Shortfall                                                         879



The Table above shows that the overall impact of implementing the Making it
Better proposals on income and expenditure results in a deficit. However the
figures have been calculated on a prudent basis, bearing in mind the potential
risks associated with releasing costs from sites that no longer deliver inpatient
services.    Discussions have taken place with Manchester PCT (as lead
commissioner) and Bury PCT about the financial support required to ensure that
this can be managed across the health economy, and not remain as a liability
exclusively for this Trust or local PCTs. The consensus view is that an agreement
can be reached concerning how this deficit can be managed. In the meantime
discussions will continue with the PCTs and the wider Network to resolve the
issue.

Capital

Pending the agreement of a Guaranteed Maximum Price the estimated capital
costs of implementing the preferred option on the North Manchester site are
shown below.




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                                                               Preferred
                            Description                         Option
                                                                 £’000
        Construction Costs (including fees)
        New Build Elements                                        22,000
        Refurbished Elements (A&E and Radiology)                   3,000
        Total Works Costs                                         25,000

        VAT (including reclaimable on refurbished areas)           4,000

        Other Fees (Cost Advisors, Clerk of Works etc)             1,000

        Equipment                                                  2,000

        Forecast Outturn for Full Business Case                   32,000


    The Trust considers that the provision of a segregated children‟s A&E as required
    by the National Service Framework for Children, Young People and Maternity
    Services is required regardless of the final decision on the Making it Better
    consultation and therefore proposes to commission this facility in advance of the
    proposed new build women & children‟s development. A secondary reason for
    bringing forward this particular element of the scheme is that it will help ensure
    the timely closure of Booth Hall and Pendlebury hospitals in June 2009.

5   Conclusion

    This Full Business Case clearly shows the need for change, and demonstrates
    that with the necessary financial support a viable business case can be
    developed for paediatric and maternity services at North Manchester and across
    the larger Pennine footprint.

    This business case has been refined in consultation with commissioners, the
    NHS North West and the Trust‟s Principal Supply Chain Partner. Further
    business cases will be prepared for the developments at Oldham and Fairfield.




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VERSION CONTROL

Date         Version number   Description of draft and changes since last draft
OBC
24/08 /06    0.4              Draft incorporating comments from IW for comment
                              by the Project Team
01/09/06     0.5              Draft incorporating Project Team members‟
                              comments, Executive Summary and revised section
                              6 (Financial and Economic Appraisal)
13/09/06     0.6              Revised draft incorporating radical solution
             0.7/0.8          Revised draft showing Scenario C as preferred and
                              Scenarios A&B within Appendices
02/10/06     0.9              Reduction to 40 paediatric beds
07/11/06     1.0              Reduction to 32 paediatric beds
29/12/06     1.1              Revised Exec Summary & narrative
02/01/07     1.2              Revised Exec Summary
04/01/07     1.3              Revised Option descriptions, front cover & revised
                              Table 19
05/01/07     1.4              Revised Sections 6 & 8 plus App. 7 risk template
18/01/07     1.5              Revised Section 5
01/02/07     1.6              Revised re Teamwork Final Report on activity
06/02/07     1.7              Revised re Capital Costs
April 2007   1.8              VfM analysis and additions re SHA comments 03/07
FBC
July 2007    1.0              Children‟s Statistics, Children‟s Service Model in
                              Appendices
Dec 2007     1.1              Updated financial and activity projections
Jan 2008     1.2              Updated financial and activity projections and risk
                              assessment and Network changes
Feb 2008     1.3              Updated financial projections




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SECTION 1 :         INTRODUCTION

1.1       Purpose of this Document

This document presents a full business case (FBC) for the development of
women and children's facilities at North Manchester General hospital, which is
part of the Pennine Acute Hospitals NHS Trust (PAHT). It makes the case for
this development, in that:

         The scheme is of strategic importance in realising two key local
          strategies, i.e.:

          –    Making it Better, Making it Real1 - to improve healthcare services for
               children, young people, parents and babies in Greater Manchester,
               East Cheshire, High Peak and Rossendale. Proposals include the
               transfer of catchment related non-specialist children‟s services from
               Booth Hall and Royal Manchester Children‟s Hospital to the North
               Manchester General Hospital site, the development of neonatal
               services and a reconfiguration of existing obstetric and children‟s
               services provided by PAHT. This strategy requires the Trust to
               support the transfer of children‟s services to North Manchester by
               2009.

          –    Healthy Futures2 - to improve and modernise health services in the
               north east of Greater Manchester.          Proposals include the
               reconfiguration of acute services across PAHT and the development
               of community services.

         The FBC is consistent with the Full Business Case for the new Children‟s
          hospital in Central Manchester, which assumed the development of
          children‟s services at North Manchester following the closure of Booth
          Hall Hospital in June 2009

         Currently there is no suitable accommodation on the North Manchester
          site. It is now not possible to complete this development in time for the
          closure of Booth Hall in June 2009. An interim solution has therefore been
          developed to accommodate the Booth Hall activity during the period to
          completion. The interim solution is likely to be in place for six months.


1   Making it Better, Making it Real, Public Consultation on Changes to Healthcare
Services for Children, Young People, Parents and Babies in Greater Manchester,
East Cheshire, High Peak and Rossendale , 12th January to 13th April 2006

2   Healthy Futures, Public consultation on the future of health care in the North
East of Greater Manchester, 12 January – 13 April 2006



                                          1

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This FBC is one of a number of business cases being submitted by several
organisations across Greater Manchester in order to implement the chosen
option (Option A) of Making it Better. The affordability of this FBC will need be
considered within the context of the decision of the Joint Committee of Primary
Care Trusts.

This is one of three business cases that the Trust will submit in relation to the
implementation of the preferred option within Making it Better, Making it Real.
The other two will concern the development of services for paediatrics (including
an Observation and Assessment department), obstetrics and neonatology at
Royal Oldham hospital and the development of Observation and Assessment
facilities at Fairfield Hospital, Bury.

1.2       Purpose of the FBC

This FBC has been prepared following the outcome of public consultation on
Making it Better and Healthy Futures in order to:

         Provide local stakeholders with a clear understanding of the current estate
          solutions to support the implementation of the preferred option in Making
          it Better and Healthy Futures.

         Identify the financial implications of the preferred solution i.e. the capital
          and revenue consequences and overall affordability.

         Support more detailed discussion and agreement with the Commissioners
          and NHS North West on the activity assumptions underpinning the FBC
          and its content.

1.3       Document Structure and Content

Table 1 below provides a summary of the content of this FBC.




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                     Table 1 : Summary of Content
 Table showing summary       Section content within this FBC
 of content of document
 Section 2                   Provides information on the strategic context for the
 Strategic Context           development, including activity assumptions.

 Section 3                   Describes the objectives         for   the   investment,   the
 Objectives, Benefits and    constraints and the benefits.
 Constraints
 Section 4                   Identifies the options for consideration.
 Options
 Section 5                   Benefits appraisal of the considered options.
 Option Appraisal
 Section 6                   Provides high level information on the capital and revenue
 Financial    &   Economic   costs of the options.
 Appraisal
 Section 7                   Identification of preferred option.
 The Preferred Option
 Section 8                   A risk analysis of the preferred option.
 Risk Assessment
 Section 9                   Project plan, method of proposed procurement and details
 Timescale, Procurement      of the project management arrangements.
 & Project Management
 Section 10                  Initial draft of process included.
 Post Project Evaluation
 Section 11
 Conclusion                  Concludes the case




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SECTION 2 :         STRATEGIC CONTEXT

2.1       Pennine Acute Hospitals NHS Trust

Pennine Acute Hospitals Trust was established in April 2002. It is one of the
largest in the country and serves a population of approximately 800,000 people.
The Trust provides acute services from the following four sites.

         North Manchester General hospital – 645 inpatient beds

         Royal Oldham hospital –663 inpatient beds.

         Fairfield hospital (in Bury) – 502 inpatient beds.

         Rochdale Infirmary – 370 inpatient beds.

2.1.1 Patient Population

The Trust serves a population of approximately 800,000 people. The vast
majority of patients are from the Trust‟s four main commissioning Primary Care
Trusts – Bury, Heywood, Middleton and Rochdale, Oldham, and Manchester.
Whilst having several factors in common there are also individual distinctive
social, economic and cultural traits as shown in Table 2 below.




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                                                                                   Table 2 : Patient Population Socio-demographic Trends by PCT

    Area                         PCT                Hospital             Gender (M:F)            % < 20          % 65+          Local Authority     Index of Multiple   Unemployment                 Ethnicity
                              Population3          Catchment                                                                  Deprivation ranking     Deprivation           (%)
                                                   population4                                                                    (out of 254)           Score5
    North Manchester            133,500               190,000                 50:50                27.2           14.2                2nd                57.54               9               14% (Black British; Asian
                                                                                                                                                                                                 British - Pakistani
    Oldham                      218,100               220,000                 48:52                22.8           16.8                     43rd          30.73              3.7                14% (Asian British –
                                                                                                                                                                                            Pakistani and Bangladeshi)
    Rochdale                    206,600               160,000                 49:51                21.9           16.6                     25th          33.69              3.9                16% (Asian British –
    (includes                                                                                                                                                                                Pakistani / Bangladeshi)
    Heywood and
    Middleton)
    Bury                        182,000               180,000                 49:51                21.1           17.5                     97th          23.53              2.8            6% (Asian British – Pakistani)



North Manchester – The old North Manchester PCT (which was the main commissioner acting on behalf of the resident population)
covered ten wards of Manchester City Council. In October 2006, North Manchester PCT merged into a larger Manchester PCT covering
the whole of the City Council‟s boundaries and 32 wards.


3
 PCT Population is based upon patients registered to GP Practices within the boundaries of PCT as they are constituted on April 1 2006. On October 1 2006, new PCTs will be established which will see North
Manchester PCT become part of a Manchester-wide PCT and Rochdale and Heywood and Middleton PCTs will come together to form a new Rochdale PCT.

4
    Hospital catchment area reflects fact that some patients travel to hospitals outside of the area within which they are GP registered


5   The overall Index of Multiple Deprivation 2004 (IMD 2004) is a composite of seven separate Domain Indices. These are: Income; Employment; Health Deprivation and Disability; Education, Skills and
Training; Barriers to Housing and Services; Crime and Disorder; and Living Environment. The score for domain was constructed by combining a series of different indicators chosen to represent the
main issues covered by that domain. Areas with higher scores for the overall IMD and individual domains are said to be more deprived than those areas with lower scores.




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                                                                 Manchester General Hospital



Oldham – Oldham PCT (which is the main commissioner acting on behalf of the
resident population) is coterminous with the Metropolitan Borough Council.
Rochdale Heywood, Middleton and Rochdale PCT (formed in October 2006
from the former Heywood and Middleton PCT and Rochdale PCT) act as the
main healthcare commissioners for the population and is coterminous with the
local authority.
Bury – Bury PCT is the main commissioner for healthcare and is coterminous
with the local authority.
Table 3 below outlines the key health indicators for the Trust‟s catchment
population. The 2007 Health Profiles for each of the Trust‟s four PCTs are shown
in Appendix 1.
                               Table 3 : Health Statistical Overview – Geographical Area Served by
                                                           Pennine Acute

Indicator                         Bury           North               Oldham         Rochdale             NW         England
                                               Manchester
Life Expectancy –
                                 75.5          71.8                  73.7           73.8               74.8         76.1
male
Life Expectancy –
                                 79.9          77.8                  78.6           78.8               79.5         80.7
female
People with limiting
                                 19%           21.5%                 20.3%          20.6%              16.4%        13.6%
long term illness
Households with
one or more person
                                 35.7%         39.5%                 39.2%          39.3%              38.4%        34.1%
with limiting long
term illness
        6
Falls                            96.25         135.27                136.13         80.28              100          N/a

Violence                         118.84        223.13                323.35         71.6               100          N/a
Alcohol specific
                                 91.23         125.43                167.5          66.12              100          N/a
conditions
Respiratory disease              111.79        180.42                137.91         100.26             100          N/a

Lung cancer                      127.87        206.52                145.16         107.52             100          N/a




6 The Rate for each local authority is calculated in relation to the total number of incidents in the North West, consequently the
rate for the North West would always be 100. Rates over 100 indicate a greater than average number of admissions while rates
under 100 indicate a lower than average number of admissions. (North West Public Health Observatory)




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                                            Manchester General Hospital



The geographical area served by Pennine Acute Hospitals NHS Trust is
characterized by its industrial legacy. Manchester‟s historical wealth was
predicated through the warehousing and onward sale of manufactured textiles,
the majority of which were produced in the mill towns of Lancashire. This
industrial legacy has had several health impacts on the area including: -

   High levels of chronic disease related to poor general health, poor nutrition
    and inadequate housing.
   High population densities across the area have contributed to historically poor
    provision and access to healthcare.
   Proportionately larger numbers of younger and older people.
   Large and growing ethnic minority populations, whose health and access to
    healthcare have been poor.
   Heavy reliance on public transport and low levels of personal car ownership

Patient flows are likely to continue to be shaped by these overarching factors,
with high levels of non-elective demand, particularly in medical specialties.
Private sector provision in the north east sector is relatively small.

2.1.2 Children’s Statistics – North East Sector

Tables 4 and 5 below detail the relevant children‟s statistics for the North East
Sector by PCT and by hospital.

                      Table 4 : Sector Statistics by PCT – Geographical Area Served by
                                                Pennine Acute
     Data         Rochdale   Oldham        North        Heywood        Bury      Sector
                    PCT       PCT        Manchester     Middleton      PCT       totals
                                            PCT           PCT

Child              28,809     46,762        25,911        15,541      36,315    153,338
Population (0-
14    yrs)   -
Census 2001

Child              8,881      14,541           9,020       4,925      11,275     48,642
Population (15
– 19 yrs) -
Census 2001

Births 2001         1729       3047            1745         828        2063      9,412

Deprivation          5           9              11           4           5         34
(number      of
wards in worst
20% on child
poverty index)




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         *Infant                   6.0*           8.2              10.7*            7.3*       4.8*
         Mortality Rate
         ONS 2002

         Perinatal                 9.8*           13.6             8.4*             6.1*       6.2*
         Mortality Rate
         ONS 2002

         *Low      birth           1.7%           1.9%             1.6%           0.7%        1.4%
         weight
         babies<1500
         grams – 2002

         Low       birth           11.8%         11.7%             9.4%           6.7%        8.5%
         weight
         babies<2500
         grams – 2002

         % Access to van           67%            66%              47%               -         74%
         or car - Census
         2001

* Based on under 20 deaths
*Low Birth rates per 1000 births

                                    Table 5 : Sector Statistics by Hospital – Geographical Area Served by
                                                                 Pennine Acute
             Data            Royal         * Booth        North            Rochdale        Fairfield   Sector
                            Oldham           Hall        Manchest’         Infirmary                   totals


        A&E               14,971           28,865        1,379             12,576          12,690      70,481
        attendances
        under 16 yrs
        - 2001/02

        A&E – 10pm        2305             3272          217               1931            1619        9348
        –       8am
        under 16 yrs
        (03/04)

        Births        –   3047             n/a           2180              1896            2234        9357
        2002

        Births - 2003     3035             n/a           2185              1922            2296        9438

        *Ward             Med 50%          n/k           n/a               60%             Med 51%
        occupancy                                                                          Sur 32%
                          Sur 30%




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                                                      Manchester General Hospital



IP medical       4122            3551          n/a               3543               2333       13,549
episodes
under 16 yrs
- 2001/02

IP surgical      994             3261          n/a               348                629        5,232
episodes
under 16 yrs
-- 2001/02

D/C surgical     738             3216          n/a               336                951        5,241
episodes
under 16 yrs
- 2001/02

*LOS             1.3 Med         2.86 Med      n/a               2.2                2.4
                                                                 (combined)         (combine
                 2.1                                                                d)
                 Surgical

Distance to      7.4m            5.9m          5.7m MRI,         13.3m              10m
neighbouring     Tameside        MRI,                            North Man,         North
hospital                                       13.3m                                Man,
                 5.7m            5.3m          Rochdale          5.7m Royal
                 Rochdale,       Royal         Infirmary,        Oldham,            13.7m
                 7.2m            Oldham                                             Royal
                 North                         7.2m Royal        5.3m               Oldham,
                 Man.            1.5m          Oldham,           Fairfield
                                 North                           General            5.3   m
                 13.7            Man.          9.4m                                 Rochdale
                 Fairfield       9.7m          Fairfield
                 General         Fairfield     General
                                 General,

                                 15.5m
                                 Rochdale
                                 Infirmary

*Ward occupancy and length of stay are taken from 2001/02 data when this work started. Since that time
reconfiguration of “beds” and usage has commenced within a number of acute trusts




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2.2      National Strategies for Women and Children's Services

The NHS is undertaking a process of service modernisation and system reform.
These changes were set out in the NHS Plan (July 2000)7 and the NHS
Improvement Plan (June 2004)8. The aim is to find new ways of delivering health
care services that are shaped around people‟s needs and individual preferences.
The provision of choice through plurality of provider is one of the core elements of
these reforms. These changes have implications on how women and children's
services are provided in the future, specifically the need to provide a range of
services in different settings.

Keeping the NHS local9 (2003) and Strengthening Accountability10 (2003) place
new duties on NHS bodies to develop local services in close consultation with
users and the public. To date there has been extensive discussions with users
and the public on the future of women and children's services.

Creating a Patient Led NHS (2005)11 paves the way for people to make a choice
about which hospital or treatment centre provides their care. Healthcare providers
now have to make information available about the services they offer, including
waiting lists and success rates.

The White Paper Your Health, Your Care, Your Say (2005)12 aims at improving all
health services provided outside of hospitals. The work is closely related to this
consultation that is also aiming to provide more services outside of hospitals in
and nearer to patients‟ homes.




7   NHS Plan, Department of Health 2000

8    NHS Improvement Plan, Putting People at the Heart of Public Services,
Department of Health, June 2004

9   Keeping the NHS Local, A New Direction of Travel, Department of Health, 2003

10   Strengthening Accountability, Involving Patients and the Public, Department of
Health, 2003

11   Creating a Patient Led NHS, 2005

12   Your Health, Your Care, Your Say, 2005



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Maternity Matters (2007)13 outlines a national framework for local improvements
to choice, access and continuity of care in maternity services. It highlights how
commissioners, providers and maternity professionals will be able to use the
health reform agenda to shape provision to meet the needs of women anf their
families.

There are also major changes, which affect the employment of staff. The Agenda
for change provides new pay, terms and conditions for the majority of NHS staff.
The European Working Time Directive places a duty on healthcare employers to
ensure that their medical staff are not working more than a 48 hour week by 2009
(thus bringing them in line with other staff groups). The Northwest Strategic
Health Authority has made a commitment to implement and achieve this standard
by September 2008.

         There has also been national guidance on the development of women
          and children's services. These have an impact on how services are
          provided and delivered in the future. This guidance is summarised below
          in Table 6.




13   Maternity Matters: Choice, access and continuity of care in a safe service, 2007



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                      Table 6 : National Guidance for Women and Children’s Services
      Guidance                                         Description
Maternity      Matters:   This publication outlines a national framework for local improvements
Choice, access and        to choice, access and continuity of care in maternity services. It
continuity of care in a   highlights how commissioners, providers and maternity professionals
safe service, 2007        will be able to use the health reform agenda to shape provision to
                          meet the needs of women and their families


The National Service      These frameworks contain recommended standards for achievement
Framework (NSF) for       over a 10 year period (5 years for maternity services). The aim is fair,
Children,     Young       high quality and integrated health and social care from pregnancy
People and Maternity      right through to adulthood, with services designed and delivered
Services, DOH, 2004       around the needs of children and families using these services.
The    Children    Act    This Act 2004 places a duty on local authorities to make
(2004)                    arrangements with other organisations, including the NHS, to
                          promote co-operation, and for other agencies to co-operate.
Every Child Matters:      A shared programme of change to improve outcomes for all children
Change for Children       and young people. It takes forward the government‟s vision of radical
                          reform for children, young people and families.
                          The programme aims to improve those outcomes for all children and
                          to close the gap in outcomes between disadvantaged children and
                          other children. It describes a framework for health, social care and
                          educational agencies which aims to change the way they currently
                          work, so they will work more effectively together. This will improve
                          the quality of services provided to children, young people and
                          families, particularly those with special needs or at risk. There will be
                          significant changes in how the future workforce will deliver care.
Choosing      Health,     This White Paper places an emphasis on the promotion of healthy
Making       Healthy      lifestyles. For children and young people this includes smoking
Choices Easier, White     cessation, reducing obesity, increasing exercise, increasing breast
Paper, 2004               feeding rates, encouraging and supporting sensible drinking,
                          improving sexual health, improving mental health and wellbeing and
                          preventing accidents. Choosing Health encourages organisations to
                          provide health services in a range of settings, for instance schools,
                          colleges and children‟s centres.
Victoria      Climbie     This report into the tragic death of Victoria Climbié called for
Inquiry, Report of an     significant changes in the quality, delivery and integration of services
Inquiry    by    Lord     for children and young people.
Laming, DOH 2003
The Report of the         The Kennedy Report (2001) looked into the deaths of children after
Public Inquiry into       heart surgery at the Bristol Royal Infirmary and helped set
Children‟s      Heart     professional standards of practice.
Surgery at Bristol
Royal      Infirmary,
Kennedy      Report,
2001
Changing Childbirth,      Identified the need for women to be the focus on maternity care and
Report of the Expert      that their choice, continuity and control should inform service
Maternity     Group,      development.
DOH 1993



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       Guidance                                        Description
The            clinical   The workforce section of the Maternity CNST standards specifies the
negligence    scheme      number of hours per week of required Consultant Obstetrician
for Trusts (CNST)         presence in the delivery suites, and takes account of the changes in
                          junior doctor availability following the implementation of the European
                          Working Time Directive.


The above documents have influenced the local planning processes, the
development of local service strategies Making it Better – Making it Real and
Healthy Futures and the development of the proposed model of care for this FBC.

Great attention to detail has been taken that Standards 6 (Children and young
people who are ill), Standard7 (Children and young people receive high quality,
evidence-based hospital care) and Standard 11 (Women have easy access to
supportive, high quality maternity services, designed around their individual
needs and those of their babies) are fully met.

2.3     Local Strategies for Women and Children's Services

There have been a substantial number of reviews over the past 20 years
regarding the future strategy for paediatric services. The outcome of these
reviews are summarised in Table 7 below.

                      Table 7 : Greater Manchester Reviews of Paediatric Services

 Year          Organisations/Form of Study                           Outcome

1985       North West Regional Health               Preferred option to concentrate all
           Authority Paediatric Committee           referral services on a teaching hospital
               Option appraisal                    site.

1989       As above but option appraisal            Manchester Royal Infirmary (MRI) was
           extended to consider site options        chosen as preferred location (when
                                                    assessed with Hope Hospital).
1993-94    Salford Health                           Recommended           developing       a
           Authority/Management Advisory            consolidated service on the RMCH site.
           Service (MAS)                            The teaching hospital site option, whilst
               Option appraisal and strategic      being more attractive operationally, was
                direction                           considered to require too much capital
                                                    investment.
1993-94    North West Regional Health               Conclusions were:-
           Authority – Advice on future needs        the need for a comprehensive
           for tertiary paediatric services.          centralised tertiary referral centre;
                                                     there was no point in expanding a
                                                      facility with a limited future;
                                                     referral centre should be located in
                                                      Greater Manchester adjacent to a
                                                      major district hospital, close to the



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 Year         Organisations/Form of Study                       Outcome
                                                   University/Research infrastructure
1994      North West Regional Office, Sir        Recommended two centres providing
          David Hull                             comprehensive secondary and some
              a report on the future            tertiary services.       Involved closing
               configuration of the secondary    Booth Hall and moving to MRI a number
               and tertiary inpatient services   of specialist children‟s services.
               within Manchester taking into
               account issues which span the
               new region
1994-95   Manchester Health   Authority,         Document covered two main areas:-
          Salford and Trafford Health             developing combined child health
          Authority                                services with a community focus and
              “Caring for our Children”           complementary outpatient, day case
               proposals for future health         and inpatient services at local
               services   for  children   in       hospitals;
               Manchester,    Salford   and       Changes in the way specialised
               Trafford and the wider North         services for children, both in the
               West region.                         short term (2-3 years) and for 2000
                                                    and beyond.
                                                 In the latter case, the report
                                                 recommended concentrating services
                                                 on RMCH in the short term. Longer
                                                 term,     the   report   recommended
                                                 relocation on the same site as a major
                                                 teaching hospital.     MRI and Hope
                                                 Hospital were identified as potentially
                                                 suitable sites.
1997      Secretary of State response to         Authorisation that tertiary paediatric
          “Caring for Our Children”              services should be concentrated on one
                                                 site      in    Central     Manchester
                                                 complemented      by    a   range     of
                                                 community, primary and secondary care
                                                 paediatric    services    across    the
                                                 conurbation in a way that will meet the
                                                 needs of local communities more
                                                 effectively.



Despite these reviews the provision of children‟s services remains virtually the
same now as in 1985.

Recently there have been two public consultation exercises, describing proposed
future service strategies and identifying preferred service configuration options,
which are directly relevant for this FBC.




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      Making it Better, Making it Real. Following an extensive period of public
       engagement on the future of women and children's services, the Joint
       Committee of Primary Care Trusts for the 17 PCTs in the Review Area
       carried out through the Children, Young People and Families‟ Network a
       formal public consultation on the future services for children, young
       people, parents and babies who receive their care from hospitals in
       Greater Manchester, East Cheshire and the High Peak.

      Healthy Futures - the Healthy Futures Joint Committee of Primary Care
       Trusts (representing five Primary Care Trusts (PCTs) Bury, Heywood and
       Middleton, North Manchester, Oldham and Rochdale) consulted on
       options to improve and modernise health services in the north east of
       Greater Manchester.

Consultation on the Healthy Futures‟ proposals and the Making it Better‟
proposals was carried out at the same time, because of the similarities in the
issues and services being discussed and to ensure that changes agreed are
compatible across both geographic and service areas. A co-ordinated approach
was put in place to support the development of compatible options.

2.3.1 Making it Better, Making it Real

The Review Area for this consultation covers a population of 3.1 million people in
Greater Manchester, East Cheshire and High Peak and 17 Primary Care Trusts
(14 PCTs from October 2006 following NHS reorganisation). PAHT is one of 10
NHS Trusts providing services within this area.

This consultation document set out a strategic vision for women and children's
services across Greater Manchester which would involve moving from the
existing service model with few community based services and 13 hospitals
providing 24 hr inpatient services to a new model of care, which is summarised
below in Table 8.

                   Table 8 : Proposed New Service Model
                              Proposed new service model

   Children and Young             Very Sick Newborn                Pregnant Women
         People                         Babies

More health-care provided      Care provided in a smaller     Ante-natal and post-natal
outside of hospitals, in or    number of units.               care to continue to be
near to people‟s homes.                                       provided at all hospital sites
                               3 neonatal intensive care      and in community settings
All hospitals with A&E         units for the very sickest     to ensure women receive
departments are to have        babies.    These will be       their care as close to home
paediatric observation and     located with large obstetric   as possible.
assessment departments.        units. These units will also
24 hour inpatient care for     provide High Dependency        In patient services to be
children and young people                                     provided through 7 or 8


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to be provided on 7 or 8    care and Special Care            obstetric units.
hospital sites.
                            In addition to the 3 hospitals   Increasing emphasis on
                            providing            Neonatal    midwifery led care and
                            Intensive Care there would       home births.
                            be 4 or 5 hospitals providing
                            special care and high
                            dependency care.



The document identified a number of pressures, which have prompted the need
to develop new models of care. These are summarised below.

      The need to change to improve standards of care in line with national
       policy and guidance.

      There is not enough care outside of hospitals for children, young people,
       parents and babies.

       Children and young people suffer from more chronic conditions now that
       can, and should be managed and treated in community settings such as
       health centres, schools, children‟s centres and children‟s own homes.
       Most of the common acute childhood illnesses can be managed safely
       and more appropriately in the child‟s own home, with suitable support
       from healthcare staff such as children‟s community nursing teams.

      Women want more choice in the setting for the birth of their baby.

       There are too many hospitals providing inpatient care for children, young
       people, parents and babies with the result that services are spread too
       thinly across all the hospital sites to ensure the delivery of high quality and
       effective care in line with national standards. Staffing pressures across
       these sites mean that wards sometimes close or have to rely on locum
       (temporary doctor) cover. It will not be possible to staff all these units by
       2009 when the European Working Time Directive becomes law and
       doctors are restricted to a 48 hr working week in line with other staff
       groups. Analysis of bed closures, the use of locums and bed occupancy
       has shown that:

       –     Over a 12 month period (between April 2005 and March 2006)
             maternity units across the Review Area were closed on over 90
             separate occasions, due to a shortage in doctors or specialist
             nurses.

       –     Over a 6 month period (March to August 2004) neonatal units in the
             Review area were closed on 310 separate occasions.




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       –     Over a 12 month period (April 2004-March 2005) some maternity
             units were staffed by locums at night for a third of a year.

       –     Over a 12 month period (April 2004-March 2005) paediatric beds in
             the Review Area had a total average bed occupancy of 56%.

       This current configuration limits the opportunity for healthcare staff to
       become experienced enough in the diagnosis and treatment of certain
       illnesses as they require a critical mass of patients to care for in order to
       maintain their skill levels.

       In addition, many of the hospitals were designed many years ago when
       illnesses were different – when children and young people stayed in
       hospital for certain illnesses and for much longer periods of time. The
       average length of stay for a child in hospital is now less than one day.
       This means that there were many unused beds on paediatric wards.

      There is evidence that sick children, young people and babies do better in
       larger units than in smaller units. There is a huge benefit in concentrating
       more specialist skills into fewer, larger units rather than spreading the
       skills and experience more thinly across a large number of smaller units.

       Other areas of the country work from a smaller number of larger units.
       Liverpool and Sheffield each have one children‟s hospital and one
       maternity unit. With up to 8 in-patient paediatric units and up to 8 in-
       patient maternity units, the Review Area will still have a comparatively
       large number of units. However, this number provides the balance so that
       they can be staffed to appropriate standards and will provide sufficient
       experience in less common conditions for the health staff who work in
       them, whilst ensuring that mothers and families do not have to travel huge
       distances to receive care.

      As the birth rate nationally is predicted to fall there will be fewer children
       and young people in the future. Also, the conditions that children and
       young people suffer are changing and do not require long in-patient stays.
       The average length of stay in hospital for most children and young people
       has reduced from 5 days in 1980 to less than 1 day now. Children now
       suffer from chronic conditions such as asthma and diabetes that can and
       should be managed outside of hospitals. Initially, five service configuration
       options were identified, options A - E. These were subsequently
       increased to 12 following the inclusion of an additional 7 options
       suggested in responses to the consultation document.




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The impact of the chosen option, Option A is summarised below

       Children's services

       The majority of non-specialist paediatric inpatient services would transfer
       from Booth Hall Children's Hospital and Royal Manchester Children‟s
       Hospital to North Manchester.

       Inpatient children's services at Rochdale and Fairfield Hospitals would be
       redistributed across Greater Manchester, primarily to Royal Oldham and
       North Manchester Hospitals.

      Obstetric inpatient services

       Inpatient obstetric services at Rochdale and Fairfield Hospitals would be
       transferred to other hospitals across Greater Manchester, primarily Royal
       Oldham and North Manchester.

      Neonatal and special care services

       Royal Oldham Hospital would become one of three hospitals providing
       level 3 neonatal intensive care across Greater Manchester.

       Special care cots at Rochdale and Fairfield Hospitals will be transferred to
       other hospitals across Greater Manchester, primarily Royal Oldham and
       North Manchester.

For option E (Do minimum).

      Non-specialist paediatric inpatient services would transfer from Booth Hall
       to North Manchester Hospital.

      No other service changes.

   On the 8th December 2006 following independent analysis of responses to the
   public consultation, an evaluation on how the options met each of the criteria
   and at a full-day meeting of the Joint Committee of Primary Care Trusts held
   in public the Making it Better Joint Committee of Primary Care Trusts
   determined that Option A should be adopted.

2.3.2 Independent Reconfiguration Panel

The Joint Overview and Scrutiny Committee established by the constituent Local
Authorities supported the outcome of the Making it Better consultation in January
2007. However, three Local Authorities (Bury, Rochdale and Salford), acting as
independent bodies, referred the decision to the Secretary of State for Health. On
the 6th February 2007 the then Secretary of State for Health, Patricia Hewittt,
announced to the House of Commons that she had referred Making It Better, to


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the Independent Reconfiguration Panel (IRP). Following this on the 21st February
2007 she further announced in the House of Commons that she had referred
Healthy Futures, which proposes changes to adult healthcare in the north east of
Greater Manchester, to the IRP.

As the regulations governing the conduct of public consultations allow for such
referrals, and both the Healthy Futures consultation and the Making it Better
consultation were high profile proposals affecting large populations this was not
unexpected.

The IRP‟s role is to advise the Secretary of State for Health.

The Terms of Reference for the review of Making it Better were as follows:-

       The Panel was asked to advise the Secretary of State:

       (a) as to whether it is of the opinion that the proposals for changes to in-
       patient services for women, babies, children and young people set out in
       the decision of the Joint Committee of Primary Care Trusts of 8th
       December 2006 will ensure the provision of safe, sustainable and
       accessible services for Greater Manchester, East Cheshire and High
       Peak. And if not, why not;

       (b) on any other observations the Panel may wish to make in relation to
       the proposals for changes to in-patient services for women, babies,
       children and young people and implications for any other clinical services;
       and

       (c) in the light of (a) and (b) above, on the Panel's advice on how to
       proceed in the best interests of local people.

On the 24th August 2007 the IRP reported the following:

       “The IRP supports the existing proposals (option A of the Making it Better
       consultation document) to provide consultant-led maternity services
       across eight sites* in Greater Manchester. Paediatric and neonatal
       services should be co-located on these sites. The IRP also supports the
       proposal that neonatal intensive care is best provided by a clinical
       network of three centres with the largest numbers of births: St Mary‟s, the
       Royal Bolton and the Royal Oldham Hospital. The neonatal intensive care
       unit at Hope Hospital in Salford – a highly rated service founded on the
       quality of its staff – should be re-established in the new locations”.




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       “The IRP has also supported the outcome of the Healthy Futures
       consultation in the north east of Greater Manchester, with the Pennine
       Acute Hospitals NHS Trust (PAHT) providing a clinical network of acute
       hospital services whilst delivering treatment in community settings
       wherever possible. The IRP agrees that it is in the best clinical interests of
       patients that three A&E services should be based at the Royal Oldham,
       North Manchester and Fairfield Hospitals”.

The IRP report was accepted in full by the Secretary of State.

2.3.3 Health Impact and Race Impact Assessment

External consultants were engaged to identify the health effects of implementing
the proposed Making it Better strategy on the local population. A Health Impact
Assessment and Race Impact Assessment was undertaken by IMPACT, the
International Health Impact Assessment Consortium at the University of
Liverpool.

The Impact analysis brought together the evidence from all the data collected
from different sources and using different methods. It identifies and characterises
the potential impacts of Making it Better describing:

   •   Health impacts – the health determinants affected and the subsequent
       effect on health

   •   Outcomes;

   •   Direction of change – health gain (+) or health loss (-);

   •   Scale – the severity (mortality, morbidity and wellbeing) and magnitude
       (size/proportion of the population affected);

   •   Likelihood of impact – definite, probable, possible or speculative based
       on the strength of the evidence and the number of sources;

   •   Latency – when the impact will occur.


The report was available to the Joint Committee of PCTs on the 8th December
2006 as part of the supporting papers for the Making it Better decision making
meeting on that day, but can be summarised as follows:




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The HIA makes a number of explicit assumptions concerning the implementation
of the Making it Better proposals for reducing 24 hour in-patient hospital obstetric,
neonatal and paediatric care from 13 to 7 or 8 sites across the Review Area, e.g.,
that consolidation of in-patient services onto a reduced number of sites can be
accommodated in terms of physical and staff capacity, however, it is recognized
that this poses challenges for some areas of the Network. Similarly it defines the
timeframe for completion of these changes as between 2010 and 2015 and
describes the likely context during that period, e.g., projected birth rates, fertility
patterns, and the distribution of ethnic minority groups. The level of analysis was
defined as the Review area.

Based on the available evidence, the Making it Better proposals will have both
positive and negative health impacts on women, babies, children and their
families. The most significant positive health impact will potentially result from
improvements in the clinical efficiency and effectiveness of care.

For mothers, the proposals will be likely to reduce the risk of maternal morbidity
and death resulting from pregnancy and child birth, particularly during delivery.
Those options that provide locally accessible 24 hour care to deprived areas
and/or populations with a high proportion of ethnic minority groups will reduce risk
in the most vulnerable groups and will contribute to reducing health inequalities.
There is the potential for even greater health gains with more ante and post natal
care provided in the community. However, the potential gains from the
development and implementation of shared models of care, care pathways and
clinical guidelines at network level which are under development are also
potentially as significant.

For new babies, the main health gain will potentially be from the increase in
accessibility to neonatal intensive care (increases from 2 to 3 sites) and greater
availability of intensive care cots. It is very likely that there will be an increase in
survival rates for pre-term (27 weeks plus) or low birth weight babies as a result
of this. There is strong evidence that the timely transfer of premature and/or low
birth weight babies positively affects their survival rates. As for mothers, whether
the proposals will benefit babies most at risk of poor neonatal outcomes,
contributing to reducing health inequalities will depend on which option is
selected. There is the potential to build on these health gains through community-
based care as well as by improving the quality of how care is provided.

For children and their families, it is likely that quality and clinical safety may
improve and that the range of treatment regimes available may improve as a
result of the consolidation of skills and resources into a smaller number of units.
Associated with this it is also likely that there will be improved health outcomes
for children in need of specialist paediatric in-patient care although it will be
difficult in the future to separate out the benefit attributable to service
reconfiguration from that resulting from medical advances in a rapidly changing
field.




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The main negative health impacts are concerned with the reduced physical
accessibility of care but this is unlikely to affect clinical effectiveness for the
majority of patients. However, it is assumed that for most women, in-patient care
will be an infrequent event, e.g. after delivery. For the majority of these people,
increases in journey times will be relatively minor. It is estimated that 1.6% of
population have a travel time of up to 50 minutes by private car or taxi to any of
the Making it Better options; this falls within the „golden hour‟ rule for critical care
interventions. It should be noted that exceptions to this may include people with
disabilities, and people who have communication or language problems which
affect travel

It is likely that there will be negative impacts on some staff affected by the Making
it Better proposals, e.g., changing the main location of employment. Although it
has not been possible to assess the impacts on the NHS workforce, evidence
from other studies has shown the negative health impacts associated with
perceived „job insecurity‟ particularly when moving from previously „secure‟ to
„insecure‟ jobs. However, it is possible to mitigate against these negative impacts
by addressing key mediators of these health effects, e.g., decision latitude and
participation. PCTs and Trusts will need to address this issue.

Black and Minority Ethnic Groups
This section brings together evidence of the potential impacts for ethnic minority
populations.

It is recognised that it is unwise always to use aggregated data for the five main
ethnic groups of the Census, as this masks heterogeneity between different
ethnic groups. Such differences may be based on a mix of elements of ethnicity
and the demographic stage of the particular group. When developing local data
collection systems, categories should always map back to the Census groups.

There is strong evidence that women from ethnic minority groups are more at risk
from maternal death in the U.K. than their white counterparts (section 6). Black
African women were 7 times more likely to die due to complications associated
with pregnancy and child birth, whilst women from other ethnic minority groups
were 3 times more likely to die. There is also a greater risk of still birth or
neonatal death with mothers‟ ethnicity as follows: Black (2.7-2.8 times greater
risk), Asian (1.6-2.0), Chinese and other (1.9).

It is unclear whether this increased risk is directly or indirectly related to ethnicity.
For example, evidence from the US indicates economic factors cannot explain
the higher risk of death in black versus Hispanic women as they have equivalent
socio-economic status (s.6); similarly as family income increases the probability
of giving birth to a low birthweight baby decreases markedly for white women, but
not for African American women.

There is evidence that women from minority ethnic groups use antenatal services
less intensively, with a higher proportion booking late. Late booking was another
key risk factor for maternal mortality and morbidity, with 20% of women who died

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booking in after 22 weeks or missing 4 routine antenatal appointments. Late
bookings prevent or delay screening and other diagnostic tests being undertaken
which impacts on potential maternal or foetal complications being identified.

There was some evidence from the literature that social and cultural barriers
between patients and health professionals may contribute to delays in accessing
care and less than optimal care, which may in turn impact on maternal and
neonatal outcomes. Vulnerable and socially excluded women found it particularly
hard to access or maintain access with services and follow-up for those who
failed to attend was poor.

Inadequate translation services were seen as a major barrier to accessing
services for those who could not speak English. It has been found that in addition
to the importance of translation services, BME communities may also experience
communication barriers which reduce access to services due to travelling, e.g., if
spoken English is a barrier to using public transport, where this is the main travel
mode. Where communication is a challenge, service users prefer local services,
trusting the more familiar than the unknown, particularly when increased distance
presents a greater barrier to access for family and visitors, by virtue of cost, time,
childcare arrangements etc.

International studies of programmes increasing social support to women during
and after pregnancy vary in their health outcomes. However, the Central
Manchester-led pilot, Race for Health, which provides link workers and providing
culturally sensitive services to pregnant women is a potential approach that could
be adopted more widely.

A full copy of the report by the International Health Impact Assessment
Consortium at the University of Liverpool is included at Appendix 2

2.3.4 Healthy Futures

The consultation document identified the following vision for the delivery of
services in the North East of Greater Manchester:

      Expand and invest in community-based care that would see an increase
       in the amount of planned care, unplanned care and long-term disease
       management taking place in the community.

      Develop hospital 'centres of excellence' that support safe, high quality
       treatment.

      Improve patient's experiences by managing their treatment more
       effectively.

      Use redesigned hospitals and facilities in the community to reduce waiting
       times for patients.



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      Make the community health facilities and hospitals excellent places to
       work so that we attract and keep the best health professionals.

The pressures for change for women and children‟s services were broadly similar
to those raised in Making it Better.

The document concluded that in the short-term there was a need to rearrange the
services currently provided from the existing four main hospital sites (Royal
Oldham, North Manchester, Fairfield and Rochdale Hospitals). In the longer
term, it concluded that there was a need to combine services onto fewer
hospitals.

A shortlist of three service configuration options was identified. These options
are as follows:

Option 1:

      A&E and acute medicine services would be provided at North
       Manchester, Royal Oldham and Fairfield Hospitals.

      Emergency surgery would be provided at the North Manchester and
       Royal Oldham Hospitals.

      Rochdale Infirmary would become a locality hospital, providing an urgent
       care centre, medical and planned surgical beds, a full range of
       diagnostics and a cardiology 'centre of excellence'. The hospital would
       continue to take many selected acute medical patients.

      A wide range of health services would be provided in 35 new community
       based health centres.

This option is compatible with the preferred option of Making it Better and was
identified as the preferred option.

A provisional decision outlining the future shape of adult health care in the north
east of Greater Manchester was taken on the 14th September 2006. The Joint
Committee of Primary Care Trusts, representing the six primary care trusts
involved in the Healthy Futures programme, met and decided that Option 1 from
the public consultation should be adopted for the delivery of health care in the
north east of Greater Manchester. The Joint Committee also agreed that access
to a surgical opinion will be available 24/7 on the Fairfield Hospital site, Bury; and
decided that further work needed to be done to ensure appropriate senior
anaesthetic cover at the Fairfield Hospital site. This decision was provisional
pending the outcome of the Making it Better public consultation previously
referred to at 2.3.1.

The Independent Reconfiguration Panel reviewed the findings and decisions of
the Healthy Futures programme alongside their review of Making it Better. They


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again endorsed the decisions made and the conclusion was accepted by the
Secretary of State.

Following the outcome of the two public consultations the following service
configuration of PAHT women and children‟s services will be required:

      The development of inpatient paediatric facilities at North Manchester, to
       accommodate the transfer of services from Booth Hall and Royal
       Manchester Children‟s Hospital. This will need to be provided by 2009.

      The development of a level 3 Neonatal Intensive Care Unit (NICU) at the
       Royal Oldham Hospital

      The transfer of inpatient obstetrics, cots and paediatric services from
       Fairfield and Rochdale Hospitals to Royal Oldham, North Manchester and
       Bolton Hospitals.

The clinical and service model for Making it Better can be summarised as follows:

                     Table 9 : Making it Better Clinical and Service Model
                                               Community        Hospital       Hospital
                                                 Every          site with        site
               Services                         Locality           24/7        without
                                                                services         24/7
                                                                               services

Community children‟s nursing teams                  √

Sub-specialties for children,          e.g.         √               √              √
asthma, diabetes, epilepsy

Out patients                                        √               √              √

Day case surgery                                                    √              √

In-patient surgery                                                  √

General surgery                                                  Some √

Accident and emergency services                                     √         √ - Rochdale
                                                                             to have
                                                                             Urgent Care
                                                                             Centre

Observation and Assessment beds,                                    √              √
trolleys/chairs, ideally located next to




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A&E

Child and Adolescent Mental Health             √             √              √
services

Services                                   Community     Hospital        Hospital
                                             Every   site with 24/7    site without
                                            Locality    services           24/7
                                                                        services
Antenatal and postnatal care                   √             √               √

Delivery of baby in hospital                                 √

Neonatal intensive care – initial                            √

Neonatal intensive care – medium to                      3 sites - √
long term care

Surgery on young children (all under                    √ - most at
2 and most under 5)                                      tertiary
                                                         centre

Gynaecology outpatients                                      √              √

Gynaecology       in-patient    surgery                      √              √
(minor)

Gynaecology       in-patient    surgery                      √              √
(intermediate)

Gynaecology       in-patient    surgery                      √         √ if hospital
(major)                                                                  at night
                                                                          model
                                                                         adopted



2.3.5 Community Service Developments

Plans are well underway to introduce Integrated Clinical Assessment and
Treatment Services (ICATS) in Greater Manchester. These services offer more
routine assessment and treatment services to patients in a community setting,
thus freeing up hospital capacity for those patients with more complex and more
urgent needs. The plans will result in many patients receiving most, if not all, of
their care nearer to home. These developments have been built into the planning
assumptions for this business case.




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As indicated in the IRP‟s recommendations both Bury PCT and Heywood,
Middleton and Rochdale PCT are considering the possibility of developing stand-
alone midwifery led birthing units within their local catchment areas. The planning
assumptions and potential activity implications of one or more stand-alone
midwife led units are not known and have therefore been excluded from this
business case. The content of this business case would not constrain the
development of this service.

Additionally, the Greater Manchester Maternity Network (with all the Acute
Trusts/Foundation Trusts in membership and with lead obstetrician and Head of
Midwifery representation from every organisation), has agreed that all in-patient
obstetric units will also have co-located midwife led birthing centres and agreed
the service specification for these. This development is in line with the
Independent Reconfiguration Panel‟s recommendation that the issue of choice for
maternity service users must be explored and the demand and feasibility of
midwife-led care in the 8 overnight obstetric units must be formally addressed by
the CYPF Network. The full document is available from the CYPF Network, but
the main points can be summarised as follows:

Maternity services need to be as safe and flexible as possible, designed around
the individual‟s needs and choice with pre and post birth care available in
community-based settings such as children‟s centres; women should be able to
go direct to a midwife for care rather than having to go to a GP; and depending
on their circumstances women should be able to choose between having a birth
at home, in a home-like unit within a hospital setting, or in a maternity hospital
supported by obstetricians and anaesthetists.

As midwife-led birth centres deal solely with normal uncomplicated deliveries
there is no need to any ante-natal or post-natal beds to be associated with the
activity. Mothers will complete the entire birthing experience (labour, delivery,
recovery, post-partum) in one room (referred to as an LDRP or birthing room) and
usually remain in that room with their baby for the whole of their stay when no
complications arise.

There must be easy access to the consultant-led obstetric unit and obstetric
theatres should the mother need to be transferred in the event of a complication
or an emergency during labour.

2.3.6 Guidance from the Greater Manchester, East Cheshire and
      High Peak Children, Young People and Families Network

The network has developed a generic model of care to modernise and improve
services across the network. The model is underpinned by the following
principles:

      Improve child‟s and family‟s care experience

      Improve access to care


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      Prevent admission

      Reduce inpatient stays

      Ensure patient safety and quality of service provision

This work has been used by the Trust and PCTs in the development of new
service models.

2.3.7 Transport and Accessibility Analysis

The Children, Young People and Families‟ Network commissioned JMP
Consulting to undertake an analysis of the effects on the populations of the
Review Area of all the options included in Making it Better. This analysis was in
respect of both public transport and private transport. The main summary
findings are shown below in Table 10.

                  Table 10 :   Additional Options Following Public Consultation
Mode          of                            Option A
Transport
Public transport At a.m. peak east Bury and west Rochdale most affected.
                  West and south of Bury see no change, north of Bury sees
                  increases of up to 10 mins. North-west Salford increases of
                  up to 20 mins. At evening off-peak Salford, Bury and
                  Rochdale affected with increases of up to 30 mins.
Private transport At a.m. peak 86.2% can access a hospital within 20 mins,
                  98.5% within 40 mins and 100% within 50 mins. At evening
                  off peak 95.5% are within 20 mins, 98.1% within 30 mins,
                  99.5% within 40 mins, and 100% within 50 mins.

                  In the morning 78.3% have no increase, 16% an increase of
                  10 mins, 4.5% an increase of 20 mins and 1.3% an increase of
                  30 mins. In the evening 82% have no increase, 16.3% an
                  increase of 10 mins and 1.7% an increase of 20 mins.



A detailed analysis is provided at Appendix 3.

2.3.8 Corporate Citizenship and Sustainability

Good Corporate Citizenship concerns itself with how NHS organisations can
embrace sustainable development and tackle health inequalities through their
day-to-day activities.




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For the Trust this means using its corporate powers and resources in ways that
benefit rather than damage the social, economic and environmental conditions in
which we live. How the Trust behaves - as an employer, a purchaser of goods
and services, a manager of transport, energy, waste and water, as a landholder
and commissioner of building work and as an influential neighbour in many
communities - can make a big difference to people‟s health and to the well being
of society, the economy and the environment

The Trust as a major employer, purchaser, user of natural resources and major
landholder is conscious of the need to be seen as a model corporate citizen. The
Trust has completed the self-assessment model and is actively looking to
improve their “scores” in a number of key areas. In addition a Sustainable Action
Plan has been developed and is now regularly monitored.

Copies of the two documents are included at Appendix 3.

2.4       Models of Care – Regional

For the last four or more years the Children, Young People‟s and Families
Network has concentrated on re-designing and modernising services for children,
women and babies across Greater Manchester, East Cheshire and High Peak.
The work has been both broad and deep and has been undertaken by clinicians
across the area. The amount of work that has been undertaken in order to agree
the new clinical model is vast. It is not “one size fits all”, and it is expected that
each locality will develop its own service models in light of the specific needs of
its own population. Appendix 4 details this portfolio of work.

2.5       Models of Care – Local

Clinicians and managers from the North East sector‟s Primary Care Trusts,
Pennine Acute Trust and other key stakeholders have been involved in
developing new models of care. Clinical Planning Groups were set up to develop
service models for paediatrics, maternity and obstetrics, gynaecology and
neonatal services.

In developing these models the clinical planning groups took account of national
guidance and emerging trends. Specifically:

         Improving local access to services.

         Developing clinically safe and high quality services.

         Supporting shorter lengths of stay and more day case surgery.

         Increasing services provided in the community, particularly for long term
          conditions.




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The models of care are based on the preferred service configuration options and
strengthen the clinical links between specialities, by co-locating services. For
example, where paediatric consultant and middle grade expertise is required
outside normal hour‟s paediatric inpatient, special care baby and neonatal units
will be co located on the same site with obstetric services.

The models also strengthen clinical links across tertiary, secondary and primary
care settings.

2.5.1 Medical Paediatrics

Outpatients will be provided on all four Trust hospital sites. Observation and
Assessment services (O&A) will be provided on sites with accident and
emergency departments. These services will be staffed by appropriately trained
nurses. At North Manchester the service will work closely with the A&E
department and the ward area.

Inpatient paediatrics will be provided on two sites (North Manchester and Royal
Oldham). These units will have arrangements to accept inpatient admissions from
O&A services provided elsewhere.

2.5.2 Paediatric Surgery

The service model for paediatric surgery was set out in general terms as part of
the Making it Better consultation. A number of principles were recognised,
including the need to ensure appropriately trained anaesthetic support was
available for paediatric surgery, and that day case surgery could be delivered on
sites which did not have overnight services as long as there was a paediatric
presence on site during the day i.e. to support outpatients and O & A units.
There has been significant discussion about the provision of paediatric day
surgery on sites that do not have inpatient beds. The available cover provided by
a paediatrician is necessary but anaesthetic support is considered necessary in
the event of a crisis.

All work deemed to be tertiary will be undertaken at Central Manchester.

The outline for in patient paediatric surgery set out in the Making It Better
consultation has been added to and enhanced following discussions with Central
Manchester and the Network.            Set out below are the proposals for the key
specialties concerned. The description of service relates to the final position of
services once the new facilities at North Manchester are available. The position
with regard to the interim period before the new building is open but after Booth
Hall closes is dealt with later in this document at 2.9.




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ENT

ENT work deemed to be tertiary (e.g. cleft lip and pallet), will transfer to Central
Manchester. The remainder will be will be delivered on the North Manchester
site with surgical support being transferred from the Booth Hall Hospital.

NMGH will also provide ENT trauma. The numbers are thought to be low but
there are a number of problems such as foreign bodies that may need out of
hours treatment.

Dental

With the exception of any work deemed to be tertiary, it is proposed that dental
services, including extractions under general anaesthetic, will be transferred from
Booth Hall Hospital to North Manchester. Because of geography some patients
may choose to go to other sites in Pennine, but the bulk of work will be at North.

Orthopaedic Surgery - Elective

There is a concern around the development of orthopaedic surgery at North
Manchester because the current complement of orthopaedic surgeons have not
had experience of dealing with children for some considerable time. It is
recognised that recruitment to paediatric orthopaedic posts is difficult and is
unlikely to ease in the coming years. It is proposed therefore to set up a hub and
spoke arrangement with Central Manchester. It is likely that this post would be
able to provide three clinical sessions in Pennine. In patient elective orthopaedics
would be centralised onto one site, at either Oldham or North Manchester. A
decision on which site is still to be decided.

Orthopaedic Surgery – Non elective

The concern of the North Manchester Orthopaedic surgeons applies equally to
paediatric orthopaedic trauma. All complex work will be transferred to CMMC
Initially and before the reconfiguration of Orthopaedics, trauma work going
through A and E which requires admission will be transferred to CMMC or
Oldham. With the subsequent reconfiguration of services the on call rota will be
strengthened by the addition of consultant staff from Fairfield. This will enable a
gradual repatriation of work back to North, and will be assisted by the support in
fracture clinic from the joint appointment with CMMC.

General Surgery - Elective

The issues for general surgery mirror those for orthopaedics, however the
number of patients involved is likely to be considerably less. For general surgery
it is proposed again that a hub and spoke arrangement is set up with Central
Manchester and with one site undertaking elective paediatric general surgery.
This location is still to be determined.



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General Surgery – Non elective

The numbers of non elective general surgical cases are likely to be low. All
complex work will be transferred to CMMC. For non complex work this could be
undertaken at North or transferred to CMMC or Oldham.

2.5.3 Obstetric and Maternity Services

The model will provide local diagnostics where possible, e.g. ante natal ultra
sound access, ante natal care, community multi disciplinary teams with much
less reliance on hospital out patient appointments for ante natal care services for
all women.

Antenatal care will continue to be provided on all four hospital sites although with
a greater proportion of care provided in a primary care setting.

The general hospital services will provide women focussed care with a choice of
home birth or a birth at one of two consultant led units at North Manchester and
Royal Oldham or the co-located midwife led birth centres at North Manchester
and Royal Oldham. . Royal Oldham will be the larger of the two obstetric units
with a maximum size of 5,000 births per annum.

Both the obstetric units will provide full acute and diagnostic hospital services on
site including high dependency care and a full range of support services.

Should the PCTs in Bury and/or Rochdale decide to proceed to develop a
standalone midwife led unit this service will also be available.

2.5.4 Neonatal and Special Care Baby Services

The neonatal services will provide multidisciplinary outreach services, care close
to home schemes, single assessment and joint care packages.

Level 2 neonatal units will be provided at North Manchester and Royal Oldham
and provide special care and high dependency care for newborns. There will
also be a level 3 unit at Royal Oldham providing neonatal intensive care.

At North Manchester the SCBU will be located one floor below the maternity unit
to provide easy access for parents. This facility will also be co-located with the
inpatient paediatric facility to ensure quick access to paediatric support in an
emergency.

To ensure smooth timely discharge teams will provide ongoing care of babies
with special needs working closely with neonatal unit staff to ensure that
transition from NICU to home is seamless.




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2.5.5 Gynaecology

Out patient services will continue to be provided on all four sites although the
volume of patients will reduce from present demand as more patients are
managed in primary care settings.

Termination of pregnancies will be provided on all sites although there will be a
development of this service in a tier II setting. The principle of day case
operating for gynaecology will mean that vast majority of patients will be operated
on in day case units.

Based on the preferred configuration of service options, Inpatient gynaecology
services will be provided at North Manchester and Royal Oldham.              As
gynaecological and obstetric consultant and middle grade level care is provided
by the same medical staff, the patient and non-elective gynaecology services
should ideally be co-located with these services.

The inpatient gynaecology services will take both emergencies and planned
elective cases. More complex and gynaecological cancer cases will be managed
on the Royal Oldham site co-located with the consultant led obstetric service.

It is proposed to develop some specialist services in the North East Sector in
Gynaecology such as sub fertility (IVF) services

The planning group also identified the opportunity to increase the range of
services provided in the community. Services included family planning, ICDU
fittings, hormone implants, colposocopy, hysteroscopy, primary GUM, infertility,
sub fertility, menorraghia services and uro gynaecology. This has been reflected
in the planning assumptions for the FBC.

2.5.6 Specialist Hospital Services

There will continue to be a reliance on St. Mary‟s Hospital for complex and high-
risk cases and deliveries.

2.6       Profile of Current Services

Women and children living in the North East sector of Greater Manchester
access services at Pennine Acute Hospitals NHS Trust four sites. These are
Fairfield (Bury), North Manchester, Oldham and Rochdale. An analysis of
relevant activity in 2006/07 for each of the sites is provided below.

Fairfield

Fairfield General Hospital over 12 months (2006/07) provided healthcare services
for:

         29,949 total in-patient spells, adults and children


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      3,498 in-patient spells for children and young people (paediatric), 11.7%
       of the total in-patient spells

      2,276 births per year, 7.6% of the total in-patient spells

      220 in-patient spells for sick babies (neonatal), less than 1% of the total
       in-patient spells

      2.5% of women have their babies at home

North Manchester

North Manchester General Hospital over 12 months (2006/07) provided
healthcare services for:

      31,544 total in-patient spells (adults and children)

      840 in-patient spells for children and young people (paediatric), 2.7% of
       the total in-patient spells

      2,646 births per year (8.4% of the total in-patient spells)

      266 in-patient spells for sick babies (neonatal) (less than 1% of the total
       in-patient spells)

      2.5% of women have their babies at home

Oldham

Royal Oldham Hospital over 12 months (2006/07) provided healthcare services
for:

      39,237 total in-patient spells (adults and children)

      5,471 in-patient spells for children and young people (paediatric),13.9% of
       the total in-patient spells

      2,993 births per year, 7.6% of the total in-patient spells

      238 in-patient spells for sick babies (neonatal), less than 1% of the total
       in-patient spells

      4.3% of women have their babies at home

Rochdale

Rochdale Infirmary over 12 months (2006/07) provided healthcare services for:



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         20,199 total in-patient spells (adults and children)

         3,969 in-patient spells for children and young people (paediatric), 19.7%
          of the total in-patient spells

         2,138 births per year, 10.6% of the total in-patient spells

         201 in-patient spells for sick babies (neonatal), less than 1% of the total
          in-patient spells

         2.7% of women have their babies at home

2.7       Estates Context

The North Manchester General hospital site is located three miles north of the
centre of Manchester on a 27.14 hectare site. The hospital has reasonable
parking and is well served by public transport. The hospital is built on a sloping
site, which has necessitated a multi-level construction; the buildings are mainly of
red brick construction with a high proportion of flat roofs. The site was originally
made up of three separate workhouses, mainly built in the 19th Century and
comprises the following:

         Crumpsall hospital – The largest of the workhouses, which is currently still
          in use as the major portion of the hospital.

         Delaunays hospital – This workhouse has now been demolished and the
          space used for a car park and the development of a day hospital and a
          staff nursery.

         Springfield hospital – This workhouse has been partially demolished, and
          the remainder provides office and laundry accommodation.

The estates strategy is to demolish and replace all of the workhouse
accommodation on this site. This is a three phase strategy. Phase one was
completed in the late 1980s. This included the development of Park House a
mental health facility, Homewood, a day hospital and an extension of the acute
hospital.

An analysis of the estate shows that over 57% of the accommodation is in a less
than acceptable physical condition and that 52% is not functionally suitable. The
cost of bringing the estate up to Condition B would be approximately £7.4m.

There are currently no paediatric facilities on site. The obstetric services and
gynaecology ward are currently located in F Block whilst the special care baby
unit is in Block G. Both of these buildings are situated in the older part of the
hospital some distance away from the newer developments. The area is very
restricted and would be difficult to extend.



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2.8    Activity and Performance

The majority of activity is commissioned by the Trust‟s four main commissioning
Primary Care Trusts – Bury, Heywood, Middleton and Rochdale, Oldham, and
North Manchester. A copy of the Trust‟s Key performance indicators for 2006-07
is included at Appendix 5.

Table 11 below shows 2005-06 actual v target for elective, non-elective and day
case procedures.

                       Table 11 :    2005-6 Actual v Targets for Relevant Specialties
       Specialty              Target              Actual           Variance             %
       Electives
Paediatrics                            319               367                 48      15.0
Obstetrics                             184                99                -85     -46.2
Gynaecology                          2,769             2,516               -253      -9.1
Total Electives                      3,272             2,982               -290      -8.9

    Non-Electives
Paediatrics                         11,568           11,227                -341         -2.9
Obstetrics                          16,799           19,109               2,310         13.8
Gynaecology                          3,705            4,408                 703         19.0
Total Non-Electives                 32,072           34,744               2,672          8.3

      Day Cases
Paediatrics                            124               175                 51      41.1
Obstetrics                              54                50                 -4      -7.4
Gynaecology                          7,647             5,608              2,039     -26.7
Total Day Cases                      7,825             5,833             -1,992     -25.5


2.8.1 Projected activity and levels and capacity requirements

Teamwork, Management Consultants were commissioned to assess the activity,
bed requirements and income changes for each of the options identified in the
strategy Making it Better. The baseline year for this analysis was 2004/05. The
activity was projected over a 10 year period and adjusted for demographic
changes. Changes in patient flows were modelled on patients attending the
nearest hospital to their postal address.

This information was used to project the number of patient „spells‟, bed days and
subsequently the number of beds and cots required to support each option. The
analysis of the impact on income is discussed more fully in Section 6 Financial
and Economic Appraisal.

The planning assumptions used by Teamwork for the activity and capacity
analysis are as follows:


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      The majority of non-specialist inpatient activity at Booth Hall and the
       Royal Manchester Children‟s hospital would transfer to North Manchester.
       An initial analysis of the activity at Booth Hall identified a 30:70 split
       between non-specialist and specialist inpatient services.

      Specialist paediatric inpatient services and surgery for under 2s will be
       carried out by the new children‟s hospital in Manchester (CMMC). There
       will be no change in inpatient flows to Liverpool and other „out of area‟
       specialist children‟s hospitals.

      75% bed occupancy for obstetric and paediatric beds.

      A total of 90 level 3 intensive care cots to be provided across three
       hospital sites, including Royal Oldham. A total of 92 level 2 intensive care
       cots to be equally distributed across 5 hospital sites including North
       Manchester. These cot numbers include capacity for the care of „out of
       area‟ newborns.

The Teamwork analysis made no assumptions on the impact of patient choice;
practice based commissioning, admission avoidance and demand management
initiatives on future activity and capacity requirements.

However, following discussions and written confirmation from the Children‟s
Network on the 7th November 2006, the original activity assumptions have been
amended in relation to paediatrics. A final written report (Version 5.0) was
produced by Teamwork on the 8th December 2006 that showed that “an
estimated 71% of the 2004/05 inpatient admissions at Booth Hall were non-
specialist” (Page 27). On the 21st December 2007, Leila Williams, Director of the
Greater Manchester, East Cheshire and High Peak Children‟s, Young People and
Families‟ NHS Network notified the Trust that Teamwork had revisited the
assumptions and provided details of the implications of the revisions for North
Manchester and Oldham. A copy of the revised modelling assumptions is
included in Appendix 6. Teamwork have said that their revisions now indicate
that 60% of Booth Hall activity is secondary in nature as opposed to the
previously reported 71%. However, the revised figures were based on 2006/07
outturn data which was significantly higher than the baseline year of 2004/05 and
indicated that the total number of inpatient spells previously reported for North
Manchester remained constant at approximately 5,600.

In June 2007 the Trust commissioned JMP Consulting, a firm of transport
planners and engineers, to undertake a study of expected patient flows following
reconfiguration of clinical services across the Trust‟s four sites. The exercise
involved the use of specialist accessibility planning software to map historical
patient travel patterns to hospitals for emergency treatment in order to determine,
based on patient postcode and journey time, which hospital a patient would travel
to should a service become unavailable at their current nearest hospital. The
outcomes of this exercise have been factored into the various non-elective
activity assumptions.

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In addition the following other assumptions have been used:-

Paediatrics

      41% of non-elective inpatient paediatric activity at Fairfield would transfer
       to North Manchester

      All paediatric A&E activity and all non-specialist day case activity will
       transfer from Booth Hall to North Manchester

      85% bed occupancy

      Reduction in average length of stay based on CHKS upper quartile length
       of stay for the PAHT cohort.

      06/07 Booth Hall Outpatient attendances applicable to Pennine has been
       reduced by 15% to reflect activity undertaken elsewhere (5% tertiary and
       10% primary care)

Obstetrics and Gynaecology

      Reprovision of existing obstetric and gynaecology services and facilities at
       North Manchester and re-provision of 40% of the non-elective
       gynaecology services and 43% of non-elective obstetric services and
       facilities from Fairfield

      A gynaecology day case rate of 69%

      85% bed occupancy

      Outpatient reduced by 10% from 06/07 outturn to reflect changes in
       commissioner intentions.

Neonatal Services

      Following a meeting of the Neonatal Network Board on the 28th February
       2006 it has been agreed that Level II Units should provide 19 cots
       comprising 1 intensive care, 3 high dependency and 15 special care cots.

The resultant calculated activity was then used to determine the required facilities
and is shown below in Table 12. A more detailed analysis that explains the
differences between the final Teamwork assumptions and those included in this
FBC is provided within Appendix 6.




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                   Table 12 :    Summary of High Level Calculated Activity
                     Description                               Activity
Paediatrics – Inpatients                                            5,941
Paediatrics – Day Cases                                             1,937
Obstetrics – Inpatients                                            10,653
Gynaecology – Inpatients                                            1,559
Gynaecology Day Cases                                               2,269
Outpatient & Attendances
Paediatric                                                          15,005
Maternity                                                            4,785
Gynaecology                                                          8,009
Paediatrics - A & E and O & A Attendances                           21,114


Following discussions with representatives of the NHS North West, the Children‟s
Network and Teamwork the capacity analysis required to undertake the above
activity is summarised in Table 13 below. The number of inpatient children‟s beds
has been reduced to reflect the inclusion of Observation & Assessment beds,
proposed shorter lengths of stay and initiatives that will take place in primary care
e.g. Care Closer to Home. The number of maternity beds has also been reduced
to take account of the ratio of consultant to midwife-led births.

                   Table 13 :    Summary of Capacity Requirements
                                                                        Capacity
                                Description                             Required

     Capacity for Booth Hall, RMCH and Fairfield Activity

     Paediatric Beds                                                           20
     Observation & Assessment Beds                                              6
     Paediatric Day Case Beds                                                   6
     Total Paediatric Beds                                                     32

     Paediatric Theatres                                                           1

     Capacity for Women and Children’s Reconfiguration

     Maternity Beds - New                                                      46
     Total Maternity Beds                                                      46

     Delivery Rooms                                                            13
     Special Care Cots                                                         19
     Obstetric Theatres                                                         2




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2.9      Interim Arrangements

Booth Hall is due to close in June 2009 and it is unlikely that the new unit at North
Manchester will be available for occupation until December 2009. Therefore
there will be an interim period of approximately 6 months where alternative
arrangements will need to be put in place. The paediatric A & E with an adjacent
temporary O & A facility will be complete in time for the closure of Booth Hall.
Additional radiology facilities for paediatrics will be temporarily brought onto the
site by means of a trailer. For medical paediatric admissions the proposal is to
convert an existing ward to take children.

It is unlikely however that there will be sufficient theatre capacity to be able to
accommodate children's paediatric surgery at North Manchester. Whilst there
are some sessions available in the current theatre timetable, these tend to fall on
a Friday afternoon. It is therefore proposed to do the following:

ENT

ENT could, for the short period of time, transfer to the Fairfield site. Initial
indications are that there would be sufficient beds and theatre capacity to
accommodate this service. However, this model is not preferred by the BHCH
ENT Surgeons as they would be working across three sites. The feasibility of
moving this work to NMGH is being evaluated with a view to this being the
preferred option.

Dental

Day case dental activity could transfer to the North Manchester site given
sufficient capacity.

Orthopaedic Surgery

It is proposed that both elective and non-elective activity around orthopaedics is
transferred to Central Manchester pending the opening of the new facility. Some
of this work could also transfer to Oldham, depending on where patients are from.

General Surgery

It is proposed that elective and non-elective general surgery is transferred to
Central Manchester pending the opening of the new facility. Some of this work
could be done at Oldham.




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2.10   Staffing

The Trust‟s Human Resources Strategy reflects the national priorities set out in
HR in the NHS Plan „More Staff Working Differently‟. The approach to human
resources in the Trust recognises that the most important factor in the delivery of
health services is an experienced, committed and trained workforce. The
strategic aims set out in the strategy are to:

      Ensure that we have a quality workforce in the right numbers with the right
       skills and diversity, organised in the right way to deliver national and local
       service priorities.

      Demonstrate that we are continually improving the working life of all staff
       employed across the Trust.

      Address the management capacity and capability required to deliver the
       Trust service priorities and changes.

      Plan for the impact on staff of developments in information technology
       and clinical advances.

      Establish processes       that   encourage     continuous     learning    and
       development.

In 2006 work was undertaken at the Trust to develop a core set of values by
which staff will be expected to conform to within the workplace. The three core
values are shown below:-

      Patient care is at the centre of everything we do. We work together to
       deliver a high quality service to provide the best possible outcome for our
       patients.

      Accountability, honesty and integrity are keys to our success both
       individually and across the Trust.

      Treating everyone with respect and promoting good working relationships
       will support individuals in reaching their full potential.

In order to embed the values into the Trust‟s culture work groups are now being
set-up in key areas including recruitment, KSF, policies and procedures,
education and training that in the coming weeks will move forward.

The four pillars in the national HR Strategy and the actions of the Trust in
response to them are set out in Table 14 below.




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                     Table 14 :     HR in the NHS Plan “More Staff Working Differently"
 Key Area       National Strategy                   Trust Progress
 Making   the   Improving    Working        Lives   The Trust has achieved IWL Practice Plus
 NHS a model    Standard                            status.
 employer
                Positively Diverse Programme        The Trust has reviewed its Diversity Policy
                                                    and is involved with the Regional Networks
                                                    to deliver the diversity targets.
                NHS Childcare Strategy              The Trust has nursery provision on three of
                                                    its four sites. The Trust also employs a
                                                    Child and Adult Care Co-ordinator to offer
                                                    information and support to staff.
                Flexible Careers Scheme             The Trust has begun to promote the flexible
                                                    careers scheme as part of its retention
                                                    initiatives and has retained some staff as a
                                                    result of this.
                Staff Involvement                   The formation of a Human-Resources Sub-
                                                    Group comprising managers and staff side
                                                    representatives to address key issues
                                                    arising from the proposed re-configuration
                                                    of Women & Children‟s services.
 Ensuring the   Modernisation of Pay                The Trust has, wherever possible,
 NHS Provides                                       responded to local and national issues in
 a      Model                                       relation to pay and welcomes the
 Career                                             development of Agenda for Change (AfC).
                                                    The Trust has now made significant
                                                    progress in implementing AfC.
                Modernisation of learning and       In 2006 the Trust appointed an Executive
                personal development                Director of Human Resources and
                                                    Organisational Development.

                                                    The Trust has a Training and Development
                                                    Strategy and performance appraisal
                                                    systems are in place for the majority of staff
                                                    supported by individual training and
                                                    development plans.
                Modernisation of professional       The Trust has in place systems to ensure
                regulation                          that staff are registered with professional
                                                    bodies.
                Modernising            Workforce    The Trust has produced a comprehensive
                Development                         workforce plan, which outlines key issues in
                                                    relation to the development of the
                                                    workforce. In addition the Trust has been
                                                    closely working with the WDC.
 Improving      Improving     Working       Lives   Progress detailed above
 Staff Morale   Standard                            The Trust monitors accidents and violent
                                                    incidents and produces an annual staff
                                                    survey.
                                                    Sickness absence is actively managed and
                                                    has reduced year on year.
                                    The
 Building       Strengthening HR Capacity in        To support the changing climate at the


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 Key Area       National Strategy              Trust Progress
 people         the NHS                        Trust significant investment has been made
 management                                    in HR management. To reflect the change
 skills                                        the Trust has appointed a Board Level
                                               Director of Human Resources and
                                               Organisational Development.


Current Position

In examining the staffing issues involved in providing an integrated Women &
Children‟s service it is important to note the following local applicable factors:-

      Ageing workforce

      Difficulty in recruitment

      Low morale

      Ways of working not wholly compatible with the proposed new
       development

      Over adherence to professional boundaries

      Legislation – Working Time Directive

      Competition from other hospitals

In acknowledgement of the above the approach taken with staff has embraced
the following:-

      Whitley grades have been provided for in the new structure.

      Implementation of Agenda for Change ensuring staff are rewarded for
       roles undertaken.

      A review of structures following the implementation of Agenda for Change
       ensuring suitable levels of local management are in place and
       consistency of service delivery.

      A fundamental theme of the modernisation programme will be the
       integration of the workforce.

      Proposals for the operational configuration for the new service have been
       discussed and agreed by individual discipline groups.

      Benefits of platform standardisation and common Standard Operating
       Procedures


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      Vertical integration – this involves a degree of extended roles between the
       staff groups below. This is consistent with the Agenda for Change and
       offers enhancements for additional roles.

The Trust has been reasonably successful to date in the recruitment and
retention of staff under very difficult circumstances. National shortages,
particularly in specialist posts have created real difficulties for Trusts nationally.
Any areas were recruitment or retention have been problematic have had
successful strategies put into place to overcome difficulties.

2.10.1 Delivering Women and Children’s Services

The Trust has developed a Workforce Plan in conjunction with a number of
internal and external stakeholders. A copy of the plan is included at Appendix 7.

The Trust has assumed that the existing funded staff establishment for women‟s
services at North Manchester would be included in the establishment for the
future services to be provided at North Manchester. Likewise it has been
assumed that a percentage of the women and children‟s staff establishment at
Fairfield will be included in this establishment. The Trust has worked with the
relevant Directorate teams to develop the additional staff establishment required
to support the transfer of children‟s services from Booth Hall and RMCH.

2.11   Recruitment Initiatives

The changes in service delivery planned for this site will need a continuing
investment in the workforce to enable the delivery of the service in the new ways
required. This reflects the objectives of the NHS Plan in delivering „more staff
working differently‟. The Trust has developed a number of initiatives to aid
recruitment and retention across all professional groups. To ensure delivery of
service the Trust will need to develop the existing workforce in addition to
increasing our recruitment from both traditional sources and through developing
new partnerships with other agencies.

Workforce discussions will take place between PAHT and CMMC during the
course of 2008. Existing staff at Booth Hall have undertaken aspiration
interviews in order to determine their preferred location of employment. Further
interviews with staff are planned to commence early in 2008.

A wide range of staff groups are involved in delivering existing women and
children's services. The Trust is fully aware of the challenges facing our current
staff and our workforce of the future. The Women & Children‟s existing staff at
Fairfield who will be affected by the transfer of services to North Manchester will
also have the opportunity to undertake aspiration interviews during February and
March 2008. We will continue to explore the potential to deliver our services in a
different way whilst ensuring that we are able to retain a quality workforce.




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2.12   Financial Context

The Trust has an operating income of approximately £450m. In 2006/07, the
Trust met all its financial duties, with the exception of achieving a breakeven
position, keeping within its borrowing and capital resource limits and making a
3.5% return on assets. Breakeven was achieved by receiving non-recurrent
support of £9.2m, with the approval of Greater Manchester SHA.

2.13   Summary of Case for Change

The case for change is summarised as follows:

      There is a local strategic imperative across Greater Manchester to
       develop children‟s services at North Manchester and to reconfigure
       women and children‟s services.       A reconfiguration of women and
       children‟s services is needed to develop high quality, modern, safe and
       sustainable services for the future. The business case will support the
       implementation of the strategies set out in Making it Better and Healthy
       Futures.

      Booth Hall is due to close in 2009 and there is an urgent need to develop
       replacement services.

      There is currently no suitable accommodation on the North Manchester
       site to support a development and expansion of women and children‟s
       services.

      The quality of the existing accommodation for obstetric, special care baby
       and gynaecology services is poor. This FBC will partly support the Trust
       estates strategy for North Manchester to replace old workhouse
       accommodation and provide modern purpose built healthcare facilities.




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SECTION 3 :        OBJECTIVES, BENEFITS & CONSTRAINTS

3.1       Objectives

The investment objectives of the project can be defined as:

         To develop modern facilities for the delivery of women and children‟s
          services at North Manchester General hospital, which enable the
          preferred model of care to be implemented.

         To enable the reconfiguration of women and children‟s services across
          PAHT to support the delivery of effective and sustainable services.

         To provide facilities within a safe, appropriate and comfortable
          environment, which are attractive to staff and patients.

         To improve the co-location of women and children‟s services and support
          services at North Manchester.

         To provide a service that will consolidate and develop the Trust‟s
          Divisional infrastructure for the management of human and other
          resources in a cost effective manner.

3.2       Benefits Criteria

The benefits criteria have been developed by the Women and Children‟s Project
Team and are described below in Table 15.




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                      Table 15 :   Women & Children’s Business Case - Benefits Criteria
                                      Benefits criteria
Criterion                                            Definition
Strategic Fit    Supports the long-term strategy for women and children‟s services across
                 Greater Manchester, specifically Making it Better, and Healthy Futures.
                 Conforms to the Trust‟s estates strategy and the development control plan
                 for North Manchester.
Clinical         Supports the implementation of the clinical service model and integrated
Quality          care pathways.
                 Supports the delivery of clinically safe services, providing critical mass
                 necessary to maintain clinical skills and expertise.
                 Ensures close proximity to related clinical and support services.
                 Supports the achievement of Trust performance targets.
Capacity         Provides the capacity needed to deliver effective services.
and              Ensures the design will support the phasing of the development if required
Flexibility      e.g. the new facility can initially be run as a single specialty unit.
                 Provides facilities that are flexible to meet changing demands for
                 healthcare.
Patient          The layout of services is designed around the needs of users and
Experience       provides attractive facilities.
Staff            Supports the recruitment and retention of appropriately trained staff.
Recruitment      Promotes integration of the workforce and modernised working practices.
and              Provides facilities that improve working lives.
Retention
Modern           Improves the quality and functional suitability of the estate.
Estate           Minimises dependence on old buildings, which are difficult to maintain.
                 Makes optimum use of estate.
                 Facilitates site rationalisation.
                 Supports further cost effective development of the estate.
Deliverability   Ensures the timely transfer of inpatient paediatric services from Booth Hall
                 and Royal Manchester Children's hospital by June 2009.
                 Ensures the timely reconfiguration of obstetric and gynaecology services.
                 Ensures a minimum of disruption to existing services during construction.
Acceptability    Has the support of staff and patients.
                 Has the support of local commissioners.


3.3        Relative Importance

The Project Team considered the weightings of each criterion. This is considered
further at 5.4

3.4        Constraints

The key constraints for this FBC are as follows:

          Facilities to support the transfer of children‟s services from Booth Hall
           must be available by 2009.




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      All options must provide a phased implementation of the service
       developments, which will enable the transfer of inpatient children‟s
       services from Booth Hall as a first phase.

      There is no suitable clinical space at North Manchester, which can be
       used to accommodate the development of women and children‟s services.
       All development options will therefore require some element of new build.

      The layout and quality of the building stock on the North Manchester
       General hospital site will limit the estate options for consideration.

      The availability of capital.




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SECTION 4 :         OPTIONS

The estates options for developing women and children‟s services at North
Manchester General hospital have been based on the preferred service
configuration options described in Making it Better and Healthy Futures.

In recognition of the different timing requirements for the proposed service
developments for children and women‟s services a strategy was formulated that
would be capable of delivering a phased development.

         Stage One of this strategy is the transfer of inpatient paediatric services
          from Booth Hall and Royal Manchester Children‟s hospital to North
          Manchester General hospital. This equates to the do minimum service
          configuration option within Making it Better.

         Stage Two of the strategy is the reconfiguration of women and children‟s
          services from four sites to two and the development of NICU services.

4.1       Developing a long list of options

The Trust has considered a number of options. These included varying the
amount of refurbishment in comparison with new build and different build
solutions i.e. traditional versus modular build.

An initial comparison of traditional build and modular build indicated that the costs
between these options would be negligible. The difference between the options
is that a modular build could be completed quicker but has a shorter life
expectancy than a traditional build. In addition there are structural implications
with modular build over three storeys high that would be difficult to address. The
particular nature of the proposed development coupled with difficulties
concerning varying site levels at North Manchester has helped form the Trust
view that modular build should be excluded from the shortlist.

Following the initial costing exercise it was decided to re-visit the assumptions
concerning new build and refurbishment in order to reduce the capital costs to a
more affordable level. To this end a significantly more radical option was put
forward for consideration. For this option an assumption was made that by 2009
the Trust would be far more efficient in its use of beds and operating theatres. In
addition a view was taken on the impact that primary care and ICATs would have
on reducing both outpatient and inpatient activity.

At present the shortlist consists of three estates development options, including a
do nothing option.




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Both of the two developed estate options include the provision of a dedicated
paediatric theatre. An analysis of existing theatre usage at North Manchester
showed that a number of “vacant” theatre sessions existed. However these
sessions frequently accommodate additional theatre lists for waiting list initiatives.
As the Trust reconfigures its clinical services over the coming years the North
Manchester site will take on more acute surgery thus putting more pressure on
the existing general theatres. The provision of a dedicated paediatric theatre will
ensure that the specialist paediatric skills required in anaesthesia and theatre
nursing will be concentrated in the one area. This will allow paediatric only lists to
be undertaken and ensure the further segregation of children from adults on the
hospital site.

4.1.1 Option 1: Combination of Refurbishment and New Build –
      Preferred Option

This option will include the refurbishment of space within the existing adult A&E
department to provide a dedicated paediatric A&E. This facility will be located on
the ground floor with close access to expanded diagnostic facilities. It will also
provide accommodation for child and adolescent mental health services. In
addition the existing fracture clinic will be relocated to enable the expansion of
the adjacent radiology facility.

This option will include the provision of a new 4 storey facility close to the A&E
department. The ground floor will include 220m2 of paediatric outpatient facilities
and re-provided office and storage accommodation. A paediatric inpatient facility
of 32 beds will be located on the first floor providing inpatient (20 beds), day case
(6 beds) and observation and assessment beds (6 beds). One operating theatre
undertaking paediatric surgery and day cases will be located on the second floor.
There will be a lift access to the theatres.

Initially in-patient obstetrics, neonatal and special care services will be transferred
from existing accommodation at North Manchester, and subsequently from
Fairfield Hospital, to the new unit. This facility will have 19 special care cots
(adjacent to the paediatric inpatient facility on the first floor), with 13 LDRP
(labour, delivery, recovery/ post-partum care) rooms/delivery suites on the
second floor. The 13 room delivery suites will be split in order to provide both
Consultant and midwife led care. Two obstetric theatres will also be provided on
the second floor. On the top floor there will be two wards comprising 46 obstetric
beds. This reconfiguration will enable the aligned services of paediatrics,
obstetrics, and neonatology (including the special care and high dependency
care baby unit) to be co-located on site.

This is the preferred option




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4.1.2 Option 2: Combination of Refurbishment and New Build -
      Radical Approach

This option includes the refurbishment of space within the existing adult A&E
department to provide a dedicated paediatric A&E. This facility will be located on
the ground floor with close access to expanded diagnostic facilities. It will also
provide accommodation for child and adolescent mental health services. In
addition the existing fracture clinic will be relocated to enable the expansion of
the adjacent radiology facility.

This option also includes the provision of a new 3 storey facility close to the A&E
department. The ground floor will include the provision for 220m2 of paediatric
Outpatient facilities, fracture clinic and office and ancillary space. A paediatric
inpatient facility of 32 beds will be located on the first floor providing inpatient (20
beds), day case (6 beds) and observation and assessment beds (6 beds). One
operating theatre undertaking paediatric surgery and day cases will be located on
the second floor. There will be a lift access to the theatres.

In this option all the existing maternity beds (37) at North Manchester will remain
in there present location on the first floor and the adjacent existing delivery suites
and obstetric theatres will be refurbished to create a further 9 inpatient maternity
beds. A 19 cot special care baby unit will be provided on the first floor of the new
build facilities adjacent to the paediatric inpatient ward. A new 13 room delivery
suite that will be split in order to provide both Consultant and midwife led care
together with two new obstetric operating theatres will be provided on the second
floor of the new development. The second floor of the new development will be
at the same level as the refurbished maternity wards within the existing building.

4.1.3 Option 3: Do Nothing

Under this option paediatric services (A&E, outpatients, day case and inpatient
service) at Booth Hall would have to be accommodated elsewhere by another
organisation.

Obstetric services, neonatal and special care services and gynaecology services
would remain in their existing accommodation on the North Manchester General
site and not co-located.




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SECTION 5 :       OPTION APPRAISAL

5.1    Introduction

This section will describe the process and the results of the non-financial
appraisal. Where information is known, the relevant text and/or tables have been
included at this stage.

                        Table 16 :     Overview of Benefits Appraisal Approach Followed




                                        Option Appraisal

                                     The overall process……..


                                                         FINANCIAL
                                                          FINANCIAL
                                                         APPRAISAL
                                                          APPRAISAL
         CONSTRAINTS
          CONSTRAINTS         LONG LIST
                             LONG LIST                                  RISK &
                                                                         RISK &
                             ……………
                            ……………           SHORT LIST
                                           SHORT LIST                 SENSITIVITY
                                                                       SENSITIVITY
                            …………….
                            …………….          …………….
                                           …………….
                                                                      APPRAISAL
                                                                       APPRAISAL
                            …………….
                            …………….         ……………..
                                           ……………..
          OBJECTIVES
           OBJECTIVES       ……………..
                            ……………..                        BENEFITS
                                                            BENEFITS
                                                          APPRAISAL
                                                           APPRAISAL
                                                                                     Preferred
                                                                                      Option
           BENEFITS
            BENEFITS
           CRITERIA
            CRITERIA




5.2    Description of Business Case Objectives

In appraising the three options for the provision of integrated women & children‟s
services, the Project Team has based their evaluation of the options on the
principles and objectives outlined in Table 17 below.




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                      Table 17 :     Women & Children’s Development - Project Objectives
                           Project Objectives                                      Ref
Overarching Objective: To develop modern facilities for the delivery of            01
women and children‟s services at North Manchester General Hospital,
which enable the preferred model of care to be implemented and will
enable the reconfiguration of women and children‟s services across
PAHT to support the delivery of effective and sustainable services.
The achievement of this overarching objective will result in:
   A service that supports the former Greater Manchester Strategic                O1
    Health Authority‟s long-term strategy for women and children‟s
    services.
   A service that is fully compliant with the Trust‟s estates strategy.           O2
   A service that supports the clinical service model and care                    O3
    pathway.
   A service that is safe, appropriate and within a comfortable                   O4
    environment.
   A service that co-locates clinical departments to achieve greater              O5
    levels of integration and collaborative working resulting in efficient
    and effective high quality patient care.
   A service that will consolidate and develop the departmental                   O6
    infrastructure for the management of human and other resources
    in a cost-effective manner.
   Additional capacity to deliver the service with facilities that are            O7
    flexible to demand.
   A service that is comprehensive, interpretative, appropriate, and              O8
    responsive to user needs.
   A service that aids recruitment and retention and promotes strong              O9
    career paths for employees in the service by ensuring a rich blend
    of experience and skills development via a workforce review and
    the engagement of the Workforce Development Confederation.
   A service that maintains and promotes good working relationships              O10
    within the Department, and with other departments within the
    Trust, and colleagues in other hospitals.
   A service that improves the quality and functional suitability of the         O11
    Trust‟s estate and facilitates site rationalisation and further
    developments.
   A service that ensures the timely transfer of paediatric and                  O12
    women‟s services from other sites.
   A service that      has    the     support    of   patients,   staff   and    O13
    commissioners.




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5.3    Identification of Benefits

A range of benefits was previously identified (see 3.2 and Table 17) which are
considered relevant to the appraisal of the options for the future provision of
women & children‟s services.

The Project Team then considered the ranking of benefits as a precursor to
weighting each benefit criterion. The criteria take into account current national,
regional and local issues surrounding women and children‟s services, together
with quality and operational issues against which options can be assessed.

The members of the Project Team assessing the benefits were as follows:-

       Dr Ruth Jameson                Medical Director
       Tom Wilders                    Director of Strategic Planning
       Mr Mahmoud Fathy               Associate Specialist ENT
       Dr Toni Tan                    Consultant Paediatrician
       John Lindars                   Divisional Director (Women & Children‟s)
       Graham Lord                    Head of Estates Development
       Stephanie Jenkins              Associate Director of Diagnostics & Support
       Alex Barker                    Clinical Nurse Manager
       Alison Brophy                  Divisional HR Manager (Women&Children‟s)
       Ian Wilkinson                  Major Projects Manager

5.4    Benefits Appraisal

The Project Team scored the three short listed options against the benefit criteria
shown in Table 17.

      Weighting of Benefit Criteria
An initial ranking and weighting based on the key drivers of the business case
was discussed and agreed as a starting point for the scoring process. The
sensitivity analysis was used to assess the effects of alternative weightings and
more optimistic scores that were put forward during the debate.

All of the results of the scoring process are detailed in Appendix 8. A summary of
the Project Teams‟ scores for all three options is shown below in Table 18.




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                                     Table 18 :   Scoring of Shortlisted Options by Option Appraisal Team
                                             Do Nothing              Option 1 (preferred)             Option 2
                                               Option                 Combination of               Combination of
Ref   Benefit Criteria      Weight                                   Refurbishment and           Refurbishment and
                                                                         New Build               New Build (Radical)
                              %          Score        Wt Score       Score        Wt Score        Score       Wt Score
1     Strategic Fit           20              3.50         70.00          8.00        160.00           7.00      140.00
2     Clinical Quality        20              3.25         65.00          7.75        155.00           7.75      155.00
3     Capacity        and
      Flexibility             10                  0             0         7.33          73.33          7.33       73.33
4     Patient
      Experience              10              3.00         30.00          8.50          85.00          7.50       75.00
5     Staff Recruitment
      and Retention           10              1.00         10.00          8.67          86.67          8.00       80.00
6     Modern Estate           10              2.60         26.00          8.00          80.00          6.20       62.00
7     Deliverability          10              1.67         16.67          8.00          80.00          7.33       73.33
8     Acceptability          10               2.00         20.00          9.00          55.00          8.00       80.00
      Total                  100             17.02        237.67         65.25         810.00        59.12       738.67




                The Project Team‟s comments on the various benefit criteria and how they
                related to the options are shown below in Table 19 (excluding Do Nothing).




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                      Table 19 :   Women & Children’s Services – Comments on Shortlist
                                                  Scores
                     Comments on Individual Benefit Criterion
1       Strategic Fit
        It was considered that both Options would go a long way to supporting
        Greater Manchester‟s long-term strategy for Making it Better. Option 1 was
        considered better than Option 2 in respect of the Trust‟s estate strategy.
2       Clinical Quality of Services
        Both options scored the same for each of the four criterions included in this
        particular element. It was considered that both options would deliver
        significant clinical benefits.
3       Capacity and Flexibility
        Both options scored the same for each of the three criterions included in this
        particular element. It was considered that the facilities would not be that
        flexible in the future to upward changes in demand as it would be difficult to
        expand both inpatient beds and operating theatres from their proposed
        locations.
4       Patient Experience
        Option 1 scored higher for each of the two criterions as it was considered that
        the additional elements of new build construction included in the option would
        create a more pleasant environment for all the users. It was noted that for the
        provision of maternity wards Option 1 was considered to be the far better
        option.
5       Staff Recruitment and Retention
        Option 1 scored slightly higher than Option 2 primarily because of the
        additional elements of new build included within the option.
6       Modern Estate
        Option 1 scored significantly higher than Option 2 on four of the five
        criterions. It was considered that including more new build elements in the
        scheme helped rationalise the estate as well as minimising the dependence
        on old building stock. Option 1 also supported further cost effective
        development of the estate.
7       Deliverability
        Option 1 scored slightly higher than Option 2 as it was considered that the
        option would be less disruptive to the provision of existing services during
        actual construction.
8       Acceptability
        Option 1 scored higher than Option 2 as it was considered that staff and
        patients would find the option more acceptable.




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     Summary
The non-financial preferred option is Option 1. The option will ensure an optimal
service to patients, whilst, at the same time maximising the benefits from
integrated services. The option is consistent with regional and national strategies
for women and children‟s services. Finally, the option reflects the requirements
of developing modern clinical services and fits with the estates strategy for the
North Manchester site.

Notwithstanding that Option 1 scored the highest it was noted by the Project
Team that Option 2 also scored highly and was also consistent with regional and
national strategies for women and children‟s services. Option 2 would also help
develop modern clinical services but did less to help support the overall estates
strategy for the North Manchester site by continuing to use old existing wards.

       Sensitivity Analysis

The scoring of the short listed options resulted in a small gap between the two. A
switching analysis showed that Option 2 would need to increase its overall score
by 10% for it to become the preferred non-financial option.

As a result of this gap it was decided that an extensive sensitivity analysis would
be undertaken to see if the outcome of the exercise changed in any material
form.

Scores that represented a more optimistic outcome were given to the options.
The result of this indicated that the difference between the two options narrowed
to less than 1%. However, changing the relative weightings made very little
difference to the overall outcome with Option 1 scoring over 9% more than Option
2.

       Overall Conclusions

Following a thorough appraisal of options, the Project Team has drawn the
following conclusions:-

                 Option 1 was considered to deliver most benefits
                 Both Options 1 and 2 would deliver significant benefits against
                  the considered project objectives
                 Switching scores and weights made only marginal differences
                  to the overall outcome
                 In respect of maternity ward provision Option 1 was far
                  superior to Option 2
                 The Project Team‟s recommendation was that Option 1 was
                  the preferred option.




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5.5    Benefits Realisation

A copy of the Benefits Realisation Plan is included in Appendix 8.




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SECTION 6 :       FINANCIAL AND ECONOMIC APPRAISAL

6.1    Background

This section sets out the revenue and affordability impact of and the relative
capital investment assumptions and requirements.
The income envelope, within which this business case is presented, is
determined by a price tariff for a specific volume of activity that has been agreed
in advance with commissioning PCTs and the Network.

The income has been derived by multiplying the projected total cases as
determined by Teamwork plus existing activity at North Manchester and Fairfield
at national tariff rate. This rate has then been adjusted for the local market forces
factor and the Trust‟s historical case mix for the specialities involved.

6.2    Revenue and Affordability Impact

Table 20 below details the overall financial position for the Trust of implementing
this element of Making it Better.




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                   Table 20 :     Income and Expenditure Position of Preferred Option
                                 Description                                Option 1
 INCOME                                                                      £’000
 Paediatrics
 Current Trust Income                                                              5,255
 Changes to Income from Internal and External Inpatient Transfers
 Inpatients                                                                        3,787
 Day cases                                                                           403
 Outpatients                                                                       6,095
 Neonates                                                                            522
 Accident & Emergency                                                              1,441
 Observe & Assess                                                                  1,447
 Total Paediatric Income                                                          18,950


 Obstetrics and Gynaecology
 Current Trust Income                                                             17,948
 Changes to Income from Internal and External Inpatient Transfers
 Inpatients                                                                      (1,438)
 Outpatients                                                                       (322)
 Total Obstetrics and Gynaecology Income                                         16,188


 TOTAL INCOME                                                                     35,138


 EXPENDITURE
 Paediatrics
 Current Trust Expenditure                                                         5,255
 Changes to Expenditure from Internal and External Transfers
 Inpatients, day cases and O&A                                                     5,538
 Outpatients                                                                       4,012
 Neonates                                                                            522
 Accident & Emergency                                                              1,540
 Total Paediatric Expenditure                                                     16,868
 Obstetrics and Gynaecology
 Current Trust Expenditure                                                        17,948
 Changes to Expenditure from Internal and External Transfers
 Inpatients and day cases                                                         -1,428
 Outpatients                                                                        -242
 Total Obstetrics and Gynaecology Expenditure                                     16,278


 Capital Charges                                                                   2,263
 Estate Costs                                                                        608
 TOTAL EXPENDITURE                                                                36,017
 (Excess)/Shortfall                                                                  879




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This position (as at 2012/2013) gives a deficit of £0.9 million. Prior to 2012/2013
there are additional cost pressures to the Trust, as services contract and expand
across the different sites within Pennine, working towards the final configuration.

By year, these pressures are shown below in Table 21.

                    Table 21 :    Trust Cost Pressures by Year
                    2009/2010           2010/2011         2011/2012           2012/2013

Description             £m                  £m                   £m              £m

Income                       -23.9               -34.8                -34.8           -35.1

Expenditure                  27.3                39.1                 37.9            36.0

Deficit                          3.4              4.3                  3.1             0.9



Discussions have taken place with Manchester PCT (as lead commissioner) and
Bury PCT about the financial support required to ensure that this can be
managed across the health economy, and not remain as a liability exclusively for
this Trust or local PCTs. The consensus view is that an agreement can be
reached concerning how this deficit can be managed. In the meantime
discussions will continue with the PCTs and the wider Network to resolve the
issue.

A more detailed breakdown of the figures in Tables 20 and 21 is included at
Appendix 9.

6.3       Capital Investment Assumptions and Requirements

Assumptions have been made on the gross internal area of clinical and non-
clinical support space required for each component of each option based upon:

         Experience of similar major schemes elsewhere within the UK.

         The distribution of blocks of activity, anticipated volume of patient
          throughput and derived bed numbers developed specifically for this
          assessment, together with experience of practice elsewhere within the
          UK.

         Pragmatic assumptions have been made concerning the extent and
          applicability of the “Improving the Patient Experience” (consumerism)
          uplift to be applied to new NHS accommodation space standards as
          promulgated by NHS Estates in December 2000. The agreed parameters
          for the calculation of space for new buildings contained in this FBC are
          based upon the latest Health Building Notes


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The Trust considers that the provision of a segregated children‟s A&E is required
regardless of any final decision on the Making it Better consultation and therefore
proposes to undertake these works in advance of the proposed women &
children‟s development. A secondary reason for bringing forward this particular
element of the scheme is that it will help ensure that the overall Women &
Children‟s development at North Manchester is completed in 2009 to facilitate the
timely closure of Booth Hall.

The proposed bed configuration allows for 15% margin of flexibility over and
above the calculated requirement to meet peaks/surges and unexpected
increases in future demands. This is regarded as a conservative assumption
consistent with matching future capacity risk with current affordability constraints.

Table 22 below details the calculated area requirements of the preferred option
including the space required for the children‟s A&E. A more detailed analysis
(schedules of accommodation) for the preferred option is included at Appendix 9
together with the relevant FB forms.

                     Table 22 :     Women & Children’s Development - Space Requirements
                                                   of Options
                                                          New/         Option

                        Description                      Refurb           1

      Gross Area (m2)                                                         8,388

      Paediatric Wards incl O&A & day case (m2)             N                 1,366

      A & E (m2)                                            R                 1,383

      Operating Theatres (m2)                               N                  891

      Obstetric Wards                                       N                 1,427

      Obstetric Delivery Suites (m2)                        N                  931

      Special Care Baby Unit (m2)                           N                  462

      Other (m2)                                           N/R
       Orthopaedic Outpatients                                                 522
       Radiology                                                               550
       Paediatric Outpatients                                                  217

      Engineering Plant Room & Communication (m2)                             2,320




Pending the agreement of a Guaranteed Maximum Price the estimated capital
costs of implementing the preferred option on the North Manchester site are
shown below in Table 23.


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                    Table 23 :     Women & Children’s Development – Capital Costs
                                                                        Preferred
                                 Description                             Option
                                                                          £’000
      Construction Costs (including fees)
      New Build Elements                                                    22,000
      Refurbished Elements (A&E and Radiology)                               3,000
      Total Works Costs                                                     25,000

      VAT (including reclaimable on refurbished areas)                        4,000

      Other Fees (Cost Advisors, Clerk of Works etc)                          1,000

      Equipment                                                               2,000

      Forecast Outturn for Full Business Case                               32,000


6.4     Revenue Assumptions

For the revenue calculations a cost base of 2007/2008 has been used
throughout.

Details of the revenue calculations can be found in Appendix 9.

Income

The income has been calculated on a weighted average tariff value. For some of
the activity this value has been provided through the work completed by
Teamwork. Where the Teamwork reports have not covered specific areas of
workload, such as gynaecology or outpatients, a further calculation has been
made. The Trust activity and associated income for 2006/2007 has been
analysed to determine the weighted average tariff value for each specialty and
point of delivery. This weighted average tariff value has then been applied to the
anticipated changes in patient flows.

There is currently no national tariff for children‟s observation and assessment
units. However, the costs of creating the Unit at North Manchester indicate that a
tariff equal to 50% of the full children‟s tariff is required in order for the unit to be
financially viable. This level of tariff has therefore been applied.

As the funding of neonatal services is currently outside of tariff, an assumption
has been made that the cost changes associated with the transfer of this service
from Fairfield to North Manchester will be met by commissioners.




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Operating Costs

Direct Costs

It is assumed that the baseline expenditure is covered by the income generated
at a weighted average tariff value as calculated in the section above.

For the subsequent changes to the services to reflect the changes in activity the
relevant operational Directorate has completed a detailed assessment. The
Directorates have provided details of their staffing requirements for the additional
activity, which will transfer from Booth Hall and Pendlebury to the Trust, and for
the anticipated flows within and outside of the Trust.

The staffing levels that have been calculated are in line with the relevant Royal
College standards and have been benchmarked for reasonableness against the
Trust‟s current staffing levels. Details of the establishments to provide the
services can be found in the Workforce Plan that supports the business case
(see Appendix 7).

Other Costs

The B Plan costing system has been used to model the requirements for other
costs (such as hotel services) on both contracting and expanding sites.

The additional estate costs associated with the additional building area have
been costed at £90 per m2.

Capital Charges

The capital charges have been calculated based on the estimated Guaranteed
Maximum Price (GMP) received by the contractor. The following life year basis
has been used:

New and existing buildings – 35 years

Equipment – 7 years

6.5       Sensitivity Analysis

There are a number of key financial risk management assumptions underpinning
this business case:

         All the additional work scheduled to go through that facility brings with it a
          stream of income at national tariff rate (MFF adjusted) for each patient
          and is in line with the activity assumptions that have been made.




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           That the contribution level is in line with that required by the Trust and can
            cover the consequential costs associated with the capital investment in
            new facilities to deliver those required changes in services.

           To eliminate the retained risk of costs (mainly semi-fixed site costs) at
            Fairfield which cannot be shifted in the short term will require wider
            strategic shifts in services not just those changes associated with women
            and children‟s services.

 Given the scale of this business case the Trust must recognise that there are
 significant financial risks associated with the planned activity and implementation
 of the project.
 Three key areas of significant financial risk have been identified which have been
 subjected to sensitivity analysis. These are as follows:

        1. Changes to activity levels

        2. Changes to the case mix

        3. Changes to the levels of costs that can be removed form contracting sites

6.5.1       Changes to Activity Levels

 The activity values used in the business case are taken from the data provided by
 the Network (via Teamwork) with further refinements being made to take into the
 most current period (2006/2007), and the study undertaken by JMP on behalf of
 the Trust in respect of anticipated patient flows.

 However, given the risks associated with the uncertainty over actual patient flows
 when the services transfer, variations have been subjected to sensitivity analysis.

 The results of the sensitivity analysis on proposed activity levels are shown below
 in Table 24.




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                    Table 24 :   Sensitivity Analysis – Changes to Activity Levels
        Specialty                Point of           +/-5%          +/-10%            -20%
                                 Delivery

                                                    £’000           £’000            £’000

 CHILDREN’S

 Paediatric Medicine         Inpatients                 285.0          569.9         1,139.9

 Paediatric Surgery          Day Cases                  190.8          381.7           717.9

 Accident & Emergency        Attendances                  72.0         144.1           288.2

 Observe & Assess            Attendances                  65.7         131.4           244.8

 Children’s Total                                       613.5        1,227.1         2,390.8

 OBSTETRICS                                             189.5          338.9           637.9

 TOTAL                                                  803.0        1,566.0         3,028.7



 In calculating these figures the weighted average tariff used for each speciality
 and point of delivery in the business case has been applied to determine the
 changes in income.

 For changes to costs, variable costs for each patient (drugs, consumables) have
 been considered, and a further adjustment made on a stepped basis for semi
 fixed costs (direct staffing) that will vary once stated levels of activity are
 achieved. Clearly there are a number of fixed costs that will not alter given the
 size of the building that has already been agreed within the health economy.
 Changes of +/- 5%, +/- 10%, and –20% have been calculated. The impact of a
 20% increase has not been included as it is considered that the current design
 and size of the building will not immediately support a change of this magnitude

6.5.2   Changes to Case Mix

 The income stated in the outline business case was calculated using the
 weighted average tariff for each specialty and point of delivery, based on costs
 and activity prior to 2006/2007.

 In reviewing the income for the Full Business Case (using 2006/2007
 information), it is apparent that the weighted average tariff has changed,
 reflecting the current case mix of patients who access the services. Given that
 there could be further changes to the case mix in the future, the current mix of
 activity has been subject to sensitivity analysis.


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The impact of a change to the case mix is shown below in Table 25.

                   Table 25 :   Sensitivity Analysis – Case Mix
           Specialty                   Point of              +/-5%          +/-10%
                                       Delivery

                                                             £’000          £’000

CHILDREN’S

Paediatric Medicine                Inpatients                      318.2        636.3

Paediatric Surgery                 Day Cases                        91.4        182.9

Accident & Emergency               Attendances                      72.1        144.2

Children’s Total                                                   481.7        963.4

OBSTETRICS                         Inpatients                      454.4        908.8

GYNAECOLOGY

Non Elective                       Inpatients                       55.1        110.2

Elective                           Inpatients                       82.3        164.6

                                   Day Cases                        72.6        145.2

Gynaecology Total                                                  210.0        420.0

TOTAL                                                             1,146.1     2,292.2



In calculating these figures, changes have only been made to the income.
Although changes to the case mix will result to a change in variable costs it has
been viewed that these are no significant and that the net impact will be minimal.

It should be noted that outpatients have been excluded from this exercise as the
tariff for outpatients is standard, and will not vary with case mix. There would be a
variation if the mix of new to follow up patients was changed but this has not
been specifically considered here.

The observation and assessment unit activity has also been excluded as it has
been determined that the unit cannot be operated at less than the tariff that has
already been calculated.




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 A separate exercise has been carried out to determine the impact on the
 business case of known changes to the tariff from 2008/2009, which would feed
 potentially feed through as a change to the weighted average tariff. Whilst the
 impact of the 2008/2009 tariff has been discounted from this business case, it
 should be noted that, based on the guidance received and considered to date,
 the impact is not significant

6.5.3     Changes to Cost Behaviours

 The transfer of the specialities and patient categories for Making It Better is
 complex.

 For example, inpatient services for women‟s and children‟s services will transfer
 from the Fairfield hospital site (some to within Pennine, and some to other service
 providers), but outpatients will remain.

 Each speciality has been separately considered to determine the impact of
 service transfers over the time period until 2012/2013 when it is anticipated that
 the transfer of all services within the Pennine Trust will be complete.

 The Trust has previously used McKinsey‟s to model the impact of service
 changes on cost behaviours and this work has been used to calculate the likely
 impact of service reductions on residual costs.

 For the most significant service contractions it has been assumed that just 5% of
 residual costs will remain on contracting sites, and this assumption is included
 within the income and expenditure position.

 However, Table 26 below demonstrates the significant variation that will occur if
 the residual costs are increased to 25%.

                      Table 26 :   Sensitivity Analysis – Cost Behaviours
        Description                   %            Children’s Obstetrics        Total

                                                      £’000          £’000      £’000

 FBC – Residual Costs                 5                  120.0          238.0    358.0

 Residual Costs                       25                 602.0         1194.0   1,796.0

 Variation                                               482.0          956.0   1,438.0



 The Trust acknowledges the wide variation that residual fixed costs has on the
 bottom line and will take positive action to ensure that fixed costs are removed
 from donor sites as quickly as possible.



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6.6    Economic Appraisal – Value for Money Analysis

The results of the OBC discounted cash flows for both options are illustrated in
Table 27 below. The EAC shows the present value of the costs (including
variations in revenue costs) as well as taking into account the life span of the
options. The detail of these calculations is included at Appendix 10.

                  Table 27 :   Discounted Cash Flow of Options


                     Description              Option 1    Option 2
                                                £’000       £’000

               Net Present Costs                111,186     110,099
               Expected Annual Costs              6,360          6,298


 As the variation in the two options was minimal a further exercise has not been
carried out for the purposes of the FBC as there is nothing to suggest that the
outcome would be any different. The exercise undertaken for the OBC showed
that Option 2 was marginally less costly in terms of net present and expected
annual costs. However, the exercise did not take account of the overall estate
benefits that will be derived from vacating the existing wards. In addition
including the costs of the link corridor that would be required with Option 2 would
also negate the small difference highlighted in the OBC exercise.




.




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SECTION 7 :       THE OVERALL PREFERRED OPTION

7.1    Process Followed to Determine the Preferred Solution

The preferred option (Option 1) was recommended by the Women & Children‟s
Project Team.

From the work undertaken and the evaluation of the options, the conclusions on
each option are presented below.

      Do Nothing
Under this option paediatric services (A&E, outpatients, day case and inpatient
service) at Booth Hall would have to be accommodated elsewhere by another
organisation. Obstetric services, neonatal and special care services and
gynaecology services would remain in their existing accommodation on the North
Manchester General site and not co-located.

The Women & Children‟s Project Team therefore considers this option to be
unsuitable in achieving the objective of developing modern facilities for the
delivery of women and children‟s services at North Manchester General Hospital.
It is also considered that “doing nothing” will not enable the preferred model of
care to be implemented nor enable the reconfiguration of women and children‟s
services across PAHT in support of the delivery of effective and sustainable
services.

      Option 1(Preferred) – Combination of Refurbishment and New Build
This option fulfils the objective of providing modern facilities for the delivery of
women and children‟s services at North Manchester General Hospital as well as
enabling the reconfiguration of women and children‟s services across PAHT to
support the delivery of effective and sustainable services.

The Project Team considered this option offered the greatest operational benefits
and recognised that the modest premium to pay in capital and revenue costs was
justified in respect of the additional benefits that would accrue from the clinical
perspective and the overall estates development control plan.

      Option 2 – Combination of Refurbishment and New Build (Radical)
This option also fulfils the objective of providing modern facilities for the delivery
of women and children‟s services at North Manchester General hospital as well
enabling the reconfiguration of women and children‟s services across PAHT to
support the delivery of effective and sustainable services.

The Project Team considers this option offers less operational benefits than
Option 1. The Project Team also recognised that Option 2 did not support the
longer-term estates development control plan for the site by retaining old existing
wards and considered that risks to patients were increased under this option.


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7.2    Summary of Key Data

The benefits, financial and economic analysis is summarised below in Table 28.

                  Table 28 :    Summary of Benefits and Financial Appraisal

                         Assessment Factor                Value
                   Benefit Score                               810
                   Capital £m                                 32.0
                   Revenue Expenditure £k p.a.             36,017
                   Income £k p.a.                          35,138
                   Shortfall £k p.a.                           879


The Women & Children‟s Project Team strongly believes that Option 1 provides
the best solution for the following reasons:-

                      It succeeds in providing modern facilities for the delivery of
               women and children‟s services at North Manchester General
               Hospital and supports the clinical service model and care pathway.
                      It enables the reconfiguration of women and children‟s
               services across the Pennine footprint and helps support the
               delivery of effective and sustainable services.
                      The preferred solution is consistent with the original
               objectives of the scheme and will be easily adapted to meet any
               changing requirements in the longer term.
                      Option 1 helps supports the overall estates development
               control plan for the North Manchester site by moving services from
               old existing wards.
                      Option 2 has inherent clinical governance risks and does
               not conform with the overall estates strategy for the North
               Manchester site

The preferred option is also consistent with the other Trust strategic objectives,
involving consolidation of services, eliminating backlog maintenance and the
provision of the former Greater Manchester Strategic Health Authority‟s long-term
strategy for women and children‟s services.




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SECTION 8 :      RISK ASSESSMENT

8.1        Introduction
This chapter details the risk assessment and management and describes the
approach the Trust has taken to ensure that project risk is managed properly.

8.2        Approach
The Capital Investment Manual identifies two steps to be carried out in the
assessment of risk in an FBC.

The first step involves validation of the analysis undertaken in the OBC and
suggests further sensitivity analysis on the costs and benefits weights and
scores. The treatment of risk in the financial appraisal and sensitivity analysis of
the costs and benefits of the options is described in Section 6. The Trust
believes that the outcome of the risk analysis between the short listed options in
the OBC is still valid and does not propose any changes to the analysis.

The second step focuses specifically on the preferred option and quantifies the
risks to identify those of highest value so that the project risk management plan
can be focused on those risks with the highest likely impact.

In line with this, the Trust has undertaken a detailed financial assessment of the
risks associated with the preferred option. The methodology followed is shown in
Figure 1 below:




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                               Figure 1 – Risk Methodology




The process of risk analysis for the FBC is in four steps and is shown in Table 29
below.

                  Table 29 :     Four Step Process of Risk Analysis Undertaken
      Step                                  Description
      1       Risk identification - developing a risk register covering key risk
              areas and individual risks within these areas.
      2       Risk assessment - estimating the probability and timing of each
              risk occurring and the impact if it should occur.
      3       Risk quantification - putting a value to each of the risks, using the
              estimates of probability, impact and timing.
      4       Risk management - developing a plan to manage all the risks
              identified in the risk register for the preferred option, including
              responsible persons and monitoring mechanism.

8.3        Approach to Risk Assessment
Two risk analyses were undertaken: one covered design and construction risks
through a workshop facilitated by the Trust‟s Principal Supply Chain Partner
(PSCP). The second assessment covered operating risks through a workshop


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facilitated by Tribal Consulting and attended by managers and clinicians from the
Trust.

8.4          Risk Identification
Ten categories of risks to the Trust were identified and considered by the Trust:

         Design
         Construction and Development
         Availability
         Operating Cost
         Service and Organisational Risk
         Variability of Revenue
         Technology and Obsolescence
         Other Project Risks
The design, construction and development risks were covered in the workshop
facilitated by the PSCP: the balance of the risk categories were covered by the
workshop facilitated by Tribal Consulting.

The risks identified under each of these categories are provided in detail in
Appendix 11.

8.5          Risk Assessment and Quantification – Capital Risks
Details of the capital risks are shown in the Estates Annex to the FBC.

8.6          Risk Assessment and Quantification – Operational Risks
A risk register was presented to the participants for discussion and agreement for
analysis purposes. This was based on a standard register that has been adopted
for a number of similar schemes. It was agreed that certain risks were not
applicable to this scheme and therefore were not evaluated. For each applicable
risk the following factors have been identified to calculate the financial impact of
the risk:

         Probability of event occurring
         Basis for quantification - what area of cost will the risk impact upon if it
          occurs
         Likely financial impact that is if the risk occurs what % of the cost
          identified above will be borne under a minimum, likely and maximum
          scenario
         Years over which the risks would occur
         Allocation of the risk (between Trust and PSCP)
Where risks could not be quantified, they were individually considered and
assessed by the group in terms of impact and strategy for mitigation.


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The results from the workshop are detailed in Appendix 11 (the risk pack).

Based on the results of the workshop, the net present cost of the risk was
calculated over the life of the scheme. This was carried out using @Risk, an
Excel™ based Monte Carlo simulation package. This software runs hundreds of
iterations to generate a comprehensive profile of the distribution of possible
outcomes.

Traditionally, spreadsheets have allowed a single point estimate for each
variable, and a small number of what-if scenarios have been run to give an idea
of the range of uncertainty. @RISK uses simulation techniques to combine all the
uncertainties that have been identified, allowing cell values in an ordinary Excel
spreadsheet to be defined as various probability functions. This allows the
equivalent of thousands of what-if scenarios to be run simultaneously generating
results that show all possible outcomes.

The overall revenue-based risk profile is shown in Figure 2 below:

                                 Figure 2 – Distribution of Values for all Risks


                                                Distribution of NPV of total risk (£k)
                                X <=25188.54                                             X <=33984.66
                                     5%                                                      95%
                     1.6




                                                                Mean = 29797.42
                     1.4




                     1.2




                      1
  Values in 10^ -4




                     0.8




                     0.6




                     0.4




                     0.2




                      0
                           22            26                        30                         34        38

                                                           Values in Thousands




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This figure shows that the expected Net Present Cost (NPC) of the operational
risks is £29,797k. There is a 95% confidence that the value of the risk will be
above £25,189k. In addition, there is a 95% confidence that the value of the risk
will be below £33,985k.

This is divided into the following risk categories as shown in Table 30 below.

                  Table 30 :   Design, Construction and Revenue Risks

                Risk                                                        £000
                                                                        Separate
                Design Risks                                             Analysis
                                                                        Separate
                Construction & development risks                         Analysis
         1      Availability and performance risks                         4,988
         2      Operating risks                                           15,956
         3      Service and organisation risks                             5,881
         4      Variability of revenue risks                               2,171
         6      Technology & obsolescence risk                               792
         7      Other risks                                                    9
                Total                                                     29,797



The key individual risks in terms of value are shown in Table 31 below. The
seven risks shown out of twenty one quantified represent over 80% of the total
value of the risk.




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                             Table 31 :    Key Individual Risks in Terms of Value

   Risk                                                              % of total     Cumulative
                         Risk Description                  Mean
 Reference                                                             risk         percentage

              Capacity and care            models not
    3.2                                                     5,126             17            17
              implemented
              Service costs higher than budget –
    2.1b                                                    4,671             16            33
              later years
              Service costs higher than budget –
    2.1a                                                    4,658             16            49
              early years
    2.2       Legislative / regulatory change               2,772              9            58
    2.4       Incorrect estimated running costs             2,726              9            67
    1.2       Availability of facilities                    2,558              9            76
    1.4       Changes in service specification              1,403              4            80



It can be seen from the above analysis that certain risks have a potential to have
a major impact on the Trust. In particular if the capacity and care models are not
implemented and service costs are higher than budget feature strongly on the top
seven list and so become the main focus of the risk management strategy.

The details of the outputs of the model are shown in Appendix 11.

Sensitivity
The NPCs of the project risks are based on the expected value of the risks and
for the purposes of the appraisals, the mean value has been used.

Table 32 shows the range of values for each of the top seven risks, as output
from the @Risk model.




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                        Table 32 :      Range of Values for each of the top Seven Risks, as
                                            Output from the @Risk Model

                                                                       5th                      95th
   Risk
                              Risk Description                      percentile      Mean      percentile
 Reference
                                                                      value                     value

                Capacity and                 care    models   not
      3.2                                                                 3,477       5,126       6,735
                implemented
                Service costs higher than budget –
      2.1b                                                                3,380       4,671       5,936
                later years
                Service costs higher than budget –
      2.1a                                                                4,511       4,658       4,812
                early years
      2.2       Legislative / regulatory change                           1,935       2,772       3,582
      2.4       Incorrect estimated running costs                         1,825       2,726       3,649
      1.2       Availability of facilities                                     0      2,558       5,698
      1.4       Changes in service specification                            441       1,403       2,587



The range represents a 90% confidence interval, i.e. that from the results, there
is 90% certainly that quantified risk lies within these limits.

Examining the overall risk outputs, if the top key risks were to be considered on
the basis of the 95th percentile value rather than the mean, then the top three
risks identified still remain the highest, based on the upper limit however there is
little difference between the values of the 3rd and 5th highest risk by value.

By examining the ranges, it can be determined that the risks identified as the
most significant remain the most significant when comparing the overall range of
values for the risk.

8.7          Risk Management
The risks identified and assessed in the risk workshop form the basis of the risk
register to manage the impact of risk on the project.

The Trust has developed risk management strategies to minimise the Trust‟s
exposure to these and other risks identified in the risk assessment workshop.

These strategies, as part of the risk register, are detailed in full in Appendix 11
and summarised in Table 33 below for the key risks above. For each risk, the risk
owner is identified and the strategy for mitigation is provided.




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                                Table 33 :   Risk Register Strategies

  Risk                                                                    Risk
          Risk Description               Risk Mitigation Strategy
Reference                                                                Owner
                           Maintain      regular     contact     with Clinical
                           commissioners (including GPs) to ensure Director
           Capacity    and new models of care are being developed.
   3.2     care models not
           implemented     Hold monitoring meetings with stakeholders
                           to check on progress in relation to the
                           development at North Manchester
                          Ensure finance systems accurately reflect Director of
                          total cost of provision                      Finance
           Service  costs Maintain strict budgetary control
           higher    than Test effect of any changes in service
  2.1b
           budget – later standards on costs of provision
           years          Ensure any cost increase resulting from
                          service changes outside the control of the
                          Trust are raised with commissioners
           Service  costs As above – however ensure that agreed Director of
           higher    than service model as part of Making it Better is Finance
  2.1a
           budget – early affordable to the Trust
           years
                              Ensure the cost effects of any legislative / Director of
           Legislative      / regulatory change are covered by tariff      Finance
   2.2     regulatory
           change                                                          Director of
                                                                           Facilities
                              Maintain strict budgetary control over Director of
                              running costs                                Facilities
           Incorrect
   2.4     estimated           Ensure systems accurately reflect costs
           running costs       relating to the new unit
                               Ensure energy efficient building
                              Ensure adequate maintenance of building          Director of
                              throughout building life                         Facilities
           Availability    of
   1.2                        Ensure significant updates to building
           facilities
                              structure are implemented in accordance
                              with standard estates planning guidelines
                              Ensure flexibility in design to ensure ability   Director of
           Changes         in
                              to easily adapt to any changes in service        Facilities
   1.4     service
                              models
           specification




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The risk register will be reviewed regularly by the project management team, with
a view to managing out and mitigating as much of the risk as possible as the
project progresses.

8.8        Conclusion
This chapter has focused on the risks associated with the preferred option.

The risks associated with the project have been evaluated and quantified; these
have then been used as the basis for focusing the risk management strategy on
those key risks that will have the greatest impact on the project.

The risk register has then been developed, detailing the ownership of each risk
and the proposed risk strategies in place to mitigate or reduce the impact of the
particular risk.




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SECTION 9 :        TIMESCALE, PROCUREMENT AND & PROJECT
                   MANAGEMENT

9.1     Timetable

The timetable for the procurement and implementation of the scheme is set out
below in Table 34.

                   Table 34 :   Timetable for Procurement and Implementation
      Month/Year                                Milestone
Jan-April 2006          Public consultation period
December 2006           Confirmation of preferred option
January 2007            OBC submitted for approval in principle
May 2007                SHA Approval to OBC
July 2007               Detailed contract discussions – date for GMP
    to                  Detailed design
November 2007           Planning permission submitted
February 2008           Financial close with Principal Supply Chain Partner
February 2008           Trust Board and PCT Board Approval
March 2008              SHA Full Business Case approval
April 2008              Enabling Works Complete, Planning Approval Received
May 2008                Works commence
October 2009            Works Complete
November 2009           Scheme Commissioning
December 2010           Service commences




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9.2     Procurement

As the scheme is in excess of £20m a value for money assessment of the PFI
procurement route compared with the conventional procurement is mandatory.
The details of this assessment in both qualitative and quantitative terms are
shown below.

9.2.1 Qualitative Assessment

A qualitative assessment assessing the viability, desirability and achievability of
PFI against an alternative procurement route is shown below in Table 35.

                    Table 35 :   Qualitative Assessment
  Qualitative Assessment Criterion                                    Comments

Viability
1. Project Level Outputs
Is the project delivery team satisfied that a        No due to difficulties in dealing with FM
long term contract can be constructed for            services arising from the development
this project? Can the contractual outputs be         being an add-on to a large existing
framed so that they can be objectively               hospital.
measured?

Is the requirement deliverable as a service          Yes but difficulties remain in delivering a
and as a long term arrangement? Can the              contract within the timeframe.
contract describe the requirements in clear,
objective, output-based terms?

Can the quality of the service be objectively        )
and independently assessed?
                                                     )   Not really. Difficulties will arise as the
Is there a good fit between needs and                )   development is an add-on to a large
contractible outcomes?                               )   existing hospital. The clinical and service
                                                     )    links will make it extremely difficult to
Can the contract be drafted to avoid                 )   manage this separately.
perverse incentives and to deliver quality
services?                                            )
                                                     )
Does the project require significant levels
of investment in new capital assets?                 Yes approximately £25m-£30m.

Are there fundamental issues relating to
staff transfer? Would any transfer be free           There would be a need to carve out small
from causing any loss of core skills that            part of FM staff.
have strategic and/or long term importance
to the procuring authority?




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Is service certification likely to be                  There are issues. Measurable criteria will
straightforward in terms of agreeing                   be agreed but this will be the same for
measurable criteria and satisfying the                 whatever procurement route is chosen.
interest of stakeholders?

Does the project have clear boundaries
(especially with respect to areas of                   Yes.
procuring authority control)? If there are
interfaces with other projects are they clear          Yes.
and manageable?

Can the service be provided without the                No. The service is too closely linked to
essential   involvement     of    authority            other Trust services. The proposed scheme
personnel?    To what extent does any                  is too small to ensure benefits of scale for
involvement negate the risk transfer that is           FM services.
needed for VfM?

Is the contractor able or likely to have
control/ownership    of   the  intellectual
property rights associated with the                    No.
performance/design/development of the
assets for the new service?

Will existing or planned elements within the           Yes. This service is on the critical path to
scope of the project – or interfacing vitally          enable the closure of Booth Hall Children‟s
with it – be complete before the start of the          Hospital
new service?

2. Operational Flexibility
Is there a practical balance between the
degree of operational flexibility that is
desired and long term contracting based on             Yes.
up-front capital investment?

What is the likelihood of large contract               Likely due to proposed changes in service
variations being necessary during the life of          delivery, demographics and technological
the contract?                                          change.

Can the service be implemented without                 Yes.
constraining the delivery of future
operational objectives?

Is there confidence that operational                   Not great confidence.
flexibility is likely to be maintained over the
lifetime of the contract, at an acceptable
cost?

3.   Equity,           Efficiency         and
Accountability
Are there public equity, efficiency or                 Yes. Economies of scale of bringing


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accountability reasons for providing the              together women and children‟s services
service directly, rather than through a PFI           onto one site will help the Trust deliver a
contract?                                             balanced financial position.

Does the scope of the service lend itself to
providing the contractor with “end-to-end”            No. The service is too closely linked to
control   of   the   relevant    functional           other Trust services.
processes? Does the service have clear
boundaries?

Are there regulatory or legal restrictions
that require services to be provided                  No.
directly?

Is the private sector able to exploit
economies of scale through the provision,             No.
operation or maintenance of other similar
services    to     other    customers   (not
necessarily utilising the same assets)?

Does the private sector have greater
experience/expertise than the procuring               No this is fundamentally core services.
authority in the delivery of this service? Are
the services non-core to the procuring
authority?

Is a PFI procurement for this project likely          No. Too small a scheme to deliver value for
to deliver improved value for money to the            money.
health service as a whole, considering its
impact on other projects?

4. Overall Viability
Overall, in considering with PFI, is the Trust
satisfied that a suitable long term contract          Not within the timescale required.
can be constructed, and that strategic and
regulatory issues can be overcome?

Desirability
1. Risk Management
Bearing in mind the relevant risks that need          Private sector is experienced in this area
to be managed for the project, what is the            so should be able to price and manage the
ability of the private sector to price and            risks involved.
manage these risks?

Can the payment mechanism and contract                Yes.
terms incentivise good risk management?

2. Innovation
Is there scope for innovation in either the           Not particularly.
design of the solution or in the provision of




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the services?
                                                     No.
Does some degree of flexibility remain in
the nature of the technical solution/service
and/or the scope of the project?

Does a preliminary assessment indicate               No.
that there is likely to be scope for
innovation?

Could the private sector improve the level           No the specialist nature of a children‟s
of utilisation of the assets underpinning the        ward and dedicated children‟s theatre plus
project (e.g. through selling, licensing,            delivery suites would negate improving the
commercially developing for third party              utilisation.
usage etc)?

3. Contract Duration & Residual
Value
How far into the future can service demand
be reasonably predicted? What is the                 Demand side may fluctuate.
expected life of the assets? What are the            Building life - 60 years.
disadvantages of a long contract length?

Are there constraints on the status of the           Yes. They must remain in the ownership of
assets after the contract end?                       the Trust.

Given the possibility of changes to the
requirement, the assets and the operating            Very unlikely as volume of change
environment, is it possible to sustain value         envisaged makes it unsuitable fro FM.
for money over the life of the contract
utilising as appropriate, mechanisms such
as benchmarking and technology re-fresh?

4. Incentives and Monitoring
Can the outcomes or outputs of the
investment programme be described in
contractual terms, which would be                    Yes.
unambiguous and measurable?

Can    the     service    be     assessed
                                                     Yes.
independently against an agreed standard?

Would incentives on service levels be
                                                     Probably not.
enhanced through a PFI payment
mechanism?


5. Lifecycle Costs
Is it possible to integrate the design, build        Possible.
and operation of the project?




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Are there significant ongoing operating               Yes there are significant recurrent revenue
costs and maintenance requirement? Are                costs that will be sensitive to the type of
these likely to be sensitive to the type of           construction used.
construction?


6. Overall Desirability
Overall, is the Trust satisfied that PFI would        No the disadvantages would outweigh the
bring sufficient benefits that would                  advantages especially on compromising
outweigh the expected higher cost of                  the required timeframe for the project.
capital and other disadvantages?




Achievability
1. Market Interest
Is there evidence that the private sector is          Yes but not within the timeframe required.
capable of delivering the required
outcome?

Does a significant market with sufficient             No not for size of the development being
capacity for these services exist in the              considered.
private sector?

Is there likely to be sufficient market
appetite for the project?                             No.

Has this been tested robustly? Is there any           Yes. Evidence suggests that the area is too
evidence of lack of market competition for            small to attract competition.
similar projects?

Have similar projects been tendered to                Similar projects have been tendered. The
market?     Has the procuring authority‟s             Trust is not committed to a PFI solution.
commitment to a PFI solution for this type
of project been demonstrated?

Does the nature of the project suggest it             No. Evidence from         other   schemes
will be seen by the market as a profitable            suggests otherwise.
venture?

Are the risks associated with design,
development         and   implementation              Yes probably.
manageable bearing in mind the likely
solutions to the project?




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2. Other Issues
Is the procurement feasible within the                 No not feasible. The June 2009 timescale
required timescale? Is there sufficient time           for procuring this facility through PFI is not
for: resolution of key Authority issues;               achievable.
production/approval     of    procurement
documentation; staged down-selection and
evaluation    of    bidders,   negotiation,
approvals and due diligence?

Is the overall value of the project significant
and proportionate to justify the transaction           Borderline.
costs?

Does the nature of the deal and/or the
strategic importance of the work and/or the            No.
prospect for further business suggest that it
will be seen by the market as a potentially
profitable venture?

Does the Authority have the skills and
resources to define, deliver and support the           Yes.
service throughout the procurement and
the subsequent delivery period?

3. Overall Achievability
Overall, is the Trust satisfied that a PFI
procurement programme is achievable,                   No the Trust is not satisfied that a PFI
given client side capability and the                   procured facility is achievable within the
attractiveness of the proposals to the                 timescales required.
market?




A separate assessment concerning the inclusion of soft services has also been
undertaken and is shown below in Table 36.

                     Table 36 :    Qualitative Assessment – Inclusion of Soft Services
  Qualitative Assessment Criterion                                     Comments

1. Design Integration
How will the soft FM providers be bought               Existing FM provider‟s views will be sought
into the design process? How early will this           during the design process. VfM solutions


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happen? What mechanisms can be used to               would   be     incorporated      whichever
ensure this?                                         procurement route is used.

Will different PFI structures affect the
incentives for the inclusion of important
providers in the design stage in different
ways?



To what extent does design integration
impact on VfM? If considerable, then is it
possible to ensure that correct incentives
are included in the project? (e.g. if this is
fundamental to delivering VfM then can it
be included in the tender assessment
criteria?).




2. Whole Life Costs
What and where is the scope for whole life           Part and parcel of everything that the Trust
savings?   How      material   are    the            is now doing.
maintenance costs?

Do these have any environmental/other                The scheme would contribute a relatively
externalities (e.g. more energy efficient            small element of the Trust‟s total stock and
buildings)?                                          therefore the perceived benefits would be
                                                     minimal.
Do the proposed risk transfers incentivise
the correct behaviour by the bidders?



3. Lower Interface Issues and Single
Point of Contact
Which mechanisms will be used to ensure              Via post project evaluation and benefits
that the benefits will be delivered? Are they        realisation assessment.
achievable and measurable (e.g. interface
key performance indicators (KPIs))?

What is the consequence if this does not
happen?

Would a single point of contact provide


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VfM? What form would be most appropriate
for the project (e.g. general manager or
helpdesk)? Is this feasible?

Is there sufficient contract management
expertise on both sides?



4.  Effective          Management           of
Resources
Will inclusion under PFI allow providers               Bargaining power already enacted via
opportunity to exploit bargaining power in             ProCure 21 arrangements.
the supply chain?

Will the soft service provider be able to cost         FM providers are benchmarked and market
inputs more cheaply due to bulk buying to              tested as a routine formality. The dates for
cover all other projects they are working              re-tender are as follows:-
on, and how much is this saving valued at?
                                                       Domestics - April 2011 but with an option
Is there potential for shared overhead                 to extend to March 2013
costs, provision of spares where combined
holding is reduced and distribution costs              Security – June 2010
shared, or bulk buying savings? How big is
the potential?

Is it possible to incentivise desired
behaviour in PFI context e.g. can
management KPIs be used?

Are differences in training incentives likely
and how will affect workforce incentives
(e.g. private sector likely to offer accredited
training scheme)?




5. Interim Resources
What are the benefits of including interim             The scheme is too small to include interim
services? When will interim services be                services within the bid criteria.
considered? Will they be part of the bid
criteria?

Are there any issues which make providing
interim services harder within the PFI
contract (e.g. will the authority be able to
account for transitional costs which are not
covered in existing service budget such as
one-off costs necessary to implement




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interim services)?

Has proper account been taken of
differences in quality/ quantity provision for
cost comparisons?




Which services are most important to the
operation of the asset? What are the risks
to the delivery of soft FM in the steady
state stage if interim services are not
provided?


       Procuring authorities must weigh
        the balance of additional costs
        against benefits provided and not
        use interim services provision as a
        way to manage short-term
        affordability issues. Rather than
        assuming that the existing service
        budget is sufficient for interim
        services, an assessment is needed
        of the difference in service
        standards and quality covered by
        existing and interim soft FM.
       Interim services will add value
        where they have been specified
        early and budgeted for correctly.
        Analysis of the benefits and risks
        must be made in the context of a
        budget which accurately reflects
        the difference between existing
        services and interim service
        provision.

6. Flexibility Requirements
Do the cost estimations take account of               Break cycles at every 10 years so scheme
flexibility issues which may arise for                can be reviewed.
particular services in the future, and what
level of contingencies will be included for
these?

Is it possible to include specified re-
assessment or break periods in the
contract to take account of changes in
service needs?




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7. Financial Incentivisation
Will it be possible to test the suitability of
the performance regime (e.g. re-checking              Yes
minimum thresholds after a certain period,
and/or the suitability of the monitoring
system)?




Is there experience with similar live projects        No
to compare that performance mechanisms
are properly calibrated and that monitoring
(e.g. self-monitoring versus user feedback)
drives the right incentives?

Does benchmarking and market testing                  Yes
provide a sound way of managing the risks
associated with pricing and ensuring
continuing quality of soft services?




8. Overall
Do the benefits of including soft services in         No.
PFI outweigh any additional costs and
constraints from inclusion?


9.2.2 Quantitative Assessment

The Treasury‟s new Value for Money (VfM) model has not been completed.
Advice has been received that this would only be completed at OBC stage in
order to prove that the Private Finance Initiative (PFI) method of procurement
would be financially viable should the Trust want to pursue it as a preferred
method of funding.      Acknowledging the unsupportive evidence from the
qualitative assessment in Tables 35 and 36 above the Trust‟s chosen
procurement methodology is to use its own capital to fund this development.

9.2.3 Procurement Options

The Trust has explored a number of potential procurement options for the
development ranging from traditional tender to ProCure 21.




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As time is of the essence the Trust decided that 3 - 4 months of normal OJEC
tendering time would be saved by progressing the scheme with its appointed
Principal Supply Chain Partner, Norwest Holst. The company have been
responsible for constructing the central pathology laboratory on the Oldham site.
The contractor has exceeded all expectations and completed all the works six
weeks ahead of programme. A good working relationship now exists between
the contractor‟s team and senior Trust staff.

9.3       Project Management Arrangements

9.3.1 Purpose

The purpose of project management is to ensure effective control of the timing,
cost and quality of the project as defined in the Capital Investment Manual and
delivery of the investment objectives.

The Chief Executive of the Trust accepts full responsibility and ownership for the
successful delivery of the project. This will be achieved through the following
management control strategy.

9.3.2 Project Management Control Strategy

The Trust Board has recognised the importance of this development to the Trust.
The project owner is the Chief Executive of the Pennine Acute Hospitals NHS
Trust who has assumed responsibility for the delivery of the project on time and
within budget allocation. A copy of the project structure is included at Appendix
12.

The Trust ensured that the development of this business case was supported by
a robust management structure. This was designed to secure wide clinical, user
and institutional involvement to shape and detail the integration of women and
children‟s services as described in earlier sections. To this end the Trust:

         Established a Women and Children‟s Project Board

         Appointed the Chief Executive of the former North Manchester Primary
          Care Trust as the Project Board lead until business case approval to
          proceed was given

The Project Board includes a number of Trust Board members together with
senior clinical representation.

Following approval to the Full Business Case the Trust‟s Director of Facilities will
take on the role of Project Director and will co-ordinate the delivery of the project
with the support of the Project Team, the chosen Contractor and the Design
Team.




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The Project Director will:

      Establish clear responsibilities and levels of authority of those involved in
       the project.

      Establish appropriate reporting mechanisms to monitor progress of the
       project that link in to the Women and Children‟s Project Board and the
       Trust Board

      Review the various sub groups for the Project and establish management
       controls for the construction period

      The principle roles of the Project Director will be to:

      Ensure that open communication mechanisms exist within the project
       between the project and external organisations, and between the project
       and the rest of the Trust

      Develop the business case and budget for the project

      Produce the project brief and Project Execution Plan

      Deliver the investment objectives as defined in the business case

      Ensure that adequate procedures are in place to monitor and control cost,
       time and quality

      Ensure continuity for service during construction

      Agree a strategy for commissioning to ensure continuity of patient care

Recognising the newly found status of NHS Project Directors within a ProCure 21
framework it is acknowledged that there is an expectation that Project Directors
will also:

      Be solution-focused

      Deliver capital developments successfully

      Directly improve the quality of patient environments

      Engage best value solutions that take account of whole life cycle
       costs rather than the lowest price

      Liaise with key stakeholders

      Manage risks


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      Model best practice as „Best Client‟

      Negotiate and manage contracts

      Promote continuous improvement

      Set clear expectations

      Set time aside for relationship building with partners

      Share technology, processes and systems with partners

      Simplify the capital development process for users/clinicians

      Structure relationships for reward and risk share linked to performance
       through partnering arrangements

The Project Team will meet formally on a monthly basis with site visits when
appropriate. In addition the team will meet on an ad-hoc basis to resolve any
unexpected issues. The Project Team will include the Project Director, the
Women & Children‟s Clinical Lead, the Divisional Director of Women & Children‟s
Services, the Women & Children‟s Services Manager and the Division‟s
Divisional Accountant.

The Design Team will be made up of an Architect, a Quantity Surveyor, an M & E
Engineer, a Structural Engineer, a Constructional Design Manager, internal
project manager and a Project Director. The project plan produced by the Project
Director includes adequate provision for the appointment of the external
professionals.

The Trust already has well-established procedures to ensure that capital
construction projects are well managed. The Trust Board must approve all
capital expenditure and receive progress reports on a monthly basis.

The internal project manager will liaise directly with the appointed professionals
and has discretion in respect of any change to the project specification. The final
specification itself will be the product of detailed discussion with the intended
users of the development and will be comprehensively documented. The Women
& Children‟s Project Team will review the specification as drawn up by the Project
Director and agree the details.

The Project Manager has full responsibility for the control and management of all
works. The particular responsibilities to be undertaken are as follows:

      To receive the master programme of contract work from the ProCure 21
       partner, to be used for subsequent monitoring.




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         To monitor contract progress against the Project Progress Report on a
          monthly basis and report to the Project Director and the Project Board.

         Prompt notification to the Project Director of any potential delays in
          construction, and taking appropriate corrective action.

         Create a structured, positive and communicative environment within which
          the project participants will be encouraged to operate.

         Establish procedures for implementing the Project Director‟s instructions
          (including changes) throughout the scheme.

         Anticipate problems both on time and cost, prepare solutions and
          recommend to the Project Director a corrective course of action.

         Establish project control and monitoring systems.

9.4       Stakeholder Involvement

The Making it Better public consultation primarily concerns itself with stakeholder
involvement. The comments and views received from the general public as well
as other interested stakeholders will be taken into account by the Joint
Committee of Primary Care Trusts prior to making a final decision on which
option is to be approved.

The Trust in conjunction with Manchester and Bury PCTs has also involved a
wide range of stakeholders from the outset in the proposed development. A
number of groups (internal and external stakeholders) have been established to
look at proposed models of care and oversee the development of the scheme
and the business case itself. The NHS North West has also been provided with
update reports on the progress of the scheme together with the associated key
risks.




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SECTION 10 : POST-PROJECT EVALUATION

10.1   Introduction

Post-Project Evaluation (PPE) is a requirement on all Trusts who are undertaking
a project of this scope and scale. This section sets out the plans that the Trust
has put in place to undertake a thorough and robust post-project evaluation. It
examines:

      The framework for post-project evaluation;

      Evaluation process.

This section also sets out how these arrangements will be managed, how
information will be disseminated and in what timescale.

10.2   Framework for Post-Project Evaluation

The Trust will ensure that a thorough post-project evaluation is undertaken at key
stages in the process to ensure that positive lessons can be learnt from the
project. These will be of benefit to:

      The Trust – in using this knowledge for future capital schemes.

      Other key local stakeholders – to inform their approaches to future
       projects.

      The NHS more widely – to test whether the policies and procedures which
       have been used in this procurement effectively.

PPE also sets in place a framework within which the benefits realisation plan can
be tested to identify which of the anticipated benefits have been achieved– with
the reasons made clear. The Trust will comply with the newly published NHS
guidance on PPE during the various evaluation stages. The plan for each of
these stages is set out below.

10.3   Evaluation Process

The evaluation will examine the following elements, where applicable at each
stage:

      The effectiveness of the project management of the scheme – viewed
       internally and externally.

      The quality of the documentation prepared by the Trust for the contactors
       and suppliers.

      Communications and involvement during procurement.

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       The effectiveness of advisers utilised on the scheme.

       The efficacy of NHS guidance in delivery the scheme.

       Perceptions of advice, guidance and support from the NHS North West
        and NHS Estates in progressing the scheme.

An outline of the method and plan for undertaking this evaluation is set out in
Table 37 below:

                              Table 37 :    Methodology for Evaluating the Project
           Attribute to be Evaluated                     Method            Evaluators

Effectiveness of the Trust Project Team
Robustness of the team                              Structured         Trust Board
The right skills were in place                      questionnaire      External advisers
The team were properly resourced                    Face to face       Main contractor
                                                    interviews
Outputs were delivered in a timely way                                 NHS North West
Outputs were of a high quality                                         NHS Estates
Communication was satisfactory
Change was well managed
Reporting on progress was satisfactory
The internal Trust organisation was supportive of
the Team
Commercial confidentiality was respected
Advisers were well managed
Appropriate feedback was given
Sufficient contact was provided to users during
the process
Overall impressions of the project delivery
Aspects which were particularly well managed
Aspects where there was room for improvement
Effectiveness of the Contractor Project Team
Same attributes as for Trust Project Team           Structured         Trust Board
                                                    questionnaire      Project Team
                                                    Face to face       External advisers
                                                    interviews
                                                                       NHS Estates




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                                           Children’s  Services   at   North
                                           Manchester General Hospital



          Attribute to be Evaluated                 Method         Evaluators

Effectiveness of Joint Working Arrangements
Structures put in place worked satisfactorily   Structured      Trust Board
Communications between parties were effective   questionnaire   Project Team
Effectiveness of problem solving                Face to face    External advisers
                                                interviews
Evidence of partnership working                                 NHS Estates
                                                                Main contractor
                                                                Project Team
Project Documentation
Content                                         Structured      Trust Board
Presentation and style                          questionnaire   External advisers
Substance                                                       Main contractor
Clarity                                                         NHS Estates
Timeliness of document issue
Overall usefulness
Structure
Aspect which were exemplars
Aspects where there was room for improvement
Communications and involvement during
procurement
Internal consultation well managed
External consultation well managed
Timeliness of communications
Effectiveness of involvement sought
Aspects which were undertaken well
Aspects where there was room for improvement
Effectiveness of Advisers
Quality of advice                               Structured      Trust Board
Timeliness of advice                            questionnaire   Project Team
Value for Money
Problem solving
Accessibility
Overall contribution
Areas of exemplary performance
Areas for improvement




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                                              Children’s  Services   at   North
                                              Manchester General Hospital



           Attribute to be Evaluated                    Method          Evaluators

Effectiveness of NHS Guidance
Comprehensive                                       Structured       Project Team
Comprehensive                                       questionnaire    External advisers
User friendly
Addressed key issues well
Areas which are exemplary
Areas where there is room for improvement


Communications and Involvement
Internal consultation well managed                  Structured       Trust Board
External consultation well managed                  questionnaire    Main contractor
Timeliness of communications
Effectiveness of involvement sought
Effective liaison with local people and residents
Aspects which were undertaken well
Aspects where there was room for improvement
Support from NHS North West & NHS Estates
Responsive                                          Structured       Project Team
Timely                                              questionnaire    External Advisers
Supportive                                                           Main contractor
Pro-active
Facilitative


Assessment of Overall Success Factors
Delivery on time                                    Structured       Trust Board
Delivery to cost                                    questionnaires   Trust Project
Delivery to high quality                                             Team Steering
                                                                     Group
Delivery of non-financial benefits
                                                                     Contractor Project
Delivery of financial benefits
                                                                     Team
                                                                     Trust advisers




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                                        Children’s  Services   at   North
                                        Manchester General Hospital



10.4   Conclusions

The Trust has identified a robust plan for undertaking PPE in line with current
NHS guidance, and this is fully embedded in the project management
arrangements of the project. Formal post project evaluation reports will be
compiled, and formally reported to the Board to ensure compliance to stated
objectives. Any material deviation will be identified and if appropriate, targets
adjusted for unforeseen changes in circumstances. The achievement of key
milestones will be monitored using commercially available project management
software.




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                                       Children’s  Services   at   North
                                       Manchester General Hospital



SECTION 11 : CONCLUSION

This business case sets out the case for change and the examination of a
feasible estates option to deliver the preferred service configuration options
described in Making it Better, Making it Real and Healthy Futures.




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                     Children’s  Services   at   North
                     Manchester General Hospital




APPENDIX 1 :   PCT HEALTH PROFILES
                     Development    of    Women      &
                     Children’s  Services   at   North
                     Manchester General Hospital




APPENDIX 2 :   HEALTH IMPACT AND RACE IMPACT
               ASSESSMENT
                      Development    of    Women      &
                      Children’s  Services   at   North
                      Manchester General Hospital




APPENDIX 3 :   TRANSPORT AND ACCESSIBILITY
               ANALYSIS, CORPORATE
               CITIZENSHIP AND SUSTAINABILITY
                     Development    of    Women      &
                     Children’s  Services   at   North
                     Manchester General Hospital




APPENDIX 4 :   MODEL OF CARE - CHILDREN
               YOUNG PEOPLE’S AND FAMILIES
               NETWORK
                     Development    of    Women      &
                     Children’s  Services   at   North
                     Manchester General Hospital




APPENDIX 5 :   KEY PERFOMANCE INDICATORS
Development    of    Women      &
Children’s  Services   at   North
Manchester General Hospital
                      Development    of    Women      &
                      Children’s  Services   at   North
                      Manchester General Hospital




APPENDIX 6 :   ACTIVITY, INCOME AND CAPACITY
               ASSUMPTIONS
                 Development    of    Women      &
                 Children’s  Services   at   North
                 Manchester General Hospital




APPENDIX 7 :   WORKFORCE PLAN
                         Development    of    Women      &
                         Children’s  Services   at   North
                         Manchester General Hospital




APPENDIX 8 :   BENEFITS APPRAISAL AND BENEFITS
                         REALISATION PLAN
                        Development    of    Women      &
                        Children’s  Services   at   North
                        Manchester General Hospital




APPENDIX 9 :   CAPITAL AND REVENUE COST
               ASSUMPTIONS




                    2
                         Development    of    Women      &
                         Children’s  Services   at   North
                         Manchester General Hospital




APPENDIX 10 :   NET PRESENT COST
                CALCULATIONS AND VALUE FOR
                MONEY MODEL RESULTS




                     3
                    Development    of    Women      &
                    Children’s  Services   at   North
                    Manchester General Hospital




APPENDIX 11 :       RISK ASSESSMENT




                4
                         Development    of    Women      &
                         Children’s  Services   at   North
                         Manchester General Hospital




APPENDIX 12 :   PROJECT STRUCTURE




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    Development    of    Women      &
    Children’s  Services   at   North
    Manchester General Hospital




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