Outline Business Case

for
Berwick Infirmary Redevelopment
4 June 2014

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 OUTLINE BUSINESS CASE – BERWICK INFIRMARY

CONTENTS PAGE

1. Executive summary ............................................................................................. 3

1.1 Outline business case .......................................................................................... 3
1.2 Aim of development ............................................................................................. 3
1.3 Current service ..................................................................................................... 3
1.4 Current estate ...................................................................................................... 4
1.5 Future services .................................................................................................... 4
1.6 Objectives ............................................................................................................ 5
1.7 Preferred option ................................................................................................... 6

2. Introduction .......................................................................................................... 6

3. Strategic context .................................................................................................. 6

3.1 Current health care services ................................................................................ 6
3.2 Performance of Berwick Infirmary ........................................................................ 8
3.3 Current estate ..................................................................................................... 8
3.4 Accessibility ....................................................................................................... 10

4. Drivers of change ............................................................................................... 11

4.1 Factors affecting the provision of healthcare services ........................................ 11

4.2 Factors affecting the provision of services at Berwick Infirmary .......................... 13

5. Demonstrating the case for change.................................................................. 15

5.1 Objectives for the new development .................................................................. 15

5.2 Constraints ......................................................................................................... 15

6. Preferred option ................................................................................................ 16

6.1 Background ........................................................................................................ 16

6.2 Preferred option ................................................................................................. 16
6.3 Capital budget .................................................................................................... 17
6.4 Programme ........................................................................................................ 17
6.5 Risk management .............................................................................................. 18
6.6 Procurement ...................................................................................................... 18
6.7 Project management arrangements ................................................................... 18
6.8 Affordability ........................................................................................................ 19

APPENDICES

Appendix 1 Clinical content 20

Appendix 2 Initial site feasibility study 22

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1. Executive summary

1.1 Outline business case

This report presents the outline business case for the entire redevelopment of Berwick Infirmary
and sets out the case for the provision of 21st century, local healthcare facilities and services.

1.2 Aim of development

Berwick is the most isolated community hospital within Northumbria Healthcare NHS
Foundation Trust, and the population has the furthest to travel for acute general hospital
healthcare services.

The Trust has undertaken extensive public engagement over recent years to review the scope
and scale of healthcare service provision. The proposed redevelopment project reflects the way
NHS care is developing nationally, with the emphasis on:

• Strengthening and building upon an integrated partnership with primary and intermediate
care, secondary care and social services to enable high quality services to be provided
locally
• Maximising the availability of services closer to patients' homes
• Strengthening the service reputation in the context of choice
• Delivering locally based assessment services for patients who may require admission,
relieving pressure on general hospital sites and, where possible, reducing waiting times
overall
• Ensuring the right care is provided in the right place and the right setting.

The proposal forms part of the Trust's longstanding commitment to improve the current site and
has featured prominently in the "Building a Caring Future" programme of major investment for
the regeneration of community hospitals. National guidance and local feedback both reinforce
the need to strengthen and build community based infrastructure, and specifically community
hospitals. This development will be a focus for integrated health and social care which will be
patient led, supported by the local community and which will provide high quality, safe and
effective care.

1.3 Current service

At present Berwick Infirmary provides a service for the Borough population of 25 800 in an area
of 972km² including Berwick, Wooler and North Belford. The population density is 27 people per
km² with half the population living in the town.

Whilst it is clear the community would prefer for a much greater range of inpatient services to be
provided at the Infirmary, there is an increased understanding and appreciation of the advances
in modern medicine and healthcare technology changes which have moved towards more
centralisation of services across the NHS in the best interests of patient safety. However, there
is understandable and significant pressure from the local community to provide ambulatory
services within the Town, where ever an appropriate clinical mass, or volume can be achieved
from a safety perspective. There is increased local awareness and appreciation of the need for
adequate volume to ensure that services are safe and effective.

The broad scope of current services at Berwick Infirmary includes:

• Inpatient services for elderly medicine, stroke and orthopaedic rehabilitation and palliative
care
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• Emergency care focussing on minor injuries and ailments, local assessment of long term
conditions (LTC) - i.e. urgent treatment for patients other than the most seriously ill (for all
non-999 cases).

• Elective care – outpatient department, diagnostics, pre-assessment and day surgical

procedures

• Chronic disease management and intermediate care through clinics and in the day hospital,
nurse-led chemotherapy service, 'living well' secondary prevention and rehabilitation.

• Midwifery led maternity service for low risk deliveries which is primarily community based but
with clinic facilities on the hospital site and a delivery suite for mums who to choose to
deliver in hospital.

• Diagnostics, including X-ray, mobile CT and MRI services provided locally.

For 2012 – 2013 the hospital activity comprised of:

• 402 FCEs* for adult inpatients

• 77 FCEs* for maternity
• 10,727 attendances in outpatients
• 11,224 Minor Injuries Unit attendances
• 970 FCEs* day cases
• 1833 attendances at the day hospital

*FCE = finished consultant episodes - this is the total amount of time a patient spends under the
care of an individual consultant.

1.4 Current estate

The need for the redevelopment is based on the limitations and age of the current estate and
buildings. The main hospital was built in 1840 with 18 beds then expanded in 1920 with a
further 14 beds. It remained in that configuration during the war with the last major
redevelopment being over 20 years ago which included the redevelopment of emergency care
services and the building of the maternity unit.

In assessing the viability of re-use and refurbishment of the existing fabric this report
concentrates on the fabric dating from 1840. The main considerations are the unsuitability of
much of the estate for modern efficient healthcare services which do not maximise privacy and
dignity for patients, the poor physical condition of the estate and the constraints of expansion
within the existing Infirmary. It is essential to ensure there is compliance with legislation by
incorporating and improving disabled access.

The future vision for Berwick is to provide 21st century healthcare services in an environment
that will maximise patient safety and clinical effectiveness whilst providing pleasant surrounding
for patients and their visitors as well as staff.

1.5 Future services

The clinical content of the new hospital will maintain all existing services with development of
future healthcare services based on the following key components:

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 • ‘Ambulatory care' - a general term used to describe models of care that build on existing
primary and community services, such as walk-in-centres, advanced access surgeries
and community hospitals

• Increased range of locally based outpatient and ambulatory care services with remote
support for specialist services via telemedicine and picture archiving and
communications systems (PACS) to enable patients to be reviewed locally

• Consultation, investigation and diagnosis such as mobile CT and MRI services provided
locally where volume permits

• Development and expansion of outpatient services in ophthalmology, Parkinson’s

disease, urology, pain clinics, fracture and chest clinics, as well as specialist nurse led
clinics

• Expansion in elective day case surgical procedures in ophthalmology including cataract

surgery and endoscopy

• Development of 'polyclinics' and 'one stop' clinics to minimise the need for additional
visits for patients and support development of ambulatory care

• Local emergency care in which patients receive rapid assessment in the Minor Injuries
Unit with doctors from the nearest larger acute hospital site advising remotely via a
telemedicine link. Based on this assessment patients requiring more intensive acute
care would be transferred to the larger hospital for direct admission to wards, avoiding
the need to wait in A&E upon arrival

• Development of nursing workforce with more training for staff as emergency nurse
practitioners, generic nurse practitioners and care facilitators. Improve patient pathways,
links with other providers and nurse to nurse referrals for palliative care patients

• Explore opportunities for intermediate care and integrated working with community
matrons for 'nurse-led assessment beds'

• It is hoped that local GPs will consider the option of taking some accommodation on the
new hospital site. This will open up some exciting opportunities for integrating further
GPs, community teams working into the practices and the clinical teams within Berwick
Infirmary.

1.6 Objectives

The primary objective is to deliver safe, high quality healthcare services for patients locally:

• responding to patients' needs whilst maintaining and improving quality of care

• providing a modern, purpose-built facility to enhance privacy, dignity and patient experience
• providing a flexible working environment from an estates, facilities and service perspective
• allowing the development of specialist services locally where volume permits from a patient
safety point of view
• providing community healthcare facilities which are accessible to all, with improved disability
access
• helping to speed up access to services and make best use of nurses skills
• developing a wider range of health and social care services in community settings

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1.7 Preferred option

The Trust has identified that its preferred option is a complete redevelopment of the Infirmary on
the existing site. Maintaining local services during the construction period will be challenging but
is possible if a multi phased construction approach is put in place. A capital budget of £25
million has been secured for this purpose.

There is a local revenue impact of the order of £1.025 million per annum which can be managed
within overall Trust budgets.

2. Introduction

The original hospital was constructed in the 1800s of stone and tiled roofs. This original
development consisted of the bell tower and two modest wings. Further development has taken
place during the 50s, 60s, 70s and 80s in a piecemeal and incremental way with a variety of
different forms and architecture being adopted.

The bell tower façade faced directly onto the town's scheduled and listed Elizabethan defences.
Whilst the hospital buildings are not listed, the bell tower façade seems to be regarded as
making a significant contribution to the fabric of the local conservation area.

Berwick is the most northern community hospital in the Trust and being over 50 miles away from
the nearest general hospital, isolation is a consideration. Berwick borough currently serves a
population of 25,800 and regionally the population for Northumberland is 309,200.

3. Strategic context

Nationally, community hospitals are recognised as being a focus for patient-led integrated
health and social care services, supported by the local community and providing safe and
effective care. The Trust's 'Building a Caring Future' programme envisages developing
community hospitals as a key component of our levels of care using important local resources
with the following key objectives:

• improving local clinical quality and enhancing patient experience and satisfaction
• reducing unnecessary hospital admissions, length of stay, inappropriate transfers to
other hospitals and potential of hospital acquired infections. This can be achieved by use
of advanced technology of telemedicine, PACS and near patient testing
• ensuring one-stop patient clinics are available to help avoid unnecessary return visits or
attendance in emergency care, reduce waiting times and missed appointments in
outpatients and day surgery
• reducing unnecessary or repeated diagnostics
• improving staff involvement, training and morale
• collaborative working with all health and social care partner agencies
• maintaining cost effective, high quality, safe and efficient services

3.1 Current health care services

At present, Berwick Infirmary provides the following range of services:

• Inpatient services for elderly medicine, stroke and orthopaedic rehabilitation and
palliative care

• Urgent care focussed on minor injuries and assessment

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• Diagnostics including X-Ray, ultrasound, barium and mobile scanners

• Physiotherapy, occupational therapy, speech therapy, podiatry and intermediate care

• Midwifery led maternity unit

• Pre-assessment and day surgical procedures

• Nurse-led chemotherapy service

• Extensive outpatient clinics and day hospital services as follows:

Outpatient services
o Audiology
o Bariatric
o Breast surgery
o Cardiology
o Colorectal surgery
o Continence
o Dermatology
o Diabetes
o Ear nose and throat (ENT)
o Elderly medicine
o Elderly mental health
o Endocrinology
o Endoscopy
o Inflammatory bowel syndrome
o Gastroenterology
o Gynaecology
o Multiple sclerosis (MS)
o Ophthalmology
o Orthodontics
o Orthopaedics
o Paediatrics
o Parkinson’s disease
o Plastic surgery
o Radiography – x-ray and ultrasound, CT and MRI scans
o Respiratory - lung function testing
o Rheumatology – including blood monitoring and podiatry
o Sleep
o Stroke review
o Syncope and falls assessment
o Telemedicine fractures
o Urology

Day hospital
o Ambulatory blood pressure
o Ambulatory ECG (heart monitoring)
o Blood monitoring and transfusions
o Dermajet (needlelss injection)
o Drug infusions
o Flow rate/bladder scanning
o Synacthen tests

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3.2 Performance of Berwick Infirmary

3.2.1 Summary of Berwick Infirmary activity

Area of Activity 2012/2013

INPATIENTS
Total FCEs 402

OUT PATIENTS
Total Attendances 10,727

DAY CASES
FCEs 970

MATERNITY
FCEs 77

MINOR INJURIES UNIT

Attendances 11,224

RADIOLOGY
Attendances 6,945

PHYSIOTHERAPY
Attendances 12,868

DAY HOSPITAL
Attendances 1,833

*FCE = finished consultant episodes - this is the total amount of time a patient spends under the
care of an individual consultant.

3.3 Current Estate

The need for the redevelopment is based on the limitations and age of the current estate and
buildings. The main hospital was built in 1840 with 18 beds then expanded in 1920 with a
further 14 beds. It remained in that configuration during the war with the last major
redevelopment being over 20 years ago which included the redevelopment of emergency care
services and the building of the maternity unit.

In assessing the viability of re-use and refurbishment of the existing fabric, this report
concentrates on the fabric dating from 1840. The main considerations are the unsuitability of
much of the estate for modern efficient healthcare services that maximise privacy and dignity to
patients, the poor physical condition of the estate and the constraints of expansion within the
existing Infirmary. It is essential to ensure there is compliance with legislation by incorporating
and improving disabled access.

The future vision for Berwick is to provide 21st century healthcare services in an environment
that will maximise patient safety and clinical effectiveness whilst providing pleasant
surroundings for patients and their visitors, as well as staff.

8
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3.4 Accessibility

The following summary* gives an overview of travel and accessibility to other main general
hospital sites:

• Private transport to Wansbeck General Hospital - 54.6 miles - 1 hour 12 minutes

• Private transport to North Tyneside General Hospital - 63.8 Miles - 1 hour 19 minutes

• Private transport to Borders General Hospital - 42 miles - 1 hour 13 minutes

• Private transport to central Newcastle hospitals - 64.9 miles - 1 hour 26 minutes

Public transport by bus from Berwick to the following hospitals:

• Wansbeck General Hospital - 54.6 miles

o Outward - 2 hours 34 minutes with a minimum of 1 change
o Last feasible return journey would be leaving at 16.38 hours taking 2.11 minutes
with 2 changes

• North Tyneside General Hospital - 63.8 miles

o Outward - 2 hours 54 minutes with between 1 and 4 bus changes
o Last feasible return journey would be leaving at 15.51 hours taking 3 hours with 3
changes

• Borders General Hospital - 42 miles

o Outward takes 1 hour 35 minutes, to 2 hours 47 minutes
o Last feasible return journey would be leaving at 17.36

*Source AA Route Planner and Journey Planner

People in the Berwick area who do not have transport in order to travel to visit relatives in
Wansbeck General Hospital can take advantage of a daily car service which the Trust runs
Monday to Friday (including bank holidays) and leaves Berwick Infirmary’s main reception at
12.30pm, arriving at Wansbeck hospital’s main reception at around 1.50pm, in time for visiting
hours. It then leaves Wansbeck hospital’s main reception at 4pm and return to Berwick Infirmary
at approximately 5.30pm. Places, which must be booked in advance, will be offered on a first-
come first-served basis. This can be done by contacting 01289 356601 between 8.30am and
4.30pm, Monday to Friday.

Northumbria Specialist Emergency Care Hospital - detailed discussions with bus companies are
still being held about bus links to the new site in Cramlington.

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4. Drivers of change

4.1 Factors affecting the provision of healthcare services

There are many drivers for change and with the publication of numerous government
documents over recent years. These have all informed the way that local services have
developed over the last recent years and form an essential back ground to the
development of the proposals for the new hospital.

• DoH 2000 The NHS Plan in improving the NHS

• DoH 2001 Compliance with NSF standards
• DoH 2003 Keeping the NHS Local – A new direction of Travel
• DoH 2004 CNO 10 key roles
• DoH 2005 The White Paper Our health our care our say : a new direction for community
services
• NHS Confederation 2006 Why we need fewer hospital beds
• DoH 2006 Our health our care our say :Investing in the future of Community Hospitals
and Services
• NHS Modernisation Agency 2005 10 High Impact Changes

DoH 2000 The NHS Plan in improving the NHS

The NHS Plan set out a vision of a service designed around the patient. Key aspects of that
vision were:

• Faster access to hospital, primary and emergency care

• Improvements to the way services are run
• Better buildings
• Better healthcare
• Better experiences of the NHS for patients.

Patients have the right to expect assurances about the quality of care that they receive
wherever they receive it in the NHS. The Health Act 1999 set out a statutory duty of quality to be
implemented through a framework of clinical governance, the systems and practices of which
ensure the highest possible standards of care for patients. Clinical governance support teams
have been set up to help organisations focus on high-quality clinical services, and the Care
Quality Commission will regularly be assessing NHS organisations’ progress towards
implementation.

DoH 2001 Compliance with NSF standards

The development of nurse led services, including clinics and the chemotherapy unit, nurse
practitioner role, (both emergency and generic), care facilitation, integrated care with
community matrons and rehabilitation team and nurse led beds, are just some of the areas
where compliance with the NSF standards were targeted. The specific clinical standards are
being implemented but the following 3 outline some more specific issues being addressed:

Standard Two The aim of this standard is to ensure that older people are
Person-centred treated as individuals and that they receive appropriate and
care timely packages of care which meet their needs as individuals,
regardless of health and social services boundaries.
Standard Three The aim of this standard is to provide integrated services to
Intermediate care promote faster recovery from illness, prevent unnecessary acute

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 hospital admissions, support timely discharge and maximise
independent living.
Standard Four The aim of this standard is to ensure that older people receive
General hospital the specialist help they need in hospital and that they receive
care the maximum benefit from having been in hospital.

DoH 2003 Keeping the NHS Local – A new direction of Travel

This guidance outlined some of the ways local hospitals can be helped to provide patient-
focused care while ensuring staff are supported to work safely without excessive workloads. It is
based upon three core principles the NHS will in future need to follow when considering
proposals for change in local hospitals and other services.

• Developing options for change with local people, not just for them.
• Redesign can offer a high quality alternative to relocating services, extending the range
of options for developing new configurations that meet local needs and expectations;
• Taking whole systems approach developed across health and social care communities
rather than for an individual hospital site, trust or organisation.
• Looking at Sustainable solutions for smaller hospitals

DoH 2004 Chief Nursing Officers' 10 Key Roles for Nurse

• Order diagnostic and investigations such as pathology and x-rays

• Make and receive referrals
• Admit and discharge patients
• Run nurse led clinics
• Prescribe medications and treatments
• Carry out a range of resuscitation procedures
• Perform minor surgery
• Triage patients using IT
• Take the lead in the way local health services are run
• Manage a case load of patients

NHS Modernisation Agency 2005 10 High Impact Changes

The NHS Modernisation Agency identified ten high impact changes that organisations in health
and social care can adopt to make significant, measurable improvements in the way they deliver
care if the principles were adopted systematically:

• the experience of patients would be greatly enhanced by more appropriate and timely
care
• hundreds of thousands of clinician hours, hospital bed days and appointments in primary
and secondary care would be saved
• clinical quality and clinical outcomes would be tangibly improved
• it would be easier to attract and retain staff and there would be more enjoyment and
pride at work

The following outline the 10 specific changes that could make the difference above:

• Treat day surgery as the norm for elective surgery

• Improve access to key diagnostic tests
• Manage variation in patient discharge
• Manage variation in patient admission
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 • Avoid unnecessary follow-ups
• Increase the reliability of performing therapeutic interventions through a Care Bundle
approach
• Apply a systematic approach to care for people with long-term conditions
• Improve patient access by reducing the number of queues
• Optimise patient flow using process templates
• Redesign and extended roles

DoH 2005 The White Paper Our health our care our say: a new direction for community
services

This guidance sets out a clear direction of shifting the important areas of service provision within
particular specialities closer to patients and local communities. To allow the hospital to excel at
the services they can provide, while more services and support are brought closer to where
people need it most

• Better access and more funding following the patient will drive personalised care. NHS
walk-in-centres will also be expanded

• services will be brought closer to people’s homes through investment in community

hospitals and facilities and shifting care safely away from hospitals

• Prevention of illness will be targeted with several measures, including the establishment
of more healthcare teams to deliver better care across institutional boundaries.

NHS Confederation 2006 - Why we need fewer hospital beds

The report cites advances in technology and new ways of treating patients as the reasons
behind why the NHS now needs fewer beds.

The number of hospital beds in England fell by 31 percent in a 20 year period, however the
number of treated inpatients increased by 57 percent.

The seven areas identified outlines the areas of change that have led to this, but the ultimate
the emphasis remains in safe efficient healthcare provision

Improved management of chronic conditions both inpatient and at home such as diabetes have
both resulted in fewer people being admitted to hospital for long periods of times. Along with
improved technology, advances in drug treatments, alterations in emergency care, advances in
surgery allowing day case and short stay surgery. All have the impact on minimising the
potential exposure to hospital acquired infections and reducing patient's individual cost as well
as the obvious cost of length of stay.

4.2 Factors affecting the provision of services at Berwick Infirmary

4.2.1 Bed occupancy at Berwick infirmary

Nationally, hospital admissions have decreased by 30% over the last 30 years so this is not only
a local issue but a national one. However it is essential to remember that these changes have
come about through better overall provision of healthcare services as more treatments become
available as day cases and/or outpatient experiences.

Lat year Berwick comfortably contained its in patient activity within 30 beds.

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4.2.2 Population projections

The trend for the Berwick population from 2003 to 2028 is in parallel with what is occurring
within Northumberland as can be seen in the two following charts.

The data has been collated into three age groups:

• They represent the population for children and teenagers 0 – 19 years, working adults 20 –
64 years, and the 'retired' elderly over 65 years
• When grouping the different age groups from strategic health authority data, they fell into
three specific trends.

The following charts represent the percentage increase for the different age groups between the
time periods for each age group.

Total Population Prediction 2003 to 2028 in Berw ick Upon Tw eed

Aged 0 - 19, 20 - 64, 65 - 85 + Years and All Ages

30
Population per Thousand

25
20 Ages 0-19
Ages 20-64
15
Ages 65+
10 All Ages
5
0
03

05

07

09

11

13

15

17

19

21

23

25

27
20

20

20

20

20

20

20

20

20

20

20

20

20

Years 2003 to 2028

T o t a l P o p u la t io n P r e d ic t io n 2 0 0 3 t o 2 0 2 8 in N o r t h u m b e r la n d
A g e d 0 - 1 9 , 2 0 - 6 4 , 6 5 - 8 5 + Y e a r s a n d A ll A g e s

350
Population per Thousand

300
250 Ages 0 - 19
200 A g e s 2 0 -6 4
150 A g e s 6 5 -8 5 +
100 A ll A g e s
50
0
03

05

07

09

11

13

15

17

19

21

23

25

27
20

20

20

20

20

20

20

20

20

20

20

20

20

Years 2003 to 2028

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The decrease can be seen within the 0-19 age group of 8% by 2011 and by 2028 is 26%. The
20-64 age group is also decreasing 1.4% by 2011 and 16.9% by 2028. The increase is for the
65 - 85+ age group is 12.9% by 2011 and 39.6% by 2028.

2003 - 2006 - 2006 - 2006 - 2006 -

2006 2011 2016 2026 2028
0-19 Years old -5.6% -8 % -16% -26% -26%
20 - 64 Years old -1.3% -1.4% - 6.1% -12.9% -16.3%
65 – 85 + Years Old +6.6% +12.9% +22.8% +37.1% +39.6%
All Ages -0.8% +0.4% 0% +1.2% +1.2%

In summary, the over 65 years of age group, for the Berwick Borough is increasing over the next
few years to 2028 as follows:
• 2011 - 27% to 7,000 people
• 2016 - 30 % to 7,900 people
• 2021 - 33.8% to 8,800 people
• 2026 - 37% to 9,700 people
• 2028 - 38% to 10,100 people

However the remaining age groups of 0-19 and 20 – 64 years of age are decreasing on the
overall population for Berwick.

5. Demonstrating the case for change

5.1 Objectives for a new development

The emphasis is the reprovision of services then the development of the estates around those
provisions

Service provision

• Improve clinical quality of care throughout the hospital

• Provision of integration services from primary, secondary and intermediate care with
incorporation of local partners if that proves feasible.

Estate provision

• Design a solution which maximises space utilisation and functional suitability

• Flexibility of building to incorporate changing needs of healthcare provision
• Affordable new build within existing resources
• Consideration of local environment constraints and conservation of area
• Patient focus design incorporating disabled access
• Maintain requirements of essence of care, privacy and dignity

5.2 Constraints

The buildings on site have been developed progressively over many years since the original
buildings were erected on the site in 1840. The development was incremental and piecemeal
which has led to an extended foot print for a relatively small hospital. The functional design of
those buildings is based upon architectures that have long been overtaken by modern clinical
practice and patients expectations for privacy and dignity. The current stock of buildings are a
significant constraint on the most effective and efficient provision of healthcare services.

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6. Preferred option

6.1 Background
In view of the longstanding commitment of the Trust and the wider community of local
stakeholders, the only tenable option is the provision of a new Infirmary building. For some
years, the Trust reviewed the availability of alternatives sites but was never able to find a
suitable one that had any reasonable chance of being secured. Furthermore, there is a
significant local preference to retain the Infirmary within the town centre. As well as having a
wider economic impact on the town as a commercial town centre, a central location also
maximises the opportunity for the new Infirmary to accommodate or interact with its partners
within the town .

6.2 Preferred option

The preferred option will maintain and reprovide all existing services within new build
accommodation on the existing Infirmary site.

The development will take place in a manner which will allow services to be maintained. Clearly
the site is very constrained and the scope for decanting is limited by space and the prohibitive
costs of providing temporary accommodation. An initial, very early feasibility has been
completed which has demonstrated that some form of multi-phase construction can be
accommodated within the site. This study is attached at appendix 2 and will need to be refined
and developed as the detailed design emerges.

The clinical content of the scheme will maintain all of the existing services on the site and will
include:

• An inpatient ward
• Minor Injuries Unit
• X-ray and ultrasound with visiting CT and MRI trucks
• Day surgery and endoscopy
• A single maternity delivery room with a birthing pool
• Outpatients combined with day hospital and therapy services
• Oncology day care
• Main entrance and cafeteria
• Body store
• Estates and facilities support accommodation

The Trust believes that GIFA for these proposals will amount to around 6564 m2. A more
detailed clinical content is included as an appendix 1. .

The Trust will work closely with its local partners to establish whether there are any other
opportunities for them to join the development in terms of either different services configurations
or in providing additional accommodation . Clearly the latter would need to be supported by
either capital contributions or agreements to pay back build costs through rentals.

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6.3 Budget

At this stage, without having completed any site investigation or design work and without having
taken any cost advice, but using NSECH actual costs as a benchmark, it is thought that the cost
of the scheme might be of the order £25 million, assuming that VAT would be reclaimable/not
payable.

£000s

18,100 Works
- Extra over for demolitions/phasing/inflation (see risk allowance below)
2,400 Fees
0 VAT - assuming reclaimable/not payable
1,000 F&E
3,225 Risk (approx 15%)
----------
24,725 Total
---------

In the first instance, funds would need to be made available to allow a detailed design to be
prepared and the appropriate consents secured. Further funding would be required in due
course to allow a construction contract to be let.

The Trust has had discussions with Northumberland County Council and agreement has been
reached to finance the scheme via a loan facility totalling £25m over 25 years. The interest rate
charge would be the appropriate rate (net of the County Council certainty discount) fixed over
the loan period. Given the projected increase in interest rates it would make sense to ensure the
loan facility is utilised by (at the latest) the end of Q1 (2014-15). The Trust has agreed that the
loan will be secured against the Berwick facility.

The financial assumptions are based upon an indicative rate of 4%, the Trust planning
submission assumed a rate of 3.90% (consistent with the PWLB rate at the time of writing the
plan). In addition to the interest charges there will be fee charges which are incorporated into
the programme budget.

Given the loan is repayable over 25 years the Trust financial plan provides for the principle
repayment of £1m per annum.

6.4 Programme

The planning authorities are likely to demand a high level of analysis to fully support any case to
demolish the existing bell tower which they have indicated forms an important part of the local
conservation area. In practice, two complete site designs will be need to be prepared and
costed to assist with this debate and to prove a case for the demolition should this be the
preferred option.

The need to construct the development in a number of phases allowing services to be

maintained will most likely require a longer overall construction period than would otherwise be
the case. It is therefore suggested that the key periods below might be considered as the basis
for more detailed programme development.

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 Activity Start End

Detailed clinical engagement with local teams Jan 2014 Feb 2014
Appoint design team Feb 2014 May 2014
Clinical design Jun 2014 Mar 2015
Works package design and procure Mar 2015 Aug 2015
Final evaluation and place GMP Sep 2015 Sep 2015
Multi (?) phase construction/decant Nov 2015 Apr 2018
Final commissioning occupy May 2018 Jun 2018
Programme risk (float) say 5 months Nov 2018

6.5 Risk management

As an experienced developer, the Trust is fully aware of the risks in taking forward large new
build development such as this. At this early stage of design, development all of the risks will lie
with the Trust but these relate only to the development of a design, securing an appropriate
planning consent and the development of a more precise construction budget.

The Trust will look to secure the eventual construction contract on a lump sum, 'guaranteed
maximum price' (GMP) basis . More detailed discussions on the range of risks that the Trust will
pass to the eventual constructor will take place later in the development process.

As a hedge against these risks, the identified budget include for a risk pot amounting to £3.2 M
or approx 15% . This will kept under review as the detailed clinical plans are developed and as
the detailed phasing and decanting arrangements are developed.

6.6 Procurement

Central guidance within the NHS strongly encourages Trusts to use the NHS Framework “P21
+” for all non PFI capital procurement. Although the Trust chose to take forward the NSECH
project outside of this framework, there were some very particular circumstances that lead to
that choice. Although that project is proceeding satisfactorily at the moment, it is perhaps too
soon to form a final view on the out come of that procurement choice.

In a project that is likely to be a reasonably complex, phased development, there are some good
arguments that the early involvement of a design build contractor in the design process would
be beneficial.

Some commentators are now seeing the very first indications of the construction market place
turning (albeit mainly in the south) so there may be at least a possibility of the Berwick project
being procured in a turning, if not rising, market place. In such an environment, the possible
price benefits of procuring work in the open market place rather than within a framework
diminish.

As a way forward, it is suggested that P21+ is used to engage a development team, secure
planning consent and develop detailed cost plans but that further consideration is given once
detailed cost plans have emerged, as to whether the P21+ Contractor is allowed to develop a
formal GMP submission or whether at that point, the project is released to the market place.

6.7 Project management arrangements

Project management arrangements will follow the well established pattern that the Trust has
adopted for its other recent capital developments.

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The Trust Board will retain a primary responsibility for the project with an Executive Director
having a personal responsibility to the Board for project delivery. The Board will review progress
on a monthly basis

The Board will rely on the Building a Caring Future Board (BACF) to review the clinical
development of the scheme. This BACF Board will receive monthly updates on the project. The
Board will rely upon the Finance Investment and Performance Committee (FIP) to review
budget and funding matters. FIP will receive reports on any and all budget variances and risk
matters as the scheme develops.

A more local Project Board will be established to deal with the detailed aspects of the Project.
This will be chaired by a senior Clinician and will ensure that local teams are fully involved and
fully participate in the development of the detailed design.

The Trust SPV, Northumbria Healthcare Facilities Management (NHFML) has been requested
to provide project management support to all of the above forums and to assist the identified
Executive Director in delivering the scheme.

6.8 Affordability

The current revenue position for the exiting site is shown below with an overview of variances
that any new development will bring.

Current revenue budget Proposed revenue budget Variance

£ £ £
Pay 3,231,996 3,281,996 50,000
Non Pay 1,032,996 1,882,552 849,556

Sub total 4,264,992 5,164,548 899,556

Loan Interest 1,000,000 1,000,000

PDC rebate (875,000) (875,000)

Total 4,264,992 5,289,548 1,024,556

The variance can be broken down as follows:

Budget line Variance Comment

£
Domestics 50,000 Increased resource to allow for single bedrooms
and increased en suite toilets/showers
Capital 614,708 Increased capital charge as a result of capital investment -
charge see below for PDC rebate.
Rates 117,831 Increased local rates will be payable for new build hospital
Utilities (6,528) Projected saving against current
Maintenance 123,599 Rebased budget to provide pro active service to the new
build - existing is emergency repairs only
Loan interest 1,000,000 New build construction funded through loan
PDC rebate (875,000) PDC rebate

Total 1,024,556

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Appendix 1 - Clinical content

BERWICK HOSPITAL REDEVELOPMENT Revision Date: 29.11.2013

2
DEPARTMENT SUMMARY m

In patient Wards 30 beds 1284

satelite physio

Urgent Care 2 Exam/assess trly rm 433

1resus room/treatment
1 plaster room/telemed
! GP office

X-Ray 1 R/D room 185

0 Fluoroscopy room assume combined
0 dental room assume combined
1 ultrasound room
CT/MRI/Dexa assume mobile visit

Maternity 1 Clinic Rooms

1 Delivery /bedroom
with birthing pool within Day Surgery

Day Surgery 2 Minor Surgery/Endo room 702 nb not a theatre

8 Recovery Bay
1 delivery room with pool

Chronic Disease 10 C/E Rooms 1440 3 with telemed

1 Treatment Room
1 Podiatry Room
1 Audiology suite
1 Dental suite (1chair)

6 Physio trmt cblls

Physio Gym as Hartford TO21

1 OT kitchen

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 1 OT bathroom
OT bedroom

Intermediate Care Office

Day Hospital waiting/lounge

Muti function Group room

Tweedmouth Clinic 244 still under discussion

Body Store 6 body stores 154

3 Coroner body store
viewing room

Administration 2x 2 person Offices 265

0 Openplan Workstations
1 Meeting Room
1 IT Training room
4 med rec wkstns
1med recs store

Medical Records 0 see TM

Main Entrance HVS shop/cafe 236

Porters/Post/CCTV
Estates 61

Ancillary Stores 285

Laundry Holding
Domestic Services stocks

Contingencies 100

TOTAL DEPARTMENTS 5389

Independent circulation 550

Plant 625

TOTAL 6564

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Appendix 2 - Initial feasibility plans

These plans were attached purely to illustrate the broad feasibility of developing the existing
Infirmary site. The intention is that these plans are revisited and redeveloped by the appointed
design team working closely with local clinical teams. Precise and detailed arrangements will
need to be put in place to allow for any departments that need to be displaced or decanted
during the construction process.

Equally, detailed studies will be required to ensure that all appropriate site infrastructure is
maintained and/or modified to ensure that utility services are maintained to all wards and
departments.

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www.northumbria.nhs.uk 23