Royal National Orthopaedic Hospital Trust. Bolsover Street Imaging Options Appraisal

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1 Royal National Orthopaedic Hospital Trust Bolsover Street Imaging Options Appraisal Introduction The Imaging Department at the Bolsover Street facility consists of two x-rays machines and one ultrasound machine. The DR and CR X-ray facilities fully support all the Outpatient clinics that run Monday to Friday and are an integral part of the services provided at Bolsover St. The ultra-sound room was an addition to the building and a variation to the contract following an agreed business proposal in mid The machine has been significantly under-utilised since the building opened in December 2009 and this paper sets out various options to enable the Board to make a decision around the future of the ultrasound service at Bolsover Street and the potential alternative uses for this space. Context The RNOH agreed the principle to maintain and redevelop outpatient facilities in Central London following an options appraisal in Simultaneously with the start of the Commissioning Project a Service Improvement Programme was initiated in October The eight elements that made up the programme were derived from clinical planning meetings undertaken during the design process and identified the areas where change to service delivery was required in order to use the building as it was intended. The projects were: Project 1: To improve the quality of care for children by the provision of play specialist support where appropriate. Project 2: To roll out the implementation of the clinic support worker to all other departments. Project 3: To review clinic room allocation to maximises clinic room throughput with right time, right place principles including working hours established to support extended opening. Project 4: To undertake demand and capacity work in Imaging to identify the correct staffing levels and skill mix to ensure the dept works at maximum capacity. Project 5: To establish an ultrasound service. Project 6: To review of therapy activity to ensure service can be maintained through the smaller dept. Project 7: To develop the seminar room space as a meeting facility including hire to external parties. Project 8: To develop a plan for Private Patients service delivery maximising available sessions and ensuring appropriate levels of support from nursing and imaging depts. The projects were complicated by a recognition that current service leads believed the service imperatives for Bolsover St had changed in the time taken to deliver the new scheme and new priorities had been established. equently, it was agreed that a workshop would be held to identify all the potential service imperatives and to identify recommendations as to which should be progressed in

2 The workshop took place on the 31 st March 2009 and the presentations included: The current activity and subsequent income generated the planned model of care overview of the accommodation capital and revenue costs of the new facility nursing service imperatives imaging service imperatives therapy service imperatives orthotics service imperatives private patients unit service imperatives teaching service imperatives clinical unit service imperatives spaces that could be identified for change of use Report Structure a) Imaging Business Case 2009 b) Activity and finances c) Options appraisal d) Conclusion A) The Imaging Business Case 2009 Projects 4 and 5 - The Imaging Business Case To establish a new NHS and PP ultrasound service (consultant led) at Bolsover St which will support clinic activity and generate new income in part of the current seminar room space. Estimated cost to implement was 60k and 12 weeks of work and projected income in a year was between 135k and 215k based on the following assumptions at the time: Use of US room Part time / Full Time Unbundled tariffs for 40 weeks per year Diagnostic scans 55 each = 20k / 35k Interventional scans at approx 500 each = 100k / 150k Private patients / Research = 15k / 30k Total income = 135k (PT) / 215k (FT) It should be noted that the business case for the US room did not take into account the cost of the radiologist and nor did it take account of the potential levels of activity that could take place. equently, the assumptions made appear to be have been flawed. B) Activity and Finance Ultrasound Activity April 2010 to September / (April to September) Stanmore Bolsover St Stanmore Bolsover St General exams (diagnostic ultrasound scans) Interventional scans Total The Imaging Services Review Board paper, May 2011 noted there were 488 USS requests with no appointment date. 251 of these were on a planned care pathway and 237 patients were on an active waiting list for an USS. Of the 237 on the waiting list, 124 (52%) were waiting for a therapeutic intervention and 113 (48%) were waiting for a diagnostic 2

3 appointment. Even with this demand the ultrasound machine at Bolsover Street has not been staffed with a full time radiologist to meet the service demand. At the moment, there are on average 522 requests per month which equates to 266 hours of scanning or 61.5 hours of scanning per week. The current capacity at Stanmore is 32 hours per week leaving a shortfall of 29.5 hours per week. So if Bolsover St was flexed up to increase throughput, all the demand should be met each week. Finance The Imaging department staff at Bolsover Street consists of 10 wte Radiographers and support workers, the duties are which are to cover all imaging facilities from 8am to 8pm. A business case for a radiologist was approved and appointment made in May 2010 but there has not been a full-time radiologist present on site at Bolsover Street since it opened in December 2009 and the US work is performed by a Stanmore radiologist being present 2 or 3 days a week. The ultrasound service at Bolsover Street is estimated to have generated a surplus of circa 80k during the period April September Indicative income and expenditure for the period April September 2011 is set out in the table below; Revenue Analysis for Ultrasound Activity Bolsover Street April to September 2011 Indicative Values k k EXPENDITURE Pay - direct and indirect Radiologist 42 Fellow 13 Helper 6 sub-total pay 61 Non-pay - direct and indirect Ultrasound lease 5 Ultrasound maintenance 2 umables/drugs 1 Building lease 14 Energy/utilities/maintenance/soft FM 2 Other 1 sub-total - non-pay 25 Overheads 24 Total Expenditure 110 INCOME NHS Activity NHS diagnostic activity 18 NHS interventional activity 175 sub-total - NHS activity 193 Other income 1 Total Income 194 Surplus/deficit (+/-) 84 3

4 If the ultrasound machine at Bolsover were to be used 5 days per week it is estimated that there would be an additional contribution of circa 500k p.a. assuming the same level of throughput per session and case-mix as for April September. Total NHS patient income from ultrasound activity at Bolsover St would increase to circa 950k p.a. The ultrasound service on the Stanmore site, which operates two ultrasound machines, generated NHS patient income of circa 900k April September 2011, i.e. each ultrasound machine generates approximately 900k p.a. from NHS patient activity. The ultrasound machines at Stanmore generate similar levels of NHS patient income per session compared to the ultrasound machine at Bolsover St. C) Options Appraisal Option 1 Status Quo To keep the presence of an ultra sound service in the Central London Site. Continued financial loss Removes the possibility of the room for other uses that might benefit more to the Bolsover Street facility clinically or financially Option 2 Ultrasound room remains but used to full potential Trust will meet waiting times around No guarantee of required management ultrasound. Further income from both interventional and diagnostic radiology Use of the room as intended (installation of ultrasound room was a variation in contract at a cost of 60k) No guarantee of enough patients travelling to Central London site Full time radiologist not currently accounted for in pay costs. Removes the possibility of the room for other uses that might benefit more to the Bolsover Street facility clinically or financially Assurance of full use required due to two years of under utilisation The imaging dept / radiologists consider a full time job at Bolsover to not be an attractive job A rota between all current radiologists unpopular leading to the machine used to a very limited time for past two years. Option 3 Room converted to an Open MRI Additional resource to the Central London Machine too large to fit into current assessment facility Would be only NHS Open MRI scanner in Central London. Potential for additional private revenue ultrasound room so not a strict replacement for US MRI if to be located on the 1 st floor would remove two clinical consulting rooms The Landlord would require assurances around noise, vibration, power requirements and venting of helium (as in 2005) Increase in imaging off site facilities to be managed No guarantee of patient numbers to cover costs London Upright Open Scanner is 0.5 miles away and two others also in the area. Direct 4

5 competition close by and many NHS have current deals with the private providers. Unknown but estimated large estate costs for installation. Ongoing running costs Option 4 Room converted to a ulting room Increase space for NHS clinics to further No ultrasound facility at Bolsover Street alleviate pressured clinics at Stanmore Minimal estate costs to make the change Ultrasound machine + associate staff move to Stanmore to increase capacity at Stanmore site Increase income at Bolsover Street through additional OPD work Option 5 Room converted to a physiotherapy space A known patient demand ensuring better use No ultrasound facility at Bolsover Street of the space Other potential spaces for growth of Minimal estate costs to make the change physiotherapy service within the building Ultrasound machine + associate staff move to Stanmore to increase capacity at Stanmore site Option 6 Room space merged with seminar room to create Seminar space for 50 Enables a seminar room space deemed Unknown demand and thus income more potentially usable for lectures, teaching etc Option 7 Hire out for Private Use Private patient income Loss of the space for RNOH use Option 8 EOS 2D / 3D x-ray imaging system 9 times less radiation dose per x-ray 1 st in the NHS Recommended for use in research Cost of around 400k with current annual maintenance costs of around 32k (3-4 x more costly than CT and 2-3 x time costly Recommended applications are the than digital radiography management of spinal deformities and lower NICE uncertain about overall impact of the limb problems such as leg length benefits and the NICE committee did not discrepancy, leg alignment and conditions that affect the hip and the knee. consider EOS to be a cost-effective use of NHS resources. D) Conclusion The Ultrasound service was a late addition and a variation to the contract for the new build at Bolsover Street following a business proposal. The service to this date has not employed a radiologist and has therefore run a very limited service since December 2009, a significant timeframe. While making an income from the interventional work the machine has only been run to one fifth of its capabilities as compared to a machine at Stanmore despite there being a waiting list for ultrasound. 5

6 There is a double financial loss over the last two years, both in the cost of running the ultrasound service and the loss of potential income with an alternative use of the room. Bearing in mind the demands on the service at Stanmore, the best outcome would be Option 2 whereby the ultrasound room is used to capacity and returns a surplus, albeit that the income at Stanmore would reduce. However, this has proved to be a significant challenge so far. This may be remedied following the appointment of the new Bolsover St Manager and will require a firm steer from the management team. The Board are therefore asked to consider the options as stated above and make a decision around the future service of the Ultrasound service at Bolsover Street. 6